Prepared for EvidenceNetwork.ca by Carolyn Shimmin
More wealth, better health
Over three million Canadians struggle to make ends meet ― and what may surprise many, is the devastating impact level of income, education and occupation can have on our health. Research shows that the old adage, the “wealthier are healthier,” holds true, as the World Health Organization (WHO) has declared poverty as the single largest determinant of health.
Income and health exist on a gradient
Substantial and robust evidence confirms a direct link between socioeconomic status and health status ― meaning people in the lowest socioeconomic group carry the greatest burden of illness. Research demonstrates that there is a “social gradient” in health that runs from top to bottom of the socioeconomic spectrum. What this means is if you were to look at, for example, cardiovascular disease mortality rates according to income groups in Canada, mortality is highest among those in the poorest income group and, as income increases, mortality rate decreases.
But how precisely does this happen? According to WHO, social and economic conditions and their effects on people’s lives determine their risk of illness as well as the actions they are able to take in order to prevent themselves from becoming ill or treating illness when it does occur. We know that poverty can affect our health in a myriad of ways. Income provides the prerequisites for health ― including housing, food, clothing, education, safety and the ability to participate in society in a meaningful way. Low income limits an individual’s opportunity to achieve their full health potential because it limits choices. This is why, in order to capture the true multi-dimensional and dynamic nature of poverty, it is more accurately recognized as social and economic exclusion ― which encapsulates the importance social support networks play, the ability to make choices about one’s life and future, and to feel control over one’s situation, when it comes to our health.
A Two-way relationship
It is said that there is a profound two-way relationship between poverty and health. What this means is people with limited access to income are often more socially isolated, experience more stress, have poorer mental and physical health and fewer opportunities for early childhood development and post-secondary education. They also often have inadequate housing, more exposure to environmental pollution and are unable to access healthy foods. In the reverse, it has been found that chronic conditions, especially those that limit a person’s ability to maintain viable stable employment, can contribute to a downward spiral into poverty. This is especially true for Canadians living with severe mental health or addictions issues ― but also individuals who are living with physically debilitating conditions ― who often find that the Canadian patchwork quilt of social benefits, including various sorts of disability insurance, public-sector payments for people living with a disability and related pension payments do not, even in combination, provide an adequate living wage. Studies do show the predominant causal relationship is more frequently from poverty to poorer health.
The situation in Canada
According to Statistics Canada, 8.8% of the population experienced low income in 2011. More than half a million, or 571,000 children aged 17 and under, lived in low income and nearly a quarter of children who lived in single-mother families lived in poverty.
According to a recent report, 235,000 Canadians experienced homelessness in 2014. On any given night, 35,000 Canadians are homeless. Nearly one in five households experience housing affordability problems, which means they are spending more than 50% of their income on rent. Homelessness is calculated to cost the Canadian economy $7 billion annually (this includes not only the cost of emergency shelters, but social services, health care and corrections).
Food insecurity is the state of being without reliable access to a sufficient quantity of affordable, nutritious food. It is estimated that about 1.1 million households in Canada experience food insecurity. According to Food Banks Canada, 882,188 Canadians relied on food banks to provide their basic dietary requirements in the month of March 2012. The risk of food insecurity increases in single-parent households and families on social assistance.
Measuring poverty in Canada: What we know
The way in which we measure and conceptualize poverty has implications for the types, characteristics, and success of policies that are developed to reduce poverty and its effect on health. In Canada, there is no official measure of poverty. Statistics Canada does not define poverty nor does it estimate the number of families living in poverty in Canada. Instead, they publish statistics on the number of Canadians living in low-income, which is one key dimension of poverty.
