Women's Health Strategic Framework 2000-2005 ACKNOWLEDGEMENTS The SWSAHS Strategic Framework for Women’s Health 2000-2005 builds on the work already undertaken in SWSAHS, over the past ten years, to improve the health of all women, especially women who are disadvantaged. It incorporates the findings and recommendations from the Review of the SWSAHS Women’s Health Plan 1995-98. It is based on the NSW Department of Health document the Strategic Framework to Advance the Health of Women 2000-2005. Many people contributed to developing the SWSAHS Strategic Framework for Women’s Health and I would like to acknowledge their work. I am especially grateful to Chris Ellery who originally worked on developing the paper and who generously facilitated planning workshops in SWSAHS around implementing its recommendations. I would like to thank Maree Gill and Louise Webb for their work in evaluating the previous SWSAHS Women’s Health Strategic Plan 1995-98 and all those people who contributed to its evaluation. Jenni Noller and David Rich generously contributed information on women with disabilities, and women affected by substance abuse and mental illness. Cathryn Cox assisted in the development of the implementation plan. Over 120 people attended the consultation forum on the draft document or have made written comments and critical suggestions for improvement. Wherever possible these comments have been incorporated into the document. The review of the current plan and development of the SWSAHS Strategic Framework for Women’s Health 2000-2005 has been done jointly with the review of the Health Plan for non-English Speaking background Communities in South Western Sydney 1995-98. I would like to thank the members of the steering committee who have generously contributed their time and expertise to this process. The members of the steering committee were Helen Edwards, Area Director Nursing & Clinical Services (Chair); Lyn Bearlin, A/Multicultural Health Coordinator; Margo Moore, Women’s Health Coordinator; Kim Coady, Aged Care Services; Jeff Flack, Bankstown Diabetes Unit; Raj Gyaneshwar, Liverpool O&G Department; Liz Harris, CHETRE; Marlene Henry, Fairfield Migrant Resource Centre; Debbie Killian, Director Bankstown Community & Allied Health; Sheila Knowlden, GP Unit; Colin MacArthur, General Manager Liverpool Health Service; Sharda Singh, Ethnic Health Coordinator; Vijaya Manicavasagar, Mental Health; Carla Saunders, Health Promotion Unit; Mark Thornell, Public Health Unit; Pam Garret, Division of Planning; Lorena Schott, Liverpool Women’s Health Centre, Prof. Ian Webster, Population Health and Anna Whelan, A/Prof. Cross Cultural Health. Margo Moore, SWSAHS Women’s Health Coordinator. TABLE OF CONTENTS: 1. OUR DIRECTION 2. OUR PRINCIPLES 3. THE POLICY & PLANNING CONTECT 4. CURRENT HEALTH ISSUES FOR WOMEN 4.1   Social factors SES status Indigenous health Cultural diversity Social support Violence against women Lesbian and bisexual women 4.2   Life cycle factors Younger women Older women 4.3   Specific health issues Reproductive health Breast & cervical screening Disability Mental and emotional health Women and substance abuse 5. DETERMINING NEEDS 6. WOMEN’S HEALTH PROGRAMS & SERVICES 7. KEY STRATEGIC DIRECTION 1: Incorporate a gender-based analysis within an equity framework to further a shared sense of direction and responsibility 8. KEY STRATEGIC DIRECTION 2: Advance research on women’s health experience and morbidity 9. KEY STRATEGIC DIRECTION 3: Advance research on women’s health experience and morbidity 10. KEY STRATEGIC DIRECTION 4: Develop and apply an appropriate health outcomes approach to women’s health 11. KEY STRATEGIC DIRECTION 5: Focus on women in most need 12. IMPLEMENTATION PLAN 13. APPENDIX 1 14. GLOSSARY 15. REFERENCES   OUR DIRECTION In June 1999 the NSW Department of Health released a Draft Strategic Framework to Advance the Health of Women. The SWSAHS Strategic for Women’s Health 2000-2005 incorporates the recommendations and directions outlined in this document. As well it builds on the work that has already been done in SWSAHS over the past ten years and incorporates the results of the recent evaluations of the existing Women’s Health Strategic Plan 1996–98 and consultations around the directions for women’s health in the new millennium. The Strategic Framework further develops the philosophical and policy frameworks that have guided women’s health in SWSAHS over this period. The way that the South Western Sydney Area Health Service (SWSAHS) addresses the health of women is integral to achieving improved health outcomes for women. Consequently, the Strategic Framework includes the eight point Guiding Principles for Implementation of Women’s Health Policy and Practice and the five Key Strategic Directions (CDCS&H 1991; DoH 1999b). These principles provide the background and articulate the assumptions implicit in developing informed, quality women’s health policy and practice that will result in achieving "Better Health, Good Health Care" for women in SWS. The five Key Strategic Directions will guide the implementation of strategies that will improve and maintain the health of women. These have been developed following extensive consultation at State and local level. They will inform the development of other Area Plans and Sector Business Plans. These Key Strategic Directions are: 1. Incorporate a Gender-based Analysis to Health within an Equity Framework to further a shared sense of direction and responsibility (Linked to SWSAHS Key Challenge 1) The term gender refers to certain roles, characteristics, responsibilities and expectations that our society ascribes on the basis of being female or male. It is broader in concept and builds on an analysis of sex differences. Gender influences different social, economic and political opportunities for women and men. Gender is also a factor that influences the use of the health system by women and impacts on women’s health status. Gender and sex role stereotyping underpins many