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PubMedDate not supplied

The influence of income on health: views of an epidemiologist.

Income is related to health in three ways: through the gross national product of countries, the income of individuals, and the income inequalities among rich nations and among geographic areas. A central question is the degree to which these associations reflect a causal association. If so, redistribution of income would improve health. This paper discusses two ways in which income could be causally related to health: through a direct effect on the material conditions necessary for biological survival, and through an effect on social participation and opportunity to control life circumstances. The fewer goods and services are provided publicly by the community, the more important individual income is for health. Under present U.S. circumstances, a policy of counteracting growing income inequalities through the tax and benefit system and of public provision appears justified.

Adult↗

PubMed1997

Determinants of behavior in homeless and low-income housed preschool children.

OBJECTIVES: To describe the characteristics of homeless and low-income preschool-aged children, and to identify family and environmental determinants of their behavior. METHODS: An unmatched case-control design was used to recruit a sample of sheltered homeless families and a comparison group of low-income housed families who were never homeless in Worcester, Massachusetts. Seventy-seven sheltered homeless and 90 low-income housed mothers with preschool-age children were assessed using a comprehensive interview protocol. Information about mothers' housing, income, service use, par-enting practices, and children's father was obtained. Data about children's background, health, and life events were included. Standardized instruments were administered to assess mothers' mental health and their children's behavior. Comparisons of homeless and low-income housed families were used to describe the sample of 167 preschoolers. Multiple linear regression was used to examine the association of various stressors, such as homelessness, and family factors with their behavior. RESULTS: Although homeless preschoolers were significantly more likely to have experienced stressful life events, undergone a care and protection investigation, and been placed in foster care when compared with low income preschoolers, differences in adverse behaviors were minimal. Although homeless children scored higher than housed children on the internalizing, externalizing, and total problem score on the Child Behavior Checklist (CBCL) (52.5 vs 49.9, 54.8 vs 51.2, and 54.4 vs 51.1, respectively), approximately equal numbers of children from both groups scored in the clinical range. With regard to determinants of behavior, mothers' emotional status was one of the strongest independent predictors of negative behavioral outcomes on both subscales. Foster care placement and death of a child's friend were predictors of adverse internalizing behavioral outcomes on the CBCL. After controlling for housing status, parenting practices, child's age, child's history of physical abuse, and specific life stressors predicted adverse externalizing behavioral outcomes. For both subscales, housing status and behavior were only marginally associated in the multivariate model. CONCLUSIONS: Both homeless and low-income children experienced significant adversity in their lives, with homeless preschool children facing more stress. However, differences in behavior as measured by the CBCL were minimal. Mothers' emotional status, in addition to various stressors, strongly predict children's negative outcomes for both CBCL subscales. These findings emphasize the importance of preventive family-oriented interventions that address the needs of preschoolers and their mothers.

Black or African American↗

PubMed1993

Insurance, income, and access to ambulatory care in King County, Washington.

OBJECTIVES: We studied simultaneous effects of income and insurance on access measures in an indigent population, focusing on Medicaid and the marginal effects of increasing income. METHODS: Surveys were distributed in waiting rooms of county clinics and welfare offices. Models examined insurance (private, Medicaid, or none), income (to twice the poverty level), single-parent status, age, gender, and presence of a regular source of care; first-order interactions were evaluated. RESULTS: In terms of ease of access, postponing care, and having a regular source of care, uninsured respondents fared worst and Medicaid recipients were at an intermediate level. However, relative to those with private insurance, Medicaid recipients had four times the odds, and uninsured respondents twice the odds of being denied care. Income had no consistent effect; however, older, poorer people may have greater problems. For preventive services, income was significant, while differences between Medicaid and private insurance were generally not significant. CONCLUSIONS: Except for denial of care, access for indigent people is improved by Medicaid but remains worse than the access of those with private insurance. Income had variable effects, but support for income criteria used for public insurance eligibility was not found.

Adolescent↗

PubMed2000

The effect of income inequality on the health of selected US demographic groups.

