Putting Prevention Into the Context and
Continuum of Women's Lives

In this last decade of the 20th century, interest and commitment to women's health have heightened. Milestones range from the addition of "women's health" as a subject heading in MEDLINE® to the inauguration of national conferences on women's health and the Journal of Women's Health, the launching of a 40-site clinical trial, and the establishment of offices on women's health throughout the U.S. Department of Health and Human Services (HHS) and in 5 States. Women, who represent half of the Nation's population, benefit from every step closer to the overarching Healthy People 2000 goals of reducing disparities and achieving access to preventive services. Yet, despite remarkable progress on some Healthy People 2000 women's health objectives, many have not been achieved.

Prevention in women's health traditionally has focused on reproduction, but women have other health priorities. In younger women, for example, staying healthy encompasses establishing good nutritional habits, making physical activity a daily routine, and never smoking. In older women, preventing injuries due to falls is just one of many ways to protect the quality of life.

Women and health professionals need to learn more about what promotes or reduces women's health-gender factors, as well as age, occupation, cultural factors, socioeconomic status, education, and family history. Certain diseases affect women exclusively, such as ovarian and cervical cancers; disproportionately, such as breast cancer, depression, and osteoporosis (see Spotlight); or differently, such as cardiovascular diseases, HIV/AIDS, and asthma.

Differences exist in the identification and modification of risk factors for diseases and in the diagnosis and treatment of diseases. Despite the fact that women utilize the health system more often than men, they are less compliant, perhaps because of their own attitudes and practices, as well as their physicians' attitudes. In addition, diagnostic testing and therapeutic procedures for women are inadequate.

Research in women's health has also been inadequate. Gender differences in areas ranging from clinical practices to understanding basic mechanisms of disease have not been explored fully. Women's symptoms can be misinterpreted. For example, some symptoms of heart disease, the number one killer of women, are different from symptoms typical for men. Physicians do not look for AIDS symptoms in women as early as in male patients, with a resulting delay in effective treatment.

The women's health agenda, however, is growing, due to increased congressional funding, the Clinton administration's support, and public attention. At a national conference in November, the Office of Research on Women's Health at the National Institutes of Health was expected to develop the research agenda on women's health for the 21st century. Plenary sessions and working groups were planned with particular emphasis on emerging gaps in knowledge about women's health across the life span, laboratory bench to bedside research issues, health status of minority women and other special populations, and career issues for women scientists.

The U.S. Public Health Service's Office on Women's Health (OWH) within HHS has a mission to improve the health of women across the life span. To foster an increased focus on women's health across the Nation, this past summer the office sponsored the National Women's Health Leadership Summit, which brought together representatives from every State and territory in the United States. They were briefed on HHS programs, managed care, and welfare reform. OWH seeks to redress inequities in research, health care services, and education that have placed the health of women at risk.

Health-Seeking Behavior

Not taking preventive health measures to protect against serious illness and not receiving screening for detecting treatable disease are associated with women's health-seeking behavior: National Health Interview Survey data from the early 1990's showed that 39.4 percent of women aged 50 and above had not received a screening mammogram in the past 2 years; 35 percent of women aged 18 and above had not received a Pap smear in the past 3 years; and 21 percent of women aged 18 and above had not received a blood pressure test in the past year. One of the study's most revealing findings was that three in five women aged 18 and over reported risk behavior in at least one of the identified risk factor categories of smoking, diet, exercise, and alcohol or drug use. Yet, the majority had not been asked about these behaviors during their last checkup.

In another study of health-seeking behavior, women with abnormal Pap smears were more likely to get followup than women with normal results, but two out of five did not get followup care. A study involving cervical cancer control showed that even with followup, many women did not complete all recommended treatments. Similarly, a hormone replacement study concluded that prescribing physicians should be aware of the noncompliance rates and try to increase their patients' adherence to therapy.

