Pillars of our Work in Health Promotion

Gender and Health

Gender and health are two strongly entwined constructs.

As leaders in health promotion and primary prevention, WHISE uses the evidence-base on the social determinants of health (in accordance with the World Health Organisation) to guide our planning and our practice. We understand that unequal power and unequal status across genders are a root cause for the inequalities faced by women and girls across their lives. As stated by the Australian Women’s Health Network (2019, p. 10):

Intersectionality

Intersectionality means paying attention to the ways in which “systems of inequality interlock to create conditions for either health equity or health inequalities” (Lopez & Gadsden, 2016, p. 3). Taking an intersectional lens on health from a woman’s perspective helps us understand that “every [woman’s] experience is fundamentally different that the experience of others, based on their unique identity and structural positions within systems of inequality and structural impediments” (Lopez & Gadsden, 2016, p. 5).

Gender inequality in the workplace

As of February 2021, Australia’s national gender pay gap stands at 13.4%, with women in full-time work earning, on average, $242.20 less per week than men (Workplace Gender Equality Agency, 2021). Over the last 20 years, the gender pay gap has ranged between 13.4% and 19%.

The pay gap starts from the time women enter the workforce. Contributing factors include: hiring and pay discrimination, female-dominated sectors attracting lower wages, women’s disproportionate share of unpaid caring and domestic work, limited workplace flexibility to accommodate women’s non-work responsibilities, and women’s greater time out of the workforce impacting career progression (Workplace Gender Equality Agency, 2021). The gender pay gap, combined with women’s higher likelihood of part-time work, impacts on their lifetime economic security and health.

In the SMR, we consistently see gender inequality based on employment type between women and men, with higher rates of women than men employed on a part-time basis.

Gender inequality in income

ABS Census data from 2016 demonstrated clear gender inequality in the proportion of women and men who earn below the minimum weekly wage (that is, $0 -$649 per week) across the SMR. In our region, the proportion of women earning below the minimum weekly wage was consistently higher than men. There were six LGAs (Kingston, Cardinia, Frankston, Casey, Mornington Peninsula and Greater Dandenong) in which the proportion of women earning below the minimum weekly wage exceeded the state average of 45.7%. While Greater Dandenong had the largest proportion of women earning below the minimum weekly wage, Cardinia had the greatest inequality with the largest gap between the proportion of women and men earning below the minimum weekly wage.

Unpaid Work

According to ABS (2016, p. 1):

“Employed women did more hours of unpaid domestic work such as housework, grocery shopping, gardening and repairs than employed men. In 2016, over half of employed men did nil or less than five hours per week of unpaid domestic work (60%) compared with a third of employed women (36%). Men were also less likely than women to do 15 hours or more per week of unpaid domestic work (8% of men and 27% of women). This pattern applied across all hours of paid work, even for those working more than 49 hours per week.”

A similar pattern is found in the SMR. As can be seen in the chart below, females bear the burden of unpaid domestic work across all 10 LGAs highlighting the gendered nature of caring/domestic responsibilities.

Gender equality in leadership

Gender disparities are consistently seen across Australian workplaces with unequal proportions of men and women in leadership roles. This perpetuates existing stereotypes about the role of women at work and in wider society; and exacerbates gender pay inequality (Women’s Health Victoria, 2021). While having women in leadership does not provide a solution for gender inequality, women’s increased representation contributes to gender equality which is a key determinant for women’s health.

Prevention of Violence Against Women

The link between gender inequality and health outcomes is clearly demonstrated in the prevalence of violence against women.

One in three Australian women will experience physical violence and one in five women over the age of 15 will experience sexual violence at some stage in their lifetime (Our Watch, ANROWS, VicHealth, 2015). Violence against women includes psychological, economic, emotional, physical and sexual violence and is the leading preventable contributor to death, disability and illness in Victorian women aged 15-44 years (Webster, 2016; Ayre, et al., 2016). Violence against women is therefore an important determinant of women’s health (Montesanti & Thurston, 2015) as it can have significant psychological effects (such as, depression and post-traumatic stress disorder) and result in poorer wellbeing (Shen & Kusunoki , 2019; Dillon, et al., 2013). In addition to these negative health impacts, violence against women is also a major contributing factor to housing instability and homelessness among women (Ponic, et al., 2011) due to difficulties with maintaining housing, paying mortgages, bills or rent, or having to live in temporary accommodations with family and/or friends (Kushel, et al., 2006).

