The Regions and the gender-specific medicine
The Regions have great autonomy when it comes to organising health care. Below is a presentation of the activities carried out by or in place in some of the Regions, as presented to the conference.
Franca Di Nuovo, Director of the Pathology Unit, Past-President of the Guarantee Committee, ASST-Rhodense, Garbagnate Milanese, Milan
Gender medicine promotion strategies put in place by Lombardy Region to promote the spread of gender culture in health care were launched in 2013 by the Guarantee Committees (Comitati Unici di Garanzia – CUG). Under the aegis of the Welfare Department, the CUG network was created, a network that functioned as a centre for connecting and integrating gender-oriented initiatives implemented by all the healthcare facilities in Lombardy. All the chairmen of the Lombardy CUGs took part in bimonthly meetings, sharing experiences and promoting gender culture. Lombardy was one of the first Regions in Italy to include gender medicine in the regulatory documents of the regional health service (Resolution of the System Rules, X/1185 of 2013). This resolution considered gender medicine to be a strategic objective and a governance tool for Lombardy’s health system and established that each Health Authority should identify at least two areas of positive action from a gender perspective, together with the inclusion of gender medicine in the annual company training plan. In 2014, a regional technical study group (gruppo regionale di approfondimento tecnico – GAT) was set up with the aim of promoting the centrality of a gender approach and regional scientific research in healthcare. In 2014, with DGR X/2989, Lombardy was the first Region in Italy to implement a winning top-down strategy, including gender medicine among the assessment objectives of the General Directors of Healthcare Facilities. These assessment objectives establish the definition of cross-cutting diagnostic/therapeutic/healthcare pathways, with process and outcome indicators from a gender perspective. 360° training activities were also conducted, both through informative events aimed at the population during EXPO, and through the implementation of conferences dedicated to all healthcare professions. In the university sphere, Italy’s first elective course in gender medicine has been planned, entitled “Taking care of a man and a woman is not the same thing” aimed at students from the Faculty of Nursing Sciences. In addition, videos, e-learning courses, printed publications and annual workshops entitled “The Health of Difference” were produced for all health and social professionals. Particular attention was paid to conducting healthcare activities both through the establishment of specific outpatient departments (osteoporosis, metabolic disorders, headaches, epilepsy, pain) and through the formalisation of Healthcare Therapeutic Diagnostics Pathways (Percorsi Diagnostici Terapeutici Assistenziali – PDTA). In 2017, the chairmanship of the Lombardy Regional Council commissioned a research project carried out by Eupolis Lombardia in collaboration with the Genders Centre for Gender & Equality in Research and Science of the University of Milan, which resulted in the policy paper entitled “The importance of gender medicine among healthcare professionals”, a summary of what has been done at regional, national and international level from a gender medicine point of view. Finally, a research centre for documentation and information on gender health was opened at the ASST Spedali Civili in Brescia. This very active centre aims to promote awareness and dissemination of gender specific medicine in the Region of Brescia.
Enzo Cucco, Centro Regionale Contro le Discriminazioni, Regione Piemonte, talks on behalf of Monica Cerruti, Councillor for Equal Opportunities, Piedmont Region
Many activities have been organised in Piedmont in recent years by Dr Tanturri and Dr Ianni Palarchio, but region-wide initiatives began just over a year ago. A regional working group was established by the Piedmont Local Departments of Health and Equal Opportunities (open also to institutions such as universities, hospitals and relevant associations) called the Gender Health Working Group (Gruppo di lavoro su Salute di Genere).
Two activities are planned:
■ Training General Practitioners: in January 2018 there will be a conference presenting a study by the Faculty of Psychology together with General Practitioners and the Italian Association of Medical Women on the expertise of General Practitioners in Turin in relation to gender health. The aim is to include this topic in the training of General Practitioners. There have also been meetings with Antonino Saitta (Piedmont Regional Councillor for Health) to look at the possibility of including this issue in GP contracts at a national level, but there has not yet been time. There is, however, willingness to include it in regional contracts.
■ Piedmont is planning the construction of a new hospital (Parco della Salute) that will bring together all the High Specialisms from all the hospitals in Turin and Piedmont. The aim of this important project was to address gender differences both from an architectural point of view and from the point of view of activities. All Molinette workers (doctors, nurses and all professionals, as well as patients and associations) were asked to give ideas on this perspective by spring 2018.
Maria Chiara Corti, Responsabile UO Strutture Intermedie e Socio-sanitarie Territoriali, Azienda Zero, Veneto Region
Dr. Corti contributes to the round table with her presentation aimed at describing both epidemiological aspects and national and regional health policy data regarding gender medicine.
