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Income-Related Inequities in Primary and Specialist Care Among First Nations Peoples Living Off-Reserve in Canada

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Abstract

Background

Improving equity in healthcare is a primary goal of health policy in Canada. Although the investigation of equity in healthcare utilization is common in the general population, little research has been conducted to assess equity in healthcare utilization within First Nations peoples living in Canada.

Objective

To examine income-related inequities in primary care (family doctor/general practitioner and nurse practitioner care) and specialist care within status and non-status First Nations adults living off-reserve.

Methods

Using the 2017 Aboriginal Peoples Survey (APS), a nationally representative survey of Indigenous peoples living off-reserve in Canada, we analyzed income-related inequities in healthcare among Indigenous adults (>18 years) who self-identified as a member of any First Nations group in Canada. Logistic regression analysis was performed to identify factors associated with the utilization of primary and specialist care. The Horizontal Inequity index (HI), which measures unequal healthcare use by income for equal need, was used to quantify and decompose income-related inequities for primary and specialist care for status and non-status, and total First Nations groups.

Results

The regression results revealed higher primary and specialist care use among females, high socioeconomic status (high income and more educated) and status First Nations peoples in Canada. The positive values of the HI suggested a higher concentration of primary care and specialist care utilization among higher income First Nations peoples after adjusting for healthcare need. These pro-rich inequities persisted for the total First Nations populations, and for those in each status group individually. The decomposition results suggested observed inequities in both primary and specialist care among First Nations peoples can be predominantly attributed to the unequal distribution of education and income.

Conclusion

Although primary and specialist services in Canada are free at the point of the provision, we found pro-rich inequities in healthcare use among First Nations adults living off-reserve in Canada. These results warrant policies and initiatives to address barriers to healthcare use within and outside health system among low-income First Nations peoples living off-reserve.

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Data Availability

We used the 2017 Aboriginal Peoples Survey (APS) Public Use Microdata File (PUMF) dataset, which is available in a public, open-access repository. The data can be accessed for a subscription fee through Statistics Canada’s the PUMF Collection.

Notes

  1. The value of the HI can be obtained by measuring the C value for \({Y}_i^{\textsf{IS}}\) using the “convenient regression” method or the formula presented in Eq. 6.

References

  1. Wagstaff A, van Doorslaer E. Equity in the finance of health care: some international comparisons. J Health Econ. 1992;11:361–87.

    Article  CAS  PubMed  Google Scholar 

  2. Wagstaff A, Van DE, Paq P. Equity in the finance and delivery of health care: some tentative cross-country comparisons. Oxf Rev Econ Policy. 1989;5:89–112.

    Article  Google Scholar 

  3. Allin S. Does equity in healthcare use vary across Canadian provinces? Healthcare policy/Politiques de santé. 2008;3:83–99.

    Article  PubMed  Google Scholar 

  4. Chan J, Polo A, Zubizarreta E, Bourque JM, Hanna TP, Gaudet M, et al. Access to radiotherapy and its association with cancer outcomes in a high-income country: addressing the inequity in Canada. Radiother Oncol. 2019;141:48–55.

    Article  PubMed  Google Scholar 

  5. Corscadden L, Allin S, Wolfson M, Grignon M. Publicly financed healthcare and income inequality in Canada. Healthc Q. 2014;17:7–10.

    Article  PubMed  Google Scholar 

  6. van Doorslaer E, Wagstaff A. Equity in the delivery of health care: some international comparisons. J Health Econ. 1992;11:389–411.

    Article  PubMed  Google Scholar 

  7. Government of Canada. Health Act: R.S.C., 1985, c. C-6. , Ottawa; 1984.

  8. Stankiewicz A, Herel M, Desmeules MM. Canada and other United Nations (UN) Member States endorsed the ’ ’Rio Political Declaration on Social Determinants of Health. Public Health Agency of Canada; 2012.

    Google Scholar 

  9. Schneider E, Sarnak D, Squires D, Shah A, Doty M. Mirror, Mirror 2017. International comparison reflects flaws and opportunities for better U.S. health care; 2017.

