Women s Health Surveillance Report Supplementary Chapters
The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada. The report is available as a summary (the present document), presenting the key findings and recommendations of each chapter, and as a full technical document, available in English and French on the CPHI and Health Canada Web sites (www.cihi.ca and www.hc-sc.gc.ca). Contents of this publication may be reproduced in whole or in part provided the intended use is for non-commercial purposes and full acknowledgement is given to the Canadian Institute for Health Information. Canadian Institute for Health Information 377 Dalhousie Street Suite 200 Ottawa, Ontario, Canada K1N 9N8 Telephone: (613) 241-7860 Fax: (613) 241-8120 www.cihi.ca ISBN 1-55392-511-4 (PDF) 2004 Canadian Institute for Health Information Cette publication est aussi disponible en français sous le titre : Rapport de surveillance de la Santé des femmes Chapitres supplémentaires ISBN 1-55392-512-2 (PDF)
TABLE OF CONTENTS Integrating Ethnicity and Immigration as Determinants of Canadian s Women Health... 1 Health Care Utilization by Canadian Women... 5 Integrating Socio-Economic Determinants of Canadian Women s Health... 7
Women s Health Surveillance Report INTEGRATING ETHNICITY AND IMMIGRATION As Determinants of Canadian Women s Health * Bilkis Vissandjee (University of Montreal); Marie Desmeules (Health Canada); Zheynuan Cao (Health Canada); Shelly Abdool (University of Montreal); Arminée Kazanjian (University of British Columbia) Health Issue Given the increasing diversity of Canadian society, ethnicity and immigration experiences are both important issues to consider when examining the social determinants of women s health. There is a considerable body of research on the relationship between ethnic background and health. As well, it has been shown that various mechanisms affect the relationship between immigration and health. Recent immigrants are generally less likely to have chronic conditions or disabilities than the Canadian-born population, but this healthy immigrant effect diminishes over time. The evidence suggests that the immigration experience itself, as well as some socio-economic determinants such as poverty, lack of education and lack of employment, are strongly correlated with immigrants health. Although self-reports of health are widely used and valid measures, they have not been used as frequently to describe the health of populations with a diverse ethnic background who undergo immigration. This chapter investigates: 1. the association between ethnicity and immigration, as measured by length of residence in Canada, and two specific self-reported outcomes: (a) self-perceived health and (b) self-reported chronic conditions; and 2. the extent to which these selected determinants provide an adequate portrait of the differential outcomes on Canadian women s self-perceived health and selfreported chronic conditions. The 2000 2001 Canadian Community Health Survey (CCHS) was used to assess these associations while controlling for selected determinants such as age, sex, family structure, highest level of education attained and household income. * The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada. 1
INTEGRATING ETHNICITY AND IMMIGRATION As Determinants of Canadian Women s Health Key Findings Data from the 2000 2001 CCHS indicate that 21% of women and men aged 18 and over were born outside Canada, and that 8% of immigrants have been in Canada for two years or less. Data from the CCHS indicate that 75% of immigrant women and men aged 65 and over selfidentified themselves as having a Western European origin. Recent immigrant women (two years or less in Canada) were less likely to report poor health than Canadian-born women (OR, or odds ratios: 0.48). This healthy immigrant effect disappeared over time in Canada. Immigrant women who have been in Canada at least 10 years were more likely to report poor health than Canadian-born women (OR: 1.31). Among men, the healthy immigrant effect also decreased with years in Canada. However, unlike immigrant women, when immigrant men had been in Canada for at least 10 years, they reported self-rated health similar to Canadian-born men. Female immigrants from South Asia were the only ethnic group that was more likely to report poor health than Canadian-born women (OR: 1.42). Among men, only those who self-identified themselves as Western European immigrants were more likely to report poorer health than Canadian-born men (OR: 1.16). Although immigrant women were less likely to report chronic conditions than Canadian-born women, this health advantage decreased over time in Canada (OR: 0.35 to 0.87 for 0 to 2 years to 10+ years compared with Canadian-born women). With respect to self-identification with an ethnic group, Western European immigrant women and men were more likely to report chronic conditions than Canadian-born women and men (OR: 1.14 and OR: 1.19 respectively). Immigrant women from South Asia and China were less likely to report chronic conditions than Canadian-born women (OR: 0.60 and OR: 0.64 respectively). Data Gaps and Recommendations The authors identified the following data gaps and made the following recommendations: The differences between women and men experiencing immigration require that large enough samples of women and men from different countries of birth, as well as countries of origin, be surveyed to ensure that culturally sensitive conclusions can be drawn. This will allow for a proper analysis of the health determinants of women from diverse ethnic backgrounds and/or experiences of immigration. Immigration experience needs to be conceptualized according to the results of past studies and included as a social determinant of health above and beyond ethnicity and culture. It is expected that the upcoming Longitudinal Survey on Immigrants in Canada (LSIC) and Ethnic Diversity Survey, conducted by Statistics Canada, will help to enhance surveillance capacity in this area. 2
