Evaluate strategies that will reform health policymaking, delivery and financing in the Australian health care system (ACU Graduate Attributes: 2, 6)

Evaluate strategies that will reform health policymaking, delivery and financing in the Australian health care system (ACU Graduate Attributes: 2, 6)

Description: This unit provides the opportunity for students to analyse issues that relate to policy development, planning and implementation in health care service delivery in Australia. Using a social justice and equity framework, there is a special focus on evaluating policies that impact on the health of disadvantaged people, as well as on strategies that will reform policymaking, delivery and financing of health care in Australia.

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The Master?s degree course is a professional program that requires development of particular attributes for accreditation purposes. These are also included in the Learning Outcomes.

On successful completion of this unit, you should be able to:

1. analyse critically relevant issues that relate to public and private interests for different levels of government in Australia using a policy analysis perspective (ACU Graduate Attributes: 2, 4).

2. evaluate contemporary Australian policies that influence aspects of health service delivery impacting on the financial burden of illness (ACU Graduate Attributes: 1, 2);

3. evaluate current policies impacting upon the regulated and unregulated workforce and unpaid health care providers in Australia.(ACU Graduate Attribute: 5);

4. appraise and reflect upon health policies that influence disadvantaged groups in Australia using a social justice and equity perspective (ACU Graduate Attributes: 1, 2, 3, 4, 5);

5. Evaluate strategies that will reform health policymaking, delivery and financing in the Australian health care system (ACU Graduate Attributes: 2, 6)


On successful completion of this unit, you should have developed your ability to:

GA1 demonstrate respect for the dignity of each individual and for human diversity

GA2 recognise your responsibility to the common good, the environment and society

GA3 apply ethical perspectives in informed decision making

GA4 think critically and reflectively

GA5 demonstrate values, knowledge, skills and attitudes appropriate to the discipline and/or


GA6 solve problems in a variety of settings taking local and international perspectives into



Weighting Learning Graduate

Assessment tasks Due date outcome/s Attributes
assessed assessed

Reflective Essay Friday, 09/09/16, 6pm 30% 1, 4 1, 2, 3, 4, 5
1,500 words

ASSESSMENT TASK 1: REFLECTIVE ESSAY: Please select ONE of the following topics:

This is an individual assessment. Students must not collude with each other.

TOPIC 1: Provide a reflective essay outlining your learning experience/s in relation to how different levels of government in Australia influence health care. In your summary, reflect on and evaluate at least two major problems that result from the current distribution of responsibilities between the Australian government and the State/Territory governments.



Using a social justice and equity perspective, reflect upon why there has been a recent trend in government policy for greater application of user charges in some areas of health care. In your reflection, outline the advantages and disadvantages of this policy trend and the implications for disadvantaged population groups.


Weighting: 30%

Length and/or format: 1500 words

Purpose: The purpose of this essay is to demonstrate the student?s ability to

understand and critically analyse public policy that may include

contemporary policies that impact on aspects of health service.

Learning outcomes assessed: 1, 4

Assessment criteria: Please refer to the relevant marking criteria for Assessment Task 1,

attached to this Unit Outline.

Whichever topic you choose, you will need to access at least six (6) peer-reviewed journal articles, as well as textbook/s to help you deepen and expand your reflections for this assessment task.

All students should ensure that they have retained a copy of their assessments before submission.


Required text

Palmer, G., & Short, S. (2014). Health care and public policy: An Australian analysis (5th ed.). South Yarra, Melbourne: Palgrave Macmillan

Recommended references

Burbank, V. K. (2011). An ethnography of stress: The social determinants of health in aboriginal Australia (1st ed.). Basinstoke, UK: Palgrave Macmillan.

Duckett, S., & Willcox, S. (2011). The Australian health care system (4th ed.). South Melbourne: Oxford University Press.

Fleming, M. L. & Parker, E. (2012). Introduction to public health (2nd ed.). Retrieved from http://site.ebrary.com.ezproxy2.acu.edu.au/lib/australiancathu/docDetail.action?docID=10537463/

Keleher, H., & MacDougall, C. (Eds.). (2011). Understanding health: A determinants approach (3rd ed.). South Melbourne, Vic.: Oxford University Press.

Taket, A. (Ed.). (2012). Health equity, social justice and human rights. Oxon, UK: Routledge.

Willis, E., Reynolds, L., & Keleher, H. (Eds.). (2012). Understanding the Australian health care system (2nd ed.). Retrieved from http://site.ebrary.com.ezproxy2.acu.edu.au/lib/australiancathu/docDetail.action?docID=10630452

Further recommended references will be made available on LEO throughout the semester.


Australian Catholic University
HLSC607 Policy and Planning in Healthcare
Assessment Task 1 ?Reflective Essay ? 30% weighting

Student Name_______________________________________ Student Number ____________

Criterion High Distinction Distinction Credit Pass Unsatisfactory

Interpretation 15 – 14 13 – 12 11.5 ? 10 9.5 ? 8 <7.5
/15 The question has been interpreted The question has been interpreted The question has been interpreted The question has been interpreted The question has not been interpreted

LO 3, 4 appropriately and has been proficiently appropriately and has been clearly appropriately and soundly addressed appropriately and adequately appropriately and has not adequately
GA 1, 2, 3, 4 addressed with exemplary elaboration addressed with effective elaboration of with accurate elaboration of sub-topics addressed with appropriate addressed sub-topics
of sub-topics sub-topics elaboration of sub-topics

Reflection 25 ? 23 22 ? 20 19 ? 16 15 ? 13 <12.5
The Reflective Essay demonstrates: The Reflective Essay demonstrates: The Reflective Essay demonstrates: The Reflective Essay The Reflective Essay does not