discriminatory practices that affect women’s health and well being eg, access to education, workforce participation and income equity. It also influences how women are treated within health services and by health service providers. Williams et al (1995) conducted a major study examining gender differences in depression. It found that women were almost twice as likely as men to be diagnosed with depression &/or anxiety disorders and major &/or longstanding depressive disorders. The study also found that women diagnosed with depression were significantly more likely to be prescribed antidepressant drugs than men with the same diagnosis. Gender differences are clearly reflected in violence and sexual assault. Men are the primary perpetrators of violence and sexual assault. However men are also much more likely to suffer public violence, often associated with sporting and social events involving alcohol. Gay men and lesbians are also frequently targets of public violence arising from homophobia and the challenge homosexuality presents to masculinity and sex role stereotypes. NSW Police research indicates that gay men are four times more likely to suffer violence than other men (NSW DoH 1998). Domestic violence, in contrast, is the main type of violence experienced by women. In Australia it is still only comparatively recently that domestic violence has been recognised as unacceptable and a crime. Previously it was considered acceptable for men to discipline their wives and rape within marriage was not recognised. Many excuses are still put forward for violence against women. Equity is generally regarded as a state of fairness and justness. It requires that the specific needs of particular groups are considered separately and acted upon accordingly. For instance, while all Australians are meant to be equal in regards to their rights and treatment by government and social institutions, their needs, interests and values will differ. Gender will often be a significant factor in determining these differences. Gender analysis Gender analysis is a methodology for assessing and redressing gender bias in policies, programs and service delivery. The basic elements of gender analysis are: To identify differences and inequalities between men and women relating to who has access to work, resources, responsibilities and decision-making power: To assess differences in women’s and men’s opportunities needs, incentives, and rewards. To assess whether the institutions involved in policy making and program implementation have the capacity to advance gender equality. To identify and remove obstacles and resistance to gender equality and equity. Treating everybody in the same way may exacerbate existing inequities. However, by acknowledging and addressing different needs, interests and values, health services and professionals can work to overcome both inequities and relative inequality. Women have particular health needs associated with their reproductive role and their social role as carers. Gender is a significant element of the complex inter-relationships with other social determinants of health which result in inequality and affect the health status of women. In order to identify and act on inequities that arise from gender the application of a gender analysis to health is essential. This approach will enable SWSAHS to identify and act on inequalities that arise from belonging to one sex or the other, from the unequal relations between the sexes, from unequal relations between women, or from discrimination on the basis of sexual orientation 2. Work in Collaboration with Others to Address the Social Determinants of Health (Linked to SWSAHS Key Challenge 2) In 1996, there were substantial differences in individual income distribution of male and female residents of SWSAHS Almost 47% of women aged 15 years and over had a very low weekly income of less than $200, compared with only 30% of men (SWSAHS 1999a). The health of women is determined by a range of social, environmental, economic, cultural and biological factors. Health programs and policies tend to emphasise the biological aspects of health care, focusing on the medical models of diagnosis, treatment and prevention of an individual’s ill health. They tend to neglect the other factors, which impact on the health of women. The way forward in women’s health requires a continuing commitment to the broader range of factors influencing the health of women. In order to do this effectively, SWSAHS will work collaboratively with the community, other government departments, non-government agencies, advocacy groups, General Practitioners and the private sector. This intersectoral collaboration will improve the capacity of the health system to maximise health outcomes for women. 3. Advance Research on Women’s Health and Morbidity (Linked to SWSAHS Key Challenge 7) It is important to ensure that the health needs of women are adequately represented on the health research agenda. Research undertaken in epidemiological and clinical research areas has been criticised for not being equally relevant to both sexes and because women are not always included in appropriate numbers among the subjects or are sometimes completely excluded. Busy Mums Wanted, a qualitative study of mothers and physical activity found that lack of partner support and sex role stereotyping was the main obstacle to physical activity for women. Strategies to improve levels of physical activity for women need to focus on equity of access to leisure, sharing of domestic tasks and child rearing and increasing women’s social supports (Lo Cascio 1999. The challenge is to understand all aspects of the impact of gender on health. Research is needed to examine the way in which gender influences a wide range of priority public health issues, such as cardiovascular disease, smoking and mental health. Such research is necessary in order to determine the critical health issues for women and the impact of gender on health outcomes. This is essential if SWSAHS is to advance as a learning and teaching organisation. 