The population health model encourages health analysts to consider both bio-medical and socio-economic determinants of health in the implementation of policies and practices. Over the last few decades, studies have connected socio-economic factors and health inequalities. New research also acknowledges that women's health is a by-product of gender-based differences resulting from social and economic inequities as well as biologically based sex differences.

Regrettably, in much of the literature, the connections between women's health and women's poverty are often overlooked. Poverty is often addressed as a gender-neutral problem. The failure to connect income inequality, health and gender is problematic due to the pervasiveness and depth of poverty among women in Canada. Overlooking this factor at the research stage makes certain that the gendered nature of poverty remains unaccounted for in policies and programs. According to Beaudry and Reichert:

If we are to define poverty as more than simply the lack of income, but a systemic deprivation of healthy human development as part of the human community, then poverty can be an extension of all the life experiences. As well, women, who have endured these histories have accepted (not willingly) the transfer of their own decision making to the state.

The Prairie Women's Health Centre of Excellence (PWHCE) has addressed the paucity of information on the health issues faced by poor women by supporting a number of research studies. This paper is a review of research papers supported by the PWHCE and is a synthesis of the policy recommendations arising from the research. These are combined with the results and recommendations from two other, external papers written at the same time, one in Saskatchewan and one in Manitoba.

The documents emphasize that multi-faceted, comprehensive strategies are required to address the health issues women face, arising from living in poverty. The narratives emerging from the research provide valuable insights into women's experiences with parenting, working and living in poverty. Donner et al's paper provides important quantitative data to broaden the understandings of the full scope of the problems. The recommendations for action are based on the voices and observations of the women themselves.

Summaries of Reports
The five recent reports reviewed from the PWHCE and the two external reports delineate the scope of women's poverty and the ways that low incomes impede well-being.

Sharing Our Stories on Promoting Health and Community Healing: An Aboriginal Women's Health Project by Connie Deiter and Linda Otway traces the history of health policies for First Nations people in Canada. The chronic disempowerment experienced by many Aboriginal people suggests that the adoption of health practices will only be realized through long-term healing and the gradual re-acquisition of basic life skills. The report goes on to summarize 98 interviews with Aboriginal women from Saskatchewan and Manitoba, including five Elders. The women interviewed connected their health status with governing policies and procedures. Poverty is identified as a major contributor to the health issues of Aboriginal women. Among its many recommendations, the report calls upon governments to recognize and accept Aboriginal concepts of health and healing.

Sexual Violence and Dislocation as Social Risk Factors Involved in the Acquisition of HIV Among Women in Manitoba by Iris McKeown, M.D., Sharon Reid, Shelly Turner and Pam Orr explores factors leading to the over-representation of Aboriginal women in the incidence and prevalence of HIV infections in Canada. The researchers investigate women's movement and dislocation from rural and remote communities to urban centres. In a study designed by the participants themselves, the women reveal that health decisions for low-income women usually involve giving up one detrimental behaviour for another that affords moderately enhanced well-being. Thus health promotion models that promote individual choice making and responsibility must be cautiously applied when women in fact have profoundly limited "choices" to make.

"We Did it Together": Low-Income Mothers Working Toward a Healthier Community by Kathryn Green emphasizes the limitations of health policies that encourage skill and knowledge development without addressing the social context of poor women's lives. The project brought together low-income mothers to discuss ways to make their communities and social environments safer for women and children. The women call for adequate financial support in a number of ways to enable all families to meet their basic needs. Other recommendations request the implementation of policies that promote parenting as important and essential and providing parents with further supports such as respite care and further financial aid.

Left in the Cold: Women's Health and the Demise of Social Housing Policies by Darlene Rude and Kathleen Thompson is a comprehensive overview of the diminishing availability of adequate housing for low-income Canadians due to federal and provincial withdrawal of funding and responsibilities. The report includes a literature review and review of policy trends in Canada over the last decade, including an analysis of housing and health policies in Regina, Saskatchewan and Winnipeg, Manitoba. The authors interviewed thirteen women who provided first-hand accounts of their housing difficulties. The report calls for the development of a gender-sensitive housing strategy that can address the shortage of adequate and affordable housing for women, particularly women raising young children, and women with disabilities or other health problems.

Mothers' Health and Access to Recreation Activities for Children in Low Income Families by Shirley Forsyth explores the intersections between children's ability to participate in recreation activities and their mother's health. Forsyth found that increases in recreation fees present challenges for low-income families who cannot cover the costs of children's involvement in activities. In Winnipeg, Manitoba families were affected disproportionately by recent increases in community and municipal fee hikes. The study verifies the cost-savings that result from even minor investments in population health related strategies. The other two key reports are summarized briefly and the findings and implications from the work are interwoven through the policy analysis.

