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By Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D.
This article was originally published in Women's Health Issues 2004;14:31-4. Copyright© 2004 by the Jacobs Institute of Women's Health.
Curriculum Development and Research Training
Women's health has recently become a major clinical field, as well as a relevant public issue (Kasper, 2002). Providing health care to women is complex and challenging, and requires the coordinated effort of a multidisciplinary team of health care professionals. To succeed in this effort health care professionals need to practice good communication skills, have access to evidence-based information and be able to translate scientific evidence into their clinical practice. As patients, women should have easy access to the latest evidence-based information designed to help them make the right decisions about their care and the care of their family members.
Recently, there has been a significant increase in representation of women in clinical trials (NIH, June 2003), including the Women's Health Initiative. These trials have yielded abundant findings with high clinical relevance to women (Cauley, et al., 2003; Hays, et al., 2003; Manson, et al., 2003). Health services research has also shown that although women seek more medical care, use more health care services, and spend more on medications than men (Roe, McNamara, & Motheral, 2002), inequalities in care still limit women's access to certain diagnostic procedures and therapies proven to be effective for specific conditions (Weisman, 1999; Bierman & Clancy, 2001; Grady, Chaput, & Kristof, 2003). Much, therefore, still needs to be done to improve access, receipt, and quality of care for this priority population.
The challenge remains to go beyond research findings to ensure that research is used to eliminate inequalities in care and foster effective improvements in the health care system and in the health and quality of life of women of all ages.
Recently, the Women's Health Interest Group was created at AcademyHealth. Its mission is to foster the development of the field of women's health services research to meet the needs of and improve the quality and outcomes of care of women across life span and for all women independent of race, ethnicity, or socioeconomic position. (AcademyHealth) Although improving health care requires a combined effort of researchers, providers, and policymakers, a special interest group such as this may play a significant role. The diversity and commitment of those involved in such a group create a unique networking opportunity for the advancement of women's health.
Interest group members (e.g., practitioners, researchers, policymakers, trainees) may have different backgrounds and work under diverse incentives, but their work complements each other and ultimately, they all share the same common goal of improving quality of care for women. The dialogue among group members should contribute to:
- Closing communication gaps.
- Identifying research priorities and joint efforts to promote curriculum development.
- Building on research skills.
- Redirecting research needs.
- Disseminating research findings.
- Developing implementation strategies.
- Informing and advocating for changes in policy to benefit women.
In summary, the Women's Health Interest Group should be able to address the following areas relevant to women's health: research, clinical practice, policy, and curriculum development and research training.
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Over the past few years, the definition of women's health has evolved beyond reproductive issues and now targets all health concerns experienced by women across lifespan and in the social context of their lives (Weisman, 1997). Currently, an expanded research agenda is being developed to address conditions specific to women and those common to both women and men. The new research includes identifying health care disparities between women and men and among female subpopulations as well as understanding gender differences in disease manifestations and response to therapy.
For example, researchers have only recently clearly identified some of the diagnostic and treatment needs of women with heart disease. A systematic review of the literature supported by the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH) Office of Research on Women's Health revealed that the lack of studies on women limits the usefulness of the research available on coronary heart disease (Grady et al., 2003). Women with heart disease remain less likely to receive proper management including procedures and drug therapies (e.g., beta-blockers, aspirin, ACE inhibitors) found to be effective in reducing the risk of coronary heart disease events. They also are less likely to be submitted to certain diagnostic tests. In addition the diagnostic value of tests to evaluate troponins, creatinine kinase, and myoglobin in women is still unknown.
As we move in direction of a gender-based approach, chronic diseases will continue to be the focus of major research efforts in women's health. This trend is given added impetus due to the fast growth of the elderly population. A broad range of opportunities is available for behavioral scientists and health services researchers interested in better understanding certain diseases and conditions, as well as the quality of care and well-being of women (Baldwin, 2003; Davenport, 2001; Legato, 2003).
Defining quality in women's care and developing a research agenda to measure women's quality of care are critical to improving the health care and health status of women and facilitating changes in policy (Weisman, 2000). As health services researchers continue to demonstrate issues with access, receipt, and quality of care for women, research should also concentrate on the development, implementation, and evaluation of models of care delivery. These models should:
- Optimize both preventive and therapeutic care for women of all ages.
- Provide women with the best care and the opportunity to be active and well-informed participants in the clinical decisionmaking process.
- Reduce and/or eliminate health care disparities.
Numerous studies have investigated key aspects of comprehensive care for women. A study comparing generalists to obstetricians and gynecologists who simultaneously provided care to women revealed that relying on generalists alone may result in substandard preventive care for nonelderly women (Henderson, Weisman, & Grason, 2002). When three types of plans (managed care, fee for service with utilization control, and traditional fee for service) were compared, managed care plans provided women similar or better access to care (Weisman & Henderson, 2001). Women under managed care plans received more gender-specific clinical prevention, but reported lower satisfaction with this type of plan. Women's health clinical centers have been shown to better integrate clinical services with research and training on women's health (Weisman & Squires, 2000). Furthermore, the delivery of services in these centers was found to have reached a more diverse population of women. Clinical care at these centers provided significantly more screening tests and counseling services and resulted in greater patient satisfaction when compared to women in benchmark samples (Anderson, et al., 2002). However, further research is needed to identify models of care that eliminate gaps and unnecessary health care visits and integrate women's preferences into their care plans.
