Health and Welfare Needs of Remote Area Women in the Northern Territory

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Health and Welfare Needs of Remote Area Women in the Northern Territory

Diane J Clark
Training Development Officer, Local Government Industry Training Advisory Board, NT

Keywords

rural women, health and welfare

Article Text

Health and Welfare Needs of Remote Area Women in the Northern Territory

At the recent International Conference on Issues Affecting Rural Communities (Townsville) Alston (1994) drew attention to the many issues faced by rural women. These issues are not peculiar to farm women in New South Wales but are faced by their counterparts throughout the rural and remote areas of Australia. This paper aims to report on a study conducted into the health and welfare needs of women living in remote areas of the Northern Territory (Clark, 1991) and to highlight the similarities in the needs of these women to those of women living in other rural areas of Australia.

A study carried out in 1991 for the Northern Territory Women's Advisory Council aimed to investigate the health needs of remote area women. Specific goals were to discover why women come to town for their health care, their perception of service delivery and to identify the gaps in services and resources either in town or in their locality.

Study Method

A questionnaire was devised to gather information from rural and remote area women. Considerable controversy abounds as to what constitutes rural and remote, so the study population was defined as those areas commonly recognised as rural, excluding the five main regional centres of the Territory.

1,898 questionnaires were circulated either directly to women or to distribution points at health centres, councils or resource centres. It is not known how many were distributed from these points but 360 usable questionnaires were returned, giving an overall response rate of 19% based on the potential distribution.

An aim of this study was to give as many women as possible the chance to contribute their views, so the study was widely promoted throughout the media and rural networks. In addition the author made personal contact with women and service providers at a number of places throughout the Territory. Women were generous with their time and responses, generating a considerable amount of information. The full results of the research are contained in a report (Clark, 1991) to the NT Women's Advisory Council.

Findings

Questionnaires were analysed to provide a picture of the background of the women and their health and welfare needs. Respondents came from all regions and sectors of the Territory as shown in Table 1.

Table 1. Responses to the questionnaire by sector and locality
Locality	n	Darwin	Katherine	Alice Springs	Barkly	East Arnhem	Not Specified
Pastoral Property	97	12	32	31	18	Nil	4
Aboriginal Community	82	26	13	26	4	10	3
Mining Town	29	8	11	Nil	Nil	6	4
Small Town	35	6	26	2	1	Nil	Nil
Roadhouse	14	1	9	1	2	Nil	1
Resort	77	Nil	Nil	77	Nil	Nil	Nil
Other*	26	9	5	10	1	Nil	1
Total	360	62	96	147	26	16	13
* research farms, police posts, fishing camps and in national parks

An idea of the potential isolation from medical and other support services was gained by questions related to distance from the health centre and nearest neighbour and access to a telephone or other means of communication such as HF radio. Table 2 shows that just over half the women live within 10 km of a community health centre and two thirds have a neighbour nearby. Only one third live within 200 km of a regional centre but 81% have access to a telephone. This may not be a private facility but could be a public call box or located at the Council or employer's office. Some respondents had access to more than one form of communication.

Table 2. Characteristics indicating the relative isolation of women in this study
Distance from health centre	Rounded %	n
On Community	60	210
10 - 200 km	28	99
201 - 650 km	12	43
Nearest neighbour
On Community	70	241
10 - 100 km	28	98
101 - 400 km	2	8
Distance from regional centre
< 200 km	31	106
> 200 km	69	236
Access to communications
Telephone	81	286
Radio Telephone	12	31
Radio Contact	25	62

Anecdotal evidence from service providers revealed that people leave the Territory when they retire to move to urban areas where services are more readily available. Certainly the statistics reveal a young population and women did comment on the unavailability of sisters and mothers to provide support during childbirth or other family events and crises. People with disabilities also reportedly move out of the Territory in search of better services. Only 8% of the respondents had a disability or chronic illness and only 10% care for an aged or disabled person. Tables 3 to 7 show other characteristics of the respondents including age, employment and marital status compared with the 1986 ABS census data and a study of rural women conducted by the Country Women's Association of Australia and the Office of the Status of Women in 1988 (OSW/CWA).

Tables 3-7. Characteristics of respondents to the 1991 survey.

