here. - Canadian Women's Health Network

WOMEN, INCOME ANDHEALTH IN MANITOBAAn Overview and Ideas for ActionPrepared by:WOMEN’SHEALTHCLINICPOVERTYI S H A Z A R D O U S TOWOMEN’SHEALTHWOMEN’SHEALTH CLINIC419 Graham Ave.WinnipegManitoba R3C 0M3telephone(204) 947-1517facsimile(204) 943-3844www.womenshealthclinic.orgReducing povertyimproves health for everyone.Together we can do it.[204] 947.1517www.womenshealthclinic.org

WOMEN, INCOMEAND HEALTH IN MANITOBA:An Overview and Ideas for ActionLISSA DONNERwith contributions fromANGELA BUSCHNAHANNI FONTAINEPrepared for & Published byWOMEN’S HEALTH CLINIC3rd Floor - 419 Graham AvenueWinnipeg, Manitoba, Canada R3C 0M3Funded byHEALTH CANADA:Health Promotionand Programs BranchManitoba/Saskatchewan RegionCopyright Women’s Health Clinic, July 2000Revised January, 2002Reprinted March, 2002ISBN 0-9694787-7-1Women, Income andHealth in Manitoba2

TABLE OF CONTENTSPageA. EXECUTIVE SUMMARY .................................................. 1B. INTRODUCTION .............................................................. 5C. INCOME DISTRIBUTION IN CANADA ............................ 61. Measurements of Poverty......................................... 62. Income Distribution in Canada.................................. 72.1 Poverty in Canada .................................................... 72.2 Canadian Women and Poverty ................................. 82.3 Aboriginal Women and Poverty ................................ 92.4 Aboriginal Women – Key Informant Interviews ......... 102.5 Visible Minority Women ............................................ 12D. THE CONNECTION BETWEEN INCOME & HEALTH..... 141. What Is Known about the Connectionbetween Income and Health? ................................... 142. Income Disparities in Canada ................................... 163. How Has the Connection betweenIncome and Health Been Explained? ....................... 17E. INCOME AND THE HEALTH OF WOMEN –WHAT WE KNOW FROM THE LITERATURE ................. 191. Measuring Women’s Socioeconomic Status ............ 192. How Health Is Measured .......................................... 203. Current Knowledge –Women’s Health and Socioeconomic Status ............ 204. The Connections with Employment Status ............... 235. Inequalities and the Health of Aboriginal Women ..... 246. Stress and Socioeconomic Status ............................ 297. Health and the SocioeconomicStatus of Older Women ............................................ 298. Gender Inequalities and theHealth of Women and Men ....................................... 30Women, Income andHealth in ManitobaF. INCOME AND THE HEALTH OF WOMEN –THE MANITOBA EXPERIENCE ...................................... 321. Introduction ............................................................... 322. Manitoba Data - Income and HealthServices Utilization among Manitoba Women .......... 333. What Does This Mean? ............................................ 373

G. DESIGNING HEALTH SERVICES TO MEETTHE NEEDS OF LOW-INCOME WOMEN ..................... 401. Vancouver/Richmond Health Board –A Framework for Women-Centred Health ................. 402. The Commonwealth Secretariat –Models of Good Practice in Women’s Health ........... 413. Women’s Health Clinic, Winnipeg, Model of Care .... 424. Aboriginal Women’s Experiences ............................. 42H. MAKING PUBLIC POLICY HEALTHIER FORWOMEN - SUGGESTIONS FOR ACTION....................... 451. The Current Context ................................................. 452. Interventions to Promote Healthier Public Policy ...... 463. Income Related Issues ............................................. 473.1 Manitoba Minimum Wage ................................ 473.2 Social Assistance Rates .................................. 483.3 Child Tax Benefit ............................................. 494. Expenditure Issues ................................................... 494.1 Telephone Rates ............................................. 494.2 Utility Rates ..................................................... 504.3 Housing ........................................................... 504.4 Child Care ....................................................... 515. Health Services Issues ............................................. 525.1 Health Planning ............................................... 525.2 Allies in Developing Healthier Public Policy .... 525.3 Delivering Programs that MeetWomen’s Needs .............................................. 536. Working with Women Living in Poverty to PromoteHealthier Policies and Appropriate Services ............. 53I. FUTURE DIRECTIONS.................................................... 54APPENDICES1 Suggestions for Future Research ............................. 552 Are Women Sicker than Men? .................................. 563 Health Service Utilization by Manitoba Women ........ 594 Interviews with Aboriginal Women Key Informants ... 615 Models of Women-Centred Care .............................. 62Women, Income andHealth in Manitoba4ENDNOTES .............................................................................. 73REFERENCES.......................................................................... 78ACKNOWLEDGEMENTS ......................................................... 84

EXECUTIVE SUMMARYTHE LINK between poverty and poor health is well established and makes commonsense. There are many ways in which poverty can lead to ill health, including lack ofaccess to affordable housing, transportation, food and non-insured health benefits,such as medications.Poverty also discriminates in more subtle ways. For example, women and their childrenwho are poor are more likely to be socially isolated, which also contributes to ill health.We do not yet completely understand all of the ways in which low income and incomeinequality in our society lead to poor health. But we do not need to completelyunderstand these mechanisms in order to act now to improve health.The link between income and health has a special importance for women. In Manitoba (asin the rest of Canada), poverty discriminates, striking women substantially more frequentlyand more severely than men. This study looks at that disparity and how income inequalityaffects the health not only of women living in poverty but of everyone in our society.Women, Income andHealth in Manitoba5Income and InequalityPoverty is a serious issue in Manitoba.This province has the country’s thirdhighest rate of poverty (18.5%) amongCanadian provinces, compared to 16.2%for all of Canada. For women, the pictureworsens: 19.9% of Manitoba women aged18 and over were poor in 1999. 1 This alsohas an impact on the lives of children andManitoba also has the second highest childpoverty rate in Canada, 23.7%. 2The disparity between women and men isremarkable. In 1999, there were 29,000 morepoor women in Manitoba than poor men –a difference of 54%. 3Marriage does not protect women frompoverty. In 1996, one in ten married coupleswere poor. And married women’s earningsare vital to their families’ well-being; withoutthem, that proportion would have risen toone in four. 4Minimum wage earners, even thoseworking full-time, live in poverty. A singlemother with one child working full-timeand earning minimum wage in Manitobalives 43.4% below the poverty line. If she ismarried with two children, even when bothspouses work full-time at minimum wage,their family will live 25% below thepoverty line.Some groups of women are especiallyvulnerable to poverty:■■■More than half (51.3%) of seniorwomen who live alone are poor. 5This has remained virtuallyunchanged in the last thirty years.Women with disabilities also face ahigher risk of poverty. In 1997, 27%of women with disabilities, aged 16 to64, lived in poverty. Almost two-thirdsof those lived more than 25% belowthe Low Income Cut Off. 6Aboriginal women are more likely tolive in poverty than non-Aboriginalwomen or Aboriginal men. In 1995,42.7% of Aboriginal women(excluding those who lived onReserves and those living in theTerritories) lived in poverty, comparedto 35.1% of Aboriginal men, 20.3%of non-Aboriginal women and 16.4%of non-Aboriginal men. 71Statistics Canada, Income in Canada, Table 8.52Social Planning Council of Winnipeg, Promises Not Kept:2001 Report on Child Poverty in Manitoba3Statistics Canada, op. cit, Table 8.54National Council of Welfare, Poverty Profile 1996, p 875Statistics Canada, op. cit., Table 56Federal, Provincial and Territorial Ministers Responsible forSocial Services, In Unison 2000: Persons with Disabilities inCanada, page 797Statistics Canada, Women in Canada 2000, page 268

Women, Income andHealth in Manitoba6■■In 1996, 31.8% of visible minoritywomen in Manitoba lived in poverty. 8Yet, they are more likely than otherCanadian women to be employedfull-time. 9Recent immigrant women haveparticularly low incomes. In 1995,their average income for all ofCanada was only $12,000, about62% of the amount earned byCanadian-born women that year. 10These disparities are becoming worse, notbetter. A recent report for the Centre forSocial Justice noted that:Not only are there more families in thelowest income category but they havealso become poorer over time: tobelong to the poorest 10 per cent ofthe population meant earning less than$11,567 in 1989. By 1997, it meantearning less than $6,591. 11Income and HealthThere are many studies showing theconnection between income and health.As the Manitoba researcher PatriciaKaufert, Ph.D has observed:locating health in the social conditionsof people’s lives is an idea which canbe dated back to the origins of thepublic health movement. 12Research shows that medical care is lessimportant in ensuring the well-being of theentire population than economic security,social support and a more equitabledistribution of income. The connectionbetween poverty and poor health hascontinued to exist even as medicinehas progressed, persisting despite thereduction in mortality and improvementsin other measures of health.Inequalities in health are not only aproblem for poor Canadians. Data fromManitoba is consistent with data from othercountries. Health status worsens at everystep down the socio-economic ladder. Poorpeople may be more at risk, but everybodyis affected.Economic inequality itselfis a health risk.Studies suggest that the distributionof income in a given society may be amore important determinant of healththan the total amount of income earnedby society members. Large gaps inincome distribution lead to increasesin social problems and poorer healthamong the population as a whole. 13What the Research Tells UsThere is a substantial body of researchlinking women’s household incomes andtheir health. While past research has foundthe connection to be weaker for womenthan for men, recent Canadian researchshows the reverse. 14 This research alsosuggests that socio-economic status andother factors beyond individual control(such as family structure, age and socialsupport) are more important to women’shealth status than lifestyle factors suchas smoking, alcohol consumption andphysical activity. Women’s health services8Statistics Canada, 1996 Census, Dimension Series,#94F009XDB960039Statistics Canada, Women in Canada 2000, page 22710ibid, page 20411Yalnizyan, A., Canada’s Great Divide: The politics of thegrowing gap between rich and poor in the 1990s, Toronto:Centre for Social Justice, 2000, page ii12Kaufert, Patricia “The Vanishing Woman: Gender andPopulation Health”, from Sex, Gender and Health, forthcoming,Cambridge University Press, 1999, page 12113Federal, Provincial and Territorial Advisory Committee onPopulation Health, Toward a Healthy Future: Second Report onthe Health of Canadians, 1999, page ix14Denton, Margaret and Walters, Vivienne “Gender differencesin structural and behavioral determinants of health: an analysis ofthe social production of health”, Social Science and Medicine, 48(1999), page 1232

Women, Income andHealth in Manitoba7that focus only on lifestyle will, therefore,not be as effective as a broader approachthat addresses poverty and the economicinequality faced by women.One consistent theme in the research isthe additional burden of ill health borneby Aboriginal women. They are at muchgreater risk of violent death and suicidethan other Canadian women. They havepoorer health than Aboriginal men or otherCanadian women; they develop chronicconditions earlier and suffer more frequentlyfrom heart problems, hypertension,diabetes, arthritis and rheumatism. Thisis compounded by the fact that Aboriginalwomen face formidable barriers in obtainingappropriate health services, includingdiscrimination, distance and cultural barriers.Poverty is also an important factor in thehealth of older women. Many factorscompound this, including poor housing,higher heating costs, increased isolation,fear for personal safety and functionalimpairments that may make day-to-day lifedifficult and painful. The link betweeninequalities in income and health is strongeven for those over the age of 85.Income & Healthin ManitobaWe examined the experience of all Manitobawomen in 1994-95, the most current yearfor which data were available. As in otherjurisdictions, there was a connectionbetween income and health servicesutilization for Manitoba women for mosthealth conditions. That is, women in lowincomeneighbourhoods were more likelyto see physicians both in hospital and inphysician offices than were women in highincomeneighbourhoods. The experienceof women in middle-income neighbourhoodsfell in between.Importantly, the reverse was true for twopreventive screening services. Women inthe highest income neighbourhoods weremost likely to use Pap smears to screenfor cervical cancer and mammogramsto screen for breast cancer.This is not intended to suggest that lowand middle-income women, whose healthcare costs are higher than those with highincomes, use the health care systeminappropriately. The solution lies not inrestricting access to the health care systemwith user fees or other mechanisms but,rather, in improving the health of thepopulation.The health effects of income inequalitiesincrease the burden of illness in all bodysystems. Discussions of women’s healthand socio-economic inequalities must bebroad enough to incorporate and build onthis information. Strategies which focusonly on reproductive and sex-specificconditions will not be successful inreducing inequalities in women’s health.Making Public PolicyHealthier for WomenHealthy public policy for low-incomewomen will require changes both insideand outside the health care system.The health care system has twoimportant roles to play:1. changing the way in which healthcare services are planned, deliveredand evaluated to better meet theneeds of low-income women;2. working with other sectors outside ofthe health care system to help themunderstand the health impactsof their policies.Manitoba health care organizationsinterested in developing health serviceswhich take issues of income, gender andhealth into account have several models toconsider. Three in particular – developed bythe Winnipeg Women’s Health Clinic, theVancouver/Richmond District Health Boardand the Commonwealth Secretariat – offerideas for improving health services to better

meet the needs of low-income women. 15Perhaps most importantly, health careorganizations must change by specificallyconsidering the needs of low-income women.The best way to do this is by includinglow-income women in the planningand evaluation of health services.In order to improve the health status oflow-income women, we will also needpolicy changes outside of the health caresystem. While these issues have nottraditionally been part of the work of thehealth care system, it has an important roleto play in encouraging organizationsoutside of health to consider the healthconsequences of their decisions. In Towarda Healthy Future, the Federal, Provincialand Territorial Advisory Committee onPopulation Health (ACPH) identified“renewing and reorienting the healthsector” as the first of three priorities andcalled on health care organizations to“initiate dialogue with other healthdeterminingsectors about the healthimpacts of policies in sectors outsidehealth and about collective actionsthat can be taken.” 16The ACPH also identified “improving healthby reducing inequities in income distributionand in literacy and education” as anotherof its priorities for action. 17It is important to take actions both toincrease the incomes of low-incomewomen and to limit the costs of essentialservices. Some ideas for action include:■increasing the minimum wage;■■■■■■■■increasing social assistance rates;broadening eligibility forEmployment Insurance;reducing the costs of publictransportation;increasing the number ofsubsidized child care spaces ;making child care fully subsidizedfor women living in poverty;reducing the cost ofbasic telephone service;making recreation programs freelyavailable for those living in poverty;providing non-insured health benefits,such as dental care and prescriptiondrugs to all those living in poverty.These are some of the many opportunitieswhich exist for decision-makers, healthservice providers and the public to use ourexisting knowledge about the connectionsbetween income and health to make ourcommunity healthier for all.While we may not have a detailedunderstanding of the mechanisms bywhich income and social status affecthealth, we know that the connectionis there. Now is the time to use theknowledge which we do have to makechanges to improve women’s health.15Vancouver Richmond Health Board, Framework for Woman Centred Care,available at: http://www.vcn.bc.ca/vrhb/, Women’s Health Clinic, Model ofCare, The Commonwealth Secretariat, Models of good practice relevant towomen and health, including research, policy, implementation, strategies,testing and evaluation.16Toward a Healthy Future: Second Report on the Health of Canadians,pages 175 to 17717Ibid.Women, Income andHealth in Manitoba8The Women’s Health Clinic is a community health centre based on the principlesof feminism, equity and diversity, promoting the health and well-being of women.Women’s Health Clinic’s approach to health is to facilitate empowerment, choiceand action. Women are encouraged to learn all they can about what contributesto their health and well-being so they can make informed decisions. The Clinichelps to bring together agencies and individuals for education and action onissues that impact significantly on women’s health.

B. INTRODUCTIONMuch work has been done to date on theconnection between poverty and ill health,and, more generally, on income andvarious measures of health and illness.The purpose of this paper is to explorethe relationship between the health ofManitoba women and their socioeconomicstatus.This paper will therefore:1. briefly describe income distribution andpoverty in Canada and Manitoba today;2. provide a summary of the literature on therelationship between income and health;3. expand that work with new informationabout the connections between women’sincome and their health, including ananalysis of data about the utilization ofhealth services by Manitoba women;4. describe some of the key health servicesissues for low-income women and presentmodels of service which addressesthose issues;5. present ideas for interventions in publicpolicy that will improve the health ofManitoba women living in poverty.Because of the significance of incomeand poverty issues for Aboriginal women,information specific to their situation andneeds has been included wherever possible.This paper has been commissioned as partof a project by the Women’s Health Clinicof Winnipeg and has been funded by theHealth Promotion and Programs Branchof Health Canada.Women, Income andHealth in Manitoba9

C. INCOME DISTRIBUTION IN CANADA1. Measurements of PovertyCanada does not have an official measureof poverty. Most researchers use theStatistics Canada “Low Income Cut Offs”(LICOs) as its measure of poverty. TheCanadian Council on Social Development(CCSD) and others have criticized thismeasure. Some, such as the FraserInstitute, have criticized it for definingpoverty too generously; that is, for includingtoo many people. 1 Others, including theCCSD have developed alternative measureswhich are more generous. 2 There is anactive debate among those involved withsocial policy in Canada about the bestway to measure poverty.The National Council on Welfare hasdescribed this controversy as follows:Statistics Canada itself has consistently maintained that it does notregard the LICOs as poverty lines, presumably because the federalgovernment does not want to give official recognition to poverty.Most social policy groups in Canada have consistently disagreedwith the position of the federal government and continue to use theLICOs as poverty lines. Despite the long-running dispute overterminology, the low income cut-offs are by far the most widely usedmeasure of poverty in Canada. The survey data and methodologyused to generate the cut-offs are done by a federal governmentagency with an international reputation for high-quality work.Statistics produced using the LICO methodology are readilyavailable to researchers inside and outside government yearafter year at modest cost. Coincidentally or not, the incomelevels of the LICOs are in the mid-range of the alternativepoverty lines that have appeared from time to time. 3Women, Income andHealth in Manitoba10

Consistent with the majority of socialpolicy experts in Canada, we haveused the Statistics Canada Low IncomeCut Offs to define “poverty” for thepurposes of this paper.In 1999, Manitoba had the third highest rateof poverty of all Canadian provinces, at18.5%, compared to 16.2% for all of Canada.Only Newfoundland (at 20.7%) and Québec(at 19.5%) were higher. Manitoba had thesecond highest poverty rate for senior womenat 28.3% and the fourth highest rate forwomen aged 18 to 64 years.Women’s poverty has a significant impacton the income of children. Manitoba hasthe second highest child poverty rate inCanada, 23.7% . The rate of poverty forManitoba children living with single-parentmothers was also the second highest inCanada at 70.7%.2. Income Distribution in Canada2.1 POVERTY IN CANADAThe following chart summarizes some 1999 Statistics Canada data about who ispoor in Canada and Manitoba.TABLE 1A SNAPSHOT OF WHO IS POORIN CANADA AND MANITOBA - 1999CANADAMANITOBANumber Percent Number PercentALL PERSONS 4,886,000 16.20% 202,000 18.50%All Females 2,699,000 17.70% 113,000 20.40%All Males 2,187,000 14.60% 89,000 16.50%SENIORS 646,000 17.70% 32,000 22.00%Senior Women 487,000 23.50% 24,000 28.30%Senior Men 159,000 10.00% 9,000 13.60%UNATTACHED SENIORS 519,000 44.00% 25,000 44.20%Unattached Senior Women 417,000 48.50% 21,000 51.30%Unattached Senior Men 101,000 31.90% 4,000 25.60%ALL CHILDRENUNDER 18 YRS. 1,298,000 18.50% 64,000 23.70%Children in 2-parent families 697,000 12.10% 34,000 15.50%Children with single mothers 521,000 55.80% 28,000 70.70%Women, Income andHealth in Manitoba11ALL ADULTSAdult women 2,080,000 17.56% 84,000 19.91%Adult men 1,508,000 13.27% 55,000 13.52%SOURCE: Statistics Canada, Income in Canada, 1999, Table 8.5

