P R E S E N T E R T O O L – R E V I S E D FA L L 2 0 1 3

INCOME AND SOCIAL STATUS

OUTLINE

• Objectives• Ted Talk• Definitions of income and social status• Income and social status as a social determinant

of health• Global and local impact of income and social

status• Poverty and primary care• Activities/Discussion

OBJECTIVES

• Be able to define income and social status

• Be able to name the millennium development goal that relates to income and social status

• Be able to provide 3 pieces of evidence that income and social status affect health

• Be able to explain to colleagues why an understanding of income and social status is necessary to provide good primary care to patients

TED TALK

Richard Wilkinson – How economic inequality harms societies (16:55)

• We feel instinctively that societies with huge income gaps are somehow going wrong. Richard Wilkinson charts the hard data on economic inequality, and shows what gets worse when rich and poor are too far apart: real effects on health, lifespan, even such basic values as trust.

• In "The Spirit Level," Richard Wilkinson charts data that proves societies that are more equal are healthier, happier societies

IN THIS TED TALK FOCUS ON:• What health and social problems are affected by income?

(life expectancy, infant mortality, math and literacy, homicides, imprisonment, teenage births, trust, obesity, mental illness, social

mobility, social capital/involvement in community life)

• How to countries try to ensure better equality?

(difference in earnings narrowed through taxation vs.. more equal earnings across the board)

• What social groups benefit from better equality in society?

(benefits extend across all social classes)

GROUP REVIEW AFTER TED TALK….• What health and social problems are affected by income?

(life expectancy, infant mortality, math and literacy, homicides, imprisonment, teenage births, trust, obesity, mental illness, social

mobility, social capital/involvement in community life)

• How to countries try to ensure better equality?

(difference in earnings narrowed through taxation vs.. more equal earnings across the board)

• What social groups benefit from better equality in society?

(benefits extend across all social classes)

DISCUSSION

• How can we define income?

• What is social status?

DEFINITIONS

• Income: Financial or material resources

DEFINITIONS

• Social status: The social and economic positions of individuals or groups within society

INCOME AND SOCIAL STATUS AS A SDOH

• Income provides the prerequisites for health...

Shelter Food Warmth

SOCIO-ECONOMIC CONDITION AS A SDOH

SOCIO-ECONOMIC CONDITION AS A SDOH

Income provides the prerequisites for health…

Shelter Food Warmth

Low income and poverty can…

• Cause stress & anxiety• Limit your choices• Influence behaviors

IMPACT OF SES ON HEALTH

• Low Socioeconomic Status = difficulty accessing health care + poorest health outcomes

• Health status improves at each step up the income and social hierarchy

• High income determines living conditions such as safe housing and ability to buy sufficient good food

• The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth

INCOME AND SOCIAL STATUS AS A SDOH

“It is one of the greatest of contemporary social

injustices that people who live in the most disadvantaged circumstances have more

illnesses, more disability and shorter lives than those who are more affluent”

(Benzeval, Judge, & Whitehead, 1995, p.1)

INCOME AND SOCIAL STATUS AS A SDOH

“Poverty can affect health in a number of ways. Income provides the prerequisites for health,

such as shelter, food, warmth, and the ability to participate in society; living in poverty can cause stress and anxiety which can damage people’s health; and low income limits peoples’ choices

and militates against desirable changes in behaviour.”

(Benzeval, Judge, & Whitehead, 1995,p.xxi)

DISCUSSION

• Is is true that income impacts the health outcomes of your patients?

• Do your patients in the lowest economic bracket experience good health?

GLOBAL & LOCAL CONTEXT

SDOH – GLOBAL (MDG)

Millennium Development Goal 1: Eradicate extreme poverty and hunger

http://www.jm.undp.org/files/u80/jpeg%20FILES%20MDG/MDG1.JPG

LOCAL CONTEXT

• It has been known for many decades that the profound improvements in health in Canada and other industrialized countries have been primarily due to the kind of societies in which we live, rather than advances in medicine or health care

• Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence.

• At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health.

LOCAL CONTEXTPoverty acts like a disease…

Just like high blood pressure, diabetes, cholesterol:

• Puts sufferers at risk of high morbidity and mortality through various pathways (increased risk of CVD, diabetes, depression, cancer)

• No other cause accounts for all the elevated risk• At extremes it can cause direct harm• Groups that move out of poverty experience a decrease in disease• Children who have lived in poverty have increased health risks as

adults• The finding is consistent across time, geography, and different

populations

LOCAL CONTEXT

• Only 47% of Canadians in the lowest income bracket rate their health as very good or excellent, compared with 73% of Canadians in the highest income group

• Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence

• At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health

LOCAL CONTEXT

• Studies suggest that the distribution of income in a given society may be a more important determinant of health than the total amount of income earned by society members. Large gaps in income distribution lead to increases in social problems and poorer health among the population as a whole

LOCAL CONTEXT

There is strong and growing evidence that higher social and economic status is associated with

better health. In fact, these two factors seem to be the most important determinants of health.”

