+ Health Promotion for Women: State of the Science Nancy Fugate Woods, PhD, RN, FAAN Biobehavioral Nursing and Health Systems, School of Nursing University of Washington + Co-authors: Women’s Health Expert Panel Writing Group Judy Berg, University of Arizona Ellen Olshansky, University of California, Irvine Joan Shaver, University of Arizona Diana Taylor, University of California, San Francisco + Aims Assess progress in the science of health promotion, including prevention, for girls and women Propose evidence-based innovations relevant to meeting needs of diverse populations of girls and women Recommend an agenda for expanding research and innovation in health promotion for girls and women Suggest strategies to influence policy agendas at the local, regional, and national level assuring nursing’s contributions to health promotion remain a critical element of health care reform + Convergence of Women’s Health Influence: 2010-2011 Federal government interest in women’s health noteworthy in 2010-2011 Renews agendas for women’s health research Evaluates the impact of women’s health research Uses evidence from women’s health research to set policy (Affordable Care Act) Creates a strategy for health promotion and prevention in the nation Extends consideration of women’s health globally The first NIH Women’s Health Research Agenda was developed in 1991 under the leadership of Ruth Kirschstein, Acting Director of the Office of Research on Women’s Health with support of NIH Director Bernadine Healey + Resurgence of Federal Commitment to Women’s Health Research Office of Research on Women’s Health, NIH. (2010) Moving into the Future with New Dimensions and Strategies: A Vision for 2020 for Women’s Health. ORWH, NIH. Institute of Medicine (2010) Women’s Health Research: Progress, Pitfalls, and Promise. Washington, CD, The National Academies Press. + Moving into the Future with New Dimensions and Strategies: A Vision for 2020 for Women’s Health (2010) + ORWH Goals for 2020 Goal #1: Increase sex differences research in basic science studies, especially at cellular and tissue levels Goal #2: Incorporate findings of sex/gender differences in the design and applications of new technologies, medical devices, and therapeutic drugs Goal #3: Actualize personalized prevention, diagnostics, and therapeutics for girls and women + ORWH Goals 2020 Goal #4: Create strategic alliances and partnerships to maximize the domestic and global impact of women’s health research Goal #5: Develop and implement new communication and social networking technologies to increase understanding of women’s health and wellness research Goal #6: Employ innovative strategies to build a welltrained, diverse, and vigorous women’s health research workforce + Women’s Health Research: Progress, Pitfalls, and Promise (IOM, 2010) + Are women’s health researchers: Addressing the most appropriate and relevant determinants of health? Focusing on most appropriate and relevant health conditions? Engaging with (studying) the most relevant groups of women? Utilizing the most appropriate research methods? Translating findings to affect practice? Conveying findings effectively for women? + Assessment of Progress MAJOR PROGRESS SOME PROGRESS Breast cancer Depression Cervical cancer Osteoporosis Cardiovascular disease HIV/AIDS + Conditions with Little Progress Unintended pregnancy Maternal morbidity/mortality Autoimmune diseases Alcohol and drug addiction Lung cancer Gynecological cancers other than cervical cancer Nonmalignant gynecological disorders Alzheimer’s Disease (IOM 2010) + Recommendations from IOM Study on Women’s Health Research (2010) Recommendation 1: US government agencies and other relevant organizations to sustain/strengthen focus on women’s health, including genetic, behavioral, and social determinants of health and change over lifetimes. Recommendation 2: The National Institutes of Health, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention - develop targeted initiatives to increase research on populations of women with highest risks and burdens of disease + IOM Study 2010 Recommendation 3: Research should emphasize promotion of wellness and quality of life; conditions that affect quality of life; better measures or metrics of quality of life to be used as outcomes Recommendation 4: NIH Cross-institute initiatives on common determinants and risk factors that underlie multiple diseases, interventions to decrease the occurrence or progression of diseases in women + IOM Study 2010 Recommendation 5: Government … funding agencies ensure adequate research participation by women, analysis of data by sex, and reporting of sex-stratified analyses. Recommendation 6: Research emphasis on how to translate research findings into clinical practice and public-health policies rapidly – to practitioner and