5002 Week 3 - Week 5
intersectionality
"People's lives and the organization of power in a given society are better understood as being shaped not by a single axis of social division, be it race or gender or class, but by many axes that work together and influence each other." Hill Collins & Bilge (2016) Critical Race Theory & Intersectionality pg 30 Week 3 Lec
Max Webber Race/Ethnicity Theory
- Ethnic groups are 'kunstlich', meaning artificial and socially constructed. - A group may have a shared sense of community, but the community does not create the group, the group create the belief of the community - Webber argued that, group formation is mobilised for social effect and not about inherent qualities = no inherent meaning
Fredrick Barth Race/Ethnicity Theory
- Ethnicity is perpetually negotiated and renegotiated - Internally identified or externally ascribed - Not something you naturally belong to, not culturally bounded - Ethnic distinctions depend on exclusion and inclusion practises: • inclusion categories are maintained based on particular qualities e.g. physical appearance, cultural practices, religion etc.
What are gender relations and how do they impact on health?
- Gender hierarchy • Not as simple as men-women binary hierarchy • Multiple femininities and multiple masculinities and gender diversity • Women may be subjugated wihtin the gender hierarchy, but middle class women may have more power in specific situation due to class privilege • Men may be subjugated in the hierarchy of masculinities based on race, sexuality, social class etc. - Gender relations: • Refers to the overarching relations between masculinites and men, femininities and women and gender diversity and gender non- conforming and trans people • Recognises that gender is relational, it is something we do in relationships to demonstrate our gender, or something that is done to us - Gender identity: how we understand ourselves and our own gender
Critical Race Theory & Structural Racism
- Sometimes called systemic or institutionalised racism - Refers to systemic ways dominant white society restricts a person/people of colour access to opportunities based on notions of race - Historical, cultural, and institutional dynamics that routinely advantage white people and produce cumulative and chronic disadvantage to people of colour • Examples: • History of oppression of people of colour • E.g. access to education, economic resources, political representation, human rights and freedom • Historical notions of superior and inferior races Historical invisibility of Structural Racimsm • Researcher and clinicians notions that differences between 'races' in terms of health outcomes is intrinsic or inherited i.e. Pre-civil war physicians attributed poor health among slaves to biological inferiority rather than slavery and living conditions McIntosh, 2004: Many white people are - Unaware of the advantages they enjoy in this society due whiteness: - Unaware of how their attitudes and actions unintentionally discriminate against persons of colour DiAngelo 2018: - Find it difficult to believe that they possess biased racial attitudes even though the are deep in our society - May try to relate e.g. I am a woman I experience discrimination too, or I come from a poor family - fail to acknowledge specific experiences of racism
What are the specific microaggressions that can be experienced by LGBTIQ+ people? What were the eight main themes found for this study? What kinds of experiences did people report?
1. use of heterosexist terminology, 2. endorsement of heteronormative culture/ behaviors, 3. assumption of universal LGBT experience, 4. exoticization, 5. discomfort/ disapproval of LGBT experience, 6. denial of the reality of heterosexism, and 7. assumption of sexual pathology/abnormality. 8. An eighth theme, threatening behaviors, emerged from the data and was independent from the original taxonomy. 1. Use of heterosexist and transphobic terminology occurs when someone uses derogatory heterosexist language toward LGBT persons (e.g., saying words like "******" or "dyke," an employer refusing to use individuals' preferred gender pronouns, or people using phrases like "That's so gay!"). 2. Endorsement of heteronormative or gender normative culture/behaviors transpires when an LGBT person is expected to act or be heterosexual or gender conforming. For instance, a heterosexual person telling a gay individual not to "act gay in public" and a parent forcing her or his child to dress according to birth sex would be both examples of endorsing heteronormative or genderist values. 3. Assumption of universal LGBT experience occurs when heterosexual people assume that all LGBT persons are the same (e.g., stereotyping all gay men to be interested in fashion or interior design or assuming all lesbian women to act or look "butch"). 4. Exoticization microaggressions take place when LGBT people are dehumanized or treated as objects. This can be exemplified by heterosexual people stereotyping LGBT people as being the "comedic relief" or asking transgender people intrusive questions about their genitalia. 5. Discomfort/disapproval of LGBT experience occurs when LGBT people are treated with disrespect and criticism, such as when a stranger stares at an affectionate lesbian couple with disgust or a heterosexual or nontransgender person tells an LGBT individual that she or he is "going to hell," they are expressing their disapproval or discomfort. 6. Denial of societal heterosexism or transphobia transpires when people deny that heterosexism and homophobia exist (e.g., a coworker telling a gay friend that he's being paranoid thinking someone is discriminating against him). 7. Assumption of sexual pathology/abnormality microaggressions come about when heterosexual or nontransgender people oversexualize LGBT persons and consider them as sexual deviants. For example, many people may assume that all gay men have HIV/AIDS or are child molesters or that transgender women are sex workers. 8. Finally, denial of individual heterosexism / transphobia occurs when non- LGBT people deny their own heterosexist and transgender biases and prejudice (e.g., someone saying, "I am not homophobic. I have a gay friend!").
What explanations exist for the impact of class on health inequity?
5002 Week 3 Lec Explanations are not mutually exclusive 1. Cultural-Behavioural • Theorises the link between class and health is a result of differences in terms of behaviours such as smoking, alcohol and drug consumption, dietary intake, physical activity, and health service usage. • Simplistic versions propose that all difference in health inequality attributable to individual behaviour, reinforcing stereotypes of irresponsible poor people. • More recent versions emphasise the role of cultural influences on behaviour, taking structural factors such as the experience of deprivation and powerlessness. 2. Materialist • Focuses on how income enables access to the goods and services that enable good health. • Decent income enables access to health care, adequate diet, quality housing, social participation. • Allows for avoidance of hazards, such as poor working conditions. 3. Psychosocial • Focuses on how social inequality makes people feel. • Feelings of inferiority or subordination stimulate stress responses which can have long term consequences for physical and mental health. • Perceptions of social status, especially in comparison to other people, is an important factor. 4. Life course idea that all the above theories are embodied in the individual -- Differences in health states between social classes result from the accumulation of social, psychological, and biological advantages and disadvantages over time. -- "The social is literally embodied,; and the body records the past" 5. Political Economy • Is a combination of materialist and psychosocial explanations • Social determinants of health shaped by higher-level structural determinants: politics, the economy, the organisation of government, the labour market. • Politics is understood as "the process through which the production, distribution and use of scare resources is determined in all areas of social existence" (Bambra et al, 2005). • Politics and the balance of power between key groups (labour and capital) determine how the government acts to reduce inequality (e.g. neoliberal or social democracies)
How can a focus on cultural difference lead to victim blaming?
