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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.

http://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



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



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



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,

https://commons.wikimedia.org/w/index.p

hp?curid=37860629

By Pandittaz4 - Own work, CC BY-SA 4.0,

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48770685

By Sona beauty palour - Own work, CC BY-SA 4.0,


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By Toglenn - Own work, CC BY-SA 3.0,


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https://commons.wikimedia.org/w/index.php?curid=37860629





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





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



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


http://oxfordcounty.ca/Portals/15/Documents/Public Health/Partners and Professionals/Reports and Publications/2017/Access to Mental Health Services in Oxford County_FINAL 20170420.pdf


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.

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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

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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.

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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.

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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.

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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



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

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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



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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https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health/what-makes-canadians-healthy-unhealthy.html

https://www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-97428.pdf

http://www.excellenceforchildandyouth.ca/sites/default/files/eib_attach/Access_FinalReport_Aug2015.pdf

http://14.139.206.50:8080/jspui/bitstream/1/2133/1/Foucault, Michel - The Order of Things - An Archaeology of the Human Sciences.pdf