women’s health update
Meeting young women’s HPV information needs? “You can’t get cancer from sex – can you?” A new Australian study, published this month, is the first to explore girls and their parents’ knowledge about HPV and the HPV vaccine since the implementation of the Australian schoolbased HPV immunisation program. A core theme from both girls and their parents in the study was a lack of knowledge: of HPV, of the HPV and cervical cancer connection, of what the vaccine does, and of how the various cervical cancer prevention strategies work together ie. the vaccine and cervical screening. Of major concern is that a lack of knowledge and understanding about HPV vaccination will have implications for adolescents’ future health practices, including sexual risk behaviour, and participation in cervical screening programmes, potentially exposing them to a greater risk of the disease the vaccine is intended to help prevent. Christy Parker, Women’s Health Action Policy Analyst, looks at New Zealand’s programme one year on and asks if we are meeting young women and their parent’s HPV immunization information needs? The New Zealand context With the new school year underway, so too is the roll out of the second year of New Zealand’s school-based HPV immunization programme delivering Gardasil to girls in year 8, alongside a catch up programme for girls in years 9 – 131. Uptake of the vaccine, at the end of the first year of the school-based programme, was not as high as was expected. The first year saw 86,000 girls and young women have the vaccine, most of them in schools. This equated to uptake by approximately half of the girls offered the HPV immunization in the schools that chose to deliver the programme2. 1 This is the final year of the school-based catch-up programme for girls in years 9 – 13 2 Ministry of Health, 2010. Not all District Health Boards elected to deliver the school-based HPV immunization programme. Of those that did, 95% of eligible schools chose to participate. Uptake has been higher among Maori and Pacific teenagers with 62% and 71% uptake respectively. Maori and Pacific teenagers were a specific target for the vaccine because they are underrepresented in cervical screening and treatment services and therefore over-represented in the incidence of cervical cancer.
The Human Papillomavirus (HPV), which is largely transmitted through sexual contact, is a necessary factor in the development of nearly all cases of cervical cancer. Gardasil, the HPV vaccine funded in New Zealand targets HPV types 16 and 18 which are associated with 70 percent of cervical cancers, and types 6 and 11 which are associated with genital warts. The vaccine has been heralded by some as a major development in the prevention of cervical cancer. Others have been more cautious. Concerns have included the infancy of the vaccine with questions about its safety and efficacy, and the development and implementation of the programme to deliver the vaccine here with its emphasis on uptake rather than informed choice. In our February 09 Update article ‘Informed choice and immunization programmes’ we questioned both the ethics and the safety of the approach to the roll out of the HPV immunization programme 3. Our concerns centered on the marketing approach to deliver the programme including inadequate information resources that 3 Parker, 2009
vol 14 no 1 • April 2010
I n s i d e ●
Managing b r e a s t f e e d i ng a nd work ● Breastfeeding workplaces will soon be only a click away ● D e v e l o p me nt s u nd e r w ay f o r e a ti ng d i s o r d e r s s e r v ices in t h e N o r t h e r n R e gi on read like advertising brochures; the decision to market the vaccine as the “cervical cancer vaccine” which obscured the link between HPV and cervical cancer; and the failure to adequately communicate the vaccine as part of a integrated approach to cervical cancer prevention alongside sexual health messages and the need for cervical screening4. It was our contention that this resulted in a climate where girls and their parents were deciding to have a vaccine, the functions of which they didn’t understand. Indeed evidence of a lack of understanding about HPV in the population preceded the roll out of the HPV immunsation programmes, with women having limited knowledge about HPV as a sexually transmitted infection, and of its role in the development of cervical cancer5. Uninformed decision making is not only in contradiction to New Zealand health consumers’ 4 The World Health Organization endorses HPV vaccination programmes as part of an integrated cervical cancer prevention strategy that includes cervical cancer screening and sexual health education. – WHO Position Paper on HPV Vaccination, Weekly Epidemiological Record, 9 April 2009 5 Hall et al, 2008; Anhang, et al, 2003
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Women’s Health Update features women’s health news, policy and scientific findings, to enable health care professionals and community-based workers to be at the forefront in women’s health. Women’s Health Update is published by the Women’s Health Action Trust
