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From Knowledge to Action: Using Sex, Gender and Health Research to Improve Policy and Practice Johnson, Paula, A. 2010-11-23

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From Knowledge to Action: Using Sex and Gender and Health Research to Improve Policy and Practice November 23, 2010 Paula A. Johnson, MD, MPH Chief, Division of Women’s Health Executive Director, Connors Center for Women’s Health and Gender BiologySex Does Matter • Every cell has a sex • Sex differences in health and disease • Models of disease not based on women • Gender plays a significant role • 1993 NIH Revitalization Act: Congress mandated inclusion of women and minorities in clinical research.Women’s Health as a Magnifier and Multiplier • Women remain the primary care givers around the world – Women are the doctors, nurses, pharmacists and therapists • In the U.S., women make over 70% of the healthcare decisions • Women are demanding consumers of health care – Seek more health information, demand more education, press for prevention • Women are the bearers of the next generation – Healthy women produce healthier children • The health of women is a key indicator of a country’s overall health– economic, education, healthIllness Onset  Pre-Illness History Illness Course  Women’s Health Across the LifespanOB and  G y n Cance r Cardio v as c ul a r Neuro s ci e nc e O rtho p ed ics  &Arthriti s Women’s Health • Discover, disseminate, and integrate knowledge on women’s health, gender biology and gender-specific care • Translate this knowledge base to the highest standard of care for women, delivered in an environment that meets the needs of the women Women’s Health Across Fields in MedicineWomen’s Health Across Disciplines Model, learn from, and encourage adoption of comprehensive and integrated care Produce and disseminate scientific knowledge on women’s health and sex- and gender-based biology. Influence women’s health policy at the institutional, local and national levels Support leaders working to improve the health of women globally through research, teaching, intervention, and care Produce leaders who have the experience, creativity, skills and determination to have a major impact in improving the health of women DEVELOP LEADERS IN GLOBAL WOMEN’S HEALTH EDUCATE, SUPPORT LEADERS OF CHANGE IMPROVE CLINICAL SERVICES & PATIENT CARE CONDUCT RESEARCH INFLUENCE POLICY IMPROVE THE HEALTH OF WOMEN & TRANSFORM THEIR CARETop Cancer Killers/Women 2008 Lung 42% (Light & Dark Blue) Of the non-smokers with lung cancer,  60% are womenLung Cancer in Women • Clinical program that addresses medical and psychosocial needs of women – National Lung Cancer Screening Trial • Provides the infrastructure for discovery – Estrogen-regulated gene associated with mesothelioma outcome • Enables partnership of investigators, clinicians, patients and advocacy organizations – Lung Cancer Mortality Reduction Act of 2009Lung Cancer in Women: Integration Across Disciplines - Research, Education, Policy380 400 420 440 460 480 500 520 79 80 85 90 95 00 04 Calendar Years De ath s i n Th ou sa nd s Males Females More Women Die from Heart Disease than Men Source: American Heart Association. Heart Disease and Stroke Statistics 2007 Update. Heart Disease Mortality in Women and Men Absolute Number of Deaths, 1979-2004 64% of women vs. 50% of men had no previous symptoms0 50 100 150 200 250 300 Heart Disease All Cancers Stroke Breast Cancer Diabetes White Black Hispanic Age Adjusted, 3-Year Cumulative Mortality Rates for U.S. Women by Race/Ethnicity 2003-2005.  Source: CDC, Mortality Rates, 2003-2005 Heart Disease is the Number One Cause of Death in Women Cause of Death Rate p er  100,00 0Illness Onset  Pre-Illness History Illness Course  Women’s Health Across the LifespanPlaque Rupture Plaque Erosion Sex Differences in Physiology of Myocardial Infarction Source: Virmani et al, Arterioscler Throm Vasc Biol.  2000;20:1262-1275.Cardiovascular Disease can be Different in Women Blockage in “male” coronary artery Blockage in “female” coronary artery Gould. Coronary Artery Stenosis and Reversing    Atherosclerosis, 2nd ed. 1999. A B P re s s u re P re s s u reCoronary Artery Disease Normal coronary artery Diseased coronary arteryHeart Catheterization and Ultrasound B A A BClinical Education and Awareness Research Improve education and