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July, 2000
Revised January, 2002

EXECUTIVE SUMMARY

THE LINK between poverty and poor health is well established and makes common sense. There are many ways in which poverty can lead to ill health, including lack of access 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 children who 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 income inequality in our society lead to poor health. But we do not need to completely understand these mechanisms in order to act now to improve health.

The link between income and health has a special importance for women. In Manitoba (as in the rest of Canada), poverty discriminates, striking women substantially more frequently and more severely than men. This study looks at that disparity and how income inequality affects the health not only of women living in poverty but of everyone in our society.

Income and Inequality

Poverty is a serious issue in Manitoba. This province has the country’s third highest rate of poverty (18.5%) among Canadian provinces, compared to 16.2% for all of Canada. For women, the picture worsens: 19.9% of Manitoba women aged 18 and over were poor in 1999. [1] This also has an impact on the lives of children and Manitoba also has the second highest child poverty rate in Canada, 23.7%. [2] The disparity between women and men is remarkable. In 1999, there were 29,000 more poor women in Manitoba than poor men – a difference of 54%. [3]

Marriage does not protect women from poverty. In 1996, one in ten married couples were poor. And married women’s earnings are vital to their families’ well-being; without them, that proportion would have risen to one in four. [4]

Minimum wage earners, even those working full-time, live in poverty. A single mother with one child working full-time and earning minimum wage in Manitoba lives 43.4% below the poverty line. If she is married with two children, even when both spouses work full-time at minimum wage, their family will live 25% below the poverty line.

Some groups of women are especially vulnerable to poverty:

• More than half (51.3%) of senior women who live alone are poor. [5]   This has remained virtually unchanged in the last thirty years.
  
  
• Women with disabilities also face a higher risk of poverty. In 1997, 27% of women with disabilities, aged 16 to 64, lived in poverty. Almost two-thirds of those lived more than 25% below the Low Income Cut Off. [6]
  
  
• Aboriginal women are more likely to live in poverty than non-Aboriginal women or Aboriginal men. In 1995, 42.7% of Aboriginal women (excluding those who lived on Reserves and those living in the Territories) lived in poverty, compared to 35.1% of Aboriginal men, 20.3% of non-Aboriginal women and 16.4% of non-Aboriginal men. [7]
  
  
• In 1996, 31.8% of visible minority women in Manitoba lived in poverty. [8]   Yet, they are more likely than other Canadian women to be employed full-time. [9]
  
  
• Recent immigrant women have particularly low incomes. In 1995, their average income for all of Canada was only $12,000, about 62% of the amount earned by Canadian-born women that year. [10]

These disparities are becoming worse, not better. A recent report for the Centre for Social Justice noted that:

Not only are there more families in the lowest income category but they have also become poorer over time: to belong to the poorest 10 per cent of the population meant earning less than $11,567 in 1989. By 1997, it meant earning less than $6,591. [11]

Income and Health

There are many studies showing the connection between income and health. As the Manitoba researcher Patricia Kaufert, Ph.D has observed:

locating health in the social conditions of people’s lives is an idea which can be dated back to the origins of the public health movement. [12]

Research shows that medical care is less important in ensuring the well-being of the entire population than economic security, social support and a more equitable distribution of income. The connection between poverty and poor health has continued to exist even as medicine has progressed, persisting despite the reduction in mortality and improvements in other measures of health.

Inequalities in health are not only a problem for poor Canadians. Data from Manitoba is consistent with data from other countries. Health status worsens at every step down the socio-economic ladder Poor people may be more at risk, but everybody is affected.

Economic inequality itself is a health risk.

