Reducing Gaps in Health:
A Focus on Socio-Economic
Status in Urban Canada
Released:
November 24, 2008
Canadian Institute for Health
Information (CIHI)
• Who: an independent, not-for-profit organization
providing essential data and analysis on Canada’s health
system and the health of Canadians
• What: comparable information; databases supported by
standards; pan-Canadian analyses
• When: opened its doors in 1994
• Where: Victoria, Edmonton, Toronto, Ottawa, Montréal
and St. John’s
• How: through partnerships with stakeholders
About the Canadian Population
Health Initiative (CPHI)
CPHI’s Mission:
• To foster a better understanding of factors that affect the
health of individuals and communities; and
• To contribute to the development of policies that
reduce inequities and improve the health and well-being
of Canadians.
CPHI’s Strategic Functions
Knowledge Generation
Policy Synthesis
Knowledge Transfer
Knowledge Exchange
CPHI’s Key Themes, 2007 to 2010
Mental Health
and Resilience
Reducing Gaps in Health
Place and Health
Promoting Healthy Weights
CPHI Council Members
(as of May 2008)
• Cordell Neudorf (Chair)
• David Allison
• André Corriveau
• Nancy Edwards
• Brent Friesen
• Judy Guernsey
• Richard Massé
• Deborah Schwartz
• Elinor Wilson
• Ian Potter (ex officio)
• Gregory Taylor (ex officio)
• Michael Wolfson (ex officio)
Expert Advisory Group Members
for This Report
• Cordell Neudorf (Chair), Chief Medical Health Officer, Saskatoon
Health Region, Saskatchewan
• Robert Choinière, Chef d’unité scientifique (lead, scientific unit),
Institut national de santé publique du Québec, Quebec
• Joy Edwards, Manager, Population Health Assessment, Population
Health and Research, Capital Health, Alberta
• Yanyan Gong, Methodologist, Health Indicators, CIHI, Ontario
• Denis Hamel, Statistician, Institut national de santé publique du
Québec, Quebec
• Barbara Harvie, Director, Clinical Information, Nova Scotia
Department of Health, Nova Scotia
Expert Advisory Group Members
for This Report (cont’d)
• Bill Holden, Senior Planner, City of Saskatoon, Saskatchewan
• Glenn Irwin, Director, Data Development and Research
Dissemination Division, Applied Research and Analysis Directorate,
Health Canada, Ontario
• Julie McAuley, Director, Health Statistics Division, Statistics
Canada, Ontario
• David McKeown, Medical Officer of Health, Toronto Public
Health, Ontario
• Nazeem Muhajarine, Research Faculty, Saskatchewan Population
Health and Evaluation Research Unit (SPHERU) and Department
Head, Community Health and Epidemiology, University of
Saskatchewan, Saskatchewan
Project Background
• In 2004, CPHI released its first Improving the Health of
Canadians report
– One chapter of that report examined income and the health
consequences of income, including trends and interpretations of
gradients in health.
• In 2006 CPHI released Improving the Health of
Canadians: An Introduction to Health in Urban Places
– The 2006 report examined neighbourhoods and health, housing
and health, and urban living and health as a starting point for
generating discussion about the health of urban Canadians.
Project Background (cont’d)
• Reducing Gaps in Health: A Focus on Socio-Economic
Status in Urban Canada was born out of a partnership
between CPHI and the Urban Public Health
Network (UPHN).
• The nature of the partnership is to further explore the
links between socio-economic status (SES) and health in
Canada’s urban areas.
Objective of CPHI’s
“Reducing Gaps in Health” Report
To provide a broad overview of the links between
SES and health in 15 Canadian census
metropolitan areas (CMAs) by examining how
health, as measured by a variety of indicators,
varies in small geographical areas in those CMAs
with different socio-economic characteristics.
CMAs Chosen for Analyses
15 CMAs that provide a broad geographic representation of
Canada’s urban areas were chosen:
• Victoria
• Regina
• Ottawa–Gatineau
• Vancouver
• Winnipeg
• Montréal
• Calgary
• London
• Québec
• Edmonton
• Hamilton
• Halifax
• Saskatoon
• Toronto
• St. John’s
Geographical Location
of the 15 CMAs
Structure of the Report
• Section 1. The Urban Lens: What Do We Know About the Links
Between Socio-Economic Status and Health?
– Provides a brief overview of the multiple links between SES and health in
urban Canada.
• Section 2. Socio-Economic Status and Health in Canada’s
Urban Context
– Presents new CPHI analyses for 15 CMAs through an examination of
hospitalization rates and self-reported health percentages across all 15
CMAs; steepness of gradients, both within and across those 15 CMAs;
regional and CMA-level analyses; and CMA-to-pan-Canadian data
comparisons for select indicators.