A final criticism of the approach to practice that focuses on the cognitive aspects of culture, traditions, customs and values, is that it fails to take into account broader social, political and economic factors which affect health and access to health care. As a result, and given the emphasis on the individual and individual responsibility within Western societies, this perspective can be particularly problematic for Indigenous peoples who may occupy a marginal position, as it can lead to 'victim blaming' for poorer health outcomes, rather than focusing on people's 'social and economic circumstances, marginalisation and oppressive internal colonial politics' (Browne and Smye, 2002, p. 29).
According to Fredericks (2009), culture and racism impact on the way in which Aboriginal women experience and engage with health services. Look at the example of Kay (p.15). How does Kay's experience relate to issues of 'white privilege', 'othering' and cultural stereotyping?
Aboriginal women treated differently by non Indigenous health care providers based on perceptions of Aboriginality and skin colour and white race privilege within health care environments Kay -- difficulty finding medical treatment for pain - they though she was imagining the pain actually due to gallbladder stones. & then assumption that she had had multiple children when actually was her first
What is meant by the terms, upper-class, middle-class, working-class and under-class?
According to Germov (2014, p.106) the class hierarchy in Australia includes: i) the upper-class who maintain control of production (capital), e.g. they own corporations, raw materials and industry and employ other people to "create a profit for them"; ii) the middle-class who hold ownership of professional skills and qualifications and are able to "attract higher wages and better working conditions than unskilled workers". For example, they may be employed as health professionals or lawyers; and iii) the working-class are essentially unskilled or semi-skilled workers who sell their labour for a wage. For example, they may work in unskilled service industry or labouring jobs. According to Western & Baxer (2007) the upper-class make up 15% of Australian society, 47% make up the middle classes and 38% make up the working classes. Australian sociologist Belinda Probert (2001) argues for a fourth social class in Australia - the 'underclass', which includes people who are unemployed or insecurely employed. Upper Class --> Established wealth, large amounts of prestige & resources - the "elite" of society, own large businesses Middle Class --> High earning working professionals - lawyers, doctors, lecturers Working class --> Manual workers, earning wages - factory workers
Why is health education regarded as ineffective if it focuses on individual factors?
Addressing the latter requires changes in public policies guaranteeing basic needs, including but not limited to healthy food choices. As Bell et al. (2011, P. 5) noted, from the perspective of health inequalities the rhetoric of 'individual choice' pervading contemporary public health conceals 'the unequal impact [of health inequalities] across the population'. In our view, public health professionals are ideally positioned and have the necessary legitimacy to advocate for policy changes that impinge on the SDH. However, for this to happen, a shift must occur among public health practitioners, who must recognize that there is no health-educational 'fix' to poverty, socioeco- nomic inequality, and political disenfranchisement. This shift could translate into research that tests theories and programs that acknowledge the role of the SDH in disease causation, practice that uses this knowledge to advocate for transforming structural conditions at their root, and a recognition of the limits of medical and public health institutions, accompanied by a professional and personal commitment to engage with other forms of praxis seeking to change the social and political contexts (Waitzkin and Britt 1989).
How are anorexia nervosa and HIV linked to gender?
Anorexia Nervosa -- 90% of anorexia nervosa cases are girls or women - Usually begins in adolescence - age when there is a particular emphasis on heterosexual attractiveness - Link to emphasised femininity and stress (femininity is always in relation to masculinity in the hierarchy of society) - Raewyn Connell 2012: -- "Shifts in social definitions of attractiveness that place a premium on women being thin have created conditions for widespread difficulty in young women's relationships with their bodies" 90% affected are women, and overwhelmingly it begins in adolescence. This is an age when a particular form of social embodiment, heterosexual attractiveness, is a vital issue for most young women in metropolitan society - within a gender order that, as Jónasdottír (1994) points out, makes women more dependent on their desirability to men than men are dependent on their desir- ability to women. Shifts in social de!nitions of attractiveness that place a premium on women being thin have created conditions for widespread dif!culty in young women's relationships with their bodies. Anorexia is in fact a gendered form of social embodiment - though not one that is normatively approved. HIV: When the HIV/AIDS epidemic was !rst recognized in the early 1980s, it was gender-structured in a contrasting way, involving networks of men. The sexual practices of gay men in rich countries were distinctively shaped by gender dynamics. Gay Liberation, a powerful collective challenge to the stigmatization of homosexual men, had been followed by the expansion of urban gay communities and a certain turn towards hegemonic masculinity as found in the heterosexual world. This included a revival of butch fashion and personal style, and sexual techniques that included rough, unprotected anal sex, which unintentionally created pathways for the virus (Levine, 1992). By the 1990s HIV/AIDS was recognized as a global issue and its gender pattern was much more complex. In southern and central Africa, where the heaviest burden has lain, transmission is mainly through heterosexual practice, and women now have a higher rate of infection than men. The social circumstances include poverty and rapid urbanization, but also involve gender orders that privilege men and subordinate women, especially young women
What is individual and systemic racism?
