Gender Sensitivity in Primary Care: Three Studies
Sensitivity to gender differences in health and healthcare needs influence gender equality in health and access to care. One of the barriers to enhancing gender sensitivity of the healthcare workforce has been related to the under-representation of women in either the workforce or patient population. This dissertation tried to understand workforce gender sensitivity when female patients are a minority group in a healthcare organization. The three studies in this dissertation focused on the Department of Veterans Affairs (VA) healthcare system where only 8% of patients are women Veterans. Because the VA has historically been designed to care for male Veterans, there are general concerns that the majority of VA workforce may not be ready to care for women Veterans or sensitive to the care needs of women Veterans. This dissertation used VA primary care provider (PCP) and staff surveys and VA administrative data from a cluster randomized controlled trial of an evidence-based quality improvement (EBQI) strategy for implementation of VA Women’s Health Patient-Aligned Care Teams (WH-PACTs). The objectives of this dissertation were to understand the VA workforce gender sensitivity, the impact of the EBQI initiative on the workforce gender sensitivity, and the relationship between the workforce gender sensitivity and primary care discontinuance among women Veterans. This dissertation is divided into three studies.
The first study examined the individual characteristics associated with gender sensitivity four years after the VA began PACT implementation in 2010. The VA PACT policy recommended tailoring PACT to meet the primary care needs of women Veterans through the implementation of WH-PACTs. To support WH-PACTs, the policy also recommends increasing the primary care workforce who are skilled in women’s health by training current employees and hiring additional qualified providers and staff. Tailoring practices from male-centric care to female-oriented care may depend, in part, on the gender-sensitive attitudes of the workforce. This study evaluated gender sensitivity within the context of the PACT policy. Using cross-sectional surveys, PCP and staff gender sensitivity was measured using a validated 10-item gender sensitivity measure. A total of 256 PCPs and staff responded (39% response rate). Using linear regression weighted for survey non-response, the results indicated that the volume of women Veterans seen locally, individual practice experience with caring for women patients, working in WH-PACTs compared to general PACTs, communication quality within clinics, and years worked at VA were significantly associated with gender sensitivity. However, each characteristic associated with gender sensitivity varied statistically between PCPs and staff.
The second study evaluated whether participation in facilitated quality improvement (e.g., EBQI), compared to self-directed QI, for WH-PACT implementation would influence gender-sensitive attitudes of the primary care workforce. Twelve VA medical centers (VAMCs) were randomized into eight EBQI sites and four control sites. The eight EBQI sites received a combination of multilevel stakeholder engagement, leadership support, QI training, formative feedback, and practice facilitation on their local QI initiatives for WH-PACT implementation. The four control sites implemented WH-PACTs on their own. Using the same validated 10-item gender sensitivity measure, PCP and staff gender sensitivity was assessed at baseline (N=256, 37% response rate) and 24-month (N=222, 29% response rate). The difference-in-differences analysis showed that the EBQI sites improved gender sensitivity over time compared to the control sites, possibly because EBQI reduced challenges associated with QI and in-turn increased interest in QI for female patients among providers and staff.
The third study assessed the relationship between the provider and staff gender sensitivity and women Veterans discontinuing from VA primary care within three years. PCPs and staff from 12 VAMCs who participated in the 2014 cross-sectional surveys (N=256) were linked to women Veterans who visited them at the same VA for primary care (N=9,958). The dependent variable was the absence of VA primary care visits among women Veterans within three years after their last primary care visit. Controlling for provider, staff, and women Veteran characteristics, multivariate logistic regression indicated that poor PCP and staff gender sensitivity was associated with women Veterans discontinuing primary care within three years.
These findings can inform policymakers as well as VA and non-VA healthcare systems transforming practices to improve care for female patients and enhancing gender sensitivity of the healthcare workforce important to closing the gender gap in health quality and outcomes.