Socioeconomic Inequalities in Health Socioeconomic Inequalities in Health Among Canadian Women with Heart Among Canadian Women with Heart

DiseaseDisease

Arlene S. Bierman, M.D., M.SArlene S. Bierman, M.D., M.SOntario Women’s Health Council Chair in Women’s HealthOntario Women’s Health Council Chair in Women’s Health

St. Michael’s Hospital, University of TorontoSt. Michael’s Hospital, University of Toronto

Academy Health Annual MeetingAcademy Health Annual MeetingJune 25, 2006June 25, 2006

Gender and Socioeconomic Inequalities Gender and Socioeconomic Inequalities in Health and Heart Diseasein Health and Heart Disease

Cardiovascular disease is a leading cause of morbidity and Cardiovascular disease is a leading cause of morbidity and mortality among Canadian womenmortality among Canadian women

Socioeconomic and gender inequalities in health and Socioeconomic and gender inequalities in health and functional status have been well documented in Canadafunctional status have been well documented in Canada

Differences in access, quality of care, health behaviors, and Differences in access, quality of care, health behaviors, and the social determinants of health have all been associated the social determinants of health have all been associated with socioeconomic inequalities among individuals with with socioeconomic inequalities among individuals with heart disease.heart disease.

However, little is known about the extent to which these However, little is known about the extent to which these factors contribute to the observed socioeconomic gradients factors contribute to the observed socioeconomic gradients in health status. in health status.

ObjectivesObjectives

Examine the determinants of socioeconomic Examine the determinants of socioeconomic inequalities in health among women in a system of inequalities in health among women in a system of universal health insurance coverage.universal health insurance coverage.

Specifically assess the contribution of Specifically assess the contribution of sociodemographic factors (income, education, sociodemographic factors (income, education, language), health behaviors (physical activity, language), health behaviors (physical activity, smoking), access to care (unmet need, regular smoking), access to care (unmet need, regular physician), and psychosocial factors (depression, physician), and psychosocial factors (depression, stress, food insecurity, and sense of community stress, food insecurity, and sense of community belonging) to these inequalities.belonging) to these inequalities.

Data Source and Study PopulationData Source and Study Population

Cycle 1.1 Canadian Community Health Survey-Cycle 1.1 Canadian Community Health Survey-2000/2001 2000/2001

Nationally representative sample covering 98% of Nationally representative sample covering 98% of population with a response rate of 84.7% (N-130,000)population with a response rate of 84.7% (N-130,000)

Study sample includes 7825 individuals age 25 and Study sample includes 7825 individuals age 25 and older reporting heart disease diagnosed by a older reporting heart disease diagnosed by a physician (women n=4024, men n=3801) physician (women n=4024, men n=3801) representative of 1.3 million individuals.representative of 1.3 million individuals.

MeasuresMeasures

Health status: global health, health utility index, Health status: global health, health utility index, activity restrictions, comorbidityactivity restrictions, comorbidity

Sociodemographic characteristics: age, income, Sociodemographic characteristics: age, income, education, languageeducation, language

Health behaviors: physical inactivity, smokingHealth behaviors: physical inactivity, smoking Health access: regular physician, self perceived Health access: regular physician, self perceived

unmet health care needunmet health care need Psychosocial factors: depression, stress, food Psychosocial factors: depression, stress, food

insecurity, sense of belonging to the communityinsecurity, sense of belonging to the community

Population CharacteristicsPopulation CharacteristicsIncome and EducationIncome and Education

Heart Disease %

Population %

Low Income

Men 11 8

Women 21 12

< HS Education

Men 44 23

Women 48 24

Fair or Poor Health amongFair or Poor Health amongCanadian Men and Women by Income*Canadian Men and Women by Income*

80.2

27.3

23.1

50.349.5

30.6

65.9

58.5

32.1

49.1

7.311.9

19.5

29.930.6

8.2

11.917.9

27.830.9

0

10

20

30

40

50

60

70

80

90

Poor Near Poor Middle Upper Middle High

Men with Heart Disease Women with Heart DiseaseMen (General Population) Women (General Population)

Per

cen

t (%

)P

erce

nt

(%)

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

Prevalence of Poor Health (HUI Prevalence of Poor Health (HUI ≤0.80) among ≤0.80) among Canadian Canadian Men and Women with Heart Disease by Income*Men and Women with Heart Disease by Income*

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

Per

cen

t (%

)P

erce

nt

(%) 43.8

73.6

17.2

27.7

0

10

20

30

40

50

60

70

80

Poor High

Men

Women

Prevalence of Prevalence of 4 or More 4 or More Chronic Conditions among Chronic Conditions among Men and Women Older by Income*Men and Women Older by Income*

23.5

42.1

7.4

14.6

37.943.7

31.6

41.6

77.8

70.7

48.3

63.3

8.511.616.114.3

16.118.8

2426

0

10

20

30

40

50

60

70

80

90

Poor Near Poor Middle Upper Middle High

Men with Heart Disease Women with Heart DiseaseMen (General Population) Women (General Population)

