Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation
Introduction
Tremendous strides are being made in understanding how the organization of societies influences the health of their members. Foremost among these characteristics is how a nation, region, or municipality chooses to distribute income and wealth among its members. In many European nations, income adequacy is a basic component of national and regional health policy [1]. In other Western industrialized nations such as the USA, Australia, and Canada, such concerns are of lower priority [2], [3]. Recognising the importance of income adequacy and income distribution as health determinants, health researchers in Canada frequently include these factors in their research. But how do researchers conceptualize income as influencing health? Is income simply an indicator by which individuals can be made targets of health promotion interventions, because poor people tend to have poorer health status and health habits? Or is income and its distribution an issue to which governments concerned with creating health policy should direct their attention, because there is something inherently health-determining in absolute and relative material deprivation [4]?
Canada has been a leader in conceptualizing societal determinants of health such as income and its distribution [5]. Concepts developed by the Canadian Institute for Advanced Research, Health Canada, and the Canadian Public Health Association – as three examples – have influenced policy developments around the world [6]. But there is increasing evidence that Canada is failing to apply its own population health concepts in health research [7]. There is also concern Canada has fallen well behind other nations in applying research findings related to income and its distribution towards policy development [8]. The result is a deteriorating public policy environment that increasingly focuses on “lifestyle” and biomedical approaches to understanding and promoting health [9].
These issues were recognized by the Institute of Population and Public Health (IPPH), a major funding agency for health research in Canada. In response to an IPPH call for analyses of how Canadian researchers were responding to emerging health research and health policy needs, we carried out an environmental scan and analysis of how income is considered in health research. We compared these findings to exemplary studies on income and health from two nations identified as having advanced policy agendas concerning income and health: UK and Finland [10]. Our findings present a surprising view – considering Canada's reputation as a leader in population health and health promotion concepts – of the current state of Canadian research infrastructure, conceptualization, and policy application of research findings.
Our findings and analysis have implications for others. For nations with less-developed health research infrastructures, our results identify what is needed to carry out research that identifies the role factors such as income, class, and socioeconomic position play in determining health. For those with more-developed research infrastructures, findings illustrate that research concepts and applications can easily deteriorate into a focus on limited lifestyle and biomedical issues. Our conceptualization of differences in models of health determinants, and the role of income within them, can assist others in designing or interpreting the results of their own local health research activities.
Section snippets
Background to the study
This research was part of an IPPH initiative to identify gaps in knowledge of “contextual factors” that influence population health. The initiatives funded included housing, social assistance and workplace environments in addition to income. Our focus on income was especially timely in light of three developments: (1) the increasing international focus on the health effects of income and its distribution [11] (2) the growing inequality among Canadians of income and wealth [12], and (3) evidence
Methodology
We identified the total population of 241 Canadian studies from 1995–2002 that applied any one (or more) indicator of income, income distribution, socioeconomic status, poverty status, or other related measures to explain the health outcomes of individuals or populations. Health outcomes included direct indicators of health such as self-rated health, quality of life, morbidity or mortality, or determinants of health such as employment status, child development indicators, child's school
Conceptualizing the Income and health relationship
We observed a spectrum of approaches towards specifying the income and health relationship, ranging from narrow and simple approaches to the broad and complex. At one end of the spectrum, health researchers simply noted the association between income and health measures without providing any explicit rationale for including income as a relevant variable. At the other end of the spectrum, health researchers provided complex, usually causative models, with extensive rationales as to why income is
Unit of analysis
The availability of carefully collected data sets allows for the analysis of the income and health relationship at the individual level. When such data are unavailable, area-level ecological analyses using income, socioeconomic status, or employment levels collected from census data are used (Table 6).
Discussion
Our research findings illustrate numerous ways in which Canadian research on income and health could be enhanced. The particular areas of weakness are (a) conceptualization of how income and its distribution contribute to population health; (b) lack of longitudinal studies of the impact of income and income-related issues upon health across the life-span; and (c) few linked data bases that allow complex analyses of how income and related issues influence health. Along with a lack of
Need for better conceptualization of non-market economic resources and how these factors interact with market income to influence health over the life-span
Income is important because it provides opportunities to meet basic needs and participate in activities normally expected of members within a society. Societies and jurisdictions differ in the extent to which these needs and participation opportunities are dependent on income alone. To illustrate, when housing availability and affordability are determined solely by the marketplace, income will be an especially important determinant of housing insecurity as well as a number of other determinants
Acknowledgements
Source of support in the form of grant: The Canadian Institutes of Health Research, Institute of Population and Public Health Grant #: NGO - 54120. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the views of CIHR.
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