Submission to:
National Women’s Health Policy
MDP 13
GPO Box 9848
CANBERRA ACT 2601
National.women’s.health.policy@health.gov.au   

The Women’s Centre for Health Matters Inc. (WCHM) welcomed the opportunity to participate in the National Women’s Health Policy consultation process and following on from those discussions decided to review and amend our original submission to ensure the interests of ACT women were fully and properly represented in the development of a new National Women’s Health Policy. 

WCHM has enhanced its response to include the following points:

Gender Equity
•	Gender sensitive health service delivery
A discussion of gender sensitive health service delivery principles/characteristics that should underpin all health policy, program and promotion activities.

Health Equity between Women
•	Institutionalised Women
WCHM has strengthened the content supporting the need to include and recognise institutionalised women as a group of women at significant risk of developing health and wellbeing issues (5.2.2 in the consultation paper).
•	Young Women
The need to improve the dissemination of sexual and reproductive health information to young women from CALD backgrounds in the ACT, which is informed by WCHM survey data. 

A Life Course Approach
•	A discussion that highlights the potential risks in relying solely on a life course approach to understanding women’s health. 

Other
•	Time Poverty 
The emerging issue of “time” as a resource and a social determinant and its impact on a woman’s ability to address health and wellbeing issues, to be considered in future research and evidence collection.
•	Climate Change
An examination of climate change and its implications for women’s health, and the emerging need to conduct and fund research into this determinant of health.
•	Mental health and wellbeing
Content strengthened to support a focus on mental health into the future.

Submission to
National Women’s Health Policy

From: Women’s Centre for 
Health Matters Inc.

November 2009

Women’s Centre for Health Matters

Submission to National Women’s Health Policy

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.

Response to Guidance Questions

WCHM has chosen to limit its responses to those questions relating to areas in which it has the most knowledge and expertise, and to support its responses with evidence published by the Centre and its partners on the specific needs of ACT women. 

1.	
Gender Equity

How can the health system be more responsive to the specific needs of women?

 In what way can the Policy actively promote participation of women in health decision making and management?

WCHM believe that the following issues are crucial in achieving a health service which is more responsive to the specific needs of women:

A.	Gender Sensitive Health Service Delivery
One of the key areas in WCHM’s 2008-2012 Strategic Plan is improving women’s access to gender sensitive health information, services and practitioners. Gender sensitive health services are more than just ‘women only’ services. After talking to women service users, providers and reviewing a wide range of literature, WCHM has identified four key qualities that must inform gender sensitive health service delivery: availability, accessibility, affordability and appropriateness. Gender sensitive health service delivery understands that ‘women are their own experts’ and that women are best placed to make decisions about the issues that affect their health and well-being. 

Gender sensitive health services should exhibit the following characteristics:

•	They offer women choices about the type of support they receive, and who provides it to them (i.e. a choice between a male or female doctor). This is of particular importance for some CALD women, for women who have suffered trauma, and/or for women who may feel uncomfortable disclosing personal information to a male practitioner.
•	They provide women with opportunities to be actively involved in their own care and treatment, including service planning and delivery.
•	They offer women choice in treatment options, which may include medication, talking therapy and/or other community-based services like peer support. 
•	They have staff that treat women with respect, give them time to talk and listen to what they have to say, including the provision of longer consultations and more preventative health measures and counselling where needed.
•	They have staff and practitioners with qualifications in women’s health and/or are trained to understand the impact of gender on health and well-being.
•	They are culturally sensitive.
•	They understand that all health issues and life events may affect men and women differently across their lifespan and use a life course approach in service planning and delivery. 
•	They take into account the ‘social determinants of health’, that is, they acknowledge the way that women’s personal circumstances and socio-economic status affects health. For example, a woman’s child and/or other caring responsibilities, her relationships, housing status, income, age, sexuality, ethnicity, religion and cultural and linguistic background, all have the potential to negatively impact upon a her health and wellbeing.
•	They employ a holistic, individual approach to service delivery that recognises that women often have a multitude of concurrent challenges, which then often leads into a cycle of difficulties (i.e. chronic pain may lead to unemployment, mental health issues and/or alcohol and drug misuse).
•	They have ‘women only’ spaces within their buildings.
•	They provide family-friendly and more specifically child-friendly environments (i.e. affordable childcare and/or supervision).  
•	They keep women’s personal information confidential at all times.
•	Services are either located near women and/or public transport routes, or an outreach program should be available in most localities.
•	Pathways of care are easy to navigate, information is provided in preferred formats, and for those women who experience difficulty in understanding and/or navigating the health system, assistance is provided.
•	They have a stable and secure funding base, which allows them to offer consistency and longevity in the support they provide. 

