conceptual guide to the health care module: conceptualizing health care work
Prepared by Pat Armstrong, Kate Laxer, Hugh Armstrong
Categories, and their definitions, matter. All social data are gathered based on a particular framing of questions. These questions themselves reflect a specific way of seeing and understanding social factors, forces, processes and relations. The answers to questions are then grouped into categories based on concepts of both what is important and how aspects relate to each other. As Deborah Stone, the noted American feminist puts it, no number is innocent (Stone 130).
Because concepts matter in the production and configuration of social data, this paper explores the concepts at work in Statistics Canada data on the health care industry. It begins by looking at how health care is defined, because the understanding of care shapes the data on who is included or excluded as workers in care. The concepts behind the data, we argue, indicate ways of seeing health care work that are integrally related to the undervaluing of women's work and that ignore critical perspectives on health. These concepts in turn are linked with those defining public and private care in the formal economy, the community and the household. Like other categories, those on the structure of work and workplaces reflect simultaneously actual changes in the work organization and conceptualizations of those changes. Similarly, the categories used for the collective organization of care providers into unions and professions both indicate how people resist and ideas about differences in forms of resistance. Finally, the paper turns to the data on the health of health care workers, arguing that while the data records alarming rates of illness and injuring, the gendered nature of the work and of the definitions for workplace hazards are largely ignored.
The purpose of this paper is to suggest questions that need to be asked before the data in this module are used and to provide some analysis of the data available to develop a picture of work in the health care industry.
women, health and care
A gendered analysis of health care work requires an understanding of what is meant by health and care. How we conceptualize the distinctions has profound implications for what is included in our analysis, as well as how we approach the analysis. In 1947, the World Health Organization (WHO) defined health as "a state of complete physical, mental, and social well being and not merely the absence of disease and infirmity" (WHO 1986). This definition grew out of and contributed to what has come to be known as a determinants of health approach. It was reflected in Canada by the Lalonde Report, a seminal document produced by the then federal Minister of Health and Welfare (Canada 1974).
From this perspective, health is also socially constructed rather than simply biologically determined or technically produced. According to the 1986 Ottawa Charter, a product of the First International Conference on Health Promotion, "Health is created where people live, love, work and play". The Ottawa Charter defined health promotion as "the process of enabling people to increase control over and to improve their health" (Canada 1986). Creating health means building healthy public policy; creating supportive work, home and community environments; strengthening community action; developing personal skills; and reorienting health services to be health promoting rather than simply treatment focused. The subsequent Adelaide Conference in 1988 defined health as a fundamental human right and stressed the importance of equity, identifying improvement of women's health as a priority not only because women suffer from inequality but also because they are critical in the daily promotion of health. Three years later, the Sundsvall Conference in 1991 highlighted the spiritual, social, cultural, economic, political and ideological dimensions of environments (http://www.who.ch/). In other words, a determinants of health approach tells us that health is critically influenced by social and physical environments, by relations as well as by structures or technologies, and not only by genes.
Health is thus created everywhere, not only within the formal health care system. And it is created in classed, racialized and gendered ways. Feminists throughout the world have emphasized the centrality of gender in the creation of health, and the gendered consequences of subordinate relations and conditions. These relations, relations that are critical in determining health are relations of ruling, as Clement and Myles (1994) put it, with women participating on unequal terms with men. The Fourth World Conference on Women (the Beijing Conference, 1995) agreed that "Women's health involves women's emotional, social, cultural, spiritual and physical well-being and is determined by the social, political and economic contexts of women's lives as well as by biology". These conclusions were based on and contributed to a broad literature establishing the invisibility and under-valuing of women's health and women's health care work. Equally important in this literature is the question of differences among women, differences related to their various social, cultural, physical and economic locations as well as to their abilities.
Canadians have been active participants in the construction of the social determinants of health approach, and in the demand for a gender-sensitive analysis and strategy in health. Health Canada recognizes 12 distinct determinants of health, although the list has changed over time (Robertson, 2001?). Indeed, any such listing is necessarily arbitrary, informed by ideology as well as by evidence. Moreover, the elements overlap and interact with each other in ways that challenge any notion of firm divisions. Like biology and gender, the other ten health determinants are changeable, albeit in the context of what is inherited in a particular society. The determinants are all about political choice and about material conditions, about both the collective and the individual. And they are all about gender.
The 12 are worthwhile considering precisely because they reflect all these aspects of policy and the social construction of data.
