RESEARCH PAPER

Income inequality and health status: a nursing issue

AUTHORS

Abstract

Peter Massey
RN, Grad Cert PH
Clinical Associate College of Nursing, Clinical Nurse
Consultant, Program Manager Health Protection,
Hunter New England Area Health Service, Population
Health, Tamworth, NSW, Australia.
[email protected]

Objective
To review the association between income inequality
and health status, and consider an appropriate nursing
response.

David Durrheim
BM, BS, Dip Tropical Medicine and Hygiene, Dip
Community Health, Masters Public Health and Tropical
Medicine, DrPubHlth
Fellow Australasian College of Tropical Medicine,
Fellow Faculty Travel Medicine, Fellow Australasian
Faculty Public Health Medicine, Service Director Health
Protection, Hunter New England Area Health Service,
Population Health, Newcastle, NSW, Australia.

Key Words
socioeconomic, nursing, population health, inequality

Primary Argument
Nursing has a rich heritage of advocating for a healthy
society established on a foundation of social justice.
The future legitimacy and success of public health
nursing depends on recognising and appropriately
addressing the social, economic and political
determinants of health in the populations served.
There is an incontrovertible association between
population health status, absolute income levels
and income inequality. Thus, along with other social
determinants of health, income differentials within
populations must be a fundamental consideration
when planning and delivering nursing services.
Ensuring that federal and state health policy explicitly
addresses this key issue remains an important
challenge for the nursing profession, the public health
system and the Australian community.
Conclusions
Higher mortality and worse health status occur
in societies with higher income inequality. The
relationship between income inequality and health
appears to be determined both by relative access to
resources for health gain and relative social position.
The association between greater income equality
and improved health may be explained by improved
social cohesion. As social factors are at the root of
much of health inequality, this knowledge needs to
invoke political action and advocacy from the nursing
profession to promote the development of healthy
public policy.
Including indicators of income inequality when
planning and monitoring nursing services will enable
services to measure to what extent they are based on
the principle of social justice.

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Introduction
Nursing has a rich heritage of nurses serving as
advocates for a healthy society based on the principle
of social justice (Drevdahl et al 2001). The role of
public health nursing in many countries, including
Australia, is varied but the focus on the populations
health is central to its role (WHO 2001). This role
includes action in the areas of preventative health
services and public policy. The future legitimacy
and success of public health nursing depends on
recognising and appropriately addressing the social,
economic and political determinants of health in the
populations served. Most notably, the relationship
between income and population health status should
not be neglected.
The link between population health status and
socioeconomic status has long been recognised.
Many diseases are more common and life expectancy
is shorter at the lower rungs of the social ladder in
each society (WHO 2003).
The World Health Organisation (2003) describes
the main social determinants of health as: social
exclusion; the social gradient; stress; a good start in
life; employment; social support; addiction; nutrition;
and healthy transport. Social exclusion is inextricably
linked with income inequality. In this paper, this
association is reviewed, and the contributions
of relative social position and community social
cohesion considered. The implications for the
planning and delivery of equitable nursing services
are discussed.
Mortality, health status and income inequality

The association between socioeconomic status

and mortality rates has been established for many
years and validated in many countries (WHO 2003),
including Australia, where McMichael (1985) found
that male mortality rates in the 1970s had an inverse
relationship with social class. In New Zealand, males
aged 1564 years in the lowest socioeconomic group
had a mortality rate 3.5 times higher than those
in the highest socioeconomic group during the
1970s and 1980s (Marshall et al 1993). Scotland
had higher mortality rates than England and Wales
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in 19801982, with greater Scottish deprivation

identified as the key determinant of this difference
(Carstairs and Morris, 1989).
The Population Health Forum, a group of academics
and other people who work to build a healthier society,
argue that the greatest health hazard is the economic
gap between the rich and the poor (Population Health
Forum 2007). More than a decade ago reports
indicated that income inequality rather than absolute
income was the most important factor underlying the
profound and increasing mortality differentials in
Scotland (McLoone and Boddy 1994), the USA and
Britain (DaveySmith and Egger 1993).
The effect of income inequality on population health
status continues to be described. Recently, manual
workers were found to be at a higher risk of death
than nonmanual workers when they live in areas with
higher income inequality within Sweden (Henriksson
et al 2007). Poverty and income inequality correlated
with teenage pregnancy rates (Crosby and Holtgrave
2006). The risk of suicide in young adults has also
been associated with income inequality (Miller et
al 2005). In an ecological study of 21 developed
countries, Pickett et al (2005) found that obesity,
calorie consumption and diabetes mortality were
associated with income inequality. The effects of
income inequality were also seen at a young age, with
11 year old children in countries with high income
inequality reporting more episodes of drunkenness
than the same age group in countries with low income
inequality (Elgar et al 2005).
Even in Italy, a country where health care and
education are universally available and a strong
social safety net exists, income inequality had
an independent and more powerful effect on life
expectancy at birth than did individual income and
educational attainment (De Vogli et al 2005).
In an analysis of combined Canadian and USA data,
Ross et al (2000) found that income inequality was
a significant explanatory variable of mortality, with
a 1% increase in the share of income to the poorer
half of working agegroup households modelled to
reduce mortality by nearly 21 deaths per 100,000
per year.

