Gender-aware Parkinson's care: a design-based study of patient perspectives on gender norms and gender-sensitive care

Background

Gender dimensions are progressively recognised as a relevant social determinant of health in people with Parkinson's disease (PD). However, little is known about the impact of gender norms and stereotypes on illness experiences of men and women with PD and what they consider important focal points for gender-sensitive PD care.

Methods

We conducted two equity-centred design (ECD) sessions on December 7, 2022 and December 8, 2022, at the Radboud University Medical Centre in the Netherlands. This participatory multi-method approach includes patients in the research and design process and was used to explore the impact of gender norms and stereotypes in illness experiences and generate patient-driven recommendations for gender-aware Parkinson's care. Quantitative survey data and design-based data were descriptively analysed, and qualitative focus group discussions were thematically analysed.

Findings

This study included thirteen men and fifteen women with PD in the Netherlands. All participants were of Dutch descent, with a median age of 65.5 years and a median clinical disease duration of 4.2 years. The gendered stereotype that "people with PD are old men" affected both men's and women's perception of living with the disease and the perceptions of their social environment. Men described masculine stereotypes related to physical strength and provider roles, while women expressed those related to feminine physical appearance and caregiver roles, influencing their illness experiences. For some, these norms influenced personal behaviours, while for others, they affected experiences through societal attitudes.

Interpretation

Our findings suggested that several gender norms and stereotypes influence the illness experiences of men and women with PD, manifesting at ideological, interpersonal, and internalised levels. Some participants internalised these norms, affecting their coping behaviours, while others encountered them in broader ideological contexts that shaped societal attitudes and interpersonal relationships. To advance gender sensitive PD care, it's essential to explore the impact of gender roles and norms, especially regarding how they might impede coping strategies, care access and utilisation for individuals of diverse gender identities.

Funding

The Gatsby Foundation and co-funded by the PPP Allowance by Health∼Holland. Travel reimbursements for participants were made available through a Parkinson's Foundation grant (PF-FBS-2026).

Key Factors in Helpfulness and Use of the SAFE Intervention for Women Experiencing Intimate Partner Violence and Abuse: Qualitative Outcomes From a Randomized Controlled Trial and Process Evaluation

BACKGROUND

Many women experience at least one type of intimate partner violence and abuse (IPVA), and although various support options are available, we still know relatively little about web-based interventions for IPVA survivors. We conducted a qualitative evaluation of the SAFE eHealth intervention for women experiencing IPVA in the Netherlands, complementing the quantitative evaluation of self-efficacy, depression, anxiety, and multiple feasibility aspects.

OBJECTIVE

This study assessed users' experiences and what, according to them, were useful and helpful aspects of the intervention.

METHODS

The intervention consisted of modules with information on relationships and IPVA, help options, physical and mental health, and social support. It also contained interactive elements such as exercises, stories from survivors, a chat, and a forum. A randomized controlled trial was conducted with an intervention arm receiving the complete version of the intervention and a control arm receiving only a static version with the modules on relationships and IPVA and help options. We gathered data through open questions from surveys (for both study arms; n=65) and semistructured interviews (for the intervention study arm; n=10), all conducted on the web, during the randomized controlled trial and process evaluation. Interview data were coded following the principles of open thematic coding, and all qualitative data were analyzed using qualitative content analysis.

RESULTS

Overall, most users positively rated the intervention regarding safety, content, and suiting their needs, especially participants from the intervention study arm. The intervention was helpful in the domains of acknowledgment, awareness, and support. However, participants also identified points for improvement: the availability of a simplified version for acute situations; more attention for survivors in the aftermath of ending an abusive relationship; and more information on certain topics, such as technological IPVA, support for children, and legal affairs. Furthermore, although participants expressed a prominent need for interactive contact options such as a chat or forum, the intervention study arm (the only group that had these features at their disposal) mainly used them in a passive way-reading instead of actively joining the conversation. The participants provided various reasons for this passive use.

CONCLUSIONS

The positive outcomes of this study are similar to those of other web-based interventions for IPVA survivors, and specific points for improvement were identified. The availability of interactive elements seems to be of added value even when they are used passively. This study provides in-depth insight into the experiences of female IPVA survivors with the SAFE eHealth intervention and makes suggestions for improvements to SAFE and comparable web-based interventions for IPVA as well as inspiring future research. Furthermore, this study shows the importance of a varied assessment of an intervention's effectiveness to understand the real-world impact on its users.

TRIAL REGISTRATION

Netherlands Trial Register NTR7313; https://tinyurl.com/3t7vwswz.

Digital self-help for people experiencing intimate partner violence: a qualitative study on user experiences and needs including people with lived experiences and services providers

BACKGROUND

Intimate partner violence (IPV) is a prevalent public health issue associated with multiple physical and mental health consequences for survivors. Digital interventions can provide low-threshold support to those experiencing IPV, but existing digital interventions have limited efficacy in improving the safety and mental health of IPV survivors. Digitally adapting an integrative intervention with advocacy-based and psychological content holds promise for increasing the efficacy of digital interventions in the context of IPV.

METHODS

This study examines the needs, acceptability and usability of an integrative digital intervention for people affected by IPV. We used the think-aloud method and semi-structured interviews with a sample of six people with lived experiences of IPV and six service providers. We analyzed the data using thematic analysis.

RESULTS

We identified the increasing general acceptance of digital support tools and the limited capacity of the current support system as societal context factors influencing the acceptance of and needs regarding digital interventions in the context of IPV. An integrative digital self-help intervention offers several opportunities to complement the current support system and to meet the needs of people affected by IPV, including the reduction of social isolation, a space for self-reflection and coping strategies to alleviate the situation. However, potentially ongoing violence, varying stages of awareness and psychological capacities, and as well as the diversity of IPV survivors make it challenging to develop a digital intervention suitable for the target group. We received feedback on the content of the intervention and identified design features required for intervention usability.

