Submission to:
ACT Women’s Health Plan

Submission to
ACT Women’s Health Plan

From: Women’s Centre for
Health Matters Inc.

March 2010

Women’s Centre for Health Matters

Submission to ACT Women’s Health Plan

Introduction
The Women's Centre for Health Matters Inc. (WCHM) is a community-based organisation that works in the ACT and surrounding region to improve women's health and wellbeing. WCHM focuses on groups of women who experience disadvantage and uses social research, community development, advocacy and health promotion to empower these women to achieve the highest possible standard of health and wellbeing.

WCHM believes that health is determined not only by biological factors, but by a broad range of social, environmental and economic factors known as the ‘social determinants of health’. We acknowledge that that the environment and life circumstances that each woman experiences have a direct impact on her health, and in many cases, women’s poor health is rooted in social disadvantage. For these reasons, WCHM is committed to taking a ‘whole of life’ and social approach to women's health, that is also firmly situated within a human rights framework.  

WCHM welcomes the opportunity to provide feedback on the Community Consultation draft of the ACT Women’s Health Plan. WCHM has chosen to structure our submission against the five implementation objectives of the Plan, and will limit its responses to those areas in which it has the most knowledge and expertise. This response is supported with evidence published by the Centre and its partners on the specific needs of ACT women, and with feedback from a variety of ACT women through focus groups and other consultation processes.  

Women’s Health Advisory Network
WCHM supports the establishment of the Women’s Health Advisory Network to assist with overseeing the rollout of the implementation, and would welcome the opportunity to be part of this.    We believe our focus on improving women's health and wellbeing, our understanding of the issues for those ACT women who experience disadvantage, the access to our research results and findings, and our wide inter-sectoral links and access to a diverse range of ACT women, would be invaluable to ACT Health in helping to inform the implementation and evaluation of the Plan, and to understand the impacts on women in the ACT.

WCHM believes that whilst consultations with women are essential in planning and delivering ACT health services to women, too often the voices of those women most likely to be using these services are not heard in the implementation stages. Every effort to include the opinions of socially isolated and marginalised women in the implementation processes and formulation of policy will be essential to ensure the final results meet the needs of these women.  WCHM therefore believes that the composition of the Advisory Network should have more community representatives.

The current composition of the network also gives disproportionate weighting to ACT Health yet as we mention below in our comments on the importance of the Social Determinants all ACT government departments have a role to play in implementing the ACT Women’s Health Plan.  Both the implementation plan and Advisory Network will be more effective by including the responsibilities of other departments for working with ACT Health to address the health issues within the social, environmental and cultural frameworks. Such departments must include Transport, Disability ACT, Office of Multicultural Affairs and Housing.  

This would help the new Plan build in the connections to other ACT policies.

The document would also benefit from clarity about the operation of the Advisory Network, its links to evaluation and adapting of services and processes as well as into the expectations of ACT Health in response to advice from the community versus ‘health specialist’ feedback.

The importance of Social Determinants as an Objective
The ACT Women’s Health Plan is to be commended for highlighting the importance of the social determinants framework which includes gender.  

Health is shaped by the environment in which women live, so a strengthened health system that covers prevention, promotion, continuity of care and health maintenance must include the provision of suitable housing, affordable child care, adequate income support, community and public transport systems in terms of accessibility and social isolation, education, and a continuum of care which is affordable to all women, tailored to their individual needs and is culturally and disability appropriate as well as understanding of sexual preferences and including an awareness of mental health issues. 

Consequently all ACT government departments have a role to play in implementing the ACT Women’s Health Plan. The new Plan needs to build in the connections to other ACT policies, around such aspects as transport, housing, sport and recreation pursuits, family and community supports which all affect women’s access to health services and information.

The implementation plan will be more effective by including the responsibilities of other departments for working with ACT Health to address health issues within the social, environmental and cultural frameworks. Such departments must include Transport, Disability ACT, Office of Multicultural Affairs, Justice and Housing.  

