Integrating Ethnicity and Migration As Determinants of Canadian Women's Health

HEALTH ISSUE: This chapter investigates (1) the association between ethnicity and migration, as measured by length of residence in Canada, and two specific self-reported outcomes: (a) self-perceived health and (b) self-reports of chronic conditions; and (2) the extent to which these selected determinants provide an adequate portrait of the differential outcomes on Canadian women's self-perceived health and self-reports of chronic conditions. The 2000 Canadian Community Health Survey was used to assess these associations while controlling for selected determinants such as age, sex, family structure, highest level of education attained and household income. KEY FINDINGS: * Recent immigrant women (2 years or less in Canada) are more likely to report poor health than Canadian-born women (OR = 0.48 CI: 0.30-0.77). Immigrant women who have been in Canada 10 years and over are more likely to report poor health than Canadian-born women (OR = 1.31 CI: 1.18-1.45).* Although immigrant women are less likely to report chronic conditions than Canadian-born women, this health advantage decreased over time in Canada (OR from 0.35 to 0.87 for 0-2 years to 10 years and above compared with Canadian born women). DATA GAPS AND RECOMMENDATIONS: * Migration experience needs to be conceptualized according to the results of past studies and included as a social determinant of health above and beyond ethnicity and culture. It is expected that the upcoming longitudinal survey of immigrants will help enhance surveillance capacity in this area.* Variables need to be constructed to allow women and men to best identify themselves appropriately according to ethnic identity and number of years in the host country; some of the proposed categories used as a cultural group may simply refer to skin colour without capturing associated elements of culture, ethnicity and life experiences.     

Pakistan's health policy: appropriateness and relevance to women's health needs

The interface between national health policy and women's health needs is complex in developing countries like Pakistan. This paper aims to assess if Pakistan's national health policy 2001 is relevant and appropriate to women's health needs. Through review of existing data on women, a profile of women's health needs was developed which was transformed into framework of analysis. This framework indicates that Pakistani women's health needs are determined by gender disparities in health and health-related sectors. Comparison of national health policy with women's health needs framework reveals that although policy focuses on women's health through prioritization of gender equity, it is however addressed as an isolated theme without acknowledging the vital role gender inequalities in health and health-related sectors play in defining women's health needs. Moreover, gender equity is translated as provision of reproductive health services to married mothers, ignoring various critical overarching issues of women's life such as sexual abuse, violence, induced abortion, etc. Health systems strengthening strategies are though suggested but these fails to recognize main obstacles of utilization of healthcare services by women including non-availability of female healthcare providers and gender-based obstacles to healthcare utilization such as illiteracy, lack of empowerment to make decisions related to health, etc. In order to be relevant and appropriate to women's health needs the policy should: (1) use gender equity in health and health-related sectors as an approach to develop a healthy policy (2) expand the focus from reproductive health to life cycle approach to address all issues around women's life (3) strengthen health systems through creation of gender equity among all cadres of health providers (4) tailoring health interventions to counter gender-based obstacles to utilization of healthcare services and (5) dissemination interventions for behavior change.     

The influence of income, education, and work status on women's well being.

This article, based on data from the Commonwealth Fund 1998 Survey of Women's Health, examines the relationship between socioeconomic status (SES) and women's health. Women living in poverty are less likely than their higher-income counterparts to have health insurance and use preventive services, and more likely to have access problems, suffer from chronic illnesses, and report low overall health scores. Women with low educational attainment are also less likely to have health insurance and to use preventive services, and more likely to report poorer health status than women with a college education. We conclude with implications for public policy.     

Determinants of the use of maternal health services in rural Bangladesh

Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. In this paper an attempt is made to examine the factors associated with the use of maternal health care services in Bangladesh on the basis of data from a survey of maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). The results from both the bivariate and multivariate analyses confirmed the importance of mother's education in explaining the utilization of health care services. Female education retains a net effect on maternal health service use, independent of other women's background characteristics, household's socioeconomic status and access to healthcare services. The strong influence of mother's education on the utilization of health care services is consistent with findings from other studies. Women whose husbands are involved in business/services also positively influenced the utilization of modern health care services. However, the study results are inconclusive with respect to the influence of other predisposing and enabling factors, such as women's age, number of previous pregnancies and access to health facilities. Multivariate logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of severity of disease condition in explaining the utilization of maternal health care appears to be significant. Multivariate analysis indicate that women having had a life-threatening condition are little over two times more likely to seek care from a doctor or nurse to treat their maternal morbidities.     

