Health Promotion for Women

by W.E. Thurston, PhD

M. O'Connor, PhD

1. In this section we look first at the history of health promotion and women's health. There is ample evidence that the Canadian women's health movement has a long history of using a social determinants, population health model to understand women's health. The principles of health promotion have historically been applied in developing programs around women's health. We then provide a conceptualization of health, health promotion and prevention. This model is based on the premise that prevention (primary, secondary, and tertiary) remains an important part of our work to promote women's health, but that it must be informed by the principles of health promotion.

HISTORY

2. Over the years, a community-based women's health infrastructure has developed in Canada. Historically, this was partially supported through initiatives of the federal government, particularly Health Canada and the Secretary of State Women's Program, and partially through provincial and municipal government funding. In large part, the movement is driven by the energy and commitment of women across the country who often work for little or no pay in communities from coast to coast. In 1981, for instance, prior to the Ottawa Charter (1986) or the Framework for Health Promotion (Epp, 1986), the St. John's Status of Women's Council and the Newfoundland and Labrador Women's Institutes joined together and obtained funding from the Health Promotion Contribution Program of Health and Welfare Canada to carry out a women's health project. To quote from the final report:

3. The women's health movement exists in harmony with and is often indistinguishable from other parts of the women's movement. Given the social determinants model, this is to be expected. In many communities, the organizations that generated women's health projects, centres or coalitions were also involved in advocating for or establishing shelters for battered women, sexual assault services, birth control services, and so on. The network is extensive: in 1993, for instance, 371 Canadian shelters for battered women were identified (MacDonald, 1993). Even in larger urban centres where numbers and distances are greater than in small towns or communities, the staff involved in these different women's health services have networked in various ways. In Calgary, for instance, there is an umbrella organization of women's groups called Women Looking Forward. On a national level, the National Action Committee on the Status of Women (NAC) serves this function. At its annual meeting, women from all over the country can meet and exchange information as well as set policy and direction for NAC's lobbying and educational functions. For many years, NAC has had a policy committee on women's health that followed a social determinants model of health.

4. Recent examples of community-based action in women's health include the initiatives of breast cancer survivors and advocates. Breast cancer survivors, seeing what AIDS activists had achieved, began to come together and to form education, support and advocacy groups (Batt, 1994). While the influence of AIDS activism on breast cancer survivors is more recent and apparent, the influence of feminist theory and the women's health infrastructure is also present. Many survivors draw on their feminist analysis in how they respond to their experiences around breast cancer (S. Batt, personal communication, Dec. 14, 1995). As a result of the advocacy of breast cancer survivors and the philosophical support of public servants in Health Canada, the National Forum on Breast Cancer became the first opportunity for researchers, clinicians and breast cancer survivors to interact face to face and to share perspectives. Since that time, more breast cancer action groups have formed across the country in small towns, as well as large centres. These groups provide support to individuals and education and advocacy to the community at large.

HEALTH, HEALTH PROMOTION, AND PREVENTION

5. Health, viewed from a social determinants perspective, is multidimensional and can be viewed as a dynamic system with two components: Health Balance and Health Potential. In Health Balance the physical, psychological, social, and spiritual aspects of our health interact to create a state of well-being or "health status" (Noack, 1987). When asked, "Compared to other people your age, how is your health?", it is our health balance that we evaluate in response. At any given time, we may be at a high or a low level of Health Balance. An equally important part of our health is our Health Potential or the resources we have to maintain or restore our Health Balance. These resources can include such things as genetic predispositions to wellness or illness (e.g., fitness or whether we experience menstrual pain), money to purchase food or services, or skills that are acquired (e.g., coping skills or assertiveness). This conceptualization of health takes us away from an individualistic orientation since many determinants of health are beyond the control of individuals. Health potential must also be assessed at the level of community (e.g., access to health care, and employment opportunities ). The social determinants model of health, as we have pointed out in the background, is nothing new to feminists and is consistent with feminist theory. The women's health movement in Canada has emphasized the role of self-help groups in collective analysis of social, economic and historical factors associated with health problems (McDonnell, 1985, cited in Horne, 1995).

6. The World Health Organization (1986, p. 246) and the Federal Government of Canada (Epp, 1986, p.6) define health promotion as "the process of enabling people to increase control over and to improve their health". Health promotion is not synonymous with prevention, which is primarily focused on problems, dysfunctions, or diseases, but no consensus has developed about the relationship between the fields. There are three levels of prevention. Primary prevention focuses on the prevention of the occurrence of problems; secondary prevention is directed at early detection of problems in order to stop their progression; and tertiary prevention is aimed at stopping the development of complications, usually described as treatment (Last, 1987). We believe that health promotion, as defined above, can be distinguished from prevention by its focus on Health Potential, or increasing people's health resources. The three levels of prevention are primarily directed at restoring Health Balance. Health promotion, therefore, must also play a coordinating role with the three levels of prevention (Thurston & McGrath, 1995; Thurston & Bowhay, 1991). The degree of linkage between health promotion and prevention depends, by definition, on the actual program objectives, activities, and projected outcomes; however, the implication is that people involved in health promotion or prevention must take a more global perspective and look at broader implications of their program activities. Prevention efforts which successfully eradicate disease by diminishing Health Potential must be suspect for long-term negative consequences on health.

