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Joint Canada/United States Survey of Health: Findings and public-use microdata file
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In an era of globalization, comparisons of health status and health systems across nations are of increasing interest.1, 2 This is certainly true for Canada and the United States — two nations who share an open border and who are similar in many ways yet very different on several policy fronts including the way health care services are organized, managed, and delivered. Accordingly, the Joint Canada/United States Survey of Health (JCUSH) was designed and conducted to collect the same information in the same manner from both Canadian and United States residents so that accurate comparisons between the two populations can be made regarding health status and access to health care services. As a result, the JCUSH is a unique and timely population health survey, conducted jointly by Statistics Canada and the National Center for Health Statistics (NCHS) of the United States Centers for Disease Control and Prevention.
Multi-country comparisons to date
Canada and the United States have been part of various existing efforts to compare countries on health related issues. The Organization for Economic Cooperation and Development (OECD), for example, regularly conducts multi-country comparisons among member countries. The OECD gathers existing administrative and survey data within each country to create a core set of key indicators to compare the health status and health care system performance across countries.3 While this approach provides valuable information, the comparability of the data is limited since different instruments and methods have been used within each country.
In an effort to overcome some of these limitations, multi-country surveys have been conducted using a standard questionnaire and methodology in an effort to produce more comparable data. For example, the Commonwealth Fund has collected data from its member countries including Canada and the United States since 1990. The Commonwealth Fund survey focuses primarily on the views, satisfaction and health care experiences of citizens accessing health care services in each country.4, 5, 6 While these data are highly comparable, the information provided is somewhat limited in scope since the survey does not capture broader information on health status, lifestyle habits, health care use and other determinants of health.
Given the limitations of current multi-country comparisons to date, international organizations such as the World Health Organization (WHO) and the OECD have called for more comparable data at the international level. Comparable statistics are required to assess and compare the performance of national health care systems and to provide a more in depth understanding of the determinants that drive good and bad health in various countries.
The JCUSH represents the first attempt to collect comprehensive information regarding health status and access to health care services using a single survey and a standard approach across countries. The survey was designed to collect comparable information on a broad range of topics including:
Because the JCUSH was conducted in the same manner in both countries, it provides a degree of comparability never before possible. As a result, direct comparisons can be made between Canada and the United States regarding health status, the extent of mobility limitations, and access to health care services.7The objective of this report is to provide a first look at the results from the JCUSH survey. The findings focus primarily on the overall similarities and differences between the two countries. The report also provides an overview of the methods and processes used to conduct the survey.
The JCUSH was conducted as a one-time telephone survey in both Canada and the United States. The survey content was drawn from the Canadian Community Health Survey (CCHS) and the National Health Interview Survey (NHIS) in the United States. This was done so that the JCUSH could provide information that can support possible harmonization of the two surveys.
The target population of JCUSH includes residents of Canada and the United States aged 18 or older living in private dwellings. The target population excludes the institutionalized population and those living in either the Canadian or United States territories. The JCUSH sample was designed to produce reliable national estimates for three age groups (18-44, 45 to 64 and 65 and over) by gender. Households were selected through a Random Digit Dialling (RDD) process. The number of persons responding to the survey was 3,505 in Canada and 5,183 in the United States. All interviews were conducted from Statistics Canada’s regional offices. Responses rates were 66% and 50% in Canada and the United States, respectively.8 (see Methodological notes - Data collection and estimation )
Comparisons between Canada and the United States were conducted for all respondents and by age and gender and for some indicators by income and health insurance status. Analyses including all respondents were age-adjusted to control for any differences in the age distribution of the two countries. Missing data including responses of "don't know", "not stated", or "refusal" were excluded from the analysis except for analyses by income. In the case of income, about 24% in the United States and 16% in Canada were missing responses. Pairwise differences between the two countries were deemed statistically significant based on a two-tailed test at level p < 0.05. (see Methodological notes – Analytical techniques)
The target population of JCUSH includes Canadian and United States adults aged 18 or older residing in households with a telephone (i.e. a land line). The following were excluded from the sample:
The JCUSH sample was stratified by province in Canada and by four geographic regions in the United States (Northeast, Midwest , West and South). In each country, the sample was proportionally allocated within each stratum based on their population sizes. The sample selection method chosen was (RDD). Statistics Canada and NCHS were responsible for drawing their own sample but equivalent designs were used to ensure comparability of the resulting data.
