DETERMINING NEEDS By considering and evaluating a variety of different data sources health services can make more informed decisions regarding service planning and delivery. TABLE 1: Identified Health Issues for Women HEALTH STATISTICS (Potential Years of Life Lost 1994) WHAT THE WOMEN SAY (Brown & Doran 1996) WHAT KEY INFORMANTS SAY (Brown & Redman 1995) Breast Cancer Heart Disease Motor Vehicle Accident Lung Cancer Suicide Tiredness PMS, Period Pain, Heavy Periods Stress, Anxiety, Depression Weight and Exercise Disturbed Sleep Arthritis Menopause Smoking Control of reproductive health Domestic Violence Mental Health Body Image & Eating Disorders Menopause Smoking among Young Women Screening for Breast & Cervical Cancer NSW DoH 1999b Table 1 indicates that women, health statistics and key informants can give a varying picture as to what constitute major health issues for women. When we look at the issues identified, we find that there are links and relationships between the three sources of information. Obviously, smoking and lung cancer reflect the same health issue, and stress, disturbed sleep and motor vehicle accidents may be related. When considering these issues from a gender perspective, the effects of sex-role stereotyping on the relationship between smoking, anxiety, stress, weight gain and body image for young women can be explored. Women participating in the Women’s Health Australia Longitudinal study identify different health problems than those reflected in mortality statistics (see Table 2). This national study of 41,500 women will examine six cohorts of women over a 20 year period. The five main themes of the study are: time use health, weight and exercise violence against women life stages and key events use of, and satisfaction with, health care services. Table 2: Most common problems reported by women Young women 18-22 years Women 45-49 years Older women 70-74 years 58% Headaches 51% Constant tiredness 45% PMS 40% Allergies 40% Severe period pain 39% Back pain 34% Difficulty sleeping 31% Skin problems 28% Heavy periods 23% Irregular periods 57% Headaches 54% Back pain 53% Constant tiredness 53% Stiff/painful joints 48% Difficulty sleeping 45% Eyesight problems 43% Allergies 41% PMS 34% Hot flushes 29% Heavy periods 67% Stiff/painful joints 55% Back pain 50% Difficulty sleeping 48% Eyesight problems 41% Poor memory 41% Constant tiredness 39% Indigestion/heartburn 35% Allergies/hayfever 32% Headaches 27% Skin problems Women’s Health Australia 1997 A 1999 survey of generalist, non-government organisations and women’s health services in SWSAHS identified the following priorities for women’s health: Health of Aboriginal and Torres Strait Islander women Health of socially disadvantaged women Health of migrant and refugee women Addressing the social determinants of health Increased research around women’s health issues Violence against women Increased resources and funding for women’s health. The Epidemiology and Surveillance Branch of the NSW Department of Health has produced a profile of key population health status and demographic indicators for each Area Health Service. These provide age adjusted rate ratios for national and state key priority areas. Table 3 presents the data for SWSAHS where women’s health indicators are significantly higher or lower than the NSW rates. These data are drawn from the 1996 census, the ABS mortality and population estimates (HOIST), the NSW Inpatient Statistics Collection and the 1997 NSW Health Survey. They give a profile for the whole population of women in SWSAHS and it is important to remember that actual rates are likely to differ significantly when examining sub-populations - smoking in pregnancy in young Australian born women or Aboriginal women, for example. Table 3: Significant differences between SWSAHS and NSW for women Significantly higher age-adjusted rates Significantly lower age-adjusted rates Languages other than English spoken at home (37.7%) Children 0-9 Coronary heart disease mortality (114.2) and separation (110.2) rates 25-74 years Unstable angina rate (121.2) Stroke (112.6) Diabetes mortality (148.3) Adequate daily intake of breads and cereals aged over 16 years (103.5) Socio-economic status (IDRD = 959) Very good or excellent self reported health women over 16 (88.0) Breast cancer incidence (88.2) and mortality (89.5) Screening mammogram 50-69 years (86.7) Colorectal cancer incidence (84.0) Melanoma incidence (69.3) Cervical screening 20-69 (93.3) Road transport-related injuries separations (85.7) Sports injuries separations (80.7) Self reported smoking in pregnancy (72.0) Alcohol related conditions separations (80.3) Adequate levels of physical activity (81.4) Often or always wear hat or cap in sun aged 16 years and over (82.9) Often or always wear sunscreen 16 years and over (90.7) NSW DoH 1999a Health and social status data and the views of women expressed in community consultations and surveys such as the Longitudinal Study show that a broad social approach to women’s health is needed if the issues of concern to consumers as well as epidemiologists are to be addressed. Determining priorities for women’s health is a complex process involving identifying needs, utilising or developing evidence based practice, consumer participation, an emphasis, wherever possible, on population based preventive programs, maximising efficient use of resources, and considerations of social justice. WOMEN’S HEALTH PROGRAMS & SERVICES A number of programs have ongoing implications in terms of determining priority issues and funding resources for women’s health. These include the: NSW National Women’s Health Program (now incorporated into the Public Health Outcomes Funding Agreement) NSW Cervical Screening program NSW Mammographic Screening program NSW Female Genital Mutilation program Aboriginal Family Health Strategy Alternative Birthing program In addition there are a number of policies and reports that require ongoing actions including: The Report on the Needs of Adult Survivors of Child Sexual Assault The Revised Draft NSW Domestic