Application of a gender-based approach to conducting a community health assessment for rural women in Southern Illinois.

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Contents lists available at ScienceDirect

Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan

Application of a gender-based approach to conducting a community health assessment for rural women in Southern Illinois Kristine Zimmermann a,*, Manorama M. Khare b, Cherie Wright c, Allison Hasler d, Sarah Kerch e, Patricia Moehring c, Stacie Geller a a

Center for Research on Women and Gender, University of Illinois at Chicago, 1640 West Roosevelt Road, M/C 980, Chicago, IL 60608, United States Division of Health Policy & Social Science Research, UIC College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107-1897, United States Southern Seven Health Department, 37 Rustic Campus Drive, Ullin, IL 62992, United States d Marion Regional Office, Illinois Department of Public Health, 2309 West Main Street, Marion, IL 62959, United States e MidAmerica Center for Public Health Practice, School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street, Chicago, IL 60612, United States b c

A R T I C L E I N F O

A B S T R A C T

Article history: Available online xxx

Rural populations in the United States experience unique challenges in health and health care. The health of rural women, in particular, is influenced by their knowledge, work and family commitments, as well as environmental barriers in their communities. In rural southern Illinois, the seven southernmost counties form a region that experiences high rates of cancer and other chronic diseases. To identify, understand, and prioritize the health needs of women living in these seven counties, a comprehensive gender-based community health assessment was conducted with the goal of developing a plan to improve women’s health in the region. A gender-analysis framework was adapted, and key stakeholder interviews and focus groups with community women were conducted and analyzed to identify factors affecting ill health. The gender-based analysis revealed that women play a critical role in the health of their families and their communities, and these roles can influence their personal health. The gender-based analysis also identified several gender-specific barriers and facilitators that affect women’s health and their ability to engage in healthy behaviors. These results have important implications for the development of programs and policies to improve health among rural women. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Community health assessment Gender-based analysis Rural health Women’s health

1. Introduction Rural populations in the United States experience unique challenges related to health and health care. Residents of rural areas suffer from high rates of cancers and chronic health conditions, including diabetes, overweight/obesity, and cardiovascular disease (CVD) (Bennett, Olatosi, & Probst, 2008; Gamm, Hutchison, Dabney, & Dorsey, 2003). A number of factors interfere with rural residents’ abilities to prevent and manage these health conditions. These include difficulty accessing health care due to lack of insurance and shortages of health care providers (Casey, Thiede Call, & Klingner, 2001; Coughlin, Leadbetter, Richards, & Sabatino, 2008; Merwin, Snyder, & Katz, 2006), travel distance to

* Corresponding author. Tel.: +1 312 413 4251; fax: +1 312 413 7423. E-mail addresses: [email protected] (K. Zimmermann), [email protected] (M.M. Khare), [email protected] (C. Wright), [email protected] (A. Hasler), [email protected] (S. Kerch), [email protected] (P. Moehring), [email protected] (S. Geller).

providers (Buzza, Ono, Turvey, Wittrock, & Noble, 2011), and lifestyle behaviors that contribute to chronic disease conditions, including smoking (Vander Weg, Cunningham, Howren, & Cai, 2011), poor dietary habits (Boeckner, Pullen, Walker, Oberdorfer, & Hageman, 2007), and physical inactivity (Patterson, Moore, Probst, & Shinogle, 2004). Rural women in particular face specific challenges in the prevention and management of disease. Researchers have shown that health behaviors among rural women are affected by their lack of knowledge about disease and disease risk (Flynn, Gavin, Worden, Ashikaga, & Gautam, 1997; Hamner & Wilder, 2008). In addition, women often cite work and family commitments as interfering with health care visits or engaging in health programs and behaviors (Eyler & Vest, 2002; Perry, Rosenfeld, & Kendall, 2008). Finally, rural women are often challenged by environmental barriers to healthy behaviors, such as lack of sidewalks and limited accessibility to fresh foods (Ainsworth, Wilcox, Thompson, Richter, & Henderson, 2003; Eyler & Vest, 2002; Liese, Weis, Pluto, Smith, & Lawson, 2007).

http://dx.doi.org/10.1016/j.evalprogplan.2014.12.004 0149-7189/ß 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Zimmermann, K., et al. Application of a gender-based approach to conducting a community health assessment for rural women in Southern Illinois. Evaluation and Program Planning (2014), http://dx.doi.org/10.1016/j.evalprogplan.2014.12.004

