Front Matter

Women’s Health in Ireland

Figure from page 1

Evidence Base for the development of the Women’s Health Action Plan

Commissioned by National Women’s Council of Ireland, Department of Health, Health Service Executive

Women’s

Health

in Ireland

Report produced by Kathy Walsh, KW Research Associates

Commissioned by National Women’s Council of Ireland, Department of Health, Health Service Executive

August 2019

The views and opinions expressed in this report are those of the author and do not necessarily reflect the official policy or position of the report’s commissioners.

Contents

List of Tables

List of Figures 2

Executive Summary 3

Structure of the paper 3

Introduction 4

Background 4

Purpose and approach 5

Why focus on women’s health? 5

Women’s health – European policy context 8

Prioritising women’s health in Ireland - the Women’s Health Action Plan 8

Section 1 – Women in Ireland 10

1.1 Total population 10

1.2 Demographics 10

1.3 A socio-economic profile 12

1.4 Health, disability and caring 13

1.5 Fertility rates and life expectancy 14

Section 2 – Women’s Health in Ireland 15

2.1 Health 15

2.2  What we know about women’s health in Ireland 16

2.3 Women’s health in Ireland at different life stages 32

2.4 Women’s lifestyle behaviours 35

2.5 Violence against women 35

2.6 Women, health and disadvantage 39

2.7 Priority groups of women 44

Section 3 – Women’s Engagement with the Health Service 57

3.1  Overview of national and international literature on women’s engagement

with health services (service use, service needs) 57

Section 4 - Health Policies and Services Relevant to Women’s Health 62

4.1 Relevant international women-specific health policies, services and initiatives 62

4.2  Current women-specific health policies, services and initiatives in Ireland 62

4.3  Health policies, services and initiatives that are relevant to women 64

4.4 Other policies that are relevant to the health of women 69

4.5 Assessment of how Ireland’s current health policy framework takes into account

women’s specific health needs 76

4.6 Models of practice in relation to Women’s Health Policy 77

Section 5 Conclusions 80

5.1 Women in Ireland 80

5.2 Women’s Health in Ireland 80

5.3  Women’s Health Concerns and Needs 81

5.4  Women’s engagement with the Health Services 83

5.5  Health policies and services relevant to women’s health 84

5.6  Models of practice in relation to Women’s Health Policy 85

5.7 In conclusion 85

Appendix 1 – Women in Ireland

Appendix 2 – Summary of Wider Determinants of Women’s Health

Bibliography

Table 4.3 Health policies under the Healthy Ireland

List of Tables

Framework that are relevant to women

Table 1.1 Families which involve females (as part

Table 4.4 Main elements of Sláintecare

of a couple/or as head of a one parent family)

Table 4.5 Other policies and strategies that impact

Table 2.1 Chronic conditions and limitations by

on women’s health and well-being

gender

Table 4.6 Health and well-being actions from the

Table 2.2 Social gradients in relation to cancer

National Disability Strategy

incidence

Table 2.3 Gender differences in mental health

List of Figures

Table 2.4 Characteristics of gender sensitive

services

Figure 1.1 Life expectancy at birth by gender,

Ireland and EU 28 (2006-2015)

Table 2.5 Six pillars of reproductive health

Figure 2.1 Determinants of health

Table 2.6 Health problems during and after

pregnancy

Figure 2.2 A three-pronged approach to

reproductive health

Table 2.7 Women’s key health needs and risks at

different life stages

Figure 2.3 Percentage of women who participate in

recreational walking by age

Table 2.8 Percentage of women who smoke (by age

and deprivation)

Figure 2.4 Women’s participation in sport by age

Table 2.9 Percentage of women who binge drink

Figure 2.5 Health issues and social determinants

(by age and deprivation)

affecting women across the life course

Table 2.10 Changes in women’s % participation

rates in various sporting activities (2017 v 2015)

