Women's Health Action Trust
Women's
Health Watch
Women's Health Update
edited by Sandra Coney
Women's Health Update Vol 5 no 1 - 4 2001 - 2002
vol 5 no 1 April 2001
- Gisborne report recommends a raft of changes for cervical screening
- Busting with Life shows there's life after breast cancer
- Can what you eat prevent breast cancer?
- New appointments for National Screening Unit
vol 5 no 2 July 2001
- Lone mothers face money worries and health risks
- New HRT guideline
- More Kiwi women use HRT
- Sexual health strategy
- Rapuora II funded
- Code of Rights breaches in Pill death case
- Gender and health
vol 5 no 3 October 2001
- Afghani women reach haven
- Breastfeeding conference report
- Sexual health at Ministry of Health
- Euros agree with Medsafe on pill
- Cervical screening audit law
- Cranberry cuts UTIs
Vol 5 no 4 January 2002
- Women drinking more alcohol
- Making screening work for Maori women
- Health information at fingertips
- Breast screening review
- Refugee resource
Lone mothers face money worries and health risks
Sandra Coney reports on recent research from Otago University which throws new light on lone mothers in New Zealand.
Otago University
research fellow Diana Sarfati was moved to look at lone mothers after
experiencing three weeks on her own with small children while her partner
was away. Her youngest, 12 weeks old, was not sleeping. Sarfati wondered
how lone mothers, with fewer material and emotional resources, coped.
Sarfati found that no one else in New Zealand had looked at the health
of lone mothers as a central issue, yet it deserved to be. Twenty-seven
percent of all families with dependent children in New Zealand are headed
by a lone mother. With the focus now on determinants of health, the
fact that lone mothers have very low family incomes should make them
an important group in developing public policy.
'Over the past 25 years the proportion of families with dependent children
headed by a lone parent had trebled,' says Sarfati. 'It is a major public
health issue.'
WINZ data shows that despite the popular view that lone mothers are
teenagers who have never married, two-thirds of lone parents are living
apart from former partners. Only 16 percent began receiving a benefit
before the age of 20. The vast majority of lone parents are women; only
one child in eight lives with a sole father.
Sarfati says she confined her study to women because overseas studies
have shown that men are not affected in the same way as women by rearing
children on their own.
'Fathers are protected against some of the adverse consequences of being
lone parents by mechanisms of entry into lone parenthood. They are more
likely to be widowed or divorced and they have better incomes and material
resources. Lone fathers tend to engender sympathy whereas women are
treated as marginal.'
Data from the 1996/97 New Zealand Health Survey was available to carry
out the research. Lone mothers were compared to mothers in couple families.
The lone mothers were younger, although a surprising 7.5 percent were
aged over 65 years. These were probably women who had taken over bringing
up a child. They were more likely to be Maori (31 percent of lone mothers
compared with 13 percent of couple mothers), they were more likely to
have no or only school qualifications and 66 percent earned less than
$20,000 a year compared with 21 percent in couple families. More than
half lived in the most deprived area quintile of New Zealand. Lone mothers
were twice as likely to be current smokers, and more than twice as likely
to be hazardous drinkers.
Sarfati used answers to the SF-36 questionnaire to compare self-reported
health. While this provided some information, it was not designed to
measure some useful indicators such as social support.
Lone mothers had lower physical health scores than couple mothers, but
these differences were largely explained by differences in socio-economic
status. However, lone mothers had significantly worse mental health
scores.
'The SF-36 is a generic measure of wellbeing,' says Sarfati, 'so we
don't know if the lone mothers had more diagnosed mental illnesses,
or higher levels of anxiety and stress. Overseas evidence suggests both.'
Lone mothers have a higher risk of social isolation and this combined
with the high demands placed on them as main provider and caregiver
can adversely affect health, both directly and through higher rates
of health risk behaviours.
Coming out of her research, Sarfati advocates measures to reduce the
number of lone parents, through better access to contraception, and
getting men to take more responsibility for children, and through greater
support for lone mothers, by reducing barriers to childcare and employment,
and making sure they are paid at decent rates.
References
Sarfati, D and Scott, K M. 'The health of lone mothers in New Zealand'
NZMJ 2001; 114: 257-60
A $348,000 research
grant from the Health Research Council will enable the ground-breaking
Rapuroa: Health and Maori Women study to be updated for the new century.
The first Rapuroa study was led by Erihapeti Murchie for the Maori Women's
Welfare League and published in 1984.
The study looked at cultural security and found that while older women
were still connected to their tribal regions and cultural practices,
this was less true of young women. Other areas studied were women's
assessment of their health, major influences on their health, such as
weight, diet, smoking and alcohol, and the relationship between wellbeing
and stressful circumstances.
For Rapuora II, Jacqui Te Kani, president of MWWL, will coordinate community
participation in the study which will be led by a team of Maori women
researchers based at the International Research Institute for Maori
and Indigenous Education at the University of Auckland.
The study will build on the earlier study and like the original Rapuroa,
will train Maori women as interviewers.
In the first stage, 72 Maori women around the country will be interviewed
about their health and this information will be used to develop and
test a survey questionnaire for the next section of the project. The
researchers will use research methods based on Maori philosophies and
practices.
Sexual and reproductive health strategy
A document outlining the overall strategic direction for sexual and reproductive health will be released by the Ministry of Health at the end of August. The strategy will include:
- sexual and reproductive health services as a public health service
- provision of a comprehensive free specialist sexual health service close to the community
- sexually transmitted disease control to ensure that at-risk groups have access to effective education
- disease control of HIV/AIDS as a sexually transmitted disease
- an emphasis on effective and available services for Maori, Pacific and young people.
