Health Related Actions: How Women Care for their Health

In 2001, 65% of women aged 18-69 years reported having a Pap smear test at least once every two years. However, 11% reported they had never had one.

Although genetic predisposition plays a role in women's health outcomes, it is possible to prevent some illnesses, more successfully treat others, and promote general good health through positive health behaviours. Women in Australia can care for their health in different ways, as appropriate for their lifestyle and their stage in the life cycle. A woman's involvement in such behaviours may also be influenced by factors such as her cultural background, financial resources, and the availability of relevant services in her geographic location.

One focus of women's health policy over the past decade has been on promoting actions such as regular breast examination, mammograms, and Pap smear testing. However, with a recent push towards broader illness prevention and health promotion, women have been advised to take more general actions such as increasing physical activity and adopting healthy eating habits.

DATA ON HEALTH ACTIONS The data presented in this article are drawn mainly from the ABS 2001 National Health Survey (NHS). The Women’s Health form in this survey was a voluntary self-completed component of the NHS and, as the questions were of a personal nature, some women may have chosen not to provide responses to all questions. As the information was self-reported, the rates of participation in a particular activity may be higher or lower than those recorded by specific medical disease registries (e.g. cancer registries). All data have been age standardised to the 2001 Australian population before comparing different groups. In the 2001 NHS, each person was classified as belonging to one of four types of income unit: lone person; lone parent with dependent child(ren); couple with dependent child(ren); or couple only. Income is assumed to be shared within such a unit. In this article, gross income of the income unit refers to the combined income of the woman and her spouse/partner (where applicable). Equivalised income of income unit is derived by applying the Organisation for Economic Co-operation and Development (OECD) equivalence scale to take into account the number of adults and dependants in that unit. For more detail refer to the National Health Survey, Users' Guide, Australia, 2001 available through the ABS web site <www.abs.gov.au>.

BREAST CANCER SCREENING

In 2002, more women died from breast cancer than from any other form of cancer. Early detection and treatment of breast cancer results in the best chance of survival, with 90% of women surviving for at least five years after detection if the cancer is localised in the breast and has not spread to other parts of the body (SEE ENDNOTE 1).

Regular examination of the breast is the most common method of detecting breast changes which may be, or may become, cancerous. Of all women aged 18 years and over, 30% reported that they had undertaken monthly breast self-examinations in 2001, with a similar proportion (27%) reporting annual doctor examinations.

Mammograms - a particularly effective way to detect cancer at an early stage - are generally only available to women aged 40 years and over, as breast tissue is too dense prior to this age (SEE ENDNOTE 2). In 2001, 51% of women aged 40 years and over reported having a mammogram for screening or diagnostic purposes at least once every two years. The proportion of women aged 40 years and over who reported ever having had a mammogram increased from 64% in 1995 to 72% in 2001.

As 70% of breast cancers occur in women over the age of 50 years, BreastScreen Australia actively seeks women aged 50-69 years for participation in its mammogram screening program (SEE ENDNOTE 2). In 2001, 74% of women aged 50-69 years reported having a mammogram at least once every two years.

In 2001, over half (52%) of women born in Australia and aged 40 years and over had mammograms every two years or more often, with women born overseas having a lower rate of mammogram examination. Women from North Africa and the Middle East were the most likely to never have had a mammogram (47%).

MAMMOGRAMS REPORTED BY WOMEN AGED 40 YEARS AND OVER(a) - 2001
		Frequency of mammograms
		Every 2 years or more often	Less often than every 2 years(b)	Never had a mammogram
		%	%	%
Region of birth
	Australia	52.2	19.7	28.1
	Other Oceania(c)	38.2	28.1	33.7
	United Kingdom and Ireland	50.4	24.8	24.8
	Other North-West Europe	47.5	20.5	32.0
	Southern and Eastern Europe	44.8	23.9	31.4
	North Africa and Middle East	*27.7	*25.3	47.0
	South-East Asia	39.7	16.8	43.5
	Other Asia	49.4	*16.8	*33.7
	Americas	45.5	*15.1	*39.4
	All other countries	37.2	34.1	28.6
Equivalised income of income unit quintile(d)
	Lowest	46.3	21.4	32.3
	Second	50.5	17.9	31.6
	Third	50.5	22.2	27.3
	Fourth	49.2	24.7	26.1
	Highest	60.1	22.3	17.6
Australia		50.8	20.8	28.4
(a) Age standardised. Women who did not state frequency of mammograms were excluded prior to the calculation of percentages.
(b) Includes those who have had only one mammogram, or who have mammograms irregularly.
(c) Includes New Zealand.
(d) Quintiles have been calculated after ranking persons by the equivalised gross weekly income of the income unit of which they are a member. For additional detail see page 77.
Source: ABS 2001 National Health Survey.

