Comparing social determinants of self-rated health across the United States and Canada

https://doi.org/10.1016/j.socscimed.2011.04.010Get rights and content

Abstract

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research—Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ—gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries—the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.

Highlights

► Study compares social determinants of health across Canada and the U.S. ► Size of effects of social determinants on health differs across the countries. ► Gender, race, nativity, education, BMI, life satisfaction have larger effects in U.S. ► Age, marital status, income, unmet health care needs have larger effects in Canada. ► Results reflect differences in social context, welfare policies of the countries.

Introduction

As wealthy developed nations, Canada and the United States share many similarities in history, culture, and living standards and styles. The two countries also differ in other important ways, namely in the funding, organization, and delivery of health care and other social welfare programs, distribution of income, and social inequities, which likely have implication for health determinants within and between the two countries (Evans and Roos, 1999, Navarro et al., 2006, Siddiqi and Hertzman, 2007, Siddiqi and Nguyen, 2010). It is within this context that this study examines the effects of social determinants of health across Canada and the United States.

Section snippets

Background

Social, demographic, economic, and behavioural risk factors play an integral part in shaping the health of Canadians and Americans alike. Collectively these factors are known as ‘social determinants of health.’ Social determinants do not exist in isolation from each other, but combine to determine the health of individuals, communities, and populations (Berkman and Kawachi, 2000, Kawachi and Kennedy, 2002, Link and Phelan, 1995, Link and Phelan, 1996, Marmot and Wilkinson, 2005, Phelan and

Data

U.S.-Canada comparative research on health outcomes has often encountered problems because of the lack of comparable data and/or sample design. The Joint Canada/United States Survey of Health (JCUSH) was conducted by Statistics Canada and the National Center for Health Statistics between November 2002 and June 2003 to overcome these problems. Given the use of a single survey and a standard methodology across countries, the JCUSH provides a unique opportunity to directly compare social

Bivariate results

Table 2 reports rates of self-rated health by each variable within each country. The columns labelled “CND” and “US” show associations between each variable and self-rated health within Canada and the United States respectively. The results in both countries are generally consistent with the social determinants of health model, where the associations between sociodemographic, socioeconomic, and risk and health care access factors and self-rated health are significant and in the predicted

Discussion

Cross-country comparisons provide a unique opportunity to examine how differences in the social context of countries shape social determinants of health. No research to date has explicitly assessed and compared a social determinants of health model across Canada and the U.S. To fill this gap in the research literature, the current study examined the effects of social determinant variables, as illustrated in Fig. 1, within and between the two populations using data from the Joint Canada/United

Acknowledgement

The author wishes to thank the anonymous reviewers for their constructive and helpful comments on earlier drafts of this paper. Financial support from the SEDAP (Social and Economic Dimensions of an Ageing Population) Research Program, which is funded by the Social Sciences and Humanities Research Council of Canada (SSHRC) through Grant No. 412-98-0008, is gratefully acknowledged.

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