    Google Scholar 

  10. Cameron BL, Carmargo Plazas MDP, Salas AS, Bourque Bearskin RL, Hungler K. Understanding inequalities in access to health care services for aboriginal people: a call for nursing action. ANS Adv Nurs Sci. 2014;37:1–16.

    Article  Google Scholar 

  11. Lafond G, Haver CRA, McLeod V, Clarke S, Horsburgh B, McLeod KM. Characteristics and residence of First Nations patients and their use of health care services in Saskatchewan, Canada: informing First Nations and Métis health services. J Eval Clin Pract. 2017;23:294–300.

    Article  PubMed  Google Scholar 

  12. Chung H, Ye M, Hanson C, Oladokun O, Campbell MJ, Kramer G, et al. Disparities in healthcare utilisation rates for Aboriginal and non-Aboriginal Albertan residents, 1997-2006: a population database study. PLoS One. 2012;7:e48355.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Shah BR, Gunraj N, Hux JE. Markers of access to and quality of primary care for aboriginal people in Ontario, Canada. Am J Public Health. 2003;93:798–802.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Loyola-Sanchez A, Hurd K, Barnabe C. Healthcare utilization for arthritis by indigenous populations of Australia, Canada, New Zealand, and the United States: a systematic review ☆. Semin Arthritis Rheum. 2017;46:665–74.

    Article  PubMed  Google Scholar 

  15. Mitrou F, Cooke M, Lawrence D, Povah D, Mobilia E, Guimond E, et al. Gaps in Indigenous disadvantage not closing: a census cohort study of social determinants of health in Australia, Canada, and New Zealand from 1981-2006. BMC Public Health. 2014;14:201.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Assembly of First Nations. The First Nations health transformation agenda. Assembly of First Nations (AFN); 2017. [cited 2023 August 1]. Available from: https://scoinc.mb.ca/wp-content/uploads/2021/06/FNHTA-AFN-wcag.pdf

  17. Pulok MH, Hajizadeh M. Equity in the use of physician services in Canada’s universal health system: A longitudinal analysis of older adults. Soc Sci Med. 2022;307:115186.

    Article  PubMed  Google Scholar 

  18. Hirello L, Pulok M, Hajizadeh M. Equity in healthcare utilization in Canada’s publicly funded health system: 2000–2014. Eur J Health Econ. 2022;1:1–15. https://doi.org/10.1007/s10198-022-01441-1.

    Article  Google Scholar 

  19. Mangalore R, Knapp M. Income-related inequalities in common mental disorders among ethnic minorities in England. Soc Psychiatry Psychiatr Epidemiol. 2012;47:351–9.

    Article  PubMed  Google Scholar 

  20. Statistics Canada and the Assembly of First Nations. A snapshot. Status First Nations people in Canada [Internet]; 2021. [cited 2022 Nov 2]. Available from: https://www150.statcan.gc.ca/n1/pub/41-20-0002/412000022021001-eng.htm

    Google Scholar 

  21. Statistics Canada. Census Program [Internet]. Census of Population; 2022. [cited 2022 Nov 14]. Available from: https://www12.statcan.gc.ca/census-recensement/index-eng.cfm

    Google Scholar 

  22. Department of Justice. A consolidation of the constitution acts 1867 to 1982. Ottawa, Canada; 2012. [cited 2023 August 1]. Available from: https://publications.gc.ca/collections/collection_2013/lois-statutes/YX1-1-2012-eng.pdf

  23. Statistics Canada: Census Program [Internet]. [cited 2021 Oct 16]. Available from: https://www12.statcan.gc.ca/census-recensement/index-eng.cfm

  24. Vowel C, Got Status? Indian Status in Canada. Indigenous Writes. A guide to First Nations, Metis, and Inuit issues in Canada; 2016. 30–9.

  25. Morency J-D, Caron-Malenfant É, Daignault D. Fertility of Aboriginal people in Canada: an overview of trends at the turn of the 21st century, vol. 7. Aboriginal Policy Studies; 2018.

    Google Scholar 

  26. Nelson SE, Wilson K. The mental health of Indigenous peoples in Canada: a critical review of research. Soc Sci Med. 2017;176:93–112.

