Womens Health Strategic Framework

Current Health Issues for Women

The definition of a women’s health issue used in this Strategic Framework is as outlined in Health Goals and Targets for Australian Women endorsed in 1993 by the Australian Health Minister’s Advisory Council, namely:

"The advancement of women’s health requires the promotion of physical, mental and social well-being, following the broad definition of health adopted by the World Health Organisation. Women’s health issues are defined as social conditions, illnesses and disorders unique to, more prevalent among, or more serious in women or for which there are different risk factors, interventions or strategies for women than for men".

It is recognised that major health gains in the health of NSW women in recent years have been achieved, including declining rates of new cases and deaths from cervical cancer,declining deaths due to coronary heart disease and increasing breast cancer 5 year relative survival rates.

However, women continue to experience higher rates of poverty and lower rates of literacy, with access to economic power and decision making not being commensurate with numbers, or needs. Women report more long term and recent health conditions and mental illness over a lifetime. Women’s Health issues are related to social factors, life cycle factors and specific health issues. In SWSAHS in 1996, 60.8% of women reported that they had no educational qualifications compared to 49.5% of men (SWSAHS1999a).

1. Social factors

Socio-economic factors

Compared to women from high socio-economic groups women from low socio-economic groups are:

55% more likely to die from lung cancer

211% more likely to die from diabetes

124% more likely to die from ischaemic heart disease

69% more likely to die from cardio-vascular disease

309% more likely to die from pneumonia / influenza

39% more likely to die from bronchitis / emphysema /asthma

65% more likely to die from car accidents

46% more likely to commit suicide.

Women are more likely than men to experience health problems related to their reproductive systems and are more likely to suffer both child abuse and violence as an adult in the home (Madden 1994; Mathers 1994).

Indigenous health

Indigenous people have the poorest health of any group in Australian society. Age specific death rates for ATSI women 25 - 54 years are approximately seven times the rate for non-Indigenous women of the same age. Aboriginal women are much more likely to have children at an earlier age with 23.4% of women aged 15-19 having at least one child. In 1997 premature birth rates in SWSAHS were 32% higher, and Aboriginal mothers were more likely to deliver low birth weight babies, 11.2% compared to 6% of other babies born in SWSAHS during 1993-97. Diabetes rates are very high for Aboriginal people, 5-19% compared to 2-7% for non-Indigenous people. (Madden 1994; NSW DoH 1999a; RACP 1999).

Sixty-five percent of Aboriginal people have been separated from a parent during their lifetime and 47% have been separated from both parents. The effects of past and current practices has a profound effect on Aboriginal communities leading to high psychiatric morbidity, substance abuse, poor health, family violence and lack of social cohesion (RACP 1999).

Cultural diversity

SWSAHS is an area of great cultural diversity, and with a significant ATSI population. Appendix 1 shows the main country of birth for major communities in each Sector. It also shows the main language groups for each Sector and the number of Indigenous and non-Indigenous Australian born women by age.

People who do not speak English at home are more likely to report fair/poor health than English speakers. Women are 98% more likely to do so. Among NESB communities, women, the newly arrived and the aged have poorer English language ability. NESB women are more likely to be on low incomes and the proportion of single parent families is higher than that for SWSAHS overall for those speaking Samoan 17.7%, Khmer 17.4%, Vietnamese 16.3% and Lao 15.4% (SWSAHS 1999a).

Unemployment rates generally are high for women who speak a language other than English at home (18.5%). For some communities unemployment rates are much higher than this. For example women speaking Kurdish 68.4%, Khmer 49.1%, Persian 43.8%, Vietnamese 39.6%, Assyrian 34.5%, Bosnian 30.9% and Samoan 30.8%. Many of these are refugee communities which places additional risks on their health. Refugees are likely to have suffered physical and emotional stress and to lack social supports, leading to poor health outcomes.

There are a number of instances where NESB women have poorer health than the general population. These include women from Oceania and the Middle East who have higher hospitalisation rates for CVD and diabetes, SE Asia for cervical cancer, Middle East for car accidents, and Northern and Western Europe for mental illness. A comprehensive review of the health of NESB residents is contained in A Profile of the Health of NESB Residents of South Western Sydney (SWSAHS 1999a).