CONCLUSION

An integrative digital self-help approach, with appropriate security measures and trauma-informed design, has the potential to provide well-accepted, comprehensive and continuous psychosocial support to people experiencing IPV. A multi-modular intervention that covers different topics and can be personalized to individual user needs could address the diversity of the target population. Providing guidance for the digital intervention is critical to spontaneously address individual needs. Further research is needed to evaluate the efficacy of an integrative digital self-help intervention and to explore its feasibility it in different settings and populations.

Traumatic Life Events and Association With Depression, Anxiety, and Somatization Symptoms in Female Refugees

Importance

Different types of traumatic life events have varying impacts on symptoms of depression, anxiety, and somatization. For women from areas of the world experiencing war and humanitarian crises, who have experienced cumulative trauma exposure during war and forced migration, it is not known whether cumulative trauma or particular events have the greatest impact on symptoms.

Objective

To examine which traumatic life events are associated with depression, anxiety, and somatization symptoms, compared with the cumulative amount, in a sample of female refugees.

Design, Setting, and Participants

For this cross-sectional study, data were collected in 2016 as a part of The Study on Female Refugees. The current analysis was conducted in 2022 to 2023. This multicenter study covered 5 provinces in Germany. Participants were recruited at reception centers for refugees. Women volunteered to participate and to be interviewed after information seminars at the different centers.

Exposure

Traumatic life events experienced by refugees from areas of the world experiencing war and humanitarian crises.

Main Outcomes and Measures

Demographic variables (age, country of origin, religion, education, relationship status, and children), traumatic and adverse life events, and self-reported depression, anxiety, and somatization symptoms were measured. Random forest regressions simultaneously examined the importance of these variables on symptom scores. Follow-up exploratory mediation models tested potential associative pathways between the identified variables of importance.

Results

For the final sample of 620 refugee women (mean [SD] age, 32.34 [10.35] years), family violence was most associated with depression (mean [SD] variable of importance [VIM], 2.93 [0.09]), anxiety (mean [SD] VIM, 4.15 [0.11]), and somatization (mean [SD] VIM, 3.99 [0.15]), even though it was less common than other traumatic experiences, including war, accidents, hunger, or lack of housing. Other factors, such as childhood sexual abuse, injury, near-death experiences, and lack of access to health care, were also important. Follow-up analyses showed partial mediation effects between these factors in their association with symptoms, supporting the unique importance of family violence in understanding mental health.

Conclusions and Relevance

The findings of this cross-sectional study of refugee women who experienced multiple severe traumas related to war in their home countries and danger encountered during their migration suggest that family violence was key to their current mental health problems. Culturally sensitive assessment and treatment need to place special emphasis on these family dynamics.

Sex differences in treatment allocation and survival of potentially curable gastroesophageal cancer: A population-based study

BACKGROUND

Although curative treatment options are identical for male and female gastroesophageal cancer patients, access to care and survival may vary. This study aimed to compare treatment allocation and survival between male and female patients with potentially curable gastroesophageal cancer.

METHODS

Nationwide cohort study including all patients with potentially curable gastroesophageal squamous cell or adenocarcinoma diagnosed between 2006 and 2018 registered in the Netherlands Cancer Registry. The main outcome, treatment allocation, was compared between male and female patients with oesophageal adenocarcinoma (EAC), oesophageal squamous cell carcinoma (ESCC), and gastric adenocarcinoma (GAC). Additionally, 5-year relative survival with relative excess risk (RER), that is, adjusted for the normal life expectancy, was compared.

RESULTS

Among 27,496 patients (68.8% men), most were allocated to curative treatment (62.8%), although rates dropped to 45.6%>70 years. Curative treatment rates were comparable among younger male and female patients (≤70 years) with gastroesophageal adenocarcinoma, while older females with EAC were less frequently allocated to curative treatment than males (OR = 0.85, 95% confidence interval [CI] 0.73-0.99). For those allocated to curative treatment, relative survival was superior for female patients with EAC (RER = 0.88, 95% CI 0.80-0.96) and ESCC (RER = 0.82, 95% CI 0.75-0.91), and comparable for males and females with GAC (RER = 1.02, 95% CI 0.94-1.11).

CONCLUSIONS

While curative treatment rates were comparable between younger male and female patients with gastroesophageal adenocarcinoma, treatment disparities were present between older patients. When treated, the survival of females with EAC and ESCC was superior to males. The treatment and survival gaps between male and female patients with gastroesophageal cancer warrant further exploration and could potentially improve treatment strategies and survival.

Effectiveness of the SAFE eHealth Intervention for Women Experiencing Intimate Partner Violence and Abuse: Randomized Controlled Trial, Quantitative Process Evaluation, and Open Feasibility Study

BACKGROUND

Intimate partner violence and abuse (IPVA) is a pervasive societal issue that impacts many women globally. Web-based help options are becoming increasingly available and have the ability to eliminate certain barriers in help seeking for IPVA, especially in improving accessibility.

OBJECTIVE

This study focused on the quantitative evaluation of the SAFE eHealth intervention for women IPVA survivors.

METHODS

A total of 198 women who experienced IPVA participated in a randomized controlled trial and quantitative process evaluation. Participants were largely recruited on the internet and signed up through self-referral. They were allocated (blinded for the participants) to (1) the intervention group (N=99) with access to a complete version of a help website containing 4 modules on IPVA, support options, mental health, and social support, and with interactive components such as a chat, or (2) the limited-intervention control group (N=99). Data were gathered about self-efficacy, depression, anxiety, and multiple feasibility aspects. The primary outcome was self-efficacy at 6 months. The process evaluation focused on themes, such as ease of use and feeling helped. In an open feasibility study (OFS; N=170), we assessed demand, implementation, and practicality. All data for this study were collected through web-based self-report questionnaires and automatically registered web-based data such as page visits and amount of logins.