4. Develop and Apply an Appropriate Health Outcomes Approach to Women’s Health (Linked to SWSAHS Key Challenge 5) Cardiovascular illness has traditionally been thought of as a major problem for men. However half of all deaths among Australian women are from CVD and 30% of these are classed as premature deaths. Women in SWSAHS have higher rates of death from CVD than men and significantly higher rates than for NSW. Research suggests that cardiovascular symptoms are liable to be investigated less thoroughly and treated less aggressively in women than in men. Oral contraceptive use for women who smoke greatly increases their risk of health attack and stroke. Age adjusted mortality rates, for women 25-64, in the lowest SES groups are 122% higher that for women in the highest SES group. An outcomes approach would look to identify and address health differentials both between men and women and between advantaged and disadvantaged women (Broom 1995; NSW DoH 1999a). The Strategic Framework recognises that health outcomes for women must take into account the many factors which influence the health experience of women, and that outcomes must be measured. Developing a health outcomes approach will mean that health services will need to identify a range of indicators, including social, economic and biological, in order to improve the health of women and, in particular, disadvantaged women. The development of indicators that are appropriate and can adequately report on women’s health outcomes is an important strategic direction to advance the provision of services to women. In developing such an approach it is essential that attention be paid to measuring what is meaningful and useful rather than simply measuring what is measurable. In many cases it will be beyond the capacity of the Area Health Service to measure health outcomes (measurement may only be possible at a State level) or such outcomes may only be measurable after a number of years eg, as part of the National or State Health Surveys. At a local level it may be more realistic to develop outcome indicators and process outcome measures and participate in the collection and analysis of data at a State and National level. 5. Focus on women in most need (Linked to SWSAHS Key Challenge 3) Reducing inequalities between women is an important step in improving the health of all women. Poverty, unemployment and social isolation are known to be important determinants of health. People from low socio-economic groups are significantly more likely to suffer disability, recent illness and serious chronic illness, and are more likely to report their health as only fair or poor when compared to people from high socio-economic groups (NHS 1992). The health of indigenous people is significantly worse than non-indigenous Australians. Many younger people are unemployed for long periods and women are much more likely than men to be in part-time employment or dependent on social The report conducted for the National Health Strategy Enough to Make You Sick: How Income and Environment Affect Health, highlighted that women of low income, when compared to women of high income are: 83% more likely to suffer disability 32% more likely to report more serious chronic illness 25% more likely to report recent illness 148% more likely to report being only in fair/poor health. security for their income. Unemployment is particularly high in some non-English speaking communities. Many migrants in SWSAHS are refugees and still suffer the effects of past torture and trauma. People with disabilities are particularly disadvantaged both in terms of their socio-economic status and discriminatory practices that affect them. Carers are predominantly women, caring for disabled children, parents and partners. Carers are generally socially disadvantaged and face significant barriers in terms of caring for their own health and well-being. A challenge for SWSAHS is to place an increased emphasis on addressing the needs of disadvantaged women (Madden 1994; SWSAHS 1999a). Applying the Strategic Framework The NSW Female Genital Mutilation program is an excellent example of how the Strategic Framework can be applied.FGM is a practice intimately connected to gender and the role of women within affected communities. It can only be understood and addressed through a gender analysis related to the social, economic and religious beliefs and practices of the communities. Preventing the practice of FGM requires work around these social determinants, developing legislation and child protection policies, informing communities about the law in relation to FGM, providing education about the adverse health effects of FGM, strengthening community networks, and developing intersectoral cooperation and partnerships between the Program and affected communities. SWSAHS is providing training for health care providers about the physical and psycho-social health effects of FGM. We are also developing local policies and protocols to better assist women affected by FGM. In this way we improve our capacity to minimise the adverse health effects of FGM. SWSAHS is working in partnership with the NSW FGM program to develop an effective communication strategy to strengthen beliefs and practices opposed to FGM. Specific research has been carried out with both men and women from the affected communities. Separate men’s and women’s working parties for each community will develop communication strategies that are appropriate and acceptable for their communities. Determining which communities are to be targeted involves assessing the level of need and making equity decisions based on the size of the affected community and the severity and extent of the practice within different communities. Outcome indicators will include: evaluating the reach and effectiveness of the communication and community education strategies; monitoring the involvement of key leaders, and men and women from the affected