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PubMed2000

Relation between income inequality and mortality in Canada and in the United States: cross sectional assessment using census data and vital statistics.

OBJECTIVE: To compare the relation between mortality and income inequality in Canada with that in the United States. DESIGN: The degree of income inequality, defined as the percentage of total household income received by the less well off 50% of households, was calculated and these measures were examined in relation to all cause mortality, grouped by and adjusted for age. SETTING: The 10 Canadian provinces, the 50 US states, and 53 Canadian and 282 US metropolitan areas. RESULTS: Canadian provinces and metropolitan areas generally had both lower income inequality and lower mortality than US states and metropolitan areas. In age grouped regression models that combined Canadian and US metropolitan areas, income inequality was a significant explanatory variable for all age groupings except for elderly people. The effect was largest for working age populations, in which a hypothetical 1% increase in the share of income to the poorer half of households would reduce mortality by 21 deaths per 100 000. Within Canada, however, income inequality was not significantly associated with mortality. CONCLUSIONS: Canada seems to counter the increasingly noted association at the societal level between income inequality and mortality. The lack of a significant association between income inequality and mortality in Canada may indicate that the effects of income inequality on health are not automatic and may be blunted by the different ways in which social and economic resources are distributed in Canada and in the United States.

Canada↗

PubMed2004

Child and family safety device affordability by country income level: an 18 country comparison.

OBJECTIVE: To compare availability, urban price, and affordability of child/family safety devices between 18 economically diverse countries. DESIGN: Descriptive: urban price surveys by local safety organisations or shoppers. SETTING: Retail stores and internet vendors. MAIN OUTCOME MEASURES: Prices expressed in US dollars, and affordability measured by hours of factory work needed to buy a child safety seat, a belt-positioning booster seat, a child bicycle helmet, and a smoke alarm. RESULTS: Prices of child and family safety devices varied widely between countries but the variation for child safety seats and bicycle helmets did not relate strongly to country income. Safety devices were expensive, often prohibitively so, in lower income countries. Far more hours of factory work were required to earn a child safety device in lower income than middle income, and middle income than higher income, countries. A bicycle helmet, for example, cost 10 hours of factory work in lower income countries but less than an hour in higher income countries. Smoke alarms and booster seats were not available in many lower income countries. CONCLUSIONS: Bicycles and two-axle motor vehicles were numerous in lower and middle income countries, but corresponding child safety devices were often unaffordable and sometimes not readily available. The apparent market distortions and their causes merit investigation. Advocacy, social marketing, local device production, lowering of tariffs, and mandatory use legislation might stimulate market growth. Arguably, a moral obligation exists to offer subsidies that give all children a fair chance of surviving to adulthood.

Child↗

PubMed2006

Provincial income inequality and self-reported health status in China during 1991-7.

BACKGROUND: The relationship between income inequality and health has been widely explored. Today there is some evidence suggesting that good health is inversely related to income inequality. After the economic reforms initiated in the early 1980s, China experienced one of the fastest-growing income inequalities in the world. The state of China in the 1990s is focussed on and possible effects of provincial income inequality on individual health status are explored. METHODS: A multilevel regression model is used to analyse the data collected in 1991, 1993 and 1997 from nine provinces included in the China Health and Nutrition Survey. The effects of provincial Gini coefficients on self-rated health in each year are evaluated by two logistic regressions estimating the odds ratios of reporting poor or fair health. The patterns of this effect are compared among the survey years and also among different demographic groups. RESULTS: The analyses show an independent effect of income inequality on self-reported health after adjusting for individual and household variables. Furthermore, the effect of income distribution is not attenuated when household income and provincial gross domestic product per capita are included in the model. The results show that there is an increased risk of about 10-15% on average for fair or poor health for people living in provinces with greater income inequalities compared with provinces with modest income inequalities. CONCLUSIONS: In China, societal income inequality appears to be an important determinant of population health during 1991-7.

