Women’s Health Resources: facilitating a community of care for midlife women

Lynn M. Meadows, Wilfreda E. Thurston, Darryl Quantz and Mary Bobey

Abstract: Since 1981 research has explored the role of women’s health centres in providing health information and education to women in a nontraditional setting. These settings have been designed to provide more appropriate, and often more comprehensive, care by responding to the specific health issues and needs of women across the age continuum. The type of care and resources provided by these centres make a significant contribution to women’s capacity for participation in decisions and action around their own health. This article examines the service delivery and perceived roles of one such centre, the Women’s Health Resources (WHR) centre in Calgary, Canada. Data for this paper were extracted from WHR evaluation forms for 199 midlife women seeking individual consultation, as well as personal interviews that were conducted with four female staff members. Clients of the WHR cited numerous reasons for seeking service at the centre, the most common being for emotional health care, nutritional consultation or more comprehensive information on a specific illness. Three major components of service provision at the centre were identified: information, psychological care and complementarity of services. Women used the information they gained from WHR services to aid in health decisionmaking and as a resource for empowerment in being partners in their own health. Clients noted that the WHR was a valuable source of additional information beyond what their own family physician and/or specialist were able to provide. The feminist and woman-centred care at WHR, in conjunction with the emphasis on education, offers an invaluable source of information and services for women. Through the shared experiences of both the clients and staff of this centre, this article provides an outline of how such services are perceived and utilized.

This manuscript was submitted on March 4, 2004. It received blind peer review and was accepted for publication on September 20, 2005.

Lynn M. Meadows, PhD Associate Professor, Departments of Family Medicine & Community Health Sciences Shopper’s Drug Mart Professor in Women’s Health University of Calgary 3330 Hospital Drive NW Calgary, AB T2N 4N1 Canada Tel: (403) 220-2752 Email: meadows@ucalgary.ca

Wilfreda E. Thurston, PhD Professor Department of Community Health Sciences Director, Institute for Gender Research University of Calgary 3330 Hospital Drive NW Calgary, AB T2N 4N1

Darryl Quantz, MSc Institute of Health Promotion Research University of British Columbia 2206 East Mall, Rm. 411 Vancouver, BC V6T 1Z3

Mary Bobey, MSc, CPsych Manager Women’s Health Resources Grace Women’s Health Centre 1441 29th Street NW Calgary, AB T2N 4J8 Introduction

Since 1981 research has documented the emergence of women’s health centres and the services they provide to women across the age continuum. These centres were primarily developed in response to the delivery model found within a traditional health care setting, which often lacked interest in and sensitivity to women’s concerns (Phillips, 1995, 1996; Phillips and Ferguson, 1999; Williams, 1996; Bierman and Clancy, 2000; Collins, 2002; Ericksen et al., 2002; Goodman et al., 2002; Mort, 2001). Evidence suggests that for some non-biomedical services, women prefer the resources found at such centres over the care provided by their family physician (Meadows et al., 2001a, Meadows et al., 2001b). While early centres focused largely on reproduction-related services (Bruce, 1981), recently more comprehensive services are available, including general internal medicine (Ryan, et al., 1999). One of the major advantages of women’s health centres is the attention paid to gender differences in service delivery and receptivity (Phelan et al., 2000). There is some evidence that the populations served by women’s health centres are biased toward certain groups (e.g., younger, less chronic illness, middle socioeconomic status) and that women are better served by general medical facilities (Phelan et al., 2000). However, when compared to women’s health centres (Curbow et al., 1998), key services (e.g., mental health services) are absent in a more general comprehensive medical care environment.

This article examines the service delivery model and role of the Women’s Health Resources (WHR) centre in Calgary, Canada as a resource for comprehensive health care for midlife women (i.e., women between the ages of 40 and 65). We focused on this age group to allow comparisons with several other concurrent studies that we are conducting on midlife women’s health in which we explore the reasons why midlife women are not participating in screening as frequently as recommended in guidelines (Champion & Huster, 1995; Herman, Speroff, & Cebul, 1995; Lantz et al., 1995). We argue that urban centres such as this provide an essential service to the women and the community they serve. Women’s Health Resources provides a vital source of health-related services and information for women’s health that fulfills a complementary role with that of more traditional biomedical services.

