Introduction

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Mortality from coronary heart disease in Scotland is higher than the United Kingdom average,¹ and within Scotland mortality is highest in the west.² A study in populations drawn from 21 countries reported that of all its centres Glasgow had the highest mortality from coronary heart disease.³

Studies in the United Kingdom and Scotland have shown socioeconomic variations in uptake of cardiology investigations and revascularisation procedures.^4-6 The questions of where in the care pathway and why the variations arise remain unanswered. Qualitative studies have identified several factors that lead to a reluctance to present with anginafor example, fear of hospitals, fear of what the doctor would say, denial of heart disease, diagnostic confusion relating to comorbidity, and low expectations of treatment. ^{7 8}

Socioeconomic status has long been recognised as an important determinant of illness behaviour and the quality of the doctor-patient relationship. ^{9 10} This study aimed to ascertain whether responses to chest pain varied with socioeconomic status.

	Methods

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The sampling frame comprised men and women aged 45-64, identified in epidemiological surveys carried out in two socioeconomically contrasting areas of Glasgow as having exertional chest pain. ^{11 12} We used purposive sampling to ensure equal representation of men and women from the two socioeconomically contrasting areas. We stratified respondents by sex and area of residence and randomly selected 15 men (mean age 58.6 years) and 15 women (mean age 57.7 years) from each area.

HMR used a semistructured interview schedule, making it clear to respondents that she was a general practitioner.¹³ We carried out the analysis as a five stage iterative process: development of a coding schedule; coding of the data; description of the main themes; linking of the themes; and development of explanations for the relations between themes. We give code numbers and respondents' sex, age, and area of residence in parentheses (D=deprived; A=affluent).

	Results

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Perceived vulnerability to heart disease
Respondents from the deprived area reported feeling more vulnerable to heart disease than those from the affluent area. This greater perceived vulnerability related to their strong family histories and greater sense of identification with high risk groups and stereotypes of cardiac patients; they were more likely to have vivid memories of witnessing angina and deaths from heart disease in young relatives. For example, R38 (male, 65, D) explained that two of his brothers and two nephews had angina; he communicated a sense of resignation to having heart disease by saying: "The whole lot of us have had angina."

The sense of vulnerability felt by the deprived respondents was often accentuated by their identification with the dominant "red and bloated" cardiac stereotype and with social groups and geographical areas associated with high risk: "I just know the research. The east end ae Glasgow is where the heart attacks are more prominent than any other part of the west of Scotland; the west side ae Scotland is most prominent in the heart attacks than any place else in the British Isles. If you are looking for a candidate for a heart attack, you've come tae the right area" (R34, male, 61, D).

In contrast, respondents from the affluent area were more likely to deny a family history of heart disease. Others presented their family histories as discrete and isolated events or reported a belief that their positive family history could be "cancelled out" by leading a healthy lifestyle. They also distanced themselves from cardiac stereotypes by speaking about them in the third person: "They'd probably be overweight. Smokes and drinks too much probably" (R30, female, 47, A).

Even though respondents from the deprived area expressed a greater sense of vulnerability than the affluent respondents, they were no more likely to report presenting with chest pain. Their illness behaviour was modified by their experience of illness and their expectations of health care.

Experience of illness
Forty four respondents made a clear general statement about their health. Of these, 21 stated that their health was good, 7 judged their health to be moderate, and 16 said that their health was poor. Of the 16 people with poor perceived health, 12 were from the deprived area; of the 21 people with good perceived health, 15 were from the affluent area. As well as often reporting poor health, people from the deprived area often reported that their health was in decline:

HMR: "How do you feel about your health at the moment?"

R44 (male, 57, D): "At the moment (laughs) I feel I'm going down hill rapidly, you know."

Respondents from the deprived area were also more likely to report other significant medical conditions and to have low expectations about longevity and ageing. R28 (female, 65, D) reported having diabetes, stroke, hypertension, and high cholesterol, and said laughingly: "You name it, I've got it, you know what I mean?"

Another respondent (R43, male, 58, D), when asked about his health, said: "I'm gettin' a lot of pain in my chest for some unknown reason."

HMR: "Are you?"

R43 (laughs): "Aye, but I think it's auld age."

HMR: "How old are you?"

R43: "I'm fifty nine on the seventh. I dunno. I've seen a few of my mates goin' away [dying], aye they never reached this one. So, the boys are all congratulatin' me, thinkin' `At least he made it to auld age pension' you know, 'cause a lot of them didnae get there."

Respondents reported three reasons for not presenting with chest pain that were related to perceived poor health. Firstly, they normalised their chest pain: "I just thought `Och, you've had to work long hours,' you know, so I thought it was just tiredness, that's all" (R54, female, 56, D). Secondly, they were unable to distinguish chest pain from symptoms of other physical conditions, such as chest infections and heartburn, or they attributed it to "stress." Thirdly, respondents with multiple health problems expressed concerns about overusing medical services:

R57 (female, 53, D): "I actually thought then `Is this the start of a heart attack? No, Jesus God, no,' but I don't know, I just left it."

