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'Welfare Moms and Welfare Bums': Revisiting poverty as a social determinant of health
Colleen Reid
The Institute for Health Research and Education, Simon Fraser University, Burnaby, British Columbia, Canada
Carol Herbert
Faculty of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
Abstract
In the last two decades health researchers have paid increasing attention to the social determinants of health and health inequalities. Broadly, two hypotheses attempt to explain health inequalities - the materialist hypothesis and the psychosocial hypothesis.
The purpose of this study was to examine the relationship between poverty and women's health from the perspectives of a group of poor women. Our qualitative study with 20 diverse women on low-income included 32 one-on-one interviews, 15 group meetings, and 30 sets of field notes. We used the analysis program Atlas.ti to sort, code, and conduct a content analysis.
Overall, our findings revealed that both hypotheses were deeply connected with the dominant ideology of poverty and the concomitant social construction of 'welfare bum' and 'welfare mom'. Socioeconomic factors limited the women's access to health promoting resources and influenced their health behaviours (such as what they ate and how much they exercised). Ideologies that promulgated negative stereotypes legitimized the systemic barriers the women faced, enforced their material scarcity, and limited their entitlements to health-promoting services and resources.
Our findings also indicated that the stereotype led the women to feel shamed, stressed, and depressed, and to adopt negative health behaviors as a way of coping and finding comfort.
Keywords
women's health, health inequalities, social determinants of health, poverty, qualitative research, sociology
Article Text
In recent decades health researchers have moved from equating health with health care and individual behaviors, to analyzing the structural and social factors that influence health and wellbeing. Increasing attention is now given to social, economic, and political 'health risk factors' and how particular groups, most often defined by socioeconomic status (SES), suffer poorer health. In this paper we argue that dominant ideologies and stereotypes of poverty which construct poor women as deviant, dependent, and undeserving have a significant negative impact on women's health. Two research questions guided this analysis: (1) In what ways does the stereotype of 'poor woman' legitimize systemic discrimination and material scarcity, and how do these barriers affect poor women's health? and (2) In what ways does the stereotype affect poor women's self-perceptions, psychosocial health, and health behaviors?
Poverty and poor women in Canada
About two thirds of the world's women live in countries where per capita income is low, life expectancy is relatively short, class and gender inequalities in income and wealth are great, and few health and welfare services are provided by the state. Despite cultural heterogeneity, most of these countries share common experiences of colonialism and imperialism which have resulted in varying degrees of subordination within the world economic system (Doyal 1995). Poverty has been defined as a relative, multi-dimensional, and dynamic phenomenon, and can be understood in both absolute and relative terms in relation to 'need,' 'standard of living,' 'limited resources,' 'lack of basic security,' 'lack of entitlement,' 'multiple deprivation,' 'exclusion,' 'inequality,' 'class,' 'dependency,' and 'unacceptable hardship' (Krieger 2001). Poverty is also a gendered phenomenon - not only are more women than men likely to experience deprivation, but women's poverty is different from men's.
In Canada low-income refers to the Low Income Cut-offs (LICOs) identified by Statistics Canada. These cut-offs define low income in relative terms, based on the percentage of income that individuals and families spend on the basic needs of food, clothing, and shelter in comparison with other Canadians. Families and unattached individuals with low incomes usually spend more than 54.7% of their income on food, shelter, and clothing (Health Canada 1999). The LICO is a consistent and well-defined method that identifies those who are substantially worse off than the average. LICOs represent levels of income where people spend too much of their money for food, shelter and clothing, based on their family size and where they live (Landucci 2003).
In Canada there has been a significant reduction in welfare payments over the last 10 years. Between 1995 and September 2003 welfare rolls in British Columbia have been reduced by 54.2%, almost 34% of which occurred in the last three years, mainly due to newly imposed restrictions in eligibility (Ministry of Human Resources 2003). In all Canadian provinces welfare payments fall significantly short of the LICO. For instance, the total welfare income in 1998 for a single parent with one child ranged from a low of 50% of the LICO in Alberta to a high of 69% in Newfoundland (National Council of Welfare 2000b).