2 • Women’s Health Update • vol 13 no 4 • October 2009 continued from page 1 right to make an informed choice6. It is also potentially dangerous- if young women do not understand the relationship between HPV and cervical cancer, and the benefits and limitations of the various prevention strategies, they cannot make informed decisions about their future health practices, such as the need to practice safer sex and participate in screening when they are older. Our concerns echoed those of Dr Hazel Lewis, Clinical Leader of the National Cervical Screening Programme, when she stated: By far the greatest risk for women is that those who have been vaccinated, and even those who have not, may mistakenly believe that cervical cancer is no longer a problem and will be less conscientious about turning up for regular smears7. We also expressed concerns that only targeting the vaccine to girls sends the wrong message to adolescents about who is responsible for the prevention of sexually transmitted infections. It could also contribute to stigma against women which can act as a barrier to both preventative and treatment seeking behaviours. New Australian Research The Australian study has identified significant gaps in the knowledge and understanding of young women and their parents who have participated in the school-based HPV immunization programme, both about HPV’s role in the development of cervical cancer and the HPV vaccine’s role in the prevention of cervical cancer. Knowledge gaps about HPV included what exactly HPV is, how it is transmitted, and the HPV/cervical cancer connection. Many of the girls and parents were unable to answer questions about what HPV was, and those that understood it to be a sexually transmitted infection tended to confuse it with HIV and herpes. Knowledge surrounding HPV transmission was varied. While approximately half of the parents and girls mentioned “sex”, it was often followed by qualifiers such as “I think”8. Others believed that HPV was a cancer, and could not understand how cancer was sexually transmitted: “But it’s cancer. You can’t get cancer from sex – can you?”, “Is cancer contagious?”9. While there was some knowledge of HPV being related to sex, the role males played in transmission was unclear to the girls. In one focus group, the girls were asked if boys could catch HPV and all of the girls answered “no”. HPV and cervical 6 The Code of Health and Disability Services Consumer Rights, 1996 7 Lewis, 2007 8 Robbins et al, 2010, line. 193 9 Robbins et al, 2010, line 204
cancer were used interchangeably by some participants and few participants demonstrated a clear understanding of the connection between the two. Knowledge gaps about the vaccine included what it protects against, how it works, the ideal time to receive the vaccine, the need for cervical smears when older, and the risks posed by the vaccine. Both girls and parents were confused about what the HPV vaccine protected the girls against and the majority of participants thought that they were now completely protected against cervical cancer10. One parent explained why they held this impression: “…just the adverts on TV. It just brought across the idea to most people that this going to stop you getting cervical cancer”11. Because the vaccine was given for free to females, many girls had come to the belief that only they, and not boys, could contract HPV: “Boys don’t have cervix, and it’s not like a sexual disease, it’s just cancer…One cancer…”12. Many of the girls did not understand how the vaccine, cervical smears, and cervical cancer were all connected and there was a range of understandings about whether cervical smears would be necessary in the future, with some being certain that cervical smears were now unnecessary. At the completion of the interviews both young women and their parents expressed frustration at their lack of information and a strong desire to be better informed. The authors of the study raise similar concerns to our own, about the risks and ethical issues posed by these knowledge gaps: Although other school-based vaccination programs face the same information delivery challenges, the difference is that a lack of understanding about HPV vaccination may directly impact future health behaviours. It is crucial that adolescents understand the continued need for utilizing protection during sexual activity and for participating in cervical screening in the future; our data indicates that adolescent understandings at the time of vaccination were unlikely to promote these behaviours13. Are we meeting young women’s HPV information needs? HPV and HPV immunization are complex health issues. The results of this Australian based study raise concerning questions about the adequacy of the information provided to support girls and their parents’ decision making in Australia’s school-based HPV immunization programme, and the impact this may have on their future 10 11 12 13
Robbins et al, 2010 Robbins et al, 2010, line 260 Robbins et al, 2010, line.308 Robbins et al, 2010, line. 433
