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Synthesis : Pulling It All Together DesMeules, Marie; Kazanjian, Arminée; MacLean, Heather; Payne, Jennifer; Stewart, Donna; Vissandjée, Bilkis Aug 25, 2004

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ralssBioMed CentBMC Women's HealthOpen AcceReportSynthesis : Pulling It All TogetherMarie DesMeules*1, Arminée Kazanjian2, Heather MacLean3, Jennifer Payne4, Donna Stewart5 and Bilkis Vissandjée6Address: 1Centre for Chronic Disease Prevention and Control, Health Canada, 120 Colonnade Rd, Ottawa, Canada, 2Faculty of Medicine, The University of British Columbia, 5804 Fairview Avenue, Vancouver, Canada, 3Centre for Research in Women's Health, 790 Bay St., 7th Floor, Toronto, Canada, 4Centre for Chronic Disease Prevention and Control, Health Canada, 120 Colonnade Rd, Ottawa, Canada, 5University Health Network, University of Toronto, 657 University Ave, Toronto, Canada and 6School of Nursing Sciences, University of Montreal, Montreal, CanadaEmail: Marie DesMeules* - Marie_desmeules@hc-sc.gc.ca; Arminée Kazanjian - arminee@chspr.ubc.ca; Heather MacLean - h.maclean@utoronto.ca; Jennifer Payne - Jennifer_payne@hc-sc.gc.ca; Donna Stewart - Donna.Stewart@uhn.on.ca; Bilkis Vissandjée - bilkis.vissandjee@umontreal.ca* Corresponding author    What the Women's Health Surveillance Report AchievesThis gender-focused Women's Health Surveillance Reportis the initial step in developing an effective, sustainablewomen's health surveillance system in Canada. Thisreport identifies key data gaps in existing national surveys,gaps that must be addressed in order to have an effectivewomen's health surveillance system. It uses data from avariety of national administrative and survey databases toexplore sex and gender differences in important areas ofwomen's health. While these data have often been consid-ered "sterile" (they were collected for other purposes andgenerally lack much of the context needed for gender anal-ysis), the report's authors have used them to provide someinsights into disparities in the distribution of determi-nants of health, health behaviours, health outcomes, andhealth care utilization for Canadian women, and to iden-tify vulnerable subgroups of women.This report provides a baseline for monitoring health out-comes, health-related behaviours, and other social andeconomic issues that affect women's lives. Its focus is arange of health issues that emerged from national consul-tations with women's health experts.Many women's health experts, with a variety of perspec-tives, came together to create the Women's Health Surveil-"expert" consultation took place in October 2002. Thiscollaboration will continue through the report's dissemi-nation and evaluation stages, as relevant stakeholderswork together to build a comprehensive and effectivewomen's health surveillance system in Canada.Some Key Messages: A Crosscutting PerspectiveRather than adopting a crosscutting perspective, theWomen's Health Surveillance Report presents informationon a series of health issues. Below are some key messagesfrom the report with respect to quality of life, the healthof Canadian women across the life cycle, and the health ofmore vulnerable women.Quality of LifeThe health-related quality-of-life indicators used in thisreport include self-perceived health, self-reported chronicconditions, and health-adjusted life expectancy (HALE).This report supports the well-known associations betweenincome, education, age-, and self-rated health. As incomeand education levels increase, women are more likely torate their health as very good or excellent. Having a part-ner also seems to contribute to a positive perception ofhealth. On the other hand, older women (65+ years),women not born in Canada, and those who engage inmultiple risk behaviours are less likely to report very goodor excellent health.from Women's Health Surveillance ReportPublished: 25 August 2004BMC Women's Health 2004, 4(Suppl 1):S30 doi:10.1186/1472-6874-4-S1-S30This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S30<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 5(page number not for citation purposes)lance Report. Expert teams drafted chapters and consultedregularly with the Steering Committee. A broader, externalBMC Women's Health 2004, 4:S30 http://www.biomedcentral.com/1472-6874/4/S1/S30Across all age groups, women are more likely than men toreport chronic conditions, comorbidity, and severe andmoderate disability. Income, education, smoking statusand age are only slightly associated with the prevalence ofreported disability. Disabled women, however, are morelikely to be single with dependent children, have lowerincomes, be unemployed, and have less tangible socialsupport and fewer positive social interactions their malecounterparts. Similarly, disabled women over age 45 wereless likely to be married than their male counterparts.Women have lower incomes and less formal educationthan men, and twice the prevalence of depression. Allthese