Table 2.11 Some key social determinants of health

Table 2.12 Traveller and Roma women’s health

Table 2.13 A definition of complex needs

Table 2.14 Health recommendations in the

McMahon report

Table 2.15 Health issues for LGBTQI+ individuals

Table 2.16 Health issues for specific LBTQI+ groups

of women

Table 2.17 Profile of Clients attending the HSE

WHP Clinic in 2017

Table 2.18 Total suspected adult trafficking

(including for labour and sex trafficking) victims

by year and gender

Table 3.1 Proportion of women visiting a GP in the

past 12 months (by age and deprivation)

Table 4.1 Women-specific health policies, services

and initiatives

Table 4.2 Health policies, services and initiatives

that are relevant to women

Figure from page 7

Executive Summary

This paper provides the evidence base for the

The evidence provided in this review confirms the

development of a Women’s Health Action Plan

need for a national women’s health action plan

(WHAP) – it provides an overview of what is

which will facilitate and provide an enhanced

known about women in Ireland in terms of

response to the health inequalities experienced

demographics, health and engagement with

by women. The review documents the significant

health services, as well as the context for the

health needs of women spanning all categories of

development of women-specific health strategies

health from healthy lifestyles to chronic disease

internationally. This is an exploratory, desk-based

to mental health. In addition, the review identifies

evidence review. The information included in

how particular groups of women, including

the review is based on publicly available, largely

women in prostitution and women living in

published data accessible for quick review. In

homelessness, are experiencing particular health

drawing together key evidence about women’s

inequalities and barriers to care.

health in Ireland, this paper provides a crucial

first step in documenting women’s health needs in

Structure of the paper

Ireland, to be supplemented by engagement with

healthcare providers – and crucially – by national

—Section 1 presents an overview of women —

level consultations with women.

in Ireland – demographics, socio-economic

profile, health, disability and caring -

This review has been undertaken to examine how

primarily based on Census 2016.

best to support a focus on women’s health needs,

within the broader context of the need to achieve

—Section 2 discusses what is known about —

gender equality in health outcomes for women

women’s health in Ireland, across life-stages,

and men in Ireland.

diseases and lifestyle behaviours, as well as

the impact of disadvantage and violence on

Over-arching Government policy, as stated in the Healthy Ireland Framework, is to reduce inequalities for all and addressing the impact of gender on health is a crucial element of this work.

women’s wellbeing. This section also provides

an overview of groups of women in Ireland

experiencing particular health inequalities.

—Section 3 moves focus to the health system, —

using existing national and international

literature to describe women’s engagement

with the health service.

A Men’s Health Action Plan is already in existence

and, once developed, the Women’s Health

—Section 4 turns to the international and —

Action Plan will complement this, in terms of a

national frameworks governing women’s

comprehensive health service response to gender

health and provides detail of health policies

differences in health behaviours, outcomes and

and services relevant to women’s health

engagement with health services. To achieve

in Ireland, Australia and the World Health

this, the WHAP must be informed by and connect

Organisation European Region.

with key women’s health policies internationally

—Section 5 provides conclusions arising from —

– theUN’s Global Strategy for Women’s, Children’s

the evidence presented in this paper.

and Adolescents’ Health 2016-2030 and the WHO

Strategy on women’s health and well-being in the

WHO European Region.

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

Figure from page 8

Introduction

Nationally, the focus on improving the health of

Background

women over the last two decades has primarily

been on maternal health and reproductive

Recent years have seen increased levels of attention

services. For the next number of decades this

to women’s health issues in Ireland. In particular, the

focus must be broadened to encompass not only

national conversation about women’s health issues

reproductive health but also mental health and

during the Referendum to provide for abortion in

chronic diseases (the leading cause of ill health

Ireland and the scrutiny of women’s experience of

and disability for women).1

healthcare as part of the CervicalCheck controversy,

has brought Ireland into a new stage in the drive to

As part of the process to develop Ireland’s Women’s

improve women’s health experiences and outcomes.

