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PubMed2005

The appearance of discretionary income: influence on the prevalence of under- and over-nutrition.

Undernutrition--protein energy malnutrition or specific nutrient deficiencies--has been an inherent characteristic of impoverished populations throughout the world. Over-nutrition, obesity and nutrition imbalance is a current concern among those with rising though still insufficient incomes. We review data to suggest that the prevalence of these forms of malnutrition in populations is highly influenced by the rate of appearance of discretionary income. In developed countries, discretionary (alternatively "disposable") income refers to funds available after obligate payments (rent, heat, and the cost of getting to work) and payment for necessities (food and clothing). For families living at or below poverty, the last dollar earned is spent on these obligations. Undernutrition is common. By contrast, likelihood for obesity or imbalance increases with rising income when that last dollar is earned without certainty that it is available for discretionary spending. In the United States, neither under- nor over-nutrition is likely when new income is free and clear of debt or obligation. This occurs at approximately three times the poverty level. While income poverty and food insecurity affect risk for malnutrition rather than outcome, nutrition education programs that address issues of income and food support increase likelihood for adherence to recommendations.

Journal Article↗

PubMed2005

The relationship between income and performance indicators in general practice: a cross-sectional study.

OBJECTIVE: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices. DESIGN: Cross-sectional survey. SETTING: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied. MAIN OUTCOME MEASURES: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators. RESULTS: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized beta = 0.66, P < 0.001; beta = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smear and two-year-old vaccination rates (standardized beta = 0.24, P < 0.01; beta = 0.18, P = 0.03; respectively). No association was demonstrated between performance indicators and income. CONCLUSION: Under the previous contract, GPs were able to maximize their income by taking on more patients, whereas achievement of performance targets had very little impact on overall income. The opportunity costs of pursuing higher-quality care might have outweighed the modest financial rewards attached to performance targets. Provided rewards for good-quality care are sufficiently high, the new GP contract is likely to tip the balance in favour of generating earnings by improving the quality of clinical care. To deliver this care, as measured by available performance indicators, our findings imply that a greater investment in practice staff will be needed.

Cross-Sectional Studies↗

PubMed2005

The politics of invisibility: homophobia and low-income HIV-positive women who have sex with women.

HIV-positive women who have sex with women (WSW) have been overlooked by government researchers, health care providers and the AIDS service community. In addition to stigmas against homosexuality and HIV in larger society, low-income, African-American and Latina HIV-positive WSWs face culturally-based stigmas and are disproportionately affected by poverty, drug addiction, homelessness, sex work and abuse. Through an analysis of sixteen intensive interviews with low-income HIV-positive WSWs of color, I critically examine the physical, emotional and psychological needs of this population and their methods of coping with HIV. I also examine the participants' percepHIV-positive women who have sex with women (WSW) have been overlooked by government researchers, health care providers and the AIDS service community. In addition to stigmas against homosexuality and HIV in larger society, low-income, African-American and Latina HIV-positive WSWs face culturally-based stigmas and are disproportionately affected by poverty, drug addiction, homelessness, sex work and abuse. Through an analysis of sixteen intensive interviews with low-income HIV-positive WSWs of color, I critically examine the physical, emotional and psychological needs of this population and their methods of coping with HIV. I also examine the participants' percepHIV-positive women who have sex with women (WSW) have been overlooked by government researchers, health care providers and the AIDS service community. In addition to stigmas against homosexuality and HIV in larger society, low-income, African-American and Latina HIV-positive WSWs face culturally-based stigmas and are disproportionately affected by poverty, drug addiction, homelessness, sex work and abuse. Through an analysis of sixteen intensive interviews with low-income HIV-positive WSWs of color, I critically examine the physical, emotional and psychological needs of this population and their methods of coping with HIV. I also examine the participants' perceptions of available support networks and patterns of disclosure in order to raise awareness of their struggle against HIV and homophobia and to assist in empowering the low-income HIV-positive WSW community.

Adaptation, Psychological↗

PubMed2006

Welfare receipt and substance-abuse treatment among low-income mothers: the impact of welfare reform.

