(HEA1c) Sociology of Medicine, Health, and Illness III: Expert, health professionals, and access to care
Wednesday Jun 19 1:30 pm to 3:00 pm (Eastern Daylight Time)
Trottier Building - ENGTR 2110
Session Code: HEA1c
Session Format: Présentations
Session Language: Anglais, français
Research Cluster Affiliation: Sociology of Health
Session Categories: Bilingue, Séances Sur Place
This session focuses on the theoretical, methodological, and empirical issues pertaining to the sociology of health and health care. Papers explore health inequities, individuals’ experiences of illness and/or interactions with health care services, intersections between work and health, health care professions, and organization of the health care system. Tags: Égalité et Inégalité, Politique, Santé et soin
Organizers: Elena Neiterman, University of Waterloo, Michael Halpin, Dalhousie University; Chair: Claudia Chaufan, York University
Presentations
Michael Slinger, University of Ottawa
The Many Faces of Mental Health: How Practitioners Enact Mental Health in Psychotherapy
In this paper, I explore how practitioners of psychotherapy enact or “do mental health”. I take a social constructionist approach to mental health and mental illness, seeking to understand how practitioners construct conceptualizations of “mental health” through the practice of psychotherapy. Despite psychotherapy’s growing popularity in recent decades, practitioners’ enactments of mental health remain poorly understood in both sociology and the clinical literature. While “mental illness” is defined through a combination of the Diagnostic and Statistical Manual (DSM-5-TR) and clinical training manuals, the concept of “mental health” is not articulated nor critically examined. Traditionally, the elimination of illness and disease was seen as the central goal of medicine, with many theorists—including Talcott Parsons, Erich Fromm, and Georges Canguilhem—arguing that “health” is primarily understood as an absence of symptoms. Several sociologists—notably Adele Clarke, Peter Conrad, and Nikolas Rose—have since challenged this view. These scholars argue that understandings of “health” have changed from the mid-1980s onwards, with patients, health care professionals, and governments increasingly orienting towards the optimization of well-being, evoked through concepts such as “flourishing” and being “better than well”. My paper builds on these theoretical frameworks, uncovering how practitioners enact “mental health” in their everyday work to examine whether psychotherapy conforms to the optimization trend observed in other areas of medicine. Using a grounded theory approach, I conducted 15 semi-structured interviews with two groups of practitioners in Ontario: clinical psychologists—who have completed a graduate program culminating in a PhD dissertation and year-long clinical internship—and MD psychotherapists—who have complete medical school, residency, and a year-long fellowship in medical psychotherapy. My investigation focused on how these practitioners attempt to produce changes in the patient’s condition—i.e., interventions—and evaluate when change has been successfully achieved—i.e., setting and monitoring goals. I argue that practitioners do not have a single, rigid enactment of mental health. Rather, practitioners flexibly enact four models of health—restoration, enhancement, management, and stabilization—with different patients at different points in therapy. Through restoration , practitioners aim to eliminate the patient’s symptoms and return them to “normal”. Practitioners alternatively define “normal” in reference to conformity to broader normative social roles or the patient’s personal values and sense of self, thus actively encouraging deviance or acting as agents of social control depending on the situation. Through enhancement , practitioners aim to improve patient well-being, often by attempting to enhance the patient’s social skills, mood, or sense of meaning. Through management , practitioners aim to maintain the gains made in therapy, teaching patients how to “become their own therapist” so they can stay healthy. Practitioners add a temporal dimension to health, encouraging extended self-surveillance to “treat” the patient’s susceptibility to imagined future symptoms and possible recurrences of mental illness. Finally, through stabilization , practitioners aim to prevent the patient from getting even worse, focusing on “stopping the bleeding”. Health is again seen as precarious, with practitioners seeking to reduce the patient’s potential for future dysfunction. However, the patient is still noticeably dysfunctional rather than “restored”, with practitioners considering that dysfunctional state a therapeutic success. In sum, enactments of mental health in psychotherapy are complex and context specific. Themes of enhancement and optimization do appear in psychotherapy, however, these practices are not recent additions but largely continuations of 1950s humanistic psychology. Furthermore, practitioners are often critical of optimization-oriented practices, preferentially enacting and endorsing other understandings of “mental health”. I propose that practitioners of psychotherapy are best thought of as possessing ambivalent attitudes towards the different enactments, alternatively endorsing and criticizing each approach depending on the patient and situation at hand.
