Gender,sexuality and the discursive representation of access and equity in health services literature: implications for LGBT communities

Background  

This article considers how health services access and equity documents represent the problem of access to health services and what the effects of that representation might be for lesbian, gay, bisexual and transgender (LGBT) communities. We conducted a critical discourse analysis on selected access and equity documents using a gender-based diversity framework as determined by two objectives: 1) to identify dominant and counter discourses in health services access and equity literature; and 2) to develop understanding of how particular discourses impact the inclusion, or not, of LGBT communities in health services access and equity frameworks.The analysis was conducted in response to public health and clinical research that has documented barriers to health services access for LGBT communities including institutionalized heterosexism, biphobia, and transphobia, invisibility and lack of health provider knowledge and comfort. The analysis was also conducted as the first step of exploring LGBT access issues in home care services for LGBT populations in Ontario, Canada.     

Human rights,transitional justice,public health and social reconstruction

Mass violence, armed conflict, genocide, and complex humanitarian emergencies continue to create major social and public health disasters at the dawn of the 21st Century. Transitional justice, a set of policies designed to address the effects of war on traumatized communities and bring justice, lies at the nexus of public health, conflict, and social reconstruction. Despite the paucity of empirical evidence, advocates of transitional justice have claimed that it can alleviate the effects of trauma, deter future violence, and bring about social reconstruction in war-affected communities. Empirical evidence – including new data and analyses presented in this article – suggests a link between trauma, mental health and attitudes towards and responses to transitional justice programs, but there has been little theoretical discussion about the intersection between public health and transitional justice, and even less empirical research to generate discussion between these two fields. Yet, public health professionals have an important role to play in assessing the impact of transitional justice on communities affected by mass violence. In this paper, we offer a conceptual model for future research that seeks to examine the relationship between transitional justice programs and their potential value to the fields of medicine and public health and discuss the methodological issues and challenges to a comprehensive evaluation of this relationship. To illustrate the discussion, we examine new data and analyses from two cases of contemporary conflicts, eastern Democratic Republic of Congo (DRC) and northern Uganda.     

Equity in public health standards: a qualitative document analysis of policies from two Canadian provinces

ABSTRACT: INTRODUCTION: Promoting health equity is a key goal of many public health systems. However, little isknown about how equity is conceptualized in such systems, particularly as standards ofpractice are established. As part of a larger study examining the renewal of public health intwo Canadian provinces, Ontario and British Columbia (BC), we undertook an analysis ofrelevant public health documents related to equity. The aim of this paper is to discuss howequity is considered within documents that outline standards for public health. METHODS: A research team consisting of policymakers and academics identified key documents relatedto the public health renewal process in each province. The documents were analyzed usingconstant comparative analysis to identify key themes related to the conceptualization andintegration of health equity as part of public health renewal in Ontario and BC. Documentswere coded inductively with higher levels of abstraction achieved through multiple readings.Sets of questions were developed to guide the analysis throughout the process. RESULTS: In both sets of provincial documents health inequities were defined in a similar fashion, as theconsequence of unfair or unjust structural conditions. Reducing health inequities was anexplicit goal of the public health renewal process. In Ontario, addressing "prioritypopulations" was used as a proxy term for health equity and the focus was on existingprograms. In BC, the incorporation of an equity lens enhanced the identification of healthinequities, with a particular emphasis on the social determinants of health. In both, prioritywas given to reducing barriers to public health services and to forming partnerships withother sectors to reduce health inequities. Limits to the accountability of public health toreduce health inequities were identified in both provinces. CONCLUSION: This study contributes to understanding how health equity is conceptualized and incorporatedinto standards for local public health. As reflected in their policies, both provinces haveembraced the importance of reducing health inequities. Both conceptualized this as rooted instructural injustices and the social determinants of health. Differences in theconceptualization of health equity likely reflect contextual influences on the public healthrenewal processes in each jurisdiction.     

