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PubMed2005

Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation.

The research identified gaps in Canadian knowledge and research activity concerning the roles that income and its distribution play in Canadians' population health. 241 Canadian research studies on income and health were considered along eight taxonomies: conceptualization of income or its proxies; theoretical underpinnings; income distribution measures; health measures; who/what was studied, pathways mediating between income and health; complexity of these pathways; research design; and presence of policy implications. The study identified the following areas of weakness: (a) poor conceptualization of income and the means by which it influences health; (b) lack of longitudinal studies of the impact of income-related issues upon health across the life-span; (c) lack of linked data bases that allow complex analyses of how income and related issues contribute to health and well-being, and (d) little inter-disciplinary work in identifying pathways mediating the income and health relationship. Advances in health policy to address the health effects of income and its distribution requires a research infrastructure that draws upon recent theoretical developments in the area and is able to access data sources to test these advanced conceptualizations.

Canada↗
PubMed2004

The impact of income: assessing the relationship between income and health in Sweden.

AIMS: This paper explores the relationship between income and health among adults in Sweden. An analysis was made as to what extent the association differs when one studies individual earnings and equivalent disposable income, as well as gender differentials. Further, a study was undertaken to investigate how, and by what magnitude, the income-health relationship changes when one controls for other structural factors, such as education and class. Finally the functional form of the relationship was scrutinized, because of its obvious policy impact. METHODS: Data came from the 1996-97 Swedish Living Condition Surveys, which include individuals aged 25-64 (n=7,201). Logistic regression was used, including various polynomial terms of the income variable. RESULTS: The results show that both earnings and disposable household income are strongly related to health, a finding that holds for both women and men. The strength of the association becomes somewhat weaker when one controls for other structural factors, but in the final model the association is in fact about the same as the bivariate association, owing to the impact of age. Moreover, a curvilinear association was revealed by the authors' analyses. CONCLUSIONS: A clear association was found between income and health, also when other structural variables are controlled for. This indicates that income, as such, is of great importance for the risk of illness. The shape of the association between income and health is consistent with earlier debates concerning the relation between income distribution and population health indicators, and, as such, indicates that income-equalizing policies may have an impact on health.

Adult↗
PubMed2006

Use of health care services by lower-income and higher-income uninsured adults.

CONTEXT: More than 45 million individuals in the United States lack health insurance, potentially limiting their access to and use of appropriate health care services. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care. OBJECTIVE: To examine whether having higher income attenuates the association between being uninsured and using fewer recommended health care services. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of data from the 2002 Behavioral Risk Factor Surveillance System, drawn from a nationally representative sample of households. Participants were community-dwelling adults (n = 194 943; 50% women) aged 18 to 64 years in 2002. MAIN OUTCOME MEASURES: Self-reported use of screening for cervical, breast, and colorectal cancer; serum cholesterol screening and measurement, aspirin use, and tobacco cessation and weight loss counseling for cardiovascular risk reduction; and serum cholesterol and glycosylated hemoglobin measurement, eye and foot examination, and influenza and pneumococcal vaccination for diabetes management. RESULTS: Among eligible adults, use of cancer prevention services ranged from 51% for colorectal cancer screening to 88% for cervical cancer screening, while use of cardiovascular risk reduction services ranged from 38% for weight loss counseling to 81% for aspirin use, and use of services for diabetes management ranged from 33% for pneumococcal vaccination to 88% for serum glycosylated hemoglobin measurement. In bivariate analyses, health insurance and annual household income were both strongly associated with use of nearly all examined health care services (P values <.01). Using multivariable analysis, increased annual household income did not significantly increase the likelihood of uninsured compared with insured adults receiving recommended health care services for cancer prevention, cardiovascular risk reduction, or diabetes management (P values >.05). CONCLUSIONS: Even among higher-income adults, lack of health care insurance was associated with significantly decreased use of recommended health care services; increased income did not attenuate the difference in use between uninsured and insured adults. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.

