Charting a course for the future of women's health in the United States: concepts, findings and recommendations

Person-centered care for diverse women: Narrative review of foundational research

Despite advocacy and recommendations to improve health care and health for persons who identify as women, women continue to face inequities in access to and quality of care. Person-centered care for women is one approach that could reduce gendered inequities. We conducted a series of studies to understand what constitutes person-centered care for women and how to achieve it. The overall aim of this article is to highlight the key findings of those studies that can inform policy, practice, and ongoing research. We conducted a narrative review of all studies related to person-centered care for women conducted in our group starting in 2018 over a 5-year period, which was general at the outset, and increasingly focused on racialized immigrant women who constitute a large proportion of the Canadian population. We organized study summaries by research phase: synthesis of person-centered care for women research, exploration of existing person-centered care for women guidance, consultation with key informants, consensus survey of key informants to prioritize strategies to achieve person-centered care for women, and consensus meeting with key informants to prioritize future research. We conducted the reported research in collaboration with an advisory group of diverse women and managers of community agencies. Our research revealed that little prior research had fully established what constitutes person-centered care for women, and in particular, how to achieve it. We also found little acknowledgment of person-centered care for women or strategies to support it in medical curriculum, clinical guidelines, or healthcare policies. We subsequently consulted women who differed by age, ethno-cultural group, health issue, education and geography, and clinicians of different specialties, who offered considerable insight on strategies to support person-centered care for women. Other diverse women, clinicians, healthcare managers, and researchers prioritized issues that warrant future research. We hope that by compiling a summary of our completed research, we draw attention to the need for person-centered care for women and motivate others to pursue it through policy, practice, and research.

Postpartum Care Visit Attendance Within 60 Days of Delivery Among Women With and Without Opioid Use During Pregnancy: An Analysis of Commercial Insurance Data

BACKGROUND

Postpartum care (PPC) is a key component of maternal health, particularly for people who use opioids during pregnancy. Little is known about the prevalence and correlates of PPC visit attendance among those using opioids compared with nonusers in a privately insured population.

METHODS

A retrospective cohort study was conducted using nationwide private insurance claims between 2011 and 2017 (N = 1,291,352 women) comparing the following opioid use groups: nonusers, nonchronic prescription users, chronic prescription users, and women with opioid use disorder (OUD). Multivariable logistic and linear regressions evaluated the odds of PPC attendance and the mean time to an initial PPC visit for each user group. Stratified models identified factors associated with PPC attendance by opioid use type.

RESULTS

Overall, 45% of the cohort attended a PPC visit and nearly 10% had any opioid use during pregnancy. More women in the three opioid use categories attended PPC than nonusers (50-56% vs. 45%). Opioid use regardless of type was associated with higher odds and earlier PPC visitation than women with no opioid use; nonchronic and chronic users had 17% and 40% greater odds of PPC than nonusers (adjusted odds ratio [aOR]: 1.17; 95% confidence interval [CI]: 1.16-1.19; aOR: 1.40, 95% CI: 1.34-1.46), whereas women with OUD had 7% higher odds (aOR: 1.07; 95% CI: 1.00-1.13). Antenatal care and psychiatric, hypertensive, and pain conditions were most strongly associated with higher odds of attending PPC; older maternal age was negatively associated with PPC. Stratified analysis showed opioid correlates varied similarly across user groups.

CONCLUSIONS

PPC use was generally low in this study cohort of privately insured women. Women who used opioids and those with chronic conditions had greater odds of attending PPC. Improved efforts are needed to engage people in PPC, as well as service integration and coordination for people who use opioids during pregnancy.

A scoping review on women’s sexual health in the postpartum period: opportunities for research and practice within low-and middle-income countries

Background

Women’s sexual health is generally defined and explored solely in relation to reproductive capacity, and often omits elements of sexual function and/or dysfunction. Concerted focus is given to women’s health during pregnancy; however, women’s sexual health is largely neglected after childbirth. This scoping review explored how the sexual health of postpartum women has been defined, measured, and researched in low- and middle-income countries (LMICs).

Methods

Articles eligible for review were those that investigated women’s sexual health during the first 12 months postpartum and were conducted among women aged 15–49 in LMICs. Eligibility was further restricted to studies that were published within the last 20 years (2001–2021). The initial PubMed search identified 812 articles, but upon further eligibility review, 97 remained. At this time, the decision was made to focus this review only on articles addressing sexual function and/or dysfunction, which yielded 46 articles. Key article characteristics were described and analyzed by outcome.