B.	
Education and Training
If we are to improve women’s access to gender sensitive health services, we must first invest in the education of our health practitioners. It is essential that all health qualifications include modules on the impact of gender on health, the concept of ‘gender sensitive health service delivery’, and the ways in which social determinants impact on women’s health and well-being. Whilst it is important to teach health professionals (such as GPs, pharmacists and nurses) about traditional ‘women’s issues’, such as pregnancy, menopause and reproductive issues, this alone is not sufficient in creating gender sensitive practitioners. Health education must also equip training practitioners with an understanding that all health issues and life events can affect men and women differently across their lifespan. Health practitioners need to be able to 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. 

C.	Access
Research has demonstrated that women are the primary seekers of health care, and health and well-being information, 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. A National Women’s Health Policy must recognise and address the barriers that women face in accessing both gender sensitive health information and gender sensitive health practitioners. 

Consultations with women in the ACT show that access and service pathways within the ACT Health system are not clear to many marginalised and isolated women. Some women experience difficulty in:
•	understanding written information due to language and/or literacy difficulties;
•	requesting and securing support when trying to negotiate the health system and treatment pathways; 
•	requesting and securing suitable interpreters (including AUSLAN).

A workforce that is sensitive and empathetic, that offers support to women who face difficulties in navigating the health system, and that provides information to women in their preferred formats (i.e. online), will inevitably provide better health outcomes for women and their families. 

WCHM supports the right of women to choose who administers their medical care, and for many women, this means choosing a female GP or other health practitioner.  In the ACT, as in other parts of Australia, there is a GP shortage, and many small medical practices have closed. Consequently women, and particularly women on low-incomes, are unable to access a female GP, a bulkbilling GP and/or a female GP that bulkbills.  

WCHM research in October 2007 found that 82.6% 
of female GP’s in Canberra did not regularly bulk bill.

In a 2008 survey of ACT women on their health and wellbeing, WCHM found that:

28.8% of respondents reported not acting on physical health and wellbeing issues due to financial constraints. Other significant barriers included: long waiting lists to see a practitioner (18.8%), a health issue not deemed a priority (17.7%), not knowing where to get help (15%), not having the time to take action (12%), not being able to access a bulk-billing practitioner (11.6%) and not having access to transport (6.6%).

WCHM is concerned about ACT women, particularly those who are on low-incomes or socially isolated, and are forgoing essential medical care because they are unable to access a GP who meets their needs.  A National Women’s Health Policy should promote innovative models of care that will reach the most isolated and marginalised women (i.e. outreach/in reach services and through-care).

D.	
Representation
In line with our values, WCHM believes that ‘women are their own experts’, and that women are best placed to make decisions regarding their health and wellbeing. Therefore, women’s involvement in consultations and senior decision-making roles in the health sector is crucial to creating health services that are more responsive to their needs. 

In decision making roles:
WCHM acknowledges that while the health sector is predominantly staffed by women, they are not always equally represented at the most senior decision-making levels. A National Women’s Health Policy should actively encourage health services to seek out female representation from minority groups for input into decision making processes (i.e. women with disabilities and women from CALD backgrounds). Moreover, many women require support in order to participate and it is essential that barriers to participation are actively addressed (i.e. accessibility of meeting location, transport, childcare and/or meeting times).

In consultations:
WCHM believes that whilst consultations with women are essential in planning and delivering Government funded health services, too often the voices of those women most likely to be using these services are not heard. Governments need to make every effort to include the opinions of socially isolated and marginalised women in the formulation of policy and practice as often the traditional consultation processes do not meet the needs of these women. For example, in some cultures it is not appropriate for women to discuss health matters with certain people (i.e. older women discussing issues with young women).  Moreover, there may also be stigma associated with personal health issues (i.e. mental illness and AOD) that prevents women from sharing their experiences, particularly in group settings. WCHM believes that the new Policy should develop and promote innovative ways for consulting traditionally ‘hard to reach’ women, and where possible, engage the community sector to consult these women on behalf of the Government.

