Current State of Income, Health and Disease Research in Canada Ron Colman and Karen Hayward Genuine Progress Index Atlantic, Halifax, NS Ron Labonte and Renee Torgerson SPHERU, University of Saskatchewan, SK Dennis Raphael and Jen Macdonald York University, Toronto, ON Social Determinants of Health Conference, York University, Nov 29 - Dec 1, 2002

Overview of Project Funded by CIHR Institute of Population and Public Health as part of the Needs, Gaps and Opportunities Initiative. Why this Project: It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent. -- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Research Objectives This project consists of an environmental scan of current and planned research activity and capacity in Canada related to the role that income -- and its distribution -- plays in population health. We aspire to: 1.Influence the research agenda and improve model building using existing income and health research findings, and; 2.find ways to improve the uptake of findings by policy makers and the general public.

Research Questions Are current Canadian researchers cognizant of, and applying the following conceptualizations within their research: 1.whether the effects of income inequality in health are the result of income inadequacy (material deprivation) or income inequality (social comparison); 2.the role of non-income resources in the health and income relationship; 3.quality of life and self-rated health psychosocial comparison between wealthy and poor groups; 4.the effect that income inequality has on other pathways (societal and community) that link social and environmental phenomena to health;

Research Methods Canadian Literature search: –Journal datasets: Webspirs, Elselvier, Publine –National & provincial funding, research & policy institutes; university-based research units – contact with researchers in the field for current research (if not available on internet) –Name search of prominent Canadian Researchers Development of template to consider the nature of income and health research in Canada and elsewhere. Key Informant interviews with prominent Canadian, UK and Finnish researchers.

Research Analysis Template development for data entry –Over 300 Canadian, UK, and Finnish empirical research pieces have been reviewed and entered into a Microsoft Excel template, using qualitative and quantitative data entry. –The quantitative element represents a vertical level of analysis which provides statistical evidence for gaps in the literature. –The qualitative element represents a horizontal level analysis of the literature which allows us to see the links between research elements.

Quality Analysis Quality analysis of literature: Study background / rationale Variables Outcomes Income/ income distribution / income inequality Research design / datasets used Theorization (implicit/ explicit) Pathways explicated biological, materialist, psychosocial, psychosocial comparison, behavioural, gender analysis, political-economic analysis Implications for policy development Areas for future research

Quantitative Analysis Quantitative elements of literature analysis, –Level of analysis used (i.e. individual, Neighbourhood, Provincial, National) –Research design (Longitudinal, Cross- sectional, sequential cross sectional, time lag) –Temporal element –Pathways explicated Hierarchical ranking of elements (implies sophistication) –Outcomes –Research design –Measurement of income/ income inequality –Conceptualization of income/ income inequality –Complexity of pathways –Theoretical background either implied or explicated –Policy implications

Hierarchical Ranking Outcomes 1.Health status –Mental health, quality of life, child behaviour –Morbidity –Mortality 2.Health care utilization –Equity and access to services, insurance, prescription drug use 3.Other –Methodological and artifactual studies 4.Lifestyle/ behavioural –Attitudes, behaviours and other prerequisites for health behaviour change (“health work”) –Diet, physical activity, smoking…

Hierarchical Ranking Research Design 1.Longitudinal / Prospective studies, life course perspective 2.Sequential cross sectional, time lag, case control 3.Cross sectional

Hierarchical Ranking Measurement of Income 1.Comparative, population level examination of income distribution / income inequality –Relative income hypothesis –Absolute income hypothesis 2.Non-comparative – studies that only look at low income individuals, or individuals who live in poverty 3.Income as a confounding variable – income is not treated as a primary independent variable

Hierarchical Ranking Conceptualization of Income 1.Combination of materialist and interpretive concepts of income 2.Interpretive - Hierarchical social comparison 3.Materialist I – income inequality at the state level as it pertains to expenditure on public goods 4.Materialist II – Socio-economic indicators such as income, wealth, educational attainment, and occupational groupings 5.No conceptualization

Hierarchical Ranking Pathways 1.Sophisticated – sees interconnectedness between pathways with explicit conceptualization 2.Intermediate – looks at pathways as mechanisms for causal/associational relationship, but provides little to no explanation 3.Undeveloped - No theoretical constructs of theory

Hierarchical Ranking Theory 1.Structural / organizational – external to the individual –Theory that locates community issues within a vertical framework –Horizontal structure –Vertical structure –External from the individual but uncritical 2.Individualistic – focused on the individual 3.No theory - Empiricist

Theory How local issues are part of overall structures within larger society Social structures (e.g. government policies and laws, gender issues, income distribution, capitalist system, globalization, etc) Local structures and community issues

Hierarchical Ranking Policy Implications 1.Political-economic structural systemic change (welfare, taxation, redistribution of wealth) 2.Social determinants of health (education, literacy, employment, social inclusion, housing, food security, community services, access to health care services) 3.Health care (health care practice and policy, practitioner behaviours) 4.Lifestyle, individual level change (smoking cessation, health education, health living) 5.No recommendations made

Areas for Future Research Preliminary findings Life course perspective: –Need for creation of and greater use of longitudinal datasets that allow for the examination of causation and associations of relationships over the life course. Complexity: –Need for research that examines the complexity of the relationships between pathways that link income to population and individual level health outcomes, particularly at the neighbourhood / community level of analysis.

Areas for Future Research Preliminary findings Measurement and conceptualization of income / income inequality; need for research that: –explores the impact that income inequality has on individuals and populations; and –explores hierarchy and social position, as well as the connection between population level income inequality and public expenditure on increasing access to resources for health (such as health insurance, social welfare, supports for the unemployed and those with disabilities).

Areas for Future Research Preliminary findings Need for research that pays particular attention to how community issues are located within vertical structures. Need for research that concludes with concrete directions for inter-sectoral and health policy action to approach the issue of income disparity, and income inequality and its impact on health.

Policy Directions and Population Health The policies that Canada has developed to improve population health reflects its more egalitarian structure. Examples include various tax and economic transfer policies that help to limit income differences across the country, as well as provision of important social services... If a healthy population is the goal, we must enter the political arena and fight to maintain the social contract that has sustained Canada as one of the world leaders in health. Stephen Bezruchka, CMAJ, 2001

Contact info: Dennis Raphael School of Health Policy and Management York University Toronto, Canada , ext