United Kingdom:

Discrimination Against Women and Young Girls in the Health Sector

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There are wide variations in health across the UK, as it is made up of sharply contrasting socio-economic regions in Scotland, Northern Ireland, England and Wales. Nevertheless, there is a reasonably high life expectancy (80.7 in 2004), and has one of the highest number of women in the workforce (46% per 100,000) of the countries studied. Women in Northern Ireland are more likely to experience poverty than men, while in England mothers in the lower social groups are two and a half times as likely to smoke before or during pregnancy, and over four times as likely to smoke during pregnancy than the more privileged. The UK has one of the higher incidences of deaths from breast and lung cancers, though with the introduction of national screening programmes and new improved treatment over the past three decades, rates are falling.

There are a relatively high number of teenage births, though in general births occur in the 20-34 year age groups. The incidence of chlamydia is high, but the National Strategy for Sexual Health and HIV, published in 2001, included targets to reduce prevalence of this and other STIs.

The following material was submitted by Hilary Thomas, Centre for Research in Primary and Community Care, University of Hertfordshire and Annie Dillon, National Women’s Council.

Women’s health

 

Life expectancy at birth for women in the UK is 80.5 which, while improved, is less than some other European countries. In common with the rest of the EU 25 the major cause of death is circulatory disease followed by cancer. 65.3% of women in the UK population perceive that their health is good or very good.1

Given that the UK comprises Scotland, Northern Ireland, England and Wales there are differences in relation to women’s health status based on social, economic and regional variations as well as the diversity of women and the experience of marginalised groups. Some brief examples are presented.

In England, people in affluent areas live longer than those in deprived areas, for women in the least deprived fifth of areas they live on average 2 years longer than those in the most deprived areas.

From 2000 to 2005 the gap in smoking levels between mothers in different socio-economic groups increased In England. Mothers in the lower social groups are two and a half times as likely to smoke before or during pregnancy and over four times as likely to smoke during pregnancy. Levels of breastfeeding are lower amongst women from lower socio-economic groups and a larger proportion give up breastfeeding by six weeks. The proportion of mothers who breastfeed is higher amongst minority ethnic groups. (Health Profile in England, 2006)

In Scotland long-standing illness, health problem or disability for women is 53.1% compared with men 46.9% (2003)3

In relation to gender inequality and Social Determinants of Health women in Northern Ireland are more likely to experience poverty than men, with women comprising almost two thirds of all income support claimants and women more likely to be employed in service sector and low paid jobs.

In relation to diversity of women, some groups are more disadvantaged than others, e.g for example Traveller women’s life expectancy is significantly lower than the mainstream population and they are more likely to describe their health as ‘poor’ or ‘very poor’

In addition, the take up of screening services was low with only one third reported to have had a smear test. (2006)4 In relation to disabled women, a study by the Equality Commission of Northern Ireland found notable inequalities in areas of mental health, emotional well-being and employment.

Women from Indian ethnic background have higher rates of CVD

Specific health policies for women

 

There is no actual overall policy which provides a coherent policy approach to women’s health, and which takes account of women’s inequality, or of women as a diverse health population. Where statistical information is used it is not always disaggregated by gender e.g. the Chief Executives report to NHS Statistics Supplement 2006. Many policies are presented in a gender-neutral fashion, e.g. ‘Our Health Our Care A New Direction for Community Services’; The Goals of the National Service Framework for Coronary Heart Disease.
The are exceptions including in the areas of Sexual Health, Sexual & Domestic Abuse and Mental Health6 (see www.dh.gov.uk and www.nimhe.csip.org.uk ) policies e.g. in 2000 the NHS Plan recognised the need to develop distinctive approaches for women and made a commitment to the provision of a women-only day centre in every health authority by 2004. The subsequent Implementation Guidance for the Women’s Mental Health Strategy ‘Mainstreaming Gender and Women’s Mental Health’ was published in 2003. This document gave recognition to the range of services and support responsive to women’s requirements already developed by women’s groups in the voluntary sector. A range of approaches, which would meet women’s needs within the context of mainstream services and establish a more flexible target for primary care trusts (PCTs) to have a women-only community day service in place by 2004 were also specified. This NHS deliverable remained a priority for 2005/06 across all regions. The guide ‘Supporting Women Into the Mainstream’ published in 2006 is intended to support the development of community-based women’s day services alongside the work to refocus day services for adults of working age, both male and female.
The National Institute for Mental Health in England (NIMHE) National and Regional Development Centre Leads for Gender and Women’s Health provides good practice examples for use by local PCTs (Primary Care Trusts/Local Health Boards).

