1 9/23/2013

Gender-based Analysis 

in Health Services Research: 

Making the Research Actionable

Chloe E. Bird, PhD

VA Cyberseminar

September 23, 2013
2 9/23/2013

Poll Question #1

• What is your primary role in VA? 

– Student, Trainee, or Fellow

– Clinician

– Researcher 

– Manager or Policy-maker 

– Other 
3 9/23/2013

Poll Question #2

• Which best describes your research 

experience?

– have not done research

– have collaborated on research

– have conducted research myself

– have applied for research funding

– have led a funded research grant
4 9/23/2013

 Moving beyond sex and gender as a control 

variable

 Assessing gender differences in care and 

outcomes 

 Engaging stakeholders and decision-makers 

 Putting gender on the map 

Outline
5 9/23/2013

 Too often research on health and health care 

adjusts for gender, race/ethnicity and 

socioeconomic status (SES) rather than assessing 

differences

 Average answers may not speak to the problems 

of any major population subgroup

 Actionable research needs to assess whether and 

how health and health care differ by sex/gender 

and for sexual minorities

Moving Beyond Gender as a Control 

Variable
6 9/23/2013

 Gender-based analysis systematically assesses 

whether and how men’s and women’s health, 

healthcare, or both differ

 Gender-stratified analyses may be necessary to 

determine whether, and to what extent, key 

predictive or causal relationships differ for men 

and women

 think of stratified models as fully interacted

 report where gender differences are significant and 

where they are not

Assessing Gender Differences 

in Care and Outcomes
7 9/23/2013

•To have an impact research needs to be 

accessible.

•Findings need to:

 speak to decision-makers and address their 

questions

 be in the metrics they use to understand and 

assess impact

 be specific and actionable 

 be relevant to local situations and organizations

For the Love of Odds Ratios
8 9/23/2013

 Differences in men’s and women’s health may be 

social, biological, or both

 Understanding when and where disparities occur 

in processes of care and outcomes is key to 

effective intervention

 Efforts to improve men’s and women’s health and 

health care may require different interventions

 Differences in incidence or prevalence may be 

addressed through prevention but not through 

diagnosis and treatment

Making Findings Actionable
9 9/23/2013

 Addressing differences in health trajectories raises 

additional questions regarding patterns of care 

and outcomes 

 Are the differences at the level of care delivery (process 

measures such as screening diagnosis, treatment, and 

follow-up) or intermediate outcomes (achieving control 

over biological risk factors such as high BP or LDL 

cholesterol)?

 Are there time trends with a diffusion curve (initially 

men get newer treatments) or are women getting 

similar care but not similar outcomes? 

Identifying Action Points
10 9/23/2013

 Whose behavior and what choices or actions are 

you seeking to impact? 

 Clinicians, patients, decision-makers who affect the 

organization of care or payment structure

 Individuals have agency but their choices/actions 

differ in part because options differ and the costs 

and consequences of particular choices differ

 To change behavior you need to also consider 

what other levels of decision-making impact 

individuals’ options and the relative costs of 

specific choices

Constrained Choice
11 9/23/2013

 Change is more likely to be achieved if you can 

identify and reach relevant decision-makers 

 Few changes are achieved only by individual 

patients and/or their respective clinicians

 Identifying the levels of decision-making relevant 

to addressing a specific problem can reveal 

additional action points and potential bottlenecks

Identifying Decision-makers
12 9/23/2013

• To gain the interest of stakeholders and decisionmakers, findings need to:

 Be clearly relevant to the outcomes of interest to 

specific stakeholders

 How does addressing gender differences in care align with 

meeting their primary goals?

 Be demonstrable as a problem locally – within the 

purview of specific decision-makers 

 Have clear levers to address the problem

Engaging Stakeholders and 

Decision-makers
13 9/23/2013

 Actionable research needs to speak to the 

decision-makers and stakeholders who can make a 

difference

 Measuring the size and nature of disparities is not 

sufficient

 Analyses need to:

 identify action points

 identify the mix of issues that must be addressed in 

order to act/intervene locally rather than (or in addition 

to) nationally

How Do Actionable and Traditional 

Academic Research Differ?
14 9/23/2013

 Moving beyond measuring average gender gaps 

and their determinants

 Think differently about generalizability

 Drill down to make findings actionable where you, 

your client, the stakeholders, or other decisionmakers want to intervene

Assessing Gender Differences 

in Care and Outcomes
15 9/23/2013

Many studies share these objectives and give some 

consideration to gender differences in health or 

outcomes, but without being actionable

 To be effective, actionable gender research has to 

 engage decision-makers 

 speak to multiple audiences at many levels of decisionmaking

 be relevant to local situations and organizations

Audiences Matter
16 9/23/2013

Poll Question #3

• Do you provide care to women VA patients? 

• I don’t see patients 

• I see only men at the VA

• I see both women and men patients 

• I only see women patients
17 9/23/2013

 Mapping disparities can reveal or confirm the 

location and geographic boundaries of hot spots 

of highly prevalent specific health problems, low 

quality care, or poor outcomes 

 Mapping can also reveal or highlight where men’s 

and women’s health and health care: 

 differ more than would be expected by chance

 are markedly above or below average

Putting Gender on the Map
18 9/23/2013

Example Hotspot Analysis 

within County Area

Nearest-neighbor hierarchical clustering of diabetics not receiving HbA1C 

primary clusters in red, secondary clusters in yellow, predominant 

race/ethnicity in background 
19 9/23/2013

Mapping can also make patterns of predictors and 

disparities accessible

 Reveal where and whether specific relationships 

are or are not significant 

 Do disparities map on to racial/ethnic or socioeconomic 

neighborhood characteristics or the availability of 

specific health services?

 Maps can go beyond individual-level data to 

assess patterns of care 

 Are those getting better and worse care treated at the 

same clinics and by the same providers? 

Mapping – Beyond Geography
20 9/23/2013

Mapping can also make patterns of predictors and disparities 

accessible

 Examining geographic data and understanding patterns 

across states, congressional districts, counties, service 

areas, VISN, or markets

 Do gender differences in care differ for those near women’s health 

centers or those living farther from medical services?

 Examining patterns of care by delivery site rather than 

patient characteristics 

 Are some facilities doing better by women?

 Are men and women getting care at different or the same 

facilities, and from different or the same clinics or providers?

 Do the patterns differ more for diagnosis than for treatment? 

Examples of Actionable Mapping
21 9/23/2013
22 9/23/2013
23 9/23/2013

Adding spatial perspective can increase 

understanding of contributing factors

Limited English Proficiency

 Inside Cluster: 43 %

 Outside Cluster: 29 %
24 9/23/2013

Illustrate Where to Target a Problem
25 9/23/2013

Decision tools help focus in on quality hotspots and 

cold spots
26 9/23/2013

 Systematically assess gender differences and 

establish their patterns and impact including social 

and economic costs

 Identify actions and intervention points that can 

address gaps in prevention, care, and outcomes

 Target findings to the relevant decision-makers 

Take Home Points
27 9/23/2013

Chloe E. Bird, PHD

Chloe@rand.org

Questions?