health behaviors. Informed health consumers are in a much better position to make decisions about their health and wellbeing, particularly in relation to appropriate preventative measures14. As the second year of the programme is rolled out in New Zealand schools, the lessons being learnt in Australia should be taken seriously here. There are some indications that we are doing better. The information resources have been reviewed and improved for the second year of the programme with more information, clearer messages about the need for cervical screening, and a gradual renaming of the vaccine as the HPV vaccine. A New Zealand phone survey of parents of teenage girls late last year showed some increase in awareness about HPV and around the need for cervical smears when older15. The need for more information however was a consistent theme. While these findings are reassuring they do not include an evaluation of girls and young women’s knowledge or understanding. In the light of the concerning findings from Australia we need to know more about whether we are meeting young women’s, and their parents’, HPV information needs in New Zealand. If we are not, we need more information on where the gaps are so that we can do better. Not only do consumers have a right to know, effective cervical cancer prevention depends on it. References Anhung, R. Wright, T. Smock, L. Goldie, S. 2003 ‘Women’s desired information about human papillomavirus’, Cancer, Vol 100, No 2, pp. 315 – 320. Hall, B. Howard, K. McCaffery, K. 2008 ‘Do cervical cancer screening patient information leaflets meet the HPV information needs of women?’, Patient Education and Counseling, Vol 72, pp. 78 – 87. Lewis, H. The potential impact of mass HPV vaccination on cervical cancer prevention: population and clinical perspectives. National Screening Unit. Ministry of Health. 2010 ‘Update to Boards of Trustees, Principals and Education Sector Groups on the HPV (Human Papillomavirus) Immunisation Programme. Parker, C. 2009, ‘Informed choice and immunization programmes’, Women’s Health Update, Vol 13, No 1, pp. 1 – 2. Robbins, SCC. Bernard, D. McCaffery, K. Brotherton, J. Garland, S. Skinner, R. 2010 “Is cancer contagious?”: Australian adolescent girls and their parents: Making the most of limited information about HPV and HPV vaccination, Vaccine, doi: 10.1016/j.vaccine.2010.02.078 Wyllie, A et al. 2009 ‘HPV Vaccine communications first track monitor’, Research Report for GSL Network on Behalf of the Ministry of Health, October, Phoenix Research. 14 Robbins et al, 2010, line 22 15 Wyllie et al, 2009
Women’s Health Update
• vol 13 no 4 • October 2009 • 3
Managing breastfeeding and work In October and November last year Women’s Health Action participated once more in Parent and Child Shows in Christchurch and Auckland. In addition to providing information on pregnancy, childbirth and breastfeeding, WHA’s also provided a comfortable area for women to breastfeed. The stand was managed by WHA staff and trustees plus volunteers from La Leche League. There was a steady stream of visitors and a number received some much welcome tips and often counseling about managing breastfeeding, highlighting the continual need for information and support to be provided to pregnant and breastfeeding women. The stand was adjacent to and complemented the Ministry of Healths’ which showed and distributed the DVD on Breastfeeding. WHA also conducted a survey on the effect of returning to work on breastfeeding. Women who were pregnant or returned to work after the birth of their youngest child were asked to complete a simple questionnaire. Over 800 responses to the survey from both shows were received. Well over half of all women who returned to work after parental leave continued to breastfeed. And interestingly more women actually continued to breastfeed on return to work than had planned to do so. Of the useable responses: 29% actually returned to work following the birth of their youngest child whereas 52% planned to do so . Of those who did return 64% also continued to breastfeed whereas 49% of those who planned to return to work intended to continue breastfeeding. The results between the two shows were significantly consistent. ie; At Christchurch 63.7% and at Auckland 64% responded that they had continued to breastfeed on return to work. The ages of the children on the mother’s return to work were also consistent with the average being 19% returning when the child was less than 3 months old; 32% when the child was 4-6 months; 23% at 7-11months and 26% when the child was 12 months or older. How women managed to continue to breastfeed on return to work included a variety of methods; 16% worked from home and fed the baby whenever needed; 10% took the baby to work for the duration of the work day; 27% breastfed immediately before and/or after work; 27% expressed breastmilk at work; 7% went to the baby to feed during breaks and 8% had a carer bring the baby into work for feeds. Most women used a combination of these methods, particularly combining breastfeeding the child before and/or after work and expressing at work. Although not collated, many women