Violence Policy. SWSAHS has a small number of designated women’s health staff including Women’s Health Nurses and Women’s Health Promotion workers. In addition it is funded for specific programs including the Cervical Screening program, the Bilingual Community Education Program in Women’s Health, and Karitane Child and family Services. Antenatal, maternity, post natal, and a broad range of gynaecology services are provided in each sector. Cancer services specific for cancer in women are also provided. Women are major users of generalist services. The Families First initiatives across SWSAHS will have a major impact on the health of women and their dependant children. There are a number of non-government Women’s Health services, some of which have a specialist focus. These include the Bankstown Older Women’s Wellness Program; the Benevolent Society Domestic Violence and Mid to Older Women’s Health teams in Campbelltown; the Immigrant Women’s Health Service, Fairfield Multicultural Family Planning and Karitane in Fairfield. The generalist Women’s Health Centres, in Bankstown, Liverpool and Campbelltown, offer a range of clinical, counselling and health promotion services. Other community based women’s support services, such as the women’s refuges and supported accommodation services, and community based drug and alcohol services, for example DAWN, an accommodation service for women recovering from drug and alcohol abuse, also play a major role in women’s social and physical wellbeing. SWSAHS has a close partnership with the NGO Women’s Health Services and the Strategic Framework will strengthen and provide direction for further collaborative work around women’s health issues. The SWSAHS Strategic Framework for Women’s Health provides direction for both specialist women’s health services and generalist services over the next five years. Table 4: Women’s Health Services in SWSAHS   Women’s Health Nurse Consultant / Specialist Women’s Health Promotion NGO Women’s Health Services Bankstown 1* 1* 1 (Aboriginal focus) Bankstown Women’s Health Centre Bankstown Older Women’s Wellness Centre Fairfield 0.4 1 0.6** Immigrant Women’s Health service Fairfield Multicultural Family Planning Karitane Liverpool   0.6 Liverpool Women’s Health Centre Macarthur 2   WILMA Women’s Health Centre Benevolent Society Centre for Women’s Health (Domestic Violence team; Mid to Older Women’s Health team; Young Women who are Parents; Advocacy, Resource & Training Unit) Wingecarribee 1     Area Services Area Coordinator Women’s Health Bilingual Community Education Coordinator 0.5 Bilingual Community Education Training & Development 0.5 Area Cervical Screening Coordinator 0.6   * Also covers Liverpool Health Service ** Also covers Bankstown and Liverpool Health Service STRATEGIC DIRECTION 1: Incorporate a Gender-Based Analysis of Health within an Equity Framework to further a shared sense of direction and responsibility Gender has a significant impact on health. Gender is distinct from sex, that is the biological existence of being female or male. Gender refers to the values, norms and expectations that society attributes to being female or male. Gender leads to different social, political and economic opportunities for women and men. These are not always equal and may change over time. Sex-role stereotyping related to gender is associated with discrimination and disadvantage for women. Existing biases within the health system may advantage some groups and disadvantage others. A consideration of the impact of gender as a factor influencing health is necessary at every level of health intervention. A gender approach proposes that women’s and men’s interactions with each other and the circumstances under which they do so, contribute significantly to any sex differences in health opportunities and constraints. The combination of a person’s biological sex and the influence of gender on their cultural, economic, and social lives will put individuals at risk of developing some health problems, while protecting them from others. Where gender differences lead to inequalities, they can create, maintain or exacerbate exposure to risk factors that endanger health. They can also affect the access to and control of resources, including decision making and education which protect and promote health. A GENDER APPROACH TO HEALTH A gender approach to aged care services, for example, would involve assessing the differing needs of older men and women. Since women generally live longer than men they suffer more years of severe disability. They generally have fewer financial resources and they still may have a carer role in regard to their partner or children. They are more likely to be widowed and suffer social isolation. Because of their social position within the family, many older women may be dependent on others for transport. They may not have had access to managing finances and this can cause difficulties for them if their partner dies. In contrast, older men who are widowed may need help with living skills such as cooking, forming good support networks, and caring for their own health. They may lack good friendship networks. Older men may face a crisis of confidence once they retire from the paid workforce and need help in finding a meaningful occupation. They may have specific health needs associated with prostate cancer and other issues of ageing. (NSW DoH 1998) Adopting a gender approach to health is essential in order to identify and act on inequities that arise from belonging to one sex or the other, or from the unequal relations between the sexes. In 2000, NSW Health will release the Gender Equity in Health Policy, and Gender Equity Checklists for policy and frontline service staff, to assist in this process. An essential component in working with our community and staff to develop a shared sense of direction for women’s health, is increasing our capacity to incorporating a gender analysis within an equity framework when working to improve the health of women. Whilst this Framework concentrates on women’s health, a gender approach has