Metropolitan income inequality and working-age mortality: a cross-sectional analysis using comparable data from five countries

Income Inequality and Population Health: Examining the Role of Social Policy

Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000-2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy.

Disparities in the Wage-and-Salary Earnings, Determinants, and Distribution of Health Economics, Outcomes Research, and Market Access Professionals: An Exploratory Study

OBJECTIVE

The aim was to estimate the wage-and-salary earnings of a sample of health economics, outcomes research, and market access (HE/OR/MA) professionals; compare male versus female and US versus non-US earnings; assess the magnitude of the effect of several human-capital and job-related covariates on the determination of earnings; and examine inequality in the distribution of earnings.

METHODS

The study used self-reported survey data collected in 2017 from a subset of HE/OR/MA professionals in the HealthEconomics.com global subscriber list. HE/OR/MA professionals in this subset completed a questionnaire. The sample consisted of 372 participants who reported their wage-and-salary earnings and other indicators. The sample was not necessarily representative of the global HE/OR/MA community. The study methods included a two-way classification model with multiple replications, an ordinary least-squares model, and three inequality indicators.

PRINCIPAL FINDINGS

The results suggested substantial disparities between the wage-and-salary earnings of respondents living in the USA and those living in other countries; mild gender disparities in earnings; greater inequality outside the USA than within the USA; and, within each location, more unequal distribution of men's earnings than that of women's earnings.

CONCLUSIONS

Although the findings may not be extrapolated to the worldwide population of HE/OR/MA professionals, they provide a point of comparison with earlier studies and offer insights into the mechanics of one of the most innovative and fastest growing health-sector workforce segments in developed as well as emerging countries.

Modal lifespan and disparity at older ages by leading causes of death: a Canada-U.S. comparison

The U.S. elderly experience shorter lifespans and greater variability in age at death than their Canadian peers. In order to gain insight on the underlying factors responsible for the Canada-U.S. old-age mortality disparities, we propose a cause-of-death analysis. Accordingly, the objective of this paper is to compare levels and trends in cause-specific modal age at death (M) and standard deviation above the mode (SD(M +)) between Canada and the U.S. since the 1970s. We focus on six broad leading causes of death, namely cerebrovascular diseases, heart diseases, and four types of cancers. Country-specific M and SD(M +) estimates for each leading cause of death are calculated from P-spline smooth age-at-death distributions obtained from detailed population and cause-specific mortality data. Our results reveal similar levels and trends in M and SD(M +) for most causes in the two countries, except for breast cancer (females) and lung cancer (males), where differences are the most noticeable. In both of these instances, modal lifespans are shorter in the U.S. than in Canada and U.S. old-age mortality inequalities are greater. These differences are explained in part by the higher stratification along socioeconomic lines in the U.S. than in Canada regarding the adoption of health risk behaviours and access to medical services.

Racial/ethnic minority segregation and low birth weight in five North American cities

Comparisons of communities across cities are rare in social epidemiology. Our prior work exploring racial/ethnic segregation and the prevalence of low birth weight (LBW) in communities from two large urban cities showed a strong relationship in Chicago and a very weak relationship in Toronto. This study extends that work by examining the association between racial/ethnic minority segregation and LBW in total of 307 communities in five North American cities: Baltimore, Boston, Chicago, Philadelphia, and Toronto. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW, controlling for community-level unemployment. In a combined model with community-level data from all cities, a 10% increase in minority composition is associated with a 0.7% increase in LBW. While racial/ethnic minority segregation and unemployment are not associated with LBW in Toronto, these social determinants have strong and significant associations with LBW across communities in the four US cities in the analysis. Subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Across communities in the US cities in this analysis, there is considerable similarity in the strength of the effect of racial/ethnic segregation on LBW. Future work should incorporate communities from additional cities, looking to identify community assets and public policies that allow some minority communities to thrive, while other minority communities suffer from a high prevalence of LBW. More work is also needed on the generalizability of these patterns to other health outcomes.

A Probe into the Wages and Salaries of Health Economics, Outcomes Research, and Market Access Professionals

OBJECTIVE

To estimate the central tendency and spread of health economics, outcomes research, and market access (HE/OR/MA) professionals' wage-and-salary earnings; compare male versus female and US versus non-US earnings levels; and examine inequality in their distribution.

METHODS

Self-reported survey data were collected in 2015 from HE/OR/MA professionals in the HealthEconomics.com global subscriber list. The study design consisted of a two-way classification model with multiple replications and three inequality indicators. HE/OR/MA professionals from the HealthEconomics.com global subscriber list completed a questionnaire. The sample consisted of 403 participants.

RESULTS

Within each location, men earned higher wages and salaries than women, and within each gender, HE/OR/MA professionals living in the USA earned higher wages and salaries than those living outside the USA. Evidence of a gap was suggested by the presence of gender and location disparities in earnings determinants. Results also suggested the presence of moderate inequality that was similar for both genders and greater for non-US than US residents.

CONCLUSIONS

This study shed light into the labor market structure of HE/OR/MA professionals and may be conducive to more rational and efficient workforce management policies.