Keywords

•women • community health

Women’s Health Resources history and development

The Salvation Army Grace Women’s Health Centre (SAGWHC) is the current iteration of a facility that began to provide women’s health services in 1904 as a home for “unwed mothers” [sic]. Throughout the ensuing 95+ years, the facility developed into the Grace Maternity Hospital and Girl’s Home and evolved into an obstetrical and gynecological hospital that gradually acquired broader surgical capacity. In recent years it was amalgamated into the local health authority to provide nonacute and acute care for women, and currently combines diagnostic and treatment services. The SAGWHC has moved from an independent and freestanding site to its current location adjacent to the acute and teaching medical care centre.

The Women’s Health Resources (WHR) centre is part of the SAGWHC. It was established in 1986 as a response to women’s demands for greater participation in their health care. The WHR programmes are designed to respond to women’s health needs beyond pregnancy and reproduction; programmes also include health promotion and illness prevention. WHR has a multidisciplinary team including psychologists, a dietician and a clinical nurse specialist who provide individual consultations to women from all backgrounds and socio-economic statuses. It was the first centre of its kind in Canada and follows a woman-centred model of care. Its stated purpose is: To meet women’s needs for health education, information and counselling to enable women to make informed decisions about their own and their families’ health, and to promote the recognition and acceptance that health and well being are the individual’s responsibility.

In this article we examine reflections of midlife women on the current role of WHR and argue that centres such as this provide essential information and services that make a significant contribution to women’s well-being.

Methods

All WHR clients seeking an individual consultation are asked to complete a selfadministered questionnaire that collects information on demographics; perceptions and beliefs about health; health-related behaviours; a summary of health status; and the use of other health resources. The majority of questions on this form are in an open-ended format, with space available for clients to make any additional comments.

This study was designed to blend the insight provided by having both qualitative and quantitative data. For this analysis, data were available from all forms collected between January 1996 and mid-June 1999. Only women between the ages of 40 and 65 were included in this analysis to allow comparisons with several other concurrent studies that we are conducting on midlife women’s health. Data from staff members at WHR were also collected using short, semistructured personal interviews that were audio-recorded and transcribed verbatim. As this was an internal quality control study, permission for the use of these data was obtained from the manager of WHR.

Data from the forms were coded and entered into SPSS for analysis using descriptive and summary statistics. Qualitative data were summarised and coded using thematic analysis aided by the techniques of immersion and crystallization (Borkan, 1999). Multiple team members met regularly to discuss emergent categories and connections, and to focus on interpretation.

Results

Data discussed here are from 199 questionnaires and interviews with 4 (female) staff members. The mean age of clients was 49.2 years (median 49), and included the full range of ages from 40 to 65. Fifty-four percent of women who obtained services from WHR have household incomes of $40,000 or greater; this is comparable to statistics for the City of Calgary which indicate that 48% of the population have household incomes of $40,000 or greater (Statistics Canada, 1996). Only 2.6% of our sample had less than a high school education, while 24.2% had a high school education, 60.8% had post secondary education and 11.3% had post graduate education. This again reflects the high educational status of most people in our city. Nearly two-thirds (64.3%) reported that they were married, while 23% reported that they were divorced or separated. Approximately 80% reported a Christian religious affiliation and 97% stated that they currently had a family physician. Women learned about WHR by word of mouth or from a friend/family member (32.2%) or from a health professional such as a nurse or physician (31.2%). The most common reasons reported for visiting WHR were emotional health (25%); specific illness/health information (20%); and nutritional consultation (17%). Many women reported more than one reason for visiting WHR. Staff members had been at the centre from 6 to 14 years and were chosen as key informants through their roles as care providers in psychological, physical and nutritional health, and administration.

Three major components of WHR’s services were identified in the qualitative analysis: the provision of information; the provision of psychological care; and complementarity of services. These are explored below.

Information provision Women highlighted the important role WHR played in the provision of health information. Those most frequently citing information needs as a reason for their visit were women with educational levels of post secondary or graduate education. These women sought information for a specific issue (e.g., menopause, osteoporosis) while others utilised WHR to get more general information. For example, a concern over peri-menopause articulated in a previous patientphysician encounter could be followed by a visit to WHR for information on hormone replacement therapy, lifestyle changes and other relevant issues. With a well-informed patient, the next patientphysician encounter could then move to decision-making regarding management. The need for education is seen in women who do not realise that a Pap smear cannot be done during menstruation, or that the best time for physical examinations is a couple of weeks after a period when breasts are less tender and lumpy, or that not consuming caffeine for 48 hours before a mammogram may help to reduce discomfort.