A new policy development that will have an impact on the approach to women’s health policy and programme development and service delivery is the Gender Equality Duty [GED], which comes into force in April 2007.
The GED is being introduced as part of the Equality Bill (2005). It requires public authorities to promote gender equality and eliminate sex discrimination. Instead of depending on individuals making complaints about sex discrimination, the duty places the legal responsibility on public authorities to demonstrate that they treat men and women fairly. All public authorities, including health providers, education and local government have to comply. The duty will also apply to charities, voluntary and private sector organisations that are providing a public service. Services provided by organisations under contract, such as community transport, will also be covered by the duty.

Gender-sensitive health policy design

 

In general the policies that are specific to women or men are related to issues that are gender specific such as cervical cancer for women, breast cancer for men, and are included in overall policies such as, for example, that relating to cancer. Where policies are related to health issues that affect both men and women they are often gender neutral.

Three primary issues and how they apply to women

 

Cancer

Cancer is the 2nd biggest killer of women in the UK. The past three decades have seen progress in reducing the impact of cancer, with death rates from breast and cervical cancer falling as a result of the introduction of national screening programmes and new improved treatment.

A cancer plan was published in 2004 with a programme of investment and reform. At that time death rates overall were higher than in Europe, partly due to late presentation at primary care level and variation of services, according to geographical area. The plan contained targets to reduce the risk of cancer including through: Early detection, Smoking reduction programmes, particularly to target disadvantaged groups, Dietary programmes to increase fruit and vegetable consumption and promotion of exercise. Postmenopausal women were specifically mentioned in relation to reducing risk of breast cancer through reducing obesity.

The NHS Breast Screening Programme was introduced between 1988 and 1991 for all women. Recently published research has shown that breast cancer death rates fell by 21.3% in women aged 55-69 between 1990 and 1998. 30% of this fall was attributed to screening and the rest to improvement and other factors (The Cancer Plan 2004). The Breast Screening Programme invites all women aged 50 to 70 for free routine breast screening every three years. There has been a substantial rise in the number of cancers detected, which is mainly due to the expansion of the screening programme since 2001 to include women up to age 70 (previously it covered women aged 50 – 64) combined with the introduction on an advanced screening technique, called two-view mammography (Two x-rays are taken of each breast). In England those aged 70 and over are strongly encouraged to self refer.

Cervical Screening Programme NHS, England: The Cancer Plan (2004) notes that ‘the cervical screening programme in this country is a success story’ (p35). Since introducing computerised call and recall the coverage rate of the screening programme has gone up to a national average of 85%. The cervical cancer death rate has been falling by 7% each year.

Sexually transmitted Infections (STI’s)

The National Strategy for Sexual Health and HIV published in 2001 included targets to reduce prevalence of STIs, HIV and AIDS as well as reduction of untended pregnancy rates and promotion of contraception services for those who need them. The strategy has a ten year time frame and takes a gendered approach, and takes account of the impact of such STIs as HPV on women in relation to Cervical Cancer. As part of the programme a National Chlamydia screening programme has commenced.

Specific healthcare policies for young girls

 

Amongst EU15 member states, prior to expansion in 2004, the UK had the highest proportion of births to mothers aged under 20. Teenage conceptions are more than twice as likely to occur in the most deprived areas, than in the least deprived. However, there is no specific mention of gender. (Health Profile of England 2006 p539)

The Teenage Pregnancy Strategy10 has set targets to:

  • Reduce by 50% England’s 1998 under-18 conception rate by 2010, with an interim target of a 15% reduction by 2004
  • Achieve an established downward trend in the under 16 conception rate by 2010
  • Reduce the inequality in rates between the fifth of wards (local electoral areas) with the highest under 18 conception rate, and the average ward rate by at least 25% by 2010
  • Increase to 60% the participation of teenage parents in education, training or employment to reduce their risk of long-term social exclusion by 2010.

An example of ‘best practice’ in women’s health

The Sandyford Initiative (www.sandyford.org)

The Sandyford Initiative is part of NHS Glasgow, and supported by Glasgow City Council. All services are free of charge, and available without the need to be referred by a doctor or another practitioner. The Sandyford Initiative was launched in Glasgow in 2000 when it brought together the Centre for Women’s Health, Family Planning, The Steve Retson Project (for men who have sex with men) and Genitourinary Medicine. The aim is to provide services using a social model of health. The initiative provides sexual and reproductive health services for women, men and young people in Glasgow, as well as counselling, information and a range of specialist services.

