Women's Health Strategy

Table of Contents

• Message from the Minister
• I. Introduction
  • Recognizing the Issues
  • Progress to Date
  • Canada's Commitments to Women's Health
  • The Women's Health Strategy: Health Canada's Response
  • Health Canada and the Women's Health Bureau
  • A Changing Environment
• II. Why the Need for a Women's Health Strategy?
  The Distinct Nature of Women's Health Issues
  • Causes of death among women
  • Diseases and conditions of women and how they experience them
  • Women's quality of life
  • Risk factors and their consequences for women
  • Gender as a determinant of health
  • Biases in the Health System
• III. What is the Women's Health Strategy?
  • Objective 1 To ensure that Health Canada's policies and programs are responsive to sex and gender differences and to women's health needs
  • Objective 2 To increase knowledge and understanding of women's health and women's health needs
  • Objective 3 To support the provision of effective health services to women
  • Objective 4 To promote good health through preventive measures and the reduction of risk factors that most imperil the health of women
• IV. Conclusion
• Glossary
• Endnotes

Message from the Minister

In recent years, the need to enhance the sensitivity of the health system to women's health issues has gained increasing recognition. Also evident has been the need for more research, particularly on the links between women's health and their social and economic circumstances.

These issues are echoed in the Platform for Action, the document adopted by Canada and 188 other nations at the close of the Fourth United Nations World Conference on Women, in September 1995. These messages were delivered clearly in August 1996 by the 300 participants at the bi-national Forum on Women's Health, which was co-hosted by Health Canada and the U.S. Department of Health and Human Services.

In its final report, the National Forum on Health also observed that the health system must pay more attention to the factors which influence women's health and be more responsive to the distinct needs of women.

In response, I am pleased to release Health Canada's Women's Health Strategy. This document is a framework to guide Health Canada in furthering the work it has already undertaken over the years. As part of the Strategy, I have undertaken to fully integrate gender-based analysis in all of my Department's program and policy development work. Two important pillars of the Strategy - funded by Health Canada - are the Canadian Women's Health Network and the five Centres of Excellence for Women's Health. The Strategy invites collaboration with other federal departments, in accordance with the considerable role that social and economic factors play in determining health.

The 1999 Budget signalled a new era of commitment by the federal government to the long term sustainability of Canada's health system. This Strategy is a significant component of our Government's health agenda and a reflection of our resolve to improve the health status of women in Canada.

Allan Rock
March 1999

Health Canada's mission is to help the people of Canada maintain and improve their health. Throughout their lives - as children, in middle adulthood and as seniors - women face life conditions and health issues specific to their biology and social circumstances. The Women's Health Strategy is designed to identify and address these issues by ensuring that in all of Health Canada's areas of responsibility, women and women's health issues will be given full consideration.

I. Introduction

This document sets out Health Canada's Women's Health Strategy and the rationale for it. It reviews some of the ways in which the health system has failed to respond adequately to women's health needs and concerns. It highlights issues surrounding causes of death among women, their illnesses and life conditions, quality of life and the social and economic factors that influence their health. Finally, it outlines a broad range of areas where Departmental actions can address these issues. The document refers to a number of concepts and terms central to understanding Health Canada's current approach, the Strategy itself and the analysis which underpins it. A glossary of the main terms appears on page 35.

Recognizing the Issues

Canadians are among the healthiest people in the world and the life expectancy of Canadian women is one of the highest. Nonetheless, our health system has not always understood the factors which influence the health status of women nor has it addressed women's issues concerning research, education, leadership and health interventions. Gender bias has affected women as users of the health system and as paid and unpaid health care providers.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Women's health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology (para. 89).

U.N. Platform for Action
Beijing, 1995

Progress to Date

In recent decades, Health Canada, its agencies and the health system as a whole, have made significant contributions to the advancement of women's health in areas such as breast cancer, tobacco use, substance abuse, HIV/AIDS, and reproductive and genetic technologies, to name but a few. In September 1996, Health Canada revised its regulatory guidelines to require that drug companies also include women in clinical trials, in the same proportion as are expected to use the drug. This will help resolve the problem of findings being generalized to women, based on research conducted only on male subjects. The National Health Research Development Program has cited women's health as a priority. These are but a few examples of Health Canada's dedication to women's health.

While these are important accomplishments, much remains to be done. The Department is conscious of the need to build on recent progress and to further a women's health agenda. Thus, it has identified women's health as a priority and has developed a strategy to begin responding to women's health concerns.

Canada's Commitments to Women's Health

This Women's Health Strategy supports the global recognition that the health system should accord women and men equal "treatment," in every sense of the word, and should strive to attain equitable outcomes for both. Canada affirmed this when it adopted the Platform for Action, the concluding document of the Fourth United Nations World Conference on Women, held in Beijing in 1995.

Prior to the Beijing Conference, the U.N. invited countries to develop national action plans to further advance the status of women. In response, the federal government released its Federal Plan for Gender Equality in August 1995. Chapter 3 of the Plan, "Improving the Health and Well-being of Women," discussed issues pertinent to the health situation of women in Canada and committed to the implementation of a women's health strategy.

The Women's Health Strategy: Health Canada's Response

The Women's Health Strategy provides a framework for Health Canada to meet the health challenges of today and tomorrow for half of Canada's population. It conforms with the Convention on the Elimination of All Forms of Discrimination Against Women; and with the principlesof the Beijing Platform and the Federal Plan: all aspects of women's lives - their health, social conditions, economic and legal status - interact and influence their well-being. While the Strategy focuses primarily on the health system, Health Canada will work with other departments to promote a holistic, multi-sectoral approach to health and social policy development.