    Article  PubMed  Google Scholar 

  27. Bombay A, Matheson K, Anisman H. The intergenerational effects of Indian residential schools: implications for the concept of historical trauma. Transcult Psychiatry. 2014;51:320–38.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ford JD, Berrang-Ford L, King M, Furgal C. Vulnerability of Aboriginal health systems in Canada to climate change. Glob Environ Change. 2010;20(4):668–80.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Adelson N. The embodiment of inequity: health disparities in aboriginal Canada. Can J Public Health. 2005;96(Suppl 2):S45–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16078555

    Article  PubMed  PubMed Central  Google Scholar 

  30. Frohlich KL, Ross N, Richmond C. Health disparities in Canada today: some evidence and a theoretical framework. Health Policy. 2006;79:132–43.

    Article  Google Scholar 

  31. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. The Lancet. 2009;374:65–75. Available from: http://www.sciencedirect.com/science/article/pii/S0140673609609144

    Article  Google Scholar 

  32. Romanow R. Building on values: the future of health care in Canada. CRNCC: Canadian Research Network for Care in the Community; 2002.

    Google Scholar 

  33. McGrail K. Medicare financing and redistribution in British Columbia, 1992 and 2002. Healthc Policy. 2007;2:123–37.

    PubMed  PubMed Central  Google Scholar 

  34. Canadian Institute for Health Information. National health expenditure trends, 1975 to 2015. Canadian Institute for Health Information; 2015.

    Google Scholar 

  35. Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. Cmaj. 2012;184:297–302.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Lee A, Morgan S. Cost-related nonadherence to prescribed medicines among older Canadians in 2014: a cross-sectional analysis of a telephone survey. CMAJ Open. 2017;5:E40–4.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Government of Canada. National Native Alcohol and Drug Abuse Program [Internet]. 2019 [cited 2023 Aug 1]. Available from: https://www.sac-isc.gc.ca/eng/1576089851792/1576089910366

  38. Government of Canada. Benefits and services under the Non-Insured Health Benefits Program [Internet]. 2019 [cited 2019 Jun 12]. Available from: https://www.canada.ca/en/indigenous-services-canada/services/non-insured-health-benefits-first-nations-inuit/benefits-services-under-non-insured-health-benefits-program.html

  39. Allan B, Smylie J. First Peoples , second class treatment: the role of racism in the health and well-being of Indigenous peoples in Canada. Wellesley Institute; 2015.

    Google Scholar 

  40. Marchildon GP. Canada: health system review, vol. 15. European Observatory on Health Systems and Policies; 2013. p. 179.

    Google Scholar 

  41. Hadskis M, Hutt L, McNally M. Dental law in Canada. Toronto, Canada: LexisNexis; 2019.

    Google Scholar 

  42. Vongdara B, Léger D, Latendresse E, Budinski R. Aboriginal Peoples Survey, 2017. Ottawa: concepts and methods guide [Internet]; 2018. Available from: https://www150.statcan.gc.ca/n1/pub/89-653-x/89-653-x2018001-eng.htm

    Google Scholar 

  43. Aday LA, Andersen RM. Equity of access to medical care: a conceptual and empirical overview. Med Care. 1981;19:4–27.

    Article  CAS  PubMed  Google Scholar 

  44. Mitchell GK, Senior HE, Bibo MP, Makoni B, Young SN, Rosenberg JP, et al. Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision. BMC Palliative Care. 2016;15(1):1–11.

    Article  Google Scholar 

  45. Bruce SG, Riediger ND, Lix LM. Chronic disease and chronic disease risk factors among First Nations, Inuit and Métis populations of northern Canada. Chronic Dis Inj Can. 2014;34:210–7.

    Article  CAS  PubMed  Google Scholar 

  46. Pu C, Bai YM, Chou YJ. The impact of self-rated health on medical care utilization for older people with depressive symptoms. Int J Geriatr Psychiatry. 2013;28:479–86.

    Article  PubMed  Google Scholar 

  47. Pu C, Tang G-J, Fang Y-T, Chou Y-J. Which domain of self-rated health best predicts medical care utilization among Taiwanese adults? J epidem. 2012;22(5):417–24.

    Article  Google Scholar 

  48. Cullati S, Mukhopadhyay S, Sieber S, Chakraborty A, Burton-Jeangros C. Is the single self-rated health item reliable in India? A construct validity study. BMJ Glob Health. 2018;3:856.

