Research Agenda for Psychosocial and Behavioral Factors in Women's Health

 

This Research Agenda for Psychosocial and Behavioral Factors in Women's Health was developed by the American Psychological Association's Women's Health Conference Advisory Committee. Chosen to represent the broad range of women's health concerns, the Advisory Committee began its work months before the conference and continued for over a year after the conference. The conference, entitled Psychosocial and Behavioral Factors in Women's Health: Creating an Agenda for the 21st Century, was convened to highlight the importance of psychosocial and behavioral factors in women's health, including the extensive research implicating behavioral and psychosocial factors in a number of major chronic diseases and conditions that influence women's health across the life span.

Before the conference, each Advisory Committee member prepared a list of recommendations in her/his area of expertise with documentation of their importance for women's health. At the beginning of the conference, the Advisory Committee met and divided into four working groups on the basis of content areas. The Advisory Committee met for a one-day working session immediately following the conference to discuss and refine the preconference recommendations and the deliberations of the working groups. This process culminated in the identification of four-draft agendas-one for each of the four working groups: Research, Education and Training, Health Services, and Public Policy.

These four agendas were further edited and refined during the year following the conference and combined to form the single agenda presented here. Over the course of its deliberations, the Advisory Committee decided to focus most heavily on the Research agenda and to provide briefer agendas on Education and Training and Public Policy. The Health Services agenda has been omitted from this report to allow a more complete focus on Health Services after the second conference, to be held September 19-21, 1996.

Chairs of the working groups were Brenda DeVellis, Ph.D., Patricia Morokoff, Ph.D., and Carolyn Mazure, Ph.D., for Research; Nancy Russo, Ph.D., for Education and Training; Helen Coons, Ph.D., for Health Services; and Renee Royak-Schaler, Ph.D., and Kelley Phillips, M.D., for Public Policy.

We thank the Advisory Committee members, especially those who served as chairs and the representatives from co-sponsoring and contributing agencies, associations and organizations. Their contributions made this report possible. We also thank those individuals who were not on the Advisory Committee but who helped with specific parts of the Agenda. They are Laurence A. Bradley, Ph.D., Jody Brown, Ph.D., Laura Brown, Ph.D., Richard Gelles, Ph.D., Vickie Mays, Ph.D., Susan Reisine, Ph.D., Ruth Striegel-Moore, Ph.D., Carol Weisman, M.D., Terrance Wilson, Ph.D., and Gail Wyatt, Ph.D.

Sheryle J. Gallant, Ph.D.
Gwendolyn Puryear Keita, Ph.D.

Scientific and public attention to issues concerning women's health has intensified in recent years. With this new emphasis has come a clear recognition that, in efforts to promote health and prevent disease, women's needs often differ from those of men. Awareness of these differences has led to funding commitments for large-scale projects such as the Women's Health Initiative, which targets women's health concerns, and the National Action Plan on Breast Cancer (NAPBC), a public-private partnership created in December 1993 to address the epidemic of breast cancer in the United States. Other efforts in women's health include the emergence of women's health as a legitimate field of scientific study and concern and the implementation of requirements that women be included in research funded by the National Institutes of Health.

Despite increased focus on medical and epidemiological aspects of women's health, research has not adequately addressed psychosocial and behavioral factors that contribute to health status. This research agenda addresses that gap. The agenda evolved out of a conference convened by the American Psychological Association in May 1994 to highlight key psychosocial and behavioral factors in women's health. The agenda, which was developed by the Conference Advisory Committee, builds on the growing body of knowledge in women's health and articulates a set of priorities for the next generation of research studies. Although some of the priorities delineated support important priorities for women's health identified at the beginning of this decade in Healthy People 2000 (U.S. Department of Health and Human Services [USDHHS], 1991), the agenda highlights the special role of psychosocial and behavioral factors in meeting these priorities. This research agenda defines research priorities pertaining to specific diseases and health practices that greatly affect women. The diseases included are those that show high mortality or morbidity rates for women and that may cause great physical disability, lowered financial resources, and poorer quality of life. Although the primary focus is on research issues, this document concludes with recommendations for educational and policy priorities that intersect with the research agenda.

The research agenda was guided by the following principles:

• The focus of research should be on understanding how the experiences of groups affect health-related issues, rather than on simply documenting group differences or differences between women and men. Women are a heterogeneous group whose experiences may vary with ethnicity and race, marital status, parental status, education, income, occupation, sexual orientation, labor force participation, and geographic location (e.g., urban vs. rural). Health needs, barriers to obtaining services, styles of coping or bases for well-being may vary among diverse cultural and socioeconomic groups.

• Gender-related psychological, behavioral, and social factors, and their interrelationships with biomedical factors, are important to consider in understanding disease and health. Like ethnic status, social class, and age, gender is associated with social realities that are different for women and men. Social and psychological experiences that are significantly related to health outcomes are important components of a research agenda in women's health.

• Psychological and behavioral factors are important predictors of well-being, vulnerability to disease, and disease outcomes. Research is needed on the psychological factors that influence health, including risk reduction, coping behavior, self-efficacy, perceptions of control, social support, and depression.

• Quality of life is an important outcome measure and includes a sense of well-being, functional health, and engagement in the psychological and social world.

• A life span-developmental approach is important in understanding health practices and outcomes. The stage of a woman’s life influences behavior and also provides a context within which health-related behavior and illness can be understood.

• Contextual factors represent cross-cutting issues that must be considered in designing, implementing, and interpreting research results in order to enhance traditional biomedical research and offer new insights. Thus, women’s health issues should be studied within the following contexts:

  • Relationships: How do women’s relationships affect health status, health behaviors, and health attitudes? How do health behaviors, attitudes, and health status affect women's relationships?

  • Ethnicity: How do women’s ethnic backgrounds shape their health, health behaviors, and attitudes?

  • Resources: How do financial and structural resources enhance or limit women’s health options?

  • Status and power: How do women’s social status, work status, and power within relationships limit health options or affect health status?

  • Gender expectations: How is health status affected by gender expectations, such as expectations for mothering/primary parenting and care giving for others who are sick or in need, expectations to serve as an emotional support system for others, and expectations for housework and other household tasks.

• If we are to have an impact on women’s risk of chronic disease, we must intervene in the four prominent health behaviors influencing chronic disease: alcohol and other substance abuse, cigarette smoking, dietary patterns, and physical activity patterns. Although we discuss these behaviors in separate sections, we recognize that controlled investigation of combinations of the behaviors is critical and to date has received little systematic attention.

Alcohol and Other Substance Abuse

Preliminary estimates from the 1994 National Household Survey on Drug Abuse (Substance Abuse and Mental Health Services Administration [SAMSHA], 1995) indicate that almost half (46.8%) of all women in the age range of 15 to 44 years have used an illicit drug at least once in their lives, 4.7 million women currently use illicit drugs, and women now constitute more than 37% of the illicit-drug-using population in the United States. Six percent of women 15 to 54 years of age have met the criteria for lifetime drug dependence (Kessler et al., 1994). Recent epidemiological research suggests that between 10% and 15% of U.S. women experience at least some drinking-related problems (Wilsnack, Wilsnack, & Hiller-Sturmhöfel, 1994) and that approximately 4% (or 4 million) of American women meet diagnostic criteria for alcohol abuse or dependence (Grant et al., 1994). Finally, more women than men are at risk for becoming dependent on the non-medical use of psychotherapeutic drugs. During 1994, 1.2 million women reported having taken prescription drugs for non-medical purposes during the past month (SAMHSA, 1995).

Although more men than women use drugs, the consequences of drug use by women are often more severe, and after initial use, women may proceed more rapidly to drug abuse than men (Griffin, Weiss, Mirin, & Lange, 1989). A national survey on pregnancy and health reported that in 1992 among women who gave birth in the United States, an estimated 221,000 used illicit drugs while they were pregnant (National Institute on Drug Abuse, in press). Pregnant drug abusers are at increased risk for miscarriage, stillbirth, low weight gain, anemia, hypertension and other medical problems (Finnegan, 1994). Their newborns may have lower birth weight and smaller head size than babies born to healthy mothers (Mayes & Granger, in press). One of the most devastating consequences of drug use for females is the risk of HIV/AIDS. AIDS is now the fourth leading cause of death among women 15 to 44 years, and nearly 70% of the AIDS cases among women are drug related (Centers for Disease Control and Prevention [CDC], 1995a). In addition, heavy alcohol use and other drug use are risk factors for a wide range of other physical and mental health disorders in women.

In past research on drug abuse, research subjects, both humans and animals, have been almost exclusively male; as a result little data has been available on women. Recently, however, gender differences have gained attention in the field of drug abuse research, and preliminary data indicate that the biological mechanisms involved in drug abuse and addiction, the progression and initiation to drug use and abuse, the antecedents and consequences of drug use and abuse, and prevention interventions and treatment for drug abuse vary considerably between men and women. Thus, more research is needed to understand these differences.

Research Priorities for Alcohol and Other Substance Abuse

• Conduct basic behavioral research (both human and animal) directed at identifying sex and gender differences in the etiology and consequences of drug use, abuse, and addiction.

Animal studies have shown that fundamental gender differences may exist in the reinforcing and stimulus properties of abused drugs. On several measures of stimulant-induced activity, females exhibited more responsiveness than males; moreover, this responsiveness varied with the estrus cycle (see Roberts, Bennett, & Vickers, 1989). Gender differences have also been reported in self-administration of cocaine. When cocaine infusions were made contingent upon increasingly higher numbers of bar presses, female rats made substantially more presses than males, and their level of cocaine self-administration varied as a function of the estrus cycle (Roberts et al., 1989).

The results of a study in humans examining gender and menstrual cycle differences in response to acute intranasal cocaine showed that mean cocaine plasma levels in women were higher in the follicular phase than in the luteal (Lukas et al., in press). Thus, studies are needed that examine the role of the menstrual cycle in modulating drug use and drug effects; gender-specific behavioral, biological, and medical effects of drug abuse; and, gender specific biological and behavioral mechanisms that underlie drug abuse and addiction.

• In epidemiological, clinical, experimental, and longitudinal studies of women’s alcohol and other drug use, examine variations within groups of women based on such characteristics as age, ethnicity, employment, marital and family status, and sexual orientation.

Because women have been greatly underrepresented in past substance abuse research, the recent shift in attention to women as a special population in substance abuse research has often failed to examine differences within the very heterogeneous group of women who report substance abuse. Based on the few studies that have examined subgroup differences among women substance abusers, we now know that certain demographic variables (e.g., age or relationship status) may be powerful predictors of women’s substance use and abuse. For example, several studies have found a correlation between women's problem drinking and the presence of a problem-drinking spouse or partner (Jacob & Bremer, 1986). Women who inject drugs are more at risk for HIV infection than men, because they are more likely to share needles with their injection-using partner and to have sex with an injection-using male partner (see Morokoff, Harlow, & Quina, 1995). Regardless of whether researchers are examining etiology, consequences, prevention or treatment, studies are needed that examine drug abuse in women of all ages, ethnic backgrounds, socioeconomic (SES) groups, and sexual orientations.

• Increase attention to patterns of multiple substance abuse in women rather than a narrower focus on either alcohol or other drugs in research on etiology, consequences, prevention, and treatment.

Despite high rates of combined use of alcohol and other drugs by substance-abusing women, much of the available research focuses on either alcohol use or the use of other drugs. Increased knowledge about the antecedents and consequences of various combinations of alcohol and other drugs could suggest more differentiated approaches to treatment and prevention of substance abuse in women. Needed research includes (a) improved measurement of simultaneous, concurrent, and alternating use of alcohol and other drugs, in both "alcohol" and "drug" research; (b) analysis of antecedents, correlates, and consequences of specific combinations of alcohol and other drugs; and (c) increased collaboration between researchers concerned with treatment and prevention of alcohol disorders and their counterparts studying other substance use disorders, including nicotine dependence.

• Evaluate the effectiveness of early identification strategies and brief interventions provided to substance-abusing women by health care professionals in medical and mental health care settings.

Evidence suggests that health care professionals may serve as a front-line for identifying women with drinking problems because such women are more likely than men to seek help for problems other than drinking and to seek help in mental health and medical settings. Unfortunately, women’s substance abuse problems tend to be under-recognized in these settings, and physicians are less likely to refer women for alcohol treatment compared with their referral rates for men (Vogeltanz & Wilsnack, in press). Moreover, recent evidence suggests that brief interventions can be as effective as longer-term treatment for some problem drinkers (Babor, 1990; Bien, Miller, & Tonigan, 1993). The effectiveness and cost-effectiveness of brief interventions by health care professionals with substance abusing women needs to be evaluated and established.

• Conduct research on antecedents, pathways, risk and protective factors involved in drug abuse by girls and women with emphasis on early identification and the full spectrum of prevention interventions.

The progression or developmental stages of drug involvement appear to differ according to gender. In the progression from legal drug use to illicit drug use, for example, cigarettes seem to play a major role for women; for men alcohol alone is sufficient (Kandel, Yamaguchi, & Chen, 1992). With regard to initiation into illicit drugs, data suggest that women are more likely to begin or maintain cocaine use in order to develop more intimate relationships, whereas men are more likely to use the drug with male friends and in relation to the drug trade (Boyd, Blow, & Orgain, 1993). The onset of drug abuse is later for females and the paths are more complex than for males. For females there is typically a pattern of breakdown of individual, familial, and environmental protective factors and an increase in childhood fears, anxieties, phobias, and failed relationships; the etiology of female drug abuse often lies in predisposing psychiatric disorders prior to abusing drugs (Brooks, Whiteman, Cohen, & Tanaka, 1992). Prevention research expanded to include interventions based on female-specific antecedents, pathways, and risk and protective factors is needed.