Results

Of the final included articles, five studies focused on positive sexual health, 13 on negative sexual health, and the remaining 28 on both positive and negative sexual health or without specified directionality. The most common outcome examined was resumption of sex after childbirth. Most studies occurred within sub-Saharan Africa (n = 27), with geographic spread throughout the Middle East (n = 10), Asia (n = 5), North Africa (n = 3), and cross-geography (n = 1); notably, all five studies on positive sexual health were conducted in Iran. Negative sexual health outcomes included vaginismus, dyspareunia, episiotomy, perineal tears, prolapse, infection, obstetric fistula, female genital cutting, postnatal pain, uterine prolapse, coercion to resume sex, sexual violence, and loss of sexual desire/arousal. Most studies were quantitative, though eight qualitative studies elucidated the difficulties women endured in receiving information specific to sexual health and hesitance in seeking help for sexual morbidities in the postpartum period.

Conclusions

Overall, the evidence base surrounding women’s sexual health in the postpartum period within LMICs remains limited, with most studies focusing solely on the timing of resumption of sex. Integration of sexual health counseling into postnatal care and nonjudgmental service provision can help women navigate these bodily changes and ultimately improve their sexual health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01399-6.

Women’s sexual health is often studied in relation to reproductive health and childbearing. While reproductive health during pregnancy and immediately after is well documented, it remains unclear how women’s sexual health is addressed, particularly within low- and middle-income countries. The aim of this review is to understand how researchers have measured, defined, and examined postpartum sexual health. In October 2021, we searched PubMed database with the following criteria: published in the last 20 years; conducted in a low- or middle-income context; examined sexual function and/or dysfunction among women aged 15–49 within 1 year after childbirth. From this inclusion criteria, we identified 46 relevant articles. Most studies were conducted in sub-Saharan Africa. Only five studies focused exclusively on positive sexual health, and the majority of studies examined the resumption of sex after childbirth. Multiple qualitative studies described women’s reluctance to seek help for postpartum sexual health issues and highlighted the difficulties they faced in receiving information specific to sexual health. Overall, the evidence base surrounding women’s sexual health after childbirth within low- and middle-income contexts is limited. Future research should examine sexual health beyond resumption of sex after childbirth and explore barriers to help-seeking for women experiencing sexual health issues. Further exploration of positive sexual health is needed across contexts.

How is patient-centred care conceptualized in obstetrical health? comparison of themes from concept analyses in obstetrical health- and patient-centred care

Background

Due to gender inequities that exist for women of childbearing age, there exists a need to deliver care tailored to their needs and preferences. Patient‐centred care (PCC) can be used to meet these needs. This review aims to compare patient care delivery between PCC and obstetrical care. This can help us address how PCC should be delivered to women before, during and after pregnancy versus how it is delivered to patients regardless of sex.

Methods

A review of literature was conducted on MEDLINE, EMBASE, CINAHL and SCOPUS for English PCC and high‐quality perinatal reviews published between 2010 and 2021. The data were analysed using a modified Walker and Avant framework.

Results

A total of 2138 unique studies were identified, with 11 PCC and 9 high‐quality obstetrical care studies included. Common defining features between PCC and obstetrical care include respect and dignity, informed decision‐making, therapeutic alliance, effective communication, social relationships and autonomy. PCC‐specific features were holistic care, empowerment, individualized care, coordinated care and empathy. Unique high‐quality obstetrical care themes included continuity of care, privacy and confidentiality, provider education and status, physical environment and equitable maternal care.

Conclusions

There are shared defining attributes between PCC and obstetrical care, including respect and dignity, informed decision‐making, the therapeutic alliance, effective communication, social relationships and autonomy. However, there remain unique defining attributes for high‐quality obstetrical care and PCC. This highlights the need for a unique approach to obstetrical care. More research on care for different physiological conditions in women is needed to address patient care that addresses different parts of the lifespan and develop frameworks that can influence health policy, patient care and health system evaluation.

Patient or Public Contribution

This study was one part of a larger, multicomponent study of how to implement PCC for women across the lifespan. While we did not specifically consult or involve women in this dual concept analysis, our larger study (content analysis of clinical guidelines and government policies, qualitative interviews with women and clinicians, Delphi study to prioritize consensus recommendations for achieving PCC for women) was guided by the experiences and input of a 50+ women advisory panel.

