Women's Health

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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:

1. 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
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2. 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.
   
   
3. 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.
   
   
4. 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.
   
   
5. 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.
   
   
6. 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:

1. 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.
   
   
2. 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.
   
   
3. 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.
   
   
4. 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.