China↗

PubMed2006

Social context and depression after a disaster: the role of income inequality.

STUDY OBJECTIVE: To examine the association between neighbourhood income inequality and depression, both overall and among those with different levels of income, in the post-disaster context. DESIGN: A representative cross sectional random digit dial telephone survey was conducted. SETTING: New York City (NYC) six months after September 11, 2001. PARTICIPANTS: 1570 respondents were interviewed, of whom 1355 provided residence information permitting their inclusion in this analysis. Past six month depression was assessed using a lay administered instrument consistent with DSM-IV criteria. Income inequality was measured with the Gini coefficient. MAIN RESULTS: The sample was demographically representative of NYC (56.2% female, 35.7% white, 6.3% Asian 24.2% African American, 29.7% Hispanic, and 4.2% other race or ethnicity) and the prevalence of past six month depression was 12.4%. In a final adjusted model, neighbourhood level income inequality was positively associated with depression but this association was not significant (beta = 7.58, p = 0.1). However, among those with low individual income (< 20,000 US dollars) there was a strong significant association between income inequality and depression (beta = 35.02, p<0.01), while there was no association among those with higher income. CONCLUSIONS: In the post-disaster context, neighbourhood level income inequality was associated with depression among persons with lower income; this group may be more socially or economically marginalized and dependent on local resources. Future research should examine potential mechanisms through which income inequality and other features of the social context may affect mental health in the post-disaster context.

Adolescent↗

PubMed2003

Income inequality and health: multilevel analysis of Chilean communities.

STUDY OBJECTIVE: The evidence supporting the effect of income inequality on health has been largely observed in societies far more egalitarian than the US. This study examines the cross sectional multilevel associations between income inequality and self rated poor health in Chile; a society more unequal than the US. DESIGN: A multilevel statistical framework of 98 344 people nested within 61 978 households nested within 285 communities nested within 13 regions. SETTING: The 2000 National Socioeconomic Characterization Survey (CASEN) data from Chile. PARTICIPANTS: Adults aged 18 and above. The outcome was a dichotomised self rated health (0 if very good, good or average; 1 if poor, or very poor). Individual level exposures included age, sex, ethnicity, marital status, education, employment status, type of health insurance, and household level exposures include income and residential setting (urban/rural). Community level exposures included the Gini coefficient and median income. MAIN RESULTS: Controlling for individual/household predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (OR: 2.94) followed by poor (OR: 2.77), low (OR: 2.06), middle (OR: 1.73), high (OR: 1.38) as compared with the very high income earners. Controlling for household and community effects of income, a significant effect of community income inequality was observed (OR:1.22). CONCLUSIONS: Household income does not explain any of the between community differences; neither does it account for the effect of community income inequality on self rated health, with more unequal communities associated with a greater probability of reporting poor health.

Adolescent↗

PubMed2003

Income related inequalities in self assessed health in Britain: 1979-1995.

STUDY OBJECTIVE: To measure and decompose income related inequalities in self assessed health in England, Scotland, and Wales, 1979-1995. DESIGN: The relation between individual health and a non-linear transformation of equivalised income, allowing for sex, age, country, and year effects, was estimated by multiple regression. The share of health attributable to transformed income and the Gini coefficient for transformed income were calculated. Inequality in health was measured by the partial concentration index, which is the product of the Gini coefficient and the share of health attributable to transformed income. PARTICIPANTS AND SETTING: Representative annual samples of the adult population living in private households in Great Britain 1979-1995. The total analysed sample was 299,968 people. MAIN RESULTS: Pro-rich health inequality was largest in Wales and smallest in England over the period because the effect of increased income on health was greatest in Wales and least in England. In all three countries, pro-rich health inequality increased throughout the period. In the early 1980s this was primarily attributable to increases in income inequality. Thereafter the increased share of health attributable to income was the principal cause. CONCLUSIONS: Reductions in pro-rich health inequality can be achieved by reducing income inequality, reducing the effect of income on health, or both.