Ministry manager
for Personal and Family Health Judy Glackin says the document will also
outline a process for developing detailed action plans covering key
areas of concern. Ms Glackin says the Ministry is putting a lot of effort
into consulting across the health sector and a sector reference group
with a broad representation has been set up to provide expert advice
and assist with consultation.
Members are: Dr Pippa MacKay; Dr Rick Franklin ; Kevin Hague; Pania
Ellison; Ingi Hayward; Fuimaono Karl Pulotu-Endemann; Olivia Tusa ;
Alan Flemming; Gillian Tasker; Catherine Healey; Nigel Dickson; Gill
Greer and Kitty Flannery.
So far the group has held three meetings. As part of the development
of the strategy, the Ministry has embarked on a stocktake of existing
services, a literature review of programme effectiveness for sexual
health services and a summary of service evaluations undertaken within
the previous five years.
A new Ministry appointee, who will lead the sexual health policy, is
due to take up the position later this month.
New hormone therapy guideline issued
A new best practice
evidence-based Guideline on the Appropriate Prescribing of Hormone Replacement
Therapy developed for the New Zealand Guidelines Group was launched
recently in Auckland. Copies of the guideline summary have been sent
to all GPs and other doctors. Funding has yet to be found for a consumer
resource.
The guideline says that HRT is not recommended for routine use, but
is the most effective therapy for managing troublesome hot flushes,
night sweats and sleep disturbance caused by these. HRT is effective
for preventing bone loss, and reduces the risk of vertebral fractures,
but there is less robust evidence about whether HRT reduces the number
of hip fractures in older women.
The most controversial aspects of the guideline are the new recommendations
not to use HRT in women with established coronary heart disease, the
lack of evidence to support the use of HRT for primary prevention of
CHD and recommendations around the risk of venous thromboembolism in
users. HRT use increase the risk three-fold although the absolute risk
is still low. The guideline recommends that where possible HRT is stopped
one month before surgery and should be withheld 90 days after surgery.
Other risks are the increase in breast diagnosis after five years of
use, and gall bladder disease.
The guideline team found little evidence that HRT is useful for a number
of conditions, including treatment and prevention of Alzheimer's disease,
loss of libido, memory loss, depression, mood, incontinence, skin ageing
and body aches and pains.
Low dose topical oestrogen is effective in treating vaginal atrophy,
and may help reduce the reoccurrence of urinary tract infections after
6-8 months of use. The non-hormonal vaginal moisturiser Replens helps
with vaginal dryness which is now available in New Zealand through Optimus
Healthcare Limited Ph: (09) 520 0022 Fax: (09) 520 2783.
The full guideline is available at www.nzgg.org.nz or for $45 a printed copy can be obtained from New Zealand Guidelines Group, PO Box 10665 The Terrace Wellington. See events page for times of two seminars for women on menopause, HRT and the guideline.
A recent study
shows that the number of women on hormone replacement therapy in New
Zealand has nearly doubled between 1991 and 1997. Fiona North and Katrina
Sharples surveyed 2000 women, and found that whereas 12 percent of women
were currently using HRT in 1991, six years later the figure was 20
percent.
The reasons women were using HRT had altered. Slightly fewer women were
using HRT for symptom relief (85 percent in 1991 and 82 percent in 1997),
and the number of women using it for prevention had increased from 42
percent to 49 percent. Osteoporosis was the reason given by nearly half
of those using it for prevention in both surveys, but the use of HRTfor
prevention of heart disease had grown from 15 percent to 27 percent.
The study data was gathered before the release of the HERS study which
showed that in women using HRT for secondary prevention of heart disease,
there were more deaths from myocardial infarcts in the first year than
in women not using HRT.
The profile of users of HRT was stable across both studies, with results
similar to surveys overseas. Women using HRT were most likely to be
highly educated and to be employed in professional, managerial and non-manual
jobs. Pakeha women were twice as likely as Maori women to be using HRT.
Ref: North, Fiona, and Sharples, Katrina. 'Changes in the use of hormone replacement therapy in New Zealand from 1991-1997' NZMJ 2001;114:250-53
New Zealand Women's Health Strategy
The Ministry of Women's Affairs has taken the lead in drafting a health strategy for New Zealand women. Submissions on the draft, which was released in April, are now closed. The Ministry's Dairne Grant says that Annette King, Minister of Health, has agreed that the strategy will sit under the New Zealand Health Strategy and that DHBs will be required to use it in their plan-ning. The Ministry is currently considering the over 70 submissions that were made on the strategy. A completed strategy is due at the end of September.
Informed consent breaches after death of woman on the Pill
A recent decision
by the Health, Commissioner has implications for GPs prescribing habits.
The case involved a woman who died in 1998 aged 32 from a blood clot
while taking the third generation oral contraceptive Femodene. She had
started the Pill in 1993 and in October 1996 transferred to another
GP in the practice. The woman received repeat prescriptions from a number
of doctors in the practice without seeing them.
The questions that arose during the investigation of the case, were,
whether the new GP should have reviewed her contraception and given
her the chance to change her method after the Ministry of Health had
issued extensive advice to doctors and patients about third generation
pills in July 1996. The Ministry's advice emphasised that continuing
on the Pill must be the woman's informed choice, but the GP said she
was within her rights to have relied on her predecessor. There were
also questions about the safety of a number of doctors renewing prescriptions
without seeing the woman and carrying out periodic checks of her health.
The Health Commissioner found a number of breaches of the Code of Rights.
He said that the woman's medication should have been reviewed at least
once a year and that when the advice by the Ministry of Health was promulgated,
it should have been reviewed at the next visit she attended. It was
not good practice to issue repeat prescriptions without carrying out
such reviews. The Commissioner found that the woman had never been advised
to have such a review. These were breaches of Right 4(1) and (2) regarding
the standards of services.
