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PubMed2004

Relationships between HIV/AIDS, income and expenditure over time in deprived South African households.

We compared 202 households with an HIV-infected member, and 202 unaffected neighbouring households, in one rural and one urban area in Free State province, South Africa. Interviews were conducted with a key informant in each household, at baseline and 6, 12 and 18 months later, with 87% follow-up. Results of the baseline and 6 months study were published previously; this paper reports on trends over the full 18 months of follow-up. We analysed changes in income and expenditure and their relationships with morbidity and mortality using multiple regression. Over 2 years, a third of affected households reported at least one death, mainly due to infectious disease. Affected households' real expenditures decreased over time, while real incomes did not, absolutely and relative to unaffected households. Mortality and morbidity independently predicted lower expenditure (adjusted relative expenditure 0.86 and 0.84, respectively), mortality predicted lower income (adjusted relative income 0.80) and higher expenditure predicted less morbidity and mortality (adjusted odds ratios for a US$100 monthly difference 0.78 and 0.65). Households' economies and HIV/AIDS were thus dynamically related, and occurred against a background of progressive poverty. Expenditure was a more sensitive indicator of the economic impact of HIV/AIDS than was income.

Acquired Immunodeficiency Syndrome↗
PubMed2006

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.

Adult↗
PubMed2006

Income-related inequality in utilization of health services in Denmark: evidence from Funen County.

AIMS: To examine income-related inequity in utilization of healthcare services in Denmark. METHODS: A health survey of 2,915 respondents in Funen County interviewed in 2000 and 2001 on health status and socioeconomic and sociodemographic characteristics was merged with various computerized registers including inpatient stays, ambulatory visits, contacts in the primary healthcare sector, and prescription medicine. The index of horizontal inequity was used to estimate the degree of horizontal inequity in utilization of healthcare services across income groups, using the indirect method of standardization to control for age, gender, and self-assessed health as a proxy for need. The standardization method rests on the assumption of equal response behaviour across income groups. RESULTS: The least advantaged with respect to income consume a bigger share of the health services than the most advantaged with the exception of dental treatments where the opposite is true. After standardization for age, gender, and health status there is no significant inequity in use of all healthcare services. However, when it comes to specific healthcare services the least advantaged have a significantly lower share of the medicine consumption and dental treatments than expected. CONCLUSION: The index of horizontal inequity suggests that the Danish healthcare system is in general equitable. In sectors with a high degree of co-payment some horizontal inequity disfavouring the lower income groups appears to be present.

Adult↗
PubMed2005

Household income and health status in children and adolescents in Britain.

BACKGROUND: Mortality, health, and well-being across the lifespan are associated with socioeconomic position (typically operationalised as occupational status). There is some evidence that adolescence represents a period of 'relative equalisation' of health inequalities. Our aim was to examine the association between inequalities in household income and health in childhood and adolescence. METHODS: Cross-sectional survey using multistage stratified random sample of households in Britain. Information was collected on 10438 children aged 5-15 years. RESULTS: Low levels of equivalised household income was associated with poorer health for 13 out of the 22 indicators examined (odds ratio P < 0.05 for > or =1 income quintile). Multivariate analyses controlling for child characteristics, parental socioeconomic status and household composition indicated that low levels of equivalised household income increased the odds of poor health for 9 out of the 22 indicators examined. There was little evidence of any systematic differences in the extent of health inequalities across age groups (5-10 and 11-15 years). CONCLUSION: Household income is related to a range of health outcomes for children and adolescents, even when other indicators of socioeconomic status are taken into account. We found little evidence that adolescence represents a period of relative equalisation of health inequalities.

Adolescent↗
PubMed1995

Expenditure patterns by age and income among mature adults: does age matter?

