4.2.5 Karen Grant
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4.2.2 AWHN Conference 6 2010 Chancellor 1: ‘It Starts at the Door’: Environmental Factors & the Quality of Care for Women
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4.2.5 Karen Grant
- 1. ‘It Starts at the Door’: Environmental Factors & the Quality of Care for Women Karen R. Grant, Ph.D. (University of Manitoba) et al. for Women and Health Care Reform 1AWHN Conference, May 2010
- 2. AWHN Conference, May 2010 2 Acknowledgements & Disclaimer • Thanks to: – Social Sciences and Humanities Research Council (grant #410-2002-1493) – Women’s Health Contribution Program, Bureau of Women’s Health & Gender Analysis, Health Canada – CHSRF/CIHR Chair in Health Services & Nursing Research – Our informants • Disclaimer: – The opinions and conclusions expressed here are those of the authors, and no endorsement by the funders, including Health Canada, is implied.
- 3. Who We Are • Pat Armstrong (Chair), CIHR/CHSRF Chair in Health Policy, NNEWH & York University • Barbara Clow, ACEWH • Ann Pederson, BCCEWH • Beth Jackson, Public Health Agency of Canada • Madeline Boscoe, formerly CWHN • Karen R. Grant, NNEWH & University of Manitoba • Margaret Haworth- Brockman, PWHCE • Morgan Seeley, York University • Nancy Guberman, UQAM 3AWHN Conference, May 2010
- 4. Research Objectives • To understand what quality of care means to women based on their everyday encounters with the health care system. • To develop empirically-based, gender-sensitive indicators of quality, based on the personal accounts of women in their interactions within the health care system. 4AWHN Conference, May 2010
- 5. Methods • Focus groups were conducted in several regions and cities in Canada in 2003/2004. • A semi-structured guide tapped into various dimensions of quality. • Interviews lasted 1½ to 2 hours. • All interviews were transcribed verbatim, and then coded and analyzed using N6. 5AWHN Conference, May 2010
- 6. Province or Region Numberof FocusGroups Numberof Participants British Columbia 4 17 Saskatchewan 4 24 Manitoba 3 20 Ontario 5 25 Quebec 6 36 Atlantic Region 3 23 TOTAL 25 145 6AWHN Conference, May 2010
- 7. Women’s Perspectives on Quality Health Care • Care that is woman-centred. • Care that is comprehensive in nature. • Care that involves a preventive focus. • Care that is integrated, involves continuity, and has a long-term focus. 7AWHN Conference, May 2010
- 8. Women’s Perspectives on Quality Health Care (cont’d) • Care that is accessible. • Care that is culturally competent. • Care that involves a range of providers who have the necessary skills. • Care that is holistic & recognizes the changing nature of women’s roles in society. 8AWHN Conference, May 2010
- 9. Step 1: Getting In • Getting to care – “Accessibility means being able to get there.” – “The greater the distance, the fewer the visits, the less care.” – Challenges for all women in relation to: • Social responsibilities (work; family care) • Social locations • The structure of care and limited services (esp. in rural/remote areas) • Transportation as integral to care. 9AWHN Conference, May 2010
- 10. Step 1: Getting In • “It starts at the door. When my arms were really bad, I could not open that door without wedging my elbow into it and grabbing it and yanking it and pulling it. There’s no wheelchair button on the door and the handle is not friendly for people who have rheumatoid arthritis or a whole bunch of other conditions...” (NS) “Universal access has not even been in the plans or the thoughts of the designers of new clinics.” (NS) “We have to have appropriate, accessible and functional caregiving facilities, whether they be for extended care or in a hospital or in a doctor’s office so that people can get in and take advantage of those facilities and use them properly.” 10AWHN Conference, May 2010
- 11. Step 1: Getting In • “Just because it has a button on the front door does not make that location physically accessible.” • “To get in, I couldn’t. The secretary had to come to open the door.” – Assumptions about “what a body is supposed to be able to do.” – Assumptions about accommodations being made, but to what standard? AWHN Conference, May 2010 11
- 12. Step 1: Getting In • The unique challenges of street-involved women: – Lack of health card – Need for the basics: “You shouldn’t be in a back alley…we’re not allowed to use washrooms… we’ve got our necessities. You can’t just drip dry… it’s a lot about safety, and in the end, that’s about your health too, right?” AWHN Conference, May 2010 12
- 13. Step 2: Staying In • Getting in is also linked to the social dimensions of care – The importance of social locations (age, class, ethnocultural background, area of residence, sexual orientation) as well as health issues and experiences. – “Attitude is the biggest barrier.” 13AWHN Conference, May 2010
- 14. Step 2: Staying In 14AWHN Conference, May 2010 • LGBTT women’s experiences dealing with heteronormativity. – The rainbow flag as a welcoming sign. – “There would be more accessibility if there was more education relieving the heterosexism that we have.” (NS) “When people are talking to other people, don’t assume anything about who you are. And whatever you are, whatever your sexuality is, it’s your own damn business. Everyone should be included.” • Inclusion and non-discrimination are at issue. This is also about safety.