OBJECTIVES: This study assessed whether documented effects of income inequality on health are consistent across demographic subgroups of the US population. METHODS: Data from the National Health Interview Survey on White and Black non-Hispanics were used. Logistic regression models were estimated with SUDAAN software. Perceived health was the outcome variable. RESULTS: The results of the multivariate analysis, in which individual family income and county-level poverty rates were included, were not consistent with existing research. In the presence of covariates, the conditional effects of inequality were restricted to Whites aged 18-44 years in the 2 highest income inequality quartiles and middle-aged Whites in counties with the highest level of income inequality. The health of Blacks of all ages, elderly Whites, and middle-aged Whites outside of the areas of highest inequality was unaffected when controls for individual characteristics and county-level poverty were in place. CONCLUSIONS: For the United States, the independent and direct contribution of income inequality to the determination of self-perceived health net of individual income and county income levels is restricted to certain demographic groups.

Adolescent↗

PubMed2004

Do interventions to increase income improve the health of the poor in developed economies and are such policies cost effective?

Health policy has shifted towards placing a greater emphasis on the role of lifestyle and life circumstances in improving health. The factors that are associated with poor health status are known, but the comparative effectiveness of specific policy interventions in improving health and reducing inequalities in health is unclear. For example, there is little evidence that specific policies aimed at providing income support or poverty eradication have any measurable impact on health. Two previous reviews have addressed the evidence in this area but in a fairly restrictive way. One considered only randomised trials and the other excluded non-cash benefits. This article builds on the previous reviews in three ways: a broader scope of study designs and types of intervention is considered; more recent literature is reviewed; and it considers the extent to which an economic evaluation framework has been applied. A systematic search of electronic databases was carried out for literature published since 1980 and in the English language. Each study was appraised in terms of its relevance to the question of interest, and the quality of the study design was appraised in terms of its capacity to provide robust answers. Few studies were found with health outcomes as their main focus. Most of the studies that used secondary data sources or survey data were of poor quality. Where economic evaluations were reported, these tended to be restricted to financial assessments. Different types of interventions were evaluated. In studies of cash benefits, there was limited evidence that they had a positive effect on some health domains, mainly psychosocial. Studies in welfare-to-work interventions produced mixed results in terms of impact on either income or health; there was no consistent relationship between income gains and health improvements. Five welfare-to-work studies included 'benefit-cost analysis', but these were essentially financial assessments. Studies of benefits in kind did not meet the quality criteria for inclusion in this article. Overall, we found no evidence of the potential cost effectiveness of income support or anti-poverty initiatives in improving health, nor is there a strong effectiveness literature on which to build such analysis. However, the hypothesis that increased income may improve health cannot be said to have been properly tested. Studies generally analyse the incremental effect of changes to the welfare system and do not estimate the health effects of current provisions. The production function for good health is complex. Increasing income may be a necessary, but not a sufficient, condition for the creation of better health in those with low incomes.

Cost-Benefit Analysis↗

PubMed1995

The effect of copayments and income on the utilization of medical care by subscribers to Japan's National Health Insurance System.

This study uses cross-sectional data from Japan's 47 prefectures covering subscribers to Japan's National Health Insurance system to analyze the effects of income and copayment levels on the utilization of medical care. Multivariate regression models were run for the years 1984 and 1989, with the utilization ratio (number of health insurance claims per 100 insurance subscribers) for total, inpatient, outpatient, and dental services as the dependent variable. Independent variables included copayment per patient day, deflated per capita income, population density, percentage of subscribers over age 65, number of beds and clinics per 1,000 persons, and number of doctors and dentists per 1,000 persons. The data were then stratified according to per capita income and percentage of insurance subscribers over the age of 65 in each prefecture. The copayment amount exhibited a small, but significant negative effect on the utilization of all medical services. Utilization of outpatient care was most sensitive to the copayment rate. The per capita income stratification models revealed the greatest copayment effect on inpatient care for the lowest income group. The results of the age stratification models support popular notions about the use of hospitals by the elderly as substitutes for elderly care facilities. The effects of copayments and income vary not only among the type of medical care (inpatient, outpatient, and dental) but also among the income and age stratifications of groups in the National Health Insurance system.

Age Factors↗

PubMed2001

Economic growth, income equality, and population health among the Asian Tigers.

