1. Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique Women’s Health in Nova Scotia Prepared for Atlantic Centre of Excellence for Women’s Health IWK, Halifax, 27 November, 2003

2. Five themes Practical utility of gender-based analysis Interactive nature of health determinants Additional women’s health indicators needed beyond usual population health indictors Data improvements and gaps - especially for diversity analysis Purpose = policy link = point to key social interventions to improve women’s health

3. Pop. health context: Romanow and the 3 burning health policy issues 1) How to treat the sick - supply side 2) How to improve the health of Canadians 3) How to check spiralling health care costs - demand side The next Royal Commission......

4. Practical: High portion of illness burden is preventable Excess Risk Factors Account for: 40% chronic disease incidence 50% chronic disease premature mortality 25% direct medical care costs 38% total burden of disease (includes direct and indirect costs)

5. 1) Descriptive: Women have distinct health needs. Causes / outcomes differ by gender 2) Normative: Ensure equal treatment, overcome biases that impede wellbeing 3) Practical: Blunt, across-board solutions often miss mark, waste money. Gender analysis allows policy makers to target health dollars Why a Gender Perspective

6. Practical: Women’s use of health services Canadian women have higher rates of: – chronic illness, physician visits – disability days, activity limitations – lower functional health status In every age group to 75, women more likely see physicians than men. Overall - 33% more likely; age 18-54 - 2-3x

7. Teen girls higher rates than boys Young women have 2x stress cf young men Surveys: young women say stress relief and weight loss = primary reasons for smoking Therefore programs, brochures, counselling targeted to girls more effective than blanket one-size-fits-all health warnings E.g., Teenage smoking

8. 1998 Federal Health Minister “I have undertaken to fully integrate gender-based analysis in all of my Department’s program and policy development work...” “...to enhance the sensitivity of the health system to women’s health issues...” “...more research...on the links between women’s health and their social and economic circumstances.”

9. 1) Income: What does it have to do with women’s health? Poverty most reliable predictor of poor health, premature death, disability: 4x more likely report fair or poor health Low income- higher risk smoking, obesity, physical inactivity, heart risk Costly: increased hospitalization: Women 15-39 = +62%; 40-64 = +92%

10. …health of single mothers Worse health status than married (NPHS); higher rates chronic illness, disability days, activity restrictions 3x health care practitioner use for mental, emotional reasons = costly Longer-term single mothers have particularly bad health (Statcan)

11. Low income children- at risk - 31 indicators More likely to have low birth weights, poor health, less nutritious foods Higher rates of hyperactivity, delayed vocabulary development, poorer employment prospects. Less organized sports, but higher injury rates, and 2x risk of death due to injury than children who are not poor.

12. Prevalence of low income- women and men -1997 & 2000

13. Prevalence of low income- women and men, Canada 1991-2000

14. Low-income children under 18, 1991-2000

15. Income: Female lone-parent families - 1997 & 2000

16. Trend: Low income rates of children: Single mother families --- 1994-2000

17. Employment of Female Lone Parents 1976-2001

18. Low Incomes : 1991-2000 Single mothers without paying jobs

19. The Economics of Single-Parenting Single mothers with pre-school children spend 12% income on child care cf 4% in 2-parent families. In one pocket......... CPI for child care, restaurant food rises faster than wages Robin Douthitt: “time poverty”. Full- time single mothers = 75 hour week

20. 2) Equity and health “What matters in determining mortality and health in a society is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.” ----- British Medical Journal 312, 1998

21. If Equality->Health, What are Trends? Average Disposable H’hold Income Ratios, 1980-98

22. GINI coefficient 1991-2000

23. Despite growing educational parity....

24. Gender wage gap remains unchanged in Canada - Ratio of Female to Male Hourly wages: 1997-2001

25. Wage inequality in Nova Scotia has remained the same - Ratio of Female to Male Hourly wages: 1998-2001

26. Explaining the gender wage gap Convergence of women’s hourly wages stalled…. despite clear educational gains. After controlling for hours worked, educational attainment, work experience, industry, occupation, and socio-demographic factors, StatsCan concluded that: … …“roughly one half to three quarters of the gender wage gap cannot be explained.” (Drolet, 2001)