- 15. Step 2: Staying In • Overweight/Obese Women – “Being overweight my whole life, the only thing the doctors wanted to do was put me on a diet. So that’s been my experience. That was my first real experience, not caring or you know, not being looked after positively.” (NS) “When I was 10, our family doctor put me on speed. My mum was thrilled to pieces because I had cleaned the whole house within an hour, because I was this bloody whirlwind, right?! But, to think, (laughing) how a doctor would put a 10 year old child on that?” 15AWHN Conference, May 2010
- 16. Step 2: Staying In • “You’re treated l like you’re a second-class citizen.” (NS) “Because of the way I look. Shouldn’t I get health care? Like everybody else should get?” • “I’ve gone to the dentist and the doctor with dandruff, and he said, ‘You need to lose weight.’ But it’s not funny; you’re very definitely treated very differently when you’re overweight. It’s almost as if every single issue that you go to the doctor with, the weight is going to impact it.” AWHN Conference, May 2010 16
- 17. Step 2: Staying In • “The thing for me, that it comes down to, is I need to feel that I have been respected. My beliefs, my lifestyle, I need as a person to feel respect. I need to feel as though I’m being treated like he would treat the next patient that came in; with as much concern, and thoughtfulness, and so on, as anybody else.” 17AWHN Conference, May 2010
- 18. One Size Does Not Fit All • Quality is easily and structurally compromised when people are othered in their encounters with the health care. The impacts include: – Compromised health status. – Avoidance of health care. – Increased marginalization. 18AWHN Conference, May 2010
- 19. Conclusions & Implications • The care that women want vs. the care that the system seems to think is important. – Developing a relationship vs. providing a service. – The values feminists articulated in the second wave are still important today. • Not only care should reflect these values, so should the accountability measures. 19AWHN Conference, May 2010
- 20. Women and Health Care Reform http://www.cewh-cesf.ca/healthreform/index.html 20AWHN Conference, May 2010
Editor's Notes
- Good afternoon. My name is Karen Grant, and it is a genuine pleasure to be here and present some of the findings of a project conducted with colleagues in a research group called Women and Health Care Reform. In the time that I have today, I’ll provide a brief overview of our study in the context of the Canadian health care system & current research on health care reform, health indicators & gender-based analysis, and describe our study & present findings on how place and space – in all of their dimensions –influence the care that women receive.
- Women and Health Care Reform (formerly the National Coordinating Group on Health Care Reform and Women) is a national research alliance in Canada, funded through the Women’s Health Contribution Agreement at the Bureau of Gender and Women’s Health, Health Canada. Together since 1998, we have been studying the many ways in which health care reforms affect women and women’s health. To date, we have explored a number of policy areas including health care privatization, home care and unpaid caregiving, long-term care, ancillary work in health care, the mental health of health care workers, primary health care reform, maternity care, emergency preparedness, and wait times for total joint arthroplasty. In all of our work, we are asking two kinds of questions: how does this area of health policy affect women? And which women? Our approach is to consider women as users of health care, as paid and unpaid health care providers, and as decision makers. We are also interested in the experiences of women in diverse social locations.
- The research that I am reporting on today grows out of our interest in health indicators, and the substantial amount of research and policy work on health system performance that more or less reached its zenith in the late 1990s and early 2000s. Governments in Canada and elsewhere around the world were preoccupied with performance measurement, and in health care, in ensuring effectiveness and efficiency within the system. A Royal Commission and a Senate Inquiry, as well as various provincial inquiries into the state of health care focused attention on health indicators and promoting efficiencies within the system, largely out of concern (it was claimed) that the public’s insatiable appetite for health care and the graying of the population would ultimately render the system unsustainable because of escalating costs. Though the rhetoric was fierce, often claiming an inevitable apocalypse, the evidence was often less than adequate to support the claims being made. We were of course concerned about how women would be affected by what was (and was not) being counted when the health system’s performance was being measured, and how the conclusions drawn would affect women as users, providers and decision-makers. Our analyses of the health indicators revealed the limitations of the measures themselves, at a conceptual level as well as in terms of how the measures were being operationalized. This led us to design a study to look at one commonly used measure – quality – in order to see if we could derive measures that would more adequately capture not only system imperatives (which is how quality has been traditionally defined in health services research) , but also perspectives based on the experiences of those who use and work in the system. Given our research mandate, we focused our attention on women’s definitions of quality. Or stated more directly: How quality is typically measured? Focus on health system performance, usually administrative data. The perspectives of those working or administering the system. Focus on the population level. Our focus: women in their everyday encounters with the system.
- Focus group study design using a semi-structured interview guide focusing on: the meaning of health care experiences with & in health care (as patients, providers & decision-makers) what makes health care good or bad what defines care as quality care what makes quality a women’s issue women’s perspectives on health care indicators of quality
- Focus groups involved a diversity of women. Key sources of differentiation included age, urban/rural residence, ethnocultural background, sexual orientation, social class, and health status (including disability status and persons living with chronic health problems). One focus group was restricted to health care providers. This table shows the distribution of focus groups across the country, as well as the total number of participants.
- Our research shows that women do have definite ideas about what quality health care is. Very briefly, they see quality in each of the ways listed on these two slides. These aspects of quality are seldom what we see being measured. Women’s perspectives on quality touch on not just the structure of care, but also the process of care. You can see that some of the descriptors of quality care are italicized. These are directly relevant to what I want to focus on today.
- The emphasis on accessible and culturally competent care is the central focus of what I want to talk about today. In most of our focus groups, concerns about access were often highlighted. Many women, with very different social locations and experiences, lamented the challenges that they faced, and talked about how barriers of various forms affected whether, when and how they used health services. They also described the consequences of barriers they faced in terms of their everyday lives, their physical and social well-being.