LO 3, 4 A consistently, well- developed self- A well- developed self-awareness and Sound self-awareness and a sound demonstrates: demonstrate:
GA 1, 2, 3, 4
awareness and exemplary ability to an ability to effectively apply concepts, ability to accurately apply concepts, Adequate self-awareness and an Adequate self-awareness and an
apply concepts/principles/theories to principles, theories to the reflected upon principles, theories to the reflected upon ability to adequately apply adequate ability to apply concepts,
the reflected upon situations, situations, experiences and personal situations, experiences and personal concepts, principles, theories to the principles, theories to the reflected upon
experiences and personal responses responses responses reflected upon situations, situations, experiences and personal
experiences and personal responses
Critical 25 – 23 22 – 20 19 – 16 15 – 13 <12.5

/25 The Reflective Essay demonstrates: The Reflective Essay demonstrates: The Reflective Essay demonstrates: The Reflective Essay The Reflective Essay does not
demonstrates: demonstrate:
LO 3, 4 An exemplary ability to critically An ability to effectively critically analyse A sound ability to accurately critically

GA 1, 2, 3, 4 analyse situations including situations including strengths, analyse situations including An ability to adequately critically An adequate ability to critically analyse
strengths/weaknesses, weaknesses, reactions, assumptions strengths/weaknesses, reactions/ analyse situations including situations including strengths,
reactions/assumptions and determine and determining new courses of action assumptions and determine new strengths, weaknesses, reactions, weaknesses, reactions, assumptions
new courses of action relevant to the relevant to health care policy courses of action relevant to health care assumptions and determining new and determining new courses of action
human resource situation An ability to effectively synthesise what policy courses of action relevant to health relevant to health care policy
care policy
An exemplary ability to synthesise is already known with new knowledge An ability to accurately synthesise what An adequate ability to synthesise what

what is already known with new and attitudes so as to develop new is already known with new knowledge An ability to adequately synthesise is already known with new knowledge
knowledge/attitudes and develop new, perspectives and attitudes so as to develop new what is already known with new and attitudes so as to develop new
insightful perspectives An ability to effectively evaluate the perspectives knowledge and attitudes so as to perspectives
develop new perspectives
An exemplary ability to evaluate the learning process that has occurred A sound ability to evaluate the learning An ability to adequately evaluate the

learning process that has occurred process that has occurred An ability to adequately evaluate learning process that has occurred

Page 14 of 21 Version: S2, 2016

the learning process that has

Structure/ 15 ? 14 13 – 12 11.5 – 10 9.5 – 8 <7.5
The Reflection provides : The Reflection provides: The Reflection provides: The Reflection provides: The Reflection does not:
LO 3, 4 An introduction that proficiently An introduction that effectively outlines An introduction that accurately outlines An introduction that adequately Provide an introduction that adequately
outlines the focus of the Reflection the focus of the Reflection the focus of the Reflection outlines the focus of the Reflection outlines the focus of the Reflection
GA 1, 2, 3, 4,
A logical, coherent structure that A logical, coherent structure that A logical, coherent structure that A logical, coherent structure that Present in a logical, coherent manner
demonstrates a highly insightful demonstrates a well-developed demonstrates sound reflective insight demonstrates some reflective
Provide a conclusion that adequately
reflection insightful reflection insight
A conclusion that accurately summarises summarises the focus of the Reflection

A conclusion that proficiently A conclusion that effectively summarises the focus of the Reflection A conclusion that adequately
summarises the focus of the Reflection the focus of the Reflection summarises the focus of the
Presentation 10 – 9 8.5 ? 7 6.5 ? 5.5 5 <5
/10 The Reflection is consistently well The Reflection is clearly and effectively The Reflection is soundly and accurately The Reflection is adequately The Reflection is not presented in a

LO 3, 4 presented in an exemplary, scholarly, presented in a scholarly, academic style presented in a scholarly, academic style presented in a scholarly, academic scholarly, academic style that is
GA 5, 8 academic style that is appropriate for a that is appropriate for a reflective essay that is appropriate for a reflective essay style that is appropriate for a appropriate for a reflective essay
reflective essay reflective essay

Effective paraphrasing is effectively Effective paraphrasing is soundly Paraphrasing is not used appropriately
Effective paraphrasing is consistently demonstrated when used to support the demonstrated when used to support the Paraphrasing is adequate when when used to support the Reflective
and proficiently demonstrated when Reflective content Reflective content used to support the Reflective content
used to support the Reflective content content
The correct wordage is used (1500 words The correct wordage is used (1500 words The correct wordage is not used (1500
The correct wordage is used (1500 +/- 10%) +/- 10%) The correct wordage is used (1500 words +/- 10%)
words +/- 10%) words +/- 10%)

Referencing 10 ? 9 8.5 ? 7 6.5 – 5.5 5 <5
/10 There is evidence of extensive reading There is evidence of wide reading used to There is evidence of a range of reading There is evidence of adequate Sources used to support the Reflection
used to support the Reflection with all support the Reflection with all literature used to support the Reflection with most reading used to support the are not of an acceptable academic
LO 3, 4 literature sources of a credible and high sources of a credible and high academic literature sources of a credible and high Reflection with some literature standard
GA 8 academic standard standard academic standard sources of a credible and high
academic standard Direct quotes are not appropriately

Direct quotes are appropriately Direct quotes are appropriately Direct quotes are mostly appropriately incorporated and are often used
incorporated and rarely used incorporated and minimally used incorporated and minimally used Direct quotes are sometimes
appropriately incorporated however, APA referencing style is not adequately
APA referencing style is consistently APA referencing style is accurately used APA referencing style is mostly accurately are often used used for in-text citations, direct quotes
and accurately used for in-text citations, for in-text citations, direct quotes and used for in-text citations, direct quotes and reference list
direct quotes and reference list reference list and reference list APA referencing style is adequately
used for in-text citations, direct
quotes and reference list
Final mark given: /100 = 30%