• Conduct research on the impact of violence and victimization on the psychosocial development and psychosocial functioning of girls and women as it relates to drug abuse and addiction.

Childhood sexual abuse has been associated with alcohol and other drug abuse in women in several clinical and non-clinical studies (e.g., Boyd, Guthrie, Pohl, Whitmarsh, & Henderson, 1994; Miller, Downs, & Testa, 1993; Teets, 1995; Wilsnack, Vogeltanz, Klassen, & Harris, 1995). For example, research findings indicate that up to 70% of women in drug abuse treatment report histories of physical and sexual abuse with victimization beginning before 11 years of age and continuing on a serial basis (Miller et al., 1993). A study of drug use among young women who became pregnant before reaching 18 years of age reported that 32% had a history of early forced sexual intercourse (rape or incest). These adolescents, compared with non-victims, used more crack, cocaine, and other drugs (except marijuana), had lower self-esteem, and engaged in a higher number of delinquent activities (Lanz, 1995). The path by which substance abuse develops following childhood sexual abuse experiences in women is unclear, and further research is needed to understand the etiology of this strong correlational finding. Well-designed and carefully evaluated prevention and intervention efforts with young childhood sexual abuse victims may help reduce subsequent substance abuse and other physical and mental disorders in women.

Furthermore, women drug abusers may have greater vulnerability to victimization than men. In a recent study of homicide in New York City, 59% of white women and 72% of African American women had been using cocaine prior to their death compared with 38% of white males and 44% of African American males. Thus, while cocaine is used by more men than women, its use is a far greater risk factor for victimization for women than for men (Tardiff et al., 1994). It is, therefore, critical that the factors involved in the relationship between drug abuse and addiction among females, and physical and sexual victimization (including partner violence) be identified and understood.

• Investigate the co-occurrence of psychiatric and substance use disorders with attention to the temporal ordering of substance use, depression, anxiety (including post-traumatic stress disorder), and eating disorders.

Studies of substance abusers in both community and treatment samples have shown high rates of coexisting psychiatric disorders, although whether psychiatric disorders antedate drug use has not been well established. Comorbidity rates between substance abuse and depression/anxiety have been reported to be as high as 80% (Christie, Burke, Reiger, Boyd, & Locke, 1988). Post-traumatic stress disorder was found to occur in about 20% of women substance abusers (Villagomez, Thomas, Lin, & Brown, 1995), and the link between eating disorders, particularly bulimia, and substance abuse has been established (e.g., Holderness, Brooks-Gunn, & Warren, 1994). For example, as many as 55% of bulimic patients are reported to have drug abuse or alcohol use problems. Conversely, 15%-40% of females with drug abuse or alcohol abuse problems have been reported to have eating disorder syndromes, usually involving binge eating (Beary, Lacey, & Merry, 1986; Hudson, Weiss, Pope, & McElroy, & Mirin, 1992; Jonas, Gold, Sweeney, & Pottash, 1987; Mitchell, Hatsukami, Echert, & Pyle, 1985; Mitchell, Pyle, Echert, & Hatsukami, 1990; Weiss & Ebert, 1983).

Further research is needed on the role of dieting and eating disorders in drug abuse etiology and on the relationship between affective and anxiety disorders and drug abuse and addiction in women. Additionally, research is needed on the examination of factors that may result in overprescription and abuse of psychotherapeutic agents.

Studies that have examined the temporal sequencing of mood disorders and substance abuse have found that depression both precedes and follows substance abuse (Schottenfeld, Carroll, & Rounsaville, 1993). Better understanding of these temporal sequences is also critical for future theory development, prevention, and treatment.

• Expand research examining the development and effectiveness of drug abuse treatment models that are specific to the unique needs of women. Such models should include treatment for addiction as well as any coexisting psychiatric disorder (e.g., depression, anxiety, post-traumatic stress disorder, eating disorder), and they must be culturally relevant.

It is widely acknowledged by drug abuse treatment researchers and providers that women who abuse drugs face a variety of barriers, including barriers to treatment entry, to engagement in treatment, and to long-term recovery. Barriers to entry include a lack of economic resources, referral networks, women-oriented services, and conflicting child-related responsibilities. Engagement in treatment and consequent long-term recovery are hampered by the primarily male orientation of traditional models of drug treatment and the lack of treatment modalities that address the specific treatment needs of women.

The development of well-designed theoretically based treatment models that address these and other female-specific issues is necessary if treatment is to be effective. These models must also address such needs as child care, transportation, assertiveness training, and vocational training. Such services and training in and of themselves do not constitute treatment, but if not provided, could result in barriers to accessing treatment and/or an inability to remain drug free. Within the context of treatment, there is also a need to examine, from the perspective of gender, the complex issues involved in relapse.

Cigarette Smoking

Use of tobacco increases the risk of death from cancer, cardiovascular diseases, and lung diseases. In women, smoking increases the likelihood of developing osteoporosis, early menopause, and decreased fertility. Since 1988 at least 147,000 women in the United States have died each year from tobacco-related illnesses. Historically, more men than women smoked cigarettes, but this gap has narrowed, and currently almost as many women (23 percent) as men (28 percent) smoke. Women currently have lower quitting rates than men, and the number of adolescent girls beginning smoking is higher than that of adolescent boys (CDC, 1993). Unmarried women are more likely to smoke during pregnancy, but women with partners who smoke are more at risk for smoking relapse after pregnancy (Mermelstein & Borrelli, 1995).

Research Priorities for Cigarette Smoking

• Conduct research to identify key factors in smoking initiation by adolescent girls.

Fewer African American than white teenagers initiate smoking; African American women start smoking at much older ages than white women (Geronimus, Neidert, & Bound, 1993). Moreover, there has been a consistent and significant decline in smoking among African Americans, and virtually no decline among whites (Johnston, O’Malley,& Bach-man, 1993). Little research is focused on the reasons for these differences or on differential smoking behavior of racial and ethnic groups of women. Further research is needed to determine effective methods for reaching adolescent girls with antismoking messages other than through the schools as well as for reaching women who initiate smoking at older ages.

• Conduct research to determine factors critical to smoking cessation and maintenance among different populations of women.

More research is needed on recruitment strategies for cessation programs that are effective for specific groups of women (e.g., women of color, blue collar women, women of lower socioeconomic status, and older women) and adjuncts to traditional cessation intervention that will be helpful to these specific groups of women. For example, research indicates that there may be racial differences in reasons for smoking (Camp, Klesges, & Reylea, 1993) and in success quitting (Windsor et al., 1993).

• Conduct research to determine how the desire to control weight and strive for thinness affects women's smoking initiation and maintenance, and how this motivation is influenced by ethnicity.

The issue of weight control for female smokers is complex. Approximately 80 percent of those who stop smoking will gain weight (average weight gain of 8-10 pounds), and women tend to gain more weight than men (Nides et al., 1994). Additionally, women smokers who relapse are likely to report that weight gain was the cause of the relapse (Pirie et al., 1991). Research is needed to examine these issues and to determine the efficacy of intensive and minimal interventions that combine smoking cessation and weight control (Glynn & Mills, 1993).

• Conduct research to determine the relationship between smoking and depressed mood.

In community studies, smoking and depression rates have been found to correlate, and depressed smokers are less likely to quit (Anda et al., 1990). The role smoking plays in coping with depressed mood needs further study.

• Conduct studies that will lead to the development of more effective strategies for motivating women to stop smoking.

Female smokers are more likely to be in a pre-contemplation stage of quitting than are male smokers. In other words, they are more likely to have no intention to stop smoking in the near future. Effective strategies should be developed to help women consider smoking cessation and to prepare them to take action. These strategies may need to be tailored by stage of life.

Diet and Obesity

Obesity is a well-established risk factor for many of the leading causes of mortality and morbidity in the United States. Cardiovascular disease and mortality are increased in women who are overweight. The lowest rates of coronary heart disease mortality and morbidity are found in women with a Body Mass Index (BMI) of 21 (equivalent to approximately 95 percent of ideal body weight). The prevalence of hypertension, noninsulin dependent diabetes, certain types of cancer, osteoarthritis, sleep apnea, and gallstones are also increased in individuals who are overweight (Manson et al., 1990).

Obesity has reached epidemic proportions among women in the United States. Thirty-five percent of women in the United States are overweight (BMI > 27.3). Obesity increases with age in American women; 20 percent of women aged 20 to 29 are overweight, compared with 34 percent of those individuals aged 30 to 39, 38 percent of those aged 40 to 49, and 52 percent of those aged 50 to 59. Obesity is particularly prevalent among ethnic minority women: 49 percent of African American women are overweight, 47 percent of Mexican Americans, compared with 33 percent of Caucasians. Obesity also disproportionately affects those of lower socioeconomic status (Kuczmarski, Fiegel, Campbell, & Johnson, 1994).

Research Priorities for Diet and Obesity

• Conduct studies that will lead to development of more effective programs for weight loss maintenance.

Because women constitute the majority of participants in organized weight loss programs, it is important to develop more effective long-term treatments for these individuals. Current weight loss programs are successful in producing initial weight loss, but maintenance of weight loss is poor. Research is needed to determine the most effective weight management strategies and procedures.

• Conduct research to determine effective approaches to the prevention of weight gain and obesity at different stages of women’s lives.

Women are likely to gain excess weight between age 25 and 34 (Williamson, Kahn, Remington, & Anda, 1990), during smoking cessation, and during the menopausal transition, and to retain excess weight following pregnancy. Research is needed to determine how best to prevent weight gain at each of these critical time periods.

• Conduct studies that will lead to the development of programs targeting the special needs of different subgroups of the obese population.

Programs are needed that target the special needs of different sociodemographic groups such as different ethnic minority, age, and rural/urban populations. Likewise, programs are needed that target women with specific behavioral problems related to their being overweight (e.g., obese binge eaters). Although more than 50 percent of middle-aged African American women are overweight, the majority of participants in university-based research studies on weight control are white. African Americans also tend to lose less weight than whites (Kumanyika, Obarzanek, Stevens, Herbert, & Whelton, 1991). It is unclear whether this difference in weight loss reflects differences in adherence to programs or differences in physiological or metabolic parameters (Wing, 1995).

• Conduct research on the relationship between psychological factors and obesity.

Although many people assume that stress leads to weight gain, little research supports this assumption, and there is little research on how other psychological factors (such as depression) influence weight and/or body fat distribution. The effects of obesity and efforts at weight loss on psychological variables and the role of psychological variables in the efficacy of weight loss attempts need further study.

• Conduct research that will provide a better understanding of the way in which behavior interacts with genetics in the development and maintenance of obesity.

Twin studies, adoption studies, and family studies show clearly that both genetics and environment play a major role in determining body weight. Research is needed to better understand the interaction between these two sources of influence. With the recent identification of genes related to obesity, there is tremendous potential for interaction between geneticists and psychologists. Identification of behavioral phenotypes related to obesity would greatly facilitate such interaction.

Physical Activity and Exercise

Physical activity holds the promise of improved physical and mental health for women. Risks of chronic disease, especially those related to aging such as cardiovascular disease, osteoporosis and diabetes, may be significantly ameliorated or, in some cases, eliminated by moderate increases in physical activity. Risk of certain cancers, stress reactivity, and depression may be reduced with physical activity, whereas immune function and well-being may be improved. However, almost 60 percent of American women, and almost 65 percent of ethnic minority women, remain sedentary (Marcus, Dubbert, King, & Pinto, 1995). Little is known about the physical and mental health consequences of physical activity or inactivity for women or the most effective methods of reliably increasing regular physical activity among women. Research could have a substantial impact on reversing the inactivity of women in this country, with potential health, economic, and quality of life benefits.

Specific knowledge of the similarities and differences across cultural, ethnic, and racial subgroups of women is minimal. Further, there is limited understanding of the factors associated with disease or disability in women who already are ill.

Research Priorities for Physical Activity and Exercise

• Conduct studies to identify the factors contributing to both the initiation and ongoing maintenance of alternative forms of physical activity that can reduce risk of cardiovascular heart disease and other chronic diseases.

Examples of ways to help women begin and maintain physical activity include moving physical activity outside of gyms and aerobics classes and integrating it into the individual’s home and work environments, or otherwise natural environments, for example, walking or taking the stairs (King, Taylor, Haskell, & DeBusk, 1990), and building physical activity into people’s lifestyles (DeBusk, Hakansson, Sheehan, & Haskell, 1990).

• Investigate factors that set the stage for either increased or decreased activity at different stages in a woman's life.

Developmental milestones such as puberty have been associated with changes in physical activity levels among women. Other important transitional stages such as entry into college or the workforce, pregnancy, parenthood, menopause, and family care giving need further study.

• Evaluate the behavioral and physiological synergy between physical activity and other health behaviors such as dietary patterns, cigarette smoking, and alcohol and other drug use.

