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Health Promotion for Women: State of the Science

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2 Health Promotion for Women: State of the Science
Nancy Fugate Woods, PhD, RN, FAAN Biobehavioral Nursing and Health Systems, School of Nursing University of Washington

3 Co-authors: Women’s Health Expert Panel Writing Group
Judy Berg, University of Arizona Ellen Olshansky, University of California, Irvine Joan Shaver, University of Arizona Diana Taylor, University of California, San Francisco

4 Aims Assess progress in the science of health promotion, including prevention, for girls and women Propose evidence-based innovations relevant to meeting needs of diverse populations of girls and women Recommend an agenda for expanding research and innovation in health promotion for girls and women Suggest strategies to influence policy agendas at the local, regional, and national level assuring nursing’s contributions to health promotion remain a critical element of health care reform

5 Convergence of Women’s Health Influence: 2010-2011
Federal government interest in women’s health noteworthy in Renews agendas for women’s health research Evaluates the impact of women’s health research Uses evidence from women’s health research to set policy (Affordable Care Act) Creates a strategy for health promotion and prevention in the nation Extends consideration of women’s health globally

6 The first NIH Women’s Health Research Agenda was developed in 1991 under the leadership of Ruth Kirschstein, Acting Director of the Office of Research on Women’s Health with support of NIH Director Bernadine Healey

7 Resurgence of Federal Commitment to Women’s Health Research
Office of Research on Women’s Health, NIH. (2010) Moving into the Future with New Dimensions and Strategies: A Vision for 2020 for Women’s Health. ORWH, NIH. Institute of Medicine (2010) Women’s Health Research: Progress, Pitfalls, and Promise. Washington, CD, The National Academies Press.

8 Moving into the Future with New Dimensions and Strategies: A Vision for 2020 for Women’s Health (2010)

9 ORWH Goals for 2020 Goal #1: Increase sex differences research in basic science studies, especially at cellular and tissue levels  Goal #2: Incorporate findings of sex/gender differences in the design and applications of new technologies, medical devices, and therapeutic drugs Goal #3: Actualize personalized prevention, diagnostics, and therapeutics for girls and women

10 ORWH Goals 2020 Goal #4: Create strategic alliances and partnerships to maximize the domestic and global impact of women’s health research  Goal #5: Develop and implement new communication and social networking technologies to increase understanding of women’s health and wellness research Goal #6: Employ innovative strategies to build a well- trained, diverse, and vigorous women’s health research workforce

11 Women’s Health Research: Progress, Pitfalls, and Promise (IOM, 2010)

12 Are women’s health researchers:
Addressing the most appropriate and relevant determinants of health? Focusing on most appropriate and relevant health conditions? Engaging with (studying) the most relevant groups of women? Utilizing the most appropriate research methods? Translating findings to affect practice? Conveying findings effectively for women?

13 Assessment of Progress
MAJOR PROGRESS Breast cancer Cervical cancer Cardiovascular disease SOME PROGRESS Depression Osteoporosis HIV/AIDS

14 Conditions with Little Progress
Unintended pregnancy Maternal morbidity/mortality Autoimmune diseases Alcohol and drug addiction Lung cancer Gynecological cancers other than cervical cancer Nonmalignant gynecological disorders Alzheimer’s Disease (IOM 2010)

15 Recommendations from IOM Study on Women’s Health Research (2010)
Recommendation 1: US government agencies and other relevant organizations to sustain/strengthen focus on women’s health, including genetic, behavioral, and social determinants of health and change over lifetimes. Recommendation 2: The National Institutes of Health, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention - develop targeted initiatives to increase research on populations of women with highest risks and burdens of disease

16 IOM Study 2010 Recommendation 3: Research should emphasize promotion of wellness and quality of life; conditions that affect quality of life; better measures or metrics of quality of life to be used as outcomes Recommendation 4: NIH Cross-institute initiatives on common determinants and risk factors that underlie multiple diseases, interventions to decrease the occurrence or progression of diseases in women

17 IOM Study 2010 Recommendation 5: Government … funding agencies ensure adequate research participation by women, analysis of data by sex, and reporting of sex-stratified analyses. Recommendation 6: Research emphasis on how to translate research findings into clinical practice and public-health policies rapidly – to practitioner and overall public-health systems levels.