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Our research targets women in rural, southernmost Illinois. The ‘‘southern seven’’ counties form a region with a population of approximately 69,000 over 2000 square miles (US Census Bureau, 2010). Compared to Illinois women overall, women in the southern seven region experience higher rates of heart disease mortality, diabetes, high blood pressure, high cholesterol, and obesity (Illinois Department of Public Health, 2006, 2010). The Southern Seven Coalition for Women’s Health (SSCWH), a group of community-based organizations and public health and health care agencies, was developed in 2007 to improve women’s health in these southern seven rural counties. To understand and determine how to best address health issues faced by women living in the southern seven region, SSCWH conducted a community health assessment (CHA). CHA is an important component of public health that involves collecting, analyzing, and using data to inform and engage communities and to develop health priorities and collaborative action plans to improve health (Friedman & Parrish, 2009). Disaggregation of CHA data by demographics, including sex, race, ethnicity, and age, is important to understanding health needs and identifying health disparities. However, this level of analysis is insufficient for understanding the full scope of factors that may affect women’s health, including social, economic, and political factors as well as differences among women (Nowatzki & Grant, 2011). For this reason, SSCWH conducted a gender-based analysis (GBA) of the CHA. According to the World Health Organization (2002): ‘‘Gender analysis identifies, analyzes and informs action to address inequalities that arise from the different roles of women and men, or the unequal power relationships between them, and the consequences of these inequalities on their lives, their health and well-being’’ (pp. 6). Reports of studies that incorporate gender analysis to understand or improve health are limited. A small number of studies, mostly conducted outside of the US, report gender-based approaches to examining risk factors for chronic diseases. For example, in one study, researchers found that young women in the US with an incarcerated parent were at an increased risk for obesity (Roettger & Boardman, 2012). In an examination of leisure time physical activity across Europe, greater gender-based equity in a country was directly correlated with women’s participation in leisure time physical activity (Van Tuyckom, Van de Velde, & Bracke, 2012). In Canada, researchers reported that smoke-free policies often had unequal or unintended effects on disadvantaged women, such as greater exposure to secondhand smoke and limited ability to manage secondhand smoke exposure (Greaves & Hemsing, 2009). The findings of studies such as these can have important implications for public health programs and policies that strive to address gender-specific health disparities. To identify, understand, and prioritize the health needs of women living in the seven southernmost counties of Illinois, we conducted a comprehensive gender-based CHA with the goal of developing a plan to improve the health of the women in this region. This paper describes this gender-based analysis in the rural seven southernmost counties of Illinois and the implications for program planning. 2. Methods SSCWH researchers designed the CHA to broadly identify and examine women’s health issues across the lifespan. Based on the health priorities previously identified by the local health department in the region, the CHA had a particular focus on cancer, cardiovascular disease (CVD), obesity, and diabetes among women. The researchers developed the CHA based on the Liverpool School of Tropical Medicine’s Gender Analysis Framework (Liverpool School of Tropical Medicine, 1999). This framework provides guidelines for a situation-specific gender analysis for use in health

planning, implementation, and research. The framework offers a guide for constructing patterns of ill-health, identifying factors affecting who gets ill, and identifying factors affecting responses to ill-health. The framework includes several social, cultural, and economic categories for understanding how gender affects health. We adapted the Liverpool Framework to ensure that we would examine the various community factors that were specific to the southern seven region and that were appropriate for the coalition to address. Our adapted framework sought to understand women’s health by examining access to health care, community resources, organizational factors, families and relationships, environmental factors, health behaviors, high-risk behaviors, knowledge, attitudes, and gender norms. We used the adapted framework to develop the CHA, which included both qualitative and quantitative data collection and analysis. The quantitative component included secondary analysis of data collected from the US Census, the Behavioral Risk Factor Surveillance System, and the Illinois Project for Local Assessment of Needs. Qualitative data included key stakeholder interviews and focus groups with women throughout the region to identify factors affecting who gets ill and how individuals respond to ill health according to the gender-analysis framework. Qualitative methods also focused on identifying community assets and strengths, examining issues related to access and availability of health care, and determining potential strategies to improve the health of women in the region. We used the qualitative data to conduct the gender-based analysis, the focus of this paper. The Institutional Review Board of the University of Illinois at Chicago approved this research. 2.1. Key stakeholders interviews The researchers defined key stakeholders as representatives of organizations, including health care providers, business owners, community organizations, and community leaders, that are affected by or can affect change in women’s health in the region. We asked SSCWH coalition members to identify professionals who met this definition. Eighty-nine names of potential interviewees were collected. Because of limited resources, the list of 89 names was reduced to an initial subset of 51, selected to achieve a broad representation of perspectives based on geographic location and area of expertise. We contacted the 51 potential interviewees via US mail to explain the purpose of the interview. A follow-up phone call was made to each potential participant to schedule an interview. Of the 51 individuals identified, 28 (26 women, 2 men) agreed to participate in an interview. The remaining 23 individuals either declined to participate or could not be reached by phone. Of the 28 interviewees, 12 (43%) were health professionals (health care providers, health educators) working at local hospitals, health clinics, rehabilitation centers, or the local health department. Ten interviewees (36%) were administrators or staff of governmental or nongovernmental organizations, educational institutions, or local businesses. Six interviewees (21%) were administrators of health agencies. One participant from this latter group was retired. After the 28 interviews were completed, we conducted a content analysis and based on the information gathered from the interviews, we determined we had reached saturation and we did not need to recruit any additional participants. Trained staff from the Southern Seven Health Department and the Center for Research on Women and Gender staff conducted the interviews either in person or by telephone. Interviewers obtained informed consent from interviewees prior to each interview. All interviews were audio recorded except one, in which the recorder malfunctioned. Immediately following this interview, the