awareness of women, investigators, physicians, and other health care providers “Learning” Practice Model  Increase research to better understand sex differences in health and disease  Expand inclusion of women in research and clinical trials • Expand reporting of results by sex, race, and by sex/race  Effectively translate research into clinical care  Use sex-specific data to consider safety of interventions • Sex-stratified quality measuresPregnancies Middle age Population with complicated pregnancy, e.g. preeclampsia Healthy population Threshold for clinical vascular or metabolic disease V asc u la r d ysfu n ctio n Adapted with permission from Sattar, BMJ,2002 Pregnancy as “Stress Test” for Cardiovascular DiseaseGestational Diabetes Mellitus and Associated Risks • Risk with subsequent pregnancy is 50-65% • 50-70% will develop Type 2 DM over the lifecourse • 20-30% will develop Type 2 DM in 7-10 years • Increased risk of Type 2 DM in children of mothers with GDM Kim, C., Newton, K.M., and Knopp, R.H. 2002. . Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care. 25::1862-1868. http://www.jci.org/cgi/content/full/115/3/485Cardiovascular Events in Women with Gestational Diabetes Shah BR, et al.  Diabetes Care. 2008; 31: 1668-1669.Gestational Diabetes and the Health of Women:  Gaps and Opportunities • Lack of guidelines on how to care for women pre- or post-pregnancy to decrease risk • Currently no formal method to track the population through billing • Need to address full scope of “cardio-metabolic disorders” in younger women who are pregnant or soon to be pregnant that affect health of women and children over the lifespanIllness Onset  Pre-Illness History Illness Course  Women’s Health Across the LifespanWomen’s Health Across Disciplines Model, learn from, and encourage adoption of comprehensive and integrated care Produce and disseminate scientific knowledge on women’s health and sex- and gender-based biology. Influence women’s health policy at the institutional, local and national levels Support leaders working to improve the health of women globally through research, teaching, intervention, and care Produce leaders who have the experience, creativity, skills and determination to have a major impact in improving the health of women DEVELOP LEADERS IN GLOBAL WOMEN’S HEALTH EDUCATE, SUPPORT LEADERS OF CHANGE IMPROVE CLINICAL SERVICES & PATIENT CARE CONDUCT RESEARCH INFLUENCE POLICY IMPROVE THE HEALTH OF WOMEN & TRANSFORM THEIR CARE0 500 1000 1500 2000 2500 3000 3500 4000 18-24 25-34 35-44 45-54 55-59 60-64 65-74 75+ # in  th ou sa nd s Age Men & Women Below 100% Poverty, U.S. 2009 Men Women Source: U.S. Census Bureau, Current Population Survey, 2010 Annual Social and Economic Supplement.Healthy Heart Study • Look at affordability of healthy diet in two lower- income, diverse Boston neighborhoods • Conducted series of focus groups to develop culturally-appropriate and heart healthy menus • Conducted cost assessments at large local grocery stores to develop conservative estimates for monthly food cost • Compared cost of heart-healthy menus to monthly allowance under federal safety-net Food Stamp programAffordability of a Healthy Diet in                  Boston Neighborhood $242 $692 $139 $465 -$103 -$227 $242 $692 $178 $554 -$64 -$138 -$400 -$200 $0 $200 $400 $600 $800 $1,000 M on th ly  C os t Cost Food Stamp Max* Cost FESS Difference Senior Food Stamp Senior FESS Family (4) Food Stamp Family (4) FESS * Fiscal Year 2004• Improve access to healthy food and safe environments for active living • Collaborate with NGOs, government agencies  and two academic medical centers to influence: – Community food environments (e.g. stores, farmer’s markets) – School food systems – Active living (e.g. open spaces/safe sidewalks) – Health care systems that support access to healthy, affordable food The Boston Collaborative for Food & FitnessGoals of the Boston Food Policy Council 1. Increase access to affordable, healthy, nutritious food for all Boston residents 2. Expand Boston’s capacity to produce, distribute, and consume local food 3. Promote food as an economic development strategy 4. Expand existing public and private partnerships and establish new partnerships with foundations and corporate leadersAccess to Healthy and Affordable Food Public Health Health Care Delivery Obesity and diabetes presenting in the physicians office Need