OBJECTIVES: We explored changing relations between substance use, welfare receipt, and substance-abuse treatment among low-income mothers before and after welfare reform. METHODS: We examined annual data from mothers aged 18 to 49 years in the 1990-2001 National Household Survey of Drug Abuse and the 2002 National Survey of Drug Use and Health. Logistic regression was used to examine determinants of treatment receipt. RESULTS: Among low-income, substance-using mothers, the proportion receiving cash assistance declined from 54% in 1996 to 38% in 2001. The decline was much smaller (37% to 31%) among low-income mothers who did not use illicit substances. Low-income, substance-using mothers who received cash assistance were much more likely than other low-income, substance-using mothers to receive treatment services. Among 2002 National Survey of Drug Use and Health respondents deemed "in need" of substance-abuse treatment, welfare recipients were significantly more likely than nonrecipients to receive such services (adjusted odds ratio=2.31; P<.05). Controlling for other factors, welfare receipt was associated with higher prevalence of illicit drug use. Such use declined among both welfare recipients and other mothers between 1990 and 2001. CONCLUSIONS: Welfare is a major access point to identify and serve low-income mothers with substance-use disorders, but it reaches a smaller proportion of illicit drug users than it did prereform. Declining welfare receipt among low-income mothers with substance abuse disorders poses a new challenge in serving this population.

Adolescent↗

PubMed1994

Low-income neighborhoods and the risk of severe pediatric injury: a small-area analysis in northern Manhattan.

OBJECTIVES: The purpose of this study was to investigate the relationship between socioeconomic disadvantage and the incidence of severe childhood injury. METHODS: Small-area analysis was used to examine socioeconomic risk factors for pediatric injury resulting in hospitalization or death in Northern Manhattan, New York, NY, during a 9-year period (1983 through 1991). RESULTS: The average annual incidence of all causes of severe pediatric injury was 72.5 per 10,000 children; the case-fatality rate was 2.6%. Census tract proportions of low-income households, single-parent families, non-high school graduates, and unemployment were significant predictors of risk for both unintentional and intentional injury. Among the socioeconomic factors considered, low income was the single most important predictor of all injuries; other socioeconomic variables were not independent contributors once income was included in the model. Compared with children living in areas with few low-income households, children in areas with predominantly low-income households were more than twice as likely to receive injuries from all causes and four and one half times as likely to receive assault injuries. The effect of neighborhood income disparities on injury risk persisted after race was controlled. CONCLUSIONS: These results illuminate the impact of socioeconomic disparities on child health and point to the need for injury prevention efforts targeting low-income neighborhoods.

Adolescent↗

PubMed2004

Environmental justice, cumulative environmental risk, and health among low- and middle-income children in upstate New York.

OBJECTIVES: We documented inequitable, cumulative environmental risk exposure and health between predominantly White low-income and middle-income children residing in rural areas in upstate New York. METHODS: Cross-sectional data for 216 third- through fifth-grade children included overnight urinary neuroendocrine levels, noise levels, residential crowding (people/room), and housing quality. RESULTS: After control for income, maternal education, family structure, age, and gender, cumulative environmental risk exposure (0-3) (risk >1 SD above the mean for each singular risk factor [0, 1]) was substantially greater for low-income children. Cumulative environmental risk was positively correlated with elevated overnight epinephrine, norepinephrine, and cortisol in the low-income sample but not in the middle-income sample. CONCLUSIONS: Cumulative environmental risk exposure among low-income families may contribute to bad health, beginning in early childhood.

Child↗

PubMed2004

Relative weight and income at different levels of socioeconomic status.

OBJECTIVES: We examined the association of relative weight with individual income at different levels of socioeconomic status among gainfully employed Finnish women and men. METHODS: We used a population-based survey including 2068 women and 2314 men with linked income data from a taxation register. Regression analysis was used to calculate mean income levels within educational and occupational groups. RESULTS: Compared with their normal-weight counterparts, obese women with higher education or in upper white-collar positions had significantly lower income; a smaller income disadvantage was seen in overweight women with secondary education and in manual workers. Excess body weight was not associated with income disadvantages in men. CONCLUSIONS: Obesity is associated with a clear income disadvantage, particularly among women with higher socioeconomic status.

