Igniting an agenda for health promotion for women: critical perspectives, evidence-based practice, and innovative knowledge translation.

Pederson, Ann ; Ponic, Pamela ; Greaves, Lorraine 等

Health promotion is a set of strategic activities designed to positively influence health and quality of life. (1) It includes activities aimed at individuals as well as those directed at entire populations. Despite the general acceptance of gender as a determinant of health and the inclusion of women and girls as important subpopulations in population health frameworks, (2) health promotion has not articulated how to integrate gender into its vision and practice. Nor has the field addressed fully how its theories, methods and activities may sustain gendered forms of oppression that contribute to women's health inequities. (3)

The recent report of the international Women and Gender Equity Knowledge Network argued that gender inequity is among the most influential of the social determinants of health (SDOH). (4) In Canada, both women and men suffer from the effects of social inequities that shape their access to resources, living conditions and health services. While women's health generally compares favourably to men's in Canada with respect to mortality, over their lifetime, on average, women experience higher rates of chronic disease and a greater burden of disability than men. (5) Further, gender differences are dynamic; recent research suggests that the life expectancy of women in British Columbia is not rising at the same rate as men's, challenging the assumption that women in the province consistently outlive men. (6) There is also increasing evidence that health care interventions--including health promotion--may be more effective if they are designed with gender in mind. (7) Indeed, Sen and Ostlin (4) suggest that "taking action to improve gender equity in health and to address women's rights to health is one of the most direct and potent ways to reduce health inequities and ensure effective use of health resources" (p.1).

Our aim is to ignite an agenda for health promotion for women. We call on practitioners, researchers and policy-makers to critically consider and address the gaps between the fields of health promotion, women's health, and health inequities. We also invite collaboration with our newly-developed CIHR-funded Emerging Team * to develop a conceptual framework that will guide the development, implementation and evaluation of evidence-based health promotion to reduce gendered health inequities.

Developing a framework for effective health promotion for women

Health promotion frameworks can be extremely complex because of the scope of health issues, settings and methods, theoretical perspectives and social contexts that they need to consider. (1) Yet frameworks can be useful for guiding evidence-based practices that take these complexities into account. Several overlapping and dynamic elements need to be considered in a framework for effective health promotion for women.

First, such a framework will necessarily be founded upon a sex-gender-diversity analysis. (8) To date, the design of health promotion programs and policies largely ignores women's social locations and how issues of gender function in shaping the lives, social context and/or health behaviour of women. Daykin and Naidoo have argued that health promotion programs may hold women responsible for the health behaviours of others such as children and male partners. (9) Other health promotion programs may be unsuccessful because they fail to adequately account for women's complex social positions, including gendered and racialized power imbalances and differential access to material resources. Depending upon how gender is integrated into programs, it may exploit gender inequities, accommodate gender differences or transform gender relations. (7) To address these concerns, women's health theorists argue that we need to apply feminist intersectionality theories, which can help uncover the interconnected ways in which systems of oppression and domination--such as gender, race, ethnicity, class, age, sexuality, language and geography--shape both women's health outcomes and the potential for women's health promotion. (3) Such an approach reflects a SDOH perspective that acknowledges the complex ways in which material circumstances, dominant ideologies and political processes shape women's diverse access to health promotion resources.

Second, the framework will need to engage with the long-standing health promotion debate on where to locate responsibility for health. (1) On one side, there is an argument that individuals hold responsibility for health through lifestyle and behavioural choices, consistent with neoliberal and medical discourses. On the other side of the debate is an argument that health arises from broader structures or social conditions, and is therefore a societal responsibility. Given such diverse views, the challenge is to develop a health promotion framework that balances women's agency and autonomy with recognition of gendered determinants of health. Health promotion researchers have begun to explore how this structure-agency dynamic helps illuminate health behaviours, particularly for vulnerable and marginalized populations. (10) However, most still focus on how the behaviour of the 'recipients' of health promotion practices are affected by social constraints. This work fails to consider how those who can change social conditions, such as health promotion programmers, health practitioners and local policymakers, might impact meso- or community-level issues thereby mediating between individual women and broader structural influences.

Third, the framework will grapple with 'what counts' as evidence and effectiveness in health promotion. The complexity of the problems and interventions that health promotion encompasses pose challenges for developing a knowledge base for health promotion, both in terms of developing interventions and assessing program effectiveness and impact. Health promotion practitioners do not necessarily accept the traditional paradigm of evidence-based medicine and practice because "it draws on a view of science that holds to a hierarchy of evidence that profiles the purported objective, quantifiable outcomes, and other measurement-based methods as superior to narrative-based 'subjective' methods". (11), p.35 Rather, as emerging research is beginning to demonstrate, health promotion practitioners recognize that their work relies upon a "complex mix" of rigorous and systematic studies, emerging learnings and promising practices. (12) From a feminist perspective, it is imperative that evidence informing health promotion for women take into account their perspectives, self-reports and lay knowledge. (13) Community-based, participatory and action research approaches provide rich opportunities for accessing women's lay knowledge because they support women to voice their experiences of health and health promotion and to initiate action to address their challenges. (14)

Finally, the framework will need to address knowledge exchange activities that work for and with women. Poole has identified the need to expand current approaches to knowledge exchange beyond those premised on a view of empirical knowledge generated by an expert researcher to be transferred in a one-way instructive process to practitioners. (15) Rather, and in keeping with feminist and participatory methods, she suggests approaches that involve and empower end-users in the development of and translation of knowledge. Such an approach would "foster understanding, reflection, and action, instead of a narrow translation of research into practice" (ref. 12, p.36, italics in original). Collins and Hayes (16) suggest that knowledge exchange efforts require a broader policy agenda to move beyond individualized responses and toward solutions that "broaden dissemination within and outside academia; to coordinate public policy strategies that engage non-health sectors; to increase public awareness of the SDOH; and to generate political will for change" (p.343). As such, public engagement is a critical factor in knowledge exchange. This means that a framework must attend to health promotion research and knowledge exchange strategies that incorporate the engagement of key stakeholders, including women themselves, along with policy-makers, researchers and practitioners.

