Measuring population health: correlates of the Health Utilities Index among English and French Canadians

An examination of health care efficiency in Canada: a two-stage semi-parametric approach

Using data envelopment analysis, we examine the efficiency of Canada's universal health care system by considering a set of labour (physicians) and capital (beds) inputs, which produce a level of care (measured in terms of health quality and quantity) in a given region. Data from 2013-2015 were collected from the Canadian Institute for Health Information regarding inputs and from the Canadian Community Health Survey and Statistics Canada regarding our output variables, health utility (quality) and life expectancy (quantity). We posit that variation in efficiency scores across Canada is the result of regional heterogeneity regarding socioeconomic and demographic disparities. Regressing efficiency scores on such covariates suggests that regional unemployment and an older population are quite impactful and associated with less efficient health care production. Moreover, regional variation indicates the Atlantic provinces (Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick) are quite inefficient, have poorer economic prospects, and tend to have an older population than the rest of Canada. Oaxaca-Blinder decompositions suggest that the latter two factors explain about one-third of this efficiency gap. Based on our two-stage semi-parametric analysis, we recommend Canada adjust their transfer payments to reflect these disparities, thereby potentially reducing inequality in regional efficiency.

A population-based analysis of life satisfaction and social support among children of diverse backgrounds in British Columbia, Canada

PURPOSE

The Satisfaction With Life Scale adapted for Children (SWLS-C) is a self-report measure of children's quality of life and has exhibited sound psychometric properties. In light of increasing ethno-cultural diversity, it is important to understand child life satisfaction across diverse subgroups. Employing children's language background as a proxy for cultural background among children in British Columbia, Canada, we examined (a) the cross-cultural measurement equivalence of the SWLS-C; and (b) cross-cultural relations of peer support and adult support with SWLS-C.

METHODS

Participants were 20,119 children (M_age 9.2; 50.2% boys) who provided data as part of a self-report child health survey (the Middle-years Development Instrument). Measurement equivalence across eight language/cultural background groups was tested via multi-group confirmatory factor analysis. Multi-level analyses were used to compare: a) SWLS-C means; and b) associations of peer support and adult support with SWLS-C scores, by language/cultural background.

RESULTS

Findings supported strict measurement equivalence between the English language/cultural background group and all other language/cultural background groups for the SWLS-C. Relative to the English language background group, SWLS-C means differed for several language/cultural background groups. Within every language/cultural background group, however, peer and adult support scale scores were significant positive correlates of SWLS-C scores.

CONCLUSIONS

This study provided evidence for measurement equivalence of a life satisfaction measure across children from diverse language/cultural backgrounds and identified between-group differences in the level of child life satisfaction that were generally consistent with prior theory and findings. Moreover, results provided evidence of promotive associations of adult support and peer support with life satisfaction among diverse groups of children.

A reference set of health utilities for long-term survivors of prostate cancer: population-based data from Ontario, Canada

PURPOSE

To measure quality of life (QOL) and utilities for prostate cancer (PC) patients and determine their predictors.

METHODS

A population-based, community-dwelling, geographically diverse sample of long-term PC survivors in Ontario, Canada, was identified from the Ontario Cancer Registry and contacted through their referring physician. Consenting patients completed questionnaires by mail: Health Utilities Index (HUI 2/3), Patient Oriented Prostate Utility Scale PORPUS-U (utility), PORPUS-P (health profile), Functional Assessment of Cancer Therapy-Prostate (FACT-P), and Prostate Cancer Index (PCI). Clinical data were obtained from chart reviews. Regression models determined the effects of a series of variables on QOL and utility.

RESULTS

We received questionnaires and reviewed charts for 585 patients (mean age 72.6, 2-13 years postdiagnosis). Mean utility scores were as follows: PORPUS-U = 0.92, HUI2 = 0.85, and HUI3 = 0.78. Mean health profile scores were as follows: PORPUS-P = 71.7, PCI sexual, urinary, and bowel function = 23.7, 79.1, and 84.6, respectively (0 = worst, 100 = best), and FACT-P = 125.1 (0 = worst, 156 = best). In multiple regression analyses, comorbidity and PCI urinary, sexual, and bowel function were significant predictors of other QOL measures. With all variables, 32-50 % of the variance in utilities was explained.

CONCLUSIONS

Many variables affect global QOL of PC survivors; only prostate symptoms and comorbidity have independent effects. Our model allows estimation of the effects of multiple factors on utilities. These utilities for long-term outcomes of PC and its treatment are valuable for decision/cost-effectiveness models of PC treatment.

