The Challenge of Isolation
Menopause Education in
Judy Thomson, RN, RM, DNE, FCN(Aust), FCN(NSW), WHNP 372 Zebina Street, Broken Hill, New South Wales, 2880, Australia
INTRODUCTION
Menopause Education
Supplying
education on aspects of the menopause to outback of far western New South Wales is one of the most challenging facets in my role as a Women’s Health Nurse Practitioner. Women’s Health Nurses function as primary health care workers by being the first level of contact for women in the community. This contact allows for appropriate referral to occur.
My current role which involves me in menopause education is
women
that of Women’s Health Nurse Practitioner for the far west region of NSW. Being the sole practitioner for such a vast region can be a daunting factor. Clinics for well women are conducted in Broken Hill at the Community Health Centre which is my base in the region. Mobile clinics are carried out at outlying areas which are accessed by flights with the Royal Flying Doctor Service or by vehicle. It is common for the undertaking of outback clinics to involve travel of 600 kilometres per day. By way of comparison it is interesting to note that Broken Hill is a mining town in far west NSW with a population of 24,000. It is situated 1,183 kilometres inland from Sydney and 5 00 kilometres north east of Adelaide. Broken Hill’s rich and colourful traditions associated with mining and trade unionism have ensured that a male dominated society prevails. Unfortunately, issues relating to women have not had
WOMEN’S HEALTH SERIIICES In March 1984, the NSW Government commissioned a review of Women’s Health Services in NSW. From the Women’s Health Policy Review Committee Report September 1985 came the recommendation that, ’The Department of Health NSW in conjunction with relevant nursing bodies establish a new category of trained nurse, that is a Women’s Health Nurse to provide gynaecological preventative health services as well as educational and counselling services for well women’...the report stated....’the committee believes that suitable trained nurses are capable of developing an independent practitioner role in delivery of preventa tive health care to well women and that’ specially trained nurse practitioners could offer a cost effective and accessible service for well women’. The diversity of the service provided is unique and ranges from: pap smears and pelvic examinations breast checks and teaching Breast Self Examination (BSE) -
-
-
-
-
~
-
-
contraceptive advice diaphragm fitting pregnancy testing, counselling and referral menopause information Sexually Transmiteed Disease (STD) screening and education
sexuality and sexual difficulties A report (Reynolds and Foote, 1990) entitled ‘Women’s Health Nurses Evaluation - A Survey of Sydney Metropolitan and Rural New South Wales Clients’ published in March 1990 by the Department of Health NSW demonstrated an extraordinarily high level of satisfaction with the women’s Health Nurse services. In the far west region ofNSW 24% ofwomen surveyed were aged between 40 and 59 years, 18% of women surveyed who consulted with a women’s health nurse sought advice/assistance on menopause. The survey also revealed that 54% of these women had visited their general practitioner in the previous 6 months. This would indicate there is an active role for women’s health nurses in menopause education. -
a
high priority.
until 1981, that all married women were engage in paid employment by unions in permitted Broken Hill. This was only achieved following legal action against the unions by the Anti-Discrimination Board. It is widely recognised that those who are unemployed or socially disadvantaged achieve a lower standard of health than those who are not disadvantaged. Promoting awareness and raising self-esteem amongst women in such communities is indeed challenging. It
was not
to
Royal Flying Doctor Service The Royal Flying Doctor Service is responsible for primary health care in the huge area surrounding Broken Hill. The size of this region is 640,000 square kilometres and it encompasses 3 states, ie Queensland, South Australia and New South Wales. The area covered is approximately the size of England and Wales but with a sparse population of 7,000 (excluding Broken Hill). Routine clinics are conducted at outlying properties and bush hospitals. When travelling on Royal Flying Doctor Service aircraft one is restricted with how much educational resources and equipment one can take. On a routine clinic flight there may be 8-9 personnel on board. Health professionals such as dentists and their assistants carry equipment weighing 50 kilograms. Medical practitioners with the Service with whom I visit
179 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
1. ~ .... ’-’,k &dquo;II
A-A.
’&dquo; &dquo;&dquo;’-.~&dquo;&dquo;&dquo;&dquo;~.l&dquo; ........ ,&dquo;&dquo;,4..