RESULTS

We found no significant difference over time between groups for self-efficacy, depression, anxiety, fear of partner, awareness, and perceived support. However, both study arms showed significantly decreased scores for anxiety and fear of partner. Most participants in both groups were satisfied, but the intervention group showed significantly higher scores for suitability and feeling helped. However, we encountered high attrition for the follow-up surveys. Furthermore, the intervention was positively evaluated on multiple feasibility aspects. The average amount of logins did not significantly differ between the study arms, but participants in the intervention arm did spend significantly more time on the website. An increase in registrations during the OFS (N=170) was identified: the mean amount of registrations per month was 13.2 during the randomized controlled trial and 56.7 during the OFS.

CONCLUSIONS

Our findings did not show a significant difference in outcomes between the extensive SAFE intervention and the limited-intervention control group. It is, however, difficult to quantify the real contribution of the interactive components, as the control group also had access to a limited version of the intervention for ethical reasons. Both groups were satisfied with the intervention they received, with the intervention study arm significantly more so than the control study arm. Integrated and multilayered approaches are needed to aptly quantify the impact of web-based IPVA interventions for survivors.

TRIAL REGISTRATION

Netherlands Trial Register NL7108 NTR7313; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7313.

Consideration of sex and gender in European clinical practice guidelines in internal medicine: a systematic review protocol

INTRODUCTION

Clinical practice guidelines (CPGs) are a powerful instrument to ensure evidence-based practice in clinical diagnostics and disease management. As knowledge about the impact of sex and gender on health and disease is emerging, the need for its transfer into clinical practice is becoming more urgent. However, a systematic evaluation of the incorporation of sex-related and gender-related knowledge into CPGs in Europe is currently not available. This systematic review will fill this gap. We will analyse the operationalisation of sex and gender in internal medicine CPGs in Europe and the translation of this information into tailored recommendations. The results will offer a baseline assessment to inform prospective sex-sensitive and gender-sensitive guideline development.

METHODS AND ANALYSIS

CPGs published by European internal medicine guidelines will be analysed according to a pre-established analysis framework. CPGs will be identified by a two-step approach, that is, through direct contact with the organisations and by a PubMed search, to ensure capture of all relevant guidelines. Prespecified keywords will be employed to identify the representation of sex-related and gender-related content throughout the CPGs. Structured data will be collected through machine-assisted text mining. Identified texts will then be manually reviewed by two independent coders using a specifically developed checklist.

ETHICS AND DISSEMINATION

This study does not require approval by an ethics board. It will provide an overview of sex and gender considerations in European CPGs in the field of internal medicine regarding the time frame 2012-2022.

P32: a sex- and gender-sensitive model for evidence-based precision medicine: from knowledge generation to implementation in the field of kidney transplantation

Precision medicine emerged as a promising approach to identify suitable interventions for individual patients with a particular health concern and at various time points. Technology can enable the acquisition of increasing volumes of clinical and "omics" data at the individual and population levels and support advanced clinical decision making. However, to keep pace with evolving societal realities and developments, it is important to systematically include sex- and gender-specific considerations in the research process, from the acquisition of knowledge to implementation. Building on the foundations of evidence-based medicine and existing precision medicine frameworks, we propose a novel evidence-based precision medicine framework in the form of the P3²model, which considers individual sex-related (predictive [P1], preventive [P2], and personalized [P3] medicine) and gender-related (participatory [P4], psychosocial [P5], and percipient [P6] medicine) domains and their intersection with ethnicity, geography, and other demographic and social variables, in addition to population, community, and public dimensions (population-informed [P7], partnered with community [P8], and public-engaging [P9] medicine, respectively). Through its ability to contextualize and reflect on societal realities and developments, our model is expected to promote consideration of diversity, equity, and inclusion principles and, thus, enrich science, increase reproducibility of research, and ensure its social impact.

The salience of gender in the illness experiences and care preferences of people with Parkinson's disease

RATIONALE

In recent years, interest in sex characteristics and gender dimensions of Parkinson's disease (PD) has increased. Yet, much remains to be understood about how gender-related aspects specifically impact the illness and experiences of care in persons living with PD.

OBJECTIVE

The purpose of this study was to explore the salience of gender-related aspects in the illness experiences and care provision preferences of people with PD.

METHODS

A descriptive qualitative study including semi-structured life story interviews was conducted with men and women living with PD in the Netherlands. Between September 2020 and February 2021, forty people with PD (20 men and 20 women) participated in digital interviews of which thirty-one (18 men and 13 women) were included in the thematic analyses for this specific study.

RESULTS

Overall, most participants did not consider gender-related aspects salient towards their illness experiences. However, when prompted, a number of participants described several stereotypical views about gender as related to the visibility of PD, emotional experiences, help seeking, role patterns and physical appearance. While most men and women with PD did not express specific gender-related preferences for their healthcare providers, those that did, all preferred women as healthcare providers. These preferences were generally related to attributed feminine traits which are considered relevant in routine, particularly sensitive, physical examinations of people with PD.

CONCLUSION

This study demonstrates that although every person has a gender identity, the salience attributed to gender varies with illness experiences and in care provision preferences between people with PD. These findings highlight the need for precise and personalized methodologies to capture more nuanced insights into the impact of gender dimensions on PD. Furthermore, drivers behind gender-related preferences in care provision are multifactorial and warrant further investigation among people with PD.

The Impact of Sex and Gender in Medicine and Pharmacology

Sex and gender play a pivotal role in health and disease. Differences can be identified in symptoms, biomarkers, lifetime experiences of diseases, incidence, prevalence, therapeutic options, health-related behavior, and resiliency. However, awareness of sex and gender differences in medicine is still limited. Systematic implementation of sex and gender-sensitive research is not yet the norm, resulting in gaps in evidence especially in the diagnosis and treatment of diseases in women. For decades research has predominantly included male persons and animals, leading to a lack of information about symptoms in female individuals or the classification of their symptoms as "atypical". Currently, the inclusion of female participants in clinical marketing access trials is mandatory. However, this does not automatically translate into sex-disaggregated analyses potentially limiting the discovery of sex-specific targeted therapeutic schemes. Consistent consideration of sex and gender in planning, conducting, analyzing, and dissemination of pharmacological research projects is an important prerequisite for closing the gender data gap. Targeted implementation strategies might help to include sex and gender aspects in different parts of the health system and thereby support the improvement of health care for all patients. Health economic aspects could be a further drive for the implementation of sex- and gender-sensitive medicine.The current chapter focuses on the role of sex and gender in biomedical research and, consequently, their potential role in pharmacology. We will explore the commonly used terminology in the field, the historical development of sex and gender-sensitive medicine (SGSM), the relevance of sex and gender to research and clinical practice and conclude with an outlook on future developments in the field.