Latest family incident figures

Across the SMR, an increase in family violence incidents over the last five years can be seen across all municipalities except for Bayside which had a small decrease (see the chart below). This reveals a concerning trend across the SMR, though the data is consistent with the Victorian trend which has seen a 7.6% increase in family violence rates in the last 12 months.

In terms of the police callouts per 100,000 population, the chart below shows that Frankston and Greater Dandenong have the highest rates of police callouts for family incidents. Glen Eira, Bayside and Stonnington have the lowest rates in the SMR.

The rates recorded over the last 12 months are particularly concerning. Research suggests that these higher rates of family violence have been significantly impacted by COVID-19 restrictions, especially in Victoria where we have experienced multiple extended lockdowns.

The impact of COVID-19 on family violence rates

A recent study conducted by Monash University found that significant increases and challenges had been seen by practitioners responding to family violence calls (Pfitzner, et al., 2020). The study found:

• An increase in the frequency and severity of violence against women (VAW).
• 59% of respondents reported that COVID-19 had increased the frequency of VAW and 50% reported it has increased the severity of VAW.
• An increase in the complexity of women’s needs was noted by 86% of respondents.
• An increase in first-time family violence reporting by women was noted by 42% of respondents.
• New forms of intimate partner violence including enhanced tactics to achieve social isolation and forms of violence specifically relating to the threat and risk of COVID-19 infection.
• For many women experiencing violence during the lockdown period, there was less ability to seek help.
• Service innovations have occurred across Victoria to enhance accessibility and effectiveness of service delivery during the COVID-19 easing of restrictions and recovery phase.
• Numerous challenges to providing support, undertaking effective risk assessment and carrying out safety planning during the COVID-19 lockdowns.

Significantly, as can be seen in the chart below, the majority of LGAs across the SMR saw noteworthy increases in the family violence incident rate between 2019 and 2020 (year ending June). In particular, Stonnington and Glen Eira saw the largest increases above 20% while Port Phillip and Kingston had the smallest increases below 10%. Bayside was the only LGA to record a decrease in the rate, albeit of only 0.8%. The SMR saw an increase of 11.4% which is higher than the state average of 7.6%.

These increases are concerning and highlight the need for continued support and primary prevention across the region.

Family violence and pregnancy

A unique aspect of family violence is that it appears to escalate when a female partner is pregnant. Data from the 2016 Personal Safety Survey shows that in Australia, “an estimated 187,800 women who experienced violence by a current partner were pregnant at some point during the relationship. Of these women, nearly one in five (18% or 34,500) experienced violence during their pregnancy” (ABS, 2017). Furthermore, “an estimated 686,400 women who experienced violence by a previous partner were pregnant at some point during the relationship. Of these women, nearly half (48% or 325,900) experienced violence during their pregnancy” (ABS, 2017).

Family violence and children

VicHealth (2017, p. 12) have reported that:

“There are 128,500 women in Australia who have experienced violence by a current cohabiting partner and had children in their care during the violence; for 74,300 (58%) of these women, the children in their care witnessed (heard or saw) the violence.”

“There are 733,900 women in Australia who have experienced violence by a previous cohabiting partner and had children in their care during the violence; for 568,700 (77%) of these women, the children in their care witnessed (heard or saw) the violence.”

Statistics from the Crime Statistics Agency (2020) reveal similar findings. The chart below displays the number of family incidents which recorded a child (or children) present. As can be seen, Casey recorded the highest number of incidents with a child (or children) present. From 2018-19 to 2019-20, all LGAs except for Bayside recorded increased numbers. Glen Eira had the greatest increase in family incidents with a child (or children) present (40%), followed by Frankston (23%) and Stonnington (20.3%). While Casey records the highest numbers of family incidents with a child (or children) present, the LGA had the smallest increase of 5.1% from 2018-19 to 2019-20. Bayside, however, had a 14.5% decrease in the number of family incidents with a child (or children) present.