obvious applicability to men’s health issues also. INTENDED OUTCOME Identification of and improved response to inequalities that arise from belonging to one sex or the other, from unequal relations between the sexes, from sexual orientation, and from inequalities between women. The following strategies will further the development of a gender approach to women’s health. KEY INITIATIVES SWSAHS to promote the Strategic Framework for Women’s Health and publicise the progress of its implementation. Strategies/Key initiatives: Incorporate gender-based analyses within an equity framework in program and service development Develop the capacity of staff to implement the Strategic Framework through their active engagement in education and training around the impact of gender, and other social determinants, on health Support the implementation of the Gender Equity Guidelines (currently being developed by the Dept. of Health) and checklists on how to incorporate gender equity into health care policy and practice Implement strategies to redress health inequalities for women Further develop models of women’s health care that are gender sensitive and publicise them widely. Have well organised, understood and utilised processes of community participation and information dissemination around women’s health issues Annual presentations/reports from each Sector on progress in implementing Strategic Framework for the Women’s Health 2000-2005.   STRATEGIC DIRECTION 2: Work in Collaboration with Others to Address the Social Determinants of Health The health of women is determined by a range of social, environmental, economic, cultural and biological factors. Health programs and policies have a tendency to emphasise the biological aspects of health care, focusing on the bio medical models of diagnosis, treatment and prevention of an individual’s ill health. However as health is influenced by a range of factors including sex, race, age, ability, socio-economic status, location, gender and culture and class, the need to identify and explore the impact of these social determinants on the health status and health behaviour of women is critical. There are clear links for, example between socio-economic status and ill health, between age and sexual orientation and violence and between Aboriginality and social and health disadvantage. Awareness of the range of these factors and their association with various health issues is acknowledged as essential in improving the health of women. Different health responses are required depending on which factors are dominant or interacting at a given time to influence health. Health issues within this broad context are best addressed in a cooperative way by many groups and sectors. The way forward in women’s health means a commitment to working collaboratively with government and non-government agencies and the community on the range of factors influencing the health of women. Working in collaboration will improve the capacity of the health system to maximise health outcomes for women. SWSAHS has already shown its capacity and commitment towards working in partnership with others to address the social determinants of health, through such initiatives as the Miller and Claymore projects and the Aboriginal Employment Strategy. INTENDED OUTCOME Increased knowledge of the links between health and the social context of women’s lives. Improved collaborative approaches to social change for women positively impacting on the health of women. The following strategies will further the development of a social determinants approach to women’s health. KEY INITIATIVES SWSAHS to develop best practice models of intersectoral women’s health programs, based on partnership models and including community groups, to address social determinants of women’s health including, unemployment, violence, housing, access to services and social supports. Strategies/Key initiatives: Seek direction from consumers and service providers in determining the best ways to address the social determinants of health within specific communities. Facilitate skill development among women to enable community advocacy, control and action on issues of concern and support community action on such issues where appropriate. Continue to improve work opportunities which reduce the negative health consequences of unemployment, especially for Aboriginal, disabled, young and long term unemployed women. Promote improved health through good management practices, which lead to increased levels of control, variety of work tasks, appropriate use of skills, and flexible work practices in the workforce. Participate in whole of government initiatives concerning the status of women, such as anti-discrimination, anti-violence and Aboriginal Reconciliation initiatives, and work within the regional network of Violence Prevention Specialists. Continue to work in partnership with other government and non-government agencies and with members of the local community to improve the social and health status of disadvantaged communities eg, Miller and Claymore projects. Extend and strengthen partnerships with other government and non-government agencies and Divisions of GPs to address women’s health status and the social determinants of health. Promote policies and programs to reduce the fear of crime and violence and create safe environments for living. Promote the development of high quality, affordable public transport networks. Promote the recognition of skills and resources and opportunities for community development in different communities eg Aboriginal communities Each Sector to identify and report on at least two programs that address the social determinants of health for women in annual business planning. Promote reporting structures that recognise a broad range of strategies including advocacy, partnership structures, community engagement and building trust and cooperation.   