Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health?

BACKGROUND: Despite enormous public sector expenditures, the effectiveness of universal coverage for health care in reducing socioeconomic disparities in health has received little attention. STUDY OBJECTIVE:s: To evaluate whether universal coverage for health care reduces socioeconomic disparities in health. DESIGN: Information on participants of the 1990 Nova Scotia Nutrition Survey was linked with eight years of administrative health services data and mortality. The authors first examined whether lower socioeconomic groups use more health services, as would be expected given their poorer health status. They then investigated to what extent differential use of health services modifies socioeconomic disparities in mortality. Finally, the authors evaluated health services use in the last years of life when health is poor regardless of a person's socioeconomic background. SETTING: The Canadian province of Nova Scotia, which provides universal health care coverage to all residents. PARTICIPANTS: 1816 non-institutionalised adults, aged 18-75 years, from a two stage cluster sample stratified by age, gender, and region. Main results: People with lower socioeconomic background used comparatively more family physician and hospital services, in such a way as to ameliorate the socioeconomic differences in mortality. In contrast, specialist services were comparatively underused by people in lower socioeconomic groups. In the last three years of life, use of specialist services was significantly higher in the highest income group. CONCLUSIONS: Universal coverage of family physician and hospital services ameliorate the socioeconomic differences in mortality. However, specialist services are underused in lower socioeconomic groups, bearing the potential to widen the socioeconomic gap in health.     

Socioeconomic and work related determinants of pregnancy outcome in southern Thailand

STUDY OBJECTIVE: To examine the effect of socioeconomic status on pregnancy outcome in an urbanised area in a rapidly developing country. METHODS: A cohort of 1797 pregnant women who attended antenatal care clinics at the two 700 bed hospitals in Hatyai city was recruited from September 1994 to November 1995. The pregnant women were followed up from the 17th week of gestation until delivery. The socioeconomic indicators selected were family socioeconomic status, maternal education, maternal occupation, family income and work exposure characteristics based upon Karasek's job content questionnaires. Pregnancy outcomes were birth weight, low birth weight, small for gestational age and preterm delivery. MAIN RESULTS: Mean birth weight correlated with socioeconomic status and income but after adjustment for parity, maternal age and height, weight at delivery day, baby sex, obstetrical complications and antenatal care utilisation, only family income remained correlated with birth weight. No association with any socioeconomic status indicators was found when using dichotomous outcome (low birth weight, small for gestational age or preterm delivery). Only high psychological job demand was associated with small for gestational age. Confounder adjustment indicated that the observed social status differences in pregnancy outcomes were mainly attributable to mother's characteristics and antenatal service use. CONCLUSIONS: Socioeconomic indicators alone were not associated with reduced fetal growth or preterm delivery in this study, which recruited mainly lower or middle class women. Karasek's psychological job demand was only weakly correlated with small for gestational age infant.     

The effects of patient characteristics on ambulatory test ordering

To investigate the relationship of patient characteristics and the use of ambulatory testing services, we examined patterns of test use for 351 patients with chronic uncomplicated hypertension, cared for by 30 private practice internists. We studied the use of visits and diagnostic tests in relation to patients' sex, marital status, obesity, employment status, occupational class, insurance coverage and severity of illness in terms of age, extent of blood pressure elevation and number of medications used in treatment. Testing services accounted for 63% of the total expenditure for testing and physician services. Females and patients with greater severity of disease had higher visit rates, and age was significantly related to increased test use. Marital status, obesity and socioeconomic characteristics were not strongly associated with patterns of testing. Our results suggest that patterns of testing for hypertensive patients are related to severity of illness in terms of age but not to patients' socioeconomic characteristics.     