The "Tiger" economies of Southeast Asia provide examples of developing nations where economic growth and increasing income equality are compatible and, when occurring together, are associated with superior health trends over time. The degree of income inequality in the Asian Tigers declined during the period of rapid economic growth. Traditionally, economists have viewed economic growth and relative parity in income distribution as incompatible, or trade-offs. This poses a public policy dilemma, since a reasonable propensity to increase a nation's overall economic well-being would mean forsaking measures that increase income parity. The Asian Tigers, however, have shown that this need not be viewed as a trade-off. Economic growth and a simultaneous increase in income equality are possible and, with respect to health outcomes, desirable. The authors propose a variety of mechanisms through which income inequality can enhance economic growth, and discuss policies in education, agricultural land reform, and housing that influence the simultaneous attainment of income equality and economic growth.

Asia, Southeastern↗

PubMedDate not supplied

The influence of race and gender on family physicians' annual incomes.

PURPOSE: Specialty, work effort, and gender have been shown to be associated with physicians' annual incomes. We hypothesized that provider race might also be associated with differences in family physicians' incomes. Therefore, we conducted a study that used survey data to explore the relationship between provider gender and race and family physicians' annual incomes. METHODS: We used survey responses collected by the American Medical Association (AMA) throughout the 1990s from 786 white male, 20 black male, 159 white female, and 12 black female actively practicing family physicians. We then used linear regression modeling to determine the influence of race and gender on physicians' annual incomes after controlling for work effort, provider characteristics, and practice characteristics. RESULTS: Female family physicians reported seeing substantially fewer patients and working fewer annual hours than their male counterparts. After adjustment for work effort, provider characteristics, and practice characteristics, black men's mean annual income was 178,873 dollars, or 9,309 dollars (5.5%) higher than that for white men (95% Confidence Interval (CI), -18,410 dollars to 37,028 dollars); white women's was 135,531 dollars, or 14,579 dollars (8.6%) lower (95% CI, -25,969 dollars to -3,189 dollars); and black women's was 107,733 dollars, or 36,963 dollars (22%) lower (95% CI, -71,450 dollars to -2,476 dollars). CONCLUSIONS: During the 1990s, female gender was associated with lower annual incomes among family physicians, substantially so for black women. These findings warrant further exploration to determine what factors might cause the gender-based income differences that we found.

Black or African American↗

PubMed1999

Is lower income associated with greater biopsychosocial morbidity? Implications for physicians working with underserved patients.

BACKGROUND: Previous studies have established a powerful relationship between socioeconomic position and health. However, there has been little attention given to the association between income, biopsychosocial morbidity, and decline in health over time among primary care patients. METHODS: Data were collected using a survey mailed to patients receiving care at a family medicine center and through a follow-up survey mailed 2 years later. The independent association between various biopsychosocial measures and family income was assessed through stepwise linear regression. After controlling for baseline health status, the effect of family income on health status at follow-up was assessed. RESULTS: Data were available from 922 active family medicine patients who responded to the initial survey and from 655 who responded to the follow-up survey. In bivariate analyses, lower family income was significantly associated with poorer health status, greater psychological distress, more family dysfunction, less social support, more behavioral risk factors, higher rates of obesity and uncontrolled blood pressure, poorer physical and mental health status, and more medical diagnoses. In a multivariate analysis, age, sex, marital status, race, social network, family criticism, smoking, fat consumption, and health status were independently associated with family income. After controlling for covariates, including baseline health status, family income was a significant predictor of health status at follow-up. CONCLUSIONS: Family income is associated with biopsychosocial morbidity and health decline. Physicians who care for poorer patients will likely be confronted by challenging and complex biopsychosocial problems.

Adult↗

PubMed1998

[Impact of maternal income on the nutrients intake of preschool children--a case study in 8 provinces of China].

The data of this study are based on the project "China Health and Nutrition Survey" carried out in 8 provinces of China from 1989 to 1998 in collaboration with the University of North Carolina at Chapel Hill, USA. Totally, 1180 and 916 mother-child pairs aged 2-6 were investigated in 1991 and 1993 respectively. Descriptive and stratified analysis is applied to investigate the impact of maternal income on the nutrients intake of children. It is found that the nutrients intake of children in higher maternal income group is greater than that in lower maternal income group. After adjusting for family income, the results show that the more contribution of the mother's income to the family, the more nutrients intake of their children, especially in lower income families. It is illustrated that the income of mother may be more important for children's dietary status than that of other members of the family.

