Exploring concepts of gender and health

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Exploring concepts of gender and health

  1. 1. ExploringConceptsof Genderand Health
  2. 2. Exploring Conceptsof Gender and Health Women’s Health Bureau Health Canada June 2003
  3. 3. Our mission is to help the people of Canada maintain and improve their health. — Health CanadaThis publication is also available on the Internet at:http://www.hc-sc.gc.ca/english/women/exploringconcepts.htmÉgalement disponible en français sous le titre :Exploration des concepts liés à la santé et au sexe socialFor more information, please contact:Women’s Health BureauHealth Canada3rd floor, Jeanne Mance BuildingTunney’s PasturePostal Locator 1903COttawa (Ontario) K1A 0K9Phone: (613) 957-2721Fax: (613) 952-3496E-mail: women_femmes@hc-sc.gc.caPermission is granted for non-commercial reproduction on condition that there is clear acknowledgement of thesource in the following form: “Health Canada, 2003”.Published under the authority of the Minister of Health.© Health Canada, 2003Catalogue No. H21-216/2003E-INISBN 0-662-34144-9
  4. 4. AcknowledgementsThe Women’s Health Bureau wishes to thank Ann Pederson, Olena Hankivsky, Marina Morrow,Lorraine Greaves, Leslie Grant Timmins and Michelle Sotto at the British Columbia Centre ofExcellence for Women’s Health for their assistance in developing this guide. We would also liketo acknowledge Dr. Margrit Eichler for her extensive contribution to this and other gender-based analysis initiatives at the Women’s Health Bureau. In addition, this project would not havebeen possible without the assistance of Status of Women Canada and the many contributorsacross Health Canada who provided substantial expertise and feedback.
  5. 5. Table of Contents1. Gender-based Analysis – A Catalyst for Change............................................................ 1 What Is Gender-based Analysis? ...................................................................................... 1 Why Is Gender-based Analysis Important? ...................................................................... 1 About This Guide ............................................................................................................. 2 How Being Male or Female Affects Your Health...............................................................32. Foundations of Gender-based Analysis.......................................................................... 5 Legal Foundations ............................................................................................................ 5 International and Domestic Commitments ...................................................................... 5 Health Canada Commitments .......................................................................................... 63. Key Concepts in Gender-based Analysis........................................................................ 8 Sex .................................................................................................................................... 8 Gender.............................................................................................................................. 8 Formal and Substantive Equality...................................................................................... 8 Diversity Analysis .............................................................................................................. 9 Population Health............................................................................................................. 9 Sex/Gender-sensitive Health Research............................................................................. 9 Gender Mainstreaming..................................................................................................... 94. Integrating Gender-based Analysis into Research, Policy and Program Development ............................................................................... 105. The Research Process and Gender-based Analysis ...................................................... 126. Policy and Program Development and Gender-based Analysis ................................... 16 1. Identify and Define the Policy Issue.......................................................................... 16 2. Define Goals and Outcomes..................................................................................... 17 3. Engage in Research and Consultation ...................................................................... 17 4. Develop and Analyze Options .................................................................................. 18 5. Implement and Communicate Policy and Program .................................................. 18 6. Evaluate Policy and Program .................................................................................... 197. Case Studies ................................................................................................................ 20 Case Study #1 – A Research Case Study: Cardiovascular Disease ................................ 20 Case Study #2 – Developing Performance Indicators and Measures for the Mental Health System ......................................................................... 25 Case Study #3 – Understanding Research on Violence ................................................. 28 Case Study #4 – Tobacco Policy..................................................................................... 30 Exploring Concepts of Gender and Health i
  6. 6. 8. Conclusion.................................................................................................................... 34 9. References ................................................................................................................... 3510. Further Reading: Selected Documents and Guides on Gender-based Analysis........... 4311. Selected Resources for Gender-based Analysis ........................................................... 48Appendix 1 – Important Policies and Legislative Measures ................................................ 56Appendix 2 – Gender-based Analysis and Social Trends..................................................... 59 ii Exploring Concepts of Gender and Health
  7. 7. Gender-based Analysis – A Catalyst 1 for ChangeBeing male or female has a profound impact account throughout the research, policy andon our health status, as well as our access to program development processes. Usedand use of health services. At Health Canada, effectively and consistently, GBA “makes forgender-based analysis (GBA) is being good science and sound evidence byintegrated as a tool in the research-policy- ensuring that biological and social differencesprogram development cycle to better between women and men are brought intoillustrate how gender affects health the foreground” (Health Canada, 2000b).throughout the lifecycle—and to identifyopportunities to maintain and improvethe health of women and men, girls and GBA “makes for good scienceboys in Canada. As such, GBA supportsthe development of health research, and sound evidence bypolicies, programs and legislation that are ensuring that biological andfair and effective, and are consistent withgovernment commitments to gender equality social differences between(see Section 2). women and men are broughtWhat Is Gender-based Analysis? into the foreground.”GBA is a process that assesses the differentialimpact of proposed and/or existing policies, GBA can be used to understand issuesprograms and legislation on women and men concerning:(Status of Women Canada, 1996). In thecontext of health, the integrated use of GBA • different population groups (e.g. Firstthroughout the research, policy and program Nations, rural residents, seniors,development processes can improve our immigrants, visible minorities, refugees)understanding of sex and gender as • certain behaviours (e.g. tobacco use,determinants of health, of their interaction physical activity, violence, intravenouswith other determinants, and the drug use)effectiveness of how we design and • the health care system (e.g. primary healthimplement sex- and gender-sensitive policies care, privatization, health reform)and programs. Ultimately, GBA brings into • diseases and illnesses (e.g. cardiovascularview the influences, omissions and disease, cancer, HIV/AIDS, mental illness)implications of our work. Within Health Canada, GBA is designed toWhy Is Gender-based Analysis promote sound scientific research, andImportant? provide relevant health information and evidence, with the goal of enhancing healthA catalyst for change, GBA ensures that a outcomes and strengthening health care.gender equality perspective is taken into Exploring Concepts of Gender and Health 1