At the individual level, people may have conscious and unconscious bias against Indigenous people and people of colour which manifests in overt or subtle acts of racism that impact on the health and well-being of those populations. Structural or systemic racism refers to ideologies and institutional practices that are entrenched in society and lead to the privileging of certain racial groups over others e.g. via access to quality education and housing, through hiring practices, via media discourses and access to political power, through legal systems and health services. The result is that Indigenous people and people of colour are less likely to receive the equivalent social, economic and health benefits as white people. This translates into higher rates of morbidity and reduced life expectancy among Indigenous people and people of colour worldwide (Solar & Irwin, 2010). As DiAngelo argues, systemic racism 'benefits and privileges whiteness by every economic and social measure' (Iqbal, 2019). The systemic privileging of white people is sometimes referred to as 'white privilege', Systemic racism also intersects with other structural determinants of health, including poverty and cultural oppression.
What are the ways that people respond to these microagressions?
Behavioral reactions included different ways that LGB individuals reacted behaviorally to microaggressions (e.g., being passive, being confrontational). Cognitive reactions involved various cognitive processes that LGB individuals reported during and after experiencing microaggressions (e.g., conforming to general society, accepting microaggressions, or feeling empowered or resilient). Emotional reactions consisted of the various types of emotions LGB people experienced when or after experiencing microaggressions. Finally, participants reported the various types of mental health problems that they experienced as a result of microaggressions, as well as the range of systems or groups that enact microaggressions.
According to Connell (2012), what are the problems of biological and sex role categories?
Biological & sex role categories - Multiple patterns of masculinity and femininity - masculinities and femininities. - Different patterns of masculinities and femininities are related to each other - Masculinities and femininities are 'embedded' in social institutions. - Hegemonic masculinity - top of the hiearchy • Ideal man is depicted as physically and strong, emotionally contained, rational, in control, able to dominate others, heterosexual, wealthy and powerful • Pressure to expel qualities associated with femininity • Ideal masculinity is based on a fantasy of reality, not based on real lives of men. Exemplars from media • Men may police each other around this notion of the ideal e.g. wimps and jocks. • Use homophobic, transphobic or misogynistic slurs (also used to verbally assault gay men, women and trans people) Associated problems with Conventional understandings of gender situates gender as binary and fixed - Scientifically problematic and obstacle to scientific progress - Leads us to overlook social and political causes of gender inequity - Can dictate how people are treated - stereotypes about gender • E.g. idea of what men and women are good at, what kinds of jobs they should do, what kind of roles they should hold in society • Leads to gender discrimination - e.g. women not promoted as idea that men are natural leaders. Men not understood as also having emotions and may struggle to find support - Shapes social policy and law - Denies existence of those people who do not identify as (mis)assigned sex at birth
According to Donnelly et al. why is colour blindness problematic in health services?
But in the very process of being color blind, they do notice and spend a great deal of energy in determining how to proceed in a color-blind fashion fails to acknowledge that persons in our society do see color and do react differently to people based on their skin tone. But by not noticing race, they ignore cultural diversity and the differential life experiences of people of color in our society. As the interviews we present later show, this creates a dilemma for social service providers. When they fail to acknowledge race and treat everyone exactly the same way, they may be seen as using a one-size-fits-all approach and not meeting the needs of diverse groups. Color blindness, in and of itself, is not always detrimental. But because Whiteness is used as the standard for behavior, appear- ance, and interaction in our society, color-blind norms are really White norms.
Why will claiming not to 'see colour' not fix racism?
Colorblindness ignores rather than addresses structural/systemic racism (only attempts to fix individual racism) One way that nurses might seek to mitigate the impacts of racism is to treat people the same regardless of race. While this sentiment is well intentioned, treating people the same ignores privilege and overlooks experiences of racism and the health impacts. In health systems, attempts to 'not see colour' are referred to as 'colour blindness' and are seen as an impediment to system change. Instead, understanding systemic racism calls on us to actively engage with how racism operates in systems to oppress and privilege particular populations and to take actions at the systems level to make change to eliminate health inequity.
Critical Race Theory
Critical Race Theory (CRT) 1977 onwards - key figures in the US: Martin Luther King Jr, Malcolm X, Sojourner Truth, Fredrick Douglass, W.E.B. Du Bois. - Inspired by the civil rights movement - Came out of critical legal studies - CRT advanced understanding of law, politics and history - Like ethnicity, idea that race, instead of being biologically between groups grounded and natural is a socially constructed concept - a product of social thought, practice and relations • Geneticists agree that racial taxonomies at DNA level are invalid • Genetic differences within a so called 'racial' group are greater than between groups - Rather than focusing on socially constructed notions of race, it attends to power and oppression in the lives of people of colour - the power of social categorising based on race continues to shape the lives of people - and has led to the privileging of white people and the oppression of Indigenous people and people of colour - Examines how race as a concept functions to maintain oppression of people of colour and the interests of the white population in institutions, labour markets and politics. - It traces histories of oppression and resistance such slavery, civil rights and racial profiling, deaths in custody - Explores how racism leads to poverty, exclusion and criminalisation of people of colour - CRT not just about theory, but seeks tangible real world impact to create a fairer world CRT - not all racism overt -- Racial Microaggressions: - Concept theorised in Critical Race studies - Brief and commonplace daily verbal, behavioural or environmental •-> i.e. words gestures, tones, dismissive looks, snubs, moving away, not being included, being overly nice, or lack of inclusive literature in health settings etc. - Can be intentional or unintentional - Communicate hostile, derogatory or negative racial slights and insults towards people of colour
Why is diabetes described as a disease of the 'biology of poverty"? What does this mean?
Diabetes is one of many diseases importantly influenced by the SDH. It is characterized by insufficient production or uptake of insulin by the tissues, which result in elevated levels of blood glucose. It has a disproportionate toll on minorities and on the poor, categories that often overlap. This well-established relationship between the SDH and diabetes led to label: the 'biology of poverty' This biology is produced by a combination of mechanisms operating since conception, and which include fetal malnutrition (Barker 2003), poorly controlled diabetes during pregnancy (Jovanovic and Pettitt 2001), stunting in young children (Branca and Ferrari 2002), food insecurity (Seligman et al. 2007), and lack of access to timely and quality medical care (White et al. 2009), among others. These mechanisms, the product of social exclusion and of an inequitable distribution of resources necessary for health, are also responsible for the intergenerational, social and biological (albeit not genetic) transmission of diabetes (Chaufan 2008).