Statistics Canada uses a number of low-income thresholds in order to capture a more complete picture of the low-income population including: the Low-Income Measurement (LIM); the Low Income Cut-Offs (LICOs); and Human Resources Development Canada’s Market Basket Measure (MBM). The LIM, which is the most commonly used measurement, is a fixed percentage (50%) of median adjusted household income. In this measurement, there are adjustments made dependent on the size of the household. The LICOs are income thresholds below which a family will likely have to devote more than 20% of their income (compared to the average family) on the necessities of food, shelter and clothing. The MBM is based on the cost of a specific basket of goods (e.g., food, clothing, footwear, transportation, shelter, etc.) for a reference family of two adults aged 25 to 49 and two children aged 9 and 13. Compared to the LICO and the LIM, the MBM is unique in that it provides thresholds for a finer geographic level allowing, for example, varying costs for rural areas in different provinces to be measured.
The three measurements used by Statistics Canada are based on a conceptualization of poverty as relative ― which means the lack of economic resources required for dignified participation in society. What this means is the LICO, LIM and MBM take into account not only what is necessary for physical well-being but also psychological and social well-being.
Another type of measurement used in Canada is the Basic Needs Measure which is based on a conceptualization of poverty as absolute ― meaning it only focuses on essentials for physical survival (like food, shelter and clothing). This measurement has been widely criticized by experts in the area of poverty and health as it does not take into account the average income of Canadians nor the average proportion of income that Canadians spend on needs. It is determined by calculating the total cost of items the individual who developed the measure, Christopher Sarlo, considers to be necessary for long-term physical well-being, and hence produces a dramatically lower income threshold.
Depending on which measurement is used, there can be quite large differences in low-income thresholds. Even when looking at the three measurements used by Statistics Canada, there are varying thresholds drawn. For example, according to the LICO, in 2011, 3 million Canadians, or 8.8% of the population lived in low income. Yet according to the MBM, in 2011, the low income rate in Canada stood at 12% ― 3.2 percentage points higher. When looking at children under the age of 18 living in low income, the difference between measures was even greater, with the MBM measurement yielding a rate of 13.7% ― some five percentage points more than the LICOs measure (8.5%).
Internationally, the Organisation for Economic Co-operation and Development (OECD) uses a similar threshold as the LICOs. Using this measure, 11.9% of Canadians experienced low-income conditions in 2010, a rate slightly higher than that of the average for all OECD member countries (11.1%). Among the G7 countries, Canada had the fourth highest rate of low income (the United States had the highest rate at 17.4%).
Also of note, following the federal government’s cancellation of the mandatory long-form census in favour of a voluntary national household survey, the methodology has changed in such a way that long-term comparisons of income trends has been made more difficult. Now as a voluntary survey, the National Household Survey is likely to under-represent those living in low income. Without census data as a comparison point it is difficult to determine the extent to which the statistics are biased. Therefore we cannot gauge the degree to which income inequality is shifting in Canada, along with who fell behind and who got ahead during the recession and the years following. This means that the one major tool that has been used to inform policy cannot be reliably used for comparisons over time anymore.
Does poverty cause poor health?
Incidence and mortality rates for several types of cancer, including lung, breast, colorectal and prostate cancer, are higher among Canadians with lower incomes. Evidence has shown that some of this is associated with higher rates of smoking and obesity, but recent research suggests that throughout the cancer-care journey, across the diagnosis and treatment pathways, from screening and early detection, to radiation therapy, surgery and enrolment in clinical trials, inequities exist in cancer outcomes and cancer care, and that lower income segments of the Canadian population are falling behind.
Heart disease and stroke are the second and third leading causes of death in Canada (following cancer). Though there has been a nearly 40 per cent decline in cardiovascular disease over the past decade in Canada ― said to be largely due to research advances in surgical procedures, drug therapies and prevention efforts ― when looking at cardiovascular disease mortality and the prevalence of risk factors according to income group, Canadians living in low income have higher rates of the disease than those of higher socioeconomic status. This is especially concerning as the inequity gap between highest and lowest income groups continues to widen in Canada.
