WOMEN'S HEALTH SERIES VOLUMES
Lifestyle changes and their impact on the health of women in the Western Pacific Region
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World Health Organization Regi(mal Office for the Western Pacific Manila 1995
Copyright © World Health Organization 1995 This document is issued by the World Health Organization - Regional Office for the Western Pacific (WHOIWPRO) for general distribution. All rights are reserved. Subject to due acknowledgement to WHOIWPRO, this document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole; provided that such is not done for or in conjunction with commercial purposes and provided that, if it is intended to translate or reproduce the entire work, or substantial portions thereof, prior application is made to the Maternal and Child Health Unit, WHOIWPRO, Manila, Philippines. The views expressed in this document are those of the principal contributor and do not necessarily reflect the policies of the World Health Organization.
Map of the WHO Western Pacific Region
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Contents Foreword Acknowledgements Introduction Changing lifestyles Modernization and its effect on health What do we moon by "lifestyle"? Agency, structure and lifestyle choices Lifestyle and hoolth promotion Lifestyle and heolth: a global and regional context Lifestyles and women's health The Situation in the Western Pacific Region Noncommunicable diseases Changes in fertility rates and child-bearing and child-rooring patterns Women in the labour force Education Nutrition Other lifestyle factors27 Conclusions and recommendations Appendix - Aspects of health policy
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3 3 4 5 6 7
9 13 13
23 24
26 26 29 31
Appendix 2 - Health promotion and nutrition Bibliography
37 41
Foreword Significant economic and social changes have occurred in the Western Pacific Region since the end of the Second World War. These changes have occurred at different rates across and within the countries of the Region, but the impact on women's health has been universal. The processes of industrialization and urbanization, and the declining influence of family ties have had both positive and negative effects on women's lives. Economic development is usually associated with changes in morbidity and mortality patterns. The demographic transition from high birth and death rates to low birth and death rates is accompanied by a reduction in infectious diseases largely caused by improved sanitation and better nutrition. However, in some countries, these gains are offset by the increase of noncommunicable diseases - the so-called 'diseases of affluence' - such as cardiovascular diseases, diabetes mellitus and cancers. While female babies display a biological advantage over male babies at birth, and though women continue to live longer lives than men, age-specific mortality data show that women's health becomes increasingly susceptible to lifestyle and environmental factors at older ages. After the child-bearing years,and more so after the age of 65 years, differentials in male and female mortality from noncommunicable illnesses narrow and are less consistent and pronounced. This monograph explores a range oflifestyle changes and their implications for the health status of women in the Western Pacific Region. These include the factors that lead to the increased incidence of noncommunicable diseases among women, changes in fertility rates and child-beafing and child-rearing practices, the increased participation of women in the labour force, changes in education and nutrition, and the increase in risk-taking behaviour in some societies.
Lifestyle changes and their impact on the health of women in the Western Pacific Region is one of a series of reports on women's health prepared in anticipation of the Fourth World Conference on Women to be held in Beijing, China, in September 1995. It is hoped that this series will help to identify where and how improvements in women's health can be made, and provide a stepping stone to future programmes that address the needs of women in the Region.
S.T. Han, MD, Ph.D. Regional Director
Acknowledgements We would like to thank the principal contributor to this monograph, Dr Elizabeth Eckermann, Director, Centre for the Body and Society, School of Social Inquiry, Deakin University, Australia
VIII
Introduction
The globalization oflaws and covenants that protect women from exploitation and abuse have had several positive effects for women, including universal suffrage, human rights and cJtizenship rights such as the right to own property and equal opportunity in the workplace (Cook,1993; Hausermann, 1993). Similarly, the gaining of national independence from colonial powers has significantly improved the status of women in many countries in the Region, with women often being instrumental figures in nationalist movements and in setting up national administrations.
However, the gains made by women have not always been linear and progressive, and developments since 1945 have also brought hazards to the health and welfare of women. The globalization of risk (Beck,1992) from environmental pollution, changed consumption patterns and global epidemics such as AIDS, and the occupational hazards (mcluding physical and mental illness and the breakdown oftraditionaI social structures) produced by urbanization and industrialization, have significantly affected women's physical, psychological, emotional and social well-being.
Lifestyle changes and their Impact on women's health In the Western Pacific Region
In times of economic recession, gains made by women in terms of economic and political rights are jeopardized, women continue to be the victims of both public and domestic violence, and women's health status in terms of morbidity levels and quality of life continues to be worse than men's.
Women in the Region continue to have low levels of participation in senior management and in governance. Many cultural and traditional aspects of lifestyle affect women's health in a variety of ways.
Changing lifestyles
Modernization and its effect on health Modernization has had varying effects on the health status of populations throughout the Western Pacific Region. The change from high fertility and mortality rates (largely. from gut and respiratory infections) to low fertility and mortality rates has been seen as cause for celebration. However, in some countries, the health gains from a reduction in infectious diseases have been offset by a significant rise in debilitating and disabling I chronic diseases. High mortality has been replaced by high morbidity and disability rates caused by the so-called 'lifestyle diseases' of 'ischaemic heart disease, cancers of the lung, colon and breast, non-insulin dependent diabetes, smokinginduced chronic lung disease and injury from car smashes' (WHO, WPRO, 1991)' 'Although their impact was first felt in the countries now industrialized, this impact is now global', with the prevention of noncommunicable diseases
'becoming a rrugor public health policy issue in developing countries as well'. However, the extent to which the decline in infectious diseases is offset by a rise in 'lifestyle diseases' varies considerably across the Region and between the sexes. Epidemiological research also suggests that 'not all noncommunicable diseases tend to increase with modernization: some tend to decrease'. For example, in 1991, the technical discussions on Changing Lifestyle and Health held by WHO Regional Office for the Western Pacific in Omiya, Japan, reported that the incidence of some cancers, such as those of the stomach, cervix, mouth and tongue, typically fell with modernization, whereas the incidence of cancers of the lung, breast, colon, rectum and pancreas tended to rise. Ischaemic heart disease, chronic obstructive hmg disease, non-insulin dependent diabetes mellitus and transport injuries also tended to increase, whereas the frequencies of stroke, liver cirrhosis, peptic ulcers and suicide had a variable relationship to modernization, largely
Lifestyle changes and their impact on women's health In the Western Pacific Region
related to baseline incidence and prevalence rates (WHO, WPRO, 1991). It has been argued that there are two phases of modernization, with 'mature industrialism' being more benign than 'early industrialism' in relation to health outcomes as a result of 'a reduction in smoking prevalence in men and the move to a lighter more varied diet' (WHO, WPRO, 1991). Thus it could be speculated that the long-term effects of modernization would in fact be a reduction in cardiovascular disease. However, 'trends in cancer mortality have generally been less favourable than the trends for cardiovascular diseases' (WHO, WPRO, 1991). Recent trends revealing increased incidence of lung cancer in women and continued high levels of breast cancer (Australian Bureau of Statistics (ABS), 1994) suggest no decline with modernization. Injuries, especially from alcohol-related road accidents, continue to be a major source of 'person-years of life lost', given the ages of those injured and killed.
What do we mean by "lifestyle"?