Social support

Eighty-three percent of sole parent families in NSW are headed by women. Sole parents, along with other groups such as the unemployed and work injured, people living with mental illness, migrants and refugees, Aboriginal and Torres Strait Islander communities, the homeless, ex-prisoners, the chronically ill and older people, are more likely to suffer from social exclusion.

Social support is an independent risk factor for disease and death. Sole parents often have limited social supports impacting on their risk of ill health and depression. A recent study found that 42% of sole parents in public housing reported at least one attempt at suicide (Radford et al 1999).

A survey in a SWSAHS public housing estate with a high proportion of women heading single parent families found that 11% of mothers had no one to turn to for social support. Only 28% of residents felt that they never or almost never felt that their problems were piling up so high that they could not be overcome and 23% fairly or very often felt this way. 56% of residents were very/extremely worried about leaving their house "in case it was burgled while they were out". This is an area, which had great safety issues related to domestic violence, break and enter, home invasion, assault and houses being burnt (Harris 1999)

Sex workers are especially likely to lack good social supports. In some parts of SWSAHS many of these women are young and may be illegal immigrants. They may have children to support either here or in their country of origin. Negotiating safe sex practices can be especially difficult for such women. There is a need for outreach sexual health services to be provided in venues that women will feel confident to attend. This is especially important in smaller communities where issues of maintaining confidentiality can be particularly difficult.

Violence against women

The Women’s Safety Survey (1996), conducted by the Australian Bureau of Statistics, found that 5.9% of women over 18 surveyed had experienced physical violence in the previous 12 month period, and a further 1.5% had been sexually assaulted. On a population basis, these figures represent 18,000 women across SWSAHS.

The risk of experiencing both types of violence in the previous 12 months was greater for:

younger women (physical violence 16.1% for women aged 18-24 compared to 8.4% for every other age group, sexual violence 4.3% compared to 1.2% for women 45 and over);

for those with a diploma or vocational training (physical 8.4% compared to 6.1% for all other categories of educational attainment; and

for unmarried women (physical 11% for de facto, separated or single women compared to 4% of married women, sexual 3.4% divorced, 5.8% separated, 4.6% never married compared to 0.9% married).

Women who had experienced physical or sexual abuse as a child were more likely then women who had not experienced child abuse to experience both physical and sexual violence: physical abuse 15.1% compared to 5%, sexual abuse 4.5% compared to 1.5% (Coumarelos & Allen 1999).

Strengthening attitudes opposing domestic violence in culturally diverse communities
A study in SWSAHS and CSAHS showed that in four NESB communities there was less awareness that domestic violence was a crime and less awareness of the seriousness of all forms of domestic violence when compared to national surveys of the general population. This study demonstrated that significant improvements in awareness and attitudes are possible where campaigns are culturally specific and involve the community in planning and implementation. The Strengthening attitudes opposing domestic violence in culturally diverse communities campaign has received national recognition as a model for health promotion work with culturally diverse communities (Lane 1998).

Lesbian and bisexual women

Lesbian and bisexual women face specific difficulties around accessing health and other social support services. Health and other workers often assume that all women identify as heterosexual. Because of the stigma attached to homosexuality many lesbian and bisexual women keep their sexual identity a secret. They may be reluctant to disclose their sexual orientation to health professionals or seek health care, and may be very concerned about issues of client confidentiality. This can have a major impact, on their sexual health, for example. It can also impact on the health service recognising and supporting their partner during periods of ill health, or on the health service recognising parenting rights and responsibilities of same sex partners. Stereotyping of lesbians may lead to workers thinking that because a woman is a lesbian she will behave in a "butch" manner, that she will not be married or have children, or that she will be sexually aggressive. Just as with heterosexual women however, lesbians come from all walks of life, have a rich diversity of cultures, and behave in many different ways.

There are still many social, religious and cultural attitudes, practices and beliefs that condone discrimination against homosexual people. For example, until recently in NSW there were laws forbidding consensual sex between men and many religious organisations will not employ lesbians or gay men. Fear of and experience of discrimination has a significant impact on people’s emotional and mental well-being. Whilst there are often many social supports available to heterosexual people in times of crisis, lesbian and bisexual women may find themselves very isolated within the community. Even within their own families many lesbian and bisexual women are vilified and isolated because of their sexuality. The effect of homophobia within society means that lesbian and bisexual women are at greater risk of violence and personal attacks, for example at school or in the community, have greater risk of abusing alcohol and other drugs as a way of coping with discrimination, and are at greater risk of mental and emotional ill-health and suicide (Vidler 1999; SWSAHS 1997).

