Health Promotion for Women: State of the Science

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 2010-2011 • 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 2010-2015 Sexual and Reproductive Health • U. S. State Department (2010) Implementation of the Global Health Initiative • International Congress on Women’s Health Issues (ICOHWI)

29. STATE OF THE SCIENCE TO PREVENTIVE SERVICES 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 • Local and country-specific models • Limited scalability • Awareness of globalization, • Appreciation of urbanization, industrialization and associated inequities • Local global • Increased use of communication and information technologies to enhance 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)