The poverty rate for women is higher than for men in every age group and disparity between socioeconomic groups is growing (Health Canada 1997). Lone-parent families headed by women have the highest incidence of poverty for all family types, a situation that has improved very little over the past decade, and older women are still more likely to be economically disadvantaged than their male counterparts. Lone mother families and women with disabilities in Canada have had 'remarkably consistent' experiences of poverty for as long as data has been available (Phipps 2003:8). Currently, almost 19% of adult women are living below the low income cutoffs - 41% of women over 65 and 56% of single mothers are low income (Health Canada 1997). In Canada the main causes of women's poverty are labor market inequities, domestic circumstances (marriage breakdown and motherhood), and welfare systems (National Council of Welfare 2000a; Ruspini 2001).
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The findings from this study have two important implications. Many health equality researchers contend that 'in order to decrease socioeconomic inequality, we need to reduce both the proportion of the population who fall behind, and the distance they fall behind' (Wilkinson 2000:267). According to Wilkinson (1996), the real solution is to identify more fundamental changes. Policies need to take aim at reducing the overall burden of disadvantage through tackling the structural sources of inequality. Economic management must aim to increase social cohesion and restore a public sphere that serves and supports poor and working-class adults and families. Policies must be developed to ensure access to educational, training and employment opportunities, particularly for single parents and people with disabilities. Even within a job-rich society there needs to be a public sphere that supports those who can't work, who haven't worked, and those eager to be educated (Fine and Weis 1998).
However, confronting the barriers that prevent poor women from accessing services and entitlements (such as discrimination and 'proving poverty'), is equally important. Legislation to protect the rights of marginalized and minority individuals, particularly concerning employment rights, welfare discrimination, and 'poor bashing', would improve conditions for women like those we interviewed. Institutional policies that condone (and in some cases rely on) discriminatory practices must be rectified so that poor women are treated with respect, consideration, and compassion. In other cases it is not the policy itself that needs to be changed, but how the policy is implemented. Being treated as 'liars' and 'cheats' often impedes the poor from accessing services or entitlements. In these cases training and awareness programs for staff and professionals are required. Importantly, some of the research participants recognized that welfare and health care workers were so overworked that the mistreatment they encountered was inevitable. Policies that support community workers, including the provision of additional personnel, smaller workloads, and increased work flexibility and support, would reduce the burden upon workers, allowing them time to care for the people they encounter.
Although low-income people, particularly women, are cut off from the ongoing economic growth enjoyed by most Canadians, 'most governments are not yet prepared to address these problems seriously, nor are they prepared to ensure a reasonable level of support for low-income people either inside or outside of the paid labour force' (National Council of Welfare 2000b: 145). Furthermore, attempts to recognize and do something about the social determinants of health are threatening to the status quo. Doing something about discrimination, stereotyping, and inequitable access to resources involves planned social and economic change (Becker 1986). Addressing these larger issues turns the concept of health into a battleground over rights and resources (Rootman and Raeburn 1994). The cultural changes required to address, and possibly improve poor women's health, require a fundamental societal shift towards valuing human development and all its potentials. Indeed, policy change does not drive social norms and cultural attitudes, rather, a shift in attitude will shape more humane, equitable, and health-promoting public policy.
The authors gratefully acknowledge funding received from the Social Sciences and Humanities Research Council (SSHRC) and the Michael Smith Foundation for Health Research (MSFHR).
References
Abood DA and Conway TL (1992) Health value and self-esteem as predictors of wellness behavior, Health Values 16(3): 20-26
BC Ministry of Human Resources (June 2 2002) Income assistance rates, Available: www.mhr.gov.bc.ca/factsheets/2002/iarates.htm
Becker MH (1986) The tyranny of health promotion, Public Health Review 14: 15-25.
Bloch C (1987) Female unemployment and knowledge of self, in PJ Pederson and R Lund (eds) Unemployment: Theory, Policy And Structure, New York NY: Walter de Gruter, pp.339-353.
