Healthcare Decision-making: Targeting Women as Leaders of Change for Population Health

This pilot study was a prospective survey of n = 500 postpartum mothers and n = 36 obstetricians (OBs) to assess characteristics, opinions, and experiences of healthcare. A convenient sample of women on the postpartum floors and OBs were invited to participate in a survey. The survey was distributed from 2013 to 2014 investigating general opinions from women about healthcare decision-making, healthcare experiences during a healthcare stay after delivery, and overall quality of life using the Patient Reported Outcomes Measurement Information System. The majority of women indicated that they made the healthcare decisions for themselves, n = 278 (57.3%) versus n = 191 (39.3%) indicated her and her spouse/partner together made healthcare decisions for her. Interestingly, only 39.3% (n = 69) of women reported that their spouse/partner were the only ones involved in their healthcare decisions whereas women reported to be more jointly involved in healthcare decisions of their spouse’s/partner’s health, n = 313 (66.6%). PROMIS® scores had a significant relationship (p = 0.022) in the global mental domain to age and insurance type with accessing the same facility for future healthcare. Further analysis revealed a significant (p = 0.013) relationship as PROMIS® global mental scores go down, the increased willingness to return to the same birthing facility for future healthcare goes up. Two specific PROMIS® global mental questions were identified as having a significant (p = 0.008) or trending towards significant (p = 0.08) negative value for Kendall’s tau indicating that the lower the score on the PROMIS® global mental question, the more likely they are to visit the same birthing facility in the future for other healthcare procedures. A substantial amount of women are responsible for their family’s health. Future studies should have a longitudinal design to assess the true lifetime impact of the birth experience for a woman on healthcare decision-making for her family. [13-15]. A woman with a higher QOL, a valid and reliable measure of health status, demonstrates high psychological, social, and cognitive functioning to support others in healthcare decision-making [14]. How does the healthcare industry use female influence of all healthcare decisions? Unfortunately, there is a dearth of evidence of a woman’s influence on healthcare decision-making and how it impacts the business of healthcare. The current pilot study investigates general opinions from women about healthcare decision-making and opinions from their obstetricians, midwives, or family medicine physicians (OBs) to provide an understanding of how women influence healthcare, their experiences during a healthcare stay after delivery, and her overall QOL relates to these perspectives. The goal of this descriptive analysis was to assess the perspective of healthcare decision-making using the characteristics of women utilizing the healthcare system and from the OBs providing this care.


Abstract
This pilot study was a prospective survey of n = 500 postpartum mothers and n = 36 obstetricians (OBs) to assess characteristics, opinions, and experiences of healthcare. A convenient sample of women on the postpartum floors and OBs were invited to participate in a survey. The survey was distributed from 2013 to 2014 investigating general opinions from women about healthcare decision-making, healthcare experiences during a healthcare stay after delivery, and overall quality of life using the Patient Reported Outcomes Measurement Information System. The majority of women indicated that they made the healthcare decisions for themselves, n = 278 (57.3%) versus n = 191 (39.3%) indicated her and her spouse/partner together made healthcare decisions for her. Interestingly, only 39.3% (n = 69) of women reported that their spouse/partner were the only ones involved in their healthcare decisions whereas women reported to be more jointly involved in healthcare decisions of their spouse's/partner's health, n = 313 (66.6%). PROMIS® scores had a significant relationship (p = 0.022) in the global mental domain to age and insurance type with accessing the same facility for future healthcare. Further analysis revealed a significant (p = 0.013) relationship as PROMIS® global mental scores go down, the increased willingness to return to the same birthing facility for future healthcare goes up. Two specific PROMIS® global mental questions were identified as having a significant (p = 0.008) or trending towards significant (p = 0.08) negative value for Kendall's tau indicating that the lower the score on the PROMIS® global mental question, the more likely they are to visit the same birthing facility in the future for other healthcare procedures. A substantial amount of women are responsible for their family's health. Future studies should have a longitudinal design to assess the true lifetime impact of the birth experience for a woman on healthcare decision-making for her family. [13][14][15]. A woman with a higher QOL, a valid and reliable measure of health status, demonstrates high psychological, social, and cognitive functioning to support others in healthcare decision-making [14].