State parties shall take all appropriate measures to eliminate the discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health services, including those related to family planning.
Article 12, Convention on the Elimination of All Forms of Discrimination Against Women

The Strategy takes up an important challenge advanced in the Platform and the Federal Plan: it promises that Health Canada will integrate gender into all its programs and policies by conducting gender-based analysis (see Glossary).

The overarching goal of the Women's Health Strategy is to improve the health of women in Canada by making the health system more responsive to women and women's health. Four objectives will support this goal:

1. Ensure that Health Canada policies and programs are responsive to sex and gender differences* and to women's health needs.
2. Increase knowledge and understanding of women's health and women's health needs.
3. Support the provision of effective health services to women.
4. Promote good health through preventive measures and the reduction of risk factors that most imperil the health of women.

* See Glossary for definitions of "sex" and "gender" differences. Recognizing the distinct needs and concerns of women and coming to terms with the biases of the health system requires understanding the two dimensions that distinguish women and men: biology and social attributes.

Health Canada and the Women's Health Bureau

Health Canada's mission is to help Canadians maintain and improve their health by providing leadership, developing policy, conducting or supporting internal and external research, collecting data, undertaking surveillance, acting as a regulatory body, promoting health, preventing disease and providing and funding direct services to First Nations and Inuit. These mandated areas of responsibility are the avenues for implementing the Women's Health Strategy.

The Strategy will be implemented within the context of Health Canada's approach to policy and program development - a population health approach (see Glossary). This approach concerns itself with the entire population or large sub-groups and rests on a body of research demonstrating that a combination of personal, social and economic factors, in addition to health services, plays an important role in achieving and maintaining health.

As part of the population health framework, Health Canada's programs and policies consider three life stages: childhood and adolescence, early to mid-adulthood and later life. Sex and gender considerations will be integrated within each of these life stages. For example, Health Canada's contribution to the National Children's Agenda and to programs for seniors will be informed by these considerations.

The Women's Health Bureau will coordinate the Strategy within Health Canada. It will monitor current and emerging issues and ensure that the Strategy remains relevant over the years. The Bureau will play an especially active role in fulfilling Objective 1 of the Strategy, as part of its mandate to ensure that gender considerations are addressed in all departmental programs and policies. It will initiate projects to enhance its policy development and monitoring function and help Health Canada move closer to achieving gender equality in all its work.

The Bureau supports five Centres of Excellence for Women's Health as well as the Canadian Women's Health Network. The policy development work of the Bureau is being informed by new knowledge generated by the Centres and by other research and health information sources, as outlined in Objective 2 of the Strategy. The Bureau will work with all program and policy sections of the Department to advance measures that will fulfil Objectives 3 and 4.

Women are not a homogeneous group. Disability, race, ethnocultural background and sexual orientation have varying influences on women's health and on their interactions with the health system. The Strategy will be sensitive to these issues of diversity. For example, several of the five federally funded Centres of Excellence for Women's Health are focusing on health issues of concern to immigrant and refugee women, Aboriginal women, women on low incomes and rural women.

A Changing Environment

Health care systems all across Canada have been undergoing significant reform and restructuring. As documented in the Final Report of the National Forum on Health, while the pattern and pace of change varies, health reform in general is motivated by a mix of fiscal pressure to contain health spending and awareness that the system is in need of significant modernization. Many features characterize our rapidly changing health care environment: reduced dependence on large health care institutions, the devolution of decision making to new regional and community structures, shorter hospital stays and greater reliance on care in the home, alternatives to fee-for-service as methods of compensating physicians, the advent of new classes of health care providers (e.g., midwives and nurse practitioners), increased emphasis on preventive measures, and the drive for efficiency - be it at the clinical or broad health system level.

In infancy and childhood, girls use fewer health services than boys. But once beyond childhood, Canadian women make greater use of a wide array of health services. Changes in our health care system will, therefore, have a significant impact on women. Reform and modernization of the health system will be positive if it means that fewer women will be subjected to unnecessary or ineffective interventions or drugs, that they will have access to better preventive medicine, to midwives and to quality care in their own home. But, if women find that access to important services is limited, or that the net effect of an increased reliance on home care simply means that women assume the greater burden of family caregiving for long-term rehabilitation or chronically ill family members, then the impact of health reform will be less positive.

Rapid changes in electronic technology are influencing the health system at many levels. The development and linking of data banks containing personal health information, the provision of treatment via tele-medicine and the reliance on the Internet for health information are significant trends. These have different implications for women and men, who neither view nor utilize health information similarly nor have equal access to it. As we enter this new world of health information technology, we must ensure that women and men benefit equally.

Other important changes on the health landscape include increasing consumer attention to, and use of complementary and alternative health practices and therapies, changing demographics marked by an aging and increasingly pluralistic society, and the globalization of trade with its effect on the health sector. All these societal changes, when viewed through a gender lens, reveal different pictures for women and for men.

II. Why the Need for a Women's Health Strategy?

Only recently have health policy makers and health service providers acknowledged in a tangible way the extent to which social, economic and cultural factors influence health. Similarly, our health system has been slow to recognize that sex and gender are other significant determinants of health. For many years, a burgeoning women's health movement called attention to biases in the health system. At first, the sense that the system was failing women was intuitive and personal. Over time, awareness grew that shortfalls in the system were more pervasive and required a comprehensive response - including changes in attitude and practice.

The Women's Health Strategy has been developed to :

1. Promote understanding of the distinct nature of women's health issues; and
2. Address the biases and insensitivities of the health system to women and their issues.