Women, Income andHealth in Manitoba122.2 CANADIAN WOMEN AND POVERTYAs the above data show, there were 29,000more poor women in Manitoba than therewere poor men. To put this another way,40% of all poor adults in Manitoba were men;60% of them were women.As Monica Townson has stated:It’s not something we have heardmuch about recently. Yet womenremain among the poorest of the poorin Canada. Over the past two decades,the percentage of women living inpoverty has been climbing steadily.As Canada enters the 21st century,almost 19% of adult women are poor– the highest rate of women’s povertyin two decades. About 2.2 millionadult women are now counted aslow-income, compared with 1.8million who had low incomes in 1980. 4From 1976 to 1999, the percentage ofwomen 15 years of age and older whowere employed in the paid labour forceincreased from 42% to 54%. During thesame period of time, Manitoba womenincreased their employment rates from46% to 56.5% 5 . Were it not for theincreased earnings resulting from themassive increase in women’s labourmarket participation, many more familieswould have slipped into poverty.The National Council of Welfare hascalculated the poverty rates for husbandwifefamilies in 1996 and the percentage offamilies who would have been poor withoutthe earnings of the women in them. InManitoba, in 1996, 10.5% of husband-wifefamilies were poor. Without the earnings ofthe wives, 25.5% would have been poor. 6This illustrates several points. Firstly,marriage itself does not protect womenfrom poverty. Secondly, married women’searnings are crucial to the economicwell-being of their families.The gender gap in poverty in Canada hasbeen the subject of international discussion.Canada was recently criticized internationallyfor the extra burden of poverty borneby Canadian women. The United NationsCommittee on Human Rights, in itsConcluding Observations on Canada’sCompliance with the International Covenanton Civil and Political Rights, stated in part:The Committee is concernedthat many women have beendisproportionately affected bypoverty. In particular, the very highpoverty rate among single mothersleaves their children without theprotection to which they are entitledunder the Covenant. While thedelegations expressed a strongcommitment to address theseinequalities in Canadian society, theCommittee is concerned that many ofthe programme cuts in recent yearshave exacerbated these inequalitiesand harmed women and otherdisadvantaged groups. TheCommittee recommends a thoroughassessment of the impact of recentchanges in social programmes onwomen and that action be undertakento redress any discriminatory effectsof these changes. 7Much attention has been paid to theextremely high rates of poverty amongchildren of single-parent mothers. Childpoverty has become a topic of much publicdiscourse, including a 1989 resolution bythe House of Commons to eliminate childpoverty by 2000. Since 1990, the numberof poor children in Canada has actuallyincreased by 103,000. 8 As the NationalAction Committee on the Status ofWomen has consistently pointed out,the children of single-parent mothersare poor because their mothers are poor.Health Canada has established Centresof Excellence for Children’s Well-being.A February 1999 discussion paper entitledFostering Knowledge Development on the

Health and Well-Being of Children inCanada recognized that “while not allchildren who are poor experience negativehealth outcomes, there is a great deal ofevidence showing a major link betweenfamily income and many measures ofhealth and well-being.” 9Less attention has been paid to the plightof unattached senior women – that is,those women 65 years of age or older whoare either single, separated, divorced orwidowed. In 1999, over 51% of thesesenior unattached women in Manitobawere poor. This number has not changedin the thirty years since the publication ofthe Report of the Royal Commission on theStatus of Women. 10Women with disabilities are also at higherrisk of poverty than either womenwithout disabilities or men withdisabilities. In 1996, 27% of womenwith disabilities aged 16 to 64 lived inpoverty. Almost two-thirds of those livedmore than 25% below the poverty line. 11As Gail Fawcett has noted, “men with disabilitiesface many of the same barriers aswomen; however, for women, the barriers areoften more pronounced and the negativeoutcomes more severe.” 12Other groups of women at higher riskfor poverty include Aboriginal women(see below 2.3), visible minority women (seebelow 2.4), and women who are separatedand divorced.2.3 ABORIGINAL WOMEN & POVERTYIn 1996, Manitoba, with approximately5% of the total population of Canada,was home to 16.1% of the country’s totalAboriginal population, 64,665 women and62,900 men. 13 Looking at this another way,in 1996, 11.7% of Manitoba’s population wereAboriginal people.The term “Aboriginal” includes First Nations,Métis and Inuit people. This terminology,while useful, does not allow exploration andanalysis of the very real differences withinand among these groups. The lives of FirstNations peoples, for example, are affectedby their status under the Indian Act. FirstNations people may be classified as“Status” or “Non-Status” Indians, “RegisteredIndians On Reserve” or “Registered IndiansOff Reserve”, “Treaty” or “Non-Treaty” or “BillC-31 Members”. For the purposes of thispaper, the term “Aboriginal” will be used torefer to all of the original people of Canada.It should also be noted that while 1996Census of Canada data is used below, someFirst Nations communities chose not toparticipate in the 1996 Census of Canada.What impact, if any, their participation mighthave had on this data is not known.TABLE 3ABORIGINAL AND NON-ABORIGINAL POVERTY RATES, 1995Women, Income andHealth in Manitoba13POVERTY RATESPERSONS 15 YEARS AND OVERMale Female Gender GapAboriginal People 35.1% 42.7% 21.60%Non-Aboriginal People 16.4% 20.3% 23.8%SOURCE: Women in Canada 2000, Table 11.14

TABLE 4AVERAGE INCOMES – ABORIGINAL AND ALL CANADIANSAVERAGE INCOME, 1995Male Female Gender GapAboriginal People $18,221.00 $13,305.00 26.90%All Canadians $31,117.00 $19,208.00 38.3%SOURCE: 1996 Census – Statistics Canada 94F0009XDB96001Women, Income andHealth in Manitoba14These data clearly show that Aboriginalwomen have higher poverty rates thaneither Aboriginal men or Non-Aboriginalwomen or men. Their average incomesare lower than those of Aboriginal men,or all Canadians. The average income ofAboriginal women in Canada in 1995was $17,812 lower than the averageincome of Canadian men. Put anotherway, for every dollar earned by Aboriginalwomen, Canadian men earned $2.34.These data are important to keep in mindwhen considering issues of income andhealth. Firstly, poverty among Aboriginalpeople is gendered, as it is among theCanadian population as a whole. Secondly,these lower income levels are a contributingfactor to the poor health status of Aboriginalwomen in Canada (see 5.3 below).The combined effects of racism and sexismare clearly evident in the income levels ofAboriginal women. Examining these issuesconsidering only Aboriginal status(and not gender), or gender (and notAboriginal status), will mask the truesituation of Aboriginal women. Thecombined effects of racism and sexismare clearly evident in the income levelsof Aboriginal women.Aboriginal people face additional barriers inthe labour market. As Michael Mendelsonand Ken Battle have noted:The labour market prospects facingAboriginal Canadians are muchworse than for other Canadians.Many Aboriginal people are unlikelyto find consistent employment in theirlifetime. The potential costs of highunemployment extend beyond thesocial sphere. The economic futureof a region is greatly diminished whena growing percentage of its workforceis unemployed. The threat to economicwell-being is especially grave for thePrairies. There is probably no singlemore important issue for theeconomic future of the Prairies,particularly Manitoba andSaskatchewan, than theadvancement of its Aboriginalhuman resources. 14 (emphasis added)2.4 ABORIGINAL WOMEN -KEY INFORMANT INTERVIEWSAs part of the data collection process forthis paper, interviews were held with keyinformants to discuss the connectionsbetween income and health forAboriginal women.Seven Aboriginal women participated inthese interviews. They were selectedbecause of their experience working inthe health care system, health researchexperience, and/or knowledge of Aboriginalwomen’s health. The interviews wereconducted by Angela Busch, an Aboriginal

Women, Income andHealth in Manitoba15woman with experience in the field. MsBusch also designed the questions whichwere asked of each of the interviewees,which are included as Appendix 4.The Aboriginal women who participated inthe health interviews had much to say onthe subject of Aboriginal women andpoverty. They recognized that poverty isendemic in Aboriginal communities, bothon reserves and in urban centres, andidentified that this as more so for Aboriginalwomen than men. They considered theimpact of poverty holistically, including itsmental, physical, emotional and spiritualeffects on the health of women.One of the recurring themes that aroseduring these interviews was that Aboriginalwomen tend to think in terms of theirchildren’s and families’ health, more oftenthan that of their own health. One of themajor problems identified for Aboriginalwomen was poor access to medical care.The interviewees identified the followingreasons why Aboriginal women have pooraccess to health care:■■■■for those who live in rural areas, healthcare facilities are limited or non-existent;for those in urban areas, women donot always have transportation (e.g.bus fare) or childcare readily available;racism and discrimination in the healthcare system were identified as majorproblems;Aboriginal women who do not havetreaty Indian status can not alwaysafford to pay for the prescriptions thatthey need.For those interviewed, poverty meant thatAboriginal women were unable to afford tomeet their basic needs. They saw povertyas largely responsible for poor nutrition orimproper diet, which they recognized couldlead to a multitude of health problems.They noted that poor women cannotalways afford to buy fresh foods and tendto consume food that is processed andvery high in fat, sugar, salt and nitrates.Diseases such as diabetes and heartdisease were identified as largelyattributable to poor nutrition. Improperdiet was noted as being an evengreater health issue for pregnantor nursing women.Poor housing and lack of housing were alsoidentified as key health issues for Aboriginalwomen who live in poverty. Inactivity andlack of exercise were noted as healthissues for Aboriginal women, specificallyas contributing factors to diabetes.Low educational levels were also seenas a factor contributing to poverty amongAboriginal women, since women who arenot well educated have a much lowerchance of securing well paid employment.The interviewees saw lack of education asa contributor to poor health, since womenwith low levels of education may notunderstand their own bodies andphysiology. This creates problems forthem in understanding preventative healthmeasures and knowledge of basichealthy living (e.g. four food groups).Interviewees discussed the problems facedby Aboriginal women during childbirth, andsaw these as a result of double discriminationfaced by being both Aboriginal andpoor. For example, one woman who wasinterviewed described situations whereAboriginal women had been left alonewhile in hospital, during the actual birthof their babies. This is an unacceptablestandard of care, placing both the womanand her baby at risk.Aboriginal women also identified difficultyin receiving help or instruction on breastfeedingwhen their child is first born. Onewoman commented that health careprofessionals have a tendency to assumethat Aboriginal women will not breastfeedtheir children.The interviewees noted that this typeof discrimination and mistreatment of

Women, Income andHealth in Manitoba16Aboriginal women in the health caresystem greatly affects their overall health.They identified poverty, as well as poortreatment and discrimination, as factorswhich can have negative effects on themental, emotional and spiritual well-beingof Aboriginal women.The majority of women interviewed sawdepression, low self-esteem and feelings oflow self-worth to be attributed to povertyamong Aboriginal women. One womanexplained that, if a woman is unable toprovide basic nutrition and housing forherself and her children, this can have adevastating effect on her mental, emotionaland spiritual health. Another woman feltthat, although a woman’s mental andemotional side would be negativelyaffected in such a situation, herspirituality would remain strong.Stress was identified as being a majorhealth issue for Aboriginal women who arepoor, because of the mental and emotionaleffects of poverty. It was noted that manyAboriginal women smoke as a result ofstress, which the interviewees understoodto be harmful to their health.Finally, many interviewees emphasizedthat Aboriginal women who are poor willignore their own health needs in orderto fulfil the health needs of their children orother family members. As an AboriginalMedical Interpreter (who requestedanonymity) told us:Aboriginal women do not make as muchmoney as their male counterparts.Especially if they are single women,there is so much more that are going todo without. So, they have more worries,mentally and spiritually, they would bemore stressed. Aboriginal women justignore their own health to lookafter others.2.5 VISIBLE MINORITY WOMENData from the 1996 Census of Canadashows high rates of poverty for visibleminority Canadians as follows:TABLE 7POVERTY AMONG VISIBLE MINORITYCANADIANS AND MANITOBANSCANADA MANITOBAMales 35.00% 30.80%Females 36.80% 31.80%SOURCE: Statistics Canada, 1996 Census,Dimension Series, Ethnocultural and SocialCharacteristics of the Canadian Population -94F0009XDB96003Based on data published in 1998 byStatistics Canada, Armine Yalnizyan hasnoted that:...Canadian-born members of visibleminority groups have only a slightlybetter earnings profile than peoplewho have just arrived in the country.Their average employment income of$18,565 was almost 39% below allother Canadian-born earners. Onlyone-third of this group of earnershave full-time full-year work, comparedto half of the rest of Canadian-bornearners. More than one in threeof the visible minority populationlive in poverty compared to 20%of the general population. 15(emphasis added)However, this remains for Canada arelatively new area of research. Theresearch of Derek Hum and WayneSimpson, using data from the StatisticsCanada Survey of Labour and IncomeDynamics, has yielded somewhat differentresults. They found that:with the exception of Black men,there is no statistically significantwage gap between visible minorityand non-visible minority groupmembership for native born workers.It is only among immigrants that thequestion of wage differentials forminorities arises, and consequently,the differential wage gap among

members of different visible minoritygroups. Furthermore, we wouldnote that there are differencesbetween men and women. Amongimmigrants, we find a wagedisadvantage for visible minoritymen relative to other men, but notfor visible minority women relativeto other women. 16 (emphasis added)They note that foreign-born women inCanada “face a disadvantage in theCanadian labour market whether theyare members of a visible minorityor not.” 17 (emphasis added)Further research will likely clarify ourunderstanding of these apparent differences.In the interim, it is clear that visibleminority Canadians, both men andwomen, face a much greater likelihood ofliving in poverty than do other Canadians.Their greater risk of poverty places uponthem a greater burden of ill health.Additionally, they face the burdensresulting from racism, which furthercontribute to stress and ill health.Women, Income andHealth in Manitoba17

D. THE CONNECTION BETWEENINCOME AND HEALTH1. What Is Known about the Connectionbetween Income and Health?Women, Income andHealth in Manitoba18There now exists a considerable literatureon the relationship between income andhealth. Robert Evans’ book Why Are SomePeople Healthy and Others Not? 18 hasbecome the Canadian classic text. Evans’main thesis is that the major determinantsof health are social and economic and thathealth care makes only a small contributionto the health of populations. Manitobaresearcher Patricia Kaufert has summarizedEvans’ model as one in which:the well-being of the populationdepends not on medical care, but ona relatively equitable distribution ofincome, on a social environmentwhich provides people with a senseof security and control, on stable andsatisfying employment, and on theavailability of social support.She goes on to note that:locating health in the social conditionsof people’s lives is an idea whichcan be dated back to the originsof the public health movement...Within the last 25 years, the LalondeReport (1974) in Canada and theBlack Report (1980) in the UK putforward many of the samearguments. 19Vivienne Walters and Margaret Dentonhave examined the Canadian as well asthe international data and have concludedthat:Research in Canada and othercountries has revealed relationshipsbetween level of health andstructures of inequality such associal economic condition, sex, raceand age. With respect to socialeconomic condition (measured byincome, occupational status, homeownership, access to a car), healthdifferences can be observedthroughout the socio-economicspectrum...Poor health is not simplyconcentrated among those whoare most deprived. Health statusdeclines with each decline insocio-economic status and thusit is important to focus on thebroader structure of socialeconomic condition rather thanon material deprivation alone,though the determinants of healthmay vary at different levels of socioeconomicstatus. 20 (emphasis added)The November, 1998 report of the BritishIndependent Inquiry into Inequalities inHealth contains a wealth of useful, currentinformation. The report summarizes thecurrent state of knowledge as follows:Socioeconomic inequalities in healthand expectation of life have beenfound in many contemporary andpast societies. In England, althoughinformation based on an occupationaldefinition of social class has only beenavailable since 1921, other dataidentifying differences in longevity byposition in society have been availablefor at least two hundred years. Thesedifferences have persisted despite thedramatic fall in mortality rates over thelast century.Inequalities in health exist, whethermeasured in terms of mortality, lifeexpectancy or health status; whether

Women, Income andHealth in Manitoba19categorised by socio-economicmeasures or by ethnic group orgender. Recent efforts to compare thelevel and nature of health inequalitiesin international terms indicate thatBritain is generally around the middleof comparable western countries,depending on the socioeconomic andinequality indicators used. Although ingeneral disadvantage is associatedwith worse health, the patterns ofinequalities vary by place, gender,age, year of birth and other factors,and differ according to which measureof health is used. 21The similarities between Canada andBritain (a shared Commonwealth heritage,both industrialized western countries,both with a universal, public medicaresystem, both with major reductions insocial spending and both with multi-culturalpopulations) make the British literatureparticularly applicable to the Canadiancontext. The American literature, whichwas also examined for this paper, was oflimited applicability to the Canadiancontext because, for many Americans,their lack of health insurance severelylimits their access to health care services.The link between income and health existsin other industrialized countries as well.Sally Macintyre summarized her findingsin an international overview of socialinequalities and health as follows:1. Socio-economic inequalities in healthhave been observed since statisticshave been available.2. They are observable in allindustrialized countries.3. They are observable in mostmeasures of health and longevity,and using most measures ofsocio-economic status.4. Their magnitude variesbetween countries.5. Main causes contributing toinequalities vary between countries.6. Health and longevity tend to have astepwise, not threshold relationshipwith socio-economic status.7. Socio-economic differentials in healthare less strong and consistent forwomen and minority populations. 22(Some recent Canadian work shows astronger connection for women thanfor men. See page 19 below.)The issue, therefore, is broader thanjust poverty. It is the inequality ofdistribution of wealth in a society,which affects the health of the wholepopulation, since differences in healthand illness exist across all socioeconomiclevels and not just betweenthe poor and the non-poor.Dennis Raphael has stated:These findings suggest that thefactors that make poor people moreat risk also affect just about everybodybut in somewhat lesserdegrees. And consistent with the viewthat we are all affected by thesesocial forces, it is now accepted thatsocieties with greater economicinequality have higher death ratesthan more egalitarian societies.This had been seen as reflectingthe poverty and illness relationshipalready described. But recentanalyses have suggested that thesesocioeconomic differences in healthactually reflect basicstructures andfunctions of a society – and how thepopulations responds to thesestructures and functions – not simplythat this group or that group arelacking resources that can beremedied by directing programsto assist the poor. 23

2. Income Disparities in CanadaGiven what is known about the positiveconnection between income inequalitiesand the health of all members in a society,it is worrisome to note that income disparitiesin Canada are increasing. In a reportfor the Centre for Social Justice, ArmineYalnizyan has noted that:In 1973, the top 10% of families withchildren under 18 earned an averageincome 21 times higher than those atthe bottom ($107,000 compared to$5,200 in 1996 dollars). That ratiogoes up and down over the course ofeach business cycle. But the last twodecades have ushered in creepingunemployment, the increasingcasualization of work, and realdeclines in wages paid to youngmen (under 35).These changes meant the ratio ofmarket incomes for the upper andlower strata ballooned over the1990s. By 1996 – still near the peakof the business cycle in this decade,and so presumably a ‘good’ time forreducing income disparities – the top10% made 314 times as much as thefamilies in the bottom 10% (anaverage $137,000 compared to anaverage annual market income ofless than $500). 24These figures are for market income, whichincludes earnings from wages, salaries,self-employment and return on investments.When transfers from governmentincome support programs are included, thepoorest 10% earned $13,522 (the lowestamount, in 1996 constant dollars, since1973), while the richest 10% earned$138,177 (higher than in previous yearsand including an average of $1,177 perperson in government transfers). Whentotal income is used, the top 10% received10 times as much as the lowest 10%. 25Yalnizyan has also documented the parallelreduction in Canada’s middle class. Whilethe richest and poorest groups in Canadagot bigger, the number of middle-incomeearners declined. She compared thenumber of families earning in a “comfortzone” of $31,666 to $55,992 (in 1996dollars) in 1973 and one generation later,in 1996. While 40% of Canadian familiesearned in this range in 1976, the numberhad decreased to 27% in 1996. 26For Canadians, who have undergone amassive reduction in social benefits(including social assistance rate reductions,reductions in the number of Canadianseligible for Employment Insurance benefits,reductions by the federal government inhealth and other transfers to the provinces)as well as the increased income inequalitiesdescribed by Yalnizyan, these data shouldbe of concern.Economic inequalities are increasing inCanada and the international research showsthat increased economic inequalities leadto decreased health for all members of asociety. For example, Dennis Raphaelhas noted that after decades of rapidlyincreasing economic inequality, the mostwell-off adult men and infants in Britainnow have higher death rates than theirleast well-off counterparts in Sweden. 27Future researchers may find increasingdisparities in the health of Canadians and adeterioration of the health and/or longevityof Canadians if we allow income inequalitiesto continue to grow.Women, Income andHealth in Manitoba20

3. How has the connection between incomeand health been explained?Dating back to the publication of the BlackReport in England in 1980, there havebeen four main explanations for theconnection between income and health.These are as follows:1. class differences in health areexplained as an artefact of measurementwith no causal meaning. Thistheses is not widely accepted.2. class differences in health are theresult of a process of natural andsocial selection. That is, ill healthleads to reduced income and socioeconomicstatus. A case can be madefor this when examining seriousmental illnesses, intellectual disabilitiesand those physical disabilities which,because of social and physical barriers,impede one’s capacity to earn.However, this does not explain theconnection between income and healthwhich is present across societies.3. class differences in health are theresult of material or structural factors.That is, individuals’ choices areconstrained by their life materialresources. This explanation has had thebroadest support among researchers,including the authors of the BlackReport and the recent BritishIndependent Inquiry into Inequalitiesin Health and, in Canada, by theNational Forum on Health.4. class differences in health are theresult of cultural and behaviouralfactors. That is, lifestyles areassociated with social class and lowerclass people smoke and drink toomuch, make poor dietary choices anddo not exercise enough. This is notwell supported by research. RecentCanadian data by Vivienne Waltersand Margaret Denton 28 , describedbelow on page 21, demonstrate thatin a recent large Canadian sample,structural determinants of healthaccounted for significantly morevariation in health status than didbehavioural factors.Sally MacIntyre has provided a furtherelaboration of “hard” and “soft” versionsof each of the above explanations in thefollowing chart. 29EXPLANATION“HARD VERSION”“SOFT VERSION”ArtefactNo relation between class and mortality;purely an artefact of measurementMagnitude of observed class gradientswill depend on the measurement of bothclass and health.Natural/socialselectionHealth determines class position,therefore class gradients are morallyneutral and explained “away”.Health can contribute to achieved classposition and help to explain observedgradients.Materialist/structuralMaterial, physical conditions of lifeassociated with the class structure arethe complete explanation for classgradients in health.Physical and psychosocial featuresassociated with the class structureinfluence health and contribute toobserved gradients.Women, Income andHealth in Manitoba21Cultural/behaviouralHealth damaging behaviours freelychosen by individuals in different socialclasses explain away social classgradients.Health damaging behaviours aredifferently distributed across socialclasses and contribute to observedgradients.