Perceptions of safety

In Victoria, women are less likely than men to feel safe when walking alone at night. The chart below shows that this trend extends to females in the SMR who are consistently less likely than males to report perceptions of safety. While the Victorian Population Health Survey 2019 did not collect data on perceived safety at the LGA level, across the SMR, only 39.6% of females reported that they felt safe walking alone at night compared to 74.6% of men (State of Victoria, 2021). While it’s difficult to directly compare with the 2017 findings where an average perception of safety has been calculated for the SMR, from 2017 to 2019, there is an approximate 3.5% decrease in the proportion of females who feel safe walking alone at night.

The chart below shows that Greater Dandenong, Casey, and Frankston have the lowest proportions with fewer than 40% of females feeling safe to walk alone at night. However, Greater Dandenong also has the smallest difference between the proportions of females and males who feel safe walking alone at night with only 45.6% of males reporting perceived safety.

Such data clearly articulates the lack of safety felt amongst a majority of women in a majority of municipalities within the SMR.

Stalking, harassment and threatening behaviour in our region

Across the SMR, stalking, harassment and threatening behaviour offences have increased since 2016 in a number of LGAs. As can be seen in the chart below, although rates have fluctuated each year, from 2016 to 2020, increases have been reported in Cardinia (25.9%), Frankston (14%), Glen Eira (5%), Kingston (2.3%), Port Phillip (2.4%) and Stonnington (34%).

As can be seen in the chart below, from 2019 to 2020, eight LGAs recorded an increase in rates with Bayside’s increase of 65.9% being the highest. Glen Eira and Greater Dandenong, however, recorded decreased rates of 15.8% and 9.7%, respectively.

Attitudes to violence against women

The high rates of violence against women and sexual offences within the SMR reveal concerning attitudes. While there is limited information about attitudes to violence against women within the SMR, the National Community Attitudes towards Violence against Women Survey (NCAS) provides some data and insights regarding (ANROWS, 2018):

• People’s understanding of, and attitudes towards, violence against women;
• Attitudes towards gender equality;
• If there has been a change over time; and
• Whether people are prepared to intervene when witnessing abuse or disrespect towards women.

Although the data presented in the survey are not disaggregated in terms of the SMR, the findings are applicable to the region given the high rates of violence against women that have been found in the SMR.

ANROWS (2018, p. 2) have highlighted the following encouraging results from the NCAS :

• “Most Australians have accurate knowledge of violence against women and do not endorse this violence.”
• “Most Australians support gender equality and are more likely to support gender equality in 2017 than they were in 2013 and 2009.”
• “Australians are more likely to understand that violence against women involves more than just physical violence in 2017 than they were in 2013 and 2009.”
• “Australians are less likely to hold attitudes supportive of violence against women in 2017 than they were in 2013 and 2009.”
• “There has been improvement in knowledge and attitudes related to 27 of the 36 questions asked in 2013 and again in 2017.”
• “There has been improvement in knowledge and attitudes related to all but two of the 11 questions asked in the 1995 NCAS and again in 2017.”

However, the following concerning results have also been discussed by ANROWS (2018, p. 2):

• “A decline in the number of Australians who understand that men are more likely than women to perpetrate domestic violence.”
• “A concerning proportion of Australians believe that gender inequality is exaggerated or no longer a problem.”
• “Among attitudes condoning violence against women, the highest level of agreement was with the idea that women use claims of violence to gain tactical advantage in their relationships with men.”
• “1 in 5 Australians would not be bothered if a male friend told a sexist joke about women.”

More work is therefore required to challenge attitudes and beliefs about violence against women. While people’s understanding about the nature of violence against women has evidently improved, only 64% of Australians recognise that mainly men commit acts of domestic violence which represents a 7% decrease since 2013 (ANROWS, 2018).