2.	Health Equity Between Women

How can the health system be more responsive to those groups of women most at risk? 

How can access to services be improved? 

Should the policy promote specialist or outreach services for particular groups of disadvantaged women? 

Should the policy aim to influence sectors outside health (e.g. education, employment, rural infrastructure)? How?

Are there particular health workforce issues that are impacting on certain groups of women?

Throughout our submission, WCHM has suggested ways in which our health service can be more responsive to women most at risk of poor health outcomes. Central to these ideas is the idea that a ‘one size fits all’ approach to women’s health is not sufficient in ensuring positive outcomes for socially isolated and marginalised women. A new Policy should consult closely with at-risk groups of women to determine how they currently access information about their health, how they prefer to access this information, and what barriers they face in accessing information about their health. Knowing this will greatly assist health services in better reaching these women.

The health care system must respond to those with special needs. We would like to highlight issues for women with the following specific needs:

•	Women with disabilities 
•	Women with mental health issues
•	Institutionalised women
•	Women from culturally and linguistically diverse (CALD) backgrounds
•	Women who are homeless
•	Young women

A.	
Women with disabilities 
A wide range of services and support are offered to women with disabilities in the ACT. However, Women with Disabilities Australia (WWDA) identified a number of significant issues for women with disabilities with regards to health and well-being, including, low self-esteem, access to information, education, physical access to services and the logistics involved in making and keeping appointments. Consequently, women with disabilities are not accessing appropriate health services at the same rates as women without disabilities – including breast and cervical cancer screening programs, bone density testing, menopause and incontinence management services. They are also more likely to receive limited education about their reproductive rights, capabilities, sexuality, pregnancy, and parenting.

B.	Women with mental health issues   
A consultation with women living with mental health issues, held by WCHM in August 2007 for the Senate Community Affairs Committee Inquiry into Mental Health Services in Australia revealed that in order to realise health equity for women living with mental health issues, mental health service delivery must incorporate the following characteristics:
:
•	There must be ‘women only’ areas available across all aspects of the mental health system, from early intervention to crisis/hospital treatment and care. Many women with mental health issues have experienced physical and sexual violence from male perpetrators, and it is not appropriate for these women to be receiving care and/or treatment in the same place as men.
•	A holistic approach must be used in treating mental health issues. The ‘social determinants of health’, that is, a woman’s personal circumstances and socio-economic status can have negative impacts upon mental health and wellbeing. Failing to recognise the importance of social determinants like a woman’s child and/or other caring responsibilities, her relationships, housing status, income, age, sexuality, ethnicity, religion and cultural and linguistic background, will not support good mental health outcomes. 
•	Women want and need continuity of care and support. Unfortunately, due to high staff turnover in the mental health sector, women do not receive it. Governments must take steps to address this issue. We expect Governments to thoroughly investigate this phenomenon and begin to address issues like pay rates (particularly in the community sector), staff training and development, and clarity of career pathways. 
•	Greater resources need to be devoted to early intervention and education. Women need to be supported when they first express need, and they should not have to wait until they are in crisis in order to receive treatment and care. 
•	In times of crisis, women with children are particularly vulnerable. Separation from children due to hospitalisation, remand or detox obligations can lead to further deterioration in mental health. The use of advanced directives, parenting support groups, self help models of support, community development initiatives and services to assist with access and reconciliation of families, could all assist in supporting women with children in times of crisis.

C.	Institutionalised women
WCHM’s Marginalised and Isolated Women Report defines institutionalised and post-institutionalised women as women who are currently, or have been, imprisoned, or detained in a detox facility, in girls’ homes (i.e. the Forgotten Australian’s and child migrants), or have been institutionalised for mental health reasons. Women who have been institutionalised for any reason are at high risk of social, economic, political, and legal marginalisation and isolation that extends beyond the institutionalised period. 