Animals↗

PubMed2001

Are the salutogenic effects of social supports modified by income? A test of an "added value hypothesis".

Older adults (54 men, 113 women; M age = 69.5 years) were examined to test the hypothesis that social supports would be more salutogenic (health promoting) for persons with lower incomes than for persons with higher incomes. Interactions of income and social supports (mean of 3 emotional scales of the Interpersonal Support Evaluation List) at study entry predicted changes 15-18 months later in a cardiovascular composite (linear combination of high-density lipoproteins-mean arterial pressure; p < .05), and natural killer cell activity (p < .05). For both outcomes, emotional supports were salutogenic for persons with lower incomes (< or =$29,000/year), but not for persons with higher incomes (>$29,000/year). In contrast, interactions of the Tangible Support Scale with income did not occur. Persons with lower incomes may derive benefits from social supports that go beyond tangible assistance.

Aged↗

PubMed2002

[Tobacco use in Mexican households: results of the Income and Expenses Survey of Households, 1984-2000].

OBJECTIVE: To analyze selected determinants of tobacco consumption in Mexican homes. MATERIAL AND METHODS: Data from the National Household Income and Expenditure Survey, 1984-2000, were analyzed. The analysis was conducted for the years 1984-1992 and 1994-2000. The likelihood of tobacco consumption in households was estimated with a logistic regression model. RESULTS: Tobacco consumption during the first period was two times more likely from decile six (OR = 2.03, 95%, CI: 2.03-2.04) and during the second period from decile eight (OR = 2.06, 95%, CI: 2.05-2.07). Households from decile one spent on average 9-22% of their income on tobacco; almost all of the households from decile ten spent only 1% of their income on tobacco. CONCLUSIONS: Households with higher income consumed more tobacco than households with low income; nevertheless, households with the lowest income devoted a greater proportion of income to tobacco consumption.

Data Collection↗

PubMed2002

Differences in income between male and female primary care physicians.

OBJECTIVES: to determine whether sex differences in income persist among primary care physicians in light of the increasing proportion of women entering the field. METHODS: We obtained sex- and age-specific self-reported data from the American Medical Association's annual survey of physicians to determine the annual income, annual income per hours worked, proportion of time in direct patient care, and outpatient productivity for family practice physicians, general internists, and pediatricians between 1989 and 1998. We compared female to male results for respondents in the 36- to 45-year-old age group as well as for the age-weighted gender aggregate. RESULTS: Female primary care physicians reported lower annual incomes (between 60% and 85% of those of their male counterparts) and lower incomes per hours worked (between 71% and 98% of those of their male counterparts). The income disparities decreased during the 10 years, at a rate of about 1% per year on average. Although the proportion of time female physicians spent in direct patient care activities was similar to that of their male counterparts, female physicians saw substantially more patients per office hour (about 17% more, on average, over time). CONCLUSIONS: Gender inequities persist in the incomes of primary care physicians. Although the disparities appear to be decreasing, female primary care physicians' increased productivity compared with men's suggests that these inequities are perpetuated in more subtle ways and warrant immediate examination and remediation.

Adult↗

PubMed2002

Medicare payment changes and physicians' incomes.

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.

Academic Medical Centers↗

PubMed2005

Household income, health and education in a rural area of Myanmar.

This study was to determine the relationship between a commonly used social stratification indicator, net equivalent income, and self-rated health, long-term disability, visual acuity status, death rate, birth rate, unsafe delivery and school enrollment in a rural area of Myanmar. Data were collected from 3,558 respondents in 805 households of all ages. Data analysis for various items was based on different age groups. The results from two income groups (highest and lowest) are as follows: the percent of those who self-rated their health as very good were 17.8% and 10.4% in the highest and lowest income groups, respectively (adjusted coefficient = 0.30, 95% Cl 0.11-0.50); those with an acute medical condition were found in 16.3% and 20.8% in the highest and lowest income groups, respectively (adjusted OR = 1.35, 95% Cl 1.08-1.68); those with long-term disability were found in 15.3% and 21.2% in the highest and lowest income groups, respectively (adjusted OR = 1.39, 95% Cl 1.05-1.84); and those with poor visual acuity at a distance of 13 feet were found in 8.1% and 13.5% in the highest and lowest income groups, respectively (adjusted OR = 1.64, 95% Cl 1.18-2.30). The birth rate ratio was 1.3, the death rate ratio was 1.2, and school enrollment was found in 92.8% and 83.2% in the highest and lowest income groups, respectively (adjusted OR = 0.34, 95% Cl 0.1-0.8). These results indicate that there is an urgent need to strengthen the health care infrastructure and educational system, targeting the poor in rural areas.

