Women's Health Matters

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Rural, Remote and Northern Women

In January, our guest expert in Le Club's Ask the Expert segment was Dawn Hemingway, MSc(Psych), MSW, RSW, Assistant Professor in the social work program at the University of Northern BC, and adjunct professor in Community Health Sciences.

A resident of northern British Columbia for more than 10 years, Dawn's teaching and research interests include northern/remote health and quality of life, women's health, disability issues, aging, social policy development, community-based organizing and research.

Dawn is a founding member and director of the Canadian Rural and Remote Health Association and of the Women North Network - a primarily web-based network connecting women across northern BC to share information, conduct research and seek policy changes to improve the health and wellness of northern women and their families.

She also serves on the board of a wide variety of women-serving organizations including the Association Advocating for Women and Children and the Northern Women's Forum as well as the Active Voice Community Coalition and the Community Planning Council. She is principle investigator on a project examining caregiving in northern communities and co-investigator on another project assessing the impact of economic decline on women in northern BC.

Dawn serves on the Women's Affiliate Project Advisory Group to the Canadian Health Network, is president of the BC Psychogeriatric Association and co-director of the BC Network for Aging Research.

Here are Dawn's answers to your questions about Rural, Remote and Northern Women:

1. Q: I live in Northern Ontario and like many women here have no primary care physician. How can I ensure I am getting what I need as far as health care? I am approaching 40 and am unsure of what tests should be performed at this age and others - is there a list of common tests for age groups? I feel left out because of the situation here and not having an established relationship with a physician.
Sturgeon Falls

A: Not having access to a primary care physician is, unfortunately, the experience of women in many rural, remote and northern communities across Canada. It does make it more difficult to be certain that you are getting the health care needed as you move toward your 40s. Sometimes you can find a doctor in a nearby community (perhaps North Bay?), but, unfortunately, it's not always possible. And sometimes the doctor that is available is not one that you want (see question 7 below). The result is that a lot more onus is placed on the individual woman to be familiar with her own needs and to seek out treatment as necessary.

Sometimes, depending on the issue, assistance can be provided by a nurse practitioner, community health nurse, or social worker, if available. Other times, travel to another city might be necessary. Connecting with other women (local or regional women's organizations or networks) can be especially useful in identifying resources that others have found helpful. You may also want to contact the closest local health authority or agency to request the services you require. As well, the following resources, available through the Women's Health Matters Resource Database, should be helpful.

The first is A Women's Guide to Common Medical Tests.

The second resource is Gynecologist's Second Opinion: The Questions and Answers You Need to Take Charge of Your Health.

And, of course, there's always the need to make the powers-that-be aware that not having regular access to a physician or nurse practitioner is simply not acceptable. In this regard, you may find the responses to questions 3 and 4 (below) of interest.


2. Q: What are the challenges these women face feeding children (two to 12-year olds)?

A: In rural, remote and northern communities, there are a number of potential challenges to feeding young children. The first is access to quality food. Depending on your location, food may have to be transported in over long distances resulting in lower quality products, especially perishable items such as fresh fruits and vegetables. Poor winter travel conditions in northern Canada may mean that supplies simply can't get through for part of the winter season; thus, resulting in families having to rely on less healthy canned products and no fresh fruits and vegetables.

Affordability can also be a huge issue in northern, rural and remote regions. Even if a wide variety of food does regularly make it to your community, the products may be marked up in price to the point where residents can only afford to purchase limited amounts and often have to forego fresh produce. Although it may be possible to cultivate some of your own produce, short growing seasons in northern climates can limit what is possible. On the other hand, if you live on or near a farm or can develop a community garden with other women, you may have ready access to fresh produce in season.

Lack of access to relevant and appropriate nutritional information may also be a problem; in particular, finding information that takes into account culture, language and literacy issues. But there are some good sources of information on-line that you might want to access.

One is the Healthy Eating and Active Living organization in northern British Columbia - better know as HEAL. It has some excellent resources that you can find here.

Other resources can be found at www.dietitians.ca.

Ensuring that children have access to good nutrition information and habits at a young age is also critical. You can introduce this information in the home but school is equally important. In smaller rural schools with multiple grades, it can sometimes be a challenge to include everything in the curriculum. As a parent, you may want to work with the local school to ensure that healthy eating habits and nutrition are taught to the children from kindergarten up to their transition to high school, including ensuring that healthy foods are available in schools.


3. Q: What would it take to improve services for women in rural, remote and northern areas?

A: What an excellent, but huge question! First, let's look at what kind of approach to health care delivery might better meet the needs of women in rural, remote and northern communities. My own view is that an innovative perspective is required - one that includes more community involvement in decision-making; taking into account the entire woman and her social, physical and emotional environment - including housing, level of income, access to proper food, etc.; developing interdisciplinary health and wellness teams that include a range of health care workers along with family care providers (most of whom are women); employing more nurse practitioners; creating decentralized women-centered services available locally; and focusing on health, wellness and prevention rather than simply on treating illness.