• Section 3. Dimensions of Socio-Economic Status and Urban Health:
A Policy Perspective
– Provides a few examples of types of policies and interventions that are
directly or indirectly linked to SES and health at municipal, provincial,
federal and international levels. A number of questions are raised that may
lead to future policy-related research.
The Urban Lens
• “Being poor is in itself a health hazard; worse,
however, is being urban and poor.”
–de la Barra
• A Canadian study using 1996 census data found
that “central cities” or the urban core of Canada’s
largest cities had a poverty rate about 1.7 times
that of the surrounding suburban areas (27% in
the urban core versus 16% in suburban areas).
The Urban Lens: Income
• A 2007 Canadian study found that the people in
Canada’s urban neighbourhoods earning the
highest income lived about three years longer
than those earning the lowest income.
• In addition:
– There was an increased number of deaths in
Canada’s poorest neighbourhoods.
– Fewer residents of the poorest neighbourhoods are
expected to survive to age 75.
The Urban Lens: Potential Cost
Savings by Reducing the Gaps
• A five-year Canadian study examined the
potential cost savings that could be realized by
reducing gaps in health across SES among
Winnipeg residents.
– The study revealed that bridging gaps in health that
exist between Winnipeg neighbourhoods to the
standards of the wealthiest neighbourhoods would
have resulted in a savings of about $62 million in
1999—or 15% of all hospital and physician
expenditures in Winnipeg in 1999.
Methodology
Literature Search
• An extensive search of academic and grey literature on
social and economic inequalities in health as they relate
to urban areas:
–
–
–
–
Initial journal search: 17,024 records
Screened for date, language, geography: 9,616 articles
Reviewed titles, abstracts: 1,704 articles
Sorted by study type, research focus, year of publication,
location of study, research hypothesis, sample descriptors,
measures, outcomes, study strengths and limitations: 984
articles remained
• A detailed methods paper outlines the literature search
What Is the Deprivation Index?
• A tool for measuring (quantifying) two forms of
deprivation:
1. Material deprivation—such as income, education and
employment ratios
2. Social deprivation—such as family structure, marital status and
incidence of persons living alone.
• Allows for comparisons of small, homogeneous groups
of individuals.
• Allows a variety of socio-economic indicators to be
analyzed based on their known relationship with health
(for example, income, education and marital status).
Benefits of Using the Institut national
de santé publique du Québec (INSPQ)
Deprivation Index:
• Accounts for both material and social factors when
assigning an overall deprivation score.
– Geographical areas are assigned into one of five quintiles
(five groups of 20%) for both material and social deprivation,
ranging from the 20% least deprived to the 20% most deprived
on each of those factors.
• Allows data to be presented at smaller levels of
geography than other indices—at Statistics Canada’s
dissemination area (DA) level.
Source
Pampalon and Raymond (2000).
Moving From Social and Material
Quintiles to Low, Average or High SES
• Quintile 1 = the 20% least deprived
• Quintile 5 = the 20% most deprived
• DAs with material and social combinations found in the top-left
(shaded) portion of the matrix below were categorized by CPHI as
“high SES.” DAs found with material and social combinations found in
the bottom-right (shaded) portion of the matrix were categorized by
CPHI as “low SES.” All other DAs were categorized as “average SES.”
Applying the Deprivation Index
to 15 Canadian CMAs
• DAs in each of the 15 CMAs were classified as either urban or
rural—those that were identified as rural were excluded from
the analyses.
• 30,294 urban DAs were included in the analyses, representing about
66% of all DAs classified as urban by CPHI (46,173 DAs).
• Those urban DAs were assigned a deprivation score of low SES,
average SES or high SES relative to their region (British Columbia,
Alberta, Manitoba/Saskatchewan, Ontario, Quebec and Nova Scotia/
Newfoundland and Labrador).
• Age-standardized hospitalization rates and self-reported health
indicator percentages were calculated within the three SES groups
for each of the 15 CMAs and for all 15 CMAs collectively (CPHI’s
pan-Canadian data).
Deprivation Index Applied to
Victoria CMA, British Columbia
Data Analysis Plan
• 21 indicators are presented
for each CMA by SES group
• Analysis based on Statistics
Canada DAs allowed the
following comparisons:
– between SES groups within
each CMA for each indicator
– between CMAs and the
overall pan-Canadian rate for
each indicator within each
SES group
Québec CMA,
Quebec
CIHI Indicators
Age-standardized hospitalization rates (2003–2004 to 2005–2006)
for longer-term chronic health problems and acute conditions
were analyzed:
• Ambulatory care sensitive
conditions (ACSC)
• Diabetes
• Chronic obstructive pulmonary
disease (COPD)
• Unintentional falls
• Injuries in children
• Mental health
• Anxiety disorders
• Asthma in children
• Affective disorders
• Injuries
• Substance-related disorders
• Land transport accidents
• Low birth weight*
* Rate per 100 live births and not age standardized.