Adult↗

PubMed2000

Income inequality and health: what does the literature tell us?

This paper reviews the large and growing body of literature on the apparently negative effects of income inequality on population health. Various hypotheses are identified and described that explain the empirically observed association between measures of income inequality and population health. We have concluded that data from aggregate-level studies of the effect of income inequality on health, i.e. studies at the population and community (e.g. state) levels, are largely insufficient to discriminate between competing hypotheses. Only individual-level studies have the potential to discriminate between most of the advanced hypotheses. The relevant individual-level studies to date, all on U.S. population data, provide strong support for the "absolute-income hypothesis," no support for the "relative-income hypothesis," and little or no support for the "income-inequality hypothesis." Results that provide some support for the income-inequality hypothesis suggest that income inequality at the state level affects mainly the health of the poor. There is only indirect evidence for the "deprivation hypothesis," and no evidence supports the "relative-position hypothesis." Overall, the absolute-income hypothesis, although > 20 years old, is still the most likely to explain the frequently observed strong association between population health and income inequality levels.

Evidence-Based Medicine↗

PubMed2004

Education and the changing shape of the income gradient in health.

Research on the social determinants of health has increasingly sought to understand the relative importance of different features of socioeconomic status. Much of the ensuing debate has wavered between education and income, with recent research leaning increasingly toward income. This research has not, however, consistently explored interactions between different features of socioeconomic status and, in trying to understand the independent effects of different components of socioeconomic status, may have missed important features of socioeconomic position. With an eye toward examining how features of socioeconomic status combine and coalesce, this paper examines variation in the income-health association by level of education. Theories derived both from medical sociology and health economics suggest synergistic interactions between income and education, but they are unclear as to the direction and magnitude of these interactions. Results from two large and nationally representative data sets (the 1996-1997 Community Tracking Study and the 1972-2000 General Social Survey) indicate that the positive relationship between income and health varies substantially in both its strength and shape by level of education. Education improves health, and its effects are larger at lower levels of income. Moreover, education reduces the strength and curvature of the income-health relationship. Consequently, those with more education have better health for all levels of income, and fewer income-based disparities exist among the well educated than among the less well educated. The linear "gradient" relationship between income and health is, thus, more characteristic of groups with higher levels of education. Additional analyses indicate that these interactions existed in the United States in each of the last three decades. The results are discussed in light of theory regarding the perpetuation of health disparities, as well as current debates regarding the apparent incompatibility of distributive versus aggregative goals in health policy.

Adolescent↗

PubMed1998

Income inequality and mortality in metropolitan areas of the United States.

OBJECTIVES: This study examined associations between income inequality and mortality in 282 US metropolitan areas. METHODS: Income inequality measures were calculated from the 1990 US Census. Mortality was calculated from National Center for Health Statistics data and modeled with weighted linear regressions of the log age-adjusted rate. RESULTS: Excess mortality between metropolitan areas with high and low income inequality ranged from 64.7 to 95.8 deaths per 100,000 depending on the inequality measure. In age-specific analyses, income inequality was most evident for infant mortality and for mortality between ages 15 and 64. CONCLUSIONS: Higher income inequality is associated with increased mortality at all per capita income levels. Areas with high income inequality and low average income had excess mortality of 139.8 deaths per 100,000 compared with areas with low inequality and high income. The magnitude of this mortality difference is comparable to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, human immunodeficiency virus (HIV) infection, suicide, and homicide in 1995. Given the mortality burden associated with income inequality, public and private sector initiatives to reduce economic inequalities should be a high priority.

Adolescent↗

PubMed2001

State-level income inequality and individual mortality risk: a prospective, multilevel study.