This perspective is best captured by what is now commonly known as a "primary health care" approach and would involve a shift from viewing traditional medical health care providers as the only experts and would integrate a wide range of health care and health promotion providers in creating a more holistic approach to health care provision. There is an excellent PDF document called Primary Health Care Reform and Women that you can access here (you will need Adobe Acrobat Reader).

Of course, the second question is how to bring about this shift. It will definitely take the political will of the vast majority of Canadians as well as of local, regional, provincial and national decision-makers. The bigger question is how to create this political will. Working for change can take many forms including information-sharing and community education; participating in research about rural health issues; organizing community coalitions to lobby and initiate social action aimed at policy change; creating local and regional women's health networks; running for political office locally and beyond; working to change the electoral and political process to one that is more participatory. In short, it requires activism. And given that women are both the biggest users and providers of health care (as paid and unpaid caregivers), we have a huge role to play in bringing about this shift in thinking and policy.

One example of a community initiative took place a few years ago in my home town of Prince George. We organized a rally of 7,000 citizens (that completely filled up our local ice rink!) to let the government know how we felt about the inadequate health services available in our community. As a result, we now have a medical program at our local university training doctors and a masters program training Family Nurse Practitioners. Both are expected to result in many more health professionals not only trained in a northern environment, but staying here to practice their skills.


4. Q: I am relatively new to the North, less than a year, but have been surprised by what I have seen in health care up here. I live in the NWT and am expecting a baby soon. I have always used midwifery care before, and now find it unavailable in my area. The local standard of care is quite conservative and I am surprised that in an area this remote there is not more of an effort to 'think outside the box' and provide care that meets women where they are. The local hospital and medical community has developed a very rigid set of procedures and there are not many choices. I thought that in a place like this the opposite would be true. What are your thoughts on this?


A: I am actually not that surprised by the situation you are facing. In locations where resources are limited, there can sometimes be a tendency to follow established policy and procedures, particularly if there is funding attached to established programs and services. At the same time, rural and remote communities are often the ones that come up with the most innovative solutions to health and wellness issues, simply because they have no other choice.

A primary health care model (see answer to question 3) probably better reflects the kind of health care you were expecting. And I'm certain that there are women in NWT who are working toward such a model. With regard to birthing, you may want to connect with the Midwives Association of the NWT to get further information about their activities and availability.

As part of the new way of looking at health care service provision, there is also a growing move toward training nurse practitioners as leaders and educators in primary health care. These practitioners are being trained to provide a wide range of health services from a holistic health perspective and are particularly valuable in rural, remote and northern communities. You may want to check out the new Master in Nursing Science: Family Nurse Practitioner at the University of Northern British Columbia site as one example of this trend.


5. Q: I really wonder how this work in eastern Canada has any relevance for women in BC, let alone rural remote such as the women on Haida Gwaii? The resources, environment, funding and socio-economics are so completely unique to our area alone. Please help me to understand how a Toronto data base and website can assist BC rural women.

A: I think the internet is a tool that we can harness to develop a community of women that crosses geographic barriers. It creates the possibility to both address issues facing women in specific regions as well as bring women together to tackle broader national concerns. Women's Health Matters, although located out east, seeks to provide information that is valuable to women from all parts of the country.

The beauty of information and communication technology (despite some difficulties with access and dial-up in remote regions that need to be addressed) is that we cannot only access information from thousands of miles away, but develop our own material, share our own experiences and make these available to other web-based sites across the country (and beyond). In many ways, the internet is the great equalizer. So, for example, health-focused networks that we are building in BC, such as the Women North Network/Northern FIRE that I'm involved with (http://www.womennorthnetwork.com), can provide Women's Health Matters with information that is most relevant to northern, rural and remote women across Canada.

Through this exchange of experience, we can strengthen the women's health movement on a national level and make more women aware of the issues faced in rural communities.

Women's Health Matters is also the women's affiliate of the Canadian Health Network, so there is a substantial collection of women-centered information available from both sites. And there are a growing number of women's health organizations in BC that are contributors to the women's affiliate. But most important, in my view, is that connecting with women out east and across the country provides an opportunity for us to support each other in our region-specific struggles and develop joint strategies to address health issues that are impacting women in all parts of Canada.

So while I don't think Women's Health Matters can replace the need for developing local and regional women's health networks, I do think it has an important role to play.


6. Q: I find that rural women (being one)have to waste so much time with rural physicians before we can have access to specialists, etc. Often by then the condition has worsened... it seems we have to wait such a long time for appointments. For example: April a phone call from family physician to uro/gyn clinic...date of appointment? December. I was lucky enough to be able to go the 100-mile trip with little or no notice for a cancellation in August. A position not a lot of people are in. At the present time there is no gynecologist within 100 some miles from this rural place...the one and only retired last year...a sad state of affairs.
Ottawa Valley

A: It is absolutely a sad state of affairs! Some of my thoughts about a different approach to health care (prevention, health promotion, community-control) and how we might get there are in the answer to question 3 and 4 above. Another means of improving access would be the further development of tele-health, so that specialists could be more readily available via technology, if not in person. Providing funding for travel to out-of-town appointments could also be an interim measure. But there are other facts that make lack of access to appropriate health care even more difficult to take. Rural and remote communities often provide substantial resources and tax dollars to more southern, urban centres - through resource extraction (mining, logging, oil and gas, etc.) as well as farming and ranching. Yet, our communities do not receive benefits from this wealth that we create. And health care is certainly a case in point. As northern, rural and remote communities, we need to organize ourselves to put this fact on the political agenda and to insist on receiving the health and other social infrastructure to which we are entitled.