Page 15 of 21 Version: S2, 2016

Policy, Politics, & Nursing Practice 12(4) 245 ?253 ? The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1527154411429198 http://ppn.sagepub.com
The health equity agenda informed by social justice and the determinants of health challenges nurses to take public policy and associated political action seriously. The World Health Organization?s (WHO) Commission on the Social Determinants of Health called on its member nations to decrease, within a generation, the unfair distribution of health attributable to social and economic conditions (WHO, 2008). It has been widely recognized that public policies largely determine the distribution of the social determinants of health and contribute to health and health inequities (Bryant, Raphael, Schrecker, & Labonte, 2010; Marmot & Bell, 2011). The sociopolitical role of nurses is undisputed (Ballou, 2000; Reutter & Duncan, 2002; Villeneuve, 2008; Warner, 2003) and theoretically grounded in moral practice, the social contract between the nursing professions and the public (Ballou, 2000), and professional values of social jus- tice (Boutain, 2005). Complex mechanisms of the natural and built environment together with the social, political, eco- nomic, and cultural environment operate to create conditions that are either conducive or opposed to health equity. These conditions are often results of public social policies that are instrumental in the distribution of the determinants of health. For example, trends in the increased burden of chronic dis- eases are reflected in geographic distributions of economic and social disparities and a rural?urban divide (Canadian Institute for Health Information [CIHI], 2008). The increas- ing segregation of urban neighborhoods along lines of income is problematic at the very least for social and health reasons (Bryant et al., 2010). Public social policies may not
have been designed to disadvantage certain populations; however, the effect of some policies may create unintended health inequities. Public policies pertaining to urban neigh- borhoods and their inequity producing effects are undeniably complex. The nature of community health nurses? daily work in the community provides a privileged position to witness the lived experiences and effects of policy-produced social and health inequities. This privileged position requires policy competence including analytical skills to connect lived experi- ences to public policy. Spenceley, Reutter, and Allen (2006) suggest that nurses need sociopolitical knowledge for effec- tive advocacy at the policy level to inform necessary changes. The purpose of this article is to present and example of a research project from a low-income neighbourhood in Halifax, Canada that explicated inequity producing effects of public policy and is intended to inform necessary policy changes. It responds to the Ottawa Charter?s (WHO, 1986) principles of primary health care, calling for individuals to gain control over their lives, and for healthy public policy and to the more recent work of WHO (2008) advocating for a global health equity agenda.
429198PPNXXX10.1177/152715441142919 8ChircopPolicy, Politics, & Nursing Practice
1Dalhousie University, Halifax, Nova Scotia, Canada
Corresponding Author: Andrea Chircop, PhD, RN, Assistant Professor, School of Nursing, Dalhousie University, 1459 Oxford Street, Halifax, NS B3H 4R2, Canada Email: Andrea.chircop@dal.ca
Public Policy Analysis to Redress Urban Environmental Health Inequities
Andrea Chircop, PhD, RN1
Abstract Public policies may not have been designed to disadvantage certain populations, but the effects of some policies create unintended health inequities. The nature of community health nurses? daily work provides a privileged position to witness the lived experiences and effects of policy-produced social and health inequities. This privileged position requires policy competence including analytical skills to connect lived experiences to public policy. The purpose of this article is to present an example of an urban ethnography that explicates inequity-producing effects of public policy and is intended to inform necessary policy changes. This study sheds light on how issues of childcare, housing, nutrition, and urban infrastructure in the context of poverty are fundamental to the larger issues of environmental health. This policy analysis documents how the Day Care Act of Nova Scotia, Canada explicates patriarchal and neoliberal gender and class assumptions that have implications for mothers? health decisions.
Keywords community health, health disparities, political action, research methodology, urban health, women?s health
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246 Policy, Politics, & Nursing Practice 12(4)
Initially, my focus was on environmental health and how mothers with young children would make environmental health decisions within their particular urban neighborhood. It quickly turned out, however, that the study participants, who were low-income mothers, had other concerns such as child care, housing, and how to feed their children. Canada does not have a universal, publicly funded early childhood education and child care program (Friendly & Prentice, 2009). This difference in mothers? priorities is significant and sheds light on how issues of child care, housing, nutri- tion, and urban infrastructures in the context of poverty are fundamental to the larger issues of environmental health. As such, the low-income mothers in this study had a broader understanding of the environment as being influenced by public policy. The purpose of this study was to explore the relationship between health and the urban environment as it is experienced and negotiated by low-income mothers within the context of everyday family life. The research questions were as follows:
Research Question 1: How are low-income mothers? everyday health decisions for their families influ- enced by their urban neighborhood? Research Question 2: How do low-income mothers understand and negotiate their experiences of pov- erty, their low-income urban neighborhood, and health?
Conceptual Framework To address my research questions and to conceptualize urban environmental health of low-income mothers, I devel- oped an ecofeminist framework (Chircop, 2008). This framework guided the critical analysis of gendered environ- mental health inequities, capturing the complexity with which gender, class, and the social and physical environ- ments interact to mediate health or health inequities. According to ecofeminism, there are important connections between the domination of women and the domination of the environment within patriarchal societies. To overcome domination, one of its forms cannot be addressed without simultaneously addressing others (Warren, 1996, 1997, 2000). Its goals are to deconstruct oppressive and exploit- ative social practices and to reconstruct more viable social and political communities. In this framework, ecofeminist analysis informed, and was simultaneously informed by, (a) empirical data that link environmental degradation to the experience of women, chil- dren, the poor, and people of color; (b) socioeconomic connections revealing shared experiences of oppressive socioeconomic structures within patriarchal societies; (c) a historical/biographical perspective that is empowering and enlightening through critical interpretations of social pro- grams and welfare policies; (d) a care-sensitive ethics to guide policy design with emotional and rational intelligence;