What is meant by the 'cook-book', 'checklist' approach to culture in nursing? What are the problems with this?
Duffy (2001, p. 489) argues that nursing education continues to espouse 'distinct cultural components (local particularities)' without taking into account the interaction of the individual with global influences such as media and the increasing use of technology. The individual gets lost in an education that, focusing on cultural characteristics and customs, provides a 'cookbook' approach to care (Duffy, 2001, p. 498). This 'cookbook' approach refers to generalised information that has been formulated about different specific groups. As argued by Duffy (2001), transcultural literature and texts are full of these generic 'cookbook' approaches. This approach in the majority of cases is used to provide generic information about people from specific culturally and linguistically diverse backgrounds. Some authors do warn the readers that this approach can lead to 'stereo- typing' as it is impossible to cover the diversity within culturally and linguistically diverse group
According to Green, what were their experiences in health services?
I was 80% of the way to being a social male already; all I needed was the medical treatment for the physical transformation, and that would get me the legal recognition I needed to proceed with my life as a man. First was reviewing the employee health insurance plan benefi ts, and noting that "any treatments or procedures related to sex reassignment, or treatments either before or after any surgery intended to alter sexual characteristics" were excluded from coverage Second - delay in receiving treatment after saying preoperative transsexual
What are the major barriers to healthy eating experienced by people on low incomes?
Eight themes emerged as key barriers to healthy eating: (1) cost of food vis-a `-vis income; (2) transportation; (3) language; (4) stigma; (5) immigration status; (6) insufficient formal/ informal food assistance; (7) work conditions; and (8) competing basic needs/constraints of poverty. We conclude that the public health and health education rhetoric of 'individual choice' is a barrier in itself to under- standing the diabetes epidemic, and that without the recognition and understanding of, and intervention upon, socioeconomic, policy, and political barriers to healthy lifestyles, the prevention of diabetes will remain out of reach. Barriers to healthy eating included the high price of healthy foods (and the comparatively low price of unhealthy foods), inadequate transportation to food outlets, limitations of food assistance, employment, and work conditions, and lastly, competing needs stemming from the sheer constraints of poverty. In the view of participants, the greatest barrier to healthy eating was the high price of food. Problems of transportation to food outlets compounded the problem of high prices.
Ways to identify links between structural determinants and health outcomes
Epidemiology data tells us a lot: - linking factors e.g. poverty and race to poor health, tells us that that some racial groups have less health interventions or high rates of discharge against medical advice BUT - Epidemiology limited, it can't necessarily explain why particular populations experience poorer health outcomes - E.g. divorced men suicide rate is high, but divorced women suicide rate decreases PHC nurses therefore also draw on: - Qualitative research exploring experiences of different population groups - Theory about specific population health issues
How might a relational approach to understanding gender support our understanding of individual and structural issues in health?
Explore underlying health implications -- eg with suicide
What recommendations do Gray et al (2020) make in regard to tackling systemic racism?
First, federal, state and local support for health dis- parities research and workforce diversity in health care and science must increase. Immediate needs include the collection and reporting of accurate and detailed national data on race, ethnicity and SDOH. Furthermore, researchers should be challenged to stretch beyond investigating implications of SDOH and health disparities to the discovery and implementation of interventions to reduce inequities. In the long- term, we must bolster financial resources allocated to pipeline programmes and minority- serving institutions, substantially increasing funding for the National Institute on Minority Health and Health Disparities (one of the lowest- funded NIH institutes in the USA), and mandating implicit bias training and mitigation for grant review committee members. Second, racism must be declared a public health crisis and resources need to be deployed to mitigate it. remains a need for a national legslative priority with long- term investment aiming to strengthen the public health infrastructure and its ability to respond efficiently and effectively to local and national public health crises, dismantle discriminatory policies and practices, and foster healthier communities, starting with the most vulnerable. Third, those most proximal to the inequity must be given voice to propose and implement solutions. Meaningful partnerships between public and private sector stakeholders, civic organizations and local grass-roots efforts will build social capital, foster resilience, cultivate political will and effectively challenge discriminatory policies, practices and norms that disproportionately affect vulnerable populations. National medical societies and organizations must also be invested in this response.
role of social position in generating health inequities
First, the central role of power. While classical conceptualizations of power equate power with domination, these can also be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action as embodied in legal system class suits. In this context, human rights embody a demand on the part of oppressed and marginalized communities for the expression of their collective social power. he central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. Second, it is important to clarify the conceptual and practical distinction between the social causes of health and the social factors determining the distribution of these causes between more and less advantaged groups. he CSDH framework makes a point of making clear this distinction. On this second point of clarification, conflating the social determinants of health and the social processes that shape these determinants' unequal distribution can seriously mislead policy.
How might health services be improved so that they are more accessible for Aboriginal and Torres Strait Islander people?
collaboration with aboriginal people
What is minority stress?
Given this discrimination on societal, institutional, and interpersonal levels, LGBT individuals may feel marginalized in American society and experience excess social stress or "minority stress" (Meyer, 1995, 2003), which in turn makes them more prone to mental health problems than heterosexual people.
Why might it be important for health professionals to recognise and address issues related to race?
If we are all the same and color doesn't matter, then no actions are needed to address the sit- uation. Thus, this color-blind perspective, combined with fictions of equality, preserves structural inequities that limit and impinge on the life chances of people of color. In summary, being color blind means that service providers may fail to acknowledge the structural obstacles and cultural dif- ferences faced by women of color and thus do little to accommo- date their diverse needs. Color blindness often renders women of color invisible, because service providers assume that they are just like White women or they respond to being treated in the same manner as White battered women.
According to Hall et al. (2015), what is implicit bias and how is it correlated with health outcomes, patient provider interactions, treatment decisions and adherence?
Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition. Negative implicit attitudes about people of color may contribute to racial/ethnic disparities in health and health care. Explicit attitudes are thoughts and feelings that people deliberately think about and can make conscious reports about. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient- provider interactions and health outcomes than treatment processes. Racial/ethnic bias in attitudes, such as feeling that White people are nicer than Black people, whether conscious or not, can lead to prejudicial behavior, such as providers taking more time with White patients than Black patients and therefore learning more about the White patients' needs and concerns.