  8. 8. Gender-based Analysis and the Population Health Approach GBA is consistent with Health Canada’s population health approach, which recognizes that health is determined not solely by health care and personal health choices, but also by other factors. Health Canada recognizes that the determinants of health, including income and social status, employment, education, social environments, physical environments, healthy child development, personal health practices and coping skills, health services, social support networks, biology and genetic endowment (sex), gender and culture, all influence health and Canadians access to, and benefits from, the health system. Population health strategies are designed to affect whole groups or populations of people—in the case of GBA, men and women. The interrelated conditions and factors that influence the health of the population over the lifespan are the focus of this approach. Systematic variations in their patterns of occurrence are identified and the resulting knowledge applied to improve health and well-being.About This GuideExploring Concepts of Gender and Health • case studies to demonstrate in concreteadvances Health Canada’s commitment to terms how GBA can be a catalyst forfully implement GBA throughout the changedepartment. One of several capacity-building • references and sources of further readingtools developed by Health Canada’s Women’s • a comprehensive list of informationHealth Bureau, it suggests ways for and resources—provincial, nationalresearchers, policy analysts, program and international—related to gendermanagers and decision makers to integrate and healthGBA into their day-to-day work. This guide • a discussion of GBA and social trendsincludes: • policies and measures that outline • an overview of government commitments the basis for all Canadians to be • key concepts in GBA treated equally • how to integrate GBA within the research- policy-program development cycle 2 Exploring Concepts of Gender and Health
  9. 9. How Being Male or Female Affects Your HealthThese examples illustrate how being male or female affects health, and suggest how thisinformation can lead to new questions and research. Some of the examples point to sex orbiologically based differences, while others refer to differences associated with gender—the socially constructed roles ascribed to men and women.Did you know? • The same drug can cause different reactions and different side effects in women and men—even common drugs like antihistamines and antibiotics (Makkar et al., 1993). Are all drugs to be used by both men and women tested for their potentially different effects on both sexes before seeking market approval? • Females are more likely than males to recover language ability after suffering a left- hemisphere stroke (Shaywitz et al., 1995). How can additional brain research help us improve the outcomes for men, based upon what we already know about how the female brain processes language? • During unprotected intercourse with an infected partner, women are two times more likely than men to contract a sexually transmitted infection and ten times more likely to contract HIV (Society for Women’s Health Research, 2001). What can be done to reduce women’s risk of contracting sexually transmitted infections? • The death rate from suicide is at least four times higher for men than it is for women. However, women are hospitalized for attempted suicide at about one and a half times the rate of men (source for both: Langlois and Morrison, 2002). Are there differences between men and women in how they respond to stress and reach out for help? What preventive measures can we take that are sensitive to these differences? Exploring Concepts of Gender and Health 3
  10. 10. • Women who smoke are 20 to 70 percent more likely to develop lung cancer than men who smoke the same number of cigarettes (Manton, 2000; Shriver et al., 2000). What is it about female physiology that accounts for this difference?• For Aboriginal women, the rate of diabetes is five times higher than it is for all other women in Canada; for Aboriginal men, the rate is three times higher (Federal, Provincial and Territorial Advisory Committee on Population Health, 1999). How can programs aimed at decreasing the incidence of diabetes take this knowledge into account?• In 2000, 70 percent of all persons aged 85 or over were female (Health Canada, 2001b). While women live longer than men, they are more likely to suffer from long- term activity limitations and chronic conditions such as osteoporosis, arthritis and migraine headaches (Federal, Provincial and Territorial Advisory Committee on Population Health, 1999). How can policies and programs accommodate the health needs of the growing number of senior women in this country? 4 Exploring Concepts of Gender and Health
  11. 11. Foundations of 2 Gender-based AnalysisGBA builds on a number of domestic and to government-wide implementation ofinternational commitments to gender equality. gender-based analysis in the development of policies, programs and legislation. Chapter 3Legal Foundations of the Federal Plan, “Improving the Health and Well-being of Women,” discussed issuesGender equality in Canada is guaranteed pertinent to the health situation of women inthrough the Constitution, under Sections 15(1) Canada and committed to the implementationand 28 of the Canadian Charter of Rights and of a women’s health strategy.Freedoms and by the many internationalhuman rights instruments to which Canada Building on the foundation of actions takenis signatory. under the Federal Plan, the federal government approved the Agenda forInternational and Domestic Gender Equality in 2000 as a government-Commitments wide initiative to advance women’s equality.In 1981, Canada ratified the United Nations Key components include engendering currentConvention on the Elimination of All Forms of and new policy and program initiatives andDiscrimination Against Women, which outlines accelerating implementation of gender-basedwomen’s human rights through ensuring analysis commitments. The Agenda forwomen’s equal access to, and equal Gender Equality is led by Status of Womenopportunities in, political and public life, as Canada, in cooperation with three otherwell as education, health and employment. federal departments: Health Canada, the Department of Justice Canada and HumanIn 1995, Canada adopted the United Nations Resources Development Canada.Platform for Action, the concluding documentof the United Nations World Conference on Several federal departments have issuedWomen in Beijing.1 It was at that conference formal gender-based analysis guidelines,that the Government of Canada presented its including the Canadian Internationalnational action plan to further advance the Development Agency, Human Resourcesstatus of women. The Federal Plan for Development Canada, the Department ofGender Equality (1995–2000) states that all Justice Canada and Status of Womensubsequent legislation and policies will Canada.2 Health Canada’s commitment isinclude, where appropriate, an analysis of embodied in the Women’s Health Strategythe potential for differential impacts on (1999b) and Gender-based Analysis Policymen and women. The first of the Federal (2000b).Plan’s eight objectives made a commitment1 http://www.un.org/womenwatch/daw/beijing/platform/declar.htm2 For international, national and provincial resource information see Section 11 of this guide. Exploring Concepts of Gender and Health 5
  12. 12. Health Canada Commitments The Gender-based Analysis Policy explains why and how Health Canada is integratingHealth Canada’s Women’s Health Strategy GBA into the day-to-day work of theprovides the framework for the department’s department.approach to incorporating gender-basedanalysis into its work. (For more detailed information about important policies and legislative measures, see Appendix 1.) The Women’s Health Strategy states that Health Canada will Women’s Health Bureau In 1993, Health Canada established the apply GBA to programs and Women’s Health Bureau to ensure that policies in key areas of the women’s health concerns receive appropriate attention and emphasis within the department, including health department. The Women’s Health Bureau is system modernization, responsible for implementing the Women’s Health Strategy and Gender-based Analysis population health, risk Policy within Health Canada, and acts as the focal point for women’s health in the federal management, direct government. The Bureau also manages the services and research. Women’s Health Contribution Program to support policy research and education in women’s health.The Women’s Health Strategy states thatHealth Canada will apply GBA to programs Women’s Health Contribution Programand policies in key areas of the department, Established in 1995, the Women’s Healthincluding health system modernization, Contribution Program (WHCP) currentlypopulation health, risk management, direct provides support to four Centres ofservices and research. Gender is recognized Excellence for Women’s Health, theas a determinant of health, one of twelve Canadian Women’s Health Network andwithin a population health approach (Health other initiatives.Canada, 1999b). This recognition “supportsgender equality in the health system” (Health In 1996, the Centres of Excellence forCanada, 2000b). Women’s Health were established to inform the policy process and narrow theThe Strategy supports the global recognition knowledge gap on sex, gender and thethat the health system should accord women other health determinants.3 The Centres areand men equal “treatment,” in every sense multidisciplinary partnerships of academic andof the word, and should strive to attain community researchers and community-basedequitable outcomes for both. organizations. The Centres address the gaps3 See Section 11 of this guide for contact information. Online information is available at http://www.cewh-cesf.ca 6 Exploring Concepts of Gender and Health