and (e) an ecofeminist analysis of oppressive conceptual frameworks of public policies. This design of an ecofeminist framework for analysis of low-income mothers? urban environmental health explains the research problem of health and environmental inequities faced by low-income mothers. It does so by addressing the dimensions of gender, particularly women?s perspectives, the environment, conceptual frameworks of public policies, socioeconomics, epistemology, empirical data, ethics, and history. It establishes important connections among these dimensions as they affect women and the environment in conjunction. This framework supports and guides research, in its diagnostic attempts to reveal oppressive social struc- tures, and institutional relationships of low-income, urban environments, as they are experienced by low-income moth- ers. The framework is future oriented toward influencing healthy public policy, seeking to change the status quo, par- ticularly by focusing on those determinants of health that are beyond the control of individuals. Based on this ecofeminist framework, I designed the research methodology informed by urban ethnography and institutional ethnography, which I then called ecofeminist ethnography.
Method An urban ethnography attempts to describe and interpret an urban social or cultural group within its context, and all its complexities from an insider perspective. Knowledge pro- duction starts with women?s experiences and involves the researcher, as he or she becomes involved in participants? lives (Williams, 1996). As such, the resulting knowledge is cocreated (Kaufman, 1994). This ecofeminist urban ethnog- raphy sought to produce knowledge about the complexities of women?s lives related to their urban environment and how these complexities affect their health decisions. According to Dorothy Smith (2005, 1999) institutional ethnography is a social theory and at the same time a method of inquiry that explores relationships between social institutions and people, from the people?s perspectives. Ethnographers learn from people by assembling different perspectives and investigating how people?s activities are coordinated by institutions. The investigation moves beyond what people know, to how their doings are connected to others? doings and the relationships of rulings. As such, the inquiry moves from the individual, to others, and to institutions. Institutional ethnography holds that people?s actions are coordinated and concerted by something beyond their own motivation and intentions; it opens up aspects of power operating in social life that are otherwise hidden (Campbell & Gregor, 2002). As such, institutional ethnography guided the investigation of oppressive conceptual frameworks?one of the dimen- sions of the ecofeminist framework. Over the course of 19 months, I recruited 11 participants including 4 key informants who participated in the study. The average age of participants was 30 years with a range from 22 to 37 years. All but two women had achieved, at a minimum,
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high school education. The number of children 5 years and below ranged from 1 to 2 and their ages ranged from 2 months to 4 years. Participants? family income was less than CAD$25,000. Ethics approval was obtained by the local uni- versity?s ethics review board. The urban neighborhood of Spryfield, a suburb of Halifax, the provincial capital of Nova Scotia in Eastern Canada, was chosen as study site because of the high percentage of low-income, single-parenting mothers compared with other neighborhoods in the province (Community Counts, 2006). The inclusion criteria were that participants would be 18-to-35-year-old low-income mothers including racial/ethnic minorities. The study included moth- ers of young children, 5 years of age and below. The choice of this participant group was based on the assumption that mothers of young children would have a vested interest in environmental health. The majority of participants (7) were interviewed twice for 1 to 2 hr each time, and 4 participants agreed to only one interview, bringing the total number of interviews to 18. Personal, conversational interviews were held in a location of the participant?s choice which included their home, the Single Parent Centre, and the community centre. Outsider or nonreactive (Ulin, Robinson, & Tolley, 2005) observations took place during my own grocery shopping in the neighbor- hood, as well as my volunteer work and participating in com- munity events.
Data Analysis Following the strategy proposed by Ulin and colleagues (2005), data analysis was initiated from the beginning of data collection and was ongoing and iterative. Initially, tran- scripts were read and reread and text was coded line by line by highlighting events, incidents, facts, feelings, insights, ideas as well as pauses. Codes were organized into units of higher abstraction or concepts. Labels for codes came from words and phrases in the text itself or from the literature or guiding theoretical framework (Rubin & Rubin, 2005). Constant comparison of concepts within and between inter- views and observations lead to the emergence of common themes. Themes were further analyzed in light of the research questions, and the guiding ecofeminist framework, by revealing oppressive social structures, historical connec- tions, institutional relationships within the urban environ- ment, and oppressive conceptual frameworks. The ongoing analysis lead to the identification of the pub- lic policy document titled Day Care Act of Nova Scotia (1989) which was retrieved from the publicly available gov- ernment website http://www.gov.ns.ca/legislature/legc/ statutes/daycare.htm. Document analysis was guided by the ecofeminist framework?s dimension of oppressive concep- tual frameworks. The methodology to explicate any oppres- sive conceptual frameworks in public policy was informed by institutional ethnography. Participants? experiences pro- vided specific information about the effects of a relevant public policy that was retrieved and analyzed. The reason
why the Day Care Act was selected for analysis was partici- pants? identification of the lack of regulated child care in the neighborhood of Spryfield at the time of data collection as a major concern shaping their everyday experiences. The intention of this document analysis was to look for an under- lying logic of domination and gender and class assumptions of public policies that have implications for participants? health decisions and experiences in their urban environments.
Findings The Absence of Regulated Child Care
Mothers identified the lack of regulated child care in Spryfield as a primary concern to them. It was not only the lack of day care spaces in general that made it difficult for mothers to reenter the paid workforce but also the lack of spaces for children of a particular age group. Participants? predicament lied in the combined challenge of not only finding a subsidized space but also a child care facility that takes children at the age of 18 months. There was a perceived lack of information about available day care spaces and subsidized day care spaces. Options of regulated child care would have enabled mothers to join the paid workforce while knowing that their children would be in a safe place. The following quote illustrates how the com- plexity of child care availability, the limited number of sub- sidized places, age requirements, the long waiting lists, and the lack of user-friendly information was very frustrating for mothers to experience and difficult to negotiate.