Using data from the 1984-85 Consumer Expenditure Survey (CES), we examined how expenditure patterns of elderly persons (aged 65-74 and 75 and over) at different income-to-needs levels differ from those of younger mature adults (aged 45-54 and 55-64) at similar income-to-needs levels. Patterns of spending are examined in a variety of areas within three domains--giving, recreation, and essentials. Several important differences exist in the ways that households headed by persons of different ages allocate their expenditures in the domains of essentials and recreation, but few differences exist in the domain of giving. Consistent income group differences exist in expenditure patterns across virtually every area within the three domains. Both age and income differences remain significant when multivariate analyses are performed; thus, the story told is one in which both age and income play important roles.

Age Factors↗
PubMed2004

The changing profile of the urban uninsured: exploring implications of rise in the number of moderate-income uninsureds.

Access to care is a major problem in urban America that increasingly affects new segments of the population. Although the demographic profile of the uninsured has changed, recording large increases in numbers of moderate-income uninsured persons, it has not been accompanied by changes in health care safety net programs or increased availability of private insurance products tailored to these groups. Any such changes, however, need to be based on a good understanding of the similarities and differences between low-income and moderate-income uninsured. Based on a telephone survey of the uninsured in three northern New Jersey counties, this study presents a systematic comparison of low-income (below 150% of federal poverty level) and moderate-income (150% to 350% federal poverty level) uninsured on attitudes to health care, perceptions regarding access to care, health status, and health care utilization. We discuss the implications of this comparison for expanding health care access and design of safety net programs and institutions.

Adult↗
PubMed2005

The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004.

PURPOSE: Recent reports on medical students' career choices suggest that lifestyle increasingly influences career decisions. The authors addressed the changing influence of lifestyle and income on career choice, how these influences differ by specialty, and the specific careers students identify as lifestyle friendly. METHOD: From 1998 to 2004, 1,334 (73%) fourth-year medical students from Brody School of Medicine at East Carolina University (no. = 485 graduates) and New York Medical College (no. = 1,348 graduates) completed a questionnaire that addressed career specialty preferences, as well as income and lifestyle concerns. Students were asked to rate career choice influences on a four-point scale (1 = no influence, 4 = major influence). Factor analysis of these influences identified seven factors including one each for lifestyle and income. RESULTS: A total of 1,327 students indicated a career preference. Lifestyle (p = .018) and income (p = .011) were found to increasingly influence medical students' career choices during the study period. Overall, the authors found significant differences between specialties in the relative contribution of these factors. Students' perceptions of specialties existed on a continuum of lifestyle friendly (e.g., radiology) to lifestyle unfriendly (e.g., obstetrics-gynecology). Contrary to previous reports, the students' responses indicate they perceived the primary care specialties as lifestyle intermediate compared to other specialties. CONCLUSIONS: Lifestyle and income have become more important to medical students in their career choice, and the relative influence of these factors varies considerably between specialties. This study suggests that previous efforts to dichotomize careers into those with controllable and uncontrollable lifestyles may mask important complexities.

Adult↗
PubMed1996

Labor force participation, income, and the use of short-term hospitals by the elderly.

OBJECTIVES: Between 1970 and 1983, the rate at which the elderly were hospitalized grew by more than 40%, whereas the rate of hospitalization for the younger population was fairly stable. Past attempts to explain the different patterns among the young and the old have focused on technology, insurance, health status, and the supply of hospital services. These attempts mostly have been unsuccessful. In this article, the author examines other possible explanations, namely, that the elderly, who experienced a decline in the rate of participation in the labor force and an increase in income over this period, used increases in available time (i.e., nonwork time) and increases in income to seek out and receive greater amounts of health care. METHODS: Using small-area data from the state of North Carolina and using the method of instrumental variables estimation, the author measures the effects of labor force participation and income on the use of short-term hospitals by the elderly. RESULTS: Areas where the elderly have high income and areas where the elderly are less likely to participate in the labor force are areas where the elderly have high rates of hospital use. CONCLUSIONS: The cross-sectional results of this study are consistent with recent labor force participation, income, and hospital-use trends associated with the elderly. The negative relation between hospital use and labor force participation suggests that public policies encouraging work at late ages, such as the scheduled increase in the normal retirement age of Social Security, may lead to a modest dampening of the demand for hospital care among the elderly.