She notes that the authors of the BlackReport accepted both the “hard” and“soft” materialist explanations and rejectedonly the “hard” versions of the otherexplanations. She then describes along-term, negative consequence ofthe focus on this debate:The ‘big question’ addressed in muchof the research literature following theBlack Report was: ‘how much canartefact, selection or behaviourscontribute to observed social classgradients in mortality?’, to which theusual answer given was ‘not much’.This can be seen as having divertedattention from two other ‘big’questions; namely, ‘what are theprecise mechanisms or pathwaysby which social inequalities in healthare generated and maintained inparticular contexts?’ and ‘whateffective actions, if any, can be takento reduce, or ameliorate the effectsof, social inequalities in health? 30As Patricia Kaufert has noted:being invisible within thedeterminants of health model mayprove deleterious for women andlimit our understanding of the waysin which the determinants of healthmay function differently for women. 32The next section of this paper, will reviewand summarize a body of literature whichhas begun to address the connectionsbetween the health of women and theirsocio-economic status.It is to this last question that we will returnin Section G of this paper, documentingbest practices for health services forpoor women.While Health Canada recognizes genderas one of twelve determinants of health,much of the research in populationhealth makes no reference, or limitedreference, to the health of women, andthe few references that are includeddeal mostly with women as mothers. 31Women, Income andHealth in Manitoba22The consequences of this are wellillustrated in the case of the Whitehall Istudy of British civil servants and coronaryheart disease. The Whitehall I study waswidely seen as the standard reference oncoronary heart disease risks in humans.It contained no data about women and sothe risk factors for coronary heart diseasein women were completely excluded, at thesame time as the study was accepted asthe gold standard reference.

E. INCOME AND THE HEALTH OF WOMEN –WHAT WE KNOW FROM THE LITERATUREWomen, Income andHealth in Manitoba231. Measuring Women’s Socioeconomic StatusThe ways in which women’s socioeconomicstatus and their health areconnected is determined in part by howone measures socio-economic status.The most common methods are:1. using the woman’s own occupation(individualistic approach). This isproblematic because it may underestimatewomen’s actual socioeconomicstatus, since many womenwith partners may work part-time ormay re-enter the labour force after anabsence to care for young children ata lower occupational grade than thatwhich they previously occupied. In aprospective study of all of the childrenborn in England, Scotland and Walesduring one week in 1958, Matthewset al concluded that they may haveunderestimated socioeconomicinequalities in women’s health byusing this approach. 332. using the “head of household’s”occupation (conventional approach).This is problematic because it mayunderestimate the effect of women’sown occupations on their health. It isalso complex because, since men andwomen tend to work in different jobs,it combines two different occupationalstructures. In this approach, a woman’smarital status is the sole criterion fordeciding which gender-segregatedoccupational class structure to use. 34However, research using this methodtends to show larger inequalities thanresearch using women’s ownoccupation. 353. using the highest occupation,income or education level in thehousehold (dominance model).Since most women earn less thanmost men, this method has the samelimitations as the conventional model.4. using measures of materialcircumstances. Some researchershave included housing tenure(in England, comparing those whoown their homes with those in privaterental housing and those in publichousing) and car ownership.5. using education as a measure ofsocioeconomic status. Because ofthe difficulties in using occupation as ameasure of women’s socioeconomicstatus, some researchers havesuggested using education. SaraArber, in the study noted above, foundthat education was strongly linked toself-assessed health for both Englishwomen and men and recommendedusing it as an alternative indicator ofsocial disadvantage for women, ratherthan own occupational class. 36Margaret Denton and VivienneWalters found that education was animportant predictor, for both men andwomen, of both self-perceived healthand functional health in a recentlypublished study using data from theCanadian National Population HealthSurvey. 376. using neighbourhood as a measureof socioeconomic status. This is themethod currently used in analyses ofManitoba Health Services InsurancePlan data by Patricia Kaufert of theUniversity of Manitoba and by theManitoba Centre for Health Policy andEvaluation. By linking Manitoba Healthdata with Census Canada data forcensus subdivisions, they havegrouped neighbourhoods into income

quintiles and compared the patterns ofhealth services utilization amongthose quintiles for women and men.This method has the advantage ofavoiding all of the problems associatedwith defining women’s socioeconomicstatus by occupation. It includes ameasure of material circumstance,noted by other authors to beimportant in understanding healthinequalities. The weaknesses of thismethod are that it works best in urbanareas and that it uses a measure ofsocioeconomic status which isgeneralized to the level of theneighbourhood, rather than aspecific individual or householdmeasure of socio-economic status.Each of the measures above which usesome measure of household income(2, 3, 4 and 6) are further limited by theassumption that income is equitablydistributed within a household. Work donefor the 1992 Report of the Women andTaxation Working Group of the OntarioFair Tax Commission, suggested that it ismisleading to assume that income within afamily is pooled so that all family membershave equal access to it. They found thatthis was particularly true in families wherewife abuse occurs. 382. How Health Is MeasuredIn the studies which are reviewed below“health” is measured in two ways:“Self-perceived health” is howsurvey respondents describe theirown health. A scale from “very poor”to “very good” is usually used.respondents answer one or morequestions about their ability to performthe tasks of daily living, or they areasked about “limiting, long-standingillnesses”; that is, conditions whichin some way limit their ability tofunction in the world.“Functional health” is a moreobjective measure becauseBoth measures provide valuable, butdifferent, information about health.Women, Income andHealth in Manitoba243. Current Knowledge – Women’sHealth & Socioeconomic StatusUnderstanding women’s socioeconomicstatus is more complicated than doing sofor men because women earn significantlyless than men throughout Canadiansociety, they have lower labour marketparticipation rates, are more likely to workpart-time and may temporarily leave thelabour force while raising young children.So, whereas for men, occupation is a goodmeasure of socioeconomic status, forwomen, the situation is more complex.If they are married, then their ownoccupation and/or income may not be agood predictor of the material resourcesavailable to the household. It is, however,important not to ignore women’s ownoccupations in analyzing socioeconomicstatus and health. To do so risks missingimportant data on women’s occupationalhealth.Given the above complexities, mostresearchers have found that the connectionbetween health and socioeconomic statusfor women is less consistent for womenthan for men. In reviewing the literature ina recent article, Sharon Matthews, OrlyManor and Chris Power stated:...there is some evidence that themagnitude of SES inequalities differs,

Women, Income andHealth in Manitoba25with women having shallowergradients than men across a broadspectrum of morbidity measures andmortality. Although smaller SESinequalities for women are citedfrequently, there are studies in whichmen and women have similar SESgradients (using both occupationaland non-occupational measures ofsocial position). 39One very recent and notable exceptionto the previous pattern of a weakerconnection between socioeconomic statusand health for women than for men is therecent article by Margaret Denton andVivienne Walters. They examined a groupof 15,144 Canadians who participated inthe 1994 National Population HealthSurvey and found that:self-perceived health and functionalhealth were associated with educationand income for both men and women,but the effects appear stronger forwomen than men. 40 (emphasis added)Sara Arber has noted that socioeconomicstatus is used to measuretwo things which may be quite differentfor women – the influence of thematerial circumstances of her householdon her health and the influence ofher own paid employment on her health.For men,these two aspects of materialposition work in concert to increaseinequalities in health, since a man’soccupation is assumed to be both aprimary determinant of his materialcircumstances and has a directbearing on his health. 41Denton and Walters used a combinationof measures of income adequacy, levelof education and occupation to measuresocio-economic status. Interestingly,they found that when they controlled foreducation and income, occupational statuswas not a predictor of health status, witha few notable exceptions.One interesting exception was that thefunctional health status (a combinedmeasure of vision, hearing, speech,ambulation, dexterity, cognition, emotionsand pain and discomfort) of women wasthe reverse of what might be expected,with women in higher status occupationsreporting poorer health. The authors state:It may be that these jobs are moretolerant of disability than are bluecollar and service jobs which willbe more physically demanding.This possibility alone points to thecomplex explanations that mayunderlie associations; we cannotalways assume the direction ofrelationships, even wheninterpretations are grounded intheories of the social productionof illness. 42Arber found similar results in herexamination of the health of women andmen in the British General HouseholdSurvey. She found that women in Class 2(lower professionals, technical workers,managers and employers in smallestablishments) reported higher levelsof chronic illness than women in semiskilledand unskilled jobs. 43In order to accurately measure women’ssocioeconomic status it is thereforenecessary to use more complex measuresthan women’s own occupations and torecognize and understand societaldifferences which influence women’ssocioeconomic status; for example,women’s patterns of labour marketparticipation, parenting leave entitlementsand the extent of wage discriminationagainst women.As Arber noted,(w)hich approach explains the mostvariance in women’s health may differbetween societies and within the same

Women, Income andHealth in Manitoba26society over time, because ofdifferences in the structure ofwomen’s employment. For example,in Finland, 90% of women work fulltimethroughout their working life,and their own occupation has astrong influence on their health. 44In Canada, where labour marketparticipation rates among women arelower, and where systemic discriminationmeans that for married women, theirown occupation or earnings may not bereflective of the socioeconomic statusof the family, this is an importantconsideration and one which isdemonstrated in Denton and Walters’finding that occupation was not a strongpredictor of women’s health status.More recently, in her background paperfor the British Independent Inquiry intoInequalities in Health, Sara Arber hasargued for:the importance of using a clearconceptual model of the linkagebetween socio-economic measuressuch as educational qualifications,occupational class, employmentstatus and material resources(such as housing, car ownership andincome) in order to fully understandinequalities in health. It is necessaryto simultaneously analyse all thesefactors using multi-variate models,and for women with partners totake into account both their owncharacteristics and the socioeconomiccharacteristics oftheir partner. 45Researchers in Manitoba may have theopportunity to do this using the results ofthe 1996 National Population HealthSurvey (NPHS). In Manitoba, the provincialgovernment paid for the cost of increasingthe sample size, so that conclusions whichare stronger statistically may be drawnfrom the data. It may be possible to buildon the work of Denton and Walters,specifically for Manitoba, by combining theManitoba NPHS data with ManitobaHealth’s existing health services utilizationdata. This would provide a uniqueopportunity to pursue these questions,and their answers, locally.Like Denton and Walters, Arber lookedat both an objective measure of health(limiting long-standing illness) and asubjective measure of health (selfassessedhealth). She found an interestingdifference between the two measures. Inher study, both car ownership and housingtenure were significantly associated withself-assessed health, but not with limitinglong-standing illness. For both women andmen, those living in public housing andthose with no car in the household reportedpoorer health. She noted that car ownershipwas a particularly salient issue for women’sself-assessed health. 46 She further notedthat “adverse material conditions havea particularly negative effect on selfassessedhealth if women are notin paid employment.” 47In a smaller, in-depth study of women inLiverpool, Ruth Young conducted a “timespaceanalysis” of women’s health-relatedbehaviours, 48 which included factors suchas car ownership and housing status, aswell as income, access to telephoneservice, task sharing within the household,location of employment and access topublic transport. She developed a framework,with four scales of “time-spaceconstraint” which work in concert toinfluence the ability of women to care fortheir own health. These four scales are:1. economic and social resources;2. domestic labour and caring constraint;3. paid employment constraint, and4. individual health status. 49The first three are the result of socioeconomicstatus and the fourth, the healthof the individual woman is correlated withsocioeconomic status. She noted thatwomen are the health managers in a

majority of British households,regardless of class or ethnic group.For women in lower socioeconomicgroups, this may have negativeconsequences.In circumstances of scarce availabletime and few resources, therefore,women may ‘choose’ to neglect theirown health needs in order to achievethe best possible overall outcome forthe family. Consequently...behaviourswhich can look ‘irrational’ or‘unreasonable’ to health professionalsoften have readily understandableorigins in the complex and sociospatialstructures which constitutewomen’s everyday lives. 50The image of the self-sacrificing motherwho, when faced with inadequate resources,gives greater importance to the needs(and sometimes wants) of her family, ratherthan to her own needs, is one which is wellentrenched in Canadian society. This hasbeen compounded by cutbacks in healthservices, which increase the burden onfamily members, mostly women, to carefor their ill relatives. The extent to whichwomen’s altruism, which is socially valuedand publicly lauded, is actually detrimentalto women’s health, is not known.Denton and Walters, in their analysis of theNational Population Health Survey data,looked at behavioural as well as structuraldeterminants of health. The behaviouraldeterminants they included in their analysiswere smoking, alcohol consumption,physical activity and over/underweight.The structural determinants which theyincluded were age, family structure, socialeconomic condition, main activity andsocial support.It is noteworthy that they found that forself-perceived health, structural variablesexplained 19% of the variation for bothmen and women, while behaviouraldeterminants accounted for 15% of thevariation for men and 11% for women.For functional health status, structuraldeterminants accounted for 21% of thevariation for men and 24% for women,while behavioural determinants accountedfor 9% of the variation for both women andmen. 51 This means that for the womenin this study, lifestyle factors accountedfor less than 40% of the varianceexplained by structural factors.This is noteworthy and should beconsidered in planning projects aimedat improving women’s health status.It suggests that a focus on access tohealth services or on lifestyle factors(diet, exercise, smoking and alcoholconsumption), rather than on structuralfactors which influence health, will beless successful than those whichinclude an understanding of the impactsof the structural determinants on thehealth of women.Women, Income andHealth in Manitoba274. The Connections with Employment StatusWe know from the work described above,that household income and women’sown education are strongly linked to theirhealth and that women’s own occupationis less strongly associated with inequalitiesin health.Bonnie Janzen, in her literature reviewpublished by the Prairie Women’s HealthCentre of Excellence, described thecomplexities in understanding theconnection between women’s employmentstatus and inequalities in health:The relationship between healthand employment among women iscomplex. Available evidence suggeststhat paid work may certainly have apositive influence on women’s wellbeingas a result of increased income,

social support, and self-esteem. Onthe other hand, the potential negativeconsequence of employment on healthalso exist, such as the stressesassociated with the ‘double day,’ orthe psychological, physical, and/orchemical hazards of a particular workenvironment. Furthermore, much of theevidence on women, work and healthis based on cross-sectional studies,making it difficult to differentiatebetween ‘healthy worker effects’and/or employment as contributingto better health. 52In their work analyzing the NationalPopulation Health Survey (1994) dataon this question, Denton and Waltersconcluded that their findings supported theliterature on the health benefit to women ofworking outside the home. Contrary to theidea that caring for children would addto the stress and workload of womenand possibly diminish their health, theyfound an association between betterfunctional health and women working a“double day” of paid employment andcaring for children. In trying to understandwhy this occurs, they hypothesized that:It may be that the ‘double day’,through role enhancement, promoteshealth, at least for some women. Orthere may be a selection effect suchthat only physically healthier womenare able to take on such demandingroles. Indeed, both explanationsmay be relevant. 535. Inequalities and theHealth of Aboriginal WomenWomen, Income andHealth in Manitoba285.1 JURISDICTIONAL ISSUESJurisdictional issues, and their implicationsfor the provision of health care services,are a major issue in any discussion of thehealth of Aboriginal people.In 1867, the British North American Actplaced “Indians and lands reserved forIndians under full legislative authority of thefederal government, while at the same timeplacing health and social services underprovincial jurisdiction.” 54 Yet of all of thetreaties signed between the Crown andFirst Nations, only Treaty Number 6 madespecific reference to health care:In the event hereafter of the Indians...being overtaken by any pestilence,or by general famine, the Queen...will grant to the Indians assistance...sufficient to relieve them from thecalamity that shall befallen them...A medicine chest shall be kept at thehouse of each Indian Agent for theuse and benefit of the Indians. 55The Indian Act of 1876 obligated thefederal government to take responsibilityfor the provision of health care serviceson reserves. It stated that the federalgovernment had the responsibility to:prevent, mitigate and control thespread of diseases on reserves...toprovide medical treatment and healthservice for Indians, to providecompulsory hospitalization andtreatment for infectious diseases...and to provide for sanitaryconditions...on reserves. 56The Government of Canada currentlyprovides health care services only toAboriginal people living on reserves. It hasargued that because “all Native people areincluded in the calculation of transferpayments to the provinces, Natives shouldbe afforded the same health servicesavailable to other provincial residents.” 57Health services on reserves are providedby the Medical Services Branch of HealthCanada. Other government services on

Women, Income andHealth in Manitoba29reserve are provided by Indian andNorthern Affairs Canada.5.2 DATA ISSUESThe National Forum on Health noted thatAboriginal women face a heightened risk ofa wide range of health problems includingboth increased morbidity and mortality. 58Yet, data about the health of Aboriginalpeople is scarce. This was noted in the1999 Statistical Report on the Health ofCanadians, which stated in part:One issue that cuts across almostall sections, however, is the relativepaucity of data on Canada’s Aboriginalpopulation and on marginalizedgroups such as street people. Whilemost of the topics in this Reportdescribe at least 97% of theCanadian population, it is importantto remember that the missing 3%often have a disproportionateshare of health problems. 59Aboriginal people, including Aboriginalhealth professionals have strong views onthe collection of health data. In March 1999,the Health Canada’s Advisory Committeeon Women’s Health Surveillance held aworkshop to discuss the development ofits plan of action.Dr. Judith Bartlett, of the Aboriginal Healthand Wellness Centre of Winnipeg statedthe following during the closing plenarysession:There needs to be a separate orenhanced surveillance system forAboriginal peoples, particularly Métis,non-status and off-reserve FirstNation people. There are no dataavailable except for those that areextrapolated from on-reserve FirstNations. The approach to issues andconcerns as expressed by the mixedgroup of women participating in thisWorkshop is not relevant or contextualto Aboriginal women (for example,the discussion of fatigue or stress).The approach to the disease entitiesmust be holistic; data needs to becollected within an Aboriginal frameworkand owned by Aboriginalpeople. Several years ago, a NationalAboriginal Women’s Conference heldin Winnipeg clearly reported that theydid not want to discuss specificdiseases (need to be holistic and lookat root causes), nor did they wishto discuss women’s health in theabsence of a discussion of men’shealth. Analysis of Aboriginal datamust not be undertaken withoutAboriginal participation – at alllevels – from initial determinationof research questions to dataanalysis, dissemination and resultantpolicy and program development.Additional rationale for specific focusand control of Aboriginal data lieswith the constitution. 60Given these reservations, the followinginformation is presented on the healthstatus of Aboriginal women.5.3 HEALTH STATUSAboriginal women have shorter lifeexpectancies than Canadian women asa whole. Data from Indian and NorthernAffairs Canada (which includes only thoseFirst Nations people whose names appearon the Indian Register maintained byIndian and Northern Affairs Canada)indicate that the life expectancy ofRegistered Indian women has increasedover time, from 65.9 years in 1975 to 75.7years in 1995. While the gap in lifeexpectancy between Registered Indianwomen and all Canadian women hasdecreased over time, it is still significant.In 1995, all Canadian women had anaverage life expectancy at birth of 81.4years. That is, they could be expected tolive almost six years more than RegisteredIndian women. 61