The paper associated with this presentation has received the Sociology of Health Research Cluster's 2024 Best Student Paper Award.
Anne Taillefer, Carleton University
L'Organisation Mondiale de la Sant (OMS) a frquemment abord la question de la crise des systmes de sant travers le monde et la variation des situations lgales et politiques rsultant en une conjoncture o les citoyen.ne.s nont pas les mmes possibilits. Elle a mis de l'avant en 2016, un modle pour dvelopper la capacit des systmes justement rpondre aux dfis sanitaires mergents et varis. Cette dmarche, organise autour des besoins des individus, reconnait leur rle crucial dans llaboration des politiques et des services de sant. En 2018, avec la Dclaration D'Astana, l'OMS proposait aux tats membres de s'engager appliquer les connaissances des mdecines non conventionnelles (MNC) - qu'elle appelle mdecine traditionnelle et complmentaire - pour renforcer les soins de sant primaires et garantir leur accs pour tous.te.s dans le respect de leurs droits, leurs besoins, leur dignit et leur autonomie. Effectivement, plus de 80 % de la population mondiale a dj recours une forme de MNC, certaines ni incluses aux systmes de sant, ni rglementes. Ce travail sappuie sur deux concepts thoriques : la dmocratie participative (DP) et la justice pistmique (J). La DP est une forme de partage et dexercice du pouvoir fonde sur le renforcement de la contribution citoyenne la dfinition et la mise en uvre des politiques dans un souci de souverainet vis--vis leur bien-tre. La J fait rfrence la reconnaissance et au respect de la diversit des savoirs et des pratiques en permettant de prendre part la production et la transmission de connaissances. Dans le contexte des soins de sant, la J contribue favoriser la DP en validant des voix et des perspectives diverses, plutt qu'uniquement celles de la biomdecine. Il s'agit d'illustrer comment ces concepts interdpendants peuvent tre exprims et mobiliss dans un contexte de soins de sant afin de mieux rpondre aux besoins des populations. Pour cela, cette tude examine le cas de la Fdration des Professionnles de la Confdration des Syndicats Nationaux (FP-CSN), un acteur cl de la socit civile qubcoise qui a particip la reconnaissance sociale, politique et statutaire de praticien.ne.s des MNC (acupuncteur.trice.s, homopathes, ostopathes, naturopathes, sage-femmes) depuis 1987. En utilisant une approche qualitative dtude de cas et en se rfrant au cadre thorique susmentionn, ce travail analyse de manire critique des archives, des journaux de dbats de commissions parlementaires sur les MNC, et des donnes dentretiens (n=13) avec des leaders dassociations de ces praticien.ne.s et de la FP-CSN. Trois exemples cls sur la faon dont la DP et la J peuvent tre exprimes dans un contexte de soins de sant ont merg de lensemble des donnes. 1) ADMISSION DE GROUPES DE PRATICIEN.NE.S DE MNC AU SEIN DUN GRAND SYNDICAT DE TRAVAILLEUR.EUSE.S: tonnamment, la FP-CSN (10 000 membres de divers secteurs en sant et services sociaux, professeur.e.s, technicien.ne.s, et lune des fdrations de la CSN (300 000 membres)), a admis des MNC. Elle a ouvertement constitu des associations de ces praticien.ne.s non rglement.e.s, risquant dtre accus.e.s dexercice illgal de la mdecine, en tant que syndicats professionnels lgitimes, autonomes et organiss; 2) PLAIDOIRIE POUR LINCLUSION DE CES PRATICIEN.NE.S AUX PROGRAMMES PUBLICS DASSURANCE SANT ET D'INDEMNISATION: la FP-CSN plaide pour linclusion de ces praticien.ne.s - aux connaissances gnralement considres illgitimes dans le systme public de sant - dans le remboursement de soins (accident du travail, assurance-automobile); 3) REPRSENTATION ACTIVE DE CES PRATICIEN.NE.S DANS LES CONSULTATIONS GOUVERNEMENTALES: la FP-CSN a particip de nombreuses consultations (commissions parlementaires, Office des professions du Qubec, Commissaire la sant) en donnant une voix aux perspectives distinctes et aux contributions des praticien.ne.s de MNC aux soins de sant, en dehors des structures finances par ltat qubcois. Les actions entreprises par la FP-CSN au nom des associations de MNC, soulignent son engagement depuis des dcennies au Qubec en faveur du PLURALISME MDICAL, cest--dire la cohabitation des savoirs et un meilleur accs leurs praticien.ne.s. Ce rle illustre son apport au modle de lOMS pour des soins de sant universels, quitables, inclusifs et financirement viables, qui respectent la diversit, valorisent la participation des citoyen.ne.s aux dcisions collectives et visent des transformations sociales lies au dveloppement de politiques dinclusion. Cette tude dmontre la ncessit dune J pour mettre en uvre une vritable DP dans les soins de sant. Des recherches supplmentaires sont ncessaires pour comprendre les mcanismes spcifiques permettant d'atteindre cet objectif.