Women, work, and preventive health care: an exploratory study of the efficacy of HMO membership

This study's purpose is to explore the possibility of competing roles (paid employment and childcare responsibilities) impinging upon women's annual Pap, breast and blood pressure screenings, and whether HMO enrollments further preventive health care for women in different situations. Using data from the National Access to Medical Care Survey of 1982, the sample includes 594 women who are HMO patients, and 2765 women having regular sources of care from providers in other settings. The findings indicate a strong association between women's relative financial responsibilities for their families and their use of preventive health services. Women who live in traditional situations (no employment outside the home, supported by a male) and women who share the financial burden with men (the "new" multiple-earner families) have substantially more Pap and breast examinations, respectively, than non-traditional family women who carry the full burden themselves. However, these latter women were more likely to have had blood pressure screening--the least expensive, most convenient procedure of those studied. Overall, HMOs did not increase preventive care for traditional family women, did help in marginally boosting the breast examinations of women who share financial responsibility with men, and in the blood pressure screenings for women in nontraditional families. The conclusions stress the importance of measures of women's employment in examining access to care, and call for closer scrutiny of HMOs' preventive care protocols for particularly vulnerable clients.     

Women and Substance Abuse Problems

HEALTH ISSUES: Differences exist in the prevalence and physical health impacts of problem substance use among men and women. These differences are also found in the mental health and trauma events related to substance use, barriers to treatment and harm-reduction services and the impact of substance use on pregnancy and parenting. Data from the 2000-2001 Canadian Community Health Survey and Canada's Alcohol and Other Drugs Survey (1994) were used to explore this issue further. KEY FINDINGS: While women use alcohol and illicit drugs at lower rates than men, the health impact of their use is significant, and in some cases greater than for men. Women are more likely to use prescribed psychoactive drugs (e.g. pain relievers, sleeping pills, tranquillizers) and most of these drugs have addictive potential and long-term negative consequences on health. Research collected from treatment centres in Canada show high rates of victimization experienced by women, which have implications for both their substance use treatment and improvement in mental health. DATA GAPS AND RECOMMENDATIONS: Significant gaps exist in our knowledge on the level, type, and impact of substance use and the adequacy of programming for Canadian women. Information that might be used to guide prevention initiatives, such as the amount of alcohol that might safely be used in pregnancy and the incidence of fetal alcohol syndrome, related birth defects and developmental disabilities are unknown. Improved surveillance, sensitive and comprehensive screening for substance use problems, accessible treatment and harm reduction programming, and coordination with the mental health and violence fields are recommended.     

Social inequalities in perceived health and the use of health services in a southern European urban area.

People of lower social class have worse health and less access to health services and preventive care. This article describes social class inequalities in health status and use of services, both curative and preventive, in Barcelona, in a country with a national health service. The cross-sectional study uses information from the 1992 Barcelona Health Interview Survey. Social class was designated using an adaptation of the British Registrar General classification. The study variables measured health status, health services utilization, and preventive practices. Bivariate and multivariate analyses were used. Some 88 percent of men in social class I and 81 percent in class V had very good or good perceived health status. For women these figures were 85.2 and 57.6 percent, respectively. Chronic illness increased with lower social class. There were no social class differences in the frequency of physician visits during the two weeks prior to the interview among people with poor perceived health. Some 60.7 percent of women aged over 29 in social class I had periodic cervical smears, but only 32 percent of those in class V; the corresponding figures for mammography were 37.8 and 11.3 percent. The national health service has advantages in terms of access to health services, but more knowledge about the quality of these services is required. The study findings are sufficient to defend the undertaking of equitable health policies, especially in providing access to preventive care for the entire population.     

The Impact of Arthritis on Canadian Women

HEALTH ISSUE: Arthritis is one of the most prevalent chronic conditions in Canada and a leading cause of long-term disability, pain, and increased health care utilization. It is also a far more prevalent condition among women than men. Information was obtained primarily from the 1998-99 National Population Health Survey and the Canadian Joint Replacement Registry. KEY FINDINGS: In 1998, the overall prevalence of self-reported arthritis or rheumatism in Canadian women was 20.0%. This rate increased to 55.6% among women over 75 years of age. Compared to women with chronic conditions, women with arthritis were more likely to experience long-term disability; report worse health; experience more pain; be dependent upon others and consult general practitioners, specialists, and physiotherapists more frequently. While men and women with arthritis under-utilize total joint replacement surgery, the degree of under-use was over three times greater for women. DATA GAPS AND RECOMMENDATIONS: There is a lack of detailed information on the use of health care services by women with arthritis. There are also no systematic data available on the prescribing of medications, access to services such as assistive devices or exercise programs, or use of community support, self-management strategies, or rehabilitation services. The burden of arthritis both on women and on society is expected to increase as the population ages. A comprehensive health strategy to reduce the impact of arthritis is required to ensure that health and support services are available in a timely manner and provided in such a way to meet the needs of Canadian women.     