Consultation with the ACT Women and Prisons Group identified three key issues for women who have experienced institutionalisation (particularly in prisons): rehabilitation, employment opportunities, and social inclusion. Moreover, mental health issues and dependencies are common problems in this group of women. The 1997 NSW Inmate Health Survey found that women in custody were twice as likely as male inmates to have been diagnosed with psychiatric problems and nearly three times as likely to be on psychiatric medication at the time of their reception into custody. Five years later the Queensland Women Prisoners Health Survey found that 57 percent of women in QLD prisons had been diagnosed with a specific mental illness, compared to 5.8 percent of women nationally. Furthermore, 69 percent of women in the same study demonstrated symptoms of depression, which was dramatically higher than the national average of 6.8 percent. 

Post-institutionalisation, women ex-prisoners often find themselves socially isolated with limited support networks. As a result of their criminal records, employment opportunities are restricted to low paying positions, and yet they must navigate their mental health issues, caring responsibilities and employment effectively. Experiencing such challenges concurrently leaves a woman more susceptible to poverty and homelessness and it is essential that Government’s continue to improve discharge practices, and develop targeted health support for these women (i.e. step up/step down programs, social support groups etc.).

Women leaving psychiatric facilities are also particularly vulnerable when it comes to maintaining good health and wellbeing. An unwanted consequence of deinstitutionalisation in the mental health sector has been the further disintegration of social connectedness amongst people living with mental health issues.   A growing amount of international literature identifies lack of community support, rather than a person’s symptomatology to be the dominant factor in re-admission, with up to half of all discharged psychiatric inpatients re-hospitalised within twelve months. In the ACT, a lack of transition support (step up/step down programs) and poor psychiatric discharge practices are major contributors to recidivism. Moreover, low levels of social support are intrinsically linked to poor mental and physical health outcomes in general.    

WCHM supports area 5.2.2 of the consultation paper which lists the groups of women most at risk of poor health outcomes; however WCHM strongly recommends the inclusion of institutionalised women in this category. As discussed, institutionalised women are at great risk of developing health and wellbeing issues, and not recognising this fact within the new women’s health policy will only further exacerbate these health inequities. 

D.	Women from CALD backgrounds 
WCHM’s Marginalised and Isolated Women Report found statistical and anecdotal research suggesting that general health and wellbeing levels are lower for women from CALD backgrounds, compared to the population at large. Research into the experiences of peri natal depression for CALD women in Melbourne, for example, indicates that there is significant prevalence of maternal depression for women who are under 25 years of age, have been resident in Australia for a short period, speak little or no English, have migrated for marriage, have no relatives in the area or no friends to confide in, have physical health problems, and/or baby feeding problems. The research also showed that socio-economic status was not a factor for women’s experience of maternal depression, and the biggest identified problem for these women was social isolation.

WCHM strongly recommends the compulsory incorporation of cross-cultural sensitivity training for all medical staff and practitioners.

E.	Homeless women
Research undertaken by Inanna Inc  in 2005 highlighted front-line service providers’ widespread beliefs that women experiencing or at risk of homelessness generally experience poor physical health. Service providers reported that although homeless women encounter similar problems to women who are not homeless, homelessness tends to perpetuate and exacerbate these problems.

Women who were homeless reported the following key issues:
•	Some women are generally unhappy with and reported bad experiences in receiving public health services;
•	Health care services are not affordable and do not generally bulk bill;
•	Access to good affordable food is an issue but not a high priority, and;
•	Women wanted to self-care where possible.

The report recommended that ACT Health and the Commonwealth fund a program that improves access to health services for women experiencing (or at risk of) homelessness in the ACT. 

F.	Young women
In our work with young women in the ACT, one of the key issues that emerged is the dissemination of information on sexual health at schools.  The draft policy identifies high risk sexual behavior in young women as a key issue.  