The role of proximity to death in need-based approaches to health care

OBJECTIVES

This study examines the role of proximity to death (PTD) in need-based approaches to health care by: (1) investigating whether PTD is a statistically significant, independent predictor of health-care use; and (2) estimating PTD's marginal impact on need-based allocation of health-care resources.

METHODS

The primary data source is the Canadian National Population Health Survey (NPHS), a longitudinal survey that uses vital statistics to confirm deaths of the respondents. We use two-part models separately for general practitioner, specialist, and short stay inpatient hospital services. We calculate per-capita allocation, with and without PTD, from the Canadian federal government to its ten provinces and by income groups.

RESULTS

PTD is a robust and important predictor of health-care resource use for each service even after adjustment for other need and non-need factors. PTD's marginal impact on allocation is relatively small in the contexts we examined, but failure to include PTD could introduce inequity in allocation by disadvantaging populations with greater need.

CONCLUSIONS

PTD is an important need indicator when modeling health-care resource requirements. It deserves greater attention in need-based approaches to health-care planning and resource allocation.

Changes over time in the health of caregivers of children with health problems: growth-curve findings from a 10-year Canadian population-based study

OBJECTIVES

We used Canadian population-based data to examine changes in the health of caregivers of children with complex health problems compared with caregivers of healthy children over a 10-year time period.

METHODS

The National Longitudinal Survey of Children and Youth collected data biennially from 9401 children and their caregivers in 6 waves from 1994-1995 to 2004-2005. We conducted growth-curve analyses of these data to model self-reported general health and depressive symptoms for 4 groups of caregivers: caregivers of healthy children, and caregivers of children with 1, 2, or at least 3 of 4 conceptually distinct indicators of child health problems. We modeled covariates for children (age, gender, only-child status) and caregivers (age, gender, education, income, marital status).

RESULTS

After we controlled for covariates, caregiver health outcomes worsened incrementally with increasing complexity of child health problems. Change in self-reported general health and depressive symptoms over the 10-year period was consistent across all groups of caregivers.

CONCLUSIONS

Poorer health among caregivers of children with health problems can persist for many years and is associated with complexity of child health problems. Attention to parental health should form a component of health care services for children with health problems.

Health-related quality of life in adults reporting arthritis: analysis from the National Health Measurement Study

Background

Arthritis is the leading cause of disability in the United States. We assess the generic health-related quality-of-life (HRQOL) among a nationally representative sample of US adults with and without self-reported arthritis.

Methods

The NHMS, a cross-sectional survey of 3,844 adults (35–89 years) administered EuroQol-5D (EQ-5D), Health Utilities Index Mark 2 (HUI2) and 3 (HUI3), SF-36v2™, Quality of Well-being Scale self-administered form (QWB-SA), and the Health and Activities Limitations index (HALex) to each respondent via a telephone interview. Weighted multiple linear regression was used to generate age-gender-arthritis-stratified unadjusted HRQOL means and means adjusted for sociodemographic, socioeconomic covariates and comorbidities by arthritis–age category.

Results

The estimated population prevalence of self-reported arthritis was 31%. People with arthritis were more likely to be woman, older, of lower socioeconomic status, and had more self-reported comorbidities than were those not reporting arthritis. Adults with arthritis had lower HRQOL on six different indexes compared with adults without arthritis, with overall differences ranging from 0.03 (QWB-SA, age-group 65–74) to 0.17 (HUI3, age-group 35–44; all P-value < .05).

Conclusion

Arthritis in adults is associated with poorer HRQOL. We provide age-related reference values for six generic HRQOL measures in people with arthritis.

Alcohol consumption and health status in older adults: a longitudinal analysis

Objective. This longitudinal study examines the relationship of alcohol consumption to mortality and changes in mental and functional health in older adults. Method.In a national population health survey, 4,187 participants aged 50 and older at baseline provided information on alcohol consumption, potential confounders, and follow-up vital status. Logistic regression estimated the odds ratio for mortality, increase in psychological distress, and decline in functional health 10 years later. Results. Compared with lifelong abstainers, light and moderate drinkers were at nonsignificantly lower risk of mortality. Among survivors, alcohol consumption showed no consistent relationship with increases in psychological distress. Occasional and light drinkers had significantly reduced risk of a substantial functional health decline, whereas moderate drinkers had nonsignificantly reduced risk. Discussion. Findings suggest that light-to-moderate alcohol consumption reduces the risk of substantial functional health decline in older middle-aged drinkers.

