ILLUMINATING SOCIAL DETERMINANTS OF WOMEN'S HEALTH USING GROUNDED THEORY

Emphasis in health policy has shifted from curative intervention to prevention and health promotion through personal responsibility for lifestyle choices and, most recently, to the social determination of health. These shifts draw attention to and legitimize women's health research that moves beyond biomedical, epidemiological, and subjective knowledge to question previously unquestioned societal norms and structures that influence women's health. The challenge is to avoid relying solely on population-based studies that support relationships between social determinants and indicators of women's health and to find ways to illuminate the processes by which social determinants interact with the health of specific groups of women. Without such research, our knowledge of how social factors that underpin women's health interact will be faceless and will not address the interplay of health and social policy within women's lives. One research method that may be useful for exploring the interplay between such policies and women's health is grounded theory. Grounded theory is a widely used approach in women's health research. The goal of grounded theory is the discovery of dominant social and structural processes that account for most of the variation in behavior in a particular situation. Despite the usefulness of this method for capturing the interaction between social conditions and women's health experiences, many grounded theory researchers restrict themselves to women's subjective experiences as a source of data for theory development. Consequently, the resultant theory's capacity to illuminate the effects of the social determinants of health is limited. The purpose of this article is to discuss how the grounded theory method can be used in a participatory way to theoretically sample structural conditions at many levels. Using examples from completed and ongoing women's health research where data have and have not been collected primarily from women themselves, we outline the benefits and process for using grounded theory to influence health and public policy in women's health.     

The view from somewhere: locating lesbian experience in women's health

In some circles of nursing practice and research, "women's health" is seen to stand for "women's reproductive and heterosexual health." In this article we offer a view of women's health that makes central the contexualized reality of the material, social, and discursive experiences of women's lives. We suggest that the barriers to adopting broader conceptualizations of health are grounded in pervasive ideologies that privilege biology and a traditional model of health over nonmedical determinants of health. Lesbian disclosure is a central experience in lesbian life, and, as such, is seen as an exemplar of research questions that challenges our taken-for-granted ideologies and contextualizes women's health experiences.     

Precarious ordering: toward a formal theory of women's caring

Given the current societal and political trends toward increasing demands on women to provide care, a conceptualization of caring that captures the common processes of diverse women's caring experiences, and makes the consequences of caring for women's health visible, is critical for the development of a health and social policy that is responsive to women. The findings of this feminist grounded theory study go beyond the current theoretical understandings of women's caring, framed as either burden or fulfilment. The complex strategies women use to manage the dissonance created by competing and changing caring demands are revealed as a process I have named precarious ordering. This middle range theory demonstrates the power and resilience in women's management through the interdependent processes of setting boundaries, negotiating, and repatterning care. In addition, the method of theoretical sampling used in this study is explicated to move toward a formal theory applicable to diverse women's caring in a wide range of health, illness, and developmental situations.     

Understanding women's journey of recovering from anorexia nervosa

Previous studies of recovery from anorexia nervosa (AN) have concentrated on discrete behavioral responses of individual women. Little is understood about the subjective process of women's recovery in the context of family, community, or society. In this feminist grounded theory study, the authors explored the perceptions of 12 women who considered themselves recovered or recovering from AN. They discovered a substantive theory of self-development that explains, within the current social context, women's journey from the perilous self-soothing of devastating weight loss to the informed self-care of healthy eating and problem-solving practices. The findings provide an urgently needed explanatory framework to inform women, clinicians, and health policy makers in their prevention and recovery efforts.     

Using grounded theory to generate a theoretical understanding of the effects of child custody policy on women's health promotion in the context of intimate partner violence

Women's health is frequently influenced by social and structural factors, largely beyond women's control, and often entrenched in public policy. Although health is acknowledged to be socially determined, the ways that social conditions affect health are rarely explicated. Grounded theory is a useful method for discovering how structural conditions influence patterns of behavior. We used grounded theory to generate a theoretical understanding of how justice system policy and services related to child custody influence health promotion processes of women and their children after leaving abusive male partners/fathers. In two diverse Canadian provinces, we interviewed single mothers who had left abusive partners as well as frontline workers and policymakers in the justice system. We identified the key dimensions of policy and services that influence the ways in which women and their children promote their health in the context of varying levels of ongoing intrusion as information, eligibility, accessibility, timeliness, human resources, safety, and diversity. In this article, the interplay between theses policy and service dimensions and women's health promotion after leaving abusive partners is discussed and suggestions are made for strengthening "healthy" custody policy.     

The importance of symbolic interaction in grounded theory research on women's health

A variety of grounded theory studies are presented in this issue of Health Care for Women International that attend to different factors and situations impacting women's health. In this paper I will provide the basic principles of symbolic interactionism (SI) for the reader unfamiliar with the conceptual underpinnings of the grounded theory research method. I will discuss why SI is a fitting perspective for use in the study of women, women's perspectives, and women's health. I will conclude with a brief discussion of challenges to researchers maintaining the symbolic interaction perspective in grounded theory research.     