Health Action Plan, the HSE, the Department

Greater understanding of the specific health needs of

of Health and NWCI project team identified the

women and the inequalities in the outcomes faced by

need for research evidence on women’s health

groups of women in Irish society – including Traveller

in Ireland. In particular, a need was identified

women, migrant women and women experiencing

to gather together existing data on women in

violence – has further bolstered the need for a

Ireland, women’s health and engagement with

coordinated focus on women’s health.

health services in Ireland and an assessment of

existing national policies and international policy

Reflecting the need to address women’s health in a strategic way, the Government’s National Strategy for Women and Girls commits to the development of a Women’s Health Action Plan by the Health Service Executive (HSE), Department of Health and the National Women’s Council of Ireland (NWCI) ‘to address the particular physical and mental health needs of women and girls’(p.45).

frameworks related to women’s health. Funding for

the development of the evidence base was provided

by the HSE. NWCI undertook project management

and following a public tender process, KW Research

Associates Ltd. was commissioned to develop and

draft this evidence paper.

The paper provides an overview of existing

literature to provide a baseline of information

about women’s health in Ireland and identification

of women-specific, or women related health

policies, services and initiatives in Ireland and

internationally. In gathering this information

together, the paper aims to support work to

ensure women’s health needs across the lifecycle

This national commitment is reinforced by the

are reflected in the forthcoming WHAP and

World Health Organisation’s Strategy on women’s

contribute to work to ensure women’s health is

health and wellbeing in the WHO European Region

integral to development of health policy, service

which provides guidance to make national policies

planning and delivery. It is intended that the

more responsive to women’s health and wellbeing

evidence provided in this paper will inform

across the life-course.

1 Abel K M., Newbigging, K. (2018). Addressing unmet needs in women’s health. British Medical Association. Retrieved from:https:// www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/womens-health; Temmerman, M., Laski, L., Mathews, Z., Say, L. (2015). ‘Women’s health priorities and interventions’. British Medical Journal, 351:h4147. Retrieved from: https://www.bmj.com/content/351/bmj.h4147

further stages in the development of the WHAP, to

national consultation with a) listening exercises

include consultation with women and engagement

with women to gather their perspectives and

with health staff and the women’s sector to

health needs and b) engagement with health

identify priority actions for the plan.

providers to better understand how health

services currently respond to and support

women’s health needs. This engagement with

Purpose and approach

women as experts in their own health and with

health providers is necessary as part of any

This purpose of this review is to provide an initial

process to develop women-centred supports

evidence base to support development of the

and services, but is particularly necessary in the

Women’s Health Action Plan (WHAP) specifically

Irish context given the limited data available on

related to four areas:

women’s engagement with health services.

—A picture of women in Ireland using key —

demographic, social and economic data;

Why focus on women’s health?

—Evidence about women’s health in Ireland; —

The World Health Organisation (WHO) recognises

—Detail of women’s engagement with health —

that the social construction of gender identity

services; and

and unbalanced power relations between women

and men affect the health seeking behaviour and

—An overview of health policies in Ireland and —

health outcomes of women and men in different

internationally which address women’s health.

ways. 3

This is an exploratory, desk-based evidence

review. The information included in the review is

As a consequence, health policies, practices and services need to reflect that women and men – because of their biological differences and gender roles – have different health needs and face different barriers in seeking to achieve good health.

based on publicly available, largely published data

accessible for quick review. The review focuses

on the determinants of women’s health, without

necessarily making comparisons between women

and men. The review was limited in some areas

by the lack of publicly available information

in relation to key areas of women’s health in

Ireland and particularly in relation to women’s

engagement with health services. This reflects

both the small number of women-specific health

The impact of gender on health

studies undertaken in Ireland and a lack of

National policy, as stated in the Healthy Ireland-

gender disaggregation in general health data and

a Framework for improved health and wellbeing

research. Lack of health data by gender is a feature

2013-254, is to reduce inequalities for all and

in global health research2 which necessitates

create a healthy Ireland, ‘where everyone can

increased prioritisation of women’s health in

enjoy physical and mental health and wellbeing

international and national health research

to their full potential, where wellbeing is valued

programmes.

and supported at every level of society and is

everyone’s responsibility’(p.5).