Assessing the relationship between health utilities, quality of life, and health services use in Alzheimer's disease

OBJECTIVES

To examine the relationship between use of multiple health services and health utilities, quality of life and other factors in Alzheimer's disease (AD).

DESIGN

Data were obtained via caregiver proxy at baseline and 3- 6- and 9-months post-random assignment among 421 community-dwelling AD patients participating in the CATIE-AD trial of anti-psychotic medications. Service use includes both institutional and outpatient services. Correlates include the AD-Related Quality of Life Scale (ADRQoL), Health Utilities Index (HUI)-III, Neuropsychiatric Inventory, Mini Mental Status Examination, and AD-Cooperative Study Activities of Daily Living Scale. Chi squared tests, t-tests and logistic regression (using general estimating equations) were used to examine the correlates of service use.

RESULTS

Three quarters (74.2%) used at least one service each month. Average monthly utilization rates for specific service types were: 4.5%, inpatient hospital; 5.6%, nursing home; 3.9%, residential care; 44.0%, AD-related outpatient; 9.4%, mental health outpatient; and 45.5%, medical-surgical outpatient. The likelihood of using any service was higher among older patients [Odds Ratio (OR) = 1.03] and non-Hispanic Whites (OR = 1.61). Each 0.10 increment on the Health Utilities Index (HUI)-III was associated with a 7.0% decrease in the odds of using one or more service (OR = 0.93). The odds of using outpatient and institutional services were 6.0% and 10.0% lower, respectively, for each 0.10 increment on the HUI-III (OR = 0.94, OR = 0.90). The AD-Related Quality of Life Scale proved significantly related to outpatient medical-surgical services only (OR = 1.01).

CONCLUSION

Findings suggest that the HUI-III could be combined with other known correlates of service use to inform population planning associated with AD.

Health among caregivers of children with health problems: findings from a Canadian population-based study

OBJECTIVES

We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.

METHODS

We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.

RESULTS

Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.

CONCLUSIONS

Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers' health and health of the children for whom they care.

Do changes in job control predict differences in health status? Results from a longitudinal national survey of Canadians

OBJECTIVE

To examine the effect of changes in job control on health behaviors, psychological distress and health status.

METHODS

Using a path analysis model, we examined the effects of change in job control over a 4-year period on levels of physical activity, smoking, and psychological distress; and on self-rated health over an additional 2 years, among a representative sample of 2221 Canadians.

RESULTS

Over the 4-year period, 280 respondents reported decreases in job control, and 256 reported increases in job control. Health at baseline was not associated with the likelihood of changes in job control. We found a graded relationship between change in job control and levels of physical activity and psychological distress over a 4-year period; and levels of self-rated health over a 6-year period, with positive change in job control associated in higher levels of physical activity and self-rated health and lower levels of distress.

CONCLUSIONS

The results of this study suggest that both level of job control and changes in job control have direct and indirect effects on health status over time. Future research should focus on developing precise measures of work exposures, and examine differences between changes in job control due to only changes in perceptions and changes due to work redesign.

Conceptualizing childhood health problems using survey data: a comparison of key indicators

Background

Many definitions are being used to conceptualize child health problems. With survey data, commonly used indicators for identifying children with health problems have included chronic condition checklists, measures of activity limitations, elevated service use, and health utility thresholds. This study compares these different indicators in terms of the prevalence rates elicited, and in terms of how the subgroups identified differ.

Methods

Secondary data analyses used data from the National Longitudinal Survey of Children and Youth, which surveyed a nationally representative sample of Canadian children (n = 13,790). Descriptive analyses compared healthy children to those with health problems, as classified by any of the key indicators. Additional analyses examined differences between subgroups of children captured by a single indicator and those described as having health problems by multiple indicators.

Results

This study demonstrates that children captured by any of the indicators had poorer health than healthy children, despite the fact that over half the sample (52.2%) was characterized as having a health problem by at least one indicator. Rates of child ill health differed by indicator; 5.6% had an activity limitation, 9.2% exhibited a severe health difficulty, 31.7% reported a chronic condition, and 36.6% had elevated service use. Further, the four key indicators captured different types of children. Indicator groupings differed on child and socio-demographic factors. Compared to children identified by more than one indicator, those identified only by the severe health difficulty indicator displayed more cognitive problems (p < 0.0001), those identified only by the chronic condition checklist had a greater likelihood of reporting allergies or asthma (p < 0.0001), and those identified as having elevated service use only were more affluent (p = 0.01) and showed better overall health (p < 0.0001). Children identified by only a single indicator were less likely to have serious health problems than those identified by two or more indicators.