communities; assessing the effectiveness of professional training and the implementation of policies and procedures to assist women affected by FGM; and assessing program sustainability in terms of strengthening Area infrastructure in relation to FGM. OUR PRINCIPLES SWSAHS recognises the importance of a social view of health acknowledging the broad range of social, cultural and economic determinants that influence health. The social view of health is central to advancing the health of women. The World Health Organisation in the document, The Social Determinants of Health - The Solid Facts, (1998) stated that: "People’s social and economic circumstances strongly affect their health throughout life, so health policy must be linked to the social and economic determinants of health" The study recommends that emphasising outcomes that can identify differences in health status is necessary. It also suggests that policies to reduce health inequalities should consider the social view of health, emphasising change beyond the health system to improve people’s social and economic circumstances, and improvements within the health system. The social health model recognises and advocates action by government services and their partners on these, and other, determinants of health. Many initiatives in women’s health and a substantial body of research have highlighted the links between women’s social experiences and position within society and their health status. The impact on health of factors such as low income, participation in employment, levels of education, poorer proficiency in English, discrimination issues, limited access to affordable quality housing and child care, as well as women’s roles and responsibilities in the family sphere have been well documented (Madden 1994; NHS 1992). These issues are not inherently experienced by women as a result of biology. They arise from the social context of women’s lives. Gender and gender relationships in society need to be considered to find answers to many important women’s health issues. Gender is recognised as one determinant, which influences health status and behaviour. The patterns of health and illness in women and men show marked differences. While some differences are biological in origin, others are due to the complex biological, social, cultural and economic influences that determine health and illness. The societal perceptions of what is ‘female’ and what is ‘male’ and the roles, responsibilities, and expectations assigned to these, impact on health outcomes for both women and men. The adoption of a gender approach to women’s health will enable SWSAHS to identify and act on inequities that arise from belonging to one sex or the other, or from the unequal relations between the sexes. These inequities 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 analysis within an equity framework allows us to move beyond a "cycle of poverty" or "social disadvantage" explanation of inequality. In a "social disadvantage" model the implicit central argument is that disadvantage, poverty and its accompanying problems are the product of a self perpetuating cycle of poverty located within individuals or groups (McConnochie et al 1993). The solution then is to break the cycle for the individual at some point. In contrast a gender analysis within an equity framework locates gender within a complex inter-relationship with race, ethnicity, class, age, and disability that together have structural effects at the social level. Such a model allows us to understand the institutional structures of discrimination and disadvantage that affect women from different backgrounds and at different life stages eg, women’s access to paid and unpaid maternity leave. This model also assists us to develop strategies that challenge institutional inequality and address the social determinants of health. Figure 1 illustrates the relationship between equity and health status. The central circle includes those intrinsic factors which at different points in their lives affect people’s socio-economic status and are related to equity and empowerment. The middle and outer circles represent those factors potentially responsive to interventions leading to improvements in social and health status. A person’s health status may also adversely affect their socio-economic status and result in discrimination and inequality. Guiding Principles for Implementation of Women’s Health Policy and Practice The implementation of the Strategic Framework for Women’s Health is guided by the principles of the National Women’s Health Policy in conjunction with the Guiding Principles for Implementation of Women’s Health Policy and Practice. The principles, outlined below, provide the background and articulate the assumptions that are needed to form the basis of informed quality women’s health policy and practice (CDCS&H 1991; DoH 1999b). GUIDING PRINCIPLES FOR THE IMPLEMENTATION OF WOMEN’S HEALTH POLICY AND PRACTICE Health is determined by a broad range of social, environmental, economic and biological factors Differences in health status and health outcomes are linked to gender, age, socio-economic status, ethnicity, disability, location and environment Health promotion, disease prevention, equity of access to appropriate and affordable services and strengthening the primary health care system are necessary along with high quality treatment services Information, consultation and community development are important elements of the health process Women’s health policy must : Encompass all of a woman’s life span and reflect women’s various roles in society, not just their reproductive role, Aim to promote greater participation by women in decision making about health services and health policy as both consumers and providers, Recognise women’s rights as health care consumers, to be treated with dignity in an environment which provides for privacy, informed consent and confidentiality, Acknowledge that informed decisions about health and health care require accessible