Income as a SDOH

Question 1

Neoliberalism and Structural Adjustment Programs

Answer 1

controversial conditions attached to IMF and World Bank loans in 1980s and 1990s (including to Haiti)
-Required cuts to state spending, opening of borders and privatization

Question 2

Why were Structural Adjustment Programs seen as a failure?

Answer 2

• did not produce economic development and led to huge increases in both inequality and poverty
• Reduced state spending on healthcare associated with poorer health outcomes; other social determinants also affected (education; food security)
• Women particularly affected; greater economic vulnerability; increased risk of domestic violence; increased burden of care; maternal health and mortality

Question 3

Global Political Ideologies: Universal Healthcare Access

Answer 3

• In more recent years, attitudes towards structural adjustments have changed (for some more than others)
• More acknowledgement of the importance of state provided services such as health and education
• World Bank now supports universal healthcare as part of social development

Question 4

Why haven’t we completely shifted away from Neoliberalism?

Answer 4

-softening of its effects
-World Health Organization now identifies poverty as the world’s leading
killer
-Despite increased research and rhetoric on the importance of social determinants of health, policy continues to focus on increasing access to healthcare rather than on social determinants
-(e.g. Canadian maternal health policy – no analysis of gender and/or poverty)

Question 5

Income as a SDoH

Answer 5

-Data shows that globally, within Canada, and within Quebec, there is a link between income and health
-Specifically, poverty is related to ill health, including lower life expectancy and mortality from range of diseases
-Poverty related to poor mental health, and to higher rates of suicide
-Income considered one of the most important determinants of health, and can be linked
to various other determinants
-The impact of income is in part determined by existing public policy

Question 6

Director of Montreal Public Health Quote

Answer 6

-“poverty weights heavily on health in both its material and social dimensions: poor education, dependence, precarious jobs, inactivity”

Question 7

Income and other Social Determinants of Health

Answer 7

• Exposure to violence
• Housing
• Food and nutrition
• Environmental Damage/ contaminants
• Education
• Working Conditions
• Stress
• Access to Healthcare

Question 8

Absolute Poverty

Answer 8

-having less than an absolute minimum income level based on the cost of basic needs

Question 9

Low-Income Cut-Offs (LICOs)

Answer 9

-income thresholds reflecting poverty of families

Question 10

Relative Poverty

Answer 10

-having less than the average standard in society

Question 11

Subjective Poverty

Answer 11

-individuals feeling as though they do not have enough to meet their needs

Question 12

Material Deprivation

Answer 12

-reflects deprivation of material goods and conveniences that are part of modern life, such as adequate housing, car or television ownership, or access to neighbourhoods with recreational facilities

Question 13

Income Inequality

Answer 13

-distribution of in a population

Question 14

Challenges associated with measuring poverty

Answer 14

• > May not reflect annual disposable income
• What public services are provided, and what is the effect on disposable income?
• > Household measures may not account for advantages of pooled resources
• Difficult to account for unequal sharing of resources within a household
• > May not account for volatility of income
• > May not take into account accumulated assets and/or debts
• > May not account for time required to earn income
• > May not account for timing of poverty during the life cycle
• E.g. poverty during early childhood may have greater effect on health
• > May not adequately adjust for additional factors/’confounders’
• > These limitations don’t necessarily diminish the legitimacy of findings but they point to what is missing from each ‘snapshot’

Question 15

Individual Income and Health

Answer 15

Numerous Canadian studies have shown a link between income and health status based on:
-Individual level-income data
-Geographic area
Income linked to health status of children including:
-Low birthweight, injury, morality, developmental problems, obesity, asthma, health care
utilization
Income linked to health of adults including
-Mental health, psychological distress, chronic diseases, stress, obesity

Question 16

Wilkins et al 2002

Answer 16

• Measured changes in mortality rates in small geographic areas of urban Canada, 1971 – 1996
• For most causes of death, differences in mortality between the rick and the poor neighbourhoods had diminished
• Some indicators saw small changes, or even increased
• 1996 estimates that 24% of PYLL (potential years of life lost) were related to income

Question 17

Institute de la Statistiques du Quebec, Ferland 2003 (data from 1987, 1998)

Answer 17

• Association between income differences and health over time
• Several health outcomes linked to gross annual income (no weakening in this link over time)
• Psychological stress increased based on inequality between rich and poor over time

Question 18

Lessard et al 1998

Answer 18

-Montreal: poverty associated with health throughout life-cycle; infant mortality, lung cancer, fertility rates, psychological distress and
suicide
-Neighbourhood poverty associated with health indicators such as infant mortality, life expectancy, and cause-specific mortality

Question 19

Income and Birth Outcomes in Quebec

Answer 19

-huge gap between the brith outcomes based on neighbourhood income

Question 20

Income and Life Expectancy in Quebec

Answer 20

• Life expectancy is highest in wealthy neighbourhoods for both women and men
• Life expectancy increases for both genders as we move from poor to wealthy neighbourhoods
• Increase is more pronounced for men than for women

Question 21

Income and Standardized Mortality Rate in Quebec

Answer 21

• The trend is the same for all-cause mortality and for four leading causes of death
• Mortality is highest in poorest neighbourhoods
• The difference in mortality due to accidental injuries is particularly large between poor and wealthy neighbourhoods

Question 22

How does income impact Health Income and Determinants?

Answer 22

• Income is associated not only with outcomes, but with ‘determinants’, including behaviours
• Income determines access to various resources
• > Housing, food, transport, medical care, etc.
• Income affects levels of stress, including chronic stress
• Income affects both our environments, and the resources we have available to respond to these environments

Question 23

How does Income affect Health: Absolute Income Hypothesis

Answer 23

-Proposes that there is a positive association between personal income and health, but the association is non-linear
-The poor are more responsive to income changes
-Redistribution of income from rich to poor should cause average health to
improve

Question 24

Absolute Deprivation Hypothesis

Answer 24

-proposes that income below a certain deprivation threshold is adverse for health, but once past this threshold, there are minimal gains to be made

Question 25

Income, Health and Public Policy

Answer 25

• The impacts of income on health are mediated by public policy
• Public policy can be used to redistribute income (through taxation)
• Publicly funded services can increase disposable income and reduce the effects of poverty
• Is healthcare universally accessible, or paid for by individuals?
• Is housing subsidized?
• Is public transportation accessible and effective?
• Is nutritious food available in less wealthy areas?
• Is childcare publicly funded and accessible?

Question 26

Income Inequality and Public Policy

Answer 26

-Income inequality can act as a barrier to addressing income as determinant through public policy
-May result in lower investment in human capital;
-> the rich have less interest in provision of public services, and higher interest in cutting state spending (lower taxation)
-> Leads to lower investment public infrastructure
-> Individuals who lack private resources will be more severely impacted, due to limited access to
material infrastructure
-Inequality may also limit investment in social capital due to diminished community solidarity and social cohesion
-Inequality may exacerbate psychosocial effects → stress and frustration → harmful to health