Conclusion

We provide information useful to researchers when selecting indicators from survey data to identify children with health problems. Researchers and policy makers need to be aware of the impact of such definitions on prevalence rates as well as on the composition of children classified as being in poor health.

Social norms, social behaviours and health: an empirical examination of a model of social capital

OBJECTIVE

To explore a model of social capital, specifically the association between socially oriented norms and behaviours and the effect that these factors have on the gradient between income and self-rated health across three different welfare states.

METHOD

We used data from the 1995-97 World Values Survey, a cross-sectional study conducted in a variety of countries including Australia, United States, Sweden and Norway (n = 5,096).

RESULTS

We found variation in the level of social capital measures across the three different welfare states. Socially oriented norms are not strongly correlated with each other, or with socially oriented behaviours. The presence of socially oriented norms or behaviours did not reduce the likelihood of lower income groups reporting poor self-rated health, relative to the highest income groups.

CONCLUSIONS AND IMPLICATIONS

Many questions still exist regarding the relationship between social capital and health, including how to measure the social capital concept and whether and how social capital affects health, independent of material and economic conditions.

Factors affecting change over time in self-reported health

BACKGROUND

Self-reported health status has become a conventional measure of health status at the population level. Further, the literature supports its use as a valid indicator of morbidity and mortality. However, relatively little attention has been paid to how self-reported health status changes over time or the factors affecting change. This paper explores the factors affecting health status change over time using data from a neighbourhood health survey.

METHODS

Two rounds (2001; 2003) of health survey data (n=671) were collected across 4 distinct neighbourhoods in Hamilton, Ontario. Logistic regression analysis is used to predict change in self-reported health status between the two time periods as well as determinants of change using a range of compositional, contextual and collective characteristics of individuals as potential explanatory variables.

RESULTS

Results reveal that approximately one third of participants experienced a change in health status between the two survey years. Interestingly, the key factors affecting change in health status are compositional characteristics of individuals (e.g., smoking, health care use) as opposed to contextual (e.g., neighbourhood of residence) or collective (e.g., marital status). Contrary to published literature, the current study does not reveal any significant links between a change in health status and either gender or age.

CONCLUSION

These results inform our understanding of both the stability of health ratings over time and the determinants of health status change. Further research should be undertaken to enhance this understanding; in particular, studies with larger sample sizes, longer time frames and more sensitive indicators of composition, context and collective are needed.

Measuring patient quality of life: is the health utility index useful?

The purpose of this paper is to report Health Utility Index Mark 3 (HUI3) scores, at baseline and at one year, for patients with psychotic disorders. Eighty two randomly selected outpatients from a Montreal teaching hospital completed the HUI3 and other measures of symptoms and side-effects. At baseline, the average Global Utility score was 0.64, which is rated in the "dysfunctional" health status range. Improvements were seen at one year follow-up in the Global, Dexterity, Cognition, and Pain Utility scores. The proportion of individuals rated in the "healthy" health status range improved by 32% from baseline to one year. HUI3 scores were negatively related to measures of psychotic symptoms and side-effects. We propose that the HUI3 should be used to assess health-related quality of life (HRQOL) in patients with psychotic disorders. Scores could be compared with other populations affected with chronic conditions (e.g., Alzheimer dementia, cancer, arthritis, etc.).

Factors affecting change over time in self-reported health

BACKGROUND

Self-reported health status has become a conventional measure of health status at the population level. Further, the literature supports its use as a valid indicator of morbidity and mortality. However, relatively little attention has been paid to how self-reported health status changes over time or the factors affecting change. This paper explores the factors affecting health status change over time using data from a neighbourhood health survey.

METHODS

Two rounds (2001; 2003) of health survey data (n=671) were collected across 4 distinct neighbourhoods in Hamilton, Ontario. Logistic regression analysis is used to predict change in self-reported health status between the two time periods as well as determinants of change using a range of compositional, contextual and collective characteristics of individuals as potential explanatory variables.

RESULTS

Results reveal that approximately one third of participants experienced a change in health status between the two survey years. Interestingly, the key factors affecting change in health status are compositional characteristics of individuals (e.g., smoking, health care use) as opposed to contextual (e.g., neighbourhood of residence) or collective (e.g., marital status). Contrary to published literature, the current study does not reveal any significant links between a change in health status and either gender or age.