How does the healthcare industry use female influence of all healthcare decisions? Unfortunately, there is a dearth of evidence of a woman's influence on healthcare decision-making and how it impacts the business of healthcare. The current pilot study investigates general opinions from women about healthcare decision-making and opinions from their obstetricians, midwives, or family medicine physicians (OBs) to provide an understanding of how women influence healthcare, their experiences during a healthcare stay after delivery, and her overall QOL relates to these perspectives. The goal of this descriptive analysis was to assess the perspective of healthcare decision-making using the characteristics of women utilizing the healthcare system and from the OBs providing this care.

Methods
The pilot study was a prospective survey of n = 500 postpartum mothers and n = 36 OBs to assess characteristics, opinions, and experiences of healthcare from July 1, 2013 to February 28, 2014. New mother participants were recruited from the postpartum floors in the hospital during a quiet time and not during any bonding with newborns or during breast feeding time. A convenient sample of women on the postpartum floors was invited to participate in the survey, except those who did not read English. Participants were asked to complete an online survey that contained no identifiable data and was taken only once. The 10-minute online survey (Survey Monkey, Palo Alto, CA) was provided to the participants using a Dell mini-laptop with Wi-Fi™ access. The online survey included the following components: demographic information, opinions of healthcare decision-making, and QOL using the Patient Reported Outcomes Measurement Information System (PROMIS) for global mental and global physical domains. The PROMIS from the National Institutes of Health (NIH) is a thoroughly validated set of multidimensional psychometric assessments [15]. The core PROMIS bank domains provide a method for measuring the entirety of a patient's physical, social, and emotional well-being (or illness) in a manner that is broadly applicable to essentially any disease state, regardless of the actual nature or number of underlying pathophysiological processes present. Institutional review board approval was obtained to conduct the study.
The data for this pilot study was analyzed using the SPSS 22.0. Means with standard deviation (SD) or standard error (SE) are reported for all measures as applicable. For all statistical analyses, a P value less than 0.05 was considered statistically significant. P-values for age are from Kendall's tau test of ordinal relationships, health insurance are from Fisher's exact test, and the PROMIS® mean scores. Data from individuals who withdrew prior to survey completion or missing data were not included in the final analysis. Conversion of the PROMIS global health scores and specific domain scores are reported as a raw score and converted to T-scores [16]. Due to the pilot nature of this study, a power analysis was not completed for the convenient samples.
Response categories for healthcare decision-making from post partum women were compiled and reported in Table 2. In general, the majority of women indicated that they made the healthcare decisions for themselves, n = 278 (57%) versus n = 191 (39%) indicated her and her spouse/partner together made healthcare decisions for her. Interestingly, only 39% (n = 69) of women reported that their spouse/ partner were the only ones involved in their healthcare decisions whereas women reported to be more jointly involved in healthcare decisions of their spouse's/partner's health, n = 313 (67%). Response categories for perceptions of healthcare decision-making from OBs were compiled and reported in Table 3. From the provider perspective, OBs reported that the majority of their delivering patients made the healthcare decisions for themselves, n = 20 (55%) versus n = 16 (44%) indicated her and her spouse/partner together made healthcare decisions for her. Only 2% (n = 2) of OBs reported that their patient's spouse/partner were the only ones involved in their patient's healthcare decisions whereas the OBs reported that their patients were more likely to be jointly involved in healthcare decisions of their spouse's/partner's health, n = 24 (71%). Surprisingly, OBs reported that they believe their patient made the healthcare decisions solely for the patient's spouse/ partner, n = 8 (24%).
Based on the patient survey results, a woman's hospital experience appeared to influence her healthcare decision for future procedures. Specifically, the majority of women surveyed indicated that they either strongly agreed, n = 127 (27%) or agreed, n = 216 (45%) that having a baby at a specific institution impacted her decision in returning to the same institution for future healthcare procedures for her family ( Figure  1). These results are supported by the OBs perspective as they either strongly agreed, n = 17 (47%) or agreed, n = 15 (42%) that having a baby at a specific institution impacted her decision in returning to the same institution for future healthcare procedures for her family (Table  3). Similarly, women strongly agreed, n = 135 (28%) or agreed, n = 254 (52%) that they would continue to use the institution for their specific healthcare needs since having a baby at the institution ( Figure 2). Again, these results mirror the OBs perspective as the OBs strongly agreed, n = 9 (26%) or agreed, n = 19 (54%) that their patient would continue to use the institution for their specific healthcare needs since having a baby at the institution.
Other categories of influence from postpartum women surveyed   on their healthcare decisions were insurance type, n = 184 (38%); a previous experience at the institution, n = 165 (34%); and her hospital experience with the staff focusing on patient safety, n = 268 (55%) and quality care, n = 367 (75%).