27. Differences among Cdn women: Nova Scotia cf Canada: 1990 = $0.82 disp.income for $1 in Ontario. 1998 = $0.73 Financial Security Nova Scotia 1984: 2.1% of national wealth. 1999: 1.8% ““ (3.1% of Canadian Pop.)

28. Share of national wealth vs. population (1984 & 1999)

29. Wealth gap in Canada: Richest 10% own 53% of wealth Richest 50% own 94.4%, leaving 5.6% for poorest 50% Poorest ¼ of Canadians own 0.1% (or one-thousandth of wealth) Among poorest 20%, 1/3 fell behind 2+ months in bill, loan, rent, mortgage = Importance of diversity approach

30. Within Atlantic Canada: Richest 10% own 49% of wealth Richest 20% = 2/3 Richest 40% = 86% Poorest 60% have 14% of wealth Poorest 10% = “negative” wealth

31. 3) Employment- a key determinant of women’s health Issues: Both overwork and unemployment are stressful- (Japanese study) Polarization of work hours - increasing the level of inequality in family earnings. Women’s health - function of paid + unpaid work - gender division of labour in household Women doubled employment, BUT still do nearly two-thirds of household work.

32. % of Women and Men Employed Canada 1976-2001

33. In Atlantic Can. -higher % of employed are women

34. Women with young children - sharpest increase in employment, Since 1976:  women without children have increased their employment rate by 26%;  women with youngest child 6-15 by 62%;  women with youngest child 3-5 by 83%;  women with youngest child 0-2 by 124%

35. Employed women with children

36. But distribution is uneven - Employment and Education 75.4% of female university graduates have a job, cf 79.3% of male graduates. But… women with less than grade 9 are less than half as likely to be employed as males – 13.6% of women cf 29.4% of men Gender analysis not just m/f but diversity - sub-groups of women - esp. vulnerable

37. Women increased professional status - I.e. strong educational improvement

38. 75% of Halifax pop.25-29 graduated high school BUT

39. 60% of Halifax pop. 25-54 post-secondary grads BUT

40. Unemployment rate in Halifax = 7%

41. BUT.... Unemployment + underemployment

42. Youth unemployment 15-24 explains entire gender gap

43. Job security - and work options

44. Job security - temp work

45. Job security – union coverage (helps explain PEI equity)

46. High decision latitude at work - related to lower stress

47. 4) While f-t women work 39 hrs cf 43 - men, women still do most unpaid housework

48. Atlantic Canada: f/t employed women also work almost as many hours as men

49. Women still do bulk of unpaid housework

50. Employed mothers (f/t) work average 75-hr week - pd+unpd Statcan: Women moving to longer work hours: 4x likely smoke more, 2x likely drink more 40% more likely decrease physical activity 80% more likely have unhealthy weight gain 2.2x more likely experience major depressive episodes cf women on standard hours

51. Stress and health behaviours - smoking

52. More Nova Scotians report high stress % of pop. 18+, reporting “quite a lot” of life stress, 2001

53. Nova Scotia health regions with “quite a lot” of stress, 2001

54. Less stressful alternatives (societal vs individual solutions)

55. Social supports are important Social networks may play as important a role in protecting health, buffering against disease, and aiding recovery from illness as behavioural and lifestyle choices such as quitting smoking, losing weight, and exercising. – See: Mustard, J.F., & Frank, J. (1991).The Determinants of Health. (CIAR Publ. No. 5).