2. Life cycle factors

Younger women

The Women’s Health Australia Longitudinal Study found that for young women 18-25 the most common causes of stress were money, study and work/employment issues and the most common way of coping was talking to a good friend. Almost 20% of the cohort reported eating (more or less) as a way of coping with stress. Mental health scores were very low for women who reported unhealthy eating practices and high levels of stress, and for women, (33% of the cohort) who reported three or more risk characteristics (Brown et al 1998).

Strong associations have been found between levels of mental disorder in young people and parental relationships, family violence, abuse, stressful experiences in life and adverse school environments (FLYHT 1998).

Smoking in younger women is a health issue, with 21% of women aged 12-17 years self reporting smoking recently (Schofield et al, 1998). The same study noted the continuing trend for more females to take up smoking than males. Women who smoke are over 20% more likely to report serious chronic illness (NHS 1992). Smoking rates are particularly high for Aboriginal women (42%). Death from lung cancer is second only to breast cancer for women’s cancer deaths and whilst deaths from lung cancer for men are falling, the number of women dying from lung cancer is increasing markedly. Chronic illness as a result of smoking is likely to continue to rise as the delayed effects of increased smoking rate for women become apparent.

General health issues for young women include:

Smoking

Drug and alcohol abuse

Diet and weight issues

Pregnancy, sexual and reproductive health

Sexuality, relationship issues and safe sex

Depression

Suicide

Behaviour problems

Body image and eating disorders

Violence and sexual assault

Older women

The Older Women’s Wellness Program provides a positive model for promoting health and well being for older women. It supports the view that it is quality of life that is the most important contributor to older women’s experience of health. "The feeling of wellness gives back to the older woman a sense that she can live with fullness and richness in her life, despite perhaps chronic ill health, despite reduced income, despite physical or mental insecurity. That feeling can restore what our culture sometimes denies – a sense of dignity, of uniqueness, of visibility, of power". (Adamson 1997 p6)

Because of women’s longer life expectancy, older women are more likely to suffer physical and mental disability and social isolation. Arthritis, dementia and osteoporosis are significant issues for older women. They are also less likely than men to own their own home or to have financial resources apart from government benefits. Sex role stereotyping means that many older women are dependent on men for transport and money management and when their partner dies they face many difficulties in independent living. Many older NESB women have poor English language proficiency which may contribute to social isolation. Major communities with a population over the age of 65 who spoke a language other than English at home include Italian, Vietnamese, Cantonese, German, Arabic and Polish.

Despite health and social difficulties associated with ageing, older women are very resourceful. The Women’s Health Australia Longitudinal Study found that for every measure of emotional health, older women (70+) scored significantly better than young and middle aged groups. They were less likely to feel depressed or anxious and more likely to feel positive about their lives than their younger counterparts. The women in the study reported that it was family and friends that added meaning to their life, pointing to the benefits of good social support (WHA 1997). It is important to build on older women’s resources and strengthen preventive programs such as physical activity programs that help prevent osteoporosis and promote flexibility, physical strength and positive social networks.

3. Specific health issues

Reproductive health

In 1997 14.4% of all births in NSW were to women from SWSAHS which also had the highest proportion of normal vaginal deliveries (76.3%). Five percent of SWSAHS births were to young women aged 12-19. The average length of stay post confinement continues to fall varying, in 1996, from 5 days for women giving birth in Bankstown Private Hospital to 2.8 days at Campbelltown Hospital compared to an average of 4 days for all NSW Hospitals.

SWSAHS has a large proportion of births to women from non-English speaking backgrounds (38.1%). NESB women are less likely to be smokers and rates of teenage pregnancy are lower for NESB women, however some groups access antenatal care much later than others. Eighty-seven percent of women born in English speaking countries commenced antenatal care before 20 weeks, compared to 55.7% of women born in Melanesia, Micronesia and Polynesia and 67.2% of women born in the Middle East and Africa. Women born in Melanesia, Micronesia and Polynesia had the highest rates of prematurity (7.9%) and their babies were far more likely to be stillborn or die in the perinatal period. Women from these countries were more likely to suffer from pregnancy induced hypertension (7.3%), gestational diabetes (7.6%) and post-partum haemorrhage (8.6%). Women from the Middle East (5.8%), SE Asia (7.9%), NE Asia (9.7%) and Southern Asia (8.7%) were also more likely to suffer from gestational diabetes compared to English speaking women (2.2%).

