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This page is an excerpt from the
Succeeding in Women's Health Newsletter
,
 

The Ireland Report on Succeeding in Women's Health
Women's Health NewsWatch
 

Leading Stories on Women's Health

January/February 2006
May-June 2006


January/February 2004
Integrating Behavioral Health Care into Obstetrics and Gynecology

Many women use their obstetrician-gynecologist for primary care, particularly during their reproductive years. Provision of behavioral health care is critical to health maintenance for many of these women. Medscape General Medicine looks at the barriers to the integration of behavioral health care into obstetrics and gynecology practice that need to be understood and addressed. 

Health advocates and academicians have proposed that understanding the relationships between the medical, psychological, psychosocial, and socioeconomic factors of women’s health is basic to the delivery of adequate health care for women. As healthcare providers for women, obstetrician-gynecologists are frequently the first, the most consistent, and often the only medical contact for their patients. They are the ones who have the ongoing opportunity to identify, treat, and help patients manage mood and anxiety disorders. The President of the American College of Obstetrics and Gynecology has stated that the College must lead in redefining obstetrics and gynecology as the women’s healthcare specialty: “We must expand our vision beyond reproduction to embrace conditions disproportionately affecting the quality of life for women, such as osteoporosis, hypothyroidism, and depression.”  

What has slowed the integration of the behavioral healthcare component of primary care training and practice in obstetrics and gynecology? The literature succinctly describes these barriers using a competing and multiple demands model. This model holds that there is not enough time for the provider to meet all the demands from the competing arenas of the provider’s needs, the organizational needs, and the patient needs. Doherty and colleagues developed a model that delineates the degree of collaboration achievable in integrating behavioral health care in different healthcare settings. Their 5-level model addresses the variability needed for medical practices to have some choice in how and to what extent they might integrate behavioral health care involving mental health clinicians along with other healthcare professionals, particularly medical providers, physician assistants, nurse practitioners, and nurses. The first level of this collaboration is one that is familiar to the current system of collaboration; healthcare and mental health professionals work in separate facilities or areas, have their own individual vision of treatment, operate in separate systems, and seldom communicate about cases. As the levels of collaboration increase, more sharing is seen, and the ability of healthcare providers to manage greater numbers of behavioral healthcare cases as well as more difficult cases is increased. The fifth level of the collaboration model reflects what the authors consider to be close collaboration in a fully integrated system: Mental health and other healthcare professionals share the same sites, the same vision, and same systems in a seamless web of biopsychosocial services. Both the providers and the patients have the same expectation of a team offering prevention and treatment. All professionals are committed to a biopsychosocial/systems paradigm and have developed an in-depth understanding of each other’s roles and cultures. Regular collaborative team meetings are held to discuss both patient issues and team collaboration.  

Obviously, the need for integration of behavioral healthcare into obstetrics and gynecology is recognized. Healthcare providers need to be trained during their medical school and residency programs in implementing various models of integrated care. 

Cassidy JM, Boyle VA, Lawrence HC. Behavioral health care integration in obstetrics and gynecology. Medscape General Medicine 5(2), 2003.        

State Policies and Women’s Health

In their benchmark report, Women’s Access to Care: A State-Level Analysis of Key Health Policies, the Kaiser Family Foundation and the National Women’s Law Center have taken an in-depth look at more than 50 key state policies that shape women’s access to health care. From private insurance to public assistance, from reproductive rights to administration positions and budgetary constraints, the report provides state-by-state information on women’s health policy using the broadest definition possible. There are several areas in which policies are fairly uniform across the country. Among the report’s key findings are the following:

·        The majority of states allow women to see an ob/gyn without a referral or as their primary care provider.

·       All states and D.C. have chosen to participate in the federal program to expand Medicaid coverage for the treatment of breast and cervical cancer to low-income women.

·       About two thirds of states have addressed mental health parity in an attempt to increase access to mental health services.

·       Nearly all states have domestic violence antidiscrimination laws, most commonly for health insurance, but also for life, disability, and property/casualty.

·       Nearly three fourths of states and D.C. have expanded Medicaid eligibility for pregnant women above the federal mandated coverage level. 

Although presently in the minority, a few states have enacted the following women’s health services: 

·        Additional laws to prosecute acts of violence or intimidation against abortion clinic staff, patients, and facilities (15 states and D.C.).