Table 3. Age of respondents
	1991 Survey	1988 Survey*	ABS Census 1986
15 - 19	3%	NA	NA
20 - 29	38%	8%	24%
30 - 39	36%	16%	24%
40 - 49	17%	17%	16%
50 - 59	3%	20%	13%
60 - 69	2%	30%	17%
Over 70	< 1%	9%	6%
*(OSW/CWA, 1988)

Table 4. Marital Status*
	1991 Survey	1988 Survey	ABS Census 1986
Partner or spouse	79%	73%	61%
*survey did not distinguish between defacto, divorced or widowed status

Table 5. Cultural Heritage
	1991 Survey	1988 Survey	ABS Census 1986
Aboriginal	1.4%	1.6%	3%
Australia	86%	88%	86%
Other (mainly UK & NZ)	13%	10%	9%

Table 6. Children in household
	1991 Survey	1988 Survey
Nil	44%	5%
1 - 2	44%	45%
3 - 5	13%	15%

Table 7. Employment Status
		1991 Survey	1988 Survey
Home duties		31%	53%
Employed		61%	44%
as:	Teacher	23%
	Nurse	5%
	Hospitality & Tourism	28%
	Pastoral	7&
	Retail	5%
	Other	32%
Student		< 1%
Pensioner		1%	35%
Other*		6%
*includes mothers supervising School of the Air

Availability of services

Women reported that the health service available to them was very basic. Table 8 shows the percentage of respondents who can obtain health care either at a health centre staffed by community nurses (CHN) and / or Aboriginal health workers (AHW) or through a visiting service. For 23% of women the only readily available medical service is an emergency service provided by the aerial medical or Royal Flying Doctor service.

Table 8. Services available in the immediate locality (community, town property, other)
Service		Visiting Services
	Resident	Regular*	Sometimes^	Never	Don't Know
Aboriginal Health Worker	53%	3%	2%	53%	42%
Community Health Nurse	64%	48%	18%	23%	12%
Doctor	35%	60%	6%	25%	9%
Welfare Officer	12%	8%	5%	47%	40%
Dietician	3%	2%	5%	56%	37%
Physiotherapist	4%	6%	7%	50%	37%
Occupational Therapist	2%	2%	5%	56%	37%
Dentist	8%	29%	22%	28%	21%
26% of respondents received none of these services
*Regular means weekly, two weekly, monthly or six weekly
^Sometimes means visits more than 6 weeks apart or irregular

A sad fact not revealed by this table is that while allied health professional services (eg physiotherapy) form part of the rural services team in each region they are badly understaffed and their visits are not well advertised. Women tend to obtain specialist medical care, allied health and community services by visiting professionals in main centres. When women were asked where they usually go for health care, it was found that just over half of the respondents consulted a doctor in a regional centre, despite the fact that 60% apparently receive a regular visit by a medical officer to their area.

Such findings are consistent with those of Alston (1994) who states that 'doctors are not attracted to rural practice . . . much of rural Australia lacks even basic health servicing. Enhanced services such as counselling, speech pathology, physiotherapy, mammography screening may be hundreds of kilometres away at the nearest regional city'. If this is true of rural Australia generally it is doubly so in the remote areas, where even the regional towns are small and chronically under serviced. Consequently consultations with health and welfare professionals and counsellors, other than medical practitioners, are rare.

Travel and accommodation

Since the service available to women in remote and rural areas is so basic many have to travel to obtain health care in the nearest town or regional centre. More than half (58%) of the respondents needed to travel to obtain health care and less than quarter (22%) received any financial assistance towards their transport and accommodation costs. Transport problems, mainly cost, prevented 25% of the respondents from obtaining needed health care and 24% reported difficulties with transport. Table 9 shows the difficulties encountered.

Table 9. Main transport difficulties experiences by respondents
Difficulty	%	n
Cost	17	10
Personal pain/ sickness/ discomfort	16	9
Bus/plane schedules mean extra night away	12	7
Impassable roads	10	6
Access to vehicle	9	5
Vehicle broke down/unroadworthy	9	5
Lack of access to or support by Aid Med	5	3
Weather conditions	2	1

Accessing health care in town often means that a family must stay overnight adding to the expense. Only 1% of respondents felt that accommodation problems had prevented them from obtaining health care when it was needed but 61% complained that the cost was a very real problem. In view of the continuing economic crisis in rural areas it is anticipated that financial considerations would be no less of a problem in 1994/5 than they were in 1991, when this survey was conducted.

Major Needs

Women were also asked to identify their needs in health and welfare services. 58% of women answered this section of the questionnaire. Table 10 shows the priorities of all respondents irrespective of background or locality.