1. Biological and Genetic Endowments. Women's bodies are different from those of men, and thus so too are their health issues. However, there is an enormous variation among women and not everyone can be easily sorted into a male or female biological category. The acknowledgement of sex differences often means a focus on reproductive health (breasts and babies), but the range of issues is much broader (e.g., indications of heart attack, processing of pharmaceuticals, responses to work environments). Biology is often seen as unchangeable, but in fact it is influenced by social contexts, contexts that are unequally structured for women and men as well as for different groups of women (e.g., lowered average puberty age and increased average height with improved living standard, class differences in birth processes). Even genes can be influenced by the environment and their meaning is influenced by the environment.
2. Gender. This term is of course used to draw particular attention to the social construction of female/male differences. Gender is an important feature of how individuals experience a world characterized by systematic patterns of oppression, with widespread inequality along structural, social and ideological dimensions. One expression of this is unequal opportunities by gender for health and health care. One result is the development of gender-based analysis, a tool for understanding, and improving how public policy is made. Such an approach does much more than analyze data by sex; it takes into account the contexts and relations in women's lives. Thus, another is the adoption of research strategies that begin with the daily activities that shape the lives of women and men. In addition to being a specific determinant, gender pervades all the other determinants.
3. Income and Social Status. It should be noted that this Health Canada category is not titled Class and Power, reflecting a particular view of material inequality. Nor does it address issues of wealth. It nevertheless recognizes some inequality linked to money and to ideas about worth. Research has established that industrial societies with the narrowest income disparities (e.g., Japan, Sweden) have the best health outcomes while those with the widest disparities (e.g., US, UK) have the worst outcomes (Wilkinson 1992). In other words, the greater the inequality in a society, the poorer the health of its population. Moreover, within a society, there is a positive statistical relationship between higher incomes and better health, throughout all income levels. The richer you are, the better you chances of enjoying good health. Women have less income than men from wages and salaries and from property. Particularly hard-hit are lone mothers in Canada, 56% of whom are living below the Statistics Canada poverty line (Statistics Canada 2000). The absence of a universal child care program for pre-school children in all but Quebec makes it very difficult for such women to participate in the paid labour force. Meanwhile, reductions in state welfare support severely limit their income when they do stay home to care for the children. Sharp reductions in the number of people cared for in hospitals or other institutions further adds to their workload, as is the case for most women.
4. Employment. Unemployment is bad for one's health. Although women now make up 46% of Canada's labour force, their official unemployment rate has in recent years been slightly lower than that of men. Women are however more likely to be discouraged from actively seeking paid work, both because they have family responsibilities and because they face discrimination in the labour force. They are thus less likely to be counted as part of the labour force or of the unemployed. In other words, unemployment rates are likely to undercount women's unemployment. Underemployment and precarious employment can also be bad for one's health. Women are much more likely than men to be working part-time and part-year while seeking full-time, full-year work, and thus to be in effect partially unemployed. Women are also more likely to be what Statistics Canada calls own-account self-employed. As Vosko and Zukevich (2003) point out, such work is often just another form of part-time, precarious employment. Indeed, even when women have full-time, full-year paid work, their employment conditions and pay often make the work precarious (See the module on precarious employment relations). And because almost all women have a second job at home doing the domestic and caring work. they face the unhealthy stress of managing two jobs. In the labour force as at home, women perform different jobs than do men. Sex segregation in paid work means that women are more likely to be in low status/high stress jobs, jobs that undermine health (Armstrong, 1996). However, their health hazards usually go unrecognized because it is women's work (Messing, 1998; Vogel, 2003).
5. Education. The more education a person has, the better their health is likely to be. Following long struggles for equal opportunity, Canadian women are now more likely than men to have completed secondary school and college, and are as likely to be enrolled in undergraduate university degree programs. They tend to be enrolled in different programs, however, leading to different jobs and pay levels. As tuition fees are hiked, women are more likely to be discouraged because women tend to have more limited access to resources. Educating women has a large impact on the education of children, in health as in other matters.
6. Physical Environments. Physical environments include traditional public health concerns such as clean air and water, pure food and drugs, housing and aggressive actions against infectious disease. They also include such factors as gun control and street safety, transportation (especially public mass transit which is used disproportionately by women and children) and access to natural light in workplaces. Household hazards such as cleaning materials, and chemicals are also an issue for women in particular, since women do more domestic work and spend more time at home than men (Rosenberg, 1990). Equipment and light, space and time are all part of the physical environment which, like the rest, affect, and are affected by, gender differentially.