The Distinct Nature of Women's Health Issues

The Women's Health Strategy underscores the recognition that in questions of health, it matters whether you are a woman or a man. Drawing on some commonly accepted examples, these differences are discussed below, in areas such as: patterns of illness, disease and mortality; the way women and men experience illness; their interactions with the health system; the effects of risk factors on women's and men's well-being and the social, cultural, economic and personal determinants of health, which are significantly affected by gender differences. Shedding more light on these issues and seeking gender-appropriate measures to respond are prime reasons for the Women's Health Strategy.

1. Causes of death among women

Women outlive men by six years^{Footnote 1} and the death rate is higher among men than women in all age groups, especially between the ages of 20 and 44, where their likelihood of dying is more than twice that of women.^{Footnote 2} These differences are mostly attributable to men dying from "external" causes, especially motor vehicle accidents and suicide.

However, there is a reversal in these statistics when it comes to cancer deaths in the age group 20-44: women in the prime of life are dying in greater numbers than men. In projections of cancer-related deaths for 1998, women in the age group 30-39, for instance, have a death rate that is one and a half times that of men. In the age group 40-49, their death rate attributable to cancer is one third higher.^{Footnote 3} These deaths are primarily due to breast cancer, the causes of which are still largely unknown.

As well, women continue to die from largely preventable conditions such as cervical cancer. Unprecedented numbers are now dying from lung cancer, another preventable disease. In 1994, for the first time, lung cancer surpassed breast cancer as the leading cancer killer of women.^{Footnote 4} While the incidence of breast cancer is lower among black women, they tend to die from the disease in greater numbers than white women, pointing to the need for attention to diversity.

Mortality is not the only significant health indicator when considering differences between women and men. Despite women's life expectancy of nearly 81 years,^{Footnote 5} their later life is often characterized by isolation, disability and health problems.

Although living 6.3 years longer than men, women only enjoy 1.5 more disability-free years of life (p. 27).
Report on the Health of Canadians, September 1996

At greater risk are women with low levels of education, low income, and low control over their work environment. These women are more likely to smoke and to be both sedentary and obese. As well, visible minority women are also more at risk, notably South-Asian and Black women.
Women, Heart Disease and Stroke in Canada, Heart and Stroke Foundation of Canada, 1997

2. Diseases and conditions of women and how they experience them

The health sector has paid a great deal of attention to the reproductive system of women, and particularly to maternal health concerns. Important successes have been achieved in this area. However, illnesses common to both women and men have not always been understood in terms of their sex and gender-based differences and, therefore, have not been appropriately addressed by the health system.

Diseases of the heart are such an example. Prevention, diagnosis and treatment must reflect an understanding that the symptoms, the course of the illness, the effect of medications and the suitability of certain surgical procedures are different for women and men. As well, historically, in the area of heart research on new medications, women were rarely included as subjects. Cardiovascular disease (heart disease and strokes) is the major cause of death and one of the major causes of disability among women. Women themselves, when asked what illness puts them at greatest risk of death, will usually identify breast cancer,^{Footnote 6} without realizing that cardiovascular disease carries greater risks. This has implications for health promotion efforts.

In most age groups, women suffer more than men from chronic conditions, particularly migraines, allergies, arthritis and rheumatism. Younger women report more back and limb problems than young men.^{Footnote 7} Training, program development and health promotion activities must be sensitive to these differences.

One of the areas of greatest difference between women and men is their respective profiles of mental health disorders. Study after study has reported higher levels of depression among women.^{Footnote 8,Footnote 9} Young women, in particular, are more apt to have a low self-image.^{Footnote 10} The rate of psychiatric hospitalization is consistently higher for women.^{Footnote 11} While men commit suicide more frequently,^{Footnote 12} women attempt suicide more often but are more likely to fail in their attempts.^{Footnote 13} All of these observations point to gender-based differences in the way in which women and men experience and cope with stress and life events, and how they signal their distress. Recent findings on the links between stress and decreased efficiency of the immune system add further impetus to the need to address stress in the lives of both women and men, with an appreciation for gender differences.^{Footnote 14}

In accord with previous studies, the NPHS revealed a higher prevalence of depression in women than men: (7.4 versus 3.7% for men in cycle 1(1994) and 5.5% versus 2.8% in cycle 2 (1996). Women were also more likely to experience recurring depressive episodes: nearly three out of four people (72%)...in both 1994/95 and 1996/97 were women.
National Population Health Survey Overview, Statistics Canada

Observations of mental health differences have specific implications for diagnosis and treatment. Many psychological assessment methods, including history taking, have not been constructed to fairly capture and adjust for gender differences and they often apply to women certain norms and definitions of mental health based on male standards.^{Footnote 15} For example, women are inevitably labelled more anxious and tense than men. The point of reference becomes important in defining what is, and what is not, pathological, and the implications for diagnosis and treatment.

Sexual and reproductive health issues are numerous and differ among women and men. While women with HIV and AIDS can experience many symptoms similar to men's, they are often faced with difficult decisions related to pregnancy and the possibility of mother-to-fetus transmission.

Although not a disease, menopause brings many physiological changes for women and places women at risk of developing cardiovascular disease or osteoporosis. These risks may be influenced by hereditary background but may also be modified by diet, smoking, daily activities and environmental factors, therefore pointing to the need for a comprehensive health strategy for these women.

3. Women's quality of life

The Women's Health Strategy recognizes that illness and the threat of death are not the only health-related concerns of women. Quality of life issues are important to them and can predispose them to ill health. A 1992 study by Vivienne Walters^{Footnote 16} revealed that 68% of women surveyed said that tiredness was their major complaint. Feeling under stress and experiencing disturbed sleep were other related complaints.

