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Oxford County
Public Health
Using Discourse
Analysis to Assess
Accessibility of Services
Laura Gibbs, M.Sc., MPH
Public Health Planner, Oxford County Public Health
March 21, 2018
www.oxfordcounty.ca/health
DISCLOSURE OF COMMERCIAL
SUPPORT
• None of the presenters at this session have received
financial support or in-kind support from a commercial
sponsor.
• None of the presenters have potential conflicts of interest to
declare.
www.oxfordcounty.ca/health
Accessibility of Health-care Services
• A key social determinant of health1
• Other social determinants can impact accessibility:
• People with lower incomes have poorer access to services that
are not covered by provincial health insurance plans (e.g., dental
care, psychologist services).1
• People with insecure housing have poor rates of healthcare
adherence and follow-up.2
3
www.oxfordcounty.ca/health
What Do We Mean by Accessibility?
• Three dimensions3
1. physical access: availability, location, capacity and resources
2. affordability: costs to providers and consumers
3. acceptability: fit with consumers’ culture, beliefs and
personality
• We often focus on location and availability (physical access).
• Satisfaction surveys may address some aspects of
affordability/acceptability and capacity (e.g., wait times).
4
www.oxfordcounty.ca/health
Social Forces: Foucault’s Discourse
• Discourses are collections of statements that produce truths
about a particular topic and direct our social practices.4-6
• truth: what we know about what something is or how we should
behave
• power: how those truths are reinforced or challenged
• practice: what we do to live up to or challenge those truths
• Discourses tell us how to think and talk about something and,
therefore, how to act.
5
www.oxfordcounty.ca/health
Discourses of Femininity
6
Feminine
Long hair
Hourglass shape
Wear makeup
Soft voice
Wear dresses
Submissive
Published by Corpus Christi Caller-Times-
photo from Associated Press - Corpus
Christi Caller-Times page 20 via
en:Newspapers.com, Public Domain,
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hp?curid=37860629
By Pandittaz4 - Own work, CC BY-SA 4.0,
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48770685
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63459322
By Toglenn - Own work, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=
15363887
www.oxfordcounty.ca/health
Challenging Discourses of Femininity
7
Feminine
Long hair
Hourglass shape
Wear makeup
Soft voice
Wear dresses
Submissive
By Gage Skidmore, CC BY-SA 3.0,
https://commons.wikimedia.org/w/inde
x.php?curid=20299483
By ABC Television - eBay itemphoto
frontphoto back, Public Domain,
https://commons.wikimedia.org/w/inde
x.php?curid=22121710
www.oxfordcounty.ca/health
Discourse and Service Accessibility
• Discourses determine what people understand about service
accessibility and how they should act. Think of them as
“established understandings” within a community.
• These established understandings then become facilitators or
barriers to utilization:
• If services are understood to be “accessible” then people try to
use them; if not, they don’t bother trying.
• Discourses of accessibility can be understood (and shaped)
through texts and images produced by the media and service
provider organizations.4-7
8
www.oxfordcounty.ca/health
Case Study: Purpose and Objectives• How do we improve access to services for children, youth and
families with mental health concerns in Oxford County?
• Objectives:
• identify and describe the number and type of mental health services in Oxford County
• characterize established understandings of mental health services in Oxford County
• illustrate how these factors affect accessibility of mental health services in Oxford County
• Link to case study: http://oxfordcounty.ca/Portals/15/Documents/Public%20Health/Partners%20and%20Professionals/Reports%20and%20Publications/2017/Access%20to%20Mental%20Health%20Services%20in%20Oxford%20County_FINAL%2020170420.pdf
9
www.oxfordcounty.ca/health
Case Study: Environmental Scan
• Service information was inconsistent and hard to find.
• High physical access in larger municipalities:
• 45 organizations provide 221 services (97 for youth)
• Woodstock, Tillsonburg, Ingersoll
• counselling services most common
• High affordability for people in larger municipalities:
• Most services are free or covered by OHIP.
• People living in rural municipalities may have increased
transportation costs and lost wages.
10
www.oxfordcounty.ca/health
Case Study: Discourse Analysis
• 60 news articles, 8 agency-authored reports
• What is true about mental health services in Oxford County?
• identified key statements describing what is known about services
• categorized based on underlying concepts defined or described
• How do the truths guide individual or community action?
• how the categories are related to each other in the texts
• e.g., cause-and-effect, equivalencies
11
www.oxfordcounty.ca/health
Discursive Tools8
• There are “tools” that texts use to construct discourses.