·        Mandated coverage of colorectal cancer screening (14 states).

·        Mandated coverage of some type of infertility treatment (15 states).

·        Dispensing emergency contraception without a prescription (4 states).

·        Some form of osteoporosis screening coverage mandate (11 states).

·        Creation of an Office of Women’s Health by legislation, executive order, or administrative action (13 states).

Copies of the report are available at the Web sites of both the Kaiser Family Foundation (www.kff.org) and the National Women’s Law Center (www.nwlc.org).  

Mayes G. Policies of importance to women’s health vary considerably among states. Medscape Ob/Gyn & Women’s Health: 8(2); 2003.

The Transition of a Women’s Health Ambulatory Service

As those of you involved in providing health care to inner-city minority women know, many barriers exist for the provision of high-quality health care. An article in the Journal of Ambulatory Care Management describing the transition of the Women’s Ambulatory Health Services at Hartford Hospital from a traditional clinic model to a culturally sensitive private practice model may serve as both a roadmap and an inspiration to you. Their final product was a much more efficient, inviting model that catered to the needs of the community it served.  

Accessibility to healthcare services and the removal of perceived barriers is critical to improving the health of inner-city poor and minority women and their children. When system issues are addressed that promote an easy first contact and continuity of care, studies have found an improvement in satisfaction with care, compliance with appointments and medication, and reduction in hospitalizations and emergency room use. In research with low-income and minority women, six dimensions emerge as important in the interaction with and removal of barrier to healthcare services: accessibility, respect, positive relationships, coordinated services, physical environment, and sensitivity to financial burdens. This article discusses these dimensions in detail. In 1992, the team in the Women’s Health Clinic (WHC) at Hartford Hospital (a tertiary care hospital in the south end of Hartford, CT), wanted to have a program based on these six dimensions of health care for the medically underserved, but the reality was quite different. The leadership team in the WHC wanted to break out of the old model of doing business. They began to ask themselves important questions about who they were, who they wanted to be, how they wanted to be perceived in the community, and how they could contribute to the people they served. They wanted to provide an environment that was accessible, easy to use, and patient centered. Realizing that management alone could not optimally redesign the clinic, the staff, nurses, physicians, and patients were beckoned to help in the planning. Most of the unlicensed staff in the clinic were from the community. They were bilingual, and many were patients utilizing the clinic for their own health needs; they knew the clinic from both the customer and provider perspective. A retreat, bringing together the team in an offsite setting, was the first step in the design change. Here they wrote the mission and vision of the new Women’s Health Services. Seven years later, Susan Maxwell, RN, MBA, and John Greene, MD, codirectors of the new Women’s Ambulatory Health Services (WAHS), won the Women’s Health Excellence Award from the National Association of Women’s Health in the category of Outstanding Ambulatory Comprehensive Women’s Services. Article describes the journey of the Women’s Health Clinic to achieve the award and where WAHS has gone since the 1999 award.    

In 1994, the WHC had approximately 2,980 patients, in 1996 the number of patients grew to 4,830, and by 2001 the number was near 7,600. Additionally, emergency department visits decreased. In 1994, 53% of the women who were patients in the ob/gyn clinic had visited the emergency room at least once during that year. By 2001, the percentage of these patients visiting the emergency room dropped to 42%. This has important implications for resource utilization at the hospital. It is a signal of success of their case coordination program. (The creation of three culturally sensitive teams that could follow the patients for their life span and the care coordinator role created the continuity sorely needed by this high-risk population.) The concept of one-stop shopping – which included financial counselors, a satellite pharmacy, a nutritionist, social workers, HIV counselor, a lab drawing station, a family-friendly atmosphere, and classroom space – made visits quick and easy for patients. High levels of patient satisfaction have been reported as well.   

This article is well worth reading to review how this team has built an award-winning program through creative thinking, committed staff, and a desire to help the patients they serve.  

Allen LW, Maxwell S, Greene JF. Building an award-winning women’s health ambulatory service and beyond. Journal of Ambulatory Care Management. Frederick: Jul-Sep 2003. Vol. 26, Iss. 3; start pg. 186.