There are several organizations in the ACT that currently run sexual health information programs in schools.  However, there is an unmet need with regards to sexual health education for young CALD women. Anecdotal evidence from our service providers in the sector indicate that young CALD women are at very high risk in terms of sexual health. Young women from CALD backgrounds experience double disadvantage; many traditional cultures do not condone open discussions about sexual health matters. Consequently, these women find it difficult to ask questions in the mixed classroom environments that exist in schools. Furthermore, these women face the danger of being ostracized from their cultural communities should their situation contravene cultural mores.  It would be of value to work with the education sector to create cross sector education models for addressing this gap. All sexual health education would need to be consistent, trustworthy and confidential at all times, in order to create a knowledgeable, empowered and sexually safe group of young women. 

3.	A Focus on Prevention
Which women in our community are most at risk of poor health?  
Should the policy identify priority groups for action?  
How can the Policy help to improve the health and wellbeing of those women most at risk?
Are there strategies or responses that are effective and able to be promoted nationally?

WCHM believes that while preventative health strategies are useful, they must go beyond ‘behavioural change’ (such as reducing smoking, drinking and obesity) and address broader ‘societal change’.  The main focus for prevention in the discussion paper is on prevention of illness and disease, and this does not recognise that social and economic disadvantage can lead to poor health. 

Health is shaped by the environment in which we live. Consequently all government departments have a role to play in health promotion. The new National Women’s Health Policy needs to be connected to other national policies, and should consider long term change around the social determinants of health. Income security, employment status, transport, sport and recreation pursuits and family and community supports affect health. A system that strengthens both prevention and wellness should include the provision of suitable housing, affordable child care, adequate income support, accessible community and public transport systems, and a continuum of care; it should be affordable to all women, tailored to individual needs and be culturally appropriate. 

WCHM supports a focus on preventative health in the new Policy, although it is important to recognise that regardless of how much resources are invested in prevention, there will always be a need for primary health services dedicated to the needs of women. Over time, a preventative approach will reduce the burden on primary health services, however in the early stages this should not be at the expense of good quality primary health care.

4.	A Strong and Emerging Evidence Base
Are there gaps in our knowledge, including the need for further research and data collection that will help to assist in the development of a robust policy and improve women’s health and outcomes in the longer term?  
Is there a need for more gender focused health research? In what ways? How can a national Policy address this need?

A.	Supporting local evidence gathering 
ACT women overall are better educated, have higher incomes, and have higher housing standards than women nationally.  However, there are a significant number of ACT women who are marginalised and isolated from their community and its wider standard of living, 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.  Key issues in the ACT, including addiction and substance abuse, transportation issues, and poor mental health all impact negatively on health and wellbeing, and are significantly more common amongst the socially and economically disadvantaged.

WCHM invests a lot of its time and resources into gathering local evidence on the specific issues affecting ACT women. This localised evidence has proven to be a vital resource for other ACT community and Government organisations, particularly in designing, evaluating and sourcing funding for their services. By gathering local evidence, WCHM is developing a better understanding of our unique community. For example, while national statistics often portray Canberrans as relatively privileged (high incomes and levels of home ownership, low rates of homelessness etc.), localised research, such as that conducted by WCHM, has revealed pockets of disadvantage and groups at risk of social isolation. Gaps in service provision and policy exist with relation to all of the groups at risk of marginalisation and isolation.  Insufficient respite for primary carers, inadequate exit points for women in refuges, not enough affordable, adequate and safe housing, transport issues, services for Aboriginal and/or Torres Strait Islander women, and support for institutionalised women with children are all issues that have arisen repeatedly.

Local evidence is necessary to help services better understand the impacts of local events in their community (i.e. the recent GP clinic closures and the opening of the new prison in the ACT).  A National Women’s Health Policy should promote evidence gathering at both a national and local level in order to develop a sound evidence base.

B.	Broadening our understanding of the word ‘evidence’
While statistics and surveys can be useful ways of gathering evidence, WCHM also supports a broader means of understanding the impact of life events on women’s health. Many women, particularly those who come from ‘story-telling’ cultures (such as Indigenous women and many CALD women) or those who have had negative experiences with Government institutions in the past, will often only share their experiences with someone they trust, in an unstructured and supportive environment and in line with their cultural customs. WCHM believes that these women’s voices often go unheard as their way of sharing their experiences does not fit within the formal consultation processes or evidence gathering methodology. Consequently, the needs of these women are not reported in formal statistics. WCHM would like a National Women’s Policy to acknowledge different types of ‘evidence’ and to take into account women’s stories, not just the statistics. 