18 IOM Study 2010 Recommendation 7: The Department of Health and Human Services - appoint a task force to develop evidence-based strategies to communicate and market to women health messages based on research results

19 Shaping Policy Supporting Women’s Health Services

20 Commitment to Women’s Health Services and Policy
Affordable Care Act – includes provisions for services for women, prohibits gender-based discrimination in denying coverage, assuring maternity care coverage as an essential benefit and increased coverage for the poor Institute of Medicine (2011) Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press National Prevention Council. (2011). National prevention strategy: America's plan for better health and wellness. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General

21 IOM Committee on Clinical Preventive Services
Recommended inclusion of USPSTF A and B Recommended Services to be included in Clinical Preventive Services with Affordable Care Act Also suggested providing additional clinical preventive services as part of ACA, including clarification of those services with incomplete evidence (C or I classification) to be included in well woman services

22 IOM Clinical Preventive Services : Suggested Well Woman Services
Diet and Physical Activity Establishing pregnancy history of CVD-related conditions Mental Health Metabolic syndrome Preconception Care Prenatal Care STIs

23 IOM Recommendations: Additional Clinical Preventive Services
Screening for gestational diabetes Human papillomavirus testing Counseling for sexually transmitted infection Counseling and screening for human immunodeficiency virus Contraceptive methods and counseling Breastfeeding support, supplies, and counseling

24 IOM Recommendations: Additional Clinical Preventive Services
Screening and counseling for interpersonal and domestic violence Well woman visits (one annually) - several visits may be needed to obtain all necessary recommended preventive services (includes 29 USPSTF A and B rated services + others recommended by the committee)

25 National Prevention and Health Promotion Strategy: America’s Plan for Better Health and Wellness
Surgeon General released first national Prevention Strategy Jun3 16, 2011 Four Strategic Directions Seven Areas of Focus

26 Four Strategic Directions
Building Healthy and Safe Community Environments Expanding Quality Preventive Services in Both Clinical and Community Settings Empowering People to Make Healthy Choices Eliminating Health Disparities

27 Seven Areas of Focus Tobacco Free Living
Preventing Drug Abuse and Excessive Alcohol Use Healthy Eating Active Living Injury and Violence Free Living Reproductive and Sexual Health Mental and Emotional Well-being

28 Global Commitment to Women’s Health
World Health Organization’s strategic plan for Sexual and Reproductive Health U. S. State Department (2010) Implementation of the Global Health Initiative International Congress on Women’s Health Issues (ICOHWI)

ORWH Research Agenda (2010) State of the Science on Health Promotion and Prevention IOM Report on Women’s Health Research (2010) Health Promotion and Preventive Services: Best Evidence Proposed Commission: Recommends Coverage of Preventive Services for Women IOM Report on Clinical Preventive Services (2011) National Prevention Council Strategy (2011)

30 Nursing’s Commitment to Health Promotion
Nursing’s early commitment to health promotion and health promoting lifestyle patterns traceable to NCNR Priority Expert Panels (1980s) to set priorities for funding Exemplified by Pender and colleagues’ work on health promotion and health protection or prevention

31 National Institute for Nursing Research Strategic Plan for Health Promotion
“Health promotion and disease prevention form the keystone of our science, reflecting current understanding of the most effective approaches to maintaining health” NINR Strategic Areas of Research Emphasis 2006

32 Changing Science of Health Promotion
FROM (1980s) TO PRESENT Individuals as the unit of health promotion: an individual responsibility Gender-ignorant models of health promotion Health promotion for predominantly healthy people Social groups, e.g. organizations, communities, larger society responsible Gender-sensitive, gender- specific models Health promotion in chronic illness, acute illness, integration with symptom management

33 Changing Science of Health Promotion
FROM TO Emphasis on individual activities, raising awareness Individual and group coaching, counseling Raising social consciousness and inviting social action Multiple interventions at multiple levels to initiate and sustain behavior changes Environmental interventions, e.g. built environment

34 Changing Science of Health Promotion
FROM TO Awareness of globalization, Appreciation of urbanization, industrialization and associated inequities Local global Increased use of communication and information technologies to enhance scalability Local and country-specific models Limited scalability

35 Recommendations from Nursing Researchers on Health Promotion
Expand development and testing of gender-sensitive interventions for women Gender as a major feature vs human experience as universal Women’s own voices and experiences, women’s own perspectives (Im and Meleis 2001)