information which is appropriately targeted for different socioeconomic, educational and cultural groups, Be based on accurate data and research concerning women’s health, women’s views about health and strategies which most effectively address women’s health needs Implementation of this Strategy and any improvement in women’s health status will require the commitment and involvement of a range of agencies, based on intersectoral partnerships Development of initiatives to improve women’s health will be on the basis of need Participation by women in the planning and delivery of health services is essential to providing a high quality, equitable and responsive health system. THE POLICY & PLANNING CONTEXT Women comprise 50.4% of the SWSAHS population, are major users of health services and provide a large proportion of the formal and informal health care either through participation in the Health workforce or as health carers in the family/private sphere. The four principal goals for the NSW Health System of healthier people, fairer access, quality health care and better value, reflect a commitment to improving the health of women. In achieving "Better Health, Good Health Care" SWSAHS has identified a number of key challenges. The strategic directions for women’s health are closely related to the SWSAHS Key Challenges and are consistent with the Strategic Directions developed at State level (SWSAHS 1998; DoH 1999): SWSAHS Key Challenges SWSAHS Women’s Health Strategic Directions Key Challenge 1: Working with our community and staff to develop a shared sense of responsibility and direction Incorporate a gender-based analysis to health within an equity framework to further a shared sense of direction and responsibility Key Challenge 2: Working in partnership with other agencies to improve health Working in partnership with other agencies to address the social determinants of health Key Challenge 7: Becoming a learning and teaching organisation. Promoting a research approach to women’s health Key Challenge 5: Developing effective and efficient health services which focus on improved health outcomes Developing and implementing an appropriate health outcomes approach for women’s health Key Challenge 3: Ensuring that people in SWS access health services according to need. Focus on women with most need: eg, Aboriginal, low SES, NESB, women with disabilities, carers, older, young women. The remaining key challenges for SWSAHS "4: Making the best use of and fairly allocating resources" and "6: Attracting and retaining the best staff", are not directly discussed in the Strategic Framework for Women’s Health. However their focus underpins a number of the key initiatives proposed under the five Women’s Health Strategic Directions. Diabetes The strategic directions for Women’s Health will influence how other Area Plans are implemented. Diabetes is one example. The Strategic Framework for Women’s Health will have major implications for analysing which groups of women are currently disadvantaged in terms of prevention and management of diabetes. How diabetes services structure their services may be different for men and women and for different groups of women. The Framework points to specific research that may need to be done around diabetes issues for women and specific strategies that may need to be developed for Aboriginal women or women from some non-English speaking backgrounds. There is increased prevalence of gestational diabetes amongst women from the Indian sub-continent, Africa, Vietnam, Mediterranean countries and Egypt, for example. This approach would build on the work already being done by diabetes services to reach disadvantaged groups of women. (SWSAHS 1999a). An analysis in 1997 of existing Area Plans looking at the needs of women, Aborigines and people of non-English speaking backgrounds found that very few Plans included any analysis of data correlated with gender, Aboriginality or ethnicity. Even when such data were included, the issues identified in the data were not addressed in terms of identified strategies specifically targeted towards high risk groups. The Women’s Heath Strategic Framework provides a structure for linking with other SWSAHS population and health issues plans. The National Women’s Health Policy has guided SWSAHS’s response to the health needs of women. SWSAHS remains committed to the implementation of the National Women’s Health Policy and the principles this policy embodies. This policy remains relevant and instrumental in shaping the development of strategies aimed at improving women’s health outcomes. The National Women’s Health Policy has guided SWSAHS’s response to the health needs of women. SWSAHS remains committed to the implementation of the National Women’s Health Policy and the principles this policy embodies. This policy remains relevant and instrumental in shaping the development of strategies aimed at improving women’s health outcomes. The goal of the National Women’s Health Policy is: "to improve the health and well-being of all women in Australia, with a focus on those most at risk and to encourage the health system to be more responsive to the needs of women" The National Women’s Health Policy outlines seven priority health issues. In NSW, a range of women’s health services, policies and programs have been developed to progress these priority health issues including: reproductive health and sexuality health of ageing women emotional and mental health violence against women occupational health and safety health needs of women as carers health effects of sex role stereotyping on women. In addition, SWSAHS is directing efforts to the five key action areas in the National Women’s Health Policy, namely: improvements in health services for women; provision of health information for women; research and data collection on women’s health; women’s participation in decision making on health; training of health care providers. [Back to Index]

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