Women, Income and Health in Manitoba: An Overview and Ideas for Action by Lissa Donner et al. provides statistics on poverty among women in Manitoba and the connections that are made to women's health status. One of the paper's particular strengths is the attention it pays to poverty among Aboriginal women and the resulting health concerns. Donner et al. identify strategies aimed at improving women's incomes, and consequently, their health. The paper makes a persuasive argument that policy initiatives on population health must consistently include women.

Women, Health and Poverty: Review and Looking Forward by Jayne Melville Whyte evaluates the success of initiatives aimed at addressing women's poverty and their well-being. Whyte also visited seven communities that sponsored projects on women's poverty with funding form Health Canada. The women Whyte interviewed provide key insights into the experience of poverty. One of Whyte's most troubling conclusions is that women's poverty is almost invisible to policy makers and program designers: "Poverty has not been seen as a women's issue - not by government and sometimes, not by women's groups, not even by anti-poverty groups".

Key Themes

From this Policy Analysis five key themes emerge:

1. The continued importance of gender-based analysis. The research confirms that health policies and programs continue to downplay the importance of socio-economic factors in women's health. The research documents the problems that low-income women face in parenting, in "choosing" healthy behaviours and in accessing services that incorporate their multiple roles as survivors, mothers and caregivers. Health promotion strategies are ineffective if they are based on the assumption that "all women are engaging in risk behaviours by choice".
2. The importance of defining and implementing population health approaches. All of the studies point to the need to define and put into operation the population health approach in ways that would more adequately address the parameters of women's poverty. In the case of social housing, for instance, governments endorse population health ideals while implementing policies that undermine its ideals. In Sharing Our Stories, one woman points out, "It makes me mad when I see hospitals closing, and doctors leaving, yet, they can build onto the casino."
3. The need for further research clearly linking health and poverty. Researchers' attempts to link well-being to economics are compromised by the interplay between a number of factors that are individually capable of affecting health. Poverty can be difficult to isolate from issues of race, social isolation, low self-esteem. The studies do connect poverty with health conditions, particularly stress and mental health concerns. Largely, however, the causal relationships between women's poverty and all types of illness and disease remain invisible and unexplored. Women's health researchers must also work to provide the epidemiological data policy makers demand.
4. The importance of women's stories of their lives and their health. Notwithstanding the above, the voices of the women in the reports provide real evidence of the challenges that low-income women confront. Their voices are descriptive and evocative. Policy models that promote personal responsibility for health without reflecting on the barriers that some individuals and communities face are inadequate. The women who were part of Sexual Violence and Dislocation, for instance, shared their past histories which led to their crucial choices in dismal circumstances. This points to the difficulties in developing effective health policies without extensive and careful consultation with women at risk.
5. The need to promote positive images of poor women, children and families. Living in poverty presents numerous challenges and risks, particularly for those women who are also mothers. Figuring out how to get enough food for the month when you're using grocery money to pay the rent, you have mall kids and no care; keeping your kids happy and out of trouble when you live in a dangerous neighbourhood and can't pay for recreation; moving a couple of times a year in the hope of finding somewhere decent to live - challenges like these fill the days of parents in poverty. One way to end "poor bashing" is to provide women in poverty with opportunities to celebrate their strengths and resourcefulness, while at the same time working towards equity and equality. Society must examine the ways that consumerism shapes values and behaviour.

Consolidated Recommendations

To create a coherent message for future work addressing poverty as a determinant of women's health, the recommendations from the studies cited in this report were analyzed and a set of twelve consolidated recommendations were formed.

1. Expand thinking and commit to further action on the determinants of health.
2. Develop comprehensive strategies for women's equality.
3. Support the creation of healthy communities.
4. Treat women's poverty seriously. Address children's poverty as a common outcome of women's poverty.
5. Commit to developing and implementing a plan to reduce and eliminate poverty.
6. Develop research agendas, policies and programs on women's health and women's poverty in partnership with poor women.
7. Foster and develop supportive networks for poor women.
8. Ensure safe and affordable housing is available for poor women and their families.
9. Commit to improving the health and well-being of Aboriginal women.
10. Develop education programs for women at risk.
11. Require appropriate training for service providers.
12. Recognize non-mainstream professionals, particularly Aboriginal Elders and traditional healers.

Conclusion
The successful implementation of the population health approach depends upon the adoption of a gender lens. The links between poverty and health, coupled with the fact that women comprise the majority of Canada poor, confirm that addressing women's poverty within the context of women's health will enhance the likelihood that reform strategies will exert a positive influence on health status.