Revisiting the Income Inequality Hypothesis With 292 OECD Regional Units

The income inequality hypothesis on the relationship between income inequality and population health has been debated for decades Disagreement exists on the hypothesis because empirical findings have reached inconsistent conclusions. At the cross-national level, the limited number of industrialized nations has created a chronic small-N problem for statistical analyses of the hypothesis. The OECD regional database containing statistics of hundreds of regional units can provide a breakthrough and is used for the first time for multiple regression in this article. It is found that income inequality is a statistically significant determinant of all the health indicators analysed. The findings support the income inequality hypothesis. In addition, the impact of income inequality seems to be stronger on infant mortality than on old-age mortality. GDP per capita also statistically significantly influences both life expectancy and old-age mortality but not infant mortality.

Towards an integrated framework for understanding the links between inequalities and wellbeing of places in low and middle income countries

As part of a larger research programme undertaking the development of a global index of wellbeing (GLOWING) through the exploration of population wellbeing in low to middle income countries (LMICs), this paper examines the role of inequality in shaping experiences of wellbeing. The paper explores various conceptualizations of wellbeing and inequality and outlines an integrated framework for understanding the importance of measuring the wellbeing of places. We conclude by urging geographers to explicitly engage with theory and cross-disciplinary research in order to adequately conceptualize the role of place in 'Beyond GDP' and progress measures.

Income inequality, life expectancy and cause-specific mortality in 43 European countries, 1987-2008: a fixed effects study

Whether income inequality is related to population health is still open to debate. We aimed to critically assess the relationship between income inequality and mortality in 43 European countries using comparable data between 1987 and 2008, controlling for time-invariant and time-variant country-level confounding factors. Annual data on income inequality, expressed as Gini index based on net household income, were extracted from the Standardizing the World Income Inequality Database. Data on life expectancy at birth and age-standardized mortality by cause of death were obtained from the Human Lifetable Database and the World Health Organization European Health for All Database. Data on infant mortality were obtained from the United Nations World Population Prospects Database. The relationships between income inequality and mortality indicators were studied using country fixed effects models, adjusted for time trends and country characteristics. Significant associations between income inequality and many mortality indicators were found in pooled cross-sectional regressions, indicating higher mortality in countries with larger income inequalities. Once the country fixed effects were added, all associations between income inequality and mortality indicators became insignificant, except for mortality from external causes and homicide among men, and cancers among women. The significant results for homicide and cancers disappeared after further adjustment for indicators of democracy, education, transition to national independence, armed conflicts, and economic freedom. Cross-sectional associations between income inequality and mortality seem to reflect the confounding effects of other country characteristics. In a European context, national levels of income inequality do not have an independent effect on mortality.

The association between income inequality and all-cause mortality across urban communities in Korea

BACKGROUND

Korea has achieved considerable economic growth more rapidly than most other countries, but disparities in income level have increased. Therefore, we sought to assess the association between income inequality and mortality across Korean cities.

METHODS

Data on household income were obtained from the 2010-2012 Korean Community Health Survey and data on all-cause mortality and other covariates were obtained from the Korean Statistical Information Service. The Gini coefficient, Robin Hood index, and income share ratio between the 80th and 20th percentiles of the distribution were measured for each community. After excluding communities affected by changes in administrative districts between 2010 and 2012, a total of 157 communities and 172,398 urban residents were included in the analysis.

RESULTS

When we graphed income inequality measures versus all-cause mortality as scatter plots, the R square values of the regression lines for GC, RHI, and 80/20 ratios relative to mortality were 0.230, 0.238, and 0.152, respectively. After adjusting for other covariates and median household income, mean all-cause mortality increased significantly with increasing GC (P for trend = 0.014) and RHI (P for trend = 0.031), and increased marginally with 80/20 ratio (P for trend = 0.067).

CONCLUSIONS

Our data demonstrate that income inequality measures are significantly associated with all-cause mortality rate after adjustment for covariates, including median household income across urban communities in Korea.

Province-level income inequality and health outcomes in Canadian adolescents

OBJECTIVE

To examine the effects of provincial income inequality (disparity between rich and poor), independent of provincial income and family socioeconomic status, on multiple adolescent health outcomes.

METHODS

Participants (aged 12-17 years; N = 11,899) were from the Canadian National Longitudinal Survey of Children and Youth. Parental education, household income, province income inequality, and province mean income were measured. Health outcomes were measured across a number of domains, including self-rated health, mental health, health behaviors, substance use behaviors, and physical health.

RESULTS

Income inequality was associated with injuries, general physical symptoms, and limiting conditions, but not associated with most adolescent health outcomes and behaviors. Income inequality had a moderating effect on family socioeconomic status for limiting conditions, hyperactivity/inattention, and conduct problems, but not for other outcomes.

CONCLUSIONS

Province-level income inequality was associated with some physical and mental health outcomes in adolescents, which has research and policy implications for this age-group.

Societal context and the production of immigrant status-based health inequalities: a comparative study of the United States and Canada

BACKGROUND

We compare disparities in health status between first-generation immigrants and others in the United States (US) and Canada.