Studies suggest that the distribution of income in a given society may be a more important determinant of health than the total amount of income earned by society members. Large gaps in income distribution lead to increases in social problems and poorer health among the population as a whole. [13]

What the Research Tells Us

There is a substantial body of research linking women’s household incomes and their health. While past research has found the connection to be weaker for women than for men, recent Canadian research shows the reverse. [14]   This research also suggests that socio-economic status and other factors beyond individual control (such as family structure, age and social support) are more important to women’s health status than lifestyle factors such as smoking, alcohol consumption and physical activity. Women’s health services that focus only on lifestyle will, therefore, not be as effective as a broader approach that addresses poverty and the economic inequality faced by women.

One consistent theme in the research is the additional burden of ill health borne by Aboriginal women. They are at much greater risk of violent death and suicide than other Canadian women. They have poorer health than Aboriginal men or other Canadian women; they develop chronic conditions earlier and suffer more frequently from heart problems, hypertension, diabetes, arthritis and rheumatism. This is compounded by the fact that Aboriginal women face formidable barriers in obtaining appropriate health services, including discrimination, distance and cultural barriers.

Poverty is also an important factor in the health of older women. Many factors compound this, including poor housing, higher heating costs, increased isolation, fear for personal safety and functional impairments that may make day-to-day life difficult and painful. The link between inequalities in income and health is strong even for those over the age of 85.

Income and Health in Manitoba

We examined the experience of all Manitoba women in 1994-95, the most current year for which data were available. As in other jurisdictions, there was a connection between income and health services utilization for Manitoba women for most health conditions. That is, women in low-income neighbourhoods were more likely to see physicians both in hospital and in physician offices than were women in high-income neighbourhoods. The experience of women in middle-income neighbourhoods fell in between.

Importantly, the reverse was true for two preventive screening services. Women in the highest income neighbourhoods were most likely to use Pap smears to screen for cervical cancer and mammograms to screen for breast cancer.

This is not intended to suggest that low and middle-income women, whose health care costs are higher than those with high incomes, use the health care system inappropriately.

The solution lies not in restricting access to the health care system with user fees or other mechanisms but, rather, in improving the health of the population.

The health effects of income inequalities increase the burden of illness in all body systems. Discussions of women’s health and socio-economic inequalities must be broad enough to incorporate and build on this information. Strategies which focus only on reproductive and sex-specific conditions will not be successful in reducing inequalities in women’s health.

Making Public Policy Healthier for Women

Healthy public policy for low-income women will require changes both inside and outside of the health care system. The health care system has two important roles to play:

1. changing the way in which health care services are planned, delivered and evaluated, to better meet the needs of low-income women;
   
   
2. working with other sectors outside of the health care system to help them understand the health impacts of their policies

Manitoba health care organizations interested in developing health services which take issues of income, gender and health into account have several models to consider. Three in particular – developed by the Winnipeg Women’s Health Clinic, the Vancouver/Richmond District Health Board and the Commonwealth Secretariat – offer ideas for improving health services to better meet the needs of low-income women. [15]

Perhaps most importantly, health care organizations must change by specifically considering the needs of low-income women. The best way to do this is by including low-income women in the planning and evaluation of health services.

In order to improve the health status of low-income women, we will also need policy changes outside of the health care system. While these issues have not traditionally been part of the work of the health care system, it has an important role to play in encouraging organizations outside of health to consider the health consequences of their decisions. In Toward a Healthy Future, the Women, Income and Health in Manitoba Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) identified "renewing and reorienting the health sector" as the first of three priorities and called on health care organizations to "initiate dialogue with other health-determining sectors about the health impacts of policies in sectors outside health and about collective actions that can be taken." [16]

The ACPH also identified "improving health by reducing inequities in income distribution and in literacy and education" as another of its priorities for action. [17]

It is important to take actions both to increase the incomes of low-income women and to limit the costs of essential services. Some ideas for action include:

• increasing the minimum wage
• increasing social assistance rates
• broadening eligibility for Employment Insurance
• reducing the costs of public transportation
• increasing the number of subsidized child care spaces
• making child care fully subsidized for women living in poverty
• reducing the cost of basic telephone service
• making recreation programs freely available for those living in poverty
• providing non-insured health benefits, such as dental care and prescription drugs to all those living in poverty

These are some of the many opportunities which exist for decision makers, health service providers and the public to use our existing knowledge about the connections between income and health to make our community healthier for all.