conditions are strongly associated with reports ofchronic pain. Further, women and men with less socialsupport report pain more frequently.The chapter on the mortality and life expectancy of Cana-dian women indicates that women have a longer HALEthan men (70.0 years versus 66.7 years). When preventa-ble deaths (e.g. those caused by smoking) are excludedfrom the analysis, however, this disparity diminishes. Assmoking-related deaths and disability continue toincrease among women and decrease among men, this sexgap is expected to narrow further.Life CycleYoung WomenYoung women are a subgroup most vulnerable to healthrisks. Research shows that smoking rates for youngwomen now exceed those of young men – and continueto rise. Young women are some of the largest consumersand abusers of alcohol, with reports of heavy alcohol useamong women aged 20–24. Further, adolescent women(15–19 years) are at highest risk of becoming anorexicand/or bulimic, and are more likely to report experiencingviolence than women 45+ years. Alarmingly, rates of non-severe violence and emotional abuse are highest in theyoungest cohort of women.Because their cervical cells are still developing and theircervical mucus is more easily penetrated by bacterialorganisms that cause disease, adolescent women are at anincreased biological risk of contracting chlamydia andgonorrhea. In 2000, the reported incidence of chlamydiaand gonorrhea was highest among women aged 15–19years as compared with older cohorts of women. Further,the greatest increases in positive HIV/AIDS tests attributedto women are found in the youngest age group (15–29years). The proportion of positive HIV tests attributed towomen aged 15–29 has increased steadily, from 14.6% in1985–1995 to 44.5% in 2001.among young women (18–24 years) than older women,and suicide rates increase over the teen years.Women in MidlifeCompared to their younger counterparts, women inmidlife (40+ years) begin to be at elevated risk for breastcancer and other gynaecological cancers, such as invasiveendometrial cancer and ovarian cancer. Women aged 50and older face a higher risk of developing cardiovasculardisease, the result of both hormonal changes related tomenopause and poor health behaviours. Two significantlifestyle changes for women in midlife include decreasedphysical activity and a greater likelihood of being over-weight.Women in their 40s often begin to experience changes insexual self-image, sometimes accompanied by diminishedsexual desire and decreased sexual responsiveness. Thesechanges are thought to be primarily a result of decreasedtestosterone levels, although changing social roles forwomen in midlife may also be a factor.In general, women aged 45 years and older are less likelyto experience depression than their younger counterparts.Older WomenAs this report shows, as women age, they are at increasedrisk for breast cancer, cardiovascular disease, gynaecologi-cal cancers, osteoporosis, and arthritis. Further, olderwomen are less likely than their younger counterparts topractise positive health behaviours, such as exercising andfollowing a healthy diet. Therefore, it is perhaps not sur-prising that women aged over 65 years have the highestrates of health care utilization. Notably, age was shown tobe a better correlate of primary health care utilization thaneither sex or geographic location. As age increases, so doesthe proportion of the population using medication, andthe number of medications consumed.Compared to the amount of data on elderly women'sphysical health and functioning, little data exists to sup-port an analysis of the non-medical determinants ofhealth, such as social support. This is a substantial datagap, given that elderly women constitute one of the poor-est and most vulnerable segments of Canadian society.Overall, the likelihood of experiencing depression tendsto decrease with age. Although psychiatric symptoms,including minor depression and anxiety, increase in theyears immediately preceding menopause, these symp-toms have been shown to diminish substantially in thepost-menopausal years.Page 2 of 5(page number not for citation purposes)Finally, the data suggest that the mental health of youngwomen is a concern. The incidence of depression is higherBMC Women's Health 2004, 4:S30 http://www.biomedcentral.com/1472-6874/4/S1/S30Vulnerable PopulationsAboriginal WomenAboriginal women face multiple health burdens, includ-ing poor health status, poverty, violence, and substanceabuse. There is some agreement that, in Canada, Aborigi-nal people's health profile resembles that of people in adeveloping country. Despite this agreement, Aboriginalhealth – and particularly Aboriginal women's health –remains poorly understood.The life expectancy of First Nations women is five yearsbelow the national average for Canadian women. Belong-ing to an Aboriginal community is also associated with anincreased risk of reporting poor/fair health status. Thehealth practices of First Nations women differ substan-tially from