METHODS

We used data from the Joint Canada-US Survey of Health. The regression models adjusted for demographics, socioeconomic status, and health insurance (the US).

RESULTS

In both countries, the health advantage belonged to immigrants. Fewer disparities between immigrants and those native-born were seen in Canada versus the US. Canadians of every immigrant/race group fared better than US native-born Whites.

DISCUSSION

Fewer disparities in Canada and better overall health of all Canadians suggest that societal context may create differences in access to the resources, environments, and experiences that shape health and health behaviors.

Relative residential property value as a socio-economic status indicator for health research

Background

Residential property is reported as the most valuable asset people will own and therefore provides the potential to be used as a socio-economic status (SES) measure. Location is generally recognised as the most important determinant of residential property value.

Extending the well-established relationship between poor health and socio-economic disadvantage and the role of residential property in the overall wealth of individuals, this study tested the predictive value of the Relative Location Factor (RLF), a SES measure designed to reflect the relationship between location and residential property value, and six cardiometabolic disease risk factors, central obesity, hypertriglyceridemia, reduced high density lipoprotein (HDL), hypertension, impaired fasting glucose, and high low density lipoprotein (LDL). These risk factors were also summed and expressed as a cumulative cardiometabolic risk (CMR) score.

Methods

RLF was calculated using a global hedonic regression model from residential property sales transaction data based upon several residential property characteristics, but deliberately blind to location, to predict the selling price of the property. The predicted selling price was divided by the actual selling price and the results interpolated across the study area and classified as tertiles. The measures used to calculate CMR were collected via clinic visits from a population-based cohort study. Models with individual risk factors and the cumulative cardiometabolic risk (CMR) score as dependent variables were respectively tested using log binomial and Poisson generalised linear models.

Results

A statistically significant relationship was found between RLF, the cumulative CMR score and all but one of the risk factors. In all cases, participants in the most advantaged and intermediate group had a lower risk for cardio-metabolic diseases. For the CMR score the RR for the most advantaged was 19% lower (RR = 0.81; CI 0.76-0.86; p <0.0001) and the middle group was 9% lower (RR = 0.91; CI 0.86-0.95; p <0.0001) than the least advantaged group.

Conclusions

This paper advances the understanding of the nexus between place, health and SES by providing an objective spatially informed SES measure for testing health outcomes and reported a robust association between RLF and several health measures.

The contribution of neighbourhood material and social deprivation to survival: a 22-year follow-up of more than 500,000 Canadians

Background: We examined the incremental influence on survival of neighbourhood material and social deprivation while accounting for individual level socioeconomic status in a large population-based cohort of Canadians. Methods: More than 500,000 adults were followed for 22 years between 1982 and 2004. Tax records provided information on sex, income, marital status and postal code while a linkage was used to determine vital status. Cox models were used to estimate hazard ratios (HR) for quintiles of neighbourhood material and social deprivation. Results: There were 180,000 deaths over the follow-up period. In unadjusted analyses, those living in the most materially deprived neighbourhoods had elevated risks of mortality (HR_males 1.37, 95% CI: 1.33–1.41; HR_females 1.20, 95% CI: 1.16–1.24) when compared with those living in the least deprived neighbourhoods. Mortality risk was also elevated for those living in socially deprived neighbourhoods (HR_males 1.15, CI: 1.12–1.18; HR_females 1.15, CI: 1.12–1.19). Mortality risk associated with material deprivation remained elevated in models that adjusted for individual factors (HR_males 1.20, CI: 1.17–1.24; HR_females 1.16, CI: 1.13–1.20) and this was also the case for social deprivation (HR_males 1.12, CI: 1.09–1.15; HR_females 1.09, CI: 1.05–1.12). Immigrant neighbourhoods were protective of mortality risk for both sexes. Being poor and living in the most socially advantageous neighbourhoods translated into a survival gap of 10% over those in the most socially deprived neighbourhoods. The gap for material neighbourhood deprivation was 7%. Conclusions: Living in socially and materially deprived Canadian neighbourhoods was associated with elevated mortality risk while we noted a “healthy immigrant neighbourhood effect”. For those with low family incomes, living in socially and materially deprived areas negatively affected survival beyond their individual circumstances.

Inequalities in the distribution of pharmacists' wage-and-salary earnings: indicators and their development

BACKGROUND

Disparities in wages and salaries can be viewed as the dispersion of a statistical distribution that responds to observed and unobserved characteristics, and reflects socioeconomic phenomena such as the interplay of supply and demand, availability of information, and efficiency of markets in their search for equilibrium.

OBJECTIVES

The aim of this study was to explore the nature of inequality in the distribution of pharmacists' wage-and-salary earnings and establish the extent to which inequality primarily occurred because of variation between/among groups or within groups of pharmacists in several classifications of human-capital and job-related preference variables.

METHODS

Data were collected through the use of a survey questionnaire mailed to registered pharmacists in South Florida, USA. Five indicators of inequality (the log earnings variance, the coefficient of variation, the lower median share, the 90-10 decile ratio, and the Gini coefficient) were estimated for eight human-capital classifications and eight job-related classifications. A one-way ANOVA model was applied to the groups in each classification to compare variation between/among versus within pharmacy groups.