Adult↗
PubMed2003

Is exposure to income inequality a public health concern? Lagged effects of income inequality on individual and population health.

OBJECTIVE: To examine the health consequences of exposure to income inequality. DATA SOURCES: Secondary analysis employing data from several publicly available sources. Measures of individual health status and other individual characteristics are obtained from the March Current Population Survey (CPS). State-level income inequality is measured by the Gini coefficient based on family income, as reported by the U.S. Census Bureau and Al-Samarrie and Miller (1967). State-level mortality rates are from the Vital Statistics of the United States, other state-level characteristics are from U.S. census data as reported in the Statistical Abstract of the United States. STUDY DESIGN: We examine the effects of state-level income inequality lagged from 5 to 29 years on individual health by estimating probit models of poor/fair health status for samples of adults aged 25-74 in the 1995 through 1999 March CPS. We control for several individual characteristics, including educational attainment and household income, as well as regional fixed effects. We use multivariate regression to estimate the effects of income inequality lagged 10 and 20 years on state-level mortality rates for 1990, 1980, 1970, and 1960. PRINCIPAL FINDINGS: Lagged income inequality is not significantly associated with individual health status after controlling for regional fixed effects. Lagged income inequality is not associated with all cause mortality, but associated with reduced mortality from cardiovascular disease and malignant neoplasms, after controlling for state fixed-effects. CONCLUSIONS: In contrast to previous studies that fail to control for regional variations in health outcomes, we find little support for the contention that exposure to income inequality is detrimental to either individual or population health.

Adult↗
PubMed1997

Racial differences in retirement income: the roles of public and private income sources.

Despite great overall improvement in the elderly's economic status over the past two decades, minority elders still comprise the poorest population group of all. Nonetheless, the income security of minority elders has not been given special attention in the scrutiny in recent years of the size and the future of various federal programs affecting older persons. Based on data from the 1971, 1981, and 1991 public-use data tapes of the Current Population Survey, the racial difference in income status of the elderly and the role of Social Security and Supplemental Security income versus that of income from private sources are analyzed in terms of how income inequality among races is ameliorated or escalated. The findings show that racial/ethnic differences in income status increased between 1970 and 1990. The findings also confirm that, for both elderly singles and couples, Social Security is the most important income source. Without it, poverty rates among elderly black couples, for example, would have increased by as much as 48.5 percentage points in 1990. Policies that would help improve the income status of the low-income elderly are discussed.

Black or African American↗
PubMed2003

Neighbourhood low income, income inequality and health in Toronto.

OBJECTIVES: This study examines the association of neighbourhood low income and income inequality with individual health outcomes in Toronto, Canada's largest census metropolitan area. DATA SOURCES: The data are from the cross-sectional component of Statistics Canada's 1996/97 National Population Health Survey (NPHS) and the 1996 Census of Population. ANALYTICAL TECHNIQUES: Individual records for Toronto residents aged 12 or older who responded to the 1996/97 NPHS were augmented with aggregated data from the 1996 Census to provide information on the average socio-economic characteristics of the respondents' neighbourhoods. Hierarchical linear models were used to estimate the effect of low income and income inequality at the neighbourhood level on selected health outcomes. MAIN RESULTS: When individual low-income status and several other individual characteristics were taken into account, the neighbourhood low-income rate and income inequality were not associated with individuals' reported number of chronic conditions or distress. However, both low income and income inequality at the neighbourhood level remained significantly associated with poor self-perceived health.

Adolescent↗
PubMed2006

Role of radiotherapy in cancer control in low-income and middle-income countries.