In their adult years, many women carry a double workload. Traditionally, they have been the family members primarily responsible for maintaining the home and caring for children and ill or elderly family members. When they joined the paid labour force, they continued these domestic duties along with employment outside the home. As a result, in the 20-44 age group, the work stress index of women is much higher than that of men.^{Footnote 17}

The media are an influential force in the socialization of women and men. They help create unrealistic expectations about weight and appearance and subtly encourage women to attach undue importance to these. Women and men respond differently to these pressures. Women, especially young women, tend to be more negatively affected by these messages, as evidenced by widespread preoccupation with weight loss,^{Footnote 18} and more seriously still, by rising rates of anorexia and bulimia.^{Footnote 19}

Natural reproductive processes such as menses, pregnancy, childbirth and menopause may cause pain and discomfort and interfere with life events. When coupled with other sources of stress, they can bring about physical and mental distress unique to women. For many years, women's advocates have stated that women and their health concerns are too often over-medicalized (i.e., over-medicated and their conditions treated as pathological) because the health sector has difficulty distinguishing between natural processes and sickness.

4. Risk factors and their consequences for women

Health risks for women and men derive from a number of factors including active high-risk behaviour, passive behaviour that precludes or undermines health, family history and social and physical environments.

Suicides, motor vehicle accidents and other types of accidents account for more sick days away from work and cause more deaths for men than for women.^{Footnote 20,Footnote 21} However, women and men do take risks of other kinds such as having unprotected sex which can result in STDs or unwanted pregnancies, or using drugs intravenously.

The reasons behind risk taking and the results which ensue vary according to gender. In regard to sexual behaviour, for instance, popular notions assume sexual assertiveness among males and relative passivity among females. Women are generally regarded as responsible for contraception but may sometimes face barriers in negotiating safer sex with a male partner. This is a factor of relevance, for example, in understanding the transmission of HIV in women. In light of recent statistics indicating that the rate of HIV among women who are tested is increasing,^{Footnote 22} we must improve our knowledge of the dynamics of women's high-risk behaviours. These behaviours are sometimes gender-specific and are changing as women's social roles and status in society evolve.

The teen pregnancy rate peaked in 1974, declined in the mid-eighties but is creeping up again particularly in the under age 15 group, where it has gone from 3.9 per 1,000 in 1987 to 5.1 in 1993 (p. 18).
Reproductive Health: Pregnancies and Rates, Canada 1974-93, Table 14B, Statistics Canada, 1996

As well, women face different risks due to factors tied to their biological and social characteristics: for instance, the prevalence of osteoporosis among older women, coupled with the loss of agility and balance, result in a high number of fractures in women, often leading to severe disability or death.

Gender-based violence is another risk factor that women face, and has wide-ranging consequences for their health and the health system. A 1993 Statistics Canada study revealed that half of Canadian women are victims of physical or sexual assault as defined by the Criminal Code at least once beyond age 16, and are most at risk from their male partners. Dating violence, violence or sexual harassment in the workplace and by professionals in the health system and sexual assault have all been documented in recent studies, as has the enormous cost of violence to the health system.^{Footnote 23}

9% of females and 6% of males aged 12-14 are beginning smokers.
1996/97 NPHS Highlights, Smoking Behaviour of Canadians, Health Canada

One of the most tragic forms of high-risk behaviour for women is cigarette smoking, as evidenced in current statistics on lung cancer mortality rates for women. The rate at which adolescent girls are taking up smoking is particularly alarming.^{Footnote 24} This wave of new smokers bodes poorly for the health of tomorrow's women. It implies that greater knowledge and effort are required to successfully reach teens of both sexes. A better understanding of gender-based differences and effective interventions are critical to the success of these efforts.

The circumstances of some women's lives reduce their access or motivation to take preventive measures to safeguard their health. Invasive cervical cancer is commonly found in those women who have never been screened or who are not screened regularly. The 1996/97 National Population Health Survey reports that Pap smear rates varied by socioeconomic status. Lifetime rates for women aged 18 and older ranged from 75% of those in the lowest household income group to 90% for those in the highest. Aboriginal women are over-represented in cervical cancer statistics and are a group for which special measures must be taken to improve use of known preventive measures.

Physical inactivity is also a problem. Women of all ages do not engage sufficiently in physical activity, despite its many positive effects on health. The health system must learn how to encourage healthy behaviours in women by developing approaches that take into account their values, lifestyles and roles.

Environmental and occupational risks are increasingly significant for women. Their occupations tend to expose them to lengthy periods of inactivity, especially in a sitting position, and to repetitive strain injury. As well, women may react differently than men to environmental contaminants. Current concern about the relationship of environmental toxins to breast cancer is an example.

5. Gender as a determinant of health

Health Canada and the provincial and territorial governments have committed to a health determinants approach. This approach recognizes that many factors in addition to health care determine the health status of an individual.

The 12 health determinants which Health Canada has identified are:

• 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;
• gender; and
• culture.

In 1996, children in female lone-parent families were five times more likely to be in a low-income situation than those in two-parent families (60.8% of female lone-parent families had low income versus 11.8% for two-parent families). Statistics Canada, 1997

These determinants are highly interactive. Income, employment and education, for instance, are inter-related and have implications for other determinants such as environments, child development and personal health practices.

Gender has a strong influence on all determinants. For example, wage gaps, low occupational status and poverty are common observations in any analysis of women's socio-economic status.

The lives of women seniors are more likely to be marked by poverty as a result of interruptions or non-participation in the paid labour force, or of low wages and few benefits.^{Footnote 25}

Medicare provides universal access to physicians and hospital services. However, because women, as a group, are less likely to be employed full-time, they are less likely to have access to uninsured services such as drugs.