C.	Providing a disaggregated analysis of statistics
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 A National Women’s Health Policy which promotes, where feasible, the further disaggregation of women’s health data to include indicators like age, cultural background and disability. 

5.	A Life course Approach

WCHM supports a new Policy which employs a life course approach to women’s health, however there are a number of limitations associated with a life course approach that must be given full and appropriate consideration, including;

•	The potential to see life course as fixed, and determined solely by a woman’s biological age. 
•	The potential to focus exclusively on the major biological events of a woman’s life (i.e. early childhood, adolescence, pregnancy and menopause) to the exclusion of the rest of her life.
•	The potential to exclude those aspects of a woman’s life that are not related to reproductive function (i.e. the relationship between older women and chronic disease, or a woman’s caring responsibilities).
•	The potential to neglect the social determinants underpinning a woman’s health and wellbeing

A life course approach has the potential to detract attention away from the diversity of women’s experiences. It is essential that a life course approach considers the complex interactions between a woman’s cultural, economic and social circumstances, as well as her location (metropolitan, regional or rural), CALD background, disability and/or sexual preference.

6.	Other Issues

A.	The 1989 National Women’s Health Policy
WCHM urges the new National Women’s Health Policy to continue to embrace and promote a social understanding of health. This includes utilising the Social Determinants of Health model (as promoted by the 1986 Ottawa Charter for Health Promotion) with regards to women’s health. WCHM also notes that while we agree that a National Women’s Health Policy should continue to set priority areas based on emerging issues and a strong evidence base, many of the key action areas and health issues that were considered a ‘priority’ 20 years ago have still not been adequately addressed, and we have still not achieved health services in Australia which are available, accessible, affordable and appropriate, particularly to those women most at risk. 

Key Action Areas of the 1989 Policy
WCHM agree that the key action areas of 1989 Policy continue to be worthy of the Government’s attention (i.e. improvements in health services to women; provision of health information; research and data collection; women’s participation in health decision making; and training of health care providers). While improvements have been made in offering dedicated women’s health services from 1989, there is still much progress to be made on the other four key action areas (WCHM has addressed these issues throughout its submission). 

Priority Health Issues of the 1989 Policy
As the with the key areas, many of the priority health issues that were identified in the 1989 Policy continue to be highly relevant to women today and should be retained in the new National Women’s Health Policy. Of particular relevance are the following areas (of the 1989) policy:

•	Reproductive and Sexual Health
•	Health of Ageing Women
•	Mental Health and Wellbeing
•	Violence Against Women

WCHM believes that these areas must remain on the women’s health ‘agenda’.

Reproductive and Sexual Health
Although WCHM believes that reproductive and sexual health should continue to be a priority in women’s health, we believe that the focus should be now be moving towards ‘choice’ and ‘access’. 

Health of Ageing Women 
As our population ages, it is essential that the health of ageing women remains a Government priority. WCHM would like the new National Women’s Health Policy to acknowledge that women experience ageing differently to men, and while on average women may live longer than men, they are significantly more susceptible to social isolation and chronic illness.

Example: A recent survey of 209 older women in the ACT by the YWCA of Canberra found that 40.1% of respondents reported feeling ‘excluded or alone’ sometimes or more often. The survey also found that these feelings of social isolation were directly linked to a woman’s social networks, that is, older women who had stronger social networks were less likely to feel excluded or alone, than those who didn’t have a strong social network. Respondents also reported a number of barriers to engaging in social activities, including time constraints (40.5%), low energy levels (34.7%), financial constraints (30.6%), health problems (20.4%), and lack of confidence (16.1%). This is of particular concern when much research points to the fact that low levels of social support are intrinsically linked to poor mental and physical health outcomes in general.     

Mental Health and Wellbeing
While the 1989 Policy referred to ‘emotional and mental health’, WCHM believes that the word ‘emotional’ is unnecessary in the new Policy as it risks encouraging gender stereotyping and bias in relation to identifying and treating mental illness. For example, stereotypical conceptualizations of women as ‘emotional’, menopausal or suffering from ‘PMS’ may engender bias in the identification and treatment of mental illness. This then often impedes good mental health outcomes for women.