&dquo;I:
attention is given also to the lack of specialist and paramedical services. Structural changes will be needed in education and innovative programmes must be designed to remove disincentives and provide professional support’ (Department of Community Services and Health, 1991). This same high case-load also means there is little or no time available to update on advances occurring in the treatment of symptoms occurring in
menopausal women. Opportunities now exist for greater utilisation of Women’s Health Nurse Practitioners, in conjunction with medical practitioners, to address this service gap. For the 72% of Australians who live in urban societies, it is
difficult, if not impossible,
to fully comprehend the isolation faced by a woman in remote areas of Australia. If domiciled on a station property, a woman may not be able to discuss her anxieties with another woman as she may be the only woman on the property and is required to perform many roles, ie housewife, labourer’s cook and teacher for her children. Being confronted with a multitude of responsibilities her own health is regulated to a low priority and often will not be considered until a crisis develops. Therefore, it is not surprising that attention to gynaecological problems is often delayed due to the pressure of performing many tasks necessary for daily existence in the outback and the vast distances that have to be travelled to seek advice. Her next-door neighbour may be 100 kilometres distant and therefore unable to give support. In hard economic times women are more reluctant, and less able, to leave their properties to seek assistance or advice for their health problems as their departure creates a void in the workforce that cannot be filled. Women of the outback do not have access to services and expertise regarding menopause which city women and their
outback clinics
supportive and a positive liaison exists. A joint professional approach to problems encountered by isolated, perimenopausal women is effective in meeting the needs are
general practitioners can access, eg menopause clinics, mammography services, bone density scanning, Hormone Replacement Therapy (HRT) monitoring or alternative therapies. Existing mammography services involve travel of distances of up to 400 kilometres one way on dirt roads or tracks to have screening performed.
~
of these women. When undertaking a clinic in a small, remote
Combating the Disadvantages
township on the Darling River, the examination couch consisted of a mattress on the floor and the cervix was visualised by a small torch held in my mouth. This technique is not recommended for practitioners’ backs nor for 2-way communication with clients. Restriction of equipment means there is no room for items such as angle poise lamps and video apparatus.
Communications are still limited in outback New South Wales. Many stations still do not have a telephone and are dependent on ’Radphone’. Radphone allows the HF radio to be manually ’patched’ via the Royal Flying Doctor Service radio base through to the telephone system. As the radio frequency is common to all users, no privacy is available. Those who do have telephones often have party lines which are renowned for their unreliability. Isolated women access each other in between the medical and ’Radphone’ sessions of the Royal Flying Doctor Service by talking on the HF radio. These sessions are known as ’Galah Sessions’, which is perhaps an unfortunate nickname for such avalued form ofcommunication. Disadvantages of this form of communication is lack of privacy, lack ofclarity (due to weather conditions) and limited availability.
Treatment in Rural Areas
Many medical practitioners in rural and remote areas of Australia have excessive workloads which do not allow adequate time for counselling of menopausal patients. ’Doctors and nurses work under extreme pressure in smaller and more remote communities, often having to cope with serious problems on a day-to-day basis, inadequately trained, supported and rewarded. Too little 180
Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
How does one discuss dry vaginas and the like with an audience
’Change of Life’
of unknown proportions possibly listening. Resource material such as books, pamphlets and videos may be distributed on a weekly basis via the flying postman or mail truck runs - with the distance from postbox to the front door being up to 5 0 kilometres on dirt roads which become impassable in wet weather. One method of combating the disadvantages of the isolation
When conducting well women clinics I have enquired of several aboriginal women if they have experienced or are experiencing problems with the ’change of life’. Most respond in the negative followed by an incredulous ’why do you ask?’. Menopause is regarded as a normal stage in an aboriginal woman’s life. In the aboriginal communities in which I have worked, relief from the problem of unplanned and unwanted pregnancies is viewed as a positive aspect of
these wnmen htre x tn nmvicit- mnre htre-to-htre contact with health
menopause. Another
factor to be considered is that the life of expectancy aboriginal women is significantly less than that of European women. This may also explain why few aboriginal women appear to experience symptoms of menopause.