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interviewer wrote a detailed summary of the interview to record as much content as possible. The average interview length was 37 min. Interviewers used a semi-structured interview guide to explore perspectives on health and health needs, factors affecting health, access to health care, and features of the community, including strengths, barriers, and resources. Interview questions addressed both the community overall and women in particular, and a subset of questions focused on the health of girls. Interviewers used probes to encourage detailed responses. The interviewers wrote brief notes immediately following each interview to summarize key points. The researchers also conducted short debriefing meetings with the interviewers to resolve any issues that may have occurred. Multiple members of the research team assisted with interview transcription. 2.2. Focus groups with community women Focus groups were organized in collaboration with coalition members and community partners to ensure participation of a broad range of women with regard to age, race, community of residence, and socioeconomic status across the seven-county area. Focus groups were held in locations such as hospitals, clinics, a public library, and churches. We recruited participants using flyers, announcements in community and church newsletters, and newspaper advertisements. Volunteers signed up by calling the local health department. Each caller was screened for eligibility, and if she met age and residency requirements, the caller was invited to attend a focus group in her community. A senior member of the research team trained health educators from the local health department to conduct focus groups. The focus group facilitators used a focus group guide that elicited perspectives on the meaning of health, the importance of women’s health, community health needs and ways to address these needs, access to health care, and community strengths, barriers, and resources. Focus group questions addressed both the community overall and women in particular. A subset of questions also focused on the health and health needs of girls. Focus group facilitators used probes to encourage detailed responses. Facilitators were also encouraged to allow natural conversation among participants, but to guide the conversation so all topics would be covered within a one-hour period. Fourteen focus groups were conducted across the seven counties with a mean of 7.9 participants per group (range: 3–13 women) (Table 1). Due to the small population size that would make recruitment a challenge, Pope and Hardin counties were combined into one target recruitment area. We conducted at least two focus groups in each of the six counties/recruitment areas. One focus group in Massac County was canceled due to a low number of enrollees. At least three focus groups were held in each of four different age groups: 18–30 years, 31–50 years, 51–70 years and over 70 years. In total, 110 women participated in focus groups. Seventy-nine (71.8%) of focus group participants were white and 31 (28.1%) were African American. Two participants (0.02%) were Hispanic. The focus group facilitator obtained informed consent from focus group participants prior to the start of each focus group. All focus

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groups were audio recorded. Each participant received a $15 gift card at the end of the session. The facilitators wrote brief notes immediately following each focus group to summarize key points. In addition, researchers conducted short debriefing calls with facilitators after the focus groups had met to resolve any issues that might have occurred. To ensure data quality, a member of the research team transcribed the focus group recordings immediately after they were completed and sent transcriptions to the facilitators to review, provide clarification if needed, and answer any questions. 2.3. Data analysis The researchers conducted a content analysis to examine focus group and interview data for purposeful and emergent patterns and themes (Patton, 2002). Preliminary analysis was conducted by two researchers who reviewed the same five transcripts to look for patterns and develop a coding scheme. The themes included health conditions, factors affecting health, gaps in services, suggested strategies and solutions, and community resources and strengths. Subthemes were created within each category. For example, subthemes of ‘‘factors affecting health’’ included ‘‘access to care,’’ ‘‘barriers,’’ ‘‘knowledge,’’ and ‘‘behavior.’’ After the preliminary analysis, one researcher reviewed and categorized all of the data by theme in an Excel spreadsheet. A second researcher reviewed the categorization to verify agreement with how the data were organized. To conduct the gender analysis, we sorted all statements related to gender into a ‘‘gender’’ category, regardless of whether they were also included in another thematic area. The gender category included constructs such as gender roles, norms, power structures, and gendered activities. The researchers then met to review and discuss the items related to gender, look for patterns in the data, summarize subthemes, and interpret the results. The purpose of the analysis was to obtain a broad perspective about women’s health in the region by analyzing all of the interview and focus group transcripts together. In conducting the analysis, the researchers noted similar themes across groups, and thematic differences were not apparent. However, respondents discussed similar issues in different ways. Specifically, interview participants typically responded in the context of their professional roles by describing patients or clients. In contrast, focus group participants were more likely to talk about themselves, friends, or family members. Similarly, while differences were seen between age groups and counties, examining differences between groups was not a primary focus of this research. 3. Results The GBA revealed two major themes related to women’s health in the region. First, the GBA highlighted the roles women play in their families and communities and how these roles influence health. Second, the GBA identified several gender-specific barriers and facilitators that affect women’s health and women’s ability to engage in healthy behaviors, including access to health care, dietary factors, environmental factors, sociocultural factors, and social support.

Table 1 Focus group participation by county and age. Alexander 18–30 31–50 51–70 70+ N (%)

7 9 11 27 (24.5)

Johnson

Massac

Pope/Hardin

Pulaski

5

3

8 13

10

4 9 (8.1)

6 9 (8.1)

Union 4

8 10 31 (28.1)

18 (16.3)

12 16 (14.5)

N (%) 26 24 27 33

(23.6) (21.8) (24.5) (30.0)