THE VIEW FROM SOMEWHERE: LOCATING LESBIAN EXPERIENCE IN WOMEN’S HEALTH

In some circles of nursing practice and research, “women’s health” is seen to stand for “women’s reproductive and heterosexual health.” In this article we offer a view of women’s health that makes central the contexualized reality of the material, social, and discursive experiences of women’s lives. We suggest that the barriers to adopting broader conceptualizations of health are grounded in pervasive ideologies that privilege biology and a traditional model of health over nonmedical determinants of health. Lesbian disclosure is a central experience in lesbian life, and, as such, is seen as an exemplar of research questions that challenges our taken-for-granted ideologies and contextualizes women’s health experiences.     

Contextualising experiences of depression in women from South Asian communities: a discursive approach

The aim of this paper is to present an interpretation of the accounts of depression provided by women from South Asian communities. The paper presents the findings from a qualitative study, conducted in the UK, which explored women from South Asian communities and their experiences of depression. It is argued here, through examples of women's accounts of their experiences, that depression is 'embodied', that is, grounded in the materiality of the body which is also immersed in subjective experiences and in the social context of women's lives. Qualitative data were collected from four focus groups and ten individual interviews with women. The analysis involved a discursive approach. Analysis revealed how women made strategic choices in how they presented their symptoms as legitimate and for gaining access to what they perceived to be appropriate healthcare. This is not to argue that this is a culturally specific phenomenon but one which is a feature of all healthcare negotiations.     

Women, menopause, and (Ms.)information: communication about the climacteric

This research utilizes a communication perspective to examine the dissemination of information about menopause in terms of women's attitudes, beliefs, and knowledge. Specifically, this study uses a grounded theory approach (Glaser & Strauss, 1967) to explore the communicative processes of misinformation concerning women's lived experiences in relation to the climacteric. Five emergent themes extracted from premenopausal, perimenopausal, and postmenopausal women's discourse are identified and described through qualitative data analysis. Findings suggest that due to a lack of consistent communication, women are generally either unknowledgeable or misinformed about menopause and its related issues. Inaccurate information concerning a health-related experience that all women undergo has negative implications for women, their practitioners, and society. Moreover, a clearer understanding of women's experiences concerning menopause may enhance communication in physician-patient interactions (PPIs).     

Exploring the promises of intersectionality for advancing women's health research

Women's health research strives to make change. It seeks to produce knowledge that promotes action on the variety of factors that affect women's lives and their health. As part of this general movement, important strides have been made to raise awareness of the health effects of sex and gender. The resultant base of knowledge has been used to inform health research, policy, and practice. Increasingly, however, the need to pay better attention to the inequities among women that are caused by racism, colonialism, ethnocentrism, heterosexism, and able-bodism, is confronting feminist health researchers and activists. Researchers are seeking new conceptual frameworks that can transform the design of research to produce knowledge that captures how systems of discrimination or subordination overlap and "articulate" with one another. An emerging paradigm for women's health research is intersectionality. Intersectionality places an explicit focus on differences among groups and seeks to illuminate various interacting social factors that affect human lives, including social locations, health status, and quality of life. This paper will draw on recently emerging intersectionality research in the Canadian women's health context in order to explore the promises and practical challenges of the processes involved in applying an intersectionality paradigm. We begin with a brief overview of why the need for an intersectionality approach has emerged within the context of women's health research and introduce current thinking about how intersectionality can inform and transform health research more broadly. We then highlight novel Canadian research that is grappling with the challenges in addressing issues of difference and diversity. In the analysis of these examples, we focus on a largely uninvestigated aspect of intersectionality research - the challenges involved in the process of initiating and developing such projects and, in particular, the meaning and significance of social locations for researchers and participants who utilize an intersectionality approach. The examples highlighted in the paper represent important shifts in the health field, demonstrating the potential of intersectionality for examining the social context of women's lives, as well as developing methods which elucidate power, create new knowledge, and have the potential to inform appropriate action to bring about positive social change.     

Meaning of healthy living for health users, professionals and managers

Qualitative research guided by grounded theory method that aimed to understand the meaning of healthy living in a community socially vulnerable for health users, professionals and managers. Data were collected through individual interview with 25 participants, among health users, professionals and managers. Data analysis was done in a comparative way according to grounded theory. For health users, healthy living is associated with basic living conditions, with inclusion opportunities and social participation and with interaction and associative possibilities; for health professionals, healthy living is related to political and social articulations; and for managers, it is related to the development of strategies that can reorient the current health model. We conclude that healthy living is a singular, plural and complex process that is built based on the imaginary and on the experiences of each human being.     

Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health

Gender-based inequalities in health have been frequently documented. This paper examines the extent to which these inequalities reflect the different social experiences and conditions of men's and women's lives. We address four specific questions. Are there gender differences in mental and physical health? What is the relative importance of the structural, behavioural and psychosocial determinants of health? Are the gender differences in health attributable to the differing structural (socio-economic, age, social support, family arrangement) context in which women and men live, and to their differential exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors? Are gender differences in health also attributable to gender differences in vulnerability to these structural, behavioural and psychosocial determinants of health? Multivariate analyses of Canadian National Population Health Survey data show gender differences in health (measured by self-rated health, functional health, chronic illness and distress). Social structural and psychosocial determinants of health are generally more important for women and behavioural determinants are generally more important for men. Gender differences in exposure to these forces contribute to inequalities in health between men and women, however, statistically significant inequalities remain after controlling for exposure. Gender-based health inequalities are further explained by differential vulnerabilities to social forces between men and women. Our findings suggest the value of models that include a wide range of health and health-determinant variables, and affirm the importance of looking more closely at gender differences in health.     

The disconnected self: consequences of abuse in a cohort of low-income white women living with HIV/AIDS

An infrequently acknowledged social factor influencing the health of low-income women is a history of physical/emotional abuse. In this article I address how abusive relationships influenced women's self-care practices. In this grounded theory study, vulnerability to abuse was established before diagnosis of HIV infection and promoted "lingering images" of a damaged self. The damaged self-images that grew out of abusive relationships provided a barrier to self-care. Data analysis uncovered a core category of disconnection from self-care. Experiences of being cared for, particularly the care of health professionals, offered supportive relationships that encouraged women to care for themselves through self-care practices.     

Older women and suntanning: the negotiation of health and appearance risks

This paper examines older women's experiences and perceptions of sunbathing, sun avoidance, and suntanned appearances. Using data from in-depth interviews with 36 women aged 71 to 94, we elucidate the motivations behind the women's sunbathing practices. Specifically, we explore how the women responded to the health and appearance risks associated with exposure to and avoidance of ultraviolet radiation as well as extant feminine beauty norms. The majority of women put their experiences of sunbathing in an emergent historical context. Although most of the women suggested that suntanned appearances were indicative of health and beauty, sunbathers tended to downplay their health risks by distancing themselves from those they considered to be most at risk, namely tanning bed users and individuals who acquired overly dark suntans. Sunbathers also emphasised the benefits of sun exposure for adequate vitamin D absorption. In contrast, the women who did not suntan tended to have experienced negative health and appearance consequences from their past sunbathing practices. Thus, these women emphasised the importance of future health over immediate appearance dividends. We discuss our findings in relation to the extant research on suntanning and the literature pertaining to health, risk, and beauty work.     

Position of The American Dietetic Association and Dietitians of Canada: Women''s Health and Nutrition

Within the past 10 years women's health has evolved to a much broader paradigm, beyond reproductive issues. From a physiological perspective, women's health now refers to the prevention, diagnosis, and management of conditions or diseases that may be unique to women, be more prevalent in women, or manifest differently in women than men. Women's health encompasses emotional, social, cultural, spiritual, and physical well-being. It is determined by the social, political, and economic context of women's lives. Nutrition is involved in the etiology or treatment of half of the 10 leading causes of death in women. The incidence of osteoporosis and extremes in body weight are approaching epidemic proportions in women. This position reviews the following health problems: cardiovascular disease, cancer, osteoporosis, weight, and diabetes mellitus. Dietetics professionals are in the perfect position to understand the issues surrounding women's health in order to deliver a message to women that will allow them to make wise decisions regarding their health. Nutrition is a critical component of risk reduction and treatment, and must be included in clinical and preventive services for women. Dietetics professionals must work to increase their knowledge about women's health issues, to promote health and education programs, to influence policy makers, to deliver the highest-quality medical nutrition therapy, and to be proactive in documenting the effectiveness of outcomes-based research.     

Determinants of rural women's health: a qualitative study in Southwest Ontario.

CONTEXT: The influences of gender and geography are increasingly being acknowledged as central to a comprehensive understanding of health. Since little research on rural women's health has been conducted, an in-depth qualitative approach is necessary to gain a better initial understanding of this population. PURPOSE: To explore the determinants of health and their influence on rural women's health. METHODS: From November 2004 to September 2005, 9 focus groups and 3 individual interviews were conducted in 7 rural southwestern Ontario communities. Sixty-five rural residents aged 26 years and older participated in the study. Semi-structured interview questions were used to elicit participants' perceptions regarding determinants of rural women's health. FINDINGS: Four Health Canada determinants (employment, gender, health services, and social environments) and 3 new determinants (rural change, rural culture, and rural pride) emerged as key to rural women's health. CONCLUSIONS: Although health determinants affect both urban and rural people, this qualitative study revealed that rural women experience health determinants in unique ways and that rural residents may indeed have determinants of their health that are particular to them. More research is needed to explore the nature and effects of determinants of health for rural residents in general, and rural women in particular.     

艾滋病与妇女健康

分析艾滋病对妇女预期寿命造成的影响,指出艾滋病其产生原因和成为一些国家主要疾病负担来源及社会经济发展的主要障碍之一,同时也论证了社会和经济等因素是目前造成女性艾滋病感染快速增长的重要原因。