Operationalization and Reporting Practices in Manuscripts Addressing Gender Differences in Biomedical Research: A Cross-Sectional Bibliographical Study

Historically, authors in the biomedical field have often conflated the terms sex and gender in their research significantly limiting the reproducibility of the reported results. In the present study, we investigated current reporting practices around gender in biomedical publications that claim the identification of "gender differences". Our systematic research identified 1117 articles for the year 2019. After random selection of 400 publications and application of inclusion criteria, 302 articles were included for analysis. Using a systematic evaluation grid, we assessed the provided methodological detail in the operationalization of gender and the provision of gender-related information throughout the manuscript. Of the 302 articles, 69 (23%) solely addressed biological sex. The remaining articles investigated gender, yet only 15 (6.5%) offered reproducible information about the operationalization of the gender dimension studied. Followingly, these manuscripts also provided more detailed gender-specific background, analyses and discussions compared to the ones not detailing the operationalization of gender. Overall, our study demonstrated persistent inadequacies in the conceptual understanding and methodological operationalization of gender in the biomedical field. Methodological rigor correlated with more nuanced and informative reporting, highlighting the need for appropriate training to increase output quality and reproducibility in the field.

Discrimination and sexual harassment – Results from the largest German medical university

Background

Discrimination and sexual harassment in the workplace and in higher education institutions are important public health issues. Here we aim at analyzing the prevalence of discrimination and sexual harassment of lecturers and students at one of the largest teaching hospitals in Europe. We assess whether there are differences between lecturers and students, women and men, and different study programs.

Methods

An online questionnaire was sent to N = 7095 students of all study programs and N = 2528 lecturers at Charité - Universitätsmedizin Berlin. The survey was conducted from November 2018 to February 2019. We investigated experienced or observed discrimination or sexual harassment at the medical faculty. Furthermore, we analyzed frequency, perpetrators, situational factors, attributed reasons and forms of harassment encountered.

Results

A total of 964 (14%) students (S) and 275 (11%) of lecturers (L) participated in the survey. Discriminatory behavior was witnessed and/or experienced by 49,6% of students (L: 31%), sexual harassment by 23,6% of students (L: 19,2%). Students state lecturers (85,9%) as main source of discriminatory behavior (L: directors/supervisors: 47,4%; students 41,0%). Sex/Gender (S: 71%; L: 60,3%) is cited most frequently as reason for discriminatory experiences. Female students and faculty experience more discrimination and sexual harassment.

Conclusions

Discrimination and sexual harassment are prevalent in academic medicine. There are differences in the reasons and sources of discrimination and sexual harassment between students and lecturers. Specific programs for lecturers and students are necessary to educate the faculty on how to prevent and respond to it and whom to address.

Key messages

• National preventive strategies should be implemented to tackle issues of discrimination and harassment in higher education institutions.

• Special attention should be paid to female students and lecturers.

"If I'd Had Something Like SAFE at the Time, Maybe I Would've Left Him Sooner."-Essential Features of eHealth Interventions for Women Exposed to Intimate Partner Violence: A Qualitative Study

Approximately one in three women worldwide experiences intimate partner violence and abuse (IPVA) in her lifetime. Despite its frequent occurrence and severe consequences, women often refrain from seeking help. eHealth has the potential to remove some of the barriers women face in help seeking and disclosing. To guarantee the client-centeredness of an (online) intervention it is important to involve the target group and people with expertise in the development process. Therefore, we conducted an interview study with survivors and professionals, in order to assess needs, obstacles, and wishes with regard to an eHealth intervention for women experiencing IPVA. Semi-structured interviews were conducted with 16 women (8 survivors and 8 professionals) between 22 and 52 years old, with varied experiences of IPVA and help. Qualitative data was analyzed using a grounded theory approach and open thematic coding. During analysis we identified a third stakeholder group within the study population: survivor-professionals, with both personal experiences of and professional knowledge on IPVA. All stakeholder groups largely agree on the priorities for an eHealth intervention: safety, acknowledgment, contact with fellow survivors, and help. Nevertheless, the groups offer different perspectives, with the survivor-professionals functioning as a bridge group between the survivors and professionals. The groups prioritize different topics. For example, survivors and survivor-professionals highlighted the essential need for safety, while professionals underlined the importance of acknowledgment. Survivor-professionals were the only ones to emphasize the importance of addressing various life domains. The experiences of professionals and survivors highlight a broad range of needs and potential obstacles for eHealth interventions. Consideration of these findings could improve the client-centeredness of existing and future (online) interventions for women experiencing IPVA.

Transient Global Amnesia (TGA): Sex-Specific Differences in Blood Pressure and Cerebral Microangiopathy in Patients with TGA

Transient global amnesia (TGA) is defined by an acute memory disturbance of unclear aetiology for a period of less than 24 h. Observed psychological, neuroanatomical and hormonal differences between the sexes in episodic memory suggest sex-specific differences in memory disorders such as TGA. The aim of this study was to determine sex-specific differences in cardiovascular risk profiles, recurrences and magnetic resonance imaging (MRI). In total, 372 hospitalised TGA patients between 01/2011 and 10/2021 were retrospectively analysed. Comparisons were made between female and male TGA patients and compared to 216 patients with acute stroke. In our sample, women were overrepresented (61.8%), especially compared to the general population in the 65−74 age category (χ2 = 10.6, p < 0.02). On admission, female TGA patients had significantly higher systolic blood pressure values and a higher degree of cerebral microangiopathy compared to male TGA patients, whereas acute stroke patients did not. No sex-specific differences were observed with respect to recurrences or hippocampal DWI lesions. Our data demonstrate sex-specific differences in TGA. The higher blood pressure on admission and different degree of cerebral microangiopathy in female TGA patients supports the theory of blood pressure dysregulation as a disease trigger. Distinct precipitating events in female and male patients could lead to differences in the severity and duration of blood pressure abnormalities, possibly explaining the higher incidence in female patients.