In 1997 in SWSAHS there were 89 confinements for women identifying as Aboriginal or Torres Strait Islander, and 21.3% of these were aged less than 20. Only 55.1% of ATSI women commenced antenatal care before 20 weeks gestation. Fifty-three percent of ATSI mothers reported smoking during pregnancy. Low birth weight prevalence rates, for ATSI babies (less than 2,500grams) born between 1993-97, were almost double those for non-ATSI babies, 11.8 compared to 6.0. Pleasingly, in 1997 low birth weight rates for ATSI women in SWSAHS were the lowest in the State (7.9%) and comparable to low birth weight rates for NSW overall (6.1%). In 1997 SWSAHS also had the lowest ATSI rate of prematurity (9%) compared to other Area Health Services. (NSW DoH 1998; NSW DoH 1999a).

It has been estimated that 25% of all pregnancies are terminated (Adelson 1996). Based on these estimates it is reasonable to assume that as many as 4,000 terminations of pregnancy are performed annually on SWSAHS residents, with only a small proportion being performed in public hospitals. There is a severe shortage of free, good quality termination services in SWSAHS. Adelson calculated the age standardised termination rates by Area Health Service and found that Central Sydney, where the majority of termination services are situated, had the highest termination ratio (1.97), almost double that of SWSAHS (1.1). Termination rates are highest for young women 15-19 years and women 40-44 years (Madden 1994). Although only 4% of women in Adelson’s study were having second trimester abortions, 30% of these were to teenage women. This suggests that there are significant barriers for young women in accessing termination services and highlights the need for locally accessible and affordable termination services.

Breast and cervical screening

Biennial cervical screening rates, from the NSW Pap Test Register, for the period ending March 1999 (55.2% for women 20-69 years) in SWSAHS are low compared to the rest of NSW (59.6%), especially for older women 50-69 (48.5% compared to 55%), (NSW CSP). Within SWSAHS, Fairfield 52.6%, and Liverpool 53.4%, had rates significantly lower than the rest of SWSAHS, whilst Camden 64.9%, and Wingecarribee 62.9%, were significantly higher than the rest of the AHS. Although the incidence of cancer increases with age, older women are less likely to attend preventive screening.

Considerable progress has been made in increasing self-reported awareness and practices around breast and cervical screening for NESB women. In the 1995 Health Survey only 5.6% of NESB women reported they had never heard of a mammogram and 11.1% of NESB women said they had never heard of a Pap test compared to 49.7% and 22.4% respectively in the 1989 survey (SWSAHS1998b).

The SWSAHS Cervical Screening Strategic Plan identifies older women, Aboriginal and immigrant women as priority groups for increasing recruitment. GPs are essential partners in improving screening rates within SWSAHS.

The Pap Test Register does not keep data correlated by ethnicity. However differences in screening rates for mammography suggest that there may be an unacceptable differential between participation of English Speaking Background women and Aboriginal and non-English speaking women. For mammography screening the current 2 yearly participation rates for ESB women 50-69 is 48%, compared to 35% for NESB women and 22% for ATSI women. Screening mammography rates for SWSAHS are lower than NSW overall. Whilst this in part reflects our greater population, and the length of time since the introduction of the screening program in SWSAHS compared to other areas, it also reflects the socio-demographic profile of the community.
SWSAHS recently conducted a successful recruitment campaign for Vietnamese women and this model will be used when working with other NESB groups. The campaign involved radio and print advertising and community education. The post campaign survey showed that more women recalled hearing a message about pap tests after the campaign (85%) than before (56%). Of those who recalled hearing the media messages, 36% reported attending for screening compared to 16% before the campaign. In 1999-2000, in partnership with WSAHS, the Area will implement a recruitment campaign for Serbian, Croatian, Bosnian and Macedonian speaking women.

