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Introduction

Marie DesMeules (Health Canada), Arminée Kazanjian (University of British Columbia), Health McLean (Centre for Research in Women's Health), Jennifer Payne (Health Canada), Donna Stewart (University of Toronto), Bilkis Vissandjée (University of Montreal)

Purpose of the Women's Health Surveillance Report

This report on the health of Canadian women is intended to: (i) determine the extent to which currently available data can be used to provide gender-relevant insights into women's health; (ii) provide information to support the development of health policy, public health programs, and interventions aimed at improving the health of Canadian women; and (iii) serve as the basis for further indicator development. The report provides information and descriptive statistics on determinants of health, health status, and health outcomes for Canadian women. To the extent possible, each chapter presents new, gender-relevant information on a health condition or issue identified as important to women's health during national expert and stakeholder consultations in 1999. Where data or appropriate data are lacking, this is documented. Recommendations for change are made at the end of each chapter, accompanied by a discussion of the gaps in and policy implications of the findings.

Background to the Women's Health Surveillance Report

The incentive to produce a comprehensive report on the health of women in Canada stems from an advisory process initiated in 1998 by the former Laboratory Centre for Disease Control (LCDC) at Health Canada. At that time, in recognition of the deficiencies in its surveillance* activities regarding women's health - and particularly vulnerable groups of women - LCDC established an Advisory Committee on Women's Health Surveillance, chaired by the Honourable Monique Bégin. The committee's mandate was to "provide advice on issues, priorities, methodologies and potential partnerships in matters of women's health surveillance". It met several times and conducted a series of national consultation workshops that involved experts on women's health, community activists, participants from government and non-government organizations, research institutes, and the private sector. The committee's final report, Women's Health Surveillance: A Plan of Action for Health Canada (1999), [1] recommended that LCDC enhance existing surveillance systems, develop new ones, and expand its use of gender-based analysis. The health conditions addressed in the report's recommendations guided the choice of chapter topics in the present document. A number of jurisdictions have recognized the need for information on gender and health. British Columbia, Ontario, and the Atlantic provinces have produced women's health reports, [2-4] as has the National Women's Law Center in the United States. [5] In the fall of 2000, a Steering Committee was formed to undertake the task of producing a national report for Canada using a multidimensional approach that would integrate information from a variety of disciplines. Such a report would serve to monitor progress in women's health and health care and to provide the necessary knowledge base to establish effective policies in health promotion and disease prevention and control.

Health Determinants

It is generally agreed that differences in health status and health outcomes between individuals-and between men and women-are determined by factors beyond biology. Global forces, including cultural, political, and ecological change, have a powerful effect on health. Against this global backdrop, a complex set of factors-such as socio-cultural and transition experiences, education, income, social status, housing, employment, health services, personal health practices, and the physical environment-comes into play. For example, in developed countries, cultural and economic shifts in attitude toward women's participation in the labour force and control over reproductive decisions have led many women to delay childbirth.

Approach of the Report

The Women's Health Surveillance Report adopts the broad definition of women's health that provided the framework for the discussion on women and health at the Fourth World Conference on Women (the Beijing Conference), held in September 1995:

Women's health involves women's emotional, social, cultural, spiritual and physical well-being and is determined by the social, political and economic context of women's lives as well as by biology. This broad definition recognizes the validity of women's life experiences and women's own beliefs and experiences of health. Every woman should be provided with the opportunity to achieve, sustain and maintain health as defined by that woman herself to her full potential. [6]

Further, this report attempts to take a gender-sensitive approach to health information where possible, taking into account the context of individual's lives (i.e. the social and cultural roles and responsibilities that differentiate women from men and subgroups of women from other subgroups). Its aim in part is to inform future gender-based analyses.

The authors of individual chapters have made use of population data from large Canadian surveys and administrative databases. Data chosen for analysis depended largely on the availability of the databases at the time of chapter development. Although such data sources can provide interesting insights, they also have limitations. For example, while they usually include a breakdown of the data by sex, they often do not provide sufficient measures by which to explore the influence of gender as determined by the context of women's lives. For example, depression is a major cause of disability worldwide. In Canada, as in other developed countries, the prevalence of depression is the same among boys and girls. After puberty, however, women are about twice as likely as men to experience a depressive episode. [7] Traditional surveillance, such as hospitalization data or physician visits for depression, provides the data on these sex differences. What it does not provide is an analysis of how depression in women varies with income, ethnic background, education, and work experience, or how women's roles can shape their susceptibility to this condition (e.g. working double-duty shifts at home and in paid work while possibly experiencing harassment or abuse in either setting).