To have the greatest impact on chronic disease risk, interventions are needed on the four prominent health behaviors influencing chronic disease: cigarette smoking, dietary patterns, physical activity patterns, and alcohol and other drug use. Typically, these four have been studied in isolation. However, physiological and behavioral synergy may occur when changes in several of these health behaviors occur simultaneously. Therefore, the controlled investigation of such health behaviors in combination is critical, and to date has received little systematic attention.

• Conduct studies to determine how work, family life, community participation, mass media and other social factors influence women's physical activity patterns.

Little is known about how the social forces in the family, the worksite, the medical setting, and other community settings may influence women at different phases of readiness and at different stages of their lives. In addition, there is virtually no research about the potentially powerful influences of the media and other environmental influences on women’s physical activity patterns.

• Expand the study of the effects of physical activity on depression, anxiety, and physiological and psychological responses to stress.

There is evidence indicating the potential role of regular physical activity in diminishing negative affective states such as depression and anxiety as well as attenuating physiological and psychological responses to stress. Yet, few studies in this area have focused specifically on women, and the mechanisms mediating this relationship need to be clarified.

Arthritis and Rheumatic Diseases

Arthritis and rheumatic disease include more than 100 different illnesses and conditions (Schumacher, Klippel, & Koopman, 1993). Arthritis is the most common self-reported chronic condition affecting women (CDC, 1995), and many of the more common and more serious forms of arthritis and rheumatic disease (e.g., osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, fibromyalgia) affect two to five times more women than men. Hence, arthritis and rheumatic diseases, which significantly affect functioning, represent a significant health problem for women. For example, among women age 15 and older, arthritis is the most frequently cited reason for activity limitations, and people with arthritis experience a disproportionately greater amount of work disability compared with people with other chronic conditions (CDC, 1995; Yelin, 1992).

Research Priorities for Arthritis and Rheumatic Diseases

• Conduct research to help identify the underlying mechanisms that account for the discrepancies among ethnic groups and social classes in the health outcomes among women with arthritis and rheumatic diseases.

Epidemiological studies have consistently demonstrated worse health outcomes among women with arthritis and rheumatic diseases who are members of ethnic minority and lower socioeconomic groups (CDC, 1994). Unfortunately, the underlying mechanisms that could account for these differences are poorly understood. Potential constructs that could explain these relationships include cultural differences in health beliefs, stress, social support and coping mechanisms, access to health care, and differential treatment patterns.

• Initiate studies to describe the complex causal connections between psychological and physical processes in arthritis and rheumatic diseases.

Current research suggests that complex, reciprocal relationships may exist between physical and cognitive and emotional processes in arthritis and rheumatic diseases. Investigations using a variety of methodological approaches are needed to unravel the causal mechanisms linking cognitions, emotions, arthritis symptoms, physiological processes, and behavior.

• Expand research on the causes and treatment of pain in patients with arthritis and rheumatic diseases.

Patients identify pain as the most serious consequence of arthritis and rheumatic diseases (Skevington, 1993). Although a great deal of pain research has been performed regarding inflammation, little is known about other pain mechanisms in patients with inflammatory and non-inflammatory arthritis and rheumatic disease. In addition, little is known about interactions between the brain and endocrine and immune systems that are involved in arthritis pain. Currently, no treatment interventions are available that completely alleviate pain in arthritis and rheumatic diseases. The development of more effective pain treatments would reduce suffering and health care costs for millions of women.

• Expand research on the epidemiology, identification, treatment, and prevention of depression in people with arthritis and rheumatic diseases.

Research suggests that people with serious chronic diseases are at greater risk for developing depressive disorders and symptoms (Wells, Golding, & Burnam, 1988). Depression alone is a devastating condition that, in the absence of other health problems, is associated with severe functional limitations. When depressive symptoms occur in combination with other chronic diseases, however, functioning levels decrease (Wells et al., 1989). Because women are at greater risk for depression as well as at greater risk for some of the more serious and more common forms of arthritis and rheumatic disease, they bear a double burden of potential disability (DeVellis, 1993). We need a better understanding of the scope and impact of depression in arthritic and rheumatic diseases as well as research on how to prevent and treat depression in this population.

• Expand research on the causes and treatment of fatigue in people with arthritis and rheumatic diseases.

Fatigue is commonly associated with many forms of rheumatic disease such as rheumatoid arthritis (RA) and fibromyalgia syndrome, yet has received little study. Research by Belza and colleagues (Belza, 1995; Belza, Henke, Epstein, & Gilliss, 1993) has found a high degree of fatigue among people with RA that interferes with discretionary and nondiscretionary activities of daily living and causes distress. Among people with RA a number of disease-related characteristics (e.g., pain, disease duration, sleep quality) place them at greater risk for experiencing fatigue. Being female, however, places one at additional risk for fatigue in RA. The causes of fatigue in both health and illness are poorly understood and need further study.

Cancer

Cancer is the second leading cause of death for women in the United States. Approximately one in three Americans will have cancer at some point during their lives. Breast, lung, and colorectal cancers have the highest incidence rates and are most likely to be causes of cancer deaths among women (Meyerowitz & Hart, 1995). The high prevalence of cancers makes it likely that all women will face the disease either in themselves or in family members. Furthermore, the availability of effective early diagnostic procedures means that cancer-related health care behaviors should be a part of every woman’s life.

Research Priorities for Cancer

• Continue intensive investigation of methods to promote cancer screening among women and of women’s reactions to such screening, particularly in groups where screening is underutilized (e.g., women who are older, poorer, or of ethnic minority status), and groups at risk for specific cancers (e.g., higher cervical cancer risk in Latina women).

Early detection of cancer leads to substantial reductions in cancer mortality. Intervention efforts directed toward health care providers should be increased because physicians’ recommendation for screening appears to be the most consistent predictor of mammography use. Further, in light of the national research focus on genetic susceptibility to cancer and the growing consumer demand for genetic screening, we need to know more about the psychological, social, and economic sequelae of being diagnosed with genetic mutations that increase breast cancer risk. It is critical to develop effective methods for delivering information to women about their personal risk and promoting accurate understanding of this risk. Interventions must be developed for women of diverse socioeconomic and ethnic backgrounds that address these special concerns and facilitate the process of making informed screening decisions.

• Expand research about the impact of cancer, particularly some common sites of cancer about which we have relatively little information (such as colorectal cancers, head and neck cancers, and lung cancers), and about the mechanisms that promote positive adjustment to cancer and its treatments within the context of women’s lives.

Research suggests that, on average, women remain psychologically resilient after being diagnosed with cancer. However, there are stressful periods during which women with particular characteristics are vulnerable to marked distress and life disruption. Continued investigation of areas of ongoing distress and factors that place women at risk for compromised adjustment is necessary. Additionally, studies of women who do well over time may further our understanding of mechanisms that promote positive adjustment. Data on psychosocial recovery following the diagnosis and initial treatment for cancer, and the areas in which problems are common or persistent, may vary by site of disease and treatment protocol. Data on quality of life and predictors of adjustment at the time of disease recurrence and throughout the period of advanced disease also are needed.

• Develop methods for improving efficiency and efficacy of psychosocial interventions for particular groups of women and identify mechanisms by which these interventions have positive psychosocial and medical effects.

Early interventions are necessary to improve psychosocial functioning and quality of life for women at risk for adverse outcomes as a result of receiving a cancer diagnosis. Research on psychosocial interventions for women with cancer has focused on testing the efficacy of supportive and educative interventions conducted in a group context. Results are promising and positive benefit has been documented on both psychological domains and mortality. Effective interventions for women who do not elect a group approach are also needed. In addition, greater attention to study of interventions for the broader family system, as well as for women who serve as caretakers for others who have cancer, is warranted. Further investigation also is needed regarding the psychological, behavioral, and immunological mechanisms through which interventions have their impact.

• Examine identified causal and protective factors that may decrease cancer incidence and mortality and the potentially complex interactions among biological, psychological, and social factors (e.g., social support, coping strategies, immunological function) that may promote or hinder survival and psychosocial adjustment.

Researchers have identified possible predictors of cancer incidence and course that require careful examination, including exogenous hormones, environmental and workplace toxins, and regular physical activity.

Psychoneuroimmunological variables also have shown great promise as predictors of cancer onset and progression. We must understand the role that these factors may play and the mechanisms that underlie their impact on cancers.

• Examine impediments to receiving medical care, effects on quality of life, optimal coping, and effective psychosocial interventions for poor women and women of color.

Cancer research has heavily focused on middle-class, non-Hispanic white women who live in urban and suburban areas. It is essential to include research with women who traditionally have not been studied. Future research will require the development of reliable and valid assessment tools specifically designed to address issues of particular relevance to these women.

Cardiovascular Disease

Despite a steadily declining rate of cardiovascular disease mortality in the United States, heart disease is still the number one cause of death in American women. More women die of heart disease than of all malignant neoplasms combined. Women also have a worse prognosis for survival after myocardial infarction (MI) than men, and African American women have the worst prognosis of all.

Research Priorities for Cardiovascular Disease

• Examine neurophysiological and neuroendocrine mechanisms unique to cardiovascular changes in women, including the effect of chronic stress on gonadal hormones and the unique neurohormonal and neurophysiological (vagal) mechanisms for stress buffering.

Research on nonhuman primates has shown that chronic social stress is related to a significant increase in coronary artery atherosclerosis, anovulatory menstrual cycles, a decrease in estrogen levels, and high central serotonergic responsivity in females. Despite the strong evidence of these associations in primates whose cardiovascular systems strongly resemble our own, the effect of chronic stress on gonadal hormones and atherosclerosis has not been investigated in women.

Another pathway that needs to be explored is that of oxytocin, a hormone secreted in pregnant and lactating women. This hormone, which differs by only two amino acids from the vasoconstrictor, vasopressin, seems to be associated with blood pressure reduction. As a rule, blood pressure decreases during pregnancy and recent research has demonstrated that exogenously administered oxytocin causes sustained reduction of blood pressure in both male and female hypertensive rats. But oxytocin release also can be stimulated behaviorally by sensory stimuli such as massage. There is a dearth of research on the unique neurohormonal and neurophysiological (vagal) mechanisms for stress buffering in women, and such research should be a priority.

• Initiate studies to determine the impact of psychosocial factors (e.g., social support, socioeconomic status, and environmental stress) on primary prevention of cardiovascular disease in African American women.

In Africa, women with large, socially integrated families have the lowest blood pressure. However, in the United States, African Americans have higher rates of hypertension than do whites of similar age. African American women also have the worst prognosis after myocardial infarction. The fact that blood pressure in Africans is much lower than in Americans of African ancestry suggests that sociocultural rather than genetic factors explain a large part of the variance in these differences. Research in black and white differences in recent years has begun to examine gender differences in cardio-vascular and hemodynamic responses to stress. But research on the chronic social psychological stressors specific to the lives of black women is almost nonexistent. Research on such factors as social support, socioeconomic status, and other psycho-social factors should be directed toward identifying patterns of high risk stressors and the mechanisms that mediate their effect on the cardiovascular system.

• Examine factors that influence adherence and behavioral change in the secondary prevention of coronary heart disease (CHD) in women.

Women are usually supportive in helping implement lifestyle changes for their husbands and other family members (e.g., dietary changes, exercise, and stress reduction) that are necessary for increasing the probability of survival. However, the lifestyle changes that are important for women’s own rehabilitation of CHD may engender negative responses from immediate family members because these changes may conflict with gender role expectations of women (e.g., traditional caretaker and nurturer). Research is needed that examines the effect of these gender role expectations on the ability of women to effect and maintain health-related lifestyle changes and the subsequent effect on quality of life, depression, and disease course.

• Expand research to clarify which psychosocial factors (or pattern of factors) increase vulnerability to cardiovascular disease and the neuroendocrine pathways that mediate them.

Epidemiological studies have repeatedly shown a significant linear association between socioeconomic status (SES) and coronary heart disease (CHD): the lower the SES, the higher the prevalence of CHD. Previous research in this field has focused on the association between low SES and poor health behaviors such as higher smoking rates, unhealthy diets, and higher rates of obesity. More recent research shows a larger proportion of chronic physical and psychosocial stressors such as jobs with high demand and low decision latitude, low social support, high job dissatisfaction, unemployment, residential areas with high crime rates, and poor access to medical treatment among people with low socioeconomic status. Many of these psychosocial factors are related to cardiovascular risk. Women with low SES are particularly vulnerable.

• Investigate the interactions among genetics, behavior, and environment in the development of coronary heart disease.

Many different physiological factors predispose an individual to increased risk of coronary events. High blood pressure, high total and LDL cholesterol, low HDL cholesterol, obesity, and diabetes are prime examples. All of these show evidence of genetic influence. Therefore, many genetic variations can predispose one to increased risk. Behavioral and environmental factors interact with underlying genetic predisposition to trigger, to enhance, or to buffer against risk. Although there is general agreement about the interaction, the quantitative and qualitative gene and environment interactions in coronary heart disease have not been well investigated and should be a target of future genetic research.

Depression

Major depression is a common and recurrent disorder. According to Epidemiological Catchment Area (ECA) data (Robins & Regier, 1991), at least 5 percent of the United States population (over 12 million Americans) will experience major depression over the course of a lifetime. Al-though this estimate is substantial, it is thought to be conservative. Longitudinal data have confirmed the recurrent nature of depressive episodes and suggests that recurrence (i.e., appearance of a new episode) occurs in greater than 50 percent of patients who recover from an initial episode (Frank et al., 1990).