36 2. Consider Intersectionality as a basis for understanding gender disparities, health disparities of women Gender Race Class Ethnicity Sexual Orientation Abledness

37 Nature of women’s experiences incorporate complexities and diversities (gender, sexuality, ethnicity, race, social class) Intersectionality not just a mediating factor in a model (Im and Meleis 2002)

38 3. Balance Emphasis on Behavioral, Integrative and Pharmacological Therapeutics
Evidence for health promotion using either behavioral or pharmacologic approaches vs combinations, bundled approaches Use of step-wise approaches, e.g. begin with a single, low risk strategy and build on it Learn from low-resources countries

39 4. Focus on Under-emphasized Conditions Disproportionately Affecting Women
Functional and stress-related disorders such as fibromyalgia, functional gut disorders, post- traumatic stress disorder, eating disorders, migraine headaches Culturally sensitive and women specific problems, e.g., incontinence, women’s sexual dysfunctions

40 5. Promote Research on Preventing Unintended Pregnancies and STIs
US rates of unintended pregnancy are high and Healthy People Goals for 2010 unmet Counseling strategies for promoting healthy reproductive and sexual behaviors across the lifespan not adequately studied Integration of behavioral change counseling and pharmaceuticals, e.g. family planning, reproductive health planning

41 6. Promote Research on Preventing and Treating Consequences of Violence against Women
Integrate with Veteran Women’s Health Agenda efforts, e.g. VA sponsored initiatives Collaborate with multi-level interventions for violence reduction in homes, communities, society Look for multiple outcomes at multiple levels, e.g. may support reduced rates of unintended pregnancy, sexual transmitted infections

42 Gender-Sensitive Models for Research on Unintended Pregnancy, STIs and Violence against Women
Awareness of ideological imperatives and epistemological assumptions – what we study and what we ignore … Sociopolitical contexts and constraints considered - empowerment, emancipation Guidelines for action > praxis (Im and Meleis 2001)

43 7. Develop and Test Technologies for Behavioral and Functional Support
Develop and test technological devices to enable women to age well in place Enhance technologies to support caregivers Adapt communications technologies for research dissemination to women Monitoring technologies for detection of health problems, communication with health professionals at a distance

44  8. Refine/Test Models for Translating Research Findings Directly to Women
Following publication of WHI results in 2002 a dramatic increase in women’s questions for primary care providers, a decrease in prescriptions for hormone therapy increased interest in complementary and alternative therapies …

45 Nursing Innovations for Promoting Women’s Health: Toward 2020
Preconception Counseling in Primary Care Unintended Pregnancy Prevention Violence Prevention Sexually Transmitted Infection Prevention Smoking Cessation Well Woman Care (Physical activity, Diet) Depression prevention

46 Preventing Unintended Pregnancy -- Promoting Preconception Health
Included in ORWH agenda Supported by IOM Report (2010) as an area in which not much progress has been made Included in National Prevention Council Strategy (2011) Recommended in IOM Report on Clinical Preventive Services (2011) Consistent with World Health Organization’s Reproductive Health Strategy

47 Dimensions of the Problem
Almost half of all U. S. pregnancies are unintended – highest rate in the industrialized world Of the 6.4 million pregnancies in the U.S. in 2001, 3.1 million were unintended 1.4 million resulted in births, 1.3 million in abortions, 430,000 in fetal losses At least half of all U.S. women will experience an unintended pregnancy by age 45 years

48 National Prevention Policies Do not Adequately Address Unintended Pregnancy
Healthy People 2000 goal: increase proportion of intended pregnancies to 70% Healthy People 2020 goal: increase proportion of intended pregnancies from 51% to 56% Places disproportionate burden on women who are poor, non-white, young women (20-29 years of age women with greater health risk women with fewer financial resources and less developed support systems

49 Lack of Attention to Unintended Pregnancy > System-wide Failure
Fragmentation of women’s health care Politicization of reproductive health surrounding abortion Overall lack of sexuality education in US – sexual health illiteracy Limited of time for health care appointments Lack of coordinated system of clinical guidelines, essential competencies, and Strategies for unintended pregnancy prevention (Taylor and James, 2011)