The Commissioner decided that the woman should have been given the chance
in the first visit after the Ministry advice was sent out to be told
of the new information about third generation Pills. A reasonable consumer
would want such information, so that breaches of rights 6(1)(b), 6(1)(e)
and 6(2) regarding the giving of information were upheld. Finally, the
Commissioner found that Right 7(1) had been breached, in that the woman
was not given the chance to make an informed choice about whether to
continue the Pill.
Inserting gender
into health determinants work is the aim of a project underway at Women's
Health Action.
Internationally, there has been a move away from seeing health as an
individual issue which can be improved through changing lifestyle and
behaviours, to looking at the social, economic and political causes
of ill-health. In New Zealand attention has been concentrated on socio-economic
status and ethnicity, with negligible attention to gender.
Gender differs from biological sex in being about socially-determined
roles (femininity and masculinity), unequal power between men and women,
and differing access to society's resources.
The WHA project will include
- a database of relevant current New Zealand work with a gender perspective
- opportunities to present papers
- networking and collaboration
- moderated, interactive on-line site for networking, discussion and news (to be launched by the end of July).
Gisborne report recommends a raft of changes for cervical screening
The Gisborne Committee
of Inquiry has delivered 46 recommendations to ensure the good health
of the National Cervical Screening Programme.
Minister of Health, Annette King, has promised that all of these will
be implemented, saying that over half have already been taken care of.
The committee was headed by QC Ailsa Duffy, with other members Druis
Barrett, representing Maori and consumer interests, and Dr Maire Duggan,
a pathologist from Canada. The committee heard from 58 witnesses, and
lasted for 18 months. The inquiry was set up after the high-profile
case of a woman, known only as 'Jane' or Patient 1, suggested that Gisborne
pathologist Dr Michael Bottrill was under-reporting cervical smears.
Although for some time in the early months of the inquiry the committee
was unsure whether it could confirm that Dr Bottrill was under-reporting,
it concluded that there was 'ample evidence' of this failure. There
was a wide discrepancy between the results of the Gisborne lab and the
Australian labs used for the reread. At least 16 women had developed
cancer because of the under-reporting.
The report says that Dr Bottrill used deficient practices in his lab,
was not accredited and lacked quality control, but that the National
Cervical Screening Programme was responsible for not detecting his failure.
The requirement that lab services purchased for the programme be TELARC
accredited, as intended in the 1990 policy of the Expert Group, got
watered down in successive iterations of policy. There was also confusion
as to responsibility about lab accreditation between the Ministry and
Health Funding Authority.
The report makes the point that TELARC registration (now IANZ) is not
a guarantee that labs will not under-report, but it does require systems
and procedures in labs that are likely to lead to good results. Cytology
labs used by the programme have been accredited since 1996.
Other omissions are outlined in the report. Lack of performance standards,
a 'sub-optimal' regionally-based register, the lack of reliable data
and the failure to conduct comprehensive audit, monitoring and evaluation
were other reasons that contributed to Dr Bottrill's poor practise not
being picked up.
While the ingredients of successful programmes were known from the late
1980s, not all these were put in place. The advice of experts was not
followed and the national co-ordinators - the first was appointed in
1990 - did not have power and authority. They also lacked the necessary
knowledge and experience to recognise the programme's systemic problems
and the risk they carried. With devolution to area health boards and
then RHAs, the ministry had little authority to require certain actions
to be carried out. There was no body with overall responsibility.
While Dr Bottrill was 'an extreme case', the report said that it could
not conclude that he was an isolated example. Without a comprehensive
evaluation of the programme, the committee said it could not conclude
that there was no under-reporting elsewhere. It said that it was essential
that the planned audit and evaluation takes place, and set a six-month
timeframe for this to occur. Legislation should be urgently passed to
remove any impediments to this.
If the evaluation does not occur, then the committee said that women
should be clearly informed of the programme's limitations. Women could
choose whether to participate in the programme or have more frequent
opportunistic smears.
If the national evaluation throws doubt on the accuracy of smears nationwide,
the committee recommends that all women who are on the register re-enroll
as new entrants and start again with two tests 12 months apart.
The report says that the NCSP must be managed within the Ministry of
Health as a separate unit with a separate budget and a manager who has
the power to contract directly with providers. The manager should hold
specialist qualifications in public health or epidemiology. The programme
register should be moved towards being a population-based register.
GPs need to be reminded that they must be alert to symptoms of cervical
cancer and not place too much reliance on smear tests in the face of
symptoms.
The Report of the Ministerial Inquiry Into the Under-reporting of Cervical Smear Abnormalities in the Gisborne Region is available online at http://www.csi.org.nz
Busting with Life shows there's life after breast cancer
The bright pink
of Busting with Life, the breast cancer survivors' dragon-boat team,
makes a distinctive splash on the sparkling water's of Auckland's Viaduct
Harbour. With an age range of 46 to 66 the team members are miles older
than other crews, but what they lack in muscle, they make up in com-mitment.
'It's a young person's sport, a very physical sport,' says Team Co-ordinator
Trish Nelson, 'and all of our women have had major upper body surgery.'
Despite this in three years the team has made huge strides, now keeping
up with the slow teams.
The Busting with Life team never aimed to cross the winning line first.
'We were never going to beat those guys,' says Trish, 'so we're out
to look good as we paddle, to look good in our uniforms and make a mark
for what we stand for. In three years our technique has improved so
much.'