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

Per

cen

tag

e (%

)P

erce

nta

ge

(%)

Prevalence of Feeling Very Stressed among Canadian Prevalence of Feeling Very Stressed among Canadian Men and Women with Heart Disease by Income*Men and Women with Heart Disease by Income*

Per

cen

t (%

)P

erce

nt

(%)

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

59.8

51.2

28 27

0

10

20

30

40

50

60

70

Poor High

Men

Women

Reported Unmet Health Care Needs of Men and Women Reported Unmet Health Care Needs of Men and Women with Heart Disease Age 25 and Older by Income*with Heart Disease Age 25 and Older by Income*

15.9

38.4

13

21.3

0

5

10

15

20

25

30

35

40

Poor High

Men

Women

Per

cen

tag

e (%

)P

erce

nta

ge

(%)

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

Food Insecurity among Canadian Men and Women Food Insecurity among Canadian Men and Women With Heart Disease by Income*With Heart Disease by Income*

2.9

55.9

24.4

9.4

55.8

62.5

6.7

63.3

15.2

37.6

0

10

20

30

40

50

60

70

Poor Near Poor Middle Upper Middle High

Men with Heart Disease Women with Heart DiseaseMen (General Population) Women (General Population)

Per

cen

t (%

)P

erce

nt

(%)

*Adjusted for age*Adjusted for age CCHS - Cycle 1.1CCHS - Cycle 1.1

Age Adjusted Odds of Fair or Poor Health Age Adjusted Odds of Fair or Poor Health Among Canadian Women with Heart DiseaseAmong Canadian Women with Heart Disease

OR p 95%CI

Poor

5.0 < .001 2.9, 8.4 Near Poor 2.1 .001 1.4, 3.3 Middle 1.8 .008 1.2, 2.7 Upper Middle 1.0 .9 .66, 1.6 High (ref) 1.0

Correlates of Fair or Poor HealthCorrelates of Fair or Poor Health OR 95%CI

Income: Poor 3.4 1.9, 6.3 Near Poor 1.6 .97, 2.6 Education: < Than High School 2.0 1,5, 2.6 High School Grad 1.1 1.1, 2.3 Language: No French or English 3.2 1.2, 8.8 Physically Inactive 2.4 1.7, 3.3 Smoking 1.1 .79, 1.9 Depression 1.7 1.1, 2.8 Stress 2.1 1.6, 2.7 Unmet Need 1.7 1.3, 2.4 Regular Physician .57 .29, 1.2 Food Insecurity 1.3 .94, 1.8 Sense of Community Belonging 1.5 1.2, 1.9

Adjusted for age

ComorbidityComorbidity OR 95%CI

Income: Poor 2.9 1.6, 5.4 Near Poor 1.4 .84, 2.3 Education: < Than High School 2.0 1.5, 2.6 High School Grad 1.8 1.2, 2.5 Number of Chronic Conditions

2 1.9 .99, 3.7 3 2.9 1.6. 5.3

4 or more 5.6 3.1, 9.9

ConclusionsConclusions Within a system of universal health care there are Within a system of universal health care there are

sizable gender and socioeconomic inequities in health sizable gender and socioeconomic inequities in health and functional status among individuals with heart and functional status among individuals with heart disease.disease.

Women with heart disease are more likely to be poor Women with heart disease are more likely to be poor than men with heart disease and poor women with than men with heart disease and poor women with heart disease are much more likely to report fair or heart disease are much more likely to report fair or poor health and higher levels of comorbidity.poor health and higher levels of comorbidity.

ConclusionsConclusions Among women with heart disease sociodemographic Among women with heart disease sociodemographic

factors (income, education, language), health behavior factors (income, education, language), health behavior (physical activity), access to care (unmet need), and (physical activity), access to care (unmet need), and psychosocial factors (depression, stress, and sense of psychosocial factors (depression, stress, and sense of community belonging) are all independently associated community belonging) are all independently associated with poor health.with poor health.

The relationship between income and health status is The relationship between income and health status is partially explained by these factors and further mediated partially explained by these factors and further mediated by comorbid chronic illness. However, poverty remains by comorbid chronic illness. However, poverty remains independently associated with poor health after independently associated with poor health after controlling for all of these factors.controlling for all of these factors.

LimitationsLimitations

The study is cross sectional and based upon The study is cross sectional and based upon self report.self report.

We did not assess the association provincial We did not assess the association provincial differences to health status.differences to health status.

Did not have information on process or quality Did not have information on process or quality of care.of care.

ImplicationsImplications

Addressing socioeconomic inequalities in health Addressing socioeconomic inequalities in health among women with heart disease is likely to require a among women with heart disease is likely to require a multifaceted approach that addresses health system multifaceted approach that addresses health system factors, risk factor reduction as well as the social factors, risk factor reduction as well as the social determinants of health.determinants of health.

Improving the health and functional status for low Improving the health and functional status for low income women with heart disease will require the income women with heart disease will require the development and evaluation of interventions aimed at development and evaluation of interventions aimed at targeting these factors.targeting these factors.