As the health system gains a better understanding of the social dynamics of health and health care, there is greater recognition that health planning has much to gain from seeking input from women. As principal family caregivers and high users of health care, women have frequent and intimate contact with the health system. Furthermore, women as a population group are vulnerable; they are disproportionately affected by many social factors - such as poverty and violence - that put them at risk for ill health and bear a high burden of health problems linked to reproduction, mental health, family violence, and aging. The purpose of the study, therefore, was to seek guidance from women, based on their knowledge, opinions, and life experiences, to shape planning for women's health and health services within Manitoba's rural South Eastman regional health authority (RHA).

Methods
To give voice to South Eastman women, the RHA partnered with a number of local women's groups to conduct a community-wide qualitative study. Between October 2000 and March 2001, 173 South Eastman women ages 19 to 85 years took part in a series of personal interviews (5), focus groups (21), and discussion groups (5) held in various communities throughout the region. Participants represented a wide range of backgrounds and viewpoints, including communities of women with special perspectives on health and health care, such as young adult women, senior women, francophone women, women with disabilities, immigrant women, women with experience of the mental health system, women with experience of domestic violence, and farm women.

Interviews, focus groups, and discussion groups explored women's health by soliciting participants' responses to three questions:

• What are the main women's health issues in your community?
• What barriers are there in your community that stand in the way of women's health and health care?
• How can South Eastman regional health authority best work with your community to improve women's health?

Women spoke from their own life experiences about health and interactions with the health care system, contributing their knowledge, opinions, personal stories, and recommendations. Each interview, focus group, and discussion group was tape recorded. The tapes were subsequently transcribed verbatim and analyzed, using standard qualitative research techniques, to delineate consistent themes. Every effort made in the presentation of the findings to describe participants' contributions in their own words.



Main Findings
Throughout the discussions, women made it clear that they consider health a priority item, that they see themselves in the traditional family caregiver/health manager roles, and that barriers to health and health care were the key issues they wanted to discuss. With remarkable consistency across all communities of women, participants identified a range of social and system factors that stand in the way of health and health care, limiting women's ability to take responsibility for their personal health and that of their families, to interact positively with the health system, and to gain access to necessary services. Despite women's diversity of backgrounds and experiences, there was agreement across all groups regarding fundamental needs for greater respect, for more accessible, holistic services, for better communications with health care providers, and for information and assistance finding the mutual support and services women need to deal with health problems. Women were also agreed on recommendations to the regional health authority for ways to work with communities to improve women's health, calling for a focus on women's health, greater access to quality information on women's health concerns, community advocacy, and systems to foster mutual support.

Policy Recommendations

Acknowledging gender as a determinant of health

• Incorporate gender-based analysis as a routine component of decision-making. This means not only ensuring that data for evidence-based decision-making are collected and analyzed in sex-disaggregated form, where available, but examining policy and planning decisions, where appropriate, with an appreciation of gender variations to assess the potential for differential impacts on women and men.
  
• Promote awareness and education on the role of gender in determining health. Awareness and education should be targeted both to the public and to health personnel, at all levels within the system. Teaching should relate to the social dynamics of gender and to differential impacts on risks to health and responses to prevention and intervention. A holistic approach should be taken, considering health in the life context rather than focusing on specific diseases and conditions.

Acknowledging gender as a determinant of health services

• Strengthen the processes that women value. Women place particular value on key processes that enhance access to health and health services, namely taking individual responsibility for health, communicating successfully with health staff, and gaining entry to the health system and access to necessary services. Education and resources are required to help women develop and enhance skills around these processes and to equip staff with the appropriate knowledge and tools to give meaningful support to all health care consumers.
• Acknowledge women's priorities. This means respecting women's collective wisdom and life experiences and acting on their priorities and suggestions. Policy-making and planning should build on women's recommendations by working with communities to facilitate networking, mutual support systems, and advocacy mechanisms for women's health and health issues, as well as fostering effective communication and information exchange between health providers and consumers.
• Involve consumers in health planning. Consumer participation in planning should be part of the health system's quality management process. This means involving consumers at various stages of program and service planning, including needs assessment, design, implementation, and evaluation. The approach enables the health system to benefit from consumer knowledge and experience in identifying and meeting community health needs, monitoring the appropriateness of services, assessing policy and planning decisions from key perspectives, including that of gender, and measuring effects in terms of health outcomes and consumer satisfaction.
• Promote and support gender-oriented health services research. There is very little information available to guide the health system in understanding the impacts of gender on health services, the interactions between gender and other determinants, and the effectiveness of interventions directed to improving health among men and women. In addition, each organization responsible for health service delivery is unique in terms of its structure and composition and the characteristics of the population served. Gender-oriented research should therefore be priorized as a basic prerequisite to planning health services for women and for men, keeping in mind that population-specific research provides the best guide to organizational decision-making.
• Promote awareness and education on the role of gender in determining health services. Awareness and education should be targeted to the public and to health personnel at all levels throughout the system. Teaching should relate to the ways in which gender can impact both the delivery and receipt of health services, focusing on health behaviours, effective and sensitive communication, power relations, and the impacts of personal values and belief systems on interactions in health settings. Tools and resources should be developed to assist in the educational process.

• Maintain a population-based, evidence-based approach to health policy-making and planning. This approach, by taking into account population diversity with respect to life circumstances and life experiences, enables the tailoring of health services to address the very wide range of health and health care needs within gender groups.

• Examine enhanced and alternative methods of service provision. The effectiveness and quality of local programs and services should be subject to review incorporating consumer perspectives, and the cost-effectiveness of enhanced/alternative service models explored.

Thanks are also extended to the Prairie Women's Health Centre of Excellence (PWHCE) for the grant which made this research possible, to members of the research team, and to regional and allied staff who assisted with the focus and discussion group components and contributed helpful suggestions on earlier drafts.

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