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SECTION I:
FAMILY THERAPY AND THE FAMILY HEALTH SYSTEMS
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A Research Revolution in Women's Health: Implications for Health Service Delivery
Robin Grass
South Nassau Communities Hospital
Estelle Weinstein
Hofstra University
Rona Feigenbaum
Nassau Community College
SUMMARY. Women's health research initiatives are emerging with evidence that there are unique diagnosis and intervention factors that provide a window into the specific health needs of women. The evidence of the need for this gender-specific research is being spurred by the establishment of The Office of Research on Women's Health by the National Institutes of Health (NIH). A review of some of the more current and salient research findings that apply to women's health and the health needs of women in different lifestyles, at different stages of the life cycle is discussed. Also considered are women's roles in the
health service delivery system and where they fit into the provision of services within the context of women's styles of accessing and using health care. Self-help and other support programs will be described as they apply specifically to women and a case will be made for providing comprehensive, multi-systemic women's health services in one facility at the community level through an overview of some of the more current and successful models.
[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com>] KEYWORDS. Women health providers, service delivery, care received, marketing
WOMEN'S HEALTH
Introduction
Until little more than a decade ago, our understanding of the health of American women was based primarily upon the scientific and medical research gleaned from studying men. Besides reproduction and other specific gynecological phenomena, the assessment and treatment interventions for health problems were based solely on the research on men. Now, a combination of several socio-cultural events interacting with one another have changed this focus, among them: changes in women's roles from traditional homemakers to the workforce which resulted in major lifestyle shifts that have implications to women's health conditions; recognition by the federal government and other funding sources of the gender and socio-cultural biases that exist in health research on women across the life cycle; changes in healthcare delivery systems including changes in the roles for women in medicine; increased managed care and comprehensive women's health center options resulting in a shift in reimbursement incentives from medical care models (where the more visits the more pay) to healthcare/ prevention models (where the less visits the more pay). These changes in our understandings about women's health also have implications for family therapists.
A report published in 1990 by the General Accounting Office (GAO) of the federal government indicated less than 14 percent of the National Institute of Health's (NIH) budget was allocated to biomedical research focused on women and only 3 of the more than 2000 researchers at that time were investigating women's health issues (Strong, 1997). Furthermore, women were not included in most clinical research or drug trials (Blumenthal, 1990), which compromises effective interventions directed at them. These findings, coupled with increased awareness that women account for more than twice the dollars spent on healthcare and have generally poorer outcomes from chronic illnesses than do men, spurred major changes in policy and greater support for gender-specific research. Moreover, women often serve as the pivotal component of the health status of the family. In that position they not only make major decisions about health behaviors and health resources, their health condition is a determining factor in the roles played by the other family members.
Recognizing the importance of women in family health spurred interest by powerful congresswomen and the appointment of such women as Bernadette Healy as the first woman to head the NIH and Donna Shalala as the Director of the Department of Health and Human Services (DHHS). Their leadership saw the creation of the Office of Research on Women's Health (ORWH) and the funding for the Women's Health Initiative (the largest clinical trials undertaken in this country) (Strong, 1997). Emerging from these endeavors is a clearer picture of the health concerns of women, more effective means of preventing and controlling diseases and identifying and intervening in mental health and social problems that affect women.
The following paper will look at these changes, their relationships to women's health, and briefly discuss the efficacy and efficiency of several alternative health care delivery systems aimed at providing comprehensive health services to women. Armed with an understanding of the family scripts that surround the health and illness status of women, family therapists can better participate with families as they construct their interactions and futures. Of particular interest is the effects of health on women as breadwinners, women as parents, and women as caregivers.
What Have We Learned: The Health Status of Women
The Data
On the average, the life expectancy for women is approximately 78.8 years, which represents a life span of 7 years more than men. The gap between men and women in the population increases as they age so that more than 60% of the U.S. population of 65 year olds are women and by 85 that increases to 70% (Blumenthal, 1995a). Blumenthal further points out that while this speaks to longer life, it does not equate to better physical or mental health for women. To highlight the point, each year, more older women than men die of cardiovascular disease, and the incidence of gastrointestinal disease is three times more common in women, as is the incidence of autoimmune diseases such as thyroid disease, lupus and rheumatoid arthritis.
There are several ways of looking at women's health concerns. One way is to look at the diseases and illnesses associated with significant junctures in the life cycle; birth to young adulthood, adolescence, adulthood, older age. Clearly, each juncture has its special gender related health phenomena. Another way to look at women's health is to study the chronic/communicable diseases and disabling physical conditions that afflict them differently than they do men such as cardiovascular disease, cancer, STD's including HIV/AIDS, and autoimmune diseases and the effect these have on the family's functioning. Another way is to study the relationship between mental health and the social problems that afflict women, particularly poverty, substance abuse and outcomes of violence against women. And, the most traditional way of looking at women and one that continues to offer important information about their health is in terms of their reproductive health including maternal health and sexual health and their effect on couple issues and parenting problems. None of these can be studied exclusively since the factors that explain them interact with one another and are skewed by ethnic and cultural membership, economics and other special population considerations, including the problems associated with accessibility to health care services.