Influence of socioeconomic and cultural factors on rural health

Objective:  To provide a framework for investigating the influence of socioeconomic and cultural factors on rural health.
Design:  Discussion paper.
Results:  Socioeconomic and cultural factors have long been thought to influence an individual's health. We suggest a framework for characterising these factors that comprises individual-level (e.g. individual socioeconomic status, sex, race) and neighbourhood-level dimensions (population composition, social environment, physical environment) operating both independently and through interaction. Recent spatial research suggests that in rural communities, socioeconomic disadvantage and indigenous status are two of the greatest underlying influences on health status. However, rural communities also face additional challenges associated with access to, and utilisation of, health care. The example is given of procedural angiography for individuals with an acute coronary event.
Conclusions:  Socioeconomic and cultural factors specific to rural Australia are key influences on the health of residents. These range from individual-level factors, such as rural stoicism, poverty and substance use norms, to neighbourhood-level social characteristics, such as lack of services, migration out of rural areas of younger community members weakening traditionally high levels of social cohesion, and to environmental factors, such as climate change and access to services.     

The association of race/ethnicity,socioeconomic status,and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES: This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. METHODS: In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. RESULTS: Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). CONCLUSIONS: Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.     

Private medicine and socioeconomic differences in the rates of common surgical procedures in Finland

The aim of the study was to evaluate socioeconomic equity in access to surgical services in Finland and to explore the contribution of private sector procedures to any inequities. Data on nine common surgical procedures performed on patients aged 25 and over were obtained from the 1987-88 Finnish Hospital Discharge Register. Socioeconomic indicators were linked to the procedure data by personal identity numbers from the 1987 population census, which was also used to derive the data on population at risk. The study revealed marked differences in rates across socioeconomic categories for several procedures. Some of these disparities are probably explained by variations in need for surgery across socioeconomic groups. However, for cataract operations and hip replacements due to arthrosis or deformity, the surgery rates favoured the better-off, despite low social status being considered a risk factor for these disorders. The correlation or disposable family income with hysterectomy and prostatectomy rates, and the low surgery rates for many procedures in the lowest income quintile also suggested socioeconomic disparities in access to services. The specific effect of private sector seems to have contributed to the socioeconomic differences in rates for, at least, hysterectomy, prostatectomy, and cataract operations. Although the Finnish health care system operates universal coverage without formal barriers to equal access, systematic socioeconomic inequity in the use of individual surgical treatments prevail. Part of these inequities is evidently due to private sector services.     

Inequalities in Use of Health Services among Jews and Arabs in Israel

Objectives. To compare the levels of utilization of health services in Jews and Arabs taking into account differences in levels of socioeconomic status (SES) in a country with a National Health Insurance Law (NHIL).
Data Source/Study Setting. A cross-sectional National Health Interview Survey was carried out in Israel based on a random sample of telephone numbers as part of the EUROHIS project (WHO European Health Interview Survey 2003–2004).
Study Design. A random telephone survey included 9,352 interviews. Questions included use of health care services, health status, and socioeconomic variables.
Principal Findings. After adjusting for sex, age, income, education, marital status, and self-reported chronic diseases, Arabs more often reported visiting a family physician (odds ratio [OR]=1.56, 95 percent confidence interval [CI]=1.35–1.81) and less often reported visiting a specialist (OR=0.73, 95 percent CI=0.60–0.89) compared with Jews. In addition, the odds ratio for hospitalization was similar among Arabs and Jews (OR=1.16, 95 percent CI=0.97–1.38). SES was associated with utilization of health care services only in the Jewish population.
Conclusions. A different pattern of utilization of health care services was observed in Arabs and Jews. This was not explained by differences in socioeconomic levels. More research is needed regarding the distribution of services between Jews and Arabs.     