Aboriginal girls and women are more likelythan other Canadian women and girls todie as the result of violence. In the periodfrom 1989 to 1993, Registered Indianwomen were 2.4 times more likely thanthe total Canadian female population todie as the result of violence. The agestandardizedmortality rate resultingfrom violence was 84.0 per 100,000for Registered Indian women and 30per 100,000 for all Canadian women. 62Aboriginal women are also more likely totake their own lives. In the period from1989 to 1993, Registered Indian girlsand women committed suicide at overthree times the rate of all Canadian girlsand women (17.4 per 100,000 comparedto 5.5 per 100,000).The 1999 Report of the First Nations andInuit Regional Health Survey containssome useful information about the healthstatus of Aboriginal women and men.The Survey was conducted in 1997 in nineregions of Canada, including Manitoba.It is not representative of all Aboriginalpeople, since only people living on reserveand Labrador Inuit were included. 63The survey included information abouthealth status by age and gender, assummarized in the following chart, whichshows the percentage of male and femalerespondents in each category:TABLE 8FIRST NATIONS AND LABRADOR INUIT PEOPLESELF-PERCEIVED HEALTH STATUS BY SEX AND AGE15 to 29Years 30 to 54 Years 55 & OverHealth Status Male Female Male Female Male FemaleVery Good - Excellent 67% 57% 51% 49% 31% 24%Poor - Fair 33% 43% 49% 51% 69% 76%No Chronic Conditions 77% 66% 56% 44% 20% 13%At Least OneChronic Condition 24% 34% 44% 56% 80% 87%SOURCE: “Activity Limitations and the Need for Continuing Care”, page 161 in First Nations andInuit Regional Health SurveyWomen, Income andHealth in Manitoba30This survey found that in every agegroup, Aboriginal and Inuit womenreported poorer health than their malecounterparts. These women alsodeveloped chronic conditions earlier in lifethan the men surveyed. In the youngestage group (15 to 29 years of age), overone-third of the Aboriginal and Inuit womensurveyed reported at least one chroniccondition, compared to one-quarter of theirmale counterparts. By age 55, the gapbetween women and men has narrowed,but the absolute numbers remainstaggering. Only 13% of women aged 55years and over reported no chronic healthconditions and only about one-quarterdefined their health as “very goodto excellent”. 64In analyzing which chronic conditionscontributed to these findings, the authorsnoted that “younger women reportedhigher rates of respiratory, cardio-vascularand arthritis problems, whereas youngermen reported higher rates of diabetes.” 65

The following chart, based on a chart fromthe Second Diagnostic on the Health ofFirst Nations and Inuit People, comparesdata from the First Nations and Inuit HealthSurvey, with information about the generalCanadian population from the 1994/95National Population Health Survey. Notethat “FN&I” refers to “First Nations andInuit” and “Gen. Can.” refers to thegeneral Canadian population.TABLE 9CHRONIC DISEASES BY SEX FOR FIRST NATIONSAND LABRADOR INUIT PEOPLE COMPARED TOTHE GENERAL CANADIAN POPULATIONRatioRatioFN&I/FN&I/FEMALE Gen. MALE Gen.Condition FN&I Gen.Can. Can FN&I Gen.Can. Can.Heart Problems 10% 4% 2.5 13% 4% 3.3Hypertension 25% 10% 2.5 22% 8% 2.8Diabetes 16% 3% 5.3 11% 3% 3.7Arthritis/Rheumatism 27% 18% 1.5 18% 10% 1.8SOURCE: Second Diagnostic on the Health of First Nations and Inuit People, page 7, based ondata from First Nations and Inuit Regional Health Survey (1999) and National Population HealthSurvey 1994/95Women, Income andHealth in Manitoba31For each of these four conditions,Aboriginal women and Aboriginal menbear a greater burden of illness than thetotal Canadian population. Of the fourconditions, Aboriginal women are thegroup most likely to suffer from threeof these (hypertension, diabetes andarthritis/rheumatism), while Aboriginalmen are the group most likely to sufferfrom heart problems.5.4 ACCESS TO HEALTH SERVICESAboriginal women face additional barriersin gaining access to health services. Forexample, they are less likely than otherCanadian women to have regular Pap teststo screen for cervical cancer. A study byH. F. Clarke et al, looked at the CervicalCytology Screening Program in BritishColumbia. The authors found that “FirstNations women’s participation is “lessregular and less frequent than otherwomen B.C.” 66 They found three mainreasons for this:1. Knowledge – Most of the womensurveyed had no or little informationabout Pap testing. Most women foundout about the Pap test during their firsttest or during their pregnancy. Some ofthe women reported that Pap testswere conducted without their knowledgeand/or consent, and that they onlyfound out when the results werereported back to the women. Mostof the women also indicated that theprocedure was embarrassing andintimidating, and most “objected togetting fully undressed and beingexposed on the examining table.”Some of the women attributed thisdiscomforting feeling to past sexualand physical abuse.

Women, Income andHealth in Manitoba322. Inhibiting and facilitating factors –Several elements inhibited the womensurveyed from having Pap tests. Theseincluded: travel away from their homecommunities, lack of knowledge ofdoctors who were receptive to theAboriginal people, and the feeling thatdoctors’ offices and clinics were coldand uninviting or located in unsafeneighbourhoods. Most womenreported that health care workers(male doctors, nurses) were insensitiveand that “sometimes a negative oreven discriminatory attitude [wasshown] to a person of FirstNations ancestry”.3. Health practices and supports –Most of the women surveyed indicatedthat they obtained most of their healthrelatedinformation from friends andfamily, rather than from health careprofessionals. Some of the womenalso reported that health preventionwas an “abstract concept and has anegative health focus…[while] healthpromotingknowledge and practicesfocus on staying healthy and are apositive approach that providespotential for greater personal controlin making choices.” 67First Nations and Inuit people surveyed forthe First Nations and Inuit Regional HealthSurvey also provided information aboutaccess to health services. The authorsfound that:A vast majority of First Nations andLabrador Inuit people had stated thatthey do not have the same level ofhealth services as the rest ofCanadians... Only 29% of peoplewith activity limitations, compared to35% of people with no limitations,agreed that they have the samelevel of health services. 685.5 KEY INFORMANT INTERVIEWSThe Aboriginal women who wereinterviewed for this paper also providedinformation and insights about these issues.Unemployment and the lack of employmentequity were identified as factors contributingto poverty among Aboriginal women. It wasnoted that single mothers in particular faceunemployment as an obstacle.High rates of domestic violence and abuseof all kinds were seen as serious forms ofinequality faced by Aboriginal women.Women who were interviewed explainedthat often abused women have nowhere togo and no one to protect them. They notedthat people will often deny or ignore theissue of domestic violence and choose topretend that the problem does not exist.The lack of treatment centres specificallydesigned for Aboriginal women wasidentified as another health care inequality.One example given was that of a womanwho was in need of alcohol addictiontreatment but could not receive the helpshe needed as her former abusive partnerwas situated at the only treatment centrein her area.Susceptibility to gambling addictions as aresult of poverty was identified as aninequality. Several women cited bingoas being a source for serious gamblingaddiction among Aboriginal women.Gambling addictions further aggravate theimpoverished situations of these womenwho are already unable to purchase basicnecessities. They described these womenas not able to afford bingo, but addicted to it.The rapid growth of cases of HIV amongheterosexual Aboriginal women was alsoidentified as a very urgent health issue.Environmental degradation was alsoidentified as a form of inequality faced byAboriginal women. One woman explainedhow environmental damage due to floodingcaused by hydro-electric dams hascontributed to increased morbidity andmortality among Aboriginal women.Traditional foods eaten by Aboriginalpeople were nutritious and not refined orprocessed, e.g. wild meat, fish, wild rice,

marsh potatoes, berries, etc. As a result ofenvironmental degradation, many of thesefoods are no longer readily available toAboriginal peoples. Subsequently, thechanges in diet from traditional toprocessed foods has contributed to diseaseand death. Further, they stated that manywomen in First Nations communities do nothave access to clean, safe drinking wateras a result of pollution, flooding andinadequate water treatment facilities.One woman stated that the biggestinequality is that “nobody wants to listento what an Aboriginal women has to sayabout her own health. If an Aboriginalwoman points to her left arm and says,‘it hurts’, they will say ‘no, it hurts righthere – and point to her right arm.”Finally, another woman made thefollowing comment, “I don’t even havethe words to describe the inequalities thatexist in the health care system forAboriginal women...”6. Stress and Socio-economic StatusWhile a detailed examination of theliterature on stress and socio-economicstatus is beyond the scope of this paper,it is interesting that one of the apparentdiscrepancies in the literature on genderand inequalities in health is the questionof stress. In a 1994 report to the HealthPromotion Directorate of Health Canada,using data from the 1990 Health PromotionSurvey, Vivienne Walters, Rhonda Lentonand Marie McKeary found that women inhigher income groups were more likely toperceive their lives as stressful thanwomen in lower income groups. 69 Thiswas consistent with earlier work done byWalters and Denton in the Hamilton area. 70In the 1994 report, they also found thatwomen with lower levels of education hadless stress than women with a universityeducation. 71 Understanding these findingswill require in-depth interviews with womento understand how the term “stress” isunderstood, and how those understandingsdiffer culturally and in women with differentlevels of education and income.Women, Income andHealth in Manitoba337. Health and the SocioeconomicStatus of Older WomenMost studies of socioeconomic inequalitiesand health have only examined workingage populations. In her background paperprepared for the British IndependentInquiry into Inequalities in Health, SaraArber commented on the relative lackof attention paid by researchers toinequalities in both women’s health andthe health of older people, as follows:The relative neglect of inequalitiesamong these two major populationgroups may be seen as reflecting bothsexism and ageism. One reason forthis relative neglect is that theconventional measures of class areoften seen as being not applicable forsections of the population who arenot currently in paid employment.However, our research shows starkinequalities in health based on thelast main occupation of women andmen for each age group, includingage 85 and over. 72 (emphasis added)The Final Report of the IndependentInquiry contains a summary of the factorswhich contribute to poor health amongolder women, including:1. Older women have a higherlow income rate than older men.2. Low income decreases their chancesof maintaining autonomy and

independence because of the costsof transport, social care and aids oradaptations to compensate forfunctional disability.3. Homes in poor condition are occupieddisproportionately by single, olderpeople, the majority of whom arewomen. These homes have higherheating costs, which again reducestheir disposable income.4. Women of all ages are more likely thanmen to be reliant on public transport.Fewer women than men own or haveaccess to a car. This gender differenceis more pronounced for older women.5. Fear for personal safety is greater inolder women than women of youngerages. This limits their ability to goout alone, yet older women are morelikely to live alone than older men andtherefore need to go out in orderto join social networks.6. Older women are more likely thanolder men to suffer from functionalimpairments sufficient to requirehelp on a daily basis to remain livingin the community. 73These are also issues for Canadianwomen. It is important when making theconnections between income andhealth to include all age groups, notonly children and those of working age.The particular needs of older womenshould be considered in interventionsto promote healthy public policies.The development of “best practices”for health care services for low-incomewomen should include attention to theneeds of older women.8. Gender Inequalities and theHealth of Women and MenWomen, Income andHealth in Manitoba34What about gender inequalities in a society?Another interesting and relatively newobservation in the literature is that, whenthe fifty states of the United States werestudied, gender inequality is stronglyassociated with both male and femalemortality. States where the status ofwomen and men varied the most(measured by rates of political participation,employment, earnings and women’seconomic autonomy) had higher mortalityrates for both women and men but,interestingly, it was men who sufferedthe most. 74In analyzing their findings, the authorsstate:Higher political participation bywomen was correlated with lowerfemale mortality rates, as well aslower activity limitations. A smallerwage gap between women and menwas associated with lower femalemortality rates and lower activitylimitations. Indices of women’s statuswere also strongly correlated withmale mortality rates, suggesting thatwomen’s status may reflect moregeneral underlying structuralprocesses associated with materialdeprivation and income inequality.However, the indices of women’sstatus persisted in predicting femalemortality and morbidity rates afteradjusting for income inequality,poverty rates and household income.Associations were observed forspecific causes of death, includingstroke, cervical cancer and homicide.We conclude that womenexperience higher mortality andmorbidity in states where theyhave lower levels of politicalparticipation and economicautonomy. Living in such stateshas detrimental consequencesfor the health of men as well.Gender inequality and truncated

opportunities for women may beone of the pathways by whichthe maldistribution of incomeadversely affects the healthof women. 75 (emphasis added)This very interesting work has begun toaddress the question of the mechanismsby which income inequalities act onwomen’s health, understanding both thedynamics of economic inequalities ina particular society and genderinequalities in particular. Devising amethod by which to apply this researchto the Canadian situation may help toincrease our understanding of theconnections between socioeconomicinequalities and women’s health.Women, Income andHealth in Manitoba35

F. INCOME AND THE HEALTH OF WOMEN -THE MANITOBA EXPERIENCEWomen, Income andHealth in Manitoba361. IntroductionWe are fortunate to have in Manitoba adatabase about the use of health servicesby the entire population of the province.The Manitoba Centre for Health Policy andEvaluation has published a series ofarticles using these data and examiningthe connections between health status andsocioeconomic status in Manitoba. 76They have found that there exists a strongconnection between socioeconomic statusand the health of Manitobans, asmeasured by health service utilization.Dr. Patricia Kaufert of the Department ofCommunity Health Sciences, Faculty ofMedicine, University of Manitoba andTeresa Mayer (a graduate student in theDepartment) collaborated with us bypreparing the following charts whichillustrate the connections between incomeand health services utilization for Manitobawomen. The methodology for datacollection and analysis is describedin Appendix 3.The charts which follow use per womanhealth care expenditure as a measure ofhealth care utilization and, therefore, as anindirect measure of ill health. This is not aperfect measure of ill health for a numberof reasons:1. It measures only the costs of thoseconditions for which women soughtmedical attention, either in-hospitalcare or physician services. This mayunderstate the burden of illnessencountered by women who managechronic diseases with infrequentmedical intervention.2. It uses the costs of services providedto women in the same income quintileas an indirect measure of the relativeburden of ill health faced by womenin that income quintile. That is, itassumes the higher the expenditure,the poorer the health.3. It measures the cost, rather thanthe frequency, of health servicesutilization. Again, this may notaccurately reflect the true burden ofill health. A one-time intervention, suchas surgery, may be more expensivethan the management of a chronicdisease, yet the surgical patient mayrecover completely, while the womanliving with a chronic disease maylive with reduced functioningon a daily basis.4. It uses neighbourhood income as ameasure of socio-economic status,rather than the socioeconomicstatus of a particular household.However, given these reservations, it is areasonable measure to use and allowsdeeper examination of the connectionsbetween income and health specificallyfor Manitoba women.These data are presented here in order tocontribute to our understanding of thesequestions and to further debate anddiscussion. They are not intended tosuggest that low and middle-incomewomen, whose health care costs arehigher than those with high incomes,use the health care systeminappropriately. The solution liesnot with restricting access to thehealth care system, but rather, inimproving the health of the population.

2. Manitoba Data – Income and Health ServicesUtilization among Manitoba WomenCHART 1HEALTH CARE EXPENDITURES ON PREGNANCY, LABOUR AND DELIVERY,CONDITIONS OF THE GENITOURINARY SYSTEM AND BREAST CONDITIONS,1994-95 PER CAPITA COSTS FOR ACUTE HOSPITAL CARE BY INCOME QUINTILE200.0180.0160.0140.0120.0100.080.060.040.020.00.0Q1 Q2 Q3 Q4 Q5Preg, L&D 189.1 148.5 132.7 128.3 103.5GU 56.3 60.3 61.6 59.8 56.6Breast 11.7 15.4 15.6 13.2 14.1Women, Income andHealth in Manitoba37The first chart in this series illustrates thedifferences in hospital utilization by womenin the five income quintiles for three typesof sex specific care: pregnancy, labour anddelivery 77 ; conditions of the genitourinarysystem such as acute infections, tumoursand other diseases; and conditions ofthe breast.The data show two trends. Firstly, there isa relationship between income quintile andhealth service utilization for pregnancy,labour and delivery. Per capita costs (thatis the total cost of services divided by thenumber of women in that quintile) arehigher for women in the lowest incomequintile than in the highest income quintileand there is a stepwise progression withthe costs of hospital care decreasing witheach increase in income. However, cautionshould be exercised in this interpretation,since the extent to which these findingsmay be the result of higher pregnancyrates among women in lower incomequintiles cannot be determined fromthese data alone.Secondly, this relationship does not holdtrue for either conditions of the genitourinarysystem or of the breast. That is,there is no connection between householdincome and either of these two groups ofdiseases. This raises some interestingquestions, which cannot be answeredby these data alone.

CHART 2HEALTH CARE EXPENDITURES ON PREGNANCY, LABOUR AND DELIVERY,1994-95, PER CAPITA COSTS FOR HOSPITAL CARE BY INCOME QUINTILE AND AGEThis chart gives a more detailed breakdown of the costs for hospital care associated withpregnancy, labour and delivery by including age as well as income quintile. The connectionbetween neighbourhood income and health services utilization is strongest amongyounger women. There is no apparent connection between income and health servicesutilization among women aged 30 to 44.As with Chart 1 above, the extent to which this may or may not be the result of higherpregnancy rates among lower income women cannot be determined from these data.Women, Income andHealth in Manitoba38

CHART 3HEALTH CARE EXPENDITURES ON PREGNANCY, LABOUR AND DELIVERY, CONDITIONS OFTHE GENITOURINARY SYSTEM, BREAST CONDITIONS AND SCREENING, 1994-95PER CAPITA COSTS FOR PHYSICIAN SERVICES BY INCOME QUINTILE25.020.015.010.05.00.0Q1 Q2 Q3 Q4 Q5Preg, L&D 22.6 18.8 17.5 17.5 14.6GU 17.4 17.0 17.4 18.2 17.8Breast 4.4 5.2 5.8 5.7 6.1Screening 7.5 8.7 9.7 10.2 11.2Women, Income andHealth in Manitoba39Chart 3 provides data about the three setsof conditions included in Charts 1 and 2,but for the cost of physician services ratherthan in-hospital care. In addition, informationis provided about screening for breastand cervical cancer. Since the costsassociated with hospital care are muchhigher than those for physician services,the per capita costs are much lower.For pregnancy, labour and delivery, thecosts of physician care provided to womenin the lowest income quintile are higherthan for women living in neighbourhoodswith higher incomes. The extent to whichthis is the result of higher pregnancyrates cannot be answered on the basisof these data.For genitourinary conditions, consistentwith the data above describing the useof hospital services, there is no associationbetween income and health careexpenditures.For screening procedures (mammographyfor breast cancer and Pap smears forcervical cancer) the trend is reversed.This reverse trend is also presentfor breast conditions.

CHART 4HEALTH CARE EXPENDITURES FOR ALL OTHER CONDITIONS, 1994-95,PER CAPITA COSTS FOR ACUTE HOSPITAL CARE BY INCOME QUINTILECHART 5HEALTH CARE EXPENDITURES FOR ALL OTHER CONDITIONS, 1994-95,PER CAPITA COSTS FOR PHYSICIAN SERVICES BY INCOME QUINTILEWomen, Income andHealth in Manitoba40Both Charts 4 and 5 illustrate the connection between income and health servicesutilization for non-sex-specific conditions. Women in lower income quintiles havehigher costs than women in higher income quintiles. The connection is strongerfor hospital based care than for physician services.