Adolescent↗

PubMed1992

Health policy and the distribution of lifetime income.

A number of health policies have implications for, and in turn can be influenced by, the distribution of income. However, current discussions define the distribution in current, not lifetime, income. This study describes a method of estimating gender and race differences in the distribution of lifetime incomes that account for mortality differences. When cohort lifetime incomes of living and deceased persons are compared, black men are found to be much worse off, whereas white women are found to be better off than existing estimates using annual income suggest. The mortality and lifetime income advantage of white women, however, is offset if, as some argue, white women have higher morbidity rates than white men of the same age. The authors use the concept of lifetime income to draw implications for health policy debates on cigarette and beer taxes, occupational safety and health, Medicaid versus Medicare spending, educational health promotion programs, and general investments in education.

Adult↗

PubMed2001

Family income and crowd out among children enrolled in Massachusetts Children's Medical Security Plan.

OBJECTIVE: To assess whether participation in a state publicly financed health insurance program, Massachusetts Children's Medical Security Plan (CMSP) , which is open to children regardless of income, was associated with disenrollment from private insurance. DATA SOURCES/STUDY DESIGN: A survey of participants in CMSP who were enrolled as of April 1998 was used. We conducted analyses to detect differences in access to and uptake of private insurance between Medicaid-eligible and in eligible children, and between children eligible for the State Children's Health insurance Program (SCHIP) and in eligible children. DATA COLLECTION METHODS: A stratified sample of children was drawn from administrative files. the sampling strategy allowed us to examine crowd out among children based on in come and eligibility for publicly funded coverage: those who were Medicaid-eligible (income pound 133 percent of the federal poverty level [FPL]) , those who were SCHIP-eligible (134-200 percent of FPL) , and those with family in comes that exceed SCHIP eligibility criteria (> 200 percent of FPL). The majority of telephone interviews were conducted with the child's parent/guardian between November 1998 and March 1999. The overall response rate was 61.8 percent , yielding a sample of 996 children. PRINCIPAL FINDINGS: Of the children in our sample whose recent health coverage was employer-sponsored insurance (59 percent), 70 percent were no longer eligible. Few children who had employer-sponsored insurance at enrollment dropped this coverage to enroll in CM SP (1 percent, 4 percent, and 2 percent by income). Compared to Medicaid-eligible children, children with incomes > 133 percent of FPL were significantly more likely to be eligible for employer-sponsored insurance but they were no more likely to have purchased offered coverage. Access to employer-sponsored insurance was limited (19 percent), and uptake was low (13 percent). We found no significant difference between SCHIP-eligible children and those whose family incomes exceeded SCHIP guidelines. CONCLUSIONS: The Massachusetts experience suggests that (1) coverage could be expanded to children with incomes up to 200 percent of FPL with little direct substitution of public coverage for private insurance, and (2) substitution among children with incomes > 200 percent of FPL, who paid a premium that may have restrained crowd out, did not differ from that among SCHIP-eligible children.

Adolescent↗

PubMedDate not supplied

Income inequalities in oral health among older adults in four Ontario communities.

We used data from telephone interviews, personal interviews and clinical examinations to assess income inequalities in oral health among older adults living in four Ontario communities. Lower income groups had significantly higher rates of edentulism than upper income groups. In dentate subjects aged 50 to 64 years, significant associations were observed between income and 9 of 10 clinical, functional and subjective oral health indicators. Among those aged 65 years and over, associations were found for only 5 of these indicators. The data suggested that the association between income and clinical and functional measures of oral health was stronger among those aged 50 to 64 years, while the association between income and subjective indicators was stronger among those aged 65 years and over. No association was noted between income and oral health status among edentulous subjects. These observations are difficult to explain because of the cross-sectional nature of the study and the complexity of the processes which may lead to social inequalities in health. Nevertheless, the data do suggest the need for the targeting of oral health promotion programs and appropriate dental services at disadvantaged groups.

Age Factors↗