  13. 13. in knowledge regarding the determinants of Health Canada also collaborates with thehealth, with particular attention paid to the Canadian Institutes of Health Researchways that sex and gender affect health and Institute of Gender and Health (IGH). Theinteract with other determinants of health. IGH supports research to address how sex and gender interact with other factors thatThe Canadian Women’s Health Network influence health to create conditions and(CWHN) represents more than 70 problems that are unique, more prevalent,organizations from all provinces and more serious or different with respect to riskterritories. CWHN supports communications factors or effective interventions for womenactivities of the Centres of Excellence for and for men.4Women’s Health and other WHCP initiatives,and is the women’s health affiliate of the In addition to these governmentCanadian Health Network, a nationally funded commitments and policies, several keyInternet-based service designed to improve concepts are important to understandingaccess to accurate and reliable health GBA. These are discussed in the next section.information.Other initiatives: As well as specific researchprojects such as the Aboriginal Women’sHealth and Healing Research Group, theprogram also currently supports two workinggroups: Women and Health Protection andthe National Coordinating Group on HealthReform and Women.4 For additional information on the Canadian Institutes of Health Research, see http://www.cihr.ca Exploring Concepts of Gender and Health 7
  14. 14. Key Concepts in 3 Gender-based AnalysisThe following definitions of key concepts the relationship between them (Healthelaborate on those already adopted in Canada, 2000b). All societies are dividedHealth Canada’s Gender-based Analysis along the “fault lines” of sex and genderPolicy (2000b). (Papanek, 1984) such that men and women are viewed differently with respect to theirSEX roles, responsibilities and opportunities, with consequences for access to resourcesSex refers to the biological characteristics and benefits.such as anatomy (e.g. body size and shape)and physiology (e.g. hormonal activity orfunctioning of organs) that distinguish malesand females. The legal concept of “substantive equality” reflectsTo improve health status, we need evidenceon how sex differences (e.g. biochemical the importance of ensuringpathways, hormones and metabolism) offer not only equality ofinsights into possible biological and geneticdifferences in susceptibility to diseases opportunity but also equality(e.g. heart disease, lung cancer) andresponses to treatment. of outcome. GBA is about substantive equality.The health sector is slowly recognizing theextent of anatomical and physiologicaldifferences between males and females andincorporating these differences in science and Formal and Substantive Equalitytreatment (e.g. in recognizing and treating The term “equality” has usually been usedheart disease and in understanding the to emphasize similarities between people.different effects of anaesthetics) (Health The legal concept of “formal equality”Canada, 2000b). requires that people in the same or similar circumstances be treated the same.GENDER Historically, treating people equally was understood to mean giving women andGender refers to the array of socially men the same opportunities, services andconstructed roles and relationships, programs. Sometimes, however, differentpersonality traits, attitudes, behaviours, treatment may be required to achieve fairnessvalues, relative power and influence that and justice when differences between peoplesociety ascribes to the two sexes on a cause disadvantages and inequality. The legaldifferential basis. Gender is relational and concept of “substantive equality” reflects therefers not simply to women or men but to 8 Exploring Concepts of Gender and Health
  15. 15. importance of ensuring not only equality ofopportunity but also equality of outcome. Sex/Gender-sensitiveGBA is about substantive equality. Health Research Sex/gender-sensitive health researchDiversity Analysis investigates how sex interacts with gender toHealth Canada’s Gender-based Analysis Policy create health conditions, living conditions and(2000b) states that the GBA framework should problems that are unique, more prevalent,be overlaid with a diversity analysis. Diversity more serious, or for which there are distinctanalysis is a process of examining ideas, risk factors or interventions for women orpolicies, programs and research to assess men. It is possible to disaggregate datatheir potentially different impact on specific based on sex and/or gender without puttinggroups of men and women, boys and girls. the data in context. Similarly, a properNeither women nor men comprise analysis of sex-disaggregated data ishomogeneous groups. Class or socio- sometimes ignored in the development ofeconomic status, age, sexual orientation, policy or programs emanating from researchgender identity, race, ethnicity, geographic and evaluation. In contrast, sex/gender-location, education, physical and mental sensitive research entails a comprehensiveability—among other things—may distinctly analysis and assessment of the findings andaffect a specific group’s health needs, the impact of recommendations on diverseinterests and concerns. Much research groups of men and women.remains to be done to identify importantdifferences and commonalities among men Gender Mainstreamingand among women with regard to health The term “gender mainstreaming” came intostatus, experiences of the health system, widespread use through the United Nationshealth behaviour and other determinants Platform for Action (see footnote 1). It refersof health. to the integration of gender concerns into policy making and research so that policiesPopulation Health and programs reduce inequalities betweenAs described earlier in this guide, the women and men (World Health Organization,population health approach concerns itself 1998). Gender-based analysis is a genderwith the entire population or large subgroups mainstreaming tool that assesses theand rests on a body of research differential impact of proposed and/ordemonstrating that a combination of existing policies, programs and legislationpersonal, social and economic factors, in on women and men.addition to health services, play an importantrole in achieving and maintaining health. Exploring Concepts of Gender and Health 9
