Income inequality and health: multilevel analysis of Chilean communities

STUDY OBJECTIVE: The evidence supporting the effect of income inequality on health has been largely observed in societies far more egalitarian than the US. This study examines the cross sectional multilevel associations between income inequality and self rated poor health in Chile; a society more unequal than the US. DESIGN: A multilevel statistical framework of 98 344 people nested within 61 978 households nested within 285 communities nested within 13 regions. SETTING: The 2000 National Socioeconomic Characterization Survey (CASEN) data from Chile. PARTICIPANTS: Adults aged 18 and above. The outcome was a dichotomised self rated health (0 if very good, good or average; 1 if poor, or very poor). Individual level exposures included age, sex, ethnicity, marital status, education, employment status, type of health insurance, and household level exposures include income and residential setting (urban/rural). Community level exposures included the Gini coefficient and median income. Main results: Controlling for individual/household predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (OR: 2.94) followed by poor (OR: 2.77), low (OR: 2.06), middle (OR: 1.73), high (OR: 1.38) as compared with the very high income earners. Controlling for household and community effects of income, a significant effect of community income inequality was observed (OR:1.22). CONCLUSIONS: Household income does not explain any of the between community differences; neither does it account for the effect of community income inequality on self rated health, with more unequal communities associated with a greater probability of reporting poor health.     

Drug formulary decision-making in two regional health authorities in British Columbia, Canada

OBJECTIVES: Growing pharmaceutical demands challenge healthcare organizations to set drug funding priorities (i.e. establish a formulary list). This responsibility typically rests with pharmacy and therapeutics (P&T) committees, yet how the process transpires within regional health authorities is unclear. The purpose of this study was to construct an explanatory model of drug formulary priority-setting as it occurs within regional health authorities. METHODS: A grounded theory approach was employed to study the practices of two regional health authority P&T committees in British Columbia, Canada. Data sources spanned committee documents, meeting observations (n=4), and semi-structured interviews with committee members (n=15). Data analysis involved coding using the constant comparative technique and writing analytic memos. RESULTS: Regional P&T committees engaged in two activities related to drug formulary priority-setting: developing auto-substitution policies and reviewing drug addition requests. Four processes were central to decision-making: (i) negotiating margins of therapeutic advantage; (ii) seeking value for the resources allocated; (iii) interfacing between community and institutional settings; (iv) situating decisions within an organizational context. CONCLUSIONS: Findings highlight opportunities for institutions to improve the fairness of agenda-setting practices, and for additional collaboration between policy-makers who prioritize drugs for publicly funded formularies applicable to institutional versus community settings.     

Drug formulary decision-making in two regional health authorities in British Columbia,Canada

ObjectivesGrowing pharmaceutical demands challenge healthcare organizations to set drug funding priorities (i.e. establish a formulary list). This responsibility typically rests with pharmacy and therapeutics (P&T) committees, yet how the process transpires within regional health authorities is unclear. The purpose of this study was to construct an explanatory model of drug formulary priority-setting as it occurs within regional health authorities.MethodsA grounded theory approach was employed to study the practices of two regional health authority P&T committees in British Columbia, Canada. Data sources spanned committee documents, meeting observations (n = 4), and semi-structured interviews with committee members (n = 15). Data analysis involved coding using the constant comparative technique and writing analytic memos.ResultsRegional P&T committees engaged in two activities related to drug formulary priority-setting: developing auto-substitution policies and reviewing drug addition requests. Four processes were central to decision-making: (i) negotiating margins of therapeutic advantage; (ii) seeking value for the resources allocated; (iii) interfacing between community and institutional settings; (iv) situating decisions within an organizational context.ConclusionsFindings highlight opportunities for institutions to improve the fairness of agenda-setting practices, and for additional collaboration between policy-makers who prioritize drugs for publicly funded formularies applicable to institutional versus community settings.     

Social space, social class and Bourdieu: health inequalities in British Columbia, Canada

This article adopts Pierre Bourdieu's cultural-structuralist approach to conceptualizing and identifying social classes in social space and seeks to identify health effects of class in one Canadian province. Utilizing data from an original questionnaire survey of randomly selected adults from 25 communities in British Columbia, social (class) groupings defined by cultural tastes and dispositions, lifestyle practices, social background, educational capital, economic capital, social capital and occupational categories are presented in visual mappings of social space constructed by use of exploratory multiple correspondence analysis techniques. Indicators of physical and mental health are then situated within this social space, enabling speculations pertaining to health effects of social class in British Columbia.     