So WCHM also recommends considering the addition of an overarching Objective that recognises the functioning of the current plan within the social determinants framework.
There are specific strategies in the document under Objective 5 which relate to social determinants.  There is also an acknowledgement of the fact that there needs to be cross sectoral collaboration (as elaborated in the strategies under Objective 3) in order to address some of the gaps in “service delivery to women.”

However as the key framework for the policy, the Objective relating to social determinants (Objective 5) is given the least priority in terms of timelines and resourcing.  June 2015 is the timeframe indicated for 5.18 and since the plan’s duration is from 2009- 2014, this will fall outside of that time frame.  This contradicts the statements in the plan about commitment to the social determinants framework as an important vision of the plan.

The social determinants framework can be better strengthened in the document by being a focus of ALL aspects of the plan rather than focuses just attention on health behaviours such as physical activity, smoking and weight issues as well as breastfeeding support.  

Marginalised groups of women
WCHM was pleased to see the inclusion within the Profile of ACT Women of the demographic profiles for two of the groups of ACT women currently experiencing significant disadvantage, marginalisation and isolation:  culturally and linguistically diverse (CALD) women and Aboriginal and Torres Strait Islander (TSI) women. 

Conversely however, we were disappointed at the absence of several other groups for whom improved access to health services and information will be essential over the life of the ACT Women’s Health Plan if they are not to be further marginalised:
•	women with disabilities, 
•	older women; and 
•	women living with mental health issues.

These groups of women need also to be discussed and their profiles given similar consideration, and specifically mentioned, for the following reasons.

•	Women with Disabilities - The recognition of women with disabilities as one of the most marginalised groups of women in the ACT is important in the context of this Plan and its strategies, as the  wellbeing of women with disabilities is limited by an inability to gain equitable access to the health system. 16.9% of the women in the ACT have a disability of which 6% have a disability that resulted in severe core activity limitation.  In the ACT 75% of women with a disability that results in core activity limitation are over 45 years of age.  There is evidence to show that income poverty, social isolation and service access are a problem for women in this cohort.  While the statistics for prevalence of service assess are not gender disaggregated, 29.3% of people in the ACT with core activity limitation had problems accessing service providers. Within the social determinants model, women in this group experience significant barriers in terms of transport, social isolation and income - all of which reduce their capacity to access health services.   There remain significant gaps in the quality of health service delivered to them because of continuing limited availability of adjustable-height examination beds in GP surgeries.

•	Older Women - As discussed in the draft Plan, the population of women is expected to increase quite significantly during the life of the plan, particularly in the 50 to 69 year age bracket. People over 65 constitute 10 per cent of the ACT population and women outnumber men in older age groups, especially in very old age.  By age 80, women outnumber men by 50 per cent in the ACT and 24 per cent of people over 65 are living in lone households, with the majority of these being female households. . A high proportion of women perform multiple caring roles and as a result, women’s experiences of old age and retirement differ significantly to that of men. Women in the older age brackets experience low income, social isolation and lack of access to health services. This 'greying' of the ACT population raises many health and social policy issues,  will increase demands on economic, healthcare and social programs and will impact on future service provision and local policy needs to cater for the even higher proportions of females as the population ages. Promoting and educating older women now on the options available to them in the ACT that will assist in maintaining good health and wellbeing, (including physical activities, social and recreational pursuits, volunteering and other community activities etc.) is one element that should be included within the parameters of the current period of the ACT Women’s Health Plan.