The objective of the JCUSH was to obtain reliable estimates at the national level for six domains: three age groups (18 to 44, 45 to 64 and 65 and over) by gender. With the RDD method, it is difficult to control the sample composition since the age and gender of the respondents are unknown beforehand. Since males 65 and over represent only about 7% of these populations, and only about 13% of households contain at least one male 65 and over, the probability of selection for persons aged 65 and over was increased to avoid the need for an overly large sample. Post-stratification was done to ensure that the final weights sum to the population estimates, for some auxiliary variables. In Canada, population estimates were based on the 1996 Census of Population, and in the United States, estimates were based on the October 2002 Current Population Survey. The auxiliary variables used to create the post-strata adjustments are age, sex and region for Canada and age, sex and race/ethnicity for the United States.
The JCUSH was administered by Statistics Canada in both countries using the Computer-Assisted Telephone Interview (CATI) method. Both the Canadian and American interviews were conducted from Statistics Canada’s regional offices using the same questionnaire and the same interviewing team. The questionnaire, designed by both countries, was administered in three languages: French and English for Canadian interviews and Spanish and English for American interviews.
Collection took place between November 4, 2002 and March 31, 2003 . Additional collection took place during several weeks in April and June 2003, and focused on encouraging participation from selected United States respondents who had previously declined to participate in the survey.
Weighted distributions and percents were produced. Missing data, including responses of "don't know", "not stated", or "refusal", were excluded from the analysis except for analyses by income. Age adjusted percents were calculated for both countries using the direct standardization method and using weights from the projected 2000 Standard United States population: 18 to 44: 0.530535; 45 to 65: 0.299194; and over 65: 0.170271. (Klein RJ, Schoenborn Ca. Age Adjustment Using the 2000 Projected United States Population. Statistical Notes Number 20 (CDC/NCHS) January 2001). The bootstrap technique was used to account for the sample design in estimating variances of percents in this report.9, 10 Statistical significance tests were conducted at the 0.05 level and 95% confidence intervals were produced.
There are limitations with the JCUSH data.
First, the survey response rates were relatively low compared with other health surveys in both Canada and the United States Even though non-response is taken into account when calculating the estimates for the entire population, no information is available on the characteristics of non-respondents.
Second, the use of the Random Digit Dialling (RDD)process excludes households with no telephone. The percentage of households with no telephone is relatively small (1.8% in Canada and 4.4% in the United States). Because the survey estimates are post-stratified based on the counts of all persons in the target population, regardless of whether the household has telephone service or not, the estimates allow inferences to be made for the entire population. The exclusion of a small portion of the population may result in a slight bias if that portion of the population has characteristics that are different from the population as a whole. Data from the United States indicate that households without a landline telephone generally have lower income levels.
Third, since the sample was collected at the national level, provincial and state level analyses are not possible in Canada and the United States, respectively.
Fourth, the data used for this analysis were self- or proxy-reported; the information was not verified by direct measures or independent sources and may therefore be inaccurate. Recall errors could also have affected reported levels for some variables. It is possible that respondents may have provided what they considered socially desirable answers to questions on issues such as smoking and body weight. Data from the JCUSH are cross-sectional and refer to one point in time. As a result, while relationships between variables can be described, causality and temporal associations cannot be inferred.
Finally, in addition to the errors inherent to any sampling method, other errors may have occurred during the survey operations. Interviewers may have misunderstood instructions, respondents may have answered the questions incorrectly, the answers may have been incorrectly recorded and errors may have been introduced in the processing and tabulation of the data. Considerable effort was made to reduce such non-sampling errors in the survey. Quality assurance measures were implemented at each step of the data collection and processing steps to monitor the quality of the data. These measures included the use of highly skilled interviewers, training of interviewers with respect to the survey procedures and questionnaire, observation of interviewers to detect problems of questionnaire design or misunderstanding of instructions, procedures to ensure that data capture errors were minimized and coding and edit quality checks to verify the processing logic. Furthermore, comparisons were made between JCUSH estimates and the respective national health surveys, where appropriate, to ensure that JCUSH estimates were in line with their corresponding national surveys.