those of the general female population in Can-ada. For example, Aboriginal women's smoking rates aredouble the national average, while alcohol dependence istwice as common among Aboriginal women as it amongtheir non-Aboriginal counterparts. Further, Aboriginalwomen who are dependent upon alcohol are more likelyto experience depression. On the positive side, Aboriginalwomen are more likely than non-Aboriginal women to bephysically active.Aboriginal women appear to be at greater risk than thegeneral female population for chronic diseases, such ascardiovascular disease, diabetes, arthritis, rheumatismand cervical cancer. Further, they have higher death ratesthan the general population from ischemic heart diseaseand stroke. Despite a trend towards an increase in breastcancer among Inuit women (1969–1973 and 1984–1988), it appears that breast cancer rates are lower amongInuit women than the rest of the female Canadian popu-lation.Approximately half of all HIV-positive tests reportedamong Aboriginal people are from women, comparedwith 16% for women in the non-Aboriginal population.Further research is required to determine the factors asso-ciated with this trend.Rates of all types of violence, including sexual assault, aremuch higher among Aboriginal women than non-Aborig-inal women. Aboriginal women also have a dispropor-tionate suicide rate: Status Indian teenaged women, forexample, are 7.5 times more likely than other Canadianteenagers to commit suicide, and Status Indian womenaged 20–29 have a suicide rate 3.6 times that of otherCanadian women of similar age. Unfortunately, nonational data are available on the prevalence of depres-sion among Aboriginal women.Lone ParentsSingle mothers are significantly more likely than part-nered mothers to be poor and to experience financialstress and food insecurity. These factors may contribute tolone mothers' significantly higher rates of distress (e.g.depressive symptoms), personal stress (e.g. feeling over-loaded), and chronic stress. Also of concern is the findingthat lone mothers living with young children experiencegreater rates of severe and non-severe violence and emo-tional abuse.Incarcerated WomenWomen in prison have a higher risk of exposure to HIV/AIDS than non-incarcerated women because of injectiondrug use, needle sharing, and risky sexual behaviour.Other health issues affecting incarcerated women not dis-cussed in this report (e.g. exposure to antibiotic-resistanttuberculosis, hepatitis C, and sexually transmitted infec-tions) require future research.Rural Versus Urban WomenThis report's findings about the health of rural versusurban women are mixed. On one hand, rural women havesignificantly higher mortality rates than urban women.For example, mortality rates among rural teenaged girls(15–19 years) are 2.50 times those of their urban counter-parts. There are also substantial geographic differences inmortality; for instance, women living in the NorthwestTerritories have a 60% higher all-cause mortality rate thanwomen living in British Columbia, and a 30% highermortality rate than that of women in Newfoundland.Rural women are also less likely than women living inurban areas to have had a Pap smear, a clinical breastexamination, or a mammogram in the previous sixmonths.On the other hand, urban women report a higher risk ofexperiencing physical violence and are more likely thanwomen in rural areas to report being sexually assaulted.Ethnic Diversity and MigrationThere is a dearth of ethnic-specific national data disaggre-gated by sex and gender. When ethnicity is available as avariable, it is often presented as broad categories that tendto create homogeneity among diverse sub-groups. Theanalysis in this report is based on a limited sample ofwomen and men reporting that they were born elsewhere,but currently live in Canada, and/or self-identifying witha specific ethnic group. Our analysis suggests that womenwho are recent immigrants report better health and areless likely to engage in most health risk behaviours, suchas smoking and regular drinking than Canadian bornwomen. As length of residence increases in Canada,Page 3 of 5(page number not for citation purposes)women were significantly more likely to report poorhealth than Canadian-born women. Reported morbidityBMC Women's Health 2004, 4:S30 http://www.biomedcentral.com/1472-6874/4/S1/S30was also higher for women and men, who had spent moretime in Canada, which is similar to the findings of otherstudies.What Else is Needed for a Sustainable Women's Health Surveillance System?Other Reports on Women's HealthThe United States and several Canadian provinces haveprepared women's health reports that provide assess-ments of women's health status and information that canbe used by health decision-makers in developingwomen's health policy and programs [1-4]. This Women'sHealth Surveillance Report is unique in that it: (i) uses aCanadian national perspective, and (ii) endeavours toclarify the utility of national secondary data (administra-tive