The term "lifestyle" has many connotations. Its use in the context of health can relate to choices by the individual, or the social structure that restricts or determines the choices that the individual can make. Sociologically, "lifestyle" has been used by Weber (1968) and Rojek (1985) to connote the 'distinctive style of life of particular status groups' (Featherstone, 1987). In other words, lifestyles act as a signifier of status and as such are determined by one's structural and social position. Very little free choice is involved. More recently, especially in the cultural studies literature, "lifestyle" has been viewed within the 'contemporary consumer
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Changing lifestyles
culture' context as connoting 'individuality, self-expression and a stylistic self-consciousness' (Featherstone, 1987). Whether one adopts a structurally and socially detennined approach to lifestyle or a 'free choice' approach (which views the individual consumer as an independent agent), has signicant implications for understanding social change and for developing health promotion strategies. Should health promotion campaigns target the individual, or should they address the structural and social forces that construct class and status groups and constrain the associated 'lifestyles'? Or can both approaches be combined as in the Ottawa Charter's (1986) catchcry, 'make healthier choices easier choices'?
food, housing, location, clothing, health services, water quality, leisure activity, thus their 1ifestyle', choices are limited. The strategies appropriate for dealing with lifestyle-generated ill-health in the case of poverty are obviously structurally oriented. Lifestyle choices are also influenced by social and cultural imperatives. CulturaIly-conditioned food preferences, child-birthing practices, domestic activities and hygiene regimes may help or hinder health status. For example, 'shugendo', a traditional religious lifestyle in Japan, involves ascetic eating and exercise regimes that closely parallel the prescriptions for health promoted in current public health campaigns, including low fat, low sugar diets and extensive running and walking (ltogo et al.,1994). In contrast, traditional-birthing practices used in parts of the Lao People's Democratic Republic and Cambodia include withholding nutritrious food from the mother after she has given birth, which can have serious deleterious effects on the health of mothers (Rice, 1994). Similarly, a cultural tradition of using smoky coal in domestic cooking in Xuan Wei County in China contributes to very high levels of lung cancer among the women in these communities (Sims, 1994).
Agency, structure and lifestyle choices Individual actions inevitably involve choice, but in many cases choices are severely constrained or circumscribed by structural factors. People living in poverty can choose to live or die, but other choices in their lives are severely constrained by lack of resources. Their
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Llfe"tyle change" and their Impact on women's
health In the Western Pacific Region
Lifestyle and health promotion The market is continually creating new opportunities for lifestyles and choices. This expansion of choices has increased the complexity of making rational and informed decisions to protect health, since behavioural factors and lifestyle contribute substantially to the main causes of death worldwide, such as heart disease, diabetes, cancer, AIDS and suicide. Consequently, knowledge about health and a capacity for selfcare become increasingly important (WHO, 1994a).
unhealthy products or services must not be overlooked. It cannot be assumed that people will make what economists call 'rational choices' that serve their health interests when faced with information about the harmful effects of certain behaviours (Berger, 1991). The globalization of the consumption of fast-food products (Ritzer, 1993) and the increased consumption of tobacco with increased affluence in some developing countries, are two examples where the removal of poverty does not necessarily lead to healthier lifestyles. This particular problem can be approached by regulating both the fast food industry and the tobacco industry, but such regulation takes time to have an effect and cannot always be total. Educational campaigns aimed at changing behaviours to enhance health are notoriously unsuccessful, as witnessed in AIDS education campaigns and their effect on condom use in the developed countries of the Region (Dowsett, 1994; Lupton, 1994). Anti-smoking campaigns have had some success, but certain groups, especially young women in developed and newly-industrializing countries, are ignoring anti-smoking messages and taking up smoking at an alarming rate (O'Connor and Daly, 1985; ABS, 1994). The association of smoking with weight loss is an added factor here.
An aspiration to 'change lifestyles' in order to 'promote health' has emerged as a dominant theme of public health policy in industrialized countries over the past decade or so. The emphasis has been placed on 'lifestyles' so that the measures thought necessary for the prevention of noncommunicabl~ diseases are clearly distinguished from those used to combat infection, such as ensuring safe water supplies, excreta disposal and immunization. (WHO, WPRO, 1991:10) However, the possibility that, once structural barriers to a 'healthy lifestyle' are removed, individuals may choose to spend their increased resources on
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Changing lifestyles
Some educational campaigns to enhance health may have unintended negative consequences, as witnessed in the epidemic of eating disorders among young women in developed countries, an epidemic that is spreading to the newly-industrializing countries. Several writers on anorexia nervosa suggest that health campaigns that promote messages such as "eat less fat, sugar and salt" may contribute to the epidemic of eating disorders (Ben-Tovim and Morton, 1989; Eckermann, 1994b). All individuals do not necessarily have the same commitment to health as the signatories to the Ottawa Charter or national health authorities. Issues about individual freedom as opposed to the common good are raised. To what extent does an individual 'exercising their freedom to smoke in the workplace jeopardize the health of others? Should doctors be given the right to withdraw their services from individuals who choose to take risks with their health? The New Public Health (Ki'ckbusch, 1986b; Ashton and Seymour, 1988) which represents the application of Alma Ata and the Ottawa Charter (1986) to the public health field, promises a social view of health which acknowledges that health is an intersectoral issue and a social justice issue, Thus provision of adequate
housing, transport, education, income and town planning, alongside community action and participation, are seen as key factors in producing good health, quality of life and well-being as well as enhancing social justice and human rights, The issues are discussed more fully in Appendix 1, Aspects of health policy, and Appendix 2, Health promotion and nutrition,
lifestyle and health: the global and regional context Just as individual wealth may not necessarily lead to better health, so too the improved wealth of the Region and countries within the Region does not necessarily produce better health. The World Health Report 1995 (WHO, 1995) recognizes that 'countries in the (Western Pacific) Region are developing rapidly but economic progress in itself does not necessarily lead to improved health'. The lifestyle choices of particular groups of people have to be placed in a global, or at least a regional, context, because the repercussions of lifestyle choices in one country may be deleterious to the health of individuals in other countries.
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Lifestyle changes and their impact on women's health in the Western Pacific Region
Lifestyles and women's health
Lifestyle-related health conditions were identified by the Global Commission on Women's Health (WHO,J994a) as one area of women's health that can 'realistically achieve future progress'. Lifestyle-related health conditions satisfied the criteria for priority health issues for women on the basis that they: • illustrate the predominant risk factors leading to morbidity and mortality in women of all ages; reflect the type of health problems women face at different periods in their lives; transcend national boundaries; and are amenable to solutions using feasible, low-cost interventions (WHO, 1994a).
such changes on health can be identified, allowing possible lifestylerelated interventions that improve health to be suggested. Acknowledging that lifestyle choices are not made in a vacuum, it was agreed by the participants at the first meeting of the Global Commission on Women's Health that:
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It could be argued that all health and illness experiences are lifestyle-related. It is difficult to separate biological from environmental and social aetiologies in most cases of illness. However, taking a longitudinal perspective, at both individual and societal levels, changes in lifestyle and the potential impact of
TIlls was seen to be the case in a broad range of lifestyle areas from smoking to sexual relations. In the case of tobacco consumption, the specific
Lifestyle changes and their Impact on women's health In the Western Pacific Region
marketing of tobacco products to young women, even in some countries to prepubescent girls, was seen as a cause for major concern. Smoking is often viewed simply as an individual act predisposing one to specific diseases, but tobacco is an addictive substance and the addiction is normally acquired during adolescence. Furthermore, the sharp differences in smoking behaviour among population groups point to the importance of social influences. It may be more appropriate to consider smoking as an individual response to a social environment than to see it as a voluntary lifestyle choice (WHO, 1994a). Similarly, 'choice' in sexual behaviour was seen as being circumscribed by differential power relations between the sexes. Where women are concerned, there may be no "choice" regarding practising safe sex, putting women at risk of HlVlAIDS and other sexually transmitted diseases. Most of/the HlVpositive women in the world have acquired the infection in their own homes. In many societies, it is considered acceptable for men to engage in extra-marital sex, while women are expected to remain monogamous. In these situations, women are usually able to do little to
control their husband's infidelity and appeals to women to practice safer sex have little value. Even if condoms were readily available and affordable (which is often not the case), women have little ability to negotiate their use. Unless the conditions of the relative powerlessness of women in sexual relationships, and the underlying problems of poverty which drive some women to trade sex for the means to support themselves and their children, are addressed, individual choice in this area remains an illusion (WHO, 1994a). The implication of the concerns expressed by the Global Commisssion on Women's Health in relation to lifestyle-generated health and illness are that a combination of structural, environmental, legal, behavioural and public policy measures need to be put in place to promote women's health. The need to develop strategies to promote healthy behaviour in women throughout their lifespan is significant not only for the health of women themselves, but also because of the implications for the health of their families and the community. Women are concerned in a special way for a number of reasons.