3. What Does This Mean?As in other jurisdictions, we have found aconnection between income and healthservices utilization for Manitoba womenfor most conditions. A strong connectionwas found in the case of pregnancy, labourand delivery, especially among youngerwomen. Further research would benecessary to determine whether, andto what extent, this is due to higherpregnancy and birth rates among lowerincome women and/or drift to lower incomeneighbourhoods as a result of pregnancyand childbirth.Carole Beaudoin of the Epidemiology Unit,Public Health Branch, Manitoba Healthprovided some additional data on thesubject of pregnancy and income for theCity of Winnipeg alone. These data are notdirectly comparable to that presented inCharts 1 through 5 above. However, itdoes show that pregnancy rates arehighest among Winnipeg women living inthe lowest income neighbourhoods, witha stepwise progression downward, sothat young women living in Winnipeg’swealthiest neighbourhoods have the lowestpregnancy rates (see Chart 6). These dataalso show that birth rates were highest,and abortion rates lowest, among youngwomen in the lowest income quintiles.Birth rates decreased, and abortion ratesCHART 61996 Pregnancy Rate According toIncome Quintiles for Winnipeg Postal Code Areas$18,324 - $34,472 $34,473 - $42,532 $42,533 - $47,421 $47,422 - $51,165 $51,166 - $84,146Women, Income andHealth in Manitoba41

CHART 7Proportion of Teen Pregnancies Resulting in a BirthAccording to Income Quintiles for Winnipeg Postal Code Areas, 1996CHART 8Proportion of Teen Pregnancies Resulting in an Induced AbortionAccording to Income Quintiles for Winnipeg Postal Code Areas, 1996Women, Income andHealth in Manitoba42increased, with each income quintile.Pregnant young women in Winnipeg’swealthiest neighbourhoods were least likelyto give birth and most likely to terminatetheir pregnancies. (see Charts 7 and 8)It is interesting to note that there wereexceptions to the association of lowerincome with higher health servicesutilization costs.Firstly, there was no connection foundbetween income and health servicesutilization for conditions of the breast andgenitourinary conditions for either hospitalbased care or physician services.Secondly, a reverse trend was found forscreening procedures –mammography forbreast cancer and Pap smears for cervicalcancer. This is consistent with the resultsof other studies, which have found thatwomen in higher income groups are morelikely to make use of screening

procedures. It is noteworthy that this is truefor Manitoba women at each income level.That is, there is a stepwise progressionfrom the lowest to the highest income group.This may be because women in higherincome groups have easier access to careor give more importance to the value ofscreening procedures for breast andcervical cancer and are therefore morelikely to do breast self-examinations, toconsult a physician regarding a suspiciousbreast lump and to be referred to aspecialist for further examination and tests.These data also demonstrate a relationshipbetween income and health servicesutilization for non-sex specific conditions,the “other conditions” illustrated byCharts 4 and 5.The health effects of income inequalitiesincrease the burden of illness in all bodysystems. Discussions of women’s healthand socioeconomic inequalities must bebroad enough to incorporate and buildon this information. Strategies whichfocus only on reproductive and sexspecificconditions will not besuccessful in reducing inequalitiesin women’s health.Women, Income andHealth in Manitoba43

G. DESIGNING HEALTH SERVICES TO MEETTHE NEEDS OF LOW-INCOME WOMENThis paper has shown the connectionsamong the issues of income, gender andhealth. Many health service providers mayfeel that these issues are beyond theirmandate or their expertise. Yet there arepractical steps that health servicesorganizations can take to addressthese issues.Three models for meeting the healthservices needs of women living in povertyare presented below. These are:1. Vancouver/Richmond Vancouver-Richmond Health Board’s Women’sHealth Planning Project Final Report.2. The Commonwealth Secretariat’sModel of Good Practice inWomen’s Health3. The Winnipeg Women’s HealthClinic’s Model of CareEach of these frameworks includemeasures which can be taken by healthservice providers to better meet the needsof low-income women, within their ownorganizations, with other health servicesorganizations and with other agencies.1. Vancouver/Richmond Health Board –A Framework for Women-Centred HealthIn January 2000, the Vancouver-RichmondHealth Board (V/RHB) released itsWomen’s Health Planning Project FinalReport. 78 Following a review of the relevantliterature and an extensive consultationprocess, V/RHB has developed aframework for women-centred health careservices delivery. The adoption of thisframework would make the health servicesdelivery system more responsive to, andaccessible to, the needs of low-incomewomen. The framework explicitly recognizesthe impact of income on the health ofwomen. Excerpts from the framework areincluded in Appendix 5. The 11 elements ofthe framework are:Women, Income andHealth in Manitoba44ELEMENT #1ELEMENT #2ELEMENT #3ELEMENT #4ELEMENT #5ELEMENT #6ELEMENT #7ELEMENT #8ELEMENT #9ELEMENT #10ELEMENT #11The Need for Respect and SafetyThe Importance of Empowering WomenInvolvement and Participation of WomenWomen’s Patterns or Preferences in Obtaining Health CareWomen’s Forms of Communication and InteractionThe Need for InformationWomen’s Decision-Making ProcessesGender-Inclusive Approach to DataGendered Research and EvaluationSocial Justice ConcernsGender-Sensitive Training

2. The Commonwealth Secretariat –Models of Good Practice in Women’s HealthWomen, Income andHealth in Manitoba45In 1996, the Commonwealth Secretariatpublished its Models of good practicerelevant to women and health, includingresearch, policy, implementation, strategies,testing and evaluation. 79 The 13 principlesincluded are reproduced below:SCOPE(1) Women’s health concerns extend overthe life cycle and are not limited toreproductive problems.(2) Women’s health problems include, butare not limited to, conditions, diseasesor disorders which are specific towomen, occur more commonly inwomen, or have differing risk factorsor course in women than in men.(3) Health must be considered in broadterms and both positively as well asnegatively. Dimensions of healthinclude the physical, mental, socialand spiritual.DETERMINANTS(4) Women’s health is directly affected bya range of socio-cultural, physicaland psychological factors.(5) Women have gender roles andresponsibilities which directly affecttheir level of access to and control ofresources necessary to protect theirhealth. These resources are external(economic, political, information/education, a safe environment freeof violence and time) as well asinternal (self-esteem, initiative)(6) Women are diverse in their age, class,race or ethnicity, religion, functionalcapacity, sexual orientation and socialcircumstances. These factors maylead to inequalities which adverselyaffect their health.COMMUNITY PARTICIPATION(7) Priority should be given to projects inwhich the issues have been identifiedas important by women themselves.Particular attention should be paid tothose issues raised by women whoare subject to inequities in their society.(8) Women from the target communityshould be involved in the planning,implementation, and evaluation orprojects involving their health.(9) Knowledge arising from projectsmust be accessible to all womenbut particularly women in the targetcommunity. This also means thatinformation must be provided informs appropriate to different levelsof education and literacy.METHODS(10) To address the complex issuesaffecting women’s health a broadbased,interdisciplinary genderedapproach is needed, involving andbringing together knowledge andmethods of social and healthscientists and other disciplineswhere appropriate.(11) Intersectoral approaches are neededto address the social factors affectingwomen’s health and life chances.These may involve the workingtogether of various governmentaldepartments with each other and withnongovernmental and communitybasedgroups and the private sector.(12) Knowledge from projects shouldalso inform and influence governmentpolicies and plans, legislation, researchand health care workers.(13) Where possible, there should beresource sharing of skills within regions.

3. Women’s Health Clinic,Winnipeg, Model of CareThe Winnipeg Women’s Health Clinicpublished its revised Model of Care inNovember, 1998. 80 The complete text ofthe Model of Care is reproduced inAppendix 5.The Women’s Health Clinic won theCommonwealth Award for Excellence inWomen’s Health Practice in 1997. ItsModel of Care is based on four principles:1. All women deserve respect and havethe right to make informed decisionsabout their health care. The WHCrecognizes the valuable and diverseexperiences which women bring to thehealth care system. In particular, theunique experiences and insights ofmarginalized women is recognized.Their involvement and participation isseen as essential for the developmentof quality, culturally appropriateservices.2. WHC is committed to facilitating theempowerment of women, individuallyand collectively.3. WHC is committed to a holisticunderstanding of health, with anappreciation for the interrelationshipof physical, social, emotional andspiritual aspects of women’s lives.4. Health promotion, primary preventionand healthy public policies are allrecognized as essential strategiesfor improving women’s health.The WHC’s has identified the followingas key elements of “woman-sensitivebest practices” in the delivery of healthcare services:■■■■■■■■■■■identifying as priority populationswomen who are most vulnerable topoor health due to factors such aspoverty and women who are morelikely to experience barriers inaccessing appropriate healthservices due to their ethnic origin,race, social class, language,sexual orientationor disability;providing women-centred services;developing a partnership between thewomen and the care provider;using the most appropriate caregiverand services;using a team approach;designing programs and services toenhance the understanding, self-care,self-help and self-advocacyabilities of women;using peer volunteers;working in partnership with othersin the community;reviewing and evaluating its own work;developing innovative programs;advocating for system change.4. Aboriginal Women’s ExperiencesWomen, Income andHealth in Manitoba46The following information obtained from theseven Aboriginal women key informantsinterviewed for this project identifies someissues which are specific to the situation ofAboriginal women. However, it is alsonoteworthy that many of the concernsraised by these women are similar tothose raised by other women, both inCanada and internationally.Most of the women who were interviewedexpressed dissatisfaction with the current

Women, Income andHealth in Manitoba47situation of health care service delivery forAboriginal women. Health Canada, andmore particularly, its Medical ServicesBranch were the main topic ofdissatisfaction for Aboriginal women.Hospitals and hospital care were alsothe subject of scrutiny by those workingin health professions.Much resentment was expressed over theinterviewees’ experience of the testing ofdrugs such as Depo Provera on Aboriginalwomen, and young Aboriginal women inparticular. Many of the women expressedanger at what they described as Aboriginalwomen being used as ‘guinea pigs’ fordrug and other medical testing and thatdrugs are prescribed to Aboriginal womenwithout obtaining their informed consent.The example of a young Aboriginal womanwho had been the subject of a case studyfor some time was raised. She wasdescribed as one of the youngest peopleto ever be diagnosed with diabetes.Unfortunately, this young woman died atthe age of twenty-four. The women wantedto know why she died of renal failure, whenso much testing and research was done onher. One woman angrily suggested thatAboriginal people are treated like guineapigs because the government feels thatthey are expendable.Shortages of nurses in hospitals was alsoidentified as a serious problem in thehealth care system.In terms of existing programs, theinterviewees noted that there are little orno health programs geared specificallytowards Aboriginal women.The interviewees described significantdissatisfaction with Medical ServicesBranch and a general sense that theMedical Services Branch has eroded rightsguaranteed in treaties. Concerns wereexpressed about the many cut-backs thathave been made to non-insured healthbenefits. It was noted however, that thereis a special needs program for non-statuspeople who can not afford to pay for theirprescriptions. It requires that an exemptionform be filled out and unfortunately mostpeople are not aware of this and otherexisting programs. It was suggested thatpoor women are faced with the impossiblechoice of deciding whether to buymedication or food.The strict guidelines of the MedicalServices Branch were also seen asproblematic. For example, if an Aboriginalperson from a rural community or FirstNation is terminally ill in hospital, familymembers would not be able to come andsupport that person, since the MedicalServices Branch will only allow oneescort, and that only in extremesituations. One woman said thatsometimes a patient is left to die aloneand that it is “really inhumane”.Many women had complaints about theracist and discriminatory treatment thatAboriginal women receive in Winnipeghospitals, particularly during child birth.Of the three Winnipeg hospitals wherewomen give birth, the St. Boniface Hospitalwas identified as the best overall. At theother facilities, the interviewees felt thatstaff racism was an issue.Several complaints were made about theway in which Aboriginal women weretreated. Aboriginal midwives, were not yetlicensed to practice in Manitoba at the timeof these interviews. (Midwifery legislationwas proclaimed in Manitoba in May, 2000.)The interviewees felt that Aboriginalwomen are not respected by hospital staff.An interviewee described an incidentwhere hospital staff wanted to immediatelyperform a D&C (dilation and curettage) ona pregnant Aboriginal woman, who wasbleeding early in her pregnancy. Theinterviewee felt that Caucasian womenwould have been offered an ultrasound todetermine the status of her pregnancy,rather than immediately terminating it.Other incidents were also described whereAboriginal women were given large dosesof analgesics during labour. One case that

was described involved a young Aboriginalwoman who was heavily medicated withDemerol. The interviewee reported thatmedical staff were trying to give heran epidural anaesthetic, despite thefact that she was too confused by themedication to give her informed consent.The interviewees identified pre-natal clinicsas examples of successful existingprograms. It was suggested that if theopportunities were available, Aboriginalwomen would be able to take better careof themselves. For example, a concernwas expressed that few Aboriginal womenhave regular Pap smears to screen forcervical cancer. Other important healthissues in need of improved programs andservices were identified as the following:early intervention, childbearing for youngAboriginal women, Elders’ health, breastcancer and menopause.Aboriginal services in hospitals andmedical interpreters were also identified assuccessful and much-needed programs.Many women who come in from outside ofWinnipeg have language barriers thatprevent them from understanding whatmedical professionals are telling themabout their health.One woman concluded that “povertyseems to be overall the greatest detrimentto Aboriginal women.”Women, Income andHealth in Manitoba48

H. MAKING PUBLIC POLICY HEALTHIER FORWOMEN – SUGGESTIONS FOR ACTIONWomen, Income andHealth in Manitoba491. The Current ContextWe know that health and income arelinked. We know that this is true forwomen and men and that this holdsacross all income levels. As well, weknow that increasing income inequalitiesin our society make all of us less healthy.Therefore the connection betweenincome and health is not only aproblem for those living in poverty,but for all of us.While this may not be new knowledgeamong those working in health policy orengaged in research, these facts are notwell known or well understood by mostManitobans. Those not living in povertytend to believe that they can isolatethemselves and their families from itseffects. They believe that poverty is aproblem which affects other people,but not themselves.In addition, decision-makers in areas otherthan health, in the health determiningsystems, may not understand theimplications which their decisions haveon the health of the community.Most in our society accept poverty assomething which is inevitable. Popularculture emphasizes individual action forself-improvement, rather than oncommunity action to reduce inequalities.One of the challenges faced by healthservices providers and equity seekinggroups interested in promoting abroader view of health promotion, is tofind a way to change these opinions.Activities to increase the awarenessof both the public and key decisionmakersabout the connections betweenincome and health and to promote thedevelopment of healthy public policy,sensitive to the needs of low incomewomen, would be one way in whichsuch groups could use this knowledgeto make public policy healthierfor women.Such a focus would be consistent with twoof the Priorities for Action identified by theFederal, Provincial, Territorial AdvisoryCommittee on Population Health (ACPH)in their 1999 Report, Toward aHealthy Future.The ACPH identified “improving healthby reducing inequities in incomedistribution and in literacy andeducation” as one of its threepriorities for action. 81The Report suggested the following six keystrategies for achieving a more equitabledistribution of income in Canada:■■■■■Increase earning capacities andemployment opportunities amongindividuals and groups that have beenleft behind. This includes women...Continue to use tax and transfer/socialpolicies to reduce inequalities amongdifferent levels of wage earners...Review the effectiveness of currentprograms that provide a safety net forCanadians who require assistance atdifferent times in their lives. Thetrends described in this report suggestthat this may be especially importantfor older women who live alone...Recognize the importance ofrecreation and social services to healthand find ways to provide equitableaccess to these services, regardlessof an individual’s or family’s abilityto pay...Find ways to ensure that all Canadianindividuals and families have their

■essential needs for shelter, privacy andsecurity met.Develop long-term strategies toprevent hunger in Canada... 82The ACPH identified “Renewing andReorienting the Health Sector” as anotherof its priorities for action and called uponthe health services system to:Initiate dialogue with other healthdeterminingsectors about thehealth impacts of policies insectors outside health andabout collective actions thatcan be taken.The Report stated:Addressing the root causes ofpoor health will mean workingwith other sectors to ensure thatthe general conditions withinsociety support health. This reportsuggests that there is a need toinitiate dialogue with other healthdeterminingsectors, particularlythose in the socioeconomic domain,about the health impacts of policiesin sectors outside health andcollective strategies that canbe adopted.The ideal outcome of thesecollaborations will be healthypublic policies in a variety ofhealth-determining sectors,particularly those in the socioeconomicdomain. The healthsector cannot do it all, nor canit impose its agenda on othersectors. It can, however, initiatedialogue and act as a catalystfor change. 83 (emphasis added)2. Interventions to PromoteHealthier Public PolicyWomen, Income andHealth in Manitoba50There are three broad types of issuesabout which equity-seeking groups couldintervene to promote healthier public policyfor women. These are:1. Income Issues, for example, theminimum wage, social assistancerates and Employment Insuranceissues.2. Expenditure Issues, for example,telephone and utility rates, child carecosts, pharmacare deductibles andthe increasing costs to consumersof purchasing health care servicesno longer provided through thepublic system;3. Health Services Issues, includingworking with Manitoba’s RegionalHealth Authorities (RHAs) to helpthem become advocates for healthierpublic policy, working with the RHAsin developing and delivering serviceswhich are sensitive both to genderand to socioeconomic status,delivering their own exemplaryprograms and providing trainingto health services professionals.Additionally, on any and all of these issues,groups could work with women living inpoverty, to help them develop the skills inneeds assessment, planning, negotiationand self-advocacy, to positively influencethe development of public policies whichmeet their needs and to provide them withthe necessary resources to help them toreach these goals.It is important to acknowledge that thepoints for potential involvement are vastand range from the wage gap betweenwomen and men, to issues of women’slabour market attachment, includingpension issues for older women, to federaland provincial income tax issues, violence

against women and its consequences forvictims of abuse and for all girls andwomen, issues related to women’sexpected and encouraged role ascaregivers for their families andcommunities, etc.What follows, then, is not a comprehensivelist of such potential interventions. Rather,it includes a few strategic issues, selectedon the basis of the following criteria:1. the desired policy change wouldclearly improve the health status oflow income Manitoba women;2 health services organizations andother community groups could workin partnership;3. the desired legislative, policy orregulatory change could reasonablyoccur within a three-year timeframe.3. Income-Related Issues3.1 MANITOBA MINIMUM WAGEThe connection between the level of theminimum wage and the depth of povertyin a community is straightforward. Theminimum wage in Manitoba is currently$6.25 per hour. This is equivalent to a fulltime, annual salary of $13,000. The chartbelow shows the Statistics Canada LowIncome Cut-Offs for Winnipeg and theamount by which someone working fulltime,earning minimum wage, would fallbelow the poverty line.MANITOBA MINIMUM WAGEHourly $6.25Annual $13,000.00MINIMUM WAGE FAMILY -ONE EARNER$ Below % BelowWinnipeg LICOs Poverty Line Poverty LineFamily of 1 $18,371.00 $ 5,371.00 29.20%Family of 2 $22,964.00 $ 9,964.00 43.40%Family of 3 $28,560.00 $15,560.00 54.50%Family of 4 $34,572.00 $21,572.00 62.40%SOURCE:Stats Canada, Low Income Cut-Offs and Low-Income Measures 75F002M-01007Having two full time minimum wage incomes reduces, but does not eliminate, the risk ofliving in poverty. A family of two adults earning minimum wage and one child, would still be$2,560, or 9% below the poverty line. The same family with two children would be $8,572or 24.8% below the poverty line.Women, Income andHealth in Manitoba51

MANITOBA MINIMUM WAGEHourly $6.25Annual $13,000.00 (one earner) $26,000.00 (2 earners)MINIMUM WAGE FAMILY -TWO EARNERS$ Below/ % Below/(Above)(Above)Winnipeg LICOs Poverty Line Poverty LineFamily of 2 $22,964.00 ($3,036.00) -13.20%Family of 3 $28,560.00 $2,560.00 9.00%Family of 4 $34,572.00 $8,572.00 24.80%SOURCE:Stats Canada, Low Income Cut-Offs and Low-Income Measures 75F002M-01007Manitoba’s minimum wage is set by thelegislature, following receipt of a reportby a Minimum Wage Review Board establishedby the provincial government. TheReview Board normally conductshearings across the province, which wouldbe an ideal opportunity for intervention.There is no fixed schedule for review of theminimum wage. Following the last reviewin December, 2001, the Minister of Labourannounced an increase of 25 cents perhour, effective April 1, 2002. This will nothave a significant impact on the poverty oflow-income earners. More interestingly, theLabour Representatives on the Reviewcalled for linking the minimum wage to theLow-Income Cutoffs. Such a proposalwould reduce the depth of poverty facedby low-income Manitobans who earnthe minimum wage.3.2 SOCIAL ASSISTANCE RATESManitoba’s social assistance rates havenot increased since 1993. The currentrates, compared to the Statistics CanadaLow Income Cut Offs for Winnipeg, areshown below.SOCIAL ASSISTANCE FAMILIESSocial $ Below % BelowAssistance Poverty PovertyWinnipeg LICOs Rate Line LineFAMILY OF 1 $18,371.00 $5,352.00 $13,019.00 70.9%FAMILY OF 2 (1 adult, 1 child) $22,964.00 $9,636.00 $13,328.00 58.0%FAMILY OF 3 (1 adult, 2 children) $28,560.00 $10,994.28 $17,565.72 61.5%FAMILY OF 4 (2 adults, 2 children) $34,572.00 $12,407.88 $22,164.12 64.1%FAMILY OF 4 (1 adult, 3 children) $34,572.00 $12,852.48 $21,719.52 62.8%SOURCE: Stats Canada Low Income Cut Offs 13-551-XPB January 1998 and ManitobaFamily ServicesWomen, Income andHealth in Manitoba52Under the previous provincial government,Manitoba moved to a single tieredprovincially administered social assistancesystem in Winnipeg, with plans to expandthis into rural and northern areas. Healthservice providers could act as a bridgebetween their low-income clients andthe Government of Manitoba to raiseawareness of the health consequencesof low social assistance rates.

