Women's health plan

4 Principles underpinning the Women's Health Plan

The Plan is underpinned by the following principles:

Addressing inequalities - Responding to the unjust and avoidable differences in people's health across the population and between specific population groups.

A life course approach - Taking advantage of the different stages in a woman's life which present both health challenges and opportunities to promote and protect health and wellbeing.

Respectful and inclusive services - Everyone who uses and provides NHS services has a right to be treated as an individual and with consideration, dignity and respect.

Gender equality and intersectionality - Acknowledging and responding to the many characterisitics and factors which shape women's lives such as ethnicity, disability, sexual identity and background.

4.1 Addressing inequalities

Inequalities in health outcomes exist between both men and women and between different groups of women in Scotland. In the most affluent areas of Scotland, women experience 25.1 more years of good health compared to the most deprived areas.^[28] Health inequalities such as this are unjust and preventable.

We can reduce some health inequalities by identifying gaps in health service provision, considering areas of best practice and developing actions to address these gaps, tailored to meet the needs of all women. However we recognise this is only part of a wider picture when it comes to health and wellbeing.

Women are individuals with individual needs, experiences and backgrounds which impact their health and wellbeing. Multiple factors affect how women care for themselves, access information, seek advice, make choices, and their risk of illness.

Social determinants of health

Health inequalities are socially determined by circumstances largely beyond an individual's control. These circumstances can disadvantage people and limit their chance to live longer, healthier lives.^[29]

The fundamental causes of health inequalities are an unequal distribution of income, power and wealth. This can lead to poverty and marginalisation of individuals and groups.

Public Health Scotland Health inequalities: What are they? How do we reduce them?

These factors cannot be solely addressed by the Women's Health Plan, however improving access to health services has an important role to play in reducing health inequalities.

Health policy and resources need to take account of the social determinants of health and delivery of healthcare has to be joined up and accessible to be most effective. By working together, health, social care and third sector organisations can support and empower women to make changes to their lifestyles and live healthier lives. Health services cannot themselves address health inequalities which relate to deprivation, homelessness and poor housing or education and lack of opportunities.

Health services can however work alongside other professionals, with different expertise. Working with local authorities, the third sector and other partners in a holistic approach to women's care can allow women the opportunity to address, for example, accessing social security support at the same time as attending her doctor for contraception or her children's health.

Social determinants of health

The social determinants of health are the conditions in which we are born, we grow and age, and in which we live and work. The factors below impact on our health and wellbeing.

• Childhood experiences
• Housing
• Education
• Social support
• Family income
• Employment
• Our communities
• Access to health services

By working together we can address some of these gaps and meet the specific and individual needs of women.

I met up with the nurses again and the whole team at the clinic, honestly I haven't looked back, the clinic is welcoming and friendly and they listen to me and advise me to take better care of my health… I know this clinic is a place I can be totally honest about my health and how I feel, I feel totally at ease with the staff and can discuss most things including my alcohol problem, I wouldn't feel comfortable discussing this anywhere else, there is no judgement and they have a supportive feel to their service, I know I will always have someone to reach out to. There is free coffee and snacks and food to take away, toiletries, you just help yourself.

WISHES (Women's Inclusive Sexual Health Extended Service), Service User.

4.2 Life course approach

During every woman's life, there are opportunities to help her improve her physical and mental health and wellbeing. Women have predictable long-term reproductive healthcare needs and more frequent interactions with health services than men.

RCOG Better for Women

The life course approach emphasises the importance of identifying opportunities to prevent disease and promote health at key stages of life from pre-pregnancy through pregnancy, childhood and adolescence, to adulthood and later life. Promoting health and disease prevention can include ensuring women have information about the benefits of building and maintaining a healthy lifestyle including being physically active and maintaining a healthy weight. It also recognises that the social determinants of health shape our health and wellbeing throughout life, and that if we can improve the conditions of daily life we can reduce health inequalities throughout a person's life.

