Shimonovich, M. , Campbell, M. , Thomson, R. M. , Broadbent, P., Wells, V. , Kopasker, D. , McCartney, G. , Thomson, H. , Pearce, A. and Katikireddi, S. V. (2024) Causal assessment of income inequality on self-rated health and all-cause mortality: a systematic review and meta-analysis. Milbank Quarterly, 102(1), pp. 141-182. (doi: 10.1111/1468-0009.12689) (PMID:38294094)
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Abstract
Context: Whether income inequality has a direct effect on health or is only associated because of the effect of individual income has long been debated. We aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality) and assess if these relationships are likely to be causal. Methods: We searched Medline, ISI Web of Science, Embase, and EconLit (PROSPERO: CRD42021252791) for studies considering income inequality and SRH or mortality using multilevel data and adjusting for individual-level socioeconomic position. We calculated pooled odds ratios (ORs) for poor SRH and relative risk ratios (RRs) for mortality from random-effects meta-analyses. We critically appraised included studies using the Risk of Bias in Nonrandomized Studies – of Interventions tool. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework and causality using Bradford Hill (BH) viewpoints. Findings: The primary meta-analyses included 2,916,576 participants in 38 cross-sectional studies assessing SRH and 10,727,470 participants in 14 cohort studies of mortality. Per 0.05-unit increase in the Gini coefficient, a measure of income inequality, the ORs and RRs (95% confidence intervals) for SRH and mortality were 1.06 (1.03-1.08) and 1.02 (1.00-1.04), respectively. A total of 63.2% of SRH and 50.0% of mortality studies were at serious risk of bias (RoB), resulting in very low and low certainty ratings, respectively. For SRH and mortality, we did not identify relevant evidence to assess the specificity or, for SRH only, the experiment BH viewpoints; evidence for strength of association and dose–response gradient was inconclusive because of the high RoB; we found evidence in support of temporality and plausibility. Conclusions: Increased income inequality is only marginally associated with SRH and mortality, but the current evidence base is too methodologically limited to support a causal relationship. To address the gaps we identified, future research should focus on income inequality measured at the national level and addressing confounding with natural experiment approaches.
| Item Type: | Articles |
|---|---|
| Additional Information: | Funding/Support:This work is supported by Wellcome Trust (218105/Z/19/Z and 205412/Z/16/Z), NHS Research Scotland (SCAF/15/02), Medical Research Council(MC_UU_00022/2), Chief Scientist Office (SPHSU17) and the European Research Council(949582). |
| Keywords: | Causality, income inequality, systematic review. |
| Status: | Published |
| Refereed: | Yes |
| Glasgow Author(s) Enlighten ID: | Katikireddi, Professor Vittal and Thomson, Dr Hilary and Kopasker, Dr Daniel and Thomson, Dr Rachel and Wells, Ms Valerie and Shimonovich, Ms Michal and Broadbent, Dr Philip and McCartney, Professor Gerard and Pearce, Dr Anna and Campbell, Ms Mhairi |
| Authors: | Shimonovich, M., Campbell, M., Thomson, R. M., Broadbent, P., Wells, V., Kopasker, D., McCartney, G., Thomson, H., Pearce, A., and Katikireddi, S. V. |
| College/School: | College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > MRC/CSO SPHSU College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing College of Social Sciences > School of Social and Political Sciences > Sociology Anthropology and Applied Social Sciences |
| Journal Name: | Milbank Quarterly |
| Publisher: | Wiley |
| ISSN: | 0887-378X |
| ISSN (Online): | 1468-0009 |
| Published Online: | 31 January 2024 |
| Copyright Holders: | Copyright © 2024 The Authors |
| First Published: | First published in Milbank Quarterly 102(1): 141-182 |
| Publisher Policy: | Reproduced under a Creative Commons License |
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