3.3 CHILD TAX BENEFITThe Government of Canada provides aChild Tax Benefit to low and middle-incomefamilies, payable monthly, and based onthe previous year’s taxable income.Provinces were given discretion wherethese funds were payable to families onsocial assistance. The previous Manitobagovernment chose to “claw back” the ChildTax Benefit from families living on socialassistance. That is, the full amountreceived from the Government of Canadais deducted from social assistancepayments, and these funds are used tofinance other programs which the provinceconsiders to be beneficial for children livingon social assistance. Underlying thisdecision is the belief that women on socialassistance would not use these funds in amanner which would best benefit theirchildren and that provincially designed,targeted programs are more efficient.The current Government of Manitoba haschanged this policy. Parents in receipt ofsocial assistance benefits are allowed tokeep any increases in the Child Tax Benefitimplemented from 2000 on. As well,parents of children under 6 are allowedto keep the entire Child Tax Benefit.Interested organizations could, basedon their experience working withmothers on social assistance, educatedecision-makers about the strengthsand competences of women on socialassistance and the need to return theChild Tax Benefit to them, so that theymay use it to act as independentadults, capable of making the bestfinancial decisions for themselvesand their children.Women, Income andHealth in Manitoba534. Expenditure Issues4.1 TELEPHONE RATESIn 1998, the Manitoba Telephone Systemappeared before the Canadian Radio,Television and TelecommunicationsCommission to make the case for an$8 monthly increase in basic phone rates.MTS argued that, as a newly privatizedcompany, they would be required to payincome taxes and that this cost should beborne by telephone system users throughan increase in the basic rate. The CRTCruled that the increase would not beallowed for 1999, but hinted that theywould respond favourably for 2000.Groups including the Public InterestLaw Centre of Manitoba Legal Aid opposedthe rate increase, arguing the cost of thetaxes should be paid by the company’sshareholders and not by consumers. Theyfurther argued that it was unfair for MTSto pass on all of the expected income taxcosts to residential customers, withbusiness customers not expected topay any of the increased costs.Higher telephone costs will mean thatsome low-income Manitobans will beforced to give up telephone service.In Manitoba, telephone service is notconsidered a necessity for those livingon social assistance. That is, unless oneis disabled, the monthly social assistancepayment does not include an amount fortelephone service. Social assistancerecipients, like other Manitobans, wouldhave to absorb the additional cost of anyrate increase allowed by the CRTC.Telephone service is important to healthbecause:1. it allows for contact in caseof emergencies;2. it allows for routine contacts withhealth care providers, schools,social service agencies, etc.;3. it reduces social isolation by allowingfor ongoing contact with family andfriends. This is especially importantfor seniors, parents at home withyoung children and people withphysical disabilities.Manitoba’s cold winter temperatures

exacerbate these problems. Those livingin rural areas also face additional challenges.In First Nations communities, only 70%of residents have telephones. In somecommunities, this is as low as 40%.Some American telephone companies offera “Lifeline” program providing lower ratesor a basic telephone service to low-incomepeople. Canadian telephone companiesoffer no such service. This is another areawhere health service providers could workwith community and consumer groups topromote change.4.2 UTILITY RATESIncreases in gas and electrical ratesdisproportionately affect those living onlow incomes, since they already spend agreater portion of their income onessential needs. Additionally, low-incomepeople tend to live in less well insulatedhousing, which is more expensive to heat.In Manitoba’s harsh climate, these arebasic health issues.Gas and electrical rates are set inManitoba by the Public Utilities Board(PUB), following applications by CentraGas and Manitoba Hydro. They followno set schedule.Manitoba Hydro has not applied for anyrate increases since 1996. The PUB doesnot at this point expect an application for ahydro rate increase.In the last year, gas prices increased andCentra Gas obtained a rate increase.Although gas prices are now beginningto decline from the high levels of 2001,interested health service providerscould work with consumers groupsand others to help make the connectionbetween utility rates and health.4.3 HOUSINGHousing costs are a major portion of thebudget of most households and housingitself is a factor which influences health.In recent years, the federal governmentand the past Manitoba provincialgovernment both withdrew support fornon-profit and co-operative housingprograms, thus leaving those on limitedincomes with few alternatives to the privatemarketplace.Housing conditions are a major issuefor Aboriginal people, both on and offreserves. The Assembly of ManitobaChiefs has reported that:Canada has a First Nationspopulation of approximately800,000 people, yet has onlyproduced 76,000 homes fromwhich this population must raisea family and build a community. 84In Manitoba, rents are regulated by theResidential Tenancies Branch (RTB) of theDepartment of Consumer and CorporateAffairs. The RTB annually sets a guideline,the maximum amount by which a landlordmay increase rent without approval fromthe RTB. For both 1999 and 2000, themaximum allowable rent increase ws set at1%. Landlords may apply to have rentsincreased above 1% if they have incurredadditional costs, for example, throughrepairs or renovations.For families living on social assistance, themaximum allowable rates for rent, as setby Manitoba Family Services (included inthe total social assistance rates shownabove), are as follows:Women, Income andHealth in Manitoba54

Household Basic Rent Rent Including UtilitiesSingle person with disabilitySingle pregnant woman $243 $2852 people $285 $3873 people $310 $4304 people $351 $471Women, Income andHealth in Manitoba55Prior to 1993, these rates were linked tothe maximum rental increase guidelinesset by the RTB. They were then de-linkedand there has been no increase in theamount paid to social assistance recipientssince that time.These very low rates lead to increasedmobility, as families are forced to move tofind cheaper accommodation. As familiesmove, children may change schools inmid-year, and children and adults bothmay lose their connections with neighbourhoodsupports. The new, less expensivehousing may also be more crowded and/orless safe, which may further contribute toa deterioration in health status.There are a number of ways in whichinterested organizations could interveneto heighten public awareness of the impactof housing conditions on health.In urban areas such as Winnipeg,community organizations may be ableto work with school divisions, andorganizations representing people withdisabilities, to raise awareness of theissue of shelter allowances for peopleliving on social assistance withprovincial decision-makers.It is also important to stress the largerissue of the need for affordable housing forall, and of the connection between goodhousing and good health.4.4 CHILD CAREHigh quality, affordable, accessible childcare programs are essential to the healthand well-being of children, their mothersand fathers. Much recent research hasfocussed on the benefits of early childhoodeducation to children and to society as awhole. (For example, the recent EarlyYears Report of the Canadian Institutefor Advanced Research 85 ).Less has been written about the impact ofthe gaps in the child care system on thehealth of women. Yet these are an obvioussource of stress for working mothers andfor those wishing to find employmentoutside of the home.According to the Manitoba Child CareAssociation (MCCA), child care in Manitobais underfunded. This underfundinghas led to a shortage of qualified staff, asthe mostly women employed in child careleave for better paying jobs. 86 As a result,approximately 25% of licensed Manitobachild care centres have receivedexemptions from the licensing requirementwhich stipulates the ratios of trained staff tochildren in centres. In response to theseconcerns, the Province of Manitobaincreased child day care funding by 18%,or $9.1 million, for the 2000-01 fiscal year.This additional funding is important to thechild care system, but several key issuesaffecting low-income women remain.These are:1. Cost of Child CareChild care costs in Manitoba, whilelower than those in other provinces,are significant. For parents of infants,the annual cost is $7,124 per year. Forthe parents of pre-school children,the annual cost is $4,794 per year.While the issue of the affordability ofuniversity tuition has had some publicprofile, the issue of the affordability

of child care has not. Yet child carefees are much higher per year thanundergraduate university tuition fees.At the University of Manitoba, theannual cost of full-time undergraduatestudy in the Faculty of Arts is $3,100.2. SubsidiesThe Province of Manitoba providessubsidies for parents of childrenwhose annual income is below athreshold amount. For a single motherwith one child, the full subsidy ispayable only to those whose netearnings are less than $13,787.Although the difference betweennet and gross earnings will vary, theChild Care Office of Manitoba FamilyServices uses an average figure of25%. In that case, a single motherwith one child in full-time child carewhose net earnings were $13,787would have gross earnings of$17,233. She would, therefore,receive less than the full subsidy,even while living $5,731 below theWinnipeg poverty line.For two parents, with two childrenin care, the situation is even worse.They would lose some of theirsubsidy with combined net incomesof $18,895. Using the Child CareOffice’s figure of 25% to estimate thedifference between net and grossearnings, this family would receiveless than full subsidy withcombined gross incomes of$23,619, a remarkable $10,953below the Winnipeg poverty linefor a family of four.3. Parent Co-PaymentsUntil 1991 parents in receipt of childcare subsidies could be charged anadditional $1 per child per day forchild care. In 1991, that amount wasincreased to $2.40 per day, or $624per year per child. This presents areal burden for many parents,especially for those living inpoverty. Manitoba Family Serviceswill not cover this cost for mothers inreceipt of social assistance, whosechildren are in child care while theytake training or look for work.Women, Income andHealth in Manitoba565. Health Services Issues5.1 Health PlanningManitoba Regional Health Authorities(RHAs) are required to conductperiodic assessments of the healthneeds of their population and tosubmit annual health plans to theManitoba Health. A review of thesedocuments by the author 87 has shownthat RHAs include little analysis ofthe health needs of low-incomewomen in these documents.Interested organizations couldwork together to assist ManitobaHealth in the development and/orselection of health indicators whichare sensitive to both gender andsocioeconomic status, for use byRHAs. They could also work withthe RHAs, to deepen their understandingof the issues of incomeinequality, gender and health asthey develop their next communityhealth assessments.5.2 Allies in DevelopingHealthier Public PolicyAs the bodies responsible for needsassessment, health planning andservice delivery at the local level,RHAs are well positioned to becomeallies for the development of healthierpublic policies, rather than onlyservice delivery agents. But to date,they have taken few initiatives toinfluence the structural determinantsof health, such as poverty.

If RHAs are open to suchcollaboration, interested organizationshave the potential opportunity to workwith them to help them fulfill theirmandate as locally responsive andresponsible health agencies, byhelping them to make the connectionsbetween income, gender and healthin their local areas. The RHAs,because of their unique position,are particularly well positioned toplace these issues on the publicagenda. However, without someadditional resources, such asresearch, professional developmentand networking, they are unlikely todo so. These resources might beprovided by other communitygroups with greater expertisein these areas.5.3 Delivering Programs thatMeet Women’s NeedsIn Winnipeg, the Women’s HealthClinic (WHC) has twenty years ofexperience in delivering communitybasedprograms to meet the healthneeds of women. This has allowed theClinic to develop its own Model ofCare and to be recognized as a leaderin the field of women’s health. TheWHC’s practice has been recognizedby its receipt of the CommonwealthPrize for Excellence in Women’sHealth. WHC also has experienceworking with women from manydifferent cultural groups andwomen of low income. The WHC hasused this experience to developexemplary projects, which couldbe adapted for use by otherhealth service providers.WHC and other organizations,especially the Prairie Women’sHealth Centre of Excellence, couldalso use their expertise to offer trainingto staff of other health serviceagencies, including the RHAs.6. Working with Women Living in Povertyto Promote Healthier Policiesand Appropriate ServicesWomen, Income andHealth in Manitoba57Some of those who best understand theimpact of poverty on health are thewomen who live that experience.Their voices can be powerful agentsfor change.In order to assist women living in poverty tobecome actively and meaningfully involvedin the health planning and communityhealth assessment processes, interestedorganizations could offer technical supportand skills development to interestedwomen, to enable them to take on theseroles for themselves. At the same time,work could be done with the RHAs to helpthem to understand the importance oflistening to the voices of these women andto structure their health assessment andplanning processes in such a way as toinclude them.These organizations could also work withlow-income women to find the mostappropriate ways to have their voicesheard in the broader public policy arena,and to recommend positive changesto existing services.The above are provided as examples only.They are meant to illustrate some of thesteps that health service providers andother community organizations can take toaddressing issues of income inequalityand, therefore, to improve the health statusof low-income women and the communityas a whole.

I. FUTURE DIRECTIONSThere are opportunities for decisionmakers,health service providers and thepublic to use the knowledge about theconnections between income and health.In order to do this, they must:1. recognize the many complex andinterwoven ways in which incomeand gender affect health;2. consider the implications on healthof decisions made outside of thehealth care system;3. design and re-design health servicessystems in ways which recognize theneeds of low-income women;4. recognize that the impact of socioeconomicinequalities affects allaspects of women’s health. Thiswill require a major shift in theperspective of health plannersand health care service providers,to incorporate gender analysis indesign, implementation andevaluation throughout the healthcare system, and not only in thoseprograms with a specific“women’s health” mandate.While we may not have a detailed understandingof the mechanisms by whichincome and social status affect health,we know that the connection is there.Now is the time to use the knowledgewhich we do have to make changesto improve women’s health.Women, Income andHealth in Manitoba58

APPENDIX 1:SUGGESTIONS FOR FUTURE RESEARCHThe limited availability of data aboutincome and poverty among Manitobawomen limited the work completed in thispaper. Statistics Canada does providespecial data sets upon request; however,the cost (minimum $1200) was beyondthe budget of this project.WHC should consider working with theWinnipeg-based consortium of fifteenorganizations, led by the Social PlanningCouncil, which jointly purchases specialdata from Statistics Canada each year.WHC would then both have the opportunityto infuse a gender analysis into their dataselection and to make use of the dataobtained. Of particular use would be dataon topics such as trends in income levelsand poverty rates for Manitoba women,especially for young women, seniors,single mothers, Aboriginal and visibleminority women.The Manitoba Health data provided for thispaper was a very useful beginning point.For pregnancy, labour and delivery, theresults indicated a correlation betweenincome and health services utilization.Future research which includes birth ratesby income quintile would provide a morethorough understanding of the issue.Women, Income andHealth in Manitoba59

APPENDIX 2:ARE WOMEN SICKER THAN MEN?Women, Income andHealth in Manitoba60Women’s reported greater use of healthcare services has led to a generalacceptance of the idea that women aresicker than men (“women get sick, mendie”) and that women are more likely toseek medical attention than men. Theseideas are based on a combination of fact(pregnancy, labour and delivery areexperiences unique to women) andassumption (women are believed to bemore likely to seek help from experts thanmen). Some recent research has begunto challenge these ideas.For example, in Manitoba in 1994-95,the per capita cost of providing femaleswith health care services funded by themedicare system was approximately 30%higher than for men. In an article in theNew England Journal of Medicine,Cameron Mustard and othersdemonstrated that after removing thecosts of sex-specific conditions(including, for women, normal andabnormal reproduction, and for women andmen, diseases of the genitourinary systemand of the breast) and considering costsfor both physicians’ services and acutehospital care, that the costs of insuredhealth care services for women wereabout the same as for men. That is, thefemale:male ratio went from 1.3 to 1.0. 88The authors did find two important agespecificsex differences in health careexpenditures even after adjusting for sexspecificconditions and care in the last yearof life. Per capita health care expendituresfor elderly men were significantly higherthan for elderly women and expendituresfor physicians’ services were higher forwomen during their childbearing years.They hypothesized that these differencesmight be an artefact of measurement or,alternatively, related to sex differences inthe occurrence of illness or in care-seekingbehaviour or social roles. Particularly,women in childbearing years, who continueto have the main responsibility fororganizing health care for their children,may have increased opportunities for theuse of health care services. 89While costs of health services are onemeasure of illness, there is also someresearch how women and men differentlydescribe their own health and how that isperceived by health service providers.Macintyre and Pritchard reported on Britishstudy of volunteers attending a researchunit investigating the common cold. In adouble-blind process, the volunteers wereinoculated with either a virus or an inertsubstance. Their symptoms were thenassessed, evaluating the presence andseverity of their colds by both a trained,medically qualified observer and by theparticipants themselves. In this study,women were no more likely than mento assess themselves as having a cold,although the clinical observer wasmore likely to rate women than men ashaving a cold. Men were significantlymore likely than women to ‘over-rate’their cold symptoms compared withthe observer’s ratings. 90In another study, Sally Macintyre andcolleagues studied a group of 1710 womenand men in the West of Scotland, abouthalf of whom were in their late thirties andhalf of whom were in their late fifties.Participants were first asked the standardquestion used in the annual British GeneralHousehold Survey:Do you have any long-standing illness,disability or infirmity? By long standingI mean anything that has troubled youover a period of time or that is likely toaffect you over a period of time?They found no significant gender

Women, Income andHealth in Manitoba61differences in response to this question. 91In this study then, women were not morelikely than men to report illness. But whathappened when respondents were probedabout the meaning of their responseswas interesting.The researchers prompted the participantswith three more questions about their selfperceivedhealth – about other healthconditions which seriously affected theirhealth, about their mental health and finallyby showing cards with lists of conditions onthem. The number of conditions reportedincreased for both men and women, butthe increases were greater for women thanfor men, suggesting that women weremore stoic than men, reporting fewerof their illnesses in response to astandard question. 92In Denton and Walters’ paper analyzingdata from the 1994 National PopulationHealth Survey, they found that morewomen (12.7%) than men (10.0%)described their own health as “fair” or“poor”. Men also had higher scores offunctional health than women. 93 However,these data were presented in a way whichdid not control for age and socio-economicstatus. Whether controlling for thesevariables would make a difference in thisparticular study is not known.In Sara Arber and Helen Cooper’s analysisof three years of British General HouseholdSurvey data for older people, they initiallyfound a similar pattern. However, theyconcluded that:...the original gender difference inself-assessed health in which olderwomen are more likely to report poorself-assessed health is mainlybecause of their older age onaverage than men, and becausethey occupied lower positions thanmen in the class structure duringtheir working life. When olderwomen’s greater likelihood of experiencingfunctional disabilities isincluded in the model, this results ina reversal of the gender difference,so that older womenare shown to be less likely to reportpoor health than older men. 94Arber and Cooper found that older womenwere less likely than older men to describetheir own health as poor, suggesting, onthe surface, that they were in better healththan the men in the survey. However, wheninformation about functional impairmentwas measured (using six tasks of dailyliving), women’s health status wassignificantly worse than that of men.They concluded that:This research supports the finding ofothers studies that there is littlegender difference in self-assessedhealth among older people in themid-1990s. However, the ‘newparadox’ that older women have amore positive self-assessment oftheir health status than men, onceage, class, income and their greaterlevel of functional disability aretaken into account, requiresfurther explanation. 95What conclusions can be drawn fromthis research? Assumptions based onstereotypes about the health of women,about their behaviour when faced withill health and about their attitudestowards their own health and illness,may be wrong. When policies andprograms are based on thesestereotypes, problems may result.The dangers of such stereotyping in thediagnosis and treatment of women wasreported recently in the British popularpress. The British Observer published anarticle in May, 2000, entitled Moaning menpush women to the back of the healthqueue. The article stated in part:…it is still commonly assumed bydoctors, surgeons, nurses and healthworkers that women complain moreoften about illness than men.This ‘tendency’ is blamed on the fact

Women, Income andHealth in Manitoba62that women are supposed to havegreater concerns about their bodiesbecause they undergo menstruation,childbirth and the menopause, whilemen are conditioned by society to bestrong and stoical. ‘It is an attitude thatpermeates the health service thoughthere is no evidence to support it,’added Macintyre. Indeed, it pointsthe other way.’The assumption that men are stoicalcan also have serious consequencesas researchers on both sides of theAtlantic have revealed. In one recentUS study, male and female actorsperformed realistic scripts in whichthey played the parts of patientssuffering from chest pains andshortness of breath. They were thenexamined by a group of 192 doctorswho were asked to describe what theywould do for their patients in similarcircumstances. The results werestriking. The doctors plumped for twomain diagnoses: either the patient hada severe cardiac problem or a psychosomaticcondition in which emotionaldisturbance, not physical illness, wasthe cause. Their choice had a greatdeal to do with the gender of theactors. ‘When confronted with thesame presenting symptoms, vitalsigns, and test results depictedin a professionally acted way,physicians were much less likelyto arrive at a cardiac diagnosis inwomen, treat women medically,believe treatments were necessaryor to make health education andlifestyle change recommendationssuch as quitting smoking,’ state theresearchers from the New EnglandResearch Institute in Boston. Bycontrast, the doctors were morelikely to rate women ‘patients’ assuffering from emotional problemsand to suggest psychiatrictreatment. In other words, ifyou complain of chest pains, youget intense cardiac care – if youare a man. If you are a woman,you could end up undergoingpsychiatric treatment.‘Women aren’t supposed to complainof heart disease and so doctors areless prepared to accept that they haveit,’ said Macintyre. ‘We make allsorts of assumptions, based onunsupported stereotypes – forinstance, that men are silent stoicswhile women are whingers – but donot test them out before we act onthem. We have got to change thatkind of thinking.’ 96 (emphasis added)