RESULTS

Pharmacists' wage-and-salary earnings were more evenly distributed than most income distributions discussed in the literature. They were more equitably distributed for full-time pharmacists than for all pharmacists in the data set. All five-inequality indicators behaved similarly. Notable differences were observed between/among groups within the gender, age group, marital status, number of children, academic degree, and type of primary pharmacy activity classifications.

CONCLUSION

Inequalities in wages and salaries have been identified both between/among and within pharmacist groups in several classifications using five commonly accepted indicators.

Counseling and Harm Reduction Centers for Vulnerable Women to HIV/AIDS in Iran

BACKGROUND

Human immunodeficiency virus (HIV) is a public health challenge facing both developing and developed nations. Although injecting drug use is even the main route of HIV transmission in Iran, sexual route is rising gradually. Vulnerable women have been considered as important bridging population for driving HIV epidemics. To increase the access to vulnerable women, in 2007, 5 pilot centers were established in risky areas to deliver comprehensive services to women who themselves or their spouses are engaged in drug use, risky sexual behavior or have history of imprisonment. Management of Sexually Transmitted Infection, psychological counseling and harm reduction are provided by female staff. The aim of this study was to report the activities conducting in 2008.

METHODS

Registered information was used to assess the demographic characteristic, HIV/ AIDS related risk factors and services delivered to clients.

RESULTS

Till March 2008, 442 clients have been admitted. Most of them (36.2%) had 25-34 years old. 14.3% were illiterate and 31% were totally jobless. The most prevalent risk factors were risky sexual behavior (27.1%) and non-injecting drug use (23.2%). Injecting drug use was detected in 11.3% of attendees. Dividing clients according to marital status, risky sexual behavior was the main risk factor in unmarried (40.2%) and divorced (26.9%) but in married and widow ones, non-injecting drug use was the most (25.8% and 36.5% respectively). Harm reduction (40.5%) and counseling (36.6%) were the most delivered services.

CONCLUSION

Since vulnerable women play a critical role to spread HIV-epidemic to general population, increasing centers provide more access to this population.

Do people die from income inequality of a decade ago?

The long-term impact of income inequality on health has not been fully explored in the current literature. Until now, 4 studies have examined the lagged effect on population/group mortality rate at the aggregate level, and 7 studies have investigated the effect of income inequality on subsequent individual mortality risk within a restricted time period. These 11 studies suffer from the same limitation: they do not simultaneously control for a series of preceding income inequalities. The results of these studies are also mixed. Using the U.S. National Health Interview Survey data 1986-2004 with mortality follow-up data 1986-2006 (n = 701,179), this study investigates the lagged effects of national-level income inequality on individual mortality risk. These effects are tested by using a discrete-time hazard model where contemporaneous and preceding income inequalities are treated as time-varying person-specific covariates, which then track a series of income inequalities that a respondent faces from the survey year until s/he dies or is censored. Findings suggest that income inequality did not have an instantaneous detrimental effect on individual mortality risk, but began exerting its influence 5 years later. This effect peaked at 7 years, and then diminished after 12 years. This pattern generally held for three measures of income inequality: the Gini coefficient, the Atkinson index, and the Theil entropy index. The findings suggest that income inequality has a long-term detrimental impact on individual mortality risk. This study also explains discrepancies in the existant literature.

The health and housing in transition study: a longitudinal study of the health of homeless and vulnerably housed adults in three Canadian cities

OBJECTIVES

While substantial research has demonstrated the poor health status of homeless populations, the health status of vulnerably housed individuals is largely unknown. Furthermore, few longitudinal studies have assessed the impact of housing transitions on health. The health and housing in transition (HHiT) study is a prospective cohort study that aims to track the health and housing status of a representative sample of homeless and vulnerably housed single adults in three Canadian cities (Toronto, Ottawa, and Vancouver). This paper discusses the HHiT study methodological recruitment strategies and follow-up procedures, including a discussion of the limitations and challenges experienced to date.

METHODS

Participants (n = 1,192) were randomly selected at shelters, meal programmes, community health centres, drop-in centres, rooming houses, and single-room occupancy hotels from January to December 2009 and are being re-interviewed every 12 months for a 2-year period.

RESULTS

At baseline, over 85% of participants reported having at least one chronic health condition, and over 50% reported being diagnosed with a mental health problem.

CONCLUSIONS

Our findings suggest that, regardless of housing status, participants had extremely poor overall health.

[Social networks, risk dyads, and their role in the epidemiology and prevention of drug related infectious diseases]

In the case of risk behaviors where infection transmission occurs through social relationships (e.g. via sharing drugs and injecting equipment, or through sexual relations), prevention should follow (among others) the path of the social network. Previous studies have shown that sharing of injecting equipment is more likely to occur in larger and denser networks and that more popular individuals are more likely to engage in risk behaviors, become infected or transmit infection. Primary targets of social network interventions are central individuals, and information diffuses from them to the more peripheral members of the network. The most effective preventions are those where social network interventions targeting high-risk, central individuals are complemented by concurrent individual counseling and/or dyad interventions. Injecting drug users in Hungary would also benefit from such a multifaceted prevention approach aiming to reduce risky injecting behavior. This population needs prevention, in whatever form available, to prevent the deterioration of the current HCV and HIV epidemiological situation in Hungary and the development of an HIV epidemic that will eventually spread over to the general population.