Statistics Canada Indicators
A subset of the Canadian Community Health Survey (CCHS) data from
cycles 2.1 (2003) and 3.1 (2005) were combined to tabulate the
percentage of people reporting excellent or very good health, as well
as reporting certain health-related behaviours:
•
“Excellent” or “very good” selfrated health (ages 12 and over;
age standardized)
•
Physically inactive (ages 12 and
over; age standardized)
•
Smoking (ages 12 and over;
age standardized)
•
Alcohol binging (ages 12 and
over; age standardized)
•
Overweight or obese (ages 18 and
over; age standardized)
•
Risk factor index, that is, 3 or 4 of
the following (physically inactive,
smoking, alcohol binging, overweight
or obese) (ages 18 and over;
age standardized)
•
Influenza immunization
(ages 65 and over)
•
Activity limitation (ages 65 and over)
Socio-Economic Status
in Urban Canada:
What Do the Data Tell Us?
Hospitalization Rates
Pan-Canadian Age-Standardized Hospitalization Rates by SES Group*
Note
* For each indicator, all rates are significantly different between low-, averageand high-SES groups at the 95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database and
National Trauma Registry data, Canadian Institute for Health Information.
Self-Reported Health
Pan-Canadian Age-Standardized Self-Reported Health Percentages
by SES Group*
Note
* For each indicator, all rates are significantly different between low-, averageand high-SES groups at the 95% confidence level except for overweight/obese,
where there is no significant difference between average- and high-SES groups.
Source
CPHI analysis of Canadian Community Health Survey, cycles 2.1 (2003)
and 3.1 (2005), Statistics Canada.
Pan-Canadian Ratios for
Hospitalization Indicators
Pan-Canadian Ratio of Age-Standardized Hospitalization Rates
Between Low- and High-SES Groups
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database and
National Trauma Registry data, Canadian Institute for Health Information.
Pan-Canadian Ratios for
Self-Reported Health Indicators
Pan-Canadian Ratio of Age-Standardized Percentages of Self-Reported
Health Between Low- and High-SES Groups
Source
CPHI analysis of CCHS, cycles 2.1 (2003) and 3.1 (2005), Statistics Canada.
Self-Rated Excellent
or Very Good Health
Pan-Canadian and Victoria CMA Age-Standardized Self-Rated “Very Good”
or “Excellent” Health by SES Groups*
Note
*Average- and high-SES group rates are significantly different from
pan-Canadian rates at the 95% confidence level.
Source
CPHI analysis of CCHS, cycles 2.1 (2003) and 3.1 (2005), Statistics Canada.
Mental Health Hospitalization Rates
Pan-Canadian and Vancouver CMA Age-Standardized Hospitalization
Rates for Mental Health by SES Group*
Note
*All rates are significantly different from pan-Canadian rates at
the 95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract
Database data, Canadian Institute for Health Information.
ACSC Hospitalization Rates
Pan-Canadian and Regina CMA Age-Standardized Hospitalization Rates for
Ambulatory Care Sensitive Conditions by SES Group*
Note
*All rates are significantly different from pan-Canadian rates
at the 95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract
Database data, Canadian Institute for Health Information.
Injury Hospitalization Rates
Pan-Canadian and Winnipeg CMA Age-Standardized
Hospitalization Rates for Injuries by SES Group*
Note
*Average- and low-SES group rates are significantly different from
pan-Canadian rates at the 95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 National Trauma
Registry data, Canadian Institute for Health Information.
Substance-Related Disorder
Hospitalization Rates
Pan-Canadian and Québec CMA Age-Standardized Hospitalization Rates
for Substance-Related Disorders by SES Group*
Note
*All rates are significantly different from pan-Canadian rates at the
95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract
Database data, Canadian Institute for Health Information.
Asthma in Children
Hospitalization Rates
Pan-Canadian and Halifax CMA Age-Standardized Hospitalization
Rates for Asthma in Children by SES Group*
Note
*All rates are significantly different from pan-Canadian rates at the
95% confidence level.
Source
CPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract
Database data, Canadian Institute for Health Information.
Reducing Gaps in Health:
Policies and Programs
Demographic and Socio-Economic
Characteristics Can Differ Widely
Between CMAs
• Questions:
– To what extent can accounting for demographic and
socio-economic characteristics help in producing actionable
interventions to address gaps in health?