Ukeme Eka, Memorial University
Research has indicated that regular access to and utilization of dental care services are crucial to preventing and managing oral diseases (Mehra et al., 2019). For instance, regular utilization of dental care services has been found to improve mental and social well-being (Kisely, 2016; Zucoloto et al., 2016), while lack of use has been linked to several chronic diseases, such as diabetes, chronic lung disease, cardiovascular disease, and cancer (Linden et al., 2013). Werneck and colleagues found that the lack of publicly funded dental care insurance for adult Canadians contributed to the high prevalence of dental disease among immigrants (Werneck et al., 2008). Access to and using dental health care services is essential for optimal population well-being. There is a paucity of research on immigrants, but previous studies have indicated that Canadian immigrants have poorer oral health status than their Canadian-born counterparts (Calvasina et al., 2014; Mehra et al., 2019; Newbold and Patel, 2006). In particular, limited research exist on the dental care use of African immigrants in Canada. In this study, we use the Immigrant Health Services Utilization framework by Yang and Hwang (2016) to explore factors that facilitate or impede African immigrants use of dental health services in St. Johns, NL. To address the objectives of the study, data were collected between June and December 2020 from a cross-section of 272 African immigrants on their dental health access and usage. Complementary log–log regression models were used to examine factors influencing immigrants decision to seek dental health services considering Yang and Hwangs framework. Overall, 43.8% of African immigrants self-reported that they used dental health services in the past 12 months preceding the survey, while 35.7% indicated they had not used dental health services. Our findings demonstrated that socioeconomic variables are strongly associated with dental health services utilization. For instance, respondents’ personal income emerged as the most powerful determinant of dental care use. Immigrants who earned $55,000 and above were about 2 times more likely to use dental health services than those with incomes below this amount. These findings highlight socio-economic barriers to using dental care in NL among African immigrants and question the rationale for private insurance given its negative impact on dental health outcomes.