professionals. This will hopefully reinforce health education and motivate those women to develop their own support groups. The population pyramid is that of a community which is ~ midway between ’young’ and ’ageing’, ie perimenopausal. As the above graph demonstrates a significant proportion of women could be classified as pre-menopausal. In the Orana and far west region of NSW the aboriginal population comprises 4,811 women (1986 census). These aboriginal women are an integral part of extended families and there does not appear to be any relevance in the ‘empty nest’ syndrome, whereas (Thomson, 1990) ’Western cultures are youth-orientated and age denying, middlescent women experience a loss of identity and inner conflict at menopause when facing the loss of their reproductive ability’ (Morse, 1990). With Koori women, age is equated with wisdom, so a ’wise old woman’ attains a high community profile while a non-aboriginal woman may be referred to as a ‘silly old woman .
and varied educational resources are utilised on various aspects of the menopause. Menopause educational kits are offered to women in outlying areas. Included in these kits are videotapes which I have found to be most useful particularly if the woman’s partner and family (if appropriate) are encouraged to share the viewing. In isolated situations where there is little media input, this method appears to promote greater understanding and support
Many
181 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
Contraceptive advice may still be required and this is an important factor not to be ignored. Also included in educational programmes on ’Women’s Health in the Middle Years’ (Bennett et al, 1985) are modules on: for the woman.
~ ~
~ ~
Menopause Sexuality Breast self examination and breast cancer Pap smears and cancer of the cervix
Osteoporosis Nutrition and weight management Exercise Stress management Self-esteem and confidence building How to talk to health professionals
~
~
Hospital for colour slide printing. References
i, .>.&dquo;
~
~
Kate Lohse, Artist, Broken Hill for the title page, and Glenys Grant, Clinical Photographer, The Royal Victorian Eye & Ear
’
~
~
ACKNOWLEDGEMENT
BENNETT D, CAHN T, EVERINGHAM F and DEGELLING D (1985). Womens health: the middle years - a manual for educators, Health Promotion Unit, Westmead Hospital, Westmead DEPARTMENT OF COMMUNITY SERVICES & HEALTH (1991). A Fair Go for Rural Health, a national rural health strategy, national rural health conference, Toowoomba, Feb 1992; Canberra,
Act 2601, Aust
Hysterectomy awareness Approaching menopause as a natural life stage provides women with several coping mechanisms and they are in a better position to exercise control over their own health. Group-work in education on the menopause is beneficial for participants but is difficult to organise in remote areas. The effectiveness of ~
MORSE C A (1990). Myths of menopause, proceedings, National Women’s Conference REYNOLDS I and FOOTE P (1990). Women’s health nurses evaluation: a survey of Sydney metropolitan and rural New South Wales, Department of Health, NSW THOMSON C S (1990). 10 year business plan for network operations Royal Flying Doctor Service of Australia (NSW section)
support groups can also be restricted by vast geographical distances and it may not be practical for frequent face-to-face contact to occur.
Disseminating information on issues such as symptoms of menopause and life changes is definitely a challenging one made even more so by the sheer vastness of Australia. Women’s Health Nurses working within a medical framework that already exists, are supplying a value-added service. Consultations are occurring between other health professionals and the community and the well-being of women is being promoted. The advent of women’s health nurses has allowed isolated women access to previously unavailable information on their health. Greater benefits will flow with the provision of education on preventive health to these women.
CONCLUSION The acute needs of women’s health in isolation are being addressed. Although this may meet short term goals, long term strategies with structured educational and counselling programmes will ensure increased advantages to individual clients and a more cost effective and efficient service. Development of such strategies is one of the major challenges facing provision of women’s health in remote areas today. Different avenues must be explored to provide up-to-date and accurate information to women in these areas. The provision of coping skills is essential and must be appropriate for individual needs. As community awareness is raised, support networks will be broadened. Development of initiatives responsive to local conditions and needs must be
encouraged.
>..
In conclusion, I would like to acknowledge the women who challenge of living and working in rural and Australia. It is my privilege to be of assistance to these remote
face the great women.
