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Research Agenda for Psychosocial and Behavioral Factors in Womens Health: Lifespan/Developmental Issues
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Aging
Gynecological and Reproductive Health
Male Violence Against Women
Occupational Stress
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.
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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.
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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.
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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.
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