The data on breast and cervical screening illustrates some of the difficulties in measuring health outcomes for women even where good data sources exist. It is not possible to accurately measure the impact of cervical recruitment campaigns for specific groups as the Register does not record ethnicity. Data from BreastScreen Western is also problematic with markedly different figures for screening depending on whether country of birth, or language spoken at home, is considered.

Disability

In 1993, 17.6% of Australian women reported having a disability with the most frequently reported disability being arthritis (20.1% of women). Women experience more years of disability, handicap and severe handicap due to their increased life expectancy and the relationship between disability and ageing (Madden 1994). Sixty-two percent of carers of people with a disability are women, with mothers being 12 times more likely than fathers to be caring for children with a handicap. The baseline survey for the Women’s Health Australia Longitudinal Study found that in SWSAHS 17.7% of women aged 45-60 and 12.6% of women aged 70-75 reported that they regularly provided care to another person because of long term illness, disability or frailty. Carers are more likely to report poor or fair health especially related to emotional and social strain and, to a lesser extent, physical and financial strain. The 1993 ABS Disability, Ageing and Carers Survey found that 46% of all people with disabilities aged 15-59 were dependent on government pension or benefit, compared to 17% for the rest of the community.

According to the 1994 National Aboriginal and Torres Strait Islander Survey (NATSI), 0.9% of ATSI people have a severe or profound participation restriction (handicap). This rate increases sharply with age and the age at which this happens is considerably younger than the rest of the population. The NATSI Survey estimated that at 45 years, 10.4% of people had a severe or profound participation restriction compared to 3.6% of the same age in the rest of the population. (SWSAHS 1999b).

Mental and emotional health

A greater proportion of women than men report mental disorders with women not in the labour force being most likely to report mental disorders. Women are more likely to suffer major depression, agoraphobia, panic disorder and obsessive-compulsive disorder. Only anti-social personality, and alcohol abuse and dependency are suffered more by men. Schizophrenia is suffered by both in equal proportion. Twice as many women as men use sleeping medications and tranquillisers/sedatives for a variety of health conditions and twice as many women than men use them specifically for "mental disorders". Women are more likely to use psychiatric services then men and women who are hospitalised with mental disorders have longer average lengths of stay (Madden 1994; Moore 1992, SMH 1999).

One explanation for this is that use of psychotropic medications is more culturally acceptable for women, and that women are more likely to acknowledge emotional problems and seek help, than men are. Men are more likely to use alcohol as a form of culturally sanctioned self-medication. Another explanation is that women have more reason to be depressed or anxious and that this is related to gender roles. In this view mental illness is "a condition which reflects the inequalities and exploitation that exist in contemporary society and the oppression of women in particular: it is a product of women’s disadvantageous social situation, and, indeed, a measure of it" (Busfield 1988, quoted in Moore 1992).

A study of self-harm in Aboriginal and non-Aboriginal single mothers living in public housing suggests that it is social indicators, rather than cultural, ethnic or mental health considerations, that are critical in understanding self harm. These social indicators include: severely constricted life chances characterised by lack of amenities for urban communication and interaction (eg, transport, phones, poor housing); financial difficulties; family composition and history; poor quality of former relationships leading to lack of trust and "no close friends"; past sexual and physical abuse; failure of helping agencies and perceived and actual oppression eg from the police in the case of Aboriginal women (Radford et al 1999)

Stress related to gender roles that may contribute to higher risk of depression includes physical and sexual assault, sexual harassment and discrimination, unwanted pregnancy, divorce, poverty and powerlessness. Epidemiological studies link mental disorder with alienation, powerlessness and poverty. The highest levels of psychiatric disorder affect married women not in the workforce and women working in low status jobs with little power and control (ibid).

Male suicide rates are higher than the female suicide rate. However women attempt suicide at a higher rate than men. Of 6944 episodes of inpatient care in 1995-96. almost two thirds (4028) were for women. Rates for attempted suicide increased by 80% for men and 115% for women over the 1991-1996 period (NSW DoH 1997c).

Women and substance abuse

Generally speaking women are less likely to consume alcohol at high risk levels (3.1% of women compared to 9.6% of men), and to use illicit drugs (11% of women compared to 19% of men). Use of alcohol and illicit drugs is highest in younger age groups. In contrast women are more likely to use medication for sleep and to be prescribed tranquillisers or sedatives and this increases with age (Madden 1994). Alcohol affects men and women differently because of their physical differences. A woman is likely to become intoxicated more quickly than a man is after drinking the same amount of alcohol. She is also likely to maintain a high blood alcohol level for a longer period of time.