APPENDIX 3:HEALTH SERVICE UTILIZATION BYMANITOBA WOMEN – EXPENDITUREBY INCOME QUINTILEWomen, Income andHealth in Manitoba63(The following description was preparedby Dr. Patricia Kaufert, Department ofCommunity Health Sciences, Facultyof Medicine, University of Manitoba)The Manitoba Health Services InsurancePlan (MHSIP) provides insurance coverageto all Canadian citizens and landedimmigrants who qualify as residents of theProvince. Coverage includes entitlementto a comprehensive range of health careservices including acute hospital care andphysician services without fees, premiumsor co-payment charges. The administrativesystem developed to run this insurancesystem has created a computerized recordof health service utilization by a completepopulation of over a million people.Extensively used in research, the reliability,concurrent validity and predictive validityof these data are now well established(Roos et al. 1987; Roos et al. 1988;Muhajarine et al. 1997).This analysis is based on three of the filescreated as part of this system; they are theRegistry file, the Physician Claims file andthe Hospital-Separation Abstract file. TheRegistry file includes information on theage and sex of every individual entitled tocoverage (virtually the entire population ofManitoba), their address and a uniqueidentifier number assigned to them byMHSIP as their Manitoba Health (MH)number. The date when an individual firstregistered with MHSIP is also entered intothe file and, if they leave the province ordie, the date when their coveragewas cancelled.A second file, the Physician Claims file, isthe product of the system of payment tophysicians. The majority of physicians inManitoba are paid on a fee-for-servicesystem with MHSIP as the unique payer.To be eligible for payment, physicians mustsubmit detailed claims cards which includetheir own code and specialty, the patient’sMH insurance number, the type of serviceprovided (tariff), the reason for the visit(diagnosis) and the date of the service.Regardless of the number of other reasonsinvolved, only the diagnosis identified bythe physician as most responsible for thevisit is entered into the file. Diagnosesare coded using the first 3 digits of theInternational Classification of Disease, 9threvision, Clinical Modification (ICD-9-CM)diagnostic codes. The Physician Claims fileincludes all claims for ambulatory care andfor care provided by physicians in hospitalon either an in-patient or outpatient basis.The few physicians who are on salarysubmit ‘dummy’ claims cards. Claimssubmitted for diagnostic imagining andlaboratory tests carried out in privatelyowned facilities are assigned a tariff codeand entered into the Physicians Claims file.Manitoba Health documents all hospitalutilization through detailed separationabstracts submitted by the province’shospitals for every patient they discharge.These abstracts include the patient’s MHnumber, the identification numbers of theattending physician(s), and up to 16 fieldsof diagnostic and procedure codes. Theseare coded using the 5-digit ICD-9-CMdiagnostic and 4-digit procedure codes.GENDER-SPECIFIC CONDITIONSWe selected all the diagnoses andprocedures specific to either women (suchas obstetric care) or men (such as testicularcancer) from the Physician Claim Fileand the Hospital Separation Abstract Fileand constructed the following categories:

Women, Income andHealth in Manitoba64pregnancy and childbirth; ‘well womancare’; diseases of the reproductivesystem; and diseases of the breast.The second category, ‘well woman care’combines the tariff codes for bilateralmammograms, the Papanicolaou (Papsmear) test for cervical cancer and theICD-9-CM code for “Encounter forContraceptive Management”. (Tariffs forunilateral mammograms were assignedto the breast disease category on theassumption that their purpose wasdiagnostic rather than screening.) Useof the PSA test to screen asymptomaticmen for prostate cancer is notrecommended in Manitoba; therefore,could not serve as an indicator ofpreventive care, equivalent in men to thePap smear or the mammogram in women(Lipskie 1998). Separate categories werecreated for diseases and conditions of thebreast and those of the reproductive(or genitourinary) system.COSTSThe fee paid to the physician is recordedon each claims card, as also are the tariffspaid for any laboratory service or otherprocedure. Hence, it is possible tocalculate the costs of services by summingthe amount reimbursed by MHSIP forevery claim submitted by physicians orlaboratories for the same individual overa given period of time (individuals areidentified by their MH number). Thisanalysis uses claims submitted from April1, 1994 to March 31, 1995. The total feesare combined and tabulated by sex andby 5-year age group.Hospital care in Manitoba is funded basedon a global facility budget rather than a percase basis; therefore, the costs of hospitalcare cannot be calculated using the samedirect method. As an alternative, theManitoba Centre for Health Policy andAnalysis has developed a system forcalculating hospital costs based on anadaptation of the refined diagnosis-relatedgroup-method(Shanahan et al., 1994;Mustard et al. 1998). Using this system, wehave estimated the costs of acute hospitalcare on an individual-by-individual basis,tabulating these costs by sex and 5-yearage group (Mustard et al. 1998). Per capitacosts for physician fees and hospital carecosts are tabulated using the 1994Manitoba population as at theDecember 1994 registry file.INCOME QUINTILESThe population was divided into fivegroups or quintiles based on averageneighbourhood household income dataderived from the 1986 Canadian Censuspublic use data base. Based on meanhousehold income, the enumeration areaswere ranked from poorest to wealthiest andgrouped into five population quintiles. Eachwoman was linked to an enumeration areaby residential postal code and a quintilerank assigned with Q1 being the poorestand Q5 the highest.RESULTSThis analysis is based on the 1,140,200individuals registered with MHSIP fromApril 1, 1994 to March 31, 1995. Thecombined cost of physician services andacute hospital care during this periodtotalled $1,189,000,000 (Mustard et al1998). Women made up 51% of the totalpopulation of 1,140,200 individualsregistered with MHSIP, but their serviceuse accounted for 57% of the total costs.The crude per capita costs of physicianservices from April 1 to March 31 are $277for women compared with $198 for men;the costs for hospital services are $887 forwomen compared with $720 for men(Mustard et al. 1998).Gender specificdiseases and conditions account forapproximately 23% of the total dollar valueof medical and hospital care used bywomen, but only 3% of the services usedby men.

APPENDIX 4:INTERVIEWS WITH ABORIGINALWOMEN KEY INFORMANTSAs noted in the body of this paper, the datacollection for this project was enriched bythe inclusion of information from sevenAboriginal women who agreed to beinterviewed.The interviews were conducted byAngela Busch.The following questions were asked ofeach participant:1. Aboriginal Women and Povertya) In your opinion, how doespoverty affect the healthof Aboriginal women?b) How does poverty affectAboriginal women’s health ina holistic sense, in terms of notonly physical, but mental andspiritual health, etc.?2. Inequalities and the Health ofAboriginal Womena) In your opinion, what doAboriginal women face interms of inequalities in regardsto their health?b) According to the National Forumon Health, Aboriginal women facea heightened risk of a wide rangeof health problems including bothincreased morbidity and mortality.In what way do you seeinequalities in health forAboriginal women playing arole in these findings?3. Meeting the Health Needs ofPoor Women-Best Practisesa) In terms of pre-existing healthservices and programs,what has worked and why?b) In terms of pre-existing healthservices and programs, what hasNOT worked and why?Each interviewee answered these openendedquestions in her own way. Someresponses were direct, others used storiesand personal experiences to illustrate theirpoints or to give the interviewer additionalinformation. There was, therefore,significant variation in the type ofresponses, all of which were recordedby the interviewer, synthesized, andincluded in the body of this report.The seven women interviewed were:1. Audrey Leader - Director of Health(Assembly of Manitoba Chiefs)2. Doreen Sanderson - Assistant to theDirector of Health (Assembly ofManitoba Chiefs)3. Darlene Birch - Aboriginal Midwife4. Randi Gage - Aboriginal Elder/Diabetes and HIV specialist5. Dee Milberg - AboriginalPsych-Health Nurse (HSC)6. Anonymous Community HealthRepresentative7. Anonymous Medical InterpreterWomen, Income andHealth in ManitobaWe wish to graciously thank each of the above womenfor their contributions, Ekosi-Meegwetch.65

APPENDIX 5:MODELS OF WOMEN- CENTRED CARE1. VANCOUVER/RICHMOND HEALTH BOARDWomen, Income andHealth in Manitoba66In January 2000, the Vancouver/RichmondHealth Board (V/RHB) released itsWomen’s Health Planning Project FinalReport. Following a review of the relevantliterature and an extensive consultationprocess, V/RHB developed a frameworkfor women-centred health care servicesdelivery. The adoption of this frameworkwould make the health services deliverysystem more responsive to, and accessibleto, the needs of low-income women. Theframework explicitly recognizes the impactof income on the health of women.The framework includes 11 elements.Excerpts from the framework appearbelow.ELEMENT #1THE NEED FOR RESPECT AND SAFETYUnderstanding this Element“Addressing women’s health in the contextof women’s lives begins with respect andsafety...women want to be listened to; theywant providers to accept the validity oftheir opinions; taking the complexities anddiversity of women’s lives into consideration...Many women avoid the health care systembecause of past encounters where theyhave experienced discrimination, or feltunsafe or unwelcome. Many women feeltheir voices are not heard within the healthcare system. Others find their concerns orcontributions are not treated with respector that the system’s response furthercompounds their problems.The health care system replicates thevalues and structures of a society wherewomen have a lower status than men, andface negative stereotypes on a dailybasis...Providers may be unaware of howtheir language and behaviours discountwomen’s realities...Respect and safety are also reflected inwhether services are accessible to thosewith different needs, e.g. disabilities,language barriers, child care, pastexperiences of violence of abuse, etc.Some women feel safer when staff andproviders reflect the demographics oftheir region...It is important for health care providers tobe aware of the effects of violence andabuse to avoid retraumatizing women...The level of documentation required by thehealth system may operate as a systemicbarrier to safety for some women,particularly those who have experiencedviolence. Women fear child apprehensionor loss of custody and may be reluctant toshare health information. In some cases,chart information has been used againstthem, or charts have been subpoenaed bythe courts; yet women may be viewed withsuspicion when they ask not to havesomething charted.”Some Ways to Apply this Element■■■■“Ensure an accessible physicalenvironment and physical safety...Provide an environment thatwelcomes diversity, with warmand welcoming staff.Listen to women, take their concerns,opinions and feelings seriously...To equalize power, let womenknow their rights.Acknowledge the likelihood of anywoman having experienced violenceand abuse. Recognize theconsequences of violence onwomen’s physical and mental health.

Women, Income andHealth in Manitoba67■■■■■Provide women-only space.Facilitate referrals to communityagencies that address violenceand other women’s issues...Address safety of workers within thehealth system, both in the workplaceand at home. Implement employmentequity for diversity.Ensure privacy and confidentialityregarding sensitive information likedependence on social assistance,requests for subsidies, answers toquestions about sexual health.Workers should take the time toexplain their role (not immediately startwriting notes/reports), identify andprovide for interpretation needs,explain the system and process,including child apprehension issues.”ELEMENT #2THE IMPORTANCE OFEMPOWERING WOMENUnderstanding this Element“Health status improves when a personhas a greater sense of control over theirlife situation.Four themes of women’s empowermentare:1. a core sense of self;2. the ability to take action basedon that sense of self;3. a sense of control over one’s life; and4. being connected with others....Women who feel individually empowered aremore likely to participate and take actionin their communities. And communityparticipation builds community capacity –the ability of individuals and groups toidentify common problems or concerns,take action to effect change within thecommunity, and to improve the quality oflife for all community members...”Some Ways to Apply this Element■■■■■■■“Encourage women to focus onthemselves as a priority.Give women space and support tochange their lives to improve theirwell-being.Facilitate the development of self-helpand support groups to provideopportunities to overcome isolation.Equalize power by letting womenknow their rights, and ensure theirrights by giving women access to theirown health files and information.Use health “coaches”, or a system ofhealth advocates, and mechanismsfor complaints to assist women tobuild knowledge and skills and havea voice. Cut down on the use oftechnical and mystifying language.Initiate community developmentprojects that facilitate women to takeaction and learn skills as motivatorsand health educators so they cancontribute to building communitycapacity.Incorporate health promotion,literacy, skill-development, andincome-generating activities intohealth projects which addressbroader development issues,e.g. community kitchens.”ELEMENT #3INVOLVEMENT ANDPARTICIPATION OF WOMENUnderstanding this Element“Social roles and limited financialresources can limit women’s participationin health service and program planning,implementation, evaluation, policy andresearch. It is important to encourage fulland equal participation by diverse womenin these activities, to ensure that women’sperspectives and needs are incorporated.”

Women, Income andHealth in Manitoba68Some Ways to Apply this Element■■■■■■■“Achieve equitable representationof women on advisory committees,steering committees and boardsand, in particular, facilitate women’sinput into decision-making aboutresource allocation.Make a commitment to involvecommunity groups and/or obtaintheir input. Work in partnership withcommunity-based women’sorganizations.Involve women from diversecommunities in all phases ofdesigning, developing andimplementing services and programsin collaboration with service providers.Support women to participate byproviding childcare, transportation,honorariums, accessible physicalenvironments, as well as mentoringfor skill-building and orientation tothe health system.Inform women and communities aboutnew knowledge, relevant data, servicedelivery and new initiatives, usingfriendly and accessible communicationstrategies.Integrate ongoing feedback processessuch as key informant surveys, exitinterviews and follow-up evaluationthree months after service. Use theinformation from these processes toenhance or change programsor services.Employ consumers to work withconsumers.”ELEMENT #4WOMEN’S PATTERNS ORPREFERENCES IN OBTAININGHEALTH CAREUnderstanding this Element“Women seek health care in the contextand circumstances of their lives. Thisdetermines when and how they seekservices, and whether they are able toaccess services at all. Women’s multipleroles as homemakers, paid workers,caregivers and family caregivers oftenmean that they will minimize their ownneeds because there are others to takecare of. They may also feel that they canor should take care of themselves.Some women lack independence of havedifficulty leaving their homes for variousreasons, e.g. women with disabilities,isolated immigrant and refugee women,women being abused by their spouse, orsenior women who are afraid or physicallyunable to leave their homes.Poverty is a factor limiting women’s accessto services. Women use public transit morethan men, and travel with dependentchildren. Shift work and night work createbarriers to access and are associated withill-health for women.Poverty particularly affects women whohave been abused, who may face healthissues that limit their ability to work.Mental health problems associated withviolence also affect the ways womenobtain health care.Lack of understanding of how the healthsystem works or what services areavailable may also limit women’s accessto services. Many women prefer to seewomen practitioners or a variety ofreasons, including religious and culturalbeliefs, past sexual abuse experiences orthe belief that women practitioners areeasier to communicate with and takemore time during appointments.Women request and use alternative,traditional and complementary therapiesmore often than men. Many women cannotafford these therapies, while others wantinformation about these therapies fromhealth care providers but do not feelsafe discussing them.”

Women, Income andHealth in Manitoba69Some Ways to Apply this Element■ “...we have come to learn that allwomen must be treated as individualsand we cannot make assumptionsabout values, attitudes or practices.Therefore, now, if we want to knowhow a women will approach her careexperience and recovery, we ask her.”■■■■■■■■■■■Change various aspects of the waycare is organized to allow formore flexible services.Extend hours of operation.Provide evening programs whenwomen and girls have free time;schedule programs for women at thesame time as those for children.Provide childcare if possible; ensurespace for children to play safely;provide adequate space forbreast-feeding mothers.Locate services together so thatwomen are not sent from person toperson to tell their story over andover (‘one stop’ services).Provide for transportation,e.g. bus tickets.Make home services available forwomen who cannot leave home easilyand for women who need them afterdischarge from hospital – or allowsome women to stay in hospital longerto recover when they have nosupport at home.Provide financially accessiblepreventive/complementary/alternative services.Offer good communication aboutservices, in simple and straightforwardlanguage and formats that areinclusive of and appropriate for diversepopulations of women, e.g. lesbians.Have access to translation andinterpretation services.Plan and provide specific services tomeet the unique needs of women.”ELEMENT #5WOMEN’S FORMS OFCOMMUNICATION AND INTERACTIONUnderstanding this Element“Gender socialization encourages womento be gentle, compassionate and nurturing.Consequently, certain patterns ofcommunication and interaction are morecharacteristic of women than of men. Forexample, women allow themselves to bevulnerable with other women, and aremore comfortable asking for help andrelying on others for support when needed.Women consider it important to have anetwork of many friends, and they oftenuse stories to describe their situationsin context.However, women who have experiencedviolence may not want to talk to others,and often prefer to have something to takeaway and read. Abused women are notlikely to share information easily, and mayhave dissociative behaviours or becomenumb to pain. If they do not recognizepain, they may not seek medical help earlyor at all.Cultural differences can also have animpact on communication and interaction.The V/RHB’s Aboriginal Health PlanningReport points out how this can affectAboriginal women: ‘Physical actionscan...be intimidating. For example,standing over someone with arms folded,asking questions too quickly, and notwaiting for an answer discouragescommunication. Aboriginal people tendto have a more reflective and deliberatespeech pattern than non-Aboriginal people.’ ”Some Ways to Apply this Element■ “Enhance communication byencouraging discussion and allocatingappropriate amounts of time orsetting up successive appointments.■ Provide venues where women canshare experiences and knowledge,or refer women to peer supportprograms...

Women, Income andHealth in Manitoba70■■Encourage women and girls to bringtheir friends/support personsto programs.Provide or refer to professionalcounselling/peer counselling.”ELEMENT #6THE NEED FOR INFORMATION“Women ask for information more thanmen, and often obtain information fromother women. As well, they often pass oninformation to others...Women’s learning styles are influenced inpart, by their forms of communication andinteraction. Women remember testimonialsfrom other women and learn from them.Exchanging stories between women maybe an important educational method.Constraints on women’s lives limit time forlearning. Literacy rates and languagetraining affect women’s access toinformation. For instance, immigrant andrefugee women in some communities donot have access to English as a SecondLanguage (ESL) training on an equallevel to men.Women may require an advocate orintermediary to get information.Education materials need to be tied directlyto women’s needs and interests and bedirected to their developmental stage andperiod of life...”Some Ways to Apply this Element■■■“Have health information resourcecentres that included trained nurses/librarians/volunteers to answerphone calls...Provide information in advanceof care when possible.Develop innovative ways to getinformation to women who are harderto reach, e.g. outreach to immigrantwomen’s workplaces.■■■■Use interpreters and communityworkers or advocates who can helpwomen use resources and gatherinformation.Provide information on issues specificto women in accessible formats, e.g.,plain language, inclusive language,translations, alternate formats.Sponsor public education/awarenesscampaigns, e.g., promote women’swellness, address caregivingroles and stress.Use principles of peer education.”ELEMENT #7WOMEN’S DECISION-MAKINGPROCESSESUnderstanding this Element“Women make health decisions not somuch from an individual perspective, butin consideration of their families, theircaregiving and interpersonal relationships,and the social and economic environmentsin which they live and work (theireconomic status).Women who have experienced violenceand coercion may have had fewopportunities to make their own decisions.Women and providers both bring importantknowledge and perspectives to decisionmaking.”Some Ways to Apply this Element■ “Encourage women to discuss thecontext of decisions, rather than tomake ‘choices.’■■Encourage women to accessinformation services.Present all options as clearly aspossible and support women in makinginformed decisions within the contextof their lives. Ensure that they feelsupported with whatever decisionthey make.

Women, Income andHealth in Manitoba71■One local agency has a peer supportand self-management frameworkfor facilitating informed consent.”ELEMENT #8A GENDER-INCLUSIVEAPPROACH TO DATAUnderstanding this Element“Data provide a basis for formulatingpolicies, monitoring change and evaluatingoutcomes. Data that reflect gender issueshelp to promote change, eliminatestereotypes, promote understanding ofthe health status of women and men, aswell as identify access issues and/orgaps in service delivery.The production of gendered statisticsrequires not only that all official datainclude a breakdown by sex, but alsothat concepts and methods used in datacollection and presentation adequatelyreflect gender issues in society and takeinto consideration all factors that canproduce gender-based bias.Data may reveal sex differences, butdifferences in health status, outcomes,success, utilization, etc. must be analyzedcarefully to reflect the influence ofgender issues.Women’s voices are an important part ofevidence. Qualitative methods of datacollection provide a particularly valuableperspective, and the information gatheredthrough qualitative methodology can informthe development of relevant quantitativedata elements as we work to better reflectthe context of women’s lives in ourtraditional databases.Data should be presented in user-friendlyways.”Some Ways to Apply this Element■ “Collect all data disaggregated by sex,socioeconomic status, age, disability,language and culture.■All variables and characteristics■■■■should be analyzed and presentedwith sex as a primary and overallclassification. This, in turn, enablesall analyses and presentations tobe sex specific.All statistics should reflectgender issues.Develop inclusive strategiesfor consulting with differentcommunities of women.Use innovative and inexpensivemethods to create ‘snapshots’ ofwomen’s health status. Snapshothealth profiles can use bothquantitative and qualitativemethodology and are a resourceefficient,methodologically sound andeffective way to gather information.Time series data collection (gatheringdata on the same questions/issues forwomen at different points in time) isanother methodology to consider forsome program initiatives. This methodsamples different groups of women ateach time, but allows us to see trendsemerging and to monitor programoutcomes. It is less costly thaneither continuous data-gatheringor longitudinal periodic studies thatrequire that the same group of womenbe tracked over a period of time.”ELEMENT #9GENDERED RESEARCHAND EVALUATIONUnderstanding this Element“We need to improve our existingknowledge of health problems specific towomen and gain a better understanding ofsex and gender differences in thoseillnesses that affect both women and men.We need to ask the appropriate questionsto capture the different experiences ofwomen and men. This will requiresustained research with adequateinfrastructures for continuity...