    Article  Google Scholar 

  49. Li C, Dou L, Wang H, Jing S, Yin A. Horizontal inequity in health care utilization among the middle-aged and elderly in China. Int J Environ Res Public Health. 2017;14:1–14.

    Article  Google Scholar 

  50. Van Doorslaer E, Clarke P, Savage E, Hall J. Horizontal inequities in Australia’s mixed public/private health care system. Health Policy (New York). 2008;86:97–108.

    Article  Google Scholar 

  51. Gravelle H. Measuring income related inequality in health: standardisation and the partial concentration index. Health Econ. 2003;12:803–19.

    Article  PubMed  Google Scholar 

  52. Pulok MH, van Gool K, Hajizadeh M, Allin S, Hall J. Measuring horizontal inequity in healthcare utilisation : a review of methodological developments and debates. Eur J Health Econ. 2020;21:171–80.

    Article  PubMed  Google Scholar 

  53. O’Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing health equity using household survey data. a guide to techniques and their implementation. Washington DC: The World Bank; 2008.

    Google Scholar 

  54. Kjellsson G, Gerdtham UG. On correcting the concentration index for binary variables. J Health Econ. 2013;32:659–70.

    Article  PubMed  Google Scholar 

  55. Erreygers G. Correcting the concentration index. J Health Econ. 2009;28:504–15.

    Article  PubMed  Google Scholar 

  56. Wagstaff A, Evan D, Watanabe N. On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. J Econom. 2003;112:207.

    Article  Google Scholar 

  57. O’Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing health equity using household survey data a guide to techniques and their implementation analyzing health equity using household survey data. World Bank Publications; 2008.

    Google Scholar 

  58. Fleurbaey M, Schokkaert E. Unfair inequalities in health and health care. J Health Econ. 2009;28:73–90.

    Article  PubMed  Google Scholar 

  59. Zangiabadi S, Costanian C, Tamim H. Dental care use in Ontario: The Canadian community health survey (CCHS). BMC Oral Health. 2017;17:1–8.

    Article  Google Scholar 

  60. Asada Y, Kephart G. Equity in health services use and intensity of use in Canada. BMC Health Serv Res. 2007;7:41.

    Article  PubMed  PubMed Central  Google Scholar 

  61. OECD. Health for Everyone? Paris: Social Inequalities in Health and Health Systems | en | OECD; 2019.

    Book  Google Scholar 

  62. Allin S, Hurley J. Inequity in publicly funded physician care: what is the role of private prescription drug insurance? Health Econ. 2009;18:1218–32.

    Article  PubMed  Google Scholar 

  63. Pulok MH, van Gool K, Hall J. Inequity in physician visits: the case of the unregulated fee market in Australia. Soc Sci Med. 2020;255:113004.

    Article  PubMed  Google Scholar 

  64. Pulok MH. Horizontal equity in the Australian healthcare system: exploring the unknowns and updating the knowns. University of Technology Sydney (UTS); 2019.

    Google Scholar 

  65. van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilisation in Europe. Health Econ. 2004;13:629–47.

    Article  PubMed  Google Scholar 

  66. Tavares LP, Zantomio F. Inequity in healthcare use among older people after 2008: the case of southern European countries. Health Policy (New York). 2017;121:1063–71.

    Article  Google Scholar 

  67. Terraneo M. Inequities in health care utilization by people aged 50+: evidence from 12 European countries. Soc Sci Med. 2015;126:154–63.

    Article  PubMed  Google Scholar 

  68. Pulok M, van Gool K, Hall J. Inequity in healthcare use among the indigenous population living in non-remote areas of Australia. Public Health. 2020;186:35–43.

    Article  CAS  PubMed  Google Scholar 

  69. Allin S, Masseria C, Mossialos E. Equity in health care use among older people in the UK: an analysis of panel data. Appl Econ. 2011;43:2229–39.

    Article  Google Scholar 

  70. Devaux M. Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries. Eur J Health Econ. 2015;16:21–33.

    Article  PubMed  Google Scholar 

  71. OECD. Health for Everyone?: social inequalities in health and health systems. Paris: OECD Publishing; 2019.

    Book  Google Scholar 

  72. Hajizadeh M, Connelly LB, Butler JRG. Health policy and horizontal inequities of health-care utilization in Australia: 1983–2005. Appl Econ Lett. 2012;19:1765–75.