50 Cochrane Collaboration (Oringanje 2010)
Unintended pregnancy can be addressed using a preventive strategy combination of risk screening and multimodal interventions that involve coordinated, focused education and increased access to contraceptives … Evidence from Nursing studies of education, skill-building, safe sexual practices, use of contraceptives indicates interventions are effective in Reducing the rate of sexual initiation (Jemmott, Villaruel) Promoting consistent condom use (Jemmott, Villaruel) Promoting condom use at last intercourse (DiIorio) Additional studies in progress (Gallegos)

51 Foundation in Research Based Interventions (www. effectiveintervention
Foundation in Research Based Interventions ( SISTER TO SISTER – developed by Dr. Loretta Jemmott from the Be Proud! Be Responsible! Program to reduce HIV/AIDS risk behaviors in African American Adolescents CUIDATE – developed by Dr. Antonia Villaruel with Dr. Jemmott – adapted HIV/AIDS risk behavior reductions for adolescent Latinos SEPA –developed by Dr. Nena Peragallo to reduce HIV/AIDS risk behaviors among Latina women No…

52 Unintended Pregnancy Prevention is Marginalized in Women’s Health Care
UCSF/ANSIRH: Improving Women's Access to Reproductive Health Services Unintended Pregnancy Prevention is Marginalized in Women’s Health Care Women’s Primary Care Pregnancy Care Unintended Pregnancy Prevention Taylor, Levi & Berg: A Public Health Model for Reducing Unintended Pregnancies 52

53 A Public Health Model for Addressing Unintended Pregnancy (Taylor and James, 2011)
Primary Care Unintended Pregnancy Prevention Sexual & Reproductive Health care across gender and lifespan Primary 1o Prevention 2o & 3o Prevention Unintended Pregnancy Prevention

54 Why Can Nursing Make A Difference?
History of gender-sensitive research Capacity for tailoring – intersectionality, culturally sensitive interventions Creation of effective programs to change outcomes related to sexual behavior, contraception (Jemmott, Villaruel) Studies of dynamic relation between sexuality, violence/coercion and self-silencing (Teitelman)

55 Unintended Pregnancy Prevention: Applying a Public Health Model
UCSF/ANSIRH: Improving Women's Access to Reproductive Health Services Unintended Pregnancy Prevention: Applying a Public Health Model Primary Prevention Preconception care Contraception counseling, dispensing, Rx Emergency contraception Rx and dispensing Secondary Prevention Pregnancy diagnostics Early pregnancy loss, ectopic pregnancy screening Pregnancy options counseling Adoption, early abortion care, referral Tertiary Prevention Late term unintended pregnancy support Adoption counseling Pregnancy termination Intro this model only: Taylor, Levi & Berg: A Public Health Model for Reducing Unintended Pregnancies

56 From Model to Action Mobilize health professionals to address national health goals Integrate primary prevention strategies into all clinical settings Require all women’s health professionals to be competent in primary and secondary prevention and management Require prevention of unintended pregnancy as a standard component of health professional education in all accredited institutions Develop a national consensus about core prevention competencies for all health professionals Advocate for prevention guidelines that are evidence-based and culturally appropriate

57 Contributions from NURSING SCIENCE
State of the Science on Health Promotion and Prevention Science Policy - NIH Proposed Commission to Recommend Coverage of new Preventive Services for Women Nursing’s Policy Positions - ACA AMERICAN ACADEMY OF NURSING

58 Policy Strategies Endorse the recommendations for additional clinical preventive services recommended by the IOM Clinical Preventive Services Committee (2011) Endorse the recommendations for prevention in the Strategies report (2011) Promote research on unintended pregnancy and prevention in the context of preconception care – NINR, NICHD Recommend critical review of the state of the science on sexual and reproductive health care, specifically unintended pregnancy, and preconception health care as an instance of well women services (Professional Organizations, USPSTF) Promote optimal training models for health professionals to integrate sexual and reproductive health services into primary care – HRSA

59 Policy Strategies (cont.)
Evaluate alternative models of service to prevent unintended pregnancy – HRSA Promote guideline development for services to prevent unintended pregnancy – AHRQ Survey effective community-based models of services related to unintended pregnancy for dissemination - – CDC Evaluate adequacy of women’s community-based services for prevention of unintended pregnancy – Institute of Medicine Study Develop training mechanisms for community-based resources on Unintended Pregnancy - CDC

60 Thank you for your interest in promoting women’s health!


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