Women’s Breast Health Services: Quality Improvement

Columbus Regional Hospital statistics indicated that the hospital had experienced increased market share with mammography services since 1995. However, even with increased market share, market projection information indicated that a number of women left the area for routine and diagnostic breast care and treatment. Information on the rationale for leaving the market was collected through focus groups of women who had sought services outside the community. In 1995, the hospital had created a Breast Health Center for the purpose of offering the community an improved mammography screening service. The environment was designed to reduce the anxiety associated with mammography by providing a setting in a separate facility on the hospital campus that was comfortable and aesthetically pleasing to women, which it was; however, the process for diagnostic services that were required after initial screening was found to be distressing. Focus group information indicated that the rationale for leaving the market was related to issues with the speed of response, the lack of coordination of activities, and a perception of quality issues with the breast health services provided by the hospital. This perception could be attributed to extensive waits for follow-up diagnostic treatment. The typical process for women with a breast abnormality often involved several specialists treating the woman. The delays between different specialists often led to delays for the woman that are marked by fear and uncertainty, as the patient was required to make numerous visits to different locations.

The improvement initiative undertaken was to create a service that provided comprehensive women’s breast screening, diagnostics, and treatment in one location. The service was to contain all elements of education, prevention, screening, diagnosis, and treatment. The intent of the effort was to reduce fragmentation of the care delivery process by providing a comprehensive, multidisciplinary approach inclusive of all disciplines in the treatment of breast health, thus alleviating some of the anxiety associated with follow-up care. Again, focus groups were conducted – the women selected had gone to another location for some part of their diagnostic process. Based on patient input, the key quality characteristics that were agreed upon included: speed and involvement in the choices to be made; access to information; a seamless process if something was found to be abnormal; confidence that the patient was going in the right direction and that someone was driving the care they were receiving; multidisciplinary care – the family doctor, cancer center, and surgeon all were to know what was going on in the care; and a consistent process from year to year.  

Using a force field analysis, the team reviewed each of the restraining forces and developed a strategy to address moving the initiative ahead. The lack of agreement on services to be offered was overcome by presenting the opportunity to provide exceptional care. The vision of the team included a nurse serving as a primary contact for the patient and as a navigator – helping the patient through a confusing system in a frightening and emotional time. The constant focus remained on patient needs. Take time to review how this team met the scheduling challenges between surgeons and radiologists. This really required some creative thinking!

The initial findings of 24.6 days from the recognition of an abnormality to diagnosis has been reduced to 48 hours, as women are called at home when an abnormality is identified in a screening mammogram and are then scheduled to come in the next day for diagnostic testing.  

THE IRELAND REPORT NOTES: The key success factors here are: physician buy-in and support of the concept of one-stop breast health care; the nurse navigator role provides a single contact for information and coordination; agreement between the radiologist and surgeon on who is to do which part of diagnostic testing is not a turf issue if the practices are working together; all services located in one location provide exceptional service to every woman. Take time to review this most informative article.           

Rust S. Improvement of women’s breast health services. Journal of Ambulatory Care Management. Frederick: Jul-Sep 2003. Vol. 26, Iss. 3; start pg. 199.

Effects of Gender on Health

There is still a need for a better understanding of how gender affects health throughout the life cycle. You might think this refers to the need to know how sex differences affect health differences. But sex and gender are not one and the same. Sex differences refer to biochemical pathways, hormones or metabolism, while gender differences refer to the range of socially constructed roles and relationships, behaviors, values, relative power and influence that society ascribes to each sex. Gender is relational and these cultural perceptions have significant consequences for health care and the health status of men and women. Gender health research investigates how sex interacts with gender to create health conditions and risk factors distinct for women and men. An example of a gender research question might be: How do certain risk-taking behaviors – including tobacco use physical activity, violence, or alcohol and drug use – impact differentially on men and women? Another might be: How do women and men interact differentially with the healthcare system to influence their access to health care, use of primary health care and use of health resources? Consider this: Women who smoke are 20-70% more likely to develop lung cancer than men who smoke the same number of cigarettes. What is it about female physiology that accounts for this difference, and why aren’t women aware of their danger from smoking that is even greater than it is for men? Did you know that females are more likely than males to recover language ability after suffering a left-hemisphere stroke? Based upon what is already known regarding how male and female brains process language, how can additional brain research help us improve the outcomes for men? The effects of gender on health can only be assessed within the context of social roles, employment, family life, education, longevity and health services. Without this contextual analysis, distinctions in health status between women and men cannot be properly defined, and policies and programs cannot be adequately informed.
DeLorey C. 2003 Healthcare Review

