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Health Care Utilization by Canadian Women Kazanjian, Arminée; Morettin, Denise; Cho, Robert Aug 25, 2004

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ralssBioMed CentBMC Women's HealthOpen AcceReportHealth Care Utilization by Canadian WomenArminée Kazanjian*1, Denise Morettin2 and Robert Cho3Address: 1Health Care & Epidemiology, Faculty of Medicine, The University of British Columbia, 5804 Fairview Avenue, James Mather Building, Vancouver, Canada, 2Centre for Health Services and Policy Research, 429-2194 Health Sciences Mall, Vancouver, Canada and 3Centre for Chronic Disease Prevention and Control, Health Canada, 120 Colonnade Rd, Ottawa, CanadaEmail: Arminée Kazanjian* - a.kazanjian@ubc.ca; Denise Morettin - morettin@chspr.ubc.ca; Robert Cho -  rcdcho@ahsmail.uwaterloo.ca* Corresponding author    AbstractHealth Issues: While women are reported to be more frequent users of health services inCanada, differences in women's and men's health care utilization have not been fully explored. Toprovide an overview on women's healthcare utilization, we selected two key issues that areimportant for public policy purposes: access to care and patterns of utilization. These issues areexamined using primarily data from the 1998/99 National Population Health Survey, complementedby the 2000 Canadian Community Health Survey and the 2001 Health Service Access Survey.Key Findings: • Women are twice as likely as men to report a regular family physician, but thatproportion is very low (15.8%).• Women report significantly shorter specialist wait times (20.9 days) than men (55.4 days) formental health, while the reverse is true for asthma and other breathing conditions (10.8 for men,78.8 for women).• Reported mean wait times are significantly lower for men than for women pertaining to overalldiagnostic tests: for MRI, 70.3 days for women compared to 29.1 days for men.Data Gaps and Recommendations: • Measurement of possible system bias and its implicationfor equitable and quality healthcare for women requires larger provincial samples of the nationalsurveys, along with a longitudinal design.• Either a national database on preventive services, or better alignment of provincial databasespertaining to health promotion and preventive services, is needed to facilitate data linkage withnational surveys to undertake longitudinal studies that support gender based analyses.BackgroundAlthough it is known that women are more frequent usersof health services than men in Canada,[1] the reasons forhealth care system structure and data that capture fee-for-service transactions but not necessarily episodes of pri-mary and/or acute care that reflect women's experiences offrom Women's Health Surveillance ReportPublished: 25 August 2004BMC Women's Health 2004, 4(Suppl 1):S33        doi:10.1186/1472-6874-4-S1-S33This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S33This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S33This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S33This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S33This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S33<supplement> <title> <p>Women's Health Surveillance Report</p> </title> <editor>Marie DesMeules, Donna Stewart, Arminée Kazanjian, Heather McLean, Jennifer Payne, Bilkis Vissandjée</editor> <sponsor> <note>The Women's Health Surveillance Report was funded by Health Canada, the Canadian Institute for Health Information (Canadian Population Health  Initiative) and the Canadian Institutes of Health Research</note> </sponsor> <note>Reports</note> <url>http://www.biomedcentral.com/content/pdf/1472-6874-4-S1-info.pdf</url> </supplement>Page 1 of 11(page number not for citation purposes)the difference in women and men's health care utilizationhave not been fully explored. For example, are womenseen as frequent users of primary care because of theillness? Complex research questions on the interactionsbetween sex, disease, health care utilization and socialroles remain largely unanswered.BMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33The literature regarding sex differences in health servicesutilization is primarily disease specific (e.g. cardiovasculardisease, chronic pain) reflecting the biomedical approachto investigating health and illness. "A considerable bodyof research on sex differences in the use of health care serv-ices has focused on differences in the way men andwomen seek care and, to a lesser extent, on the degree towhich the diagnostic and therapeutic steps taken by phy-sicians may vary according to the sex of the patient."