Economy, community and mortality in British Columbia, Canada

Stimulated by the growing body of literature relating economic inequalities to inequalities in health, this article explores relationships between various economic attributes of communities and mortality rates among 24 coastal communities in British Columbia, Canada. Average household income, a measure of community wealth, was negatively related and the incidence of low incomes, a measure of poverty, was positively related to age-standardized mortality. Both were more strongly related to female than male mortality. Mean and median household income, the incidence of low incomes and a lack of disposable income, and the proportion of total income dollars derived from government sources were significantly related to mortality rates for younger and middle-aged men but not for elderly men. Mortality rates for younger and middle-aged women were not explicated by these economic attributes of communities: among elderly women only, mortality rates were higher in communities with a lower average household income and in those with a higher incidence of low incomes. Finally, a higher concentration in white-collar industries was related to higher mortality rates for females, even after controlling for other economic attributes of communities. These results do not obviously support a psychosocial argument for an individual-level relationship between income and health that assumes residents perceive their status primarily in relation to other members of the same community, but do provide moderate support for the materialist argument and moderate support for the psychosocial argument that assumes community residents perceive their status in relation to an encompassing reference group. Other viable interpretations of these relationships pertain to ecological characteristics of communities that are related to both economic well-being and population health status; in this instance, concentration in specific economic industries may help to understand the ecological relationships presented here.     

Income inequality,household income,and health status in Canada: a prospective cohort study

OBJECTIVES: This study sought to determine whether income inequality, household income, and their interaction are associated with health status. METHODS: Income inequality and area income measures were linked to data on household income and individual characteristics from the 1994 Canadian National Population Health Survey and to data on self-reported health status from the 1994, 1996, and 1998 survey waves. RESULTS: Income inequality was not associated with health status. Low household income was consistently associated with poor health. The combination of low household income and residence in a metropolitan area with less income inequality was associated with poorer health status than was residence in an area with more income inequality. CONCLUSIONS: Household income, but not income inequality, appears to explain some of the differences in health status among Canadians.     

Cryptococcus gattii dispersal mechanisms, British Columbia, Canada

Recent Cryptococcus gattii infections in humans and animals without travel history to Vancouver Island, as well as environmental isolations of the organism in other areas of the Pacific Northwest, led to an investigation of potential dispersal mechanisms. Longitudinal analysis of C. gattii presence in trees and soil showed patterns of permanent, intermittent, and transient colonization, reflecting C. gattii population dynamics once the pathogen is introduced to a new site. Systematic sampling showed C. gattii was associated with high-traffic locations. In addition, C. gattii was isolated from the wheel wells of vehicles on Vancouver Island and the mainland and on footwear, consistent with anthropogenic dispersal of the organism. Increased levels of airborne C. gattii were detected during forestry and municipal activities such as wood chipping, the byproducts of which are frequently used in park landscaping. C. gattii dispersal by these mechanisms may be a useful model for other emerging pathogens.     

Envisioning healthy futures: Youth perceptions of justice-oriented environments and communities in Northern British Columbia Canada

Through an anti-colonial and critical race theoretical framework as well as arts-based methods (photovoice) that engage Indigenous and non-Indigenous youth, we explore the question: what do youth perceive as healthy and just environments and communities? Youth identified two overarching, strength-based messages: Firstly, youth demonstrate the need for a structural-level analysis of the conditions that influence individual-level outcomes of environmental health. Secondly, youth perspectives on healthy and justice-oriented environments and communities challenge environmental health scholars to consider youth as powerful actors. Youth perspectives of healthy and justice-oriented communities present a necessarily structural perspective to consider not only the impacts of environmental decision-making on health, but the conditions that have allowed for harmful impacts. In doing so, youth demonstrate the need for intersectional and complex understandings of health and wellbeing when discussing the environment. And, as we argue here, challenge us as scholars of environmental health to do the same.     