Optimization of eHealth interventions for intimate partner violence and abuse: A qualitative study amongst Arabic-speaking migrant women

AIMS

This interview study focuses on the needs and wishes of Arabic-speaking migrant women in the Netherlands to culturally adapt and optimize the digital support platform SAFE (safewomen.nl) for intimate partner violence and abuse (IPVA) for their use.

DESIGN

This is a qualitative interview-based study.

METHODS

We conducted the study between March 2020 and 2021. The study entailed 16 semi-structured interviews with Arabic-speaking women in the Netherlands with a migration background.

RESULTS

Findings suggest that a cultural gap, a lack of knowledge of the Dutch law, and the prevalence of restrictive gender roles amongst the participants and their spouses affected their acknowledgement of the different forms of IPVA. Furthermore, mental health consequences of IPVA were also strongly stigmatized. Clear information in their native language, summarizing infographics and potential interactive features should be main components of any eHealth intervention for this target group.

CONCLUSION

The participants in our study deemed e-help a potentially valuable support option for women experiencing IPVA in their community. The impact of IPVA on mental health is currently overlooked within this target group and should be emphasized in future interventions.

IMPACT

Cultural sensitivity proved crucial in understanding the concepts of IPVA amongst women with migrant backgrounds. To ensure effective eHealth interventions for migrant women, they should be involved in the design and delivery of these interventions.

History and development of sex- and gender sensitive medicine (SGSM)

Sex- and gender-sensitive medicine has evolved from a feminist approach into an innovative cross-cutting approach to doing medicine. In the present chapter we define what sex and gender are in the context of biomedical research and describe the history of the development of this scientific approach. Looking back at crucial events in the U.S.A., Canada and Europe, we will outline how a structural framework has been established, ready to be filled with clinical and applied knowledge and to change the practice of medicine for decades to come.

Harassment as a consequence and cause of inequality in academia: A narrative review

A growing body of literature suggests that over the past 30 years, policies aimed at tackling harassment in academia have had little discernable effect. How can this impasse be overcome to make the higher education sector a safe space for everyone? We combine the areas of harassment and inequality, intersectionality, policy-practice gaps, gender sensitive medicine, as well as corruption and whistleblower processes to identify lacunae and offer recommendations for how to apply our recommendations in practice. We have been searching the most influential, relevant, and recent literature on harassment and inequality in our respective fields of expertise. By studying conceptual overlaps between the different fields, we were able to create insights that go beyond the insights of the most recent reviews. Our synthesis results in three concrete recommendations. First, harassment and inequality are mutually reinforcing. Failure to adequately tackle harassment contributes to perpetuating and reproducing inequality. Further, the intersectional nature of inequality has to be acknowledged and acted upon. Second, enforcing anti-harassment policies should be a top priority for universities, funders, and policymakers. Third, sexual harassment should be treated as institutional-level integrity failure. The higher education sector should now focus on enforcing existing anti-harassment policies by holding universities accountable for their effective implementation - or risk being complicit in maintaining and reproducing inequality.

FUNDING

We have received no funding for this research.

Prevention Strategies for Sexual Harassment in Academic Medicine: A Qualitative Study

Sexual harassment and gendered discrimination in the workplace are global issues that can affect anyone regardless of their age, gender, job title, or field of employment. The medical field is also relevantly concerned, yet effective prevention measures are scarce. The purpose of this study was to explore preventive options for sexual harassment in an academic medical context from the employees' perspective and to develop transferable strategies. We conducted semi-structured interviews with 15 female physicians and 15 female nurses working at a tertiary referral center in Berlin, Germany, in the months of April to November 2015. The one-on-one interviews addressed the perception of sexual harassment and available and desirable preventive measures. Data were analyzed by qualitative content analysis. The participants outlined preventive measures at two levels: individual and institutional. Individual options included personal safety measures and individual protection strategies against patients, peers, and superiors. Institutional strategies included guidelines and workplace policies, structured complaint and reporting procedures, formal training options, and organizational development and leadership strategies. The current study highlights how the prevention of sexual harassment hinges on a combination of individualized and system-wide measures to capture the personal as well as the organizational dimension of sexual harassment. Only a concerted effort addressing both aspects will sensitize the workforce, support the victims, and prevent sexual harassment in medical institutions.

The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices

Background

Human-centered design (HCD) approaches to health care strive to support the development of innovative, effective, and person-centered solutions for health care. Although their use is increasing, there is no integral overview describing the details of HCD methods in health innovations.

Objective

This review aims to explore the current practices of HCD approaches for the development of health innovations, with the aim of providing an overview of the applied methods for participatory and HCD processes and highlighting their shortcomings for further research.

Methods

A narrative review of health research was conducted based on systematic electronic searches in the PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, and Sociological Abstracts (2000-2020) databases using keywords related to human-centered design, design thinking (DT), and user-centered design (UCD). Abstracts and full-text articles were screened by 2 reviewers independently based on predefined inclusion criteria. Data extraction focused on the methodology used throughout the research process, the choice of methods in different phases of the innovation cycle, and the level of engagement of end users.

Results

This review summarizes the application of HCD practices across various areas of health innovation. All approaches prioritized the user’s needs and the participatory and iterative nature of the design process. The design processes comprised several design cycles during which multiple qualitative and quantitative methods were used in combination with specific design methods. HCD- and DT-based research primarily targeted understanding the research context and defining the problem, whereas UCD-based work focused mainly on the direct generation of solutions. Although UCD approaches involved end users primarily as testers and informants, HCD and DT approaches involved end users most often as design partners.