Lifestyles and women's health
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Decisions concerning women's health have intergenerational effects. Women are invariably the ones who make decisions on health behaviour and seek health services for the family. Women are increasingly subject to the health risks inherent in the new environment of sedentary occupations, excessive consumption and stressful lifestyles. As industrialization and urbanization evolve, lifestyles change, and healthdamaging behaviours related to this change increase.
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In both developing and developed countries, females are being targeted as the new "market" by advertisers of tobacco and alcohol products, further predisposing women to immediate and long term health consequences of addiction. When women migrate, their vulnerability to sexually transmitted diseases and HIV infection increase. High unemployment and lack of community and family support may result in women engaging in some kind of sexual barter (WHO, 1994b).
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While men have higher mortality rates from suicide, women predominate for attempted suicides, the typical suicide attempter is a single woman under the age of25, often as young as 15;
Thus the Global Commissiqn on Women's Health stresses the deleterious effects of tobacco and alcohol consumption, dangerous sexual practices and living in stressful environments on women's hes!th. It must be added that women suffer dangers to their health from men's lifestyle choices as well, such as excessive alcohol consumption, unsafe sexual practices and employment in industries that expose men and their families to toxic substances.
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The situation in the Western Pacific Region
Data associated with changes in lifestyles for many parts of the Region are inadequate. While there are many data from developed countries such as Australia and New Zealand, not so much information is available from newly-industrializing and developing countries. For the purposes of this discussion, the Region has been divided into developed countries with high income economies (Australia, Japan and New Zealand), newly-industrializing economies (people's Republic of China, Hong Kong, Malaysia, Republic of Korea and Singapore), Sou~east Asia (Brunei Darussalam, Cambodia, Lao People's Democratic Republic, Macao, Mongolia, the Philippines and Viet Nam) and the Pacific island countries and areas (American Samoa, Commonwealth of the Northern Mariana Islands, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Federated States of Micronesia, Nauru, New Caledonia, Niue, Papua New Guinea, Republic of Palau, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu and Wallis and Futuna).
Noncommunicable diseases The elements oflifestyle that are seen to contribute to increased morbidity and mortality from noncommunicable diseases include: • lower levels of physical activity due to mechanization, accompanied by insufficient compensatory exercise and insufficient compensatory control of food intake, factors that are seen to lead to obesity, which in tum can result in non-insulin dependent diabetes mellitus; increased consumption of animal fat and sugar, which is seen to cause raised blood cholesterol concentration which can result in heart attack; increasing tobacco use, the fmal health outcome of which is seen as chronic obstructive lung disease; and
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lifestyle changes and their Impact on women's health In the Western Pacific Region
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exposure to and acute heavy drinking of alcohol, which may lead to hypertension, with the final health sequelae of liver cirrhosis and injuries from car accidents (WHO, WPRO,1991).
Cambodia, the Lao People's Democratic Republic, Niue, Papua New Guinea, Solomon Islands and Viet Nam have no noncommunicable diseases among their five leading causes of mortality. The pattern for women parallels that for the population as a whole in each country.
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I··• •·••·••· Countries in the Region were rated using an index of noncommunicable disease mortality based on the number out of the five leading causes of death that are chronic noncommunicable diseases or injury. The ratings varied from five to zero (WHO, WPRO, 1991). For American Samoa, Australia, Brunei Darussalam, Guam, Mariana Islands and the Federated States of Micronesia, all five major causes of mortality are attributable to noncommunicable diseases. Four out of the five major causes of mortality in the Cook Islands, Hong Kong, Japan, Macao, Malaysia, Marshall Islands and Singapore are attributable to noncommunicable diseases. China, Fiji, French Polynesia, Kiribati, Nauru, New Caledonia, New Zealand, Palau, the Philippines, the Republic of Korea, Samoa, Tonga and Tuvalu all have three and Vanuatu has one.
Developed countries with high income economies Noncommunicable diseases are the major causes of death, morbidity and disability for both men and women in Australia and New Zealand.
In Australia, although women's life expectancy at birth has risen steadily since the end of the Second World War and remains six years longer than for men, for the last two decades ischaemic heart disease, malignant neoplasms
The situation In the Western Pacific Region
(cancers) and cerebrovascular disease (stroke) have been the major causes of death for women (accounting for 60 per cent of all female deaths), and have started a decline in the lifespan advantage of women over men (which peaked in 1980 to 1982) (ABS,1994). Although 'age-standardized death rates for ischaemic heart disease and cerebrovascular disease for both sexes have decreased markedly' over the last 25 years, cancer became the principal cause of death for Australian men in 1990 and for Australian women one year later in 1991. Malignant neoplasms also 'contributed the largest component of years of potential life lost (YPLL) for females in 1992, accounting for 30.7 per cent ofYPLL for females aged 65 years or less', with the most common cause -of cancer death in females in 1993 being 'breast cancer... followed by cancer of the trachea, bronchus and lung and then colon cancer' (ABS,1994). 'Age-standardized death rates for female breast cancer have shown little change over the last 50 years' and age-specific death rates for cervical cancer have actually declined 'in most groups since 1960 when the Pap smear test was introduced to Australia'. However, 'female agestandardized death rates from lung cancer continue to increase, whereas the male rates have decreased in recent years'. The increase in tobacco consumption among women in the last five decades has been contrasted with a decline in smoking among men
throughout the 1980s and 1990s. This is starting to show in gender differentials in age-standardized death rates for lung cancer in the 1990s (ABS, 1994). 'Accidents, poisonings and violence contributed more to years of potential life lost (17.2 per cent) than total heart disease for females. aged between 0 and 65 years' and the 'distribution of female suicide deaths by age has changed markedly between 1960 and 1993. Whereas females in the middle age groups were more likely to suicide in 1960, the largest proportion of suicides are now in the younger age groups' (ABS, 1994). Although male suicides exceed those of females, women make more attempts at suicide than men. The morbidity and disability status of women in Australia closely parallels the mortality profile, with noncommunicable disease and disorders being the major source of loss of quality of life. However, it must be noted that some aspects of the mortality, morbidity and disability profile for Aboriginal Australian women more closely resemble those of developing countries, with infectious diseases and maternal and infant mortality rates remaining high, although this is coupled with high rates of nutritionally-generated diabetes. Diseases of the circulatory system remain the leading cause of death for Aboriginal women, followed by respiratory diseases, neoplasms and injuries and poisonings (ABS, 1994).
Lifestyle changes and their impact on women's health in the Western Pacific Region
The lifestyle activities of Australian women were researched by the Australian Bureau of Statistics in 1994. The main findings in relation to women and lifestyles were that:
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Fewer women than men smoked (24.7 per cent compared with 32.1 per cent). This was the case in all age groups except 18 to 24 year olds. On average, women smoked fewer cigarettes per day and smoked cigarettes of a lower tar content than men. A smaller proportion of female smokers (11.3 per cent) had begun smoking before the age of 15 years than had male smokers (19.3 per cent). A smaller proportion of females (51.8 per cent) than males (73.5 per cent) drank alcohol in the week prior to the interview. Women were more likely to have drunk wine than any other alcoholic beverage. This was true of all ages except 18 to 24 year-old women, who were more likely to drink spirits. Males of all ages were more likely to drink full strength beer. The average daily consumption of alcohol was substantially lower for females (13.2 millilitres) than males (31.0 millilitres), 18 to 24 year-olds reported the highest average daily alcohol intake for both sexes.
Women are more likely to use sunscreen than men (64.4 per cent compared with 52.0 per cent). Use sunscreen of decreased progressively with age for both sexes. 64.8 per cent of females took part in exercise in the two weeks prior to the interview. Although exercise participation levels for males were similar (65.9 per cent), males were more likely to engage in vigorous exercise than females. For both sexes, the amount of exercise decreased with age. Women had healthier eating habits than men. They ate less fat and were less likely to add salt to their food. Women were less likely to be overweight or obese than men (29.6 per cent compared with 43.6 per cent). Women were more likely to be underweight than men (17.2 per cent compared with 6.2 per cent). 72 per cent of females took medication in the two weeks prior to interview. The use of medication increased with age. Females were less likely than males to use illicit drugs (ABS, 1994).
