Income as a SDOH Flashcards
Neoliberalism and Structural Adjustment Programs
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
Why were Structural Adjustment Programs seen as a failure?
- 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
Global Political Ideologies: Universal Healthcare Access
- 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
Why haven’t we completely shifted away from Neoliberalism?
-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)
Income as a SDoH
-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
Director of Montreal Public Health Quote
-“poverty weights heavily on health in both its material and social dimensions: poor education, dependence, precarious jobs, inactivity”
Income and other Social Determinants of Health
- Exposure to violence
- Housing
- Food and nutrition
- Environmental Damage/ contaminants
- Education
- Working Conditions
- Stress
- Access to Healthcare
Absolute Poverty
-having less than an absolute minimum income level based on the cost of basic needs
Low-Income Cut-Offs (LICOs)
-income thresholds reflecting poverty of families
Relative Poverty
-having less than the average standard in society
Subjective Poverty
-individuals feeling as though they do not have enough to meet their needs
Material Deprivation
-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
Income Inequality
-distribution of in a population
Challenges associated with measuring poverty
- > 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’
Individual Income and Health
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
Wilkins et al 2002
- 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
Institute de la Statistiques du Quebec, Ferland 2003 (data from 1987, 1998)
- 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
Lessard et al 1998
-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
Income and Birth Outcomes in Quebec
-huge gap between the brith outcomes based on neighbourhood income
Income and Life Expectancy in Quebec
- 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
Income and Standardized Mortality Rate in Quebec
- 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
How does income impact Health Income and Determinants?
- 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
How does Income affect Health: Absolute Income Hypothesis
-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
Absolute Deprivation Hypothesis
-proposes that income below a certain deprivation threshold is adverse for health, but once past this threshold, there are minimal gains to be made
Income, Health and Public Policy
- 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?
Income Inequality and Public Policy
-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