7. Population health promotion is based on a number of principles:

8. The Ottawa Charter (1986) further states: "Caring, holism and ecology are essential issues in developing strategies for health promotion. Therefore, those involved should take as a guiding principle that, in each phase of planning, implementation and evaluation of health promotion activities, women and men should become equal partners". Health promotion theory and practice is concerned with justice and equity, therefore, feminists health proponents and health promotion activists could be natural allies.

9. While Canada has been seen as a world leader in the field of health promotion (Kickbush, 1986), critics have pointed out inherent dangers in some of the health promotion policies. Seen from a certain point of view these policies fit too well into costcutting initiatives and attempts to privatize health. Canada's public health agenda, as it appeared in Achieving Health for All (Epp, 1986), broadened the field of health promotion from one that focused on lifestyle changes and individual prevention to one that promised to redress inequities within the health and social system. In theory, it moved toward social reform and action, addressing the issue of healthy environments and questions of power and control (Ottawa Charter 1986; Vertinsky, 1992). Yet women's concerns do not always reach the level of policy development and implementation. We have had some important contributions in Canada in the form of centres funded for research on violence against women and the promise now of research centres on women's health. The economic policies of our governments, however, are preventing a truly radical change in the perception of women's work and health.

10. If public policy explicitly asks for community developmentthe form of selfcare, mutual aid, fostering public participation, or strengthening community services (to use the language of Epp's health promotion framework)we must be aware of its possible implications for women's lives and health. When community development entails the empowerment of community members and their real participation in the identfication of issues, and of setting agendas, then we will have a truly collectivist and negotiated process. Healthy public policy must entail a broad contextual understanding of women's lives and women's health. This implies a comprehension of violence against women, racism, the structures of poverty, and the ideologies of caring.

EXEMPLARY CANADIAN INITIATIVES

11. In this section we will describe some recent Canadian health projects or initiatives which exemplify the principles of health promotion for women described above. The first, Nobody's Perfect, is a support program for young, single, low income parents. It is an example of a program that addresses justice and equity, is multisectoral and multidisciplinary, and has benefits beyond the goal of enhancing parenting skills. It allows participants to look at parenting and associated problems in the broader context of their everyday lives. The other examples are discussed in less detail. The Breast Cancer Information Exchange Pilot Projects are intended to widely disseminate breast cancer information in a way that is empowering to recipients. Four of the pilot projects are described very briefly and more information is provided on the fifth. These projects show, among other things, how participation can be encouraged to overcome barriers between health care providers and consumers, how organizations and sectors can collaborate to reach a common goal, and how national programs can facilitate communication and efficient use of resources while following principles of health promotion. The Pap Awareness Project is an example of using the principles of health promotion to improve secondary prevention of cervical cancer. It is an example of health providers and women working together. The Women and Tobacco initiative is described briefly to illustrate how feminist analysis brings a fresh perspective to a social determinants model. Finally, we describe the McMaster Research Centre for the Promotion of Women's Health, a multidisciplinary centre with a focus on the promotion of women's health in the workplace.

NOBODY'S PERFECT

12. Nobody's Perfect (NP) is a parenting support program supported by the former Family and Child Health program in the Health Promotion Directorate of Health Canada. It was developed in the Atlantic Region and implemented nationally in partnership with a variety of provincial governmental and nongovernmental organizations, including First Nations, and continues to be used across the country. NP was based on a number of assumptions and operating principles consistent with health promotion. It was designed to enable parents to increase control over and to improve their child's health by addressing issues of justice and equity, building upon participant's strengths, enhancing mutual support as well as self-help, and using a multidisciplinary, multifactorial analysis of the issues. These programs see child and parent health as interconnected and mutually reinforcing.

13. The first principle of NP is that health is holistic and must be viewed in terms of both individual and social factors. NP recognizes that poverty is associated with ill health in all aspects of our lives and that income, cultural and social milieu of the community largely determine the extent to which resources are developed for and devoted to child health. In many communities, support systems and are not readily accessible to parents. NP, therefore, addresses issues of justice and equity. NP was developed for those parents with the least access to services and parenting Health Potential; that is, NP "targets parents who possess one or more of the following characteristics: young; single; low-income; low-education; and those who experience social, cultural or geographic isolation" (VanderPlaat, 1989, p. 1).

14. The interconnection of parental and child health is also recognized in NP. One assumption states that parents tend to place their children's needs above their own and to look for resources designed to restore the imbalance in their children's health; however, because parental and child health are intertwined, resources to maintain the balance of health for both are necessary. Another assumption is that parenting involves a set of skills or resources that are not genetic, or obtained at birth and can, therefore, be supported by a community.

15. The priorities for program development incorporate the holistic nature of health and include both self-help and mutual support, relying on group activities where mutual support, peer criticism, self-help and education can occur. Mutual support and self-help are two of the three mechanisms considered intrinsic to health promotion in Achieving Health for All (Epp, 1986). The assumption that solutions to parenting resource problems should be practical, inexpensive, and positive is in keeping with the focus on justice, as well as with popular opinion within the field of health promotion program planning. Finally, the philosophy of NP, as described in the BC Experience, "that each parent brings rich experiences and feelings to the group" and that facilitators are trained in the participant-focused approach (Rechler & Rogers, 1993, p.11), reflect an orientation to critical education or conscientization as described by Friere which can lead to social change as well as individual change, a goal of health promotion. This orientation helps avoid victim blaming where the individual is seen, or comes to be seen, as personally responsible for her inadequacies or lack of resources and for the solutions. Avoidance of victim blaming is critical to health promotion.