•	Women living with mental health issues - People living with mental health issues constitute one of the most vulnerable, disadvantaged and marginalised groups in contemporary Australian society and for women living with mental health issues, this disadvantage is two fold. In the ACT, there are approximately 23,000 women living with diagnosed mental or behavioural conditions, with 23.5 per cent of these women reporting only poor to fair health status. Fourteen thousand women in the ACT are experiencing economic disadvantage. Women with diagnosed mental or behavioural conditions are over-represented in the lowest income quintile (approximately 7,300 women). Unpartnered women with children in receipt of income support payments are more than twice as likely to have a mental disorder than the general population, and the labour force participation rate for people living with mental illness stands at just 28.2 per cent. WCHM focus groups with women with mental health issues have revealed significant difficulties in relation to seeking out health and wellbeing information, and understanding the information that they do find.  Moreover, women living with mental health issues frequently suggest that the stigmatisation, discrimination and cognitive impairment associated with their mental illness prevents them from accessing appropriate healthcare and other services or asserting their needs to healthcare providers. The draft Plan has neglected to include a demographic profile of their unique needs, or consider how the social determinants including gender impact upon their ability to maintain good health and wellbeing. 

Humanitarian and Refugee women in the ACT
In addition while CALD women are recognised as a key group there is little mention of one of the most disadvantaged groups from within that grouping. WCHM is finalising a Report titled “Navigating a Whole New World: Access to Healthcare and Utilisation of Health Services by Southern Sudanese Women in the ACT” which highlights substantial barriers to accessing health services and information for women from new and emerging communities of Humanitarian and Refugee entrants to the ACT.  

Newly arrived communities, particularly newly emerging communities, are faced with many difficulties in accessing effective health care when settling in the ACT and Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of understanding by health providers of the complex cultural concerns of refugees can all contribute to limiting access to health care

In the report and other consultations with other groups of women and service providers by WCHM, there is evidence that that low access to health services by these women is largely related to socio-cultural barriers to information seeking, inadequate or inappropriate types of information sources and lack of culturally appropriate information, which has led to a very limited understanding of the operation of the ACT health system and in some instances the women utilising the health care services as a last resort.  

The research also suggests that there is an increasing need to implement adequate and appropriately targeted health care, and that with the dynamic flux of new communities, outreach efforts must be continuously renewed and re-oriented to reach new arrivals and connect them with health services. 

Strategies also need to include greater cultural sensitivity to these groups in health care and support services.

Outcomes and Indicators
The inclusion of measurable outcomes and indicators within the Plan would ensure that the implementation is accountable.

Conclusion
WCHM congratulates ACT Health on the inclusion of women’s access to, and satisfaction with, information, not just services.  WCHM is currently finalising a Report based on a survey of ACT Women about how they currently access information about their health and well-being and how they prefer to access this information, as well as about the gaps in health and well-being information and the barriers that ACT women face in accessing this information.  The research shows that when women have access to appropriate health and wellbeing information they are able to make informed choices about their own and their family’s health and access the relevant services.  There is a shift in the current environment towards women wanting to be better informed about, and taking more responsibility for, their health and wellbeing and this requires good quality, trustworthy, appropriate and timely health information within the ACT.  

WCHM looks forward to working with ACT Health, and contributing to, the further development and implementation of the new ACT Women’s Health Plan.
 
Objective 1: Incorporate gender mainstreaming across service delivery areas.

WCHM welcomes the inclusion of ‘gender mainstreaming’ as a key high level objective of the ACT Women’s Health Plan, so that the needs of women are better understood and that services are provided which are appropriate to their needs and delivered effectively.  WCHM would welcome the opportunity to contribute to the development of this policy and to include the findings from our current research with women from the ACT.

Evidence suggests that practitioners who implement this knowledge into their services, that is those who are ‘gender-sensitive’, achieve better health outcomes for women, by understanding the gender differences between men and women and the gendered experiences of life and health. These same health services will understand that gender mainstreaming is not about treating men and women the same, nor is it exclusively about providing ‘women only’ services, but rather, it is about taking the time to understand the individual, their lives, their health and caring for them holistically: 

In WCHM’s current research on ACT women and their views on access to health and wellbeing information, we sought views about the barriers for them in relation to GPs  While GPs were considered the primary source of health and wellbeing information for most ACT women respondents, one of the key issues raised by women were in relation to the gender sensitive manner of the interactions that women had with doctors, the lack of a trusted and personal relationship with GPs and the lack of time given for discussion by the GPs.

