Socioeconomic Inequalities in Health Among
Canadian Women with Heart Disease
Arlene S. Bierman, M.D., M.S
Ontario Women’s Health Council Chair in Women’s Health
St. Michael’s Hospital, University of Toronto
Academy Health Annual Meeting
June 25, 2006
Gender and Socioeconomic Inequalities
in Health and Heart Disease
 Cardiovascular disease is a leading cause of
morbidity and mortality among Canadian women
 Socioeconomic and gender inequalities in health and
functional status have been well documented in
Canada
 Differences in access, quality of care, health
behaviors, and the social determinants of health have
all been associated with socioeconomic inequalities
among individuals with heart disease.
 However, little is known about the extent to which
these factors contribute to the observed
socioeconomic gradients in health status.
Objectives
 Examine the determinants of socioeconomic
inequalities in health among women in a system of
universal health insurance coverage.
 Specifically assess the contribution of
sociodemographic factors (income, education,
language), health behaviors (physical activity,
smoking), access to care (unmet need, regular
physician), and psychosocial factors (depression,
stress, food insecurity, and sense of community
belonging) to these inequalities.
Data Source and Study Population
 Cycle 1.1 Canadian Community Health Survey-
2000/2001
 Nationally representative sample covering 98% of
population with a response rate of 84.7% (N-130,000)
 Study sample includes 7825 individuals age 25 and
older reporting heart disease diagnosed by a
physician (women n=4024, men n=3801)
representative of 1.3 million individuals.
Measures
 Health status: global health, health utility index,




activity restrictions, comorbidity
Sociodemographic characteristics: age, income,
education, language
Health behaviors: physical inactivity, smoking
Health access: regular physician, self perceived
unmet health care need
Psychosocial factors: depression, stress, food
insecurity, sense of belonging to the community
Population Characteristics
Income and Education
Heart Disease Population
%
%
Low Income
Men
Women
< HS Education
Men
Women
11
21
8
12
44
48
23
24
Fair or Poor Health among
Canadian Men and Women by Income*
90
80.2
80
70
65.9
Percent (%)
60
58.5
50
50.3
49.5
49.1
40
30.6
30
32.1
29.9
30.9
27.8
20
19.5
17.9
10
30.6
27.3
23.1
11.9
11.9
7.3
8.2
0
Poor
Near Poor
Men with Heart Disease
Men (General Population)
*Adjusted for age
Middle
Upper Middle
High
Women with Heart Disease
Women (General Population)
CCHS - Cycle 1.1
Prevalence of Poor Health (HUI ≤0.80) among
Canadian Men and Women with Heart Disease by Income*
73.6
80
70
Percent (%)
60
50
43.8
40
27.7
Men
Women
30
17.2
20
10
0
Poor
*Adjusted for age
High
CCHS - Cycle 1.1
Prevalence of 4 or More Chronic Conditions among
Men and Women Older by Income*
90
80
77.8
70.7
Percentage (%)
70
63.3
60
48.3
50
37.9
40
41.6
43.7
42.1
31.6
30
26
24
18.8
20
14.3
10
16.1
*Adjusted for age
16.1
14.6
11.6
0
Poor
Near Poor
Men with Heart Disease
Men (General Population)
23.5
Middle
8.5
7.4
Upper Middle
High
Women with Heart Disease
Women (General Population)
CCHS - Cycle 1.1
Prevalence of Feeling Very Stressed among Canadian
Men and Women with Heart Disease by Income*
70
59.8
60
51.2
Percent (%)
50
40
28
27
30
Men
Women
20
10
0
Poor
*Adjusted for age
High
CCHS - Cycle 1.1
Reported Unmet Health Care Needs of Men and Women
with Heart Disease Age 25 and Older by Income*
38.4
40
Percentage (%)
35
30
21.3
25
20
Men
Women
15.9
13
15
10
5
0
Poor
*Adjusted for age
High
CCHS - Cycle 1.1
Food Insecurity among Canadian Men and Women
With Heart Disease by Income*
70
62.5
60
55.9
63.3
55.8
Percent (%)
50
40
37.6
30
24.4
20
15.2
9.4
10
6.7
2.9
0
Poor
Near Poor
Men with Heart Disease
Men (General Population)
*Adjusted for age
Middle
Upper Middle
High
Women with Heart Disease
Women (General Population)
CCHS - Cycle 1.1
Age Adjusted Odds of Fair or Poor Health
Among Canadian Women with Heart Disease
Poor
Near Poor
Middle
Upper Middle
High (ref)
OR
p
95%CI
5.0
2.1
1.8
1.0
1.0
< .001
.001
.008
.9
2.9, 8.4
1.4, 3.3
1.2, 2.7
.66, 1.6
Correlates of Fair or Poor Health
OR
Income:
Poor
Near Poor
Education: < Than High School
High School Grad
Language: No French or English
Physically Inactive
Smoking
Depression
Stress
Unmet Need
Regular Physician
Food Insecurity
Sense of Community Belonging
Adjusted for age
3.4
1.6
2.0
1.1
3.2
2.4
1.1
1.7
2.1
1.7
.57
1.3
1.5
95%CI
1.9, 6.3
.97, 2.6
1,5, 2.6
1.1, 2.3
1.2, 8.8
1.7, 3.3
.79, 1.9
1.1, 2.8
1.6, 2.7
1.3, 2.4
.29, 1.2
.94, 1.8
1.2, 1.9
Comorbidity
OR
Income:
Poor
Near Poor
Education: < Than High School
High School Grad
Number of Chronic Conditions
2
3
4 or more
95%CI
2.9
1.4
2.0
1.8
1.6, 5.4
.84, 2.3
1.5, 2.6
1.2, 2.5
1.9
2.9
5.6
.99, 3.7
1.6. 5.3
3.1, 9.9
Conclusions
 Within a system of universal health care there are
sizable gender and socioeconomic inequities in health
and functional status among individuals with heart
disease.
 Women with heart disease are more likely to be poor
than men with heart disease and poor women with
heart disease are much more likely to report fair or
poor health and higher levels of comorbidity.
Conclusions
 Among women with heart disease sociodemographic
factors (income, education, language), health
behavior (physical activity), access to care (unmet
need), and psychosocial factors (depression, stress,
and sense of community belonging) are all
independently associated with poor health.
 The relationship between income and health status is
partially explained by these factors and further
mediated by comorbid chronic illness. However,
poverty remains independently associated with poor
health after controlling for all of these factors.
Limitations
 The study is cross sectional and based upon
self report.
 We did not assess the association provincial
differences to health status.
 Did not have information on process or quality
of care.
Implications
 Addressing socioeconomic inequalities in health
among women with heart disease is likely to require a
multifaceted approach that addresses health system
factors, risk factor reduction as well as the social
determinants of health.
 Improving the health and functional status for low
income women with heart disease will require the
development and evaluation of interventions aimed at
targeting these factors.