In 1993, the majority (56%) of senior women living alone or with unrelated persons, had low incomes. This compared with 38% of unattached senior men (p. 85). Women in Canada, Third Edition, Statistics Canada, 1996

6. Biases in the Health System

The health system, not unlike society at large, tends to type-cast women and men based on longstanding traditional roles and attitudes. This has affected women both as users of the health care system and as caregivers, and has occurred in four ways:

1. A narrowness of focus;
2. Ignoring or circumventing women - an exclusion that translates into reduced access to resources; and under-representation in, or absence from, governance, research and education materials;
3. Treating women the same way as men when it is inappropriate to do so; or
4. Treating them differently when it is not appropriate.

Narrowness of focus

• Society and biology ascribe to women the traditional role of mother and child-bearer. The health system has reflected this reality through its historical preoccupation with the reproductive system and especially with maternity. While benefits have accrued in that Canada has one of the world's lowest rates of infant and maternal mortality,^{Footnote 26,Footnote 27} women's health extends beyond reproduction. The conventional way in which medicine has been practised, in contrast to a holistic approach, is another example of a narrow perspective.
• Narrowness of focus is also manifested in the reluctance of the health system to view health as more than an absence of illness and health system interventions as more than medical or surgical. Some health care providers may also exhibit a narrowness of focus, for instance, by assuming all women are heterosexual, which increases the discomfort level of lesbians and can result in an avoidance of the system or treatment oversights.

Exclusion

• Women are under-represented as policy makers, decision makers and educators in many segments of the health sector. Certain groups of women are doubly disadvantaged in these respects, because of their ethnicity or their sexual orientation or because they have a disability and are less likely to be included in key roles and areas of the health system.
• Where women's representation is high within a profession, that profession tends to be less valued than one where men predominate. Generally, women are over-represented in nursing and under-represented in most fields of medical specialization - the gatekeepers and decision-making disciplines of medicine.
• In a 1994 report, the Medical Research Council's Advisory Committee on Women's Health Research Issues estimated that only 5% of the Council's research funds went specifically to women's health issues. Exclusion of women from research results in problems of validity and important data gaps.

Treating women the same way

• The health system may inappropriately treat women and men the same way. As discussed, misdiagnoses of women with heart disease occur because the expectation is that women will display the same symptoms that men display.
• Women's role in the family, as guardians of the health of family members and as primary caregivers in most instances, differentiates them from male patients and is not always recognized by health practitioners. Women often interact with the health system on behalf of their spouse, children, parents or other relatives. As such, women may need more time and attention from the health system, and attention of a different sort.
• As patients, women's early discharge from hospital can have different consequences than for men and often takes place in the absence of an understanding on the part of the health system that more women than men live alone or will return to a family situation where they are the primary executor of household duties and are likely to be without a family caregiver.
• Because health practitioners often assume that women will assert themselves as readily as men do when interacting with the health system, they do not encourage them to take part in care and treatment decisions. In focus groups on women's health, participants stated that they "wanted to make their own choices regarding medical controls, tubal ligation and their reproductive abilities, irrespective of age."^{Footnote 28}
• In some instances, treatment programs will assemble members from both sexes in a single group program despite the fact that women may have had different life experiences that cause them to feel overwhelmed or threatened in a mixed environment.

Treating women differently

• Public education messages designed to prevent unwanted pregnancies have reinforced prevailing attitudes that place most of the burden of responsibility on young women. It would be more appropriate and effective to target both women and men.
• Women have long reported that health care providers talk down to them and trivialize their complaints. As previously mentioned, the health system also has conferred on women's health processes a pathological status in situations where life conditions were natural.
• The biases of the health system affect not only users of services but also paid and unpaid caregivers. The nursing profession, which is primarily composed of women, experienced a long struggle to gain recognition both in its professional standing and its remuneration.

43% of Canadian women have changed doctors because they were dissatisfied with the way they were being treated. Four of the six most frequent reasons were related to the "doctor's attitude". Women's College Hospital Health Survey, March 1995

The Women's Health Strategy will seek to address these biases and inequities by encouraging a focus beyond maternity; by promoting greater participation of women in decision making; by shedding more light on the biological and social differences that explain when and why women and men ought not to be treated similarly, and proposing improvements; and by encouraging more comparable or similar treatment when warranted.

It should be noted that both women and men can be negatively affected by the health system. The implementation of the Women's Health Strategy does not minimize the difficulties that men may experience, or negate the fact that they too have health concerns specific to their biological and social circumstances.

The next section of the document highlights the main components of the Women's Health Strategy. The Strategy, in its totality, responds to health status issues that most critically affect women, to the limited role of women in decision making and to research and education gaps. It proposes processes and methodologies for ensuring that these areas become sensitive to the sex- and gender-specific needs of women.

III. What is Health Canada's Women's Health Strategy?

The Women's Health Strategy is an integrated framework for addressing major women's health issues. It consolidates Health Canada's current and new initiatives. The Strategy has seven main attributes: it is balanced, respectful of diversity, egalitarian, evidence-based, coherent, multi-sectoral and incremental.

The goal of the Women's Health Strategy is to improve the health of women in Canada by enhancing the responsiveness of the health system to women and women's health.

To meet its goal, the Strategy is organized around four main objectives which are intended to bring about changes to the way Health Canada discharges its major responsibilities: its leadership, networking and coordination roles; policy development; research, surveillance and data collection activities; regulatory functions; direct service delivery; and its work to promote health and prevent disease.

Balance will be respected in that the Strategy will focus on all age groups; on bio-medical and social aspects of health; on policy and program elements; on individual and population health issues; and on women as users of health care as well as caregivers, paid and unpaid.