Age Factors↗
PubMed2004

The effect of income inequality and macro-level social policy on infant mortality and low birthweight in developed countries--a preliminary systematic review.

OBJECTIVE: To carry out a preliminary systematic review of literature to address the question - among rich nations (or states within nations) what is the evidence that income inequality and differences in macro-level social policy affect rates of infant mortality and low birthweight (LBW)? STUDY DESIGN: A systematic literature review. SEARCH STRATEGY: Medline database (1968-August 2003) was searched for empirical studies of the relationship between macro-level economic and social policies in rich nations and rates of infant mortality (IMR) and LBW. Cross-national comparison of infant mortality and LBW that did not compare the effects of macro-level economic and social policies was excluded from the review as were studies including less developed countries. Keywords representing IMR and LBW were entered into Medline along with exposures related to international comparison and macro-level policy. Abstracts obtained from the initial search were reviewed for relevant studies. Full papers of potentially relevant studies were obtained and reviewed for inclusion. Secondary search of papers cited in included papers was undertaken. For this review, papers were not excluded on the basis of quality although methodological limitations were commented on and taken into account in interpreting the results. Summary statistics were not estimated. RESULTS: Twelve studies, fulfilling the inclusion criteria, were identified. Ten studies examined the association of IMR with income inequality, eight of which reported a statistically significant positive association with higher levels of inequality after adjustment for a range of variables. Six studies reported significant positive associations of IMR with other indicators of less re-distributive social and economic policy. Associations with LBW were reported in four studies; three showed significant positive associations with higher levels of income inequality and one showed no association with low levels of parental leave entitlement. Methodological differences, particularly the wide range of variables used to adjust for confounding, make interpretation of the findings difficult. CONCLUSIONS: The results of this review represent a preliminary attempt to summarize the literature linking macro-level economic and social policies in rich nations with IMR and LBW. The findings, taking account of the methodological limitations of the review and of the included studies, suggest a statistically significant association between IMR and higher income inequality and other indicators of less re-distributive social policy. Only three studies examined the association of income inequality with LBW and, although they suggest a significant association, further studies will be needed to confirm this finding.

Developed Countries↗
PubMed1990

Income level, gender, ethnicity, and household composition as predictors of children's school-based competence.

In the United States, being black, male, or growing up in a low-income and/or single-parent household have all been identified as risk factors for maladjustment during childhood. Interpretation of these findings is, however, often difficult because of the well-known associations among these variables. In the present study, we compared predictions of 3 different forms of children's competence from each of these 4 variables. In a sample of 868 black and white elementary school children from 2-parent and mother-headed 1-parent homes, we studied 3 aspects of school-based competence: conduct, peer relations, and academic achievement. Results showed that although the independent variables accounted for different amounts of variance in each domain of competence, income level and gender were better overall predictors of children's competence in conduct and peer relations than were ethnicity or household composition. Income level and ethnicity were better overall predictors of academic achievement than were gender or household composition, although each of the 4 variables made a significant contribution. Overall, income level and gender were thus the strongest predictors of children's competence. Black children were, however, more likely than white children to live in low-income homes. Our results thus highlighted some correlates of the unequal distribution of economic resources among black and white children growing up in the United States today.

Achievement↗
PubMed1996

The influence of insurance status and income on health care use among the nonmetropolitan elderly.

The objective of this research is to examine the influence of income and type of insurance coverage on the use of health services among the nonmetropolitan elderly. A model of health services utilization is used as the foundation for examining this issue with data from a telephone survey of a randomly selected sample of residents from four nonmetropolitan counties in Pennsylvania. Results indicated that those elders with Medicaid coverage were less likely to visit a doctor than respondents with private insurance or Medicare only, even after controlling for income and other relevant factors. Further, lower income respondents with Medicare were less likely to visit the dentist than those with private insurance (Medicare does not cover dental care). In contrast, neither income nor insurance predicted hospital use. As such, the health and dental care needs of many lower income nonmetropolitan elders may potentially be going unmet. In general, findings highlight the continued relevance of economic barriers to the use of such services among the nonmetropolitan elderly.