Are two doctors better than one? Women's physician use and appropriate care.

This study examines nonelderly women's concurrent use of two types of physicians (generalists and obstetrician-gynecologists) for regular health care and associations with receipt of preventive care, including a range of recommended screening, counseling, and heart disease prevention services. Data are from the 1999 Women's Health Care Experiences Survey conducted in Baltimore, Maryland, using random digit dialing (N = 509 women ages 18 to 64). Key findings are: 58% of women report using two physicians (a generalist and an ob/gyn) for regular care; seeing both a generalist and an ob/gyn, compared with seeing a generalist alone, is consistently associated with receiving more clinical preventive services, including screening, counseling, and preventive services related to heart disease. Because seeing an ob/gyn in addition to a generalist physician is associated with receiving recommended preventive services (even for heart disease), the findings suggest that non-elderly women who rely on a generalist alone may receive substandard preventive care. The implications for women's access to ob/gyns and for appropriate design of women's primary care are discussed.     

Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women’s Health

This study evaluated the quality of primary care services provided in 15 National Centers of Excellence in Women’s Health (CoE) clinical sites in operation in 2001 using self-reported clinical preventive services and patient satisfaction as indicators of quality of care. A sample of 3,111 women served by the CoE program was surveyed and compared with quality of care benchmarks from national and local community surveys. The benchmark surveys were: a nationally representative sample of 2,075 women from the 1998 Commonwealth Fund Survey of Women’s Health; a community sample of women who lived within a geographical catchment area for three CoEs; and a sample of 71,438 women in the 1999 Consumer Assessment of Health Plans Study (CAHPS) of commercial managed care plans. Adjusting for region, age, education, perceived health status, and managed care enrollment, women in the CoEs weremore satisfied with their care and had received significantly more screening tests and counseling services than women in the benchmark samples. The largest effects among primary care services were for physical breast examination, mammogram (ages 50+), and counseling for smoking, domestic violence, and sexually transmitted diseases.     

Utilization of health care services in Brazil: gender, family characteristics, and social status]

OBJECTIVE: To investigate the pattern of utilization of health care services by men and by women in Brazil. METHODS: We used data from the Brazilian National Household Sample Survey (Pesquisa Nacional por Amostra de Domicílios) carried out in 1998. Logistic regression models were developed to analyze information concerning men and women who had and who did not have restrictions in their routine activities due to health problems during the 15 days before the survey. The individual variables considered were: labor market position (type of employment), amount of schooling completed, and race. Also analyzed were family-related variables: per capita family income, size of the family, and, for the head of the family, the amount of schooling and labor market position. The two-level models (with family and individual variables) showed an effect from family characteristics, but the variables analyzed did not explain that effect. RESULTS: Women used health services more often than did men, even after controlling for restrictions in routine activities due to health reasons. The use of health services by men and women was dependent on family income and on the social status of the individual, indicating a pattern of social inequality. In both the group with restrictions in their activities and in the group without such restrictions, the men and women differed from each other in their utilization of health care services. Family variables were more important in explaining the utilization of health services among people without restrictions in their activities. CONCLUSIONS: Policies aimed at reducing inequalities in access to health care services must take into consideration the differences between women and men as well as the importance of family characteristics. It is also important to stress the need to include the dimensions of gender and family in the design of health service utilization models.     

Gender differences in healthcare utilization and medical indicators among patients with diabetes

OBJECTIVE: To describe differences in healthcare utilization and health indicators of patients with diabetes, according to gender. STUDY DESIGN: A population-based outcome study conducted on 21,277 diabetic patients between the ages of 45 and 64 years who are members of the second largest health maintenance organization in Israel. METHODS: Data on healthcare utilization (process indicators) and health problems (outcome indicators) were obtained from computerized medical records that are stored routinely by the organization. The study period was the year 2002. RESULTS: Significantly (P < 0.05) lower healthcare utilization was observed in men compared with women for all indicators examined (number of visits to physicians and the performance of urine, lipids and creatinine tests). Nonetheless, men showed better health outcomes (lower low-density lipoprotein cholesterol, triglycerides, HbA1c). CONCLUSIONS: Women who suffer from diabetes use more healthcare services and have a higher morbidity rate compared with men. Future research should seek to identify the factors contributing to this observation, which can potentially make an important contribution to the development of disease management strategies that target diabetic women.     