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Gender-based studies may result in improvements in morbidity and mortality and allow the development of quality indicators and measures, which if implemented as best practices may lead to decreases in health care costs and elimination of inequalities in care. As Legato (2003) states, "the most important task is to convince the scientific, medical and lay public that women are a source of invaluable information that improves health of all patients." For example, gender differences on widely used measures of quality of primary and secondary prevention of cardiovascular disease have been reported. These differences may represent a major opportunity to improve health for all and make reporting of gender-stratified objective quality measures routine for health plans (Bird, et al., 2003). The Women's Health Measurement Advisory Panel of the National Council on Quality Assurance is expected to make a major contribution in this area (Weisman, 2000). The panel is developing quality measures relevant to health plans on top priority health conditions for women (e.g., cardiovascular disease, diabetes, and osteoporosis).
The integration of social and biological research is of great help to clinicians and policymakers. This may allow better understanding and facilitate proper management of gender-specific and nonspecific health issues (Bird & Ricker, 2002). Moreover, it is also crucial that health care professionals be culturally sensitive to the needs of a diverse population. Health literacy of patients and cultural competency of health care professionals, particularly those directly involved in therapeutic decisions, are interrelated and can exert significant influence on health outcomes (Nunez & Robertson, 2003).
Finally, identification and integration of factors associated with variations in clinical care and/or performance
measures across comprehensive care for women are critical. This information is needed to develop quality improvement strategies including those targeting reduction of health care disparities.
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Policy and coverage decisions are highly dependent on evidence-based information. This ensures access to new and innovative technologies and procedures that can improve quality of health care and reduce disparities. Policies targeting the basic needs of women are in place, but require continuous review to ensure that all women across life stages have access to reasonable care that emphasizes health promotion and disease prevention. As we move toward addressing the needs of middle-aged and older women and their risks of developing chronic conditions, it may be necessary to establish new standards of care and develop new policies (Baldwin, 2003). Policies also are needed to ensure educational programs are funded to increase awareness of chronic diseases and prevention strategies that can reduce disease burden and improve quality of life of women and the well-being of their family members. As coverage policies change or are expanded, the role of research becomes even more important (Davenport, 2001). It is crucial, though, that any new knowledge be accompanied by strategies that can better assure translation of research findings to policymakers (Bierman, 2003; Clancy, 2003).
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Curriculum Development and Research Training
Medical schools in the United States have improved their women's health curriculum (Keitt, et al., 2003). The Office of Women's Health at the Health Resources and Services Administration successfully led an effort to ensure inclusion of women's health in curricula of medical schools (Women's Health in the Medical School Curriculum, 1996), dental schools (Women's Health in the Dental School Curriculum, 1996), and baccalaureate nursing schools (Women's Health in the Baccalaureate Nursing School Curriculum, 2001). This effort has been extended to schools of pharmacy and schools of public health. Academic centers need to explore strategies to ensure the inclusion of sex and gender analysis in scientific research and the teaching of gender-based issues (Legato, 2003).
Further efforts should seek adequate faculty funding and training in women's health (Keitt et al., 2003). Addressing this need, the National Institutes of Health Office of Research on Women's Health has a unique, innovative program that tackles career development and the building of research skills in women's health. AHRQ also funds a career development grant awards program for independent scientists or mentored clinical scientists who want to develop skills in health services research (www.ahrq.gov/fund/training/trainix.htm). Moreover, health care professionals should be encouraged to take advantage of the training opportunities the American Medical Association provides to increase physician's knowledge on health literacy and make them more culturally competent (www.ama-assn.org).
We hope that the members of the Women's Health Interest Group at the AcademyHealth will enable us to keep abreast of curriculum and training needs and foster continual evolution of health care professionals in addressing and meeting the health care needs of women. Health services researchers are now challenged to expand their research skills. It is no longer enough to demonstrate the evidence, but as one plans a study, it is necessary to have a vision for the next steps that will assure knowledge transfer and implementation of research findings. To promote this approach, AHRQ is currently seeking to fund studies with a strategic implementation component. Partnership is crucial, and serves to facilitate effective communications to policymakers and accelerate the adoption of research findings (Clancy, 2003). By working together, the members of the AcademyHealth Women's Health Interest Group can significantly contribute to the advancement of women's health services research by addressing issues that will lead to improved health care for women and also meet the needs of decision and policymakers.
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Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D., is a cardiovascular pathologist trained at the National Heart, Lung, and Blood Institute. As the Agency for Healthcare Research and Quality's Senior Advisor on Women's Health, Dr. Correa oversees the development of a national research agenda for women in consultation with prominent members of the research community, and other government agencies. Her main areas of interest include gender-based medicine particularly related to chronic diseases, medication use outcomes and safety, and disparities in health care for women.
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