Sexual and Reproductive Health

“Sexual and reproductive health [SRH] includes the right to healthy and respectful relationships, inclusive, safe and appropriate services, access to accurate information, and effective and affordable methods of family planning and fertility regulation” (Department of Health and Human Services, 2017, p. 2).

Reproductive access and rights

Through a mapping of SRH services in the region in 2018, WHISE found that women lacked information and access to contraception. A rise in pregnancy testing was found by a number of organisations providing this service. Twenty-five per cent of respondents identified an increase in pregnancy testing over the previous year.

It was also found that the most ‘popular’ form of contraception from organisations providing this service was condoms. Out of those organisations that provide contraception, 82.5% provided condoms in contrast to other forms of contraception. This statistic may explain the rise in pregnancy testing sought, particularly when rates for Implanon insertion remained low.

Contraceptive implant

Within the SMR, we can see that uptake rates for the contraceptive Implant are consistently low. Data from the Victorian Women’s Health Atlas (2021) reveal that in 2018, nine out of 10 LGAs were below the state average with Casey being the only LGA to have rates of uptake higher than the state average. The chart below shows that between 2016 to 2018, on average, Glen Eira has the lowest rates of uptake while Bayside, Cardinia, Casey and Frankston tend to have the highest rates of uptake.

Contraceptive IUD

The rates of Intra Uterine Device (IUD) uptake vary in the SMR. As can be seen in the chart below, Greater Dandenong has the lowest rates in the SMR. We can see that this has been the case from 2016 to 2018. Interestingly, the uptake of the contraceptive IUD across the SMR has steadily been increasing from 2016 to 2018 except for in Bayside and Cardinia where rates dropped from 2017 to 2018. In 2018, Glen Eira, Stonnington and Bayside reported rates of uptake higher than the state average (Women’s Health Victoria, 2021).

Low uptake of Long Acting Reversible Contraception (LARC) remains a significant barrier to women’s SRH. While condoms remain a very popular form of contraception, rises in pregnancy testing indicate challenges in relation to the types of contraception women might have access to.

Service provision

WHISE has identified issues of unmet service provision. It was found that 59% of organisations who responded to the 2018 Service Mapping research stated that they were unable to appropriately provide SRH services for specific unmet needs. Some of their concerns included:

• Their inability to provide culturally appropriate SRH information
• A lack of female GPs or women’s health clinics
• Long waiting lists for IUD insertion
• A lack of easily accessible youth friendly sexual health practitioners

These practitioners and service providers further outlined various reasons for their inability to adequately respond to specific needs in their service provision. These included:

• Inadequate or no funding for certain aspects of SRH
• Inability to adequately refer clients to more specialised services
• Lack of consistently available health practitioners
• Lack of appropriately qualified and experienced health practitioners

STI rates: Shifting attitudes

Throughout Australia, high levels of STIs continue to occur. There is often misinformation or misunderstanding about the impact or health consequences of STIs. For many sexually active individuals, STI symptoms may not be obvious. It is therefore important to continue to educate about STIs and their consequences.

Throughout the SMR, high rates of STIs have been identified which mirror the national trends. In particular, high rates of syphilis, chlamydia, gonorrhoea, and hepatitis B have been found in a number of municipalities in the SMR. In addition, high rates of HIV have been found amongst a large proportion of males in other municipalities.

Cervical screening participation

Low participation in cervical screening (formerly known as Pap Screening) is found in Cardinia, Casey, Frankston and Greater Dandenong (see the chart below). These four municipalities are below the state average of 57.8% participation in 2016 with Greater Dandenong having the lowest participation of 51.2% (Women’s Health Victoria, 2021).

In December 2017, a five-yearly Cervical Screening Test replaced the two-yearly Pap test. The new Cervical Screening Test is more effective than a Pap test previously undertaken every two years (Department of Health, 2018). It will be interesting to see whether this impacts on screening rates.

Although Cervical Screening is not considered an STI screen, it does screen for and detect HPV which can lead to cervical cancer. As such, Pap screening participation has been placed in this section.

HPV vaccination

“The HPV vaccine has significantly lowered the risk of HPV-related cancers for thousands of women around the world” (Cancer Council NSW, 2017).