High-frequency use of corrections,health, and social services,and association with mental illness and substance use

Background

A subgroup of individuals becomes entrenched in a “revolving door” involving corrections, health, and social welfare services. Little research has investigated the numbers of people that are in frequent contact with multiple public agencies, the costs associated with these encounters, or the characteristics of the people concerned. The present study used linked administrative data to examine offenders who were also very frequent users of health and social services. We investigated the magnitude and distribution of costs attributable to different categories of service for those in the top 10 % of sentences to either community or custodial settings. We hypothesized that the members of these subgroups would be significantly more likely to have substance use and other mental disorders than other members of the offender population.

Methods

Data were linked across agencies responsible for services to the entire population of British Columbia spanning justice, health, and income assistance. Individuals were eligible for inclusion in the study if they were sentenced at least once in the Vancouver Provincial Court between 2003 and 2012. We examined the subset of participants who fell within the top 10 % of sentences and at least two of the following service categories: community physician services; hospital days; pharmaceutical costs; or income assistance between 2007 and 2012. We examined two groups of offenders separately (those in the top ten percent sentenced to community supervision or to custody) due to differences in time at risk and availability to receive community-based services.

Results

From more than 14,000 offenders sentenced in Vancouver’s Downtown Eastside, very High Frequency service users associated with community (n = 216) and custody (n = 107) sentences incurred average attributable public service costs of $168,000 and $247,000 respectively over a 5-year period of observation. Health-related costs for both groups were over $80,000 per person, primarily associated with hospital admissions. Across both groups, 99 % had been diagnosed with at least one mental disorder and over 80 % had co-occurring substance use and another mental disorder.

Conclusions

A subset of offenders with concurrent psychiatric disorders receives extremely high levels of service from health, social welfare, and justice sectors in close temporal succession. Members of this subpopulation require targeted supports in order to produce positive outcomes and prevent the perpetuation of a costly and ineffective revolving door.

     

Policing ‘Vancouver’s mental health crisis’: a critical discourse analysis

In Canada and other western nations there has been an unprecedented expansion of criminal justice systems and a well documented increase in contact between people with mental illness with the police. Canadian police, especially in Vancouver, British Columbia (BC), have been increasingly at the forefront of discourse and regulation specific to mental health. Drawing on critical discourse analysis, this paper to explores this claim through a case study of four Vancouver Police Department (VPD) policy reports on ‘Vancouver’s mental health crisis’ from 2008 to 2013, which include recommendations for action. Analyzed is the VPD’s role in framing issues of mental health in one urban space. This study is the first analysis to critically examine the VPD reports on mental health in Vancouver, BC. The reports reproduce negative discourses about deinstitutionalization, mental illness and dangerousness that may contribute to further stigma and discrimination of persons with mental illness. Policing reports are widely drawn upon, thus critical analyses are particularly significant for policy-makers and public health professionals in and outside of Canada.     

Housing First the conversation: discourse,policy and the limits of the possible

Researchers, policy-makers, and political leaders in Canada and the US are championing the ‘Housing First’ (HF) intervention as a solution to homelessness. HF supplies people experiencing both homelessness and challenges around mental health with housing and a range of supports that can include case-coordination, psychiatry, and primary care. While HF’s impact on the housing status of individual participants has received considerable scientific and public consideration, less attention has been paid to its effects on societal conversations related to housing, public services, and social justice. We explore some of the impacts, not of HF the intervention, but of HF the conversation – the way public documents related to HF interact with broader discourses. Specifically, we examine the potential for this conversation to undermine the ultimate goal of ending homelessness in Canada. We conclude that positioning program interventions – no matter how important in the current context – as singular solutions to issues like homelessness or preventable chronic disease risks obscuring distal causes and marginalizing systemic responses.     

Social space, social class and Bourdieu: health inequalities in British Columbia, Canada

This article adopts Pierre Bourdieu's cultural-structuralist approach to conceptualizing and identifying social classes in social space and seeks to identify health effects of class in one Canadian province. Utilizing data from an original questionnaire survey of randomly selected adults from 25 communities in British Columbia, social (class) groupings defined by cultural tastes and dispositions, lifestyle practices, social background, educational capital, economic capital, social capital and occupational categories are presented in visual mappings of social space constructed by use of exploratory multiple correspondence analysis techniques. Indicators of physical and mental health are then situated within this social space, enabling speculations pertaining to health effects of social class in British Columbia.     