Barriers to Prevention

What keeps women from getting needed services? Women mention transportation and cost difficulties, scheduling problems, and motivational issues. The very programs that could most effectively increase screening rates sometimes have had to limit recruitment because the demand for clinical services exceeds the resources. In other cases, financial constraints prevent key services from being publicized and provided to all eligible women and limit the ability of women to enter the health system.

Barriers to preventive services can be divided into these categories: system factors (costs and lack of coverage; accessibility; inconvenient appointment process and time), motivation (deciding to go, making appointments, finding transportation), concerns about procedures or results; time/role conflicts; and forgetting.

Access and insurance are critical issues for a number of reasons. Women on the average earn less than men and make up a larger portion of the population holding jobs that usually do not have health insurance. Many women rely on their spouses for health insurance and risk being dropped if they are divorced or widowed. Women bear the major responsibilities for the health needs of uninsured children, including women of the next generation. Women live longer and have more chronic illnesses and conditions, needing access to specialists and lifelong treatments, which often cost more.

In terms of preventive services, many women are underserved, including women over age 50, persons with low incomes, members of racial and ethnic minority groups, residents in rural areas, and undereducated women. Women also are likely to be underinsured as well as underserved.

Studies show that women may lack perception of risk-they lack awareness and knowledge that certain diseases have prevention options (see Spotlight). A woman's own physical condition also can be a deterrent. Overweight women, for example, may not seek care because of poor body image; their diagnosis may be complicated by the weight; and their physicians' attitudes may affect care negatively.

Some women are not assertive in seeking health care, waiting for their physician to recommend services, such as mammography. Thus, providers have an increased responsibility for patient education about preventive screening services that can reduce morbidity and mortality.

Lack of reminders about needed care is cited often. The Colorado Department of Health uses a statewide computerized system to track the screening status of 150,000 women for their lifetimes and issues reminders to mammography providers. Other strategies include integrating preventive services at primary health care sites and community-based outreach programs.

At another level, women do not make their own health a priority; they are too busy balancing work and family obligations. The Food and Drug Administration's Office of Women's Health has piloted the "Women's Health: Take Time To Care" educational outreach program to help women take better care of themselves, for their own sake and for their families. The pilot featured outreach to minority communities and joined with pharmacists about using medicines wisely. FDA also has developed educational programs about teenage smoking and increased calcium consumption among female teenagers.

Certain groups of women face particular problems getting needed services. Sexuality can be a factor. For example, lesbians are at greater risk for some diseases, such as lung cancer, but may be unaware of the risks, may not seek help, and may not get sensitive care.

Chronically ill and disabled women may face more problems than most women, including more difficult access to health care. Sometimes the problem is just equipment-an examination table low enough for a disabled woman to get on and off. A mammogram reading may be inadequate because the woman cannot get into the proper position (new equipment design is alleviating this problem). Sometimes physicians are more focused on the disability and do not pursue preventive needs, such as pregnancy counseling.

Women in prison represent a growing phenomenon for justice and health officials. Many facilities face difficulty in providing adequate health care and supportive services for women.

Women's Health in the Future

Efforts to increase clinical preventive services for women include establishing more integrative women's health services, such as "one-stop shopping" centers for all aspects of women's clinical care as part of a health system or standalone facility.

In medical education and research, there is a need for women's health curricula and studies. In addition, more women need to be recruited into health leadership positions.

For many American women, prevention is not yet a household word. Women need information and encouragement to seek services and take steps to reduce risks. Women also need counseling from health professionals, referral for screening, and reductions in barriers, such as lack of insurance, lack of transportation, and work and child care difficulties. As practiced, some managed care programs have built-in incentives to prevent access to costlier care. Improving clinical care of women depends on increasing knowledge of women's health issues throughout each phase of the life cycle. Women need to know the facts so that they can exercise the necessary preventive vigilance. They also need the support of their families, health care professionals, and health systems, as well as the health information media and their communities as a whole.

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