Table 10. Major needs identified by respondents
Need	%	n
Access to low cost family accommodation with cooking facilities, close to hospital	45	94
Access to information on: - local schedules and venues of visiting services - services available in main centres - health education literature and videos	28	60
More frequent visits by doctors and all health professional to local health centres and by mobile patrol	26	55
A telephone counseling service as a step towards gaining information or making contact with counsellors	21	44
A home help service for emergencies	20	40
Better financial assistance towards travel and accommodation costs	9	18

It is evident that the health service available to women in remote and rural areas is very basic. Conditions requiring regular therapy or treatment and preventative health care necessitate a trip to town. This involves considerations greater than those facing women living in urban areas. Some examples of considerations relating to transport alone have already been outlined in Table 9. Discussions with women and service providers, in addition to information from the questionnaires, revealed a range of views about the accessibility of services to bush women and their families. This is not surprising considering the vast geographic and climatic area from which the sample was drawn.

Constantly changing policy and delivery strategies on the part of the service providers aggravate the situation and contribute to high staff turnover and a poor perception of the service by its clients. What is surprising is that women are remarkably tolerant of the situation and have realistic priorities about what could be made available to them. Next to the provision of low cost family accommodation close to hospitals, women wanted access to good quality information to aid them in reaching decisions about health care for themselves and their families.

Information and education

Women may be restricted in accessing services because they are not adequately informed of the times and venues of visiting health professionals. Some allied health, welfare and dental professionals visit remote health centres on an ad hoc basis. Their services are available to everyone in the community and surrounding area but they are not well advertised. Even the women living at the community visited by the professionals felt that they had little information about expected visits. Station women often found out that the dentist or other professional had been to the local health centre after the visit or when it was too late to make an appointment. Appointment diaries are filled very quickly with clients known to the health centre staff and the visiting professionals work to a tight schedule.

Local health staff are not always able to advertise visits in advance because they are not given sufficient notice to take advantage of community newsletters and local advertising channels. Costly trips to town could often be avoided and remote area clinics better utilised with more forethought and forward planning.

Limited access to health services plus the lack of choice of doctor prevents some women from obtaining the care they need. Ide (1986) noted of South Australian country women, that 'it is difficult to get follow-up treatment, advice on and supplies of contraceptives when required, as well as pregnancy support. . . . Some country towns only have one doctor and no woman doctor'. Women in this study also expressed the need for a woman doctor and access to counsellors skilled in a range of issues. They also requested literature, seminars and workshops where they could obtain more information about women's and family health in order to make informed decisions about accessing care not readily available to them in the bush.

An Aboriginal service

Another barrier to accessing the service is the strongly held perception that the rural health service is for Aboriginal people and that community nurses and doctors only see non-Aboriginal people 'out of the goodness of their heart'. Although this is only a perception it represents a very real barrier to a number of women, who commented on their reluctance to approach busy nurses and medical officers with any condition other than an emergency. Concerns relating to child development or their own health were often not voiced for fear of appearing neurotic. Women felt their problems were both trivial and trivialised against the considerable health needs of Aboriginal people.

Some service providers agreed that there is a basis for this perception because of the huge health problems of Aborigines. One nurse, sensitive to the situation, admitted that she had given short answers to concerned new mothers when faced with a long queue of very sick Aboriginal children at an infant health clinic. Expecting women 'to cope' in difficult, stressful and isolated situations is not the answer and is an attitude that may deter less confident women from seeking much needed health care. There are no easy solutions but the problems must not be swept aside.

Staff turnover and attitudes

Medical officers servicing the rural health centres change frequently and are often young and inexperienced. Women commented on the lack of knowledge and insensitivity to women's' health concerns by some young doctors. It takes time to build the rapport necessary for an effective client-doctor relationship in this sensitive area, so it is important that remote area medical officers take the time and interest to be responsive to women's' health issues.

Interviews with service providers indicated that the district medical officers did not always regard themselves as 'GPs'. They prefer remote area women to identify a family doctor in a regional centre and access preventive health care when in town or on holiday. Where money is short and holidays an infrequent luxury this is not an option. Women commented that it is not easy to take time off from work or home duties to visit town for anything but emergency care. They also felt that this method did not provide any avenue for follow-up or continuity of care.

Women said they would prefer to obtain pap smears, treatment and advice from a mobile women's health service, staffed by skilled professionals, similar to the mobile cancer screening and education clinic operating in Western Australia (Farr, 1986). This service has provided a successful option, creating access to women's' health services and better overcoming the problem of limited choice of medical practitioner.

A better local service

In addition to the need for information on services and schedules, women also wanted a better local service so they can access a wider range of health professionals and counsellors. If a better local service could be achieved remote area women would not have to travel to town so often for health care. Nevertheless there will still be occasions when consultations with specialists and hospitalisation are necessary. When this occurs women identified the need for better financial assistance, under the Patient Assisted Travel Scheme (PATS), for costs incurred.