The evidence gathered in this paper represents

the first part of the evidence necessary to develop

the WHAP. This will need to be supplemented with

2 Sugimoto, C., Ahn, Y.Y., Smith, E., Macalusco, B., Larivière, V. (2019). ‘Factors affecting sex-related reporting in medical research: a cross-disciplinary bibliometric analysis’. The Lancet, 393: 550-9. Retrieved from: https://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(18)32995-7/fulltext

3 World Health Organisation Europe. (2016). Strategy on women’s health and well-being in the WHO European Region. Copenhagen: WHO. Retrieved from: http://www.euro.who.int/en/health-topics/health-determinants/gender/publications/2016/strategy-onwomens-health-and-well-being-in-the-who-european-region-2016

Government of Ireland. (2013). Healthy Ireland – a framework for improved health and wellbeing. Dublin: The Stationery Office. Retrieved from: https://health.gov.ie/wp-content/uploads/2014/03/HealthyIrelandBrochureWA2.pdf

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

There is an increasing focus on the health

policy planning and service delivery.6 Gender

inequities which exist between groups in society

mainstreaming seeks to achieve gender equality

in terms of the social determinants of health. The

through assessment of gender inequality and

social determinants of health are the economic

integrating a gender sensitive approach into

and social conditions that influence individual

health service planning and delivery. Between

and group differences in health status. They arise

2010 and 2012, the HSE and NWCI undertook

from inequalities in the conditions of daily life

a major project on gender mainstreaming,

and the fundamental drivers of these conditions

publishing Equal but Different: A Framework for

• inequities in power, money and resources. The

integrating gender equality in Health Service Executive

WHO Strategy on women’s health and wellbeing

Policy, Planning and Service Delivery7.

in the European Region5 states that ‘gender is

The recognition of gender differences in health

a determinant of health, alongside social and

provides justification for the creation and use

environmental determinants, and which identifies

of specific plans and policies to address the

gender mainstreaming as a mechanism to achieve

distinct health needs of women and men. For

gender equity’.

example, there are areas of health (e.g. smoking,

binge drinking, suicide) where men fare worse

Gender is a determinant of health because it shapes life experiences and socio-economic realities, resulting in different health outcomes and different health care needs for women and men.

statistically, and others (such as self-harm,

most aspects of reproductive health and certain

cancers) where an increased focus and specific

actions for women are necessary. Despite this,

the different and distinct health experiences of

women and men remains absent from general

health policy and service development. It is also

Sex and gender are particularly relevant in some

the case that many health services and policies

health sectors (mental health, cancer, cardiovascular

remain built around expectations and features of

disease, etc.) while gender inequalities cut across all

male patients, with associated treatments also

forms of inequality including poverty, economic and

often based on male-dominated studies and trials.

educational disadvantage, disability, age, ethnicity

This approach presents difficulties for women.

and sexual orientation. For women to attain the

optimum level of health over their lifetime, health

Women’s health needs

systems need to plan for women’s biological

The headline news on women’s health is good.

differences and gender roles.

The health status and life expectancy of women in

Ireland has improved dramatically in the last two

It is also the situation that women and men use

decades. Irish women live on average almost four

health services differently, with their experience

years longer8 than Irish men.

of health influenced by gender differences, from

employment to caring responsibilities. One

Women’s health is determined not only by

of the ways that the Irish health service has

physical make-up, but also by a range of other

responded to the impacts of gender on health

factors including sex, and gender, as well as other

has been through gender mainstreaming, an

social determinants across the life course. This

internationally recognised approach which

means that health is a product of the conditions

integrates gender into the mainstream of

in which women are born, grow, live, work and

5 World Health Organisation (2016) Strategy on women’s health and wellbeing in the WHO European Region. Copenhagen: WHO. Retrieved from: http://www.euro.who.int/en/health-topics/health-determinants/gender/publications/2016/strategy-onwomens-health-and-well-being-in-the-who-european-region-2016