Social Determinants of Women's H

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					  Genuine Progress Index for Atlantic Canada
    Indice de progrès véritable - Atlantique

 Social Determinants of
Women’s Health in Canada
 Health Canada Policy Forum,
     Ottawa, 9 October, 2003
Pop. health context: Romanow and
 the 3 burning health policy issues
  1) How to treat the sick - supply side
  2) How to improve the health of
  3) How to check spiralling health care
    costs - demand side
  The next Royal Commission......
  Practical: High portion of
illness burden is preventable
Excess Risk Factors Account for:
• 40% chronic disease incidence
• 50% chronic disease premature mortality
• 25% direct medical care costs
• 38% total burden of disease (includes
  direct and indirect costs)
 Why a Gender Perspective
1) Descriptive: Women have distinct health
  needs. Causes / outcomes differ by gender
2) Normative: Ensure equal treatment,
  overcome biases that impede wellbeing
3) Practical: Blunt, across-board solutions
  often miss mark, waste money. Gender
  analysis allows policy makers to target
  health dollars
  Practical: Women’s use
     of health services
• Canadian women have higher rates of:
  – chronic illness, physician visits
  – disability days, activity limitations
  – lower functional health status
• In every age group to 75, women more likely
  see physicians than men. Overall - 33% more
  likely; age 18-54 - 2-3x
E.g….. Teenage smoking
• Teen girls higher rates than boys
• Young women have 2x stress cf young men
• Surveys: young women say stress relief and
  weight loss = primary reasons for smoking
• Therefore programs, brochures, counselling
  targeted to girls more effective than blanket
  one-size-fits-all health warnings
  1998 Federal Health Minister
• “I have undertaken to fully integrate
  gender-based analysis in all of my
  Department’s program and policy
  development work...”
• “ enhance the sensitivity of the health
  system to women’s health issues...”
• “...more research...on the links between
  women’s health and their social and
  economic circumstances.”
1) Income: What does it have
 to do with women’shealth?
 • Poverty most reliable predictor of
   poor health, premature death, disability:
   4x more likely report fair or poor health
 • Low income- higher risk smoking,
   obesity, physical inactivity, heart risk
 • Costly: increased hospitalization:
   Women 15-39 = +62%; 40-64 = +92%
……health of single mothers
• Worse health status than married
  (NPHS); higher rates chronic illness,
  disability days, activity restrictions
• 3x health care practitioner use for
  mental, emotional reasons = costly
• Longer-term single mothers have
  particularly bad health (Statcan)
Low income children- at risk -
        31 indicators
• More likely to have low birth weights, poor
  health, less nutritious foods
• Higher rates of hyperactivity, delayed
  vocabulary development, poorer
  employment prospects.
• Less organized sports, but higher injury
  rates, and 2x risk of death due to injury than
  children who are not poor.
 A/c Roy Romanow……:
• “If you’re at the bottom of the
  income ladder, odds are you’re
  going to find yourself at the
  bottom of the health ladder.”
• “So, if we’re serious about making
  Canadians the healthiest people in
  the world, then we have to be
  serious about closing the gap
  between rich and poor.”
Prevalence of low income-
women and men: 1991-2000
Low-income children
under 18, 1991-2000
Income: Female lone-parent
    families - 1997 & 2000
Trend:Low income rates of children:
 Single mother families ---1991-2000
Employment of Female Lone
    Parents 1976-2001
 Low Incomes :     1991-2000
Single mothers w/out paying jobs
        The Economics of
• Single mothers with pre-school children
  spend 12% income on child care cf 4% in
  2-parent families. In one pocket .........
• CPI for child care, restaurant good rises
  faster than wages
• Robin Douthitt: “time poverty”. Full-
  time single mothers = 75 hour week
      2) Equity and health
“What matters in determining mortality
 and health in a society is less the
 overall wealth of the society and more
 how evenly wealth is distributed.
The more equally wealth is
 distributed, the better the health
 of that society.”
       ----- British Medical Journal 312, 1998
If Equality->Health, What are Trends?
Average Disposable H’hold Income Ratios, 1980-98
                       Richest 20% : Poorest 20%
                        1980      1990     1998
Canada                   8.2      7.1     8.5
Newfoundland             7.6      5.8      7.3
Prince Edward Is.        7.4      6.2      6.7
Nova Scotia              7.1      6.2      8.5
New Brunswick            6.7      6.1      7.0
Quebec                   7.6      6.9      7.9
Ontario                  7.8      7.1      8.3
Manitoba                 8.8      6.7      7.6
Saskatchewan             8.1      7.3      7.4
Alberta                  9.1      7.4     10.4
British Columbia         9.3      7.6      8.0
GINI coefficient 1991-2000
Despite growing educational
     Gender wage gap remains
-   Ratio of Female to Male Hourly wages: 1997-2001