According to Hall, what is the relationship between racial bias and other intersecting factors e.g. gender?
Implicit bias toward people of color may indeed interact with other characteristics such as gen- der, age, sexual orientation, na- tional origin, and disability status to produce differential treatment outcomes. There is evidence of implicit bias based on gender, age, sexual orientation, ethnicity, religion, and disability in the general population. Researchers should also measure bias based on social identity characteristics in addition to race/ethnicity, such as age, gender, socioeconomic status, national origin, sexual orientation, gender identity, religious orientation, and disability status. Bias can exist on multiple social dimensions, and patients with multiple minority identities may be particularly affected. In addition, measuring various demographic characteristics among patients and providers would allow more advanced hypothesis testing. For ex- ample, a patient's gender may moderate the relationship be- tween a provider's implicit racial/ ethnic bias and quality of care, and providers in some specialties may
How do PHC nurses work across the structural and intermediary determinants of health?
In PHC nursing, structural determinants are addressed through health promotion efforts, including attending to upstream social determinants of health through multi-sector action, community empowerment and participation, as well as advocacy for changes to public and social policy, legal recognition and rights, and influence over cultural and social values. Health promotion also attends to the down-stream or 'intermediary' determinants (Solar & Irwin, 2010), for example by ensuring that health services are equitable, affordable (universal) and appropriate for diverse populations. Structural and intermediary determinants are also addressed at the individual and local level by upskilling individuals and communities to access information, skills and resources to engage in collective action to change the structural determinants and the material, social and cultural conditions that impact on them, as well as the skills to mitigate (to some degree) the psychosocial and behavioural impacts of structural determinants. EG: effective action might include down-stream efforts to increase child nutrition by providing free breakfast and lunches in schools and by creating access to community gardens, as well as upstream efforts to advocate for systems change and improve community job training opportunities and employment.
How are the barriers to healthy eating 'structural rather than behavioural'?
In our study, the barriers to healthy eating were structural rather than behavioral. By this, we do not wish to create a false dichotomy between structure (i.e., social relations, institutional arrangements, and social and economic policies) and human behavior. Rather, we mean that whatever knowledge about healthy eating and lifestyles participants did have, or however good their intentions to adopt those lifestyles appeared to be, structural constraints on behaviors, food-related or otherwise, made adopting healthy ones all but impossible. Structural constraints to healthy eating included the high price of healthy foods (relative to income); the cost and inconvenience of transportation to well supplied and better-priced food outlets; language barriers between vendors in such outlets and study participants; the complexity of using food stamps at farmers' markets which recreated the stigma associated with the traditional paper format of food stamps; barriers to food assistance imposed by eligibility requirements related to immigration status; insufficient informal food assistance (e.g., food pantries) that could not guarantee either quantity or quality of foods; work conditions tied to precarious and low-paying employment that placed healthy eating out of participants' reach; and finally, competing basic needs and the sheer constraints of poverty, whereby participants were forced to choose among meeting their housing, nutritional, or other basic needs.
What is the danger of focusing on cultural difference?
It has been argued that when the focus of education is on cultural difference, there is a danger of reinforcing an ethnocentric approach to care and, in some cases, a paternalistic approach to health care provision
Why should nurses be aware of their own culture and biases?
It is argued by Erlen (1998) that to respect other cultures, the health professional must first recognise their own culture and any biases that may impact on their practice. As the literature on cultural sensitivity increases there is a growing consensus that health care professionals need to be aware of their own 'cultural beliefs, attitudes and feelings' (Duffy, 2001,p. 498) to facilitate their understanding of people who may be from a different background.
Why might a person be unaware that they have made a statement that is a microaggression?
Racism and other forms of discrimination have been embedded as part of American society on social, political, and economic levels Supporters of Arizona SB-1070 are likely to not consider themselves to be racist; in- stead, they genuinely believe that they have the best interests of the country in mind. However, the environment that is created when such legislation is enforced and supported may create feelings of discomfort, anger, sadness, and other negative emotionsThus, such discriminatory laws fit the criteria of environmental microaggressions.
Marxist Theory
Marxist --> Focus on Capitalist bourgeoisie (Upper Class - control means of production; 21st century see Increasing concentration of wealth in the richest layer of society) & Petty "bourgeoisie" (middle class) vs the Proletariat (working class - Sell labour time to capitalists • Labour time exploited to create profit in 21st century see Increasing number globally • More people working in factories than ever before.) Claims: The structure of capitalism rewards businesses for that most successfully reduce wages of the working class. • Profit motive - dangerous working conditions, insufficient resources for living. Social class not just a result of economic power. Social "honour" or status also important. Professions such as medicine have high status because of scarcity. Professions may practice social closure to limit entry into the profession, thereby increasing status.
Donnelly et al. argue that white privilege is invisible. What do they mean?
McIntosh (1989) likens White privilege to an "invisible weightless knapsack [full] of special provisions,
Men's health concerns
Men's -- Specific health issues related to sexual characteristics E.g. - Testicular cancer, prostate enlargement, etc that Predominantly impact men BUT - Not exclusive to men, also impact women e.g. - Transgender women can also have testicular cancer - Trans women with a prostate can have prostate enlargement and benefit from screening Overall men have a lower life expectancy than women - 80.5 years for men compared to 84.6 years for women - Leading causes of death preventable • coronary heart disease, lung cancer, suicide, vehicle accident BUT - Middle-class men can expect to live longer than the average man - Lower life expectancy predominantly among: • Men low SES • Men rural areas • Aboriginal men
What are the three kinds of microaggessions (p235.), and how are each described?