Major depression can cause severe impairment in social and physical functioning and is a major precipitating factor in suicide. It has been associated with higher medical costs, greater disability, poor self-care and adherence to medical regimens, and increased morbidity and mortality from medical illness (Katon & Sullivan, 1990).

Women are approximately two times more likely than men to suffer from major depression (McGrath, Keith, Strickland, & Russo, 1990), and dysthymia (Robins & Regier, 1991). Thus, empirical investigations of depression should be a major focus of a women's health research initiative.

Research Priorities for Depression

• Conduct research to determine gender-related risk factors for depression.

Considerable research effort has contributed to advancements in the diagnosis and treatment of major depression. However, the etiology of depression and why depression is twice as likely in women as in men is not well understood. Understanding risk factors for onset, severity, and relapse of depression should be a target of future research. Models for understanding the etiology of major depression and subtypes of depression should consider direct and indirect effects of study variables as well as interactions.

• Expand research on differential treatment response by women and men.

Little is known about differential treatment response patterns for major depression in women and men. This is true for established and new, psychopharmacological and psychosocial treatments, and should be a focus of research. Outcome measures should be expanded to include various measures of cognitive and psychosocial functioning as well as symptom assessments. Response to psychopharmacological treatments can be considerably affected by psychosocial experience, and consequently, somatic treatments also should be included in (a) investigations of differential treatment response patterns for women and men and (b) the larger research agenda for women's health.

Although effective interventions often are available, the majority of people with psychological disorders do not obtain professional treatment. Even among people with a history of three or more comorbid disorders, less than 50 percent ever obtain specialty sector mental health treatment (Kessler et al., 1994). Data are needed on barriers to treatment and on how to facilitate (a) entry into treatment and (b) treatment compliance and retention, particularly for high prevalence disorders for women such as depression.

• Expand research on risk factors for depression among different populations of women.

Data are limited on risk factors for depression in various subgroups of women including lesbians, ethnic minority women, rural women, and older women. For example, although little research has been conducted on depression among lesbians, available information indicates that lesbians may be at higher risk for depression than heterosexual women. Moreover, the rate of suicide attempts by lesbians, particularly African American and Latina lesbians, appears higher than among heterosexual women (National Institute of Mental Health, 1987). Additionally, risk factors for conditions unique to women, specifically postpartum depression, also should be identified.

• Expand research and therapeutic attention to women with depressive symptoms who do not meet criteria for major depression.

High utilization of medical services and social impairment are associated with presence of depressive symptoms as well as with diagnosed depression. Individuals with depressive symptoms have comparable, or higher, rates of emergency department use, use of medications, medical consultations for emotional problems, attempted suicide, and days lost from work as individuals with diagnosable depression (Glied & Kofman, 1995; Johnson, Weissman, & Klerman, 1992). Understanding subacute depressive syndromes, and their relationship to psychosocial functioning, should also be a research target.

• Expand research examining the effects of treating depression on recovery and survival in women with medical conditions.

More than 60 percent of office visits to physicians are made by women, and women have higher morbidity rates. In addition, the "mortality advantage" over men has been decreasing, that is, the ratio of male to female deaths has been declining (Rodin & Ickovics, 1990). Major depression is a source of increased morbidity and an independent risk factor for mortality in patients with medical conditions (Frasure-Smith, Lesperance, & Talajic, 1993). Identification and treatment of depression in women with medical disorders, and in aging women who tend to have higher rates of medical illness, should be a focus of research.

Eating Disorders

Approximately 2% of adult women meet current diagnostic criteria for anorexia nervosa or bulimia nervosa (Fairburn & Beglin, 1990; Hall & Hay, 1991), and even greater prevalence rates have been found among adolescent girls (Lucas, Beard, O’Fallon, & Kurland, 1991; Whitaker et al., 1990). In addition, an estimated 2 to 4 percent of women experience a clinically significant syndrome of disordered eating that does not fit current criteria for any of the major eating disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 3rd ed., 1980; Striegel-Moore & Marcus, 1995). Eating disorders have a profoundly negative effect on physical and psychological health and on social and vocational adjustment. In many cases, these disturbances in health and adjustment are long lasting or even irreversible. Eating disorders are significantly associated with a variety of psychiatric disorders, including depression, anxiety disorders, personality disorders, and substance abuse (Striegel-Moore & Marcus, 1995).

Research Priorities for Eating Disorders

• Improve classification to better characterize the full spectrum of eating disorders, including the range of problems grouped under "eating disorders not otherwise specified" (EDNOS), and to examine the usefulness of binge eating disorder (BED) in particular.

Currently, diagnostic criteria are based on the clinical picture of individuals presenting for treatment, yet only a fraction of individuals with an eating disorder ever seek therapy for their eating disorder. Important questions remain about the proper classification of eating disorders.

• Conduct studies to determine incidence and prevalence of eating disorders in a representative sample of adolescent and adult women, including ethnic minority women. Studies should also examine whether the current diagnostic criteria adequately address the spectrum of eating disorders in ethnic minority women.

The Epidemiological Catchment Area (Robins & Regier, 1991) study included only anorexia nervosa but not bulimia nervosa or "eating disorders not otherwise specified" in its diagnostic interview. Additionally, virtually excluded from major research studies are women of color, women from rural communities, and women representing lower SES groups. Inclusion of a more diverse group of women is critical to developing an empirically based classification of eating disorders, to testing hypotheses regarding differential risk based on membership in a particular subgroup, and to developing therapeutic and preventive interventions that are maximally effective for all women. For example, preliminary studies among women of color suggest that they have higher rates of eating disorder symptoms than had been commonly assumed.

• Conduct research to identify risk factors (such as dieting) associated with different eating disorders.

Dieting is generally thought to be a risk factor for the development of an eating disorder. But research that examines the role of dieting in the context of other risk factors would be useful. Given the pervasive negative stereotypes about obesity and a broad-based acceptance of dieting as a weight loss strategy, little research has focused on the potential adverse consequences of dieting. Identifying risk factors for eating disorders is critical to developing effective prevention programs.

• Test etiological models of eating disorders that encompass both biological and psychosocial pathways and address patterns of comorbidity.

A range of etiological factors have been hypothesized to contribute to the development of an eating disorder. Twin studies and family genetic studies have found significant familial aggregation of eating disorders; however, whether and to what degree eating disorders are genetically determined is not clear. Recently, experts have proposed that the development of an eating disorder may be best understood by models that encompass both psychosocial and biological pathways.

• Conduct studies that will lead to the development of effective interventions for the full spectrum of eating disorders.

Significant advances have been made in the treatment of bulimia nervosa and binge eating disorder. To date, individuals with eating disorders not otherwise specified, who outnumber those with anorexia nervosa or bulimia nervosa, have been excluded from controlled clinical trials. Moreover, in many trials, comorbidity, especially in the form of substance abuse, has been an exclusion criterion. As a consequence, rigorous treatment outcome data are missing for the largest number of individuals in need of treatment. The results of current treatment methods for anorexia nervosa remain disappointing. Relatively little research has been devoted to developing improved methods for its treatment.

HIV and AIDS

Over the last decade, women have accounted for an increasing percentage of people with HIV/AIDS in the United States, rising from 6.6 percent in 1985 to 18 percent in 1994 (CDC, 1994). As of December 1994, 58,428 American women were diagnosed with AIDS. More than half of these women are African American; one quarter, White; one fifth, Hispanic (CDC, 1993a). Although women across the entire life span are living with HIV/AIDS, the majority are of reproductive age and living in poverty. They also are likely to be single parents caring for children, some of whom are infected as well. Furthermore, women with HIV/AIDS may be diagnosed at a later point in the disease course than men, and they are more likely to face barriers to health and mental health care, social services, and community support.

These alarming epidemiologic trends underscore an urgent need to identify and explain the social and behavioral risk factors for HIV, especially among African American and Hispanic/Latina women, as well as adolescent girls, regardless of ethnic group membership. Further, although effective strategies for HIV prevention across and within ethnic groups are vital, the large number of women already living with HIV/AIDS suggests the need for research on demographic, psychosocial, disease, and treatment factors associated with adaptation, quality of life, and long-term survival.

There are major gender differences in sexual behavior that are critical in the analysis of HIV transmission in women. Although having multiple partners can be a major risk factor for women, having only one partner who engages in risky behavior places women at increased risk. Women appear to have a greater chance than men of becoming infected per coital act, and younger women may be vulnerable because of their immature cervical tissue. Younger women also are more likely to have an older, more experienced partner who places them at risk for sexually transmitted diseases (STDs) and HIV. Likewise, women may be especially vulnerable to infection as a result of their patterns of sharing drug injection equipment with a sex partner. Women are more likely than men to have an injection-drug using partner (Feucht, Stephens, & Roman, 1990), to have only one needle-sharing partner (Brown & Weissman, 1993), who is typically a sex partner, and to often use drug injection equipment after their male partner (Castro, Valdiserri, & Curran, 1992).

Research Priorities for HIV and AIDS

• Conduct studies to identify distinctive patterns of behaviors and social conditions among cultural and age-based subgroups of women that determine their risk of infection and determine how women protect themselves against sex with risky partners.

The extent to which patterns of sexual behaviors and intravenous drug use are similar among African American, Hispanic, and adolescent women of all backgrounds is not well understood (Amaro, 1995; Cochran & Mays, 1989). Ethnic differences in high-risk sexual activity, substance abuse, and HIV within the context of familial and peer group networks also have yet to be identified.

Women tend to have substantially fewer sex partners than men. Consequently, it is crucial that prevention efforts help women understand the risk level associated with particular partners. Research needs to explore sexual communication between heterosexual partners within and across different ethnic groups. For example, to what extent and under what conditions do men disclose risk factors for HIV and other STD infection, disclose their intravenous drug use, and/or disclose their serostatus? To what extent and under what conditions do women communicate in a sexually assertive manner to find out sexual history information from potential partners? How are decisions made regarding condom use? How do relationship dynamics influence needle sharing? Additional research on the role of sexual coercion, sexual assault, and domestic violence in the transmission of HIV also is vital to prevention efforts.

• Increase research on predictors of risky behaviors focusing on issues such as power in various relationships, physical and/or sexual abuse, and alcohol and other drug use; conduct research that will translate identified predictors of risk into effective interventions to reduce risk.

Several factors have been found to increase women’s vulnerability to HIV infection, including history of sexual abuse, current experience of physical abuse in the primary relationship, sexual assertiveness, and alcohol and other drug use. Research should examine these possible predictors of risk separately for women from different ethnic groups. Moreover, models of behavior change should be developed and evaluated that incorporate issues of reproduction as well as STD prevention for women. These models should be based on issues identified with diverse populations of women across age, educational, and economic backgrounds and should incorporate healthy sexual practices.

• Evaluate programs designed to decrease women's risk associated with injection drug use (e.g., treatment and needle exchange programs).

Effective, research-based substance use prevention and drug treatment programs for women are vital. Outcome-based, comprehensive programs that are gender and culture specific and provide training in jobs skills, AIDS awareness, sexual assertiveness, childcare, and sexual abuse survivor issues should be developed. A number of model programs are currently under way that require careful evaluation.

Needle exchange programs also should be evaluated, especially their effectiveness for women. Some studies indicate that women have less access to needle exchange programs than men (Brown & Weissman, 1993; CDC, 1993a). Increasing women's utilization of such programs is a high priority because it can save lives immediately.

• Determine the effects of HIV/AIDS on women’s psychological functioning.

Few studies have investigated the psychological sequelae of HIV and AIDS among women and their families. Longitudinal, comprehensive research needs to address the relationships among sociodemographic factors, disease and treatment factors, drug use, caregiving, sexual abuse, domestic violence, and continued substance abuse or high risk sexual behavior following diagnosis, coping, resilience, adjustment difficulties, isolation, social support, quality of life, immune functioning, and survival among women with HIV/AIDS. In addition, these psychosocial and behavioral factors should be evaluated in women with HIV/AIDS who also are homeless, disabled, have enduring mental illness or are older. This research should assess ethnic and cultural expectations for women such as providing caretaking functions for others and how these roles are carried out over the course of HIV infection. Research in these areas is necessary for the development of outcome-based interventions aimed at enhancing self-care, coping, resilience, and quality of life for the broad range of women and families living with HIV/AIDS.

• Conduct studies to assess barriers to obtaining medical and psychological treatment for women with HIV infection or AIDS.

Innovative, outcome-based programs that reduce barriers to health care, mental health care, and social services for women with HIV/AIDS should be developed. Community-based programs targeting women of color and families must address barriers (e.g., poverty, language, child care, transportation, gender and ethnic bias in services, and HIV-related discrimination) to care and service.

Aging

Women older than age 65 are becoming an increasingly large segment of the United States population. In 1990, 12.5 percent of the population was 65 or older; this percentage will rise as the baby boom generation ages. Older women outnumber their male counterparts three to two, and for those 85 and older, there are five women for every two men (U.S. Bureau of the Census, 1992).

Although women live longer, they have higher morbidity than men. Older women report more chronic, non-life-threatening impairments than men, and spend more years with chronic, debilitating diseases. Moreover, older women tend to have more multiple chronic conditions than men, which can increase the severity of a major health condition and impose limitations on treatment strategies (Gatz, Harris, & Turk-Charles, 1995). Consequently, research on the health needs of aging women will become increasingly important.