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The same pattern can be found in New Zealand, where the cancer, stroke and heart disease rates for women are approaching the levels for men largely
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The situation in the Western Pacific Region
as a result of several decades of increased levels of smoking among women (Bonita, 1993). 'It has been estimated that smoking causes one in five cancers in New Zealand' (Statistics New Zealand, 1993). The Household Health Survey conducted by Statistics New Zealand (1992 to 1993) and the Life in New Zealand Survey (1989 to 1990) provide copious data on women's health-related behaviours and associated health and illness states. Cancer has recently overtaken coronary heart disease as the leading cause of death among women, with the breast being the most common site of cancer in women, followed by the colon and the lung. Twenty-three per cent of female deaths in New Zealand are due to coronary heart disease, and heart disease was the leading cause of death in women aged 60 years and over in 1990 ( Statistics New Zealand, 1993). In 1991, affective psychoses (mental disorders in which there is a severe disturbance of mood) were tqe leading cause of women's first admission to psychiatric hospitals. Both sexes have shown increasing rates of admission to psychiatric hospitals for alcohol dependence and abuse over the last 20 years, but the increase in rates for women has been greater than for men (Statistics New Zealand, 1993). The majority of sexually transmitted disease clinic patients are between 15 and 24 years old, with 80 percent being aged 30 years or under. Women attend
the clinics at a younger age than men. Thirty-eight percent of women clients are teenagers, compared to 14 percent of men. In New Zealand, a high rate of unprotected intercourse in teenagers is indicated by the very high national rate of teenage pregnancies compared with other developed countries. A recent study of adolescents in New Zealand suggested a decreasing rate of condom use among young women, an increasing number of partners and an increased rate of sexually transmitted diseases (Statistics New Zealand, 1993). Female attendances at sexually transmitted disease clinics exceeded male attendances for the first time in 1992. Currently, women make up only a small percentage (six per cent) of mv -positive cases, but given the implications of the fmdings in relation to other sexually trfulSmitted diseases and unsafe sexual practices in New Zealand, this situation could change dramatically in the next decade. In relation to lifestyle factors, women on the whole, like men, have reduced their consumption of tobacco, but rates of smoking remain highest 'among those under 25 years and among Maori' . Athough women consume less alcohol than men and are less likely to consume large quantities and on a regular basis, those aged 15 to 24 years 'have the greatest proportion of heavy drinkers' (Statistics New Zealand, 1993). Women are 'less likely than men to be overweight and more than twice as
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Lifestyle changes and their impact on women's health in the Western Pacific Region
likely to be wlderweight' using Body Mass Index (weight in kg divided by the squre of the height in m). Young women aged 15 to 24 years have 'the highest proportion classified as "underweight'" (Statistics New Zealand, 1993). It was found that 64 per cent of women, but only 45 per cent of men, had modified their diet to lose weight. Women were more likely to modify their diet to 'feel better', but a smaller proportion of women than men modified their diet to lower the risk of disease (Statistics New Zealand, 1993). 'New Zealand women are high users of contraception' and are having fewer children than two decades ago. 'Sterilization is now a major method of fertility control in New Zealand', especially once families are completed. Women in New Zealand are also using abortions to control fertility more frequently than in the past. 'In 1992, the ratio of abortions to live births was 195.9 per 1000. Abortions are most common among women aged 20 to 24 years. Across all age groups, Maori and Pacific island women have higher rates of abortion than women of other ethnicities' (Statistics New Zealand, 1993). A higher proportion of 'women than men do not get the amount of physical exercise recommended as part of a healthy lifestyle'. As women age they greatly reduce their exercise (Statistics New Zealand, 1993). Recreational and leisure activities are an important aspect
of lifestyle in relation to well-being. Among women in New Zealand, these activities centre around social interaction, entertainment and low level physical exertion. Women's favourite leisure pursuits as mentioned in the Life in New Zealand Survey included reading, visiting friends, watching television and video tapes, gardening and listening to music. Japan has both 'lifestyle' and infectious diseases among the five leading causes of death. From 1972 to 1982, the rate of heart-diseases related deaths dropped by 2l.6 per cent for males and 34.5 per cent for females. A major reason is probably that animal fat.intake and blood cholesterol concentrations have not yet risen to levels associated with epidemics of ischaemic heart disease, although there is cause for some concern from recent reports in the larger cities. There appear to be cultural factors at work in Japan that limit the influence of typical dietary and consumption changes usually associated with economic development. Although they are exposed to passive smoking from their male partners, women in Japan are not taking up tobacco smoking to the same extent as women in other developed countries. The smoking prevalence rate in the late 1980s for women aged 35 to 64 years was 14 per cent (WHO, WPRO, 1991). The same percentage of the female population (35 to 64 years) suffered from hypertension.
The situation In the Western Pacific Region
Newly-industrializing economies In China, perinatal diseases exist alongside the lifestyle diseases of malignant neoplasms and cerebrovascular diseases as the major causes of death for women. Obesity is rare among adult women, with the average Body Mass Index being 24.5. Hypertension is becoming more common, with 19 per cent of adult women reporting hypertension, and the diabetes prevalence rate reached 21.5 per cent in the late 1980s. Average cholesterol levels for adult women are a low 4.3 mrnolll. Although the smoking prevalence rates among men are high (61 per cent), women are not taking up smoking at a rapid rate. Hong Kong displays many of the lifestyle diseases, with some of the dietary and stress-level changes echoing those of industrialized countries, but again female smoking prevalence rates remain low (four per cent). Malaysia also has smoking prevalence rates for adult women of only four per cent, compared to male prevalence rates of 41 per cent, but preliminary figures suggest that this pattern is changing for young Malaysian women. Malaysia continues to have a mix of infectious and lifestyle diseases, but noncommunicable disease mortality and morbidity will soon outstrip communicable dsiseases (WHO, WPRO, 1991).
The Republic of Korea maintains a low smoking rate for adult women of seven per cent, compared to the adult men's rate of 69 per cent, and a mix of mortality causes including high rates of injuries, accidents and suicides. Singapore follows the other Asian nations' pattern of a low female smoking rate (three per cent) compared to that of males (35 per cent), but these figures disguise a tendency to high levels of smoking uptake among young women. Singapore's mortality pattern suggests a sharp increase in cerebrovascular diseases, heart disease and cancers. The Government of Singapore is aware of these trends and is committed to maintaining and improving the health of Singaporeans. The National Healthy Lifestyle Programme (NHLP) was launched in 1992 to encourage Singaporeans to be responsible for their own health and to adopt healthy lifestyles. Target groups for intervention programmes under the NHLP have been identified and include the young, uniformed groups, women, fue working population and older people. Targets for risk factor levels for the major diseases of importance in Singapore have been set for the year 2000. National surveys are carried out at regular intervals to determine the prevalence of the diseases of importance and their risk factor levels, and the progress in reaching the set targets.
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j Jt
Lifestyle changes and their impact on women's health in the Western Pacific Region
Southeast Asia Brunei Darussalam, Macao, and Mongolia closely resemble Australia and New Zealand in their mortality and morbidity patterns for women, with cancer, heart disease and cerebrovascular diseases dominating their major causes of death, morbidity and disability. The Philippines has an increasing proportion of its mortality and morbidi ty attri butable to noncommunicable diseases, but high rates of infant and maternal mortality and tuberculosis skew its mortality pattern towards that of the countries of mainland Southeast Asia. High rates of uptake of smoking, especially among young women, suggest that the pattern may change dramatically in the next few decades. Cambodia, the Lao People's Democratic Republic and Viet Nam continue to experience infectious diseases as the major source of mortality and morbidity. Cholera, tuberculosis, malaria and perinatal infectious diseases continue to dominate the list of mortality causes in these countries. It is difficult to get statistics on smoking and dietary patterns in these countries, but there is little evidence of Western patterns of lifestyle disease emerging in the next decade.