WCHM also wishes to see greater application of gendered analysis in the field of mental health. Gender differences have an impact on mental health and the experience and course of women’s mental illness. To date, ‘gender neutral’ or ‘gender blind’ approaches have neglected the unique needs of women with mental health problems and perpetuated mental health inequalities between men and women. Evidence suggests that practitioners who implement gender sensitive knowledge into their services achieve better health outcomes for women. 

Research has found that the prevalence of psychiatric disorders, particularly mood, anxiety and eating disorders, is greater in women than in men.  Moreover, looking at mental health through a gender lens also reveals differences in the course of illness and the different impact of biological, psychological and social factors in the causation of illness. There are differences between men and women when it comes to age of onset, symptoms, comorbidity with other illnesses and ways in which mental illnesses are expressed. For example, depression in women is more often characterised by appetite, sleep disturbance and fatigue, and is more likely to be accompanied by anxiety.  Women are more likely than men to seek help from, and/or to disclose mental health problems to their primary health physician, but then conversely, are less likely than men to disclose problems relating to drug and alcohol use. 

In addition to these physical and emotional differences between men and women, social and cultural circumstances have a unique impact upon women’s mental health. For example, there is a strong inverse relationship between social status, and physical and mental health outcomes. This greatly affects women, as in almost every society, women’s status remains lower than men’s. Women’s low status is reflected in the high incidence of violence against women; women’s lower socio-economic status; an under-representation of women in positions of power; and an over-representation of women in part-time and casual work, amongst other things.  A consequence of violence against women for example, is that they are more likely to experience mental health problems, particularly depression, anxiety, eating disorders and substance abuse. Financial insecurity also appears to predispose women to mental illness, as demonstrated in the findings of the WCHM commissioned report, Social Determinants of Women’s Health and Wellbeing in the Australian Capital Territory.

Women are more likely than men to be diagnosed with depression, “… even if they have similar scores on standardized measures of depression or present with identical symptoms. Furthermore, historically, research has concentrated on the relationship between a woman’s reproductive functioning and her mental health. Recent studies have indicated that in fact, a woman’s physiological and reproduction functioning has minimal impact upon her mental health and wellbeing if psychosocial factors are given appropriate consideration. Any negative impacts resulting from domestic violence, caring responsibilities, alcohol and drug dependency, housing status, income and the current state of a woman’s relationships and support networks, must be considered and addressed in conjunction with the treatment of mental illness symptoms. To ignore the wider context of a woman’s life and the potential for it to negatively affect her mental health and wellbeing is not smart practice.

WCHM believes that women’s mental health and wellbeing should continue to be a priority for the new Policy as it continues to be a primary risk factor for social isolation and a barrier for accessing health care.

Example: Recent research performed by WCHM found that roughly 17.8% of ACT women have experienced mental or behavioural health conditions (including alcohol and drug dependency). The 2004-05 National Health Survey (ABS) also found that while most ACT women experience low levels of ‘psychological distress’ (56.2%), 29.2% of ACT women reported ‘moderate’ levels of psychological distress, 11% of ACT women reported high levels of psychological distress and 4,500 ACT women reported ‘very high’ levels of psychological distress. 

Violence against Women
WCHM believes that violence against women and the impact it has on women’s health and wellbeing should continue to be a Government priority, however, we also believe that the National Women’s Health Policy should acknowledge that violence against women is not simply a ‘women’s issue’ but rather, a broader societal issue. A National Women’s Health Policy should link its aims and actions directly into the National Plan to End Violence Against Women.

B.	Time Poverty
Time is emerging as the new resource that is in acute scarcity for women.  Researchers Lydal Strazdins and Bernadette Loughrey of ANU note that “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.”  In WCHM’s Health and Wellbeing Issues for Women in the ACT survey (March 2008), the main personal barrier for women in addressing their health and wellbeing issues was time. And again, in WCHM’s most recent ACT Women’s Health Information Survey (August 2009), many women anecdotally expressed time constraints as a major reason for not seeking health and well being information or support. 

