Dear
Colleague Letter
Preface
EXECUTIVE
SUMMARY
Many
diseases affect women disproportionately, predominately,
or differently than they do men. The view of women’s
health has also moved away from maternist traditions
toward broader conceptualizations based on social, educational,
and economic status, as well as on reproductive choices
and family composition. Within this context, a partnership
of five Federal agencies1
has been instrumental in examining
the integration of women’s health in the training
curricula of the health professions.
Given
its orientation to the health of populations, and
anecdotal information about increasing interest in
women’s health, the Association of Schools of
Public Health (ASPH), in collaboration with the Federal
agencies’ women’s health partnership,
undertook a curriculum review study in 2003 of women’s
health in accredited schools of public health (SPHs).
The aim of the study was to assess how women’s
health is addressed in required and elective courses
for the Master of Public Health degree (MPH). Through
this project, ASPH and its Federal partners sought
to expand the available information at SPHs regarding
an increased recognition of women’s health issues
across the life span.
Project
Approach and Methods
ASPH organized an approach to the project that involved
several working groups and a set of structured data
collection activities. The initiative included convening
a Women’s Health Interest Group, consisting
of women’s health faculty from each of the 34
schools of public health, and an expert advisory group
(EAG), which additionally included experts in women’s
health from associations involved in education and
practice of public health and women’s health
experts from Federal agencies. A focus group methodology
was selected for collecting information about what
a typical MPH graduate is exposed to in core MPH courses
concerning women’s health. This strategy was
adopted to ascertain nuanced information regarding
factors involved in pursuing a women’s health
focus in the MPH curriculum, and individual perspectives
about what should be done to build upon the current
status of such interests and efforts. Nine focus groups
were conducted in July and August of 2004, each addressing
a particular perspective: The women’s health
faculty focus groups discussed “what should
be taught” in core MPH programs in regard to
women’s health, and the core course faculty
focus groups discussed “what is taught.”
These focus group discussions also addressed barriers,
opportunities, and strategies related to enhancing
and expanding a focus on women’s health in MPH
programs.
An
on-line survey of ASPH interns and fellows in August
2004 provided a sampling of student and recent alumni
experience and perspectives regarding women’s
health-related topics in core MPH courses. Concurrently,
information on course offerings related to women’s
health was systematically abstracted from SPH 2003
course catalogues. The course data were then vetted
by the designated women’s health interest group
member from each school. A final step in preparing
this report entailed convening the EAG in a daylong
meeting in October 2004 to consider findings and develop
a set of recommendations.
Findings
The primary recommendation of the project, as informed
by the data and with the advice and expertise from
the women’s health EAG, was that MPH core curricula
incorporate the following educational components:
- Knowledge
of the major sex and gender differences in health
and disease across the life span, particularly in
terms of physiological, behavioral, and societal
factors that influence health behaviors and health
status among culturally and socioeconomically diverse
populations;
- Understanding
of the similarities and differences between men
and women concerning interaction and communication
with the health care system, and the impact of multiple
social roles and life cycle events on shared health
care decision making for self and family; and
- Knowledge
of the historical and contemporary social and cultural
determinants of health and wellness across the life
span, particularly with respect to sex and gender
roles.
These
statements of principle are intended to move beyond
exclusive attention to women’s health for several
reasons. First, study participants acknowledged the
legitimacy of and sought to address counterarguments
to a women-specific focus that pose the question,
“Why women’s health and not men’s
health?” Secondly, and equally important, participants
sought to address the general concern in the field
of public health about health disparities as reflected
in “Healthy People 2010 Objectives for the Nation,”
U.S. Department of Health and Human Services (HHS)
priority initiatives, and Institute of Medicine (IOM)
reports. This expanded approach enables ASPH and Federal
partners to achieve the multiple objectives of addressing
prior neglect of women’s health in both public
health research and graduate education, as well as
implementation of IOM-recommended workforce competencies
for public health professionals related, in particular,
to genetics, cultural competence, communication, and
diversity.
Other
specific findings from the focus groups, student survey,
and course review include the following:
- Sex
and gender differences, diversity within gender,
social determinants of health, and a lifespan perspective
should provide the foundation efforts to incorporate
women’s health into the MPH core curriculum.
Women’s health faculty proposed that the current
focus in public health on health disparities and
cultural competency should serve as the backdrop
and rationale for inclusion
of women’s health concepts in the educational
core curricula of MPH students. There was substantial
agreement among core course faculty, as well as
among students surveyed, that these women’s
health concepts were important. Moreover, the students
and recent alumni surveyed overwhelmingly indicated
that they anticipated needing women’s health
knowledge in their professional careers
.
-
There should be greater emphasis on women’s
health in the MPH core curriculum through integration
into core courses rather than by requiring a separate
course specific to women’s health. The main
themes identified for integration into core courses
included sex and gender differences, health disparities,
and cultural competence.
-
The principles identified as important by women’s
health faculty currently are incorporated into the
core MPH curriculum to at least a moderate degree.
Overall, about one-third of the participating faculty
believed that the concepts and principles identified
as essential already received full exposure when
they considered the entire array of course offerings
for their MPH programs.
Student survey results appear to confirm these faculty
reports.
The
systematic review of 2003 SPH course catalogues
and follow-up with each school representative identified
a total of 324 women’s health-related courses.
Slightly less than 20 percent (60 of 324) of the
total number of courses identified appeared to have
a focus on women’s health beyond reproductive
health, maternal and child health, or nutrition.
Sixty women’s health courses were found, 112
MCH/Perinatal, 74 Reproductive Health/Family Planning,
and 78 other courses, which included specific courses
such as midwifery and specific nutrition courses.
