Framework

Women's Health Indicator Frameworks
 
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Capturing a comprehensive picture of women’s health requires choices be made concerning what health indicators are included. The indicators must be of a small enough number to be manageable, but broad enough to still capture the complexities of the full spectrum of health and illness. Health indicator frameworks help fulfill this goal by establishing a theoretical framework of health on which indicator selection can be based. For example, the women’s health indicators in The Source are listed according to the categories in the World Health Organization’s indicator framework.
 
This page highlights prominent health frameworks in Canada as well as critical international examples. Most focus directly on women’s health, however broader frameworks are also examined when relevant. The frameworks are listed chronologically to show their evolution from lists or clusters of indicators, to more complex conceptual frameworks that capture the links and causal relationships between health domains and associated indicators.  A brief description of each framework is provided as well as a link to the webpage when available.
 


 
The Canadian Health Indicator Framework
 
Though it is does not explicitly include sex or gender, the Canadian Health Indicator Framework is included here as it is one of the foundational health indicator frameworks in Canada. It was first established in 1999 by Statistics Canada and CIHI as a core set of indicators for health reporting. Over time, the core set expanded to include more indicators. Indicators are organized into four tiers:
 
  •    Health Status, which documents the overall health of the population
  •    The Determinants of Health, which underpins Health Status and includes factors that affect our health and influence how and when we use health care.
  •    Health System Performance lies below determinants of health and includes indicators that measure how well health care services are delivered.
  •    The last tier, Community and Health System Characteristics includes indicators measuring less direct determinants health status in three domains: community, resources, and health systems [1].
 
Though the indicators are organized into tiers, the relationship between the tiers does not imply causality. The tiers are instead a method of dividing health into concrete topic areas of interest. This framework is well accepted nationally and internationally, and has informed the development of other frameworks, such as the Health Information Framework.
 

 
Health Information Framework
 
In 2002, the Third International Meeting on Women and Health of the WHO Kobe Centre identified a need to compare internationally used health indicators in terms of their capacity to evaluate the group’s expressed goal – gender equity in health. Gender health inequities refer to gendered differences in health outcomes, access to health services and opportunities to promote and maintain health that are “unfair and avoidable or remediable” [2].  Eliminating or reducing gender health inequities is supported by gender-sensitive health indicators that can measure and monitor when inequities occur. In 2003, The La Trobe Consortium from Melbourne, Australia undertook a review of internationally used health indicators. Recognizing that a framework was needed to guide the selection of indicators, the La Trobe Consortium analyzed existing health indicator frameworks. They determined that most existing frameworks had a narrow, biomedical focus, and were therefore inadequate for capturing the breadth of women’s health, which is affected by the social determinants of health and other factors outside of the biomedical focus. The La Trobe Consortium built on three existing frameworks that used a determinants of health approach (including the Canadian Health Indicator Framework) and developed a new framework, called the Health Information Framework, which is presented below. As can be seen by the equity arrows on the right-hand side, this framework applies an overarching lens of equity across all indicators and topic areas.
   
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The Health Information Framework is rooted in a determinants of health model that posits that health is influenced by an array of factors, including individual, population-level, cultural, social and economic factors. The four tiers (Health Status, Determinants of Health, Health System Performance and Community and Health and Welfare System Characteristics) reflect the notion that health is directly and indirectly affected by a number of factors [2]. Similar to the Canadian Health Indicator Framework, the framework’s structure is not suitable for demonstrating links or causal relationships between tiers or indicators.
 
 
 
World Health Organization - Core Set of Leading Health Indicators
 
The World Health Organization (WHO) conducted further work on the 1095 indicators of women’s health identified by the La Trobe Consortium to reduce them to a manageable core set of 37 indicators. To guide their selection, the WHO further modified the Health Information Framework. The framework was initially comprised of four tiers: Health Status; Determinants of Health; Health Systems and Community and Health and Welfare Systems Characteristics. The fourth tier, Community and Health and Welfare System Characteristics was eventually excluded from the framework as these indicators would have been difficult to measure [2]. This framework faces the same limitations as the Health Information Framework, in that it does not indicate causal relationships between its elements.
 
This international women’s health indicator framework has become one of the mostly widely used to measure and monitor women’s health across the globe. It was the basis for the classification of indicators on The Source and in many other reporting mechanisms.
 

 
Pan American Health Organization - Conceptual Framework for Gender Equity Analysis in Health
 
In 2005, the Pan American Health Organization (PAHO) developed a framework containing a selected set of 28 indicators for analysis of gender equity in health. The PAHO indicator framework builds off the WHO framework. It highlights structural and systemic discrimination against women, and recognizes that gender plays a major role in fueling health inequities, influencing health determinants, health outcomes and access to health-care services. This framework can be found in Basic Indicators for Gender Equity Analysis in Health. The framework is based on four conceptual domains: health, equity, gender and citizen participation [3]. The health indicators themselves are organized into clusters, but do not indicate causal relationships.

