The social determinants of health and health service access: an in depth study in four poor communities in Phnom Penh Cambodia

ABSTRACT: BACKGROUND: Increasing urbanization and population density, and persisting inequities in health outcomes across socioeconomic groupings have raised concerns internationally regarding the health of the urban poor. These concerns are also evident in Cambodia, which prompted the design of a study to identify and describe the main barriers to access to health services by the poor in the capital city, Phnom Penh.Sources and MethodsMain sources of data were through a household survey, followed by in-depth qualitative interviews with mothers, local authorities and health centre workers in four very poor communities in Phnom Penh.Main findingsDespite low incomes and education levels, the study communities have moderate levels of access to services for curative and preventive care. However, qualitative findings demonstrate that households contextualize poor health and health access in terms of their daily living conditions, particularly in relation to environmental conditions and social insecurity. The interactions of low education, poor living conditions and high food costs in the context of low and irregular incomes reinforce a pattern of "living from moment to moment" and results in a cycle of disadvantage and ill health in these communities. There were three main factors that put poor communities at a health disadvantage; these are the everyday living conditions of communities, social and economic inequality and the extent to which a society assesses and acts on inequities in their health care access. CONCLUSIONS: In order to improve access to health and health services for the urban poor, expansion of public health functions and capacities will be required, including building partnerships between health providers, municipal authorities and civil society.     

Culture, class, and service delivery: The politics of welfare reform and an urban bioethics Agenda

Conclusion  Culture and class remain contested terrains in policy narratives about the right of the urban poor to access health and social services delivery systems under welfare reform. An urban bioethics agenda is needed to address these dilemmas that have arisen in the context of PRWORA and had an impact on access to health and social services in the urban environment.^2;18 Such efforts, however, must address the intellectual framing of the urban poor, as well as the public policies that inscribe deterministic and stereotypical ideas about the poor alongside incomplete portraits of barriers to greater social and occupational mobility. The focus of social science researchers on the delineation of behavioral characteristics among an urban “underclass” in some instances further marginalizes and stigmatizes an already isolated urban poor. Even though Wilson, the Harvard sociologist who popularized the term “underclass” in his earlier research, has now largely disowned it, tales and stories a bound in the social policy and health literature. The media also commonly underscore perceptions that establish rumor as social science and promote stereotypes that the poor are lazy and unwilling to work. Wilson, who has analyzed contextual and neighborhood factors such as the migration of jobs to the suburbs, has also declared stance that is in opposition to those, such as New York University political science professor Lawrence Mead, who embrace a “culture of poverty” thesis and have set the tone for some welfare reform initiatives by arguing that behavior, and not joblessness, is the key, “My guess,” Mead stated after welfare reform was enacted in 1996, ”is that culture came first, and drove away the economy or the good jobs, rather than the other way around,” ^21(p3)These statements continue to have dramatic impacts on the stigmas attached to public programs by promoting the idea that those in spatially concentrated radical and ethnic groups in urban areas are not members of the working class. Such perceptions have also contributed to a belief that those who participate in publicly subsidized social welfare and health insurance programs do not work. Whether one accepts that the denial of health care to citizens and noncitizens in contemporary America derives in large part from the promotion of images of the poor as pathological, states have moved steadily to institute a variety of policies under welfare reform that continue to prescribe narrower eligibility criteria for access to service delivery systems. This is occurring as the US Congress hesitates to restore excluded populations, and there are reports of questionable practices targeted at those who are eligible based on current legislation. On several occasions, for example, the Civil Rights Division of the US Department of Health and Human Services has made inquiries (and issued sanctions) in cases for which state and local governments have discriminated against potential Medicaid and TANF applicants by ignoring regulations that stipulate that applications be delivered to applicants on request in a timely manner.³ While it is the explicit responsibility under welfare reform of the US Congress to pass legislation restoring eligibility to excluded populations, an urban bioethics agenda framed in a historical context has much to offer prevailing policy discourses. If, as political theorist Stone notes, a policy alternative is to be judged “by the company that it keeps,” then urban bioethicists can offer human rights paradigms and additional policy alternatives based an assessments of earlier historical experiences of stigmatization that embodied similar forms of evil.²³     

US opinions on health determinants and social policy as health policy

To examine what factors the public thinks are important determinants of health and whether social policy is viewed as health policy, we conducted a national telephone survey of 2791 US adults from November 2008 through February 2009. Respondents said that health behaviors and access to health care have very strong effects on health; they were less likely to report a very strong role for other social and economic factors. Respondents who recognized a stronger role for social determinants of health and who saw social policy as health policy were more likely to be older, women, non-White, and liberal, and to have less education, lower income, and fair/poor health. Increasing public knowledge about social determinants of health and mobilizing less advantaged groups may be useful in addressing broad determinants of health.     