I have a spot hopefully for him. I just have to call. But he?s not 18 months yet so I have to wait until the exact day. [. . .] I put him on the waiting list back in April, I believe. Or something like that. It was in the sum- mertime anyway. So he?s been on the list for a little bit. And I called and asked them where he was, and they said to call back after school begins so they can tell who goes to pre-school. And then they?ll know how many spots. But it?s a subsidy spot so I can?t pay a whole spot. Which is hard . . . I have to wait until a subsidized spot opens, and I also have to wait for him to be 18 months. So a subsidized spot when he?s 18 months might not always match up. So I could be waiting until next say March even until he can get in, which would hold us back even more, because we are waiting and we are waiting. (Nadine)
Negotiating Urban Infrastructure The urban infrastructures that needed to be negotiated on a daily basis by participants included housing and finding an affordable and appropriate place of residence to safely bring up their children. Decision where to live had to be made within a short period of time in order not to jeopardize a public housing option. An additional concern identified by participants about
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248 Policy, Politics, & Nursing Practice 12(4)
negotiating residence location was related to personal safety, ranging from fear of criminal activities, such as drug use and prostitution, to dangerous driving. Narratives about their loca- tion of residence revealed a sense of ?ghettoization? as well as images of neighborhood aesthetics. When I asked Maggie how she feels about living in Greystone, a public housing complex, her response illustrated the harsh reality of social exclusion:
People are automatically assuming that you?re Ghetto. I think that we?re just isolated from the rest of the city. It?s like we?re on top of this hill, there?s no, there?s only one way in, one way out. Nobody goes up there, or past there, unless they know somebody that lives up there, or they live up there.
Urban infrastructure, particularly the built environment, includes many different services that are delivered by vari- ous providers such as government (federal, provincial, municipal), not-for-profit organizations, and private enter- prises. Participants? stories of living in Spryfield included positive and negative experiences with service options in their neighborhood. The Single Parent Centre, a not-for- profit organization to support young parents, received unanimous and overwhelmingly positive feedback from par- ticipants. The center?s services include prenatal classes, breast-feeding support, literacy programs, community kitchens, help with income tax, and many others. Playgrounds and parks form part of the urban infrastruc- ture. According to mothers? narratives, they played a signifi- cant role in their negotiations of daily activities with young children. Transportation in the form of bus or public trans- port services, or the provision of sidewalks and street con- nectivity, are key elements of modern urban development and infrastructure that affect residents? daily activities. Very often, transportation determined accessibility to other ser- vices or destinations within and outside a neighborhood.
Negotiating Nutrition Most mothers want to be able to fulfill the nutritional needs of their family. Participants? income levels clearly affected nutritional choices. Tracey, whose income on assistance was very low had no options other than the local food bank to supplement the nutritional needs of her family. In compari- son with living in poverty in rural areas where many resi- dents may have access to a kitchen garden to supplement the family?s food supplies, the situation in urban areas is often different without access to a plot of land to garden. In the case of Julia and Tracey, even the option of a food bank is hardly sufficient. The food supplies Tracey had received the previous week lasted only for 1 day. The work of negotiating family nutrition has been illus- trated as complex, particularly as it took place within a con- text of personal and environmental poverty, that is, within a low-income urban neighborhood. Insufficient financial resources meant that mothers had to rely on the meager
rations of the local food bank to supplement groceries, and some mothers had to borrow money to bridge the time until payment of child tax benefits. Participants were knowledge- able about the timing and location of sales that did not nec- essarily align with the payment date of income assistance. Hunting and fishing were creative strategies used by moth- ers to supplement groceries. Left with few or no options, mothers had to contend with lesser quality, quantity, and variety of food products as compared with availability in higher income neighborhoods, and the lack of transportation made the work of grocery shopping even more laborious. In this climate of managing against all odds, mothers were aware that the cheaper foods are not always the healthier ones, yet still attempted to teach their children healthy eating.
Mothers? Invisible Balancing Act for Negotiating Health Negotiation, according to the Oxford English Dictionary (2009), is an act of skillful maneuvering to overcome an obstacle. It is important to acknowledge that an obstacle for some might not be considered an obstacle by others, as it depends largely on a person?s social location within a give context. Thus, obstacles created by poverty can remain invisible to mainstream society, as can be the tacit knowl- edge of those who have to overcome them. The themes of absence of regulated child care, negotiation of urban infra- structure, and negotiating nutrition are examples of obsta- cles mothers in Spryfield need to overcome to support their children in growing up healthy. Through my personal obser- vations of participants during interviews, I found that their concern for their children was paramount at this point in their lives. ?As long as my kids are good, I?m good. Really? (Pauline). This quote illustrates a constant undercurrent of all mothers? narratives of their lives in Spryfield. Providing children with a good start in life and a bright future was a major motivational factor identified by all participants. Participants in this study were motivated to change their cur- rent material circumstances. The mothers? daily balancing act included a weighing of their physical and their social needs and those of their chil- dren against their reality of living in poverty, in a low-income urban neighborhood. The determinants of health, particu- larly gender, socioeconomic status, and the urban environ- ment, acted as barriers and constraints to mothers? successful negotiation efforts for health.
Interpretation and Discussion of Findings The interpretation and discussion of the findings take place within the ecofeminist framework. Furthermore, I will answer the research questions as analytical categories. How are low-income mothers? everyday health decisions for their families influenced by their urban neighborhood? The logic