  16. 16. Integrating Gender-based Analysis 4 into Research, Policy and Program DevelopmentResearch, policy and program development substantive equality, responsiveness toare inextricably linked. Through an iterative diversities and the meaningful engagement ofprocess, each builds on and constrains the a wide range of stakeholders at all stages ofother, depending on the other for accuracy, decision making. Depending on the policyinclusiveness and acceptability. Gender bias in environment, priorities may change, but GBAany of these activities has implications for the remains an integral dimension of governmentothers, as well as for the ultimate beneficiaries decision making.of the government’s initiatives—the womenand men, girls and boys of Canada. Integrating the gender perspective GBA is not an add-on, but is integrated into each step of the research-policy-program- The objectives of GBA development process.5 Consideration of sex are substantive equality, and gender allows for more meaning to be absorbed from the actions we take, the policy responsiveness to diversities instruments and research methods we and the meaningful choose, the diverse groups of women and men we consult and our knowledge of the engagement of a wide range determinants of health. of stakeholders at all stages Responding to diversity of decision making. Gender does not operate in isolation, but in relation to other factors such as race, ethnicity, level of ability, age, sexualThe interlocking nature of these activities and orientation, gender identity, geographicthese contexts requires that GBA be a location and education. Therefore, GBAconstant thread in existing analyses or in a should also be overlaid with a diversitystrategy to be put into action only once analysis, which allows us to see how a(Council of Europe, 1998). Done well, GBA program or policy may affect the distinctsystematically informs the processes of health needs of specific groups of womenconducting research and program evaluation, and men.the outcomes of which determine policies,programs and legislation. Its objectives are5 For step-by-step suggestions about how to incorporate GBA into the research-policy-program development process, see Sections 5 and 6 of this guide. 10 Exploring Concepts of Gender and Health
  17. 17. Understanding trends parameters of our actions, and ourAs a contextualized tool, GBA considers the understanding of health.impact of past, current and emerging socialpatterns and trends on sex and gender (see Inclusive research and consultationAppendix 2). Congruent with a population GBA also increases substantive equality byhealth approach, GBA recognizes that health involving a wide range of stakeholders inarises in the everyday conditions of life: decision making and by using the widestknowledge of these diverse conditions and array of evidence possible. Opportunities forsocial trends and how they change over time citizens to talk with one another and withis especially important for policy and program decision makers lead to mutual learning,development. which, in turn, leads to more effective policy (Policy Research Initiative, 2002). In research,Incorporating GBA into government the use of both quantitative and qualitativedecision making methods, and participatory methods thatGBA is, like most “new products,” involve those who are being researched inincorporated into an already existing setting the research question and vetting theframework. In this case, the framework is process and reporting of research, canmade up of dynamic and interlocking significantly enrich our pictures of health.processes and mechanisms used in Policy making and program planning are alsogovernment decision making. We also enriched by getting more people into theneed to consider historic events, current picture to identify issues and suggest options.government direction, length of thegovernment’s term in office, and prior policy The next section of this guide suggests howdirections and commitments. These factors to integrate GBA into the research process.constrain or widen our perspective, the Exploring Concepts of Gender and Health 11
  18. 18. The Research Process and 5 Gender-based AnalysisResearch is an important tool for reducing • failing to disaggregate data based on sexgender biases in policy development and • failing to analyze sex-disaggregated dataprogram planning. The exclusion of sex and • failing to report the results of sex-gender as variables in any type of health disaggregated data analysesresearch is a serious omission that leads to • the relegation of qualitative data to aproblems of validity and generalizability, supplementary role, defining it as havingweaker clinical practice and less appropriate merely anecdotal value (Grant, 2002)health care delivery (Greaves et al., 1999). Consideration of the following questions at each stage of the research process should Research needs to be help reduce gender bias in the research conducted in ways that are process.6 sensitive to manifestations Formulate Research Questions of sex and gender, or it may • Does the research question exclude one sex when the conclusions are meant to perpetuate rather than be applicable to both sexes? If yes, illuminate sex and reformulate the question so that it is applicable to both sexes or so that it is gender biases. applicable to only one sex. • Does the research question exclude oneResearch needs to be conducted in ways that sex in areas that are usually seen asare sensitive to manifestations of sex and particularly relevant to the other, such asgender, or it may perpetuate rather than family and reproductive issues in researchilluminate sex and gender biases. Research on about men or paid work in research aboutsex, gender and health may also suffer from women? If yes, give attention to the rolesignificant shortcomings. These include: of the other sex. • treating sex like any other variable and • Does the research question take the male failing to put it into context as the norm for both sexes, thereby • assumptions about gender neutrality and restricting the range of possible answers? the consequent failure to provide gender- If yes, reformulate the question to allow sensitive research for the theoretically possible range. • treating sex and gender as the same thing6 This series of research questions is adapted from Dr. Margrit Eichler, “Moving Toward Equality: Improving the Health of All People: Recognizing and Eliminating Gender Bias in Health,” Health Canada (draft), Women’s Health Bureau, 2000c. Permission is granted for non-commercial reproduction of this adaptation on condition that Dr. Margrit Eichler is clearly acknowledged as the author. For a fuller discussion, refer to Dr. Margrit Eichler, Feminist Methodology, Current Sociology, April 1997, Vol. 45(2): 9–36. 12 Exploring Concepts of Gender and Health
  19. 19. • Does the research question take the • Does the literature address issues of family or household as the basic analytical diversity among women and men? If no, unit when different consequences for note the exclusions and limits of the women and men within the family or literature. household can be anticipated? If yes, change the question so that the unit of Research Design analysis corresponds to the level at which • If the phenomenon under investigation observations are made. affects both sexes, does the research• Is the research question different for the design adequately represent both sexes? two sexes though their circumstances are If no, include the under-represented or equivalent? If yes, reformulate the excluded sex. If the balance of previous question. research has largely excluded one sex, a one-sex study may be highly appropriate.• Does the research question assume that men and women are homogeneous • Of the major variables examined in the groups when the impact of the health study, are they equally relevant to men issues being studied may be different for and women? To women and men from a different groups of men and women? If variety of diverse groups? Is the diversity yes, explore differences among the men within subgroups identified and analyzed? and among the women, not just those If no, correct the imbalances by including between the men and the women. variables that affect the under-represented group.• Does the research question construct men as actors and women as acted upon? If • Does the study take into account the yes, explore the role of women as actors potentially different life situations of men and of men as acted upon. and women? If no, explore the context in a gender-sensitive manner.Literature Review • When dealing with issues that affect• Does the phenomenon under families or household, is it possible that consideration affect both sexes? If so, the event, issue, attribute, behaviour, does the literature give adequate experience or trait may be different for attention to each sex? If no, note the different family members. If yes, identify under-represented or excluded sex. and study separately individual actors with a view for potential gender differences.• Have studies concerning family roles and This may involve a drastic revision of the reproduction given adequate attention to research design. the role of men? In all other studies in the literature being reviewed, has the role of • Is the same research focus, method or women been given adequate attention? approach used for both females and Are different types of families taken into males? If not, is the different focus, account? If no, compensatory studies on method or approach justified? If no, the under-represented or excluded sex provide a detailed rationale. may be necessary before drawing conclusions. Exploring Concepts of Gender and Health 13