Women, Income andHealth in Manitoba72Major health research gaps exist forpopulations of women such as lesbians,bisexual and transgendered; First Nations,Inuit and Metis women; immigrant andrefugee women; women of colour; andwomen with disabilities, particularlyresearch that reflects their prioritiesand needs.Evaluations of women’s services shouldinclude a gender perspective.The findings of women’s health research isnot being adequately communicated towomen, particularly those who arelow-income.”Some Ways to Apply this Element■ “Research and develop moreappropriate, gender-sensitiveindicators of women’s healthand well-being.■■■■Involve women in settingresearch agendas.Use inclusive methodologies thatrespect and empower women’svoices, e.g. participatoryaction research.Include gender analysis inoutcome evaluations.Disseminate research findings towomen’s communities inappropriate formats.”ELEMENT #10SOCIAL JUSTICE CONCERNSUnderstanding this Element“People who work with women see manywomen who are affected by socialdeterminants like poverty anddiscrimination. Workers may beoverwhelmed by how to help individualwomen or by how to have an impact onsocietal levels of poverty and injustice.The V/RHB addresses social justice issueswithin Statement #3 of their mission, visionand principles:‘The framework for the delivery ofhealth care will be based on theideals of integrity, excellence, socialjustice and access to service;respecting the rights of everyindividual regardless of socioeconomicstatus or personal beliefor disability; supporting the effortsof our diverse communities to workcooperatively to address the issuesof health and safety in theirneighbourhoods as they apply to thebroader determinants of health.’ ”Some Ways to Apply this Element■ “Support the involvement of serviceproviders and all women in advocatingfor women’s achievement of political,cultural, social and economic equality.■■■■■■■Use institutional positions and power toadvocate for change.Embed gender equity in policydevelopment.Provide advocacy around incomeassistance and disability benefits.Provide court support for women incustody processes.Advocate for people who cannot gohome from rehabilitation programsor hospital unless they have anappropriate level of care or structuralchanges are made to their homesto accommodate disabilities.Assist women in recovery who needhousing to link up with other womenwho can offer short-termaccommodation.Provide clothing exchanges for womensearching for or starting jobs.”

ELEMENT #11GENDER SENSITIVE TRAININGUnderstanding this Element“Providers of services and programs needresources and support in order to recognizethe need for and provide women-centredcare on an ongoing basis. Where gendersensitivetraining exists now, it is oftendependent upon individual workers whobring forward this perspective.There is a clear need for gender-sensitivetraining in the area of violence againstwomen, so that service providers canrecognize and respond appropriately towomen who may have been abused.Models of training need to includeconsumers as full partners in developingand implementing training projects.Training needs to address underlyingsocietal assumptions about women.”Some Ways to Apply this Element■■Provide relevant and current women’shealth research and informationresources.Assign staff to look at other serviceswith gender-sensitive programmingand report back.” 98Women, Income andHealth in Manitoba73■■■■“Provide a comprehensive gendersensitivitytraining program that can beadapted and integrated into all levelsof services and program delivery.Include issues related to diversity andmarginalized women, e.g. streetworkers, Aboriginal, lesbian.Have the training facilitated byexperienced consultants with acombination of professionals,community agencies andcommunity women.Provide periodic updates, currentinformation, and awareness workshopsfor board, staff and volunteers.Appoint a staff and advisorycommittee to oversee implementationand monitoring of gender-inclusiveprograms.

Women, Income andHealth in Manitoba742. WINNIPEG WOMEN’S HEALTHCLINIC MODEL OF CAREPHILOSOPHYThe Women’s Health Clinic Model of Careis based on the following philosophy andprinciples.1. All women deserve fundamentalrespect and have the right to makeinformed decisions about their healthcare. In particular, it is recognized that:a) all women bring valuable anddiverse experiences as careproviders of family and friends,as workers, and as consumers ofhealth services. Their ideas andinsights should be encouragedand valued in developing healthservices appropriate to theirneeds; andb) women from equity communities,including Aboriginal women,immigrant women, visible andlanguage minority women, womenwith disabilities, and lesbians,bring unique experiences andinsights to an understanding ofhealth and illness. Oftenmarginalized in the planning ofhealth service delivery, theirinvolvement and participation isessential for the developmentof quality, culturallyappropriate services.2. Health status improves when a personhas a greater sense of control overtheir life situation. Women’s HealthClinic is committed to facilitating theempowerment of women, individuallyand collectively, in all its programsand services.3. A person’s health must be understoodholistically, with an appreciation for theinterrelationship of physical, social,emotional and spiritual aspects.APPROACHThe Women’s Health Clinic approach todelivery of services is based on theprinciples and philosophy outlined above.Key elements of woman-sensitive,“best practices” include:Priority PopulationsIn keeping with its population healthapproach, Women’s Health Clinicprograms and services strive toserve the needs of:(a) women who are mostvulnerable to poor health dueto factors such as poverty; and(b) women who are more likely toexperience barriers in accessingappropriate health servicesdue to their ethnic origin, race,social class, language, sexualorientation or disability.Women-Centred ServicesThe woman, in the context of hercommunity, is the centre ofWomen’s Health Clinic serviceplanning and delivery. Sufficienttime is taken with each woman togain an understanding of how herunique background and life situationimpacts upon her health.Interventions and educationalstrategies are flexible and variedand may involve linkages beyondthe formal health care system.These services may be offered bythe Clinic directly or through referralto other service providers oragencies, such as justice, education,housing or employment.Develop a Partnership Betweenthe Woman and Care ProviderPrograms and services are based onthe assumption that the womanbrings a valuable perspective of herlife situation and her body. She mustfeel empowered to make informeddecisions about her health and healthcare. Accordingly, staff andvolunteers de-emphasize

Women, Income andHealth in Manitoba75differences between womanand care provider, and seek todevelop a partnership with her inaddressing her health issues.Most AppropriateCaregiver and ServicesEvery effort is made to ensure thatwomen receive the most appropriateservice, provided by the mostappropriate service provider, in themost appropriate location. Womenmay access services through avariety of avenues and routes ofentry as appropriate to their particularsituation and needs. Services andapproach offered may includeinformation, education, supportthrough groups or individualcounselling, medical treatments,health screening, advocacy,community action, as well aslinkages with the secondary, tertiary,rehabilitation and long term care orother sectors. Services sensitivelyaddress a wide range of issues(such as sexuality, childhood sexualabuse, violence) which have not beenadequately addressed by health careproviders in the past and try to ensurethat appropriate care is provided.Team ApproachWomen’s Health Clinic staff are madeup of an interdisciplinary team ofhealth care providers who workcollaboratively and includeprofessional, paraprofessionaland volunteer staff.EmpowermentPrograms and services are designedto enhance the understanding, selfcare,self-help and self-advocacyabilities of the woman. This isachieved by:1. providing a wide range ofaccessible information andeducation services with a keyrole being played by the Clinic’sResource Centre, as well assupport and training servicesbased on adult educationprinciples;2. facilitating the development ofunderstanding and skills throughsocial action groups aroundissues of concern to womensuch as breast implants, newreproductive and genetic technologiesor birthing options; and3. structuring the Clinic to includea system of participatorymanagement and involvementof community members inagency decision-makingand evaluation processes.Use of Peer VolunteersPeer volunteers play a key role inpromoting the empowerment ofclients through modelling self-helpskills, demystifying medicalinformation, and bringingcommunity perspectives to thedesign and delivery of services.Therefore, Women’s Health Clinicprovides training to women ofvarious backgrounds in order toenable them to develop informal andformal helping and leadership skillsin the provision of health information.Community InvolvementWomen’s Health Clinic works inpartnership with variouscommunities concerned aboutthe health of women, building onthe strengths and interests of itspartners, including volunteers,clients, service providers or othermembers of the community.Evaluation andCost-EffectivenessWomen’s Health Clinic recognizesthe importance of ongoing reviewand evaluation of the approaches

and service strategies it uses, takinginto account sound information andevidence about how programs,services and approaches aremeeting the health needs ofdiverse women. This requires thedevelopment of effective methods forfeedback and evaluation, bothqualitative and quantitative, andattention to the cost-effectivenessof various strategies.Innovative Program DevelopmentWomen’s Health Clinic is committedto continuous development andre-focussing of its service approachbased on new understandings ofwomen’s needs and issues. TheClinic collaborates with communitywomen and researchers and works atintegrating newly gained knowledge.Advocacy for System ChangeWomen’s Health Clinic works toidentify critical emerging issues forwomen’s health and brings togetherkey stakeholders to developinnovative policy recommendationswhich are responsive towomen’s needs and concerns.The design and delivery of allWomen’s Health Clinic programsand services reflect theunderstanding that:1. Gender is a key determinant ofhealth. For example, womenwithin all socio-economic andcultural backgrounds are at ahigher risk than men ofexperiencing poverty, abuse andviolence, all of which serve toseriously undermine healthstatus.2. Women’s health status isinfluenced by a variety of socialand structural factors, includingsocial status, income andemployment, education, andsocial supports; and3. Gender-sensitive health careservices help women reclaimand re-define normal lifetransitions (such as childbirthor menopause) which have beenoverly medicalized orpathologized.4. Health promotion, primaryprevention and healthy publicpolicy are essential strategiesfor improving women’s health.In addition to individual workwith clients, Women’s HealthClinic also emphasizescommunity and group basedapproaches as a means to effectpositive change in women’shealth status.Women, Income andHealth in Manitoba76

ENDNOTES1. Sarlo, Christopher, “Poverty in Canada - 1994” in Fraser Forum, February, 1994and quoted in National Council of Welfare, A New Poverty Line: Yes, No orMaybe?, pp 8-92. Ross, D. et al, Canadian Fact Book on Poverty, Chapter 5 page 2 see table 5.1and the discussion in Chapter 23. National Council of Welfare, A New Poverty Line: Yes, No or Maybe, p. 54. Townson, Monica, A Report Card on Women and Poverty, p.15. Statistics Canada, Women in Canada 2000, pp 116 to 1176. National Council of Welfare, Poverty Profile 1996, p. 867. United Nations Human Rights Committee, Concluding Observations of UN HumanRights Committee, para. 208. Statistics Canada, Income in Canada, Table 8.59. Health Canada, Fostering Knowledge Development on the Health and Well-Beingof Children in Canada: A Discussion Paper10. Townson, op. cit., p. 111. Federal, Provincial and Territorial Ministers Responsible for Social Services, InUnison 2000: Persons with Disabilities in Canada, p. 7912. Fawcett, Gail, Bringing Down the Barriers: The Labour Market and Women withDisabilities in Ontario, p. 13.13. Statistics Canada, 1996 Census, Nation Series14. Mendelson and Battle, Aboriginal People in Canada’s Labour Market, p. 115. Yalnizyan, The Growing Gap, p 28, using data from Statistics Canada, The Daily,May 12, 1998, p. 916. Hum, Derek and Simpson, Wayne Wage Opportunities for Visible Minorities inCanada, p. 3417. ibid p 3318. Evans, R. G. Introduction in Why Are Some People Healthy and Others Not?The Determinants of Health of Populations19. Kaufert, Patricia “The Vanishing woman: gender and population health”, p. 121Women, Income andHealth in Manitoba7720. Denton, Margaret and Walters, Vivienne Gender differences in structural andbehavioral determinants of health: an analysis of the social production of health,p. 122221. Acheson, Sir Donald, Independent Inquiry into Inequalities in Health, Part 1“The Current Position”

ENDNOTES (continued)22. Macintyre, Sally, “Social Inequalities and Health” in Strickland, S.S. and Shetty,P.S., editors Human Biology and Social Inequality, pp 31 - 3223. Raphael, Dennis From Increasing Poverty to Societal Disintegration:Economic Inequality and the Future Health of Canada, pp 4 -524. Yalnizyan, Armine, op. cit., p. 4525. ibid, p. 4726. ibid, pp 48 - 4927. Raphael, op. cit., pp 4 - 528. Denton and Walters, op. cit., pp 1226- 122829. MacIntyre, Sally, “The Black Report and beyond: what are the issues?”, p. 72730. Ibid, p. 74031. Kaufert, op. cit., pp 123 - 12432. ibid, p. 13033. Matthews, Sharon, Manor, Orly, Power, Chris “Social inequalities in health:are there gender differences?”, p. 5734. Arber, Sara “Comparing inequalities in women’s and men’s health:Britain in the 1990s”, pp 773-77435. Matthews et al, op. cit., p. 5736. ibid, pp 780 - 78137. Denton and Walters, op. cit., pp 1229 and 123238. Townson, A Report Card on Women and Poverty, p. 639. Matthews, Sharon, Manor, Orly, Power, Chris “Social inequalities in health:are there gender differences?” p. 4940. Denton and Walters, op. cit., p 123241. Arber, S. “Revealing women’s health: Re-analysing the general household survey”in H. Roberts (ed) Women’s Health Counts, London: Routeledge, 1990 andquoted in Janzen, B.L., Women, Gender and Health: A Review of theCurrent Literature, p. 25Women, Income andHealth in Manitoba7842. Denton and Walters, op. cit., p. 123243. Arber, op. cit., p. 77844. ibid, p. 774

ENDNOTES (continued)45. Arber, Sara “Topic Report: Gender” prepared for the British Independent Inquiryinto Inequalities in Health, p. 1046. ibid, p. 77947. ibid, p. 78248. Young, Ruth “Prioritising family health needs: a time-space analysis of women’shealth related behaviours” Social Science and Medicine 48 (1999), pp 797-81349. ibid, p. 80850. ibid, p. 81051. Denton and Walters, op. cit., pp 1226- 122852. Janzen, B.L., Women, Gender and Health: A Review of the Current Literature, p. 553. Denton and Walters, op. cit., p. 123354. Long and Dickason, Visions of the Heart, p. 24455. ibid, p. 24456. ibid, p. 24457. ibid, p. 24558. Health Canada, “An Overview of Women’s Health – Special Populations” inNational Forum on Health, Final Report Volume II: Synthesis Reports and IssuesPapers, p. 159. Health Canada, Statistical Report on the Health of Canadians, p. 760. Health Canada, Women’s Health Surveillance: A Plan of Action for Health Canada,Report from the Advisory Committee on Women’s Health Surveillance, 1999 andavailable to download at: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/whs-ssf/index.html61. Indian and Northern Affairs Canada, Basic Departmental Data, 1999, p. 2462. ibid, p. 1363. First Nations and Inuit Regional Health Survey National Steering Committee,First Nations and Inuit Regional Health Survey, 199964. Elias, B., Kaufert, J., Reading, J. and O’Neill, J. “Activity Limitation and the Needfor Continuing Care”, Chapter 5 in First Nations and Inuit Regional Health Survey,1999, p. 161Women, Income andHealth in Manitoba7965. ibid, p. 16166. Clarke, et al “Reducing Cervical Cancer Among First Nations Women”, p. 3667. ibid, pp 36 to 38

ENDNOTES (continued)68. Elias, et al, op. cit., p. 16769. Walters, Vivienne, Lenton, Rhonda, McKeary, Marie Women’s Health in theContext of Women’s Lives, p. 1170. Walters, V. and Denton M., “Stress, depression and tiredness among women:the social production and social construction of health” unpublished manuscript,quoted in Walters, Lenton and McKeary, op, cit., p. 1171. ibid, p. 3272. Arber, Sara, “Topic Report: Gender,” p. 1073. Acheson, Sir Donald, Independent Inquiry into Inequalities in Health,The Stationery Office, 1998 Part 2 Chapter 11, p. 774. Kawachi et al, “Women’s status and the health of women and men: a view fromthe States,” p. 24-2575. ibid, p. 2176. see for example, Roos, N. P. and Mustard, C. “Variation in Health and HealthCare Use by Socioeconomic Status in Winnipeg, Canada: Does the SystemWork Well? Yes and No77. This includes all women for whom physicians submitted claims for pregnancyrelated care, including pregnancies ending in miscarriage or therapeutic abortion.78. Vancouver/Richmond Health Board, Women’s Health Planning Project, page 1479. Correspondence, Dr. Qhing Qhing Dlamini, Head, Health Department,Commonwealth Secretariat, October 11, 199680. Women’s Health Clinic, Winnipeg, Canada, Model of Care, November, 199881. Federal, Provincial and Territorial Advisory Committee on Population Health,Toward a Healthy Future, p. 17582. ibid, p. 18683. ibid, p. 17784. Azure, Ed and Longpre, Nahanni, “Take Control, Take Charge, Building for ourFuture”, Assembly of Manitoba Chiefs Housing Conference, undated85. McCain, Hon. Margaret Norrie and Mustard, J. Fraser Reversing the Brain Drain,The Early Years Report, Canadian Institute for Advanced Research, 1999Women, Income andHealth in Manitoba8086. Deborah Mayer, Manitoba Child Care Association, in interview with the author,September 7, 1999.87. Horne, T, Donner, L and Thurston, W.E., Invisible Women: Gender and HealthPlanning in Manitoba and Saskatchewan and Models for Progress, p. 56

ENDNOTES (continued)88. Mustard, Cameron, Kaufert, Patricia, Kozyrskyj, Anita and Mayer, Teresa“Sex Differences in the Use of Health Care Services,”New England Journal of Medicine 338 (1998) p. 167889. ibid, p. 168290. Macintyre and Pritchard “Comparisons between the self-assessed andobserver-assessed presence and severity of colds” Social Science and MedicineVol 29 (11), pp 1243 - 1248, quoted in Macintyre, Sally, Ford, Graeme, Hunt, Kate“Do women ‘over-report’ morbidity? Men’s and women’s responses to structuredprompting on a standard question on long standing illness,”Social Science and Medicine 48 (1999), p. 9091. ibid, p. 9392. ibid, p. 9593. Denton and Walters, op. cit., p. 122594. Arber, Sara, Cooper, Helen “Gender differences in health in later life: the newparadox?,” p. 7495. ibid, p. 7596. McKie, Robin “Moaning men push women to back of health queuem”U.K. Observer, May 7, 200097. Vancouver/Richmond Health Board, Women’s Health Planning Project FinalReport, pp 16 to 26Women, Income andHealth in Manitoba81

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ACKNOWLEDGEMENTSThe author would like to express her gratitude to the many peoplewho assisted in the development of this project.Firstly, to Madeline Boscoe and Barbara Wiktorowicz of the Women’sHealth Clinic, Winnipeg, and Pat Hope of the Health Promotion andPrograms Branch, Manitoba/Saskatchewan Region, Health Canada,for the opportunity to engage in this project.Secondly, to Dr. Patricia Kaufert of the Department of Community HealthSciences, Faculty of Medicine, University of Manitoba, for her generosityin reviewing drafts of this paper.Teresa Mayer of the Department of Community Health Sciences, workingunder Dr. Kaufert’s supervision, produced the data necessary for theanalysis of the health status of Manitoba women.Jackie Pantel of the Department prepared the charts included in this report.Dr. Cam Mustard also provided advice and assistance prior to his departurefrom Manitoba.Thank you also to the Access and Confidentiality Committee of ManitobaHealth (Susan Rodgers, Secretary) for releasing the data to us whichappear as Charts 1 - 5.Carole Beaudoin of the Epidemiology Unit of Manitoba Health wasgenerous with both her time and her data. She prepared Charts 6 - 8.Ken Battle and Michael Mendelson of the Caledon Institute, Kevin Lee ofthe Canadian Council on Social Development and Darren Lezubski of theSocial Planning Council of Winnipeg were generous in sharing information.Christiane Gour, Senior Statistical Officer, Indian and Northern AffairsCanada, answered methodological questions about Aboriginal Women: ADemographic, Social and Economic Profile, and provided additional data.Staff of the Winnipeg office of Statistics Canada answered many questionsand were always helpful.Finally, thank you to Dr. Sara Arber of the University of Surrey, who sentvaluable, unpublished work to a complete stranger in response to a request.Women, Income andHealth in Manitoba88