Nearly two million Canadians live with diabetes ― a disease in which the body either cannot produce insulin or cannot properly use the insulin it produces leading to high levels of glucose in the blood which in turn can damage organs, blood vessels and nerves. Evidence shows that rates of diabetes are higher among low-income groups. Low socioeconomic status is associated with: higher rates of type 2 diabetes; more prevalent risk factors for type 2 diabetes; and higher levels of morbidity and mortality. In fact, the income gap in mortality has widened over the last decade among patients with diabetes in Canada. The trend is most pronounced among individuals under the age of 65, who do not have access to universal drug coverage.
When it comes to the treatment and care of people living with diabetes, poverty has been shown to be associated with problems concerning knowledge acquisition and medical compliance. Research demonstrates that individuals living in low income are more likely to be hospitalized for diabetes and are less likely to receive recommended diabetes care than individuals with higher incomes.
In Canada, mental illness is the second leading cause of disability and premature death. Research demonstrates that Canadians living in the lowest income group were three to four times more likely than those in the highest income group to report their mental health as fair to poor. A study found that people in lower-income groups had a greater risk of developing high levels of psychological distress over a 12-year period compared with those in higher-income groups. The higher levels of depressed mood and anxiety were associated with job strain, financial problems, marital and family discord, and unsafe housing.
Research evidence for children
More than one in seven children live in poverty ― this places Canada 15 out of 17 similar developed countries. Children who live in poverty are more likely to have low birth weights, asthma, type 2 diabetes, poorer oral health and suffer from malnutrition. Children in low-income households also have higher rates of death due to unintentional injuries than other children ― unintentional injuries are the leading cause of morbidity and disability in Canada.
Poverty in childhood is associated with a number of health conditions in adulthood. Children who grow up in poverty are, as adults, more likely to experience addictions, mental health difficulties, physical disabilities and premature death. Children who experience poverty are also more likely to live in poverty as adults.
Costs on the health care system
People living in poverty face more barriers to access and care. It has been found that Canadians experiencing low-income are more likely to report that they have not received needed health care in the past 12 months. Also, Canadians in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on the weekends, and 40% more likely to wait more than five days for a doctor’s appointment. Individuals in low income are also twice as likely as those in the highest income group to visit the emergency department for treatment.
Research shows that compliance with medical treatment also tends to be lower among individuals living in poverty which can lead to pain, missed appointments, increased use of family practice services and increased emergency department visits. Researchers have reported that Canadians in the lowest income groups are three times less likely to fill prescriptions and 60% less able to get needed tests because of cost.
Possible future directions
Experts have pointed to a myriad of approaches both in regards to practice and policy to tackle poverty and its impact on the health of Canadians. At the level of practice, some have suggested that health care professionals treat poverty the same as any other risk factor a patient may present with, providing resources and tools that may help health care consumers identify provincial, territorial and federal programs for which they might qualify.
On the policy level, the very complex nature of poverty denotes the need for policymakers in the health sector to work collaboratively with those in a broad range of both government and non-governmental agencies in order to develop innovative networks of social assistance, economic and employment policies that effectively reduce the number of Canadians who experience poverty. Some suggested ways in which to address health inequities include: creating a defined measurement for poverty and a methodology to measure inequities over time in Canada; a guaranteed annual income approach; a national food security program; a national affordable housing program; and investment in early childhood education.
Experts available for interview
Our commentaries on poverty
The Canadian doctor who prescribes income to treat poverty
Child poverty a Canadian problem // La pauvreté infantile, un problème canadien
Why our governments need to address poverty now // Pourquoi nos gouvernements doivent s’attaquer dès maintenant à la pauvreté
Elimination of poverty requires more than a growing economy — it requires a dedicated plan
Poverty costs Canada billions of dollars every year
This doctor treats poverty like a disease
Another kind of poverty // Une autre sorte de pauvreté
Poverty linked to multiple health problems in new mothers // Étude sur les liens entre pauvreté et problèmes de santé multiples chez les nouvelles mères
Our videos on poverty
Why Canadian doctors should be on the front lines of the anti-poverty struggle
Ending Homelessness in Canada is Possible
Our infographic on poverty
For more information, see also:
Listen to our podcast with Dr Danielle Martin and Evelyn Forget:
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