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3.1. Women’s roles in the family and community The GBA provided insight on women’s roles in their families and communities and how they are valued. The GBA also identified challenges women face in engaging in healthy behaviors due to their multiple roles. 3.1.1. Caregiver role is valued Participants discussed women’s multiple roles as caregivers for children, parents, and grandchildren, as well as caring for their communities through service and volunteerism. The caregiver roles that many women in the region play were roles that were viewed as having value by family members, community members, and by women themselves. These roles were often regarded as important to women’s identities and to the health of communities overall. [Women have] the most power to influence the health of the community by taking care of themselves, their children, their families, their blocks, their church. (Health care provider) According to participants, the caregiver role is closely linked to personal, family, and community health. Many respondents discussed the concept of ‘‘being healthy’’ in the context of women’s roles. Common components of health included ‘‘being able to balance multiple roles,’’ ‘‘not being a burden to anyone,’’ ‘‘setting a good example for the family’’ or ‘‘being a good role model,’’ ‘‘spending time with friends and family,’’ and ‘‘taking care of family.’’ Several participants also recognized the caregiver role as a source of motivation for women to take care of themselves as well as those around them. In order for us to be around to see those children become adults and we have grandchildren, there are some things that we have to do for ourselves, and sometimes it requires that we be a little bit selfish about it. (Agency administrator) However, for some older women, the absence of a care giving role affected women’s health behaviors, particularly related to eating behaviors. I’m by myself, it just doesn’t pay me to try to fix a big healthy or non-healthy meal for just one person... I will just grab this but it isn’t really healthy, but it is easy and it is there. (Alexander County Focus Group, ages 71+) 3.1.2. Multiple roles lead to ‘‘role strain’’ ‘‘Role strain’’ is defined as conflict among one’s life roles that leads to difficulty in fulfilling the obligations of those roles (Erdwins, Buffardi, Casper, & O’Brien, 2001; Goode, 1960). Research participants often acknowledged that women’s roles today are different from those in previous generations. Women may occupy multiple roles, such as working ‘‘double shifts’’ as wage-earners outside the home in addition to working in the home and volunteering in their communities. These multiple roles can lead to role strain. Women may also be less likely to be married than in the past and are therefore less likely to have financial or care giving support from a partner. The multiple roles women play can add to their stress and limit their time for self-care, including engaging in physical activity and going to the doctor. Participants noted that women often fail to take care of their own health needs. [Women are] going to take care of everybody first and they’re going to leave their needs last... You need to be setting a good example for [your children], and starting the change with yourself. (Health care provider)

3.1.3. Women face an unequal burden to maintain healthy communities Research participants frequently described the critical role of women in promoting the health of their communities. Participants rarely discussed women’s roles in relation to men or suggested that men in the community should accept a greater burden for improving health. Thus, personal and family health appeared to be primarily a responsibility belonging to women. Changing the health of women can change the health of the children and partners. She is the one who purchases the food, cooks it, takes them to the doctor, attends the classes, so changing her behavior will benefit them all. Changing that piece can change the entire community. (Health educator) 3.1.4. Barriers and facilitators to women’s health The GBA identified several factors that had either a positive or negative effect on healthy living, including access to health care, dietary factors, environmental factors, sociocultural factors, and social support. These factors are not always specific to women, but may affect women more significantly due to women’s roles in the community and role strain. 3.1.5. Access to health care A major challenge for women to accessing health care in the rural areas is the lack of health care providers, and particularly specialty providers such as obstetricians and gynecologists (Casey et al., 2001; Coughlin et al., 2008; Merwin et al., 2006). Participants discussed women’s access to care being affected by the lack of health care providers, challenges in scheduling health care appointments, lack of eligibility for services due to economic factors, and lack of awareness about available services. Even if they have the opportunity to have state insurance they may not be able to see a caregiver that is even remotely close, they may be available but not accept new patients or because there are not enough providers in the community. (Health Educator) Those with the highest needs—many of them do not have insurance and they seem to fall through the cracks. Their income is just not high enough to afford insurance but it is high enough that they cannot qualify for other programs. (Educator) We do not know what is available and would not know where to look for it... It adds so much stress and we do not know where to start. (Johnson County focus group, ages 51–70) 3.1.6. Dietary factors Several participants identified the challenges to accessing healthy foods, which are more expensive or not available at local stores. Combined with women’s limited time or lack of knowledge about healthy food preparation, women are likely to buy fast foods or processed foods for themselves and their families. You can get what you want in terms of healthy food, but it is easier and cheaper to buy the food that is not good for you. (Hardin County focus group, ages 18–30) We are 30 miles away from any shopping area and a Walmart or Kroger or any large grocery store. (Health care provider) People my age in this area don’t seem to have a very good idea of what healthy is. I see a lot of people cooking with a lot of oil, and everything is fried and nothing is baked. (Health care provider)


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Other important factors regarding food choices relate to women’s care giving roles. Participants discussed choosing foods that are convenient for women’s busy schedules and preferable to their families.

indoor gym besides schools is owned by one of the churches... We just don’t have a lot of facilities to do things in with young children. (Health care provider)

Rather than preparing the healthy foods that we need, it’s quicker to go down to the convenience mart and get a pizza and pop it in the oven. (Agency administrator)

3.1.8. Sociocultural factors Participants also indicated sociocultural factors as barriers that women may face to being healthy. These factors include body image and socially constructed notions about women’s appearance, which can interfere with their participation in health-related activities.