Contextual effects on health care access among immigrants: Lessons from three ethnic communities in Hawaii

Immigrant health care is the product of the dynamic interaction between societal factors and the individual's socio-economic and cultural characteristics. Our knowledge about immigrant health care, however, has been limited to individual characteristics, without paying attention to the social context in which immigrants reside. This paper explores the effects of social contexts on access to health care among recent immigrants. As a natural experiment, it compares health care experiences of three immigrant groups in Hawaii – Filipinos, Koreans, and Marshallese – who are situated in different social contexts including immigrant health policy, ethnic community, and individual networks. Through household surveys conducted between October 2005 and January 2006, information of 378 recent immigrant adults on health care access, health insurance status, socio-demographic characteristics, linguistic and cultural factors, health status, ethnic community social capital, and social networks was obtained. The results of analyses show that Marshallese respondents have better access to health care than the other two groups, in spite of their lowest socioeconomic status. The high insurance rate of the Marshallese, mainly associated with a state health policy that provides health insurance assistance for the Marshallese, is the major contributor of their greater health care access. While Filipino immigrants do not benefit from state insurance assistance, high levels of health care resources and social capital within the Filipino community enable them to have significantly better health care access than Koreans, who have higher income and educational attainment. Interestingly, the advanced family/kinship networks are associated with better levels of immigrant health care access, while the increase of co-ethnic friend networks is related to lower access to health care. This study implies that restoration of immigrants' eligibility for public health insurance assistance, development of health care resources and social capital within ethnic communities, and mobilization of immigrant networks would be effective starting points to improve health care access among immigrants.     

Social capital, health, and Francophone minorities

The goal of this article is to outline the analytical perspectives of the concept of social capital regarding health and health management. Social capital, as defined in terms of social networks and resources, has a positive impact on a number of areas, notably the health, well-being, and social and economic development of communities. It is also a useful tool for implementing social policy, especially for marginal populations, the elderly, social assistance payments, etc. An action strategy based on the support and development of networks is the key to achieving the social development, health, and well-being of populations. The social ties promoted by these networks provide people with social, cognitive, and emotional support. This has a direct impact on their self-esteem and sense of personal achievement. They also facilitate access to social resources, including social advancement opportunities. In this paper, we examine the vitality, determinants of health, and health management of Canada's minority Francophone communities.     

Social capital and the third way in public health

The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. We review current hypotheses on the social capital and health link, and examine the empirical evidence available as well as its implications for health policy. With regard to theory, we contend that the construct as currently employed in the public health literature, lacks depth compared to its uses in social science. In addition, social capital presents itself as an alternative to materialist structural inequalities (class, gender and race) by bringing to the forefront of social epidemiology an appealing common sense idealist social psychology to which everyone can relate (e.g., good relations with your community are good for your health). The use of social capital invokes a romanticized view of communities without social conflict (e.g., Neo - Tocquevillian nineteenth century associationalism) and favours an idealist psychology over a psychology connected to both material resources and social structure. We argue that the evidence on social capital as a determinant of better health is still scant or ambiguous - depending on the definition that is used. Even if confirmed, social capital hypotheses call for social determinants beyond the proximal realm of social psychology. We also maintain that social capital is used in public health as an alternative to both state-centred economic redistribution (e.g., living wage, full employment, and universal health insurance) and party politics (e.g., gaining control of the executive branch of the government). Social capital represents a ' privatization ' of both economics and politics. Such uses of social capital mirror recent Third Way policies in Germany, UK and US. If Third Way policies end up losing support in Europe, its prominence there might be short lived. In the USA, where the working class is less likely to influence social policy, interest in social capital could be longer lived or, alternatively, could drift in the academic limbo like other psychosocial constructs which at one point were heralded as the next ' big idea '.     

Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context

Abstract

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.     

Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health

This review examined the interactions between the correctional system and the health of urban populations. Cities have more poor people, more people of color, and higher crime rates than suburban and rural areas; thus, urban populations are overrepresented in the nation's jails and prisons. As a result, US incarceration policies and programs have a disproportionate impact on urban communities, especially black and Latino ones. Health conditions that are overrepresented in incarcerated populations include substance abuse, human immunodeficiency virus (HIV) and other infectius diseases, perpetration and victimization by violence, mental illness, chronic disease, and reproductive health problems. Correctional systems have direct and indirect effects on health. Indirectly, they influence family structure, economic opportunities, political participation, and normative community values on sex, drugs, and violence. Current correctional policies also divert resources from other social needs. Correctional systems can have a direct effect on the health of urban populations by offering health care and health promotion in jails and prisons, by linking inmates to community services after release, and by assisting in the process of community reintegration. Specific recommendations for action and reseach to reduce the adverse health and social consequences of current incarceration policies are offered.     

Spatial and social determinants of urban health in low-, middle- and high-income countries

Urban populations around the world face increasingly common health problems. This is partly because of common spatial and socio-economic factors that result in substantial inequalities in health among urban populations. Spatial methods can now map out dimensions of urban living, such as the segregation of poor communities as a result of population concentration of poverty in deprived neighbourhoods. Even in rich countries such as the UK, separate from the health disadvantages of living in a poor neighbourhood, if you live in a neighbourhood that is surrounded by deprivation, you have a higher risk of mortality. However, neighbourhood deprivation is not synonymous with poor social capital. Some communities can be resilient to the health-damaging aspects of living in a poor neighbourhood if they have access to social support and other social ties.     

Epidemiology in the era of globalization: skills transfer or new skills?

BACKGROUND: Globalization carries information and technology opportunities and risks in widened inequalities, a resurgence of old health risks and reversal of health gains. METHODS: The paper explores the implications for epidemiological work in southern Africa and through two case studies-occupational health and equity in health-profiles challenges faced in that region. RESULTS: Occupational epidemiology is confronted by weak monitoring and regulatory systems, healthy worker effects, surveillance filters, and migration. Occupational disease determinants are masked by the combined effects of work, wider environmental risks, and high poverty-related disease. Health burdens associated with new production and trade patterns are thus largely unrecognized. Even when made visible, they may be ignored by economically vulnerable states and workers. Work on equity in health indicates the relevance of social and political determinants in the distribution of health resources. The shift of the cost burden of human immunodeficiency virus (HIV)/AIDS to poor communities and the weak public health response to HIV/AIDS suggest that economic and health reforms associated with globalization have both increased health inequalities and weakened social and political forces promoting equity and solidarity values in public health. CONCLUSIONS: Epidemiology can demystify disease sources and explain determinants in a manner that impacts on public policy and action. Under current conditions of globalization this implies addressing methodological challenges and enhancing uptake of evidence in policy processes. Given the intensifying political struggle around health resources, increased attention needs to be given to participatory forms of inquiry that strengthen the influence of poor communities and public interest values in health policy.     

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.     

Poverty,Housing, and the Rural Slum: Policies and the Production of Inequities,Past and Present