          1997 1998   1999 2000   2001
Av. hrly 81.5% 81.3% 80.9% 80.5% 80.7%
          78.5% 78.1% 79.1% 77.2% 79.8%
Av. hrly
          82.9% 82.5% 82.3% 81.9% 82%
Av. wkly
          69.1% 69.2% 69.4% 69.3% 69.5%
  Explaining the gender wage
• Convergence of women’s hourly wages
  stalled…. despite clear educational gains.
• After controlling for hours worked, educational
  attainment, work experience, industry,
  occupation, and socio-demographic factors,
  StatsCan concluded that: ……..
• ….“roughly one half to three quarters
  of the gender wage gap cannot be
  explained.” (2001)
Regional wealth gap grows:
  e.g. Atlantic cf Ontario,
• 1990 = $0.82 disp.income NS for $1 in
  Ontario. 1998 = $0.73

Financial Security Atlantic Canada
• 1984: 5.4 % of national wealth.
• 1999: 4.4 % “          “
(7.8% of Canadian population)
 Share of national wealth vs.
population     (1984 & 1999)
    Wealth gap in Canada:
• Richest 10% own 53% of wealth
• Richest 50% own 94.4%, leaving 5.6% for
  poorest 50%
• Poorest ¼ of Canadians own 0.1% (or
  one-thousandth of wealth)
• Among poorest 20%, 1/3 fell behind 2+
  months in bill, loan, rent, mortgage
= Importance of diversity approach
     3) Employment- a key
     determinant of women’s
• Both overwork and unemployment
  are stressful- (Japanese study)
• Polarization of work hours -increasing
 the level of inequality in family earnings.
• Women’s health - function of paid + unpaid
 work - gender division of labour in household
• Women doubled employment, BUT still
 do nearly two-thirds of household work.
 % of Women and Men
Employed Canada 1976-2001
 Women with young children -
 sharpest increase in employment,
Since 1976:
   women without children have increased
    their employment rate by 26%;
   women with youngest child 6-15 by
   women with youngest child 3-5 by
   women with youngest child 0-2 by
Employed women with
   But distribution is
uneven -Employment and
• 75.4% of female university graduates
  have a job, cf 79.3% of male graduates.
• But… women with less than grade 9 are
  less than half as likely to be employed as
  males – 13.6% of women cf 29.4% of men
• Gender analysis not just m/f but
  diversity - sub-groups of women - esp.
   Women increased professional
I.e. strong educational improvement
Job security - temporary work
Job security – union coverage
High decision latitude at work
Official unemployment rate
Unemployment +
Youth unemployment 15-24
explains entire gender gap
4) While f-t women work 39 hrs cf
  43 - men Women still do most
        unpaid housework
 Employed mothers (f/t) work
 average 75-hr week - pd+unpd
Statcan: Women moving to longer work hours:
• 4x likely smoke more, 2x likely drink more
• 40% more likely decrease physical activity
• 80% more likely have unhealthy weight gain
• 2.2x more likely experience major depressive
  episodes cf women on standard hours
Stress and health behaviours -
Less stressful alternatives
Social supports are important