overall public-health systems levels. + IOM Study 2010 Recommendation 7: The Department of Health and Human Services - appoint a task force to develop evidence-based strategies to communicate and market to women health messages based on research results + Shaping Policy Supporting Women’s Health Services + Commitment to Women’s Health Services and Policy Affordable Care Act – includes provisions for services for women, prohibits gender-based discrimination in denying coverage, assuring maternity care coverage as an essential benefit and increased coverage for the poor Institute of Medicine (2011) Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press National Prevention Council. (2011). National prevention strategy: America's plan for better health and wellness. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General + IOM Committee on Clinical Preventive Services Recommended inclusion of USPSTF A and B Recommended Services to be included in Clinical Preventive Services with Affordable Care Act Also suggested providing additional clinical preventive services as part of ACA, including clarification of those services with incomplete evidence (C or I classification) to be included in well woman services + IOM Clinical Preventive Services : Suggested Well Woman Services Diet and Physical Activity Establishing pregnancy history of CVD-related conditions Mental Health Metabolic syndrome Preconception Care Prenatal Care STIs + IOM Recommendations: Additional Clinical Preventive Services 1. Screening for gestational diabetes 2. Human papillomavirus testing 3. Counseling for sexually transmitted infection 4. Counseling and screening for human immunodeficiency virus 5. Contraceptive methods and counseling 6. Breastfeeding support, supplies, and counseling + IOM Recommendations: Additional Clinical Preventive Services 7. Screening and counseling for interpersonal and domestic violence 8. Well woman visits (one annually) - several visits may be needed to obtain all necessary recommended preventive services (includes 29 USPSTF A and B rated services + others recommended by the committee) + National Prevention and Health Promotion Strategy: America’s Plan for Better Health and Wellness Surgeon General released first national Prevention Strategy Jun3 16, 2011 Four Strategic Directions Seven Areas of Focus + Four Strategic Directions Building Healthy and Safe Community Environments Expanding Quality Preventive Services in Both Clinical and Community Settings Empowering People to Make Healthy Choices Eliminating Health Disparities + Seven Areas of Focus Tobacco Free Living Preventing Healthy Drug Abuse and Excessive Alcohol Use Eating Active Living Injury and Violence Free Living Reproductive Mental and Sexual Health and Emotional Well-being + Global Commitment to Women’s Health World Health Organization’s strategic plan for 2010-2015 Sexual and Reproductive Health U. S. State Department (2010) Implementation of the Global Health Initiative International Congress on Women’s Health Issues (ICOHWI) ORWH Research Agenda (2010) STATE OF THE SCIENCE TO PREVENTIVE SERVICES State of the Science on Health Promotion and Prevention IOM Report on Women’s Health Research (2010) IOM Report on Clinical Preventive Services (2011) National Prevention Council Strategy (2011) Health Promotion and Preventive Services: Best Evidence Proposed Commission: Recommends Coverage of Preventive Services for Women + Nursing’s Commitment to Health Promotion Nursing’s early commitment to health promotion and health promoting lifestyle patterns traceable to NCNR Priority Expert Panels (1980s) to set priorities for funding Exemplified by Pender and colleagues’ work on health promotion and health protection or prevention + National Institute for Nursing Research Strategic Plan for Health Promotion “Health promotion and disease prevention form the keystone of our science, reflecting current understanding of the most effective approaches to maintaining health” NINR Strategic Areas of Research Emphasis 2006 + Changing Science of Health Promotion FROM (1980s) TO PRESENT Individuals as the unit of health promotion: an individual responsibility Social groups, e.g. organizations, communities, larger society responsible Gender-ignorant models of health promotion Gender-sensitive, genderspecific models Health promotion for predominantly healthy people Health promotion in chronic illness, acute illness, integration with symptom management + Changing Science of Health Promotion FROM TO Emphasis on individual activities, raising awareness Raising social consciousness and inviting social action Individual and group coaching, counseling Multiple interventions at multiple levels to initiate and sustain behavior changes Environmental interventions, e.g. built environment + Changing Science of Health Promotion FROM