16. The core of the NP Program is five books providing information that will help parents cope with body, safety, mind, behaviour, and parenting. "Body explains normal growth, maintaining health and recognizing illness. Safety provides information on accident prevention and first aid. Mind describes the social, emotional and intellectual development of children. Behaviour offers a problem-solving method for handling common behaviour problems. Parents addresses a variety of ways in which parents can meet their own needs as well as those of their children" (NP Brochure). The content of the five NP books is multidisciplinary, drawing on knowledge from psychology, sociology, nursing, medicine, etc. Each subject is looked at from a multifactorial perspective; for example, the Mind includes developmental factors, emotional, and social factors that affect children's mental health. Multidisciplinarity and multifactorial programs are central to the practice of health promotion.

17. In each book the material is aimed at the three levels of prevention: Primary, avoiding accidents, behaviour problems, and associated parental stress or grief; Secondary, recognizing the warning signs of problems both in the child and oneself and having regular check-ups; and tertiary, treating problems or getting help through activities such as first aid, or behaviour modification. All of the information and skills are presented with the intention of increasing self-help, coping skills, social support, self-confidence, and self-image. Thus prevention is being accomplished within a health promotion framework.

18. Parent support programs that are designed from a health promotion perspective have a number of secondary benefits such as the prevention of family violence. Parent support programs that support consciousness raising, mutual support, enhanced personal well-being, and skill development address the barriers to problem solving that abused women face, thus encouraging them to take rapid action to either avoid a relationship where abuse happens or to take action to leave such a relationship. In addition, parents can come to understand the consequences of their own childhood experiences of abuse which indirectly benefits their children. The content of parent support programs in a health promotion framework clearly is directed to the prevention of child abuse or neglect and to the enhancement of child well-being.

BREAST CANCER INFORMATION EXCHANGE PILOT PROJECTS

19. Health Canada announced a major breast cancer initiative in 1992 which included the National Forum on Breast Cancer, enhanced research support, and activities to coordinate screening, to set guidelines for care, to enhance continuing education for health professionals, and aid to the Canadian Breast Cancer Network, a national coalition of breast cancer survivors and survivor groups. Another component of the initiative was the funding of five breast cancer information exchange projects which are intended to assist persons living with breast cancer and their families, care givers, and those at risk of contracting breast cancer in making informed decisions about a variety of concerns related to breast cancer. A call for proposals was made and the selected projects were based on collaboration between treatment, research and consumer groups, and were funded in December 1992 for a five year period.

20. We will provide a brief description of four of the projects and more detail on the fifth to illustrate the adoption of a health promotion framework. All of the projects routinely network through the project coordinators and collaborate in exchange of resources. Occasionally, materials are developed for a national audience and are reviewed by all of the projects.

21. The Atlantic Breast Cancer Information Project (ABCIP) is led by a Steering Committee comprised of the presidents of the four Atlantic divisions of the Canadian Cancer Society. A 20 member advisory committee has overseen projects such as development of a resource manual for regional information; regional information on unconventional therapies; information menu cards and corresponding packages; and an internet cancer discussion and support group. The Quebec Breast Cancer Information Exchange Network is led by an Executive Committee composed of the project director, the Director of finances for Hôpital Hôtel-Dieu de Montréal and a representative from the Quebec Ministry of Health. An advisory committee representing many stakeholders was formed and a provincial survey of knowledge conducted. Network "substations" are being created around the province. In the Ontario project, an Advisory Panel provides the strategic direction for the project and a Project Team oversees day to day operations. Five breast cancer survivors from the Panel and the team form an Executive Committee. Examples of project activities include: production of a newsletter; a database of services; the book, A Guide to Unconventional Therapies; development of a Multicultural Communities Initiatives Work group; and funding of two consortiums which will undertake projects in the north of the province. The British Columbia (B.C.)/Yukon Breast Cancer Information Project is sponsored by the B.C. Cancer Agency and the regional division of the Canadian Cancer Society (CCS). Of 15 Advisory Panel members, 8 are breast cancer survivors. Among other things, the project has expanded and marketed the CCS cancer information telephone line; produced a newsletter; surveyed women living with breast cancer; and promoted the book "Breast Cancer: All You Need to Know to Take an Active Part in Your Treatment".

22. Breast Cancer InfoLink, Prairies/NWT (BCIL) is the fifth project serving Manitoba, Saskatchewan, Alberta and the North West Territories. Established by a consortium of the Alberta Cancer Board, the Canadian Cancer Society, and The University of Calgary, Department of Community Health Sciences, the project has an Advisory Panel with representatives from the consortium as well as from the groups that the project intends to serve: family physicians and oncology nurses (health professionals; the Alberta Farm Women's Network (rural women); the Breast Cancer Program of Manitoba; the Department of Health and Human Services of NWT; 8 breast cancer survivors (some of whom also represent groups such as Reach for Recovery and the Canadian Breast Cancer Network); and one woman who is in the category of high risk.