Socioeconomic status and smoking: analysing inequalities with multiple indicators

BACKGROUND AND AIMS: Socioeconomic differences in smoking have been well established. While previous studies have mostly relied on one socioeconomic indicator at a time, this study examined socioeconomic differences in smoking by using several indicators that reflect different dimensions of socioeconomic position. DATA AND METHODS: Data derive from Helsinki Health Study baseline surveys conducted among the employees of the City of Helsinki in 2000 and 2001. The data include 6243 respondents aged 40-60 years (response rate 68%). Six socioeconomic indicators were used: education, occupational status, household income per consumption unit, housing tenure, economic difficulties and economic satisfaction. Their associations with current smoking were examined by fitting sequential logistic regression models. RESULTS: All socioeconomic indicators were strongly associated with smoking among both men and women. When the indicators were examined simultaneously their associations with smoking attenuated, especially when education and occupational status were considered together, and when income and housing tenure were introduced into the models already containing education and occupational status. After mutual adjustment for all socioeconomic indicators, housing tenure and economic satisfaction remained associated with smoking in men. In women, all indicators except income and economic difficulties were inversely associated with smoking after adjustments. CONCLUSIONS: Smoking was associated with structural, material as well as perceived dimensions of socioeconomic disadvantage. Attempts to reduce smoking among the socioeconomically disadvantaged need to target several dimensions of socioeconomic position.     

Socioeconomic pattern of smoking in Japan: income inequality and gender and age differences

PURPOSE: To elucidate the influence of individual socioeconomic status on smoking in Japanese adults. METHODS: Using a nationally representative sample (20,206 men and 21,093 women aged 18 to 54 years), the relation between smoking and socioeconomic characteristics was analyzed by sex and age group (18 to 24, 25 to 39, and over 40 years). RESULTS: The smoking prevalence was 57.0% for men and 16.6% for women. Living in an urban area was a negative factor for smoking in men, while a positive factor in women. Being married was positively associated with smoking in the younger population, but negatively associated in the older population. A relation between lower income and smoking was found in all groups, except in men aged 18 to 24 years. The income-related difference was most pronounced in the population aged 25 to 39 years: OR of smoking for the highest income quintile compared with the lowest was 0.60 (95% CI, 0.51-0.71) for men and 0.29 (95% CI, 0.23-0.35) for women. CONCLUSIONS: Socioeconomic status, especially income, substantially predicted smoking in the Japanese population, while the impact differed according to sex and age groups. Effective anti-smoking strategies require consideration of the gender and age differences in the socioeconomic pattern of smoking.     

The impact of socioeconomic level on influenza vaccination among Italian adults and elderly: a cross-sectional study

OBJECTIVE: To assess the predictive factors of influenza vaccination among Italian adults, focusing on socioeconomic differences. METHODS: A cross-sectional study was carried out using interview and self-reported data on 102,095 subjects aged 25-89 years from the national survey "health conditions and health care services use" conducted in Italy in 1999-2000. Analyses were stratified by age and multiple logistic regression models were used to estimate odds ratios (OR) of influenza vaccination. RESULTS: Approximately one in six individuals (17.3%) received an influenza vaccine in the previous 12 months. Older age, poor health status and former smoking were all positively associated with influenza vaccination (P-value<0.05). Lower educated individuals and subjects with manual occupations were less likely to be vaccinated than those better off, with an OR ranging from 0.65 (95% CI 0.55, 0.77) to 0.82 (95% CI 0.71, 0.93). Among individuals aged 65-89 there was no apparent influence of both variables on the likelihood of receiving the influenza vaccine. CONCLUSIONS: Socioeconomic inequalities in influenza vaccine uptake were present among the adults but not among the elderly. Because in Italy the National Health Service provides influenza vaccination to the elderly free of charge, it is possible that this policy attenuated the socioeconomic differential.     