3.1.7. Environmental factors Another influence on women’s health is related to the rural environment. One major challenge in a rural environment is transportation (Liese et al., 2007; Sarnquist et al., 2011). Several participants cited transportation issues with health care access, grocery shopping, and attending health programs or physical activity classes. Residents may need to travel long distances for employment or services, they may not have access to a vehicle, or they may not be able to use the minimal public transportation options that are available in the area. Transportation is hard for some people. It doesn’t seem like it would be, but a car, to some people, is a huge luxury. (Health care administrator) We don’t have access to health care programs, fitness centers. If you live in Cairo and you want to go to the Zumba class... If you don’t have a car you don’t have access. (Government employee) I think a lot of people would participate in [Weight Watchers] if they came in and were to set up in different churches... Last year it was done in Ullin, but a lot of people didn’t have transportation to get there. (Government employee) Participants also discussed availability of spaces to be physically active, where safety and availability of sidewalks are another environmental consideration that can limit physical activity. Due to the large geographic area of the seven-county region, walking trails and other outdoor activities that are accessible for some residents may not be accessible for others. In addition, participants indicated that residents may be unaware of available resources or unaccustomed to using them. The reality is most of our communities don’t have walking trails or bike trails. We have gyms, but there’s a cost, and in this kind of economy they’re not really feasible for most families. (Retired) I don’t think we have any organized public promotion of what we have in our area. But we do have a lot of walking trails, a lot of outdoor things, possibilities for outdoor activities that keep you active and healthier. But I don’t think they’re really promoted in any way. (Health care provider) Several participants also noted limited healthy recreational activities in the region, with family-oriented activities particularly lacking. Because of small population size, residents may lack resources such as gyms and community centers that exist in many larger communities. However, some participants recognized value in facilities like churches and schools—resources that may be underutilized. There is not a lot to do in this community other than to go out to eat and gamble. (Massac County focus group, ages 51–70) In the bigger cities they have community centers where they have all that stuff. We don’t have a community center. The only

I think women have a poor self-image when they begin to gain weight, and whether it’s medical weight gain or imbalance of caloric and lack of exercise, or whatever the problem may be, I think that women typically don’t feel good about it, and they don’t want to be seen, necessarily, in tight gym clothes. So they don’t exercise at all. (Retired) 3.1.9. Social support Participants discussed the need for strategies that help women to incorporate healthy behaviors into daily routines and to make health a priority. Participants recommended educational and support programs in places where women already gather, such as work sites and churches. Expanding social support opportunities was a suggestion of several interview and focus group participants. I think that we do need groups for women... just for them to be able to get together and have some open, clear discussion about whatever the issues are. (Agency administrator) Pair up and walk. I don’t like to walk by myself but I can certainly walk. (Alexander County focus group, ages 71+) Focus group participants frequently discussed the social groups and networks from which they obtained social support, including their neighbors and their churches. The church I go to... it is just like one big family. We always, we were all raised together and we still attend the same church so that is just like a family thing. (Alexander County focus group, ages 71+) Overall, the GBA revealed that women’s roles and responsibilities in and outside of the home influence women’s health in the region. These roles and responsibilities, coupled with barriers in the community, create challenges for women to be healthy. However, several community factors, such as social support, may provide opportunities for improving health. Focus group and interview participants recommended implementing programs with a women’s focus as a way to improve women’s health as well as the health of families and other community members.

4. Discussion SSCWH conducted a community health assessment with a gender-based analysis to understand women’s health in the rural seven southernmost counties of Illinois. Through the GBA, SSCWH discovered that women’s roles in their families and communities, as well as facilitators and barriers in the community, may have important influences on the health of women and their ability to engage in healthy behaviors. An important finding of the research was the understanding that women in the region often serve in caregiver roles both within the family and in the larger community, and often find satisfaction from the care giving role. Previous research supports the finding that women often take pride in their role as family and community


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caregivers (Messia, DeJong, & McLoughlin, 2005). Community service and volunteerism can provide a woman with social rewards and solidify her position in her community. Our GBA suggests that acknowledging women’s care giving role may be an opportunity to help women engage in healthy activities and behaviors to improve their health and better fulfill their caregiving roles. The commitments associated with care giving responsibilities, however, can also interfere with a woman’s ability to engage in healthy activities and behaviors. Consideration of the care giving role may be helpful in developing programs to promote positive health behaviors for women. Such health promotion requires developing activities or strategies that suit women’s busy schedules, including family-focused activities. This finding supports previous research that personal and professional responsibilities and lack of family support may interfere with a women’s ability to engage in health behaviors such as physical activity (Komar-Samardzija, Braun, Keithley, & Quinn, 2012; Nies & Motyka, 2006; Perry et al., 2008). Participants commonly described women’s health as being important to the region in part because of the roles women play in caring for their families and communities. However, placing the burden on these women to transform the health of future generations of residents can be problematic from a gender-equity perspective. While women can be important leaders in their communities in addressing health needs, strategies are needed to minimize excess burden that women may face and determine whether men should share more responsibility for community health. Community partners must work together to determine how to minimize women’s stress and promote self-care while allowing women to maintain the social rewards and status offered by the community caregiver role. Similar to other studies, this research found that participants discussed the importance of social support in supporting and maintaining healthy lifestyle behaviors (Eyler & Vest, 2002; Krummel, Koffman, Bronner, Davis, & Greenlund, 2001). This suggests the need to develop or enhance social support networks to improve women’s health. One possible mechanism for this is promoting health through group activities in spaces where women already gather, such as churches and worksites. Previous research has demonstrated the success of women’s health interventions conducted in familiar settings. For example, in one study, rural women who reported high levels of social support at church had higher levels of vigorous physical activity compared to women with low levels of social support at church (Kegler, Swan, Alcantara, Wrensford, & Glanz, 2012). These researchers also found that church-based social support was also associated with walking and total metabolic equivalents (METs). In addition, in a study of a natural helper program conducted in worksites and targeting rural, blue collar women, intervention participants had significant increases in their fruit and vegetable consumption but no changes were observed in the comparison group (Campbell et al., 2002). Programs in familiar settings can enable women who are already acquainted to support, encourage, and motivate one another as they engage in health-related behaviors. The community barriers and facilitators to women’s health in the southern seven region, combined with the recognition of women’s roles and role strain, may also have important implications for the development of programs to promote health. Many barriers to achieving health identified in this research, including access to health care (Ahluwalia, Tessaro, Greenlund, & Ford, 2010), transportation barriers (Sarnquist et al., 2011), and dietary factors (Liese et al., 2007), are common among rural populations and may disproportionately affect low-income women. Programs and services are required that reach rural women and help them overcome barriers while considering the socioeconomic constraints they face. Examples include community-based screening