Accommodation

Hospitalisation causes considerable stress to families living in remote areas due to the distances involved. Family disruption is further aggravated because regular visits by family and friends are not economically possible. Terminally ill patients and their families experience great additional suffering when economic considerations are added to their other problems. Mothers accompanying child patients face the additional stress of coping with a sick child alone. Other children may have been left at home, which is also a cause for concern because child-care facilities are sadly lacking in remote areas. Antenatal women face at least two weeks in town prior to the birth; a lonely and traumatic time, especially for first time mothers.

Respondents to this study expressed similar views to those of Schaeffer (1985) who stated that South Australian country women felt that 'good quality low cost family accommodation close to the hospital' is a priority. Women also identified the need for good support services to be available to women coping alone in these situations.

Child-care

Remote area women also felt disadvantaged by the lack of child-care facilities. They expressed concern if they have to leave their children with their partners because they felt that the latter were less careful of the children, especially when pre-occupied with work. An alternative was to take the children to town with them and attempt to find child-care there. Most urban child-care facilities are full and their emergency places soon taken up. Remote area women face tiring days in town, minding excited children as well as conducting the business which brought them there in the first place. If a doctor's visit is involved, they may be forced to take the children with them or cancel the appointment. The latter option is often taken, especially for routine or preventative health care.

Solutions

Certainly there are no easy solutions to the tyranny of distance and a sparse population, neither is there any doubt that 'women in rural areas face serious problems maintaining an adequate standard . . . of health care for themselves or their families' (Alston, 1994). The women in this study felt strongly that their health service was deficient, particularly in the areas of prevention, education and counselling. Support services for the aged and disabled are minimal and the regular medical service is not as accessible as service providers would like to believe. Nevertheless women accepted that they cannot have all the services that are available in urban areas. They did, however, believe they should have an equitable service and offered innovative, relatively low cost strategies which could drastically improve health service delivery to remote areas.

Women respondents to this survey identified the following strategies to improve health and welfare service delivery:

Medmail, a health promotion and education service for women, providing informational material by mail, should be re-instated
A service directory for regional centres and local health centres should be prepared
A toll-free counselling service for the rural areas should be established
Multidisciplinary mobile teams to provide preventive health care and health education should be formed
Low cost family accommodation, with child-care facilities, close to the hospital in each regional centre, should be provided
The need for an equitable level of financial assistance to rural people seeking health care in town needs to be addressed.

Outcomes

It is encouraging to report that the Northern Territory government has implemented a number of these strategies:

Women's Info-net: an innovative service which incorporates the Medmail concept with toll-free telephone information and counselling service for all women in the Territory. This service has also actioned the preparation of a service directory.
Low cost accommodation close to the hospital has been identified for most of the regional centres.

These initiatives are timely and welcome and it is to the credit of the Northern Territory Women's Advisory Council that these issues have been identified and that action has been successfully taken on behalf of remote area women. Nevertheless there is still a long way to go if remote area women are to enjoy a health service equitable with that of their urban counterparts. Reports show that rural and remote women throughout Australia have similar needs; a fact which must strengthen their voice and support their case to redress these inequities. That they are active in identifying and gaining cost efficient options to meet their needs should also be noted and promoted in order to gain on-going support to deliver health services to the bush.

Acknowledgments

I wish to thank the Northern Territory Women's Advisory Council for permitting the preparation of this paper from the commissioned report and all the women who contributed their views to the investigation.

Aspects of this paper were based on a presentation to the Public Health Association Conference held in Alice Springs, 30 Sept - 2 Oct 1991.

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References

Alston, M. 1994. Meeting the needs of rural women. Paper presented to the International Conference on Issues Affecting Rural Communities, Townsville.

Clark, D. 1991. A Study of the Health and Welfare Needs of Women Living in Remote Areas of the Northern Territory. Report prepared for the Northern Territory Women's Advisory Council, Darwin.

Ide, M. 1986. Caring for the health of isolated women National women's health conference: Women's health in a changing society Proceedings vol 2.

Farr, V. 1986. Preventive health care for isolated women National women's health conference: Women's health in a changing society Proceedings vol 2.

OFS/CWA (Department of the Prime Minister and Cabinet, Office of the Status of Women and the Country Women's Association of Australia). 1988. Life has never been easy Canberra: AGPS.

Schaeffer B. 1985. The isolation of country women Bulletin of the Australian Federation of University Women 24.

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