23. The project coordinator of BCIL has met with 11 groups of women throughout Alberta to discuss their information needs, their preferred sources and format and timing of information. The women were involved in discussing the best services for rural settings; medical as well as non-medical dimensions of their experiences with breast cancer; and their ideas for collaborating and coordinating breast cancer information tailored to the needs of different audiences. The coordinator also brought together the various support groups and programs for women with breast cancer in the two major urban areas, Calgary and Edmonton. This was the first time that many of these groups had exchanged information. All of the consultations have fed into design of a needs assessment process and questionnaires to reach 7 groups: women living in the NWT; aboriginal women; women living in remote communities; survivors who do not belong to a breast cancer support group; women at risk because of history in a first degree family member; rural physicians and primary health care providers; and women at the pre-diagnosis stage (i.e., women who have a breast lump or an abnormal mammogram).

24. A Community Contact (CC) model has been developed to enable women to share information. It will be piloted in 2 rural Alberta and a northern Manitoba site in 1996. A CC is someone who will act as a local resource person for women in the community who want breast cancer information. BCIL will provide training (a resource manual has been developed), basic expenses and will link the community contacts in a network. A resource for others as well as the CCs is a Breast Cancer Reference Manual, a comprehensive information guide. The manual is being developed by a committee of breast cancer survivors and health professionals from the region and will be reviewed by a group of health professionals. A video highlighting the range of support possible for breast cancer patients will target newly diagnosed women and is being produced for BCIL by Take Charge Athletics (a breast cancer support group) and The University of Calgary.

CERVICAL SCREENING: PAP AWARENESS PROJECT (PAP)

25. The Pap Awareness Project (PAP) is a two year project implemented under the Awareness and Education Program, an intervention study designed to reduce morbidity and mortality from cervical cancer. The four year intervention study is intended to determine effective ways to increase compliance with cervical cancer screening recommendations. The study collected baseline data on the frequency, knowledge and attitudes about Pap smear screening in women and physicians in two cities. A random digit dial telephone survey of women aged 20 to 69 years and a mailed survey of all physicians providing cytology screening were two of the methods used to collect baseline data.

26. The PAP is being developed using a community mobilization approach to involve direction, input and decision making at the community level. A Community Advisory Committee (CAC) oversees the development and implementation of education projects. A key objective of the PAP is the involvement of women from under-screened groups in the planning, implementation, and delivery of education projects to inform women about the importance of regular Pap smear screening. The second component of the Awareness and Education Program is the Physician Working Group. This volunteer group of eight physicians will develop educational materials to increase physician compliance with recommendations for Pap smear screening. A Community Coordinator has been hired to support the implementation of both the PAP and Physician Working Group and to liaise between the two projects. The PAP is housed at the Red Deer Regional Health Unit which provides operational support (e.g., mail services, local telephones).

27. The goal of the PAP is to reduce the incidence of, and mortality from, cervical cancer in Red Deer, Alberta by increasing the number of women who are screened regularly with cervical cytology. An emphasis will be placed on targeting women 18 to 69 years of age who have not had a Pap smear within the past three years (under-screened women). The first objective of the program is to develop and implement a community based awareness and education program using a collaborative team approach to:

28. The second objective is to involve all key stakeholders, and specifically women from the under-screened groups, in the planning, development and implementation of the PAP by seeking their participation as members of the Community Advisory Committee and working groups to carry out specific projects of the PAP.

29. A third objective is to collaborate with the Physician Working Group so that women are given a consistent message about Pap smear screening and to facilitate communication of issues between the PAP and Physician Working Group.

30. The intervention study was initially perceived by some members of the medical community as an attempt to "take over" Pap smear screening for the women of Red Deer. This issue was addressed by individual contact with a number of physicians in the community and by a presentation at rounds at the Red Deer Regional Hospital by the principal investigator. The relationship of the PAP with community physicians is a critical one since physicians are the main providers of Pap smear screening. It should be noted that many positive responses have been received from Red Deer physicians about the project and that eight physicians have agreed to serve on the Physician Working Group. Project staff and the CAC of the PAP (which will include a physician) will need to consider this past history, in addition to the stresses resulting from the restructuring of the health care system, as the education and awareness programs are developed and introduced into the community.

WOMEN AND TOBACCO

31. The first Canadian workshop on Women and Tobacco in 1988 was attended by representatives from about 60 women's groups. Through workshops, the participants, most of whom were women, came up with six major recommendations:

32. In reviewing progress to date, Horne notes that few initiatives outside of those sponsored by women's groups have adopted a woman-centred analysis. Thus, most programs tend to be individually focussed and to ignore the broader social context.

33. In 1994, Canada introduced the Tobacco Demand Reduction Strategy (TDRS) with three key elements: legislation, public education and research. The Tobacco Sales to Young Persons Act set a national age limit at 18 for sales of tobacco and increased fines for illegal sales. Development of several gender specific programs has been another key focus. The manual "Evening the Odds" was developed in partnership with the Canadian Association for Advancement of Women and Sport for use by community leaders to identify ways for educators and the sport community to prevent smoking and increase fitness in young women. The "Child-to-Child Program" encourages aboriginal children aged 9 to 12 to research health issues in their communities and to set goals for change. "Quit 4 Life" includes a self-help kit for teens and a toll-free line for information. Over half of the callers have been girls. A program tailored to low-income women deals with the stressors connected to living on a low income or social assistance and provides child care and transportation. It is being piloted across Canada. Gender sensitive research has found that adolescent girls have concerns related to self-image and body weight which are linked to smoking rates. Other research has shown that women continue to be represented as smokers (Health Canada, 1995b). One of the most valuable contributions of TDRS has been research which has confirmed the associations between inequity and lack of power and smoking among women.