  20. 20. • Is the sex of all participants in the study, • Are data interpreted by taking males as including researchers and research staff, the norm? If yes, take females as the norm reported and controlled for? If no, report and compare the two. and control where possible and necessary. • Are practices that abuse or subjugate Where not possible, acknowledge and women or negate their human rights discuss the potential distorting effects presented as culturally appropriate or of the sex of the various research justified in the name of a supposedly participants. higher value? If yes, describe and analyze such practices but do not excuse or justifyResearch Methods and them.Data Gathering • Does the analysis pathologize normal • Has the research instrument been female biological processes or normalize validated on diverse groups of both male biological processes? If yes, create sexes? If different instruments are used alternative accounts. without compelling reasons, develop an instrument that is applicable to both sexes • Have the potentially different implications and to diverse groups of both sexes. If for the two sexes of the particular different instruments are necessary, justify situation, condition or event under their use in detail. investigation been made explicit? If not, make them explicit. • Does the research instrument take one sex (race, class, etc.) as the norm for both • Are gender roles or identities presented sexes and thus restrict the range of in absolute terms? Are stereotypes possible answers? If yes, reformulate the perpetuated? If yes, acknowledge gender instrument to allow for the theoretically roles and identities as socially important possible range. and historically grown, but make it clear that they are neither necessary, natural or • Are opinions asked of one sex about the normatively desirable. other treated as fact rather than opinion? If yes, reinterpret other-sex opinions as • When both sexes are included, is equal statements of opinion and no more. attention given to female and male responses? If no, create the appropriate • Are the same coding procedures used for balance. males and females? If no, make coding procedures identical. Language of Research Reporting and Research ProposalsData Analysis and Interpretation • When both sexes are mentioned together • If only one sex is being considered, are in a phrase, does one sex consistently conclusions nevertheless drawn in general precede the other? If yes, alternate in terms? If yes, make conclusions sex- some manner. specific where only one sex is considered, • Are any gender-specific terms used for or change the research design and generic purposes? If yes, use generic consider both sexes. terms when referring to both sexes. 14 Exploring Concepts of Gender and Health
  21. 21. • Are any generic terms used for gender- • Are females and males depicted in specific situations? If yes, use sex-specific stereotypical ways? If yes, eliminate the terms when referring to one sex. stereotypical representation and replace with a more realistic one.Visual Representations • Are men and women depicted in ways that represent their diversity (e.g. images• Are men and women appropriately of visible minorities, of people with represented, given their relative disabilities, of gay and lesbian couples)? importance with respect to the topic If no, incorporate these and other facets under study (e.g. significance of the of diversity into the images. problem for each sex, proportion of the population of each affected by the problem)? If no, correct the imbalance by fairly representing the excluded or under-represented sex. Exploring Concepts of Gender and Health 15
  22. 22. Policy and Program Development 6 and Gender-based AnalysisThere are various models of policy and These questions could be used to assess anyprogram development. This guide suggests particular policy and program developmentthe following six stages of policy and program model that is being used in a given situation.development: It is important to remember that the decision- 1. Identify and define the policy issue making environment alters what can be seen 2. Define goals and outcomes and the actions that can be taken. The 3. Engage in research and consultation processes that lead to the actions and 4. Develop and analyze options initiatives of policy and program development 5. Implement and communicate policy within this environment are dynamic and recur and program over time. 6. Evaluate policy and programThese stages are a simplified representation 1. Identify and Define theof policy and program development and do Policy Issuenot necessarily capture all of the subtleties of The policy agenda is determined by athese processes. In addition, it is assumed in complex interplay of ideas and values thatthis model that evaluation feeds back into can be emotionally and ideologically ladenpolicy and program development to ensure (Stone, 1989). Research is often the main toolthat subsequent policies and programs are to detect current issues, problems andevidence-based. challenges in the field of health. Equally important are events such as elections,Overall, GBA integrated into policy and disasters, critical current events and legalprogram development models should address decisions. Many players are involved inthese questions: setting the agenda—government institutions, individuals (politicians, bureaucrats, • Are differences in the contexts of the lives academics, researchers, think tanks), interests of men and women, boys and girls groups and the media. addressed? • Is the diversity within subgroups of Questions to ask: women and men, girls and boys identified and analyzed? • Is the issue or problem properly defined? • Are men and women engaged in the • Is it a health issue? If yes, how will the processes in meaningful ways to assess issue be situated in the population health the impacts? approach? • Are intended and unintended outcomes • Is it under federal/provincial/territorial identified? jurisdiction? • Are other social, political and economic • Who has defined the issue and why? realities taken into account? • What evidence has been marshalled to support this framing of the issue? 16 Exploring Concepts of Gender and Health
  23. 23. • Has the issue been portrayed • Do you need additional information to comprehensively to reflect the needs of do a full analysis of a policy or program? women and men, girls and boys? • If yes, how will you obtain this • What are the values, biases, knowledge information? Possible sources include a and experiences at play in the framing of literature search, the media, public this issue? opinion data, non-governmental • Does this issue require policy analysis/ organizations, interest groups/advocacy development/further research? groups/community organizations, policy documents/speeches from the2. Define Goals and Outcomes throne, federal government research committees, research organizations,Once the issue or problem is thoroughly academics, Statistics Canada, Healthunderstood, the next stage is to identify Canada, Canadian Institute for Healthpossible responses to it and to articulate Information, etc.these as goals and outcomes. • What are the stated goals of government in terms of the policy? Using the widest array of • What are the expected health outcomes evidence is important in from the policy? • What will the activities be? developing solid programs • What are the indicators of success? • Who is the policy/program intended to and effective policies. benefit? • What attempts have been made to 3. Engage in Research and remedy the issue or problem in the past? Consultation What were some of the outcomes of these Using the widest array of evidence is attempts? In what ways were these important in developing solid programs and outcomes different for men and women, effective policies. Comprehensive evidence boys and girls? gathering includes both men and women in • What is the current proposal to solve the the process of defining what needs to be problem? What assumptions are built into researched, what is missing in evidence the policy (e.g. established priorities and gathered to date, and how to interpret data. processes of department or division)? Both quantitative and qualitative data are • How does the issue or problem affect men required. Qualitative research complements and women (and boys and girls) and and enlivens quantitative data, broadens the different groups of women and men (and base for decision making and sharpens the girls and boys) differently (e.g. do the picture we are able to take of the health of objectives of the policy or program make the Canadian population. assumptions about the social roles of both sexes)? (Note: As a vital and central part of GBA, • How can the equity interests of different research is discussed in greater detail in groups be reconciled? Section 5.) Exploring Concepts of Gender and Health 17