CONCLUSION

These results inform our understanding of both the stability of health ratings over time and the determinants of health status change. Further research should be undertaken to enhance this understanding; in particular, studies with larger sample sizes, longer time frames and more sensitive indicators of composition, context and collective are needed.

Correlates of health-related quality of life in type 2 diabetes

AIMS/HYPOTHESIS

We assessed the impact of medical comorbidities, depression, and treatment intensity on quality of life in a large primary care cohort of patients with type 2 diabetes.

METHODS

We used the Health Utilities Index-III, an instrument that measures health-related quality of life based on community preferences in units of health utility (scaled from 0=death to 1.0=perfect health), in 909 primary care patients with type 2 diabetes. Demographic and clinical correlates of health-related quality of life were assessed.

RESULTS

The median health utility score for this population was 0.70 (interquartile range 0.39-0.88). In univariate analyses, older age, female sex, low socioeconomic status, cardiovascular disease, microvascular complications, congestive heart failure, peripheral vascular disease, chronic lung disease, depression, insulin use and number of medications correlated with decreased quality of life, while obesity, hypertension and hypercholesterolaemia did not. In multiple regression analyses, microvascular complications, heart failure and depression were most strongly related to decreased health-related quality of life, independently of duration of diabetes; in these models, diabetes patients with depression had a utility of 0.59, while patients without symptomatic comorbidities did not have a significantly reduced quality of life. Treatment intensity remained a significant negative correlate of quality of life in multivariable models.

CONCLUSIONS/INTERPRETATION

Patients with type 2 diabetes have a substantially decreased quality of life in association with symptomatic complications. The data suggest that treatment of depression and prevention of complications have the greatest potential to improve health-related quality of life in type 2 diabetes.

Measuring health status and decline in at-risk seniors residing in the community using the Health Utilities Index Mark 2

PURPOSE

The purpose of this study was to assess the responsiveness of one measure of HRQL, the HUI Mark 2 (HUI2), to changes in health status over time in an older community-based population.

METHODS

The sample consisted of 192 individuals age 65 and over residing in their homes and receiving health and support services in Calgary, Canada. Subjects received three assessments at 6-month intervals using the HUI2, to measure health-related quality of life (HRQL), and the Minimum Data Set for Home Care (MDS-HC) for demographic and health status information. Change scores were calculated as the difference between scores at the second and third assessments. The relationship between the HUI2 and other measures of health status were examined using t-tests and ANOVA. Associations between the magnitude of decline in HUI2 and declines on other measures were examined using multiple linear regression.

RESULTS

Lower HUI2 scores were significantly associated with the presence of depressive symptoms, impairment in activities of daily living (ADL), and clinical instability at baseline. Over 6 months of follow-up, HUI2 decline was associated with worsening depressive symptoms, increase in the number of chronic conditions, and age 85 and over.

CONCLUSION

The HUI2 measure of HRQL in older persons at risk for institutionalization appears to reflect health status at a point in time and to be responsive to changes in health status over time.

Self-reported health status of the general adult U.S. population as assessed by the EQ-5D and Health Utilities Index

OBJECTIVE

This study aimed to describe the self-reported health status of the general adult U.S. population using 3 multi-attribute preference-based measures: the EQ-5D, Health Utilities Index Mark 2 (HUI2), and Mark 3 (HUI3).

METHODS

We surveyed the general adult U.S. population using a probability sample with oversampling of Hispanics and non-Hispanic blacks. Respondents to this home-visit survey self-completed the EQ-5D and HUI2/3 questionnaires. Overall health index scores of the target population and selected subgroups were estimated and construct validity of these measures was assessed by testing a priori hypotheses.

RESULTS

Completed questionnaires were collected from 4048 respondents (response rate: 59.4%). The majority of the respondents were women (52.0%); the mean age of the sample was 45 years, with 14.8% being 65 or older. Index scores (standard errors) for the general adult U.S. population as assessed by the EQ-5D, HUI2, and HUI3 were 0.87 (0.01), 0.86 (0.01), and 0.81 (0.01), respectively. Generally, younger, male and Hispanic or non-Hispanic black adults had higher (better) index scores than older, female and other racial/ethnic adults; index scores were higher with higher educational attainment and household income. The 3 overall preference indices were strongly correlated (Pearson's r: 0.67-0.87), but systematically different, with intraclass correlation coefficients between these indices ranging from 0.59 to 0.77.

CONCLUSIONS

This study provides U.S. population norms for self-reported health status on the EQ-5D, HUI2, and HUI3. Although these measures appeared to be valid and demonstrated similarities, health status assessed by these measures is not exactly the same.