[2]Statistics Canada reports findings from the 2000 Cana-dian Community Health Survey (CCHS), including indi-cators on health services utilization. These data show thatwhile 81.3% of the population, 12 years and older, hadcontact with medical doctors in the previous 12 months,87.2% of the female population reported such contact inthe same period.[3] Conversely, women and girls weremuch less likely to have had no contact with medical pro-viders (12.5%) than men and boys (24.5%).A subsequent national survey specifically examined accessto health care services, identified as a key issue in currenthealth care debates.[4] The authors argue that while infor-mation on health services utilization is a valid measure ofaccess, it does not provide the complete picture pertainingto the choices and experiences of those accessing the sys-tem. This survey addresses issues of access in two majorareas: first contact services and specialized services forthose aged 15 years and older. Difficulties in access to rou-tine care were reported by approximately 11% whoaccessed such care and by 18% who accessed immediatecare. Difficulties were reported by approximately 20% ofthose who used specialized services. Types of barriers,waiting times and patients' opinion regarding acceptabil-ity of waiting times were also examined. This report didnot contain an analysis by sex and gender.Evidently, the concepts of access and utilization are oftenused without further delineation, or diverse definitionsare used in various studies. It is, therefore, difficult to esti-mate valid measures of either concept: How much accessis desirable remains debatable, and large variation inopinion exists on appropriate levels of utilization for pop-ulation groups. Acute care is the focal point of the Cana-dian system, and it favours those who have the power tosuccessfully negotiate the system. Therefore, understand-ing the effect of sex and gender on health care utilizationand access requires an analytic framework that acknowl-edges these complexities.There is a much greater expectation for women than mento present themselves for medical care or consultation.Women are dependent on the health care system tomammogram if aged 50 or older; they talk to their doctorabout the risk of osteoporosis at 50 and obtain a bonedensity test if 65 and older. The risk of perpetuating theview that women are not only over-users of the system rel-ative to men but also "sicker" than men is high without athorough analysis of the "gendered" body for the use ofhealth care resources. Major data limitations hamper ourability to include such analysis here.In order to provide an overview of health care utilizationby women, two health surveillance issues were selectedthat are important for public policy purposes: access tocare and patterns of utilization. Our approach to women'shealth provides a critical lens through which to examinepossible system bias that may result in health service ineq-uities. Although the implications for health services utili-zation of men's and women's social and cultural roles area key factor in understanding women's health care experi-ences, the exploration of factors beyond the biologicalremains a serious challenge for women's healthsurveillance.MethodsLiterature ReviewA literature review of the major computerized biblio-graphic databases MEDLINE, HealthStar, EMBASE,CINAHL, PyscInfo, and Contemporary Women's Issuesfrom 1995 onwards was conducted. Selected Canadianstudies that have used previous versions of populationsurveys or national databases are presented in the Discus-sion section to provide a contextual backdrop to findingsfrom this study.Data SourcesCross-sectional data were examined primarily from the1998/99 National Population Health Survey (NPHS).More specifically, the 1998/99 NPHS data includedresponses to questions about the number of times therespondent had seen a health care provider in the previ-ous year and where the most recent contact with a medicalprofessional took place. For an analysis of preventivehealth services utilization, data were examined from the2000 Canadian Community Health Survey (CCHS) toobtain optimal information about these services (seeAppendix for information on NPHS and CCHS methods).The data have been organized in such a way as to describesex differences in health care utilization and, where possi-ble, to further examine these differences by combiningone or more variables: age and geography. Ideally, a morein-depth exploration of gender would have been con-ducted, but because of limitations in sample size thatanalysis could not always be done.Page 2 of 11(page number not for citation purposes)ensure, control or terminate their fertility; healthy womenare expected to have a Pap smear if sexually active and aBMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33Data from the 2001 Health Service Access Survey (HSAS)were also examined. This survey allowed further investiga-tion of sex differences in health care utilization. HSAS var-iables used in this analysis include having a regular familydoctor or the reasons for not having one; use of specialistservices; and waiting times (see Appendix for informationon HSAS data).MeasuresContact with Primary Care ProviderRespondents who had seen or talked on the telephonewith a variety of health care providers about their physi-cal, emotional or mental health in the previous 12months were included. It was assumed that they had seena primary care provider if they answered that they hadseen a) a family doctor or a general practitioner, or, if agedless than 18, a pediatrician; b) a vision care provider (suchas an optometrist or ophthalmologist; unfortunately, sep-arating the two professions was not possible); or c) or anurse for care or advice. Those who answered that theyhad seen an "other medical doctor" were excluded,because this category included practitioners who providedspecialized care. Initially, the number of times a primarycare provider was seen was grouped into five categories: 1,2–4, 5–9, 10–19, 20+.Place of Most Recent ContactPlace of contact with the health care provider was con-structed from responses to the question Where did themost recent contact take place? The responses from thenational survey were grouped into four main categories.Access to First Contact Services and Specialized ServicesRespondents who indicated that they had a regular familyphysician and those who indicated that they had seen aspecialist for a new illness or condition.Statistical AnalysisThis secondary analysis is based on data from StatisticsCanada cross-sectional surveys. Frequency distributionsand cross-tabulations are used to describe overall healthservices utilization. The data were weighted to reflect theCanadian population. In accordance with Statistics Can-ada guidelines, estimates that were based on a sample offewer than 30 were suppressed because of the unreliabilityof the estimate. Statistical tests were conducted usingweighted proportions. The statistical significance of pro-portions is expressed as 95% confidence intervals (CI) cal-culated by the bootstrap method. The statisticalsignificance of means was tested using t tests, and valuesof p < 0.05 were considered statistically significant.ResultsOverall Utilization of Health ServicesOverall, there is a statistically significant differencebetween the sexes regarding the frequency of contact witha primary care provider (as defined above) in the previous12 months. While the most frequently reported categoryof health care utilization is 2 to 4 contacts for both womenand men (46.8%, 47.0% respectively), women are far lesslikely than men to report only one health care contact(17.8%, 95% CI 16.6, 18.9 versus 26.1%, 95% CI 24.6,27.5) and more likely to report 5 or more health care con-tacts in the previous year (95% CI 33.9, 36.7 versus25.5,28.4 respectively) (Figure 1).The relation between number of primary care contacts, sexand geographic location (rural/urban) was then examined(Figure 2). The table shows similarity between rural andurban frequency of contacts, reflecting higher reported fre-quency of contact by women regardless of location.As expected, age is more important than sex or urban/rural location. Of the people who report having had anycontact with a primary care provider in the previous 12months, the largest proportions of high contact (5+ times)are in the age group 65 + for both rural (52.5%) and urban(53.2%) women as well as for rural (51.5%) and urban(50.7%) men.Number of times primary care provider was seen in previous 12 months, by sexFigur  1Number of times primary care provider was seen in previous 12 months, by sex. Statistics Canada, National Popu-lation Health Survey, 1998-99.Page 3 of 11(page number not for citation purposes)BMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33With regard to sex differences in the location of primarycare services (Figure 3), although the doctor's office is themost frequently reported place last visited by men andwomen (81.7% and 84.5% respectively), women are farless likely than men to have first contact in the emergencyunit. The likelihood of women contacting emergency serv-ices is about half that of men (2.0%, 95% CI 1.5–2.3, ver-sus 3.6%, 95% CI: 2.7–3.8 respectively).Access to Family Physicians and SpecialistsRegarding issues of access, selected data from the 2001HSAS showed that most Canadians (88%) report havinga regular family doctor.