Current women's health services often focus on one issue at once which can lead to women falling through the gaps. If key life stages, such as puberty and menopause, were identified to target women, then holistic wellbeing assessments could help to reduce health inequalities, inform healthy lifestyle choices and increase early interventions.

Lived Experience Engagement Report

Within healthcare services the life course approach presents multiple opportunities not only for disease intervention but also in prevention of future ill health. In addition to women's health services (obstetrics, gynaecology, sexual health), other clinical services can use opportunities during consultations to discuss pre-pregnancy care, fertility, cervical screening, bone health etc. For example, a woman attending with her child for immunisation or accessing contraception services could also be given information about mental health support, how to access cervical screening or options for her if she is a victim of domestic abuse. Similarly a woman attending for cervical or breast screening could be offered information about menopause and risk of heart disease or osteoporosis. Health services working together, for example obstetrics and gynaecology along with cardiology, can assist women who have had complications such as pre-eclampsia and as such are at risk of heart disease in later life.

A life course approach throughout women's life stages

Lack of, or poor transition from paediatric to adult healthcare services can mean people miss out on routine follow-up and present with more complex or acute needs further down the line. This has a significant impact on the person and is often at increased cost to healthcare services. For young women, a lack of transition can mean they don't have the necessary information relating to their condition and how this can impact contraceptive choices or pregnancy.

Maggie Simpson, Senior Nurse Specialist and Lead Clinician Scottish Obstetric Cardiology Network

The different stages in a woman's life present both health opportunities and challenges. Many aspects of women's health are present in more than one life stage. Each stage presents important and differing opportunities to promote and protect health and wellbeing. Life changes and roles, including work and caring responsibilities, can impact women's wellbeing and their ability to access health services at any stage of life.

Girls and young women – puberty to around 25

This stage of a woman's life sees the onset of periods, sexual activity and fertility for many. It is important for children and young people to learn about their bodies and how to stay healthy and safe from an early age. It is particularly important for girls and young women to understand what is normal or abnormal in relation to periods and their bodies as they grow and to be supported throughout this life stage.

For many young women with long-term health conditions, the transition from paediatric to adult care is a crucial phase. It is essential that women have adequate education about their condition, self-management options, and risk reduction factors. Appropriate transfer to the right adult healthcare professional and medical specialties is also important. This includes access to pre-pregnancy care and counselling with healthcare professionals with expertise in this area. In this life stage many women will also require pregnancy support.

From an early age women's experiences can also include responsibilities such as caring, work, as well as school, college or university and developing independence. All these things can impact women's physical and mental wellbeing and their ability to access health services.

Middle years – around 25 to 50 years

Disease prevention and promotion of a healthy lifestyle should continue throughout adulthood. During their reproductive years many women will need help to manage their periods, to access contraception, abortion care and sexual health services, and to manage the impact of existing long-term health conditions. These services should be easily accessible for all women, culturally competent and centred on the woman's needs and preferences. In this life stage women will be invited to attend cervical screening, and may require support to attend for this if, for example, they have a disability or have experienced trauma.

It can be very difficult for those who have experienced neglect in childhood, abuse, violence, rape, trafficking or torture to undergo intimate examinations or to even discuss these. That is why it is so important that healthcare staff in particular should be aware of the impact of trauma and adopt a gentle, patient-centred approach to work towards any necessary examinations.

Dr Alison Scott, Consultant Obstetrician and Gynaecologist, specialising in sexual health, NHS Lothian.

In Scotland the average age of first-time mothers is currently around 31.^[30] Planning for pregnancy and optimisation of health and lifestyle before pregnancy improves outcomes for both mother and baby. Accessible information about pre-pregnancy care should be available and health professionals can use opportunities such as attendance for routine contraception to discuss the importance of planning a pregnancy and signpost to sources of information. Pregnancy represents a major life change and a stress challenge to a woman's body. Sometimes this leads to the development of conditions such as gestational diabetes or pregnancy-induced hypertension. These conditions may be indicators of increased risk of heart disease in later life. Women should be aware of this and management of such conditions may require joint working between clinical specialities such as obstetrics, primary care, diabetes care and cardiology. For women with pre-existing health conditions, collaborative working between these teams for pre-pregnancy health optimisation is essential.