Cross-sectional and longitudinal associations of BMI with socioeconomic characteristics

OBJECTIVE: To examine cross sectional and longitudinal associations of socioeconomic position and neighborhood environments with BMI in a middle-aged and bi-ethnic cohort. RESEARCH METHODS AND PROCEDURES: Analyses were based on 13,167 subjects (45 to 64 years) who participated in the Atherosclerosis Risk in Communities Study, a population-based study. Census block groups were used as proxies for neighborhoods and were characterized using a summary socioeconomic score. BMI was measured at baseline and at three follow-up visits over a 9-year period. RESULTS: Individual and neighborhood socioeconomic characteristics were independently and inversely associated with BMI at baseline in women [mean difference in kilograms per meter squared per unit increase in socioeconomic category (SE) for white and black women respectively; -1.56 (0.14), -1.59 (0.19) for education; -1.07 (0.10), -1.18 (0.18) for income; and -1.04 (0.09), -0.77 (0.18) for neighborhood characteristics]. Results for men were not as consistent. Baseline BMI was negatively associated with income in white men but was positively associated with education, income, and neighborhood characteristics in black men. BMI increased over time regardless of gender or race and in most age groups. In whites, there were no consistently patterned differences in longitudinal trends in BMI by individual or neighborhood socioeconomic characteristics. However, in blacks, there was some evidence of greater increases in the higher socioeconomic status groups. DISCUSSION: Socioeconomic factors are inversely associated with BMI in middle-aged women, possibly reflecting socially patterned exposures occurring in childhood and adolescence. However, recent increases over time in BMI are either not clearly patterned by socioeconomic factors or are greater in the higher socioeconomic status groups.     

Differences in Use of Health Services Between White and African American Children Enrolled in Medicaid in North Carolina

Objectives: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. Methods: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for NorthCarolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect ofrace, controlling for other variables such as low birth weight, WICparticipation, and mother's age, education, and marital status. Since allchildren enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled.Results: African American children had consistently lower Medicaidexpenditures and lower use of health servicesthan did White children,after statistically controlling for other maternal and infantcharacteristics that affect health service use, including child WICparticipation. For example, total annual Medicaid expenditures were $207–303 less for African American children than for White children,controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. Conclusions: African American children enrolled in Medicaid use healthservices much less than White children, even when controlling forsocioeconomic status and other factors that affect service use. Linkingstate administrative databases can be a cost-effective way of addressingimportant issues such as racial disparities in health service use.     

Inequities in Ambulatory Care and the Relationship Between Socioeconomic Status and Respiratory Hospitalizations: A Population-Based Study of a Canadian City

PURPOSE

Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care–sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.

METHODS

Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease–related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient’s usual physician (eg, payment mechanism, sex, years in practice).

RESULTS

We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93).

CONCLUSIONS

In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care–sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.     

Geographic and demographic variation in the prevalence of overweight Canadian children

OBJECTIVE: To examine the geographic and demographic variation in the prevalence of overweight Canadian children. RESEARCH METHODS AND PROCEDURES: Using BMI data from the 1981 Canada Fitness Survey and the 1996 National Longitudinal Survey of Children and Youth, this study assessed: 1). the prevalence of overweight and obesity among Canadian boys and girls ages 7 to 13 years; 2). secular trends in the prevalence of overweight from 1981 to 1996, by province and adjusted for age and sex; and 3). provincial variation in the prevalence of overweight, before and after adjusting for socioeconomic and demographic characteristics. RESULTS: The prevalence of boys and girls classified as overweight in 1996 was 33% and 26%, respectively. The corresponding figures for obesity were 10% for boys and 9% for girls. Provincial variation was observed with a trend of increasing risk of being overweight from west to east. Socioeconomic status was inversely related to the prevalence of overweight regardless of geographic region. The risk of being overweight was more related to geography (province) than demographic variables (income and family background); however, the effect of secular trends (1981 to 1996) exceeded the effect of geographic or demographic variables. DISCUSSION: The prevalence of childhood overweight and obesity is increasing in all areas of Canada and can be explained only partially by geographic or demographic characteristics.     

Factors influencing utilization of the curative health services among children aged 6-60 months in Bahrain (Part II)

Two hundred twenty one out of 2587 children aged 6-60 months were selected at random from 8 villages in Western region of Bahrain. The data were collected by interviewing the mothers and checking out the health records. The study revealed that family size, mother's education, socioeconomic status and mother's attitude toward the curative services were significant factors for the use of the curative care. However, no significant relationships were found between the utilization of the curative care and age and sex of child, family structure and the situational factors.     