The information resources at WHR are available for use both on an individual basis and/or with guidance from a staff member at WHR. These include an extensive library, Internet access and a

variety of workshops including such topics as hormone replacement therapy, stress management and incontinence. Women viewed these resources as invaluable in gaining access to information. One woman commented: “The centre is up to date on state of the art issues in women’s health.” Staff at WHR also echoed these sentiments: “The health consultants are very experienced [and] have a breadth of knowledge. We have professional resources at our fingertips so that we can give [women] the answers that they’re looking for.“

Women used the information obtained from WHR in decision-making and in preparation for interactions with other health professionals. A philosophy of empowerment was highlighted by both clients and staff members. One woman wanted “more information on treatments by doctors.” In expressing a need for “more of a support group…” however, women were referring to information and resources from professionals at WHR to aid in their decision-making and preparation for visits to their own physicians. One staff member noted: “We’re helping women get information so they’re better informed, and to help in their interactions in referrals to other experts. They are prepared to sit down one on one with a health professional and actually draw up an action plan.” Another staff member emphasised the breadth of information: “They can gather various kinds of information so they’re getting a more rounded approach…to make their decision. It gives them a broader perspective.”

One client wrote: “I’m seeking an understanding of my needs and problems for myself, seeking knowledge so I can be more active in my health care.” At WHR women also have access to referral information whether seeking a family physician or names of other specialists or professional health services. The staff of WHR do not, however, make direct referrals. One woman noted: “I was wondering about changing doctors…I hope to find clarification for my feelings here.”

Psychological services Twenty-five percent of women seeking an individual consultation at WHR were requesting help for emotional health issues through an appointment with one of the four part-time psychologists. Use of these services was almost uniform across educational levels, with slightly greater use of these services by women with high school education and least use by women with graduate level education. Individual counselling is provided through self-referral, without charge and in a timely manner for issues ranging from depression and anxiety to dealing with stress associated with work or family. One woman wrote: “When I’ve come here I’ve believed there is a real caring for us.” Both clients and providers indicated that the focus on the client’s needs and feelings provides an ideal environment for woman-centred care.

Over two-thirds of clients identified emotional health as a key aspect of being healthy, yet less than half rated their own emotional health as good or excellent, compared to 64% who rated their physical health as good or excellent. One way of meeting this need is through this service, “More networking between women provides more info[sic] that helps women in their search for wellbeing.” The staff members at WHR recognize the importance of this service: “They [the women] find it supporting because somebody listens. Because they’re not rushed to put it [their problem] in five minutes.”

The approach taken at WHR also aids in communicating problems that may be difficult to articulate. Emotional problems that are not viewed as “really serious” (e.g., mild depression, general anxiety, relationship problems, or verbally abusive situations) are often discounted or missed in typical clinical encounters. One staff member noted: “I think the best thing that we do here is that we listen and we care.”

Complementary services Women usually consulted their family practitioner prior to requesting an individual consultation at WHR. Although women are encouraged to selfrefer, health professionals were the source of referral for 63% of clients at WHR. This reflects a general recognition by physicians and other health providers of the importance of WHR.

Women noted that WHR allows them the time and freedom to explore issues related to their health care needs including questions regarding patient/physician relations, lifestyle, exercise, and assertive communication. Of particular note was the use of WHR for nutrition related information, especially among those with less than high school education and those with graduate education. Women are aware of time limits that constrain their interactions with physicians, often encountering limits of one presenting problem per visit. Sometimes women need more information about a problem: “I have concerns that are not answered by my doctor,” or underlying issues that may not be addressed in a clinical encounter: “My doctor has been unable to explain reasons for extreme problems…” Women also want information about typical treatments and greater detail than is usually supplied in a clinical encounter. Our data suggest that family physicians are providing information and services but women have health needs beyond what can be dealt with in a brief, often rushed, clinical encounter. The fact that physicians or nurses initiate many referrals to WHR suggests their support of WHR in this community.

Discussion

Women are well aware of the need to take responsibility for their own health and well-being (Meadows, Thurston and Berenson, 2001). Increasingly the ideal model is one of shared care; an approach that best utilises available resources and avoids placing undue and inappropriate responsibility on either women or their physicians (Meadows, Thurston and Berenson, 2001). Women who seek health related information and resources through WHR reported three main areas of need: information to aid in their understanding and decision-making related to health problems or concerns; support for emotional health issues; and a source of complementary services to augment what is available in the physician/patient encounter. This information is important for primary, secondary and tertiary preventive care, and includes some services such as nutritional information that are not typically classified as complementary to those supplied by physicians, but form an important part of the determinants of health. Women who have reliable information regarding their personal health concerns can play an active role in their decisions (Mechanic & Cleary, 1980; Sherwin, 1992). Both women and