Local and country-specific models Limited scalability Awareness ofTO globalization, Appreciation of urbanization, industrialization and associated inequities Local Increased use of communication and information technologies to enhance scalability global + Recommendations from Nursing Researchers on Health Promotion 1. Expand development and testing of gender-sensitive interventions for women Gender as a major feature vs human experience as universal Women’s own voices and experiences, women’s own perspectives (Im and Meleis 2001) + 2. Consider Intersectionality as a basis for understanding gender disparities, health disparities of women Gender Race Class Ethnicity Sexual Orientation Abledness + Nature of women’s experiences incorporate complexities and diversities (gender, sexuality, ethnicity, race, social class) Intersectionality not just a mediating factor in a model (Im and Meleis 2002) + 3. Balance Emphasis on Behavioral, Integrative and Pharmacological Therapeutics Evidence for health promotion using either behavioral or pharmacologic approaches vs combinations, bundled approaches Use of step-wise approaches, e.g. begin with a single, low risk strategy and build on it Learn from low-resources countries + 4. Focus on Under-emphasized Conditions Disproportionately Affecting Women Functional and stress-related disorders such as fibromyalgia, functional gut disorders, posttraumatic stress disorder, eating disorders, migraine headaches Culturally sensitive and women specific problems, e.g., incontinence, women’s sexual dysfunctions + 5. Promote Research on Preventing Unintended Pregnancies and STIs US rates of unintended pregnancy are high and Healthy People Goals for 2010 unmet Counseling strategies for promoting healthy reproductive and sexual behaviors across the lifespan not adequately studied Integration of behavioral change counseling and pharmaceuticals, e.g. family planning, reproductive health planning + 6. Promote Research on Preventing and Treating Consequences of Violence against Women Integrate with Veteran Women’s Health Agenda efforts, e.g. VA sponsored initiatives Collaborate with multi-level interventions for violence reduction in homes, communities, society Look for multiple outcomes at multiple levels, e.g. may support reduced rates of unintended pregnancy, sexual transmitted infections + Gender-Sensitive Models for Research on Unintended Pregnancy, STIs and Violence against Women Awareness of ideological imperatives and epistemological assumptions – what we study and what we ignore … Sociopolitical contexts and constraints considered - empowerment, emancipation Guidelines 2001) for action > praxis (Im and Meleis + 7. Develop and Test Technologies for Behavioral and Functional Support Develop and test technological devices to enable women to age well in place Enhance technologies to support caregivers Adapt communications technologies for research dissemination to women Monitoring technologies for detection of health problems, communication with health professionals at a distance + 8. Refine/Test Models for Translating Research Findings Directly to Women Following publication of WHI results in 2002 a dramatic increase in women’s questions for primary care providers, a decrease in prescriptions for hormone therapy increased interest in complementary and alternative therapies … + Nursing Innovations for Promoting Women’s Health: Toward 2020 Preconception Unintended Violence Counseling in Primary Care Pregnancy Prevention Prevention Sexually Transmitted Smoking Infection Prevention Cessation Well Woman Depression Care (Physical activity, Diet) prevention + Preventing Unintended Pregnancy -Promoting Preconception Health Included in ORWH agenda Supported by IOM Report (2010) as an area in which not much progress has been made Included in National Prevention Council Strategy (2011) Recommended in IOM Report on Clinical Preventive Services (2011) Consistent with World Health Organization’s Reproductive Health Strategy + Dimensions of the Problem Almost half of all U. S. pregnancies are unintended – highest rate in the industrialized world Of the 6.4 million pregnancies in the U.S. in 2001, 3.1 million were unintended 1.4 million resulted in births, 1.3 million in abortions, 430,000 in fetal losses At least half of all U.S. women will experience an unintended pregnancy by age 45 years + National Prevention Policies Do not Adequately Address Unintended Pregnancy Healthy People 2000 goal: increase proportion of intended pregnancies to 70% Healthy People 2020 goal: increase proportion of intended pregnancies from 51% to 56% Places disproportionate burden on women who are poor, non-white, young women (20-29 years of age women with greater health risk women with fewer financial resources and less developed support systems + Lack of Attention to