Mental Health Comorbidity Patterns and Impact on Quality of Life Among Veterans Serving During the First Gulf War

PURPOSE

To examine the patterns of coexisting (comorbid) mental disorders and whether comorbidity influences quality of life ratings in a sample of U.S. veterans.

PATIENTS AND METHODS

The Iowa Gulf War Study Case Validation study evaluated 602 military personnel, two-thirds of whom had symptoms of depression, cognitive dysfunction, or chronic widespread pain, who were activated or on active duty sometime during the first Gulf War (GW). Mental health disorders were defined using the SCID-IV, and the Health Utilities Index Mark 3 (HUI3) was used to measure health-related quality of life (HRQoL). Comorbidity was defined as having two or more mental disorders that spanned across at least two separate categories (e.g., depressive disorders and anxiety disorders).

RESULTS

Over 35% of veterans with a current mental disorder had at least one other comorbid mental disorder. Those with mental disorder comorbidity had lower HUI scores than veterans with only one or less mental disorders (mean 0.41 +/- 0.30 vs. 0.72 +/- 0.25, p < 0.0001).

CONCLUSION

The co-occurrence of mental disorders that span at least two mental disorder categories is associated with impaired HRQoL in this veteran population. Early identification of mental health comorbidity may lead to interventions to enhance HRQoL among military personnel.

Quantifying the effect of health status on health care utilization using a preference-based health measure

The purpose of this study was to quantify the effect of health status on current and future payments and number of visits to health professionals in a large, representative community sample in British Columbia, Canada. The study population was comprised of all respondents to the 1994/5 cycle of the Canadian National Population Health Survey (NPHS) who were 12 years of age or older and residing in the province of British Columbia (N = 2084). Health status was measured with the Health Utilities Index (HUI). Two outcomes were defined for each subject: (a) the sum of all healthcare costs covered by the Medical Services Plan, incurred during a given fiscal year, and (b) the total number of visits to all health practitioners during the same year. Outcome data were obtained for a period 1994-1998. We examined the relationship between the HUI and healthcare use in a multivariate log-linear model. In the full sample, better health in 1994-1995 was associated with lower healthcare cost and lower number of visits from 1994 through 1998. The overall adjusted cost ratio was 0.89 (99% CI = 0.85, 0.94) and the overall adjusted visit ratio was 0.91 (99% CI + 0.87, 0.95). The effect of health status on the costs of care and on the number of visits was similar in men and women, was stronger in persons less than 45 years of age compared to those 45+, and was not different according to place of residence. We conclude that the HUI is a strong predictor of health services use over 5 years. A 0.1 improvement in health utility is associated with a 10% reduction in the costs of care and number of visits to health professionals.

Neighbourhood influences on health in Montréal, Canada

This paper examines neighbourhood effects on health within a large Canadian city--Montréal. Our approach is to consider that individual health outcomes are determined both by individual and neighbourhood characteristics and we consciously take on the problem of neighbourhood definition by developing 'natural' neighbourhoods. Our data come from the Montréal health region sample of the 2000/1 Canadian Community Health Survey, a comprehensive national survey that contains information on health outcomes as well as behavioural and socio-demographic information. Respondents were placed into 'naturally' defined neighbourhoods as opposed to arbitrary geostatistical units, responding to calls in the literature to develop more meaningful units of analysis. We also compare the 'natural' neighbourhood approach with the use of standard census tracts as the unit of analysis. Results show significant between-neighbourhood variation in health status with about 3% of the variance in the Health Utilities Index captured at the neighbourhood level, even after controlling for a variety of socio-demographic and behavioural variables at the individual level. Models using census tracts as the unit of analysis had remarkably similar results to the 'natural' neighbourhood models, suggesting that census tracts are good proxies for natural neighbourhood boundaries in studies of neighbourhood effects on health.

The health of Canadians on welfare

BACKGROUND

Welfare programs provide income assistance to individuals whose resources are insufficient to meet their needs and who have exhausted all other avenues of support. With continued reductions in welfare in many provinces, the health of the nearly 2 million Canadians who rely on it may be compromised. This study examines the relationship between receipt of welfare and adult recipients' general, mental and social health, and selected chronic conditions.

METHODS

We undertook a secondary analysis of data from the 1996/97 National Population Health Survey. To differentiate between disabled and non-disabled welfare recipients, we stratified our analysis by long-term disability status as defined by self-reported restricted activity.