Relationship between body mass index and the use of healthcare services in Australia

OBJECTIVE: To examine the relationship between body mass index (BMI) and the use of medical and preventive health services. RESEARCH METHODS AND PROCEDURES: This study involved secondary analysis of weighted data from the Australian 1995 National Health Survey. The study was a population survey designed to obtain national benchmark information about a range of health-related issues. Data were available from 17,033 men and 17,174 women, > or =20 years or age. BMI, based on self-reported weight and height, was analyzed in relation to the use of medical services and preventive health services. RESULTS: A positive relationship was found between BMI and medical service use, such as medication use, visits to hospital accident and emergency departments (for women only); doctor visits, visits to a hospital outpatient clinics; and visits to other health professionals (for women only). A negative relationship was found in women between BMI and preventive health services. Underweight women were found to be significantly less likely to have Papanicolaou smear tests, breast examinations, and mammograms. DISCUSSION: This research shows that people who fall outside the healthy weight range are more likely to use a range of medical services. Given that the BMI of industrialized populations appears to be increasing, this has important ramifications for health service planning and reinforces the need for obesity prevention strategies at a population level.     

What women don't know about contraception

Women need accurate information about the various forms of contraception from which they may choose. Findings from four recent national telephone surveys conducted among reproductive-age women in the US since 1993, however, indicate that women in the US are not well informed or are misinformed about oral and other forms of contraception. Brief summaries are presented of the following surveys: the 1993 Gallup Organization follow-up survey conducted for the American College of Obstetricians and Gynecologists of 995 women's views on contraception, the 1995 Lou Harris and Associates telephone poll conducted for the American Medical Association of US women's attitudes and perceptions about reproductive health matters, the January 1996 Kaiser Family Foundation survey of 279 women's perceptions about contraception, and the Health Benefits of Contraception, ARHP survey of 280 women. The second part of this latter survey will be completed later in 1996. The common theme in the four surveys is that women do not have enough accurate information about contraception. Reproductive health professionals need to take advantage of every opportunity to provide such information, correct misperceptions, improve their counseling skills, and spread the word about the health benefits of contraception.     

Adapting health services to the specific needs and utilization patterns of the new Spaniards. 2008 SESPAS Report

Because of the progressive increase in the number of immigrants and the uncertainty about the capacity of the Spanish health service to deal with the quantitative and qualitative increases in demand, the possibility of introducing changes to adapt our services to the new situation should be considered. Beginning with an analysis of the factors that influence health status and use of the health service, based on the National Health Survey (NHS), the European Statistics on Income and Living Conditions (EU-SILC) and the European Community Household Panel (ECHP), we compare the health profiles and patterns of medical resources utilization between the national and foreign populations. The pattern of demand for health services in the immigrant population corresponds basically to the needs of a young population in good health. According to NHS data, resource utilization among immigrants can even be lower than that among the national population. Assessing the link between health status and demand for healthcare from a dynamic point of view, by identifying variations in patterns of health and patterns of demand for healthcare, is important to identify imbalances in resources and to establish an appropriate hierarchy of preventive and treatment priorities.     

Are rural residents less likely to obtain recommended preventive healthcare services?

BACKGROUND: This study examined rural-urban differences in utilization of preventive healthcare services and assessed the impact of rural residence, demographic factors, health insurance status, and health system characteristics on the likelihood of obtaining each service. METHODS: National data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and the 1999 Area Resource File were used to evaluate the adequacy of preventive services obtained by rural and urban women and men, using three sets of nationally accepted preventive services guidelines from the American Cancer Society, U.S. Preventive Services Task Force, and Healthy People 2010. Logistic regression models were developed to control for the effect of demographic factors, health insurance status, and health system characteristics. RESULTS: Rural residents are less likely than urban residents to obtain certain preventive health services and are further behind urban residents in meeting Healthy People 2010 objectives. CONCLUSIONS: Efforts to increase rural preventive services utilization need to build on federal, state, and community-based initiatives and to recognize the special challenges that rural areas present.     