also indicated that they were working part-time or flexible hours which allowed them greater opportunity to continue to breastfeed. Additional comments made by the mothers when discussing whether or not they continued to breastfeed on return to work revealed a mix of positive and negative experiences. Unfortunately a number of women reported that their employer would not allow them to breastfeed, told them to feed in the toilets, pressured them to increase their hours, provided no flexibility in length or timing of breaks and were generally not supportive. One sector which stood out in this area was the health sector which was found to be very unsupportive or at best while not being obstructive offered no assistance, with women having to find a private space and organise the times themselves. Encouragingly though, a number of positive experiences were also reported with women commenting how ‘fantastic’ or ‘totally supportive’ their employer was, some allowing the mother to bring the baby to work when the infant was very young so it could be fed on demand. These reports related to employers across all sectors and all organisation sizes, and confirms Women’s Health Action’s view that the attitude of
the employer is one of the key factors in having a breastfeeding friendly workplace. Arranging a space and/or extra breaks does not seem to be difficult if the employer is willing. While the legislation requiring employers to provide adequate space and break times to breastfeed is essential, WHA has recognised that a positive organisational culture and good communication systems are also vital for a woman to successfully breastfeed on return to work which is why these areas are included in the assessment for Breastfeeding Friendly Workplace (BFW) Certification. WHA’s BFW project is currently being adjusted to have all relevant information and resources on a dedicated website with the capability for employers to register and be audited for BFW Certification on-line. This will be launched soon. In the meantime organisations or individuals requiring information on breastfeeding friendly workplaces can contact Cathie Walsh, the BFW Coordinator cathie@womens-health.org.nz
Breastfeeding friendly workplaces will soon be only a click away By logging on to www.bfw.org.nz, employers and employees will soon be able to get detailed information and resources about breastfeeding and work plus gain certification as a Breastfeeding Friendly Workplace (BFW). This new site has been established by Women’s Health Action to:
• Provide information to support breastfeeding women’s return to work • Assist employers to meet their legislative obligations under the Employment Relations (Infant Feeding) Amendment Act • Add value by providing certification for employers who meet a standard of
international best practice WHA is delighted that the Certification process has been endorsed by the EEO Trust. For further information, contact Cathie Walsh at cathie@womens-health.org.nz
Developments underway for improved eating disorders services in the Northern Region The establishment of a residential service for those experiencing severe eating disorders is underway in the upper North Island. The lack of a specialist in-patient service for eating disorders has been a glaring gap in services in the region with patients requiring specialist in-patient care being sent to Australia. Treatment in Australia is not only expensive. It also results in much greater stress on service users and their partners/families at an already very difficult time. Health Minister Tony Ryall made the establishment of a residential treatment programme in Auckland a priority in last year’s budget with the announcement of around $26 million to be invested nationally over four years for the treatment of eating
disorders. A Request for Proposal (RFP) was released at the end of February by Auckland District Health Board for a provider, most likely a non-governmental organization, to supply residential and day programmes services for eating disorders in the Auckland Metro area. The request is for 24 hour home-like residential accommodation with capacity for nine beds providing medical stabilization, supported and/or supervised meals, evidence based treatment and relapse prevention planning, close monitoring of physical and mental wellbeing, engagement with family/ whanau, and planning for transition back into the community. Additional Day Programme
services will be provided for service users based in the community to support their recovery. It is planned that the nine beds and day programmes will be fully functional by the 31st March 2011 with a staged implementation starting in September this year. This is good news for those experiencing severe eating disorders, and their families/ whanau, in the upper North Island. Watch this space for improvements in primary and secondary eating disorders services once the residential service is established. Improvements to all levels of the service are necessary to ensure intervention comes at an early stage and as few people as possible require residential care.