Conclusions

We have provided an overview of the currently applied methodologies and HCD guidelines to assist health care professionals and design researchers in their methodological choices. HCD-based techniques are challenging to evaluate using traditional biomedical research methods. Previously proposed reporting guidelines are a step forward but would require a level of detail that is incompatible with the current publishing landscape. Hence, further development is needed in this area. Special focus should be placed on the congruence between the chosen methods, design strategy, and achievable outcomes. Furthermore, power dimensions, agency, and intersectionality need to be considered in co-design sessions with multiple stakeholders, especially when including vulnerable groups.

Sex and Gender-Related Differences in COVID-19 Diagnoses and SARS-CoV-2 Testing Practices During the First Wave of the Pandemic: The Dutch Lifelines COVID-19 Cohort Study

Background: Although sex differences are described in Coronavirus Disease 2019 (COVID-19) diagnoses and testing, many studies neglect possible gender-related influences. Additionally, research is often performed in clinical populations, while most COVID-19 patients are not hospitalized. Therefore, we investigated associations between sex and gender-related variables, and COVID-19 diagnoses and testing practices in a large general population cohort during the first wave of the pandemic when testing capacity was limited. Methods: We used data from the Lifelines COVID-19 Cohort (N = 74,722; 60.8% female). We applied bivariate and multiple logistic regression analyses. The outcomes were a COVID-19 diagnosis (confirmed by SARS-CoV-2 PCR testing or physician's clinical diagnosis) and PCR testing. Independent variables included among others participants' sex, age, somatic comorbidities, occupation, and smoking status. Sex-by-comorbidity and sex-by-occupation interaction terms were included to investigate sex differences in associations between the presence of comorbidities or an occupation with COVID-19 diagnoses or testing practices. Results: In bivariate analyses female sex was significantly associated with COVID-19 diagnoses and testing, but significance did not persist in multiple logistic regression analyses. However, a gender-related variable, being a health care worker, was significantly associated with COVID-19 diagnoses (OR = 1.68; 95%CI = 1.30-2.17) and testing (OR = 12.5; 95%CI = 8.55-18.3). Female health care workers were less often diagnosed and tested than male health care workers (OR_interaction = 0.54; 95%CI = 0.32-0.92, OR_interaction = 0.53; 95%CI = 0.29-0.97, respectively). Conclusions: We found no sex differences in COVID-19 diagnoses and testing in the general population. Among health care workers, a male preponderance in COVID-19 diagnoses and testing was observed. This could be explained by more pronounced COVID-19 symptoms in males or by gender inequities.

Sex-differences in symptoms and functioning in >5000 cancer survivors: Results from the PROFILES registry

BACKGROUND

Previous reports highlight the greater number of side effects that women experience during cancer treatment, but little is known about sex differences in symptoms and functioning in long-term survivors.

METHODS

We investigated sex differences in the prevalence of physical (EORTC QLQ-C30) and emotional symptoms (Hospital Anxiety and Depression Scale) and loss of functioning (EORTC QLQ-C30) in 5339 cancer survivors (55% males). General linear models were computed to assess the differences in symptoms and functioning between female and male cancer survivors and between survivors and an age-matched reference population.

RESULTS

The direct comparison between female and male cancer survivors identified more symptoms, such as nausea and vomiting (M = 5.0 versus. 3.2), insomnia (M = 26.1 versus. 15.9), anxiety (M = 5.2 versus. 4.2), and lower physical (M = 77.5 versus. 82.5) and emotional functioning (M = 83.4 versus. 86.3), in female survivors. However, comparison with an age-matched reference population demonstrated that several symptoms, such as fatigue, dyspnea, anxiety and depression, appeared to be more frequent in male patients. The investigation of functioning domains - compared with a reference population - highlighted further sex-specific differences. Female survivors experienced a moderate net loss in physical and cognitive functioning (-6.1 [95% CI = -8.1; -4,1] and -5.2 respectively [95% CI = -7; -3.5]), whereas male survivors displayed a significant net loss in role and social functioning compared to the reference population (-9.9 [95% CI = -11.2; -8.6] and -7.7 [95% CI = -9.6; -7.6] respectively).

CONCLUSION

To adequately capture sex differences in symptoms and functioning in long-term cancer survivors, a comparison with a reference population should always be considered. In our study population, this adjustment highlighted a significant and unexpected long-term impact on male patients. Role and social functioning were especially impacted in male patients, emphasizing the need to further investigate these gendered domains.

Professionals' views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands

BACKGROUND

The COVID-19 pandemic and lockdown evoked great worries among professionals in the field of domestic violence and abuse (DVA) as they expected a rise of the phenomenon. While many countries reported increased DVA, the Netherlands did not. To understand this discrepancy and the overall impact of the lockdown on DVA support services, we interviewed DVA professionals about their experiences with DVA during the rise of COVID-19, the impact of the lockdown on clients and working conditions, and views on eHealth and online tools.

METHODS

Semi-structured interviews were conducted among 16 DVA professionals with various specializations. This data was analyzed using open thematic coding and content analysis.

RESULTS

Most professionals did not see an increase in DVA reports but they did notice more severe violence. They experienced less opportunities to detect DVA and worried about their clients' wellbeing and the quality of (online) care. Furthermore, their working conditions rapidly changed, with working from home and online, and they expressed frustration, insecurity and loneliness. Professionals feel eHealth and online tools are not always suitable but they do see them as an opportunity to increase reach and maintain services when physical contact is not possible.

CONCLUSION

This study suggests DVA was probably under-detected during the lockdown rather than not having increased. The Dutch system heavily relies on professionals to detect and report DVA, suggesting a need for critical evaluation of the accessibility of professional help. Professionals experienced significant challenges and should themselves be supported psychologically and in their changed work practices to maintain their ability to aid survivors.