56. Social Supports: NS low in Atlantic region - those reporting high levels, over age 12, 2001

57. Key Social Supports- Volunteerism and Family Health Canada uses volunteerism as a key indicator of a “supportive social environment” that can enhance health. All four Atlantic provinces = highest rates of volunteer work in the country. More women than men volunteer

58. Volunteerism: Atlantic Provinces lead (formal rate)

59. But volunteerism has declined --here and nationally

60. Volunteerism rests on narrower base: Fewer volunteers - longer hours NS lost 30,000 volunteers 1997- 2000 Work hours of remaining volunteers up 32% So volunteer service hours increased 18% despite loss of volunteers - burnout danger

61. Family violence = key indicator of women’s health CIHI, Statcan identify crime as “non- medical determinant of health.” But women’s health analysis requires special indicators - family violence, like unpaid work, is key indicator. Family identified as key pillar of social support - determinant of health. But family violence may undermine social support, health

62. Family=high % of all violence Spousal violence = 18% of all violence reported to police. Women = 85% of all reported spousal abuse = 6x rate for men Nearly 1/3 of all reported female victims of violence in Canada attacked by spouse Unreported - much higher = 8% all women with partner attacked past 5 years.

63. Importance of diversity approach. E.g 1: Aboriginal women’s health Life expectancy = 76.2 cf 81 (non-Abor.) Higher rates hypertension, cervical cancer, circulatory & respiratory diseases Diabetes = 3x non-Abor. Fem = 2x male HIV/AIDS = 2x non-Abor. 50% female Abor AIDS cases = IV drug use cf 17% 9% Aboriginal mothers under 18 cf 1%

64. Aboriginal women’s health 3x mortality due to violence. 25-44 = 5x Alcohol-related accidents = 3x Fetal alcohol syndrome. Over 50% view alcohol abuse as problem in community 3x suicide rate cf non-Aborig. women

65. Eg2: Regional disparities require special attention / intervention E.g Cape Breton…. High unemployment and low-income rates, Much higher incidence of chronic illness, disability, and premature death than Halifax Highest age-standardized mortality rate in Maritimes Highest death rate from circulatory disease, heart disease in Maritimes – 30% above national average

66. Of 21 Atlantic health districts, Cape Breton has highest rates of: Cancer death (231.8 per 100,000) – 25% higher than the national average, lung cancer Deaths due to bronchitis, emphysema, and asthma (9.2 per 100,000) –50%+ higher than the national average High blood pressure– 21.7%, (24.3% women 19% men = 72% higher than the Canadian rate. The next highest rates are in south- southwest Nova Scotia

67. Cape Breton = highest: Arthritis and rheumatism: 31% of women, 23% of men Activity limitation (34%), followed by Colchester, Cumberland, and East Hants counties (30.1%) Life expectancy: 72.8 years for men, and 79.4 for women. (Canada: 75.4 years - men and 81.2 years -women

68. Disability-free life expectancy Cape Bretoners have an average disability-free life expectancy of only 61.8 years, seven fewer than the national average, and the lowest of all the 139 health regions in Canada. This means that Cape Bretoners can expect to live considerably more years with a disability than other Canadians.

69. Potential years of life lost highest number of potential years of life lost due to both cancer and circulatory diseases. Cape Bretoners lose 2,261.9 potential years of life per 100,000 population due to cancer – 41% higher than the national average of 1,603.7, and they lose 1,684 potential years of life per 100,000 population due to circulatory diseases – 65% higher than the national average of 1,020.7.

70. Women have generally healthier behaviours: NS: Women healthier diets. 5+ servings fruit/veg/day: F = 38.1%; M = 26.8% Daily smokers: F = 21.2%; M = 25.8% Physically Active: F = 23.4%; M = 18.5% Overwt (BMI 27+): F = 33.8%, M = 44.1% Obesity (BMI 30+): F = 19,3%, M = 22.7% Heavy drinking: F = 15.4%, M = 36.6% BUT...

