International Women's Day: Gender in healthcare
Think:Health cultivates and articulates the best in health research and news.
The following episode, which aired on Sunday 13 March 2016, features:
- Exploration of the role gender plays in healthcare (01:12);
- Challenges migrant women face under Australia's healthcare system (07:31);
- Chiropractic care for headaches (13:52); and
- Results of a UTS initiative helping educate midwives in Papua New Guinea (21:04).
Academic guests:
- Dr Michelle DiGiacomo - Senior Research Fellow in the Faculty of Health at UTS and the Centre for Cardiovascular and Chronic Care.
- Della Maneze - PhD candidate at UTS and Western Sydney University.
- Craig Moore - PhD candidate in the Faculty of Health at UTS.
- Alison Moores - Project Manager in the Faculty of Health at UTS and Member of the WHO Collaborating Centre for Nursing, Midwifery and Health Development.
Host/s:
- Ellen Leabeater, 2ser
- Jake Morcom, 2ser
START OF TRANSCRIPT
Ellen Leabeater: Hello, welcome to Think Health. I'm Ellen Leabeater. This week we celebrated International Women's Day, so we'll be taking a look at the role gender plays in healthcare. We'll also be looking at why more people are turning to chiropractic care to treat their headaches and migraines, and…
Alison Moores: …no one there that could help them, so now there's a skilled midwife who can provide the care that they need, and the women are responding. Papua New Guinea is due to have another survey of its health and its demographics, in the next year or so, and that will tell us…
Ellen Leabeater: …what it's like to educate midwives in Papua New Guinea. Caregiving, unpaid work, longer life spans, these are the issues that impact many women in Australia's health system. The Australian Bureau of Statistics says that women account for 71 per cent of primary carers of older people and people with disabilities, and mothers spend twice as much time caring for young children than fathers. Informal care means a lower income and the combination of this means women often don't look after themselves. They are also living longer than their male counterparts and living longer with chronic disease.
So how does our health system accommodate the needs of women? Michelle DiGiacomo has been asking this very question. She's a senior research fellow in the Faculty of Health at UTS.
Michelle DiGiacomo: Well gender is often overlooked in healthcare. There's a lot of the one size fits all approach to services. But gender recognises the unique experiences and needs of men and women. So it's not to say that one is more important than the other, but it's just recognising and appreciating that there are some differences.
Ellen Leabeater: Your recent research has looked at how chronic conditions in particular affect women. What sort of chronic conditions are we talking about?
Michelle DiGiacomo: So, chronic conditions such as cardiovascular disease and diabetes, arthritis, osteoporosis, dementia, depression, cancer is becoming a chronic disease and so on. So those types of conditions that last for usually more than six months and it just becomes something that people need to self manage in a way, in addition to dealing with health services for support.
Ellen Leabeater: Those chronic conditions, they don't target one gender, they target both genders. Why women in particular? Why do they need extra help in these services?
Michelle DiGiacomo: Well what we've found and what the research tells us is that women tend to live longer than men, and when they do that they usually live with a bit more disability. So as a result of some of the roles that they have in society…
Ellen Leabeater: You've talked about the societal role that women play, what role do the majority of women have in society?
Michelle DiGiacomo: Women are predominantly the caregivers throughout their lives but particularly in middle and older ages. They are caregiving for family, friends, spouses, parents, so this is something that just continues and they don't often identify as a caregiver or a carer but rather it's something that is part of their natural roles in their relationships. So that's one of the important things that they do and they take on a lot of that work that's informal, it's unpaid, and it means that they sometimes aren't looking after themselves.
Ellen Leabeater: Women are living longer, we all know that men die much younger than women. Are these women then living by themselves? How do they go then accessing healthcare services?
Michelle DiGiacomo: Many older women live alone, and depending on their access to transportation, their mobility, their physical mobility and just general wellbeing, also their social networks and their ties, that will really have an impact on whether or not they can engage just even with society and with health services and seek care when needed.
Ellen Leabeater: So how can health services better interact with women?