Adult↗

PubMed2000

Adverse selection and price sensitivity when low-income people have subsidies to purchase health insurance in the private market.

Policymakers interested in subsidizing low-income people's purchase of private insurance face two major questions: will such subsidies lead to adverse selection, and how large do the subsidies have to be to induce large numbers of eligible people to purchase the insurance? This study examines New Jersey's short-lived experience with a premium subsidy program, Health Access New Jersey (Access Program). The program was for people in families with incomes below 250% of the poverty level who were not eligible for health insurance provided by an employer, or Medicaid or Medicare, and who wished to purchase policies in the state's individual health insurance market, the Individual Health Coverage Program. Surveying a random sample of Access Program policyholders, we compared their demographic and socioeconomic characteristics, as well as their health status, to those of other New Jersey residents who had family incomes below 250% of the poverty level to determine whether there was any evidence of adverse selection among the people who enrolled in the Access Program. The people who enrolled were not in worse health than uninsured people with incomes below 250% of the poverty level, but they were quite price sensitive. Most enrollees had incomes within the low end of the income eligibility distribution, reflecting the structure of rapidly declining subsidies as income increased.

Adult↗

PubMed2003

Public health and aging: health-related quality of life among low-income persons aged 45-64 years--United States, 1995-2001.

Health-related quality of life (HRQOL) data are used to track population trends, identify health disparities, and monitor progress in achieving national health objectives for 2010. Low-income (i.e., annual household income of <15,000 dollars) adults aged > or =55 years have substantially more unhealthy days than low-income adults aged > or =65 years and adults aged 55-64 years with higher incomes. To verify this finding and determine whether it extends to low-income adults at younger ages, CDC analyzed HRQOL and related factors among a subset of respondents to the 1995-2001 Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which found that low-income adults aged 45-64 years have worse HRQOL than all other adults. Unemployment, inability to work, and activity limitation partially explain these HRQOL disparities in this age-income group. Targeting these risk factors and improving access to health care and social services (e.g., job training programs) could help increase the quality and years of healthy life and eliminate health disparities for persons in this age group.

Adult↗

PubMed1995

Women in low income groups smoke more: Canterbury 1976-92.

AIM: To examine the relationship between income and levels of smoking in women of child-bearing age. METHODS: Census area units within the Christchurch region were divided into five groups according to average income for each of the census years 1976, 1981 and 1991 respectively. Smoking rates were obtained from census data for 1976 and 1981. For 1992, data from a questionnaire on smoking during pregnancy and obstetric records were used. RESULTS: For all years, higher proportions of women from low income groups smoked. The overall percentage of female smokers in Canterbury fell slightly from 31.6% in 1976 to 27.5% in 1981. There were 27.1% of pregnant women smoking in 1992. There were marked changes by economic groups. The percentage of smokers in the highest income group fell from 24.8% in 1976 to 21.0% in 1981: an 18% fall. Smokers in the lowest income group increased from 36.8% in 1976 to 39.8% in 1981. The same patterns were seen for smoking in pregnancy in the 1992 data. CONCLUSION: While the downward trend for smokers in the high income groups is good news, it is of concern that the proportion of smokers in the lower income groups remains so high. Young women have the highest rates of smoking, which is of special concern when they become pregnant. Smokefree intervention programmes need to be specifically targeted at these groups.

Adolescent↗

PubMedDate not supplied

The impact of income redistribution on fertility in Canada.

This paper speculates on the role of income redistribution as a means of raising fertility in Canada. It is argued that if the relationship between income and fertility is non-linear at the household level, then changes in the income distribution in a society have important consequences for changes in aggregate fertility. In order to test this hypothesis, a simple fertility model is estimated using micro-data collected in the 1981 Canadian Census. The relationship between income and fertility is found to be nonlinear with properties that indicate that transfers of income from "rich" to "poor" households will likely further depress the overall level of fertility in Canada.