Analysis of the women's QOL was conducted using the PROMIS® global mental and global physical domain raw scores and T-score conversions. The PROMIS global physical and global mental raw scores were 9.3 (±3.9) with a T-Score of 32.4 (±4.2) and 14.1 (±3.9) with a T-Score of 48.3 (±3.7), respectively. Of the women surveyed, PROMIS® n (%)  scores had a significant relationship (p = 0.022) in the global mental domain to age and insurance type with accessing the same facility for future healthcare on a 1-5 scale (Table 4). Further analysis revealed a significant (p = 0.013) relationship as PROMIS® global mental scores go down, the increased willingness to return to the same birthing facility for future healthcare goes up (Table 5). Lastly, two specific PROMIS® global mental questions were identified as having a significant (p = 0.008) or trending towards significant (p = 0.08) negative value for Kendall's tau indicating that the lower the score on the PROMIS® global mental question, the more likely they are to visit the same birthing facility in the future for other healthcare procedures ( Table 6).

Discussion
This pilot study reinforced financial market data that women selfreport to be the major healthcare decision-makers for themselves and jointly with their spouse/partner's health. More importantly, the study revealed that having a baby with a specific healthcare system appears to    influence women to return to the same institution for future healthcare services herself and her family. Healthcare systems and population health initiatives need to understand the importance of the birth experience to a woman and how this may persuade her healthcare decision-making process. Even with stable birth rates and obstetric units facing narrow financial margins, institutions should observe the value in investing in women's health services due to the influential nature of women and healthcare decision-making [17].
With healthcare reform, patients more than ever need navigation about medical conditions, access to qualified health professionals, and how to connect with the best medical information [18,19]. Despite public health and population health initiatives, much remains to be understood regarding engaging communities and families in health promotion [20]. Women make up 50.8% of the US population and 78.4% of the labor force in healthcare [21]. In 2013, the US labor force of mothers with children was almost 70% [22]. In 2022, women are projected to represent approximately 47% of the US labor force [23]. Thus, intentionally putting women as the focal point for patientcentered decision making and population health initiatives may be a productive strategy for improving patient reported outcomes [23]. Iravani et al. reported women's expectations during her pregnancy and labor included security, a sense of control, empowerment, respect, and trust to be well established prior to the birth experience [24]. This research along with our findings support the necessary ingredients for a woman to have a positive birth experience and consequently more likely to return to an institution for future services. Moreover, Nease et al. performed a study that found healthcare decision-making involvement and being young of age, more educated, employed, and female to have a significant association [25]. Similarly, our convenient sample mirrors these characteristics with 76% of women reporting to have a bearing on healthcare decision-making for their family.
A woman's healthcare decision-making influence is not just a United States (US) phenomenon. Overall, studies appear to report consistent data in regards to the characteristics of women inspiring healthcare change. Dev et al reported evidence from other developing countries that show that age and family structure are the strongest determinants of a woman's authority in decision-making [26]. In these countries, women making health-care decisions are an indicator of empowerment as typically they have not been able to make these decisions due to them being a female. In parallel, European countries report to have a significant difference between gender and education for patients involved in decision-making in a clinical encounter whereby women dominate over their male counterparts [27].
There are several limitations to this study which include a convenient sample at the institution providing the woman healthcare services providing a potential bias from the patients. Additionally, there was also a lack of diversity in the sample of race and ethnicity even with the institution being an urban hospital; however, the socio-demographics of the survey match our institutions' overall demographics in race, ethnicity, and insurance type. Plus, patients recruited for the study were mostly first time postpartum mothers within 48-hours of delivery and may have been experiencing hormonal shifts impacting their responses. The participants willing to complete the study may represent a specific sub-group of women whereby not fully capturing a representative sample of all women. Lastly, we didn't ask women to report their culture, religion, and beliefs in regards to family structure which may impact her ability to make healthcare decisions for her and her family. Overall, this limits our ability to conduct multivariable statistical analyses; however, future studies should incorporate this methodology.
This prospective pilot survey study indicates that women believe they have a direct effect on healthcare decision-making for their family. A substantial amount of women are responsible for their family's health and believe this impression begins with a life event of giving birth. However, with labor and delivery units closing across the US, health systems may be missing an opportunity to grow their loyal customer base and succumbing to the short term cut-back that obstetric units are money losers. The results of this study appear to indicate otherwise. Future studies should have a longitudinal design and control group to assess the true lifetime impact of the birth experience for a woman on healthcare decision-making for her family.