and health education opportunities for women and their families, offered at times and in locations that are convenient and accessible. Lack of awareness about health programs and health care services among women, as seen in this research, calls for a collaborative approach in which organizations and businesses that serve women work together to promote and improve access to existing health resources and services (Woolf, Dekker, Byrne, & Miller, 2011). Through the collaboration of coalition members, SSCWH engages local leaders, health professionals, and other stakeholders that have a vested interest in the health of their communities to improve women’s health and the health of the community overall. Based on the results of the CHA and GBA, SSCWH developed a strategic plan to improve women’s health in the region and address the health challenges women face. Activities recommended by SSCWH include physical activity groups such as walking clubs and exercise classes; worksite wellness programs; development of a resource guide that highlights available health and wellness opportunities; use of technologies such as websites, text messages, and social media to promote health; nutrition education programs and cooking classes; and community-based health screenings. An example of a program currently being implemented by SSCWH based on the CHA and GBA is known as the ‘‘Faith-Based Collaborative.’’ The program offers a 12-week lifestyle behavior change intervention, offered in partnership with area churches, to reduce CVD risk in women. The intervention uses an evidencebased curriculum (Khare et al., 2014) that was modified based on the GBA findings to help participants understand and overcome the gender-specific constraints that women in the region face. At the end of the intervention, participants as well as other church members and community membersmen and womenhave an opportunity to participate in monthly health promotion activities to receive ongoing education and social support. The monthly activities are community based and community driven, designed to meet the needs of each community served. By inviting the broader community to participate in monthly activities, partners, family members, and other individuals in women’s social networks can support women in their efforts to change their lifestyles. In addition, the message of healthy lifestyle behaviors can be disseminated to a wide audience. Throughout their participation in the program, churches are provided with resources to provide services such as childcare or transportation to increase women’s participation in the program. This initiative addresses several of the themes and challenges discussed above. The study described in this paper was limited in several ways. Coalition members identified key stakeholders based on their own professional knowledge or relationships. Researchers only interviewed those individuals who agreed to participate during followup phone calls. Hence, participants were likely to have a unique interest in women’s health and, therefore, may not represent the views of the region overall. In addition, while focus groups attempted to reach a broad representation of women in the population, due to limited resources, it was not possible to conduct focus groups that covered all ages in every county. Further, we were unable to make generalizations by race in this study. Although we successfully recruited a diverse sample of focus group participants by race, focus groups recruitment did not specify race. We also did not ask key stakeholders about race-specific health issues. However, because interview and focus group responses were repeated across groups, the researchers are confident that the views expressed are valid. Finally, research biases are often unavoidable when conducting qualitative research. To mitigate these biases, multiple researchers participated in each stage of the research process.