A cross-national analysis of how economic inequality predicts biodiversity loss

We used socioeconomic models that included economic inequality to predict biodiversity loss, measured as the proportion of threatened plant and vertebrate species, across 50 countries. Our main goal was to evaluate whether economic inequality, measured as the Gini index of income distribution, improved the explanatory power of our statistical models. We compared four models that included the following: only population density, economic footprint (i.e., the size of the economy relative to the country area), economic footprint and income inequality (Gini index), and an index of environmental governance. We also tested the environmental Kuznets curve hypothesis, but it was not supported by the data. Statistical comparisons of the models revealed that the model including both economic footprint and inequality was the best predictor of threatened species. It significantly outperformed population density alone and the environmental governance model according to the Akaike information criterion. Inequality was a significant predictor of biodiversity loss and significantly improved the fit of our models. These results confirm that socioeconomic inequality is an important factor to consider when predicting rates of anthropogenic biodiversity loss.

Association between the food retail environment surrounding schools and overweight in Canadian youth

Introduction

There is growing interest in how the physical environment influences obesity. Few studies have considered how the food retail environment surrounding schools influences overweight in students.

Objective

To determine whether there is a relationship between food retailers surrounding schools and overweight among Canadian youth.

Design

Cross-sectional study.

Setting/methods/subjects

The number of food retailers was obtained within a 1 km and 5 km radius around 178 schools in Canada. Retailers included full-service restaurants, fast-food restaurants, sub/sandwich retailers, doughnut/coffee shops, convenience stores and grocery stores. An index of total food retailer exposure was also created. Multilevel analyses were used to control for individual- and area-level covariates.

Results

None of the individual food retailers was associated with an increased likelihood of overweight. The total food retailer index was most strongly related to overweight, but in the opposite direction to that hypothesized. At 1 km, students attending schools with at least one food retailer had a lower relative odds of overweight (OR = 0·70, 95 % CI 0·61, 0·81). At 5 km, students attending schools with the highest exposure to the total food retailer index had a lower relative odds of overweight (OR = 0·56, 95 % CI 0·47, 0·68) compared with students attending schools with no exposure.

Conclusions

Exposure to various types of food retailers in school neighbourhoods was not associated with an increased likelihood of overweight in Canadian school-aged youth. The opportunity to make healthy choices from a variety of options and the unique Canadian context may explain the findings.

Mortality associated with gastrointestinal bleeding events: Comparing short-term clinical outcomes of patients hospitalized for upper GI bleeding and acute myocardial infarction in a US managed care setting

OBJECTIVES

To compare the short-term mortality rates of gastrointestinal (GI) bleeding to those of acute myocardial infarction (AMI) by estimating the 30-, 60-, and 90-day mortality among hospitalized patients.

METHODS

United States national health plan claims data (1999-2003) were used to identify patients hospitalized with a GI bleeding event. Patients were propensity-matched to AMI patients with no evidence of GI bleed from the same US health plan.

RESULTS

12,437 upper GI-bleed patients and 22,847 AMI patients were identified. Propensity score matching yielded 6,923 matched pairs. Matched cohorts were found to have a similar Charlson Comorbidity Index score and to be similar on nearly all utilization and cost measures (excepting emergency room costs). A comparison of outcomes among the matched cohorts found that AMI patients had higher rates of 30-day mortality (4.35% vs 2.54%; p < 0.0001) and rehospitalization (2.56% vs 1.79%; p = 0.002), while GI bleed patients were more likely to have a repeat procedure (72.38% vs 44.95%; p < 0.001) following their initial hospitalization. The majority of the difference in overall 30-day mortality between GI bleed and AMI patients was accounted for by mortality during the initial hospitalization (1.91% vs 3.58%).

CONCLUSIONS

GI bleeding events result in significant mortality similar to that of an AMI after adjusting for the initial hospitalization.

Immigrant women and cervical cancer screening uptake: a multilevel analysis

BACKGROUND

Contextual factors may play an influential role in determining individual uptake of preventive health care services, especially among potentially vulnerable subpopulations. Using cervical cancer screening as a case study, this paper examines the multilevel factors associated with Pap testing in native-born and immigrant women.

METHODS

Cross-sectional multilevel logistic regression models were used to identify the individual- and neighbourhood-level characteristics that might explain differences in the lifetime uptake of Pap testing among immigrants and native-born women between the ages of 18 and 69 residing in the Montreal, Toronto and Vancouver Census Metropolitan Areas (CMAs). Individual-level data were drawn from the Canadian Community Health Survey (Cycle 2.1, 2003) and linked with census tract profile data from the Canadian Census (2001).