Gender and Coronary Heart Disease Prevention

An article in the Journal of Cardiovascular Nursing focuses on a fundamental sociocultural factor that influences both primary and secondary coronary heart disease (CHD) prevention behavior – gender. There is a complex interplay among and between the sociocultural environments in which women live and the biophysical outcomes they experience. There has been some investigation regarding the relationship of gender to coronary heart disease prevention and risk factor management. However, mechanisms underlying the influence of gender on these important outcomes have not yet been fully examined or explained.  

The empirical literature is abundant with evidence that modifying particular behaviors to prevent CHD, or its sequelae, works. Yet, the American Heart Association Task Force on Compliance maintains that people’s reluctance to engage in risk reduction and disease prevention behaviors “is far more prevalent and varied than previously thought, [and argues that] more effective interventions are needed to reduce risk and improve patient outcomes. Rates of noncompliance are estimated at greater than 90%. How people frame or place their experiences into their everyday lives or sociocultural context will influence how they proceed with disease prevention activities. Gender influences people’s beliefs about health and their capacity to make lifestyle changes.  

A number of social factors may influence women’s understanding and appreciation of their health as well as their ability to engage in behaviors aimed at both the primary and secondary prevention of CHD. These factors are linked primarily to women’s typically lower socioeconomic status (e.g., education, occupational status, marital status, parenthood, income) and the social roles that women hold. Women’s internal “other” orientation may limit their focus and capacity to access health information for themselves and then to act on it. Women may value the health and/or well being of others in their families over themselves.  

Today a variety of models exist to assist clinicians as they work to enhance the compliance of people who are facing behavioral change to reduce their CHD risk. Historically, recommendations, typically made to patient by physicians, were offered and adherence was expected. The role of gender was generally not considered. For example, how might the social role of women influence the point at which they are ready to make decisions or take action? How might women and men use their social networks differently or use them at all? How do gender-based health values influence health behavior and how are those values learned, applied, and changed?

THE IRELAND REPORT NOTES: The problem of gender-based differences in prevention behaviors will not be well managed or solved until the mechanism that underlie these choices are identified. The next generation of CHD prevention research in this area will need to be gender-based. It will require long-term commitment from funding agencies and the scientific community to assure well-designed work from a variety of perspectives. In addition, clinicians need to assess their women patients’ readiness and desire to be active participants in healthcare decisions. Clinicians need to identify, adopt, and utilize gender-appropriate strategies aimed at enhancing patients’ involvement in their health care.      

King KM and Arthur HM. Coronary heart disease prevention: Views on women’s gender-based perceptions and meanings. Journal of Cardiovascular Nursing, 09-01-2003; 18(4): start page 274.    

Botox and Risks

Botox sales are soaring. This mass-market wrinkle cure used by 500,000 Americans has transformed the drug’s maker, Allergan Inc., into one of corporate American’s glitziest success stories. However, the pharmaceutical firm is beset by complaints from federal regulators over its marketing tactics and growing consumer wariness about the safety of the drug. The Food and Drug Administration repeatedly has chastised Allergan for advertisements that it says suggest the drug is effective for unapproved uses and has criticized the company for minimizing the drug’s side effects. There is also concern that some doctors, in their enthusiasm for Botox, may not always be acting in their patients’ best interests. Interviews with Botox patients and an informal review of consent forms that physicians have patients read and sign suggest that some doctors are failing to disclose important information about some serious potential side effects of Botox.  

Allergan, meanwhile, has aggressively defended its product in the face of increased public scrutiny. Botulism toxin (Botox is a trade name) is the most deadly substance know. During the 1980s and early 1990s, it was a key part of Iraq’s arsenal of biological weapons. Perhaps the danger associated with butulinum toxin has fueled the public’s fascination with Botox. Allergan officials stress Botox’s safety record, dating to the late ’70s, when clinical trials of the drug began. In California, the state medical board reports just six complaints against Botox in the last two years; none of the complaints resulted in disciplinary action against any doctors. But according to documents filed with the FDA, the agency has received dozens of report of severe side effects, including some deaths and prolonged hospitalizations, possibly associated with Botox use from 1989 to 2001. The FDA said it has not studied the events sufficiently to determine if Botox was the cause or a contributing factor in those incidents. FDA officials say an ongoing analysis of these and other reports has turned up nothing alarming.