Gender Specific Research and Diseases
While the leading causes of death remain the same for both men and women (National Center on Health Statistics, 1992), only recently is information indicating that the causes, symptoms, and treatment approaches can differ considerably between genders. For example, the implications of gender specific information in the diagnosis and treatment associated with cardio-vascular problems points to significantly different causal factors, indicating different treatment approaches. While coronary artery disease is the leading cause of death among women (236,000 women die each year) it has different life cycle patterns than it does in men. Between the ages of 45 and 54, 1 in 9 women has evidence of heart disease and by age 65 the rate is 1 in 3 (Blumenthal, 1995a). Because men were seen as more vulnerable to heart disease throughout the lifecycle, and because symptoms of heart disease have been explained as they appear in men, women are often misdiagnosed and there is less aggressive and less timely treatment for women than for men. This may contribute to the differences in death rates observed one year after a heart attack (49% in women as compared to 31% in men) (Morrison, 1997).
Observational studies that are only recently being confirmed by controlled research point to dramatic increases in the incidence of heart disease as women pass menopause. They are further confirming that the presence of estrogen lends some protection, but the data that fully explains how, how much and other important factors about estrogen, is not yet definitive. Hence, one of the present research priorities is hormone replacement therapies (HRT) and the efficacy of them as a preventative of heart disease.
From the studies that have been conducted thus far, what has emerged is that the use of HRT has a decreasing effect on the risk for coronary artery disease; that there is somewhere between 0.3 and 2.3 years of added life expectancy for women that are using HRT; and that there is a reported improved quality of life (Zubialde, Lawler, & Clemenson, 1993). Included in the inquiries is a search for more knowledge such as the effect of estrogen replacement therapy (ERT) alone (“;non-opposed”) versus estrogen administered with progesterone (“;opposed”). Also, emerging from the HRT research are interesting spurious findings such as: HRT seems to provide protection against osteoporosis which is the leading cause of debilitating bone fractures in older women; and evidence of a decreased risk of Alzheimer's disease among women users. But, ERT unopposed has been associated with an increased risk of breast and endometrial cancer, the degree of which is not yet clear.
It is hoped that the research initiatives on women will attempt to finally explain more definitively when to use HRT, how to use it, on whom and for how long. As we await more conclusive data, the use of HRT is presently a personal decision made between a woman and her physician with consideration for such factors as whether or not she has a uterus and what her individual familial risk is for certain cancers. These protocols are subject to change whenever new results are found.
Another example that underscores the need for gender research is toward a better understanding and treatment for cancer. Until approximately 60 years of age, women and men develop cancer at about the same rate but, in later life cancer, is diagnosed more frequently in men than in women (about half of American men will develop cancer in their lifetime as compared to one third of women.) Yet, the rate of lung cancer among women has increased 400 percent over the past 30 years and lung cancer represents the leading cause of death from cancer among American women. Breast cancer, the second leading cancer death over the lifetime, has shown a markedly increasing incidence in less than two decades from 1 in 20 women to 1 in 8 women survivors (Blumenthal, 1995a). Furthermore, a woman's rate of breast cancer is more than twice a man's risk of prostate disease before age 60 (American Cancer Society, April, 1997). The data explaining these differences in patterns of incidence are mounting as the research continues, with the overriding evidence that gender specific data gleaned over the next decade will better explain the problems, increasing the effectiveness of prevention and treatments.
Life Cycle Issues
The socio-cultural factors associated with lifestyle choices over the life cycle, coupled with physiological factors, also provide a unique picture of the health needs of women during the various stages of their lives. The biology of puberty, reproductive experiences, the changes of menopause, the changing roles of women in activity, sport, work, the special pressures of society on women's appearances, and other social behaviors, are important factors that influence women's health status differently over their lifetime. As women attempt to balance their family responsibilities with career and sometimes family of origin caretaker roles, their health shows evidence of decline. A litany of discussion is finally occurring as this picture becomes clearer.
In addition to these social factors are problems related to women accessing health care services. More than 14 million women of child-bearing age are without medical insurance and several million of these do not have coverage for prenatal care (Harvey, 1990). The socio-economic restrictions associated with unequal salaries also comes with the realization that working women of middle age are less likely than men to have insurance benefits paid by their employers. Women pay higher premiums than men when they have insurance, and they are twice as likely not to have insurance at all (Morrison, 1997). In this environment, as families stretch their income and women often put their own health care needs aside until they become more serious and expensive.
The graying of America is such that the fastest growing segment of the population is 85+ years and the majority of this group are women. The social factors that influence women's access to health care are even more confounded among older women. According to Sofaer and Abel (1990), the chronic diseases more common to these women such as breast cancer, depression, arthritis and hypertension are less extensively covered by Medicare than are the acute illnesses more common to older men such as heart attack, lung cancer, pneumonia, prostate disease, etc. Moreover, since women are more often the primary caretakers, especially as they and their partners age, they are more likely to experience lapses in employment and hence, lapses in insurance benefits. Furthermore, as they caretake, they are less likely to be identified or treated for their own health problems (Sofaer & Abel, 1990).
The type of setting in which a woman receives her medical treatment is a predictor of the type of prevention and extent of services she is likely to receive throughout her lifetime. For example, young adolescent women often receive their health care from several specialists at one time (pediatricians, family practitioners, family planning clinics, etc.) and their use of health services is most often when in crisis or episodic in nature. This leaves gaps in screening and other preventive health activities (Berry, Schubiner, & Giblin, 1990). Women of child-bearing age who are not under the care of an obstetrician/gynecologist (OB/GYN) are less likely to receive screening for breast, cervical cancer or high blood pressure on a regular basis. And, older women, who more often receive their care from internists or family practitioners, are even less likely to receive recommended preventive services (Clancy & Massion, 1992). The...