access to healthy, affordable food Access to healthy, afforda ble food supported by the physician Access to healthy, afforda ble food supported by the community Obesity and diabetes presenting in the community Why?P h ys ic ia n Pr actic e Co m m u n it y H o sp it al Aca d em ic  M ed ical  Ct r Patient Family Neighborhood Community Population Heal th  C a re  Deli ve ry H eal th  Car e D eli ve ry  Sy ste m Public Health Levels of Integration Low Medium High Integration Across Fields: Public Health and Health Care DeliveryIntegration Across Disciplines: Research, Policy, AdvocacyCONNORS CENTER FOR WOMEN’S HEALTH AND GENDER BIOLOGY HC Reform: Goals / Research Questions a. Define a strategy and framework for creating an effective women’s health implementation agenda within ACA b. Examine the intersection of women’s health and health reform - structure, process and outcomes (see next slide) c. Synthesize work being done by federal agencies; identify gaps; then translate evidence into action d. Define a research agenda with an action agenda attached e. Begin to develop models of care for women across the lifespan f. Discuss practicality of implementation at the state level/ identify threads of assistance Global Women’s Health “… In the new global economy, individual countries and regions would find it difficult to make economic or social progress if a disproportionate percentage of their female population remained poor, uneducated, unhealthy and disenfranchised.” Hilary Clinton on the                                                             U.N. Fourth World Conference on WomenWomen’s Health Across Disciplines Model, learn from, and encourage adoption of comprehensive and integrated care Produce and disseminate scientific knowledge on women’s health and sex- and gender-based biology. Influence women’s health policy at the institutional, local and national levels Support leaders working to improve the health of women globally through research, teaching, intervention, and care Produce leaders who have the experience, creativity, skills and determination to have a major impact in improving the health of women DEVELOP LEADERS IN GLOBAL WOMEN’S HEALTH EDUCATE, SUPPORT LEADERS OF CHANGE IMPROVE CLINICAL SERVICES & PATIENT CARE CONDUCT RESEARCH INFLUENCE POLICY IMPROVE THE HEALTH OF WOMEN & TRANSFORM THEIR CARE 11/18/10  6:55 pm• Has become one of the fastest growing countries in the world • Has the second highest rate of HIV infection in the world • 1 in 3 pregnant women are HIV positive (2007) • Global Women’s Health Fellows study efficacy of preventing HIV transmission through breastfeeding • Research findings integrated into approaches of the Ministry of Health • Developing relationship with new medical school to help develop women’s health curriculum Integration Across Disciplines in Botswana : Research, Education and Policy 11/18/10  6:55 pm• One of the least developed countries in the world • Among the highest maternal mortality rates in Africa • Vice President Joyce Banda aims “to assist women and girls gain social and political empowerment through entrepreneurship and education’’ • Adopting culturally-appropriate models of integration across disciplines • Serve as example/”case study” for leadership development in global women’s health Integration Across Disciplines in Malawi: Leadership and Policy 11/18/10  6:55 pmLeadership for Women’s Health: Building the Field Globally to Improve Lives Identify Global Leaders Support and Develop Leaders Establish Field of Women’s Health Leadership Sustain Leaders Globally Identify and recruit the most promising and up-and-coming leaders in different world regions Support growth by making available full, multi-disciplinary resources of Harvard University Build the field through robust research and case development Develop a sustained training and collaborative network to improve the health of women around the globe 11/18/10  6:55 pmDEVELOP LEADERS IN GLOBAL WOMEN’S HEALTH EDUCATE, SUPPORT LEADERS OF CHANGE IMPROVE CLINICAL SERVICES & PATIENT CARE CONDUCT RESEARCH INFLUENCE POLICY IMPROVE THE HEALTH OF WOMEN & TRANSFORM THEIR CARE Women’s Health Across the Lifespan Women’s Health Across Disciplines Women’s Health:                                                     Integration Across the Lifespan and Disciplines 11/19/10  4:57 pm

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