According to the 1998 National Drug Strategy Household Survey, nearly 40% of the female population aged 14 years and over drink alcohol on at least one day each week. Compared with the1995 survey, there appears to be slightly higher use in 1998 across all illicit drugs groups included in the survey, both in terms of lifetime use and use in the last 12 months. Young females accounted for a large part of the overall increases in use of illicit substances (notably marijuana/cannabis), and it appears that for some substances female use is now on a par with use by males. Between 1995 and 1998 the proportion of the population aged 14 years and over who had ever used an illicit drug increased from 39% to 46%. The increase in overall prevalence rates in 1998 is partly explained by younger females matching their male counterparts in rates of usage between 1995 and 1998 (AIHW 1999).

Substance abuse, especially injecting drug use, places people at greater risk of contracting HIV/AIDS, Hepatitis C and other sexually transmissible diseases. Women who are affected by substance abuse have special concerns. They are at greater risk of physical and sexual assault, poverty, imprisonment, homelessness and social discrimination. Child sexual and physical assault is in itself a significant risk factor for adult substance abuse and mental and emotional ill health. The social stigma associated with drug and alcohol abuse means that many people are reluctant to approach health or other support services because of fear of discrimination or fear of losing their children.

Alcohol and other drugs are sometimes used as a form of self medication by people affected by mental illness. Psychiatric disorders, especially depression and anxiety disorders, are frequently associated with alcohol abuse among women. A history of being abused, emotionally, physically, or sexually is often associated with women who suffer from both a mental illness and substance abuse. Such women may face a variety of associated difficulties that require intervention, including other health-related problems, housing instability or homelessness, and the effects of past or current physical or sexual abuse. Women affected by mental illness and substance abuse are more likely to report being victims of crime, compared with their male counterparts. The impact of the victimization exacerbates their problems. They tend to stay in treatment less time than those without such a diagnosis and therefore to have more relapses and poorer outcomes. These findings suggest that women with a dual diagnosis need a substantially different treatment paradigm from men (Hall & Farrell 1998; Merikangas & Gelernter 1990; Reiger et all 1990).

Women affected by substance abuse have particular needs during pregnancy and post-natally but often experience inadequate prenatal and postnatal care. Women affected by substance abuse are at increased risk for ectopic (tubal) pregnancy, stillbirth, low weight gain during pregnancy, miscarriage, hypertension, anaemia and other medical problems. Their newborns may have lower birth weight and smaller head size than babies born to other mothers, and may have a chemical dependency requiring treatment.

A gender approach within an equity framework
A major factor in keeping women affected by drug and alcohol abuse from seeking or accepting treatment is their role as caretakers of children, elderly parents, or other relatives. Women also may not seek treatment out of fear of prosecution by the legal system, and fear they will lose their children, concerns that are well-founded.

Even when women do seek treatment, they face long waiting lists and find that many programs will not accept pregnant women or those with children. When women can find and do accept treatment, they benefit most from programs that address not only their chemical dependency and mental illness, but also provide services that meet their basic needs, such as food, clothing, shelter, child care, and medical care.

A gender analysis of drug and alcohol issues and a collaborative approach to the social determinants of health will greatly inform the development of the new SWSAHS Drug and Alcohol Plan.

Children of women affected by substance abuse are at risk with studies showing an increased risk of suicide in young people who have a history of family discord and violence, parental alcoholism or imprisonment, physical or sexual abuse and being placed in substitute care during childhood (SWSAHS 1997). The 1998 National Drug Strategy Household Survey found that children of parents who used cannabis or other illicit drugs were much more likely to use such drugs themselves compared to other children (AIHW 1999).

Child protection and child development issues are a major concern for women affected by substance abuse, or where their partner is affected by drug and alcohol abuse. There is a clear need for Drug and Alcohol services to be working in close partnership with other health services, for example, by providing play groups for women and children attending methadone programs, outreach services for immunisation of young children, easy access to advice and support around issues relating to pregnancy and breastfeeding, safe detoxification services and proclaimed places for women, and housing support.

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