due to ageing populations and increased survival rates from myocardial infarction , heart failure ( hf ) is now at epidemic levels in high - income countries [ 1 , 2 ] . as a result ,
the costs of caring for people with hf are very high and rising . over past decades , a primary strategy in reducing the personal and cost - related hf burden has been to promote the use of evidence - based medication prescribing [ 35 ] . however , over the last 5 years , there has been a growing recognition that to reduce the hf burden , it is vital to also address hf self - care [ 615 ] ; that is ,  the decisions and strategies undertaken by the individual in order to maintain life , healthy functioning and wellbeing  . after being comparatively neglected for many years , self - care is now recognized as a 
effective hf self - care improves the performance of the heart , reduces the demands of the body on the heart , and promotes general wellbeing .
evidence to support the importance of self - care in each of these areas has improved vastly over recent decades .
there is now strong evidence from large randomized trials and cohort studies that mortality , morbidity , and symptoms can be improved in key self - care domains through consumption of key medications [ 17 , 18 ] , behavioural / lifestyle management ( including smoking cessation , and salt , fluid and weight management ) [ 1 , 15 , 19 ] ,    timely use of health services , regular physical activity and good social relationships [ 1 , 15 ] .
self - care of hf is important because the vast majority of ongoing care is undertaken by the person with hf and their caregiver(s ) in the home  outside of the direct presence , supervision , or support of the health professional in a healthcare setting   [ 9 , 11 ] .
recognition of the importance of self - care has been made in recent clinical guidelines [ 1 , 15 , 1922 ] .
although recent research on self - care and its determinants has recognized a number of influential factors ( including age , knowledge , coping skills , confidence , cognition ) , the influence of sex and gender on hf self - care is not well understood . to increase our understanding of the influence of sex and gender on hf self - care , we reviewed existing qualitative studies of self - care in hf patients .
these studies specifically contained data on the influence of sex and gender on self - care practices .
with the definition of hf self - care guiding the paper  and the perception of hf self - care as a complex process , qualitative research studies were selected for inclusion .
qualitative studies have been used extensively in health research to understand user approaches and behaviours .
qualitative approaches do not presuppose the topics or factors that will be identified in a research study as influencing self - care .
as such , qualitative methods are used to inform the understanding of complex phenomena prior to quantitative research .  
a qualitative systematic paper is used to synthesize findings from similar qualitative studies [ 25 , 26 ] .
sex was defined in the review as  the classification of living things , generally as male or female according to their reproductive organs and functions assigned by the chromosomal complement  .
gender was defined as the , distinct and individual properties of men and women that are  expressed through the values they hold , their psychosocial characteristics , and ultimately their behaviours 
gender also has interactive or contingent dimensions of social identity ; individual properties of masculinity or femininity are elicited from men and women in some social contexts , but not others [ 30 , 31 ] .   the search strategy involved general and specific terms in relation to hf . to be included in the review ,
studies had to include , adults over 18 years of age , be in english , men only , women only or mixed - sex studies that specifically explored the influence of gender or sex using qualitative or mixed ( qualitative and quantitative ) methods .
the search included studies using different qualitative methodologies ( including grounded theory , interpretive descriptive , and ethnography ) and various techniques for data collection ( including interviews and focus groups ) . studies that contained data for people with coronary heart disease were excluded because these populations have different self - care needs compared to hf patients .
surveys were also excluded as these studies do not constitute qualitative research as conventionally defined .  
a search was done for studies published from 1995 to 2010 that were indexed in ovid medline , ovid medline , ovid embase , ovid psycinfo , csa sociological abstracts , ovid aarp ageline , ebsco academic search complete , ebsco cinahl , ebsco socindex , isi web of science : social sciences citation index and science citation index expanded and scopus . over 110 keywords
were used around heart failure and self - care ( e.g. , heart , self - manage * ) and relevant research methods ( e.g. , semistructured , interview , narrative methods ) .
quality of the studies meeting the inclusion criteria was independently assessed using the critical appraisal skills programme ( casp ) tool for qualitative research a valid tool for the assessment of quality in qualitative research .
data extraction was undertaken by the primary author for each paper and checked by the second author .
