Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis

BMJ 1998;317:917-921 ( 3 October )

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Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis

Bruce P Kennedy, deputy director, ^a Ichiro Kawachi, associate professor, ^b Roberta Glass, research specialist, ^a Deborah Prothrow-Stith, professor. ^a

^a Division of Public Health Practice, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115, USA, ^b Department of Health and Social Behavior, Harvard School of Public Health

Correspondence to: Dr Kennedy kennedy{at}hsph.harvard.edu

Objective: To determine the effect of inequalities in income within a state on self rated health status while controllingfor individual characteristics such as socioeconomicstatus.
Design: Cross sectional multilevel study. Data were collected on income distribution in each of the 50 states in theUnited States. The Gini coefficient was used to measure statewideinequalities in income. Random probability samples of individualsin each state were collected by the 1993 and 1994 behaviouralrisk factor surveillance system, a random digit telephone survey.The survey collects information on an individual's income, education,self rated health and other health riskfactors.
Setting: All 50states.
Subjects: Civilian, non-institutionalised (that is, non-incarcerated and non-hospitalised) US residents aged 18 yearsor older.
Main outcome measure: Self rated health status.
Results: When personal characteristics and household income were controlled for, individuals living in states withthe greatest inequalities in income were 30% more likely to reporttheir health as fair or poor than individuals living in stateswith the smallest inequalities inincome.
Conclusions: Inequality in the distribution of income was associated with an adverse impact on health independent ofthe effect of householdincome.

Key messages

Inequalities in the statewide distribution of income are associated with self rated fair or poor health, even after individual income and other risk factors are accounted for
The effects of income distribution on self rated health were not limited only to those in the lowest income groups; those in the middle income groups in states with the greatest inequalities in income rated themselves as having poorer health than those in middle income groups in states with the smallest inequalities
The effects of income inequality on self rated health are as strong as other individual risk factors
Social and economic policies that affect income distribution may have important consequences for the health of the population

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