title: 'Heart attack' symptoms and decision-making: the case of older rural women.
abstract: BACKGROUND
  Women are just as vulnerable to 'heart attacks' (used throughout this study to mean 'myocardial infarction') as men and are often unaware of many associated symptoms. Researchers have illustrated that women have difficulty identifying the symptoms of cardiovascular disease, with patients often delaying treatment after the onset of symptoms. Some individuals wait hours or even days before seeking medical care. This is particularly concerning for older rural women because the rates of death from cardiovascular disease and cancer are higher in some rural areas. Despite idealistic views of country life as being active, less stressful, and possessing strong social and community support, rural Americans are more likely than their urban counterparts to face challenges to maintaining health.<br /><b>
  
  
  OBJECTIVE
  </b>The purpose of this paper is to utilize information gathered from a qualitative study exploring older rural women's identification of symptoms and health decision-making specific to heart attack vignettes.
  
  
  METHODS
  Snowball sampling was the main approach utilized to access participants; after an initial contact was successful, participants contacted additional older rural women to see if they might be willing to participate in an interview. This resulted in a final sample of 33 women who resided in rural Midwestern areas of the USA, were 65 years or older, lived in a county defined as rural by the US Census, and were willing to participate in a face-to-face interview. Each interview included a demographic questionnaire, a health questionnaire, and three health vignettes with follow-up questions. Vignettes provided a way of initiating discussions about health decisions without invading the privacy known to be important to rural residents. The term 'heart attack' was used in the interviews because it was thought to be better recognised than the medical term 'myocardial infarction'. All data were audio taped, transcribed, and coded using line-by-line coding. Data were analyzed using content analysis.
  
  
  RESULTS
  The study showed that women had difficulty identifying heart attack symptoms when they did not have previous exposure to the symptoms either through personal experience or educational programs. Individuals incorrectly identified symptoms of a heart attack by associating symptoms with sleep problems, stroke, arthritis, stiffness in the neck, influenza, nerve damage, osteoporosis, bone cancer, tooth infection, and a pulled muscle. Misdiagnosis of symptoms most often led to a delay in seeking treatment in these women. Additionally, the women in this study discussed a reluctance to access care because of concerns related to maintaining their privacy, belief that the ambulance would take too long to reach them, and they did not want to bother their relatives for help.
  
  
  CONCLUSIONS
  The findings of this study suggest implications for educational programs and interventions in rural environments and provide information that can facilitate better-informed communication between healthcare professionals and rural women.
authors.affiliation: 290 McNeal Hall, 1985 Buford Avenue, St. Paul, MN 55108. jack0580@umn.edu.
authors.forename: M N G
authors.initials: MN
authors.lastname: Jackson
authors.affiliation: 290 McNeal Hall, 1985 Buford Avenue, St. Paul, MN 55108. jmccullo@umn.edu.
authors.forename: B J
authors.initials: BJ
authors.lastname: McCulloch
mesh_terms: D000368:Aged; D003657:Decision Making; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000503:physiopathology / Q000523:psychology*; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D036301:Qualitative Research; D012424:Rural Population; D012959:Socioeconomic Factors; D014481:United States; D016387:Women's Health