Research Priorities for Aging

• Increase research on the risk factors for developing disease, effective prevention practices, and effective treatments for chronic diseases most likely to affect women.

The prevalent chronic conditions of older women include arthritis, hypertension, hearing and vision problems, heart conditions, orthopedic problems, urinary incontinence, migraine headaches, and depression (U.S. National Center for Health Statistics, 1994). Despite their high prevalence and critical role in disability, nonfatal chronic conditions have had far less biomedical, clinical, and epidemiologic attention than fatal conditions. Research is particularly important in these areas for women.

• Expand research attention given to all aspects (biomedical, epidemiological, psychosocial) of osteoarthritis.

Osteoarthritis is the most common chronic condition in middle and late life. Its prevalence is about 50 percent higher among women than men. Although it is a long-standing pathology among humans, it has had far less scientific attention than ostensibly more recent illnesses such as ischemic heart disease and lung cancer.

• Research is needed on prevalence of disabilities among women, their incidence and duration, and on risk factors and efficacious interventions for disability.

As interest in quality, as well as quantity, of later life grows, so does the need for information about the extent and causes of disability. Women's age-specific rates of disability exceed men’s and warrant investigation. For example, we must know whether certain combinations of disease and impairments have an especially strong disabling impact on women (e.g., arthritis and vision impairment; hearing impairment and hypertension) and if these clusters have a similar impact on men, or exacerbate disability more strongly for women.

• Examine factors affecting older women’s perceptions of health and increase understanding of the link between perceptions of health and mortality.

Research indicates that self-rated health is a better predictor of survival than are objective measures of health (Kaplan, Barell, & Lusky, 1988). It also remains a significant predictor of survival beyond the statistical influence of other factors, such as objective health status, health practices, health services use, life satisfaction, social networks, religious involvement, socioeconomic status, and functional abilities (Gatz et al., 1995).

• Studies of mobility and independence (including unassisted walking, assisted walking, use of transportation systems) in usual settings are needed, especially studies of what factors maintain mobility and what interventions relieve mobility problems.

Mobility is a highly-valued function throughout life. It includes ability to get around in one’s home, neighborhood, and community. More strategies to maintain physical vigor and independence in different settings should be explored. For example, there are often conflicting goals in some nursing homes between the staff's desire to finish meals in the dining hall as quickly as possible by using wheelchairs and the need of the elderly to maintain physical vigor by walking on their own.

Gynecological and Reproductive Health

The most frequent reasons for a physician office visit and short hospital stays among women of reproductive age are normal pregnancy care, postpartum care, contraceptive and procreative management (including abortion and sterilization procedures), and complications of pregnancy. Because these events are part of the normal life cycle, and given the magnitude of numbers of women affected, it is critical that we fully understand the psychosocial aspects of each reproductive life stage and its consequences.

Prenatal care for low income women in the United States is inadequate, and receipt of care is based on other factors in addition to financial status, particularly for ethnic minority women (Mor, Alexander, Kogan, Kieffer, & Hulsey, 1995). Strategies should be developed for assisting pregnant women to change diet, quit smoking, and stop substance abuse. Labor continues to present a substantial source of pain and trauma for many women with continued controversies existing over the role of women in the management of their own labor and delivery experiences. Moreover, obstetrical care is often based on tradition rather than scientific rationale (Chalmers, Keirse, & Enkin, 1989).

Research Priorities for Gynecological and Reproductive Health

• Conduct studies to determine factors that facilitate the development of positive self- and body image during puberty.

Research has shown that menarche may be the beginning of change in girls’ self- and body image and that many adolescent girls develop a negative sense of themselves and their bodies during puberty. This lack of a positive self-image can put them at risk for multiple other problems (e.g., alcohol abuse, partner abuse, eating disorders, risky sexual behavior, and unwanted pregnancy). Research that identifies the critical stages in the development of a positive self-image could contribute to a database on which effective adolescent programs can be built.

• Examine sexual decision making within a relational goals perspective.

Menarche sets the stage for significant decisions about sexual activity and contraception. As increasing numbers of adolescent women become sexually active and face decisions concerning safe sex, pregnancy, prenatal care, teenage parenting, or abortion, it is important that factors associated with young women’s sexual decision making, particularly within a relational context, are understood. For example, what factors influence girls' sexual and contraceptive decision making? What is the role of sexual coercion in the process? Most work to date in this area has focused on intrapersonal characteristics associated with beginning sexual activities and deciding to use contraceptive or STD prevention mechanisms. Future research needs to adapt a relational goals perspective and study how these factors influence decision making.

• Develop and evaluate behavioral interventions to change diet and exercise, to stop smoking, to abstain from alcohol or other drug use during pregnancy; examine barriers to low income women receiving prenatal care; and expand research on factors affecting labor, including length of labor, use of drugs during labor, and infant birth outcomes.

A widely expressed concern is that many low income women have inadequate prenatal care and that lack of prenatal care is associated with negative birth outcomes. A research program that identifies the barriers to receiving this care would be extremely beneficial.

Strategies should be developed to assist pregnant women in changing their diets, quitting smoking, and stopping substance abuse. Some research is currently under way to assess effectiveness of manual-based cognitive-behavioral interventions to change behaviors that negatively impact on birth outcomes, but these programs need wider scale evaluations. Furthermore, interventions are needed for specific populations of women such as women with gestational diabetes, alcohol or drug addiction, or other problems.

Some studies have indicated important benefits for women who receive continuous labor support from doulas (labor assistants/coaches) during labor as compared with women not receiving this support. These benefits include reduced rates of caesarean section deliveries, forceps deliveries, epidural anesthesia and other labor and birth variables (Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991). These preliminary findings provide a potentially important intervention that should be pursued.

• Determine the important needs for consumer information and education among menopausal women and how this information can best be disseminated.

Questions remain regarding factors that promote well-being among menopausal women; what psychosocial and behavioral interventions are effective in preventing and treating distressing symptoms of menopause and chronic diseases associated with midlife. Research is needed on how women obtain information (e.g., physicians, popular press), and the impact of accurate, biased, and/or negative information they receive (e.g., overemphasis on likelihood of negative affective reactions). Research is also needed on which attitudes toward or expectations about menopause or midlife are predictive of positive or negative menopausal experience.

• Investigate the determinants and psychosocial correlates of infertility, as well as the physical and psychological consequences of treatments for infertility.

Infertility and impaired fecundity affect almost five million women in the United States. Continued investigation of the etiology of infertility is warranted, as is development of interventions designed to modify behavioral (e.g., STD prevention) and environmental determinants of infertility. Consequences of limited access to medical treatment for infertility require study, as do the health consequences and safety of infertility treatments. Examination of risk factors for negative psychosocial outcomes in those who confront infertility is required, as is documentation of the efficacy of interventions designed to decrease psychological morbidity.

Male Violence Against Women

Multiple forms of violence against women cause serious physical health consequences. For example, in primary care practice, women who have been raped report more symptoms of illness and more negative health behaviors, including alcohol use, smoking, and failure to use seat belts, than non-victimized women. They visit their physicians more than twice as often as women who have not been raped. Approximately 21 percent of women using emergency surgical services are there because of the physical sequelae of partner abuse and 51 percent of women murdered in the United States during the first half of the 1980s were victims of partner homicide (Koss et al., 1994).

Research Priorities for Male Violence Against Women

• Develop consensus research definitions of the behaviors encompassed under the general rubric of violence against women.

Progress in the field is retarded when the literature is noncumulative. Single studies that obtain adequate incidence and prevalence data from ethnic and language minorities and other groups underrepresented in research are unlikely without substantially more financial resources than are currently available. These studies are critical in accumulating an adequate picture of high- risk groups for violence. This effort depends on shared understandings of the phenomena of violence, including its many guises. Most studies currently focus on physical abuse or rape, primarily because they are easier to identify and measure and are potentially lethal. However, almost all battered women describe psychological abuse as the most hurtful.

• Effective methods of screening for violence should be developed and tested for use in all points of entry to the health care system, including mental health, emergency medicine, and primary care.

Effective methods of screening to identify women affected by violence are a prerequisite to studying the outcomes of abuse-sensitive medical care. A number of important outcomes must be evaluated, including the effect of medical attention to violence on perceived health, utilization of health services over time, and patient satisfaction.

• Perform studies of violence against women as a risk factor for various diseases from a multivariate perspective.

The role of violence exposure as a risk factor for disease must be examined for a range of diseases and diagnoses. Research designs should be capable of examining alternative explanations for associations between victimization and disease. Victimization may lead to disease directly or indirectly, or both disease and victimization could be influenced by a similar set of variables, which creates the illusion of correlation between them.

• Expand and enhance research on sociocultural correlates of violence.

Violence against women occurs within a sociocultural context. Greater understanding of the sociocultural factors that promote and maintain violence against women provide the theoretical rationale for the development and assessment of education and prevention interventions. Included in this recommendation is research on the factors that create the predisposition toward violent behavior, situational variables that trigger the expression of violence, and social processes that allow violence to continue without negative consequences to the perpetrator. In addition, ethnographic research is needed to delineate the definitions of various forms of violence such as rape and spousal abuse within subgroups and their preferred methods for addressing these behaviors. These definitions and preferences may influence the choice to make use of services for victims of battering or rape.

• Develop systematic and quantifiable measures to evaluate treatment programs for victims and perpetrators of violence; approach evaluation from a life span perspective.

Although there is a general belief that shelters, advocacy, and other programs are helpful, there is little actual evaluation research data that confirms or refutes this belief. This is especially true for various subpopulations and cultural groups of women who seek services as victims of male violence. Also needed is documentation of the complex process victimized women go through in attempting to manage and end the violence in their lives. This research would be more focused on resiliency than is currently the norm. Such studies are different from those that examine continuing rates of physical or psychological abuse as outcome measures and that measure the behavior of the perpetrator, not something over which the woman has direct and immediate control. Programs for perpetrators also need further study. As with programs for victims of violence, research is needed to identify which programs work for which types of individual. Finally, studies of violence perpetration from a life span perspective are needed. Such studies would aim to identify the progression of a perpetrator’s career of violence and the impact of victimization on life decisions at later stages of development.

Occupational Stress

A large body of literature on occupational stress has identified certain job and organizational characteristics as having deleterious effects on the psychological and physical health of workers. These stressors include high workload demands coupled with low job control, role ambiguity and conflict, lack of job security, poor relationships with coworkers and supervisors, and repetitive, narrow tasks. Unfortunately, these stressful attributes characterize many of the jobs that are traditionally female (e.g., clerical/data entry work, caregiving). Stress from such work can give rise to low job satisfaction, poor job performance, and impaired health (Swanson, Piotrkowski, Keita, & Becker, 1997).

Research Priorities for Occupational Stress

• Examine implications and importance of "classic" occupational stress and moderator variables.

The primary survey instruments that have been developed to examine occupational stress were developed to study stress among men (i.e., primarily white male populations). These include the scales examining classic stressors and moderators such as job demands and control, role ambiguity and conflict, and relationships with others at work. However, there is some evidence that gender differences exist in importance of these "classic" factors (e.g., some studies have found that social support is a more potent stress buffer/moderator for women than men). These gender differences and their implications deserve further exploration.

• Examine the prevalence and impact of occupational stressors specific to women and ethnic minority groups.

Stressors specific to women and ethnic/minority groups have not been examined sufficiently, both for their prevalence and their health impact. These include factors such as discrimination, various forms of harassment, and career issues related to gender and ethnicity (e.g., perceptions of qualifications and effectiveness modified by gender and ethnicity).

• Determine the effectiveness of various job design and work organization strategies in ameliorating physical and psychological health problems associated with stressors.

Many predominantly female occupations are highly repetitive and monotonous, with high workload demands. Research is needed to address these issues including strategies such as job enlargement and rotation, and attention to the temporal aspects of work.

Traditional work environments have been geared to men's roles. The changing gender composition of today's workplace requires different strategies to make the workplace more supportive of families and the many roles of women. New strategies, including flextime and job-sharing, need further study. In addition, the characteristics of "women-friendly" workplaces, with regard to factors including management styles, communication patterns, support structures (e.g., mentoring) provide an important opportunity to obtain data on how workplaces could be redesigned to benefit everyone.

• Identify key job stressors that may influence the incidence of workplace violence and determine what actions are effective in eliminating or ameliorating these stressors.

Gender differences in fatal workplace violence have become apparent in recent years (e.g., homicide is the leading cause of fatal workplace injury for women). There is some evidence that women in certain occupations are more vulnerable to nonfatal violence than men, for example, patients hitting, kicking, or scratching health care workers (Bureau of Labor Statistics, 1994), and that in general women are the primary victims of certain forms of nonfatal workplace violence (e.g., various forms of harassment). There is also some evidence that job stress may influence the incidence of nonfatal violence in the workplace. However, little is known about the prevalence and characteristics of nonfatal workplace violence.

Examine gender-related differences and similarities in work-family and family-work spillover effects.
Dual-income families now are the norm rather than the exception. Research efforts in this area, however, are just beginning. Moreover, little work has examined child care and household task-sharing arrangements that can be effective in reducing stress in working women.

Although women are a majority of health care consumers, women's issues in health services research have not received adequate attention. Recent debates over health care reform and the continued growth of managed care systems have highlighted a number of important questions about how women access health care through the life span, the quality of relationships between women and their physicians, the ways in which health care delivery systems define the scope of women's health care services and coordinate care, and the components of women-centered care.