While we may not have a detailed understanding of the mechanisms by which income and social status affect health, we know that the connection is there. Now is the time to use the knowledge which we do have to make changes to improve women’s health.

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APPENDIX 5
MODELS OF WOMEN-CENTRED CARE

2. Winnipeg Women’s Health Clinic Model of Care

PHILOSOPHY

The Women’s Health Clinic Model of Care is based on the following philosophy and principles.

1. All women deserve fundamental respect and have the right to make informed decisions about their health care. In particular, it is recognized that:
   • all women bring valuable and diverse experiences as care providers of family and friends, as workers, and as consumers of health services. Their ideas and insights should be encouraged and valued in developing health services appropriate to their needs; and
     
     
   • women from equity communities, including Aboriginal women, immigrant women, visible and language minority women, women with disabilities, and lesbians, bring unique experiences and insights to an understanding of health and illness. Often marginalized in the planning of health service delivery, their involvement and participation is essential for the development of quality, culturally appropriate services.
   
   
2. Health status improves when a person has a greater sense of control over their life situation. Women’s Health Clinic is committed to facilitating the empowerment of women, individually and collectively, in all its programs and services.
   
   
3. A person’s health must be understood holistically, with an appreciation for the interrelationship of physical, social, emotional and spiritual aspects.

APPROACH

The Women's Health Clinic approach to delivery of services is based on the principles and philosophy outlined above. Key elements of woman-sensitive, "best practices" include:

Priority Populations
In keeping with its population health approach, Women’s Health Clinic programs and services strive to serve the needs of:

• women who are most vulnerable to poor health due to factors such as poverty; and
• women who are more likely to experience barriers in accessing appropriate health services due to their ethnic origin, race, social class, language, sexual orientation or disability.

Women-Centred Services

The woman, in the context of her community, is the centre of Women’s Health Clinic service planning and delivery. Sufficient time is taken with each woman to gain an understanding of how her unique background and life situation impacts upon her health. Interventions and educational strategies are flexible and varied and may involve linkages beyond the formal health care system. These services may be offered by the Clinic directly or through referral to other service providers or agencies, such as justice, education, housing or employment.

Develop A Partnership Between the Woman and Care Provider

Programs and services are based on the assumption that the woman brings a valuable perspective of her life situation and her body. She must feel empowered to make informed decisions about her health and health care. Accordingly, staff and volunteers de-emphasize differences between woman and care provider, and seek to develop a partnership with her in addressing her health issues.

Most Appropriate Caregiver and Services

Every effort is made to ensure that women receive the most appropriate service, provided by the most appropriate service provider, in the most appropriate location. Women may access services through a variety of avenues and routes of entry as appropriate to their particular situation and needs. Services and approach offered may include information, education, support through groups or individual counselling, medical treatments, health screening, advocacy, community action, as well as linkages with the secondary, tertiary, rehabilitation and long term care or other sectors. Services sensitively address a wide range of issues (such as sexuality, childhood sexual abuse, violence) which have not been adequately addressed by health care providers in the past and try to ensure that appropriate care is provided.

Team Approach

Women’s Health Clinic staff are made up of an interdisciplinary team of health care providers who work collaboratively and include professional, paraprofessional and volunteer staff.

Empowerment

Programs and services are designed to enhance the understanding, self-care, self-help and self-advocacy abilities of the woman. This is achieved by:

1. providing a wide range of accessible information and education services with a key role being played by the Clinic's Resource Centre, as well as support and training services based on adult education principles;
   
   
2. facilitating the development of understanding and skills through social action groups around issues of concern to women such as breast implants, new reproductive and genetic technologies or birthing options; and
   
   
3. structuring the Clinic to include a system of participatory management and involvement of community members in agency decision-making and evaluation processes.