Writing social determinants into and out of cancer control: An assessment of policy practice

A large literature concurs that social determinants of health (SDH) are demonstrable, important, and insufficiently attended to in policy and practice. A resulting priority for research should be to determine how the social determinants of health can best be addressed. In this paper we support the more effective transfer of social determinants research into policy by: (1) describing a qualitative analysis of thirty-two cancer control policy documents from six English-speaking OECD countries and two transnational organizations, demonstrating great variability in the treatment of social determinants in these policies; (2) critiquing these various policy practices in relation to their likely impact on social determinants of health; and (3) advancing a tool that policy writers can use to assess the way in which social determinants of health have been addressed in their work. In the sample of policy documents, the distinction between structural and intermediate determinants, population-based and targeted interventions, and their respective relationships to equity were not always clear. The authors identified four approaches to social determinants (acknowledging SDH, auditing SDH, stating aims regarding SDH and setting out actions on SDH), and five ways of writing about the relationship between social determinants and cancer risk. These five discourses implied, respectively: that group membership was intrinsically risky; that not enough was known about SDH; that risk arose from choices made by individuals; that groups were constrained by circumstance; or that structural change was necessary. Socio-cultural factors were generally presented negatively, though New Zealand policies modeled a possible alternative. Based on their empirical work, the authors propose a matrix and a set of questions to guide the development and assessment of health policy.     

Caring,competence and professional identities in medical education

This paper considers the multiple discourses that influence medical education with a focus on the discourses of competence and caring. Discourses of competence are largely constituted through, and related to, biomedical and clinical issues whereas discourses of caring generally focus on social concerns. These discourses are not necessarily equal partners in the enterprise of medical education. Discourses of competence tend to be privileged while those discourses of caring are often marginalised. Medical students learn to be physicians, and develop professional identities, in the context of these competing discourses. This paper documents a qualitative study designed to explore how professional identities are developed in the context of competing discourses. The study included a Foucauldian discourse analysis of medical education curriculum documents (67 problem-based learning cases in total), 26 h of observation of a small group learning experience (a problem-based learning tutorial), and in-depth, open-ended interviews with five medical students and nine medical educators at a Canadian medical school. The paper describes how professional identities are developed in relation to discourses of competence, noting that students displayed what they considered to be desirable professional identities of confidence, capability and suitability. Also explored are the professional identities demonstrated in relation to discourses of caring, including those of benevolence and humbleness. Despite current conceptualisations, medical education is ripe with potential. The data indicate Foucauldian “spaces of freedom”—sites at which the complexity of the practice of medicine and the interwoven natures of the discourses of competence and caring might be taken into account as a means of challenging taken for granted cultural norms and broadening the medical gaze.     

Offloading social care responsibilities: recent experiences of local voluntary organisations in a remote urban centre in British Columbia, Canada

Services offered by voluntary organisations are an integral but often overlooked component of health and social care. Of late, there has been a renewed interest in voluntary welfare provision as a viable alternative to state and market. Recent developments in welfare provision in Canada appear to have brought greater social care roles for the voluntary sector at the same time as new and arguably more restrictive funding and accountability mechanisms are being imposed by different arms of the state. To explore these issues more closely, the present paper examines the impressions and experiences of voluntary and formal sector providers of services for senior citizens and people with disabilities in a remote urban centre (population less than 100 000) in the interior of British Columbia, Canada. Two important operational pressures provide the context of the analysis: (1) reform of provincial government funding and regulation of voluntary services; and (2) the restructuring of welfare provision, especially in the areas of health care and social services. The authors found evidence of an escalating incursion of the state into local voluntary sector affairs that needs to be understood in the context of long-standing institutional links between government and 'professional' voluntary welfare provision in British Columbia. The results point to three important directions in contemporary local voluntary provision: (1) an emerging ethos of accountability, efficiency and competition in voluntary provision; (2) increasing pressure to centralise volunteer services; and consequently, (3) the potential erosion of flexibility and personalisation that are seen to characterise the voluntary sector.     