  24. 24. with the current policy environment and Sources to Consult about GBA government objectives. Options should be Consultation with knowledgeable and assessed for their potentially adverse effects informed sources is also an important and differential impact on women and men part of the research, policy and program and diverse groups of women and men, girls development process. Sources that you and boys. Future directions and research can consult include Health Canada’s needs (e.g. gaps in knowledge) should also Women’s Health Bureau, women’s health be identified. organizations and a wide variety of • What are the probable short- and long- governmental and non-governmental term effects of the policy on men and organizations working in the field of women, boys and girls? Are both sexes health, including those listed in the treated with equal concern, respect and “Selected Resources for Gender-based consideration? Is the diversity among Analysis” section of this guide. men and women, boys and girls, being considered?Effective and meaningful consultation and • How does your knowledge of theinvolvement outside of government is attitudes of decision makers affect youressential to enable Health Canada to fulfil its recommendation?legislative mandate, deliver programs, launch • How have other government departmentsnew initiatives and build public trust. As responded to this issue or problem? Isnoted by the Office of Consumer and Public there an interdepartmental strategy thatInvolvement at Health Canada, individuals can be proposed?and organizations become involved in publicpolicy decisions in a variety of capacities. 5. Implement and CommunicateThere is a growing range of approaches to Policy and Programsupport meaningful participation: from a This stage includes the adoption,limited role in decision making to broader implementation and communication ofparticipation, and from traditional public recommendations. To ensure a coordinatedconsultations to open-ended models of response, consultation with otherpublic involvement. Therefore, involvement departments and/or the creation ofstrategies must be designed deliberately, and interdepartmental mechanisms may occur.in collaboration with participants, taking into It is critical that communication andaccount the nature of the issue, the people dissemination of the policy be gender-who are interested in and affected by sensitive and reflect an awareness of otherdecisions and the rationale for public social differences.involvement in decision making (Health • Is timing a factor?Canada, 2000d). • How does the choice of media affect dissemination to women, men and diverse4. Develop and Analyze Options groups of both?This stage includes making realistic, evidence- • How does language affect thebased recommendations that are congruent transmission of the message? 18 Exploring Concepts of Gender and Health
  25. 25. • How are stakeholders involved (e.g. how decision-making cycle, returning to the are you going to include program agenda-setting stage. participants in the implementation)? • How will the outcome of this policy or • How can other departments be involved program be evaluated (including in the implementation? monitoring and accountability)? • What will the indicators be?6. Evaluate Policy and Program • How will experiential knowledge and theEvaluation research is designed to judge the opinions of diverse groups of men andmerits of a government policy or program. women, boys and girls, be drawn upon inIt includes the systematic collection, analysis the evaluation?and interpretation of information concerning • How will the differential impacts of thethe need, design, implementation and impact policy or program on women and men,of public policy or a program (Hayes, 2001). boys and girls be evaluated?Evaluation, performance monitoring and • Were goals met? Was policy administeredpolicy indicators help us to determine what effectively? What should come next?is and is not working, and for whom. • What changes should be made in theEvaluation reflects back upon policy and policy or program so it is more responsiveprogram formulation and implementation, to the needs of diverse groups of menbut points forward to the next round of the and women? Exploring Concepts of Gender and Health 19
  26. 26. Case Studies 7The effects of gender on health are seen in (Legato, 1998). Evidence-based research isthe context of employment, family life, required to understand and respond to theeducation, longevity, health care treatment significant sex- and gender-based factors that—indeed, in most areas of life. Without a combine to affect cardiovascular health. Forcontextual analysis of data, distinctions in example, we are learning that sex-basedhealth status between women and men, girls factors affect the presentation of symptoms ofand boys, cannot be properly defined, myocardial infarctions. Gender-related factorspolicies and program development cannot affect when women and men seek treatmentbe properly informed, and the distinct health as well as the responses of healthneeds of diverse groups cannot be met. practitioners to men and women presenting with cardiac symptoms (Schulman et al.,The following four case studies illustrate how 1999). The combined effects of sex anddramatically different our understanding of gender, in interaction with other healtha health issue can be when GBA is not determinants, affect health status, healthimplemented and when it is. We will look at: system responses and eventual health(1) cardiovascular disease; (2) mental health outcomes (Greaves et al., 1999).in the specific context of developingperformance indicators and measures for the CVD, which includes myocardial infarction,mental health system; (3) research on ischemic heart disease, valvular heart disease,violence; and (4) tobacco policy development. peripheral vascular disease, arrhythmias, high blood pressure and stroke, has a history ofCase Study #1 being considered a men’s disease. It is onlyA Research Case Study: very recently that CVD has been recognizedCardiovascular Disease as the major cause of death in Canada for women as well as men (Heart and StrokeHistorically, considerations of sex and gender Foundation of Canada, 1999). One result isdifferences have not been considered in that women are greatly under-represented inresearch on most diseases. This omission has medical research related to cardiovascularhad far-reaching consequences for accurate disease (Heart and Stroke Foundation ofdiagnosis, effective treatment and prevention Canada, 1997; Beery, 1995).of cardiovascular disease (CVD) for women.7 For example:Using male norms and standards for CVD • Women were excluded from a large studyresults in numerous and potentially fatal of aspirin as the primary preventative for“pitfalls” in both diagnosis and treatment cardiovascular death in men (Steering7 CVD is a critical issue to be addressed in Canadian society. In 1993, the direct costs of CVD (e.g. hospitals, physicians and drugs) were $7.27 billion. Indirect costs (e.g. costs related to mortality, long-term and short-term disability) were $12.7 billion. CVD is the largest cost category among all diagnostic categories in Canada (Moore et al., 1997). 20 Exploring Concepts of Gender and Health
  27. 27. Committee of the Physicians’ Health Some Examples of Sex and Study Research Group, 1989). Subsequent Gender Differences in CVD to this research, women and men were Risk Factors treated with aspirin for CVD. Data have since shown that aspirin is effective for this • Age: Acute myocardial infarction and indication in men but not women ischemic heart disease become important (Hamilton, 1992; McAnally, Corn and health problems starting at age 45 for Hamilton, 1992). men and 55 for women. Congestive heart failure and stroke affect older individuals • A 1992 study in the Journal of the with much higher hospital admission rates American Medical Association found that over age 75 for both women and men. women are excluded from 80% of the (Heart and Stroke Foundation, 1999). trials for myocardial infarction (Gurwitz, Col and Avorn, 1992). The authors • Hypertension: High blood pressure is a concluded that findings from the trials major risk factor in cardiovascular disease could not be generalized to the patient and is two to three times more common in population that experiences the most women than in men (Society for Women’s morbidity and mortality from acute Health Research, 1999). myocardial infarction—namely, women. • Cholesterol levels: High levels of the • Doses of drugs given to women with heart “bad” LDL (low-density lipoprotein) disease are often based on studies of cholesterol are a risk factor for CVD for primarily middle-aged men even though men. Low levels of the “good” HDL the hormonal status, average older age (high-density lipoprotein) cholesterol and smaller body mass of women may may be a bigger risk factor for women affect drug concentrations, effectiveness, (LaRosa, 1992; 2002). side effects and toxicity (Heart and Stroke Foundation of Canada, 1997). • Diabetes: Diabetes represents a greater risk factor in CVD for women than forFrom the current state of research, we have men (Laurence and Weinhouse, 1997;begun to identify some of the ways that Canadian Women’s Health Network,sex/gender differences are relevant to risk 2001). The higher prevalence of diabetesfactors, symptoms and patterns of CVD, in Aboriginal women than in Aboriginaland the implications these differences have men compounds their risk of CVD.for diagnosis and interventions, includingprevention for men and women. As well, • Smoking: For women aged 50 or underthere are many lessons to be learned who smoke, the risk of dying from a heartfrom CVD-related research in the past to attack is three times greater than that ofensure better health outcomes for women an ex-smoker. For women smokers agedin the future. 35 or older and taking oral contraceptives, the risk is higher still (Canadian Women’s Health Network, 2001). We know that the Exploring Concepts of Gender and Health 21