HMR: "You didn't call your doctor then?"

R57: "No, because at that particular point I thought I was goin' tae the doctor far too much an' I don't know why, I think sometimes the doctor thinks you're playin' on it. And then I say, no I'll leave it just to see, 'cause I'm not one for actually bothering the doctor."

Past experience and future expectations of health care
Respondents from the deprived area were more likely to report negative experiences of health care and to have lower expectations of health care. The quality of interactions was determined by the degree of social alignment between the doctor and the respondent, the degree to which knowledge about health was shared in the consultation, and the extent to which respondents felt at fault for their health problems.

None of the respondents from the socially deprived area was personally connected with the medical profession, but 10 affluent respondents stated that they or their spouse worked in medical or allied professions. Affluent respondents were also more likely to report friendships with doctors and privileged access to health care. For example, R11 (male, 58, A), who was under pressure to get back to work, reported that his general practitioner arranged a cardiology appointment that afternoon by fax.

In the deprived area, several respondents reported difficulty accessing health services. For example, R54 (female, 56, D), who has laryngeal carcinoma, had presented many times before being referred:

HMR: "How long had you had the sore throat before you went to your doctor?"

R54: "I'd been goin' to him on and off for about two years and complainin' an' just gettin' cough bottles and antibiotics and, of course, everything they blame on smoking."

The extent to which knowledge was shared also varied with socioeconomic status. The more affluent respondents reported greater formal medical knowledge and more extensive sharing of knowledge with their general practitioner: "We [himself and the general practitioner] always sit and have a chat and he says `Oh I read this interesting paper in the Lancet the other day and it says `da-da-da' " (R13, male, 47, A). In contrast, people from the deprived area often felt that they were not given adequate information: "They [doctors] just say `you have to do this, you have to do that' and that's it. I'm a question asker, and they don't like me asking questions" (R53, female, 62, D).

The issue of blame was discussed by respondents from both areas. Heart disease was linked to risk behaviours and to negative personality traits such as selfishness: "not thinkin' ae other people before yourself" (R48, female, 51, D); weakness: "people that drink or weaklings" (R28, female, 65, D); and laziness: "I think if you were a sort of lazy layabout and suddenly got up and asked the heart to do all these things you might have problems" (R49, female, 51, D). However, deprived respondents were more likely to report being personally involved in risk behaviours and to feel at fault for their chest pain: "You only get what you deserve. The books tell you that, and the telly and the papers tell you that" (R34, male, 61, D).

Many of the deprived respondents believed that their general practitioner would blame them for their health problems. For example, when asked whether he had consulted his general practitioner about his chest pain, R41 (male, 53, D) said: "No, they just tell you tae give up smokin', that's aw." Respondents who believed that they led a healthy lifestyle (mainly from the affluent area) rarely considered themselves to be to blame for their chest pain.

	Discussion

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Medical sociologists have long recognised the importance of illness biography¹⁴ and social class ^{9 15} in determining illness behaviour. More recent research has shown the impact of previous encounters with medical professionals on subsequent consulting behaviour¹⁶ and indicated that fear of blame may deter patients from presenting.¹⁷ Some of the themes identified in our study as being relevant to socioeconomic variations in illness behaviourfor example, diagnostic confusion and past experience of health carehave been suggested by previous studies of chest pain, but because those studies were based on socioeconomically homogeneous samples they were not able to make socioeconomic comparisons. Moreover, the participants in those studies had already received a clinical diagnosis of angina, and it is likely that their recall of events was influenced by their subsequent care. This study, by using a sample identified at the beginning of the care pathway before a diagnosis had been made, and drawn from two socially contrasting areas, was able to explore in some depth the relation between socioeconomic status and responses to undiagnosed chest pain.

Our study indicates that some of the observed socioeconomic variation in uptake of cardiology services may originate from decisions made by patients, which in turn relate to family and social norms of ill health, to past and present health and expectations of future health, and to past experience of health care. Normalisation of symptoms and diagnostic confusion and are likely to apply to illness behaviour in general. The theme of self blame and fear of chastisement, which underpinned the quality of past experience of health care, is likely to be particularly relevant to chest pain because of the common association between heart disease and an unhealthy lifestyle.

This study was designed to explore the socioeconomic differences in responses to chest pain, in order to generate hypotheses. We suggest that socioeconomic variations in the decision to present may be partly explained by respondents' perceptions of what constitutes normal health, by their illness biographies and expectations of future health, and by the perceived quality of previous encounters with health professionals. Future research is needed to test these hypotheses. Meanwhile, the possible implications for ensuring equity of access to cardiology services should be considered by professionals working in primary care and health promotion.

	Acknowledgments

We thank the Wellcome Trust for funding this study and the men and women who gave up their time to be interviewed. We also acknowledge the help of Ian Cowan in preparing the manuscript.

Contributors: See bmj.com

	Footnotes

Funding: Wellcome Trust (grant number 047007).

Competing interests: None declared.

The full version of this article appears on bmj.com

	References

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(Accepted 13 March 2002)