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CHARMAINE McPHERSON,

RN, PhD

ELIZABETH McGIBBON,

RN, PhD

JOSEPHINE ETOWA,RN, PhD

The social, economic and political

circumstances of individuals,

families, communities and

countries are closely related to their

health outcomes. Social determinants

of health (SDH) refers to the social,

economic, and political conditions that

influence health and well-being. Using

a social justice perspective, we make

a case for affirming health-care access

as an SDH. Equality and equity are

discussed, with an emphasis on their

relationship with oppression. Using

everyday clinical examples, we outline

the cycle of oppression that leads to

social injustice. We conclude with a call

to action for all nurses.

Health-CareAccess

ABSTRACTThe social determinants of health (SDH) are recognized as

important indicators of health and well-being. Health-care

services (primary, secondary, tertiary care) have not until

recently been considered an SDH. Inequities in access to

health care are changing this view. These inequities include

barriers faced by certain population groups at point of care,

such as the lack of cultural competence of health-care

providers. The authors show how a social justice perspective

can help nurses understand how to link inequities in access to

poorer health outcomes, and they call on nurses to break the

cycle of oppression that contributes to these inequities.

as a Social Determinant of Health

PEER-REVIEWED FEATURE

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The social determinants of health figure prominently in recent

national and international health policy documents and initiatives

(Canadian Nurses association [CNa], 2005; Wilkinson & Marmot,

2003). although most nurses are knowledgeable about the sDH,

how these determinants are linked to social injustice through

inequities in health-care access is not well understood.

The Public Health agency of Canada (2007) and other

stakeholders recognize health services as an sDH; however,

there has been little sustained attention to inequities in access to

health care and how they are linked to differences in morbidity

and mortality for various populations (Mcgibbon, in press).

Access refers not only to the availability of required services

but also to how the services are delivered at point of care (e.g.,

cultural competence of health-care providers). These inequities

play an important role in creating poorer health outcomes.

a discussion of inequities in health-care access from a social

justice perspective directs our attention to the ways in which

inequities are created and maintained. in the study of health

inequity, social justice refers to the ethical virtue of collective

responsibility for the fair and just distribution of the goods and

services of society (rawls, 1971). in this context, the measure of

a society is how it treats its most vulnerable citizens. in Canada,

poverty is the strongest determinant of health, and poverty rates

The social determinants of health

employment, unemployment and working conditions•

income and its equitable distribution•

food insecurity•

housing •

early childhood development•

education•

health care (primary, secondary, tertiary)•

social exclusion•

social safety nets•

identity (including gender, race, social class, •

dis(ability) and sexual orientation)

Adapted from The Toronto Charter for a Healthy Canada, 2003; R. Wilkinson & M. Marmot, 2003.

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in Canada, poverty is the strongest

determinant of health, and poverty rates have not improved over the

last two decades.

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have not improved over the last two

decades (raphael, 2007). a social justice

perspective prompts us to ask some

difficult questions:

Why do certain groups of people •

consistently live in poverty and have

poorer health outcomes, even when

biology and genetics are considered?

Why is there a higher suicide rate •

among lesbian, gay, bisexual and

transgendered adolescents (Kitts,

2005)?

if we all have the right to health care, •

as outlined in the Canada Health Act,

then why do inequities in access

exist?

Equality, equity and access to care. understanding the difference

between equality and equity is central

to this discussion. if we treat everyone

equally, we don’t install wheelchair

ramps, tailor health services for those

who are homeless, or provide health

interpreters for immigrant families.

Equity in health care refers to the fair

distribution of the goods, services and

opportunities necessary for physical,

psychological and spiritual health: “if

overall equity is to be achieved, each

individual’s needs must be met and every

individual must have the opportunity

to achieve full potential as a human

being” (CNa, 2006). accordingly, in the

design and implementation of health

care with equitable access, policy-

makers and practitioners must make

accommodations for the needs of

individuals, families and communities.

One of the reasons inequities in access

to care exist is the cycle of oppression

that operates throughout society.

Oppression and inequities in access to care. Figure 1 illustrates

the cycle of oppression that can be

seen in practice settings and in policy

decision-making. For example, consider

health-care access for social assistance

recipients. starting with biased

information about social assistance

recipients, practitioners may develop a

stereotype, such as the commonly held

belief that people receiving assistance

are lazy. in fact, the reasons for

unemployment among social assistance

recipients are multiple and complex.