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of domination that results in low-income women having inadequate housing and nutrition is based on neoliberal notions that the housing and food retail markets are value free and that every citizen has the same choice of housing and food retail. Neoliberal ideology regards the presence of children as a matter of individual choice. This ideology dis- regards the fact that many low-income mothers (a) live below the poverty line and (b) have child care responsibili- ties and obligations such as feeding their children, which places them on unequal footing with mid-to-high-income earners without child care responsibilities. Thus, the actual accessibility of free-market commodities is unequal and the logic of domination denies realities of existing social inequi- ties that are embodied by these low-income mothers. The result of this denial or lack of acknowledgement results in oppression of the ?downs? in the social hierarchy and per- petuates the position of power and privilege of the ?ups.? Shelter and nutrition are basic needs, and mothers? narratives about the influences of their urban environment on their daily health decisions reveal the magnitude public policies have on their everyday lives in the form of barriers to meet- ing basic needs. In Canada, affordable housing is largely defined as spend- ing less than 50% of one?s income on rent (Canada Mortgage and Housing Corporation, 2011). The lack of sufficient, affordable housing initiates a cascade to situations of inade- quate after-rent income for families, inadequate financial resources to cover food-related expenses, and ultimately food insecurity and poor health. Food insecurity includes a lack of appropriate caloric intake as well as a lack of nutri- tious food quality. According to McIntyre and Rondeau (2009), food security determines ?life, health, dignity, civil society, progress, justice, and sustainable development? (p. 188). As such, food security is fundamental to the physi- cal and social environments of a civil society. Issues of food insecurity and lack of affordable housing need to be discussed within a broader context of the social determinants of health. These issues are significant for this study as it calls for the integration of the physical and social environments and their relationship to health. It emphasizes the need and also the opportunity for interdisciplinary col- laboration in addressing complex realities of urban infra- structures and their impact on gender and health. In Canada, children live in poverty because their mothers live in poverty or below the low-income cut-off (Canadian Research Institute for the Advancement of Women, 2005). Low income cut-off is the official measure used by Statistics Canada to convey income levels of families that spend a greater portion of income on food shelter and clothing rela- tive to an average family of similar size and according to geographic location (Statistics Canada, 2011). Macro-level, federal policies that determine federal transfer payments to the provinces, and provincial policies that determine the level of financial assistance to families who live in poverty, are examples of systematic oppression.
The logic of domination that operates through neoliberal ideology understands that by keeping welfare payments and government investments in urban infrastructures to a mini- mum, the government is able to facilitate private market growth. The growth of private markets results in the creation of employment opportunities for all citizens to enjoy, result- ing in increased tax revenues through income tax and a reduction of the need for welfare payments and provisions of free services. Low-income mothers are the ?downs? who are not contributing to income tax revenues; they need to be dis- couraged from dependence on the state, as not to draw valu- able resources that could otherwise contribute to market expansion and ultimately benefit their own situation as inde- pendent consumers. The prevailing value judgment of low- income mothers regards them as not contributing and of using public funds. The care work mothers do is not valued in a monetary exchange economy; rather low-income mothers are judged as deficient, lacking, burdensome, and undeserving. The lack of sufficient low-cost or public housing in com- bination with an increased demand in food banks serves as a message of discouragement to its users and is an attempt to keep people from forming a dependence on public housing and free food. The issue of inadequate and scarce low-cost or public housing and the necessity to use local food bank pro- visions were particularly challenging in an urban environ- ment, where possibilities of food cooperatives or the opportunity to grow one?s own food are limited. The cre- ation of urban environments such as Spryfield is a gendered environmental health issue as it exposes disproportionately more women and their children to unhealthy environments. The idea of control over one?s personal choices, as impor- tant for health, as suggested in the Ottawa Charter (WHO, 1986), was merely an illusion for participants in this study. Although the study findings illustrate ?personal? experiences and insights, the common themes reveal ?structural? deter- minants of health, in particular public policies that function like strong currents in rapid waters. In addition to the influ- ence of public policy on mothers? health decisions for safe housing and healthy nutrition, the provincial child care pol- icy in Nova Scotia is another example of policy-created impediments to healthy choices. Participating mothers voiced a desire to join the work- force but were inhibited from doing so by provincial child care policy. Nova Scotia?s child care policy is built on the assumption that the private market will satisfy the social and economic need for child care by providing sufficient child care spaces in locations of need at the right time. Once child care spaces have been created by the private market econ- omy, the government regulates this service through the Day Care Act. In the neighborhood of Spryfield, at the time of this study, the private market did not provide sufficient regu- lated and affordable day care opportunities for mothers with young children, to enable them to join the paid workforce. This situation contradicts the logic of discouraging
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dependence on the state, where clearly the private market has not fulfilled its promise to create child care opportunities, leaving these mothers without a choice. One of the ?roots of the root causes? of inequities in this study is the structural impediment of the absence of regu- lated child care that would otherwise enable mothers to reen- ter the paid workforce or educational institutions, thereby increasing their financial resources to a level that enables health decisions consistent with their knowledge, beliefs, and intentions. The province of Nova Scotia does not directly provide child care services; rather it provides start-up funding for nonprofit and corporate, private operators of child care ser- vices, which are regulated by the province through the Day Care Act (1989). The focus of the act is the licensing of day care services in Nova Scotia. Child care licensing and related standards fall under the program of Early Childhood Development Services within the Department of Community Services. The logic behind this policy is that the private mar- ket will fill the need for required child care spaces in Nova Scotia. Nova Scotia?s policy on regulated child care is problem- atic as it is based on the assumptions that the private sector will create and operate child care facilities and that there is equal access to these services. This means that a crucial responsibility for social programs is relegated