Non-presenting author: Eric Tenkorang, Memorial University
Monica Gagnon, University of Toronto
Recent Canadian immigration policy has led to an increase in the number of people living in Canada with precarious immigration status, who are disproportionately racialized as non-White, often lack health insurance, and experience discrimination in health care settings. In Ontario, health policy requires that coverage be provided to newborns even if the parents are not covered under the Ontario Health Insurance Plan (OHIP). A parent does not need to have an authorized immigration status in Canada for the baby to be eligible for OHIP as long as their primary place of residence is Ontario. Problematically, despite the fact that newborn citizen residents of the province are immediately eligible for health coverage, this policy is not consistently upheld in Ontario birthing hospitals. I used the concept of bordering to examine how people deemed outsiders to Canada are socially excluded within this health care context. Bordering practices filter people according to who is perceived to belong or not to belong, determining who is included or excluded, who is entitled or unentitled, and who is deserving or undeserving. I analyzed health policy documents and conducted interviews with health care providers, administrators, and researchers about processes of, and negotiations around, denial of OHIP registration. I found that newborns who meet OHIP eligibility requirements may be denied registration in Ontario hospitals due to gaps in provincial policy, restrictive institutional policies, or assessments of deservingness by frontline staff that are based on the parents’ immigration or insurance status. When a parent is without OHIP coverage, questions are raised about their child’s entitlement to OHIP. Hospital OHIP denials make it harder for a newborn to get health care, and some may end up going without coverage indefinitely. I theorize denial of OHIP registration to babies born in Ontario hospitals, and policies that allow for inconsistent application within and across hospitals, as bordering practices that allow gatekeepers to control access to membership and citizenship, differentiating between “us” and “them.” I show how bordering in Ontario health care happens at both the policy and administrative levels and I identify four mechanisms for how it is practiced at each level: omission, devolution, obfuscation, and intimidation. These mechanisms are sometimes practiced independently and sometimes overlap. In omission, the issue is not addressed, or no directive is provided. In devolution, power over decision-making is pushed to lower levels. In obfuscation, the policy is not clearly communicated or the source of the discrimination is obscured. In intimidation, a culture of fear is created, discouraging questioning or resistance. The negative effects of bordering practices in health care are evident in lack of health coverage for eligible newborns, arbitrary barriers to care, undue strain on uninsured parents and their advocates, discrimination and racial profiling in the health care system, stymied advocacy efforts, and the creation of tiers of citizenship. Ultimately, my research argues that unjust denial of access to health coverage threatens the realization of the right to health, marginalizing people deemed to be outsiders. In the context of increasing immigration to Canada, ensuring that the right to health of immigrants with precarious status is not undermined is of utmost importance.
Claudia Chaufan, York University
In April of 2020, the World Health Organization (WHO) released the report Managing the COVID-19 infodemic: A call to action, declaring that “the 2020 pandemic of Coronavirus disease (COVID-19) [had] been accompanied by a massive ‘infodemic.’” Soon afterwards UN Secretary General Antonio Guterres tweeted, also alluding to COVID-19, that “a tsunami of misinformation, scapegoating and scaremongering [had] been unleashed.” The tweet was followed by a March 2021 report from the Centre for Health Security at the Johns Hopkins Bloomberg School of Public Health, warning that “health-related misinformation and disinformation” were undermining the public response to COVID-19, and, about a year later, by a Department of Homeland Security infographic, Disinformation Stops With You , alerting about the “risks to democratic institutions” of “misinformation”, “disinformation”, and “malinformation” – dubbed MDM and conceptually including “infodemic” - distinguishing these terms based on the presumed intentionality of the agents producing or spreading them. These and similar calls to “manage” any form of discourse produced by individuals or groups skeptical of the “scientific consensus” are emerging from dominant social institutions, and have been paradigmatically captured in a recent report by the United Nations Educational, Scientific and Cultural Organization (UNESCO), dubbed Guidelines for the Governance of Digital Platforms , whose goal is to protect “free, high-quality, and independent media and information tools” to both safeguard “freedom of expression and the right to information” and control the “threat” of “dis- and misinformation, hate speech, and conspiracy theories.” As per UNESCO, this goal requires “a multistakeholder approach” including partnerships among governments, regulatory agencies, civil society, and digital media platforms. The ambitious nature of this goal notwithstanding, there has been scant critical examination within academia of what social and political institutions and actors spearheading these calls mean by MDM in the COVID-19 context, of the standards against which truth and falsehood of claims should be assessed, and of the implications of the premises underlying these meanings for public policy, equity, and civil, social, and political rights. Drawing from the traditions of critical policy, discourse, and document analysis, we critically review the literature produced by selected dominant social institutions – academic medicine, academic social sciences, and NGOs – by applying Arksey O’Malley’s scoping review framework, enhanced by Levac et al.’s team-based approach. We summarize, and appraise this literature systematically while assessing its implications for the health and well-being of populations affected by policies informed by dominant concepts of MDM. This presentation reports preliminary findings of our investigation.
Non-presenting authors: Camila Heredia, York University; Natalie Hemsing, York University; Jennifer McDonald, York University