OBJECTIVES: Previous studies have linked state-level income inequality to mortality rates. However, it has been questioned whether the relationship is independent of individual-level income. The present study tests whether state-level income inequality is related to individual mortality risk, after adjustment for individual-level characteristics. METHODS: In this prospective, multilevel study design, the vital status of National Health Interview Survey (NHIS) respondents was ascertained by linkage to the National Death Index, with additional linkage of state-level data to individuals in the NHIS. The analysis included data for 546,888 persons, with 19,379 deaths over the 8-year follow-up period. The Gini coefficient was used as the measure of income inequality. RESULTS: Individuals living in high-income-inequality states were at increased risk of mortality (relative risk = 1.12; 95% confidence interval = 1.04, 1.19) compared with individuals living in low-income-inequality states. In stratified analyses, significant effects of state income inequality on mortality risk were found, primarily for near-poor Whites. CONCLUSIONS: State-level income inequality appears to exert a contextual effect on mortality risk, after income is adjusted for, providing further evidence that the distribution of income is important for health.

Adolescent↗

PubMed2006

The influence of income and race on total knee arthroplasty in the United States.

BACKGROUND: The associations among income, total knee arthroplasty, and underlying rates of knee osteoarthritis are not well understood. We studied whether high-income Medicare recipients are more likely to have a knee arthroplasty and less likely to suffer from knee osteoarthritis. METHODS: Two data sources were used: (1) the 2000 United States Medicare claims data measuring the incidence of total knee arthroplasty by race, ethnicity, zip (postal) code income, and region (n = 27.5 million) and (2) the National Health and Nutrition Examination Survey (NHANES III) for individuals with an age of sixty years or more (n = 1926) with radiographic and clinical evidence of osteoarthritis. Logistic regression methods were used to adjust for covariates. RESULTS: At the national level, age-adjusted rates of total knee arthroplasty in the high-income quintile were no higher than those in the low-income group (odds ratio, 0.98; 95% confidence interval, 0.96 to 1.00). Within regions, access to care was better for high-income groups (odds ratio, 1.19; 95% confidence interval, 1.17 to 1.22). Racial disparities in arthroplasty were significant (p < 0.001); the odds ratio was 0.36 (95% confidence interval, 0.34 to 0.38) for black men and 0.45 (95% confidence interval, 0.41 to 0.49) for Asian women. There was no evidence of an income gradient for most clinical and radiographic measures of arthritis. The exception was a significant negative association between income and pain on passive motion (p < 0.05). CONCLUSIONS: High-income Medicare enrollees are no less likely to have osteoarthritis than low-income enrollees but have somewhat better access to care. Racial disparities are more important than those that are attributable to socioeconomic status.

Aged↗

PubMedDate not supplied

Misclassification of income quintiles derived from area-based measures. A comparison of enumeration area and forward sortation area.

BACKGROUND: Census-based methods are often used to estimate socioeconomic status. We assessed the agreement between Forward Sortation Area (FSA) and Enumeration Area (EA) derived income levels for all patients undergoing cardiac catheterization in Alberta, Canada, from 1995-1998. METHODS: Income quintiles were calculated from census data for FSA and EA level. FSA- and EA-derived income measures were compared for misclassification. Both methods were then applied to the data to determine 4-year survival by income grouping in 21,446 patients following catheterization. RESULTS: The variability in EA-derived incomes for any given FSA-derived income is large. Only 40% of income quintiles are in agreement between the methods. For EA-based analyses, there is a linear relationship between higher income and lower mortality across all quintiles, while for FSA-based analyses, only the lowest income quintile had significantly higher mortality. DISCUSSION: Assuming that FSA-based methods are more likely to misclassify income compared to EA-based measures, the results for the FSA-based analyses are more likely to be erroneous. EA-derived measures should therefore be used when individual data are not available.

Alberta↗

PubMed2005

[Skewed income distribution and geographical mortality differences].

