Elsevier

The Lancet

Volume 357, Issue 9263, 14 April 2001, Pages 1168-1171
The Lancet

Articles
Lay constructions of a family history of heart disease: potential for misunderstandings in the clinical encounter?

https://doi.org/10.1016/S0140-6736(00)04334-8Get rights and content

Summary

Background

Family history is recognised as a risk factor for coronary heart disease (CHD) by epidemiologists, health professionals, and the public, and could act either as a spur or barrier to changing health behaviour. However, there has been no systematic investigation of which factors affect whether people regard themselves as having a family history of CHD or not.

Methods

We used purposive sampling to select 61 men and women who were middle class or working class from a large cross-sectional survey. Half the respondents had indicated in this previous survey that they had heart disease in their family. The range of understanding of the meaning of having a family history was explored in detailed qualitativesemistructured interviews.

Findings

Perception of a family history of heart disease depended on knowledge of the health of family members, the number and closeness of relatives with heart conditions, the age of affected relatives, and the respondent's sex and social class. Men, particularly working-class men, required a greater number of close relatives to be affected to perceive that they had a family history. Even when respondents judged that heart disease ran in their family, they did not always perceive themselves as at increased risk because they felt different in crucial ways from affected relatives.

Interpretation

The factors that people and epidemiologists judge as relevant to establish presence of a family history can differ. We suggest that these differences could lead to misunderstandings between doctor and patient, which could undermine advice on CHD risks and associated behavioural changes.

Introduction

A decrease in coronary-prone behaviour (and more detailed understanding of the barriers to change) is a priority for public health.1, 2 Family history is recognised as a risk factor for CHD both by epidemiologists3, 4, 5 and the public.6, 7 Furthermore, some research has suggested that having a family history could act either as a spur or a barrier to changing health behaviours,7 although few studies have researched this link.8 C Davison and colleagues' qualitative research suggests that people regard family patterns of illness as important in the origin of heart disease, but these investigators did not asses whether people saw themselves as being at increased familial risk, or how people might reach decisions about their familial risk. These omissions are important since evidence suggests that advice on behavioural change in clinical practice9, 10 is more effective when based on a clearer understanding of cultural norms informing health beliefs, attitudes, and practice.11, 12, 13

Qualitative research methods are appropriate for detailed exploration of cultural attitudes and norms. Such methods have been portrayed as antithetical to quantitative ones;14 with qualitative research characterised as hypothesis-generating and quantitative research as hypothesis-testing.15 However, both research methodologies can complement each other.

We have formulated questions on perceptions of familial risk in two large-scale surveys of different population groups in the west of Scotland16, 17 to identify people who perceived that they had a family history of heart problems, and those who did not. Our analysis has shown that people often report some kind of illness or weakness in their family, and heart disease is the most frequently mentioned illness. In the Midspan Family Study,17 16% of people thought that they had a family weakness due to heart disease. We also examined the relation between a perceived family history of heart disease and smoking, a major coronary risk factor,16 and independent data on parental deaths (the Midspan Family Study has mortality data over 20 years).17 By comparison with people whose parents were both alive, those who had a parent who had died from CHD were over three times as likely to report a perceived family history of heart disease and those with two parents who had died from CHD were almost eight times as likely to report having a family history. However, some people who had at least one parent who had died of CHD did not think that there was a family history of heart disease.

In view of these findings we aimed to clarify what people actually understand by a family history. From our quantitative study, we concluded that a reported family history is related to sex, social class, and parental deaths from CHD. We report here the qualitative phase of our study.

Section snippets

Study population

We purposively selected interview respondents18 from the Midspan Family Study, 1996.19 Systematic, non-probalistic sampling is often used in qualitative studies to identify groups of people with specific characteristics or circumstances.18 We selected our sample to assess accounts of family histories of heart disease in two groups; half who thought that heart disease ran in their family, and half who thought that no illnesses or weaknesses ran in their family. Questions on perceptions of family

Results

Genes, or heredity, were mentioned spontaneously as a cause of heart disease by more than two-thirds of the respondents, and almost all agreed that heredity was an important factor when asked specifically about it later in the interview. When deciding whether they had a family history, respondents considered the number of relatives affected, their age, and their relationship to the respondents. In accord with clinical definitions of a family history5 more weight was given to deaths in first

Discussion

A family history of heart disease is open to many interpretations. We have confirmed the importance of heredity in lay notions of the causes of heart disease. There are some factors (number and age of relatives affected, and relationship to index person) that people and doctors or epidemiologists judge relevant when establishing the presence or absence of a family history. But we have also identified four areas in which lay interpretations differed from medical understandings.

First, although

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