Aged↗
PubMed1997

Health and social cohesion: why care about income inequality?

Throughout the world, wealth and income are becoming more concentrated. Growing evidence suggests that the distribution of income-in addition to the absolute standard of living enjoyed by the poor-is a key determinant of population health. A large gap between rich people and poor people leads to higher mortality through the breakdown of social cohesion. The recent surge in income inequality in many countries has been accompanied by a marked increase in the residential concentration of poverty and affluence. Residential segregation diminishes the opportunities for social cohesion. Income inequality has spillover effects on society at large, including increased rates of crime and violence, impeded productivity and economic growth, and the impaired functioning of representative democracy. The extent of inequality in society is often a consequence of explicit policies and public choice. Reducing income inequality offers the prospect of greater social cohesiveness and better population health.

Global Health↗
PubMed2005

Income distribution, public services expenditures, and all cause mortality in US States.

INTRODUCTION: The objective of this paper is to investigate the relation between state and local government expenditures on public services and all cause mortality in 48 US states in 1987, and determine if the relation between income inequality and mortality is conditioned on levels of public services available in these jurisdictions. METHODS: Per capita public expenditures and a needs adjusted index of public services were examined for their association with age and sex specific mortality rates. OLS regression models estimated the contribution of public services to mortality, controlling for median income and income inequality. RESULTS: Total per capita expenditures on public services were significantly associated with all mortality measures, as were expenditures for primary and secondary education, higher education, and environment and housing. A hypothetical increase of 100 US dollars per capita spent on higher education, for example, was associated with 65.6 fewer deaths per 100,000 for working age men (p<0.01). The positive relation between income inequality and mortality was partly attenuated by controls for public services. DISCUSSION: Public service expenditures by state and local governments (especially for education) are strongly related to all cause mortality. Only part of the relation between income inequality and mortality may be attributable to public service levels.

Adult↗
PubMed1983

Childhood disablement and family incomes.

Data on the incomes of families with a severely disabled child were obtained by replicating the Family Expenditure Survey. These data were compared with income data from a control group of families with children, drawn from the FES for the same period. The participation rates, hours, and earnings of the women with a disabled child were all found to be substantially lower than those of women in the control group, differences between the samples increasing with the age of the youngest child. The earnings of men with a disabled child were also lower than those of men in the control group, though differences were more pronounced among non-manual workers. Loss of parental earnings was not made good by social security benefits paid on account of disablement. In general the incomes of the families with a disabled child were lower than those of the control families, the magnitude of the differences increasing with family income and the age of the youngest child. Nevertheless, one group of families with a disabled child--manual workers whose youngest child was under 5--had slightly higher incomes than similar families in the control group.

Adolescent↗
PubMed1998

Do housing tenure and car access predict health because they are simply markers of income or self esteem? A Scottish study.

OBJECTIVE: To investigate relations between health (using a range of measures) and housing tenure or car access; and to test the hypothesis that observed relations between these asset based measures and health are simply because they are markers for income or self esteem. DESIGN: Analysis of data from second wave of data collection of West of Scotland Twenty-07 study, collected in 1991 by face to face interviews conducted by nurse interviewers. SETTING: The Central Clydeside Conurbation, in the West of Scotland. SUBJECTS: 785 people (354 men, 431 women) in their late 30s, and 718 people (358 men, 359 women) in their late 50s, participants in a longitudinal study. MEASURES: General Health Questionnaire scores, respiratory function, waist/hip ratio, number of longstanding illnesses, number of symptoms in the last month, and systolic blood pressure; household income adjusted for household size and composition; Rosenberg self esteem score; housing tenure and care access. RESULTS: On bivariate analysis, all the health measures were significantly associated with housing tenure, and all except waist/hip ratio with car access; all except waist/hip ratio were related to income, and all except systolic blood pressure were related to self esteem. In models controlling for age, sex, and their interaction, neither waist/hip ratio nor systolic blood pressure remained significantly associated with tenure or care access. Significant relations with all the remaining health measures persisted after further controlling for income or self esteem. CONCLUSIONS: Housing tenure and car access may not only be related to health because they are markers for income or psychological traits; they may also have some directly health promoting or damaging effects. More research is needed to establish mechanisms by which they may influence health, and to determine the policy implications of their association with health.