BACKGROUND: A prominent theme in current health research is whether large income inequality in a society in itself has negative consequences for population health, in addition to the effects of individual risk factors. The present study investigates whether mortality in Norway during the 1990s was higher in geographical regions with particularly skewed income distributions. MATERIAL AND METHODS: Register data for all inhabitants aged 25-66 in Norway in 1992 were used (N = approx. 2.2 millions), including information about deaths 1993-99. Norwegian municipalities were grouped into 23 regions. Gini coefficients indicating the degree of inequality in the income distribution were calculated for each region. Deaths 1993-99 were analysed by means of multiple logistic regression. RESULTS: Odds ratios for deaths 1993-99 were strongly influenced by well-known individual risk factors such as sex, age, marital status, educational level, personal income, and disability. In addition, odds ratios for death were significantly associated with the regions' gini coefficients when adjustments were made for average income level in the regions. This effect of income inequality was pronounced for people with low education, but almost absent among those with higher education. Moreover, the income inequality effect was to some extent driven by special circumstances in Oslo, Norway's capital city, with its high mortality among the less educated and a particularly non-egalitarian income distribution. However, the pattern of higher mortality associated with higher levels of income inequality among the less educated was also observed in the 22 regions outside Oslo. INTERPRETATION: We found a discernible, although not very strong, association between regional income inequality and mortality levels among the less educated. Several interpretations for this statistical tendency could be proposed; the social processes generating this tendency should be clarified further.

Adult↗

PubMed1990

[Stretching the income in the demand for food and other goods in marginal urban populations in the city of Guatemala].

The purpose of the present study was to evaluate the impact of changes in income and retail prices on the consumption of foods by low income groups living in Guatemala. A representative sample of 200 low-income families living in a marginal area of Guatemala City, known as "El Milagro", was studied. Of five surveys conducted, two concerned food demand exclusively. In the first one the food consumption survey used was the 24-hr recall method, and the second survey was related to income expenditures, obtaining weekly information on expenses on foods and in other items. The expenditures were utilized to estimate the elasticity of demand, including foods. Total family expenses were used as an estimation of total income. Analyses of the data were obtained by forming three income groups: families with per capita expenses below the per capita cost of the foods basket; families with per capita expenses within the cost of the food basket, and the cost of a modified food basket (all expenses); families with an income above the modified food basket. The analyzed data clearly confirmed that: a) food expenses increase less as a response to income increases than expenses for other family needs; the income elasticity for foods high in carbohydrates content is lower with respect to food of animal origin and the income elasticity of the demand for rice and wheat bread are higher in comparison to the more basic foods such as beans, maize and maize products, roots and tubers.

Child↗

PubMed1989

Changes in mortality by income in urban Canada from 1971 to 1986.

The reduction of socio-economic inequities in health is now an explicit objective of health policy in Canada. This study examines changes in mortality by income in urban Canada from 1971 to 1986 in terms of both relative and absolute differences between income groups. Street address information as shown on death certificates was used to code census tract of usual place of residence for deaths occurring to residents of Canada's Census Metropolitan Areas (CMAs) in 1971 and 1986. After exclusion of residents of health care institutions, 73,995 deaths were included in the study for 1971, and 88,129 for 1986. These deaths were analyzed by income quintile (based on census tract incidence of low income), age, sex, and cause of death. In 1971, the difference in life expectancy at birth between the highest and lowest income quintiles was 6.3 years for men and 2.8 years for women. By 1986, these differences had decreased to 5.6 years for men and 1.8 years for women. However, relative mortality (lowest compared to highest income quintile) at most ages changed only slightly over the 15 years. Relative infant mortality, for example, was 1.97 in 1971 and 1.82 in 1986. In 1986, 21% of total potential years of life lost (PYLL) prior to age 75 could be attributed to differences in quintile death rates compared to rates for the highest income quintile. Approximately 45% of this "excess" PYLL was for persons under 45 years of age. In 1971, the comparable figure was 67%. In 1986, the major causes of death contributing to income inequalities in mortality were: circulatory diseases, accounting for 25% of excess PYLL related to quintile differences; accidents, poisonings and violence, accounting for about 17%; and neoplasms, accounting for 15%. Respiratory diseases, ill-defined conditions, metabolic diseases and perinatal conditions each contributed 6-7% of excess PYLL. From 1971 to 1986, in terms of age-standardized morality rates (ASMRs) for all ages, certain causes of death showed increased mortality together with greater inequality by income, especially for males: these causes included lung cancer, suicide, metabolic diseases other than diabetes, and ill-defined conditions. Other causes of death showed either little change or less inequality by income but higher ASMRs: these included breast cancer, colon and rectal cancer, arterial diseases, alcoholism, mental disorders, and diseases of the nervous system.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed1986