STRATEGIC DIRECTION 3: Advance Research on Women’s Health Experience and Morbidity It is important to ensure that the health needs of women are adequately represented on the health research agenda. Research topics funded in epidemiological and clinical research areas have been criticised for not being equally relevant to both sexes and that women are not always included in appropriate numbers among the subjects, or excluded altogether. In non-reproductive health areas, research has often excluded women due to the variability associated with pregnancy and menstrual cycles. These conditions represent normal states for most women and therefore should be included in study designs as appropriate. Ensuring that women are visible in the collection of routine statistics and that women are included in the design and implementation of research studies, will further the understanding of women's health issues. Routine data correlated with sex will inform the knowledge base of health care providers and researchers. Similarly if the diverse needs of women are to be understood, data should also be correlated with socio-economic status, ethnicity and age. Highlighting Diversity: NSW Review of Services for NESB women with Postnatal Distress and Depression This qualitative study involving NESB mothers and health professionals identified additional risk factors for NESB women that contribute to developing postnatal distress and depression: Migration Isolation due to language and culture Conflict between traditional practices and those advocated by Australian health services Cross cultural marriages Refugees with a history of torture and trauma Gender of the baby. It also identified strategies health services can implement to reduce the risk of postnatal distress and depression for NESB women (McCarthy 1996). The recognition of sex differences in health status has led to the study of those conditions which tend to be significantly more prevalent in one sex or the other, for example, breast cancer in women. The emerging challenge is to understand all health issues through a gender analysis. Future research is needed to examine the way in which gender impacts on a wide range of NSW priority public health issues. Such research is necessary in order to determine the critical health issues for women and the impact of gender on health outcomes. Research must also consider the many factors influencing women’s health including ethnicity, class, sexual orientation, age and disability. Research which reflects the diversity of women’s experiences of health is best placed to inform and enhance the provision of a health care system that is responsive and inclusive of factors determining health including gender. Resources need to be committed to research to obtain improved health gain for women. Such research will inform the planning and development of women specific services and services addressing health gain for women. It will also improve the provision of all health information and health care. Sex-specific research will be required as well as research examining women and men, so that improved health outcomes can be achieved for all. INTENDED OUTCOME A more comprehensive and informed picture of women’s health needs to improve the quality and effectiveness of services and programs in improving health. The following strategies will further the development of research on women’s health. KEY INITIATIVES SWSAHS to promote further research on: the impact of gender on health, the interaction between gender and other social determinants of health, including, race, age, disability, socio-economic status, and on non-reproductive aspects of women’s health Strategies/Key initiatives: Promote the collection of data which is compiled by sex, as well as by age, socio-economic status, Aboriginality and ethnicity Initiate partnerships with research organisations to advance understanding on women’s health eg, the Women’s Health Australia Longitudinal study. Establish a women’s health research interest group Foster close communication between consumers, researchers, practitioners and policy makers to develop research programs to inform the development of women’s health Develop strategies to promote the inclusion of women as subjects and in the design and implementation of epidemiological and clinical research Promote innovative, quantitative and qualitative methods to document gender inequalities in health and health service delivery Promote research, which analyses activities across the life span to provide evidence based knowledge on the health risks of women in the home and workplace.     STRATEGIC DIRECTION 4: Develop and Apply an Appropriate Health Outcomes Approach to Women’s Health Focusing on the outcomes of a health intervention rather than the health intervention itself, is a shift from reporting activity to reporting results or outcomes. Outcomes may be intended or unintended and can be positive or negative. The development of performance indicators that can be applied to measure outcomes then become increasingly important. The process of developing performance indicators and agreed outcomes for any population group draws attention to information gaps, data quality and availability, timeliness of data and utility in everyday health practice. Developing indicators for health is difficult because health has multiple objectives and multiple outcomes. Health is the result of complex interactions between many social, economic and biological factors. Elements of an outcomes approach within an equity framework Health status: mortality, morbidity, wellness, quality of life, disability Risk factors: environmental, social, behavioural, genetic, medical, public policies Equity factors:sex/gender, access, age, employment, Aboriginality, ethnicity, location, ability Capacity indicators:infrastructure, service availability, training, program sustainability Social justice:unfair and avoidable health differentials, discrimination, resource allocation. In addition the way in which health interventions work to produce health outcomes is the subject of considerable debate. However, commitment to advance the development of performance indicators that can adequately report on women’s health outcomes is an important strategic