ARCHIVED - Measuring Health Inequalities Among Canadian Women: Developing a Basket of Indicators

Investigator Name: Arlene S. Bierman, M.D., M.S

Project Completion Date: October 2007

Research Category: Research

Institution: St. Michael's Hospital, University of Toronto

Project Number: 6795-15-2003/6380018


Summary

Incorporating Gender and Equity into Health Indicator Reporting
Health indicator measurement and reporting provide essential tools for informing and monitoring efforts to: 1) improve population health; 2) improve access to quality, and outcomes of health care services; and 3) reduce inequities in health and health care. Because men and women have different patterns of illness, morbidity and mortality, different experiences with health care, and very different social contexts, the measuring and monitoring of gender differences in health status and health care must be an integral component of improvement efforts. Furthermore, there are significant inequities in health among women that are associated with socioeconomic position, ethnicity, and geography. Therefore, it is also necessary to examine performance on indicators specifically for different subgroups of women.

Incorporating analyses of gender and equity into women's health indicator reporting can be accomplished first by stratifying indicators by sex and then by important non-medical determinants of health: income, education, ethnicity, and geography. This double stratification will provide important information about differences between and among men and women, as well as insights into how the non-medical determinants of health may affect men and women differently. A policy of gender mainstreaming in Canada would help assure that the health needs of women are addressed as a component of efforts to improve both health system performance and population health. However, since mainstream efforts may not address issues of importance to women's health, there is also a need for targeted reports on women's health.

Sex or Gender?
Although there is a clear distinction made between sex and gender, in reality when focusing on health outcomes, the effects of sex and gender can be very difficult if not impossible to disentangle. For example, while sex influences who will get lung cancer and who will survive it, social factors influence who smokes and is therefore at greater risk. These factors differ by gender and socioeconomic position. Social factors may also affect access to care and the quality of care received.

Upstream or Downstream?
Health inequities produced by social factors are often manifested through preventable or treatable clinical conditions. Advances in medicine have resulted in the development of effective health care interventions that can prevent premature mortality and morbidity from a range of disease and illness. Access to quality health care can improve the health of all population groups, which is particularly important for those of lower socioeconomic position, whereas poor access and quality of care can compound these inequities.[1] Health care is a determinant of health and a mediator between the social determinants of health and health outcomes. Coordinated efforts that address the social determinants of health and the quality of health care services could serve to optimize health outcomes and reduce health inequities.

A Women's Health Indicator Framework
In order to develop a Women's Health Indicator Framework for reporting we reviewed existing: 1) determinants of health frameworks; 2) gender equity frameworks; and 3) health indicator frameworks for women's health and health inequalities. We reviewed both Canadian and international work (including UK, US, Australia, Sweden). This Women's Health Indicator Framework is dynamic and recognizes that the non-medical determinants of health are the primary determinants of health status, and that population and individual health outcomes are mediated by community and health system characteristics and health system performance. This framework also recognizes that sex and gender influence how all these factors impact on an individual's experience with care and their health outcomes. The Women's Health Indicator Framework can serve as a tool to bring policymakers, providers, and the public together to achieve consensus on priorities and to select a core set of women's health indicators for reporting and monitoring to help achieve the objectives of Health Canada's Women's Health Strategy.

Health Inequities among Canadian Women
We report large gender and socioeconomic inequities in health on multiple indicators derived from the Canadian Community Health Survey (CCHS) capturing multiple domains. Identified disparities on these indicators among women associated with socioeconomic position are often greater than the observed differences between men and women. On the measures examined, health inequities were typically largest among women and men who report having common chronic diseases (arthritis, diabetes, and heart disease), underscoring the need for cross-sectoral initiatives to address structural factors that increase the risk of chronic illness as well as public health and health system interventions to improve chronic disease prevention and management. Current models of care delivery commonly result in suboptimal care for chronic illness and are particularly ill-suited for the care of individuals with multiple chronic conditions. Because women are more likely to have multiple chronic conditions they are disproportionately affected by the mismatch between the way health care is organized and the needs of persons with chronic disease. A national gender-sensitive chronic disease prevention and management strategy could play an important role in supporting efforts to improve the health of and reduce inequities among Canadian women. Selected findings are highlighted below:

  • Canadians in the lowest income group are nearly four times more likely than those in the highest income group to report fair or poor health (31% vs. 8% for women; 31% vs. 7% for men). Large differences in health status are similarly associated with education.
  • Among women and men reporting chronic conditions (arthritis, diabetes, or heart disease) the absolute difference in health status between low and higher income women and men is much greater. For example, among low income women with diabetes 61% report fair or poor health compared to 22% of women in the highest income category.
  • Canadians in the lowest income group are twice as likely as those in the highest income group to report their health to be worse than last year (22% vs. 11% for women; 19% vs. 9% for men). Among low income women reporting arthritis, 33% report that their health is worse than it was one year ago compared to 18% of women in the highest income category.
  • Although manageable, pain is responsible for activity limitations in 65% of low income women and 62% of low income men, where as pain is responsible for activity limitations 39% of higher income women and 37% of higher income men who report having arthritis. A large socioeconomic gradient in activity restriction due to pain among men and women with arthritis is present.
  • Among low income women for whom screening is indicated, 24% report that they have not had a Pap test, 25% report that they have not had a mammogram, and 29% report that they have not had a clinical breast exam within the last 5 years.

Our analysis also identified areas where men were disadvantaged. For example, men are less likely to have a regular medical doctor or have a mental health consultation and more likely to report daily smoking and binge drinking. Mainstreaming sex and gender based analyses and incorporating them routinely into health indicator reporting will also provide essential information to support improvement in men's health.

Moving Forward
Canada has a long tradition of examining socioeconomic inequalities in health, recognizing the central role of the non-medical determinants of health in determining the health status of individuals and populations. Sex and gender-based analysis is recommended both as federal policy and by the Canadian Institutes of Health Research. Comprehensive reports on women's health have been produced nationally and by many provinces. It is time to move beyond reporting and to choose and use indicators as a tool to drive improvement in population health and to reduce well documented health inequities associated with gender and socioeconomic position.

Indicators selection is dependent on the objectives for their use. When quality indicators are used to assess inequities in access, quality, and outcomes of care they can also serve as a powerful tool to drive equity in health. A core set of women's health indicators for ongoing monitoring should therefore be selected based upon an explicit strategy to improve women's health and to promote health equity among women. Indicator selection will require a comprehensive examination of Canadian data to identify a full range of women's health indicators for reporting. Health Canada's Women's Health Strategy provides a strong foundation for moving forward. Core indicators should be selected based upon clear priorities derived through a broad-based consensus process.

Achieving equity in health will require coordinated social policy that addresses the social determinants of health and health policy that supports improvements in public health together with health care delivery responsive to gender and diversity issues. Performance measurement and reporting based on a core set of women's health indicators, linked to targeted improvement activities, interventions to address the social determinants of health, and policy-relevant research to increase our understanding of the root causes of health inequities and what works to address them are all elements for designing and implementing programs and policies that lead to measurable improvements in women's health.

  1. Bierman AS, Dunn JR. Swimming upstream. Access, health outcomes, and the social determinants of health. J Gen Intern Med. Jan 2006;21(1):99-100.

The views expressed herein do not necessarily represent the views of Health Canada

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