182 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
Menopause Education in
Judy Thomson, RN, RM, DNE, FCN(Aust), FCN(NSW), WHNP 372 Zebina Street, Broken Hill, New South Wales, 2880, Australia
INTRODUCTION
Menopause Education
Supplying
education on aspects of the menopause to outback of far western New South Wales is one of the most challenging facets in my role as a Women’s Health Nurse Practitioner. Women’s Health Nurses function as primary health care workers by being the first level of contact for women in the community. This contact allows for appropriate referral to occur.
My current role which involves me in menopause education is
women
that of Women’s Health Nurse Practitioner for the far west region of NSW. Being the sole practitioner for such a vast region can be a daunting factor. Clinics for well women are conducted in Broken Hill at the Community Health Centre which is my base in the region. Mobile clinics are carried out at outlying areas which are accessed by flights with the Royal Flying Doctor Service or by vehicle. It is common for the undertaking of outback clinics to involve travel of 600 kilometres per day. By way of comparison it is interesting to note that Broken Hill is a mining town in far west NSW with a population of 24,000. It is situated 1,183 kilometres inland from Sydney and 5 00 kilometres north east of Adelaide. Broken Hill’s rich and colourful traditions associated with mining and trade unionism have ensured that a male dominated society prevails. Unfortunately, issues relating to women have not had
WOMEN’S HEALTH SERIIICES In March 1984, the NSW Government commissioned a review of Women’s Health Services in NSW. From the Women’s Health Policy Review Committee Report September 1985 came the recommendation that, ’The Department of Health NSW in conjunction with relevant nursing bodies establish a new category of trained nurse, that is a Women’s Health Nurse to provide gynaecological preventative health services as well as educational and counselling services for well women’...the report stated....’the committee believes that suitable trained nurses are capable of developing an independent practitioner role in delivery of preventa tive health care to well women and that’ specially trained nurse practitioners could offer a cost effective and accessible service for well women’. The diversity of the service provided is unique and ranges from: pap smears and pelvic examinations breast checks and teaching Breast Self Examination (BSE) -
-
-
-
-
~
-
-
contraceptive advice diaphragm fitting pregnancy testing, counselling and referral menopause information Sexually Transmiteed Disease (STD) screening and education
sexuality and sexual difficulties A report (Reynolds and Foote, 1990) entitled ‘Women’s Health Nurses Evaluation - A Survey of Sydney Metropolitan and Rural New South Wales Clients’ published in March 1990 by the Department of Health NSW demonstrated an extraordinarily high level of satisfaction with the women’s Health Nurse services. In the far west region ofNSW 24% ofwomen surveyed were aged between 40 and 59 years, 18% of women surveyed who consulted with a women’s health nurse sought advice/assistance on menopause. The survey also revealed that 54% of these women had visited their general practitioner in the previous 6 months. This would indicate there is an active role for women’s health nurses in menopause education. -
a
high priority.
until 1981, that all married women were engage in paid employment by unions in permitted Broken Hill. This was only achieved following legal action against the unions by the Anti-Discrimination Board. It is widely recognised that those who are unemployed or socially disadvantaged achieve a lower standard of health than those who are not disadvantaged. Promoting awareness and raising self-esteem amongst women in such communities is indeed challenging. It
was not
to
Royal Flying Doctor Service The Royal Flying Doctor Service is responsible for primary health care in the huge area surrounding Broken Hill. The size of this region is 640,000 square kilometres and it encompasses 3 states, ie Queensland, South Australia and New South Wales. The area covered is approximately the size of England and Wales but with a sparse population of 7,000 (excluding Broken Hill). Routine clinics are conducted at outlying properties and bush hospitals. When travelling on Royal Flying Doctor Service aircraft one is restricted with how much educational resources and equipment one can take. On a routine clinic flight there may be 8-9 personnel on board. Health professionals such as dentists and their assistants carry equipment weighing 50 kilograms. Medical practitioners with the Service with whom I visit
179 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
1. ~ .... ’-’,k &dquo;II
A-A.
’&dquo; &dquo;&dquo;’-.~&dquo;&dquo;&dquo;&dquo;~.l&dquo; ........ ,&dquo;&dquo;,4..