34. Successful strategies in dealing with the issues of smoking and tobacco use require participation, cooperation and collaboration between various sectors. When dealing with women, girls and tobacco, significant partnerships have been forged with the women's health movement, women's groups, anti-poverty groups, Aboriginal communities, and women's health and fitness providers. (Health Canada, 1995b, p. 8).

THE MCMASTER RESEARCH CENTRE FOR THE PROMOTION OF WOMEN'S HEALTH

35. The McMaster Research Centre for the Promotion of Women's Health (MRCPOWH) has been funded by Health Canada and the Social Sciences and Humanities Research Council of Canada for five years, from 1993Its mandate is to establish a basis for new, communitygenerated approaches to the promotion of women's health. For the first five years the Centre is focusing its research primarily on women and work: paid and unpaid, in the home and outside the home. Conducting participatory action research, the Centre will investigate a diversity of occupations, a diversity of health issues, and a diversity of population groups. The research is designed to include actions for social change.

36. Although the Centre acknowledges that there are many ways to conduct research on women's health, it emphasizes the following principles: women's knowledge of their own health needs is essential to the design of any health promotion intervention; social investigation and action should be part of the same process; research should give immediate benefits to the community; and research should offer longresults by aiming to eliminate the structural sources of the identified problem (Denton, et al., 1994).

37. Instead of studying women as mothers, wives or reproductive agents, the Centre focuses on women and work, believing that women's labour, having been invisible, underpaid or unpaid, is crucial to the quality of life and health in women's lives. Research includes: specific workplace conditions (either in the home or outside); the effects of working conditions on women with specific health problems (e.g., disabilities, chronic diseases); and work as it affects women with diverse backgrounds.

38. Major research projects in the Centre can be classifed in four groups: 1. the health of women working in community based health and social service agencies; 2. the health of immigrant, refugee and visible minority women; 3. women with disabilities; and 4. young women and mothers. Included within these categories are for instance a project documenting a lesbian support group for a woman diagnosed with breast cancer: "weaving care outside 'family'"; or the health experiences and indicators among black female sole parents; or a study of support needs for women with multiple sclerosis.

39. Most notable about these projects is the degree to which community is involved in the research process from the needs assessment stage to the implemention of action for change. The research is informed by feminist pinciples, avoiding the treatment of women as objects, promoting women's voices in program and policy planning, and empowering women to take control of their lives. The kind of research and documentation in process ranges from survey and focus group data collection to popular theatre and collections of women's narratives. The sites of research include among others a nonfood processing factory, Children's Aid Societies, HomePrograms, various grasswomen's groups including many immigrant and refugee groups.

MAJOR CHALLENGES

40. In selecting the six major challenges for health promotion and women's health, we allowed those that were most salient to us at the time to take priority. In keeping with our approach to health promotion, the challenges cannot be seen as separate with easily definable boundaries. The lack of gender sensitive research, for instance, is linked to the relative absence of women in policy making positions and to a failure to integrate feminist understanding and critique into the relevant disciplines. Single issue intervention models allow many people to ignore the issue of violence against women, and so on. While our list of challenges is not exhaustive, we believe the reader will find ample food for thought.

1) GENDER SENSITIVE RESEARCH

41. The lack of sensitivity to gender issues in research continues to be a major challenge. Just as epidemiological and biomedical researchers have generalized their findings to women when their studies included only males (Phillips, 1995), public health and health promotion researchers have treated gender as a secondary variable. While the justice and equity principles of health promotion (WHO, 1986) should make health promotion proponents and feminists natural allies, in fact, the field of health promotion is no more likely to take gender seriously than other fields (Thurston, 1994) and the literature on health determinants has not consistently treated gender as an important variable (Health Canada, 1995).

42. Eichler (1991) has identified seven types of sexist research, four primary and three derived from the primary, but so common that separate notice is warranted. While these are applied to research, they have major implications for practice and program development. The first, Androcentricity, involves viewing the world from a male perspective. Overgeneralization occurs when studies extrapolate from a gender biased sample to the whole population. Ignoring sex as an important variable is called Gender Insensitivity and the Double Standard, as the name implies, involves evaluating, treating, or measuring identical factors in men and women by different means. The first derived type of sexist research is Sex Appropriateness where human traits are assigned to or considered more important for one gender. Familism occurs when the unit of attention or analysis is the family, whereas individuals within the family are actually affected differently. Finally, Sexual Dichotomism occurs when the sexes are treated as unique social and biological groups. Each of these types of sexist research is described in detail with examples in Eichler's (1988) book which is highly recommended.