According to Strazdins’ study, 62% of full time mothers and 78% of employed single mothers indicated that they are “always or often rushed.”  Time pressure is linked to health risk factors such as obesity, chronic pain, unhealthy eating habits and mental health issues such as psychological distress.

The inclusion of time as a ‘finite resource’, like income, would be of particular value when considering the social factors that promote or inhibit health and wellbeing for women in Australia. “The solutions to urgent public health and environmental problems are competing in what is a time-scarce market. Work has intensified and work hours are rising, while demographic trends create acute pressures for adults combining working with caring. Meanwhile the modern epidemics of obesity, diabetes and heart disease are putting pressure on health service costs. The challenge is to design interventions that will succeed.”

Time poverty is a reality that limits women’s ability to utilize and access provisions or enhancement measures created by public policy. A National Women’s Health Policy should work cross-sectors to ensure that policies include “time” as a health determinant, and develop policies that assist women to better find the time to address the health and wellbeing of themselves, and their families. For example, a more time-flexible health sector that includes out-of-hours and weekend clinics should be considered an essential component of a new women’s policy. Furthermore, WCHM believes that any future evidence-based research into the interaction of social, economic, environmental and psychological determinants on women’s health must include this concept of “time poverty”. 

C.	Women and Climate Change
 According to the Global Gender Gap Report 2009, Australia lags behind in many indicators in terms of measurements of  “dividing resources equally between men and women”  or gender parity.  In terms of “Health and Survival”, Australia ranked 78 behind countries like Sri Lanka, Trinidad and Tobago.  Even though we were ranked on top in education equity, this did not translate into parity in terms of health and economic equity.

Climate change is therefore a crucial determinant of women’s health, as any transformation of the current scenario to one with more scarcity would increase existing inequities.  Writing on women and climate change, Lorena Aguilar points out that “…people’s vulnerability to risks depends in large part on the assets they have available.  Women, particularly poor women, face different vulnerabilities than men.” Australian women’s overall lower social status will consequently near guarantee greater suffering from the effects of climate change, in comparison to men.

Women’s Health Victoria published a “Gender Impact Assessment” that identified some of the areas where inequities will increase in Australia.  These included:

Natural Disasters
The seasonal threat of bushfires in regions like the ACT will intensify with climate change. There is very little gendered research available on the behavior and response of women during such situations. Such research is needed to inform both emergency services and in future planning for disasters.

Rising Cost of Living
It is common perception that most women in the ACT enjoy high economic status.  While this is largely true, according to the WCHM commissioned report Social Determinants of Women’s Health and Wellbeing in the Australian Capital Territory, 11.1% of women in the ACT experience relative economic disadvantage. The large gap between the wealthy and the poor in the ACT demonstrates that there are already high health inequities and that the women in the lower socio-economic groups are “at risk of much poorer health in the community than if there was a smaller difference between the advantaged and the disadvantaged.”  This was clearly indicated in the report findings in which six times as many women in the lowest income groups reported fair or poor health compared women in the highest income categories.

Rising costs of food, transport and services will have a disproportionate impact on women who are already disadvantaged. The WCHM study also found that there was a direct link between socio economic advantage and healthy food consumption.  Effects of climate changes in terms of rising costs will increase unhealthy behaviors in already disadvantaged women.

Some of the suggested ways to mitigate the potential for an increased disparity between men and women as a consequence of climate change were suggested by both Lorena Aguilar and the Women’s Health Victoria paper. The protection and enhancement of women’s assets, for example, should be part of climate change strategies, as changes in economic circumstances will impact on a woman’s health and well being.  Women also need access to information and knowledge and to “risk management instruments.”

Climate change is both an opportunity and a threat in the area of women’s health disparities.  It is an opportunity to include women’s health in the planning for both Australia’s and the world’s environmental future. It becomes a threat if we miss this opportunity to place women’s health and wellbeing at the core of Australia’s response to climate change. 

WCHM considers the emerging issue of climate change and its implications for women’s health to be an essential area for future research and development and urges the Government to include this issue within the policy principle, a strong and emerging evidence base.

7.	Conclusion
In conclusion, this submission aimed to highlight issues from the perspective of women of the ACT.  WCHM looks forward to the development of the new National Women’s Health Policy.

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