to private market forces. It is an example of ?ideals of democratic capitalism [. . .] that exist normatively, but are always vio- lated in practice? (Trudeau & Cope, 2003, p. 779). In this neoliberal system, realities of unequal access based on race, class, and gender are denied because the private market the- oretically has ?open access.? Neoliberal ideology presents itself as value free, supporting a value-free and neutral mar- ket to the benefit of all citizens. This ideology implies per- sonal responsibility for race, ethnicity, class, gender, sexual orientation, and so forth in that whoever falls outside of the dominant prototype of the free-market citizen is somehow deficient. Clearly, for the study participants, this situation consti- tutes a situational, structural impediment related to their role of mothering young children under dire material circum- stances. The experience of financial hardship as a result of motherhood and the absence of child care have been found to result in social isolation of young mothers in a recent study based in Australia (Baker, 2009). A public policy that con- strains mothers? enjoyment of the same rights to employ- ment as others in society contributes to social exclusion by denying full citizenship as an employee with all the opportu- nities resulting from improved material conditions. According to Trudeau and Cope (2003), systemic social exclusion is embedded in neoliberal welfare states, perpetuating a ?hier- archical social differentiation? (p. 782). Although the phrase social exclusion was not used or spoken by study partici- pants, their stories about daily life in Spryfield provided evi- dence of social exclusion.
Participants? characterization of their neighborhood (Greystone) as a ghetto has meanings and implications for their own health and well being, as well as for the larger community. As Maggie said, ?Nobody ever has to drive by that eyesore. So, the taxpayers aren?t going to complain about it because they don?t see it.? The fact that this public housing project is ?out of sight? and spatially set apart, con- veys, on one hand, a message to its residents that they do not belong to the rest of Spryfield, or Halifax, and, on the other hand, a message to the wider community that ?they, up on the hill? do not exist or should be hidden. Because the spatial location of Greystone makes it invisible to nonresidents, it does not become an issue for those in the community that might have more political and/or economic power to change the housing situation. In this study, Pauline?s expression that ?there is some trashy people here,? is an example of the association of phys- ical appearance of the neighborhood with the characteristics of its residents. According to ecofeminist philosophy, this association is prevalent in oppressive conceptual frame- works that perpetuate inequities based on a perceived lesser value of a geographic region as well as its residents. Particularly for a population that is experiencing daily stressors related to life in poverty, a physically pleasing, wel- coming, and safe environment could provide residents with ?salutogenic? benefits. The integration of ?green infrastruc- ture? in urban areas as a strategy for public health promotion was proposed by Tzoulas and colleagues (2007) as beneficial for both natural ecosystems and human health. Visits to playgrounds and parks were central activities of mothers and their young children. Mothers were looking for certain characteristics of playgrounds including age- appropriate equipment, a variety of creative features that would support different activities and sustain children?s interest, safety features, cleanliness, and a place for moms to sit and observe while children were playing. Within their immediate neighborhood, none of the existing playgrounds included all these characteristics. The playgrounds closest to the mothers? homes were often vandalized, had unsafe play structures and flooring, and often had no place to sit and watch their children play. Implicit in this arrangement is the message that mothers and children in other, richer neighborhoods deserve access to appropriate playgrounds within their reach, creating and reinforcing inequity in rec- reational opportunities based on class. Different urban environments are created for different neighborhoods and their residents, as a result of failure of urban governance (Kjellstrom & Mercado, 2008), premised on beliefs that middle- and upper-class residents have earned (through their income and property taxes) access to appropriate rec- reational spaces and are deemed to take ownership and good care of public spaces and equipment, as such they have earned trust with urban planners. According to Liz, one of the participants, these different environments may be a result of different tax revenues from different
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neighborhoods within the city. Children from Greystone and Spryfield learn from early on that playgrounds are often better in other neighborhoods. The accessibility of organized, recreational sports such as hockey or golf was identified as problematic for most par- ticipants due to the high costs associated with membership fees and equipment. In Canada, the discourse on healthy life- style is largely dominated by a call to increased physical activity and healthy eating (Frank & Engelke, 2001; Sallis & Glanz, 2009; Tomalty & Haider, 2009; Veugelers, Sithole, Zhang, & Muhajarine, 2008). This discourse is also preva- lent in the environmental health arena, where active trans- portation in the form of walking and biking together with a diet of local and preferably organic foods have become moral imperatives (Alkon, 2008; Clarke, Cloke, Barnett, & Malpass, 2008; Francis et al., 2005; Tomalty & Haider, 2009). This focus on individual behavior change to take responsibility for ones? health and the environment is consis- tent with the neoliberal agenda that puts the onus squarely on individuals, at the same time as new markets for recreation, sports, and food industries are created. The commodities offered by the sports, recreation, and food industries, partic- ularly organic foods, are out of reach for low-income families and benefit largely the higher socioeconomic classes who can afford to purchase these goods and services. This situa- tion is another example of social exclusion, specifically, the exclusion from participating in a ?green? and ?healthy? life- style. This neoliberal market approach to ?healthy living? disenfranchises people living in poverty and sends the mes- sage that they are not entitled to healthful activities and nutritious foods. In summary, this study?s findings support existing evi- dence of the influence of ill-conceived public policy on the health decisions of low-income mothers living in low- income urban neighborhoods, such as Spryfield. Oppressive conceptual frameworks in the form of neoliberal ideology are pervasive in public policies that shape the urban social and physical environments of low-income neighborhoods. Mothers? efforts to meet their families? basic needs of shelter and nutrition are framed by their policy-created socioeco- nomic location, the presence of young children, and the lack of regulated child care in their neighborhood. These condi- tions that contribute to social exclusion further influence mothers? health decisions through the type of resources available within their low-income neighborhood, including ghetto-like housing arrangements, an inadequate transporta- tion infrastructure, neglected and unsafe playgrounds, insuf- ficient employment and educational opportunities, and insufficient family services. Within this context, the study?s second question is explored. How do low-income mothers understand and negotiate their experiences of poverty, their low-income urban neighborhood, and health? Mothers? negotiations for their own and their children?s health included prudent, financial, and safety decision making about housing, as previously discussed. To