Use of Peer Volunteers

Peer volunteers play a key role in promoting the empowerment of clients through modelling self-help skills, demystifying medical information, and bringing community perspectives to the design and delivery of services. Therefore, Women’s Health Clinic provides training to women of various backgrounds in order to enable them to develop informal and formal helping and leadership skills in the provision of health information.

Community Involvement

Women’s Health Clinic works in partnership with various communities concerned about the health of women, building on the strengths and interests of its partners, including volunteers, clients, service providers or other members of the community.

Evaluation and Cost Effectiveness

Women’s Health Clinic recognizes the importance of ongoing review and evaluation of the approaches and service strategies it uses, taking into account sound information and evidence about how programs, services and approaches are meeting the health needs of diverse women. This requires the development of effective methods for feedback and evaluation, both qualitative and quantitative, and attention to the cost-effectiveness of various strategies.

Innovative Program Development

Women’s Health Clinic is committed to continuous development and re-focussing of its service approach based on new understandings of women’s needs and issues. The Clinic collaborates with community women and researchers and works at integrating newly gained knowledge.

Advocacy for System Change

Women’s Health Clinic works to identify critical emerging issues for women's health and brings together key stakeholders to develop innovative policy recommendations which are responsive to women’s needs and concerns.

The design and delivery of all Women’s Health Clinic programs and services reflect the understanding that:

1. gender is a key determinant of health. For example, women within all socio-economic and cultural backgrounds are at a higher risk than men of experiencing poverty, abuse and violence, all of which serve to seriously undermine health status.
   
   
2. women’s health status is influenced by a variety of social and structural factors, including social status, income and employment, education, and social supports; and
   
   
3. gender-sensitive health care services help women reclaim and re-define normal life transitions (such as childbirth or menopause) which have been overly medicalized or pathologized.
   
   
4. health promotion, primary prevention and healthy public policy are essential strategies for improving women's health. In addition to individual work with clients, Women’s Health Clinic also emphasizes community and group based approaches as a means to effect positive change in women’s health status.

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¹  Statistics Canada, Income in Canada, Table 8.5
²  Social Planning Council of Winnipeg, Promises Not Kept: 2001 Report on Child Poverty in Manitoba
³  Statistics Canada, op. cit, Table 8.5
4  National Council of Welfare, Poverty Profile 1996, p 87
5  Statistics Canada, op. cit., Table 5
6  Federal, Provincial and Territorial Ministers Responsible for Social Services, In Unison 2000: Persons with Disabilities in Canada, page 79
7  Statistics Canada, Women in Canada 2000, page 268
8  Statistics Canada, 1996 Census, Dimension Series, #94F009XDB96003
9  Statistics Canada, Women in Canada 2000, page 227
10 ibid, page 204
11 Yalnizyan, A., Canada’s Great Divide: The politics of the growing gap between rich and poor in the 1990s, Toronto: Centre for Social Justice, 2000, page ii
12 Kaufert, Patricia "The Vanishing Woman: Gender and Population Health", from Sex, Gender and Health, forthcoming, Cambridge University Press, 1999, page 121
13 Federal, Provincial and Territorial Advisory Committee on Population Health, Toward a Healthy Future: Second Report on the Health of Canadians, 1999, page ix
14 Denton, Margaret and Walters, Vivienne "Gender differences in structural and behavioral determinants of health: an analysis of the social production of health", Social Science and Medicine, 48 (1999), page 1232
15 Vancouver Richmond Health Board, Framework for Woman Centred Care, available at: www.vcn.bc.ca/vrhb/, Women’s Health Clinic, Model of Care, The Commonwealth Secretariat, Models of good practice relevant to women and health, including research, policy, implementation, strategies, testing and evaluation (For full texts see the complete version of this Report.)
16 Toward a Healthy Future: Second Report on the Health of Canadians, pages 175 to 177
17 Toward a Healthy Future, page 175

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