Medical student exposure to women's health concepts and practices: a content analysis of curriculum at Canadian medical schools

BACKGROUND

Women's health (WH) includes a broad array of concerns and challenges that affect health across the lifespan. Considerable research shows that women continue to experience disparities in access to and quality of care. Apart from surveys of medical trainees and faculty, little research and none in Canada examined medical curriculum for WH. This study assessed how Canadian medical schools integrate WH in their curriculum.

METHODS

We used deductive and summative content analysis to describe instances and the nature of WH topics in program and course descriptions that were publicly-available on web sites of Canadian medical schools. We reported results using summary statistics and text examples. We employed a framework, tested in our prior research, that included mention of women's health principles and practices relevant to any health concern or condition including factors (e.g. sex, gender, social determinants) that influence health, and access to or quality of care.

RESULTS

We retrieved 1459 documents from 16 medical schools (median 49.5, range 16 to 301). Few mentioned WH (125, 8.6 %), and the quantity of mentions varied by school (range 0.0-37.5 %). Pre-clerkship course documents more frequently mentioned WH (61/374, 17.3 %, chi square 43.2, p < 0.00001) compared with clerkship course documents (58/1067, 5.4 %). Core course documents more frequently mentioned WH (72/542, 13.3 %, chi square 29.0, p < 0.00001) compared with elective course documents WH (47/899, 5.2 %). Overall, documents more frequently referred to the WH domain of social determinants of health (88, 70.4 %). Few documents addressed women's health (21, 16.8 %), sex or gender (19, 15.2 %), other considerations (15.2 %) or principles/components of women's health (2, 1.6 %). Most documents that mentioned WH provided little detail about what those concepts referred to or how to optimize WH.

CONCLUSIONS

Based on program and course descriptions, WH may not be well-integrated at Canadian medical schools, and future physicians may not be consistently exposed to the full breadth of WH. This reveals opportunities for enhancing WH in the medical curriculum. Future research is needed to engage stakeholders including women in developing, implementing and evaluating competencies and corresponding curriculum that reflect the full range of WH concepts and practices.

Patient-Centered Care for Women: Delphi Consensus on Evidence-Derived Recommendations

OBJECTIVE

Patient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW.

METHODS

We used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women's health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7.

RESULTS

The response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6).

CONCLUSION

The recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW.

Identifying strategies to implement patient-centred care for women: Qualitative interviews with women

OBJECTIVE

Patient-centred care (PCC) is one approach for mitigating gendered inequities in health care quality. Little is known about how to implement PCC for women (PCCW). This study explored women's views about PCCW implementation.

METHODS

Descriptive analysis of semi-structured qualitative telephone interviews with diverse women about PCC using an established 6-domain PCC framework.

RESULTS

Participants were 33 women who varied in health care experience, age, education and setting. Themes were consistent across these characteristics. Women said that clinicians often dismissed their healthcare concerns. We transformed desired PCC elements into strategies to implement PCCW, 27 at the point-of-care (i.e. assume a non-judgmental disposition, demonstrate active listening, elicit questions, acknowledge emotions, explore preferences for treatment, and offer self-care information) and 3 at the system level (education for women/girls and clinicians about PCCW, widespread access to women's-only services or women clinicians).

CONCLUSION

Many women experienced suboptimal PCC. By sharing their PCC experiences, women identified PCC elements of importance to them, and insight on actionable point-of-care and system-level strategies to implement PCCW.

PRACTICE IMPLICATIONS

This study revealed numerous ways that clinicians can foster PCCW, and insight on how healthcare managers and policy-makers can support PCCW implementation.

Multi-level strategies to tailor patient-centred care for women: qualitative interviews with clinicians

BACKGROUND

Patient-centered care (PCC) is one approach for ameliorating persistent gendered disparities in health care quality, yet no prior research has studied how to achieve patient-centred care for women (PCCW). The purpose of this study was to explore how clinicians deliver PCCW, challenges they face, and the strategies they suggest are needed to support PCCW.

METHODS

We conducted semi-structured qualitative interviews (25-60 min) with clinicians. Thirty-seven clinicians representing 7 specialties (family physicians, cardiologists, cardiac surgeons, obstetricians/gynecologist, psychiatrists, nurses, social workers) who manage depression (n = 16), cardiovascular disease (n = 11) and contraceptive counseling (n = 10), conditions that affect women across the lifespan. We used constant comparative analysis to inductively analyze transcripts, mapped themes to a 6-domain PCC conceptual framework to interpret findings, and complied with qualitative research reporting standards.