7. Q: Hi. I have never been comfortable with a male doctor doing certain examinations. However, I live in a small rural town where the only doctor is male. I have no problem going to him if I have a sore throat or something, but I am not undressing in front of the man. And, of course, Pap tests right now are out of the question. There is a larger town about a hour's drive away where a couple of female doctors practice. They won't see me though, because I already have a primary care doctor where I live. What should I do?

A: In terms of the immediate problem, you may want to explain to the female physicians in the nearby town that you only wish to see them for pap tests and related matters, if you haven't already. Perhaps with that explanation, they'd be willing to accommodate you and send a report to your family doctor. Alternatively, you may want to contact the closest women's organization or Centre of Excellence for Women's Health, Women's Hospital or women's health network for other alternatives that they may know of. Or you could travel periodically to the nearest town where there is a walk-in clinic with a woman physician. Of course, you shouldn't have to go through this rigmarole in order to access a physician of your choice.

There are a range of barriers to women seeking reproductive screening including cultural issues, past sexual and physical abuse issues, lack of physicians in some communities, and lack of female physicians, as you are experiencing. There are also a number of new initiatives taking place that might be of interest to you.

I'm not sure what part of the country you are from, but there is a project taking place in British Columbia through which nurses are being trained as Advanced Practice Nurses who will be doing the reproductive screening - pelvic exams, pap tests and clinical breast exams. A key feature of the training going on in BC are the Teaching Associates (women who make themselves available for training purposes) who are grounded in feminist philosophy and assist physicians and nurses in learning how to do pelvic and breast exams in ways that are responsive to women's needs. You could contact the Northern Health Authority for further information about this women's health initiative.

For more thoughts about how to tackle the bigger systemic issues, you might find the answers to questions 3, 4 and 6 helpful.


8. Q: I am very interested to learn more about something I read about recently in a scientific magazine. It showed surgery being performed remotely in a northern town that didn't have its own facilities. The doctor was in a large city centre using a computer and the surgery was done thousands of miles away with a robotic arm device, while nurses and other health-care support people stood by. Is this type of thing really being done right now, or is this science fiction? If it is real, is it done in Canada? Would the cost of this type of service ultimately be more economical and less invasive than transporting a very sick person miles away from home when they need surgery? Is this the way health care is going?

A: What you are talking about is a type of telehealth - harnessing technology to make use of the skills of medical personnel located in larger, urban centers to address the health care needs of residents in rural, remote and northern communities. The remote surgery technique you read about is known as telerobotics. It can also be employed in training medical personnel, known as telementoring.

Telerobotics employs cutting edge technology to reproduce a surgeon's natural finger, hand and wrist movements via a robot that may be used in a surgical procedure hundreds of miles away. Telementoring uses the same technology to harness the skills of an experienced surgeon to train a less experienced surgeon, or one unfamiliar with a particular technique, who works in a remote location. In the long run, it is hoped that this revolutionary approach to surgery and mentoring will help overcome some of the access and training issues faced by residents and physicians in rural and remote communities.

The Centre for Minimal Access Surgery at St. Joseph's Hospital in Hamilton, Ontario, supported by the Faculty of Health Sciences at McMaster University, has received substantial funding from Health Canada in order to study telerobotics and telementoring and to test them in rural, remote and northern Canadian communities. This revolutionary work, tested at sites in North Bay, Ontario and Chicoutimi, Quebec, is receiving international recognition. And, although telerobotics as a routine approach to rural medical may be some years off, it's certainly looking like it could become a integral part of rural health care delivery in the not too distant future.

You will find a recent report about this telerobotics initiative here.



9. Q: I live in an Aboriginal community in northern Manitoba. My mother has diabetes and so does one of my brothers. I am concerned because I have heard that Aboriginal women have a much higher rate of diabetes, but I don't know why. The local doctor here just tells me to stay healthy by eating right and exercising, but I am not satisfied that I am getting all the advice I should. Are there any sources of information where I can learn more? Is there any way I can help protect myself from getting this disease - or is inevitable, based on my genetics?

A: There are a number of information sources that you may want to check out. An organization called Healthy Eating and Active Living (HEAL) located in northern British Columbia would be a good start. HEAL is a grassroots initiative brought about by local people. It incorporates a network of community initiatives across northern BC that focus on access to healthy foods and physical activity, both of which (as your doctor pointed out) can prevent or decrease the risk of developing Type 2 diabetes and other chronic diseases. Now overseen by the Northern Health Authority, HEAL is one of the projects funded by Health Canada as part of the Canadian Diabetes Strategy. One HEAL site that specifically addresses Aboriginal peoples and diabetes can be found here.

Another source of information you should find helpful is the Aboriginal Diabetes Initiative. Good luck!


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