Unintended Pregnancy > System-wide Failure Fragmentation of women’s health care Politicization of reproductive health surrounding abortion Overall lack of sexuality education in US – sexual health illiteracy Limited of time for health care appointments Lack of coordinated system of clinical guidelines, essential competencies, and Strategies for unintended pregnancy prevention (Taylor and James, 2011) + Cochrane Collaboration (Oringanje 2010) Unintended pregnancy can be addressed using a preventive strategy . . . combination of risk screening and multimodal interventions that involve coordinated, focused education and increased access to contraceptives … Evidence from Nursing studies of education, skill-building, safe sexual practices, use of contraceptives indicates interventions are effective in Reducing the rate of sexual initiation (Jemmott, Villaruel) Promoting consistent condom use (Jemmott, Villaruel) Promoting condom use at last intercourse (DiIorio) Additional studies in progress (Gallegos) + Foundation in Research Based Interventions (www.effectiveintervention.org SISTER TO SISTER – developed by Dr. Loretta Jemmott from the Be Proud! Be Responsible! Program to reduce HIV/AIDS risk behaviors in African American Adolescents CUIDATE – developed by Dr. Antonia Villaruel with Dr. Jemmott – adapted HIV/AIDS risk behavior reductions for adolescent Latinos SEPA –developed by Dr. Nena Peragallo to reduce HIV/AIDS risk behaviors among Latina women Unintended Pregnancy Prevention is Marginalized in Women’s Health Care Women’s Primary Care Pregnancy Care Unintended Pregnancy Prevention A Public Health Model for Addressing Unintended Pregnancy (Taylor and James, 2011) Primary Care Unintended Pregnancy Prevention 2o & 3o Prevention Primary 1o Prevention Sexual & Reproductive Health care across gender and lifespan Unintended Pregnancy Prevention + Why Can Nursing Make A Difference? History of gender-sensitive research Capacity for tailoring – intersectionality, culturally sensitive interventions Creation of effective programs to change outcomes related to sexual behavior, contraception (Jemmott, Villaruel) Studies of dynamic relation between sexuality, violence/coercion and self-silencing (Teitelman) Unintended Pregnancy Prevention: + Applying a Public Health Model Primary Prevention Preconception care Contraception counseling, dispensing, Rx Emergency contraception Rx and dispensing Secondary Prevention Pregnancy diagnostics Early pregnancy loss, ectopic pregnancy screening Pregnancy options counseling Adoption, early abortion care, referral Tertiary Prevention Late term unintended pregnancy support Adoption counseling Pregnancy termination + From Model to Action Mobilize health professionals to address national health goals Integrate primary prevention strategies into all clinical settings Require all women’s health professionals to be competent in primary and secondary prevention and management Require prevention of unintended pregnancy as a standard component of health professional education in all accredited institutions Develop a national consensus about core prevention competencies for all health professionals Advocate for prevention guidelines that are evidence-based and culturally appropriate Contributions from NURSING SCIENCE Science Policy NIH Proposed Commission to Recommend Coverage of new Preventive Services for Women Nursing’s Policy Positions - ACA AMERICAN ACADEMY OF NURSING State of the Science on Health Promotion and Prevention Policy Strategies 1. Endorse the recommendations for additional clinical preventive services recommended by the IOM Clinical Preventive Services Committee (2011) 2. Endorse the recommendations for prevention in the Strategies report (2011) 3. Promote research on unintended pregnancy and prevention in the context of preconception care – NINR, NICHD 4. Recommend critical review of the state of the science on sexual and reproductive health care, specifically unintended pregnancy, and preconception health care as an instance of well women services (Professional Organizations, USPSTF) 5. Promote optimal training models for health professionals to integrate sexual and reproductive health services into primary care – HRSA + Policy Strategies (cont.) 6. Evaluate alternative models of service to prevent unintended pregnancy – HRSA 7. Promote guideline development for services to prevent unintended pregnancy – AHRQ 8. Survey effective community-based models of services related to unintended pregnancy for dissemination www.effectiveinterventions.org – CDC 9. Evaluate adequacy of women’s community-based services for prevention of unintended pregnancy – Institute of Medicine Study 10. Develop training mechanisms for community-based resources on Unintended Pregnancy - CDC + Thank you for your interest in promoting women’s health!