The Sandyford initiative has a website with sections for staff and for service users. This staff part of the site has been specifically designed to provide background information for health professionals, policy makers and other interested parties.

There is also a section of the site designed for the public and for GPs in Glasgow.

In general, there appears to have been a move from a focus on women’s health specifically and to incorporate it within equality focussed structures. For example In the past year as part of restructuring of health boards in Glasgow the Women’s Health team were disbanded and restructured into a new equality team. The focus includes a social, economic and inequalities in health, with women’s health incorporated in this health promotion work.

It is worth noting that five years ago Glasgow Women’s Health, which was part of the Healthy Cities Programme defined a model of women’s health as follows:

‘The Glasgow Model of Women’s Health identifies the need to invest in women in order to overcome inequality, to adopt a model of health which takes social factors into account, to involve women, to work in partnership across agencies and to develop city wide strategies.’ (2000/01)

Mental health policies

The mental health policies (as mentioned above) are notable because they include a recognition of women’s specific mental health/ill health experience and need. A notable example of best practice is the women-centred responsive approach taken as well as the recognition of such services developed by women’s voluntary organisations in response to past gaps in service provision.

Further gender influences on patterns of health

Sexual Abuse and Domestic Violence

There is now a recognition at policy level11 that sexual abuse and violence are causative factors in physical and mental ill health in children, adolescents and adults both women and men. There is a gender and equality perspective, with a high economic and social burden on health services. Currently a programme to tackle the root causes of mental and physical ill health, which takes a whole system approach, is underway12.

 

Main reference documents:

1. Annandale E, The sociology of health and medicine: a critical introduction. 1998, Polity Press.

2. Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health care systems in transition: Portugal. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.

3. Branco MJ, Nunes B, Contreiras T. Um estudo sobre a prática de cuidados preventivos nos cancros da mama e do colo do útero, em Portugal Continental. Observatório Nacional de Saúde, Lisboa, 2005.

4. Dias CM, Falcão IM, Falcão JM. Contribuição para o estudo da interrupção voluntária da gravidez em Portugal Continental (1993 a 1997): estimativas utilizando dados da rede de médicos sentinelas e dos diagnósticos de altas hospitalares (grupos de diagnósticos homogéneos). Revista Portuguesa de Saúde Pública 2000; 2: 55-63.

5. DGS. Plano Nacional de Saúde 2004-2010. Direcção Geral da Saúde …more

6. DGS. Elementos estatísticos, Saúde 2003. Direcção Geral da Saúde. 2005. Lisboa.

7. Fantini MP, Stivanello E, Dallolio L, Loghi M, Savoia E. Persistent geographical disparities in infant mortality rates in Italy (1999-2001): comparison with France, England, Germany, and Portugal. European Journal of Public Health 2006;16(4):429-32.

8. Fernandes A, Perelman J, Mateus C. Gender differences in access to health care. Intermediary report for the Portuguese Ministry of Health. 2006. Lisboa.

9. Lisboa M, Vicente LB, Barroso Z. Saúde e violência contra as mulheres. Direcção Geral da Saúde. 2005. Lisboa.

10. Loureiro MI. A study about effectiveness of the health promoting schools network in Portugal. Promotion and Education 2004; XI(2): 85-92.

11. MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and neonatal mortality for primary caesarean and vaginal births to women with ‘no indicated risk,’ United States, 1998-2001 birth cohorts. Birth. 2006;33(3):175-82.

12. Marques-Vidal P, Dias CM. Trends and determinants of alcohol consumption in Portugal: from the National Health Surveys 1995 to 1996 and 1998 to 1999. Alcoholism Clinical and Experimental Research 2005; 29(1): 89-97.

13. Santana P. Geografias de saúde e do desenvolvimento. Almedina. 2005. Coimbra.

14. United Nations. The World’s Women Report 2005 …more

15. Van Doorslaer E, Masseria C and the OECD health equity research group members. Income-related inequality in the use of medical care in 21 OECD countries. OECD Health Working Papers 2004; 14.

16. WHO Regional Office for Europe. Atlas of Health in Europe. World Health Organization Regional Office for Europe. 2003. Copenhagen.

17. WHO Regional Office for Europe: Highlights on Portugal. World Health Organization, Regional Office for Europe. 2004. Copenhagen.

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