Americas↗

PubMed2001

Low family income and food insufficiency in relation to overweight in US children: is there a paradox?

OBJECTIVES: To investigate associations between family income, food insufficiency, and being overweight in US children aged 2 to 7 and 8 to 16 years, to discuss mechanisms that may explain these associations, and to propose design and data requirements for further research that could effectively examine this issue. METHODS: Data from the Third National Health and Nutrition Examination Survey were analyzed. Children were classified as food insufficient if the family respondents reported that their family sometimes or often did not get enough food to eat. The prevalence of overweight was compared by family income category and food sufficiency status within age-, sex-, and race-ethnic-specific groups. Odds ratios for food insufficiency are reported, adjusted for family income and other potential confounding factors. RESULTS: Among older non-Hispanic white children, children in families with low income were significantly more likely to be overweight than children in families with high income. There were no significant differences by family income for younger non-Hispanic white children, non-Hispanic black children, or Mexican American children. After adjusting for confounding variables, there were no differences in overweight by food sufficiency status, except that younger food-insufficient girls were less likely to be overweight, and non-Hispanic white older food-insufficient girls were more likely to be overweight than food-sufficient girls (P<.10). CONCLUSION: Further research to evaluate whether food insecurity causes overweight in American children requires longitudinal quantitative and in-depth qualitative methods.

Adolescent↗

PubMedDate not supplied

Geographical pattern analysis of income migration in the United States.

"How one conceptualises the impacts of migration depends on whether one takes the viewpoint of aggregate area-level income change, of per capita change, or of longer-term (future earnings) change. Several empirical analytical measures are proposed in order to conceptualise the various income impacts of migration.... [A] decomposition procedure is developed for examining how the changes in per capita income of states reflect three different income differentials: those between (a) in-migrants and 'stayers', (b) out-migrants and 'stayers', and (c) in-migrants and out-migrants. Examination of these measures, and of typologies based on them, highlights how income migration significantly and differentially impacts upon U.S. states. The methods are illustrated here in the context of an important new American data source: the 1993-94 migrant income data released by the U.S. Internal Revenue Service."

Americas↗

PubMed2002

The effect of education and income on need and willingness to undergo total joint arthroplasty.

OBJECTIVE: Individuals with lower socioeconomic status (SES) receive less arthritis care, including joint arthroplasty. However, no studies have considered the expectations or needs of the patients. Our objective was to assess the effect of education and income on the potential need for, and the willingness to consider hip and knee arthroplasty. METHODS: Through a mail/telephone survey of 48,218 persons ages 55 years or older residing in 2 areas of Ontario, Canada, 3,307 individuals with moderate-to-severe hip/knee problems were identified. These individuals received a questionnaire to assess education, income, arthritis severity, and comorbidity. In a subset of these subjects, we conducted interviews to evaluate the willingness to consider arthroplasty, and we also performed clinical and radiographic examinations of the joints to validate self-reports of arthritis. The potential need for arthroplasty was defined as the presence of severe arthritis (as scored by the Western Ontario and McMaster Universities Osteoarthritis Index), with no absolute contraindications to surgery. Separate logistic regression models examined the independent effects of education and income on the potential need for, and definite willingness to consider arthroplasty, after controlling for age, sex, and region of residence. Potential unmet need was estimated as the proportion of subjects with the need for arthroplasty who were not already on a surgery waiting list, who were definitely willing to consider arthroplasty, and who had evidence of arthritis by examination and radiography. RESULTS: Response rates were at least 72% for all questionnaires and interviews. Less education (adjusted odds ratio [OR] 1.57 for less than high school versus postsecondary education, 95% confidence interval [95% CI] 1.17-2.11) and lower income (adjusted OR 1.83 for </=$20,000 versus >$40,000, 95% CI 1.24-2.70) were independently associated with a greater likelihood of having the potential need for arthroplasty. Among the subjects with potential need, neither education nor income was independently associated with a definite willingness to consider arthroplasty. Thus, taking willingness into consideration, individuals with less education and/or lower income were more likely to have potential unmet need for arthroplasty. CONCLUSION: Persons with lower SES had a greater need for, and were equally willing to consider arthroplasty, compared with those with higher SES. Thus, observed SES disparities in the rates of performed arthroplasties cannot be explained by a lower need or less willingness to undergo arthroplasty in those with lower SES.