Pacific island countries and areas The Pacific island countries and areas in the Western Pacific are experiencing epidemics of noncommunicable diseases such as diabetes and ischaemic heart disease. Populations that appear to be experiencing significant rises in noncommunicable diseases in this Region include Fiji, Malaysia, the Federated States of Micronesia and Samoa. Above-average increases in mortality from these diseases have been experienced in Nauru (and among Australian Aborigines), and the noncommunicable disease epidemics in these populations show little signs of abating (WHO, WPRO, 1991). However, the situation is highly variable across the Pacific islands. The leading causes of mortality are lifestyle-related in American Samoa, Guam, the Mariana Islands and the Federated States of Micronesia. The Cook Islands and the Marshall Islands have most mortality related to lifestyle factors, while the mortality patterns in Papua New Guinea and the Solomon Islands fit entirely within the infectious diseases pattern, with perinatal diseases (including meningitis and tuberculosis), malaria, respiratory diseases and injuries, accidents and suicides being the major causes of death for both men and women.
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20
The situation In the Western Pacific Region
Smoking prevalence rates for women in the Pacific islands are the highest in the Region. In Fiji, smoking among indigenous women reaches 44 pel cent, in French Polynesia 46 per cent, Guam 40 per cent, Tonga 38 per cent and in Nauru 59 per cent. Kiribati with 70 per cent and Papua New Guinea with 80 per cent of the adult women smoking provide the highest levels of female smoking in the world. Obesity is perceived as a major health problem leading to diabetes and heart disease in many of the Pacific islands. However, it is not the weight per se that is a problem, but the changed dietary patterns. In countries like Niue the government is concerned about th~ high rates of obesity, ~stimated to be 46 per cent among all women and over 60 per cent for women aged 30 to 59 years. Obesity is seen as being the result of changed nutritional and occupational patterns. Attempts are being made to deal with the problem through a series of Diet and Healthy Lifestyle workshops run by the Department of Community Affairs in each village in Niue. A national weightloss competition is being held which will culminate in a prize-giving ceremony in October 1995 (Niue Department of Community Affairs, 1995). Similarly, in Palau, statistics show an increasing number of older women in particular are developing chronic diseases, largely generated by nutritional problems and lack of exercise.
Rates of death and disability from car accidents remain a major source of concern. In Tonga, the number of deaths per 10 000 vehicles was 17.7 in the 1980s (compared to 3.4 in Australia), which constituted 14.4 per 100 000 poulation (18.6 per 100000 in Australia). In Fiji and the Solomon Islands the death rate from car accidents was 18.5 per 10 000 vehicles and in Papua New Guinea, a massive 60 (WHO, WPRO, 1991).
Changes in fertility rates and childbearing and childrearing patterns The developed countries with high income economies in the Region have experienced a slight decline in fertility rates over the last two decades. Most of this decline occurred prior to the 1970s. In Australia, the total fertility rate declined from 2.1 in 1975 to 1980 to 1.9 in 1980 to 1985, and has remained at that level since (ESCAP, 1994a). Japan has also experienced a slight decline, from 1.8 in 1975 to 1980 (ESCAP, 1994a)to 1.6 in 1990 to 1995 (WHO, WPRO, 1994). The fertility rate in New Zealand has remained stable at just over 2 since 1975. Thus women's lifestyles in these countries have not changed significantly in relation to child-bearing over the past two
Lifestyle changes and their impact on women's health In the Western Pacific Region
decades, although the follow-on effect of reduced fertility rates in prior decades mean that women are playing a declining role as grandparents and as cross-generational child-carers. Singapore's fertility pattern closely resembles that of the developed countries with high income economies, with its reduction in fertility having come about in earlier decades. Singapore's fertility decline among the educated had become a source of concern for the Government by the 1970s and policies were put in place to reverse the trend. However, Singapore's fertility rate has declined slightly, from 1.9 in 1975 to 1980 to 1.7 in 1990 to 1995. It is in the newly-industrializing economies other than Singapore that the most dramatic changes have taken place. In Hong Kong, the fertility rate declined from over 2 in the 1980s (ESCAP, 1994a) to only 1.3 in 1992 (WHO, WPRO, 1994). The one-child policy in China has contributed to a decline in fertility from 2.9 it 1975 to 1980 to 2.2 in 1990 to 1995. Malaysia has experienced a decline from 4.2 in 1975 to 1980 to 3.6 in 1990 to 1995, and in the Republic of Korea there has been a dramatic drop from 2.8 in 1975 to 1980 to 1.8 in 1990 to 1995. Thus women's lifestyles in relation to childbearing have gone through a recent transformation.
The countries of Southeast Asia have a variety of fertility rates and rates of reduction in fertility. Brunei Darussalam (3.1) and Macao (1.5) have fertility rates and rates of fertility decline close to the developed countries whereas Cambodia (3.5), Lao People's Democratic Republic (6.7), Viet Nam (3.9) and the Philippines (3.9) continue to have moderately high fertility rates and little decline. In Mongolia, the fertility rates declined from 5.5 in 1975 to 3.4 in 1995. Other than in Macao, women continue to spend a large amount of their time in child-rearing, while working in the informal sector of the economy. However, the continued high levels of infant mortality (Lao People's Democratic Republic and Cambodia 117 per 1000 Ii ve births, the Philippines 57 per 1000 live births and Viet Nam 52 per 1000 live births) reduce the effects on women's time spent in child-rearing. Despite massive family planning campaigns initiated by the Philippines government in recent years, adherence to fundamentalist Catholic religious practices among a large proportion of the population in the Philippines have kept the birth rate high and this is accompanied by high levels of infant mortality. The Pacific island countries continue to display high fertility rates. The Marshall Islands have one of the highest fertility rates at 7.2 followed by the Federated
The situation In the Western Pacific Region
States of Micronesia 5.2, the Solomon Islands with a relatively stable 5.3, Vanuatu with 5.1 and Papua New Guinea with 5.4. Samoa has displayed little change in its fertility rate over the last few decades, the 1994 rate was 4.8. In some countries of the Pacific infant mortality rates remain high and thus the implications for child-rearing are not as drastic as the fertility rates suggest. For example, Tuvalu has a total fertility rate of three, but an infant mortality rate of nearly 74 per 1000 live births and Kiriba1i. has a fertility rate of 3.8 but a high infant mortality rate of 65 per 1000 live births. Similarly, the Marshall Islands have an infant mortality rate of 63 per 1000 live births and Tokelau 65 per 1000 live births. Papua New Guinea's high fertility rate is matched with a high infant mortality rate of 57 per 1000 live births. Thus in many isla.'1ds of the Pacific women continue to spend a significant amount of time pregnant and invol ved in child care, blilt this is accompanied by the tragedy of multiple infant deaths. It will be some time before these
for-all targets or will reach the HF A 2000 targets in relation to infant mortality by the year 2000 (WHO, 1995). The age at first marriage influences the age at which women have children, how many children they have and many other factors in their lives, such as education, employment and involvement in community activities, which are linked to women's status. The median age at first marriage for women in the Region is 24 years or over in Japan, Australia and the newlyindustrializing economies, and 20 to 25 years in Southeast Asian countries. While the average age at marriage in the Pacific islands remain in the late teens, current levels represent substantial increases over the levels of earlier decades. Women in most countries of the Region give birth to their first-born after the age of 25 years. Together with the increasing adoption of contraception and family planning, delayed marriages are enabling women to have fewer children. On average, women in developed countries have no more than two children. Average family sizes in moderately-developed countries have declined as well, to three or four children. In countries where the age of marriage and contraceptive use have not risen so rapidly, family size remains higher at four or more children.