Socioeconomic status and asthma prevalence in young adults: the European Community Respiratory Health Survey

The authors assessed the association between asthma prevalence and socioeconomic status at both the individual and center levels simultaneously.by using data from 32 centers in 15 countries. Included were 10,971 subjects aged 20-44 years selected from the general population and interviewed in 1991-1992. Socioeconomic status at both the individual and aggregated levels was measured on the basis of occupation and educational level. Associations were assessed by using multilevel models adjusted for age, sex, body mass index, parental asthma, childhood respiratory infections, presence of immunoglobulin E to common allergens, rhinitis, smoking, and occupational exposure to irritants. Asthma prevalence was higher in lower socioeconomic groups, whether defined by educational level (odds ratio for finishing full-time studies-<16 vs. >19 years = 1.28, 95% confidence interval: 1.00, 1.64) or social class (odds ratio for semiskilled and unskilled manual workers vs. professional/managerial = 1.51, 95% confidence interval: 1.20, 1.90), regardless of atopic status. The relation was consistent between centers. Irrespective of individual socioeconomic status, subjects living in areas in which educational levels were lower had a higher risk of asthma (p < 0.05). This center-level association partially explained geographic differences in asthma prevalence, but considerable heterogeneity still remained. The authors concluded that community influences of living in a low-educational area are associated with asthma, independently of subjects' own educational level and social class.     

Calcium intake in youth: sex, age, and racial differences in NHANES II.

METHODS. Data from the NHANES II survey were used to determine whether the calcium intake of children ages 3-18 met the minimum recommended daily allowance. In addition, the impact of age, race, sex, and socioeconomic status on calcium intake and the density of calcium intake was explored. RESULTS. The results indicated significant differences between groups of children based on age, sex, and race (P less than 0.05). Males across all age groups (3-5, 6-7, 8-10, 11-12, 13-18) had a higher calcium intake than females. In addition, calcium intake levels among males always met or exceeded the minimum RDA. Levels among all blacks started below the minimum RDA in the age group 3-5. During the adolescent years, calcium intake again fell below the RDA for black males and for females of both races, with the calcium intake of the adolescent females resembling that of the group ages 3-5. In a multiple regression model sex, age, race, and total energy intake predicted 49% (P less than 0.0001) of the variance in calcium intake. Socioeconomic status (using parents' reported income) was not a significant predictor. Another regression model was used to examine the relationship among age, race, sex, and socioeconomic status and its effect on the density of calcium intake (mg/kcal). While the overall model was significant (P less than 0.0001) it accounted for only 3.5% of the variance. CONCLUSION. Age, sex, and race of the child significantly predicted the density of calcium (P less than 0.05); however, parents' gross income did not (P less than 0.81), indicating that income level does not contribute to explaining these differences.     

The relationship of prenatal care and pregnancy complications to birthweight in Winnipeg, Canada.

OBJECTIVES. Prenatal care is commonly understood to have a beneficial impact on birthweight. This study describes socioeconomic differences in utilization of prenatal medical care and birthweight in a population with universal health insurance. METHODS. Measures of prenatal care utilization, incidence of pregnancy complications, and birthweight were obtained from physician reimbursement claims and hospital separation abstracts for 12,646 pregnant women. Maternal socioeconomic status was derived from small-area census data. RESULTS. Infants born to women in the poorest income quintile had lower birthweights than infants born to wealthier women. Much of the difference was associated with a higher prevalence of complications, smoking, unmarried status, and inadequate prenatal care among low-income women. The difference in birthweight between adequate and less than adequate care groups was small, and the benefit associated with prenatal care was no greater among women with pregnancy complications. CONCLUSIONS. The lower utilization of prenatal care by poorer women accounted for a small proportion of the difference in birthweight. Socioeconomic differences in birthweight are primarily attributable to factors not directly influenced by early prenatal medical care.