Aged↗

PubMed1993

Accessibility of dental services according to family income in a non-insured population.

The aim of this study was to examine the effect of family income on accessibility to dental services among adults in Norway. The analysis was performed on a set of national data collected in 1989, which was representative of the non-institutionalized Norwegian population aged 20 years and above. The sample size was 1200 individuals. The data were analyzed according to a two-part model. The first part determined the probability of whether the consumer had demanded the services or not during the last year according to family income. The second part estimated how the amount of services utilized depended on family income, for those with demand. The elasticity of the odds of having demanded the services with respect to family income was 0.48. Family income had no effect on the amount of services utilized. Additional analyses also showed that there was no effect of family income on the probability of having received a filling or a crown when visiting the dentist. In Norway, almost all costs for dental services are paid by the consumer. It is not possible from the data alone to say whether subsidized dental care is an effective way of reducing the inequalities in demand.

Adult↗

PubMed2005

Reducing child malnutrition in Tanzania. Combined effects of income growth and program interventions.

Malnutrition is associated with an inadequate diet, poor health and sanitation services and inadequate care for young children. A combination of income growth and nutrition interventions are therefore suggested to adequately tackle this issue [Haddad, L., Alderman, H., Appleton, S., Song, L., Yohannes, Y., 2003. Reducing child malnutrition: how far does income growth take us? World Bank Econ. Rev., 17, 107-131.], yet evidence to support this claim is often not available, especially for African settings. This paper evaluates the joint contribution of income growth and nutrition interventions towards the reduction of malnutrition. Using a four round panel data set from northwestern Tanzania we estimate the determinants of a child's nutritional status, including household income and the presence of nutrition interventions in the community. The results show that better nutrition is associated with higher income, and that nutrition interventions have a substantial beneficial effect. Policy simulations make clear that if one intends to halve malnutrition rates by 2015 (the MDG objective), income growth will have to be complemented by large scale program interventions.

Anthropometry↗

PubMed2004

Income inequality and self-rated health in US metropolitan areas: a multi-level analysis.

Income inequality has been found to affect health in a number of international and cross-national studies. Using data from a telephone survey of adults in the United States, this study analyzed the effect of metropolitan level income inequality on self-rated health. It combined individual data from the 2000 Behavioral Risk Factor Surveillance System with metropolitan level income data from the 2000 Census. After controlling for smoking, age, education, Black race, Hispanic ethnicity, sex, household income, and metropolitan area per capita income, this study found that for each 1 point rise in the GINI index (on a hundred point scale) the risk of reporting Fair or Poor self-rated health increased by 4.0% (95% confidence interval 1.6-6.5%). Given that self-rated health is a good predictor of morbidity and mortality, this suggests that metropolitan area income inequality is affecting the health of US adults.

Black or African American↗

PubMed2005

The income-associated burden of disease in the United States.

In this study, we estimate the total burden of disease associated with income in the US. We calculate the relationships between income and life expectancy, health-adjusted life expectancy, annual years of life lost (YLLs), and health adjusted life years (HALYs). We used the 2000 US Medical Expenditure Panel Survey to derive quality of life estimates by income and age, the 1990-1992 US National Health Interview Survey linked to National Death Index data through the end of 1995 to derive mortality risks by income and by age, and 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population by age-group. The bottom 80% of adult income earners' life expectancy is 4.3 years and 5.8 HALYs shorter relative to those in the top 20% of earnings. This translates into the loss of 11 million YLLs and 17.4 million HALYs each year. Compared with persons living above the poverty threshold, those living below the poverty threshold live an average of 3.2 million fewer HALYs per year-a difference of 8.5 HALYs per individual between age 18 and death. The income-associated burden of disease appears to be a leading cause of morbidity and mortality in the US.

Adolescent↗