direction in the development of women’s health in NSW. Developing a health outcomes approach must include the measurement of the social indicators impacting on women’s health eg, increased social supports in disadvantaged communities, increased access to basic services and infrastructure such as transport and childcare, increased public and private safety for women. INTENDED OUTCOMES Better data to inform evidence-based practice and enhanced quality and effectiveness of service delivery. The following strategies will further the development of a health outcomes approach to women’s health. KEY INITIATIVES SWSAHS to incorporate priority health outcomes within planning frameworks and implement programs that are consistent with these priorities. Strategies/Key initiatives: Disseminate information on priority health outcomes for women developed by the NSW Health Department and provide feedback to NSW Health on priority outcomes identified at the local level Develop and promote evidence based interventions around priority women’s health issues. Provide training and skills development around achievable and appropriate outcome evaluation of programs Promote community and NGO involvement in determining appropriate outcomes at a local and Area wide level Develop projects that identify and address the social determinants influencing women’s health outcomes Monitor and publicise outcome indicators for women’s health including: Health Status: eg, mortality, morbidity, wellness, quality of life Risk/Protective Factors: eg, behavioural, environmental, genetic, social, medical, policies Equity Indicators: eg, access, location, gender, demographic, socio-economic Capacity: eg, service availability, infrastructure, program sustainability, staff training. Continue to monitor outcomes in key priority areas including breast and cervical screening, injury, cardio-vascular disease, diabetes, mental health and physical activity,   STRATEGIC DIRECTION 5: Focus on women in most need A fundamental issue of social justice is that although the past twenty years has seen a marked increase in prosperity and substantial reductions in mortality in the Australian population as a whole, the gap between the health and prosperity of people at the top and the bottom of the social scale has not reduced or is widening (RACP 1999). Compared to other metropolitan Area Health Services, South Western Sydney is an area of social disadvantage. Both indices of socio-economic status, the index of relative socio-economic disadvantage (IRSD) and the index of education/occupation (EDUCOCC) show that SWSAHS is below average. Women are much more likely to be on low incomes compared to men. Indigenous women have significantly worse health than non-indigenous women. Although significant improvements have been made over the past 10 years in NESB women’s understanding of and participation in preventive practices such as breast and cervical screening there is still an unacceptable differential between participation of ESB women and Aboriginal and non-English speaking women in screening programs. Although women with disabilities are more likely to suffer socio-economic and health disadvantage they are very unlikely to be specifically targeted for health improvement programs. The recent survey of women’s health initiatives across SWSAHS showed that no generalist services reported programs specifically targeted towards women with disabilities and that this was the group least likely to be specifically targeted by Women’s Health services. People with disabilities or with drug and alcohol dependency are more likely to become homeless and homelessness is associated with significantly high rates of mortality and morbidity. (Acheson 1998). A Profile of the Health of People from Non-English Speaking Backgrounds in SWSAHS has detailed information on relative disadvantage suffered in specific NESB communities. Some communities experience very high levels of unemployment, low income levels, low levels of qualifications and poor language ability. These include Vietnamese, Khmer, Chinese, Assyrian, Bosnian, Lao, Samoan and a number of minority groups. INTENDED OUTCOME Reduce health differentials affecting women and improved health services for disadvantaged women. Increased equity and social justice within health. The following strategies will further a focus on women in most need. KEY INITIATIVES SWSAHS to promote development of programs and services focusing on women with most need Strategies/Key initiatives: Develop and further consolidate partnerships with community organisations focussed on women with most needs, eg, disability services, Aboriginal organisations, NESB organisations, carers’ organisations, youth services, unemployment services, aged services, women with mental illnesses, lesbian and bisexual women, women affected by substance abuse, women affected by HIV / AIDS and Hep.C, and women affected by torture and trauma. Reduce barriers associated with gender, Aboriginality, ethnicity, ability, age, social status and geography for services and programs of SWSAHS to an insignificant level. Promote the employment of women where appropriate, especially in services where there are few female staff eg, drug and alcohol services, Obstetricians and Gynaecologists, psychiatry. Incorporate specific strategies focusing on Aboriginal women’s health issues Maintain and expand initiatives that address the health of Aboriginal women, older women, women with disability, women as carers, women of non-English speaking backgrounds and women from low socio-economic groups Promote the expansion of support and health services for women with dependant children and the flexible provision of child health and support services for women with most need Promote the development of services that address gaps and are focused on the needs of women who experience health inequities and direct funding towards such initiatives Use Annual Business Plans and performance Agreements to identify and report on strategies specifically targeted towards women with most needs. [Back to Index]