and survey) in providing gender-relevant informationfor women's health policy and program decision-making.This important baseline information is necessary fordeveloping a women's health surveillance system.Making the Grade on Women's HealthA National and State-by-State Report Card, prepared by theNational Women's Law Center in the United States[1],reviewed 32 measures of women's health status and 32measures of women's health policy. While some of thehealth issues dealt in the U.S. report with were the same asthose in the Women's Health Surveillance Report, the U.S.report focused mainly on inequities in access to healthcare, which is less applicable to the Canadian situation.Within Canada, different provinces and regions – includ-ing Atlantic Canada (1999; updated in 2003), BritishColumbia (2000), and Ontario (2002) – have reported onwomen's health [2-4]. Like the Women's Health Surveil-lance Report, these publications provide a gender-relevantperspective on women's health. This approach recognizesthat health and its determinants are not distributedequally between men and women or, for that matter,among women themselves, and aims to identify particu-larly vulnerable groups. While they take differentapproaches, there are similarities in these reports withrespect to issues dealt with and the results obtained.The Atlantic report showed, through illustrative examples,the utility of a "determinants of health" approach toassessing women's health status in the region[2]. Itaddressed issues including socio-economic determinantsof health, lifestyle and preventive factors, and disease. Thereport noted the highly interactive nature of the determi-nants of health and identified some significant data gapsand limitations. The British Columbia report used the sixprovincial health goals and their corresponding objectivesand indicators as a framework for the report[3]. Like theprovided a comprehensive description of the current stateof women's health in the province. It looked at health andthe determinants of health, and was organized aroundfive themes: demographics, morbidity indicators, repro-ductive health, health behaviours, and subpopula-tions[4].These reports, and the research teams that worked onthem, provide opportunities for further insight into andcollaboration towards strengthening women's health sur-veillance in Canada.Beyond this ReportDuring the consultation process and subsequent develop-ment of the Women's Health Surveillance Report, severalstakeholders and women's health experts suggested moreor different women's health issues that could/should havebeen included. Not all these topics are discussed here, fora variety of reasons. For example, there are data availableon respiratory diseases among women, which should beaddressed in future reports. In some cases, such as abor-tion and hysterectomies, insufficient data are available fora comprehensive analysis. Also there are other importantissues such as anxiety in women and pelvic pain for whichthere are no appropriate data. There is clearly a need tocontinue the process of consensus building, and furtherthe development and validation of women's health indi-cators. The agreement on a framework and a core set ofgender-sensitive women's health indicators will be animportant step towards establishing a comprehensive andvalid scope for future reports.Such a framework and indicators would facilitate appro-priate and useful data collection. While it has been possi-ble to provide some sex- and gender-relevant data analysisfor all issues covered in this report, almost all chapterauthors have commented on the limitations of the sec-ondary data available for constructing the most appropri-ate gender variables. The authors of several chaptersexpressed the need for more suitable data for gender-sen-sitive analysis, particularly the following:• More contextual data pertaining to women's circum-stances, such as women's roles (e.g. employee, wife,mother, caregiver) and women's use of health careresources (qualitative and quantitative research shouldcomplement each other and help to determine the mostuseful contextual variables).• Longitudinal data that would allow a better understand-ing of the links between health behaviours and healthoutcomes.Page 4 of 5(page number not for citation purposes)Atlantic report, it was intended to demonstrate an alterna-tive approach to women's reporting. The Ontario report• Representative samples in health surveillance systems toreflect the diversity of the Canadian population withBMC Women's Health 2004, 4:S30 http://www.biomedcentral.com/1472-6874/4/S1/S30respect to ethnic background and length of residence inCanada, especially to assess the needs of recent immi-grants.• Longitudinal data that would provide information ofthe influence on changing socio-economic environments,of transition experiences and their interaction with genderroles, ethnicity, migration experiences and health.