Let's talk about sex

    Inspired by her mother and daughter, Colleen Norris’ latest research examines how gender roles, social support, and housework can impact health

    By Yolanda Poffenroth on December 15, 2016

    American humourist Erma Bombeck said that housework, if you do it right, will kill you. 

    Surprisingly, she wasn’t that far off from the truth. According to Dr. Colleen Norris (Dip ’78, BScN ’82, MN ’92), women tend to have worse symptoms and are more likely to die from heart disease than men. She says that factors such as the responsibility of managing the home are likely the reasons why. 

    Globally, cardiovascular diseases are the leading cause of death. Virtually everyone is going to be struck somehow with heart disease due to lifestyle and environment, explains Norris. Researchers have even seen eight-year-olds who have some level of cardiovascular disease.

    “Heart disease is still the number one killer of women and men in Canada,” says Norris, a professor with the Faculty of Nursing and Scientific Director for the Cardiovascular Health and Stroke Strategic Clinical Network. “Even though it’s widely perceived to be a ‘man’s disease’, women are just as likely to suffer from it as men.”

    There's more to the relationship than just sex

    In 1995 Norris landed a job with the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH). The newly created APPROACH Registry would collect data on everyone in Alberta who goes for an angiogram and follow up with them for quality of life outcomes of care.

    “We always worry about whether someone lives or dies from a heart attack rather than what happens after,” says Norris.

    “ My relationship with women—whether friend, loved one, or even just the shared experience of being a woman—is what really drives me in my research.” — Colleen Norris

    It was the first time she had ever heard or even thought about what a person’s quality of life might be after surviving a heart attack—and it motivated her to complete a PhD in Epidemiology. 

    After collecting data for several years, some curious trends started to emerge from the APPROACH Registry. “Women were consistently reporting worse quality of life outcomes than men and we couldn’t pinpoint why,” says Norris, who designed and directed the follow-up evaluation of APPROACH for her PhD studies. “Even when controlling for sex, there was something over and above a person’s biological attributes that was creating these different quality of life outcomes.” 

    Norris began to investigate gender and gender roles—socially manufactured roles, behaviours, expressions and identities—as a possible explanation for the differences in health status.

    After spending four years following nearly one thousand Canadians under the age of 55 who were suffering from heart disease, Norris and her colleagues found that gender roles, such as being the primary caregiver, had much more to do with surviving a heart attack than biology.

    As one of the GENdEr and Sex determInantS of cardiovascular disease (GENESIS) investigators, Norris used a new scale developed by the team—the GENESIS Gender Index (GGI)—to untangle characteristics related to sex and gender. 

    After evaluating 40 factors, including marital status, blood pressure, personal income and time spent on housework, the team identified seven attributes that appear to play a role in determining a patient’s outcome. Those who scored high on traits that ranked as more feminine or less masculine were much more likely to have a poorer recovery.

    Out of the blue

    “Those who are both chiefly responsible for household work and the primary wage earner, are four times more likely to return to the hospital with another heart event during their recovery,” explains Norris. “That is significant.”

    Other studies have shown that women who work outside the home are often still responsible for the household management. Many women finish their work shift and go home to start their ‘second shift’ of housework and other responsibilities. When Norris asked patients how many hours of housework they did each week, some women were putting in upwards of 66 hours, but the average for men was four hours—with many not doing any housework at all.

    “The stress levels of a person who works outside the home at a job they want to do and that they find fulfilling are much different than the person who takes a low-paying job because they need the money,” says Norris. “Once you add in the stress and responsibility of running a house, your body isn’t getting a chance to recover the way that it needs.”

    There’s a myth that people have heart attacks out of the blue, but it’s simply not true says Norris. The body is great at providing feedback; you just have to listen to what it’s trying to tell you. Although necessary, it can be incredibly difficult to sit down and say, ‘if I am taking this task on, what task can I stop so that I can take care of myself?’