RESULTS

Clinicians said that women don't always communicate their health concerns and physicians sometimes disregard women's health concerns, warranting unique PCC approaches.. Clinicians described 39 approaches they used to tailor PCC for women across 6 PCC domains: foster a healing relationship, exchange information, address emotions/concerns, manage uncertainty, make decisions, and enable self-management. Additional conditions that facilitated PCCW were: privacy, access to female clinicians, accommodating children through onsite facilities, and flexible appointment formats and schedules. Clinicians suggested 7 strategies needed to address barriers of PCCW they identified at the: patient-level (online appointments, transport to health services, use of patient partners to plan and/or deliver services), clinician-level (medical training and continuing professional development in PCC and women's health), and system-level (funding models for longer appointment times, multidisciplinary teamwork to address all PCC domains).

CONCLUSIONS

Our research revealed numerous strategies that clinicians can use to optimize PCCW, and health care managers and policy-makers can use to support PCCW through programs and policies. Identified strategies addressed all domains of an established PCC conceptual framework. Future research should evaluate the implementation and impact of these strategies on relevant outcomes such as perceived PCC among women and associated clinical outcomes to prepare for broad scale-up.

Is patient-centred care for women a priority for policy-makers? Content analysis of government policies

BACKGROUND

Considerable research shows that women experience gendered disparities in healthcare access and quality. Patient-centred care (PCC) could reduce inequities by addressing the patient's clinical and personal needs. Healthcare policies can influence service delivery to optimise patient outcomes. This study assessed whether and how government policies recognise and promote PCC for women (PCCW).

METHODS

We analysed the content of English-language policies published in Canada from 2010 to 2018 on depression and cardiac rehabilitation - conditions featuring known gendered inequities - that were identified on government websites. We extracted data and used summary statistics to enumerate mentions of PCC and women's health.

RESULTS

We included 30 policies (20 depression, 10 cardiac rehabilitation). Of those, 20 (66.7%) included any content related to PCC (median 1.0, range 0.0 to 5.0), most often exchanging information (14, 46.7%) and making decisions (13, 43.3%). Less frequent domains were enabling self-management (8, 26.7%), addressing emotions (6, 20.0%) and fostering the relationship (4, 13.3%). No policies included content for the domain of managing uncertainty. A higher proportion of cardiac rehabilitation guidelines included PCC content. Among the 30 policies, 7 (23.3%) included content related to at least one women's health domain (median 0.0, range 0.0 to 3.0). Most frequently included were social determinants of health (4, 13.3%). Fewer policies mentioned any issues to consider for women (2, 28.6%), issues specific to subgroups of women (2, 28.6%) or distinguished care for women from men (2, 28.6%). No policies included mention of abuse or violence, or discrimination or stigma. The policies largely pertained to depression. Despite mention of PCC or women's health, policies offered brief, vague guidance on how to achieve PCCW; for example, "Patients value being involved in decision-making" and "Women want care that is collaborative, woman- and family-centered, and culturally sensitive."

CONCLUSIONS

Despite considerable evidence of need and international recommendations, most policies failed to recognise gendered disparities or promote PCC as a mitigating strategy. These identified gaps represent opportunities by which government policies could be developed or strengthened to support PCCW. Future research should investigate complementary strategies such as equipping policy-makers with the evidence and tools required to develop PCCW-informed policies.

How is patient-centred care conceptualized in women's health: a scoping review

Background

Gendered disparities in health care delivery and outcomes are an international problem. Patient-centred care (PCC) improves patient and health system outcomes, and is widely advocated to reduce inequities. The purpose of this study was to review published research for frameworks of patient-centred care for women (PCCW) that could serve as the basis for quality improvement.

Methods

A scoping review was conducted by searching MEDLINE, EMBASE, CINAHL, SCOPUS, Cochrane Library, and Joanna Briggs index for English-language quantitative or qualitative studies published from 2008 to 2018 that included at least 50% women aged 18 years or greater and employed or generated a PCCW framework. Findings were analyzed using a 6-domain PCC framework, and reported using summary statistics and narrative descriptions.