• Social networks may play as important a
  role in protecting health, buffering against
  disease, and aiding recovery from illness
  as behavioural and lifestyle choices such as
  quitting smoking, losing weight, and
  – See: Mustard, J.F., & Frank, J. (1991).The
   Determinants of Health. (CIAR Publ. No. 5).
Social Supports: pop. 12+, 2001
      Social Supports-
Volunteerism - a saving grace
 • Health Canada uses volunteerism as a
   key indicator of a “supportive social
   environment” that can enhance health.
 • Volunteerism declining: 1997-2000
   Canada lost 960,000 volunteers.
      1997 = 29% men, 33% women vol’d
      2000 = 25% men, 28% women
 • Remaining volunteers work 9% more
Family violence = key indicator
      of women’s health
  • CIHI, Statcan identify crime as “non-
    medical determinant of health.” But
    women’s health analysis requires
    special indicators - family violence, like
    unpaid work, is key indicator.
  • Family identified as key pillar of social
    support - determinant of health. But
    family violence may undermine social
    support, health
     Family=high % of all
• Spousal violence = 18% of all violence
  reported to police.
• Women = 85% of all reported spousal abuse
  = 6x rate for men
• Nearly 1/3 of all reported female victims of
  violence in Canada attacked by spouse
• Unreported - much higher = 8% all women
  with partner attacked past 5 years.
 Aboriginal women’s health
• Life expectancy = 76.2 cf 81 (non-Abor.)
• Higher rates hypertension, cervical cancer,
  circulatory & respiratory diseases
• Diabetes = 3x non-Abor. Fem = 2x male
• HIV/AIDS = 2x non-Abor. 50% female
  Abor AIDS cases = IV drug use cf 17%
• 9% Aboriginal mothers under 18 cf 1%
Aboriginal women’s health
• 3x mortality due to violence. 25-44 =
• Alcohol-related accidents = 3x
• Fetal alcohol syndrome. Over 50%
  view alcohol abuse as problem in
• 3x suicide rate cf non-Aborig. women
 Regional disparities require
special attention / intervention
           E.g Cape Breton….
 • High unemployment and low-income rates,
 • Much higher incidence of chronic illness,
   disability, and premature death than Halifax
 • Highest age-standardized mortality rate in
 • Highest death rate from circulatory disease,
   heart disease in Maritimes – 30% above nat.av.
Of 21 Atlantic health districts, Cape
    Breton has highest rates of:
   • Cancer death (231.8 per 100,000) – 25%
     higher than the national average, lung
   • Deaths due to bronchitis, emphysema, and
     asthma (9.2 per 100,000) –50%+ higher
     than the national average
   • High blood pressure– 21.7%, (24.3%
     women 19% men = 72% higher than the
     Canadian rate. The next highest rates are
     in south-southwest Nova Scotia
  Cape Breton = highest:
• Arthritis and rheumatism: 31% of women,
  23% of men
• Activity limitation (34%), followed by
  Colchester, Cumberland, and East Hants
  counties (30.1%)
• Life expectancy: 72.8 years for men, and
  79.4 for women. (Canada: 75.4 years - men
  and 81.2 years -women
Disability-free life expectancy
 • Cape Bretoners have an average
   disability-free life expectancy of only
   61.8 years, seven fewer than the
   national average, and the lowest of all
   the 139 health regions in Canada.
 • This means that Cape Bretoners can
   expect to live considerably more years
   with a disability than other Canadians.
  Potential years of life lost
• highest number of potential years of life lost
  due to both cancer and circulatory diseases.
• Cape Bretoners lose 2,261.9 potential years of
  life per 100,000 population due to cancer –
  41% higher than the national average of
• and they lose 1,684 potential years of life per
  100,000 population due to circulatory diseases
  – 65% higher than the national average of
    Women have generally
    healthier behaviours
• Women healthier diets. 5+ servings
  fruit/veg/day: F = 43%; M = 32%
• Daily smokers: F = 19%; M = 24%
• Overweight (BMI = 27+): F = 28%, M =
  36% Obesity (BMI = 30+):    F = 14%, M
  = 16%
• Heavy drinking: F = 11%, M = 28%
But female smoking rates
declined later and slower
      Teen Smoking rates by Gender
        age 15-19,  1996 vs. 2001


                      24%                                24%



               1996                               2001

                            Male   Female
More women physically
    Health behaviours vary
e.g.: % Overweight, pop, 20-64,   2001
 Mammogram: Women, 50-69,
routine screening within last two
           years, 2001
 Cape Breton, W. Nfld = low
mammogram screening, high
  breast cancer death rate
    Pap smear test
% of women 18-59 years, 2001
  The physical environment is an
  important determinant of health
  - Health Canada
“At certain levels of exposure, contaminants in our
  air, water, food and soil can cause a variety of
  adverse health effects, including cancer, birth
  defects, respiratory illness and gastrointestinal
Factors relating to housing, indoor air quality, and
  the design of communities and transportation
  systems can significantly influence our physical
  and psychological well-being.”
    Access to Health care
• Women use more health care services than
  men, thus are disproportionately affected
  by barriers.
• Atlantic Canadians have greater difficulties
  accessing care than most other Canadians.
• The barriers result from less availability of
  key health care services in rural areas,
  rather than from longer waiting times.
   In Sum:
• Women have distinct health issues.... that have
  social and economic roots
• Diversity approach –special needs of Aboriginals,
  disabled, minorities, recent immigrants,
  disadvantaged regions, etc.
• 3 interventions that can improve women’s health,
  save health costs:
     1) reduce time-overwork stress
     2) eliminate gender wage gap
     3) reduce poverty of single parents
      Can it be
Improving women’s health
  today will benefit future
 generations of Canadians
Genuine Progress Index for Atlantic Canada
  Indice de progrès véritable - Atlantique