RESULTS

After controlling for the potentially confounding effects of age, sex, and education, regardless of whether or not they reported restricted activity, adults on welfare when compared to those not on welfare had significantly higher odds of reporting poor/fair health, poor functional health, depression, distress, and poor social support. Among those without restricted activity, welfare recipients had greater odds of heart disease when compared to those not on welfare; no associations were observed between welfare status and obesity, diabetes, or hypertension.

INTERPRETATION

These findings indicate that adults on welfare struggle with a broad spectrum of health problems; the increasing inadequacy of welfare benefits may put them at even greater health risk. The impact of welfare program reforms on the health and well-being of recipients must be assessed and monitored.

The health of Canadians on welfare

BACKGROUND

Welfare programs provide income assistance to individuals whose resources are insufficient to meet their needs and who have exhausted all other avenues of support. With continued reductions in welfare in many provinces, the health of the nearly 2 million Canadians who rely on it may be compromised. This study examines the relationship between receipt of welfare and adult recipients' general, mental and social health, and selected chronic conditions.

METHODS

We undertook a secondary analysis of data from the 1996/97 National Population Health Survey. To differentiate between disabled and non-disabled welfare recipients, we stratified our analysis by long-term disability status as defined by self-reported restricted activity.

RESULTS

After controlling for the potentially confounding effects of age, sex, and education, regardless of whether or not they reported restricted activity, adults on welfare when compared to those not on welfare had significantly higher odds of reporting poor/fair health, poor functional health, depression, distress, and poor social support. Among those without restricted activity, welfare recipients had greater odds of heart disease when compared to those not on welfare; no associations were observed between welfare status and obesity, diabetes, or hypertension.

INTERPRETATION

These findings indicate that adults on welfare struggle with a broad spectrum of health problems; the increasing inadequacy of welfare benefits may put them at even greater health risk. The impact of welfare program reforms on the health and well-being of recipients must be assessed and monitored.

Is position in the occupational hierarchy a determinant of decline in perceived health status?

This study examines the extent to which position in the occupational hierarchy is predictive of declines in perceived health status over a 48 month period in a representative sample of the Canadian labor force. We hypothesized that the proportion of workers reporting a decline in health status would be greater among persons in lower position in the occupational hierarchy, and that these differences in risk would primarily be explained by characteristics of the psychosocial work environment and secondarily by the baseline prevalence of adverse health behaviors. The study cohort was defined as labor force participants aged 18-64 who reported good, very good or excellent health in the 1994 baseline wave of Canada's National Population Health Survey and who participated in the 1998 follow-up survey. Between 1994 and 1998, 16.6% of labor force participants reporting excellent, very good or good health status at baseline reported a decline in perceived health status. For men, the age-adjusted odds of decline in perceived health status were 1.80 (95% CI: 1.24-2.63) and 1.74 (95% CI: 1.19-2.54) for the two lowest occupational classes relative to the highest occupational class. There was no association between position in the occupational hierarchy and the prospective risk of health status decline for women. For men, the association between position in the occupational hierarchy and decline in perceived health status was moderately reduced but remained statistically significant following adjustment for baseline health, health behaviors and psychosocial work exposures. Adjustment for household income did not alter these findings. When stratified by gender, position in the occupational hierarchy was associated with the prospective risk of health status decline for men but not for women. Among men, the collective influence of health behaviors and psychosocial work exposures explained a moderate component of the decline in perceived health status. A more robust measurement of the characteristics of labor market experiences would be expected to improve understanding of the relationship between work and health in this sample.

Adjusting distributions of the Health Utilities Index Mark 3 utility scores of health-related quality of life

The Health Utilities Index Mark 3 (HUI3) is a multi-dimensional, preference-based measure of health status and health-related quality of life (HRQoL). HUI3 scores correlate strongly with self-ratings of health status and functional disability and vary according to age, gender and occupation. In comparative studies relating to HRQoL, it is necessary to carry out adjusted comparison of the health status of the different groups. taking into account unbalanced distribution of confounding variables. This paper describes a stratification method to adjust the distributions of HUI3 scores. This method provides a graphical representation of adjusted distribution of HUI3, which can also be used to adjust other HRQoL scores. Cross-sectional data from the 1998/1999 National Population Health Survey (NPHS) in Canada were used to verify the proposed method. Male agriculture workers and male construction workers in Canada had quite different age distributions but similar HUI3 distributions. After adjusting the age distribution of the construction group to match the distribution of agriculture group, the mean HUI3 score of the former significantly decreased.