Women’s health can only truly be understood by considering not only the biological and physiological, but also the social, cultural, economic and personal contexts of a woman’s life  - the social determinants of health.  It will be important that the diversity of women’s experiences is built in, and that the impact on their access to and need for services, is understood.  WCHM considers it essential that any approach therefore builds in and considers the interactions between a woman’s cultural, economic and social circumstances, as well as her others circumstances such as location, age, CALD background, disability and/or sexual preference etc.  Unequal access by some women in the ACT to the resources necessary for good health (eg good housing, income and healthy food) has a direct impact on their health.

We note that ACT Health is not expected to finalise its gender mainstreaming policy until June 2010, and in the meantime that some real opportunities may be lost for incorporating the collection of relevant gender disaggregated data into the implementation of new initiatives prior to the policy being finalised. 

In order to properly inform a gender mainstreaming framework, the Plan recognises that gender analysis including the implementation of gender impact statements and the development of sex-disaggregated data needs to occur. This is a commitment that WCHM supports and knows to be of value to ACT women.  ACT women may be overall better educated, have higher incomes, and have higher housing standards than women nationally, however, as the Plan suggests, there are a significant number of ACT women who are marginalised and isolated from our community and its wider standard of living, and this is at a great cost to their health and wellbeing.  

Due to the lack of accurate, sex-disaggregated data on marginalised and isolated groups, it is almost impossible to quantify the number of women in the ACT that are experiencing marginalisation and isolation.  WCHM believes that sex-disaggregated data alone is not sufficient for building an accurate picture of women’s health, particularly when it comes to women who experience disadvantage. WCHM supports the further disaggregation of ACT women’s health data to include indicators like age, cultural background and disability.

The Building a Strong Foundation framework for promoting mental health and wellbeing in the ACT is one example of a framework that will implement some new programs during the life of ACT Women’s Health Plan but for which the data for evaluation purposes may not incorporate gendered data from the beginning - as a result the Evaluation may not include an understanding of the different impacts and results between men and women experiencing mental health issues of the programs and their implementation. 

Objective 2: Ensure that policies, guidelines, models of care and strategies are formulated to improve the delivery of health services to women.

WCHM commends the recognition of appropriate and gender sensitive models of care and service pathways for women and for acknowledging the issues of safety and high quality services for women.  A ‘one size fits all’ approach to women’s health is not sufficient in ensuring positive outcomes for socially isolated and marginalised women, and it is necessary that the healthcare system is responsive to the specific needs of these different groups.  It will also be important to reflect the findings from WCHM’s recent research about the preferences for women for community based / gender sensitive approaches to complement the current mainstream system of GPs and hospitals – especially in relation to prevention and early intervention.  

WCHM would be happy to share the findings of that research to inform the further development of the Plan in particular the needs identified by ACT women for:
•	describing/defining  the scope of practice (including confirmation of qualifications) and the tiered levels of intervention that are available within the ACT so that women understand the options and know that they don’t have to go to a doctor for all health and wellbeing needs and information; and
•	a local response which assists in building Internet literacy by supporting ACT women to understand how to assess and identify trusted sites – by enabling women to access trusted information they will be able to make more rational and informed health decisions without needing to access GPs every time to check information

As suggested in the implementation plan of the ACT Women’s Health plan, a competent and flexible workforce that is able to meet service demands when and where women need them, is also key to ensuring improvements in the delivery of health services to women.  Therefore WCHM considers it vital that the Government commits to investing in the education and training of our health practitioners. Training modules relating to the impact of gender on health, the concept of ‘gender sensitive health service delivery’ and gender mainstreaming, and the ways in which social determinants impact on women’s health and wellbeing, will equip health practitioners with the knowledge they need to deliver their services in a way that reflects the key principles of this Plan.  