secure food for their families with the remaining after-rent income, mothers had to make frugal decisions and constantly look for deals and sales in local food stores and discount ?Dollar Stores.? According to participants? stories, many people in Spryfield can afford only the less healthy foods, meaning less fresh fruits and vegetables, oils, and more pro- cessed foods. The ability to purchase foods in general was largely dependent on the timing of participants? welfare pay- ments or child tax benefit payments, making it very difficult to take advantage of special deals offered by neighborhood- based grocery stores. Most participants had to use the food bank where there was very little choice over food quantity and quality. Strategies to secure food included borrowing money and participating in this study, which was motivated by obtaining grocery gift certificates for most participants. Amount and timing of income assistance were structural bar- riers to food security, and NGOs such as the Metro Food- bank or the Single Parent Centre, as well as relatives were places of last resort for mothers to secure food for their fami- lies. It was low-income mothers? resourcefulness, knowl- edge, and creativity in negotiating a variety of strategies that kept their families fed.
Concluding Reflections Participants? local knowledge about their neighborhood and how to negotiate health for themselves and their families has contributed experience-based evidence. The findings from this study add to the existing data and knowledge about urban, gendered environmental health inequities (CIHI, 2008; Green, 2000; Raphael & Bryant, 2004; Sen & ?stlin, 2007; WHO, 2006) and are intended to inform public policy. The contributions of this study to existing knowledge are two- fold. First, it adds insights into the physical and social urban environments through the lived experience of low-income mothers in low-income urban neighborhoods, particularly, the structural, policy-created impediments to healthy choices through the absence of regulated child care in this neighbor- hood which prevented mothers from joining the paid work- force to improve their material circumstances and the life trajectories of their children. Second, this study is an exam- ple of the creation of experience-based evidence to inform public policy that is relevant to low-income mothers living in low-income urban neighborhoods. Mothers? balancing act for negotiating health included their knowledge and skills to negotiate safe and affordable housing, to provide food for the family, to parent creatively within a neoliberal social and often neglected physical envi- ronment, and making personal sacrifices to enable healthier life trajectories for their children. Motherhood is still charac- terized as something that occurs naturally and instinctively and is based on ideologies of self-sacrifice. The currently held popular assumption that reproductive control equals ?choice? of motherhood has implications for ideologies of mothering (Baker, 2009). For example, the ?post-feminist?
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phenomenon of the ?yummy mummy? (Baker, 2009, p. 277) defines motherhood as liberated and cool, as opposed to tra- ditional and old fashioned. Contributing to this perspective is an affluent, stylish mothering, reinforced by the media?s por- trayal of celebrity mothers. This ?post-feminist? representa- tion of motherhood is problematic for its privileged position and punitive consequences for not living up to it in the form of a moral economy that values financially stable and planned parenthood, at the same time condemning mothers who have to rely on welfare benefits as shameful (Baker, 2009). The real moral issue that is skillfully avoided in public discourse, however, is that it is not merely unfortunate and unjust but simply wrong to perpetuate a system that places low-income mothers and their families in a position of inad- equate resources that inhibits ?healthy choices? in the first place. The balancing act of mothers is evidence of their con- tributions to raising children, the next generation of citizens, to the best of their abilities given their situations. The find- ings of this study provide evidence that the neoliberal wel- fare state, through its public policies, is not fulfilling its social contract toward all of its citizens, particularly low- income mothers living in low-income urban neighborhoods. The ecofeminist framework?s dimension of care-sensitive ethics guides recommendations for public policy. A care- sensitive ethics for public policy, based on rational and emo- tional intelligence, exhibits empathy for health inequities and is against any form of oppression advanced by the logic of domination (Chircop, 2008). According to ecofeminist philosophy, ethical decision making requires emotional and rational intelligence and the ability to care about oneself and others. The ability to care about others requires empathy, which in turn requires an understanding of a situation from the other?s perspective. This understanding can be facilitated by experience-based studies like this one that placed the other?s perspective in the form of narrative voice at the centre. At the same time, community health nurses? daily work enables the collection of similar data; that is the social and health effects of public policy. Neoliberal ideology has become a prevalent discourse that may result in unconscious infiltration of its oppressive conceptual framework into public policy design. Without the knowledge from vulnerable populations, policy makers do not have appropriate evidence for the design of policies that alleviate health inequities. Warren?s (2000) insight that just or ecologically perfect decisions are impossible when institutional structures are unjust is supported by the findings of this study. In this sense, the toxic environment for low- income mothers in Spryfield is the absence of regulated child care that has far-reaching implications that make it not only difficult but also often impossible to live an ecologically per- fect lifestyle. On the contrary, low-income mothers get blamed for not doing their part for the environment. This is an opportunity and a moral imperative for nursing research and education to engage fully in political analysis of the social determinants of health to achieve health equity.
Acknowledgment I wish to acknowledge and thank Dr. Barbara Downe-Wamboldt, Dr. Angela Gillis, Dr. Trish Glazebrook, and Dr. Brenda Beagan for their guidance and support. I am grateful to all research partici- pants who made this research possible.
Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding has been provided by the Killam Foundation, the Dalhousie University Faculty of Health Professions, and Nursing Research Fund
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Bio Andrea Chircop, PhD, RN, is an assistant professor in the School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada.
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