Income-related Health Inequality Research Articles

Income-related inequality in health outcomes among older individuals in China: A measurement and decomposition analysis

Population aging in China presents a significant challenge, with projections indicating that individuals aged 65 and above will exceed 30% of the total population by 2050, thereby increasing health-care and long-term care (LTC) demands. Therefore, this study aimed to examine income-related inequality in self-rated health (SRH) and functional ability among older individuals in China while also examining the contribution of socioeconomic factors to health inequality. Data were drawn from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey. Well-established tools, such as concentration curves, the Erreygers concentration index (EI), and decomposition analysis, were employed to elucidate income-related inequality in health within the sample. The results revealed that for SRH, both unstandardized and standardized concentration curves were observed below the 45° line, with unstandardized EI at 0.068 and standardized EI at 0.033. For functional ability, both unstandardized and standardized concentration curves were observed above the 45° line, with unstandardized EI at −0.016 and standardized EI at −0.003. These results suggest that, after controlling for demographic factors, the better-off group is more likely to report better SRH and less likely to experience functional limitations compared to the worse-off group. Furthermore, this inequality in health outcomes is predominantly driven by socioeconomic factors rather than demographic factors. For SRH, income emerges as the primary contributor to total inequality. Similarly, for functional ability, income emerges as the key factor driving inequality, disproportionately affecting the less affluent population. Consequently, it is crucial for the government to protect older individuals with lower socioeconomic status to mitigate income-related inequality in health by directly providing cash aids and formal LTC, which could contribute to promoting healthy aging in the context of global aging.

The association between allostatic load and guaranteed annual income using the Canadian Longitudinal Study on Aging: A cross-sectional analysis of the benefits of guaranteed public pensions

BackgroundOld Age Security (OAS) represents an public policy through which income-related inequalities in health may be improved. The goal of this cross-sectional study was to investigate the health benefits of receiving OAS in financially insecure older Canadians. MethodsUsing data from the Canadian Longitudinal Study on Aging (CLSA) (n=15,691), ordered logistic regression was used to measure associations between financial insecurity and allostatic load. ResultsReceiving OAS as highest personal income source appeared to remove the health penalty of being financially insecure. While financial insecurity was associated with worse allostatic load in both males and females not receiving OAS, those receiving OAS as highest personal income source had better allostatic load compared to other financially insecure older adults (ORM: 0.398, 95 % CI: 0.227, 0.696; ORF: 0.677, 95 % CI: 0.483, 0.949). DiscussionWhile longitudinal data would be needed to draw causal inferences, these results suggest OAS may play a role improving health outcomes and narrowing income-related health inequalities. Such findings may have important implications on older adults, other vulnerable populations, and future directions of Canadian health and public policy.

Aversion to health inequality — Pure, income-related and income-caused

We design a novel experiment to identify aversion to pure (univariate) health inequality separately from aversion to income-related and income-caused health inequality. Participants allocate resources to determine health of individuals. Identification comes from random variation in resource productivity and information on income and its causal effect. We gather data (26,286 observations) from a sample of UK adults (n = 337) and estimate pooled and participant-specific social preferences while accounting for noise. The median person has strong aversion to pure health inequality, challenging the health maximisation objective of economic evaluation. Aversion to health inequality is even stronger when it is related to income. However, the median person prioritises health of poorer individuals less than is assumed in the standard measure of income-related health inequality. On average, aversion to that inequality does not become stronger when low income is known to cause ill-health. There is substantial heterogeneity in all three types of inequality aversion.

Does exposure to democracy decrease health inequality?

Abstract Exposure to (a liberal) democracy can have an impact on both the political attention and visibility of the needs of marginalized populations, as well as the design of health policies that can influence the distribution of population health. This paper investigates the effect of exposure to democracy, that is, the number of years spent in a democracy as measured by democracy indexes, on various measures of inequality in self-reported health across European countries. We use an instrumental variable strategy to leverage the potential endogeneity of a country’s exposure to democracy, drawing on both bivariate (socioeconomic) and univariate health inequality measures. Our estimates provide evidence that an additional year in a democracy reduces both bivariate (income-related) health inequality and overall (univariate) health inequality. Our preferred specification suggests a two-point rank reduction in inequality with an additional year under a democracy. The effect is mainly driven by a reduction of “health poverty” alongside other effects.