The impact of gender in the COVID-19 pandemic

Data worldwide is pointing towards an increased mortality of men a from COVID-19, while infection rates are equal or higher in women. Immunological differences might play a role in this as well as differences in risk factors and co-morbidities. In addition, differences in exposure, testing, case definitions and access to healthcare might play a role. Differences in symptoms have been reported, as well as potential differences in therapeutic choices. Also, the phenomenon of “long COVID” with all its psychophysical consequences appears to be more common in women. In addition to the consequences of the acute infection, COVID-19 is significantly impacting economies, social systems and political priorities. I will try to give a general overview of the current situation, starting from a medical standpoint and moving into the wider social consequences of this pandemic. I will highlight how the lack of attention to sex and gender can impact statistics, potential therapies and vaccines, livelihoods and the healthcare sector as a whole.

The Impact of Sex and Gender on the Multidisciplinary Management of Care for Persons With Parkinson's Disease

The impact of sex and gender on disease incidence, progression, and provision of care has gained increasing attention in many areas of medicine. Biological factors–sex–and sociocultural and behavioral factors–gender–greatly impact on health and disease. While sex can modulate disease progression and response to therapy, gender can influence patient-provider communication, non-pharmacological disease management, and need for assistance. Sex and gender issues are especially relevant in chronic progressive diseases, such as Parkinson's disease (PD), because affected patients require multidisciplinary care for prolonged periods of time. In this perspective paper, we draw from evidence in the field of PD and various other areas of medicine to address how sex and gender could impact PD care provision. We highlight examples for which differences have been reported and formulate research topics and considerations on how to optimize the multidisciplinary care of persons with PD.

The Coronavirus Disease 2019 Outbreak Highlights the Importance of Sex-sensitive Medicine

The novel coronavirus disease 2019 (COVID-19) pandemic has revealed important differences between the sexes in epidemiology, risk factors, clinical course, mortality and socioeconomic dimensions of the disease in all populations worldwide. This has emphasised the need for a better understanding of diversity aspects in healthcare to improve prevention, treatment and long-term consequences. In this article, the authors describe the most relevant knowledge thus far on sex differences regarding COVID-19.

The impact of sex differences on genomic research

Sex and gender differences affect all dimensions of human health ranging from the biological basis of disease to therapeutic access, choice and response. Genomics research has long ignored the role of sex differences as potential modulators and the concept is gaining more attention only recently. In the present review we summarize the current knowledge of the impact of sex differences on genomic and epigenomic research, the potential interaction of genomics and gender and the role of these differences in disease etiopathogenesis. Sex differences can emerge from differences in the sex chromosomes themselves, from their interaction with the genome and from the influence of hormones on genomic processes. The impact of these processes on the incidence of autoimmune and oncologic disease is well documented. The growing field of systems biology, which aims at integrating information from different networks of the human body, could also greatly benefit from this approach. In the present review we summarize the current knowledge and provide recommendations for the future performance of sex-sensitive genomics research.

Health-Related Needs and Barriers for Forcibly Displaced Women: A Systematic Review

The number of forcibly displaced people has been steadily increasing over the last decades. Women represent a large proportion of this population. Due to gender roles, duties of care, educational and economic imbalances, their experiences during flight and relocation differ from those of men and children. The currently available information about their specific health-related needs and barriers to access is scarce. We sought to explore the specific needs of the female refugee population employing a user-centered perspective. Rather than focusing on provider-designed interventions, we aimed at defining what female refugees want and need and which priorities they define themselves.

We searched PubMed, Medline, EMBASE, Cochrane Library, and Scopus to identify publications that explored the unique experiences of female refugees between January 1, 2008 and June 30, 2018. Publications needed to address the health needs of refugees, asylum seekers, or displaced individuals, include at least 50% women in their study and employ a user-centered perspective. A framework of themes was identified and applied to all publications.

We identified 1945 publications of which 13 could be included in the present review. Twelve of these publications employed qualitative and/or innovative methodology. We identified 5 broad categories of health-related needs (immediate health care, communication, cultural/spiritual, social, and economic).

The identified publications described the need for complex, coordinated approaches. Concerted action providing information and culturally sensitive care, while supporting language acquisition and economic empowerment is essential to improve the health status of female refugees. Transformative interventions need to address multiple axes of unequal access for female refugees to improve their overall health.

Gender medicine and oncology: report and consensus of an ESMO workshop

BACKGROUND

The importance of sex and gender as modulators of disease biology and treatment outcomes is well known in other disciplines of medicine, such as cardiology, but remains an undervalued issue in oncology. Considering the increasing evidence for their relevance, European Society for Medical Oncology decided to address this topic and organized a multidisciplinary workshop in Lausanne, Switzerland, on 30 November and 1 December 2018.

DESIGN

Twenty invited faculty members and 40 selected physicians/scientists participated. Relevant content was presented by faculty members on the basis of a literature review conducted by each speaker. Following a moderated consensus session, the final consensus statements are reported here.

RESULTS

Clinically relevant sex differences include tumour biology, immune system activity, body composition and drug disposition and effects. The main differences between male and female cells are sex chromosomes and the level of sexual hormones they are exposed to. They influence both local and systemic determinants of carcinogenesis. Their effect on carcinogenesis in non-reproductive organs is largely unknown. Recent evidence also suggests differences in tumour biology and molecular markers. Regarding body composition, the difference in metabolically active, fat-free body mass is one of the most prominent: in a man and a woman of equal weight and height, it accounts for 80% of the man's and 65% of the woman's body mass, and is not taken into account in body-surface area based dosing of chemotherapy.

CONCLUSION

Sex differences in cancer biology and treatment deserve more attention and systematic investigation. Interventional clinical trials evaluating sex-specific dosing regimens are necessary to improve the balance between efficacy and toxicity for drugs with significant pharmacokinetic differences. Especially in diseases or disease subgroups with significant differences in epidemiology or outcomes, men and women with non-sex-related cancers should be considered as biologically distinct groups of patients, for whom specific treatment approaches merit consideration.

Sex-Specific Patient Journeys in Early Parkinson's Disease in the Netherlands

Objective: To reconstruct a sex-specific patient journey for Dutch persons with Parkinson's disease (PD) during the first 5 years after diagnosis.