Results

A total of 9267 studies were identified, 6670 were unique, 6610 titles were excluded upon title/abstract screening, and 11 were deemed eligible from among 60 full-text articles reviewed. None were based on or generated a PCCW framework, included solely women, or analyzed or reported findings by gender. All studies explored or described PCC components through qualitative research or surveys. None of the studies addressed all 6 domains of an established PCC framework; however, additional PCC elements emerged in 9 of 11 studies including timely responses, flexible scheduling, and humanized management, meaning tailoring communication and treatment to individual needs and preferences. There were no differences in PCC domains between studies comprised primarily of women and other studies.

Conclusions

Given the paucity of research on PCCW, primary research is needed to generate knowledge about PCCW processes, facilitators, challenges, interventions and impacts, which may give rise to a PCCW framework that could be used to plan, deliver, evaluate and improve PCCW.

What constitutes patient-centred care for women: a theoretical rapid review

BACKGROUND

Women experience disparities in health care delivery and outcomes. Patient-centred care for women (PCCW) is needed. This study examined how PCC has been conceptualized and operationalized in women's health research.

METHODS

We conducted a theoretical rapid review of PCCW in MEDLINE, EMBASE, CINAHL and SCOPUS from 2008 to 2018 for studies involving women aged 18 years or greater with any condition, and analyzed data using an established 6-domain framework of patient-centred communication.

RESULTS

We included 39 studies, which covered the following clinical areas: maternal care, cancer, diabetes, HIV, endometriosis, dementia, distal radius fracture, overactive bladder, and lupus erythematosus. The 34 (87.2%) studies that defined or described PCC varied in the PCC elements they addressed, and none addressed all 6 PCC domains. Common domains were exchanging information (25, 73.5%) and fostering the patient-clinician relationship (22, 64.7%). Fewer studies addressed making decisions (16, 47.1%), enabling patient self-management (15, 44.1%), responding to emotions (12, 35.3%), or managing uncertainty (1, 2.9%). Compared with mixed-gender studies, those comprised largely of women more frequently prioritized exchanging information above other domains. Few studies tested strategies to support PCCW or evaluated the impact of PCCW; those that did demonstrated beneficial impact on patient knowledge, satisfaction, well-being, self-care and clinical outcomes.

CONCLUSIONS

Studies varied in how they conceptualized PCCW, and in many it was defined narrowly. Few studies examined how to implement or measure PCCW; thus, we lack insight on how to operationlize PCCW. Thus, further research is needed to confirm this, and whether PCCW differs across conditions, knowledge needed to inform policies, guidelines and measures aimed at improving health care and associated outcomes for women.

How do and could clinical guidelines support patient-centred care for women: Content analysis of guidelines

OBJECTIVES

Patient-centred care (PCC) improves multiple patient and health system outcomes. However, many patients do not experience PCC, particularly women, who are faced with disparities in care and outcomes globally. The purpose of this study was to identify if and how guidelines address PCC for women (PCCW).

METHODS

We searched MEDLINE, EMBASE, National Guideline Clearing House, and guideline developer websites for publicly-available, English-language guidelines on depression and cardiac rehabilitation, conditions with known gendered inequities. We used summary statistics to report guideline characteristics, clinical topic, mention of PCC according to McCormack's framework, and mention of women's health considerations. We appraised guideline quality with the AGREE II instrument.

RESULTS

A total of 27 guidelines (18 depression, 9 cardiac rehabilitation) were included. All 27 guidelines mentioned at least one PCC domain (median 3, range 1 to 6), most frequently exchanging information (20, 74.1%), making decisions (20, 74.1%), and enabling patient self-management (21, 77.8%). No guidelines fully addressed PCC: 9 (50.0%) of 18 depression guidelines and 3 (33.3%) of 9 cardiac rehabilitation guidelines addressed 4 or more PCC domains. Even when addressed, guidance was minimal and vague. Among 14 (51.9%) guidelines that mentioned women's health, most referred to social determinants of health; none offered guidance on how to support women impacted by these factors, engage women, or tailor care for women. These findings pertained even to women-specific guidelines. Reported use or type of guideline development process/system did not appear to be linked with PCCW content. Based on quality appraisal with AGREE II, guidelines were either not recommended or recommended with modifications. In particular, the stakeholder involvement AGREE II domain was least addressed, but guidelines that scored higher for stakeholder involvement also appeared to better address PCCW.

IMPLICATIONS

This research identified opportunities to generate guidelines that achieve PCCW. Strategies include employing a PCC framework, considering gender issues, engaging women on guideline-writing panels, and including patient-oriented tools in guidelines. Primary research is needed to establish what constitutes PCCW.