Some physicians caution that the drug’s side effects deserve more study. A 10-year Italian study published last year on the drug’s effectiveness on facial spasm concluded that side effects to Botox were minimal and transient – longer-term effects are unknown.
LA Times, Sept 22, 2003          

Women at the Forefront

The March edition of Future magazine honors women’s contribution to medicine, examines how women’s particular talents are shaping the world of health, and explores the medical challenges they face throughout their lives. 

Female health issues are attracting more attention and research worldwide. This edition of Future asks why breast cancer, the most common female cancer with one in ten affected, is still on the increase and how women can be helped, and help themselves. Henri Rozenbaum, President of France’s AFEM (The French Association for the Study of Menopause) the world’s oldest national menopause association, gives expert insight into a major turning point in every woman’s life. And they take a sobering look at the pain of osteoporosis and the rising threat of heart disease amongst younger women. The magazine looks through the past and celebrates women’s contribution to medical history. Future profiles healthcare heroines, including Mary Putnam, who overcame resisitance from the medical establishment to become the first woman to study at the renowned Ecole de Medecine in Paris in 1868, and Marie Curie, radioactivity pioneer and the first woman to win the Nobel Prize. Future talks to female healthcare workers on their daily rounds. They interview “Ms. Nature” – Annette Thomas, Managing Director of the Nature Publishing Group and one of the most influential figures in scientific publishing. Geeta Rao Gupta, President of the Washington-based International Center for Research on Women, explains the health and economic benefits of better education for girls in the developing world. Lastly, Future takes a light-hearted look at how women seem to cope better with illness and confirms what we all suspected: women get colds, men get flu.

Of particular interest was an article entitled, “The Future is Female”. The author contends that the 21st century woman will transform the existing economic and social order, pointing out that one outstanding trait of women is the way they think. Psychologists report that when women cogitate, they gather more data than men, integrate these details faster and put them into more complex patterns. As they make decisions, women weight more variables, consider more options, and see a wider array of solutions to a problem. Women tend to think in webs of factors, not straight lines. The author calls this broad, contextual, holistic, feminine perspective “web thinking”. Men tend to focus their attention instead. They discard what they regard as extraneous data, compartmentalize relevant material, and analyze information in a more linear path – what has been called “step thinking”. Both ways of thinking stem, in part, from brain anatomy and physiology. The female brain has more nerve pathways connecting the two hemispheres while the male brain is more compartmentalized. And testosterone, the predominantly male hormone, tends to focus one’s attention on the present. Both “web thinking” and “step thinking” are still valuable. But American executives report that women’s outstanding contribution to the business community is their “more varied, less conventional” point of view. Related to women’s web thinking is their propensity to think long-term, their imagination and their superior ability to embrace ambiguity – more assets in our complex age.

These male and female predispositions are associated with hormones. Estrogen is associated with nurturing behaviors in all mammals. With their preference for cooperating, consensus-building, working in egalitarian teams and their long-term, holistic view, women bring fresh perspectives to the business world. Women are also well-built for our emerging communications age. Women excel at basic articulation as well as at verbal memory and many other verbal aptitudes – again, associated with the predominately female hormone, estrogen. Women’s verbal abilities are also enabling them to excel in school. Today more American women than men graduate from high school and college. As more and more women become educated, they are acquiring the tools to move into lucrative, influential jobs in today’s “knowledge” economy. And as women seep into business, the media and educational institutions, they will spread their tastes for cooperation, flexibility, diversity and egalitarian team-playing, as well as their broad, contextual view of issues and ideas. 

Albert Einstein once said, “The significant problems we face today cannot be solved by the same level of thinking that created them.” We are inching toward a collaborative society, a global culture in which the merits of both men and women are becoming understood, valued and employed. As the female mind becomes unleashed in our modern era, we may build a more peaceful, healthy world. 

Future – the Aventis Magazine; Women and Health 3/2003; and Fisher HE, The future is female.                     

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