云南省贫困农村妇女对基本生育健康服务的利用

本文对云南省2个县3个乡的1766名已婚育龄妇女的基本生育健康服务利用状况进行了调查分析。结果表明,农村妇女对基本生育健康服务的利用普遍不足,贫困妇女对服务的利用更低。妇女对各项基本生育健康服务的利用也不平衡,表现为对孕产期保健服务、妇科病防治服务和计划生育术后追踪服务的利用不足,对计划生育手术服务的利用相对较多。     

The Role of Federally Funded Health Centers in Serving the Rural Population

CONTEXT: Federally funded health centers attempt to improve rural health by reducing and eliminating access barriers to primary care services. PURPOSE: This study compares rural health center patients with people in the general rural population for indicators of access to preventive services and health outcomes. METHODS: Data from the annual reporting system for federally funded health centers, the 1999 Uniform Data System, and published national census data were used to provide sociodemographic comparisons. Selected health status indicators, preventive services utilization, and health outcomes were obtained from a survey of health center patients, and the results were compared with the National Health Interview Survey and National Vital Statistics. FINDINGS: Unlike the nation's rural population, the majority of rural health center patients are of minority race/ethnicity, live at or below poverty, and are either uninsured or on Medicaid. Despite having higher prevalence of traditional access barriers than the general rural population, rural health center patients are significantly more likely to receive certain preventive services and also to experience lower rates of low birthweight, particularly for African American infants. However, rural health center patients are not more likely to have received influenza vaccination or up-to-date mammogram screening. CONCLUSIONS: Health centers provide access to essential preventive care for many of the most vulnerable rural residents. A national strategy to expand the rural health center network will likely help to ensure improved health for the considerable proportion of rural residents who still lack access to appropriate services.     

Feasibility of a tailored intervention to improve preventive care use in women

BACKGROUND: Women age 50 years and older are in need of multiple preventive health care services. Despite recent improvements in rates of delivery of preventive care services, especially within managed care organizations, substantial numbers of women are still being underscreened. Efforts to improve delivery of preventive care services have often focused on one outstanding service despite the fact that patients often are in need of many services. METHODS: A total of 893 women age 50 to 55 years were mailed a self-administered survey to identify outstanding preventive health care service needs. Patients in need of three or more outstanding preventive health care services were identified from survey respondents to participate in a feasibility study evaluating a tailored, customized intervention called Tic Tac Health. RESULTS: Five-hundred ninety-one women returned the survey (67%). Four-hundred forty-eight (76%) women were in need of one or more preventive health services; 92 (16%) were in need of three or more. Twenty-two patients (24%) completed the Tic Tac Health card. The women who completed the card were similar to those who did not. CONCLUSIONS: Despite documented physician visits, presence of managed care health insurance, and a designated primary care provider, a significant number of women are still in need of multiple preventive health services. An intervention targeting multiple preventive health services was demonstrated to be both feasible and effective. Further evaluation via a randomized controlled trial should be conducted to determine if an intervention like Tic Tac Health would be an effective modality for improving rates of receipt of multiple preventive health care services.     

Gender and health inequalities among adolescents and adults in Brazil, 1998.

OBJECTIVES: To assess the extent of gender inequalities in health status and health services utilization among adolescents and adults in Brazil. METHODS: A representative sample of 217,248 individuals from 15 to 64 years of age was obtained from the National Household Sample Survey (Pesquisa Nacional de Amostras por Domicílios, PNAD) conducted in 1998 by the Brazilian Institute of Geography and Statistics and funded by the Ministry of Health. The study focused on three outcome variables (self-assessed health status, medical visits, and hospitalizations (except childbirth)) and five exposure variables (age, gender, ethnicity, income, and education). Unconditional logistic regression and Mantel-Haenszel stratified analysis was employed. Prevalence rate ratios were calculated for each stratum. Confidence intervals were calculated using the Taylor series, with a 95% confidence interval (95% CI). RESULTS: Women were more likely to report fair or poor health than men (odds ratio (OR) = 1.33; 95% CI: 1.31-1.35). Gender disparities were significant for all ages, household income brackets, and education levels, and were always unfavorable to women (1.17 < or = OR < or = 1.44). Gender disparities for medical visits were higher for those in good health; tended to fall as age, income, and education increased; and were always favorable for women (1.12 < or = OR < or = 2.06). Gender disparities in hospitalization rates decreased with age, varied according to income and education level in each age group, and were always favorable for women (1.16 < or = OR < or = 1.66). CONCLUSIONS: The difference in self-reported health status for men and women became even greater after adjusting for socioeconomic variables, suggesting that poorer women have more pronounced, relative differences than men do. The impact of structural determinants, such as education and income, is considerably smaller than the social construct of gender, although the former are more important predictors. Women use health services more often than men do, which is consistent with their health needs. However, medical visit rates show an inverse relationship to health care needs, suggesting an inequitable access to outpatient care, mainly preventive care.