It is important that training opportunities associated with the outcomes of this Plan go beyond what are traditionally considered ‘women’s issues’ (i.e. pregnancy, menopause and reproductive health), and instead, equips practitioners with an understanding that all health issues and life events can affect men and women differently across their lifespan, and that good health care will recognise and respond to a broader range of factors which impact upon women’s health, including but not limited to, domestic violence, mental health, eating disorders, the effects of ageing and disability, and women’s multiple and often conflicting roles as workers, mothers and/or carers. 

Objective 3: Form effective and collaborative partnerships with women and stakeholders within ACT Health, other government agencies, non-government organizations, General Practitioners and private providers to address gaps in service delivery to women.

WCHM commends the commitment to collaboration and to establish cross sectoral partnerships – these will be essential to creating a holistic approach to health that can truly reflect the social determinants model.  The policy will be more effective in this area by including strategies to work with other government departments outside of health to create collaborative approaches to addressing health within the social, environmental and cultural frameworks, and not just from a medical/clinical perspective of health.  Such departments should include transport, education, multicultural and disability agencies, and housing.  

Some cross sectoral partnerships might include:
•	Collaboration between the education and health sectors in the planning and delivery of health information in schools and colleges;
•	Collaboration between migrant services and health in alleviating social isolation issues for CALD women, 
•	Recognition of transport issues in the ACT and the barriers that transport still creates for women in the ACT in accessing health services.

Objective 4: Facilitate timely access to the care required by women across the continuum of care, from hospital to community based settings.

While hospital and community based settings for care are crucial, an ACT Women’s Health Plan must also recognise and address the barriers that women face in accessing appropriate, relevant and timely health information, not just services. The Plan must also recognise the central role of good quality health and wellbeing information in women’s ability to successfully manage their own and their family’s health, and therefore also facilitate timely access to the information required by women. 

Research has demonstrated that women are the primary seekers of health care not only for themselves, but for their children and other family members. Despite this, women face significant challenges in trying to manage their own and their family’s health. An ACT Women’s Health Plan must recognise and address the barriers that women face in accessing appropriate, relevant and timely health services. The Plan must also recognise the central role of good quality health and wellbeing information in women’s ability to successfully manage their own and their family’s health, and therefore also facilitate timely access to the information required by women. 

Consultations with women in the ACT show that access and service pathways within the ACT Health system are not clear to many women. WCHM research has revealed difficulty in navigating ACT health and wellbeing information and services, and identifying the need for a local and centralised information source that links ACT women to the information already available and which is structured around them as individuals and consumers.

In WCHM’s recent survey of ACT women as health and wellbeing information seekers, 41% (n=273) of respondents reported experiencing significant barriers in obtaining the health and wellbeing information they require. 

Some other common barriers identified by the survey respondents were having to rely upon a GP because of not knowing where else to get reliable information; “lack of truly reliable sources”; and lack of understanding from health professionals.

WCHM is concerned about ACT women, particularly those who are on low incomes or socially isolated, and are foregoing essential medical care because they are unable to access services that meet their needs. No matter where women live, enabling them to navigate the health system is essential for better access to appropriate health services –but ACT women need assistance to get the best possible advice and health care.   

An ACT Women’s Health Plan should promote innovative models of information and care delivery that will reach the most isolated and marginalised women (i.e. outreach/in reach services and through-care). This reflects the thoughts of many participants of the WCHM health and wellbeing information survey who reported wanting health and wellbeing information and sources to be where they are.

WCHM believes that the Plan should also recognise the importance of building women’s health literacy (rather than simply communicating its importance) in order to support positive health outcomes for  ACT women.  

The current actions within the Plan are focussed on ‘medical-oriented’ services and settings, rather than ‘information-based’ services.  WCHM would be happy to share its findings in further developing the Plan.

Objective 5: Improve and integrate the coordination and roll out of health promotion, illness prevention, early intervention and health maintenance initiatives to women within a social determinants of health framework.