Does social capital aid in leveling the income gradient in child mental health? A structural analysis of the left-behind and not-left-behind Chinese children

BackgroundFew prior studies have investigated the income gradient in child mental health from a socio-environmental perspective. In an age when child mental health problems in a rapidly changing social environment have become a worldwide issue, an understanding of the socio-environmental mechanisms of the income disparities in child mental health outcomes is imperative and cost-effective.MethodsBy conducting structural equation analyses with Chinese nationally representative survey data, this study explored the family income gradient in child depression and its potential socio-environmental pathways at the neighborhood, family and school levels, differentiating left-behind and not-left-behind children.ResultsWe found a robust family income gradient in depressive symptoms. Neighborhood cohesion mitigated the income gradient in depressive symptoms by playing a suppression role. School social capital acted as a mediator. Neighborhood trust, neighborhood safety and family social capital played no significant impact. The mitigating and mediating roles of social capital components were significant among only the not-left-behind children.ConclusionsTo reduce income-related inequalities in child mental health in the long run, integrating policies that directly reduce poverty with policies that improve distal socio-environments is necessary.

Income-Related Health Inequalities under COVID-19 in Greece

Income-Related Health Inequalities under COVID-19 in Greece

Coastal proximity and visits are associated with better health but may not buffer health inequalities

Societies value the marine environment for its health-promoting potential. In this preregistered study, we used cross-sectional, secondary data from the Seas, Oceans, and Public Health In Europe (SOPHIE) and Australia (SOPHIA) surveys to investigate: (a) relationships of self-reported home coastal proximity and coastal visits with self-reported general health; (b) the potential of both to buffer income-related health inequalities; and (c) the generalizability of these propositions across 15 countries (n = 11,916–14,702). We find broad cross-country generalizability that living nearer to the coast and visiting it more often are associated with better self-reported general health. These results suggest that coastal access may be a viable and generalized route to promote public health across Europe and Australia. However, the relationships are not strongest among individuals with low household incomes, thereby challenging widespread assumptions of equigenesis that access to coastal environments can buffer income-related health inequalities.

Cross-country comparison of income-related inequality in physical functional disability among middle-aged and older adults: Evidence from 33 countries

Physical functional disability is prevalent among middle-aged and older adults, with substantial health inequality. This study compared cross-country variation in the prevalence and inequality of physical functional disability and investigated the potential determinants of household income-related inequality.This cross-sectional study used data from 33 countries between 2017 and 2020, containing 141 016 participants aged 55 years and older. Physical functions were grouped into three domains: activities of daily living (ADLs), instrumental activities of daily living (IADLs), and mobility function. Physical functional disability of each domain was indicated by having some difficulty with the activity. We first estimated the prevalence of physical functional disability in each country. Second, the concentration index was used to quantify household income-related health inequality. Finally, recentred influence function (RIF) decomposition method was used to decompose the inequality into individual and country-level determinants.Physical functional disability prevalence was higher in lower-middle-income countries than in high-income countries and more prevalent in the poor-income groups in all study countries. Besides, health inequality in different domains of disability was higher in high-income countries than in low-income countries. Regarding determinants of health inequality, we found that individual married, tertiary education, and country-level health infrastructure and resources were associated with reduced health inequality. In contrast, age, unhealthy lifestyles, and chronic diseases were associated with increased health inequality.Inequality in physical functional disability among middle-aged and older adults varies substantially across countries, with individual and macro determinants being contributing factors. Policies to achieve healthy ageing and reduce the inequality of physical function disability can focus on improving individual healthy lifestyles and country health care facilities.

Environmental pollution and socioeconomic health inequality: Evidence from China

Recent work on socioeconomic health inequality has explored the possible determinants, but there is a lack of empirical evidence examining the associations between environmental pollution and socioeconomic health inequality. Most of studies employed the one-dimensional decomposition method, focusing on health but ignoring rank, to analyze the factors of health inequality. Hence, we fill this gap by using nationally representative individual-level data, employing the recentered influence function regressions method (a two-dimensional decomposition method), and estimating the marginal effect of environmental pollution on socioeconomic inequality in three health outcomes in China straightforward: physical discomfort, chronic disease, and self-rated health. Findings show that environmental pollution increases the income related health inequality of people, and the effect is larger for the middle-aged. The evidence of the possible channel through which environmental pollution is correlated with socioeconomic health inequality is also provided. In the face of environmental pollution, the rich pay more attention to their health condition and increase beneficial health behaviors, such as increasing sleeping hours, decreasing smoking, or having a more balanced diet, compared with the poor. It partly explains why environmental pollution widens the income related health inequality. These findings imply that reducing environmental pollution is an effective strategy for improving environmental quality and narrowing the income related health inequality.