We studied historical materials to examine the conditions that gave rise to California''s rural slums, the consequences of their emergence, and how interpretations of housing, health, and welfare policies by government officials, and public health officials in particular, produced health inequities for residents of these communities. For more than a century, successive groups of immigrants and domestic migrant laborers have worked on California''s farms and faced numerous challenges, among them a lack of safe and affordable housing, poor working conditions, and denial of public services. Although these experiences are not new, nor are they unique to agricultural workers, they illustrate a longer history in which inequities and injustices have been rooted in the exploitation and disposability of labor. Ameliorating or even redressing inequities will require understanding the social determinants of health through ecological approaches that can overcome the historical, social, and political causes of inequity.FOR MORE THAN A CENTURY, waves of immigrants, predominantly non-White, have composed the agricultural workforce in California.1 By the early twentieth century, public health played a significant role in reinforcing constructions of race and class, particularly regarding immigrant populations.2 Nativist rhetoric often intertwined diseases with immigrants and reinforced the idea that immigrants threatened the health of the United States. In some cases, immigrants were excluded or were denied access to general assistance and health care services. In other cases, immigrants refused these services for fear of being deemed a public charge and running the risk of deportation.Although the 1937 California Welfare and Institutions Code formalized an obligation for local counties to provide access for general assistance and medical care for the indigent, regardless of an individual''s migration status, use of these services required proof of residency, which was at times an insurmountable burden for immigrants and domestic migrant agricultural workers who followed the crops.3 These requirements affected and depended on the ability to establish formal residency as well as where such residency was established.Rather than focusing on the history of immigration and public health in urban communities, we examined the impact of health and housing policies on populations in rural California.4 By documenting this history, particularly regarding housing and formal residency for agricultural laborers in rural areas in the post–World War II period, we sought to address an important gap at the intersection of labor and public health history and illustrate how the inequities agricultural workers experienced were embedded in differential treatment toward immigrants and the disposability of labor. Government officials and public health officials, in particular, participated in worsening the inequities through their application and interpretation of health and welfare policies.     

Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical,cost-effectiveness and health diplomacy considerations

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012–2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.     

Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics?

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as 'appropriate' or 'inappropriate'. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women. Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these 'inappropriate' facilities remained strong, graded and in the expected direction. Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, 'good' facilities should be given technical support and supplied with drugs and equipment.     

Social capital, disorganized communities, and the third way: understanding the retreat from structural inequalities in epidemiology and public health.

The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. The authors review current hypotheses on the social capital and health link, and examine the empirical evidence and its implications for health policy. The construct of social capital employed in the public health literature lacks depth compared with its uses in social science. It presents itself as an alternative to materialist structural inequalities (class, gender, and race) and invokes a romanticized view of communities without social conflict that favors an idealist psychology over a psychology connected to material resources and social structure. The evidence on social capital as a determinant of better health is scant or ambiguous. Even if confirmed, such hypotheses call for attention to social determinants beyond the proximal realm of individualized sociopsychological infrastructure. Social capital is used in public health as an alternative to both state-centered economic redistribution and party politics, and represents a potential privatization of both economics and politics. Such uses of social capital mirror recent "third way" policies in Germany, the United Kingdom, and United States. If third way policies lose support in Europe, the prominence of social capital there might be short lived. In the United States, where the working class is less likely to influence social policy, interest in social capital could be longer lived or could drift into academic limbo like other psychosocial constructs once heralded as the next big idea.     

Outpatient care utilization in urban Kerala, India

CONTEXT: Kerala is characterized by a high density of public and private health infrastructure. While less inequality in access has been reported in this Indian state, few studies have looked at problems found within cities. Escalation of costs of private services and reduced public investments could generate some inequalities in access for the poor. OBJECTIVE: To assess factors associated with utilization and source of outpatient care in urban Kerala, and to discuss policy implications with regards to access to care. METHODS: A multilevel analysis of individual and urban characteristics associated with utilization and source of outpatient care was conducted using data from a 1995-96 survey by the National Sample Survey Organisation on health care in urban Kerala. RESULTS: There is a high level of utilization (83.6%) of allopathic medical services. Controlling for illness severity and age, utilization thereof was lower for the very poor (OR 0.13 [0.03; 0.49]), inhabitants of medium towns (OR 0.20 [0.05; 0.70]), and inhabitants of cities with a lower proportion of permanent material (pucca) houses (0.21 [0.06; 0.72]). Among all users, 77% resorted to a private source of care. Utilization of a private provider was less likely for the very poor (OR 0.13 [0.03; 0.51]) and individuals from casual worker households (OR 0.54 [0.30; 0.97]), while it was more likely for inhabitants of cities from both low public bed density districts (OR 4.08 [1.05; 15.95]) and high private bed density districts (OR 5.83 [2.34; 14.53]). Problems of quality and accessibility of the public sector were invoked to justify utilization of private clinics. A marked heterogeneity in utilization of outpatient care was found between cities of various sizes and characteristics. CONCLUSION: This study confirms high utilization of private outpatient care in Kerala and suggests problems of access for the poorest. Even in a context of high public availability and considering the health transition factor, relying on the development of the private sector to respond to increasing health care needs could create inequalities in access. Investing in the public urban primary care system and ensuring access to quality health care for the poorest is warranted.     