For example, women may have difficulties accessing health care for financial reasons (e.g., lack of health insurance or inadequate insurance) and for non-financial reasons (e.g., barriers associated with inconvenient hours or locations, a lack of child care, cultural barriers). Women may have difficulties communicating with male physicians about sensitive issues such as sexual behavior or domestic violence. Women may find that their health care plans limit the scope of needed services (e.g., preventive tests, mental health services) through restrictive benefit structures. Because reproductive health care tends to be provided by different physicians or in different settings than other components of basic care, care may not be coordinated and mental health services may be omitted.

Research Priorities for Health Services

• Identify and understand non-financial barriers to use of key preventive health services (e.g., prenatal care, mammography screening) by women.

Informational deficits, attitudinal factors, and cultural barriers may be as important as financial factors in inhibiting use of preventive services that are key to women’s health and quality of life. Research is needed to identify and elaborate the psychosocial factors that promote women’s use of basic services at different stages of the life span.

• Develop a better understanding of ways in which physician gender influences the quality of women's health care.

Current information about women's communication with their physicians and about physicians' influences on women's receipt of services suggests that physician gender may play a role in several ways. Some studies, for example, suggest that specialty may be more important than physician gender in determining services received. Research is needed to clarify whether female physicians in different specialties communicate more effectively than male physicians with female patients, whether they provide more preventive services, and whether they are more sensitive to psychosocial issues. Interventions to improve physician training depend on clarification of these issues.

• Analyze differences in provision of services and outcomes of care in different types of service systems.

Managed care systems, particularly certain types of HMOs, may provide opportunities for integrating reproductive and other components of women’s basic health care. However, little is known about how managed care systems define the scope of services for women, the types of coordination mechanisms used, or the types of outcome monitoring most appropriate for women. These issues must be resolved before the services and outcomes analyses can be accomplished.

• Analyze the relative advantages and disadvantages of women-centered health care for the health of women.

The growth of women's health centers of various types - ranging from comprehensive primary care centers to highly specialized centers focusing on a specific service or condition - has raised questions about the uniqueness of these centers and their ability to respond to the specific health care needs of women.

• Analyze the effectiveness of increased utilization of mental health services for improving overall health, and for reducing medical services utilization and costs.

Research has shown that much of the higher cost associated with unnecessary medical treatment would be avoided with early mental health treatment. Moreover, extensive research has shown a direct link between behavior and many of the nation's leading health problems. In addition, recent research strongly suggests that immunological functioning and immune-related diseases are affected by psychological stress. Increased attention to mental health issues may have a significant impact on overall health.

 

Major changes are needed in approaches to education and training in the health professions if we are to produce health scientists and professionals with the knowledge, skills, and sensitivity required to generate and apply new knowledge concerning the health needs of women from all ethnic groups over the life cycle and in diverse social and cultural contexts. In particular, a comprehensive approach is required that both critiques traditional approaches and provides innovative and exciting alternatives, and that is responsive to women's diverse sociocultural contexts and identities.

Guiding Principles

Guiding principles for the development of curricula for the training of health professionals include the following:

• Training health professionals to recognize and value diversity is of paramount importance to ensure the quality of health care.

Institutions that offer health education should actively enhance the diversity of their curriculum, student bodies, faculty, administration, and governing bodies.

• Health professionals should be taught to value equalitarianism and collaboration with their clients, patients, and research participants.

The goal is to enable patients to become active collaborators in the health-promoting process and to make the most informed judgments about participating in the health enterprise.

• A model of human behavior that assumes individuals are active and adaptive (rather than passive victims) leads to more effective health interventions.

Blaming or pathologizing women and other subordinate groups for the manner in which they cope with the challenge of surviving in a sexist, racist, classist, homophobic, "ablist", and violent environment is a poor intervention strategy. Health professionals need to be taught to recognize the dynamics and sequelae of the many coping strategies developed by relatively powerless individuals, their cultural components and validity.

• Lectures, textbooks, and other pedagogical materials should challenge negative stereotyped thinking and assumptions regarding individual, cultural, and other differences in the framing of research and other questions, interpretations of research findings, characterizations of peoples and illnesses, and therapeutic possibilities.

• Educators of health professionals need to create or adapt mechanisms that encourage students/trainees to collaborate, to respect and value themselves and their fellow students/trainees, to be intolerant of sexual, racial, or any other harassment, and to interrupt such behavior should it occur.

• Health professionals should be encouraged to see themselves as part of a larger social system which creates, exacerbates, or ignores health problems as well as diminishes or eliminates them.

Training in awareness, analysis, and amelioration of these problems should be intrinsic to the education of all health professionals.

• There should be continuous evaluation of and reflection on values, ethics, and practices.

In particular, health professionals need to examine accepted practices that benefit or accommodate themselves more than those they serve (e.g., self-referrals, unnecessary surgeries, skimming the cream of a pool of research participants to maximize favorable outcomes for therapeutic evaluations). Supercilious attitudes toward nontraditional and indigenous therapies need reexamination.

• Health is a complex function of the interaction of economic, political, cultural, biological, psychological, physiological, spiritual, and familial factors.

Health prevention and intervention efforts that do not take into account this complexity will be less effective than they could be.

Education and Training Priorities

• Include health professionals from all health-related fields and subfields in transformation efforts.

• Design programs targeted to multiple educational levels from undergraduate to postdoctoral, and to diverse training settings, encompassing universities, hospitals, community health centers, clinics, medical schools, other professional schools, vocational schools, and continuing education venues.

• Make the conceptual model for a women's health curriculum a biopsychosocial one that is interdisciplinary in nature, crossing departmental boundaries.

In addition, medical schools should provide an integrated clinical experience in women's health across the four years of their programs.

• View curriculum development as a dynamic process; design it to be responsive to new psychosocial and behavioral research theories, methods, and findings.

• Transform all aspects of the education and training experience, including content, process, and climate.

Content. Educators need to develop appropriate lectures, textbooks, and other materials, including videos, films, computer-assisted instruction, electronic classroom bulletin boards, and instrumentation for use in the classroom and the laboratory; establish on-line resources, including syllabi banks and other resource materials (WMST-L and the Women's Studies on-line resources at the University of Maryland at Baltimore provide a model for these actions); and make women better consumers of health care and more self-care and self-help oriented.

Process. In addition to training educators in traditional pedagogical techniques, new skills are needed that will equip them to (a) intervene in social dynamics of the laboratory and classroom that undermine the performance of women and ethnic minorities and (b) break through the resistance of colleagues and students who find their values and beliefs challenged by this new knowledge.

Climate. Educators need to develop positive learning environments for women and minorities (including designing environments that emphasize cooperation and collaboration rather than competition); address issues of sexual harassment and discrimination, preventing their occurrence, ameliorating their effects, and empowering women who have such experiences; provide positive role models and supportive mentoring relationships; and promote women's full participation in policymaking roles in education and training settings, including academic institutions, and accreditation, licensing, and regulatory bodies.

• Reconceptualize professional roles and career development in the health professions to support integration rather than fragmentation of research, teaching, and practice functions.

• Design research training experiences in both quantitative and qualitative methods for application to women's health issues including new and innovative research models and methods, collaborative and community-based research approaches, econometric models, and evaluation techniques.

• Train health professionals for the traditional roles of researcher, practitioner, consultant, teacher, and administrator, as well as for the responsibility of communicating their knowledge to the public and to the media.

Communicating effectively with the media is particularly important, given the important role that women's magazines play in educating women about health issues.

• Train learners in all content areas to (a) consider the relationship of women's multiple identities and circumstances to their health care and (b) appreciate the profound implications for women's health of biological and social factors differentially associated with gender, ethnicity, age, and disability.

• Communicate knowledge of and sensitivity to the way differences in gender role norms, expectations, and power may affect health promotion and disease prevention in diverse ethnic groups.

For example, women may do most of the meal planning and preparation or be the one to make sure dependents visit health care providers. When ill, these women may have difficulty getting sufficient rest because of having to care for dependents' needs.

• Incorporate new knowledge about women's health into curriculum offerings dealing with diseases/disorders that are common in, unique to, or more prevalent in women.

Information on risk factors, etiology, outcomes, and interventions of diseases/disorders all need to be included. Here priority areas include osteoporosis, HIV infection, eating disorders, depression, anxiety disorders, substance abuse, systemic lupus erythematosus, cancer, reproductive-related conditions, and heart disease.

• Educate health care providers that women may respond differently to drug therapy on the basis of gender-related differences in pharmacokinetics and pharmacodynamics.

Drug doses may need adjustment for women of different ages, in different menstrual phases, or of different ethnic group membership. All of these issues require further evaluation in multi-ethnic studies.

• Design reproductive health curricula to equip health professionals with knowledge and skills that will enable them to help women (a) understand and enjoy their own sexuality; (b) regulate pregnancy and childbearing effectively and safely; (c) remain free of disease, disability, and death associated with sexuality and reproduction; and (d) bear and rear healthy children.

Examination of links between inequalities in women's power and status and their sexuality and reproductive health would be included (e.g., violence and unwanted pregnancy; poverty and low birth weight; SES, substance abuse, and AIDS/HIV infection; ethnicity and sexuality).

• Develop institutional structures to promote interdisciplinary research collaboration and build new biopsychosocial models of women's health over the life cycle and in differing cultural contexts.

The establishment of offices that focus on women's issues in various agencies, such as the National Institutes of Health, Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, Food and Drug Administration, and the Veterans Administration, is an important step. To be effective, however, they must be adequately staffed and funded, with the clout needed to have an impact on the funding of other offices as well. Although the concerns of such institutional structures would encompass more than training, they do need to exercise leadership in the training area through the funding of research training workshops, and pre- and postdoctoral fellowships specifically targeted for women's health.

• Develop training programs specifically focused on women's health and mainstream knowledge into other types of training programs.

Develop policy that mandates addressing issues of diversity in programs receiving training grants, including both trainee selection and program content, just as there is policy mandating inclusion of women in study populations.

Create new training opportunities, including multidisciplinary training centers, specialized training institutes, and faculty/staff development offerings modeled after the National Institute of Mental Health staff college courses on women's mental health of the early 1980s.

• Expand sources of funding for curriculum development and integration projects, both in the public and private sector.

Real and lasting progress in improving the health of all American women will require significant shifts in policy by government at the federal, state, and local levels, as well as by other public and private institutions. Through their decisions, these bodies set priorities, allocate resources, and establish structures. In today's political climate, focusing significant attention on issues of women's health will take sustained and concerted action by advocacy groups, funding agencies, and interested public officials.

Broad Goals for Public Policy Efforts

The following are broad goals for public policy efforts to advance women's health:

• Develop health policy at local, state, and national levels that is informed by the changing social and economic contexts of women's lives.

• Provide information and education to women about healthy lifestyles, important preventive services, results of health research, efficacy of treatments, and availability of health care and related services in their communities.

• Reduce financial barriers to women's access to health care by assuring adequate health insurance coverage for preventive and other services, regardless of women's employment status, income, or health status.

• Reduce non-financial barriers to women's access to health care by providing health services that are culturally appropriate and accessible to women in the communities where they live and work.

• Ensure the appropriate training and adequate numbers of primary care providers (physicians and non-physicians) for women's basic health care.

• Ensure that managed care systems are sensitive to women's health care needs and appropriately integrate the components of women's health care.

• Ensure that women are adequately represented among health research participants and that needed research is conducted on women's health problems.

• Protect women's right to seek needed health services and to make decisions about their own health care.
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Public Policy Priorities for Specific Groups Priorities for Research Funding Agencies

• Maintain adequate funding for a broad spectrum of women's health research, including psychosocial and behavioral areas as well as research on the delivery and appropriateness of women's health services.

• Maintain stringent guidelines for inclusion of women and minorities in study populations.

• Require broad dissemination of research results and use developing technology to make results more available through libraries, the Internet and other outlets.

• Continue efforts to increase the number of women and ethnic minority researchers through training opportunities.

• Fund large-scale national research initiatives in women's health addressing issues such as prevention and health promotion, reproductive health, and chronic disorders. An example is the Women's Health Initiative.

• Fund comprehensive, multiagency, multidisciplinary efforts to examine major health issues affecting women such as HIV, coronary heart disease, lung cancer, breast cancer, teen pregnancy, and male partner violence.

• Create new funding mechanisms for developing innovative settings for ongoing community-based and public health interventions.

Priorities for Policymakers (Congress and Administration)

• Include requirements to assess the impact on women of all proposed health care and health insurance reform policies. Such assessments would be similar to the environmental impact assessment requirement for development projects.

• Preserve and strengthen offices of women's health and women's health research and other infrastructures involved in women's health research. A paramount concern is that these offices receive adequate funding.

• Maintain and strengthen mechanisms to coordinate women's health activities across federal agencies.

• Mandate dissemination of research results to women and their health care providers.

• Clarify and strengthen the Public Health Service (PHS) guidelines on the inclusion of women and ethnic minorities in study populations.

• Create a Women's Health Advisory Committee to the Secretary of Health and Human Services with a diverse membership of researchers, advocates, policymakers, providers, and consumers to assess the progress of federal and state agencies on addressing guidelines, action plans, and goals on women's health. For example, it would set realistic goals and timetables and monitor progress on the PHS Action Plan for Women's Health.