The first part of her presentation shows some regional data on chronic pathologies, such as COPD, congestive heart failure and dementia, which have different characteristics depending on gender, such as prevalence and burden of care. Her experience in an American context took place in the 1990s, when Dr Bernadine Healy had stirred the scientific and clinical world with her observation that in cardiology women were less well treated and less represented in clinical trials. So it was that in the USA several clinical and epidemiological studies were initiated, but often only on women. On her return to Italy, Dr Corti took part in an important epidemiological study conducted in two Local Health Authorities in the Veneto Region (the Pro.V.A project; Veneto Elderly Project), which involved a population of around 3100 subjects aged over 65 years. Dr Corti, in her capacity as epidemiological director, undertook to ensure that both the sexes were represented proportionally in the study. From the initial data it was clear that comorbidity in elderly people was extremely important and that the female population was more afflicted. It emerged, therefore, that in designing healthcare policies it is fundamental not to concentrate on an individual illness, but on multimorbidity, paying close attention to understanding the distinctive elements of chronic pathologies in the two sexes.
Motion 1-00974 approved by the Chamber on 27th March 2012, committed the Government to including among the aims of the national healthcare plan the promotion of and the support for gender medicine as an interdisciplinary approach between the different areas of medicine, in order to outline better health service provision criteria that take gender differences into account.
The Regional Health Plan (Piano Socio Sanitario Regionale – PSSR) 2012-2016, as a consequence, provided for the development of basic and clinical scientific research into gender difference in all medical specialisms, the organisation of health services in order to guarantee equality and appropriateness of treatment in men and women, training of health operators, adoption of prevention initiatives with informative campaigns and incorporation of gender medicine into university curricula and specialisation schools to foster interdisciplinary practices.
In addition, gender medicine was one of the main topics of the 2010 and 2017 Regional Finalised Health Research calls. In the Veneto Region there is the Regional Centre for Gender Medicine, based at the University Hospital of Padua, in the General Medicine Complex Operational Unit, the cornerstone of crucial academic and scientific initiatives and a source of stimulus for health planning activities coordinated by the Region.
There are several possible development areas for Gender Medicine in Veneto, including, under the coordination of the Regional Centre: the constitution of a permanent Regional Observatory on Gender Medicine for the dissemination of good practices and the development of knowledge; collaboration with research centres in the Veneto Region and universities; dissemination and promotion of scientific work through publications (e.g. gender medicine journals in the Veneto Region); synergy with the Regional Epidemiological System to strengthen gender epidemiology.
Silvia Maffei, Fondazione CNR - Regione Toscana “G. Monasterio”, Pisa, talks on behalf of Anna Maria Celesti, Coordinator of the Regional Center for Health and Gender Medicine, Tuscany Region
Tuscany started to deal with gender medicine with Regional Decree no. 4193 of October 2011, which established a permanent committee on gender issues in medicine. This committee was designed to assess specific health and gender indicators with a multidisciplinary approach. In November 2013, the first book was published, “La Salute di Genere in Toscana” (Gender Health in Tuscany) by ARS Tuscany, which was translated into English. The ARS then published and disseminated posters on gender differences (nutrition, obesity, diabetes, osteoporosis, cardiovascular diseases, occupational accidents, road traffic accidents, work-related stress, etc.).
The committee established priority issues to which the regional health authorities have adhered, for example: gender differences in cancer screening of the rectum, in patients with heart attacks, in patients being screened for prostate and breast cancer, in the cardiotoxicity of chemotherapies.
In resolution no. 75 of 7th February 2014 in relation to the priority actions for the regional social and healthcare system for the year 2014, the establishment at regional level of a ‘Regional Coordination Centre which develops, together with the Health Authorities, a series of actions in the field of Gender Health” (Centro di Coordinamento regionale che sviluppi, in integrazione e coerenza con le Aziende sanitarie, una serie di Azioni nell’ambito della Salute di Genere) is planned. The Centre is included among the structures of the Regional Clinical Governance according to the Art. 43 of the Regional Law of 25th July 2017. The Regional Coordination Centre’s first objective has been the establishment of the Gender Medicine Centres for the coordination of gender health in order to implement guidelines defined by the regional coordination centre. The Centres for gender health are: 12 Local Health Authorities (USLs), 4 University Hospitals (AUOP) and the G. Monasterio Tuscan Foundation. With subsequent measures, some regional regulations were amended and the role of the Regional Centre was redefined. It can be summarised as follows: connecting all hospitals, promoting personal care, raising awareness and training among health workers, disseminating gender health policies to reduce inequalities, developing research on risk factors for diseases and prevention both primary and secondary, verifying adherence to screening, and developing innovative solutions to facilitate access to services.
Through these actions the Health Authority of the Region of Tuscany has embraced the theme of gender health by giving it an official, legal and well-defined role.
Caterina Ermio, President of the Italian Association of Medical Women (Associazione Italiana Donne Medico – AIDM), Neurology Operational Unit Director, Presidio Ospedaliero Giovanni Paolo II, Lamezia Terme)
The Department Head of the Health Sector of the Calabria Region understood the need to instil a culture surrounding gender medicine. Based on a regional resolution, a round table on gender medicine has been formed, for which Dr Ermio is responsible. There has already been an initial meeting on Chronic Obstructive Pulmonary Disease.