countries reach the fertility and infant mortality levels of the developed countries, but changing patterns of female labour participation reflect some improvement in these indicators. Guam and New Caledonia have significantly reduced their infant mortality rates and it is projected that some countries in the Pacific have already met the health-
Lifestyle changes and their Impact on women's health in the Western Pacific Region
Women in the labour force Women's participation in the formal workforce has increased significantly over the last few decades across most parts of the Region, with the exception of Papua New Guinea, Cambodia, Lao People's Democratic Republic, the Philippines, Singapore and Hong Kong. The positive outcome of this feminization of the workforce is greater social and economic independence for women and, in some countries, a higher level of political participation. However, women remain vulnerable as the 'flexible' sector of the workforce in times of economic recession. This has been particularly evident in countries that have undergone meYor political and economic transitions over the past decades, such as Mongolia. The major gains for women's political and economic rights earned during the communist regime have been seriously undermined with the deregulation of Mongolia's economy over the past five years. Asia has traditionally had high labour participation rates for women and this trend continues. Women's labour force participation rates are highest in China, where over 75 per cent of women work (Asian Development Bank (ADB), 1993), and this is the continuation of a pattern established under the communist regime in 1949. Creches are provided for childcare in factories in urban areas
to enable women to work. In the countryside, less-formal arrangements are made for child care so that women can participate in agricultural production. However, there are some variations across provinces and across age groups. Economic activity rates for women in Mongolia remain high at 42.3 per cent (1980) and 43.1 per cent (1990) (ESCAP, 1994a), but recent reports suggest that these levels may be currently under threat (Mongolian country report, 1995). In Cambodia, the Lao People's Democratic Republic and Viet Nam, the overall female labour participation rate is over 60 per cent, despite fall~ in the activity rate for women in Cambodia and the Lao People's Democratic Republic, and this is consistent across the lifespan (ADB, 1993). (Slightly lower figures are reported by ESCAP, but the figures for China and the Southeast Asian mainland remain the highest for the Region.) However, in the Philippines and the Republic of Korea, women's labour participation rates are higher for the 50 to 54 years cohort than for the 30 to 34 years cohort, reflecting the tendency for women in more affluent groups to withdraw from the labour force during child-rearing. In Hong Kong, women's economic activity rate has fallen from 37.2 per cent (1980) to 36.8 per cent (1990) and in Singapore from 32.6 per cent (1980) to 31.2 per cent (I990). Women in the
The situation in the Western Pacific Region
Republic of Korea have made slight labour force participation gains, from 26.6 per cent (1980) to 29.8 per cent (1990) which resembles the rise in Malaysia from 27 per cent (1980) to 27.9 per cent (1990). In Australia and New Zealand, women's labour force participation rates have risen significantly since women's temporary removal from paid labour during the post-war baby boom, but the rise has tapered off over the last decade, with the female economic activity rate increasing from 34.4 per cent in 1980 to 35.9 per cent in 1990. New Zealand had a slightly higher increase, from a 29 per cent female economic activity rate in 1980 to 32 per cent in 1990 (ESCAP, 1994a). Similar figures and increases are evident for Japan, 36.3 per cent in 1980 to 37.5 per cent in 1990. Women in the Pacific islands have not increased their labour force participation rates to the same extent as women in the developed and newly induStrializing nations and Southeast Asia (ADB, 1993). The impact on women's health of the feminization of the labour force in some countries and the reduction in labour force participation in others is variable. Economic and political gains may be offset by the uncertainty of continued employment, unhealthy and dangerous work environments and the multiple stresses of playing a dual role of worker
and homemaker. Women's predominance, and increasing predominance, in commlIDity, social and personal services exposes them to significant stresses and mental health risks. Women in most cOlIDtries of the Region are more likely than men to work as employees rather than as selfemployed. For example, in Samoa the percentage of active women who are employees is 86.3 per cent, compared to 36 per cent for males. Another negative aspect of the feminization of the labour force has been women's increased exposure to industrial and other occupational hazards, including toxic substances, unsafe physical environments and stress. The types of employment that women tend to be engaged in include low-paid factory work, piece-work and outwork. In situations where women's participation in the paid workforce has not been offset by greater contributions from partners and others in the domestic sphere, women continue to perform a double shift of domestic chores and responsibilities alongside the expectations of their employers. The impact on women's health of such 'double shifts' is dramatic. There are few statistics on women's share of household tasks, but those that are available suggest that in all parts of the Region, women undertake at least 70 per cent of household tasks and responsibilities, often on top of a fuIltime job.
Lifestyle changes and their impact on women's health in the Western Pacific Region
Education There have been gains to women in terms of primary, secondary and tertiary education over the last two decades in all countries of the Region. Given the established relationship between levels of education and literacy, especially of mothers, and health status of populations, (Powles, 1977), this augurs well for women's health. Certainly, increased levels of education for women have had an effect on fertility rates, contraceptive use and personal and public hygiene practices. Lower infant and maternal mortality rates are associated \vith increased access to education for women except in the Philippines, where high levels of female literacy and female education have not been associated with a decline in either infant or maternal mortality. Other faclors, including the influence of the Catholic church on contraceptive and other family planning practices in the Philippines, seem to intervene in the process of reducing infant and maternal mortality. Using a female education index that incorporates average years of schooling, number of female students per 100 male students in both primary and secondary schooling and female gross enrolment rates in primary and secondary education, the countries of the Western Pacific Region can be divided into four
groups, from a very good female education index to very poor (Population Action International, 1994). In the very good group, Australia, Japan and New Zealand have virtual equity between the sexes in relation to education. Mongolia, the Philippines, the Republic of Korea, Hong Kong, Singapore and Malaysia have a good record on gender equity. China has a fair record, but a significant closing of the gender gap in relation to education is needed, and Lao Peoples Democratic Republic and Papua New Guinea have a poor record where major redressing of gender balance is needed. The Pacific islands and areas generally have very high literacy rates for women, but varying records in relation to education for women and girls.
Nutrition There are a variety of social, cultural and traditional uses of nutrition in the Western Pacific Region. In some cases, preference for sons produces systematic undernutrition of girl children. Dieting, especially among young women and girls, is an ever-increasing problem, with malnutrition being the consequence for many. In some developed and developing countries of the Region, problems have started to emerge with voluntary self-starvation by girls.
The situation In the Western Pacific Region
One of the long-term consequences of overexercise and dieting, osteoporosis, may be the lifestyle disease of the 21st century. An epidemic of eating disorders has emerged in the West and in some newly industrializing countries (Fichter et ai, 1983; Fairburn, 1984; Szmukler, 1985; International Journal of Eating Disorders, 1-12). Unhealthy diets play an important role in how changing lifestyles affect health, particularly in their association with many of the noncommunicable diseases. The problem of obesity from inappropriate diet occurs in many countries of the Region, especially in the Pacific islands.
households may suffer from a variety stresses related to the difficulty of supporting and bringing up a family on their own, in addition to the traurnas of abandonment, separation or divorce. Risk-taking among young women is often used as a rite of passage or as a display of independence. The importance of asserting independence and power over one's body and one's life may override physical health outcomes. Permissive sexuality, drugs (including alcohol, tobacco and diet pills) fast driving, high-risk sports and underor over-nutrition are all used by young women as ways of asserting their independence. This has become particularly pronounced at the end of the twentieth century as unemployment and a drive towards higher levels of education for girls have raised the usual age of economic independence. The period of 'limbo' time between gaining political rights and becoming economically independent has risen so that many young women do not gain total independence until well past 20 years of age. This period of uncertainty and unclear expectations in relation to adult behaviour can lead to young women choosing their own independence rituals or rites of passage, many of which involve enormous risk to their health.