RESULTS

Findings reveal significant between-neighbourhood variation in uptake. After controlling for age, marital status, access to a regular doctor and socio-economic status, a woman's immigrant status and cultural origin appear to be significantly associated with ever having had a Pap test. In particular, the uptake of cervical cancer screening is less common among recent immigrant women and women of Chinese, South Asian and other Asian backgrounds.

INTERPRETATION

There appear to be significant differences between neighbourhoods and CMAs in the uptake of Pap testing. Findings point to the role of cultural origin, which largely accounts for these differences. This indicates the need to promote greater information and awareness of public health services for cervical cancer screening, especially among recent immigrant women with such backgrounds.

Income inequality measures

The Gini coefficient has been the most popular method for operationalising income inequality in the public health literature. However, a number of alternative methods exist, and they offer researchers the means to develop a more nuanced understanding of the distribution of income. Income inequality measures such as the generalised entropy index and the Atkinson index offer the ability to examine the effects of inequalities in different areas of the income spectrum, enabling more meaningful quantitative assessments of qualitatively different inequalities. This glossary provides a conceptual introduction to these and other income inequality measures.

Is inequality at the heart of it? Cross-country associations of income inequality with cardiovascular diseases and risk factors

Despite a number of cross-national studies that have examined the associations between income inequality and broad health outcomes such as life expectancy and all-cause mortality, investigations of the cross-country relations between income inequality and cardiovascular disease (CVD) morbidity, mortality, and risk factors are sparse. We analyzed the cross-national relations between income inequality and age-standardized mean body mass index (BMI), serum total cholesterol, systolic blood pressure (SBP), obesity prevalence, smoking impact ratio (SIR), and age-standardized and age-specific disability-adjusted life-years (DALYs) and mortality rates from coronary heart disease (CHD) and stroke, controlling for multiple country-level factors and specifying 5- to 10-year lag periods. In multivariable analyses primarily limited to industrialized countries, countries in the middle and highest (vs. lowest) tertiles of income inequality had higher absolute age-standardized obesity prevalences in both sexes. Higher income inequality was also related to higher mean SBP in both sexes, and higher SIR in women. In analyses of larger sets of countries with available data, positive associations were observed between higher income inequality and mean BMI, obesity prevalence, and CHD DALYs and mortality rates. Associations with stroke outcomes were inverse, yet became positive with the inclusion of eastern bloc and other countries in recent economic/political transition. China was also identified to be an influential data point, with the positive associations with stroke mortality rates becoming attenuated with its inclusion. Overall, our findings are compatible with harmful effects of income inequality at the national scale on CVD morbidity, mortality, and selected risk factors, particularly BMI/obesity. Future studies should consider income inequality as an independent contributor to variations in CVD burden globally.

Unpacking income inequality and population health: the peculiar absence of geography

BACKGROUND

A large and growing body of literature investigating the negative relationship between income inequality and population health (at different geographic scales) has developed over the past several years, although the relationship is not universal apparently. We argue that there has been a peculiar absence of geography in studies of the relationship between income inequality and population health and that explanations for the mixed results have been hampered by an inattention to geography.

METHODS

Using methods of spatial pattern visualization, outlier analysis and comparative case study analysis, we investigate the role of "geography" as a means of "unpacking" the relationship between income inequality and health in Canada and the United States.

RESULTS

The findings demonstrate how analyzing the study of income inequality and population health in the context of place makes otherwise obscure patterns visible and opens up new questions and opportunities for investigating how unequal places may be less healthy than more egalitarian ones. Rather than dismissing the importance of income inequality and health because it does not appear to exist at all times and in all places, we raise questions such as: Under what conditions does the relationship between income inequality and population health hold? and What, if anything, is similar about places where it does (or does not) hold? as crucial questions requiring a different kind of analysis than has been common in this literature.

CONCLUSION

We recommend that place and health studies seek this balance between universalistic and particularistic explanations of place and health relationships in order to best understand the socio-geographic production of health.

Immigrant women and cervical cancer screening uptake: a multilevel analysis

BACKGROUND

Contextual factors may play an influential role in determining individual uptake of preventive health care services, especially among potentially vulnerable subpopulations. Using cervical cancer screening as a case study, this paper examines the multilevel factors associated with Pap testing in native-born and immigrant women.

METHODS

Cross-sectional multilevel logistic regression models were used to identify the individual- and neighbourhood-level characteristics that might explain differences in the lifetime uptake of Pap testing among immigrants and native-born women between the ages of 18 and 69 residing in the Montreal, Toronto and Vancouver Census Metropolitan Areas (CMAs). Individual-level data were drawn from the Canadian Community Health Survey (Cycle 2.1, 2003) and linked with census tract profile data from the Canadian Census (2001).

RESULTS

Findings reveal significant between-neighbourhood variation in uptake. After controlling for age, marital status, access to a regular doctor and socio-economic status, a woman's immigrant status and cultural origin appear to be significantly associated with ever having had a Pap test. In particular, the uptake of cervical cancer screening is less common among recent immigrant women and women of Chinese, South Asian and other Asian backgrounds.