Brunner E and Marmot M (2000) Social organization, stress, and health, in M Marmot and RG Wilkinson (eds) Social Determinants of Health, Oxford UK: Oxford University Press, pp.17-43.
Calnan M and Williams S (1991) Style of life and the salience of health: an exploratory study of health related practises in households from differing socio-economic circumstances, Sociology of Health and Illness 13(4): 506-529.
Crawford R (1980) Healthism and the medicalization of everyday life, International Journal of Health Services 10: 365-388.
Crawford R (1984) A cultural account of ‘health': control, release, and the social body, in JB McKinlay (ed) Issues in The Political Economy of Health Care, New York: Tavistock Publications, pp.60-103.
Denzin NK (1994) The art and politics of interpretation, in NK Denzin and YS Lincoln (eds) Handbook of Qualitative Research, Thousand Oaks CA: Sage, pp.500-515.
Doyal L (1995) What Makes Women Sick: Gender And The Political Economy Of Health, London UK: Macmillan.
Evans RG (2002) Interpreting And Addressing Inequalities In Health: From Black To Acheson To Blair To -? 7th Annual Lecture, London UK: Association of the British Pharmaceutical Industry; Office of Health Economics; Canadian Institute for Advanced Research.
Fine M and Weis L (1998) The Unknown City: The Lives of Poor and Working-Class Young Adults, Boston MA: Beacon.
Fraser N and Gordon L (1997) A genealogy of dependency: tracing a keyword of the US welfare state, in N Fraser (ed) Justice Interruptus: Critical Reflections on the 'Postsocialist' Condition, New York NY: Routledge, pp.121-149.
Gamble S (1999) The Routledge Critical Dictionary of Feminism and Postfeminism, New York NY: Routledge.
Graham H (1990) Behaving well: women's health behaviour in context, in H Roberts (ed) Women's Health Counts, London UK: Routledge, pp.195-219.
Greaves L (1996) Smoke Screen: Women's Smoking and Social Control, Halifax NS: Fernwood Publishing and Scarlet Press.
Health Canada (1997) Final Table June 26 1997: Determinants and Lifespan NDG (Table), Ottawa ON: Health Canada.
Health Canada (1999) Statistical Report on the Health of Canadians, Charlottetown PEI: Federal, Provincial, and Territorial Advisory Committee on Population Health.
Kelly DM (1996) Stigma stories: four discourses about teen mothers, welfare, and poverty, Youth and Society 27(4): 421-449.
Krieger N (2001) A glossary for social epidemiology, Journal of Epidemiology and Community Health 55(October): 693-700.
Krieger N and Zierler S (1995) Accounting for health of women, Current Issues in Public Health 1(1): 251-256.
Labonte R (2000) Health promotion and the common good: Toward a politics of practice, in D Callahan (ed) Promoting Healthy Behaviour: How Much Freedom? Whose Responsibility? Washington DC: Georgetown University Press, pp.95-115.
McDonough P and Walters V (2001) Gender and health: reassessing patterns and explanations, Social Science and Medicine 52: 547-559.
Miles MB and Huberman AM (1994) Qualitative Data Analysis: An Expanded Sourcebook 2nd edn, Thousand Oaks CA: Sage.
Ministry of Human Resources (2003) Monthly Statistics - Support Clients by Family Type, BC Statistics www.bcstats.gov.bc.ca
Minkler M (2000) Personal responsibility for health: Contexts and controversies, in D Callahan (ed) Promoting Healthy Behaviour: How Much Freedom? Whose Responsibility? Washington DC: Georgetown University Press, pp.1-22.
Morris W (ed) (1982) The Houghton Mifflin Canadian Dictionary of the English Language, Markham ON: Houghton Mifflin.
National Council of Welfare (2000a) Justice and the Poor: A National Council of Welfare Publication, Ottawa ON: Minister of Public Works and Government Services Canada.