The team wants to very visibly show others with cancer that they can
lead a full and active life. 'People tell us we've encouraged them to
keep going when they're at a low ebb' says Trish. For individual women
in the team, many of whom had not been physically active before having
breast cancer, it's also been a huge plus. Trish says they're fitter,
more confident, and 'after the trauma of what they've had, they're shown
they're quite normal.' There's now a second crew, hailing from Christchurch,
called 'Abreast of Life'.
The Auckland team trains twice a week on the water at Lake Pupuke during
the season, and does a big walk every Sunday, a routine they keep up
during the winter. Big regattas are held in Wellington, Hamilton, Auckland
and Lake Karapiro. There's also fund-raising and a need to find sponsors
for fees and equipment. This year the Cancer Society sponsored putting
the team's name on a dragon-boat with the web site address.
How do other teams regard the Busting with Life crew? 'We get so much
respect from them,' says Trish. 'We're old enough to be their mothers
and they think we're awesome.'
Busting with Life's web site: http://www.bustingwithlife.org.nz
Can what you eat prevent breast cancer?
Recent media articles
have claimed so, prompting the Cancer Society to take an in-depth look.
Penny St John summarises the findings.
There is strong evidence that increased physical activity may play a
role in preventing breast and colon cancers, according to a recent report
from the New Zealand Cancer Society. However the report says that there
is not enough evidence from scientific studies to make clear recommendations
that a particular diet will help prevent breast cancer, although increasing
fruit and vegetable consumption may help.
Increasing public interest in links between nutrition and cancer prevention
prompted the Cancer Society to com-mission a review of the current research.
New research also means dietary recommendations are changing.
Breast cancer
Increasing age is a risk factor for breast cancer, with 70 percent
of cases occurring in women over 50. Family history, early menarche
(aged 12 or younger) and late age at menopause also play a part. The
main risk factors for breast cancer are associated with high levels
of the hormone oestrogen.
Breast cancer rates vary more than five-fold between countries, suggesting
environmental causes that could be modified. However, the evidence linking
diet with risk of breast cancer is inconsistent.
Links between dietary fat and the risk of breast cancer are limited,
although it is possible dietary fat intake during childhood and adolescence
may affect breast cancer risk several decades later. Although prospective
studies have not related total fat intake to breast cancer risk, there
is some evidence the type of fat may be important. Studies using olive
oil showed that it gave some protection. Whether the protective effects
were due to the monounsaturated nature of the oil and/or the antioxidant
content is unknown.
Higher intakes of vegetables may be associated with a lower riskof breast
cancer and there is weak evidence that fruit is protective.
There is also some evidence that higher meat consumption, particularly
red and fried meat, is associated with a higher risk of breast cancer.
However some researchers have suggested high meat consumers may not
consume enough fruit and vegetables, which may be protective.
There is weakly consistent evidence that higher intakes of vitamin A
(either total, preformed retinol or carotenoids) are associated with
a reduced rate of breast cancer. Supplementation offers no added benefit
to women whose dietary intakes of vitamin A are already adequate.
More research is needed into the possible protective effect of phytoestrogens
(isoflavones and lignans) from soy products. There is interest in phyto-estrogens
but the jury is still out in terms of evidence.
The evidence for a relationship between risk of pre-menopausal breast
cancer and Body Mass Index (BMI) is inconsistent. There is some evidence
for a positive association between breast cancer and BMI in postmenopausal
women. Postmeno-pausal obese women generally have higher levels of available
oestrogen than normal weight women. Central obesity, in particular,
may be associated with increased risk of breast cancer. Higher levels
of physical activity may reduce the risk of breast cancer. Whether this
is through the maintenance of a healthy body weight or other factors
is not clear but a protective effect has been shown.
Alcohol intake has been associated with an increased risk of breast
cancer. Although the evidence remains inconsistent, in several studies,
even one to two drinks per day resulted in an increased risk.
The current
evidence
On the evidence, it's not possible to make clear recommendations
that a particular diet will help prevent breast cancer. It is likely
that eating plenty of fruit and vegetables, avoiding or minimising alcohol
intake, keeping body weight within recommended levels and taking plenty
of physical activity may be helpful, as is the case for other cancers.
General conclusions
The report also looked at the role of nutrition in lung, prostate and
bowel cancers, as well as looking at specific nutrients such as Folic
Acid and antioxidants. It concludes an increased focus on physical activity
is a goal that should be achievable by most New Zealanders and the evidence
is very strong to support this recommendation.
There is not enough evidence to recommend optimum levels of fruit and
vegetable consumption, although the recent COMA working party stated
any increase would help.
Cancer risk can be reduced by:
- eating a high proportion of plant foods (fruits, vegetables, grains, and beans)
- eating moderate amounts of lean meat and reduced fat dairy products,
- minimal high-fat foods, especially saturated fat
- minimal if any alcohol
- a balance of energy intake and physical activity.
The full report and references are on the Cancer Society website:www.cancernz.org.nz
New appointments for National Screening Unit
The Ministry of
Health National Screening Unit's has a new Group Manager and Clinical
Director.
The new Group Manager is Karen Mitchell, while Dr Julia Peters takes
the key position of Clinical Director.
The Director-General of Health, Dr Karen Poutasi, said the two appointments
are the first in a number of new appointments as the National Screening
Unit is strengthened and developed into an autonomous business unit
operating within the Ministry. The unit is increasing in size from the
current nine to 33 people.
'Karen Mitchell is an experienced senior manager, who has worked in
the UK for the past 11 years in a range of consultant, advisory and
management roles within the health service. Most recently Karen was
a senior manager at King's College Hospital in London.'
'Dr Peters is someone who is known to many in the public health sector.