Socioeconomic deprivation, medical services accessibility, and income-related health inequality among older Chinese adults: evidence from a national longitudinal survey from 2011 to 2018.

Health inequality poses a challenge to improving the quality of life of older adults as well as the service system. The literature rarely explores the moderating role of medical services accessibility in the association between socioeconomic deprivation and health inequality. This study examines the socioeconomic deprivation and medical services accessibility associated with health inequality among older Chinese adults, which will contribute to the medical policy reform. Using data from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we analyse 14,232 older adults. This paper uses a concentration index (CI) to measure the income-related health inequality among the target population and employs a recentered influence function-concentration index-ordinary least squares (RIF-CI-OLS) model to empirically analyse the correlation between socioeconomic deprivation and health inequality among older Chinese adults. Based on the correlation analysis, we discuss the moderating effect of medical services accessibility. We find that health inequality exists among older Chinese adults and that the relative deprivation in socioeconomic status (SES) is significantly associated with health inequality (β∈ [0.1109, 0.1909], P < 0.01). The correlation between socioeconomic deprivation and health inequality is moderated by medical services accessibility, which means that an increase in medical services accessibility can weaken the correlation between socioeconomic deprivation and health inequality. China needs an in-depth reform of its medical services accessibility system to promote the equitable distribution of medical services resources, strengthen medical costs and quality management, and ultimately mitigate the SES reason for health inequality among older Chinese adults.

Trajectories of the socioeconomic gradient of mental health: Results from the CLSA COVID-19 Questionnaire Study

As the coronavirus disease (COVID-19) pandemic prolongs, documenting trajectories of the socioeconomic gradient of mental health is important. We describe changes in the prevalence and absolute and relative income-related inequalities of mental health between April and December 2020 in Canada. We used data from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study and the pre-pandemic CLSA Follow-up 1. We estimated the prevalence proportion, the concentration index (relative inequality), and the generalized concentration index (absolute inequality) for anxiety and self-reported feeling generally unwell at multiple points in April-December 2020, overall, by sex and age group, by region, and among those who reported poor or fair overall health and mental health pre-pandemic. Overall, the prevalence of anxiety remained unchanged (22.45 to 22.10%, p = 0.231), but self-reported feeling generally unwell decreased (9.83 to 5.94%, p = 0.004). Relative and absolute income-related inequalities were unchanged for both anxiety and self-reported feeling generally unwell, with exceptions of an increased concentration of self-reported feeling generally unwell among the poor, measured by the concentration index, overall (-0.054 to -0.115, p = 0.004) and in Ontario (-0.035 to -0.123, p = 0.047) and British Columbia (-0.055 to -0.141, p = 0.044). The COVID-19 pandemic appeared to neither exacerbate nor ameliorate existing income-related inequalities in mental health among older adults in Canada between April and December 2020. Continued monitoring of inequalities is necessary.

Estimating Income-Related Health Inequalities Associated with Tobacco and Alcohol Consumption in Namibia.

Disparities in resources and access to material opportunities are important determinants of income-related health inequality. This paper hypothesises that the gradient of the inequality in health between the poor and the rich is likely to depend on differences in lifestyle practices including tobacco use and alcohol abuse. Using the 2015/16 Namibia Household Income and Expenditure Survey and the Erreygers corrected concentration index, we estimate the effect of tobacco and alcohol use on income-related health inequalities. A decomposition technique was used to estimate the separate and joint contribution of tobacco and alcohol use to income-related health inequalities. The results indicate that tobacco use widens the income-related health inequality gap while alcohol consumption reduces health disparities. The simultaneous consumption of these goods has a stronger multiplicative effect on income-related health inequality. For instance, the simultaneous consumption of both goods contribute up to 1.03% of the inequality in health while tobacco use alone contributed only 0.6%. While policy options for each of these goods could be essential in reducing inequalities in health, there is a need to advocate additional measures that could simultaneously control the consumption of both goods.

Income-related health inequality among rural residents in western China.