The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC

The concept of social care is valuable in examining how responsibilities for social support are distributed amongst private, public and voluntary interests. We argue that social care is embedded in place, by which we mean the social relations that determine who provides what are closely connected with the physically bounded settings of meaning and interaction in which these activities and relations occur. To illustrate the usefulness of these conceptions, we present a case study of the restructuring of work and welfare arrangements in Mackenzie, British Columbia, a remote and resource-dependent community in the province's northern interior.     

Social and political factors influencing the functioning of regional health boards in British Columbia (Canada)

Health reform is associated with changes in the way the health system works and in the roles of major stakeholders, such as governments, health professionals, and the lay public. This paper reviews the immediate relevance of these social and political elements to health boards, particularly those with lay board members; source documents include peer-reviewed articles, and government documents and news releases in Canada especially. Also presented are the perceptions of 130 regional health board members in British Columbia (BC), Canada, who responded to our 1996 survey questionnaire. Two sets of social and political factors are identified and discussed in this paper. The first set deals with the composition of health board members (qualifications, representation, and selection). Our findings suggest that there is now less attention focusing on the composition of health boards in BC. This may contribute to a re-focusing of attention on the boards' effectiveness in working with stakeholders and in influencing the health system. The other set of social and political factors deals with the relations of health boards with key stakeholder groups. The responses to our questionnaire suggest that the health boards in BC may have had some success in addressing the concerns of various stakeholder groups. However, the respondents also suggested that the stakeholder groups needed to be more understanding and involved in the regionalization (decentralization) process. Health boards that have lay representatives, including regional health authorities in Canada, face similar social and political factors immediate to their operation.     

Discourses of joint commissioning

Increasing attention has focused on the role of joint commissioning in health and social care policy and practice in England. This paper provides an empirical examination of the three discourses of joint commissioning developed from an interpretative analysis of documents by Dickinson et al. (2013; BMC Health Services Research, 13) and applied to data from our study exploring the role of knowledge in commissioning in England. Based on interviews with 92 participants undertaken between 2011 and 2013, our analysis confirms that the three discourses of prevention or empowerment or efficiency are used by professionals from across health and social care organisations to frame their experiences of joint commissioning. However, contrary to Dickinson et al., we also demonstrate that commissioners and other stakeholders combine and trade off these different discourses in unexpected ways. Moreover, at sites where the service user experience was central to the commissioning process (joint commissioning as empowerment), a greater sense of agreement about commissioning decisions appeared to have been established even when the other discourses were also in play.     

Best research – For what? Best health – For whom? A critical exploration of primary care research using discourse analysis

Health research is fundamental to the development of improved health and healthcare. Despite its importance, and the role of policy in guiding the kind of research that gets addressed, there are very few empirical studies of health research policy. This paper redresses this, exploring the means by which one area of health research policy is shaped, enabled and constrained. We ask: what are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate; and what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we employed a Foucauldian approach to discourse analysis to explicitly recognise the historical, social and ideological origins of policy texts; and the role of power and knowledge in policy development. We adapted Parker's framework for distinguishing discourses as a means of selecting and analysing 29 key policy documents; 16 narrative interviews with historical and contemporary policy stakeholders; and additional contextual documents. Our analysis involved detailed deconstruction and linking across texts to reveal prevailing storylines, ideologies, power relations, and tensions. Findings show how powerful policy discourses shaped by historical and social forces influence the type of research undertaken, by whom and how. For instance, recent policy has been shaped by discourse associated with the knowledge-based economy that emphasises microscopic ‘discovery’, exploitation of information and the contribution of highly technological activities to ‘UK plc’ and has re-positioned primary care research as a strategic resource and ‘population laboratory’ for clinical research. Such insights challenge apolitical accounts of health research and reveal how health research serves particular interests.     