Women s Health Surveillance Report It is important to adopt a gender-sensitive approach to the development of indicators in order to account for the cultural differences in the pathways of experiencing health and to recognize that these experiences impact on the distribution of health by socio-economic position. It is also important to have a broader interpretation of the health effects of potential advantageous and disadvantageous conditions; for example, it would be useful to try and account for the social capital of women and men who undergo experiences of immigration (network, resilience, ease of access and differential degree of control of resources by women, men and other members of the family). Issues such as accessibility (cultural, geographic, linguistic and financial), appropriateness and adequacy of health services are unlikely to be unique to women and men experiencing immigration and need to be systematically accounted for in surveillance and research. There should be consideration of the underlying socio-economic and socio-political forces that shape the life conditions of women and men who are from a diverse background and/or undergo immigration. Variables need to be constructed to allow women and men to best identify themselves appropriately according to ethnic identity and number of years in the host country. Some of the proposed categories used as a cultural group may simply refer to skin colour without capturing associated elements of culture, ethnicity and life experiences. Variables need to be constructed to reflect the ability to cope, which has been shown to be associated with a better trajectory of healthy life in a new country and/or culture. Research approaches need to account for the fact that reporting of perceived health and presence of chronic conditions is sensitive to ethnicity as well as migration experience. A variety of research strategies need to be developed in order to monitor, conduct research and derive policies that are congruent and appropriate when studying the impact of ethnicity and immigration experiences of both men and women. 3
Women s Health Surveillance Report HEALTH CARE UTILIZATION by Canadian Women * Arminée Kazanjian (University of British Columbia); Denise Morettin (University of British Columbia); and Robert Cho (Health Canada) Health Issues Although it is reported that women are more frequent users of health services in Canada, the reasons for the gender difference in health care utilization have not been fully explored. How women use and benefit from the health care system and how this differs for men requires raising complex research questions regarding the interaction of several variables: sex, well-being, disease, system characteristics, health care utilization and social roles. In order to provide an overview on health services utilization by women, the authors selected two key issues that are important for public policy purposes: access to care and patterns of utilization. This approach to women s health provides a critical lens through which to examine possible system bias that may result in health service inequities. While the implications of men s and women s social and cultural roles on health services utilization are key to understanding women s health care experiences, the exploration of factors beyond the biological remains a serious challenge for women s health surveillance. In this study, access to care and patterns of utilization were examined using data primarily from the 1998 1999 National Population Health Survey (NPHS), complemented by the 2000 2001 Canadian Community Health Survey (CCHS) and the 2001 Health Service Access Survey (HSAS), as these data became publicly available. Key Findings Women were more likely than men to report having a regular family physician: 8.8% of women versus 15.8% of men reported having no regular family doctor. The main reasons reported for not having a regular physician differed somewhat between women and men. Women were more likely than men to report five or more contacts a year with a primary care provider and far less likely than men to report only one contact a year. Women reported significantly shorter wait times (20.9 days) than men (55.4 days) to obtain specialist services for mental health, while the reverse was true for asthma and other breathing conditions (men reported waiting 10.8 days, women 78.8 days). * The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada. 5
HEALTH CARE UTILIZATION by Canadian Women Reported mean wait times were significantly lower for men than for women for overall diagnostic tests (men 31.4 days, women 53.1); in particular, reported magnetic resonance imaging (MRI) wait times were 70.3 days for women, compared to 29.1 days for men. Older women (70+) were significantly more likely than younger women (50 to 69) to report infrequent screening mammograms (two years or more since last mammogram). (Note: Canadian Task Force on Preventive Health Care recommendations for clinical examination and mammography do not extend to women over the age of 69 years.) Urban women were significantly more likely (60%) than rural women (56%) to report a Pap test taken less than a year ago. (Note: Canadian women are currently advised to have an annual Pap test once sexually active or at age 18 with a reduction in screening frequency to every three years after two normal tests to the age of 69. ) Data Gaps and Recommendations The authors identified the following data gaps and made the following recommendations: Recent national surveys report from much larger national samples than previous surveys of this type; for surveillance purposes, however, mostly sex-specific and only some sex-sensitive research questions regarding access and health care use can be explored by cross-sectional surveys of this size. More detailed and comprehensive information (e.g. a list of providers that includes a range of alternative providers/therapists and a longitudinal design to capture causal relationships between utilization, the life-course and outcome) is required to capture more accurately, and in a richer context, the range of women s health care experiences to improve knowledge of equity and quality in health services. As hospital and medical care is largely under provincial/territorial jurisdiction, the measurement of possible system bias and its implication for equitable and quality health care for women requires larger samples of the national surveys, along with a longitudinal design. National databases, or closer alignment in the development of the various provincial databases, are needed for health promotion and preventive services. This will facilitate data linkage with national surveys for the purposes of undertaking longitudinal studies that support gender-based analyses. Increased use of data linkage between provincial administrative databases and national surveys reduces the heavy burden of longitudinal surveys, supports the validation of measurement tools and enhances our understanding of women s health. Maxwell CJ, Bancej CM, Snider J, Vik SA. Factors important in promoting cervical cancer screening among Canadian women: findings from the 1996-97 National Population Health Survey (NPHS). Can J Public Health 2001; 92(2):127 33. 6