Michelle DiGiacomo: Well what we found in the research is that women report that they're feeling rather disempowered by some of their interactions with health providers. Dismissed, avoided, these were some of the experiences they talked about. Just not feeling empowered and able to advocate for themselves and their own care. Sometimes it's because they really haven't been orientated or socialised to be assertive and prominent in those healthcare discussions. Some women from culturally and linguistically diverse backgrounds might even feel intimidated, may not understand the language that's being used.
Even if they have a level of English were they can communicate, sometimes that's misunderstood by health professionals that they understand what's really going on.
Ellen Leabeater: So health services need to be tweaked a little bit more to address half the population. What more can be done?
Michelle DiGiacomo: Some of the findings from our research indicate that there needs to be more development of programs for particularly women from culturally linguistically diverse backgrounds. So within a framework of cultural beliefs and consideration of these gender issues using interpreters more in healthcare, and bilingual health workers and community educators is really important. We found that although some health professionals are using them, not enough and not all. Yes there is a shortage of interpreters in healthcare but it's really important to facilitate women's voice and empowerment.
Health services can improve on facilitating a welcoming, comfortable and safe environment and develop and sustain partnerships and networks. Also offer respect, flexibility, responsiveness and just to generally be mindful of varied contexts and tailoring to the needs of different groups of women in general. Considering what's going on, what are their circumstances, what's going on in their lives. So as not to impose a blanket maybe service or program that they can't access, that they don't feel comfortable using, something like that.
Ellen Leabeater: Michelle DiGiacomo, senior research fellow in the Faculty of Health at UTS. Not only do women have trouble with the health system but so too do migrant women. Della Maneze is a PhD student at the University of Technology Sydney and Western Sydney University. She's been studying what Filipino migrants and Filipino women in particular find challenging about Australia's healthcare system.
Della Maneze: Unfortunately there's not much research done on Filipino Australian - the health of Filipino Australians. But there have been increasing incidents of chronic diseases like cardiovascular disease, diabetes, cancers and mental health issues such as depression, anxiety and all that.
Ellen Leabeater: When we're talking about mental health issues, I know from previous stories that we've done on the program people from other countries, in their home country mental health issues may not be talked about as much. So when they come to Australia they find that continues, they find it difficult to talk about. How do Filipino women feel about discussing their mental health issues with health practitioners?
Della Maneze: They are very reticent about approaching mental health services because there's a huge stigma in our community about mental health issues, mental health illness. So most of them, most of us don't approach health services regarding mental health issues. So that's a bit difficult for Filipino women, or Filipino migrants in general to consult health professionals.
Ellen Leabeater: You mentioned earlier that English is a barrier, as you would expect. Can you tell us a little bit more about that?
Della Maneze: In my interview with Filipino women in the research, many of them said that they lack confidence in their English language skills. English in the Philippines is taught in school and it's usually as a medium of government and business transactions. It is not the language we use every day, so there is a social connotation that if you speak English you are educated, of a higher social status and so many are reluctant to admit that they cannot speak English. Or some will pretend that they understood, for fear of being thought of as stupid or uneducated, and they mentioned this in their interviews.
Ellen Leabeater: I think one woman was saying that they nod their head to whatever the doctor's saying, even if they don't understand it.
Della Maneze: Yes, so they understand but they can not explain in English. One older woman said that they have only a little English. If in time of stress, of illness or emergency room presentations for example they often forget their English, so they fumble for words to explain their symptoms.
Ellen Leabeater: So English is a barrier to accessing health services. Are there any other barriers that you've identified for migrant women in particular that need to be overcome?
Della Maneze: Yeah, cultural attitudes and beliefs for example, many of the women, for example one woman who has uncontrolled diabetes and taking insulin, and she says she's okay because she's not bedridden, she can still walk around, she's not flat on her back. With this kind of attitude she's less likely to see self care as an important priority. So another is for example a cultural clash on health practices. Like one of the women recalled that when she was giving birth she was asked to shower after 30 minutes, and this is such a no-no in the Philippines because of the hot and cold belief that showering will reduce physical resistance to illness.
One lady was saying that there are many illnesses in the Philippines that are difficult to English-size, you know, difficult to explain in English to health professionals.