The vaccine has been shown to reduce cervical cancer and remains an important aspect of SRH. Despite this, several LGAs in the SMR have lower rates of HPV vaccination (see the chart below). Cardinia, Casey and Greater Dandenong reveal a lower coverage, particularly in relation to Dose 3 of the vaccination. It is important for all three doses to be administered as this ensures full protection against HPV-related cancers.

References

ABS, 2017. Personal Safety, Australia. [Online] Available at: https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4906.0~2016~Main%20Features~Key%20Findings~1
[Accessed 18 June 2021].

ANROWS, 2018. Are we there yet? Australians’ attitudes towards violence against women & gender equality: Summary findings from the 2017 National Community Attitudes towards Violence against Women Survey (NCAS), Sydney, NSW: ANROWS.

Australian Women’s Health Network, 2019. The Australian Women’s Health Charter. Canberra: Australian Women’s Health Network.

Ayre, J. et al., 2016. Examination of the burden of disease of intimate partner violence against women in 2011: Final report, Sydney, NSW: ANROWS.

Cancer Council NSW, 2017. An Australian success story: The HPV vaccine. [Online] Available at: https://www.cancercouncil.com.au/blog/australian-success-story-hpv-vaccine/
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Chen, J., 2017. Intersectionality Matters: A guide to engaging immigrant and refugee communities to prevent violence against women. Melbourne, Victoria: Multicultural Centre for Women’s Health.

Crime Statistics Agency, 2020. Family incidents. [Online] Available at: https://www.crimestatistics.vic.gov.au/crime-statistics/latest-crime-data-by-area
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Department of Health, 2018. National Cervical Screening Program, Canberra: Commonwealth of Australia.

Department of Health and Human Services, 2017. Women’s sexual and reproductive health: Key priorities 2017-2020, Melbourne: State of Victoria.

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Kushel, M. B., Gupta, R., Gee, L. & Haas, J. S., 2006. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med, 21(1), pp. 71-77.

Lopez, N. & Gadsden, V. L., 2016. Health inequities, social determinants, and intersectionality. Washington DC, USA: National Academy of Medicine.

Montesanti, S. R. & Thurston, W. E., 2015. Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women’s Health, Volume 15.

National HPV vaccination program register, 2015. Population Based Coverage,

Our Watch, ANROWS, VicHealth, 2015. Change the Story: A shared framework for the primary prevention of violence against women and their children in Australia, Melbourne: Our Watch.

Pfitzner, A., Fitz-Gibbon, K. & True, J., 2020. Responding to the ‘shadow pandemic’: practitioner views on the nature of and responses to violence against women in Victoria, Australia during the COVID-19 restrictions, Melbourne: Monash Gender and Family Violence PRevention Centre, Monash University.

Ponic, P. et al., 2011. Leaving ≠ moving: Housing patterns of women who have left an abusive partner. Violence Against Women, 17(12), pp. 1576-1600.

Shen, S. & Kusunoki , Y., 2019. Intimate partner violence and psychological distress among emerging adult women: A bidirectional relationship. Journal of Women’s Health, Volume 28, pp. 1060-1067.

State of Victoria, 2021. Victorian Population Health Survey 2019 – Summary of results. [Online] Available at: https://www.bettersafercare.vic.gov.au/reports-and-publications/vphs2019
[Accessed 17 June 2021].

VicHealth, 2017. Violence against women in Australia: An overview of research and approaches to primary prevention, Melbourne: Victorian Health Promotion Foundation.

Webster, K., 2016. A preventable burden: Measuring and addressing the prevalence and health impacts of intimate partner violence in Australian women (ANROWS Compass, 07/2016), Sydney, NSW: ANROWS.

Women’s Health Victoria, 2021. Victorian Women’s Health Atlas. [Online] Available at: https://victorianwomenshealthatlas.net.au/#!/atlas/Sexual%20and%20Reproductive%20Health/SRH/HIV/SRH_05/2017%20Rate%20(per%2010,000)/169/F/metropolitan/all/false
[Accessed 21 June 2021].

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[Accessed 9 June 2021].