Income-related health inequality in Canada

This study uses data from the 1994 National Population Health Survey and applies the methods developed by Wagstaff and van Doorslaer (1994, measuring inequalities in health in the presence of multiple-category morbidity indicators. Health Economics 3, 281-291) to measure the degree of income-related inequality in self-reported health in Canada by means of concentration indices. It finds that significant inequalities in self-reported ill-health exist and favour the higher income groups--the higher the level of income, the better the level of self-assessed health. The analysis also indicates that lower income individuals are somewhat more likely to report their self-assessed health as poor or less-than-good than higher income groups, at the same level of a more 'objective' health indictor such as the McMaster Health Utility Index. The degree of inequality in 'subjective' health is slightly higher than in 'objective' health, but not significantly different. The degree of inequality in self-assessed health in Canada was found to be significantly higher than that reported by van Doorslaer et al. (1997, income related inequalities in health: some international comparisons, Journal of Health Economics 16, 93-112) for seven European countries, but not significantly different from the health inequality measured for the UK or the US. It also appears as if Canada's health inequality is higher than what would be expected on the basis of its income inequality.     

Income inequality, primary care, and health indicators

BACKGROUND: The significant association of income inequality with a variety of health indicators is receiving increasing attention. There has also been increasing evidence of a link between primary care and improved health status. We examined the joint relationship between income inequality, availability of primary care, and various health indicators to determine whether primary care has an impact on health indicators by modifying the adverse effect of income inequality. METHODS: Our ecologic study used the US states as the units of analysis. In analyzing the data, we looked at the associations among income inequality, primary care, specialty care, smoking, and health indicators, using Pearson's correlation coefficients for intercorrelations and the adjusted multiple regression procedure. To examine the effect of inequality and primary care on health outcome indicators, we conducted path analyses according to a causal model in which inequality affects health both directly and indirectly through its impact on primary care. RESULTS: Our study indicates that both primary care and income inequality exerted a strong and significant direct influence on life expectancy and total mortality (P <.01). Primary care also exerted a significant direct influence on stroke and postneonatal mortality (P <.01). Although levels of smoking are also influential, the effect of income inequality and primary care persists after controlling for smoking. Primary care serves as one pathway through which income inequality influences population-level mortality and at least some other health outcome indicators. CONCLUSIONS: It appears possible that a primary care orientation may, in part, overcome the severe adverse effects on health of income inequalities.     

Location, location, location: contextual and compositional health effects of social capital in British Columbia, Canada

After decades of epidemiological exploration into individual-level risk factors for ill health, a recent surge of interest in the health effects of socially patterned attributes of geographically defined 'places' has given the structural side of the agency-structure debate new prominence in population health research. Utilizing two original data sets, one pertaining to features of communities in British Columbia, Canada and the other to characteristics of individuals living in them, this article distinguishes the health effects of socially patterned attributes of communities, including the social capital of communities, from the health effects of characteristics of residents that contribute to social capital, e.g., trust and participation in voluntary associations. Results from multilevel analysis demonstrated that, of three different individual-level measures of health and well-being (and including measures of long-term limiting illness and self-rated health), only a measure of depressive symptoms had variability that could be reasonably attributed to the level of the community. The social capital of communities in the form of the availability of public spaces explained some of this variability, but in the direction contrary to expectations. Overall, location (community of residence) did little to explicate health inequalities in this context. The strongest predictors of health in multivariate and multilevel models were characteristics of individual survey respondents, namely, income, trust in politicians and governments, and trust in other members of the community. Breadth of participation in networks of voluntary association was not significantly related to health in multivariate models.     

HCV co-infection in HIV positive population in British Columbia,Canada

Background  

As HIV and hepatitis C (HCV) share some modes of transmission co-infection is not uncommon. This study used a population-based sample of HIV and HCV tested individuals to determine the prevalence of HIV/HCV co-infection, the sequence of virus diagnoses, and demographic and associated risk factors.     

Salmonella enterica Serovar Agbeni, British Columbia, Canada, 2011

TO THE EDITOR: Infection with Salmonella enterica serovar Agbeni is rare. In Canada, it was reported 8 times during 2000-2010 and never in the province of British Columbia (2011 population?4.5 million) (Public Health Agency of Canada, unpub. data). In June 2011, an outbreak of S. enterica ser. Agbeni affecting 8 persons was identified in British Columbia; pulsed-field gel electrophoresis patterns for all isolates were identical. Although no specific source was identified, 2 features were noted: 1) diagnosis through urine specimens for 3 of 8 persons and 2) a longer than typical incubation period for Salmonella spp. infection.     

Work-related injury among direct care occupations in British Columbia, Canada

Objectives

To examine how injury rates and injury types differ across direct care occupations in relation to the healthcare settings in British Columbia, Canada.

