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XALANX/MARGOT PETROWSKI/KUZMA/SHUTTERSTOCK

PEER-REVIEWED FEATURE

ELIZABETH
McGIBBON,
RN, PhD

JOSEPHINE
ETOWA,
RN, PhD

CHARMAINE
McPHERSON,
RN, PhD

Health-Care
Access

as a Social Determinant of Health

ABSTRACT
The 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.

he 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.

September 2008

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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.

Margot
Petrowski/SHUTTERSTOCK
Mikael
Damkier/Shutterstock

In Canada, poverty
is the strongest
determinant of health,
and poverty rates have
not improved over the
last two decades.

24

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?

Figure 1: The cycle of oppression

1. Biased Information
5. Oppression

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 dont 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
individuals 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, policymakers 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

2. Stereotype
4. Discrimination
3. Prejudice

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

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 dont 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
arent 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

September 2008

25

than men (World Health Organization

[WHO], 2000). Researchers have linked
womens 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 womens 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). Canadas aboriginal
people and African-Canadians report
consistent barriers in accessing to care,
including racism among service providers
(McGibbon & Bassett, 2008).

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.

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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

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.

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?

TAKING ACTION
Inequities in access are sustained through systemic, policybased oppression. Nurses are well positioned to build on the
professions solid historical roots of advocacy and political action
to break the cycle of oppression. Social justice is a key aspect of
CNAs 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
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.
Margot Petrowski/SHUTTERSTOCK

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