1. Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique Social Determinants of Women’s Health in Canada Health Canada Policy Forum, Ottawa, 9 October, 2003

2. Pop. health context: Romanow and the 3 burning health policy issues 1) How to treat the sick - supply side 2) How to improve the health of Canadians 3) How to check spiralling health care costs - demand side The next Royal Commission......

3. Practical: High portion of illness burden is preventable Excess Risk Factors Account for: 40% chronic disease incidence 50% chronic disease premature mortality 25% direct medical care costs 38% total burden of disease (includes direct and indirect costs)

4. 1) Descriptive: Women have distinct health needs. Causes / outcomes differ by gender 2) Normative: Ensure equal treatment, overcome biases that impede wellbeing 3) Practical: Blunt, across-board solutions often miss mark, waste money. Gender analysis allows policy makers to target health dollars Why a Gender Perspective

5. Practical: Women’s use of health services Canadian women have higher rates of: – chronic illness, physician visits – disability days, activity limitations – lower functional health status In every age group to 75, women more likely see physicians than men. Overall - 33% more likely; age 18-54 - 2-3x

6. Teen girls higher rates than boys Young women have 2x stress cf young men Surveys: young women say stress relief and weight loss = primary reasons for smoking Therefore programs, brochures, counselling targeted to girls more effective than blanket one-size-fits-all health warnings E.g….. Teenage smoking

7. 1998 Federal Health Minister “I have undertaken to fully integrate gender-based analysis in all of my Department’s program and policy development work...” “...to enhance the sensitivity of the health system to women’s health issues...” “...more research...on the links between women’s health and their social and economic circumstances.”

8. 1) Income: What does it have to do with women’shealth? Poverty most reliable predictor of poor health, premature death, disability: 4x more likely report fair or poor health Low income- higher risk smoking, obesity, physical inactivity, heart risk Costly: increased hospitalization: Women 15-39 = +62%; 40-64 = +92%

9. ……health of single mothers Worse health status than married (NPHS); higher rates chronic illness, disability days, activity restrictions 3x health care practitioner use for mental, emotional reasons = costly Longer-term single mothers have particularly bad health (Statcan)

10. Low income children- at risk - 31 indicators More likely to have low birth weights, poor health, less nutritious foods Higher rates of hyperactivity, delayed vocabulary development, poorer employment prospects. Less organized sports, but higher injury rates, and 2x risk of death due to injury than children who are not poor.

11. A/c Roy Romanow……: “If you’re at the bottom of the income ladder, odds are you’re going to find yourself at the bottom of the health ladder.” “So, if we’re serious about making Canadians the healthiest people in the world, then we have to be serious about closing the gap between rich and poor.”

12. Prevalence of low income- women and men : 1991-2000

13. Low-income children under 18, 1991-2000

14. Income: Female lone-parent families - 1997 & 2000

15. Trend: Low income rates of children: Single mother families --- 1991-2000

16. Employment of Female Lone Parents 1976-2001

17. Low Incomes : 1991-2000 Single mothers w/out paying jobs

18. The Economics of Single-Parenting Single mothers with pre-school children spend 12% income on child care cf 4% in 2-parent families. In one pocket......... CPI for child care, restaurant good rises faster than wages Robin Douthitt: “time poverty”. Full- time single mothers = 75 hour week

19. 2) Equity and health “What matters in determining mortality and health in a society is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.” ----- British Medical Journal 312, 1998

20. If Equality->Health, What are Trends? Average Disposable H’hold Income Ratios, 1980-98

21. GINI coefficient 1991-2000

22. Despite growing educational parity

23. Gender wage gap remains unchanged - Ratio of Female to Male Hourly wages: 1997-2001

24. Explaining the gender wage gap Convergence of women’s hourly wages stalled…. despite clear educational gains. After controlling for hours worked, educational attainment, work experience, industry, occupation, and socio-demographic factors, StatsCan concluded that: …….. ….“roughly one half to three quarters of the gender wage gap cannot be explained.” (2001) –

25. Regional wealth gap grows: e.g. Atlantic cf Ontario, Canada: 1990 = $0.82 disp.income NS for $1 in Ontario. 1998 = $0.73 Financial Security Atlantic Canada 1984: 5.4 % of national wealth. 1999: 4.4 % ““ (7.8% of Canadian population)

26. Share of national wealth vs. population (1984 & 1999)

27. Wealth gap in Canada: Richest 10% own 53% of wealth Richest 50% own 94.4%, leaving 5.6% for poorest 50% Poorest ¼ of Canadians own 0.1% (or one-thousandth of wealth) Among poorest 20%, 1/3 fell behind 2+ months in bill, loan, rent, mortgage = Importance of diversity approach

28. 3) Employment- a key determinant of women’s health Issues: Both overwork and unemployment are stressful- (Japanese study) Polarization of work hours - increasing the level of inequality in family earnings. Women’s health - function of paid + unpaid work - gender division of labour in household Women doubled employment, BUT still do nearly two-thirds of household work.