Many women in their 40s will begin to experience symptoms of peri-menopause. Some women will also experience early (before the age of 45) or premature menopause (before the age of 40).

Later years – around 51 years and over

In this period of life, women often experience increasingly complex health needs.

For most women this life stage includes the onset of menopause. For some women transition through the menopause is straightforward. Other women have multiple physical and mental health symptoms which can impact their quality of life.

During, and leading up to, this life stage it is important that women have access to information on the options for managing the physical and mental symptoms of the menopause. Whilst not all women will choose or require medical interventions, it is important that they are supported to manage their menopause in ways that are appropriate for their lives and personal choices. Women will also start to be invited to attend breast screening, bowel screening and continue to access cervical screening, and may require support to access these services. Women may also require ongoing sexual health support and services.

Good healthcare for women as they age requires a level of service integration but the payback to the NHS is potentially enormous. Not only by dealing with entirely predictable issues in a timely and cost effective manner, but by exploiting the opportunities these routine encounters provide to pass on effective public health information and amplify these messages to the entire population.

RCOG Better for Women

Additionally, musculoskeletal conditions and osteoporosis can affect quality of life as women get older. Appropriate lifestyle advice, including being physically active, and treatment of these conditions can lead to increased ability to interact socially, work and participate in family life. As women age, the risk of dementia, cancer and cardiovascular disease increases. Proactively supporting women to transition through menopause provides further opportunities for promotion of a healthy lifestyle, which may decrease the risk of early onset of some of these conditions.

Women's Life Course

Women's health needs at life stages include

Girls and young women

Relationships, RSHP Education (relationships. sexual health and parenthood), HPV vaccination, Menstrual health, Sexual health, including contraception and abortion care, Pregnancy care, Mental health, Management of long-term conditions, and Pelvic health.

Middle years

Menstrual health, Sexual health, including contraception and abortion care, Cervical screening, Pregnancy care, Assisted conception, Mental health, Management of long-term conditions, Early menopause, and Pelvic health.

Later years

Menopause, Sexual health, Cancer screening, Heart health, Osteoporosis and bone health, Dementia, Mental health, Management of long-term conditions, and Pelvic health.

4.3 Gender equality and intersectionality

Multiple social, structural and individual factors lead to health inequalities. Every individual has different needs and different experiences.

The Women's Health Plan aims to take an intersectional approach which recognises that many women and girls in Scotland will face multiple, and often overlapping, disadvantages and barriers to accessing good healthcare.

Intersectionality acknowledges that there are many different factors that make up people's identities, for example their sex, gender, ethnicity, sexual orientation, socio-economic background, disability, religion and more. Relationships between ethnicity, socio-economic position and health for example, are extremely complex.^[31]

A research report, 'Our Bodies, Our Rights'^[32] published by Engender in 2018 describes how disabled women in Scotland report experiencing specific barriers when accessing a range of services, such as sexual health services, including lack of accessible facilities, specialist equipment, and accessible information. This highlights the importance of considering, in this case, how sex, gender and disability intersect and the specific needs and experiences of disabled women. It is important for healthcare professionals, and health policy makers, to recognise that a failure to take an intersectional approach can lead to further discrimination or disadvantage.

Similarly, a report in 2020 of the All-Party Parliamentary Group's Inquiry on Endometriosis in the UK explained how potential cultural barriers may deter women from accessing help for menstrual problems – so this highlights the importance of understanding how sex, gender and culture and religion can intersect.

In certain cultures, menstruation is still considered as dirty, and many are subject to missing out on aspects of their daily lives such as family occasions or visiting religious institutions because they are menstruating. This can lead to young people growing up with limited knowledge of menstruation because their families shy away from discussing the issues with them, and thus delay seeking medical help or treatment.

Natalie – contributor to APPG on Endometriosis Inquiry Report

Intersectionality

How different aspects of a person's identity overlap to form their unique experience.