Other lifestyle factors The numbers of never-married, widowed and separated women are increasing in the Region andiglobally. Studies in Western countries show that single women in remunerative employment enjoy relatively more freedom and satisfaction than other groups of women, whereas women who are unmarried and unemployed may be the least satisfied group of women (Verbrugge, 1983). Women heads of
Conclusions and recommendations
Conclusions Modemization has changed the roles of women in many societies. The traditional housewife-mother role has diminished as more women become active in the economy and the community. Women in many parts of the Region are increasingly in a position to choose to postpone marriage or remain unmarried, and to choose when to have children and how many children they will bear. However, women are also affected by increases in the incidence of widowhood arising from the longer lifespans of women, and in the increasing incidence of separation, divorce and abandonment. These changes to the ways women live have both positive and negative effects on their health. The benefits from reduced incidence of communicable diseases and longer lifespans are countered by changing physical and emotional demands on women that may
lead them to adopt unhealthy behaviours and lifestyles. The number of women affected by diseases associated with unhealthy diets, obesity and tobacco, alcohol and drug consumption, has been increasing over time. Perhaps one of the most significant factors from a lifespan perspective is the vulnerability of girls and young women to the effects of advertising by large corporations, to the vagaries of the employment market, to conflicting messages about identity and to the unintended consequences of health promotion. The information from many countries in the Region suggests that lifestyle risks that could seriously compromise health are most prevalent among the 15 to 24 year-old cohort of women. These include issues associated with smoking, drinking alcohol, sexual behaviour and other risktaking activities, as well as problems with gender identity and the effects of sex-role stereotyping.
Lifestyle changes and their impact on women's health In the Western Pacific Region
Recommendations 1. Efforts to achieve gender equity in relation to economic, political, social anc\ legal rights for women that will inevitably lead to improved health status should continue. 2. Health promotion programmes should be developed that acknowledge that health has both a structural and an individual dimension, recognizing the need to promote a combination of 'lifestyle' and structural changes to deal with the so-called lifestyle diseases. 3. The regulation ofillhealth-producing industries such as tobacco, alcohol and some food industries should be supported. 4. Health promotion should maintain a heaIth- rather than a diseaseoriented approach. 5.
7. Total-population campaigns that ignore both the different biological and social construction of women's bodies should be avoided. 8. Physical health should not be privileged over mental health. 9. The fact that the 'lifestyle' approach is typically a construction of public health for industrialized, predominantly Western countries, should be recognized, and cultural and societal differences should be taken into consideration in the development and implementation of programmes that address lifestyle changes and health in other countries. 10. A time series analysis approach that assumes that all countries will follow the same developmental and illness pattern path should be avoided. 11. The particular vulnerability of girls and young women to a variety of risk-taking activities, including smoking, heavy drinking of alcohol, starvation diets, excessive exercising, unsafe sex, dangerous driving and drug abuse, needs urgent consideration. Issues of self-esteem and status are important factors here.
An evangelical approach, to health promotion should be avoided, acknowledging that bald universal messages may have unintended consequences
6.
The social and cultural significance of food should be studied, and should have priority over nutrient intake terminology in health promotions that concern the diet.
Appendix 1 Aspects of health policy
'the hygienic person' and 'the hygienic family'. It represented a clear example of the disciplinary society. Hannaway (1981) and Tesh (1982) document how this emphasis on private hygiene was transformed in the nineteenth century to an environmentally-based public health. Tesh (1982) argues that there were essentially four major theories of disease causation that prevailed in nineteenth century Britain - contagion theory, personal behaviour theory, atmospheric theory and supernatural theory - each of which had an equal chance of becoming ascendant. Tesh suggests that the eventual hegemony of an atmospheric 'miasma' theory was not based on scientifically-endorsed evidence but was 'inextricably linked to nineteenth century beliefs about the proper organization of society and more fundamentally to convictions about the nature of human beings' (Tesh, 1982). Tesh (1988) suggests that political beliefs and values still circumscribe the 'possible' and the 'acceptable' in public health policy. Currently, Tesh argues, three theories compete for ascendancy;
Labisch argues that health offered 'an instrument both for neutral controlling of behaviour and for a socially pacificatory way of dealing with social problems'. The ideological dimension of this process was that 'obligation towards health' became synonymous with the 'right to health' (Labisch, 1985). Nineteenth century Germany was characterized by the spread of 'the hygienic culture' and the production of
lifestyle changes and their impact on women's health In the Western Pacific Region
germ theory, lifestyle theory and environmental theory; and lifestyle theory has the edge for a variety of economic and political reasons. The individual is given a strong sense of agency, his or her death or illhealth is seen as a symbol offailure of vigilance. To retain the integrity of the self and the body, the individual must monitor and check their behaviour to make sure that it fits the prescriptions laid down by a higher authority, 'public health'. Davis and George (1988) suggest that the increase in such things as jogging, keep-fit classes and healthy diets are a testament to the increasing extent to which we are becoming a population of the 'worried well' (Davis and George, 1988). The integrity of the body is elevated to a supreme value which is supposed to structure the decisions we make about life. Health becomes an end in itself (Berliner, 1977). Given these ideological underpinnings, it is no wonder that current public health policy continues to ignore voluntary undernutrition. It is not named as a public health issue in any significant policy statement despite the finding of the ABS Report that there is 'a positive epidemic of pervasive and extremely intense concerns about weight, shape and diet amongst young women' (ABS, 1994). Similarly, a National Heart Foundation of Australia Study (1983) found that between the ages of 25 to 39 years there is a greater percentage
of women underweight than obese and the Australian National Dietary Survey of Schoolchildren No. 2 Nutrient Intakes revealed that 'there is an apparent marked increase in the proportion of girls aged 12 to 15 years whose intake does not meet the RDI for protein, carbohydrates, fats, and energy intake generally'. The often-proposed progression of disorder from sin to crime to illness seems to have come full circle with the remoralization of body practices in the trend towards 'healthism' (Crawford, 1980). Self-starvation is one category which defies this progression. Selfstarvation was never a sin, it was in fact the reserve of saints, and thus exemplary behaviour. Such ambiguous attitudes towards self-starvation as an illness/sin are maintained in the late twentieth century. Self-starvation went from sainthood to patienthood (Brumberg, 1988) then to an ambiguous characterization as exemplary government of the body yet 'perverse' at the same time. Lifestyles have become medicalized but at the same time moralized, and guilt becomes a mYor tool for public health programmes. However, unless the intersectoral approach to public health critically assesses the empirical foundations on which its methods are based, it may end up just as culpable as the 'lifestyle' approach in producing unintended consequences.
B.
-
Appendix 1 - Aspects of health polley
Davis and George endorse Foucault's arguments concerning the disciplinary society in relation to health when they argue that it is hard:
Both 'new' and 'old' public health operate on the assumption that obesity produces coronary heart disease, diabetes and other illnesses. They both appear to uncritically accept the assumption of the Better Health Commission that' poor nutrition and obesity play a primary role in the prevalence of coronary heart disease in Australia' (BHC, 1989). Such claims need ~or qualification. The social and cultural construction of 'fatness' is ignored in official health policy documents.
Both clinical medicine and public health involve discipline, regulation and surveillance (the lifestyle health p(omotion arm of public health as well as the intersectoral arm). The unintended consequences of the New Public Health and its effects on the population may be no more benign than either clinical medicine or lifestyle health promotion. Unless public health is prepared to abandon the dominant discourses on disease causation in relation to obesity and mortality and morbidity, it becomes just as culpable as other forms of health promotion in producing unintended consequences such as obsessive concerns about weight, shape, and size, especially among the young.
If the choice to ignore such issues were merely a matter of benign neglect, the implications would not be so dire. However, the emphasis on obesity to the exclusion of undernutrition is far from benign when it filters through into policy and health promotion programmes. Gluttony and sloth, two of the seven deadly sins are seen as being embodied in obesity. Despite the 'ideology of affluence' which prevails in developed societies, the state (at both state and federal levels) complains of lack of funds for health initiation. Ultimately therefore, economic values rather than social values prevail in public health policy decisions. The sources of knowledge that are called upon to inform public health reflect the ascendent values. Economists, bureaucrats and the medical profession continue to dominate the field of policy formulation.