The ACT Women’s Health Plan is to be commended for highlighting the social determinants framework and in particular its inclusion of gender as a social determinant. 

One of the emerging social determinants in the ACT, particularly in relation to women, is “time poverty”:  “Time pressure also challenges urban, health and environmental policy because many interventions have an unacknowledged time dimension. People need time to keep healthy, to exercise and to maintain strong social and family bonds. If urban designs or environmental solutions can reduce time demands they may directly improve health and social outcomes. However, where they increase time demands they may have unanticipated health costs, create disincentives for the uptake of interventions and disadvantage those who are most time poor.” 

WCHM recently conducted a major survey of 700 women in the ACT in terms preferences of and access to health information.  Time was brought up as a barrier by all focus groups of women who were part of this survey.  Lack of time prevents not only access to services and information, but also the uptake of healthy behaviours or policy initiatives.  

The ACT Women’s Health Plan identifies women as carers as a social demographic that is one of the “key drivers for change”.  It is also women in this group who have caring duties who are most time poor.  The plan is to be commended for the recognition that women in this group need “flexible health services”.  In a broader context, the ability to maintain health promoting behaviours and to access health information and services needs to recognise time (availability of after hours services for example) as a crucial need for ACT women.

Health information and promotion needs to be sensitive to culture, gender and the competing stresses and priorities of the individuals it is targeting; it needs to properly consider the context of the women it is trying to reach, rather than a one-size fits all approach. An example of this came from a WCHM focus group with older women who felt that there is a negative focus in the provision of health information to ageing women, and thought that general health and wellbeing information and preventative health campaigns should inform women about the possibilities for them at particular ages and life stages, not the risks and health conditions associated with being a particular age. The negative focus of information, particularly preventative health information was a source of concern for the participants. 

The items currently listed under objective five do not sufficiently address the diverse needs of women in the ACT. In order to effectively roll out health promotion, illness prevention, early intervention and health maintenance initiatives to women, the Plan needs to consider the important issue of health literacy overall. Currently the Plan asserts the need to communicate the importance of health literacy; however, WCHM believes that instead, the Plan should recognise the importance of building women’s health literacy:

“Health literacy is the ability to make sound health decisions in the context of everyday life – at home, in the community, at school, in the workplace, in the health care system, in the marketplace and in the political arena. It enables people to increase their control over their health, their ability to seek out health information, to navigate complex systems, take responsibility and participate effectively in all aspects of life.”

Research indicates strong links between levels of health literacy and overall health and wellbeing outcomes. People lacking health literacy are often misinformed about their bodies and the nature and causality of disease, and may not understand the relationship between lifestyle factors such as diet and exercise and various health outcomes. 

The Plan should articulate that low health literacy is a barrier to receiving effective information and care, and enjoying good health outcomes. A commitment to develop ACT women’s health literacy would recognise the particular needs of disadvantaged groups, such as Aboriginal and Torres Strait Islander women, women from new and emerging communities, older women and vulnerable young women. 

“Health information alone will not be useful to people who do not feel they have the power to act. Other complementary strategies are needed, such as community development and participatory health education…The health care system also needs to acknowledge the lack of power which many people feel, and to explore ways in which it can assist people in taking more control over their lives and their health.”

WCHM agrees that health promotion, illness prevention, early intervention and health maintenance initiatives for women are vitally important to their health and wellbeing, and the health and wellbeing of communities. However, such undertakings can only be effective when they recognise the diverse needs of different groups of women, including the different ways in which they access and respond to health and wellbeing information and messages. Prevention, promotion, intervention and maintenance efforts also need to be sensitive of gender and culture to reach women effectively. 

While the Plan must provide health and wellbeing information that is appropriate and relevant for different groups of women, it must also undertake to provide pre-emptive life course health and wellbeing information for all women. WCHM research has found that health and wellbeing information specific to different life stages is hard to find in the ACT.