Ellen Leabeater: With that in mind what can health professionals do to assist Filipino migrant women in the healthcare system.
Della Maneze: Yes, first is being aware of the patient as an individual, because there are many zones of grey in the English language skills for example of Filipino women. There's a general impression that those from the Philippines can speak English, and so many health professionals take it for granted that they can speak in English. So they speak so fast or they speak in jargons and they are not understood, yet they will not say - the patients will not say that I don't understand, because of the social implications of being able to speak English. Another is being mindful of the patient, observing the body language.
Is there hesitancy there? Because they are very hesitant to question health professionals because they're seen as experts, so you don't question experts otherwise they will be offended, so they don't want to offend healthcare professionals. I think an important thing is to take time to make patients feel comfortable and to assure patients that they can ask questions without offending the healthcare professional.
Ellen Leabeater: Della Maneze, PhD student in the Faculty of Health at UTS and Western Sydney University, speaking there about the experience of Filipino migrants in Australia's healthcare system.
[You're listening to Think Health. On 2ser 107.3.]
Ellen Leabeater: It's one of the most common symptoms of pain, but why are they under-diagnosed? The headache can be the result of a number of things; lack of sleep, stress, a head injury or even a few too many G&Ts from last night. Sometimes they're a one off, but when they're recurring, people look for further treatment. But one treatment many people overlook is chiropractics. Craig Moore is a PhD candidate in the Faculty of Health at UTS. He spoke with Jake Morcom about chiropractic care for headaches and why we under-diagnose them.
Craig Moore: Yes, well headaches are often under-diagnosed and undertreated, particularly in medical settings. There's a few reasons for this. Some headache patients have never actually sought medical care, and a lot of these people just tend to treat acute attacks if and when they occur outside of medical care. Some have sought medical care but have not been terribly happy with the results in terms of the effectiveness or side effects with the medications and safety concerns. Then the third reason is in fact to do with the medical doctors themselves. A fairly high percentage of medical doctors still don't necessarily take the time to specifically diagnose a patient's headache type.
Jake Morcom: So what sort of types of headaches are there?
Craig Moore: Well there's a huge number of headache types and sub-types listed in the International Classification of Headache Disorders. But perhaps the most common recurrent headache types are tension headache, migraine, and what's called cervicogenic headache, which is just a fancy name for neck headache. But tension headache is huge, it's the most commonly reported health problem globally. Migraine is huge, it's the seventh largest cause of disability globally. Neck headache affects about five per cent of all adults globally at some stage. Interestingly a headache type that's increasing in prevalence is a type that's actually called medication overuse headache. That's a headache that occurs more and more often as people treat headache more and more often with many of the headache drugs available.
Jake Morcom: How do you do a diagnosis, or how do you determine what is a headache, from what is a migraine?
Craig Moore: There is very specific criteria that is used to diagnose individual headache types. So for example the diagnosis of tension headaches, tension headaches are described as more often both sides of the head. They tend to feel like a pressing or a tightening feeling on both sides of the head. They tend to be milder or more moderate in intensity and they don't have any associated complications that migraines have. Migraines for example tend to be a more severe headache, they're on one side of the head more often.
Migraines can really restrict your physical activities and can be associated with nausea or vomiting.
Jake Morcom: So how do people normally manage their headaches?
Craig Moore: One of the great challenges with headache treatments is the management of them. People either take drugs for an acute attack, or a lot of people take medications to prevent their headaches, particularly if they're prone to headaches on a very frequent basis. Over time people who are using headache medications, many of the headache medications more and more often run the risk of actually increasing their frequency of headaches as a direct result or consequence of the overuse of these medications.
So there's a range of healthcare providers that can be involved in headache management. Most often people would first consider going to a GP, and in many countries that might even be followed by a neurologist where a headache is becoming complicated and difficult to manage. But other headache providers could involve counsellors and psychologists. Then of course you have allied health professionals like chiropractors, osteopaths and physiotherapists who are providing a physical treatment or what we call manual therapy.