Commission on Social Determinants of Health Conceptual Framework

In recent years, indicator frameworks have become more sophisticated by modeling causality between categories of indicators. By doing so, frameworks move beyond being a categorization mechanism and begin to postulate a more dynamic, interconnected model of health and health behaviours.

One important international example was published by the World Health Organization’s (WHO) Commission on Social Determinants of Health in 2008. It identifies socioeconomic and political factors such as governance, policy, cultural and societal norms and values as fundamental determinants of health responsible for giving rise to social positions including education, occupation, income, gender, ethnicity and race. In turn, these social positions influence specific determinants of health such as material circumstance, social cohesion, psychosocial factors, behaviours and biological factors [4].

     

Though the Commissions’ indicator framework was not a women’s health framework, it did recognize gender as a critical aspect of social position and thus an important factor to monitor in any standard set of indicators. 
              


       

     
 
Dynamic Gender-inspired Health Determinants Model

In 2009, the Women’s Health Research Network of BC released a dynamic gender-inspired health determinants model, which unlike the Commission’s framework, posits that sex and gender are fundamental determinants of health  that intersect with other key social statuses and processes, including age, race, class, ethnicity, immigrant status and geographic location. In this model, sex and gender are understood to influence access to important resources, including employment, education, childcare, safe neighbourhoods, and health services. Gender is understood to be a structural determinant of health rather than just a characteristic of individuals or populations [5].

Gender and Equity Health Indicator Framework

Also in 2009, the Project for an Ontario Women’s Health Evidence-Based Report (POWER) featured a Gender and Equity Health Indicator Framework. As with the framework put forth by the Women’s Health Research Network, the POWER framework locates gender as a central element that shapes and is shaped by all other health domains. The framework is based on:

       


A holistic definition of women’s health including emotional, social, cultural, spiritual, physical, political, economic and biological aspects.   
The social determinants of health, such as income, education, socio-cultural factors, housing, employment, health services, personal health practices and physical environment are emphasized as being important drivers behind women’s health. 
The distinction between “sex” and “gender”: The framework distinguishes between “sex” which are the biological differences between men and women, from “gender” which refers to “the differences associated with societal roles and the context of women’s lives”. 
Equity is central to the POWER study’s framework, as the Report’s main objective to contribute to the body of evidence on gendered health inequities. 
Stakeholder input from women’s health stakeholders across Ontario was instrumental in indicator selection and identifying priority areas for reporting [6].
The POWER Study indicator framework recognizes that the non-medical determinants of health are the primary determinants of health status and that population and individual health outcomes are mediated by community and health system characteristics as well as health system performance. The framework also recognizes that sex and gender influence how all these factors impact on experiences with care and health outcomes. The POWER framework is currently being used as the foundation for the POWER report, chapters of which are available on POWER’s website. 

The Gender Migration and Health Conceptual Framework

In some cases, researchers have developed indicator frameworks for understanding the health of smaller subpopulations. This specialization is intended to increase accuracy of results by taking the unique experiences of that population into account. 
The Gender Migration and Health Conceptual framework is a critical example that focuses on the health of immigrant women. It is found in Measuring Health Inequalities Among Canadian Women: Developing a Basket of Indicators.

         

The framework asserts that the geopolitical environment encompasses all of the other health determinants including who immigrates, the country of origin and place of settlement.  The health of immigrants is influenced by factors in their country of origin as well as factors in their host nation.  Socially constructed gender roles from the host and settlement countries act at all levels to create a difference in health outcomes between immigrant men and women [6].

In addition to showing the directional relationships between indicators, this framework recognizes that different subgroups of women experience distinct sets of health determinants. Gender plays a key role in producing health outcomes and is shown to interact with both pre-migration and resettlement determinants of health to affect health outcomes.

There is a trend towards increasing complexity of women’s health frameworks, as we learn more about women’s health, women’s health indicators and the instrumental role that sex and gender play in shaping women’s health.  

References
[1] Canadian Institute for Health Information and Statistics Canada(2003).  Health Indicators.  Accessed on December 8, 2009 from www.cihi.ca/indicators/en/pdf/framework.pdf
[2] Lin V., Gruszin S., Ellickson C., Glover J., Silburn K., Wilson G. and Poljski C (2007).  Comparative evaluation of indicators for gender equity and health.  International Journal of Public Health 52(S1): S19-S26.
[3] PAHO, Gender Ethnicity and Health Unit (2005).  Basic Indicators for Gender Equity Analysis in Health. Accessed on December 8, 2009 from www.paho.org/english/ad/ge/basicindicators.pdf
[4] Commission on Social Determinants of Health (2007).  A Conceptual Framework for Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health DRAFT.  Accessed on December 8, 2009 from www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf
[5] Benoit C., Shumka L. (2009) Gendering the Health Determinants Framework:  Why girl’s and women’s health matters: Women’s Health Research Network. Accessed on December 8, 2009 from www.whrn.ca/why-girls-and-womens-health-matters-download.php.
 [6] Clark J.P. and Bierman Arlene (2009).  Ontario Women’s Health Equity Report.  The Power Study Framework, Chapter 2.  Accessed on December 8, 2009 from www.powerstudy.ca/webfm_send/50