(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: Paper Presentations
Session Language: English, French
Research Cluster Affiliation: Sociology of Health
Session Categories: Bilingual, In-person Session
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: Equality and Inequality, Health and Care, Policy
Organizers: Elena Neiterman, University of Waterloo, Michael Halpin, Dalhousie 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.
Anne Taillefer, Carleton University
The World Health Organization (WHO) has frequently addressed the issue of the crisis in healthcare systems around the world and the variation in legal and political situations resulting in a conjuncture where citizens do not have the same healthcare opportunities. In 2016, it put forward a model for developing the capacity of systems to respond to emerging and diverse health challenges. This approach, organized around the needs of individuals, recognizes their crucial role in shaping health policies and services. In 2018, with the Astana Declaration, the WHO proposed that Member states commit to applying the knowledge of unconventional medicines (UCM) - called by the WHO Traditional and Complementary Medicine - to enhance primary healthcare and guarantee access for all, while respecting their rights, needs, dignity and autonomy. Over 80% of the worlds population already uses some form of UCM, many of which are neither included in health systems nor regulated. This work draws jointly on two theoretical concepts: participatory democracy (PD) and epistemic justice (EJ). PD is a form of sharing and exercising power, based on strengthening citizens contribution to the definition and implementation of policies, with a concern for sovereignty over their well-being. EJ refers to the recognition and respect for the diversity of knowledges and practices, enabling people to take part in the production and transmission of knowledge. In the healthcare context, EJ may help to foster PD by amplifying and validating diverse voices and perspectives, rather than those of biomedical healthcare professionals alone. This work aims to illustrate how the interrelated theoretical concepts of PD and EJ may be expressed, engaged, and elaborated within a healthcare context to better meet the healthcare needs of populations. To do so, this study examines the case of the Fdration des Professionnles de la Confdration des Syndicats Nationaux (FP-CSN), a key player in Quebec civil society that has been involved through various initiatives in the social, political, and statutory recognition of UCM practitioners (acupuncturists, homeopaths, midwives, naturopaths, osteopaths) since 1987. Using a qualitative single case study approach and with reference to the aforementioned theoretical framework, this work critically analyzes archives, parliamentary commission journals of debate on the subject of UCM, and interview data (n=13) with leaders of associations of these practitioners and of the FP-CSN. Three key examples of the ways in which PD and EJ can be expressed within a healthcare context emerged from the dataset. 1) ADMISSION OF UMC PRACTITIONER GROUPS WITHIN A LARGE LABOR UNION: Remarkably, the FP-CSN (10,000 members from various sectors in health and social services, teachers, technicians, and one of the CSN's federations (300,000 members)), admitted the membership of UCM. It has openly constituted groups of these unlicensed practitioners, at risk of being charged with the illegal practice of medicine, as legitimate, autonomous and organized professional unions; 2) ADVOCACY FOR THE INCLUSION OF UCM PRACTITIONERS IN PUBLIC HEALTH INSURANCE AND COMPENSATION PROGRAMS: The FP-CSN advocated for the inclusion of these practitioners - whose knowledge is usually considered illegitimate in the public healthcare system - for the reimbursement of healthcare services provided (workers compensation, auto insurance); and, 3) ACTIVE REPRESENTATION OF UCM PRACTITIONERS WITHIN GOVERNMENT CONSULTATIONS: The FP-CSN actively participated in many government consultations (e.g., Parliamentary Commissions, the Office des professions du Qubec and the Health Commissioner) giving voice to the distinct perspectives and ongoing contributions of UCM practitioners to healthcare, outside of Quebecs publicly-funded health structures. The actions undertaken by the FP-CSN in favor of UCM associations, highlight its decades-long commitment in Quebec to MEDICAL PLURALISM, i.e., the cohabitation of knowledge and better access to these unconventional health practices. This role illustrates its contribution to the WHO model for universal, equitable, inclusive, and financially viable healthcare, which respects diversity, values citizen participation in collective decision-making and aims for social transformations linked to the development of inclusive policies. Overall, this study shows the necessity of EJ for implementing true PD in healthcare. More research is needed to understand specific mechanisms to better achieve this goal.
La démocratie participative en santé et la justice épistémique: étude de cas de la Fédération des Professionnèles - CSN et des médecines non conventionnelles
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