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Building a new life after separation
Auckland, 10 April 2010 9.30am – 4.30pm, $30-$50 Surviving separation after a relationship can bring a range of emotions such as grief, anger and confusion. You will learn practical as well as coping skills to help you reclaim yourself and begin to rebuild your life again. Bookings essential, ph 09 376 3227
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CEDAW Consultation Meeting - Hibiscus Coast (Orewa)
20 April 2010 from 9.30am Red Beach Methodist Church Red Beach Road, Red Beach If you would like to attend these meetings please RSVP to Belinda Greenwood on belindagreenwood@hotmail.com
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Working with Sexual Abuse 3rd Annual Northern Regional Symposium, SAFE Network
Auckland, 29 - 30 April ‘Community Solutions to a Community Problem’ Hosted by Auckland Sexual Abuse HELP, Rape Prevention Education, Counselling Services Centre & SAFE Network Inc. For information about registration or to submit an abstract please visit www.safenz.org.
Nga maia o Aotearoa me te waipounamu– hui a tau (Nga Maia Maori Midwives National Hui)
30 April - 2 May 2010 Maraeroa marae, 216 Warspite Ave, Porirua, Wellington More details may be obtained from the Nga Maia administration support person Chloe Mackenzie at ngamaia. admin@xtra.co.nz or at (03) 353 2597 Scholarships available for Maori midwifery students, applications close April 5th, contact Chloe Mackenzie. Working Women’s seminar on May Day, 1 May 2010 from 9am – 4.30pm St John’s Centre, Dixon St, Wellington. Enquiries to workingwomenseminar@gmail.com
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Working Women’s seminar May Day, 1 May 2010 from 9am – 4.30pm St John’s Centre, Dixon St, Wellington. Enquiries to workingwomenseminar@gmail.com
WONS Women’s Health Short Course 24 April from 9am – 4.30pm DisabilityResource Centre 14 Erson Ave, Royal Oak, Auckland Register online at http://www.wons.org.nz/
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Breastfeeding: A Lifetime Investment
Christchurch 14 May, Auckland 15 May Four international speakers on topical breastfeeding issues. For more information or to register Email office@ capersbookstore.com.au or go to www.capersbookstore. com.au
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6th Australian Women’s Health Conference
18 – 21 May 2010 Hobart, Tasmania Addressing ‘Women’s economic health and wellbeing’, ‘Women’s Mental Health and Wellbeing’, ‘Preventing Violence
Against Women’, ‘Women’s Sexual and Reproductive Health’, ‘Improving Women’s Access to Publically Funded and Financially Accessible Health Services’. See: www. awhn.org.au
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BREASTFEEDING UPDATE AND ETHICS IN LACTATION PRACTICE
Wellington 12-13 June, Auckland 7-8 October, Dunedin 9-10 October For more information or to register Email office@ capersbookstore.com.au or go to www.capersbookstore. com.au
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Keeping Birth Normal & Grief and Loss: The Crying Time
Christchurch 15-16 June Auckland 18-19 June Two one-day workshops for midwives and other health professionals, run by experienced midwives Shea Caplice and Hannah Dahlen. For more information or to register email office@ capersbookstore.com.au or go to www.capersbookstore. com.au.
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Attn: Midwives - Office Space to Lease!
MAMA Inc. is looking for people to share their rooms in Morningside, Auckland. Join their group of midwives, acupuncturists, massage therapists, psychotherapist and other natural therapists. Space available ranges from an entire suite of offices to sharing a space for a half day. Plenty of free parking and easy access to building all hours For more information Phone 09 815 8108, 027 474 4652
Women’s Health Update is produced by Women’s Health Action Trust • Edited by Jo Fitzpatrick To receive copies of Women’s Health Update, make suggestions about future contents or send items for publication please contact: Women’s Health Action Trust • PO Box 9947, Newmarket, Auckland, NZ 2nd Floor, 27 Gillies Avenue • Ph (09) 520 5295 • Fax (09) 520 5731 • email: info@womens-health.org.nz Internet address: http://www.womens-health.org.nz • Women’s Health Update is published with the assistance of the Ministry of Health
Women's Health Action Trust celebrating 20 years 1989-2009