29. % of Women and Men Employed Canada 1976-2001

30. Women with young children - sharpest increase in employment, Since 1976:  women without children have increased their employment rate by 26%;  women with youngest child 6-15 by 62%;  women with youngest child 3-5 by 83%;  women with youngest child 0-2 by 124%

31. Employed women with children

32. But distribution is uneven -Employment and Education 75.4% of female university graduates have a job, cf 79.3% of male graduates. But… women with less than grade 9 are less than half as likely to be employed as males – 13.6% of women cf 29.4% of men Gender analysis not just m/f but diversity - sub-groups of women - esp. vulnerable

33. Women increased professional status- I.e. strong educational improvement

34. Job security - temporary work

35. Job security – union coverage

36. High decision latitude at work

37. Official unemployment rate

38. Unemployment + underemployment

39. Youth unemployment 15-24 explains entire gender gap

40. 4) While f-t women work 39 hrs cf 43 - men Women still do most unpaid housework

41. Employed mothers (f/t) work average 75-hr week - pd+unpd Statcan: Women moving to longer work hours: 4x likely smoke more, 2x likely drink more 40% more likely decrease physical activity 80% more likely have unhealthy weight gain 2.2x more likely experience major depressive episodes cf women on standard hours

42. Stress and health behaviours - smoking

43. Less stressful alternatives

44. Social supports are important Social networks may play as important a role in protecting health, buffering against disease, and aiding recovery from illness as behavioural and lifestyle choices such as quitting smoking, losing weight, and exercising. – See: Mustard, J.F., & Frank, J. (1991).The Determinants of Health. (CIAR Publ. No. 5).

45. Social Supports: pop. 12+, 2001

46. Social Supports- Volunteerism - a saving grace Health Canada uses volunteerism as a key indicator of a “supportive social environment” that can enhance health. Volunteerism declining: 1997-2000 Canada lost 960,000 volunteers. 1997 = 29% men, 33% women vol’d 2000 = 25% men, 28% women Remaining volunteers work 9% more hours

47. Family violence = key indicator of women’s health CIHI, Statcan identify crime as “non- medical determinant of health.” But women’s health analysis requires special indicators - family violence, like unpaid work, is key indicator. Family identified as key pillar of social support - determinant of health. But family violence may undermine social support, health

48. Family=high % of all violence Spousal violence = 18% of all violence reported to police. Women = 85% of all reported spousal abuse = 6x rate for men Nearly 1/3 of all reported female victims of violence in Canada attacked by spouse Unreported - much higher = 8% all women with partner attacked past 5 years.

49. Aboriginal women’s health Life expectancy = 76.2 cf 81 (non-Abor.) Higher rates hypertension, cervical cancer, circulatory & respiratory diseases Diabetes = 3x non-Abor. Fem = 2x male HIV/AIDS = 2x non-Abor. 50% female Abor AIDS cases = IV drug use cf 17% 9% Aboriginal mothers under 18 cf 1%

50. Aboriginal women’s health 3x mortality due to violence. 25-44 = 5x Alcohol-related accidents = 3x Fetal alcohol syndrome. Over 50% view alcohol abuse as problem in community 3x suicide rate cf non-Aborig. women

51. Regional disparities require special attention / intervention E.g Cape Breton…. High unemployment and low-income rates, Much higher incidence of chronic illness, disability, and premature death than Halifax Highest age-standardized mortality rate in Maritimes Highest death rate from circulatory disease, heart disease in Maritimes – 30% above nat.av.

52. Of 21 Atlantic health districts, Cape Breton has highest rates of: Cancer death (231.8 per 100,000) – 25% higher than the national average, lung cancer Deaths due to bronchitis, emphysema, and asthma (9.2 per 100,000) –50%+ higher than the national average High blood pressure– 21.7%, (24.3% women 19% men = 72% higher than the Canadian rate. The next highest rates are in south-southwest Nova Scotia

53. Cape Breton = highest: Arthritis and rheumatism: 31% of women, 23% of men Activity limitation (34%), followed by Colchester, Cumberland, and East Hants counties (30.1%) Life expectancy: 72.8 years for men, and 79.4 for women. (Canada: 75.4 years - men and 81.2 years -women

54. Disability-free life expectancy Cape Bretoners have an average disability-free life expectancy of only 61.8 years, seven fewer than the national average, and the lowest of all the 139 health regions in Canada. This means that Cape Bretoners can expect to live considerably more years with a disability than other Canadians.

55. Potential years of life lost highest number of potential years of life lost due to both cancer and circulatory diseases. Cape Bretoners lose 2,261.9 potential years of life per 100,000 population due to cancer – 41% higher than the national average of 1,603.7, and they lose 1,684 potential years of life per 100,000 population due to circulatory diseases – 65% higher than the national average of 1,020.7.

56. Women have generally healthier behaviours Women healthier diets. 5+ servings fruit/veg/day: F = 43%; M = 32% Daily smokers: F = 19%; M = 24% Overweight (BMI = 27+): F = 28%, M = 36% Obesity (BMI = 30+): F = 14%, M = 16% Heavy drinking: F = 11%, M = 28% BUT...

57. But female smoking rates declined later and slower

58. Teen Smoking rates by Gender age 15-19, 1996 vs. 2001

59. More women physically inactive

60. Health behaviours vary regionally: e.g.: % Overweight, pop, 20-64, 2001

61. Mammogram: Women, 50-69, routine screening within last two years, 2001

62. Cape Breton, W. Nfld = low mammogram screening, high breast cancer death rate

63. Pap smear test % of women 18-59 years, 2001

64. The physical environment is an important determinant of health - Health Canada “At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments. Factors relating to housing, indoor air quality, and the design of communities and transportation systems can significantly influence our physical and psychological well-being.”

65. Access to Health care Women use more health care services than men, thus are disproportionately affected by barriers. Atlantic Canadians have greater difficulties accessing care than most other Canadians. The barriers result from less availability of key health care services in rural areas, rather than from longer waiting times.

66. In Sum: Women have distinct health issues.... that have social and economic roots Diversity approach –special needs of Aboriginals, disabled, minorities, recent immigrants, disadvantaged regions, etc. 3 interventions that can improve women’s health, save health costs: 1) reduce time-overwork stress 2) eliminate gender wage gap 3) reduce poverty of single parents

67. Can it be done?...1900s/1980s...

68. Improving women’s health today will benefit future generations of Canadians

69. Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique www.gpiatlantic.org