43. One area in which sexist and gender insensitive research and practice has weakened program effectiveness is prevention of wife battering. If we examine the challenges (reducing inequities; increasing prevention; enhancing coping), mechanisms (self-care; mutual aid; healthy environments), and strategies (fostering public participation; strengthening community health services; coordinating healthy public policy) of the Canadian health promotion framework (Epp, 1986), we can easily see how a women's health issue such as wife abuse can be addressed: economic inequities; self-help books; support groups; strengthening community shelter services. The fact remains that the tertiary health care system has not addressed wife abuse in any meaningful way after more than 15 years of research and education (Abbott, Johnson, Koziol-McLain, Lowenstein, 1995), nor have the public health system (Sorenson & Saftlas, 1994) or health promotion advocates. In 1985, Nuttal, Greaves and Lent identified wife battering as "an emerging problem in public health" (p. 297); ten years later, this problem has barely broken the surface and the silence continues (Thurston, 1995a).

2) PARTICIPATION OF WOMEN

44. Confusion surrounds the terms used to describe participation by members of the public in health care decision-making. Windle and Cibulka (1991) state that there is disagreement over such basic terms as "citizen", "consumer" and "participation", and the term "public" can be added to this list. In fact, these terms are used interchangeably in the literature on public/citizen/consumer participation in health care. Public is a more general term and it is argued that hospital boards, for instance, have always included representatives of the public. Consumers are those members of the public who have had direct experience as users of a health care service; and may include those members of the public in a particular catchment area who could potentially be users of the service(s) (Bellin, 1991; Feingold, 1977; Hochbaum, 1977). The latter is applicable to primary care and/or health promotion programs. Consumers are all members of the public, but not all members of the public can be considered consumers. The distinction between public and consumer is that consumers are participating primarily because of the perspective and expertise they bring as users of a service.

45. Participation has meant either sharing of power or complete citizen control in the decision-making process, or no redistribution of power in the decision-making process and the public being "educated" and/or "consulted with" (Hochbaum, 1977; Checkoway, 1982). The demand for public participation in health care, both at an individual and collective level, has roots in the women's movement (Siler-Wells,1988).

46. In the political arena, numerous provincial and federal government reports, and the World Health Organization, have advocated for increased public participation in health care at both the individual and collective level (Siler-Wells, 1988; Crichton, Hsu & Tsang, 1990; Mhatre & Deber, 1992; Premier's Commission, 1989; Premier's Council, 1991). In 1965, the Report of the Royal Commission on Health Services commented that: "the achievement of the highest possible health standards for all our people must become a primary objective of national policy and a cohesive factor contributing to national unity, involving individual and community responsibilities and actions" (Siler-Wells, 1988). A recent review of Canadian provincial health commissions and reports (Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, and Nova Scotia) revealed that increased public participation was one of the major principles advocated by all the provinces (Mhatre & Deber, 1992).

47. In an effort to better understand what public participation means in the context of health care, and how it can be more productively fostered, MacKean and Thurston (1995) developed a conceptual model with two major components: 1) Arnstein's (1969) "ladder of citizen participation", which is commonly cited in the public participation literature; and 2) factors that influence how far up the participation ladder the public gets in health care decision-making. These factors include characteristics of: the context or setting; public participants and the support offered them; the change that is occurring; the participatory techniques used; and finally, the goals and objectives of public participation. For instance, societal expectations of the role that is to be played by patients and the role that is to be played by health care professionals has had a huge impact on public participation at both levels. The concept of the willing, passive and compliant patient (Parson's sick role) is integrated in health care. Also, there is a mystique around medicine and a general public perception that it is far too complex a field for the average person to understand (Checkoway, 1982; Havinghurst, 1986). The beliefs of professionals working in an organization with respect to whether public participants will be supportive allies may affect their support of public participation in the organization. For example, if health care professionals view the interests of the public as being more aligned with their own than the administration, they may be interested in forming an alliance with the public. Conversely, the administration may be very pro public participation if they feel the public's interests are more compatible with their own than the physicians (e.g., changing the emphasis of primary care from treating illness to prevention). Historically, people with power do not willingly give it up (Arnstein, 1969); so the authority of citizen or public groups needs to be clearly defined (Bracht, 1991), ideally with legal, formal authority (O'Neill, 1992). Public participants need a mandate from the users or the community that they are drawn from. If a public participant has no constituency to draw upon for ideas and support, the probability of being effective is generally reduced. Godbout (1981) and O'Neill (1992) discuss the importance of ensuring that there are mechanisms in place for public representatives to access their constituents. Furthermore, while health professional representatives generally have fellow committee members from whom they can seek validation of ideas if needed, the token public representative is doomed to isolation.

48. Batt (1994) identified the problem of access in her book: One question, though, is how we will form our committee, let alone find our 150 delegates. The other committees have the university and cancer infrastructure from which to draw representatives. We have a constituency that is largely invisible and silent" (p. 341-2). Women are characteristically the gatekeepers of the family's health and put the health of others before their own. A question that must be addressed is: How to involve women without increasing their burden?

3) HEALTH REFORM AND INCREASED CARING ROLES FOR WOMEN

49. A further interpretation of the term 'participation' might be the work that the community can do to promote health. Whereas this notion is consistent with an empowering and enabling health promotion context, as envisioned in the Ottawa Charter, it can also be manipulated for economic, costgoals on the part of governments at a time of fiscal restraint. Often added responsibilities are given to the "community" without necessary enabling resources. When the work of caretaking is moved from the hospitals and the state to the community, it inevitably impacts on women's lives more significantly than on men's.