• More contextual Aboriginal data.Consideration was given to standardizing the broad socialconcepts (e.g. age, education, employment, housing, eth-nicity, immigrant groups, etc.) used to examine gender inthis report. Given the diversity of the issues addressed,however, it seemed inappropriate to categorize these vari-ables arbitrarily. It was decided, instead, to use the resultsof the report as a basis for recommending the most appro-priate categories for gender-based analysis. Accordingly, a"concept dictionary" could be developed, providing pro-posed categorizations for their use in future gender-rele-vant analyses.The analyses, and this report, have focused primarily onthe individual. The importance of more "upstream" polit-ical, social, cultural, and economic determinants ofhealth, however, must be acknowledged. As well, indica-tors that measure, monitor, and report on these determi-nants – and on risk factors, exposures, interventions, andhealth outcomes – must be built in to any sustainablewomen's health surveillance system.Although a systematic life-course approach was not taken,authors of various chapters have chosen to focus onwomen in specific age groups. A systematic investigationof women's health risks across the different stages of life(early life, childhood, adolescence, and early, middle, andlate adult life), however, can provide insights into the bio-logical, psychosocial, and social factors that interact toinfluence women's health. Our understanding ofwomen's health would benefit from increased knowledgein this area, and more emphasis should be placed onhealth across life stages in future reports.A sustainable women's health surveillance policy devel-opment cycle, as envisioned by the Advisory Committeeon Women's Health Surveillance[5], requires interdisci-plinary input (from researchers, health practitioners, datacollectors, analysts and interpreters, policy and programdevelopers, and communicators) at all stages. Input frompolicy and other decision-makers can help guide data col-lection and analysis. Similarly, an understanding of theneeds of policy and communications teams could helpsurveillance experts can help inform and focus policy andprogram decision-making. The more inclusive the surveil-lance system, and the more multifaceted the perspectivesand approaches to it, the more likely it is to be sustainableand relevant to policy.Next StepsThe core research team identified the following next stepsin the process of developing a sustainable, nationalwomen's health surveillance system in Canada:• Evaluating this report to determine the extent to whichit is a practical and useful tool for women's health policyand program development• Compiling the longer-term recommendations fromstakeholders and experts into a format that can informfuture women's health reports. Here, it would be useful toinclude a systematic assessment of the recommendations'possible effectiveness.• Further work with diverse partners to develop and vali-date a gender-sensitive framework for and indicators ofwomen's health that can be used in the preparation offuture reports. These tools would facilitate the standardi-zation of data and the comparison of data between thegroups that use them. Further, they would assist in settingpriorities.• Continued engagement of women's health experts andother stakeholders in the process of refining a gender-sen-sitive model of surveillance that can form the evidencebase for women's health policy and programming.The Women's Health Surveillance Report aims to provide auseful tool for examining women's health, a tool that canhelp policymakers set specific health goals for Canadianwomen, improve Canadian women's health, and informthe development of Canada's national health goals.References1. National Women's Law Centre; FOCUS on Health & Leadership forWomen, Center for Clinical Epidemiology and Biostatistics, University ofPennsylvania School of Medicine; the Lewin Group. Making the grade onwomen's health: a national and state-by-state report card Washington, DC:National Women's Law Center; 2000. 2. Colman R: Women's health in Atlantic Canada: a statistical portrait. Hali-fax: Maritime Centre of Excellence for Women's Health. Atlantic RegionFora on Women's Health and Wellbeing 2000.3. Women's Health Bureau: Provincial profile of women's health: a statisticaloverview of health indicators for women in British Columbia. Ottawa: HealthCanada 2000.4. Stewart DE, Cheung AM, Ferris LE, Hyman I, Cohen MM, Williams JI:Ontario women's health status report. Prepared for the Ontario Women'sHealth Council by The University Health Network Women's Health Pro-gram, The Centre for Research in Women's Health and the Institute forClinical Evaluative Sciences 2002.5. Advisory Committee on Women's Health Surveillance: Women'sPage 5 of 5(page number not for citation purposes)focus both data analysis and the reporting of results. Aswell, trends and important health patterns identified byhealth surveillance: a plan of action for Health Canada. Ottawa: HealthCanada 1999.


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