Jake Morcom: So this comes into the area of chiropractic. Why is that relevant in the area of headaches and migraines?
Craig Moore: Headaches is about the third most common reason people tend to seek chiropractic care, after low back pain and neck pain, headaches is the third most common reason. There's certainly a growing body of research to support why they would do that. We're seeing basic science research that is showing an association between our neck and problems with the muscles and joints in the neck and the common recurrent headaches such as tension headache and migraine. We're also seeing for example studies showing that the greater the neck disability the more often many of these people will get a migraine.
In fact many people with migraine report having neck pain either just before the migraine or during the migraine or having neck pain immediately after the migraine. So we're certainly seeing a lot of evidence that problems with the muscles and joints of the neck can be involved in many of these headaches.
Jake Morcom: So what exactly does the chiropractor do in this situation? How are they helping the person who's experiencing that headache?
Craig Moore: Most often the treatment is called manual therapy. So this is described as hands on treatment primarily targeting the neck and shoulders, sometimes even the joint and muscles around the jaw as well. But typically it might involve spinal manipulation, joint or spinal mobilisation or massage techniques or other musculoskeletal techniques involving the hands and involving the affect you can have on muscles and joint articulations.
Jake Morcom: Might people seek chiropractic headache treatment in the same way for migraines?
Craig Moore: The research to date is showing certain manual therapy methods work better for migraines, and other manual therapy methods might work better for neck headache and tension headache. For example the tension headache the techniques that we use tends to be more focused on the muscles, massage, working on trigger points, stretching muscles around the neck and shoulders. Whereas we're seeing with migraine and cervicogenic headache, in other words neck headache, that for example spinal manipulation is more likely to be effective.
So as research continues what we're seeing is manual therapy isn't necessarily effective in turning off a headache when you're in the middle of a headache. But a course of manual therapy or hands on treatment of the neck is showing results that can influence future headaches and the repeating of headaches, so what we call preventative treatment.
Ellen Leabeater: Craig Moore, PhD candidate in the faculty of health at UTS, speaking with Jake Morcom.
[You're listening to Think Health on 2ser 107.3]
Ellen Leabeater: Papua New Guinea is a four hour plane trip from Sydney, yet when it comes to the difference in maternal and child mortality it's worlds apart. Australia's infant mortality is 3.3 per 1000 births. In PNG it's over 60. Part of this is due to poor access for care for women during pregnancy. For the last four years the World Health Organisation's Collaborating Centre for Nursing Midwifery and Health Development at UTS, has tried to improve the education and number of midwifery graduates in PNG. The initiative has recently wrapped up. Alison Moores was part of the program and has been looking at how successful it has been.
Alison Moores: I guess if you compare it to here there is very little resources. You might work in a clinic with a tin shed and no running water. Women walk for miles in labour to come for care, and often stay at home because it's too hard to get to a health centre.
Ellen Leabeater: So they're not birthing in a hospital as we imagine today?
Alison Moores: No, some do, those that live in cities do but 80 per cent of the population are in rural areas. So about 50 to 60 per cent of those still deliver at home because it's too hard to get to a health centre. Those that deliver at home have very little skilled help, and that's where the problems are recurring.
Ellen Leabeater: Why are there so few midwives in PNG?
Alison Moores: I think over the last 10 years or so there's been a lot of problems with trying to educate midwives in the first place, and we had problems with the quality of their education, and so many of them were graduating and not being able to register. They had to be taken out of the nursing workforce, so midwifery at the moment in PNG is a post graduate qualification. It's very expensive to study in PNG, and for them to leave their families and find the money to study was really difficult.
Ellen Leabeater: You're part of the Maternal And Child Health Initiative, can you tell us a bit more about that?
Alison Moores: Yeah, the Maternal And Child Health Initiative was a four year program that UTS were contracted to to supply Australian and international midwives to work alongside the midwifery educators in Papua New Guinea to help improve and strengthen the capacity of the PNG educators to teach.
Ellen Leabeater: Did you do anything with the education offered to midwives to make it easier?