Method: We analyzed a national administrative medical claims database containing data of all patients newly diagnosed with PD between 2012 and 2016 in the Netherlands. We performed time-to-event analysis to identify the moments when patients received care from neurologists, allied healthcare therapists or general practitioners. We also extracted relevant clinical milestones: unexpected hospitalization for PD, pneumonia, orthopedic injuries, nursing home admission, and death. Using these data, we constructed the patient journey stratified for sex.

Results: We included claims data of 13,518 men and 8,775 women with newly diagnosed PD in the Netherlands. While we found little difference in neurologist consultations, women visited general practitioners and physiotherapists significantly earlier and more often (all p-values < 0.001). After 5 years, 37.9% (n = 3,326) of women had visited an occupational therapist and 18.5% (n = 1,623) a speech and language therapist at least once. This was 33.1% (n = 4,474) and 23.7% (n = 3,204) for men. Approximately 2 years after diagnosis, PD-related complications (pneumonia, orthopedic injuries, and PD-related hospitalization) occurred for the first time (women: 1.8 years; men: 2.3 years), and after 5 years, 72.9% (n = 6,397) of women, and 68.7% (n = 9,287) of men had experienced at least one.

Discussion: Considering the strengths and limitations of our methods, our findings suggest that women experience complications and access most healthcare services sooner after diagnosis and more frequently than men. The identified sex differences extend the debate about phenotypical differences in PD between men and women.

Prevalence of Sexual Harassment in Academic Medicine

This cross-sectional internet-based survey study analyzes sexual harassment among physicians in an academic tertiary referral center in Germany.

Normative reference data, determinants, and clinical implications of right atrial reservoir function in women assessed by 2D speckle-tracking echocardiography

AIM

We aim to determine normative reference data of phasic right atrial (RA) strain and to investigate determinants, possible clinical implications as well as feasibility and reproducibility of RA strain analysis.

METHODS AND RESULTS

Right atrial strain was analyzed in 266 participants of the cross-sectional Berlin Female Risk Evaluation (BEFRI) study using 2D speckle-tracking echocardiography (2D STE). To determine reference values, phasic RA strain was determined in a subgroup of 123 individuals without known cardiovascular diseases or risk factors. Mean RA reservoir strain (RAS), RA conduit, and contraction strain in this reference group were 44.9 ± 11.6%, 27.1 ± 9.5%, and 17.0 ± 5.9%, respectively. Regarding possible clinical implications, RAS was significantly reduced in women with a BMI ≥ 25, compared with women with a BMI < 25 (35.5 ± 11.1% vs 43.4 ± 11.6%, P < 0.0001). RA strain analysis showed a good feasibility (92.7%); intra- and inter-observer variability was low (<5%). BMI, global longitudinal peak systolic LV strain (LVGLS%), RA area, TAPSE, and early diastolic myocardial relaxation velocity of the RV (RV-e') were significantly associated with RA mechanics in a multivariate logistic regression analysis.

CONCLUSION

In this cross-sectional trial, we determined reference values, feasibility and reproducibility, clinical and echocardiographic determinants, and possible clinical implications of RA strain analysis. Our data may help to introduce the analysis of RA mechanics into future echocardiographic routine use.

Near-death experiences, attacks by family members, and absence of health care in their home countries affect the quality of life of refugee women in Germany: a multi-region, cross-sectional, gender-sensitive study

BACKGROUND

The year 2016 has marked the highest number of displaced people worldwide on record. A large number of these refugees are women, yet little is known about their specific situation and the hurdles they have to face during their journey. Herein, we investigated whether sociodemographic characteristics and traumatic experiences in the home country and during the flight affected the quality of life of refugee women arriving in Germany in 2015-2016.

METHODS

Six hundred sixty-three women from six countries (Afghanistan, Syria, Iran, Iraq, Somalia, and Eritrea) living in shared reception facilities in five distinct German regions were interviewed by native speakers using a structured questionnaire. Sociodemographic data and information about reasons for fleeing, traumatic experiences, symptoms, quality of life, and expectations towards their future were elicited. All information was stored in a central database in Berlin. Descriptive analyses, correlations, and multivariate analyses were performed.

RESULTS

The most frequent reasons cited for fleeing were war, terror, and threat to one's life or the life of a family member. Eighty-seven percent of women resorted to smugglers to make the journey to Europe, and this significantly correlated to residence in a war zone (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.4-4.6, p = 0.003) and homelessness prior to fleeing (OR = 2.1, 95% CI = 1-4.3, p = 0.04). Overall the described quality of life by the women was moderate (overall mean = 3.23, range of 1-5) and slightly worse than that of European populations (overall mean = 3.68, p < 0.0001). The main reasons correlating with lower quality of life were older age, having had a near-death experience, having been attacked by a family member, and absence of health care in case of illness.

CONCLUSIONS

Refugee women experience multiple traumatic experiences before and/or during their journey, some of which are gender-specific. These experiences affect the quality of life in their current country of residence and might impact their integration. We encourage the early investigation of these traumatic experiences to rapidly identify women at higher risk and to improve health care for somatic and mental illness.

Implementation Strategies for Gender-Sensitive Public Health Practice: A European Workshop

OBJECTIVES

Providing a robust scientific background for the focus on gender-sensitive public health and a systematic approach to its implementation.

METHODS

Within the FP7-EUGenMed project ( http://eugenmed.eu ) a workshop on sex and gender in public health was convened on February 2-3, 2015. The experts participated in moderated discussion rounds to (1) assemble available knowledge and (2) identify structural influences on practice implementation. The findings were summarized and analyzed in iterative rounds to define overarching strategies and principles.

RESULTS

The participants discussed the rationale for implementing gender-sensitive public health and identified priorities and key stakeholders to engage in the process. Communication strategies and specific promotion strategies with distinct stakeholders were defined. A comprehensive list of gender-sensitive practices was established using the recently published taxonomy of the Expert Recommendations for Implementing Change (ERIC) project as a blueprint.

CONCLUSIONS

A clearly defined implementation strategy should be mandated for all new projects in the field of gender-sensitive public health. Our tool can support researchers and practitioners with the analysis of current and past research as well as with the planning of new projects.