Adolescent↗
PubMed2001

The role of income differences in explaining social inequalities in self rated health in Sweden and Britain.

STUDY OBJECTIVE: To analyse to what extent differences in income, using two distinct measures-as distribution across quintiles and poverty-explain social inequalities in self rated health, for men and women, in Sweden and Britain. DESIGN: Series of cross sectional surveys, the Swedish Survey of Living Conditions (ULF) and the British General Household Survey (GHS), during the period 1992-95. PARTICIPANTS AND SETTING: Swedish and British men and women aged 25-64 years. Approximately 4000 Swedes and 12 500 Britons are interviewed each year in the cross sectional studies used. The sample contains 15 766 people in the Swedish dataset and 49 604 people in the British dataset. MAIN RESULTS: The magnitude of social inequalities in less than good self rated health was similar in Sweden and in Britain, but adjusting for income differences explained a greater part of these in Britain than in Sweden. In Britain the distribution across income quintiles explained 47% of the social inequalities in self rated health among women and 31% among men, while in Sweden it explained, for women 13% and for men 20%. Poverty explained 22% for British women and 8% for British men of the social inequalities in self rated health, while in Sweden poverty explained much less (men 2.5% and women 0%). CONCLUSIONS: The magnitude of social inequalities in self rated health was similar in Sweden and in Britain. However, the distribution of income across occupational social classes explains a larger part of these inequalities in Britain than in Sweden. One reason for this may be the differential exposure to low income and poverty in the two countries.

Adult↗
PubMed2004

Does income inequality harm health? New cross-national evidence.

The provocative hypothesis that income inequality harms population health has sparked a large body of research, some of which has reported strong associations between income inequality and population health. Cross-national evidence is frequently cited in support of this important hypothesis, but the hypothesis remains controversial, and the cross-national work has been criticized for several methodological shortcomings. This study replicates previous work using a larger sample (692 observations from 115 countries over the 1947-1996 period), a wider range of statistical controls, and fixed-effects models that address heterogeneity bias. The relationship between health and inequality shrinks when controls are included. In fixed-effects models that capture unmeasured heterogeneity, the association between income inequality and health disappears. The null findings hold for two measures of income inequality: the Gini coefficient and the share of income received by the poorest quintile of the population. Analysis of a sample of wealthy countries also fails to support the hypothesis.

Health Services Accessibility↗
PubMed2004

Income inequality, race, and child well-being: an aggregate analysis in the 50 United States.

Interest in income inequality as a predictor of health has exploded since the mid-1990s. Recent analyses suggest, however, that the effect of income inequality on population health is not robust to a control for the racial composition of the population. That observation raises two interpretational questions. First, does income inequality have an independent effect on population health? Second, what does the effect of racial composition on population health mean? We use data from the Urban Institute's Assessing the New Federalism project and the Kids Count Databook to evaluate the aggregate effects of income inequality on diverse measures of child well-being (e.g., infant mortality, high school drop-out rates) in the 50 U.S. states. We replicate the finding that, net of the racial/ethnic composition of the population, the effects of income inequality are not significant. Moreover, the effects of racial composition on child well-being appear to be compositional (i.e., they reflect the less positive outcomes observed among racial/ethnic minorities) rather than contextual (i.e., representing the independent influence of social context). Whereas cross-level effects are still possible, our results cast doubt on the health relevance of these aggregate characteristics of the population.

Accidents↗