Microassaults are defined as the usage of explicit and intended derogations either verbally or nonverbally, as demonstrated through name-calling, avoidant behavior, or discriminatory actions toward the intended victim (Sue, Capodilupo, et al., 2007). For example, maliciously calling a person of Asian descent "Oriental" and telling a Latino person to "go back where you came from" are both forms of microassaults. Microinsults are often unconscious and are described as verbal or non- verbal communications that convey rudeness and insensitivity and demean a person's heritage or identity (Sue, Capodilupo, et al., 2007). For instance, when persons with disabilities are spoken to in a condescending tone or when women are told they aren't capable of something, subtle messages are sent that these individuals are inferior to the dominant group (i.e., able- bodied persons or men). Microinvalidations are also often unconscious and include communications that exclude, negate, or nullify the realities of individuals of oppressed groups (Sue, Capodilupo, et al., 2007). An example includes a white student telling a student of color that she or he complains about race too much. While seemingly innocuous, such a message indirectly invalidates the racial realities that the person of color faces on a regular basis.
Critiques of functionalist, interactionist & Marxist approaches
Page 7/30. Week 3 Pre Rdgs
Effects of Racial Microaggressions - Critical Race Theory
Racial Microaggressions: - Slowly sap the energy of the recipient • Cumulative effects are damaging - self doubt, frustration, isolation, reduced wellbeing - Health and mental health impacts - Exhausting - often left to question encounters • E.g. when the person raises a concern, telling them they are sensitive, or that you don't see colour, leaves them feeling as though their observation is in question (Sue et al., 2007)
Bourdieu
Social Position is determined by three main forms of capital (resources): • Economic (income, property) • Social (social connections) • Cultural (skills, credentials, style of speech) • Structural system of social relations ("field") • Habitus: how the system is structured, and the process by which it is expressed and continues. • Social groups or classes share the same "habitus" of different forms of economic, social and cultural capital
What is meant by the term social class?
Social class is a central concept in population health and a key structural determinant of health. Social class is taken as a marker of a person's socioeconomic position, which refers to a person's educational, income and occupational resources, and the status they hold based on these. Social class is often measured by 'Socio-Economic Status' (SES), which is a statistical measure of income, education and occupation level (Germov, 2014). Most studies that report on class inequalities use statistical data about SES. However, class is more than just SES measures. As Connell (1977, p.33) notes, class is also about culture, or 'lived reality'. It is about the day to day experiences of living and working, of shared values and life-styles, of accessing institutions for work, education or health, as well as style of speaking, social connections, and (for 'lower'- classes) the experience of marginalisation, discrimination and stigma (Germov, 2014, p.207). Social class has a direct impact on health. EG Working-class Australians are "worse off than people from more advantaged backgrounds... [with] substantially higher mortality and morbidity rates, but with poorer access to health services... [they are] more likely to experience high rates of recent illnesses, serious chronic illness and disability" (Gray, 2006, p.263). As Gray (2006) notes, "the poor health outcomes for working-class people are linked to factors such as 'poor living and working conditions', exposure to hazards at work, poor housing, lack of safety in poor areas, poor access to health services, financial constraints in regard to leisure and lifestyle choices, stress, lack of hope, and experiences of stigma and marginalisation (Germov, 2014; Gray, 2006). Power and resources are distributed unevenly in societies. --> Some groups have access to more resources than others •--> there is a hierarchy in how these resources are distributed •--> These different layers (or "strata") in this hierarchy are referred to social classes.
What are systemic stratifiers? Can you give examples?
Social stratification at its core is related to the 'unequal distribution of power, prestige and resources among groups in society' (Solar & Irwin, 2010, p. 20). It is described as systemic or structural since it operates via accepted social and cultural values and practices across established social institutions, including governments and public policy, media, legal and education systems, labour markets (including through hiring practices, workplace opportunities and workplace policies), families and health systems. This in turn impacts on downstream or 'intermediary determinants' of health, including material resources, psychosocial and behavioural factors. Material resources refers to access to income, housing, meaningful work, land, community safety and legal support, as well as access to health services and quality food. Social contexts, which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions. Social stratification in turn engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability. Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes per se).
Women's health concerns
Specific health issues related to sexual characteristics E.g. - breast and cervical cancers - Pregnancy and child birth • Promoting maternal health is top of WHO agenda • 810 women die every day during pregnancy and childbirth • Most maternal deaths are preventable • Etc. - Predominantly impact women BUT - Not exclusive to women, also impact men e.g. - Cisgender and transgender men can also have breast cancer - Trans men with a cer vix are susceptible to cer vical cancer and benefit from cervical screening Women Higher life expectancy than men, but higher burden of disease • 49% one or more chronic conditions • Coronary heart disease leading cause of total burden of disease: • Dementia leading cause of death - Intersecting health issue: Eg women who live in poverty have higher burden of disease. & EG health issues related to gender inequity - Maternal deaths: • Access to health services. Access to education and equitable income Etc. -- Coronary heart disease: • Research and treatment is male focused Also anoerexia and gender based violence Tackling underlying structural gender inequity are salient issues PHC and health
How does gender play out in health professions?
pay gap stereotypes overlooking/ignoring issues
How are notions of masculinity and femininity related to the health?
This gender stereotype has been consistently linked to psychological stress Gender discrimination Scientifically problematic and obstacle to scientific progress - Leads us to overlook social and political causes of gender inequity - Can dictate how people are treated - stereotypes about gender - Assumes men and women are natural, homogenous and binary categories Eg anorexia nervosa linked to emphasised femininity and stress hierarchy of masculinities impacts on all men
Why criticisms are there of the 'healthism' discourse?
The phenomenon of persistent blind spots in public discourses concerning diabetes and other health inequalities is consistent with the ideology of 'healthism', which, as Robert Crawford noted over 30 years ago, calls for individuals to take more responsibility for their health rather than rely on 'costly and inefficient' medical services. Then as now, this ideology is used to 'justify the retrenchment from rights and entitlements ...and to divert attention from the social causation of disease in the commercial and industrial sectors' (Crawford 1977, p. 663). Thus, the author concluded, personal behavior theories of disease causation precluded any social and economic reforms in the pursuit of health and enshrined the values of laissez-fair capitalism - they were a 'homage to middle-class life' (Tesh 1988). But however effective health education and lifestyle interventions might be for particular individuals, they will not slow down the diabetes pandemic. Addressing the latter requires changes in public policies guaranteeing basic needs, including but not limited to healthy food choices.
