1. Socioeconomic Inequalities in Health Among Canadian Women with Heart Disease Arlene S. Bierman, M.D., M.S Ontario Womens Health Council Chair in Womens Health St. Michaels Hospital, University of Toronto Academy Health Annual Meeting June 25, 2006

2. Gender and Socioeconomic Inequalities in Health and Heart Disease Cardiovascular disease is a leading cause of morbidity and mortality among Canadian women Cardiovascular disease is a leading cause of morbidity and mortality among Canadian women Socioeconomic and gender inequalities in health and functional status have been well documented in Canada Socioeconomic and gender inequalities in health and functional status have been well documented in Canada Differences in access, quality of care, health behaviors, and the social determinants of health have all been associated with socioeconomic inequalities among individuals with heart disease. Differences in access, quality of care, health behaviors, and the social determinants of health have all been associated with socioeconomic inequalities among individuals with heart disease. However, little is known about the extent to which these factors contribute to the observed socioeconomic gradients in health status. However, little is known about the extent to which these factors contribute to the observed socioeconomic gradients in health status.

3. Objectives Examine the determinants of socioeconomic inequalities in health among women in a system of universal health insurance coverage. Examine the determinants of socioeconomic inequalities in health among women in a system of universal health insurance coverage. Specifically assess the contribution of sociodemographic factors (income, education, language), health behaviors (physical activity, smoking), access to care (unmet need, regular physician), and psychosocial factors (depression, stress, food insecurity, and sense of community belonging) to these inequalities. Specifically assess the contribution of sociodemographic factors (income, education, language), health behaviors (physical activity, smoking), access to care (unmet need, regular physician), and psychosocial factors (depression, stress, food insecurity, and sense of community belonging) to these inequalities.

4. Data Source and Study Population Cycle 1.1 Canadian Community Health Survey- 2000/2001 Cycle 1.1 Canadian Community Health Survey- 2000/2001 Nationally representative sample covering 98% of population with a response rate of 84.7% (N-130,000) Nationally representative sample covering 98% of population with a response rate of 84.7% (N-130,000) Study sample includes 7825 individuals age 25 and older reporting heart disease diagnosed by a physician (women n=4024, men n=3801) representative of 1.3 million individuals. Study sample includes 7825 individuals age 25 and older reporting heart disease diagnosed by a physician (women n=4024, men n=3801) representative of 1.3 million individuals.

5. Measures Health status: global health, health utility index, activity restrictions, comorbidity Health status: global health, health utility index, activity restrictions, comorbidity Sociodemographic characteristics: age, income, education, language Sociodemographic characteristics: age, income, education, language Health behaviors: physical inactivity, smoking Health behaviors: physical inactivity, smoking Health access: regular physician, self perceived unmet health care need Health access: regular physician, self perceived unmet health care need Psychosocial factors: depression, stress, food insecurity, sense of belonging to the community Psychosocial factors: depression, stress, food insecurity, sense of belonging to the community

6. Population Characteristics Income and Education

7. Fair or Poor Health among Canadian Men and Women by Income* Percent (%) *Adjusted for age CCHS - Cycle 1.1

8. Prevalence of Poor Health (HUI 0.80) among Canadian Men and Women with Heart Disease by Income* *Adjusted for age CCHS - Cycle 1.1 Percent (%)

9. Prevalence of 4 or More Chronic Conditions among Men and Women Older by Income* *Adjusted for age CCHS - Cycle 1.1 Percentage (%)

10. Prevalence of Feeling Very Stressed among Canadian Men and Women with Heart Disease by Income* Percent (%) *Adjusted for age CCHS - Cycle 1.1

11. Reported Unmet Health Care Needs of Men and Women with Heart Disease Age 25 and Older by Income* Percentage (%) *Adjusted for age CCHS - Cycle 1.1

12. Food Insecurity among Canadian Men and Women With Heart Disease by Income* Percent (%) *Adjusted for age CCHS - Cycle 1.1

13. Age Adjusted Odds of Fair or Poor Health Among Canadian Women with Heart Disease

14. Correlates of Fair or Poor Health Adjusted for age

15. Comorbidity

16. Conclusions Within a system of universal health care there are sizable gender and socioeconomic inequities in health and functional status among individuals with heart disease. Within a system of universal health care there are sizable gender and socioeconomic inequities in health and functional status among individuals with heart disease. Women with heart disease are more likely to be poor than men with heart disease and poor women with heart disease are much more likely to report fair or poor health and higher levels of comorbidity. Women with heart disease are more likely to be poor than men with heart disease and poor women with heart disease are much more likely to report fair or poor health and higher levels of comorbidity.

17. Conclusions Among women with heart disease sociodemographic factors (income, education, language), health behavior (physical activity), access to care (unmet need), and psychosocial factors (depression, stress, and sense of community belonging) are all independently associated with poor health. Among women with heart disease sociodemographic factors (income, education, language), health behavior (physical activity), access to care (unmet need), and psychosocial factors (depression, stress, and sense of community belonging) are all independently associated with poor health. The relationship between income and health status is partially explained by these factors and further mediated by comorbid chronic illness. However, poverty remains independently associated with poor health after controlling for all of these factors. The relationship between income and health status is partially explained by these factors and further mediated by comorbid chronic illness. However, poverty remains independently associated with poor health after controlling for all of these factors.

18. Limitations The study is cross sectional and based upon self report. The study is cross sectional and based upon self report. We did not assess the association provincial differences to health status. We did not assess the association provincial differences to health status. Did not have information on process or quality of care. Did not have information on process or quality of care.

19. Implications Addressing socioeconomic inequalities in health among women with heart disease is likely to require a multifaceted approach that addresses health system factors, risk factor reduction as well as the social determinants of health. Addressing socioeconomic inequalities in health among women with heart disease is likely to require a multifaceted approach that addresses health system factors, risk factor reduction as well as the social determinants of health. Improving the health and functional status for low income women with heart disease will require the development and evaluation of interventions aimed at targeting these factors. Improving the health and functional status for low income women with heart disease will require the development and evaluation of interventions aimed at targeting these factors.