Case studies

“S. had an extremely emotionally and physically abusive father. She stated that, as a result, she always carried a lot of inner pain, hurt and anger, and she was deeply dissatisfied with her life. She had had several relationships with unsuitable and sometimes abusive men. She believed that she has been so desperate for love that she would go into a relationship with any man who showed interest in her. After six sessions she reported that she feels “really good” and “healed of many negative feelings from the past”. She was also able to remember more of her past, which felt like a release. She was able to feel calm and unaffected when a man she had just met cancelled his first date with her. She commented: “‘the counselling I have received has healed me tremendously...this is the most loving, nurturing and helpful program that I have ever come upon.’” L. was peri-menopausal and had done a considerable amount of self-help reading but was still struggling with anxiety and heavy bleeding. When she came to Women’s Health Resources lifestyle changes (diet, exercise and stress management) were suggested and the Clinical Nurse Specialist helped her with questions to discuss with her physician. L. followed up with lifestyle changes and there was a significant improvement in her general health however her heavy bleeding continued. Her physician referred her to a gynecologist. L. was not happy with the consultation. WHR’s Clinical Nurse Specialist encouraged her to seek another opinion. L. did and tried prescription drugs to control her bleeding. These did not help and a hysterectomy was suggested. L. returned to WHR. Information about hysterectomies, including whether to retain ovaries or not was provided along with stress management. L. subsequently had the hysterectomy and phoned WHR to express her thanks for “hanging in with her” while she made her decisions and for the “huge difference it made” in her life.

B. arrived at Women’s Health Resources devastated and in shock. He husband of 34 years had just told her he was leaving her for another woman. B. felt totally alone, rejected and extremely ashamed. She described looking in the mirror and not being able to see the reflection of her face. Counselling helped her recognize that she had options and resources available to cope with this difficult situation. B. commented on how coming to Women’s Health Resources made her feel “normal and that there was life after being dumped by her husband”.

the staff at WHR share a vision of women as knowledgeable individuals, preparing for and augmenting information from their physicians with that available at and through WHR.

The philosophy that guides WHR encourages the perspective that a physician appointment is a professional encounter, not a social visit. WHR programmes and staff support women’s efforts to meet with their physicians with clearly defined problems and as much information as possible. The programmes are designed to teach women that, like their physicians, they need to be prepared for the clinical encounter. For both emotional and physical health, information is one of the first steps toward self-help for women with health issues (Waller & Batt, 1999). This sharing of information empowers women through joint ownership of knowledge that could otherwise be a symbol of power (Symon, 2000). Such information is essential in order for women to advocate for a better health care system that reflects their needs (Deetz & Mumby, 1990; Waller et al., 1999).

The staff and resources at WHR support a holistic and feminist philosophy of care that views women as active partners in their search for health and well-being. As part of this feminist approach it is emphasized that women’s perceptions, experiences and knowledge are valid and that WHR has a commitment to providing resources that empower women to partner in their own pursuit of health. WHR programmes and staff provide an invaluable source of information and services that make a significant contribution to women’s well-being, particularly in our current provincial (if not arguably nation-wide) environment of having too few primary health care resources for preventive care (Meadows, Thurston and Berenson, 2001).

At WHR the staff is available to take an unbiased approach to dealing with women’s emotional health problems. For example, depression arising from an abusive situation is viewed positively, an appropriate reaction to a bad situation. Counselling takes into account the wholeness of the woman’s life. Women come to WHR because there is a staff of qualified professionals who are able to provide them with evidence-based information, counselling and other resources.

The evaluative feedback from women who use the services of WHR suggest a convergence of provider services and consumer needs. Physicians and other professionals from whom women seek help view WHR as a complementary resource for health. The focus on education, a holistic approach and being a professional resource for women has earned WHR a well-deserved reputation. A comprehensive review of women’s health centres identified the SAGWHC as providing exceptional service. In discussing her interview with the Coordinators for WHR, Crook (1995) wrote, “During the interview I thought fleetingly that if someone would just give these women a couple of million dollars to implement resource centres like this one across the country, women’s health would be transformed” (p. 229). Our research suggest that this women’s health centre provides invaluable services that make important contributions to women’s capacity for health and therefore for women’s active participation in preventive health care.

Acknowledgements

The authors would like to thank Dr. Catherine Scott for feedback regarding the manuscript and Kathy Dirk for editorial assistance.