  28. 28. Advancing CVD Research and Knowledge Through the Heart Health Initiative, Health Canada works closely with provincial departments of health and more than 1,000 organizations in the public, private and voluntary sectors to support an integrated approach to reduce and prevent deaths and illness due to CVD. The First International Conference on Women, Heart Disease and Stroke, funded by Health Canada, was held in Victoria, British Columbia in May 2000 to increase awareness of the problem of heart disease and stroke in women. The conference highlighted current scientific advances, gaps in knowledge and research opportunities for CVD in women. The 2000 Victoria Declaration on Women, Heart Diseases and Stroke was released at the conference.8 toxicants in tobacco affect many of “healthy weight” (Canadian Women’s women’s biological systems differently Health Network, 2001). Sex and gender from men’s, but not enough research has differences in relation to weight and body focused on the sex and gender specific size need further research. impacts of tobacco on CVD. The increase • Ethnicity: Ethnicity and gender are in rates of smoking among young girls important factors in CVD. For example, between 1994 and 1997, (30%) compared Aboriginal women experience higher to 17% among young boys, is a cause for death rates than the general Canadian concern (Heart and Stroke Foundation of female population for both ischemic heart Canada, 1999). disease and stroke (Heart and Stroke • Inactivity: More women than men are Foundation of Canada, 1999). There are physically inactive in the 15- to 24-year- also gender differences in CVD among old age group and in the over 65 age South Asian and Black populations (Heart groups (Federal, Provincial and Territorial and Stroke Foundation of Canada, 1997). Advisory Committee on Population • Socio-economic Status and Stressors: Health, 1999; Heart and Stroke Poor education, lower income, family Foundation of Canada, 1999). responsibilities and impoverished • Weight and Body Size: An increase in social connections uniquely predispose body fat, especially intra-abdominal fat, is women to disease and slow recovery associated with adverse blood cholesterol (Eaker, Pinsky and Castelli, 1992). Much levels, a higher incidence of CVD, insulin more research is needed on how resistance and breast cancer (Naimark, exposure to particular stressors, over Ready and Lee, 2000). The risk of heart the life cycle, affects CVD differently attack is three times higher in women who for women and men. are overweight than in those who have a8 Not yet officially ratified, the 56-page declaration asks that five values—health as a fundamental human right, equity, solidarity in action, participation and accountability—be adopted by scientists, health advocacy groups, government agencies, the media and others to serve as the foundation for the development, implementation and evaluation of all policies, programs and services earmarked for improving women’s heart health. See http://www.cwhn.ca/resources/victoria_declaration/ 22 Exploring Concepts of Gender and Health
  29. 29. Symptoms and Patterns of Disease less likely than men to have invasive • The onset of heart disease typically procedures such as coronary angiography, develops up to 10 years later in women’s coronary angioplasty or coronary artery lives than in men’s (Heart and Stroke bypass surgery (Maynard et al., 1992). Foundation of Canada, 1999). • During the past decade, heart attack • Some women have symptoms that are survival has improved due to different from those typically experienced thrombolytics (clot-buster medicine) like by men. For example, chest pain is the TPA and streptokinase. However, these most common symptom of heart attack drugs appear to be given to women less for both women and men. However, often than men. Large studies have also studies show that women are more likely found that women’s survival improves with to have subtle symptoms of heart attack, these drugs, but not to the same extent such as indigestion, abdominal or mid- as men’s, though the reason is unknown back pain, nausea and vomiting. More (Women’s Heart Foundation,1999/2000). research is needed to explore the reasons • In all age groups, hospitalization rates for for these differences and their clinical ischemic heart disease are much higher implications (Society for Women’s Health among men than women. The reasons Research, 2003; Doyal, 1998). for this are unclear (Heart and Stroke • Since it is still not well known that heart Foundation of Canada, 1999). disease is the number one killer of women • Women tend to have longer periods (Anderson, 2002), many women may be of hospitalization for CVD-related ignoring the symptoms of heart disease illnesses. The average length of stay and waiting too long to seek medical for women is 13.1 days compared to help. This is compounded by physicians 11.4 days for men (Heart and Stroke who do not take the symptoms women Foundation of Canada, 1999). present as serious. As a result, CVD in • The majority (80%–90%) of heart women is often dismissed or overlooked transplant recipients are male (Young, (Laurence and Weinhouse, 1997). 2000). More research is needed as to the causes.Diagnosis and Interventions • Few of the screening and diagnostic Outcomes of CVD: Some Sex and tests available for heart disease (e.g. Gender Differences electrocardiograms, exercise stress tests) • During the first six months after an initial have been specifically tested on women, heart attack, 31% of women and 23% of thus their efficacy is unknown (Collins, men have a second heart attack (Society Bussell and Wenzel, 1996). for the Advancement of Women’s • Some research suggests that women are Health, 1997). not diagnosed and treated as aggressively • Women fare less well than men following as men for CVD (Khan et al., 1990 in myocardial infarction, coronary artery Laurence and Weinhouse, 1997, 85–110) bypass graft surgery and coronary For example, in one study, women were Exploring Concepts of Gender and Health 23
  30. 30. angioplasty (Women’s Heart Foundation, the development of programs and 1999/2000; American Heart Association, services (Heart and Stroke Foundation 2002). of Canada, 1997). • The number of CVD-related deaths • More research to investigate how other among women will likely surpass CVD- social determinants of health (e.g. income related deaths among men in the near and poverty, culture and racism) have an future. This is because women tend to live impact on the development of CVD over longer than men and there are high CVD a person’s life cycle and how these rates among older people (Heart and determinants can be addressed to Stroke Foundation of Canada, 1999). improve health outcomes for women and men.Recommendations This CVD case study illustrates the need toAt a minimum, what is needed: integrate an understanding of sex and gender • CVD health promotion and disease into research methods and analyses. Doing prevention programs that take into so can uncover and eliminate gender bias in account the differences in social roles all stages of the research process, for between women and men. This includes example, when: programs that address different barriers to • formulating the research question smoking cessation, physical activity and • assessing the literature reviewed healthy nutrition encountered by women • designing the research methods and men. • gathering, analysing and interpreting data • More research on the underlying • writing about research, by ensuring use of pathophysiology of heart disease and appropriate language, and stroke and how these differ for men and • presenting non-stereotypical illustrations women. Research is also needed on the or other visual images to communicate effectiveness of prevention interventions. research This will enhance the evidence base for Some Lessons from Research on Women For many years, women have been prescribed combined (estrogen and progestin) Hormone Replace Therapy (HRT) to relieve some symptoms of menopause, such as hot flashes. Earlier studies suggested that the use of HRT products might help to prevent heart disease in post- menopausal women. However, randomized clinical trials conducted as part of the Women’s Health Initiative in the U.S. were terminated in July 2002 after demonstrating that hormone therapy carries greater risks than benefits and should not be prescribed to women for prevention of heart attack, stroke or any other CVD disorder. In fact, HRT increases the risk of CVD, including stroke. Widespread prescription of HRT products to millions of women proceeded before clinical trials provided clear evidence of long-term safety and effectiveness in relation to CVD. This example reinforces the need for precaution in moving from limited research results to broad practice in large populations of women (Health Canada, 2002; National Institutes of Health, 2003). 24 Exploring Concepts of Gender and Health
  31. 31. Case Study #2 gender discrimination (Boyer, Ku and Shakir, 1997). Although some mental health plansDeveloping Performance Indicators and policy documents across Canada (e.g.and Measures for the Mental Ministry of Health, the 1998 British ColumbiaHealth System Mental Health Plan) have begun toEven when research has shown significant sex acknowledge the unique mental healthand gender differences in a health area, and experiences and needs of different groups ofthis knowledge has been integrated into men and women, it has not translated intopolicy statements, it may still not be reflected the use of GBA tools in mental healthin the tools that are designed to monitor and planning or in a commitment to gather dataassess the performance of the health system. disaggregated by sex and other variables (e.g. race, ethnicity, socio-economic status).With regard to mental health, we know thatwomen more often than men are diagnosed A clear example of this is evident ifwith affective disorders, personality disorders we examine a sample performanceand post-traumatic stress disorder (World monitoring tool.9 If we look at Framework AHealth Organization, 2000). Even when (see page 26), it is apparent that knowledgewomen and men receive the same diagnoses about sex and gender and other diversity(e.g. the rates of schizophrenia and bipolar variables that have an impact on mental healthdisorder are the same for men and women), are not applied in the performance indicators.the onset and course of the illness may differ(Seeman, 1983). The onset of schizophrenia is Sex disaggregation of data, while not alwaysearlier in men and, for reasons that are not reported, is generally available to policyfully understood, the course and outcome of makers, as are breakdowns by age, becausethe disease are typically worse for men than the data are collected. But other data onfor women. diversity variables such as race, ethnicity and sexual orientation are not usually collected.Mental health care treatment and access to Policy makers and program developers needservices are different for different groups of to think of ways to collect information thatconsumers. For example, men predominate in can tell us more about the interaction andlong-term psychiatric institutions while women meanings of mental illness, race, ethnicity,are more likely to use outpatient services culture and sexual orientation, among other(Rhodes and Goering, 1994). Social and factors. Currently, such data collection raiseseconomic marginalization also affect mental ethical concerns that need to be carefullyhealth (World Health Organization, 2001). considered.Populations with high rates of poverty andcommunities that experience racism or other Three of the domains, indicators andforms of social ostracism (e.g. homophobia measures adapted from a typical provincialand ageism) are particularly at risk for mental performance monitoring tool, are describedhealth problems (Boyer, Ku and Shakir, 1997). in Framework A without GBA. Framework BWomen from these groups are especially (see page 27) follows with GBA incorporatedvulnerable to health problems because of into the same monitoring tool.9 The tool presented in this example is adapted from a typical provincial performance monitoring tool. Exploring Concepts of Gender and Health 25
  32. 32. Framework A: A Performance Monitoring Tool for Mental Health Without Gender-based Analysis DOMAINE INDICATOR MEASURESAccess/Responsiveness Service access – number and percent of persons with serious illness (SMI) receiving one insured treatment service per annum – percent of persons with SMI receiving community mental health servicesQuality/Appropriateness Emergency psychiatry – rate of acute care re-admissions re-admission rates within 30, 60, 90 days of discharge – rate of emergency presentations, within 30, 60, 90 days of dischargeOutcomes (Population Mortality ratios – mortality rates for persons& Consumer) receiving an insured health benefit for schizophrenia and bipolar disorderIf Framework A were used to assess the way savings of almost $85,000 per person couldthe system is functioning, important sex and be achieved if earlier and accurate diagnosisgender differences might be obscured or were to occur.missed altogether. For example, research hasshown that the diagnoses of borderline Framework B corrects for this problem ofpersonality disorder (BPD) and disassociative missed and delayed diagnosis by capturingidentity disorder (DID) are more often given data on rates of acute care re-admissions byto women; both of these diagnoses are sex and diagnosis. Although it may notassociated with extreme childhood sexual correct entirely for misdiagnoses, ifabuse and trauma (O’Donohue and Greer, Framework B were used it would be evident1992). Research suggests that this population that women with severe abuse and traumahas difficulty accessing adequate services, histories have a high rate of re-admissions.and providers indicate that these womenrepeatedly use emergency services (Morrow Additionally, by including sex, gender,and Chappell, 1999). One Canadian study diagnoses and diversity (e.g. race, age,that followed 15 women diagnosed with ethnicity, gender identity, ability) asMultiple Personality Disorder (the older term variables, more data are gathered that mayfor DID) found that these women often go help identify how the system is functioningundiagnosed for over eight years (Ross and differently (or the same) for diverse groupsDua, 1993). The costs to the health system of men and women.are enormous: the authors estimate that 26 Exploring Concepts of Gender and Health
  33. 33. Framework B: A Performance Monitoring Tool for Mental Health With Gender-based Analysis DOMAINE INDICATOR MEASURES (note that sex disaggregated data may be not be available in each case)Access/Responsiveness Service access by sex – number and percent of men and and other diversity women with serious mental illness variables (SMI) receiving one insured treatment service per annum – type of service accessed by men and women by age, ethnicity, sexual orientation, etc. – percent of men and women with SMI receiving community mental health services – survey of women’s service organizations to find out the ways in which they are supporting women with SMI and to find out their capacity to do this effectively – survey of ethnic-specific and settlement organizations supporting people with SMI – survey of gay, lesbian, bisexual and transgender organizations supporting people with SMIQuality/Appropriateness Emergency psychiatry – rate of acute care re-admissions by re-admission rates by sex and diagnosis within 30, 60, sex, diagnosis and other 90 days of discharge diversity variables – rate of emergency presentations by sex and diagnosis within 30, 60, 90 days of discharge Diverse male and female – satisfaction surveys, key informant consumer perception of interviews, focus groups service appropriateness The perception of service appropriateness by immigrant populations and ethnic minoritiesOutcomes (Population Mortality ratios by sex and – mortality rates for men and women& Consumer) other diversity variables receiving an insured health benefit for schizophrenia and bipolar disorder Exploring Concepts of Gender and Health 27

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