Women's Health Curriculum for Medical Students

OBJECTIVES

Knowledge of women's health is important for physicians in various specialties, but training often is inadequate. The objective of this project was to develop, implement, and evaluate a women's health curriculum for medical students at the University of Florida College of Medicine in Gainesville.

METHODS

After reviewing previous pertinent literature and assessing institutional factors, we developed an interdisciplinary women's health elective for medical students. We present the curricular design for the course. The 2-week elective explores women's health topics such as disease prevention, screening, breast health, osteoporosis, and cardiovascular health. Teaching methodology includes case-based lectures, reading assignments, and clinic sessions at multiple sites.

RESULTS

Senior medical students worked in a variety of clinical settings and were assigned a women's health project, a pretest before starting the elective, and a posttest after completion of the course. A statistically significant increase was seen in the students' mean posttest (98.8%) versus pretest (85.6%) scores (difference 13.1%; 95% confidence interval 7.3-19.0, P < 0.0001).

CONCLUSIONS

Designing curricula that promote lifelong professional competency in the field of women's health can be challenging. At the University of Florida, we have successfully created and implemented a medical student elective in women's health using local resources and expertise. This elective satisfies important women's health training requirements, has been well received by our students, and has resulted in increased women's health-specific knowledge. The experience at our institution may be useful for other programs interested in developing a women's health curriculum geared toward medical students utilizing minimal resources.

Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care"

PURPOSE

Despite the recognized importance of patient involvement in primary care interactions, little information describing women's needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings.

DATA SOURCES

Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries.

CONCLUSIONS

Participants wanted to learn how to "stand up" for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self-esteem. Ultimately, they identified the right way to "talk back" to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians.

IMPLICATIONS FOR PRACTICE

Nurse practitioners working in the primary setting are especially well situated to support self-management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.

The Evolution of Women's Health Education: The Cleveland Clinic's Women's Health Fellowship as a Model

Our goal in this paper is twofold. First, it provides a brief overview of the macrotrends in women's health education over the last 25 years. Second, these trends are a backdrop for a discussion of women's health education as exemplified by a detailed review of the curriculum for the Women's Health fellowship at the Cleveland Clinic Foundation. We have termed the underpinning of the curriculum the "leadership triad" consisting of (1) clinical skills, (2) focused research, and (3) interdisciplinary education. These elements are presented in a detailed curriculum for a 2-year fellowship program. We see these elements as fundamental to the Cleveland Clinic's fellowship program, and a useful model for those contemplating or refining their advanced women's health curriculum.

Factors influencing women's decisions about timing of motherhood

OBJECTIVE

To examine the factors that influence women's decisions about the timing of motherhood from a life span perspective.

DESIGN

Qualitative.

SETTING

Large Western Canadian city with a high rate of infants born to women aged 35 years and older.

PARTICIPANTS

45 Canadian women aged 20 to 48 years.

RESULTS

Independence, a stable relationship, and declining fertility influenced women's decisions about the timing of motherhood. Women integrated child developmental transitions into a projected life plan as they considered the timing of motherhood. Partner readiness and family of origin influences played a lesser role. Delayed childbearing has become more socially acceptable, with subsequent negative connotations associated with younger motherhood. Parental benefits have limited influence on the timing of motherhood.

CONCLUSIONS

Recognition by nurses of the various and complex factors that influence women's decisions about the timing of motherhood may flag the importance of pregnancy-related counseling for woman across the fertility life span. Policy decision makers must be cognizant of the need for additional high-risk obstetric and neonatal health services when societal norms encourage women to delay childbearing in favor of completing education and establishing a career.

Perspective: Gender as a Health Determinant and Implications for Health Education

Gender is a health determinant, but gender itself is influenced, in part, by biological and psychological variables. Understanding gender's influence on health therefore requires an understanding of the determinants of the construct gender. A review of certain gender determinants is presented. The authors consider the modifiability of these determinants and present recommendations about which of these determinants should be targeted for health promotion and policy creation activities. In concluding, they argue that gender is a multidetermined construct that encompasses many factors that may be modifiable through intervention, and consideration of all of these factors should be vigorously pursued.

Retention of Pregnancy-Related Weight in the Early Postpartum Period: Implications for Women’s Health Services

OBJECTIVE

To examine the proportion of women who reached their prepregnant weight at 6 weeks postpartum and the average amount of weight retained or lost by this time; to determine predictors of early (6 week) postpartum weight retention; and to propose related implications for women's health care and services.