Strategies to Reduce Exclusion among Populations Living in Urban Slum Settlements in Bangladesh

The health and rights of populations living in informal or slum settlements are key development issues of the twenty-first century. As of 2007, the majority of the world''s population lives in urban areas. More than one billion of these people, or one in three city-dwellers, live in inadequate housing with no or a few basic resources. In Bangladesh, urban slum settlements tend to be located in low-lying, flood-prone, poorly-drained areas, having limited formal garbage disposal and minimal access to safe water and sanitation. These areas are severely crowded, with 4–5 people living in houses of just over 100 sq feet. These conditions of high density of population and poor sanitation exacerbate the spread of diseases. People living in these areas experience social, economic and political exclusion, which bars them from society''s basic resources. This paper overviews policies and actions that impact the level of exclusion of people living in urban slum settlements in Bangladesh, with a focus on improving the health and rights of the urban poor. Despite some strategies adopted to ensure better access to water and health, overall, the country does not have a comprehensive policy for urban slum residents, and the situation remains bleak.Key words: Informal settlements, Social exclusion, Slums, Slum settlements, Urban health, Bangladesh     

Family, friend or foe? Critical reflections on the relevance and role of social capital in health promotion and community development

Social capital has been the focus of considerable academic and policy interest in recent years. Despite this interest, the concept remains undertheorized: there is an urgent need for a critical engagement with this literature that goes beyond summary. This paper lays a foundation for a critical dialogue between social capital and health promotion, by examining problematics in the conceptualization and practice of social capital building and linking these to models of community development, a cornerstone health promotion strategy. In so doing, the paper contributes to the existing literature by providing a theoretical exposition and critique of various threads in social capital discourse, and linking these threads explicitly to community development practice. Distinctions between communitarian, institutional and critical approaches to social capital are elaborated, and the relationships between these three approaches and three models of community development-social planning, locality development, and social action-are discussed. The existing social capital literature is then critically examined in relation to three key themes common to both literatures: community integration, public participation, and power relations. This examination suggests that social capital cannot be conceived in isolation from economic and political structures, since social connections are contingent on, and structured by, access to material resources. This runs counter to many current policy discourses, which focus on the importance of connection and cohesion without addressing fundamental inequities in access to resources. This paper posits that approaches to community development and social capital should emphasise the importance of a conscious concern with social justice. A construction of social capital which explicitly endorses the importance of transformative social engagement, while at the same time recognising the potential negative consequences of social capital development, could help community organizers build communities in ways that truly promote health.     

The political context of social inequalities and health

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980) -- social democratic, Christian democratic, liberal, and ex-fascist -- in four areas: (1) the main determinants of income inequalities, such as the overall distribution of income derived from capital versus labor, wage dispersion in the labor force, the redistributive effect of the welfare state, and the levels and types of employment/ unemployment; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families, such as child care and domiciliary care; and (4) the level of population health as measured by infant mortality rates. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations, such as reducing infant mortality. The erroneous assumption of a conflict between social equity and economic efficiency, as in the liberal tradition, is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities. The data used in the study are largely from OECD health data for 1997 and 1998; the OECD statistical services; the comparative welfare state data set assembled by Huber, Ragin and Stephens; and the US Bureau of Labor Statistics.     

Indigenous Peoples,settler colonialism,and access to health care in rural and northern Ontario

In Canada rural and northern communities, particularly Indigenous communities, face challenges disproportionate to their urban counterparts in accessing health care services. Existing health research on rural communities has tended to emphasize and reinforce the rural/urban dichotomy in access to and delivery of services, leaving the notion of “rural” as an under-interrogated concept. Drawing on a qualitative study of health care providers, community members, and Indigenous Elders, we explore Indigenous people's beliefs about vaccination to complicate notions of rurality in order to illuminate the ways in which space and settler colonialism both shape and limit choices around health care access.