&dquo;I:
attention is given also to the lack of specialist and paramedical services. Structural changes will be needed in education and innovative programmes must be designed to remove disincentives and provide professional support’ (Department of Community Services and Health, 1991). This same high case-load also means there is little or no time available to update on advances occurring in the treatment of symptoms occurring in
menopausal women. Opportunities now exist for greater utilisation of Women’s Health Nurse Practitioners, in conjunction with medical practitioners, to address this service gap. For the 72% of Australians who live in urban societies, it is
difficult, if not impossible,
to fully comprehend the isolation faced by a woman in remote areas of Australia. If domiciled on a station property, a woman may not be able to discuss her anxieties with another woman as she may be the only woman on the property and is required to perform many roles, ie housewife, labourer’s cook and teacher for her children. Being confronted with a multitude of responsibilities her own health is regulated to a low priority and often will not be considered until a crisis develops. Therefore, it is not surprising that attention to gynaecological problems is often delayed due to the pressure of performing many tasks necessary for daily existence in the outback and the vast distances that have to be travelled to seek advice. Her next-door neighbour may be 100 kilometres distant and therefore unable to give support. In hard economic times women are more reluctant, and less able, to leave their properties to seek assistance or advice for their health problems as their departure creates a void in the workforce that cannot be filled. Women of the outback do not have access to services and expertise regarding menopause which city women and their
outback clinics
supportive and a positive liaison exists. A joint professional approach to problems encountered by isolated, perimenopausal women is effective in meeting the needs are
general practitioners can access, eg menopause clinics, mammography services, bone density scanning, Hormone Replacement Therapy (HRT) monitoring or alternative therapies. Existing mammography services involve travel of distances of up to 400 kilometres one way on dirt roads or tracks to have screening performed.
~
of these women. When undertaking a clinic in a small, remote
Combating the Disadvantages
township on the Darling River, the examination couch consisted of a mattress on the floor and the cervix was visualised by a small torch held in my mouth. This technique is not recommended for practitioners’ backs nor for 2-way communication with clients. Restriction of equipment means there is no room for items such as angle poise lamps and video apparatus.
Communications are still limited in outback New South Wales. Many stations still do not have a telephone and are dependent on ’Radphone’. Radphone allows the HF radio to be manually ’patched’ via the Royal Flying Doctor Service radio base through to the telephone system. As the radio frequency is common to all users, no privacy is available. Those who do have telephones often have party lines which are renowned for their unreliability. Isolated women access each other in between the medical and ’Radphone’ sessions of the Royal Flying Doctor Service by talking on the HF radio. These sessions are known as ’Galah Sessions’, which is perhaps an unfortunate nickname for such avalued form ofcommunication. Disadvantages of this form of communication is lack of privacy, lack ofclarity (due to weather conditions) and limited availability.
Treatment in Rural Areas
Many medical practitioners in rural and remote areas of Australia have excessive workloads which do not allow adequate time for counselling of menopausal patients. ’Doctors and nurses work under extreme pressure in smaller and more remote communities, often having to cope with serious problems on a day-to-day basis, inadequately trained, supported and rewarded. Too little 180
Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
How does one discuss dry vaginas and the like with an audience
’Change of Life’
of unknown proportions possibly listening. Resource material such as books, pamphlets and videos may be distributed on a weekly basis via the flying postman or mail truck runs - with the distance from postbox to the front door being up to 5 0 kilometres on dirt roads which become impassable in wet weather. One method of combating the disadvantages of the isolation
When conducting well women clinics I have enquired of several aboriginal women if they have experienced or are experiencing problems with the ’change of life’. Most respond in the negative followed by an incredulous ’why do you ask?’. Menopause is regarded as a normal stage in an aboriginal woman’s life. In the aboriginal communities in which I have worked, relief from the problem of unplanned and unwanted pregnancies is viewed as a positive aspect of
these wnmen htre x tn nmvicit- mnre htre-to-htre contact with health
menopause. Another
factor to be considered is that the life of expectancy aboriginal women is significantly less than that of European women. This may also explain why few aboriginal women appear to experience symptoms of menopause.