• (Dis)ability
• Sexual Orientation
• Culture
• Gender
• Ethnicity
• Age
• Education
• Income
• Geography
• Sex
• Race
• Religion

Gendering health policy

We are committed to ensuring gender is a foundational consideration in the development of health policy going forward, acknowledging that women often face inequalities because they are women. We have developed a set of principles which will be integral to how we make change.

Our Principles for Gendering Health Policy

1. The right to health is a fundamental human right, everyone has the right to the highest attainable standard of physical and mental health.

2. All health services and systems must be accessible, available, appropriate and high quality.

3. Systematic inequality which negatively impacts women's health should be addressed and challenged.

4. Healthcare provision should be intersectional, gender-competent and culturally competent.

5. Health policy decisions should be aligned with the European Convention on Human Rights and the Convention on the Elimination of Discrimination Against Women, and other international human rights treaties (see Annex D).

4.4 Respectful and inclusive services

The right to health is a fundamental human right. It means the right of everyone to the highest attainable standard of physical and mental health.

For this to happen, services and systems that help us to live long healthy lives should be

• accessible
• available
• appropriate
• high quality.^[33]

Healthcare services must be responsive and adaptive to the individual needs of women, with practitioners adequately trained to be able to help women, particularly those who have been affected by trauma or adversity. These principles recognise the importance of promoting services for all women, providing women with information on the availability of services, and allowing women to choose how, when and where they can access services.

Change Our Style To Shared Decision-Making

Build A Personalised Approach To Care

We must listen to the people we care for, understand what matters to them, and give the information and support they need to make informed decisions about their care.

Chief Medical Officer - Realistic Medicine

What do we mean by 'Trauma Informed' Practice?

Being 'Trauma Informed' means being able to recognise when someone may be affected by trauma, adjusting how we work to take this into account and responding in a way that supports recovery, does no harm and recognises and supports people's resilience.

Opening Doors: Trauma Informed Practice for the Workforce on Vimeo

Healthcare Improvement Scotland have developed standards to ensure consistency in approach to healthcare and forensic medical services for anyone who has experienced rape, sexual assault or child sexual abuse.

Healthcare and forensic medical services for people who have experienced rape or sexual assault standards

Cultural competence

Scotland's population has become increasingly ethnically diverse.^[34] Different ethnic population groups can often experience very different health outcomes, representing stark inequalities.^[35]

The proportion of the population belonging to a non-White ethnic group increased four-fold in Scotland between 1991 and 2011 and projections suggest that by 2031, around 20% of the total population (and 25% of children) of Glasgow, Scotland's largest city, will belong to a non-White minority group.^[36] It is important that the healthcare system is responsive to these changes. It is also important that all health and social care professionals approach people from all cultures with openness and without judgement and are responsive to the individual needs of their patients and community. The importance of healthcare professionals acknowledging and addressing unconscious bias has also been highlighted by the RCOG in their position statement on racial disparities in women's healthcare^[37] .

For services to be truly accessible it is vital that women have choice about how and when they access care which takes into account the complexities of women's lives.

Women told us that while they felt uncomfortable about talking about intimate health issues with male GPs or interpreters they also felt uncomfortable specifically requesting a female GP and interpreter. They expressed concerns over confidentiality if they come from a small community where they may know or know of the interpreter personally and feel uncomfortable sharing intimate issues.

Lived Experience Engagement Report

All women must be able to make informed choices about their health, including those who do not have access to digital technology, whose first language is not English or who have a learning or other disability. Actions included within the Plan recognise the importance of ensuring that all women are appropriately informed about their options and supported to make choices that are right for them as individuals.

The NHS Charter of Patients' Rights and Responsibilities, summarises what everyone is entitled to when using NHS services and receiving NHS care in Scotland.

Public health messaging should take into account language barriers, literacy levels, cultural factors, religious beliefs and differential access to health-related information among diverse communities.

Expert Reference Group on COVID-19 and Ethnicity