[5] Men are less likely to have aregular family physician than women (15.8% of the menversus 8.8% of the women reported having no regulardoctor). The reason for not having a family doctor differsbetween men and women (Figure 4). Men report a singlemain reason – they did not try to contact a family doctor– in contrast to women, who report several: they did nottry to contact one, family doctors are not taking newpatients or their family doctor has either left or retired.Utilization of Specialists by Sex, Age and Chronic ConditionsData on use of specialists, by age group, were examined,controlling for chronic conditions. Among those withoutchronic conditions, a higher percentage of women in the30 to 54 year age group report seeking specialist care thanmen of the same age group. Distribution of specialist uti-lization among those with one or more chronic condi-tions across age is similar in men and women (Figure 5).Waiting TimesThree main categories were examined with respect to wait-ing times: time to specialist care, time to surgery, and timeto diagnostic test. Statistically significant differencesbetween the sexes are reported for some conditions: menwait significantly less time than women for asthma andNumber of times primary care provider seen in previous 12 months, by sex and rural/urban locationFigur  2Number of times primary care provider seen in previous 12 months, by sex and rural/urban location. Statistics Canada, National Population Health Survey, 1998-99.Place of most recent primary care contact by sexFigure 3Place of most recent primary care contact by sex. Statistics Canada, National Population Health Survey, 1998-99.Reasons reported for not having a regular family doctor, by sexFigure 4Reasons reported for not having a regular family doc-tor, by sex. Statistics Canada, Health Service Access Survey, 2001 (CCHS supplement).Page 4 of 11(page number not for citation purposes)BMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33other breathing conditions (p = 0.0006) but appreciablylonger to see a mental health specialist (p = 0.035).Although some differences in wait times for surgery arereported by sex, these are not statistically significant. Themean waiting time for MRI (magnetic resonance imaging)is a great deal longer for women than for men (p <0.0001), and this is also true for CAT (computerized axialtomography) scans (p = 0.048) (Figure 6).Preventive Health ServicesUsing the 2000 CCHS data, three types of preventivehealth services were examined: mammography, breastexamination and Pap smear. Some differences in patternsof use by age were expected, reflecting both biological andsocial constructions of health and wellness. As well, indi-vidual variation in the utilization of these preventive serv-ices was anticipated, reflecting the mixed evidence ontheir effectiveness and the different recommendationsfrom various clinical guidelines. Different patterns amongrural residents as compared with urban residents werealso expected.MammographyThe 2000 CCHS questions about mammography areaddressed to women 35 years and older who have had amammogram. For this analysis, respondents weregrouped into four age groups: 49 and under, 50 to 59, 60to 69 and 70+ (Figure 7). The two groups, 50 to 59 and 60to 69, are very similar in recency of test, carried out lessthan 2 years ago. The Canadian guidelines recommendmammography for women aged 50 to 69 at 2-year inter-vals. This analysis shows utilization outside these guide-lines among younger and older women. Age is anot be concluded from the survey that these are therespondents' "usual" frequency of testing.Residency location is significant in terms of the currenttiming of obtaining a mammogram. Rural women areslightly more likely to report having obtained a mammo-gram less than 2 years ago (75.2%, 95% CI: 73.8, 76.5)than urban women (73.5%, 95% CI: 72.7, 74.4). Earlyinformation from the CCHS 2000 indicates higher overallrates of screening mammography within a year, about70%, since the rates reported in NPHS 1996 analyses, at63%.Clinical Breast Examination (CBE)The 2000 CCHS asked female respondents 18 years of ageand older questions regarding CBE by a doctor (about65% of respondents have had a breast examination withinthe previous year). When asked more specifically aboutthe last time such a procedure was done, there was a smallbut statistically significant (p < 0.0001) difference in thecurrent timing of the examination for younger age groups(18 to 24 and 25 to 34) as compared with the older ages.In addition, there was a statistically significant differencebetween rural and urban residents in the reported recencyof a CBE by a doctor (p < 0.0001). Rural women wereslightly more likely (36.8%, 95% CI: 34.6, 39.0) thanurban ones (32.7%, 95% CI: 31.6, 33.7) to have had abreast examination