Health equality has drawn much public attention in both developed and developing countries. China, the largest developing country, has implemented a new round of health system reform to improve health equality since 2009. This study aims to examine the magnitude and sources of income-related health inequality in western rural regions of China. Data were obtained from the Survey of Rural Economic and Social Development in Western China conducted in 2014, in which 14,555 individuals from 5,299 households in 12 provinces were included. Health outcome variables of interest were self-rated health status, prevalence of chronic disease and four-week illness. Concentration index was calculated to assess magnitude of income-related health inequality, and nonlinear decomposition analysis was performed to identify the sources of health inequality. The Concentration indexes for poor self-rated health status, prevalence of chronic disease and four-week illness were -0.0898 (P<0.001),-0.0860 (P<0.001) and -0.1284 (P<0.001), respectively. Income and education were two main sources of health inequality, accounting for about 25-50% and 15% contribution to the inequality. Ethnicity made <10% contribution to income-related health inequality, and enrollment in New Rural Cooperative Medical Scheme contributed to <1%. This study found slight income-related health inequality among rural residents in western China, implying that although China has made substantial progress in economic development and poverty alleviation, health inequality in western rural region should still be concerned by the government. To achieve health equality further, the Chinese government should not only strengthen its reimbursement mechanism of the current health insurance scheme to improve affordability of primary healthcare for residents in western rural regions, but also implement health poverty alleviation policies targeting socioeconomically vulnerable population and ethnic minorities in future.

Edgar Sydenstricker, a pioneer of health economics

The economist Edgar Sydenstricker, who spent most of his working life at the United States Public Health Service and at the Milbank Memorial Fund, examined a wide range of health economics issues. He contributed to the debate around the cause of the disease pellagra. This research was followed by many studies quantifying income-related health inequalities. Sydenstricker was heavily involved in the use of surveys to collect information and he was instrumental in the development of the first US National Health Survey. Other contributions include extending health insurance in the United States and methods of evaluating public health programs.

Revisiting income-related health inequality in China: changes before and after the 2009 healthcare reform

ABSTRACTIn 2009, the Chinese government launched a systemic healthcare reform. Despite the massive investment in the health sector, little is known about how health inequality across economic classes has changed after the reform. Using data from the China Health and Nutrition Survey (CHNS), this study traces the income-related health inequality (IRHI) before and after the reform with the corrected concentration index (CCI). Furthermore, the inequality change is decomposed into income and non-income factors.

Health indicators and poor health dynamics during COVID-19 pandemic.

It is expected that the coronavirus pandemic will exacerbate inequality in wellbeing compared to the pre-pandemic situation. However, there are theories (e.g., the Conservation of Resource (COR) theory) that acknowledge situation-specific lower wellbeing for individuals who typically have more resources. The argument is that perception of loss might occur differently across the socioeconomic spectrum such that individuals with higher socioeconomic status perceive that they experience more loss. Therefore, given the pandemic situation, it is possible that indicators of poor wellbeing (e.g., depression) becoming less concentrated among the poor, contrary to expectation. Given the above, we examine income-related inequality in self-assessed health and depressive symptoms in South Africa. This is done using both pre-pandemic data (i.e. National Income Dynamic Study) and data collected during the pandemic (National Income Dynamic Study-Coronavirus Rapid Mobile Survey). Consistent with expectation, we find that poor self-assessed health is not only disproportionately concentrated amongst the poor, but this concentration has increased compared to the pre-pandemic period. However, contrary to expectation, depressive symptoms have become less concentrated amongst the poor compared to the pre-pandemic period. We note that while there may be an alternative explanation for this change in trend, it may also be due to situation-specific lower wellbeing for individuals who typically have more resources. We argue that this has implication for tracking population health in a crisis.

Does high-speed rail relieve income-related health inequalities? A quasi-natural experiment from China

IntroductionThe rapid increases in income and high-speed rail (HSR) construction in China raise the prospect of reshaping the space economy, the exploration of which, from the perspective of optimised transportation networks, can provide insights into alleviating the increasing health inequalities. MethodsBased on matched data of prefecture-level cities and Chinese Labor Dynamic Survey packages from 2014 to 2018, we used the ordered probit model and ordinary least squares (OLS) with time- and city-fixed effects to estimate the effects of HSR on personal health status. We calculated the degree of income-related health inequalities and decomposed the contributive degree of HSR to health inequalities by decomposing the concentration index (CI) and Blinder-Oaxaca, respectively. ResultsPersonal health status showed significant differences under different income levels and in areas with and without HSR. The estimated coefficients regarding HSR on personal health status were 0.112 in the ordered probit model and 0.167 in the OLS model. The CI of health inequalities showed a positive coefficient of 0.059, with a pro-rich phenomenon. Contribution decomposition of CI showed that HSR accounted for an important contribution of 1.919% to health inequalities. Blinder-Oaxaca decomposition revealed that the contribution of HSR to overall CI was 0.075% from 2014 to 2018. CI decomposition also demonstrated a decreasing trend over time in the HSR's contribution to increasing health inequalities. Further, mechanism analysis showed that HSR improved health more significantly among high-income groups in ways that included improved high quality of healthcare services, socioeconomic status, and social capital. ConclusionsThere is a pro-rich distribution of health in China, and HSR exacerbates health inequalities more significantly among high-income groups in several ways, including high-quality healthcare services, socioeconomic status, and social capital. Furthermore, HSR has the potential to decrease health inequalities in the future.