Women's health issues are different from men's in a number of ways. Failure to acknowledge these differences has led, in the past, to biases in the health system. Health Canada's Women's Health Strategy (1999) has classified these biases as follows: [8]

• Narrowness of focus - concentration on issues concerning women's reproductive processes (leading in some cases to over-medicalization of normal processes).
• Inappropriate grouping of women with men - the assumption that the course of disease and the consequences of treatment are the same in both sexes (e.g. drug trials and epidemiological studies using only male subjects).
• Exclusion - women's exclusion from policy-making, research, and medical specialties, and thus from positions of power.

Some biases are now being addressed. Canadian governments have a clear mandate to collect, integrate, analyze, and interpret data about women's health and gender differences in health as a basis for developing policies and interventions to improve health outcomes and reduce health inequalities (see Chapter "Women's Health Surveillance: Implications for Policy").

Developing the Women's Health Surveillance Report: the Process

In July 2000, the Canadian Population Health Initiative (CPHI) launched a Request for Proposals (RFP) to fund research that would generate new knowledge on the determinants of health. The RFP was predicated on five "Strategic Themes and Questions":

1. Why are some communities healthy and others not?
2. To what extent do Canada's major policies and programs improve population health?
3. How do social roles at work, in the family, and in the community affect health status over the life course?
4. What are the population health effects of broad factors in social organization in Canada and other wealthy countries?
5. What is Canada's relation to population health from a global perspective?

Several of the themes encompassed questions intended to address the social determinants of health from a number of perspectives, including gender.

In June 2001, CPHI Council approved funding for the Women's Health Status Report: A Multidimensional Look at the Health of Canadian Women, which addresses the first and third of CPHI's Strategic Themes and Questions. CPHI contributed $125,000 to this research, and Health Canada provided $105,000. A steering committee was formed, which represented a wide mix of partners from across Canada, with representatives from the University of British Columbia, University of Toronto, Université de Montréal, Dalhousie University, Health Canada, Statistics Canada, the F/T/P Working Group on Women's Health Status of Women Forum and the Canadian Institute for Health Information.

In line with the focus and scope of the report, expert authors from a variety of academic institutions and disciplines were selected to research and write the various chapters. They were encouraged to concentrate on aspects of their topic that were interesting from a gender perspective. Chapters were reviewed externally (see Acknowledgements for review details), and the reviewers. comments and suggestions were provided to the authors, who were asked to incorporate them where feasible. Authors were not required to incorporate all of the reviewer's comments, but they were asked to provide a rationale for their decisions.

The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada. The report is available as a summary (the present document), presenting the key findings and recommendations of each chapter, and as a full technical document, available in English and French on the CPHI and Health Canada Web sites (www.cihi.ca and www.hc-sc.gc.ca).

References

1. Advisory Committee on Women's Health Surveillance. Women's health surveillance: A plan of action for health Canada. Ottawa: Health Canada, 1999.
2. Women's Health Bureau. Provincial profile of women's health: a statistical overview of health indicators for women in British Columbia. Ottawa: Health Canada, 2000.
3. Stewart D.E., Cheung A.M., Ferris L.E., Hyman I., Cohen M.M., and Williams J.I. Ontario Women's Health Status Report. Prepared for the Ontario Women's Health Council by The University Health Network Women's Health Program, The Centre for Research in Women's Health and The Institute for Clinical Evaluative Sciences. February 2002.
4. Colman R. Women's health in Atlantic Canada: a statistical portrait. Halifax: Maritime Centre of Excellence for Women's Health. Atlantic Region Fora on Women's Health and Wellbeing, 2000.
5. National Women's Law Centre, FOCUS on Health & Leadership for Women, Center for Clinical Epidemiology and Biostatistics, UoPSoM, the Lewin Group. Making the grade on women's health: a national and state-by-state report card. Washington D.C.: National Women's Law Center, 2000.
6. Phillips S. The social context of women's health: goals and objectives for medical education. Can Med Assoc J 1995;154(4):507.11.
7. Stewart DE, Rondon M, Damiani G, Honikman J. International psychosocial and systemic issues in women's mental health. Arch Women's Mental Health 2001;4:13.7.
8. Health Canada. Health Canada's women's health strategy. 1999. Cat: H21.138/1997. URL: http://www.hc-sc.gc.ca/pcb/whb.

* Defined as the systematic collection over time of health information, its classification, analysis/determinants, and dissemination. The purpose of surveillance is to monitor health trends and issues of importance in populations so that appropriate action can be taken, and to provide a solid basis for effective health policy, program decisions, and targeted interventions.

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