HEALTH DISPARITY IN SASKATOON Analysis to Intervention Dr. Mark Lemstra Dr. Cory Neudorf Senior Epidemiologist Chief Medical Health Officer Saskatoon Health Region Saskatoon Health Region SPECIAL THANKS Research team Christina Scott, Tanis Kershaw, Wendy Sharpe, Norman Bennett, Josh Marko, Lynne Warren, Terry Dunlop, and Gary Beaudin. Professional guidance Professor Johan Mackenbach and Dr. Anton Kunst from Erasmus University in the Netherlands. Funding The Canadian Institutes for Health Research for their financial support of the grant titled “Reducing Health Disparity in Saskatoon” (grant # 149320). Art work Permission to use the image titled “The Broadway Bridge” displayed on the cover was obtained from The Glen Scrimshaw Gallery. For more information about the artist and his prints contact Glen Scrimshaw at [email protected]. Cover design and layout by DBlack Communication Inc. ABOUT THE AUTHORS Mark Lemstra is a senior epidemiologist with the Saskatoon Health Region. Mark has a Bachelors degree in Science, a Masters degree in Physical Medicine and Rehabilitation, a Masters degree in Public Health, a Masters degree in Epidemiology, a Doctor of Science degree in Public Health, a Doctor of Science degree in Epidemiology, a PhD in Psychiatry and a PhD in Epidemiology. Cory Neudorf is the Chief Medical Health Officer for the Saskatoon Health Region. Cory has a degree in Medicine, a fellowship in Community Medicine and a Masters degree in Health Science. Cory is also an Associate Clinical Professor with the Department of Community Health and Epidemiology at the University of Saskatchewan. For copies of this report Additional copies of this report can be obtained from the Saskatoon Health Region Public Health Observatory website: http://www.saskatoonhealthregion.ca/your_health/ps_public_health_pho_about.htm For inquiries or questions about the report please contact: Dr. Mark Lemstra Dr. Cory Neudorf 101-310 Idylwyld Drive North 101-310 Idylwyld Drive North Saskatoon, SK S7L 0Z2 Saskatoon, SK S7L 0Z2 Email: [email protected] Email: [email protected] How to cite this report Lemstra M, Neudorf C. Health disparity in Saskatoon: analysis to intervention. Saskatoon: Saskatoon Health Region; 2008. TABLE OF CONTENTS Credits and Special Thanks . inside front cover Background and Context . 3 Main Research Findings . 6. Main Evidence Based Policy Options . 8 Letters of Support . 9. 1. Introduction . 83 1 .1 . Socioeconomic status and health status . 84 1 .2 . Socioeconomic status, cultural status and health . 89 1 .3 . Explanations of socioeconomic inequality in health . 92 1 .4 . Structure of section 2 and section 3 . 94 1 .5 . References . 98 2. Socioeconomic Status and Health Status in Saskatoon . 101. 2 .1 . A systematic review of depressed mood and anxiety by socioeconomic status in adolescents aged 10-15 years . 102. 2 .2 . A systematic literature review of drug and alcohol use by socioeconomic status in adolescents aged 10-15 years . 112. 2 .3 . Health disparity by neighbourhood income . 126 2 .4 . Health disparity: the role of economic status and Aboriginal cultural status after multivariate adjustment . 136 2 .5 . Suicide ideation: the role of economic and Aboriginal cultural status after multivariate adjustment . 147 2 .6 . Daily smoking in Saskatoon: the independent effect of income and cultural status . 157 2 .7 . Disparity in childhood immunizations: limited association with Aboriginal cultural status . 166. 2 .8 . Risk indicators for depressed mood in youth: lack of association with Aboriginal cultural status . 181 2 .9 . The role of economic and cultural status as indicators for alcohol and marijuana use among adolescents . 201. 2 .10 .High healthcare utilization and costs associated with lower socioeconomic status: results from a linked dataset . 214. 2 .11 .Health disparity knowledge and support for intervention in Saskatoon . 225. 2 .12 .Summary of the research results . 238 1 3. Evidence Based Policy Options. .243 3 .1 . Evidence based policy options to reduce health or social disparity . 243. 3 .1a . What other jurisdictions are doing to reduce health or social disparity . 245 3 .1b . Income disparity . 254 3 .1c . Education disparity . 269 3 .1d . Housing disparity . 286. 3 .1e . Employment disparity . 301 3 .1f . Disparity in access to health services . 312 3 .1g . Disparity between cultural groups . 320 3 .2 . Health or social disparity progress to date in Saskatoon . 329 3 .3 . Summary . 331. 3 .4 . Summary of evidence based policy options . 333. 3 .5 . Limitations . 342. 3 .6 . National and international context . 343 3 .7 . References . 