50. Home care and homemaker services are the primary vehicles throughout Canada by which services are provided to clients. Volunteers also provide a significant and valuable service to clients through friendly visiting, delivery of mealswheels and other important services. Prior to 1960, only 27 homemaker services existed in Canada, and by 1982 approximately 540 agencies were in operation. Home Support Canada estimated that in 1992, fortyeight to fifty thousand people were involved in homemaking across Canada with an estimated 14,000 homemakers working in Ontario (Martin Matthews, 1992). The employment of registered nurses in Ontario's home care programs nearly doubled during the period between 1984 and 1989 going from 2337 in 1984 to 3944 (Hiscott, 1993). The demand for therapists and case managers has also increased accordingly. The volunteer labour force is indispensable to the human service system. In Ontario alone there are just under 2 million volunteers who provide approximately four and a half billion dollars worth of work every year and contribute 352,990,000 hours of volunteer labour each year (graff, 1987). Investigations have begun into women's work of "caring" both within families and outside the home, in paid or unpaid work (Anderson & Elfert, 1989; Armstrong, et al. 1994; Aronson, 1990, 1991, 1992; Baines, Evans & Neysmith, 1991; Croft, 1986; Dalley, 1990; Evans, 1991; Ferguson, 1991; Finch ,1984; Finch & Groves, 1983; Graham, 1983, 1985; Guberman, 1990; Heller, 1986; Hooyman, 1987; James, 1989; Laurence, 1992; Medjuck, O'Brien & Tozer 1992; Wuest, 1993). Wuest (1993) points out that current Canadian "Health care professionals are complicit in sustaining women's oppression by reinforcing . . . institutions" that use women's unpaid caring labour (p. 407).

51. The theoretical framework for analyzing this under or unpaid women's work must be based on a recognition of institutional and ideological structures that inform women's lives. What remains in the private realm is traditionally held to be invisible to the public. What is accepted to be "natural", unskilled and "feminine" (i.e., women's caring and emotional labour) must be shown to have a fundamental place in society's system of production and reproduction (James, 1989). The basic division and opposition between public and private care must be examined (Aronson,1991). The ideology and practices that maintain a system of informal care must be acknowledged both in setting up alternatives to informal care and in finding sufficient support systems for those doing informal care (Aronson, 1991). The basic ideology of "familism" (Dalley, 1990; Wuest, 1993) which "fosters relationships of domination and subordination , patterns of domestic labor, altruistic care giving of children and the elderly, and patterns of dependency, all of which serve women poorly" (Wuest 1993, p. 408) must be exposed. The actual skills, demands, conditions and effects of the job of care giving must be examined and accounted for. Each of these fields would need detailed investigation. In 1983, Rimmer outlined the "true [economic] costs of community care" paying particular attention to the sacrifices women must make in order to care for their relativesresulting in longpoverty, dependence and ill health. Yet, public policy has not changed in the interval.

4) INTEGRATION OF FEMINIST UNDERSTANDING

52. Related to the issue of sexist research is the issue of models of knowing, ethical analysis, communication, and program planning which may be biased and not gender neutral as assumed. Belenky, Clinchy, Goldberger and Tarule (1986) talk about gender differences in understanding the world with implications for pedagogy. Larrabee (1993) has brought together a collection of writings continuing on the theme of gendered moral development and the implications for ethical analysis. Harding (1986) has identified some of the sexism in the philosophy of science. A critical area women's health issue which has not been informed by gendered and feminist analysis is the prevention of child sexual abuse. One of the defining characteristics of theories is whether they are informed by feminist criticism (Yll, 1993). Feminist theorists view abuse within a broad social context within which gender and power are key elements. Linkages between various forms of violence are made through these elements and social institutions (e.g., the family) are understood, in part, by examining these elements. Feminist theorists have made less of a contribution to understanding child abuse than other forms of violence against women (e.g., wife abuse); however, it has been argued convincingly that psychological and sociological theories which ignore gender and power issues are unlikely to advance our understanding (Yll, 1993).

53. One of the reasons that people avoid discussions of theory is that they hope to avoid the ideological battles identified by Edwards and Lohman (1994). In discussing the backlash directed at professionals in situations where a large number of cases of CSA have been identified, Edwards and Lohman (1994) observed that the different meanings that people place on events can become part of an ideological battle. Certain perspectives challenge the status quo in power relations in society, notably the feminist theories, and see child sexual abuse as a means of oppression and maintenance of power; however, in opposition to this, others (e.g., Krivacska, 1992) maintain that CSA is an act of sexual expression where power is used as a tool. Failure to declare our beliefs or theories allows us to sidestep potential ideological conflicts and to operate as though agreement on assumptions was implicit.

54. The major professionals involved in CSA prevention (e.g., teachers, physicians, nurses, social workers, psychologists, lawyers, police) are not generally seen as social change agents. Therefore, CSA has become a field where professional careers can be made without challenging social structures; Edwards and Lohman (1994) refer to some "expert" spokespersons as "moral entrepreneurs". It is therefore neither necessary nor desirable to initiate debates over theoretical frameworks. The field of CSA has never had a grassroots movement similar to the battered women's movement or rape crisis movement (even though CSA prevention has been modelled on sexual assault prevention (Yll, 1993)). The relative absence of activists in CSA prevention may explain why feminist theory has had less impact on CSA prevention: they simply were not present to initiate theoretical debates.