data were extracted on the focus of the study , the population ( i.e. , patients , family / caregivers , health professionals ) , sample ( i.e. , men only , women only , mixed ) , type of sampling ( i.e. , convenience , purposive , theoretical , other ) , number and age of the sample , sample setting ( i.e. , country ) and the method / approach of the study ( i.e. , grounded theory , interpretive , mixed methods , ethnography , critical theory phenomenology , etc . ) and data collection methods ( i.e. , face to face / telephone interviews ) . quality was assessed independently using the casp tool with disagreements resolved by consensus .  
this involved the primary author reading each study to identify , based on the team 's approach to self - care , the main self - care needs of patients / lay caregivers and links between different needs and age .
these represent the main findings of each study as presented by the participants in the studies   [ 33 , 36 ] .
the details of each study in terms of setting and quality were also extracted and taken into account at this stage .
stage two ( second - order coding ) involved the researchers examining the relationships between concepts identified in the findings from the matrices .
second - order interpretations of common or reoccurring concepts were sought and interpreted in the context of study quality and setting .
for the third stage ( synthesis ) , the main concepts identified during the second stage ( second order interpretations ) were used to reinterpret each paper and reconsider the relationships between the papers .
after initial screening of 537 studies , 78 papers were retrieved , and reviewed in full . from these studies , six studies were identified that used qualitative methods containing or examined themes related to gender differences in hf patient 's perceptions and experiences ( table 1 ) .
these studies recruited patients with a wide range of ages ( 35 to 95 years ) .
sample sizes ranged from 4 to 32 with a total of 61 women and 31 men .
phenomenographic  approach [ 38 , 39 ] , two studies from the united states of america ( usa ) used a  phenomenology 
approach [ 40 , 41 ] , and two studies ( usa and australia ) used 
all the included studies used semistructured interviews as a method of data collection , and recruited patients   18 years of age with nyha classifications of class ii or iii .
the six qualitative studies varied in methodological quality ( 2 high quality , 1 medium quality , and 2 low quality papers ) .
the qualitative studies chosen were systematically evaluated to comprehend the influence of gender on hf patients ' willingness and capacity for effective self - care .
the stated foci of studies were illness experiences [ 3841 ] or barriers and facilitators of hf self - care [ 42 , 43 ] .
however , each used gender as a means to interpret data that resulted in similar categories / themes .
these similarities not only identify relevant issues , they also support the value of each study and their findings .   
the data from all these studies , having been organized into various themes / categories , gave adequate illustration of the different aspects of the self - care experience of men and women with hf .
the qualitative research objectives covered several aspects about living with hf , including : ( 1 ) new self concept , ( 2 ) physical limitations , ( 3 ) negative emotions / losses , ( 4 ) support / deepening relationships , ( 5 ) rejuvenate / rest , ( 6 ) hope , ( 7 ) uniqueness of gender .
participants were recruited from outpatient clinics [ 38 , 39 ] ; professional referrals , unspecified healthcare settings , and from a previously hospitalized sample of hf patients .
the most overarching theme identified across the sexes in relation to hf was the overwhelming physical limitations experienced by men and women  their loss of energy , high fatigue and shortness of breath / breathlessness affected all aspects of life , including occupation , social , and recreational roles [ 3843 ] .
this occurred even when participants were not clear what was causing their symptoms , for example , some women reported difficulty in differentiating hf symptoms from their wider emotions .
reductions in physical activity in the form of sitting or sleeping were used to prevent and/or alleviate symptoms in all the studies .
taking time to try and complete the activities of daily living , while accepting the fact they may not complete the task was common across sexes [ 3843 ] .
life after a diagnosis of hf , compared to past functioning , and social roles , was seen in negative terms by both sexes .
however , women viewed themselves in a range of more negative ways , including : being  handicapped  , 
sick  ,  burdensome  or  worthless  [ 39 , 41 , 42 ] .
fears of death , isolation , of being a burden , and struggles with depression and unhappiness over their physical limitations were common across the sexes [ 3942 ] .
however , again women experienced more negative feelings of anger and hate towards their hf [ 40 , 41 ]   and reported greater loss of hope [ 41 , 43 ] .
the women worried over a lack of money , not being able to care for others or of being dependent on others [ 39 , 40 , 42 ] .
some women increased coping by consciously refocusing   their mental energy in ways more productive for dealing with their hf    or placed great hope in maintaining their present level of functioning [ 39 , 42 ] .