Diversity among women and the fact that they are not a homogeneous group is recognized. Health Canada is sensitive to ethnocultural heritage, sexual orientation, level of ability and demographic characteristics that alter women's experience of health and their interactions with the health system.

The Strategy is premised on an egalitarian relationship between the user and the provider of services and recognizes women and men as equal partners in the development of policy, research and services.

The Strategy will be evidence-based, informed by concerns identified by women and the health system and by data and research findings which shed light on the differences between women's and men's health concerns.

Strategies developed for women and analysis of issues in one area must connect with strategies and analysis in others; each can benefit from the other, thus ensuring that the Strategy is coherent.

The Strategy will be multi-sectoral, recognizing that social and economic factors play an important part in securing and maintaining health and that the involvement of partners from many areas in both the governmental and non-governmental sectors is essential.

Finally, the Strategy will be incremental. It will adapt to emerging issues and new knowledge.

The Strategy is primarily focused on Health Canada's policies and programs and on pursuing activities within Canada. However, Health Canada will, from time to time, work in partnership with other countries and international organizations, on matters of common interest that advance the women's health agenda at home and globally.

The following pages set out the four objectives of the Strategy and identify some of the key activities that will be undertaken to fulfil them.

Objective 1: To ensure that Health Canada's policies and programs are responsive to sex and gender differences and to women's health needs

The federal government is committed... to ensuring that all future legislation and policies include, where appropriate, an analysis of the potential for different impacts on women and men (p. 17). Setting the Stage for the Next Century: The Federal Plan for Gender Equality, 1995

Once attained, Objective 1 would result in the Department having fully integrated gender into its day-to-day operations. It represents Health Canada's commitment to doing business in a way that is sensitive to women's health needs and concerns. To support this process, a number of steps will be taken:

• 1.1 In keeping with the commitment in the Federal Plan for Gender Equality, Health Canada will, as a matter of standard practice, apply gender-based analysis to programs and policies in the areas of health system modernization, population health, risk management, direct services and research.
• 1.2 Tools, methods and training material will be developed to assist in implementing these gender impact assessments across the Department and to orient senior managers to the requirements of this practice.
• 1.3 Women's health issues will be taken into consideration in the annual planning exercises of the Department.
• 1.4 A gender perspective will inform Health Canada's approach to ethical issues and consideration will be given to those of particular concern to women.
• 1.5 The inclusion of gender considerations and differential impact will be one of the criteria when assessing research and demonstration proposals for which Health Canada funding is being sought.
• 1.6 Boards or advisory bodies which fall under the purview of the Minister of Health will be encouraged to seek equal representation of women and men and the inclusion of persons who are knowledgeable and sensitive to gender and diversity issues.
• 1.7 Women's organizations and health organizations interested in women's health will be consulted on key policy files.
• 1.8 A plan will be developed to mobilize interdepartmental collaboration in identifying objectives and initiatives that will address socio-economic issues of women related to health.
• 1.9 Gender considerations will be addressed in departmental work on children, to ensure that the distinct issues of girls and boys will be taken into consideration in policies and programs.
• 1.10 Gender considerations will be addressed in departmental work on the health and health system impacts of aging.
• 1.11 Gender analysis of Health Canada's legal work, including legal advice, litigation, legal policy and legislation, will be carried out by the Legal Services Unit, supported by the Unit's Gender Equality Specialist who is designated by Justice Canada.

Objective 2: To increase knowledge and understanding of women's health and women's health needs

The Women's Health Strategy will be evidence-based. Health Canada plays a significant role in the collection and analysis of data and the support of a number of research programs and activities. The Strategy will make this research more relevant to women's health concerns. Findings will be widely shared, in simple and straightforward language. Objective 2 will be supported by the following:

• 2.1 The five Centres of Excellence for Women's Health will continue to generate and synthesize new knowledge about women's health, particularly in respect to the determinants of health, for the purposes of informing the policy process.
• 2.2 The impact on women and women's health of health reform and restructuring will be a prime focus of research conducted by the Centres of Excellence for Women's Health.
• 2.3 A federal research plan on women's health will be developed to guide and help coordinate priority-setting among federally funded research programs. Women's health issues will be promoted in the further development of the Canadian Institutes of Health Research concept. A National Advisory Group will help guide the work of the Centres and the Women's Health Bureau with respect to women's health research.
• 2.4 The Women's Health Bureau will continue to support the Canadian Women's Health Network (CWHN), which represents over 70 organizations based in all provinces and territories. It will provide a communications infrastructure for women's health in Canada.
• 2.5 The Canada-U.S.A. Program of Cooperation's two joint initiatives on Research and on Clearinghouses/ Information Networks will, respectively, build the capacity for Canada and the United States to share women's health research and research findings and link the CWHN and the U.S. National Women's Health Information Centre.
• 2.6 Comprehensive health status and utilization indicators will be developed to capture age, sex and gender differences and to reflect the 12 health determinants recognized by Health Canada. The Women's Health Bureau will work with health data collection agencies, including the Canadian Institute for Health Information (CIHI), to address gender biases in methodology and gaps in the data. A women's health report will be released every four years.
• 2.7 The Women in Clinical Trials policy announced in September 1996 will be monitored.
• 2.8 Through the renewed Family Violence Initiative, Health Canada will continue to support research related to the health consequences of violence against women. The results of these studies will be disseminated by the National Clearinghouse on Family Violence.
• 2.9 Via the Canadian Health Services Research Foundation, the Nurses Using Research and Service Evaluations (NURSE) Fund will support research on nursing, a health profession comprised predominantly of women.
• 2.10 The Canadian Health Services Research Foundation, designed to provide substantial new resources for health services research in Canada, will be encouraged to place a high priority on women's health issues.
• 2.11 In-depth research on high priority women's health issues will be supported, e.g., the causes of breast cancer including environmental concerns; chronic illnesses; mental health, including self-esteem of the girl child; and barriers to the utilization of services such as diversity and socio-economic issues.
• 2.12 Research in the area of complementary and alternative health care will be accelerated, including evaluating the risks and benefits of alternative health care providers.
• 2.13 In establishing the Centres of Excellence for Children's Health and Well-being, Health Canada will ensure that gender considerations are addressed.