Women s Health Surveillance Report INTEGRATING SOCIO-ECONOMIC DETERMINANTS of Canadian Women s Health * Bilkis Vissandjee (University of Montreal); Marie DesMeules (Health Canada); Zhenyuan Cao (Health Canada); and Shelly Abdool (University of Montreal) Health Issue The association between a number of socio-economic determinants and health has been amply demonstrated in Canada and elsewhere. Studies examining similarities and differences between women and men in the relationship between socio-economic status (SES) and mortality or morbidity have directed attention to socio-economic gradients in health as one of the potential explanations for gender differences in health. Over the past decades, women s increased labour force participation and changing family structure, among other changes in the socioeconomic environment, have altered social roles considerably, leading one to expect that the pattern of disparities in health among women and men will also have changed. Perceived health incorporates a variety of physical, cultural and emotional components of health, which, taken together, comprise individual healthiness. As a broad indicator of health-related well-being, self-assessment of health has been extensively used within epidemiological and sociological studies and is recognized as being a robust measure of health status. Using data from the Canadian Community Health Survey (CCHS) 2000 2001, this chapter investigates the association between selected socio-economic determinants of health such as family structure, highest level of education attained, total household income, type of dwelling reported, self-assessment of food insecurity, occupation and two specific self-reported outcomes among women and men: (a) self-perceived health and (b) self-reported chronic conditions. Key Findings The CCHS data show that 10% of men aged 65 and over reported being in the lowest income quartile, versus 23% of women within the same age bracket. In addition, 40% of men and 33% of women between the ages of 45 and 64 reported being in the highest income quartile. Logistic regression multivariate analysis indicated that lower household income and lower education were significantly associated with an increased prevalence of poor self-rated health among women (OR: 1.94 and OR: 1.89). This analysis controlled for age, smoking status and other SES factors. Partnered women with children had the lowest risk of poor self-rated health compared to women with other family structures. Very similar associations between these socio-economic factors and health were found among men. * The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada. 7
INTEGRATING SOCIO-ECONOMIC DETERMINANTS of Canadian Women s Health Being in the lowest household income quartile was also related to an increased prevalence of reported chronic conditions (OR: 1.18). However, the association between various levels of educational attainment and reported chronic conditions was inconsistent when smoking and other SES factors were simultaneously controlled for. Food insecurity was associated with a lower frequency of reported chronic conditions (OR: 0.88 and 0.86 for women and men respectively). This may be due to lower observed prevalence of obesity among respondents reporting food insecurity. Other factors, such as under-reporting or under-detection among participants reporting food insecurities, may also be contributing to this observed association. Differences in the relationship between SES and health were also found by sex. This analysis controlled for age, smoking status and other SES factors. Household income was negatively associated with chronic conditions among women, but this association was not seen among men. In addition, compared with full-time employees, self-employed men were less likely to report a chronic condition (OR: 0.91), whereas self-employed women were more likely to do so (OR: 1.12). While female homemakers reported fewer chronic conditions than full-time female employees (OR: 0.86), they also reported poorer self-perceived health than their fulltime employed counterparts (OR: 1.28). The main difference between women and men in the CCHS data examined relates to employment status and its association with self-perceived health and self-reported chronic conditions. Data Gaps and Recommendations When determinants such as age, educational attainment, employment status and other material circumstances (dwelling type, food insecurity status, etc.) were adjusted for, the association between income and self-rated health remained statistically significant for both women and men, with a gradient observed. Because it was shown that socio-economic determinants of health are context-sensitive and evolve over time, the authors recommend that studies be designed to examine the complex temporal interactions between a variety of social and biological determinants of health over the life course. Examples include: 1. the ways in which socio-economic resources are acquired through training and lost through failing health across the life-course; 2. the differential in the responsibilities of women and men with respect to the care provided to both the very young and the very old; 3. accounting for other types of unpaid work and being a homemaker according to the differential experiences of men and women; 4. distinguishing between individual and household income, reflecting women s ability both to access this income and to have decision-making power to use it for individual and family health and well-being; 5. redefining family structure to include recomposed families and intergenerational households; 6. the need to increase the understanding of how gender-related variability (in the way that people come to know, remember and report health outcomes, such as chronic conditions and perceptions of one's health) is culturally bound; and 7. the need to increase the understanding of the different ways males and females interpret and answer questions of self-rated health. In addition, it is important to understand the influence of potential mediating variables, such as depression, a condition known for its gender differences, on a particular gender s view and interpretation of health. For example, it may be that one gender has a more clinical approach to health, whereas the other has a more holistic view as to what makes up health. These views may be reflected in self-rated health measures. 8
Women s Health Surveillance Report In addition to new approaches in study design, the authors note that there is a need for different types of studies on health, including: longitudinal studies to assess the differential influence of social and economic determinants on women and men, which will allow temporal changes to be examined, and qualitative studies to complement the understanding of the gendered impacts of these complex determinants on women s and men s health. 9