71. But female smoking rates declined later and slower

72. Teen Smoking rates by Gender age 15-19, 1996 vs. 2001

73. Health behaviours vary regionally: NS high rates m/f: e.g.: % Overwt (BMI 27+), pop. 20-64, 2001

74. And within regions: eg Obesity (BMI=>30), NS regions, aged 20-64, 2001

75. Cape Breton, W. Nfld = low mammogram screening, high breast cancer death rate

76. The physical environment is an important determinant of health - Health Canada “At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments. Factors relating to housing, indoor air quality, and the design of communities and transportation systems can significantly influence our physical and psychological well-being.”

77. NS: 2nd-hand smoke exposure on most days in the last month, regions, 2001 2001

78. Access to Health care Women use more health care services than men, thus are disproportionately affected by barriers. Atlantic Canadians have greater difficulties accessing care than most other Canadians. The barriers result from less availability of key health care services in rural areas, rather than from longer waiting times.

79. In Sum: Women have distinct health issues.... that have social and economic roots Diversity approach –special needs of Aboriginals, disabled, minorities, recent immigrants, disadvantaged regions, etc. 3 interventions that can improve women’s health, save health costs: 1) reduce time-overwork stress 2) eliminate gender wage gap 3) reduce poverty of single parents

80. Can it be done?...1900s/1980s...

81. Improving women’s health today will benefit future generations of Nova Scotians

82. SOME ADDITIONAL SLIDES – NOT PART OF PRESENTATION The slides that follow were not part of the presentation – and include a few additional details on behavioural determinants of health

83. Women have generally healthier behaviours Women healthier diets. 5+ servings fruit/veg/day: F = 43%; M = 32% Daily smokers: F = 19%; M = 24% Overweight (BMI = 27+): F = 28%, M = 36% Obesity (BMI = 30+): F = 14%, M = 16% Heavy drinking: F = 11%, M = 28% BUT...

84. Behavioural pathways – Atlantic Canadians eat less f ruits and vegetables

85. % less than 5 servings of fruit and veg. per day, Nova Scotia, 2001

86. Alcohol consumption: % consuming 5+ drinks 12+ times/year (2001)

87. Nova Scotia: % consuming 5+ drinks 12+ times a year, (2001)

88. Tobacco: % of pop. who are current smokers 1985 and 2001

89. But female smoking rates declined later and slower

90. Smoking: % who are daily smokers (age 12 and over, 2001)

91. Nova Scotia- % of daily smokers by health district, 2001

92. More women physically inactive

93. Physically active or inactive. % of pop. (2000)

94. Nova Scotia % Physically active : by health district (2000)

95. % Overweight- aged 20-64, 2001

96. Nova Scotia: % of overweight men and women: (BMI=>27), aged 20-64, 2001

97. Obesity: increasing, NS men highest BMI=30+, 1994/95- 2000

98. Mammogram: Women, 50-69, routine screening within last two years, 2001

100. Cape Breton = lowest mammogram screening, highest breast cancer rate

101. Pap smear test % of women 18-59 years, 2001

103. The physical environment is an important determinant of health - Health Canada “At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments. Factors relating to housing, indoor air quality, and the design of communities and transportation systems can significantly influence our physical and psychological well-being.”

104. Second hand smoke: exposure on most days in the last month, 2001

105. Access to Health care Women use more health care services than men, thus are disproportionately affected by barriers. Atlantic Canadians have greater difficulties accessing care than most other Canadians. The barriers result from less availability of key health care services in rural areas, rather than from longer waiting times. Atlantic Canadians are generally highly satisfied with the quality of the health care services they receive.

106. In Sum: Women have distinct health issues.... that have social and economic roots 3 interventions that can improve women’s health, save health costs: 1) reduce time-overwork stress2) eliminate gender wage gap3) reduce single parent poverty Can it be done?......1900s/1980s.......

107. Improving women’s health today will benefit future generations of Nova Scotians