Methods

Data were derived from a standardised operational database in three BC health regions. Injury rates were defined as the number of injuries per 100 full‐time equivalent (FTE) positions. Poisson regression, with Generalised Estimating Equations, was used to determine injury risks associated with direct care occupations (registered nurses [RNs], licensed practical nurses [LPNs) and care aides [CAs]) by healthcare setting (acute care, nursing homes and community care).

Results

CAs had higher injury rates in every setting, with the highest rate in nursing homes (37.0 injuries per 100 FTE). LPNs had higher injury rates (30.0) within acute care than within nursing homes. Few LPNs worked in community care. For RNs, the highest injury rates (21.9) occurred in acute care, but their highest (13.0) musculoskeletal injury (MSI) rate occurred in nursing homes. MSIs comprised the largest proportion of total injuries in all occupations. In both acute care and nursing homes, CAs had twice the MSI risk of RNs. Across all settings, puncture injuries were more predominant for RNs (21.3% of their total injuries) compared with LPNs (14.4%) and CAs (3.7%). Skin, eye and respiratory irritation injuries comprised a larger proportion of total injuries for RNs (11.1%) than for LPNs (7.2%) and CAs (5.1%).

Conclusions

Direct care occupations have different risks of occupational injuries based on the particular tasks and roles they fulfil within each healthcare setting. CAs are the most vulnerable for sustaining MSIs since their job mostly entails transferring and repositioning tasks during patient/resident/client care. Strategies should focus on prevention of MSIs for all occupations as well as target puncture and irritation injuries for RNs and LPNs.Direct care occupations comprise the largest proportion (58%) of healthcare employees in Canada and consist of registered nurses (RNs), licensed practical nurses (LPNs) and care aides (CAs).^1,2,3 Engkvist et al. (1998) describe a similar grouping of nursing occupations in Sweden with general RNs, state registered nurses (LPNs) and auxiliary nurses (CAs).⁴ Such employees work in various settings (acute care, nursing homes and community care) across the healthcare system. These settings, providing care specific to the needs of patients/residents/clients, have very differing task requirements. Due to shortages in the direct care occupations, workers have more opportunities to choose where they prefer to work. While wage differentials may influence recruitment and retention, as Spetz (2003) has noted, wage increases are not viable solutions for resolving the workforce shortages; work conditions were more important for recruiting and retaining personnel.⁵ Thus a study of differential risk of injuries for the various direct care occupations in different health settings is warranted.RNs can work as independent practitioners in all settings or as team members that assign clients and/or client care functions appropriately. LPNs do not work in isolation but as team members and must exercise clinical judgment in accepting assigned client care functions within their own level of competence.⁶ In many nursing homes, LPNs have been used interchangeably with CAs. CAs must work with the support of RNs and LPNs in providing help to patients/residents/clients with their activities of daily living (such as assistance with personal hygiene, dressing, eating and mobility). This often involves lifting, transferring and repositioning of patients/residents/clients.In the health sector across Canada in 2004, 62.5% of RNs were working in acute care, whereas 13.4% were working in community health and 10.5% in nursing homes.⁷ Jansen et al. (2000) reports that LPNs were predominantly (57%) in acute care, 33% in nursing homes and 10% in community care.⁸ CAs were predominantly working in nursing homes with some in community care and a smaller proportion in acute care.⁹ In the future, it is likely that more nurses will be required to work in nursing homes or community care because of policy changes that focus on reducing the number of chronic care residents in acute care settings, and an ageing population who will need ongoing care whether in their home, assisted living or nursing homes. RNs and LPNs may choose not to work in these settings if they perceive these work environments have higher injury risks than acute care.Changes in the nature of care provided to patients/residents/clients and shifts in work patterns have a great impact on the nursing profession.¹⁰ Because of the different tasks and roles for the three nursing occupations within different care settings, each nursing occupation may have different injury experiences.^8,11,12 Identifying these different patterns of injury through subgroup analysis by care types may allow for more effective targeting of prevention efforts, as well as help nursing staff make informed decisions. The aim of the present study was to examine how injury characteristics and incidence among the three nursing occupations differ in relation to acute care, nursing homes and community care settings in British Columbia (BC), Canada. Time‐at‐risk data can provide more accurate injury rates than general rates published by Workers'' Compensation Boards in Canada and the USA.