Provider arrangements for mental health services in 'The New NHS'

Mental health services in England, in common with many other European countries, have been the subject of sustained government attention during the 1990s. Since the election of the Labour administration in Britain in May 1997, mental health services have been discussed in most Department of Health documents on health and social care policy, and mental health services in England have a new national strategy. At the same time, the local provision of mental health services within NHS Trusts has been undergoing organisational change. This paper sets out the policy context and evidence base for the reorganisation of provider arrangements for mental health services. In addition, the results of a documentary analysis of unpublished reviews of provider arrangements in 10 localities are presented. The review identified three major themes: firstly, the reconfiguration of NHS Trusts is based around Specialist Mental Health Trusts and Community and Mental Health Trusts; secondly, the joint provision of services and/or the integration of services between health and social services is starting to appear and; thirdly, the delegation of responsibility to localities based on Primary Care Group/Social Services boundaries is being discussed. The paper discerns a number of trends and points to the need for further research, in particular into the relationship between organisational arrangements and effective service delivery.     

Chidren's Health Care: Brief Report. A Multidisciplinary Approach to the Role of Senior Therapist on a Child Psychiatry Unit

The function of "Senior Therapist" was developed by the social worker and the head nurse ar the Inpatient Child Psychiatry Unit of the British Columbia Children's Hospital The role of the Senior Therapist lead to a modification of the usual medicai model by involving other professionals in primary patient care, discharge planning, and follow-up services for the young patients and their families The program serves as a model of innovative clinical services.     

Putting Mental Health on the Agenda for HIV+ Women: A Review of Evidence from Sub-Saharan Africa

This article reviews the scientific literature regarding mental health services for poor HIV-infected women in sub-Saharan Africa and argues that they should constitute part of the healthcare agenda for these women. Key evidence points to the growing feminization of the HIV epidemic, as well as the differential social and economic impact of HIV on women. Further, HIV and poverty, both disproportionately affecting women, contribute independently and cumulatively to the risk for poor mental health. The limited empirical evidence regarding the mental health of this population is discussed. Multi-level psychosocial services, integrated within general health provision, are required to ensure long-term psychological benefits for HIV-infected women in the region.     

Wilp Wa'ums: colonial encounter, decolonization and medical care among the Nisga'a

The Nisga'a Nation of Northwestern British Columbia have been pioneers in the area of obtaining administrative control over health services. This would seem to mark the end of medical colonialism for this First Nation. But the author argues that health program devolution, in this case, was part of a longer tradition of incorporating aspects of non-Native medicine in a way that supported Nisga'a social structure. Nevertheless, the author argues that health program devolution is part of the process of decolonization since it has supported the traditional social structure, enhanced community self-esteem and provided an opportunity for the locus of control to shift from the medical profession and the federal government to Nisga'a people. This paper sets the development of Nisga'a-centered health care in a historical context that sees the Nisga'a exerting a resistive will in the context of medical colonialism in twentieth century British Columbia.     

Inquiry reports as active texts and their function in relation to professional practice in mental health

Inquiries into adverse events make a significant contribution to the way risk is understood in modern society and the reports they produce therefore represent an important textual development. Despite their importance, there have been few empirical studies to evaluate the impact of inquiry reports as documents, particularly with regard to their symbolic functions and their intertextuality with media accounts. This paper focuses on the function of homicide inquiry reports in mental health in the UK. Such reports have been significant because they are symptomatic of increased levels of anxiety associated with mental illness in post-community care society and also because they have served to exacerbate these anxieties. The paper draws upon social workers' accounts from an empirical study to demonstrate how reports have behaved as active documents in structuring social relations and responses to risk in mental health. The paper argues that inquiry reports in this field have taken on the status of modern allegories with powerful symbolic functions, through which they have actively reconstituted defensive practice among professionals. It is concluded that these findings are relevant in other fields such as medicine, where the wider impact of inquiry reports warrants closer attention.