More than half the cases of cancer in the world arise in people in low-income and middle-income countries. This proportion will rise to 70% by 2020. These are regions where the annual gross national income per person is less than 9386 US dollars. Radiotherapy is an essential part of the treatment of cancer. In high-income countries, 52% of new cases of cancer should receive radiotherapy at least once and up to 25% might receive a second course. Because of the different distribution of tumour types worldwide and of the advanced stage at presentation, patients with cancer in low-income and middle-income regions could have a greater need for radiotherapy than those in high-income countries. Radiotherapy for cure or palliation has been shown to be cost effective. Many countries of low or middle income have limited access to radiotherapy, and 22 African and Asian countries have no service at all. In Africa in 2002, the actual supply of megavoltage radiotherapy machines (cobalt or linear accelerator) was only 155, 18% of the estimated need. In the Asia-Pacific region, nearly 4 million cases of cancer arose in 2002. In 12 countries with available data, 1147 megavoltage machines were available for an estimated demand of nearly 4000 megavoltage machines. Eastern Europe and Latin America showed similar shortages. Strategies for developing services need planning at a national level and substantial investment for staff training and equipment. Safe and effective development of services would benefit from: links with established facilities in other countries, particularly those within the same region; access to information, such as free online journal access; and better education of all medical staff about the roles and benefits of radiotherapy.

Cost-Benefit Analysis↗
PubMed1982

Does income affect mortality? An analysis of the effects of different types of income on age/sex/race-specific mortality rates in the United States.

This article explores the question of whether or not higher incomes are associated with lower mortality rates. Some recent research on this issue has suggested that income either has no effect on or may even be positively correlated with mortality rates. By contrast, earlier studies consistently found a negative relationship--higher income (or economic status) was generally associated with lower mortality rates. This paper extends the prior research in two significant ways. First, the issue is analyzed separately for eight adult and four infant age/sex/race-specific population cohorts. Second, total family income is broken down into several components to investigate whether different types of income have differential effects on mortality rates. In addition, the problem of untangling the joint effects of education and income on mortality also is explored. The results tend to support the hypothesis that higher income is associated with lower mortality rates. However, the magnitude of the impact of income is small, although it is consistently larger for infants than for adults.

Adolescent↗
PubMed2002

Income inequality, individual income, and mortality in Danish adults: analysis of pooled data from two cohort studies.

OBJECTIVE: To analyse the association between area income inequality and mortality after adjustment for individual income and other established risk factors. DESIGN: Analysis of pooled data from two cohort studies. The relation between income inequality in small areas of residence (parishes) and individual mortality was examined with Cox proportional hazard analyses. SETTING: Two population studies conducted in Copenhagen, Denmark. PARTICIPANTS: 13 710 women and 12 018 men followed for a mean of 12.8 years. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: Age standardised mortality was highest in the parishes with the least equal income distribution. After adjustment for individual risk factors, parish income inequality was not associated with mortality, whereas individual household income was. Thus, individuals in the highest income quarter had lower mortality than those in the lowest quarter (adjusted hazard ratio for men 0.51 (95% confidence interval 0.45 to 0.59) and for women 0.60 (0.54 to 0.68)). CONCLUSION: Area income inequality is not in itself associated with all cause mortality in this Danish population. Adjustment for individual risk factors makes the apparent effect disappear. This may be the result of Denmark's welfare system, based on a Nordic model.

Adult↗
PubMed2005

Associations between income inequality and mortality among US states: the importance of time period and source of income data.

OBJECTIVES: We used census data to examine associations between income inequality and mortality among US states for each decade from 1949 to 1999 and tax return income data to estimate associations for 1989. METHODS: Cross-sectional correlation analyses were used to assess income inequality-mortality relationships. RESULTS: Census income analyses revealed little association between income inequality and mortality for 1949, 1959, or 1969. An association emerged for 1979 and strengthened for 1989 but weakened for 1999. When income inequality was based on tax return data, associations were weaker for both 1989 and 1999. CONCLUSIONS: The strong association between income inequality and mortality observed among US states for 1989 was not observed for other periods from 1949 through 1999. In addition, when tax return rather than census data were used, the association was weaker for 1989 and 1999. The potential for distal social determinants of population health (e.g., income inequality) to affect mortality is contingent on how such determinants influence levels of proximal risk factors and the time lags between exposure to those risk factors and effects on specific health outcomes.