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Although some commentators still question the

relationship between income inequality and
population health, a recent authoritative review of
the evidence (Wilkinson and Pickett 2006), including
168 analyses in published 155 reports, found that
a large majority (70 per cent) of these analyses
conclude that poorer health was experienced in
societies where income differences were bigger.
According to Wilkinson and Pickett (2006) many of the
studies that showed no association were measuring
inequality in small populations with a limited range
of social class differences and thus were unable to
show the association.
In a review of the social determinants of health, the
World Health Organisation (2003) concluded that
relative poverty, as well as absolute poverty and
social exclusion, had major impacts on health. The
distribution of income and inequality of its distribution
is the main factor defining relative poverty. Relative
poverty denies people access to housing, education,
transport and other societal benefits. Being treated
as less than equal and being excluded from society
can lead to poorer health experience (WHO 2003).
How income inequality results in poorer health
is not fully understood. Explanations include the
effect that income inequality has on negative
emotions and stress behaviours, an innate dislike
of inequality (Godoy et al 2006), the influence of
invidious social comparisons, and a reduction of
social capital (Zimmerman and Bell 2006). The level
of environmental disorder and quality of the built
environment are also important factors and primarily
explained the effect of income inequality on overdose
deaths in New York City (Nandi et al 2006). In a study
by Siahpush et al (2006) the psychological effects
of income inequality in Melbourne, Australia, were
clearly demonstrated, with smoking being associated
with a higher level of perceived income inequality,
lower perception of relative material wellbeing and
living in a community with a lower degree of trust
and safety.
The greater the length of time that people live in
disadvantaged circumstances, the more likely their
health will be worse (WHO 2003). It appears that
this effect is cumulative over an individuals lifespan,
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with childhood and adult social and economic

conditions combining to determine health experience
(Langenberg 2005). Thus the disconcerting trend of
increasing income inequality in many countries does
not bode well for future health equality (Shaw et al
2005). Wilkinson (1997a) considers that the
processes of social stratification explain the link
between income inequality and health, a relationship
that is further clarified by an understanding of the
role of social cohesion (Wilkinson 1997b). Labonte
(1999) describes social cohesion as the palpable
and powerful gluey stuff that binds individuals to
groups, groups to organisations, citizens to societies.
Wilkinson (2002, 1997b) argues that social cohesion
and health deteriorate simultaneously with increasing
income inequality. Income equalitys link with better
health has been directly attributed to greater social
cohesion (Wilkinson 1997a).
The Nursing Perspective

This important link between income inequality,

social disadvantage and poor health status deserves
careful consideration and action by the 21st century
nursing profession.
It is well recognised that health systems are not
conventionally organised to deliver more or better
health services to people at the bottom of the
class structure, but if this is addressed, marked
improvements in health status are possible. This call
for justice is supported by evidence that health risks
are reduced by favourable changes in organisational
justice (Kivimaki et al 2004). Drevdahl et al (2001)
suggest that nursing practice must apply justice as
a key principle to resolve the tension between the
health of individuals and the health of populations.
It is easy to focus on the health of individuals and
neglect the socioeconomic struggles at population
level. Improved access and quality of schooling,
health care, social welfare and working conditions
were identified by Lynch et al (2000) as the principal
areas where strategic investments would improve
population health. Nursing has a central role in
advocating for these investments.
As social factors are at the root of much of health
inequality, health status is of concern to policy makers
in every sector, not solely those in the public health

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sector and this concern needs to invoke political

action (Baum 2005, Marmot 2005).
The WHO (2003) has argued that developments in
the policy areas of wages and salaries, protection
from discrimination and social exclusion, removal
of barriers to health care services and reductions
in social stratification are required. Advocacy by
nurses individually and as professional collectives
for government policy to address these issues
could result in important changes to reduce
income inequality and improve the health of the
population.

profession to promote the development of healthy

public policy. A measure of income inequality should
be used when planning and monitoring nursing
services.

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Conclusions
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in societies with higher income inequality. The
relationship between income inequality and health
appears to be determined both by relative access to
resources for health gain and relative social position.
The association between greater income equality
and improved health may be explained by improved
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