DATA SOURCES

The literature review was based on a search of Medline for the years 1986 to 2004 using the keywords postpartum weight with inclusion of additional articles known to the authors that did not appear in the electronic search.

STUDY SELECTION

The resulting 83 articles were scrutinized to identify those that reported data on weight retention at 6 weeks postpartum (range, delivery to 3 months) and associated anthropometric, social, obstetric, or behavioral predictors. A total of 12 articles met inclusion criteria for the review.

DATA EXTRACTION

Data were extracted related to the proportion of women achieving their postpartum weight at 6 weeks postpartum, the amount of weight retained or lost up to 6 weeks postpartum, and predictors of amount of weight retained or lost.

DATA SYNTHESIS

On average, at 6 weeks postpartum, women retain 3 to 7 kg of the weight gained during pregnancy, with at least two thirds exceeding their prepregnant weights. Gestational weight gain is the most significant predictor of weight retention.

CONCLUSIONS

Women vulnerable to obesity and weight gain need weight-related health care and improved access to such care to promote weight loss after 6 weeks postpartum.

Characteristics of and problems with primary care interactions experienced by an ethnically diverse group of women

PURPOSE

To reflect women's voices as they discussed characteristics of health care interactions and spontaneously identified problems in primary care interactions.

DATA SOURCES

Five successive meetings with an ethnically diverse group of eight women were held to discuss primary care interactions with nurse practitioners. Field notes, seating charts, participant interaction notations, session transcripts, and audiotapes were repeatedly reviewed to identify significant statements. These were grouped into common categories to identify essential themes. Results were validated with participants.

CONCLUSIONS

Components of primary care interactions included the process of making an appointment, access to the clinic, comfort of the waiting area and clinic rooms, and interactions with staff and clinicians. Problems were identified with interactions. The overarching issue was a lack of caring--a pervasive attitude demonstrated when clinicians failed to show concern, did not listen, were not trustworthy, or treated the women with disrespect or prejudice.

IMPLICATIONS FOR PRACTICE

The women strongly valued caring clinicians. Caring, according to these women, is demonstrated when clinicians treat women as equals and show respect for their individual knowledge and life experiences.

Integrating Socio-Economic Determinants of Canadian Women's Health

HEALTH ISSUE: The association between a number of socio-economic determinants and health has been amply demonstrated in Canada and elsewhere. Over the past decades, women's increased labour force participation and changing family structure, among other changes in the socio-economic environment, have altered social roles considerably and lead one to expect that the pattern of disparities in health among women and men will also have changed. Using data from the CCHS (2000), this chapter investigates the association between selected socio-economic determinants of health and two specific self-reported outcomes among women and men: (a) self-perceived health and (b) self-reports of chronic conditions. KEY FINDINGS: The descriptive picture demonstrated by this CCHS dataset is that 10% of men aged 65 and over report low income, versus 23% of women within the same age bracket. The results of the logistic regression models calculated for women and men on two outcome variables suggest that the selected socio-economic determinants used in this analysis are important for women and for men in a differential manner. These results while supporting other results illustrate the need to refine social and economic characteristics used in surveys such as the CCHS so that they would become more accurate predictors of health status given that there are personal, cultural and environmental dimensions to take into account. RECOMMENDATIONS: Because it was shown that socio economic determinants of health are context sensitive and evolve over time, studies should be designed to examine the complex temporal interactions between a variety of social and biological determinants of health from a life course perspective. Examples are provided in the chapter.

Position of the American Dietetic Association and Dietitians of Canada: Nutrition and Women’s Health

It is the position of the American Dietetic Association (ADA) and Dietitians of Canada (DC) that women have specific nutritional needs and vulnerabilities and, as such, are at unique risk for various nutrition-related diseases and conditions. Therefore, the ADA and the DC strongly support research, health promotion activities, health services, and advocacy efforts that will enable women to adopt desirable nutrition practices for optimal health. Women are at risk for numerous chronic diseases and conditions that affect the duration and quality of their lives. Although women's health-related issues are multifaceted, nutrition has been shown to influence significantly the risk of chronic disease and to assist in maintaining optimal health status. Dietetics professionals strongly support research, health promotion activities, health services, and advocacy efforts that will enable women to adopt desirable nutrition practices for optimal health.