Priorities for Professional and Women's Health Advocacy Associations

• Disseminate research findings in professional journals, the media, electronic communications systems, and other outlets accessible to a broad range of audiences, including policymakers and consumers.

• Inform policymakers and health care providers of research results and gaps in current knowledge.

• Ensure adequate training and supply of professionals who provide women's basic health care.

• Maintain strong advocacy activities to ensure that women's health issues remain a priority and conduct advocacy training for members.

• Create linkages among women in communities, researchers, practitioners, and policymakers in women's health such as electronic communication systems to keep pace with the rapid changes taking place in the world.

• Develop linkages with organizations whose missions are to promote the election of women and to ensure that those organizations have science-based information about the health needs of women. Those organizations can, in turn, help educate and inform candidates for office.

Priorities for Health Care Providers

• Ensure appropriate training and supply of women's primary care providers.

• Ensure integration of all components of women's health care in managed care plans.

• Ensure that health providers and insurance plans do not discriminate against women in benefit structures or provision of services.

• Make use of current research results in efforts to remove barriers to access for underserved populations.

• Integrate findings of women's health research into practice.

• Involve schools, religious organizations, women's groups and other community entities in health screening, prevention, diagnosis, and treatment efforts.

• Ensure that psychosocial and behavioral issues are included in the training of health care providers.

Priorities for Researchers

• Translate research findings into practical applications in primary care and community settings and disseminate results widely to policymakers, community groups, health providers, and other researchers.

• Identify gaps in scientific knowledge about women's health.

• Develop partnerships with health provider and community groups to disseminate research results and identify issues that future research and policy should address.

Priorities for the Media

• Report women's health research as accurately and in as much depth as possible.

• Report how research results affect and apply to various subpopulations of women.

• Report the impact on women of health care reform proposals, health insurance reform proposals, and other developments related to the funding of health care.

• Report the impact of federal, state, and/or local health policies on women, including different subpopulations of women.

• Ensure that stories on women's health are informed by the changing social and economic contexts of women's lives.

• Inform and educate women about healthy lifestyles, important preventive services, results of health research, efficacy of treatments, and availability of health care and related services in their communities.

Amaro, H. (1995). Love, sex, and power: Considering women's realities in HIV prevention. American Psychologist, 50, 437-447.

American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: Author.

Anda, R. F., Williamson, D. F., Escobedo, L. G., Mast, E. E., Giovino, G. A., & Remington, P. L. (1990). Depression and the dynamics of smoking: A national perspective. Journal of the American Medical Association, 264, 1541-1545.

Babor, T. F. (1990). Brief intervention strategies for harmful drinkers: New directions for medical education. Canadian Medical Association Journal, 143, 1070-1076.

Beary, M. D., Lacey, J. H., & Merry, J. (1986). Alcoholism and eating disorders in women of fertile age. British Journal of Addiction, 81, 685-689.

Belza, B. L. (1995). Comparison of self-reported fatigue in rheumatoid arthritis and controls. The Journal of Rheumatology, 22, 639-643.

Belza, B. L., Henke, C. J., Epstein, W. V., & Gilliss, C. L. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research, 42, 93-99.

Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315-336.

Boyd, C., Blow, F., & Orgain, L. (1993). Gender differences among African American substance abusers. Journal of Psychoactive Drugs, 25, 301-305.

Boyd, C., Guthrie, B., Pohl, J., Whitmarsh, J., & Henderson, D. (1994). African-American women who smoke crack: Sexual trauma and the mother-daughter relationship. Journal of Psychoactive Drugs, 26, 243-247.

Brooks, J. S., Whiteman, M., Cohen, P., & Tanaka, J. S. (1992). Childhood precursors of adolescent drug use: A longitudinal analysis. Genetic, Social, and General Psychology Monographs, 118, 197-213.

Brown, V., & Weissman, G. (1993). Women and men injection drug users: An updated look at gender differences and risk factors. In B. S. Brown & G. M. Beschner (Eds.), Handbook on risk of AIDS: Injection drug users and sexual partners (pp. 173-194). Westport, CT: Greenwood Press.

Bureau of Labor Statistics. (1994). Violence in the workplace comes under closer scrutiny. Issues in labor statistics [Summary Rep. No. 94-10]. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics.

Camp, D. E., Klesges, R. C., & Reylea, G. (1993). The relationship between body and weight concerns and adolescent smoking. Health Psychology, 12, 24-32.

Castro, K. G., Valdiserri, R. O., & Curran, J. W. (1992). Perspectives in HIV/AIDS epidemiology and prevention from the Eighth International Conference on AIDS. American Journal of Public Health, 82, 1465-1470.

Centers for Disease Control and Prevention. (1993a). The public health impact of needle exchange programs in the United States and abroad. Atlanta, GA: Author.

Centers for Disease Control and Prevention. (1993b). Priorities for women's health. Atlanta, GA: Author.

Centers for Disease Control and Prevention. (1994). Arthritis prevalence and activity limitations - United States, 1990. MMWR - Morbidity and Mortality Weekly Report, 43, 433-438.

Centers for Disease Control and Prevention. (1995a). HIV/AIDS Surveillance Report, 7, 10.

Centers for Disease Control and Prevention. (1995b). Prevalence and impact of arthritis among women - United States, 1989-1991. MMWR - Mortality and Morbidity Weekly Report, 44, 329-334.

Chalmers, I., Keirse, M., & Enkin, M. (1989). A guide to effective care in pregnancy and childbirth. London: Oxford University Press.

Christie, K., Burke, J., Reiger, D., Boyd, J., & Locke, B. (1988). Epidemiological evidence for early onset of mental disorders and higher risk of drug abuse in young adults. American Journal of Psychiatry, 145, 971-975.

Cochran, S. D., & Mays, V. M. (1989). Women and AIDS-related concerns: Roles for psychologists in helping the worried well. American Psychologist, 44, 529-535.

DeBusk, R. F., Hakansson, U., Sheehan, M., & Haskell, W. L. (1990). Training effects of long vs. short bouts of exercise. American Journal of Cardiology, 65, 1010-1013.

DeVellis, B. M. (1993). Depression in rheumatologic diseases. Bailliere's Clinical Rheumatology, 7, 241-257.

Fairburn, C. G., & Beglin, S. J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry, 147, 401-408.

Feucht, T., Stephens, R., & Roman, S. (1990). The sexual behavior of intravenous drug users: Assessing the risk of sexual transmission of HIV. The Journal of Drug Issues, 20, 195-213.

Finnegan, L. P. (1994). Perinatal morbidity and mortality in substance using families: Effects and intervention strategies. Bulletin on Narcotics 46, 19-43.

Frank, E., Kupfer, D. J., Perel, J. M., Cornes, C., Jarrett, D. B., Mallinger, A. G., Thase, M. E., McEachran, A. B., & Grochocinski, V. J. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093-1099.

Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). Depression following myocardial infarction: Impact on 6-month survival. Journal of the American Medical Association, 270, 1819-1825.

Gatz, M., Harris, J. R., & Turk-Charles, S. (1995). The meaning of health for older women. In A. L. Stanton & S. J. Gallant (Eds.), The psychology of women's health: Progress and challenges in research and application (pp. 491-530). Washington, DC: American Psychological Association.

Geronimus, A. T., Neidert, L. J., & Bound, J. (1993). Age patterns of smoking in U.S. Black and White women of childbearing age. American Journal of Public Health, 83, 1258-1264.

Glied, S., & Kofman, S. (1995, March). Women and mental health: Issues for health reform [background paper]. The Commonweath Fund, Commission on Women's Health, p. 25.

Glynn, T., & Mills, S. (1993, June). Report of the National Cancer Institute Expert Advisory Group on Women and Smoking. Washington, DC: National Cancer Institute.

Grant, B. F., Harford, T. C., Dawson, D. A., Chau, P., DuFour, M., & Pickering, R. (1994). Prevalence of the DSM-IV alcohol abuse and dependence, United States, 1992. Alcohol Health and Research World, 18, 243-248.

Griffin, M. L., Weiss, R. D., Mirin, S. M., & Lange, U., (1989). A comparison of male and female cocaine abusers. Archives of General Psychiatry, 46, 122-126.

Hall, A., & Hay, P. J. (1991). Eating disorder patient referrals from a population region 1977-1986. Psychological Medicine, 21, 697-701.

Holderness, C., Brooks-Gunn, J., & Warren, M. (1994). Co-morbidity of eating disorders and substance abuse: Review of the literature. International Journal of Eating Disorders, 16, 1-34.

Hudson, J. I., Weiss, R. D., Pope, H. G., Jr., McElroy, S. K. & Mirin, S. M. (1989). A comparison of male and female cocaine abusers. American Journal of Alcohol Abuse, 18, 75-85.

Jacob, T., & Bremer, D. A. (1986). Assortative mating among men and women alcoholics. Journal of Studies on Alcohol, 47, 219-222.

Johnson, J., Weissman, M. M., & Klerman, G. L. (1992). Service utilization and social morbidity associated with depressive symptoms in the community. Journal of the American Medical Association, 267, 1478-1483.

Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (1993). National survey results on drug use from the Monitoring the Future Study, 1975-1992. Volume I, secondary school students. U.S. Department of health and Human Services. Rockville, MD: National Institute on Drug Abuse.

Jonas, J. M., Gold, M. S., Sweeney, D., & Pottash, A. L. C. (1987). Eating disorders and cocaine abuse: A survey of 259 cocaine abusers. Journal of Clinical Psychiatry, 48, 47-50.

Kandel, D. B., Yamaguchi, K., & Chen, K. (1992). Stages of progression in drug involvement from adolescence to adulthood: Further evidence for the gateway theory. Journal of Studies on Alcohol, 53, 447-457.

Kaplan, G., Barell, V., & Lusky, A. (1988). Subjective state of health and survival in elderly adults. Journal of Gerontology: Social Sciences, 43, S114-S120.

Katon, W., & Sullivan, M. D. (1990). Depression and chronic medical illness. Journal of Clinical Psychiatry, 51, 3-14.

Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C. (1991). Continuous emotional support during labor in a U.S. hospital. Journal of the American Medical Association, 265, 2197-2201.

Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H-U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.

King, A. C., Taylor, C. B., Haskell, W. L., & DeBusk, 1990). Identifying strategies for increasing employee physical activity levels: Findings from the Stanford/Lockheed exercise survey. Health Education Quarterly, 17, 269-285.

Koss, M., Goodman, L., Fitzgerald, L., Russo, N. F., Keita, G. P., & Browne, A. (1995). No safe haven: Male violence against women at home, at work, and in the community. Washington, DC: American Psychological Association.

Kuczmarski, R. J., Fiegal, K. M., Campbell, S. M., & Johnson, C. L. (1994). Increasing prevalence of overweight among U.S. adults. The national health and nutrition surveys, 1960 to 1991. Journal of the American Medical Association, 272, 205-211.

Kumanyika, S. K., Obarzanek, E., Stevens, V. J., Herbert, P. R., & Whelton, P. K. (1991). Weight-loss experience of black and white participants in NHLBI-sponsored clinical trials. American Journal of Clinical Nutrition, 53, 1631-1638.

Lanz, J. B. (1995). Psychological, behavioral and social characteristics associated with early forced sexual intercourse among pregnant adolescents. Journal of Interpersonal Violence, 10, 188-200.

Lucas, A. R., Beard, C. M., O'Fallon, W. M., & Kurland, L. T. (1991). 50-year trends in the incidence of anorexia nervosa in Rochester, Minnesota: A population-based study. American Journal of Psychiatry, 148, 917-922.

Lukas, S. E., Sholar, M., Lamas, X., Kouri, E., Wines, J. D., Kragie, L., & Mendelson, J. H. (in press). Gender differences in plasma cocaine levels and subjective effects after acute cocaine administration in human volunteers.

Manson, J. E., Colditz, G. A., Stampfer, M. J., Willett, W. C., Rosner, B., Monson, R. R., Speizer, F. E., & Hennekens, C. (1990). A prospective study of obesity and risk of coronary heart disease in women. New England Journal of Medicine, 322, 882-889.

Marcus, B. H., Dubbert, P. M., King, A. C., & Pinto, B. M. (1995). Physical activity in women: Current status and future directions. In A. L. Stanton & S. J. Gallant (Eds.), The psychology of women's health: Progress and challenges in research and application (pp. 349-380). Washington, DC: American Psychological Association.

Mayes, L. C., & Granger, R. H. (in press). Teratologic and developmental effects of prenatal drug exposure: Alcohol, heroin, marijuana, and cocaine. In M. Lewis (Ed.), Child and adolescent psychiatry: A comprehensive textbook. New York: W. B. Saunders.

McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. F. (Eds.). (1990). Women and depression: Risk factors and treatment issues: Final Report of the American Psychological Association Task Force on Women and Depression. Washington, DC: American Psychological Association.

Meyerowitz, B. E., & Hart, S. (1995). Women and cancer: Have assumptions about women limited our research agenda? In A. L. Stanton & S. J. Gallant (Eds.), The psychology of women's health: Progress and challenges in research and application (pp. 51-84). Washington, DC: American Psychological Association.

Miller, B. A., Downs, W. R., & Testa, M. (1993). Interrelationships between victimization experiences and women's alcohol use. Journal of Studies of Alcohol (Suppl. No. 11), 109-117.