Censuses↗
PubMed1984

Regional income differences and the definition of income: the case of Malaysia.

"Data from the Malaysian Family Life Survey are used to examine the sensitivity of urban/rural income differentials to the definition and measurement of income. Measured income differentials vary with the extent to which nonmarket activities are included in the scope of income, how the distribution of income is summarized, and whether one adjusts for differences in hours of work, household size and composition, ethnic composition, and other sociodemographic characteristics. For example, depending on the measure chosen, estimates of the amount by which urban income exceeds rural income in Malaysia range from 9 percent to 141 percent."

Asia↗
PubMed2002

Income, income inequality and health: what can we learn from aggregate data?

It has been suggested that, especially in countries with high per capita income, there is an independent effect of income distribution on the health of individuals. One source of evidence in support of this relative income hypothesis is the analysis of aggregate cross-section data on population health, per capita income and income inequality. We examine the empirical robustness of cross-section analyses by using a new data set to replicate and extend the methodology in a frequently cited paper. The estimated relationship between income inequality and population health is not significant in any of our estimated models. We also argue there are serious conceptual difficulties in using aggregate cross-sections as a means of testing hypotheses about the effect of income, and its distribution, on the health of individuals.

Cross-Sectional Studies↗
PubMed1979

Comparing the medical utilization and expenditures of low income health plan enrollees with Medicaid recipients and with low income enrollees having Medicaid eligibility.

The study examines the medical care (hospital, physician, drug, diagnostic) utilization and expenditures of low income persons enrolled in a prepaid health plan with a matched group of Medicaid recipients. The study also examines the medical care utilization of low income persons enrolled in a prepaid health plan with a similar group of low income persons enrolled in the health plan but also eligible for Medicaid benefits. Utilization and population-at-risk data were obtained from the Kaiser-Permanente Medical Care Program of Portland, Oregon and from the State of Oregon Welfare Division. A hypothesis of lower hospital utilization by low income enrollees compared with Medicaid recipients was accepted. A hypothesis of higher ambulatory care utilization was accepted for diagnostic procedures and prescription use, but rejected for office visit utilization. An analysis of the findings appeared to implicate the Medicaid program for differences observed. The hypotheses of no significant differences in inpatient and ambulatory medical care utilization of low income health plan enrollees with and without Medicaid eligibility were generally rejected. Low income enrollees with concurrent Medicaid had consistently higher utilization rates for all services resulting in substantially higher medical care expenditures per person. The findings appear to contribute some useful information to planning or establishing policy for Medicaid Prepayment programs or other programs enrolling low income persons in prepaid health plans or HMOs.

Adolescent↗
PubMed2005

Wider income gaps, wider waistbands? An ecological study of obesity and income inequality.

OBJECTIVES: To see if obesity, deaths from diabetes, and daily calorie intake are associated with income inequality among developed countries. DESIGN: Ecological study of 21 developed countries.Countries: Countries were eligible for inclusion if they were among the top 50 countries with the highest gross national income per capita by purchasing power parity in 2002, had a population over 3 million, and had available data on income inequality and outcome measures. MAIN OUTCOME MEASURES: Percentage of obese (body mass index >30) adult men and women, diabetes mortality rates, and calorie consumption per capita per day. RESULTS: Adjusting for gross national per capita income, income inequality was positively correlated with the percentage of obese men (r = 0.48, p = 0.03), the percentage of obese women (r = 0.62, p = 0.003), diabetes mortality rates per 1 million people (r = 0.46, p = 0.04), and average calories per capita per day (r = 0.50, p = 0.02). Correlations were stronger if analyses were weighted for population size. The effect of income inequality on female obesity was independent of average calorie intake. CONCLUSIONS: Obesity, diabetes mortality, and calorie consumption were associated with income inequality in developed countries. Increased nutritional problems may be a consequence of the psychosocial impact of living in a more hierarchical society.