As a public health physician and Manager of the HFA's National Screening
Team, she led the team for over two years, during which time the national
breastscreening programme was estab-lished and several key initiatives
were carried out to strengthen the National Cervical Screening Programme.
As Clinical Director, Julia will work with Karen to establish the new
unit and will increasingly focus on the clinical and technical aspects
of the two cancer screening programmes,' Dr Poutasi said.
The National Screening Unit is responsible for carrying out all the
national functions of the two population-based cancer screening programmes
- the National Cervical Screening Programme (NCSP) and BreastScreen
Aotearoa (BSA).
The Unit, which has offices in Auckland and Wellington, has a total
budget of some $60 million.
Refugee Afghani women reach safe haven in New Zealand
Annette Mortensen, Refugee Health Coordinator for Auckland District Health Board, outlines the health needs of the new arrivals.
Last month, after a much publicised journey, Afghani women off the Tampa arrived in Auckland. They were among the tens of thousands of women in Afghanistan who effectively remain prisoners in their homes under Taleban edicts.
There are over 40 million refugees and displaced peoples worldwide of whom two-thirds are women and girls. Less than one per cent of the world's refugees reach the safety of a country of asylum.
New Zealand is one of only nine resettlement countries. We accept an annual quota of 750 refugees and about the same number of asylum seekers are granted refugee status annually. These refugees have the status of New Zealand residents and are eligible for all publicly funded health and disability services. So are asylum-seekers who are in the process of applying for refugee status. The selection of quota refugees is targeted at those in greatest need of resettlement, with particular attention to emergency cases, medical/disabled cases and women-at-risk.
Most refugees in New Zealand in the last ten years have come from Iraq, Iran, Bosnia, Somalia, Sudan, Ethiopia, Sri Lanka, Kosovo, Burma and Afghanistan.
New Zealand reserves a special place of 10 per cent of the quota for women who are particularly at risk of sexual violence. These are women and their children who are on their own in refugee camps, whether they are single, widowed, abandoned, unaccompanied minors, lone heads of households, or who have been separated from male family members by the chaos of flight or during voluntary repatriation. At every stage of flight displaced women and children are vulnerable to rape and sexual abuse by border guards, soldiers, citizens in their country of asylum, and other refugees.
Taleban rules mean that Afghani women and girls are virtually imprisoned in their homes, unable to gain any education, work, feed themselves or seek health care for fear of'punishment'. Women accused of defying Taleban edicts are humiliated or beaten by officials of the Department for the Promotion of Virtue and Prevention of Vice. The Taleban has taken scores of young women of the ethnic minority group, Hazara, as servants to be married off to Taleban militia deployed at war fronts. Women in Afghanistan have an average family size of 6.7 children, lose over a quarter of all children under five years of age, face a maternal death rate of 1700 per 100,000 and have a life expectancy of 45 years.
In general refugees on arrival are in poor health. Public health screening reveals infection rates for communicable and tropical diseases that tend to mirror the rates reported in the country of origin. Tuberculosis is over 400 times higher than the rate of disease in the general New Zealand population. Half of new arrivals are malnourished and need treatment for iron deficiency, intestinal parasites and poor dental health. Those from African countries present HIV infection rates of 2.6 per cent. Opportunistic HIV testing in this population is important including antenatal screening. One of the main gynaecological problems encountered among women from Northeast Africa is female genital mutilation (FGM). Screening identifies FGM in 98 per cent of females six years and over from African countries. FGM is associated with menstrual, urinary, obstetric, sexual and mental health problems.
Refugee women and their families face significant psychological difficulties resulting in ongoing mental health problems and in particular posttraumatic stress disorder. Some are referred for ongoing management to specialised mental health services such as Refugees As Survivors.
Most women from refugee backgrounds will have had limited access to health care prior to arrival in New Zealand. Our system of general practitioners and of referral to a specialist will be unfamiliar and require careful explanation. Many will have had no family planning education, little or no previous health screening, particularly cervical and breast screening and may have psychosexual and mental health issues following trauma, rape and abuse during flight, and a lack of adequate follow up care and treatment in New Zealand. Women from refugee backgrounds will have difficulty accessing health care services in New Zealand due to language, financial and cultural barriers and difficulty finding childcare and transport. Generally many women need support with getting to specialist referrals.
Many recent refugees in New Zealand come from Muslim countries. It is useful for health professionals to know some of the beliefs and practices of Islam and how these may impact on the provision of health care, including diet, dress and hygiene, gender roles, and family planning. The dietary codes of Islam forbid the consumption of non-Halal foods, for example pork and non-Halal meat. As Halal foods are not yet available in New Zealand hospitals, clients need to be asked which foods are appropriate for them. During the month of Ramadan, adult Muslims are required to fast from the hour before sunrise until sunset. This necessitates the organisation of medication schedules to accommodate this. Pregnant, lactating and menstruating women and the ill are exempt from fasting. Islam has strict rules regarding physical contact and modesty between the sexes. Accordingly, some Muslim women will prefer a female health care provider.
Women from refugee backgrounds may be reluctant to use family planning services due to religious beliefs, cultural attitudes and lack of education. Others may follow cultural contraceptive practices, for example, withdrawal,'safe' period or breastfeeding. It is important to find culturally appropriate ways to discuss family planning. In many cultures it is unacceptable for women to discuss family planning when men are present. It is important to ensure that any male present during a consultation is given the opportunity to leave. As well in general it is best to use the services of a female interpreter only.
While culture and ethnicity are a major factor to be considered in addressing the health care needs of refugee women other factors such as the experience of violence and sexual assault, multiple grief and loss, and the trauma of resettlement are also a major influence on a client's state of health and response to health care.