Objective 3: To support the provision of effective health services to women

Health Canada has a role to play in supporting groups and jurisdictions that have direct responsibility for the delivery of health services. The Department is responsible for interpreting and enforcing the Canada Health Act whose principles constitute the framework for Canada's publicly financed health care system. In addition to strengthening knowledge, as outlined in Objective 2, the federal government provides leadership and support for the development of public awareness, health practices and educational aids. It also delivers or funds health services for First Nations and Inuit. The Women's Health Strategy will encourage and promote a wide range of activities in these areas:

• 3.1 The Government's commitment to interpreting and enforcing the Canada Health Act will consider the particular needs of women by ensuring that gender impacts of policy interpretations or changes are fully assessed.
• 3.2 Gender impact analysis will inform Health Canada's contribution to the development of health system accountability frameworks.
• 3.3 Health Canada initiatives in support of health system modernization and expansion will include a gender impact assessment.
• 3.4 Attention will be given to issues of access, including health services for women who are under-served because of social, geographical or economic barriers.
• 3.5 Model tools will be developed to assist educators, service providers and planners to conduct a gender analysis of their work.
• 3.6 Alternative methods of reimbursement of health professionals aimed at reducing incentives for the inappropriate provision of services will be explored.
• 3.7 The effects of health system restructuring on women's roles as paid and unpaid workers will be monitored with particular attention to the following issues: attrition, job loss, retraining, workplace environment, ability to deliver quality care, privatization and the shifting of responsibility to volunteers and relatives.
• 3.8 Health Canada will seek the input and participation of Aboriginal women in the development of programs to strengthen home and community care and in developing health information systems in First Nations communities.
• 3.9 Effective regulation of reproductive and genetic technologies that will protect women and women's dignity will be pursued. Post-market and long-term fertility drug surveillance will be further developed.
• 3.10 Effective post-market surveillance and adverse events monitoring systems that safeguard women's health will be implemented.
• 3.11 Health Canada will continue to encourage the involvement of Aboriginal women as it negotiates transfer agreements on health with First Nations, according to the federal policy on the inherent right of Aboriginal self-government.
• 3.12 The Canada-U.S.A. Program of Co-operation on Breast Cancer will support policy makers, researchers, service providers and advocates by encouraging the sharing of expertise and experience.
• 3.13 Greater attention to mental health issues as they affect women - particularly adolescents and seniors - will be intensified, given the over-representation of women in mental health statistics. Attention to eating disorders, and to assessing the importance of mental health interventions in primary care are examples of work to be conducted in this area.
• 3.14 Effective models of care for women seniors will be promoted to address end of life issues and over-institutionalization; and to support caregiving in the home and palliative care.
• 3.15 Collaboration will continue with other federal departments and health provider organizations to sensitize health and other practitioners to female genital mutilation.
• 3.16 Efforts will be continued to educate health care professionals and women themselves to reduce over-medicalization and over-prescribing of drugs.
• 3.17 In collaboration with the medical profession and other partners, evidence-based decision-making will be promoted through the increased use of tools such as the Canadian Guide to Clinical Preventive Health Care.
• 3.18 The development of models of best practice will be supported to better address certain issues such as violence, abortion, mental health.
• 3.19 Skill-building models will be developed to support increased participation of women in decision-making roles and prepare them to be effective advocates and participants on boards, committees and in the health system in general.
• 3.20 In follow-up to the report of the Advisory Council on Health Infostructure, departmental consultations and the ensuing response will take account of women's needs and concerns.
• 3.21 The Department will continue to lead and coordinate the multi-departmental Family Violence Initiative, which will maintain its emphasis on violence against women as a thematic priority.

Objective 4: To promote good health through preventive measures and the reduction of risk factors that most imperil the health of women

Health Canada has a responsibility to reach individuals before they adopt health-threatening lifestyles and to assist them in avoiding high-risk situations, behaviours and products that lead to health conditions or disease. To fulfil this Objective, Health Canada's Women's Health Strategy has identified a number of measures:

• 4.1 Health Canada will be more proactive in ensuring that women have access to safe and effective drugs, procedures and medical devices.
• 4.2 The Canadian Perinatal Surveillance System aimed ultimately at promoting effective and efficient care during pregnancy and the neonatal period will be strengthened.
• 4.3 Health promotion and disease prevention activities will be undertaken to reduce cervical cancer mortality and morbidity through more extensive screening.
• 4.4 In its efforts to further promote increased availability and quality of breast cancer screening, Health Canada will continue to work with the provinces and territories to foster screening programs and will ensure that mammography is carried out correctly and accurately through the regulatory provisions of the Radiation Emitting Devices Act and the development of a national standard for the installation and use of this equipment.
• 4.5 Health promotion projects will be initiated to counter inactivity and increase active living and fitness among women of all ages.
• 4.6 Prevention programs for women at risk for HIV/AIDS will be supported, in collaboration with community groups, public health and national and professional organizations.
• 4.7 The reduction of environmental hazards that threaten women's health will be the focus of prevention activities. Health Canada will accelerate screening and assessment of new and existing substances, improve management and control of toxic substances and track progress.
• 4.8 The reduction of physical and psychological occupational health hazards that undermine women's health and well-being will also be addressed.
• 4.9 Through initiatives such as the Canada-U.S.A. Program of Co-operation on Smoking Cessation Among Young Women and Adolescent Girls, Health Canada will continue to support health promotion activities and document trends and the effects of regulatory controls on smoking behaviours.
• 4.10 The identification and dissemination of best practices in smoking prevention, cessation and protection for girls and young women will be undertaken. Knowledge development, training and dissemination of best practices to address maternal smoking, post-partum smoking relapse, smoking among girls and young women and children's exposure to environmental tobacco smoke are initiatives to be pursued.
• 4.11 Stay-in-school values and healthy lifestyles for Aboriginal youth will be promoted, in particular for girls who, later as adults, will play an important role in the health of their communities.
• 4.12 Work on supportive environments for children, youth and families and seniors will be promoted within a framework of gender equality.
• 4.13 Health promotion activities to reduce teen pregnancies will be pursued within a context of health determinants.
• 4.14 The development of information and best practices to help families, and women in particular, to harmonize work and family demands and to cope with the stress that it places will be developed.
• 4.15 Health Canada will undertake work to address high priority chronic health concerns of women:
  • A coordinated national strategy will address cardiovascular health promotion and disease prevention in Canadian women.
  • Work will proceed in partnership with the Osteoporosis Society of Canada to produce a preventive guide for women.
  • The Canadian Diabetes Prevention and Control Strategy and the Aboriginal Diabetes Initiative will address the needs and concerns of women in diabetes prevention and control, education, care and treatment and surveillance.
• 4.16 To facilitate the implementation of national nutrition guidelines for maternal and infant health and to promote women's nutritional health through healthy eating and support for making healthy eating choices, e.g., an improved nutrition labelling system and public education will be undertaken.
• 4.17 Health Canada will modernize and strengthen the federal food safety program with new measures to enhance surveillance systems, improve scientific capacity and increase regulatory activities.
• 4.18 Health Canada will provide additional support to First Nations and Inuit communities, as well as non-Aboriginal communities, to improve prenatal health and nutrition in order to reduce high infant mortality and negative birth outcomes.
• 4.19 The role of the media in socializing children and youth has been recognized and Health Canada will continue to support media awareness and consumer literacy through strategies and dissemination of best practices to increase the media literacy skills of girls and young women so that they make healthy lifestyle choices.

IV. Conclusion

The development of Health Canada's Strategy for Women's Health was guided by statistical data, issues identified and documented in the literature as well as in briefs presented by women's and health organizations. The initiative will continue to be refined and further developed on the basis of the recommendations emanating from the workshops of the Canada-U.S.A. Women's Health Forum, from emerging trends and new knowledge and from consultations which are organized from time to time by Health Canada.

In June 2000, the United Nations General Assembly will hold a special session on Women's Equality, to review progress by member states in the implementation of the 1995 Beijing Platform for Action. The purpose of the meeting is also to propose a vision for the years to come. Health Canada's strategy for advancing women's health will contribute to Canada's vision.

Glossary

Sex

Sex (as in "sex differences") refers to biological characteristics such as anatomy (e.g., body size and conformation) and physiology (e.g., hormonal activity or functioning of organs). These characteristics can be very different for women and men and should be taken into account by the health system. Yet, the health system has often been blind to these biological differences. Examples include design of medical devices such as artificial hip replacements and angioplasty instruments based on the male body as the standard, but expected to fit women. The term "sex" is also used when referring to the two main groupings of the human species, as in "clinical trials included both sexes".

It would appear that the experience of a particular social position must be different for women and men in ways which are not captured by the crude measures of class, household income, marital status and work. ^{Footnote 29}

Gender

Gender (as in "gender differences") refers to the array of socially determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. "Gendered" norms shape the nature of health issues and influence the health system's practices and priorities. For example, women are more vulnerable to sexual or physical violence, low income, lone parenthood, gender-based causes of health risks and threats (e.g., accidents, STDs, suicide, smoking, substance abuse, prescription drugs, physical inactivity); often the system addresses these issues without taking into account their gendered nature. Measures to address gender inequality and gender bias within and beyond the health system will improve population health.

N.B. Biological traits influence gender characteristics and vice versa. For instance, gender roles influence the nature and extent of violence between men and women but sex differences also play a role in that women are generally smaller and less physically strong. Gender and sex are interactive.

Gender-based Analysis

A process whereby policies or programs are assessed to determine their actual or potential differential impact on women and men. The term has gained international acceptance, however, it does not denote the inclusion of sex-based analysis (i.e., an analysis of biological differences), which is in effect inherent to the analysis used within Health Canada.

Some of the best kept secrets of longevity and good health are to be found in one's social, economic and cultural circumstances. ^{Footnote 30}

Gender-based analysis is an evidence-based approach that will lead to programs and policies which are not biased on the basis of either sex or gender. Gender-based analysis helps to ensure that the differential economic, political, social and biological circumstances of both girls and boys, and women and men are taken into account. Gender-based analysis will render transparent issues such as the under-representation of women in decision-making or the absence of women in research. It may similarly highlight imbalances in addressing men's health issues.

Population Health

The document Strategies for Population Health. Investing in the Health of Canadians defines population health as an approach that differs from traditional medical and health care thinking in two main ways. (1) Traditional health care focuses on risks and clinical factors related to particular diseases. Population health strategies address the entire range of factors that determine health. Health is affected not only by the type of care and services provided, but also by social and economic factors such as social status, income, level of education, child development and social supports, commonly known as "health determinants". (2) Health care deals with individuals one at a time - usually individuals who already have a health problem or are at a significant risk of developing one. Population health strategies are designed to affect the entire population.