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Despite these limitations, we believe this is one of the first GBAs to be conducted in the US to specifically address the health needs of rural women. We plan to further explore these issues and work with the community to develop and evaluate programs and policies to address the health needs of women in southern Illinois. Future research plans also include further analysis of the focus groups collected for this study to compare and contrast county and age-specific perspectives. 5. Conclusions and lessons learned Incorporating a gender-based analysis into a CHA is a way to understand gender-specific factors that affect health in a community and how such factors can be addressed. We used a gender-based analysis framework to identify social and cultural factors that affect the health of women and communities in the southern seven region of Illinois. Using the lessons learned in the GBA, SSCWH can develop effective community-based strategies and interventions to support women in making positive health changes within the context of their daily lives. By focusing on women, SSCWH health promotion efforts aim to improve women’s health and, by extension, the health of their families and communities. This gender-based framework used for this research provides a template for other rural communities to assess their needs and develop tailored interventions to reduce disparities related to chronic diseases in women. Acknowledgements We wish to thank the members of Southern Seven Coalition for Women’s Health for their contributions to the community health assessment and strategic planning process and for their ongoing commitment to improving women’s health. This publication was made possible by grant number 1CCEWH101009-01-00 and 1CCEWH111024-01-00 from the Office on Women’s Health (OWH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the OWH, the Office of the Assistant Secretary for Health, or the Department of Health and Human Services. References Ahluwalia, I. B., Tessaro, I., Greenlund, K. J., & Ford, E. S. (2010). Factors associated with control of hypertension, hypercholesterolemia, and diabetes among low-income women in West Virginia. Journal of Women’s Health, 19(3), 417–424. Ainsworth, B. E., Wilcox, S., Thompson, W. W., Richter, D. L., & Henderson, K. A. (2003). Personal, social and physical environmental correlates of physical activity in African-American women in South Carolina. American Journal of Preventive Medicine, 25(3 (suppl. 1)), 23–29. Bennett, K. J., Olatosi, B., & Probst, J. C. (2008). Health disparities: A rural-urban chartbook. Columbia, SC: Rural Health Research and Policy Centers, South Carolina Rural Health Research Center Retrieved July 25, 2012, from hhttp://rhr.sph.sc.edu/report/ %287-3%29%20Health%20Disparities%20A%20Rural%20Urban%20Chartbook%20%20Distribution%20Copy.pdfi. Boeckner, L. S., Pullen, C. H., Walker, S. N., Oberdorfer, M. K., & Hageman, P. A. (2007). Eating behaviors and health history of rural midlife to older women in the midwestern united states. Journal of the American Dietetic Association, 107(2), 306–310. Buzza, C., Ono, S. S., Turvey, C., Wittrock, S., & Noble, M. (2011). Distance is relative: Unpacking a principal barrier in rural healthcare. Journal of General Internal Medicine, 26(Suppl. 2), 648–654. Campbell, M. K., Tessaro, I., DeVellis, B., Benedict, S., Kelsey, K., Belton, L., et al. (2002). Effects of a tailored health promotion program for female blue-collar workers: Health works for women. Preventive Medicine, 34(3), 313–323. Casey, M. M., Thiede Call, K., & Klingner, J. M. (2001). Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine, 21(3), 182–188. Coughlin, S. S., Leadbetter, S., Richards, T., & Sabatino, S. A. (2008). Contextual analysis of breast and cervical cancer screening factors associated with health care access among United States women, 2002. Social Science and Medicine, 66(2), 260–275. Erdwins, C. J., Buffardi, L. C., Casper, W. J., & O’Brien, A. S. (2001). The relationship of women’s role strain to social support, role satisfaction, and self-efficacy. Family Relations, 50(3), 230–238.

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Eyler, A. A., & Vest, J. R. (2002). Environmental and policy factors related to physical activity in rural white women. Women & Health, 36(2), 111–121. Flynn, B. S., Gavin, P., Worden, J. K., Ashikaga, T., Gautam, S., et al. (1997). Community education programs to promote mammography participation in rural New York State. Preventive Medicine, 26(1), 102–108. Friedman, D. J., & Parrish, R. G. (2009). Is community health assessment worthwhile? Journal of Public Health Management and Practice, 15(1), 3–9. Gamm, L., Hutchison, L., Dabney, B., & Dorsey, A. (2003). Rural healthy people 2010: A companion document to Healthy People 2010 (vol I–III). College Station, TX: Texas A&M University Retrieved July 25, 2012, from hhttp://www.srph.tamhsc.edu/centers/rhp2010/publications.htmi. Goode, W. J. (1960). A theory of role strain. American Sociological Review, 25(4), 483– 496. Greaves, L. J., & Hemsing, N. J. (2009). Sex, gender, and secondhand smoke policies: Implications for disadvantaged women. American Journal of Preventive Medicine, 37(2), S131–S137. Hamner, J., & Wilder, B. (2008). Knowledge and risk of cardiovascular disease in rural Alabama women. Journal of the American Academy of Nurse Practitioners, 20(6), 333–338. Illinois Department of Public Health (2006). IPLAN: Illinois project for local assessment of needs. Springfield, IL: Illinois Department of Public Health Retrieved July 15, 2011, from: hhttp://app.idph.state.il.us/i. Illinois Department of Public Health (2010). Illinois behavioral risk factor surveillance system. Springfield, IL: Illinois Department of Public Health Retrieved July 15, 2011, from hhttp://www.idph.state.il.us/health/statshome.htmi. Kegler, M. C., Swan, D. W., Alcantara, I., Wrensford, L., & Glanz, K. (2012). Environmental influences on physical activity in rural adults: The relative contributions of home, church and work settings. Journal of Physical Activity & Health, 9(7), 996–1003. Khare, M. M., Koch, A., Zimmermann, K., Huber, R., Moehring, P. A., Wright, C., et al. (2014). Heart smart for women: A lifestyle change intervention to reduce cardiovascular risk in rural women. Journal of Rural Health, 30(4), 359–368. Komar-Samardzija, M., Braun, L. T., Keithley, J. K., & Quinn, L. T. (2012). Factors associated with physical activity levels in African–American women with type 2 diabetes. Journal of the American Academy of Nurse Practitioners, 24(4), 209–217. Krummel, D. A., Koffman, D. M., Bronner, Y., Davis, J., Greenlund, K., et al. (2001). Cardiovascular health interventions in women: What works? Journal of Women’s Health and Gender Based Medicine, 10(2), 117–136. Liese, A. D., Weis, K. E., Pluto, D., Smith, E., & Lawson, A. (2007). Food store types, availability, and cost of foods in a rural environment. Journal of the American Dietetic Association, 107(11), 1916–1923. Liverpool School of Tropical Medicine (1999). Guidelines for the analysis of gender and health. Liverpool School of Tropical Medicine Retrieved July 25, 2012 from hhttp:// www.lstmliverpool.ac.uk/research/academic-groups/international-health/gender-and-health-group/guidelinesi. Merwin, E., Snyder, A., & Katz, E. (2006). Differential access to quality rural healthcare: Professional and policy challenges. Family and Community Health, 29(3), 186–194. Messia, D. K. H., DeJong, M. K., & McLoughlin, K. (2005). Expanding the concept of women’s work: Volunteer work in the context of poverty. Journal of Poverty, 9(3), 25–47. Nies, M. A., & Motyka, C. L. (2006). Factors contributing to women’s ability to maintain a walking program. Journal of Holistic Nursing, 24(1), 7–14. Nowatzki, N., & Grant, K. R. (2011). Sex is not enough: The need for gender-based analysis in health research. Health Care for Women International, 32(2), 263–277. Patterson, P. D., Moore, C. G., Probst, J. C., & Shinogle, J. A. (2004). Obesity and Physical Inactivity in Rural America. The Journal of Rural Health, 20(2), 151–159. Patton, M. Q. (2002). Qualitative analysis and interpretation. In Qualitative research & evaluation methods (3rd ed., pp. 431–534). Thousand Oaks, CA: Sage Publications. Perry, C. K., Rosenfeld, A. G., & Kendall, J. (2008). Rural women walking for health. Western Journal of Nursing Research, 30(3), 295–316. Roettger, M. E., & Boardman, J. D. (2012). Parental incarceration and gender-based risks for increased body mass index: Evidence from the National Longitudinal Study of Adolescent Health in the United States. American Journal of Epidemiology, 175(7), 636–644. Sarnquist, C. C., Soni, S., Hwang, H., Topol, B. B., Mutima, S., & Maldonado, Y. A. (2011). Rural HIV-infected women’s access to medical care: Ongoing needs in California AIDS care. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 23(7), 792–796. US Census Bureau (2010). American factfinder web site. Retrieved Nov 14, 2011, from: hhttp://factfinder2.census.govi. Van Tuyckom, C., Van de Velde, S., & Bracke, P. (2012). Does country-context matter? A cross-national analysis of gender and leisure time physical inactivity in Europe. European Journal of Public Health. http://dx.doi.org/10.1093/eurpub/cks009 (first published online March 1, 2012). Vander Weg, M. W., Cunningham, C. L., Howren, M. B., & Cai, X. (2011). Tobacco use and exposure in rural areas: Findings from the behavioral risk factor surveillance system. Addictive Behaviors, 36(3), 231–236. Woolf, S. H., Dekker, M. M., Byrne, F. R., & Miller, W. D. (2011). Citizen-centered health promotion: building collaborations to facilitate healthy living. American Journal of Preventive Medicine, 40(1 (suppl. 1)), S38–S47. World Health Organization (2002). Director-General’s Executive Statement on WHO Gender policy: Integrating Gender Perspectives into the Work of WHO. World Health Organization (pp. 6). Retrieved July 19, 2012 from hhttp://whqlibdoc.who.int/hq/ 2002/a78322.pdfi. Kristine Zimmermann, MPH, is an Assistant Director at the University of Illinois at Chicago Center for Research on Women and Gender. She has over ten years of