National Council of Welfare (2000b) Poverty Profile, 1998, Ottawa ON: National Council of Welfare.
Phipps S (2003) The Impact of Poverty on Health: A Scan of Research Literature, Ottawa ON: Canadian Institute for Health Information.
Raphael D (2001) Inequality Is Bad For Our Hearts: Why Low Income And Social Exclusion Are Major Causes Of Heart Disease In Canada, Toronto ON: North York Heart Health Network.
Reid C (2004) The Wounds of Exclusion: Poverty, Women's Health, and Social Justice, Edmonton AB: The Qualitative Institute Press.
Reid C (2003) ‘We're not a part of society, we don't have a say': Exclusion as a determinant of poor women's health, in Segal M and Demos V (eds) Gender Perspectives on Health and Medicine: Key Themes. Advances in Gender Research Vol 7, Amsterdam NL: Elsevier Science, pp.227-275.
Repetti RL and Wood J (1997) Families accommodating to chronic stress: unintended and unnoticed processes, in Gottlieb BH (ed) Coping With Chronic Stress, New York NY: Plenum, pp.191-220.
Rootman I and Raeburn JM (1994) The concept of health, in A Pederson, M O'Neill and I Rootman (eds) Health Promotion In Canada: Provincial, National And International Perspectives, Toronto ON: WB Saunders, pp.56-71.
Ruspini E (2001) The study of women's deprivation: how to reveal the gender dimension of poverty, International Journal of Social Research Methodology 4(2): 101-118.
Ruzek S and Hill J (1986) Promoting women's health: redefining the knowledge base and strategies for change, Health Promotion 1(3): 301-309.
Ryan GW and Bernard R (2000) Data management and analysis methods, in NK Denzin and YS Lincoln (eds) Handbook of Qualitative Research 2nd edn, Thousand Oaks CA: Sage, pp.769-802.
Scheff TJ, Retzinger SM and Ryan MT (1989) Crime, violence, and self-esteem: review and proposals, in AM Mecca, NJ Smelser and J Vasconcellos (eds) The Social Importance Of Self-Esteem, Berkeley CA: University of Berkeley Press, pp.165-199.
Shaw M, Dorling D and Smith GD (2000) Poverty, social exclusion, and minorities, in M Marmot and RG Wilkinson (eds) Social Determinants Of Health, Oxford UK: Oxford University Press, pp.211-239.
Standing K (1998) Writing the voices of the less powerful: research on lone mothers, in J Ribbens and R Edwards (eds) Feminist Dilemmas in Qualitative Research: Public Knowledge And Private Lives, London UK: Sage, pp.186-202.
Statistics Canada (1996) 1996 Census Nation Tables Statistics, Canada. Available: www.statscan.ca/english.
Swanson J (2001) Poor-Bashing: The Politics Of Exclusion, Toronto ON: Between the Lines.
Wall NB (1993) The beautiful strength of my anger put to use, in L Carty (ed) And Still We Rise: Political Mobilizing In Contemporary Canada, Toronto ON: Women's Press, pp.279-298.
Walters V, Lenton R and Mckeary M (1995) Women's Health in the Context of Women's Lives (Report) Ottawa ON: Health Promotion Directorate, Health Canada.
Wendell S (1996) The Rejected Body: Feminist Philosophical Reflections On Disability, New York NY: Routledge.
White P, Young K and Gillett J (1995) Bodywork as a moral imperative: some critical notes on health and fitness, Society and Leisure 18(1): 159-182.
Wilkinson RG (1992) Income distribution and life expectancy, British Medical Journal 304(6820): 165-168.
Wilkinson RG (1996) Unhealthy Societies: The Afflictions of Inequality, London UK: Routledge.
Wilkinson RG (2000) Putting the picture together: prosperity, redistribution, health, and welfare, in M Marmot and RG Wilkinson (eds) Social Determinants Of Health, Oxford UK: Oxford University Press, pp.256-274.
Young IM (1990) Justice And The Politics Of Difference, Princeton NJ: Princeton University Press.
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