Not surprisingly, the elective courses were more
frequently offered in the largest schools. Only
two schools did not offer courses in the categories
named.
- Challenges
in promoting a targeted emphasis on women’s
health include the limited number of public health
faculty with expertise in women’s health,
and aspects of the academic culture related to independence
of faculty in determining course content. In addition,
schools of public health exercise broad latitude
in determining their overall curricular approach
and the specific assemblage of their MPH degree
requirements. The concept that the faculty focus
group said would
be most difficult to incorporate into the MPH curriculum
is the lifespan approach to women’s health.
- Faculty
expertise and research interests are important factors
in determining the extent to which women’s
health is or could be taught in the core MPH curriculum.
The interest levels of both deans and students also
are key drivers in this regard. Student interest
in women’s health appears to exist, as reported
by both faculty and students, with over 75 percent
of students reporting that women’s health
would be important to their careers to a moderate
or substantial degree. A long-
term strategy would be needed, however, to expand
the cadre of public health faculty with expertise
in the area of women’s health.
- Compiling
and sharing resources specific to women and public
health among all schools could be a significant
help to core course faculty. Particularly important
for inclusion would be data sets, case examples
or modules, bibliographies, and course syllabi.
Opportunities to promote inclusion of women’s
health concepts in the core MPH curriculum are present
when faculty recruitments and curricula review are
underway in the schools of public health. Moreover,
more efforts can be made to collaborate with faculty
colleagues from schools of medicine, nursing, and
women’s studies programs in schools of arts
and sciences. In addition, staff from State and
local health departments, and faculty from the HHS
National Centers of Excellence in Women’s
Health can be approached to further enhance the
presentation of women’s health in schools
of public health.
Recommendations
As conceptualized in this report, leadership for implementation,
while a collaborative/partnership effort, falls primarily
into two domains: that of the Association of Schools
of Public Health; and that of the Federal partner
agencies—Health Resources and Services Administration
(HRSA), Office of Women’s Health (OWH); the
Department of Health and Human Services (HHS), Office
on Women’s Health (OWH); the National Institutes
of Health (NIH), Office of Research on Women’s
Health (ORWH); the Centers for Disease Control and
Prevention (CDC), Office of Women’s Health (OWH);
and the Agency for Healthcare Research and Quality
(AHRQ) Senior Advisor on Women’s Health. Additional
suggestions are offered for consideration by philanthropic
organizations and by professional journals.
Association
of Schools of Public Health (ASPH)
For its part, ASPH should take the following steps
toward implementation:
1.
Promote, through a public statement promulgated by
the deans of the schools of public health, the incorporation
of content specific to sex and gender differences
in health problems into the core MPH curriculum.
2.
Establish an ad hoc advisory group to guide efforts
that promote integration of the aforementioned key
principles related to sex and gender in the MPH curriculum.
The charge of this advisory group would be to:
a) develop a set of educational competencies specific
to sex and gender health differences that would provide
the basis for development of public health teaching
materials and courses;
b) develop and promulgate recommendations for specific
strategies for incorporating concepts related to sex
and gender health differences into the MPH core curriculum
(for example, identifying the specific concepts and
teaching materials that fit best in each public health
core discipline), using the competencies noted above
as the focus;
c) guide development of a set of teaching resources
on sex and gender health differences and make them
available via the Internet to all SPH faculty and
academic administrators. Such resources would include
syllabi, readings, data sets, case examples, and teaching
and assignment modules that would be keyed to the
competencies noted above;
d) examine information further and deliberate issues
related to developing a set of recommended elective
courses on women’s health; and
e) explore further the potential for drawing on women’s
studies programs and on Federal
programs, to strengthen the teaching of sex and gender
health differences in schools of public health.
3.
Continue to include student perspectives in this and
all other curricula development and use SPH exit surveys
and other appropriate mechanisms to monitor the extent
to which recommended changes yield desired outcomes.
Federal
HHS Partner Agencies
HHS partner agencies should take the following steps
toward implementation:
- Assemble
educational resources for SPH faculty interested
in incorporating sex and gender specific content
into MPH core courses and/or developing women’s
health-specific elective courses. Online resources
can be posted on the HRSA Web site (www.hrsa.gov)
or on the National Women’s Health Information
Center Web site (www.womenshealth.gov)
with linkages to all HHS agencies.
- Promote
further attention and support to public health and
research training programs funded by HHS that focus
on integrated models, such as the NIH Building Interdisciplinary
Careers in Women’s Health (BIRCWH) program,
the National Centers of Excellence in Women’s
Health program, a variety of CDC public health training
programs, and the HRSA Geriatric Education Centers.
- Increase
the number of junior faculty development awards
that focus on sex and gender health differences
research and outcomes, and that involve graduate
student roles, recognizing the importance that research
funding has on graduate education.
- Continue
to support and expand funding opportunities for
schools of public health and other health professions
training programs in their collaborative efforts
to integrate the study of sex and gender differences
into graduate education curricula.
Additional
Suggestions
The EAG discussed the potential contributions of philanthropic
organizations. Specifically noted was the model of
the American Legacy Foundation’s funding for
curricula development and dissertation research specifically
related to elimination of tobacco-use. EAG members
further suggested that consideration be given to soliciting
the interest of a professional journal (e.g., American
Journal of Public Health, Public Health Reports, Women’s
Health Issues/Jacobs Institute) in publishing a special
theme issue or supplement devoted to enhancing attention
to women’s health in graduate education programs.
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Women's Health
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