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Kaplan, George A; Pamuk, Elsie R; Lynch, John W; Cohen, Richard D; Balfour, Jennifer L
doi: 10.1136/bmj.312.7037.999pmid: 8616393
Abstract Objective: To examine the relation between health outcomes and the equality with which income is distributed in the United States. Design: The degree of income inequality, defined as the percentage of total household income received by the less well off 50% of households, and changes in income inequality were calculated for the 50 states in 1980 and 1990. These measures were then examined in relation to all cause mortality adjusted for age for each state, age specific deaths, changes in mortalities, and other health outcomes and potential pathways for 1980, 1990, and 1989-91. Main outcome measure: Age adjusted mortality from all causes. Results: There was a significant correlation (r=0.62, P<0.001) between the percentage of total household income received by the less well off 50% in each state and all cause mortality, unaffected by adjustment for state median incomes. Income inequality was also significantly associated with age specific mortalities and rates of low birth weight, homicide, violent crime, work disability, expenditures on medical care and police protection, smoking, and sedentary activity. Rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance, and educational outcomes were also worse as income inequality increased. Income inequality was also associated with mortality trends, and there was a suggestion of an impact of inequality trends on mortality trends. Conclusions: Variations between states in the inequality of the distribution of income are significantly associated with variations between states in a large number of health outcomes and social indicators and with mortality trends. These differences parallel relative investments in human and social capital. Economic policies that influence income and wealth inequality may have an important impact on the health of countries. Key messages There was a significant correlation (r=0.62) between the proportion of total household income received by the less well off 50% of households and variation between states in death rates for the United States Income inequality was also significantly related to changes in mortality with smaller declines between 1980-90 in those states with greater income inequality Income inequality was associated with a large number of other health outcomes and with measures related to investments in human and social capital Economic policies that increase income inequality may also have a deleterious effect on population health
Kennedy, Bruce P; Kawachi, Ichiro; Prothrow-Stith, Deborah
doi: 10.1136/bmj.312.7037.1004pmid: 8616345
Abstract Objective: To determine the effect of income inequality as measured by the Robin Hood index and the Gini coefficient on all cause and cause specific mortality in the United States. Design: Cross sectional ecological study. Setting: Households in the United States. Main outcome measures: Disease specific mortality, income, household size, poverty, and smoking rates for each state. Results: The Robin Hood index was positively correlated with total mortality adjusted for age (r=0.54; P<0.05). This association remained after adjustment for poverty (P<0.007), where each percentage increase in the index was associated with an increase in the total mortality of 21.68 deaths per 100000. Effects of the index were also found for infant mortality (P=0.013); coronary heart disease (P=0.004); malignant neoplasms (P=0.023); and homicide (P<0.001). Strong associations were also found between the index and causes of death amenable to medical intervention. The Gini coefficient showed very little correlation with any of the causes of death. Conclusion: Variations between states in the inequality of income were associated with increased mortality from several causes. The size of the gap between the wealthy and less well off—as distinct from the absolute standard of living enjoyed by the poor—seems to matter in its own right. The findings suggest that policies that deal with the growing inequities in income distribution may have an important impact on the health of the population. Key messages The size of the gap between the wealthy and less well off—as distinct from the absolute standard of living enjoyed by the poor—seems to be related to mortality Policies that deal with the growing inequities in income distribution may have a considerable impact on the health of the population
Carr-Hill, Roy A; Rice, Nigel; Roland, Martin
doi: 10.1136/bmj.312.7037.1008pmid: 8616346
Abstract Objective: To identify the socioeconomic determinants of consultation rates in general practice. Design: Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload. Results: Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of “indices of deprivation” is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas. Conclusions: Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice. Key messages Characteristics of individual patients are much more powerful predictors of consulting patterns than the characteristics of the areas in which patients live The effects of individual socioeconomic factors themselves vary in different geographical areas Resource allocation methods based on area of residence (for example, Jarman score) will always be inferior to an approach that takes into account the characteristics of individual patients
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