These stereotyped views of clients

mean that practitioners may be missing

important contexts related to income,

transportation and access to employment

and child care when they are developing

care plans or making referrals.

stereotypes can lead us to think in

a particular way that demonstrates

prejudice. if we believe that people

receiving assistance are lazy, we may

think they don’t really want to work.

Then, when we act in a particular

way, based on our prejudice, we

are participating in discrimination.

When we treat people on social

assistance disrespectfully during a

nursing assessment, we are actively

discriminating. in this way, we are

contributing to lack of full access to

competent and compassionate health

care. When our discriminatory actions

are supported by systemic power within

the health-care system — for example,

when substandard intake assessments

aren’t challenged — oppression is

the result. The cycle of oppression

perpetuates policy-making that supports

social injustice. it is important to note

that biased information, stereotyping,

prejudice, discrimination and oppression

often happen without the perpetrators

noticing or acknowledging the problem.

The resulting social injustice is evidenced

in poorer health outcomes for a growing

number of Canadians.

Social injustice is bad for your health. People living in poverty, women,

seniors, people of colour and LgBT

people tend to have generally poorer

health outcomes. For example, women

around the world, and across all age

groups, have higher rates of depression

Figure 1: The cycle of oppression

Adapted from J. Etowa & E. McGibbon, 2003.

5. Oppression1. Biased information

2. stereotype

3. Prejudice

4. Discrimination

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Reflecting on social justice, the social determinants of health and inequities in access

Practice

Does my practice area offer education sessions on social justice, the •

sDH and inequities in access (e.g., the relationship between postnatal

outcomes and unemployment or between seniors’ health and the cost

of home heating)?

Do i routinely associate client “non-compliance” with the possibility that •

the client has no money for transportation or prescribed treatments?

is lack of action on my part a form of discrimination? •

Education

Do i incorporate social justice, the sDH, and inequities in access in my •

teaching of the specialty areas (e.g., the relationships between cardiac

outcomes, race, gender)?

Does my institution offer faculty training on social justice and health?•

is lack of action on my part a form of discrimination?•

Research

am i encouraged to ask research questions that address the issues of •

marginalized peoples?

What steps do i take to ensure diverse participants and perspectives are •

included in my sample?

Do i use appropriate research methods (e.g., participatory engagement) •

to study inequities in health care?

Management and Policy

Does my workplace implement policies that explicitly address social •

justice, the sDH and inequities in access? are these policies reviewed

regularly?

What happens when i apply the CNa social justice gauge (2006) to the •

policy documents of my workplace? Of my political party?

How does my political party perform on social justice issues such as •

child poverty and homelessness?

access to home care has been left out

of the national policy agenda, with grave

consequences for the health of many

vulnerable populations, including seniors

and chronically ill children (shamian, 2007).

geographic location can compound these

inequities. For example, registered nurses

studies have shown that certain groups of people do not have adequate access to health services because of discrimination based on their social class, race, ethnicity or sexual orientation.

than men (World Health Organization

[WHO], 2000). researchers have linked

women’s depression with poverty,

inequality and discrimination (Belle &

Doucet, 2003), as well as with family

violence and violence due to war and civil

unrest (WHO, 2000). aboriginal peoples

living on reserve have reported rates of

heart disease 16 per cent higher than

the overall Canadian rate, and aboriginal

women and men have life expectancies

4.8 and 8 years shorter, respectively,

than overall Canadian rates (indian and

Northern affairs Canada, 2003).

studies have shown that certain

groups of people do not have adequate

access to health services because of

discrimination based on their social

class, race, ethnicity or sexual orientation

(Fish, 2007; Karlsen & Nazroo, 2002).

Discrimination at point of care has been

documented as a significant barrier in

terms of black women’s access to health

services in Canada (Enang, 2002). in

the u.s., black women are less likely

to be diagnosed with cervical cancer

before third stage and are less likely

to have appropriate follow-up (akers,

Newmann, & smith, 2007). similarly,

african-american lung cancer patients

are less likely to receive chemotherapy

(Earle et al., 2000). Canada’s aboriginal

people and african-Canadians report

consistent barriers in accessing to care,

including racism among service providers

(Mcgibbon & Bassett, 2008).

caring for seniors in rural areas often

face challenges in connecting them with

appropriate health-care resources. People

living in rural, remote and fly-in communities

who have to travel to appointments with

specialists are subjected to an unfair

financial burden as well.