– Would interventions targeted toward those who are
over-represented in low-income populations help to reduce
gaps in health?
What Policies Seem to Be
Working in Other Countries?
• Evidence from the United Kingdom: “Tackling
Inequalities in Health: A Programme for Action”
– Interventions geared toward major elements contributing to gaps
in health (e.g. smoking, heart disease and teenage pregnancy)
– Significant narrowing of gaps in infant mortality, heart disease
and cancer mortality
• Evidence from Sweden: A National Public Health Policy
– Focused on development of social capital, reduction of income
inequality and relative poverty, and increased employment
– Reductions in smoking rates across the entire population;
illicit drug use among school-aged children; and work and
traffic accidents
Examples of Policies and Programs
That Seem to Be Working in Canada
• Federal level: Income support for seniors and children
– 6% of seniors live below Statistics Canada’s low income cut-off
(LICO) versus 11% for the rest of the population (2005)
– LICO rate in children decreased from 19% (1996) to 12% (2005)
• Provincial level: Mother-Baby Nutrition Supplement
Program (Newfoundland and Labrador)
– Participants received monthly financial supplements to help
defray cost of food throughout pregnancy
– Birth weight of children was significantly higher for mothers who
received benefits in all trimesters of their pregnancies
Examples of Policies and Programs
That Seem to Be Working in Canada
(cont’d)
• Municipal level: The “Yes, I Quit” smoking cessation
program in St. Henri, Montréal, Quebec
– A trained community facilitator provided low-income women
with strategies to help them quit smoking (such as stress-coping
mechanisms and strategies to avoid weight gain)
– At one-, three- and six-month follow-up, 31%, 25% and 22% of
participants, respectively, reported that they had quit smoking
Improving the Evidence Base
for Policy-Making
• Social determinants of health often cannot be
examined in a scientifically randomized fashion.
• Natural experiments may take the form of
observational studies in which researchers
monitor, rather than control, the distribution of an
intervention to a particular group of people.
• Natural experiments can provide opportunities
for strengthening the knowledge base for
informed policy decision-making.
Addressing Research-Policy Gaps
• Benefits of engaging policy-makers throughout the entire
research process include:
– Helps researchers to anticipate end-user needs so that they can
better tailor the design of research products for policy-makers;
– Provides policy-makers with access to timely and relevant
research results;
– Fosters a mutually beneficial relationship where research
informs policy and policy needs inform research;
– A better understanding of research results by highlighting key
points from a policy perspective; and
– An efficient working relationship that draws on the specific skills
and strengths of researchers and policy-makers.
Conclusions
Reducing Gaps in Health: A Focus on
Socio-Economic Status in Urban Canada
Key Messages
• The analyses demonstrated differences—to varying degrees—in
hospitalization rates and self-reported health percentages within and
across the 15 CMAs.
• Those differences were associated with SES, measured at the
smallest geographical unit possible—Statistics Canada’s DAs.
• Age-standardized indicator rates were generally higher for the
low-SES group than for the average-SES group and generally
higher among the average group than for the highest-SES group
with the extent of the gaps varying among indicators.
• There are variations in the degree of these gaps among the
15 CMAs profiled. Observable differences were noted between
CMAs for some of the indicators examined.
What Do We Still Need to Know?
•
What lies behind admissions for conditions for which hospitalization is
potentially avoidable? To what extent are hospitalizations for ambulatory
care sensitive conditions, for example, a proxy for access to primary care?
What other factors may be related to such hospitalizations?
•
To what extent are differences between CMAs in terms of economic, social,
demographic and other factors related to differences in health outcomes
between and within CMAs?
•
How are differences in population composition (that is, percentage of recent
immigrants, Aboriginal Peoples and single-parent families) and population
trends (that is, population growth rates) related to differences within and
between CMAs?
•
Which interventions or combinations of interventions are most likely to
reduce gaps in health within and across urban areas?
•
What are the financial costs associated with gaps in SES and health?
•
Do policies that are effective in improving SES also lead to positive health
outcomes and reductions in gaps in health?
Conclusion
• New CPHI analyses of 15 Canadian CMAs emphasize
the complex relationship between SES and health in
urban Canada.
• The report demonstrates that significant differences exist
between each SES group in 20 of the 21 health
indicators examined.
• The report provides evidence to support the value of
examining gaps in health across an SES gradient rather
than focusing on the two dichotomous extremes (that is,
high versus low SES).
Our Partners
Institut national de santé
publique du Québec
Statistics Canada
Urban Public Health Network
It’s Your Turn
cphi@cihi.ca
www.cihi.ca/cphi