Following the program’s commencement in 1991, Breastscreen Australia introduced mobile screening units to offer services to women across Australia (SEE ENDNOTE 3). Since then, there has been increasing access to breast screening facilities by women in more remote areas. In 2001, women aged 40 years and over in Major Cities, Inner Regional and other areas, had similar rates of regular biennial mammograms (ranging from 50%-52%). Women in the highest income quintile were more likely to have had biennial mammograms (60%) than those in the middle quintiles (around 50%) or lowest quintile (46%), despite screening being free or available at a minimal cost.

HEALTH CARE AMONG ABORIGINAL AND TORRES STRAIT ISLANDER WOMEN In 2001, of those women who provided a response, a similar proportion of Indigenous and non-Indigenous women aged 40 years and over had regular mammograms (50% and 52% respectively). Research has found that Indigenous women may have a lower likelihood of developing breast cancer than non-Indigenous women, but that it is more likely to be fatal once it has developed (SEE ENDNOTE 4). Aboriginal and Torres Strait Islander women had a higher incidence rate of, and a higher mortality rate from, cervical cancer, than non-Indigenous women (SEE ENDNOTE 5). In 2001, Indigenous women were less likely to have had regular Pap smear tests than non-Indigenous women (58% compared with 66%). The data presented in the following table are proportions of those women who provided a useable response (approximately 85%-90% of women). As a result, the figures are different from those published in National Health Survey: Aboriginal and Torres Strait Islander Results, Australia, 2001 (ABS cat. no. 4715.0). MAMMOGRAMS AND PAP SMEAR TESTS REPORTED BY WOMEN(a) - 2001 Indigenous Non-Indigenous % % Mammograms(b) Has regular mammograms(c) 50 52 Does not have regular mammograms 21 20 Never had a mammogram 29 28 Pap smear tests(d) Has regular tests(c) 58 66 Does not have regular tests 30 23 Never had a test 11 11 (a) Age standardised. Women who did not state the regularity of their Pap smear tests or mammograms were excluded prior to the calculation of percentages. (b) Women aged 40 years and over. (c) Regular mammograms or Pap smear tests may be annual, biennial or more than 2 years apart. (d) Women aged 18-69 years. Source: ABS 2001 Indigenous Health Survey.

PAP SMEAR TESTS

In 2001, cervical cancer caused the death of 227 Australian women, a rate of 2.1 deaths per 100,000 population (see Australian Social Trends 2004, Cancer trends, pp.72-76). It is one of the most preventable and curable of all cancers - up to 90% of cases of the most common type of cervical cancer can be prevented if cell changes are detected and treated early (SEE ENDNOTE 6).

A Pap smear test is a screening procedure in which a number of cells are collected from a woman's cervix and examined for any changes in appearance which may indicate a risk for, or the development of, cervical cancer (SEE ENDNOTE 6). The proportion of women who reported ever having had a Pap smear test remained relatively stable between 1995 and 2001 at around 90%.

According to current recommendations for Pap smear testing, all women aged between 18 years and 69 years who have ever had sex should have at least one Pap smear test every two years (SEE ENDNOTE 7). In 2001, 65% of women in this age group were meeting these recommendations. Women aged 30-39 years were the most likely to have had biennial Pap smear tests (80%), and women aged 60-69 years were the least likely (48%). The proportions of women reporting having Pap smears at least once every two years were similar across Major Cities, Inner Regional and other areas (between 64% and 69%).

Some studies have linked decreased awareness of, and participation in, Pap smear testing to language and cultural barriers experienced by recent immigrants (SEE ENDNOTE 8, ENDNOTE 9). In 2001, the proportion of women aged 18-69 years who reported having a Pap smear test at least once every two years ranged from two-thirds (67%) of women born in Australia to less than half (48%) of women born in South East Asia.

Income levels also appear to relate to how often women have Pap smear tests, with women in the higher income quintiles having higher rates of biennial Pap smears than women in the lower quintiles. In 2001, 66% of women in the highest income quintile had biennial Pap smears, compared with 61% in the middle quintile and 50% in the lowest quintile.