For further information please contact Annette Mortensen: Public Health, 2 Owens Rd Epsom, Private Bag 92605, Symonds St, Auckland 1001 Ph (09) 2621855, Fax (09) 6307431, Mob: 021442 590, E-mail: amortensen@adhb.govt.nz HIV and FGM information has been developed by Nikki Denholm and is available from: hiv@exposure.org or fgm@exposure.org.
Government decides about law for cervical screening audit
Law changes to assist audit of the National Cervical Screening Programme were announced at the launch of the new National Screening Unit in early October. Minister of Health, Annette King, outlined government plans to introduce legislation to allow auditors access to women's information on the NCSP register, as well as slides held by labs. But women's consent would be required before auditors could access women's clinical records such as treatment records and smeartaker/GP records.
The Ministry had received 101 submissions on its discussion document on the proposed changes. Most supported access to register information and slides, but 51 of 69 submissions that commented on access to clinical records, opposed this being done without consent, including many women's groups, Cancer Society, and the Ministries of Women's and Consumer Affairs. If women cannot be found to give consent, then the Director-General can require a health professional to provide relevant information. The Ministry is looking at extending such provisions to other screening programmes.
There will be further consultation on proposals to make'opt off' a once only opportunity rather than with each smear, and to specify that consent to access clinical records occur at the time a woman is diagnosed with cervical cancer or her information goes to the National Cancer Registry.
The full cabinet minute is available at www.executive.govt.nz/ministry/king.
ÔBreastfeeding - ancient art, modern miracle'
Sian Burgess, breastfeeding advocate at Women's Health Action, reports on the Australian Breastfeeding Association's 4th Conference which she attended last month.
The conference title was a major theme. Breast-feeding has indeed become a modern day miracle when women overcome the obstacles they must face in order to breastfeed.
The other theme was around the misleading issue of'choice'. The choice between bottle and breast is contrived and not based on physiological reality. The biological, physiological, neurobehavioral, evolutionary and anthropological contention is that maternal skin-to-skin contact is the natural habitat for all newborns and in this habitat they have programmed niche behaviour to breastfeed. The initiation of breastfeeding belongs to the baby. Babies breastfeed and mothers lactate. There is an urgent need to restore this original paradigm.
All over the world women will tend to initially breastfeed their babies, but there is a huge drop-off in the numbers who continue to breastfeed exclusively for six months and who continue breastfeeding into the second year and beyond. Support for women to breastfeed is increasingly difficult in Western societies where families, women, and motherhood are undervalued or only given lip-service. Cultural and societal attitudes, workplace policies and paid maternity and parental leave all impact on breastfeeding. The objective for public health promotion is to address these issues.
Almost every speaker spoke about the public health imperatives in breast-feeding somewhere in their address. There is a dearth of outstandingly successful programmes out there. One exception was the Tasmanian Support Breastfeeding Coalition TV advert that came out of research that showed that the key issue in young women's disinclination to breastfeed was breastfeeding in public. The research findings were given to M&C Saachi who came up with a very clever scenario of a man eating his lunch sitting on a toilet with the sound of a toilet next door being used. The voice over was:'You wouldn't eat here, so why should a baby?' We need to establish that breastfeeding in public is a mother's right.
Several speakers looked at how the media shapes attitudes. Newspapers tended to focus on the risks of breastfeeding for infants. Anything about contaminants in breast milk is instant news. Or media present breastfeeding as titillating or quirky with headlines such as'How The Nipple Nazis Tried To Win The Battle Of The Bulge' or'Breastfeeding - it Sucks'.
Child-centred messages such as'breastfeeding is best for your baby' can cause resistance as they are interpreted by some women as meaning that it's their duty to breastfeed. Idealizing the nursing relationship is not a marketable concept to all audiences. It's interpreted as being anti-mother and certainly as anti-feminist.
Formula manufacturers have a powerful impact through their marketing of bottle feeding. The WHO Code on the Marketing of Breastmilk Substitutes has had some effect, but recent monitoring of the 20 main baby food companies shows that they continue to breach the code. Marketing has moved onto sponsorship and research with companies increasingly using legal loopholes to avoid compliance.
There were also some fascinating speakers on early life programming for adult disease and the links with breastfeeding. Research in the UK shows a relationship between those born in 1910 -1920 who were formula fed and deaths from coronary heart disease and diabetes.
The weather was warm the Australians were hot especially in the light of the Ansett debacle it was good to own another passport.
Stuart Bruce has been appointed senior analyst, Child & Family Policy, and Sarah Turner, manager, Child & Family, to lead work on sex, reproduction, STIs, well child, family start and breastfeeding. A high-level strategy for sexual and reproductive health is to be launched by the Minister of Health on 18 October. This will be followed by the development of five action plans.
Self-help adherents have long claimed that cranberry juice is good for urinary tract infections in women, and now there's evidence from a randomised controlled trial to back it up.
UTIs are common in women, with up to 60% of women experiencing this miserable condition at least once in their lives. Sexual activity is the most important risk factor and some women suffer repeated infections. Most at risk are women 25-29 years and over 55 years.
Cranberry juice and products contain condensed tanins called proanthocyanidins that possess antiviral, antibacterial, antiadhesive and antioxidant properties. They have been shown to act against the coliform bacteria that cause most UTIs. Resistance to antibiotics has led to interest in alternative methods.
In this Finnish study, 150 women with UTIs were randomly allocated to one of three groups: the first groups received 50 ml of cranberry-ligonberry juice concentrate daily for six months; the second received 100ml of lactobacillus GG drink five days a week for one year, and the third served as an open control group. The participants could add water to their drinks but no sugar.
The first UTI was treated with antibiotics and women had to show urine with no bacterial growth before they were randomised into the groups. Urine samples were taken throughout the trial.