Income-related health inequality in urban China (1991-2015): The role of homeownership and housing conditions.

Unprecedented economic growth has been experienced over the several decades worldwide, but such rapid economic growth wasn't accompanied by equally-substantial improvement in health, especially health inequalities between the rich and poor. This study examines the role of housing in income-related health inequalities (income-health gradient) in urban China. We here analyze 1991-2015 China Health and Nutrition Survey data to ask how housing affects income-related health inequalities in urban China. We find pro-poor inequalities in self-reported bad health but pro-rich inequalities in objective bad health (general overweight/obesity, central obesity and high blood pressure). Housing conditions serve to reduce the health gradient, especially for objective health. On the contrary, homeownership exacerbates the health gradient. Improving housing conditions thus appears to be an effective way of reducing the income-health gradient in urban China.

Income-Related Mortality Inequalities and Its Social Factors among Middle-Aged and Older Adults at the District Level in Aging Seoul: An Ecological Study Using Administrative Big Data.

This study investigated income-related health inequality at sub-national level, focusing on mortality inequality among middle-aged and older adults (MOAs). Specifically, we examined income-related mortality inequality and its social factors among MOAs across 25 districts in Seoul using administrative big data from the National Health Insurance Service (NHIS). We obtained access to the NHIS’s full-population micro-data on both incomes and demographic variables for the entire residents of Seoul. Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were calculated. The effects of social attributes of districts on SIIs and RIIs were examined through ordinary least squares and spatial regressions. There were clear income-related mortality gradients. Cross-district variance of mortality rates was greater among the lowest income group. SIIs were smaller in wealthier districts. Weak spatial correlation was found in SIIs among men. Lower RIIs were linked to lower Gini coefficients of income for both genders. SIIs (men) were associated with higher proportions of special occupational pensioners and working population. Lower SIIs and RIIs (women) were associated with higher proportions of female household heads. The results suggest that increasing economic activities, targeting households with female heads, reforming public pensions, and reducing income inequality among MOAs can be good policy directions.

Estimating income-related and area-based inequalities in mental health among nationally representative adolescents in Australia: The concentration index approach.

Despite the awareness of the importance of mental health problems among adolescents in developed countries like Australia, inequality has not been widely researched. This study, is therefore, aimed to measure and compare household income-related and area-based socioeconomic inequalities in mental health problems (bullying victimization, mental disorders–single and multiple, self-harm and suicidality–ideation, plan and attempt) among Australian adolescents aged 12–17 years. Young Minds Matter (YMM)—the 2nd national cross-sectional mental health and well-being survey involving Australian children and adolescents conducted in 2013–14, was used in this study to select data for adolescents aged 12–17 years (n = 2521). Outcome variables included: bullying, mental disorders, self-harm, and suicidal ideation, plan and attempt. The Erreygers’s corrected concentration index (CI) approach was used to measure the socioeconomic inequalities in mental health problems using two separate rank variables–equivalised household income quintiles and area-based Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) quintiles. The prevalence of mental health problems in the previous 12-months among these study participants were: bullying victimization (31.1%, 95% CI: 29%-33%), mental disorder (22.9%, 95% CI: 21%-24%), self-harm (9.1%, 95% CI: 8%-10%), suicidal ideation (8.5%, 95% CI: 7%-10%), suicidal plan (5.9%, 95% CI: 5%-7%) and suicidal attempt (2.8%, 95% CI: 2%-3%). The concentration indices (CIs) were statistically significant for bullying victimization (CI = -0.049, p = 0.020), multiple mental disorders (CI = -0.088, p = <0.001), suicidal ideation (CI = -0.023, p = 0.047) and suicidal attempt (CI = -0.021, p = 0.002), implying pro-poor socioeconomic inequalities based on equivalized household income quintiles. Similar findings revealed when adolescents mental health inequalities calculated on the basis of area based IRSAD (Index of Relative Socio-economic Advantage and Disadvantage) quintiles. Overall, adolescents from economically worse-off families experienced more mental health-related problems compared to those from economically better-off families. This has implications for prevention strategies and government policy in order to promote mental health and provide equitable healthcare facility.