References

Bierman, A.S., & Clancy, C.M. (2000). Making capitated Medicare work for women: Policy and research challenges. Women’s Health Issues, 10, 59-69. Borkan, J. (1999). Immersion/crystallization. In B.F. Crabtree & W.L. Miller (Eds.), Doing qualitative research (2nd ed., pp. 179-194). Thousand Oaks, CA: Sage Publications. Bruce, J. (1981). Women-oriented health care: New Hampshire Feminist Health Center. Studies in Family Planning, 12, 353-363.

Champion, V., & Huster, G. (1995). Effect of interventions onstage of mammography adherence. Journal of Behavioral Medicine, 18, 169-187. Collins, K.S. (2002). Evaluation of the National Centers of Excellence in Women’s Health: Sustaining the promise. Women’s Health Issues, 12, 287-290. Crook, M. (1995). My body: Women speak out about their health care. New York: Plenum Press.

Curbow, B., Khoury, A.J., & Weisman, C.S. (1998). Provision of mental health services in women’s health centers. Women’s Health, 4, 71-91. Deetz, S., & Mumby, D.K. (1990). Power, discourse, and the workplace: Reclaiming the critical tradition. In J.A. Anderson (Ed.), Communication yearbook/13 (pp. 18-47). Thousand Oaks, CA: Sage Publications. Ericksen, J., Dudley, C., McIntosh, G., Ritch, L., Shumay, S., & Simpson, M. (2002). Clients’experiences with a specialized sexual assault service. Journal of Emergency Nursing, 28, 86-90. Goodman, R.M., Seaver, M.R., Yoo, S., Dibble, S., Shada, R., Sherman, B., Urmston, F., Milliken, N., & Freund, K.M. (2002). A qualitative evaluation of the National Centers of Excellence in Women’s Health Program. Women’s Health Issues, 12, 291-308. Herman, C.J., Speroff, T., & Cebul, R.D. (1995). Improving compliance with breast cancer screening in older women. Results of a randomized controlled trial. Archives of Internal Medicine, 155, 717-722. Lantz, P.M., Stencil, D., Lippert, M.T., Beversdorf, S., Jaros, L., & Remington, P.L. (1995). Breast and cervical cancer screening in a low-income managed care sample: The efficacy of physician letters and phone calls. American Journal of Public Health, 85, 834-836. Meadows, L.M., Thurston, W.E., & Berenson, C. (2001). Health promotion and preventative measures: Interpreting messages at midlife. Qualitative Health Research, 11, 450-463. Meadows L.M., Thurston, W.E., & Melton, C. (2001). Immigrant women’s conceptualizations of health. Social Science & Medicine, 52, 1451-1458. Mechanic, D., & Cleary, P.D. (1980). Factors associated with the maintenance of positive health behavior. Preventive Medicine, 9, 805-814.

Mort, E.A. (2001). Patient-centered decision making: Empowering women to make informed choices—experience in the United States. Women’s Health Issues, 11, 319325.

Phelan, E.A., Burke, W., Deyo, R. A., Koepsell, T.D., & LaCroix, A.Z. (2000). Delivery of primary care to women. Do women’s health centers do it better? Journal of General Internal Medicine, 15, 8-15. Phillips, S. (1995). The social context of women’s health: Goals and objectives for medical education. Canadian Medical Association Journal, 152, 507-511. Phillips, S. (1996). Sexual harassment of female physicians by patients: What is to be done? Canadian Family Physician, 42, 7378.

Phillips, S.P. & Ferguson, K.E. (1999). Do students’attitudes toward women change during medical school? Canadian Medical Association Journal, 160, 357-361. Ryan, C.A., Ghali, W.A., Boss, R.D., Moskowitz, M.A., & Freund, K.M. (1999). Care during menopause: Comparison of a women’s health practice and traditional care. Journal of Women’s Health & GenderBased Medicine, 8, 1295-1302. Sherwin, S. (1992). No longer patient: Feminist ethics and health care. Philadelphia, PA: Temple University Press. Statistics Canada. (1996). Calgary: Sources of income, family and household income and families: social and economic characteristics, occupied private dwellings, and housing costs. Available: http://library.mtroyal.ca/dli/commdata/Calgar y/incfamch.htm Symon, G. (2000). Information and communication technologies and network organization: A critical analysis. Journal of Occupational and Organizational Psychology, 73, 389-414. Waller, M., & Batt, S. (1999). Advocacy groups for breast cancer patients. Canadian Medical Association Journal, 152, 829833.

Williams, P. (1996). Sick of dying: Neglect, misinformation and gender bias have festered unchecked in women’s health care. Homemaker’s, 48-54.