by a doctor more than 1 year ago (Fig-ure 8).Pap SmearThe 2000 CCHS data were used to determine the last timewomen reported having a Pap smear test, whether thereAge distribution of those who sought specialist care, by sex and chronic conditionFigure 5Age distribution of those who sought specialist care, by sex and chronic condition. Statistics Canada, Health Service Access Survey, 2001 (CCHS supplement).Page 5 of 11(page number not for citation purposes)significant factor with regard to the last time amammogram was received (p < 0.0001). However, it can-was a difference between women who had had a recentPap smear and women who had not, and whether theseBMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33differences could be associated with age or geographiclocation. The Canadian guidelines suggest that all sexuallyactive women be tested annually until three negative Papsmears have been reported, and then tested every 3 yearsuntil age 69.As expected, the reported currency of Pap smear testing isinversely related to age. For example, 18 to 24 year oldsare more than twice as likely (41.5%, 95% CI: 39.4, 43.6)as those 55 and older (17.6%, 95% CI: 16.7, 18.5) toreport having had a test in the previous 6 months (Figure9). Almost 60% of women aged 55+ and 40% of those 35to 54 report having had a Pap test done more than 1 yearsmear test was done: 60% (95% CI: 59.3, 60.8) of urbanresidents compared with 56% (95% CI: 54.8, 57.2) ofrural ones report having their test done less than a yearago.DiscussionOverall Utilization of Health Services and AccessThe systematic review of the literature undertaken toinform the analysis provides some interesting context tothe interpretation of our findings. The results of this studyare generally consistent with findings from a range ofCanadian studies examining physician and hospitalutilization by population groups.[2,6-9] This study hasMean waiting time (days) for selected services, by sexFigure 6Mean waiting time (days) for selected services, by sex. * indicates significant difference, p = 0.05--- data suppressed because of small cell sizeStatistics Canada, Health Service Access Survey, 2001 (CCHS supplement).Page 6 of 11(page number not for citation purposes)ago. Residing in an urban area provides a small but statis-tically significant advantage regarding the last time a Papextended these observations by reporting some new find-ings. The approach has been to provide a general overviewBMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33of women's use of health care resources across all ages toinvestigate possible system bias that may result in healthservice inequities.Overall, the findings confirm that access to first contactwith the system is generally high, in that women report aslight advantage over men. There are differences betweenmen and women regarding reasons for not having a regu-lar family physician and also differences regarding fre-quency of service utilization. While some insight is gainedby examining further sex-specific utilization of specialistservices for selected conditions, surgical interventions andof prevalence of illness, care-seeking behaviour and socialroles, appropriateness of care and health outcomes by sexand gender.Waiting TimesWaiting times and wait lists have become the bane of theCanadian health system and related debates about a sys-tem in crisis, yet there is no general consensus about whatconstitutes appropriate wait times for medical and surgi-cal care. Provincial and regional wait lists for diagnostictests are debated in the context of fiscal policies that havenot kept up with the rapid diffusion of expensivediagnostic technologies that could affect the quality ofhealth care in Canada. Our findings indicate importantdifferences between men and women in waiting times toreceive specialist care for asthma/other breathing condi-tions and for mental health. It is difficult to explain theconsiderably longer time women have reported waitingfor asthma treatment and men have reported for treat-ment regarding mental health problems without furtheranalyses of respondents' health status, attitudes regardingaccess to health care, and other health care seeking behav-iors. However, we can speculate that the reason for thelarge differences may be explained, at least in part, by thedegree to which the diagnostic and therapeutic servicesprovided by physicians vary according to the sex of thepatient. Very little knowledge exists about this aspect ofhealth care utilization, other than recent work onwomen's higher use of prescription medication for certainmental health conditions.Preventive Health Services and the Medicalization of Life Cycle TransitionsLast time had mammography, by age