    It’s something that Norris has struggled with previously. As part of the so-called ‘sandwich generation’ she was working full-time while raising her daughter and two sons and providing care for her aging parents; more recently she took on the role of caregiver while her husband dealt with cancer.

    The analysis made it clear to Norris that health care providers need to pay close attention to patients who score high on the GGI and have high stress. “At the end of the day, regardless if you are male or female, if you have a high GGI score, you are in trouble; we need to figure out how we can help you cope and what supports we can provide so that you don’t return to the hospital,” she says. 

    “When you’re responsible for managing a household and working full-time as well as providing both childcare and elder care, guess what gets lost? You. You and your health get lost and as a consequence your health is affected negatively.”

    Norris believes that health care providers need to start having conversations with patients about their stress, social support, and what they’re doing at home.

    Til Death Do Us Part

     Even marriage itself has an impact on health outcomes. 

    Studies have consistently shown that married men have better health outcomes than divorced or single men, and that married women have poorer health outcomes than single women. 

    When Norris’ father had coronary bypass surgery, her mother became his caregiver. 

    “I saw the burden that dad's post bypass care needs placed on mom,” she says. “Yet when mom had a knee replacement, dad didn't take on the caregiving role; he instead asked me to hire a nurse to cover the times that I couldn't be with her.”

    Once again, it comes down to gender relationships and social support, says Norris.

    “What actually matters to a woman's health outcome is social support—does she have the perception that she is cared for and has assistance available from other people? Does this social support exist for her?”

    Her research showed that regardless of whether a woman was married or not, what mattered most was if she had a daughter or close female friend for social support. 

    “Men had better health outcomes if they were married and having social supports didn't matter—only whether they had a wife or not,” says Norris. “There’s some thought that once married, perhaps the woman takes on a caregiver role to her husband, which contributes to better health outcomes for him. But when there isn’t anyone in her life to provide the same kind of support that she’s giving to her husband, her health outcome suffers.”

    What's the matter What Matters?

    In Scotland, the National Health Service started a program called 'What matters to you?' Instead of health care providers asking ‘what’s the matter?’ they ask ‘what matters to you?’ The aim of the program is to encourage and support more meaningful conversations between people who provide health and social care and the people, families and carers who receive health and social care.

    “It's assumed that if a cardiac patient is sent home with a prescription for six medications, they’ll take all six medications,” says Norris. “It’s up to the health care team, with our wealth of knowledge, to have a conversation with the patient. We can help prevent them from coming back to the hospital by simply asking the patient what’s important to them. If they can’t afford all of their medications, which ones are the most important to their health? Or if they've taken a particular statin before and didn’t like how it made them feel—okay, let’s talk to the doctor about trying a different one.”

    As associate director of research for the division of cardiac surgery at the University of Alberta Hospital and the Mazankowski Alberta Heart Institute, Norris often ends up going on rounds.

    She’s seen patients' eyes flash to their partner when told by the cardiologist that they’ve had a heart attack and can't drive for six weeks. “You know that there's not a chance that will happen,” says Norris. “As a nurse, my response would be to go back to the patient and explain that those are the rules because if they are driving and an accident occurs, their insurance won't cover them.”

    It's all about asking the patient what they need to make their recovery happen.

    Taking a few moments to have a conversation about the things that really matter helps establish a relationship with the patient, and also understand them in the context of their own life and the things that are most important to them. With this insight, health care providers are in a much better position to work with the patient to find the best way forward for them.

    “Every nurse knows in their heart, in their soul, that it's not just getting a patient a prescription for a pill to lower their blood pressure,” says Norris. “If there is stress going on at home and it hasn't been addressed, or even mentioned, all we're doing is putting a bandage on a festering wound.”

    Nurses need to start asking questions no matter their field—no matter if they're in a hospital or in an immunization clinic, explains Norris. “Just initiate that conversation with a patient, because we know stress and health are intertwined. If they have a baby who's screaming and a toddler running around and they have no help, it must be stressful at home. Simply asking them what their day has been like can get the conversation started.”

    Whatever you do, just start talking—it can help more than you know.