Effect of income and WIC on the dietary intake of preschoolers: results of a preliminary study.

Dietary composition of energy and four nutrients targeted by the Supplemental Food Program for Women, Infants, and Children (WIC) were assessed among a random sample of 106 children aged 1 to 5 years. Fifty-one percent of children were from households with incomes above WIC eligibility levels. Of the 49% of children from households eligible for WIC by income, 42% participated in WIC. Children from low-income households were significantly more likely to have low dietary intakes of energy, vitamin C, and iron than children from higher-income households. Low-income children participating in WIC were significantly less likely to have low iron intakes than children who were eligible by income level but not participating in WIC. The percentage of children with low intakes of vitamin A and calcium did not significantly vary by household income level or by participation in WIC. Data from this preliminary study indicate that low-income children in the sample surveyed are at higher risk for consuming diets low in energy and two of four nutrients targeted by the WIC program than are children from higher-income households and that participation in WIC improves the iron intake of low-income children.

Ascorbic Acid↗

PubMed1985

Income of new retired workers by age at first benefit receipt: findings from the New Beneficiary Survey.

Using data from the New Beneficiary Survey (NBS) of the Social Security Administration (SSA), this article examines how income sources and total monthly income received by newly retired social security beneficiaries vary with the age at which the first benefit check was received. The NBS respondents who received a first benefit at age 65 or older were better off economically than were those who received a first benefit at ages 62-64. At the time of the interview, 18-30 months after receiving a first benefit, these older beneficiaries had higher levels of total income and were more likely to have income from earnings and assets. Pension receipt rates did not vary by the age at which the first social security benefit was received except for married women retired workers, for whom the rate was higher at the older ages. The largest proportion of aggregate income (slightly more than one-third) was derived from social security benefits. More than 90 percent of the NBS Medicare-only respondents--a sample of nonbeneficiaries who were eligible for monthly cash benefits but had established their entitlement only for the purpose of enrolling in the Medicare program--reported earnings income. They had lower rates of pension receipt and higher rates of asset income receipt than the retired workers. The Medicare-only respondents had substantially higher incomes than did retired workers, and most of their aggregate income was from earnings. The NBS retirees were generally in better financial condition than a group of social security beneficiaries aged 65 or older from all benefit categories in the Current Population Survey Income Supplement with whom they were compared.

Age Factors↗

PubMed1995

The distribution of OASDI taxes and benefits by income decile.

On average, persons receiving Social Security benefits tend to have lower current incomes than do persons paying Social Security taxes. This article documents OASDI's income distributional patterns by dividing the 1992 Current Population Survey population into 10 income deciles and tabulating benefits received and taxes paid by each decile. The benefits and taxes, when compared with non-Social Security income, are progressive: as income rises from decile to decile, the ratio of benefits to income falls, and, except at the highest deciles, the ratio of taxes to income rises. A large component of the current income distributional pattern is associated with age: the young on average receive more income and pay more taxes; the old on average receive more benefits. However, when benefits and taxes are tabulated for income deciles within specific age groups, a general progressivity is still observable, although it is weaker than that for the population as a whole.

Adolescent↗