PAP SMEAR TESTS REPORTED BY WOMEN AGED 18-69 YEARS(a) - 2001
		Frequency of Pap smear tests
		Every 2 years or more often	Less often than every 2 years(b)	Never had a Pap smear
		%	%	%
Region of birth
	Australia	66.8	24.2	9.0
	Other Oceania(c)	58.8	33.1	8.1
	United Kingdom and Ireland	65.0	29.8	5.2
	Other North-West Europe	54.8	38.6	*6.6
	Southern and Eastern Europe	65.8	18.1	16.0
	North Africa and Middle East	56.4	25.6	*18.0
	South East Asia	47.8	19.5	32.0
	Other Asia	49.4	27.5	23.0
	Americas	56.0	30.8	*13.0
	All other countries	55.5	18.1	26.0
Equivalised income of income unit quintile(d)
	Lowest	49.7	34.0	16.0
	Second	55.8	31.3	12.0
	Third	60.7	28.5	10.0
	Fourth	60.3	28.4	11.0
	Highest	66.1	25.7	8.2
Australia		64.8	24.5	10.7
(a) Age standardised. Women who did not state the frequency of their Pap smear tests were excluded prior to the calculation of percentages.
(b) Includes those who have had only one Pap smear test and those who have Pap smear tests irregularly.
(c) Includes New Zealand.
(d) Quintiles have been calculated after ranking persons by the equivalised gross weekly income of the income unit of which they are a member. For additional detail see page 77.
Source: ABS 2001 National Health Survey.

CONTRACEPTION AND PROTECTION

A major issue for women is being able to control their fertility, including preventing unwanted pregnancies. In 2001, the most common method of contraception used by sexually active women aged 18-49 years, was taking oral contraceptives (33%). Although very effective in preventing pregnancy when taken as directed, oral contraceptives do not provide protection against sexually transmitted diseases (STDs).

Following an increased awareness of the Human Immunodeficiency Virus (HIV) in the early 1980s, and the promotion of condoms as protection against infection, the rate of HIV infection appears to be falling (SEE ENDNOTE 10). However, there is concern that the transmission of other STDs may be rising.10 In 2001, condoms were used by 28% of sexually active women aged 18-49 years.



The use of condoms declined with age from 48% of sexually active 18-24 year old women, to 12% of 45-49 year olds. Condom use may also be linked to the permanency of a woman's sexual relationship. In 2001, sexually active women aged 18-49 years who were neither married nor in a de facto relationship had a higher rate of condom use (42%) than women who were in such relationships (22%).

LIFESTYLE FACTORS

Lifestyle behaviours such as good nutrition and physical activity are preventative factors against cardiovascular disease, stroke, diabetes, some cancers, obesity, and osteoporosis (SEE ENDNOTE 11, ENDNOTE 12). Conversely, smoking is a recognised risk factor for several illnesses (see Australian Social Trends 2003, Health risk factors among adults, pp. 74-78).

VEGETABLE AND FRUIT INTAKE, PHYSICAL ACTIVITY, AND CURRENT SMOKER STATUS REPORTED BY WOMEN AGED 18 YEARS AND OVER(a) - 2001
		4 or more serves of vegetables(b)	2 or more serves of fruit(b)	Physically active(c)	Non-smoker(d)
		%	%	%	%
Region of birth
	Australia	37.2	57.7	26.8	77.6
	Other Oceania(e)	32.1	54.3	25.9	74.3
	United Kingdom and Ireland	26.8	58.5	36.6	77.4
	Other North-West Europe	26.4	62.3	31.2	71.6
	Southern and Eastern Europe	22.1	68.3	24.2	82.9
	North Africa and Middle East	*8.7	57.0	*14.5	86.6
	South East Asia	20.3	57.8	11.5	89.8
	Other Asia	33.8	54.0	25.3	93.3
	Americas	25.3	58.0	23.0	80.0
	All other countries	23.8	64.2	29.2	91.9
Equivalised income of income unit quintile(f)
	Lowest	31.9	56.4	26.8	68.3
	Second	34.2	54.6	24.0	74.6
	Third	36.5	57.6	23.5	80.4
	Fourth	33.5	60.6	25.7	83.0
	Highest	33.9	63.4	31.5	83.7
Australia		33.6	58.3	26.3	78.9
(a) Age standardised.
(b) Usual intake per day. Women who did not state their daily fruit or vegetable intake were excluded prior to the calculation of percentages.
(c) Includes moderate and high levels of deliberate exercise only, undertaken in the two weeks prior to interview. Levels are based on frequency, intensity and duration of exercise.
(d) Does not currently smoke but may have smoked in the past.
(e) Includes New Zealand.
(f) Quintiles have been calculated after ranking persons by the equivalised gross weekly income of the income unit of which they are a member. For additional detail see page 77.
Source: ABS 2001 National Health Survey.