    Article  Google Scholar 

  73. Pulok MH, van Gool K, Hall J. Horizontal inequity in the utilisation of healthcare services in Australia. Health Policy (New York). 2020;124:1263–71.

    Article  Google Scholar 

  74. Devaux M, De LM. Income-related inequalities in health service utilisation in 19 OECD Countries, 2008-2009. In: OECD Health Working Papers. Paris, France: OECD Publishing; 2012. Report No.: 58.

    Google Scholar 

  75. World Health Organization. Primary health care (Now more than ever). Geneva, Switzerland: World Health Organization; 2008.

    Google Scholar 

  76. Romanow RJ. Commission on the future of health care in Canada. Building on values: the future of health care in Canada; 2002.

    Google Scholar 

  77. Browne AJ, Smye VL, Rodney P, Tang SY, Mussell B, O’Neil J. Access to primary care from the perspective of aboriginal patients at an urban emergency department. Qual Health Res. 2011;21:333–48.

    Article  PubMed  Google Scholar 

  78. Puxley C. Brian Sinclair inquest to look at hospital backlogs; man died after 34-hour ER wait. The Canadian Press; 2014.

    Google Scholar 

  79. Kurtz DLM, Nyberg JC, Van Den Tillaart S, Mills B, (OUAHRC) TOUAHR. Silencing of voice: an act of structural violence urban aboriginal women speak out about their experiences with health care. Int J Indig Health. 2013;4:53.

    Article  Google Scholar 

  80. Tang SY, Browne AJ. “Race” matters: Racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context. Ethn Health. 2008;13:109–27.

    Article  PubMed  Google Scholar 

  81. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:1–9.

    Article  Google Scholar 

  82. Rotondi MA, O’Campo P, O’Brien K, Firestone M, Wolfe SH, Bourgeois C, et al. Our Health Counts Toronto: Using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada. BMJ Open. 2017;7:1–8.

    Article  Google Scholar 

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Acknowledgements

We would like to thank Thunderbird Partnership Foundation for reviewing the manuscript.

Code Availability

The code can be obtained from the corresponding author upon a reasonable request.

Funding

The authors acknowledge funding for this research provided by the Research Nova Scotia Establishment Grant program (grant #: 1017). MH is supported by a Tier II Canada Research Chair in Health Economics through the Canada Research Chairs (CRC) Program (grant # CRC-2020-00219; https://www.chairs-chaires.gc.ca/home-accueil-eng.aspx). DM is supported by a Tier II Canada Research Chair in Indigenous Peoples’ Health and Well-Being through the CRC Program (grant # CRC-2021-00436).

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Authors and Affiliations

  1. School of Health Administration, Dalhousie University, Halifax, Canada

    Mohammad Hajizadeh

  2. Faculty of Medicine, Dalhousie University, Halifax, Canada

    Benjamin L. Keefe

  3. Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada

    Yukiko Asada

  4. Department of Psychiatry and School of Nursing, Dalhousie University, Halifax, Canada

    Amy Bombay

  5. School of Health and Human Performance, Dalhousie University, Halifax, Canada

    Debbie Martin

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  1. Mohammad Hajizadeh
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Contributions

All authors contributed to the conception and design of the study. MH and BK performed the statistical analyses, and all authors interpreted the results. MH drafted the manuscript, and BK, YA, AB, and DM helped with drafting and revisions. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Mohammad Hajizadeh.

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Ethical Approval

The data used for this study is publicly available and therefore required no ethics approval. This data was processed at Statistics Canada to ensure that no information is identifiable. Additionally, this project was conducted as part of a successful research grant entitled: “The dynamics of health inequalities faced by Indigenous populations in Canada: What factors account for the inequality”, which has been granted ethics approval by Dalhousie University (REB No: 2017-4295).

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Hajizadeh, M., Keefe, B.L., Asada, Y. et al. Income-Related Inequities in Primary and Specialist Care Among First Nations Peoples Living Off-Reserve in Canada. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01739-7

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