Household food insufficiency is associated with poorer health

The purposes of this study were to estimate the prevalence of household food insufficiency in Canada, to identify sociodemographic characteristics of households most likely to report food insufficiency and to examine the relationship between food insufficiency and physical, mental and social health. These objectives were achieved through an analysis of data from the 1996/1997 National Population Health Survey. An estimated 4% of Canadians, 1.1 million people, were found to be living in food-insufficient households. Single-parent families, households reporting their major source of income as welfare, unemployment insurance or workers' compensation, those who did not own their own homes and households in Western Canada were more likely to report food insufficiency. The likelihood of reporting food insufficiency increased dramatically as income adequacy deteriorated. Individuals from food-insufficient households had significantly higher odds of reporting poor/fair health, of having poor functional health, restricted activity and multiple chronic conditions, of suffering from major depression and distress, and of having poor social support. Individuals in food-insufficient households were also more likely to report heart disease, diabetes, high blood pressure and food allergies. Men in food-insufficient households were less likely to be overweight; after adjusting for potentially confounding variables, no other associations were found between food insufficiency and body mass index. These findings suggest that food insufficiency is one dimension of a more pervasive vulnerability to a range of physical, mental and social health problems among households struggling with economic constraints.

Bayesian extensions of the Tobit model for analyzing measures of health status

Self-reported health status is often measured using utility indices that provide a score intended to summarize an individual's health. Measurements of health status can be subject to a ceiling effect. Frequently, researchers want to examine relationships between determinants of health and measures of health status. In this article, Bayesian extensions of the classical Tobit model are used to study the relationship between health status and predictors of health. The author examined models where the conditional distribution of health status was either normal or lognormal, and allowed for both homoscedasticity and heteroscedasticity. Bayes factors were then used to compare the evidence for a given model against that for a competing model. The author found very strong evidence that the distribution of the Health Utilities Index, conditional on age, gender, income adequacy, and number of chronic conditions, was normal with nonuniform variance, compared to the competing models.

Can the health utilities index measure change?

BACKGROUND

The Health Utilities Index (HUI) is a multidimensional, preference-weighted measure of health status. It comprises eight health attributes, aggregated into a single utility score.

OBJECTIVES

The purpose of the study was to investigate the ability of the HUI to detect changes in health status in a general population cohort.

RESEARCH DESIGN

Health status changes were analyzed in the full cohort and in persons who were diagnosed with chronic conditions, hospitalized, or became restricted in daily activities.

SUBJECTS

To assess responsiveness, longitudinal data was used from the National Population Health Survey conducted in Canada in 1994 - 1995 and 1996 - 1997. We used cross-sectional data from the 1996 sample to classify chronic conditions into mild, moderate, and severe.

MEASURES

Two measures of responsiveness were calculated: Standardized Response Mean (SRM) and Sensitivity Coefficient (SC). The HUI was compared with a global health index-the Self-Rated Health (SRH) scale.

RESULTS

HUI scores improved between the two NPHS cycles in all age-sex groups, except men 65 years of age and older. Among the respondents who remained free of chronic conditions, improvements were seen primarily in the cognitive and emotional domains. The HUI deteriorated among persons who were diagnosed between the two cycles with a severe chronic condition, were hospitalized, or became restricted in activity, but not in those diagnosed with a moderate condition. The SRMs were generally smaller for the HUI compared with the SRH.

CONCLUSIONS

The HUI responds to changes in health status associated with serious chronic illnesses. However, changes in the HUI do not always coincide with changes in self-reported health. Properties of the HUI scales require further study.

Cross-cultural comparisons of health status in Canada using the Health Utilities Index

OBJECTIVE

The purpose of this study was to examine the differences in health status, as measured by the Health Utilities Index (HUI), among seven cultural groups in Canada defined by place of birth and language.

DESIGN

The study analysed cross-sectional data from the National Population Health Survey conducted by Statistics Canada in 1994-95.

RESULTS

Age-standardized prevalence of dysfunction, defined as HUI < 0.83, varied from 12.7% in English-speaking immigrants to 17.8% in French-speaking Canadians. Considerable differences between the groups were found in the reporting of pain, emotional function, and cognitive function. The variation in HUI scores across the cultural groups could not be explained by differences in socioeconomic status and self-reported chronic conditions.

CONCLUSIONS

Although the healthy immigrant effect is probably responsible for some of the variation in health status among cultural groups in Canada, considerable differences exist within the immigrant and Canadian-born populations. Cultural factors may have a substantial effect on the reporting of pain and mental health problems. Further studies are needed to determine the cross-cultural validity of the HUI.