345 2 BACKGROUND AND CONTEXT A study conducted by the Saskatoon Health in preventing disease prevalence . As well, Region in 2006 compared the health status behaviours also had limited independent of residents within Saskatoon’s six lowest associations with health outcomes; mainly income neighbourhoods to the rest of the city because the prevalence of risk behaviours is and found substantial disparities in suicide often associated with income status (Sections attempts, mental disorders, injuries and 2 .6, 2 .7 and 2 .9) . The results from Saskatoon poisonings, diabetes, chronic obstructive are consistent with the results from other pulmonary disorder, coronary heart disease, jurisdictions in that the determinants of health chlamydia, gonorrhoea, hepatitis C, teen births, (and behaviours) fall mainly outside the health low birth weights, infant mortality and all cause care treatment sector. A new finding also mortality (Section 2 .3: Health Disparity by materialized through the more comprehensive Neighbourhood Income) . Although disparity research . Aboriginal cultural status was found in health outcomes by socioeconomic status to have a much more limited association is well known, the magnitude of the disparity (if any) with poor health outcomes or risk in health outcomes found in Saskatoon is behaviours after statistical adjustment for other shocking for a city in the western world . variables like income status . This suggests For example, the infant mortality rate in that the health status of Aboriginal residents in Saskatoon’s low income neighbourhoods was Saskatoon can be improved substantially with 448% higher than the rest of the city; which is appropriate social intervention . For example, worse than developing nations . the 2007 Saskatoon School Health Survey (Section 2 .8) found that Aboriginal children Upon completion of the research, over 200 between the ages of 10-15 were initially 181% community consultations were initiated more likely to suffer from depressed mood with various government representatives, than Caucasian children . However, after academics, community groups and community statistical adjustment for other variables like associations . The purpose of the consultations socioeconomic status, Aboriginal children were was to transfer knowledge of the vast disparity only 13% more likely to have an independent in health to the Saskatoon community and to association with depressed mood . Here is gather opinion on what needs to be done to another example . In the Saskatoon Health help alleviate this complex problem . As a result Region, the prevalence of lifetime suicide of these consultations, a number of regional ideation (thoughts) is 11 .9% . Reviewing by initiatives were implemented (Section 3 .2) . Income, 6 .1% of high income Caucasians and The initial Health Disparity by Neighbourhood 3 .8% of high income Aboriginal people had Income study led to more comprehensive lifetime suicide ideation (Section 2 .5) . research to examine the relationship between The rationale for the more comprehensive socioeconomic status and health status in research was to establish a finite number Saskatoon residents . These additional studies of determinants which were independently have demonstrated that income status often associated with health disparity in Saskatoon . has the strongest independent association Given the reality of limited human and financial with disparity in the prevalence of diseases or resources, it is important to ascertain the main disorders in Saskatoon residents (Sections 2 .4, determinants of health upon which a positive 2 .5 and 2 .8) . Utilization of physician or mental return on investment is likely . If the main health services had limited (if any) association 3 determinants of health responsible for health for children, such as poverty reduction . It is disparities are variables like income status important to note, however, that the evidence and educational status, a comprehensive based policy options in this report should be and coordinated set of policy options will be viewed in combination rather than in isolation . required to reduce extensive health disparity Some policy options are to address immediate in Saskatoon . needs, while others are long term strategies that address macro level social structures . In order to develop a comprehensive and For example, short term income and housing coordinated approach to reduce extensive stability measures are intended to provide the health disparity in Saskatoon, two additional necessary support and stability to low income actions were taken . First, 5000 residents from residents to allow longer term educational Saskatoon were contacted at random by and employment initiatives to have a realistic telephone to determine which health and chance of success . social disparity interventions they were willing to support (Section 2 .11) . Second, over