Lifestyle changes and their Impact on women's health in the Western Pacific Region
'A strife of (vested) interests' (Sax, 1984) still characterizes public health policy in all countries of the Western Pacific Region as we approach the promised Year 2000 health watershed. However, as Tesh argues 'more powerful than vested interests, more subtle than science,. political ideology has, in the end, the greatest influence on disease prevention policy' (Tesh,1988). Individualism as an ideal is liberating, but individualism as an ideology 'hobbles the development and implementation of effective disease prevention policies' (Tesh,1988). Major inequalities in health remain despite the WHO directive of Health For All by the Year 2000, and unI~ major changes are instituted in public health campaigns, women may become thll 'unintended' victims of the Davis and George (1988) pessimistic scenario:
Australia's Better Health Commission's response to the public WHO directive in promoting 'obesity' as the major health issue of the late twentieth century may represent such a scenario. Brumberg (1988) argues that social transformations in the economic and cultural role of food and in sexuality created the ideal conditions for the development of 'anorexia nervosa' in young women. She suggests that the prescription that 'hedonism and discipline must co-exist' in our 'obesophobic society' creates massive confusion especially for young women caught in a 'transitional moment'. where 'a: new future is being tentatively charted for women but gender roles and sexuality are still constrained by tradition' (Brumberg,1988). Given the lack of models to help direct them, young women 'embrace the cult of diet and exercise' as the 'closest thing our secular society offers women in terms of a coherent philosophy of self' (Brumberg,1988). Brumberg suggests that 'eating disorders' may be more accurately conceived of as 'consumption disorders' of capitalism. Thus a 'sizeable number of our young women .. regard their body as the best
Appendix 1 • Aspects of health policy
vehicle for making a statement about their identity' and in a society where 'consumption and identity are pervasively linked (the anorectic)... makes nonconsumption the perverse centrepiece of her identity' (Brumberg,1988). The implications for policy are enormbus. Rather than turning back the clock in a nostalgic bid for a more certain past, Brurnberg argues for the creative use of the imagination in developing multi-
disciplinary strategies for prevention and treatment of all 'consumption disorders'. Undermining the suspect positivist base of obesophobia would be a significant starting point. Teasing out the 'health' and 'aesthetic' dimensions of obesophobia would help to demystify some of the contradictory discourses which construct the social reality of many young women and would minimize the cultural ambiguities of prescriptions for sainthood and selfhood.
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35
Appendix 2 Health promotion and nutrition
Androgenizing, 'total population' tendencies in health promotion research have been particularly inappropriate for women. For example, the use of the Body Mass Index and total weight (rather than relative distribution of weight) to establish risk of heart disease is, for women, not only inappropriate but may also have serious unintended consequences, as acknowledged by a key report on eating disorders in Australia (Ben-Tovim and Morton, 1989). The same case can be made for population-based cholesterol-lowering campaigns since the scientific data supporting the need for such campaigns is currently being seriously disputed (Hughes,1994). Similarly, the 'untoward effects' of such campaigns systematically affect women more than men (Eckermann, 1994b) given that women make up 90 per cent of the diagnosed cases of' anorexia nervosa' and bulimia' (Ben-Tovim & Morton, 1989).
Numerous examples of the problems of assuming the 'globalization of risk' and applying aggregated data to specific populations can be found in the nutrition area. Applying inappropriate data to specific populations was glaringly illustrated in the following report in one of Australia's more respectable newspapers:
Lifestyle changes and their impact on women's health in the Western Pacific Region
Further reading revealed that the article was based on preliminary results from a United States study of 400 males aged 15 to 34 years. In the health field, just any body or group of bodies will not do to standardize measures and develop health campaigns to be used with heterogenous populations articulated by gender, age, social class, race, ethnicity, geographical location and other dimensions of difference. Single generic health promotion messages such as 'eat less fat, less sugar, less salt' are inappropriate. For a young woman on starvation rations of a lettuce leaf and a wafer biscuit a day, such a message means 'cut out the wafer biscuit'. Similarly, for populations whose calorific intake is inadequate, such global messages make no sense. Yet some populations within 'developed countries' contain groups of people living under third world conditions (for example in some Australian Aboriginal communities). The sentiments ofhealthism (Crawford, 1986), as manifested in the Body Owners Manual (Coonan et al., 1984) which focuses on persistent selfsurveillance of the body, may have a negative impact on women's health. ln current public health policy throughout the Region, problems of obesity are emphasized to the exclusion of 'anorexia nervosa' and 'bulimia'. No mention is made of the problem of
obsessive observance of body
maintenance programmes or the tffects of rigid adherence to such regimes on mental health. The jury is still out on the relationship between mild obesity and health status (Roughan, 1986; Kalucy and Ben-Tovim, 1986). Thus the 'unintended consequences' of evangelical promotion of the 'fitness' industry are not dealt with at all. The vested commercial and professional interests in maintaining the concept that obesity is the major health hazard of modem Australian society remain almost hegemonic. The discourse of public health which predominates throughout the Region is couched in a language of health promotion and illness prevention which emphasizes 'lifestyle', 'monitoring', 'habits', 'fitness' and 'cholesterol' (Lupton, 1993). The language framework of public health discourse is not conducive to discussions of food refusal. The inherent message in relation to food is: 'Less, less, less', less fat less sugar, less salt, the very ingredients that add weight. The 'more, more, more' message is: more fibre, more complex carbohydrates, more water - the ingredients for weight loss. Although the proviso of 'safe' behaviours is presented as the escape clause against obsessive adherence to prescriptions for behaviours, no specific information or guidelines are provided
Appendix 2 - Health promotion and nutrition
to deal with the possibility of individuals taking prescriptions for behaviour to extremes. The last thing that self-starvers need is education about nutrition. If anything, self-starvers and binge-purgers know as much as most dietiti~s and nutritionists about the calorific content of various foods. They have taken on board all of the prescriptions of reduced fat, salt and sugar, of increased exercise, of vegetarianism, and of regular weighing to 'measure' and monitor input and output of energy (Kalucy, 1987). Although eating disorders appear to be a Western phenomenon, we must be alert to the possible detrimental effects of the Western 'health and fitness' industry in non-Western countries. Finau and Fifita's (1986) research in Fiji leads them to issue a warning about the need to distinguish between nutrition (as a scientific discipline) and food and eating (as cultural phenomena). Role confusion as an important variable in contributing to the emergence of 'eating disorders' in the West seems to have particular significance to nonWestern countries, where the conflicting pressures between traditional and Western modes of thought have created massive uncertainties (Sipolo, 1986, Civilized Girl). Finau and Fifita's (1986) work warns of this problem, suggesting that countries like Fiji need to take
prophylactic steps to build up immunity to Western diseases and disorders, including 'eating disorders'. Contrary to the ANBSP report (BenTovim and Morton, 1989), which regards the 'prospects for primary prevention (of 'eating disorders' as) bleak', it is suggested that there are significant opportunities for prevention of both detrimental eating activities and pre-morbid concems about body weight and shape at the primary level. Industries and organizations concerned with health and fitness campaigns can be encouraged to temper their evangelical activities and concentrate their energies on dealing with selfesteem issues alongside, or even better, prior to, their specific dietary and physical fitness programmes. The Body Image Programme instituted in South Australian schools is one such attempt to address the problem of the relationship between body and self esteem. However, attempts to intervene on a primary health basis at the secondary school level are not always appropriate. Self-esteem programmes need to be offered to children prior to puberty, preferably at . kindergarten or junior primary level. Dealing with self- esteem issues during or after puberty can be counterproductive, especially if it goes against the 'macho' ethos which develops in many Year 9 and 10 classes.
Lifestyle changes and their impact on women's health in the Western Pacific Region
It is the 'pervasive nature of this preoccupation' that makes the authors of the report pessimistic. The report quotes Polivy and Herman's (1987) argument that:
There are several areas where such societal changes may be possible. Rather than dismiss the possibilities of primary prevention intervention, it is potentially the most amenable area for instituting change. Clues as to where to start in this project are offered by the conclusion to the ANBSP:
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