55. Another reason for ignoring theory and, feminist theory in particular, is that the changes required appear smaller and more manageable. For instance, Radomsky (1995) indicated that only major changes in models of training and practice will enable physicians to address CSA in adults, and by implication, in children. But changing the biomedical model would bring wider changes to the profession and subsequently to the health care system. As Sherwin (1992) sees it: physicians' "view of reality is seldom challenged, even when the subject matter on which they speak extends beyond scientific evidence" (p. 5). Thus, although physical examination is currently irrelevant in 50% of cases (Heiman, 1992; Johnson, 1991) and, if secondary prevention or early identification is successful, it should be irrelevant in a higher proportion of cases, it is still recommended that physicians be trained to physically exam children to diagnose CSA. Part of the reason for placing credence on "medical evidence" is the ideological position that it is more objective and more credible than a child's statement and that position is also difficult to change. In fact, physicians should be looking for signs other than physical evidence and must rely on communication from the child, a practice approach more in keeping with Radomsky's (1995) view.

56. As identified in a review of the prevention literature (Bagley, Thurston & Tutti, 1996; Bagley & Thurston, 1986), the consequences of ignoring theory go beyond failure to identify the significant points for intervention and models for programs, although this consequence is serious enough. Blaming the victim can result from a failure to analyze sociocultural forces that create victims. A "blame the victim" response can result in iatrogenic treatment. When the victim is a very young child, some people need another "victim" or scapegoat and the professional may become a target (Edwards and Lohman (1994) and may become hesitant to identify CSA (Elias, 1994). Ignoring theory and feminist critique allows us to tinker with existing programs or services rather than to question the premises upon which they are based. It also allows us to place equal weight on issues that may have very different roles in etiology of abuse or outcome of prevention (e.g., "serious consequences" for the family of false positive suspicions). Without attention to theory, the writing about CSA continues to obscure important variables; for instance, it is usually disproportionately mothers who attend prevention programs, not fathers, so the use of a generic term such as parent in reports misleads the reader. Finally, it has been argued that expert models (where the professional diagnoses the problem and recommends an intervention) tend to disempower those who are the targets for help, to make systemic change unlikely, and to perpetuate victimhood and the "need" for experts (Kretzmann & McKnight, 1993).

5) THE STATUS OF WOMEN IN POLICY-MAKING POSITIONS

57. Despite successes attributable to the women's movement, studies continue to show that men are over-represented in positions of leadership in universities, the health care sector and other professions. This is such common knowledge that we will spend no time discussing the facts. The result is that the power for setting the research and practice agendas; reviewing grant and program applications; and deciding which networks are supported and who gets information, among other things, is biased against women and visible minorities.

58. Current social policy is out of step with social reality. Current policies focused on privatization and devolution of health and social services to the "community" have disproportionately discriminated against women. The framework and principles of health promotion include justice and equity and should ensure that healthy public policy is developed by including the voices of the most marginalized in society and ensuring that their needs are addressed. However, the theoretical underpinnings of social policy have been patriarchal and the welfare state, past and present, has done little to empower women (McCormack, 1991). In order to create healthy public policy that is equitable, feminist theoretical analysis is critical (Green, 1994). Points of conflict for women with public policy occur around many issues (e.g., child care, midwifery, cancer treatment) and efforts to resolve conflict can result in social change. Collaboration between groups involved with different points of conflict but with similar ideologies can enhance the change process and, perhaps more importantly, can prevent burnout among change agents.

59. The climate of rapid social change provides an opportunity to realign policy with the lived realities of all people. Women's groups must obviously be engaged in the process; however, these are typically non-profit with a small resource base outside of the members. Development of effective strategies to meaningfully involve marginalized groups in partnerships, public participation and policy development is necessary to advance authentic healthy public policy.

6) PREVENTING INTIMATE VIOLENCE

60. Preventing intimate violence is a major challenge for the health system but also for how we work in health promotion. The statistics on violence against women are staggering and it impacts on the physical, social, emotional , psychological and spiritual health of every victim. The consequences for the health of women in general have received little attention outside of feminist writing (Thurston, 1995b). As identified earlier, despite the congruence between the new view of health and the issue of violence against women, community health and tertiary care professionals have played a limited role in preventing this violence. Few programs address the fact that as many as two out of ten female participants may be experiencing ongoing physical abuse. Although as many as 25% of pregnant women may be battered, for instance, how many prenatal programs take this into consideration? North and Rothenberg (1993) recognized that violence could be an outcome of partner notification of HIV status, but this connection is rarely made in the literature. One reason for this is the single issue intervention approach.

CONCLUSION

61. While there are many challenges to be faced in making health promotion more relevant for women, we would like to conclude on a positive note. Certainly, much progress has been made in improving the status of women in society and there is reason to be optimistic that this will continue. Furthermore, because of the principles of health promotion, there is goodwill towards women and visible minorities within the field. The congruence between feminist theory, the policies of the women's health movement and the principles of health promotion should make progress easier than has often been the case. The establishment of three to five centres of excellence in women's health based on a social determinants model will also serve to advance the field.

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