INTERPRETATION

There appear to be significant differences between neighbourhoods and CMAs in the uptake of Pap testing. Findings point to the role of cultural origin, which largely accounts for these differences. This indicates the need to promote greater information and awareness of public health services for cervical cancer screening, especially among recent immigrant women with such backgrounds.

Unpacking income inequality and population health: the peculiar absence of geography

BACKGROUND

A large and growing body of literature investigating the negative relationship between income inequality and population health (at different geographic scales) has developed over the past several years, although the relationship is not universal apparently. We argue that there has been a peculiar absence of geography in studies of the relationship between income inequality and population health and that explanations for the mixed results have been hampered by an inattention to geography.

METHODS

Using methods of spatial pattern visualization, outlier analysis and comparative case study analysis, we investigate the role of "geography" as a means of "unpacking" the relationship between income inequality and health in Canada and the United States.

RESULTS

The findings demonstrate how analyzing the study of income inequality and population health in the context of place makes otherwise obscure patterns visible and opens up new questions and opportunities for investigating how unequal places may be less healthy than more egalitarian ones. Rather than dismissing the importance of income inequality and health because it does not appear to exist at all times and in all places, we raise questions such as: Under what conditions does the relationship between income inequality and population health hold? and What, if anything, is similar about places where it does (or does not) hold? as crucial questions requiring a different kind of analysis than has been common in this literature.

CONCLUSION

We recommend that place and health studies seek this balance between universalistic and particularistic explanations of place and health relationships in order to best understand the socio-geographic production of health.

Towards an epidemiological understanding of the effects of long-term institutional changes on population health: A case study of Canada versus the USA

This paper uses a comparative case study of Canada and the USA to argue that, in order to fully understand the associations between population health and the socioeconomic environment we must begin to place importance on the dynamic aspect of these factors--examining them as they evolve over time. In particular, for institutional and policy shifts that often unfold over decades, population health must attend to these big, slow moving processes by adopting a historical perspective to the knowledge base. We compare Canada and the USA on basic health outcomes and a range of determinants of health for which routine data have been collected for all or most of the period between 1950 and the present. During the analysis that follows, we are able to establish that, at the level of society (i) greater economic well being and spending on health care does not yield better health outcomes, that (ii) public provision and income redistribution trump economic success where population health is concerned, and (iii) that the gradual development of public provision represents the buildup of social infrastructure that has long-lasting effects on health status. Our case study shows what can be gleaned from a comparative perspective and a long-term view. The long view allows us to detect the gradual divergence in health status between these two societies and to trace potential institutional causes that would otherwise go unnoticed. The perspective introduced here, and in particular the comparison of Canada and the USA, provides strong support for the use of cross-national comparative work, and a historical perspective on the investigation of societies that successfully support population health.

For whom is income inequality most harmful? A multi-level analysis of income inequality and mortality in Norway

This study investigates the degree to which contextual income inequality in economic regions in Norway affected mortality during the 1990s, above the effects of mean regional income and individual-level confounders. A further objective is to explore whether income inequality effects on mortality differed between socioeconomic groups. Data were constructed by linkages of administrative registers encompassing all Norwegian inhabitants. The outcome variable was all-cause mortality during 6 years (i.e., died 1994-1999 or alive end of 1999). Men and women aged 25-66 in 1993 were analysed. Regions' mean income and income inequality (in terms of gini coefficients) were calculated from consumption-units-adjusted family disposable income. Individual-level variables included sex, age, marital status, individual income, education, and being a recipient of health-related welfare benefits. Multilevel logistic regression models were fitted for 2,197,231 individuals nested within 88 regions. After adjusting for regional mean income and individual-level variables, the odds ratio (OR) for mortality 1994-1999 was 1.028 (95% CI 1.023-1.033) on the gini variable multiplied by 100. Analyses of cross-level interactions indicated some, albeit modest, income inequality effects on mortality in the upper income and educational categories. Among those with low individual income, low education, and among recipients of health-related welfare benefits, mortality effects of higher regional income inequality were significantly stronger than among those more advantageously placed in the social structure. The results of this study differ from previous studies which have suggested that contextual income inequality has a minor impact on population health in egalitarian countries. The results indicate that in Norway, neither a comparatively egalitarian income distribution nor generous and comprehensive welfare institutions hindered the emergence of regional-level income inequality effects on mortality, and these effects were particularly marked among socioeconomically disadvantaged groups. Explanations for the results are discussed.

Comparing Health And Health Care Use In Canada And The United States

Results from the Joint Canada/United States Survey of Health (2002-2003) reveal that health status is relatively similar in the two countries, but income-related health disparities exist. Americans in the poorest income quintile are more likely to have poor health than their Canadian counterparts; there were no differences between the rich. In general, Canadians were more like insured Americans regarding access to services, and Canadians experienced fewer unmet needs overall. Despite higher U.S. levels of spending on health care, residents in the two countries have similar health status and access to care, although there are higher levels of inequality in the United States.