Adult↗
PubMed1999

Projecting retirement income of future retirees with panel data: results from the modeling income in the near-term (MINT) project.

Cross-sectional data capture only a point in time and miss individual changes in earnings, labor force participation, marriage, fertility, and health. Because panel data follow individuals over time, they do not have this problem. The problems or concerns with cross-sectional data may be compounded when these data are used to make projections. Iams and Sandell (1997) found that using panel data on earnings explained much more variation in future earnings than using cross-sectional survey data. Panel data are also needed to estimate Social Security benefits, especially for women. Because of auxiliary benefits paid to spouses, ex-spouses, and widow(er)s of entitled workers, an individual's Social Security retirement benefit depends not only on his or her earnings history, but also on his or her marital history and the earnings histories of current and previous spouses. When we compare projected unreduced Social Security benefits with what they would be if we didn't have marital history or earnings history data for men, we find that: Benefits computed using only earnings histories are not very different from benefits computed using both earnings and marital histories. Benefits computed using only current earnings and marital histories underestimate benefits for those in earlier birth cohorts and overestimate benefits for those in the most recent birth cohort. Benefits computed without either marital or earnings histories underestimate benefits for all birth cohorts, but by much more for earlier cohorts than for more recent cohorts. For women we find that benefits computed without marital or earnings histories underestimate benefits in all birth cohorts. The largest differences are for women in earlier birth cohorts. Using both marital and earnings histories to estimate unreduced Social Security benefits, we find that men are projected to continue receiving higher benefits than women, although the gap is expected to narrow as the baby boomers near retirement age. We also look at the composition of projected total income available at retirement for those with incomes in the 45th-55th percentiles of the income distribution and find that: Total income at retirement is projected to be larger for men than for women in every birth cohort. Women are projected to receive the largest share of their total income from Social Security benefits. Men are projected to receive the largest share of their total income from other income sources, although this share declines as the baby boomers near retirement age.

Cohort Studies↗
PubMed2000

Individual income, income inequality, health, and mortality: what are the relationships?

OBJECTIVE: To examine the pathways between income inequality, self-rated health, and mortality in the United States. DATA SOURCE: The first National Health and Nutrition Examination Survey and Epidemiologic Follow-up Study. DESIGN: This was a longitudinal, multilevel study. DATA COLLECTION: Baseline data were collected on county income inequality, individual income, age, sex, self-rated health, level of depressive symptoms, and severity of biomedical morbidity from physical examination. Follow-up data included self-rated health assessed in 1982 through 1984 and mortality through 1987. PRINCIPAL FINDINGS: After adjustment for age and sex, income inequality had a modest independent effect on the level of depressive symptoms, and on baseline and follow-up self-rated health, but no independent effect on biomedical morbidity or subsequent mortality. Individual income had a larger effect on severity of biomedical morbidity, level of depressive symptoms, baseline and follow-up self-rated health, and mortality. CONCLUSION: Income inequality appears to have a small effect on self-rated health but not mortality; the effect is mediated in part by psychological, but not biomedical pathways. Individual income has a much larger effect on all of the health pathways.

Adult↗
PubMed1999

Assessing ecologic proxies for household income: a comparison of household and neighbourhood level income measures in the study of population health status.

This paper examines the validity of using ecologic measures of socioeconomic status as proxies for individual-level measures in the study of population health. Based on a representative 5% sample of households in a Canadian province, the study integrated three sources of information: administrative records of individual health care utilization, records of deaths and 1986 census records which contained information on household income and average neighbourhood income. Thirteen measures of health status were developed from these sources of information. The hypothesis that risk estimates derived from ecologic income measures will be attenuated relative to estimates obtained from household income was not supported. These results provide evidence for the use of ecologic-level measures of income in studies which do not have access to individual-level income measures.

Adolescent↗