These four elements--a sex-gender-diversity analysis, structure-agency debate, what counts as evidence, and innovative knowledge exchange--will underpin our Team's developing conceptual framework. The framework will be instrumental in identifying the theoretical, methodological and practical considerations necessary to advance women's health promotion interventions and research. We hope this agenda will also inspire others to explore related dimensions of women's health inequities in collaboration with our Team.

Received: November 3, 2009

Accepted: January 23, 2010

REFERENCES

(1.) O'Neill M, Pederson A, Dupere S, Rootman I (Eds.), Health Promotion in Canada: Critical Perspectives, 2nd Ed. Toronto, ON: Canadian Scholars' Press Inc., 2007.

(2.) Health Canada. Exploring Concepts of Gender and Health. Ottawa, ON: Minister of Public Works and Government Services Canada, 2003.

(3.) Reid C, Pederson A, Dupere S. Addressing diversity in health promotion: Implications of women's health and intersectional theory. In: O'Neill M, Pederson A, Dupere S, Rootman I (Eds.), Health Promotion in Canada: Critical Perspectives, 2nd Ed. Toronto, ON: Canadian Scholars' Press Inc., 2007;75-89.

(4.) Sen G, Ostlin P. Unequal, Unfair, Ineffective and Inefficient. Gender Inequity in Health: Why It Exists and How We Can Change It. Final Report to the WHO Commission on Social Determinants of Health, Women and Gender Equity Knowledge Network, 2007.

(5.) Health Canada. Women's Health Strategy. Ottawa: Women's Health Bureau, 1999.

(6.) Fang R, Millar J. Is the province of British Columbia the healthiest jurisdiction to ever host an Olympic and Paralympic Winter Games? Summary Report. Vancouver, BC: Provincial Health Services Authority, 2006.

(7.) Interagency Gender Working Group. The 'So What?' Report. A Look at Whether Integrating a Gender Focus into Programs Makes a Difference in Outcomes. Washington, DC: Population Reference Bureau, 2004.

(8.) Johnson J, Greaves L, Repta R. Better Science with Sex and Gender: A Primer for Health Research. Vancouver: Women's Health Research Network of British Columbia, 2007.

(9.) Daykin J, Naidoo N. Feminist critiques of health promotion. In: Bunton R, Nettleton S, Burrows R (Eds.), The Sociology of Health Promotion: Critical Analysis of Consumption, Lifestyle and Risk. London and New York: Routledge, 1995;59-69.

(10.) Ponic P. Embracing Complexity in Community-based Health Promotion: Inclusion, Power and Women's Health [dissertation]. Vancouver: University of British Columbia, 2007.

(11.) Reimer Kirkham S, Baumbusch JL, Schultz ASH, Anderson J M. Knowledge development and evidence-based practice: Insights and opportunities from a postcolonial feminist perspective for transformative nursing practice. Adv Nurs Sci 2007;30(1):26-40.

(12.) Armstrong R, Waters E, Crockett B, Kelleher H. The nature of evidence resources and knowledge translation for health promotion practitioners. Health Promot Int, 2007;22(3):254-60.

(13.) Naples N. Feminism and Method: Ethnography, Discourse Analysis, and Activist Research. New York, NY: Routledge, 2003.

(14.) Reid C, Brief E, Ledrew R. Our Common Ground: Cultivating Women's Health through Community-based Research: A Primer. Vancouver: BC Women's Health Research Network, 2009.

(15.) Poole N. How can consciousness raising principles inform modern knowledge translation practices in women's health? Can J Nurs Res 2008;40(2):76 93.

(16.) Collins PA, Hayes MV. Twenty years since Ottawa and Epp: Researchers' reflections on challenges, gains and future prospects for reducing health inequities in Canada. Health Promot Int 2007;22:337-45.

Ann Pederson, MSc, [1] Pamela Ponic, PhD, [1] Lorraine Greaves, PhD, [1] Sue Mills, PhD, [1] Jan Christilaw, MD, [2] Wendy Frisby, PhD, [3] Karin Humphries, DSc, [4] Nancy Poole, MA, [1] Lynne Young, PhD [5]

Author Affiliations

[1.] BC Centre of Excellence in Women's Health, Vancouver, BC

[2.] BC Women's Hospital and Health Centre, Provincial Health Services Authority, Vancouver, BC

[3.] School of Human Kinetics, University of British Columbia, Vancouver, BC

[4.] Department of Medicine, University of British Columbia, Vancouver, BC

[5.] School of Nursing, University of Victoria, Victoria, BC

Correspondence: Ann Pederson, BC Centre of Excellence in Women's Health, E311-4500 Oak Street, Box 48, Vancouver, BC V6H 3N1, Tel: 604-875-3715, Fax: 604875-3716, E-mail: apederson@cw.bc.ca

Conflict of interest: None to declare.

* Promoting Health in Women (Phi9) is a new Canadian Institutes of Health Research (CIHR) Emerging Team funded to collaboratively develop a conceptual framework for women's health promotion through literature and evidence reviews, case study analysis, and innovative knowledge exchange practices. The Phi9 Team is a group of multidisciplinary investigators, staff and trainees who represent the population health, clinical and health services pillars of CIHR. We are engaged in a variety of health promotion practice and research projects located in university, hospital, community and government settings.