What is the structural framework of culture? How is this different?
The second approach incorporates culture within a wider, structural framework, focusing on social position to explain health status rather than on individual behaviours and beliefs. It includes perspectives on the impact of the colonial process on the ongoing relationships of Indigenous and non-Indigenous people and how this affects health and health care. The second approach is broader and focuses on the social position of individuals rather than behaviours and beliefs to explain health status. Derived from the work of postcolonial scholars, this approach has recently gained acceptance under the rubric of cultural safety. The concept of, cultural safety derived from the second approach to culture and practice has potential but evidence to show how it is being incorporated into practice is lacking and health professionals appear to be unclear about its meaning.
What does Connell (2012) mean by the gender order?
The structure of gender relations in a given society at a given time may be called its gender order; and the structure of gender relations in a given institution may be called its gender regime. Categorical thinking does not have a way of conceptualizing the dynamics of gender: that is, the historical processes in gender itself, the ways gender orders are created and gender inequalities are created and challenged.
What kinds of privileges do white people take for granted? How might white privilege play out in terms of access to health services and interventions?
Theory: Invisibility of Whiteness --McIntosh, 2004 Reading: Invisible knapsack-- - If I should need to move, I can be pretty sure of renting or purchasing housing in an area which I can afford, and in which I would want to live. - I can be pretty sure that my neighbours in such a location will be neutral or pleasant to me - I can turn on the television or open to the front page of the paper and see people of my ethnicity widely represented - I can arrange to protect my children most of the time from people who might not like them. - I can swear, or dress in second hand clothes, or not answer letters, without having people attribute these choices to the bad morals, the poverty or the illiteracy of my race - I can do well in a challenging situation without being called a credit to my race - I'm never asked to speak for all the people of my ethnic group
According to Williamson & Harrison (2010) what are the criticisms of focussing on the cognitive aspects of culture - values, beliefs and traditions (and assuming that all members of a cultural group hold these views)?
There are two main approaches to culture; the first focuses on the cognitive aspects of culture, the 'values, beliefs and traditions' of a particular group, identified by language or location such as, 'Chinese women' or 'Arabic speaking women'. This approach views culture as static and unchanging, and fails to account for diversity within groups. Most of the literature focuses on the cognitive aspects of culture and recommends learning about the culture of specific groups which is presumed to apply to everyone. This generic approach can, lead to stereotyping and a failure to identify the needs of the individual receiving car -- A criticism is that this approach fails to take into account broader social, political and economic factors which affect health and access to health care. Stereotyping of individuals may result.
McIntosh Embedded and Active forms of oppression
They take both active forms, which we can see, and embedded forms, which as a member of the dominant group one is taught not to see
Ethnicity
Usually refers to groups that share a common identity based ancestry, language or culture, or experiences of migration or colonisation • But: Ethnicity has no inherent social or biological reality, but is a classification system that has been constructed or for societal purposes.
How might nurses address upstream determinants of health for low SES groups?
Via health promotion activities. Nurses can also attend to intermediary issues such as improving access to nutrition, housing and health services to ensure that people impacted by health issues are not further disadvantaged. For example, health professionals can advocate for universal, free health services, as well as supporting people through collaborative patient self-management practices that attend to health and social issues e.g. access to work or financial support. Nurses also work with improvised communities to collaboratively design health services to ensure they meet local needs.
Why have people of colour been disproportionally impacted by Covid-19? What factors relate to access to healthcare and other intermediary determinants?
Vulnerability, and specifically vulnerability in health, is not equally distributed. It tends to be concentrated in areas where SDOH (for example, limited educational attainment, low socioeconomic status, unemployment, discrimination and structural racism) and the non- medical health- related social needs that result from these SDOH contribute to downstream adverse health outcomes (such as cancer, cardiovascular disease and obesity). With poor access to and low utilization of high- quality health care, those who are vulnerable are also medically underserved. Thus, the observed racial and ethnic disparities in COVID-19 cases, hospitalizations and deaths in the USA1 is a symptom of upstream systemic inequity
Australian class analysis
Week 3 Lec
CSDH Framework
Week 3 Pre Readings
How did Marx, Weber and Bourdieu conceptualise class?
Week 3 PreRdgs
What is meant by cultural safety in nursing?
When discussing the concept of cultural safety, Kirk- ham et al. (2002, p. 227) describe it as requiring 'a reconsideration of the disparate power relations within and beyond health care and the historical and social processes that organise these relationships'. Ramsden defined cultural safety as 'an outcome of nursing and midwifery education that enables safe service to be defined by those that receive the service Using the concept of cultural safety, nurses and midwives are encouraged to reflect and analyse how power relationships and history have impacted on the health of individuals. The goal of cultural safety is to provide care that is 'effective' and 'determined' by the individual (Spence, 2003, p. 224).
In the paper by Chaufan et al. (2012), one participant says that it is 'a full-time job being poor'. What do they mean?
Y (staff): You know, it's a full time job to be poor. For someone that, you know, immigration status isn't an issue, like say, lose their job, they have no savings, and they are living pay check to pay check. So then, they would come and say, let's apply for it all. And while we are waiting for your unemployment check to come, food stamps, and medical ...let's sign you up, we have a contact too with PG&E, to sign people up for the care program, which is a discount. --- barrier to healthy eating was the sheer constraints of poverty and competing basic needs. These competing needs often remained unmet, even in those cases in which clients were eligible for the range of means-tested social programs that they were able to sign up for with the assistance of NGO staff. Full time job - have to apply for help, go through programs, contact welfare etc and live paycheck to paycheck
How are services for battered women unintentionally oriented towards white women?