7. Social Environments. Environments are not only about physical structures. They are also about social relations. Most women are less powerful than most men and therefore less able to resist sexual harassment and violence. Power also varies with racialized groups and immigration status. Men are more often involved in violence, however, and frequently suffer physically as a result. Values too are part of the environment that influences health. Both women and their work are often undervalued compared to men. Moreover, dominant attitudes can also undermine health. Welfare policies, for example, reveal the gendered ways in which society is organized. Reductions in assistance rates affect women in particular, because they are the majority of those on welfare, and the reductions do more than lower income; they also send a message about worth. So too do 'spouse-in-the-house' rules for welfare eligibility which disqualify women, but not men, who are judged to be living with partners of the other sex.
8. Social Support Networks. Social support is critical to health, and women are more likely to give and receive such support than men. Women are more likely to foster social contacts, which are healthy. However, they are also more likely than men to live alone because they tend to marry older men, to live longer. Compared to previous generations, women have fewer children, and see those few children leave home and move to other communities, often hundreds or thousands of kilometres away. 9. Healthy Child Development. This health determinant cannot be separated from conditions for healthy mothers, although it is often presented as if this were the case. Ages 0-5 are now viewed as particularly important for mental and physical growth, but social supports for childrearing, such as child care services and welfare payments, have been reduced in recent years at the same time as the pressure on women to work for pay has increased. Yet mothers are still held primarily responsible for child development and are too often blamed when things go wrong.
10. Personal Health Practices and Coping Skills. While the previous health determinants are at least as much social and collective as they are individual and personal, this determinant is primarily defined as being about our own habits and the initiatives taken to maintain, improve or risk our health. Yet mothers are often held responsible, blamed for their partner's and children's nutrition, personal hygiene and health education. Moreover, the interpretation of this determinant usually ignores the role social structures play in creating our possibilities for healthy life styles and behaviours.
11. Culture. The term culture is used, but it could be interpreted to encompass the health hazards of racialization as well. As is the case with income and social status, the terms used imply a particular way of viewing social relations. Canada is described as a multicultural society, with annual immigration exceeding 200,000, from all corners of the world. Immigrants frequently experience a decline in health status after they come to Canada. There are multiple reasons for this decline, including immigrant women's more limited access to training in one of the two official languages which restricts their ability to participate fully in Canadian society. Meanwhile, the Aboriginal peoples who make up about 6% of the population have appreciably lower health status than the rest of Canadians, including immigrants. There are some strategies underway to combat racism, to curb the global transfer of diseases, and to ensure equitable access to health education and health care, but there is still a long way to go.
12. Health Services. Health services are defined as only one of the determinants of health. Health services are fundamentally a women's issue (Armstrong et.al. 2002; grant et.al. 2004). Women are the overwhelming majority of those providing care. They are also a majority of those receiving health care, although they are a minority of the formal decision-makers in health services. Thus, changes in care such as increased financial or other barriers particularly affect women, especially given their lower incomes. Differential treatment issues are just beginning to enter public media and health care practices themselves. For example, there is evidence of more diagnosis of heart attacks in men and of symptoms as solely psychological for women, resulting in more prescribing of mood-altering drugs for women and surgery for men. These determinants reflect a shift in thinking from an exclusive emphasis on curative to health promotion approaches, at least in theory and policy discourses.
In spite of the emphasis on the social, however, this list of determinants largely ignores the larger issue of political economies and power inequalities at the global, national and local levels and the ways political economies influence health and care. The most popular determinants of health approaches provide no context for the social determinants of health (Poland et.al., 1998). And there is little explanation for changes over time or among groups, except for those explanations that look to individual practices or values. 'Globalization' is usually seen as primarily a matter of international trade in goods, services and to a lesser extent people. Yet the international, unequal movement of capital, of information, of culture and of workers sets the stage for each of these determinants. International agreements are negotiated and enforced mainly through the World Trade Organization (WTO). The most obviously relevant for health are TRIPS (Trade Related Aspects of International Property Rights), important for drug patents and patenting life forms, and GATS (General Agreement on Trade in Services), given that in the industrialized world such services account for two-thirds of all jobs. Whether Canadian health care is subject to these agreements is a matter of debate, although the Romanow Commission on the Future of Health Care (Canada, 2002: chap.11) has warned that the public system of care is at risk and urges clarification to protect public care. The rules for health care workers are even less clear. However, there is no question that there is a large international market in female-dominated occupations such as nursing and that global agreements influence health and care.