• Foucault describes many tools – including four “similitudes.”
• Similitudes show how “things” resemble each other in order to
construct something as meaningful.
• Example: analogy is used to show that two seemingly unlike
things are the same.
12
www.oxfordcounty.ca/health
Case Study: Established Understandings
• Oxford County has good quality services available.
• Individual providers have respected credentials or they have lived
experience of mental illness and system navigation.
• Service provider organizations take action to improve processes
or gain accreditation.
• There isn’t enough capacity to meet demand.
• Increased funding – particularly from provincial ministries – is the
key to solving the problem.
• Services don’t meet the needs of youth in particular.
13
www.oxfordcounty.ca/health
Case Study: Established Understandings
• Stigma limits service access in four ways, including:
• making people feel judged by others
• limiting people’s use of existing mental health services, thereby
reducing demand
• Increased knowledge will improve service access.
• Sharing personal stories is a way to educate people about mental
health concerns and what supports are available.
• Everyone is responsible in some way.
14
www.oxfordcounty.ca/health
Environmental scan
• Physical access
location (geography)
availability (when, to whom)
resources (types of providers)
capacity (number of spots)
• Affordability
• costs to provider
costs to consumer
• Acceptability
• fit with culture
• fit with beliefs
• fit with personality
Discourse analysis
• Physical access
location (within a system)
availability (timeliness)
resources (appropriateness)
capacity (skill/expertise)
• Affordability
costs to provider (and funder)
costs to consumer
• Acceptability
fit with culture
fit with beliefs
fit with personality
15
Case Study: Getting a Fuller Picture
www.oxfordcounty.ca/health
Case Study: Accessibility in Oxford County
1. may be poorer in rural areas because low physical access
impacts affordability
2. is negatively affected by stigma – as people don’t know
about or want to access the services that are available
3. is poorer for youth because despite the high number of
services available for this age group, they aren’t acceptable
to them
16
www.oxfordcounty.ca/health
Other Applications of Discourse Analysis
• impact evaluation of public health messages
• e.g., daily physical activity recommendations9
• formative evaluation to shape advocacy and policy
development activities
• e.g., supervised consumption sites
• understanding how particular established understandings
came to be and how they have changed historically to apply
those lessons to new issues
• e.g., anti-smoking discourses applied to cannabis activities
17
www.oxfordcounty.ca/health
References1. Canada. Public Health Agency of Canada. What makes Canadians healthy or unhealthy? [Internet]. Ottawa,
ON: Government of Canada; 2013 [cited 2018 Mar 14]. Available from: https://www.canada.ca/en/public-
health/services/health-promotion/population-health/what-determines-health/what-makes-canadians-healthy-
unhealthy.html
2. Toronto Public Health. Housing and health: unlocking opportunity [Internet]. Toronto, ON: City of Toronto; 2016
[cited 2018 Mar 14]. Available from: https://www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-97428.pdf
3. Ontario Centre of Excellence for Child and Youth Mental Health. Evidence in-sight: access to child and youth
mental health services [Internet]. Ottawa, ON: Ontario Centre of Excellence for Child and Youth Mental Health;
2015 [cited 2018 Mar 14]. Available from:
http://www.excellenceforchildandyouth.ca/sites/default/files/eib_attach/Access_FinalReport_Aug2015.pdf
4. Foucault M. The archaeology of knowledge. Trans Sheridan Smith AM. New York, NY: Harper & Row; 1972.
5. Markula P, Pringle R. Foucault, sport and exercise: power, knowledge, and transforming the self. London, UK:
Routledge; 2006
6. Foucault M. Governmentality. In: Rabinow P, Rose N, editors. The essential Foucault. New York, NY: The New
York Press; 2003. p. 229–245
7. Prior L. Following in Foucault’s footsteps: text and context in qualitative research. In: Hesse-Biber SN, Leavey,
P, editors. Approaches to qualitative research: A reader on theory and practice. New York NY: Oxford University
Press; 2004. p. 317– 333
8. Foucault M. The order of things: an archaeology of the human sciences. London, UK: Routledge; 2005.
Available from: http://14.139.206.50:8080/jspui/bitstream/1/2133/1/Foucault,%20Michel%20-
%20The%20Order%20of%20Things%20-%20An%20Archaeology%20of%20the%20Human%20Sciences.pdf
9. Dallaire C, Gibbs LB, Lemyre L, Krewski D. The gap between knowing and doing: how Canadians understand physical
activity as a health risk management strategy. Sociol Sport J. 2012;29(3):325-47
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