professionals. This will hopefully reinforce health education and motivate those women to develop their own support groups. The population pyramid is that of a community which is ~ midway between ’young’ and ’ageing’, ie perimenopausal. As the above graph demonstrates a significant proportion of women could be classified as pre-menopausal. In the Orana and far west region of NSW the aboriginal population comprises 4,811 women (1986 census). These aboriginal women are an integral part of extended families and there does not appear to be any relevance in the ‘empty nest’ syndrome, whereas (Thomson, 1990) ’Western cultures are youth-orientated and age denying, middlescent women experience a loss of identity and inner conflict at menopause when facing the loss of their reproductive ability’ (Morse, 1990). With Koori women, age is equated with wisdom, so a ’wise old woman’ attains a high community profile while a non-aboriginal woman may be referred to as a ‘silly old woman .
and varied educational resources are utilised on various aspects of the menopause. Menopause educational kits are offered to women in outlying areas. Included in these kits are videotapes which I have found to be most useful particularly if the woman’s partner and family (if appropriate) are encouraged to share the viewing. In isolated situations where there is little media input, this method appears to promote greater understanding and support
Many
181 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
Contraceptive advice may still be required and this is an important factor not to be ignored. Also included in educational programmes on ’Women’s Health in the Middle Years’ (Bennett et al, 1985) are modules on: for the woman.
~ ~
~ ~
Menopause Sexuality Breast self examination and breast cancer Pap smears and cancer of the cervix
Osteoporosis Nutrition and weight management Exercise Stress management Self-esteem and confidence building How to talk to health professionals
~
~
Hospital for colour slide printing. References
i, .>.&dquo;
~
~
Kate Lohse, Artist, Broken Hill for the title page, and Glenys Grant, Clinical Photographer, The Royal Victorian Eye & Ear
’
~
~
ACKNOWLEDGEMENT
BENNETT D, CAHN T, EVERINGHAM F and DEGELLING D (1985). Womens health: the middle years - a manual for educators, Health Promotion Unit, Westmead Hospital, Westmead DEPARTMENT OF COMMUNITY SERVICES & HEALTH (1991). A Fair Go for Rural Health, a national rural health strategy, national rural health conference, Toowoomba, Feb 1992; Canberra,
Act 2601, Aust
Hysterectomy awareness Approaching menopause as a natural life stage provides women with several coping mechanisms and they are in a better position to exercise control over their own health. Group-work in education on the menopause is beneficial for participants but is difficult to organise in remote areas. The effectiveness of ~
MORSE C A (1990). Myths of menopause, proceedings, National Women’s Conference REYNOLDS I and FOOTE P (1990). Women’s health nurses evaluation: a survey of Sydney metropolitan and rural New South Wales, Department of Health, NSW THOMSON C S (1990). 10 year business plan for network operations Royal Flying Doctor Service of Australia (NSW section)
support groups can also be restricted by vast geographical distances and it may not be practical for frequent face-to-face contact to occur.
Disseminating information on issues such as symptoms of menopause and life changes is definitely a challenging one made even more so by the sheer vastness of Australia. Women’s Health Nurses working within a medical framework that already exists, are supplying a value-added service. Consultations are occurring between other health professionals and the community and the well-being of women is being promoted. The advent of women’s health nurses has allowed isolated women access to previously unavailable information on their health. Greater benefits will flow with the provision of education on preventive health to these women.
CONCLUSION The acute needs of women’s health in isolation are being addressed. Although this may meet short term goals, long term strategies with structured educational and counselling programmes will ensure increased advantages to individual clients and a more cost effective and efficient service. Development of such strategies is one of the major challenges facing provision of women’s health in remote areas today. Different avenues must be explored to provide up-to-date and accurate information to women in these areas. The provision of coping skills is essential and must be appropriate for individual needs. As community awareness is raised, support networks will be broadened. Development of initiatives responsive to local conditions and needs must be
encouraged.
>..
In conclusion, I would like to acknowledge the women who challenge of living and working in rural and Australia. It is my privilege to be of assistance to these remote
face the great women.
182 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 14, 2015