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REFERENCES akers, a.Y., Newmann, s.J., & smith, J.s. (2007). Factors underlying

disparities in cervical cancer incidence, screening, and treatment in the united states. Current Problems in Cancer, 31(3), 157-181.

Belle, D., & Doucet, J. (2003). Poverty, inequality, and discrimination as sources of depression among u.s. women. Psychology of Women Quarterly, 27(2), 101-113.

Canadian Nurses association. (2005). Social determinants of health and nursing: A summary of the issues [Backgrounder]. Ottawa, ON: author.

Canadian Nurses association. (2006). Social justice…a means to an end, an end in itself [Discussion paper]. Ottawa, ON: author.

Earle, C., Venditti, L., Neumann, P., gelber, r., Weinstein, M., Potosky, a. et al. (2000). Who gets chemotherapy for metastatic lung cancer? Chest, 117, 1239-1246.

Enang, J.E. (2002). Black women’s health: Health research relevant to black Nova scotians. in C. amaratunga (Ed.), race, ethnicity and women’s health (pp. 43-82). Halifax, Ns: Halcraft Printers.

Etowa, J., & Mcgibbon, E. (2003). Critical social science perspectives on racism and health. Paper presented at the Canadian association of schools of Nursing National Conference, Halifax, Ns, May 2003.

Fish, J. (2007). getting equal: The implications of new regulations to prohibit sexual orientation discrimination for health and social care. Diversity in Health and Social Care, 4(3), 221-228.

indian and Northern affairs Canada. (2003). Basic departmental data 2002. First Nations and Northern statistical section. Corporate information Management Directorate. Ottawa, ON: author.

Karlsen, s., & Nazroo, J. (2002). relation between racial discrimination,

social class, and health among ethnic minority groups. American Journal of Public Health, 92(4), 624-631.

Kitts, r.L. (2005). gay adolescents and suicide: understanding the association. Adolescence, 40(159), 621-628.

Mcgibbon, E. (in press). Health and health care: a human rights perspective. in D. raphael (Ed.), Social determinants of health: Canadian perspectives (2nd ed.). Toronto, ON: Canadian scholars’ Press.

Mcgibbon, E., & Bassett, r. (2008). Barriers in access to health services for rural Aboriginal and African Canadians: A scoping review. Preliminary report to Canadian institutes of Health research.

Public Health agency of Canada. (2001). What determines health? available from http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php

raphael, D. (2007). Poverty and policy in Canada: Implications for health and quality of life. Toronto, ON: Canadian scholars’ Press.

rawls, J. (1971). A theory of justice. Cambridge, Ma: Belknap Press of Harvard university Press.

shamian, J. (2007). Home care: The unfinished policy. Ottawa, ON: Victorian Order of Nurses.

Strengthening the social determinants of health: The Toronto Charter for a Healthy Canada. (2003). available from http://www.atkinson.yorku.ca/sHPM

Wilkinson, r., & Marmot, M. (2003). Social determinants of health: The solid facts (2nd ed.). Copenhagen: World Health Organization.

World Health Organization. (2000). Women’s mental health: An evidence based review. geneva: author. available from http://whqlibdoc.who.int/hq/2000/WHO_MsD_MDP_00.1.pdf

ELIZABETH McGIBBON, RN, PhD, is aN assOCiaTE PrOFEssOr iN THE

sCHOOL OF NursiNg, sT. FraNCis XaViEr uNiVErsiTY, aNTigONisH,

NOVa sCOTia.

JOSEPHINE ETOWA, RN, PhD, is aN assOCiaTE PrOFEssOr,

DaLHOusiE uNiVErsiTY, HaLiFaX, NOVa sCOTia.

CHARMAINE McPHERSON, RN, PhD, is aN assisTaNT PrOFEssOr iN

THE sCHOOL OF NursiNg, sT. FraNCis XaViEr uNiVErsiTY.

TAKING ACTION inequities in access are sustained through systemic, policy-

based oppression. Nurses are well positioned to build on the

profession’s solid historical roots of advocacy and political action

to break the cycle of oppression. social justice is a key aspect of

CNa’s core values and is considered to be a valid and achievable

policy goal (2006). Our challenge to all nurses is to act on the

clear connections between social injustice and health-care access

as a social determinant of health.

it is imperative that the nursing profession begins to routinely

incorporate social justice thinking in practice, education,

research, and management and policy. advocating for the

design and delivery of more equitable access to health care is

crucial. as the largest group of health professionals in Canada,

nurses have the power to promote and lobby for equity in the

health-care system. n

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