During the six months of the study. 16% of the women in the cranberry group, 39% of the women in the lactobacillus group and 36% of the women in the control group had at least one episode of UTI. This is a 20% reduction in absolute risk in the cranberry group compared to the control group. At the end of a year, there were still fewer UTIs in the cranberry group.
Ref: Kontiokari, T, et al. BMJ 2001; 322: 1-5
European medicines agency confirms NZ advice on the Pill
The main European agency on medicines evaluation has come up with advice on the safety of 3rd generation oral contraceptives that matches NZ Medsafe advice.
The agency says that the risk of a blood clot with 3rd generation Pills is twice that of 2nd generation Pills. It said that the risk is highest in the first year of use.
The full report can be found at www.emea.eu.int. Medsafe information for women is at www.medsafe.govt.nz/Consumers/medicine/oralcontraceptives.htm.
Cordelia Lockett reports on disturbing results from a recent survey of alcohol consumption in New Zealand.
An increasingly liberal social climate around alcohol may explain the marked rise in consumption by women and young people between 1995 and 2000. A recently released report - Drinking in New Zealand - based on a comparison of national surveys conducted by the Alcohol and Public Health Research Unit (APHRU), shows significant increases in the frequency and quantity of alcohol consumed (including increases in heavy drinking) by women and young people of both sexes, as well as increases in alcohol-related problems - particularly among young women. Problems included an inability to remember things done while drinking and feeling ashamed about something done while drinking.
APHRU researcher Dr Ruth Habgood was surprised by some of the results:'Since the 1999 law change (which allowed 18 and 19-year-olds to legally purchase alcohol) you might reasonably expect an increase in young people's drinking, but in women the increase has been right across the board - in every age group. What it shows is that the men's alcohol market is saturated, so advertisers have to target other groups - such as women and young people.'
Habgood believes one of the main reasons for the increase in women's drinking is greater accessibility.'There has been a shift from the old booze barns to more pleasant places to drink - such as cafes and restaurants. Women feel more comfortable drinking in these places.'
The increase in women's drinking reflects the liberalisation of the policy environment around alcohol in New Zealand in the last decade. The 1989 Sale of Liquor Act allowed increased availability of alcohol in terms of licensed premises and longer trading hours. In 1992 alcohol advertising on television and radio was introduced. Then, in 1999, the minimum purchase age dropped from 20 to 18 years. This liberal social climate is reflected in the APHRU surveys: people found takeaway alcohol easier to obtain and expressed a greater tolerance towards getting drunk and towards drinking at any time of the day.
The introduction of wine into NZ supermarkets was followed by a 17% increase in overall wine sales and has contributed to increased consumption by women. In dollar terms alcohol is the biggest-selling category of products in supermarkets, and as marketers know, women are the major shoppers, so targeting them makes good business sense.
The increase in women's independent disposable income may also have contributed to their changed drinking habits. Women have more access to money and can spend it on alcohol. Changes in women's social roles have meant that they may feel less stigma associated with drinking. Women can do anything - including getting completely inebriated!
Christine Rogan of Alcohol Healthwatch believes another reason for the increase in women's drinking may be that there is a universally-accepted idea that alcohol is good for you. And women, being particularly receptive to health-related messages, have picked up on this. Rogan says recent suggestions that a small amount of wine may benefit those at risk of heart disease, have been exaggerated and misconstrued.'People believe what they want to believe. The take-home message is that alcohol is good for you'.
Competition for what the alcohol industry calls'share of throat' is fierce. As overall consumption drops, marketing managers have looked to fresh targets, such as women and young people. Since about 1997 women have been deliberately targeted by the alcohol industry. In the beer market, in addition to the traditional male-orientated, blokey campaigns (think Lion Red, Speights), a whole new marketing strand has been developed. Two main strategies have been employed to create and communicate'brand values' that are seen as relevant to women.
One strategy, to capture health and weight-conscious women, uses labels like'light' and'natural' with associated positive images of healthy and low-calorie (they're not). The second is dark, high-alcohol, bitter beer with connotations of being rich in nutritious vitamins and minerals. The latter'boutique' beer is designed to appeal to women who may not necessarily consider themselves beer drinkers, but who nevertheless enjoy red wine, black coffee or dark chocolate!
The alcohol industry is also battling over access to young people with the introduction of the fashionable'alcopops' (ready-to-drink alcoholic mixes) and youth-conscious TV campaigns such as DB's Export Gold'Flatmates' campaign. Young women particularly are attracted to the fast-proliferating variety of colourful designer ready-to-drinks.
The increases in consumption among young people generally, shown by the surveys, are a great concern to those working in the public health sector, however, the most dramatic increase of any group was in young women aged 18-19, who showed an increase from 17% to 33% in those drinking six or more glasses of wine on a typical drinking occasion.
So women are drinking more, so what?
While women still drink less than men overall (although in some age groups they are catching up; particularly young women who are adopting male binge-drinking habits), women who abuse alcohol face more severe long-term health complications than men.'Women metabolise alcohol very differently to men and often don't realise that they are at greater risk of physical and social harm,' says Rogan. She quotes a study at Auckland Hospital that showed that 55% of all cases of alcohol poisoning were female (whereas only 25% of overall alcohol consumption is by females).
Another alcohol-related issues for women is the risk of having a child with alcohol-related brain damage. The effects of alcohol on the unborn foetus are well documented, but while the Ministry of Health recommends abstaining from any alcohol during pregnancy, a recent survey of pregnant women showed 36% continued to drink in pregnancy, with 13% drinking heavily or binge-drinking. In teenaged girls, a disturbing 82% continued to drink during pregnancy.