Although nutritional requirements change over a woman's lifetime (e.g. in response to pregnancy or menopause), the National Health and Medical Research Council generally recommends that adults consume five serves of vegetables (including legumes) and two serves of fruit per day (SEE ENDNOTE 13). In 2001, around a third (34%) of women aged 18 years and over usually ate four or more serves of vegetables daily, while over half (58%) ate the recommended two serves of fruit.

A woman's cultural background may influence her consumption of fruit and vegetables, as different cultures have different food preferences. In 2001, women born in Australia were the most likely to usually consume four or more serves of vegetables per day (37%). Women from Southern and Eastern Europe were the most likely to eat two or more serves of fruit per day (68%). While women's levels of income did not appear to affect their daily consumption of vegetables, the usual intake of fruit was higher among women in the higher income quintiles.

It is recommended that adults undertake 30 minutes of moderate-intensity physical activity (such as brisk walking) on most days of the week (SEE ENDNOTE 11). However, in 2001, just 26% of women reported being physically active, in terms of taking moderate to high levels of deliberate exercise for recreation, sport or fitness in the previous two weeks. Between 1989-90 and 2001, the proportion of people exercising at a moderate or high level remained relatively stable (see Australian Social Trends 2003, Health risk factors among adults, pp. 74-78).

The level of deliberate exercise, taken for recreation, sport or fitness in the previous two weeks, undertaken by women aged 18 years and over varied in relation to their region of birth. A smaller proportion of women who were born in South East Asia had undertaken moderate or high levels of exercise for recreation, sport or fitness in the previous two weeks (12%), compared with women born elsewhere. The highest proportion of physically active women were from the United Kingdom and Ireland (37%), and Other North-West Europe (31%). Of women born in Australia, 27% were physically active in this way.

In 2001, over three-quarters (79%) of women were non-smokers. Women in higher income quintiles were less likely to smoke than those in lower income quintiles. Smoking status also varied in relation to region of birth, with women from South East Asia and Other Asia among the least likely to smoke (90% and 93% respectively were non-smokers).

Between 1989-90 and 2001, the proportion of women who were current smokers decreased from 24% to 21%. Over that period, women aged 18-24 years experienced the greatest reduction in smoking (in 1989-90, 36% of women in this age group were current smokers, compared with 27% in 2001). However, smoking increased among women aged 35-44 years (from 25% in 1989-90 to 27% in 2001) (see Australian Social Trends 2003, Health risk factors among adults, pp. 74-78).

ENDNOTES

1 National Breast Cancer Centre, <http://www.nbcc.org.au/pages/info/early.htm>, accessed 18 August 2003.
2 Commonwealth Department of Health and Ageing, ‘BreastScreen Australia: Who should have a mammogram?’ <http://www.breastscreen.info.au/who/index.htm>, accessed 31 October 2003.
3 Commonwealth Department of Health and Ageing, <http://www.health.gov.au/pubhlth/strateg/cancer/breast/index.htm>, accessed 4 August 2003.
4 Kong, G 1998, ‘Breast Cancer and Aboriginal and Torres Strait Islander women - a national report’, Aboriginal and Islander Health Worker Journal, vol. 22, no. 3, pp. 3-5.
5 Bailie, R et al. 1998, ‘Data for diagnosis, monitoring and treatment in Indigenous health: the case of cervical cancer’, Australian and New Zealand Journal of Public Health, vol. 22, issue 3, pp.303-306.
6 Commonwealth Department of Health and Ageing,<http://www.cervicalscreen.health.gov.au/papsmear/what.html>, accessed 3 November 2003.
7 Commonwealth Department of Health and Ageing,<http://www.cervicalscreen.health.gov.au/papsmear/who.html>, accessed 4 August 2003.
8 Rice, P (ed) 1999, Living in a new country: understanding migrants health, Ausmed publications, Ascot Vale, Australia.
9 Cheek, J et al. 1999, 'Vietnamese women and pap smears: Issues in promotion', Australian and New Zealand Journal of Public Health, vol. 23, pp. 72-76.
10 de Looper, M and Bhatia, K 2001, Australian Health Trends 2001, Australian Institute of Health and Welfare, AIHW Cat. No. PHE 24, Canberra.
11 Commonwealth Department of Health and Ageing, 1998, Developing an Active Australia: A framework for action for physical activity and health, Canberra.
12 Better Health Channel 2002, <http://www.betterhealth.vic.gov.au/bhcv2/ bhcarticles.nsf/pages/Food_requirements_ during_different_life_stages?Open Document>, accessed 16 July 2003.
13 National Health and Medical Research Council, 2003, Dietary Guidelines for Australian Adults, Canberra.

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