1. Canadian Public Health Association 2008 Annual Conference Halifax, Nova Scotia, May 31 – June 4, 2008 Does Province of Residence Matter to the Health and Wellness of Canadians in the Lowest Income Category? Raymond Fang, John Millar & Lydia Drasic Public & Population Health BC Provincial Health Services Authority

2. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 2 It is well known that socioeconomic status (SES) is a strong predictor of health. Better health is associated with having more income, more years of education, and a more prestigious job, living neighborhoods with residents at higher education and income levels and a healthier lifestyle as modifiable determinants. Within the low income populations, however, does the province of residence matter to people’s health? The objective of this study was to examine the geographic inequalities in health within the low income Canadian populations. Study Objective

3. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 3 █ Data: Population from 10 provinces in the lowest income quintile (1/5th population) and aged 45 and over according to the national household income distribution derived by income, size of household and community size based on the Canadian Community Health Survey 2005 Share Data. Data and Method █ Method: Adjusting for covariates such as age, gender, education level and immigration status, multivariate logistic regression was used to calculate odds ratios ( e.g. OR=1.5 indicates the event is 50% more likely to happen than the baseline ) for comparing provinces/regions on the risks of chronic diseases and poor self-perceived health.

4. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 4 Background 1: Risk of Chronic Diseases Associates with Income - The socioeconomic dimension (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people aged 45 and over. Five income quintiles cover 20% of population each based on household income, number of household members and community size. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.)

5. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 5 Life Expectancy at Birth (LE) MaleFemale Newfoundland & Labrador 77.0 (3) 82.1 (4) Prince Edward Island 75.6 (10) 80.8 (10) Nova Scotia 76.3 (6) 81.5 (9) New Brunswick 76.1 (8) 81.9 (7) Quebec 76.5 (5) 82.0 (6) Ontario 77.5 (2) 82.1 (4) Manitoba 75.7 (9) 81.6 (8) Saskatchewan 76.3 (6) 82.2 (3) Alberta 77.0 (3) 82.3 (2) British Columbia 78.0 (1) 82.9 (1) Canada 77.082.1 (Data source: Statistics Canada) Background 2: Where to live if you want to live longer? - The geographic dimension

6. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 6 Odds Ratios DiabetesHeart DiseaseArthritis Newfoundland & Labrador 1.421.081.35 Prince Edward Islands 1.221.451.42 Nova Scotia 1.321.521.34 New Brunswick 1.211.391.21 Atlantic Region1.331.411.30 Quebec1.061.010.67 Ontario1.041.131.28 Manitoba 0.790.700.79 Saskatchewan 0.960.780.96 Alberta 0.890.860.89 Prairie Region0.870.781.05 BC0.810.790.91 Background (continued) Where to live if you want to lower your risk of chronic diseases? (population from all income categories) █ Worse (at 0.05 level) █ Worse (at 0.10 level) █ Better (at 0.05 level) █ Better (at 0.10 level) █ Not Significant (at 0.10 level) (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people in the lowest income quintile aged 45 and over. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.. Only elevated odds ratios were listed)

7. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 7 What about Our Low-Income Population? Socioeconomic dimension Geographic dimension Do they have the same health status? Are they being cared equally across the country? Are there differences in their lifestyle across provinces?

8. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 8 Each Province/Region versus Other Provinces/Regions

9. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 9 2.84 0.470.55 0.81Prairie Region 1.381.401.181.431.66Atlantic Region 1.451.371.301.371.211.45Ontario 1.500.80BC Alberta 1.290.74 Saskatchewan 0.690.700.80 Manitoba 0.540.600.800.52Quebec 1.55 1.31 New Brunswick 1.441.351.261.472.30 Nova Scotia 0.501.841.91 Prince Edward Islands 1.311.291.271.42 Newfoundland & Labrador Self-Perceived mental health as poor Self- Perceived health as poor Mood DisorderArthritisCancerHeartDiabetesHypertension Chronic Condition Odds Ratios Comparasons with the other provinces in the lowest income quintile nationally █ Significantly worse (at 0.05 level) █ Significantly worse (at 0.10 level) █ Significantly better (at 0.05 level) █ Significantly better (at 0.10 level) (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people in the lowest income quintile aged 45 and over. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.) 1.80 1.22

10. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 10 Compared with British Columbia – the overall healthiest province

11. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 11 Odds Ratios Chronic ConditionHypertensionDiabetesHeartCancerArthritis Mood Disorder SP-health as poor SP-mental health as/poor Newfoundland & Labrador 1.741.361.41 Prince Edward Islands 1.760.33 Nova Scotia 1.891.791.371.360.58 New Brunswick 1.611.682.39 Atlantic Region1.691.251.471.270.65 Quebec0.571.200.690.430.52 Ontario1.251.230.52 Manitoba 0.540.57 Saskatchewan 0.52 Alberta 1.26 Prairie Region0.73 BCBaseline (1.00) Comparasons with BC in the Lowest Income Quintile █ Significantly worse (at 0.05 level) █ Significantly worse (at 0.10 level) █ Significantly better (at 0.05 level) █ Significantly better (at 0.10 level) (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people in the lowest income quintile aged 45 and over. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.)

12. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 12 Compared with Quebec – the healthiest province for low-income population

13. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 13 Odds Ratios Chronic ConditionHypertensionDiabetesHeartCancerArthritis Mood Disorder SP-health as poor SP-mental health as/poor Newfoundland & Labrador 1.981.451.351.801.741.98 Prince Edward Islands 2.782.54 Nova Scotia 3.291.501.321.531.971.69 New Brunswick 1.821.341.621.641.581.854.61 Atlantic Region2.311.411.231.421.271.841.501.802.83 QuebecBaseline (1.00) Ontario2.011.221.241.781.931.962.27 Manitoba 0.751.53 Saskatchewan 1.481.431.67 Alberta 2.011.532.071.70 Prairie Region1.631.211.511.681.54 BC1.740.831.442.321.93 Comparasons with Quebec in the Lowest Income Quintile █ Significantly worse (at 0.05 level) █ Significantly worse (at 0.10 level) █ Significantly better (at 0.05 level) █ Significantly better (at 0.10 level) (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people in the lowest income quintile aged 45 and over. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.)

14. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 14 Each Province or Region in the Second Lowest Income Quintile versus The Lowest Income Quintile – Quebec

15. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 15 Odds Ratios Chronic ConditionHypertensionDiabetesHeartCancerArthritis Mood Disorder Newfoundland & Labrador 1.511.47 Prince Edward Islands 1.561.37 Nova Scotia 2.001.791.59 New Brunswick 1.331.41 Atlantic Region QuebecBaseline (1.00) Ontario1.631.511.43 Manitoba Saskatchewan 1.541.46 Alberta 1.321.67 Prairie Region BC1.381.591.32 Elevated Risk in the 2 nd Lowest Income Quintiles of Other Provinces vs that in the Lowest Income Quintile in Quebec █ Significantly worse (at 0.05 level) █ Significantly worse (at 0.10 level) █ Significantly better (at 0.05 level) █ Significantly better (at 0.10 level) (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people in the lowest income quintile aged 45 and over. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.. Only elevated odds ratios were listed)

16. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 16 A Snapshot of Lifestyle Determinants of Health in the Lowest Income Quintile across Regions in Canada (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people aged 45 and over. Five income quintiles cover 20% of population each based on household income, number of household members and community size.)

17. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 17 Distribution and Characteristics of Populations Aged 45 and Over within National Lowest Income Quintile (Data source: Statistics Canada Canadian Community Health Survey Cycle 3.1 (2005); Study population consist of people aged 45 and over. Five income quintiles cover 20% of population each based on household income, number of household members and community size. Odds ratios were obtained from multivariate logistic regression models adjusting for age, sex, education and immigration status.)

18. Does Province of Residence Matter to the Health of Canadians in the Lowest Income Category? Canadian Public Health Association 2008 Annual Conference, Halifax, Nova Scotia, May 31 – June 4, 2008 18 █ Conclusions: We studied Canadian populations aged 45 and over from the lowest income quintile and identified the province of residence does matter to the health and wellness of Canadians in this income group. Health and wellness were determined not only by the level of income but also by the province to live. █ Results: Low income people in Quebec enjoyed the lowest rates of chronic disease and were least likely to feel their health conditions as poor. Provinces in Atlantic Region and Ontario were worse in most if not all chronic health conditions. Manitoba and Saskatchewan had lower chance of heart disease and diabetes, respectively. BC was better in hypertension but worse in mood disorder. No significant difference was found between Alberta and other provinces. Results and Future Work █ Future Work: Our results emphasize the importance of understanding the role of places on health for reducing the geographic inequities in health. Further analysis will be performed in this area to model health inequities in at neighbourhood level with more sophisticated data on social policy, environment and nwighbourhood economic level from the new Census data.