Public Health Agency of Canada (2004)

POVERTY AND PRIMARY CARE

WHY SHOULD FAMILY DOCTORS CARE?

• As family doctors we deal with preventative care...In fact, Income is now a part of the Preventative Health Care Checklist Forms that we use in family medicine

• Knowing that income and social status have such a profound effect on health therefore matters in our everyday work

• Advocating for our patients and finding ways to help them overcome income and social barriers is key to good health

• Recognizing the additional health risks of patients living in poverty is crucial in our everyday work

PRIMARY CARE

• How do differences in income, “where we are in relation to one another” matter for primary care?

POVERTY AND HEALTH

Income: Increasing poverty is seen to go hand-in-hand with increasing income inequality

Poverty directly harms the health of those with low incomes while income inequality affects the health of all

http://www.povertyandhumanrights.org/docs/incomeHealth.pdf

POVERTY, INEQUALITY AND HEALTH

• No examination of the health effects of poverty can ignore the relationship between economic inequality and poverty

• Societies that are economically unequal have higher levels of poverty

http://www.povertyandhumanrights.org/docs/incomeHealth.pdf

SOCIO-ECONOMIC STATUS AND HEALTH

• Those with very low socioeconomic status have the most difficulty accessing health care and usually experience the poorest health outcomes

• Those of higher socioeconomic status experience ready access to health care and increased opportunities for engaging in health-promoting behaviours and therefore have better health outcomes

• Is this true for your patients? Do your patients in the lowest economic bracket experience good health?

http://cbpp-pcpe.phac-aspc.gc.ca/topic/determinants/5/page/1mes

CANMEDS ROLES: HEALTH ADVOCATE

QUESTION

• What is the low income cut-off for a family of four in Toronto before tax?

POVERTY IN CANADA

• Income is now a part of the Preventative Health Care Checklist Forms that we use in family medicine

• What is the low income cut-off for a family of four in Toronto before tax? ($41,198)

• Cut-offs change depending on where you live (rural vs. urban, population size)

Gary Bloch MD CCFPSt. Michael’s Hospital DFCM

Assistant Professor, DFCM, UofT

ARGUMENTS FOR ADDRESSING POVERTY IN PRIMARY CARE

• Argument 1: This is required by the fundamentals of family medicine (health advocate, communicator, resource to a defined community)

• Argument 2: Poverty is a major risk factor for disease so requires intervention

• Argument 3: Poverty is a disease and warrants treatment like any other

Gary Bloch MD CCFPSt. Michael’s Hospital DFCM

Assistant Professor, DFCM, UofT

HOW CAN FAMILY DOCTORS INTERVENE AND ADVOCATE FOR THEIR PATIENTS WITH LOW

INCOMES?

Gary Bloch’s Poverty Tool – delineates ways to advocate for patients

PREVENTATIVE CARE CHECKLIST

ACTIVITY• Imagine you are a single person on Ontario Works. Your receive

$592 per month. Write down your usual monthly expenses excluding rent. Calculate how much money you would have left for rent once you had taken care of all other expenses in a given month.

• What kind of monthly income is needed in Toronto for someone to meet their basic needs (food, shelter, electricity, transport)?

• What is the minimum amount you could live on per month with your current rent/mortgage?

• What months are most expensive in Toronto?

ACTIVITY - DEBATE

“Doctors to Governments: Tax us. Canada is worth it!”

Doctors For Fair Taxation

http://www.youtube.com/watch?v=o_GsqskLvaw

Debate: Be it resolved that doctors as health advocates,

should pay higher taxes

ACTIVITYDivide into groups of 4

Brainstorm ways in which Canadian family doctors can advocate to enhance equality:

a) On behalf of their patients?

• (disability forms – WSIB/ ODSP/CPP, welfare supplements – transport/medical supplies/special diet, tax forms-child benefits, old age security and guaranteed income supplement, disability benefits, social worker referral)

b) On behalf of society?

• (fair taxation, advocate for public services and systems, advocate for income equality, ensure employees have benefits)

ACTION PLAN

• After today’s workshop, make a list of tangible action plans to implement in your respective practices.