When invoking the Black community explanation, respondents rarely acknowledged that shelter location, ethnic composition of shelter staff and clients, or admissions policies might have discouraged Black women from seeking services. The othering implicit in assumptions that women of color are different and take care of their own is an important component of White privilege. The Black community explanation is not the only stereotype that is invoked. In service provision to battered women, as in many other areas of our society, there is the danger of seeing Black as synonymous with poor (Cole, 2001). Blacks are often also stereotyped as being more aggressive and more likely to use drugs and alcohol than Whites. This type of racial stereotyping was evident in the following response to a question on racial and ethnic tensions among shelter residents These (often contradictory) stereotypes create a double bind situation for Black women. When they use battered women's ser- vices, they risk being stereotyped as poor, aggressive, drug-using women and savvy manipulators trying to milk the system. Their needs may be seen as less real or urgent than those of White women. On the other hand, when they avoid the system, their ability to withstand violence is offered as an explanation, and they are assumed to have their own cultural resources for dealing with abuse. Either way, the end result is a lack of comprehensive outreach in their communities and a dearth of culturally compe- tent violence programming suited to their specific needs. Although they were trying to avoid racism, the respondents made implicit assumptions about women of color that often dis- advantaged these women. They talked at length about how women of color were different from White women, handled things in their own communities, and were not always in need of services from mainstream (i.e., White) agencies.
How did/does 'white privilege' occur?
White privilege is a system of benefits, advantages, and opportunities experienced by White persons in our society simply because of their skin color. the authors show how White privilege is intricately connected to executive directors' claims of color blind- ness, the othering of women of color, and viewing White as the norm. Whiteness has three dimensions: a structural advantage (racial privilege), a standpoint for viewing ourselves and others, and cultural practices that are unmarked or unnamed and thereby presumed to be normative.
What is the experience of Aboriginal Australian women whose Aboriginality was not recognised by health service providers?
assumed she was a white australian -- realise 'how easy she has it - easier to mingle and be seen as normal'
What is transcultural nursing? What are the problems with this approach?
concept of transcultural nursing as first depicted by Leininger (1988) in the United States. Leininger believed that people from a different cultural background to the care giver had different expectations; therefore nursing required a theoretical framework in which to provide suitable care. Leininger argues that transcultural nursing is: ...a formal area of study and practice focussed on comparative holistic cultural care, health, and illness patterns of people with respect to differences and similarities in their cultural values, beliefs, and lifeways with the goal to provide culturally congruent, competent, and compassionate care [original in italics] (Leininger, 1997, p. 342). Leininger (1997, p. 342) states that to provide appropriate transcultural nursing care, nurses must have an understanding of other cultures and look for culture specific 'symbols, expressions, and meaning of specific and diverse cultures' The theory is a holistic, culturally based care theory that incorporates broad humanistic dimensions about peo- ple in their cultural life context.
What civil rights are LGBTIQ+ people still denied?
for example, transsexualism was added as a disorder in the DSM in 1980, and gender identity disorder is still endorsed by both the American Psychiatric Association and American Psychological Association. In addition, at the time of this writing, LGBT people are allowed to get married in only five US states and Washington, DC (Human Rights Campaign, 2010), and some states have denied same-sex couples from adopting children. In addition, according to a report by the US General Accounting Office in 2004, same-sex couples are denied 1,138 benefits, rights, and protec- tions, which negatively impacts policies concerning Social Security, taxes, employee benefits, and medical care (Levitt et al., 2009). Furthermore, Title VII of the Civil Rights Act (1964) prohibits workplace discrimination based on sex, race, color, religion, and national origin, but it does not directly cover sexual orientation or gender identity (Berkley & Watt, 2006).
How are people from lower-classes blamed for health outcomes?
many health professionals adopt 'individualistic explanations' for the poor health outcomes among poor people and focus on downstream behavioural factors such as the lifestyles choices - e.g. the they maintain the belief that people who are in the lower-classes have bad health outcomes because they have poor management of exercise and diet, medication etc. (Germov, 2014). Therefore, health professionals often fail to acknowledge the impact of structural determinants of health on working-class people, and instead 'blame the victim' for their health situation. This may be compounded by a biomedical focus in health services, which ignores social factors and holds people responsible for health outcomes through the doctrine of 'regimen and control' and notions of compliance. In practice, this means that the most disadvantaged people in the Australian community are not only likely to become ill, they will also have the most trouble accessing services (due to financial and time constraints, fear of stigma etc.), and when they do access help they are more likely to be blamed for their health problem (discrimination), and in some instances treatment may even be withheld (exclusion).
According to Nadal et al. (2012) what is a microaggressions?
microaggressions- subtle forms of discrimination toward oppressed groups. Microaggressions are "brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that com- municate hostile, derogatory, or negative slights and insults toward members of oppressed groups" (Nadal, 2008, p. 23) Research has found that microag- gressions can occur in various settings and have detrimental impacts on the individuals who experience them
Why might Aboriginal Australian women not return to health services?
not knowing what to do and what happens culturally uncomfortable - health care services seen as white womens places
The author argues that health services reflect the historical, political, cultural, social and economic values, and power relations of society. What does she mean?
power is embedded within interactions and within place - health services built on dispossessed land and the dominate whiteness continues to affect healthcare interactions
What do the authors mean by the concept of 'othering' and how does this relate to racial stereotyping?
process of othering women of color, drawing on ste- reotypes to explain why they were different from White women and not in need of (or receptive to) services. The othering implicit in assumptions that women of color are different and take care of their own is an important component of White privilege. Although many executive directors assumed that we were asking about African American women when we asked about women of color, we found the process of othering at work when they mentioned Latina, Asian, and Native American women. As was the case with Black women, oftentimes, all women of a certain racial and ethnic group were assumed to be similar. Popular stereotypical images of the group were invoked, and within-group variation was ignored (Hamby, 2000).
What is the difference between the term social class and socio-economic status?
social class often measured by socio-economic status - proxies used to identify social class but not the social class itself
Explain the relationship between structural determinants of health and psychosocial wellbeing and health behaviours?
some upstream social determinants of health are 'structural', meaning they are the result of systemic patterns of social inequity that 'create social stratification [hierarchies] and assign individuals to different social positions' within those hierarchies (Solar & Irwin, 2010, p.5). The WHO 2010, 'Conceptual framework for action on the social determinants of health' (Figure A) identifies the most important structural determinants of health as socioeconomic status (class, income, education, occupation), race and gender (Solar & Irwin, 2010).