Rogan believes what is needed is a high profile public health campaign - like the highly successful drink-driving campaigns - targeting young women and addressing the risks of unhealthy alcohol use.'The drink-driving ads have been great, but unfortunately the message from them could be interpreted that as long as you're not driving, it's OK to get completely blitzed. What we need is a major campaign of similar intensity, to challenge that.'
Reference: Drinking in New Zealand: National Surveys Comparison 1995 & 2000, Alcohol & Public Health Research Unit, November 2001 email: aphru@auckland.ac.nz
| Increases in women's alcohol consumption | ||
| 1995 | 2000 | |
| Average annual volume consumed by women | 5.4 litres 7 glasses/wk | 7.3 litres 9 glasses/wk |
| Percentage who exceeded 10 litres per annum Percentage who exceeded 20 litres per annum Percentage of heavier drinking occasions | 15% 5% 31% | 20% 7% 42% |
| Six or more drinks per occasion (all ages ) (and for 18-19 year-olds) (and for 25-29 year-olds) (and for 30-39 year-olds) | 7% 11% 11% 5% | 11% 33% 20% 11% |
| Four plus drinks at least weekly 16-17 year-olds Feeling drunk once a week or more (all ages) Percentage of 18-19 year-olds who are drinkers | 10% 4% 78% | 21% 6% 89% |
| Number of drinking occasions p.a. (all ages) (and for 14-15 year-olds): (and for 16-17 year-olds): | 126 39 67 | 136 67 92 |
Making screening work for Maori women
Camille Guy talked to Aroha Harris about her new position in screening.
Tackling the reluctance of Maori women to participate in breast and cervical screening programmes is the task facing the new Maori health screening development manager. Aroha Harris takes up this newly created position within the National Screening Unit from a background in health and social services.
Of Ngati Whatua descent, Aroha has a strong network within the Maori health sector. She was formerly Maori women's health manager at National Women's Hospital and has most recently worked in the areas of child and adolescent mental health in South Auckland.
Maori women are a key focus group for both the National Cervical Screening Programme and BreastScreen Aotearoa. This reflects concern over the high incidence of both breast and cervical cancer, but Aroha Harris is careful not to emphasise those statistics. Scare-mongering is not the approach she intends taking in her new role.
ÔMaori women don't wish to be portrayed as having bad statistics,' says Aroha.
Some of the barriers to Maori women coming forward for screening include geographical distance, lack of transport, and shyness about bodily examination, especially by male doctors. Then there is the issue of cost.
Maori women's sense of priority may mean their own health takes a back seat.
'If the need is to put food on the table then that is it,' says Aroha.
Maori women need to be assured that the screening procedures are safe, both clinically and culturally. They may need support during examination.
Aroha is presently reviewing existing services and is looking at which can be improved and what new ones need to be created. She will be rethinking how to make the best use of providers This may entail making use of what is already to hand or will require additional resources. There is government support for the development of specific policies for Maori women.
Speaking at the announcement of Aroha Harris's appointment, Associate Health Minister Tariana Turia described the appointment as an'important milestone' and said that the government was committed to ensuring the national screening programmes were well resourced.
Aroha will be leading the team covering the screening of Maori women through-out New Zealand. She acknowledges that each locality will be different.
'What works for Auckland cannot be developed in, say Taranaki. The job involves rethinking every part of the strategy,' says Aroha.
It will be a huge and challenging job, but several months into it, Aroha says it is one she already loves.
Health information at fingertips
 | At the Maori Women's Welfare League conference, Sally Hughes (right) of the National Screening Unit shows Daisy Phillips a clever new tool for educating women about screening. The touch screen kiosk is portable and can be set up wherever women gather, such as conferences and shopping malls. A simple touch on the screen enables users to navigate the Healthy Women web site, providing answers to women's questions about screening. This innovative new technology for improving access to information about screening is being piloted by the NSU. |
Independent review of BreastScreen Aotearoa
International screening expert, Professor Jocelyn Chamberlain, is to review BreastScreen Aotearoa, the national breast screening programme. Professor Chamberlain will arrive in early February and spend 15 days reviewing the programme, meeting with Ministry of Health staff, service providers and other stakeholders. BSA is entering its second screening round and Professor Chamberlain will review progress and identify any areas where improvement is needed.
Professor Chamberlain has a strong academic background and has made a considerable contribution to cancer screening programmes in the United Kingdom through advisory groups and publications. At present she is chair of the South West Wales Cancer Institute, University of Wales, and Emeritus Professor of Community Medicine, Institute of Cancer Research, University of London.
Professor Chamberlain's terms of reference require her to provide opinion and advice on:
- The implications of the Gisborne Inquiry recommendations for BSA
- Any deficiencies in the programme after two years
- The ability of the programme to meet its objectives given its current operation and configuration, including consideration of information systems employed
- The ability of the current monitoring, audit and analysis activities to ensure that a high quality programme is being delivered to the women of New Zealand
- Programme achievements when compared with programmes internationally.
She will report by 20 April 2002.
The new Refugee Health Care - A Handbook for Health Professionals will provide a useful resource not only for health professionals, but for any community or government agency that has contact with members of refugee and migrant communities.
The handbook, by the Ministry of Health, gives important background information on refugees from the range of originating countries and outlines common physical and mental health issues among refugee people. It has a section on refugee women and their specific health needs.
The back of the handbook holds useful information about health education resources available and a contact list.
To order copies contact: Heather Conland, Folio Communications Ltd, PO Box 12-102, Wellington, Ph: (04) 499-5989 (04) Fax: 499-1277 Email: hconland@foliocom.co.nz
Or you can download it from the internet at www.moh.govt.nz