groupFigure 7Last time had mammography, by age group. Statistics Canada, Canadian Community Health Survey, 2000.Last time breasts were examined by doctor (rural/urban)Figure 8Last time breasts were examined by doctor (rural/urban). Statistics Canada, Canadian Community Health Sur-vey, 2000.Last time had Pap smear, by age groupFigure 9Last time had Pap smear, by age group. Statistics Can-ada, Canadian Community Health Survey, 2000.Page 7 of 11(page number not for citation purposes)diagnostic technologies, more complex analyses and lon-gitudinal data are needed to delineate the relative effectsThere is a much greater expectation for women than mento present themselves for medical care or consultation.BMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33Although women's passage through the life cycle is both asocial and biological process, the focus of attention inmedicine is confined to biological processes, interpretedby health care systems and providers as requiring medicalmanagement. In comparison, medical management ofmen occurs only in the military and sometimes when theystart employment. In that context, our review of cross-sec-tional studies referring to earlier versions of the popula-tion surveys used in this analysis provides a historicbackdrop from which to interpret our findings.The literature alludes to increased rates of screening mam-mography during the last 5 to 6 years, yet the evidence isat best mixed and confounded by historic differences inthe Canadian and U.S. guidelines.[10,11] An analysis oftrends for 1981–94[12] traced the early implementationof breast screening program mammography across theprovinces and the impact of the National Breast ScreeningStudy on the number of mammograms during thatperiod. That analysis used data from multiple sources:NPHS 94/95, fee-for-service data from provincial healthplans and data from screening programs, where available.While the historic data showed important provincial dif-ferences in numbers screened, this 1998/99 analysis indi-cates that the differences were small. More recent analysesof 1996/97 NPHS data concluded that "50% of womenaged 50–69 have not had a time-appropriate mammo-gram".[13] When compared with the U.S. rates in 1994,the overall percentage of Canadian women reporting thatthey had received a mammogram in the previous year waslower: 40% and 31% respectively.[14] The screening rateswere more similar in the two countries for women aged 50to 69, partly because of consistency in clinical policies;screening was substantially higher in the United Statesamong women aged 40 to 49 as clinical policies inCanada do not endorse screening for this age group. Itwould be most informative to undertake longitudinalcomparative studies of U.S. and Canadian women toquantify the relative influence of the health system, clini-cal policy and individual care-seeking behaviour onscreening mammography and health outcomes.Using the 1987 Quebec Health Survey and linking it withfee-for service physician payment data,[15] more compre-hensive analyses were undertaken to examine the contri-bution of health services utilization variables in amultivariate model of the recency of mammography usefor women aged 50 to 59 years. The study concluded thatthe volume of general and gynecologic medical care, butnot regularity and continuity of care, was associated withrecency of mammography.behaviour, usually associated with use of screening mam-mography but also with Pap smear testing. The literaturesuggests that physician practice behaviour can explain, inpart, variations in utilization rates.[15,16] A survey ofrural family physicians in Ontario, undertaken to examinesex differences in medical practice related to cervical andbreast cancer screening, provides interesting findings per-taining to CBE.[17] While no physician sex differenceswere observed in screening mammography rates, the self-reported screening rates for Pap tests and CBE were higheramong female than male physicians. The latter reportedthat patients asked them more frequently for a referral toanother physician to perform Pap tests and CBE.Canadian women are currently advised to have an annualPap test "once sexually active or at age 18 with a reductionin screening frequency to every three years after two nor-mal smears to the age of 69".[17] Maxwell et al. used the1996/97 NPHS to determine factors important in the pro-motion of cervical cancer screening.