Gender and Socioeconomic Inequalities in Health and Heart Disease Socioeconomic Inequalities in Health Among Canadian Women with Heart Disease Arlene S. Bierman, M.D., M.S Ontario Women’ Women’s Health Council Chair in Women’ Women’s Health St. Michael’ Michael’s Hospital, University of Toronto Academy Health Annual Meeting June 25, 2006 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. 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 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. Data Source and Study Population Cycle 1.1 Canadian Community Health SurveySurvey2000/2001 Nationally representative sample covering 98% of population with a response rate of 84.7% (N(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. Population Characteristics Income and Education Heart Disease Population % % Low Income Men Women < HS Education Men Women 11 21 8 12 44 48 23 24 1 Prevalence of Poor Health (HUI ≤0.80) among Canadian Men and Women with Heart Disease by Income* Fair or Poor Health among Canadian Men and Women by Income* 90 70 70 65.9 60 60 58.5 50 50.3 49.5 Percent (%) Percent (%) 73.6 80 80.2 80 49.1 40 30.6 30 32.1 29.9 30.9 27.8 20 30.6 19.5 23.1 11.9 11.9 17.9 10 27.3 7.3 8.2 43.8 50 Men Women 40 27.7 30 17.2 20 0 10 Poor Near Poor Middle Upper Middle Men with Heart Disease Men (General Population) High 0 Women with Heart Disease Women (General Population) Poor CCHS - Cycle 1.1 *Adjusted for age High CCHS - Cycle 1.1 *Adjusted for age Prevalence of Feeling Very Stressed among Canadian Men and Women with Heart Disease by Income* Prevalence of 4 or More Chronic Conditions among Men and Women Older by Income* 90 80 70 77.8 70.7 60 51.2 50 48.3 50 41.6 37.9 40 43.7 42.1 31.6 30 26 24 23.5 18.8 20 14.3 10 16.1 16.1 Poor Near Poor Men with Heart Disease Men (General Population) Middle 8.5 7.4 Men Women 27 20 0 CCHS - Cycle 1.1 Poor High CCHS - Cycle 1.1 *Adjusted for age Reported Unmet Health Care Needs of Men and Women with Heart Disease Age 25 and Older by Income* Food Insecurity among Canadian Men and Women With Heart Disease by Income* 38.4 70 62.5 60 35 55.9 63.3 55.8 50 21.3 25 Men Women 15.9 13 15 10 Percent (%) 30 20 28 30 10 Upper Middle High Women with Heart Disease Women (General Population) *Adjusted for age 40 40 14.6 11.6 0 Percentage (%) 59.8 60 63.3 Percent (%) Percentage (%) 70 40 37.6 30 24.4 20 15.2 9.4 10 6.7 2.9 5 0 0 Poor *Adjusted for age Poor High Near Poor Men with Heart Disease Men (General Population) CCHS - Cycle 1.1 *Adjusted for age Middle Upper Middle High Women with Heart Disease Women (General Population) CCHS - Cycle 1.1 2 Age Adjusted Odds of Fair or Poor Health Among Canadian Women with Heart Disease Correlates of Fair or Poor Health OR 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 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 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 Adjusted for age 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. 3 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. 4