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experience in community health education, implementation of behavioral interventions for disease risk reduction, and coordination of collaborative projects. She has a Master of Public Health Degree from the University of Illinois at Chicago.

Manorama Khare, PhD, is a Research Assistant Professor at UIC College of Medicine at Rockford. She is a public health researcher with extensive experience planning, implementing and evaluating programs related to women’s health and diversity in higher education. Her technical expertise includes program evaluation, planning and implementation of community-based programs, quantitative and qualitative research methods, quasi-experimental research designs, survey development, and multivariate data analysis.

Cherie Wright, BS, is a Community Health and Wellness Coordinator at the Southern Seven Health Department in Ullin, Illinois. She has over eight years of experience facilitating health education programs in collaboration with schools, churches, and communities. She has expertise in cardiovascular disease prevention, healthy cooking and eating, physical activity, and teen pregnancy.

Allison C. Hasler, MPH, is a Regional Health Officer for the Illinois Department of Public Health. She has five years of experience facilitating health education programs in collaboration with schools, churches, and communities, and has worked in public health education for the past seven years. Allison has her Bachelor’s Degree in Health

Education and her Master of Public Health Degree, both from Southern Illinois University in Carbondale. Sarah Kerch, MPH, is a former Graduate Research Assistant at the University of Illinois at Chicago Center for Research on Women and Gender. She has five years of public health experience, including the development and evaluation of strategies to address maternal and child health disparities, as well as the growing impact of chronic disease. She has a Master of Public Health Degree from the University of Illinois at Chicago. Patricia A. Moehring, BS, is the Community Health Education Director at Southern Seven Health Department, a local health department that serves the rural seven southernmost counties of Illinois. Ms. Moehring has nearly 30 years of public health experience working with communities, agencies, and schools in multiple areas of prevention including teen pregnancy, tobacco use and secondhand smoke, cancer, and chronic diseases. She also has experience in management of public health programs and clinical services. Stacie Geller, PhD, is the G. William Arends Professor of Obstetrics and Gynecology, and Director of the Center for Research on Women and Gender and the National Center of Excellence in Women’s Health at the University of Illinois at Chicago. Dr. Geller is a health services researcher with expertise in women’s health issues, including maternal mortality and morbidity; community-based research; complementary and alternative medicine; and women’s leadership and mentoring.


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