[17] They found that"the estimates from the NPHS fail to indicate the dynamicnature of Pap test participation (i.e. regular, opportunisticand first time testing) and the temporal relationshipbetween promoting factors and participation." They alsonoted that the NPHS is unable to provide data aboutwomen's beliefs, knowledge and attitudes regarding can-cer and preventive health practices. The present analysis ofthe 2000 CCHS data is also limited in the conclusions thatcan be drawn about regular Pap testing patterns and com-pliance with screening recommendations.A study from Quebec using data linkage developed logis-tic regression models to examine women's use of healthservices in relation to Pap smear use.[18] Regularity ofcare was the most important predictor of recency of Papsmear testing among several utilization variables.Individual characteristics, such as women's age, maritalstatus and the presence of inflammatory diseases of thegenital organs, were strong predictors that remainedsignificant even after utilization variables were controlledfor.Limitations of the AnalysisIn the Discussion section specific observations have beenmade about the availability of data as well as its qualityand appropriateness for comprehensive gender-relevantanalysis. The analysis includes a few key aspects of healthservices pertinent to surveillance. Hospital utilization hasnot been examined because an overall analysis of volumeof services would not be meaningful, and condition-spe-cific morbidity is covered elsewhere.Also excluded from the analyses has been the use of alter-Page 8 of 11(page number not for citation purposes)Clinical breast examination is generally reported in the lit-erature as an important aspect of preventive healthnative care practitioners. This is a rapidly increasing areaof utilization and traditionally associated with women'sBMC Women's Health 2004, 4: http://www.biomedcentral.com/1472-6874/4/S1/S33use of health resources. However, as provincial healthprofession statutes vary greatly in terms of their regulationand public funding, it is futile to examine such specificutilization without the appropriate sample design.Finally, we did not examine the appropriateness ofwomen's use of health services, from a perspective of thegrowing medicalization of women's life cycle transitions.That would require longitudinal data as well as richer dataon the context of women's lives.Recommendations• For surveillance purposes, more detailed and more com-prehensive information is required that would addresssex-sensitive and gender-relevant research questions; e.g. alist of providers that include a range of alternative provid-ers/therapists, or a broader range of social, environmen-tal, and health system indicators that affect women indifferent ways than they affect men.• A longitudinal design is essential to capture causal rela-tions between utilization, the life-course and health out-comes in order to capture more accurately, and in a richercontext, the range of women's health care experiences.• As health care is under provincial jurisdiction, largerprovincial samples of the national surveys are necessary,together with a longitudinal design, in order to measurepossible system bias and its implication for equitable andhigh-quality health care for women.• Either a national database on preventive services or bet-ter alignment of provincial databases pertaining to healthpromotion and preventive services is needed to facilitatedata linkage with national surveys and to undertake lon-gitudinal studies that support gender-relevant analyses.• Facilitation (and technical support) of data linkagebetween administrative databases and national surveys isessential to reduce the heavy burden of extensive longitu-dinal surveys, and to support the validation of survey-based measurement tools, as well as to enhance ourunderstanding of gender and health.BibliographyAdvisory Committee on Women's Health Surveillance: Women's health sur-veillance: a plan of action for Health Canada. Ottawa (ON): Minister of PublicWorks and Government Services Canada 1999.Ahmad F, Stewart DE, Camerson JI, Hyman I: Rural physicians' perspec-tives on cervical and breast cancer screening: a gender-basedanalysis. J Women's Health Gender-Based Med 2001, 5(2):201-08.Applied Research and Analysis Directorate: Healthy Canadians: A federalreport on comparable health indicators 2002 [http://www.hc-sc.gc.ca/iacb-Beland F, Lemay A, Boucher M: Patterns of visits to hospital-basedemergency rooms. Soc Sci Med 1998, 47(2):165-79.Bird CE, Rieker PP: Gender matters: an integrated model for under-standing men's and women's health. Soc Sci Med 1999, 48:745-55.Blais R, Maiga A, Aboubacar A: How different are users and non-usersof alternative medicine? Can J Public Health 1997, 88(3):159-62.Brown AD, Magistretti AI, Stewart DE: Women's Health in HospitalReport 2001. Preliminary studies: volume two, exploring nursing,women's health, population health. 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