conversely , men reported a wider range of positive and negative emotions compared to women .
age appeared to moderate men 's emotions  with younger men being more negative about hf and the negative effects on life .
while women saw supportive relationships as being based on having someone to talk to [ 3943 ] , women in all the studies frequently reported that they did not have another close person they could rely on to even help with activities of daily living [ 39 , 40 , 42 , 43 ] .
conversely , men reported having more tangible support with family members being involved in supporting their hf self - care [ 38 , 43 ] . with the assistance of family , men had more confidence in interpreting symptoms of hf and self - care [ 38 , 43 ] .
this paper identified that though hf has severe effects on the physical and psychosocial wellbeing of both sexes , women frequently experience more negative emotions in relation to the hf , tend to have lower confidence , poorer social and family support , and see the future as more bleak .
age and culture did appear to influence the experiences and reactions to hf in conjunction with gender and sex .
these patterns in women are a cause for concern because achieving effective hf self - care is difficult for both sexes .
this process is complex as it requires a range of activities , skills , confidence and sustained efforts .
as hf is associated with older age , women comprise more than half of the already large population with hf [ 44 , 45 ] .
achieving optimal conditions for effective self - care in the large female hf population is therefore of high clinical significance .  
though people with hf tend to be at risk for poor psychosocial health with 40% having   depression or depressive symptoms , women are particularly vulnerable to adverse psychosocial health and support .
this may be because women with hf tend to have more symptoms than men [ 47 , 48 ] .
however , it may also be related to the lower psychosocial and family support identified in the studies in this review or to a reluctance of men to voice being isolated or fearful .
that said , there is wider evidence from observational studies that psychosocial factors are more adverse in women with hf and that these psychosocial factors not only affect wellbeing but also hf self - care [ 4951 ] .
the large size and distinctive self - care needs of the population of women with hf suggest that more gender - sensitive approaches are needed for care and disease management .
while supporting self - care is now recognized to be a vital part of effective disease management , there is as yet little appreciation or acknowledgement in clinical guidelines that women have distinct or greater needs for psychosocial support than men with hf .
this paper and other evidence [ 4951 ] indicate that women need additional support around psychosocial factors and self - care that is sensitive to elements of gender and sex .
health professionals providing care to people with hf during the self - care management phase should be aware of the vulnerability that women can experience around psychosocial health and support .
where possible , families , partners and other lay caregivers should be mobilized to provide effective support to the women with hf not only around self - care but also in relation to more general psychosocial wellbeing .
in addition to increasing psychosocial support , antidepressant medications should be considered for women who are suitable candidates . as with most systematic reviews ,
this review was confined to studies that had been published . while there is a sizable body of qualitative research into hf , relatively few studies included or incorporated gender into analyses .
the data in the studies contain only preliminary insights into how gender influences hf patients ' willingness and capacity for effective self - care .
further research is needed into understanding the nature and influences on psychosocial factors in women with hf .
the effects of contextual factors such as being married , widowed , ethnicity , living alone , years of hf experience , education , income and age on women need further exploration .
, women with hf tend to have considerably more negative views of the future , themselves and their ability to fulfill social self - care roles .
women also report having less support for psychosocial wellbeing and self - care . as a highly vulnerable population ,
women need more and better support from health professionals , families and caregivers for psychosocial wellbeing and self - care .
 to improve patient support , it is important to understand how people view and experience heart failure ( hf ) self - care . 
 this systematic review of qualitative studies included all published studies that examine the influence of sex and gender on hf self - care . 
 a systematic search was done for papers ( 19952010 ) indexed in ovid medline , ovid medline , ovid embase , ovid psycinfo , csa sociological abstracts , ovid aarp ageline , ebsco academic search complete , ebsco cinahl , ebsco socindex , isi web of science : social sciences citation index and science citation index expanded , and scopus . 
 after screening of 537 citations , six qualitative studies identified that differences existed in perceptions of symptoms with women having less family involvement and psychosocial support around self - care . 
 moreover , women had considerably more negative views of the future , themselves and their ability to fulfill social self - care roles . 
 women with hf represent a highly vulnerable population and need more support for psychosocial wellbeing and self - care . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion
5. Conclusions