Alison Moores: The Australian Government did, they chipped in with scholarships for students to come and study. So they paid for tutorial costs and they also improved the facilities, reference books, libraries, classrooms, dormitories were all improved to make it easier for students to come. The students were given a scholarship, a bursary to come.
Ellen Leabeater: You've recently looked at research looking at whether these students went on to get jobs. What were the results?
Alison Moores: Well we found 90 per cent of the graduates, particularly from the first two years, they were the two years I focused on, 90 per cent were working as midwives, with about another three per cent working as educators and teaching others. So that's really exciting.
Ellen Leabeater: What about the extra seven per cent?
Alison Moores: Some of them returned to nursing jobs that they were in, and we found out of 174 graduates only three or four were not working at all.
Ellen Leabeater: These midwives are working but are they having an impact?
Alison Moores: Yeah, well certainly anecdotally they are. We've got wonderful stories of graduates working in very isolated rural and remote positions who are saving lives and they are noticing the difference. Women are coming because there's a skilled midwife at their local health centre. Where before the women stayed at home because they might turn up at a health centre and there'd be no one there that could help them. So now there's a skilled midwife who can provide the care that they need, and the women are responding.
Papua New Guinea is due to have another survey of its health and its demographics, in the next year or so, and that will tell us for sure whether mortality and morbidity is improving. But the graduates are certainly telling us that they're noticing the difference themselves.
Ellen Leabeater: Currently the most recent statistics, what are the child and maternal mortality rates like?
Alison Moores: It's one of the worst in the world, four hours north of Sydney four or five women die every day in childbirth in PNG and 773 deaths per 100,000 births. We have about four per 100,000 births in Australia. So it's shocking, it's second in the Asian Pacific, it's second highest to Afghanistan. So that gives you a bit of quantifiable, you know, PNG is not in a war zone and mostly it's the isolation of the women and the difficulty in accessing healthcare that is the main problem. So the more midwives we can get out into rural and isolated areas the more likely it is that women will get the care they need.
Ellen Leabeater: In PNG a lot of women are birthing in rural areas. Did these midwives go on to work in rural areas?
Alison Moores: Yeah, we found 40 per cent of those that responded are working in rural areas. That was about what we thought and what we were hoping for. Because there's been a huge shortage of midwives for the last 10 or 15 years there are still a fair few working in hospitals in major towns. But they are still critically short of midwives as well, so I think it's going to take some time yet before the country's got enough midwives. The initiative helped to more than double the population of midwives in PNG, but they probably need that many again.
Ellen Leabeater: Is the program continuing?
Alison Moores: No, the funding's unfortunately just finished in December last year, and we're just finishing the evaluation of the program at the moment and making recommendations so it will continue. But it's all a bit up in the air, overseas funding at the moment.
Ellen Leabeater: Assuming that the funding doesn't continue, does PNG have the resources to continue to build their midwifery workforce?
Alison Moores: I think the biggest strength they have is in the capacity of the educator. We have - I think the initiative has improved the capacity of Papua New Guinea educators. They are skilled and enthusiastic and ready to continue, but they do need the financial support to still attract students to the course to have the resources to keep training.
Ellen Leabeater: If the funding does continue, what's next?
Alison Moores: The curriculum is being reviewed this year and they're hoping to extend the length of the course for midwives. The feedback that the students and the graduates gave was that there was a lot of information packed into a 12 month program, and the international standards for midwifery is an 18 month program, and that seems to coincide. So at the moment they're putting an 18 month program through the regulatory bodies to improve the education even further. Many of the graduates want to go on to be teachers but they need to be taught how to be teachers. So there's opportunities there to develop education for them to teach the next generation of midwives in PNG.
Ellen Leabeater: Alison Moores, midwifery researcher in the WHO Collaborating Centre at UTS. Don't forget if you'd like to find out more about anything you heard today, you can visit us at 2ser.com/thinkhealth. You can also tweet us at 2ser. Please remember that journalists are not doctors. If we've made you ask questions, which is great, go and see your GP. This show is produced with the support of the University of Technology Sydney, Faculty of Health. Remember to subscribe, rate and review us on iTunes if you enjoyed what you heard today.
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