Income distribution and mortality: implications from a comparison of individual-level analysis and multilevel analysis with Swedish data

BACKGROUND

This follow-up study analyses whether there is an association between income distribution in Swedish municipalities and risk of death from all causes in the total Swedish population aged 40-64 years and compares the results obtained with analyses performed on individual-level analysis and multilevel analysis.

METHODS

Individual-level data on social and economic circumstances were obtained from various official records and were linked to the national cause-of-death register. Analyses were made with two methods, an individual-level regression and a multilevel regression. The study population comprised all people 40-64 years of age in the 1990 Swedish census, altogether 2.57 million people in 284 municipalities.

RESULTS

The main results showed that in the individual-level regression the income distribution showed a positive and significant association (risk ratio = 1.29; 95% CI = 1.24-1.34) with higher mortality for those living in municipalities with higher income inequality. This association was not found in the multilevel regression analysis (RR = 1.03; 95%CI = 0.94-1.13).

CONCLUSION

There seems to be no association between income distribution and mortality in Sweden when considering the possibility of clustering in municipalities. Further studies on the relationship between income inequality and health should aim at elucidate processes within area-level units.

Income inequality and population health: A review and explanation of the evidence

Whether or not the scale of a society's income inequality is a determinant of population health is still regarded as a controversial issue. We decided to review the evidence and see if we could find a consistent interpretation of both the positive and negative findings. We identified 168 analyses in 155 papers reporting research findings on the association between income distribution and population health, and classified them according to how far their findings supported the hypothesis that greater income differences are associated with lower standards of population health. Analyses in which all adjusted associations between greater income equality and higher standards of population health were statistically significant and positive were classified as "wholly supportive"; if none were significant and positive they were classified as "unsupportive"; and if some but not all were significant and supportive they were classified as "partially supportive". Of those classified as either wholly supportive or unsupportive, a large majority (70 per cent) suggest that health is less good in societies where income differences are bigger. There were substantial differences in the proportion of supportive findings according to whether inequality was measured in large or small areas. We suggest that the studies of income inequality are more supportive in large areas because in that context income inequality serves as a measure of the scale of social stratification, or how hierarchical a society is. We suggest three explanations for the unsupportive findings reported by a minority of studies. First, many studies measured inequality in areas too small to reflect the scale of social class differences in a society; second, a number of studies controlled for factors which, rather than being genuine confounders, are likely either to mediate between class and health or to be other reflections of the scale of social stratification; and third, the international relationship was temporarily lost (in all but the youngest age groups) during the decade from the mid-1980s when income differences were widening particularly rapidly in a number of countries. We finish by discussing possible objections to our interpretation of the findings.

Increasing geographical inequalities in health in New Zealand, 1980-2001

BACKGROUND

Recent studies have noted widening health inequalities between rich and poor areas in a number of OECD countries. This paper examines whether health in New Zealand has become more geographically polarized during the period 1980-2001, a time of rapid social and economic changes in New Zealand society.

METHODS

Mortality records for each year between 1980 and 2001 were extracted for consistent geographical areas: the 21 District Health Boards operating in New Zealand in 2001 and used to calculate male and female life expectancies for each area. The geographical inequalities in life expectancy were measured by calculating the slope index of inequality for each year between 1980 and 2001.

RESULTS

Although overall life expectancy has increased during the period of study, New Zealand has experienced increased spatial polarization in health, with a particularly sharp rise in inequality during the late 1980s and early 1990s. Since the mid-1990s regional inequality has remained at stable but high levels. The polarization in mortality was mirrored by a growth in income inequality during the 1980s and 1990s.

CONCLUSIONS

Health inequalities as expressed geographically in New Zealand have reached historically high levels and show little sign of abating. In order to tackle health inequalities, a greater commitment by the New Zealand government to a more redistributive social and economic agenda is required. Furthermore, issues of differentiated and health selective migration, emigration, and immigration need to be addressed as if these are important they should matter more for New Zealand than for almost any other developed nation-state.

Speaking truth to power: nursing's legacy and moral imperative

Critical caring has been proposed as a mid-range theory to guide public health nursing. One of its carative health promoting processes, contributing to the creation of supportive and sustainable physical, social, political, and economic environments, is particularly suited to enacting Nightingale's legacy of political action as an expression of caring. Increasing evidence supports the link between broad societal influences on health inequities. Relative and absolute poverty are significant influences on health and contribute significantly to differential health statuses of populations within and between countries. Nurses, who practice at the intersection of public policy and personal lives, are, therefore, ideally situated and morally obligated to include political advocacy and efforts to influence health public policy in their practice. The health of the public and the future of the profession may depend on it.

Is income inequality a determinant of population health? Part 1. A systematic review

This article reviews 98 aggregate and multilevel studies examining the associations between income inequality and health. Overall, there seems to be little support for the idea that income inequality is a major, generalizable determinant of population health differences within or between rich countries. Income inequality may, however, directly influence some health outcomes, such as homicide in some contexts. The strongest evidence for direct health effects is among states in the United States, but even that is somewhat mixed. Despite little support for a direct effect of income inequality on health per se, reducing income inequality by raising the incomes of the most disadvantaged will improve their health, help reduce health inequalities, and generally improve population health.