Mitchell, J. E., Hatsukami, D., Echert, E. D., & Pyle, R. L. (1985). Characteristics of 275 patients with bulimia. American Journal of Psychiatry, 142, 482-485.

Mitchell, J. E., Pyle, R., Echert, E. D., & Hatsukami, D. (1990). The influence of prior alcohol and drug abuse problems on bulimia nervosa treatment outcome. Addictive Behavior, 15, 169-173.

Mor, J. M., Alexander, G. R., Kogan, M. D., Kieffer, E. C., & Hulsey, T. C. (1995). Determinants of prenatal care use in Hawaii: Implications for health promotion. American Journal of Preventive Medicine, 11(2), 79-85.

Morokoff, P. J., Harlow, L. L., & Quina, K. (1995). Women and AIDS. In A. L. Stanton & S. J. Gallant (Eds.), Psychology of women's health: Progress and challenges in research and application (pp. 117-169). Washington, DC: American Psychological Association.

National Institute of Mental Health. (1994). Mental health concerns for minority women in the United States: Directions for research in the twenty first century. Proceedings of the National Institute of Mental Health, Office of Special Populations Task Force on Mental Health of Minority Women.

National Institute on Drug Abuse. (in press). National Pregnancy and Health Survey. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health.

Nides, M., Rand, C., Dolce, J., Murray, R., O'Hara, P., Voelker, H., & Connett, J. (1994). Weight gain as a function of smoking cessation and 2-mg nicotine gum use among middle-aged smokers with mild lung impairment in the first 2 years of the Lung Health Study. Health Psychology, 13, 354-361.

Pirie, P. L., Murray, D. M., & Luepker, R. V. (1991). Smoking and quitting in a cohort of young adults. American Journal of Public Health, 81, 324-327.

Roberts, D. C. S., Bennett, S. A. L., & Vickers, G. J. (1989). The estrous cycle affects cocaine self-administration on a progressive ratio schedule in rats. Psychopharmacology, 98, 408-411.

Robins, L. N., & Regier, D. A. (1991). Psychiatric disorders in America. New York: The Free Press.

Rodin, J., & Ickovics, J. R. (1990). Women's health: Review and research agenda as we approach the 21st century. American Psychologist, 45, 1018-1034.

Schottenfeld, R., Carroll, K., & Rounsaville, B. (1993). Comorbid psychiatric disorders and cocaine abuse. In F. Tims & C. Leukefeld (Eds.), Cocaine treatment: Research and clinical perspectives (pp. 31-47). NIDA Monograph, Washington, DC: U.S. Government Printing Office.

Schumacher, H. R., Klippel, J. H., & Koopman, W. A. (1993). Primer on the rheumatic diseases. Atlanta, GA: Arthritis Foundation.

Skevington, S. M. (1993). The experience of pain in rheumatological disorders. Bailliere's Clinical Rhematology, 7, 319-335.

Striegel-Moore, R. H., & Marcus, M. D. (1995). Eating disorders in women: Current issues and debates. In A. L. Stanton & S. J. Gallant (Eds.), The psychology of women's health: Progress and challenges in research and application (pp. 445-490). Washington, DC: American Psychological Association.

Substance Abuse and Mental Health Services Administration. (1995). Preliminary estimates from the 1994 National Household Survey on Drug Abuse. Advance Report No. 10.

Swanson, N., Piotrkowski, C. S., Keita, G. P., & Becker, A. B. (in press). Occupational stress and women's health. In S. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Psychosocial and behavioral factors in women's health: A handbook for medical educators, practitioners, and psychologists. Washington, DC: American Psychological Association.

Tardiff, K., Marzuk, P., Leon, A. C., Hirsch, C. S., Stajic, M., Portena, L., & Hartwell, N. (1994). Homicide in New York City: Cocaine use and firearms. Journal of the American Medical Association, 272, 43-46.

Teets, J. M. (1995). Childhood sexual trauma of chemically dependent women. Journal of Substance Abuse Treatment, 27, 231-257.

U.S. Bureau of the Census. (1992). Sixty-five plus in America. Current Population Reports, Special Studies, P23-178RV. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services. (1991). Healthy People 2000: Full report with commentary (DHHS Pub. No. PHS 91-50212). Washington, DC: U.S. Government Printing Office.

U.S. National Center for Health Statistics. (1994). Current estimates from the National Health Interview Survey, 1992 (DHHS Publication No. PHS 94-1517). Washington, DC: U.S. Government Printing Office.

Villagomez, R. E., Thomas, M. J., Lin, M. M., & Brown, L. S. (1995). Post-traumatic stress disorder among inner city methadone maintenance patients. Journal of Substance Abuse Treatment, 12, 253-257.

Vogeltanz, N. D., & Wilsnack, S. C. (in press). Alcohol problems in women: Risk factors, consequences, and treatment strategies. In S. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Psychosocial and behavioral factors in women's health care: A handbook for medical educators, practitioners, and psychologists. Washington, DC: American Psychological Association.

Weiss, S. R., & Ebert, M. H. (1983). Psychological and behavioral characteristics of normal-weight bulimics and normal-weight controls. Psychosomatic Medicine, 45, 293-303.

Wells, K. B., Golding, J. M., & Burnam, A. (1988). Psychiatric disorder in a sample of the general population with and without chronic medical condition. American Journal of Psychiatry, 145, 976-981.

Wells, K. B., Stewart, A., Hays, R. D., Burnam, A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., & Ware, J. (1989). The functioning and well-being of depressed patients: Results from the Medical Outcomes Study. Journal of the American Medical Association, 262, 914-919.

Whitaker, A., Johnson, J., Schaffer, D., Rapoport, J., Kalizow, K., Walsh, J., Davies, M., Braman, S., & Dolinsky, A. (1990). Uncommon troubles in young people. Archives of General Psychiatry, 47, 487.

Williamson, D. F., Kahn, H. S., Remington, P. L., & Anda, R. F. (1990). The 10-year incidence of overweight and major weight gain in US adults. Archives of Internal Medicine, 150, 665-672.

Wilsnack, S. C. (1995). Alcohol use and alcohol problems in women. In A. L. Stanton & S. J. Gallant (Eds.), Psychology of women's health: Progress and challenges in research and application (pp. 381-443). Washington, DC: American Psychological Association.

Wilsnack, S. C., Wilsnack, R. W., & Hiller-Sturmhöfel, S. (1994). How women drink: Epidemiology of women's drinking and problem drinking. Alcohol Health and Research World, 18, 173-181.

Wilsnack, S. C. Vogeltanz, N. D., Klassen, A. D., & Harris, T. R. (1995). Childhood sexual abuse and women's substance abuse: National survey findings. Manuscript submitted for publication, University of North Dakota School of Medicine.

Windsor, R. A., Lowe, J. B., Perkins, L. L., Smith-Yoder, D., Artz, L., Crawford, M., Amburgy, K., & Boyd, N. (1993). Health education for pregnant smokers: Its behavioral impact and cost benefit. American Journal of Public Health, 83, 201-206.

Yelin, E. (1992). Arthritis: The cumulative impact of a common chronic condition. Arthritis and Rheumatism, 35, 489-497.

Conference Committee

Sheryle Gallant, PhD
Conference Chair
University of Kansas
Lawrence, KS

Gwendolyn Puryear Keita, PhD
Conference Director
American Psychological Association
Washington, DC

Renee Royak-Schaler, PhD
Program Committee Chair
University of North Carolina
Chapel Hill, NC

Joyce Barham
Rockville, MD

Lillian Comas-Diaz, PhD
Transcultural Mental Health Institute
Washington, DC

Helen Coons, PhD
Hahnemann University
Philadelphia, PA

Patricia Kobor
American Psychological Association
Washington, DC

Kelley Philips, MD
Empire Mental Health Choice
New York, NY

Sandra Schwartz Tangri, PhD
Howard University
Washington, DC

Wanda Robinson
Conference Coordinator
American Psychological Association
Washington, DC

Advisory Committee Members

Dyanne D. Affonso, RN
Emory University
Atlanta, GA

Leona Aiken, PhD
Arizona State University
Tempe, AZ

Hortensia Amaro, PhD
Boston University
Boston, MA

Barbara L. Anderson, PhD
Ohio State University
Columbus, OH

Norman B. Anderson, PhD
Duke University Medical Center
Durham, NC

Nancy E. Avis, PhD
New England Research Institute
Watertown, MA

Faye Belgrave, PhD
George Washington University
Washington, DC

Lisa Berkman, PhD
Yale University
New Haven, CT

Deborah J. Bowen, PhD
Fred Hutchinson Cancer Center

Seattle, WA

Annette Brodsky, PhD
Harbor, UCLA Medical Center
Torrance, CA

Linda Burhansstipanov, DrPH
AMC Cancer Research Center
Denver, CO

Martha Raines Burt, PhD
Urban Institute
Washington, DC

Joan C. Chrisler, PhD
Connecticut College
New London, CT

Deborah L. Coates, PhD
City University of New York Graduate Center
New York, NY

Alice Dan, PhD
University of Illinois
Chicago, IL

Brenda DeVellis, PhD
University of North Carolina
Chapel Hill, NC

Lee Lee Doyle, PhD, MA
University of Arkansas for Medical Sciences
Little Rock, AR

Mary Jane England, MD
Washington Business Group on Health
Washington, DC

Karen Paige Ericksen, PhD
University of California
Davis, CA

Ellen Gritz, PhD
The University of Texas
Houston, TX

Jean Hamilton, MD
Duke University
Durham, NC

Helen Hazuda, PhD
University of Texas
San Antonio, TX

Anne S. Kasper, PhD
Campaign for Women’s Health
Washington, DC

Abby C. King, PhD
Stanford University School of Medicine
Palo Alto, CA

Jean King, PhD
University of Massachusetts Medical Center
Worcester, MA

Mary Koss, PhD
University of Arizona
Tucson, AZ

Robin A. LaDue, PhD
University of Washington
Seattle, WA

Wilhelmina A. Leigh, PhD
Joint Center for Political & Economic Studies
Washington, DC

Carolyn Mazure, PhD
Yale-New Haven Hospital
New Haven, CT

Beth Meyerowitz, PhD
University of Southern California
Los Angeles, CA

Patricia Morokoff, PhD
University of Rhode Island
Kingston, RI

Leslie Primmer
Congressional Caucus for Women’s Issues
Washington, DC

Tracey Revenson, PhD
City University of New York Graduate Center
New York, NY

Nancy Felipe Russo, PhD
Arizona State University
Tempe, AZ

Rosalie Sargraves, PharmD
University of Oklahoma
Oklahoma City, OK

Sally A. Shumaker, PhD
Bowman Gray School of Medicine
Winston-Salem, NC

Annette L. Stanton, PhD
University of Kansas
Lawrence, KS

Cheryl B. Travis, PhD
University of Tennessee
Knoxville, TN

Nancy Valentine, RN, PhD
Veterans Administration
Washington, DC

Lois M. Verbrugge, PhD, MPH
Institute of Gerontology
The University of Michigan
Ann Arbor, MI

Donna M. Waechter, PhD
Uniformed Services University of the Health Sciences
Bethesda, MD

Kenneth A. Wallston, PhD
Vanderbilt University
Nashville, TN

Sharon C. Wilsnack, PhD
University of North Dakota
Grand Forks, ND

Rena Wing, PhD
University of Pittsburgh
Pittsburgh, PA

Nancy Fugate Woods, PhD
University of Washington
Seattle, WA

Agency/Foundation Advisors

Cheryl A. Blackmoore, PhD
National Center for Chronic Disease
Prevention and Health Promotion
Centers for Disease Control and Prevention
Atlanta, GA

Patricia Bryant, PhD
National Institute of Dental Research (NIH)
Bethesda, MD

Mary Johnson, PhD
The Commonwealth Fund
New York, NY

Joan Leiman, PhD
The Commonwealth Fund
New York, NY

Jan Moore, PhD
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA

George Roberts, PhD
Office of Minority Health
Centers for Disease Control and Prevention
Atlanta, GA

Vivian T. Chen, MSW, ScD
Bureau of Primary Health Care
Rockville, MD

Marian E. Primas, PhD
Bureau of Primary Health Care
Rockville, MD

RoAnne Dahlen-Hartfield, DNSc, RN
American Nurses Association
Washington, DC

Eleanor Z. Hanna, PhD
National Institute on Alcohol Abuse and Alcoholism (NIH)
Rockville, MD

Robin Hill, PhD
National Heart, Lung, and Blood Institute (NIH)
Bethesda, MD

Sarah Knox, PhD
National Heart, Lung and Blood Institute (NIH)
Bethesda, MD

Mary C. Knipmeyer, PhD
Substance Abuse and Mental Health Services Administration
Rockville, MD

Marcia Ory, PhD
National Institute on Aging (NIH)
Bethesda, MD

Delores L. Parron, PhD
National Institute of Mental Health (NIH)
Rockville, MD

Rosemary Torres, JD
National Institutes of Health
Bethesda, MD

Willo Pequeqnat, PhD
Office on AIDS/National Institute of Mental Health (NIH)
Rockville, MD

Anne Shemer, PhD
Pfizer, Inc.
New York, NY

Naomi Swanson, PhD
National Institute of Occupational Safety and Health (CDC)
Cincinnati, OH

Cora Lee Wetherington, PhD
National Institute on Drug Abuse
Rockville, MD

Leslie Zebrowitz, PhD
National Science Foundation
Arlington, VA