Body mass index (BMI)/Obesity: BMI score for an individual is obtained by dividing weight in kilograms by the square of height in metres. The measure excludes pregnant women and those less than 3 feet in height or 7 feet and over. Individuals with a BMI of 30 or more were classified as obese, a definition of obesity that is endorsed by the World Health Organization (WHO). In this study, the WHO categories used are as follows: BMI < 18.5 (underweight), 18.5 ≤ BMI < 25 (normal weight), 25 ≤ BMI < 30 (overweight), and BMI ≥ 30 (obese).
Current daily smoker: In this study, current daily smokers are individuals who report having smoked at least one whole cigarette and now smoke cigarettes every day.
Depression: In this study, depression is represented as the likelihood of a major depressive episode (MDE) based on responses to a subset of questions from the Composite International Diagnostic Interview. These questions cover a cluster of symptoms for depressive disorder, which are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).11 Responses to these questions were scored and transformed into a probability estimate of a diagnosis of major depressive episode. If the estimate was 0.9 or more (that is, 90% certainty of a positive diagnosis), the respondent was classified as having had a depressive episode in the past year.
Income quintile: For Canada and the United States separately, respondents who reported household income were divided into quintiles by country as follows. First, the household income of each respondent was adjusted for household size by dividing the income by the square root of the number of persons residing in the household. Then, respondents were ranked according to the adjusted household income and were assigned a quintile group such that the weighted count of each quintile group contained approximately one-fifth of the population reporting household income. Respondents with missing household income were excluded from the construction of quintiles and are reported separately.
Mobility limitation: Individuals have mobility limitation if they report that they “cannot do”, or find it “very difficult”, “somewhat difficult” or “a little difficult” to do any of three activities related to mobility (walking a quarter of a mile, standing for two hours and climbing ten steps without resting). A mobility limitation is considered severe if the respondent said he/she either could not do any of the activities or found it very difficult. It is considered highly severe if the respondent said he/she could not do any of the activities.
Unmet health care need: Individuals are considered to have an unmet health care need if over the previous 12 months they felt that they needed a health care service but did not receive it when they needed it.
Comparative analyses between Canada and the United States were conducted in five main areas: health status, risk factors, income differences and health, access to health care services, and quality and satisfaction with health care services.
Health status is compared between Canada and the United States using a range of measures including self-reported health, mobility limitation and depression.
Self-reported health provides a good indication of individuals’ overall health status which encompasses a range of dimensions including both physical and mental health. Individuals were asked to assess their general health status as either “excellent”, “very good”, “good”, “fair” or “poor”. The majority of respondents in both countries reported that they were in good, very good or excellent health with somewhat more Canadians (88%) than Americans (85%) classifying themselves in these categories. The results were consistent for all age groups except for those 65 years of age and over.
Americans, however, were more likely to report “excellent” health than Canadians (26% versus 24%). This was related to the larger proportion of Americans 65 years of age and over reporting “excellent” health compared with Canadians in the same age group (15% versus 8%).
There were some small differences between Canadian and American women. More American women were at either end of the health status spectrum. A greater proportion of American women reported being in “excellent” health (25%) than Canadian women (23%). American women were also more likely to report fair health (11% versus 8%). There were no differences between males in the two countries.
Mobility limitations are an important aspect of health status since they can affect an individual’s ability to participate in society. Individuals were asked if they had any difficulties with a range of activities including walking, standing or climbing. Overall, Americans and Canadians had similar rates of mobility limitation, slightly more Americans reporting some level of difficulty with mobility (25%) than Canadians (24%). This is likely due to the somewhat higher rate of Americans who reported highly severe limitations: 6% of Americans reported that they “could not” walk, stand or climb compared with 4% of Canadians. In turn, this difference is mainly accounted for by the higher percentage of women with highly severe mobility limitations (i.e. cannot walk, stand or climb) in the United States (7%) versus Canada (4%); rates for men were similar.
Mental health is an important population health issue in both countries. A series of mental health related questions was used to determine whether or not an individual had experienced a major depressive episode in the previous 12 months. (see Definitions) Approximately 8% of respondents in both countries had likely experienced a major depressive episode in the previous year. In both countries, the rates were higher among females than among males. Approximately 7% of males in each country had experienced a major depressive episode compared with approximately 10% among women in both countries. There were no significant differences in rates of major depressive episodes between the two countries for any age group or gender.
Risk factors such as smoking and obesity are important determinants of health status. Smoking is a major risk factor for cancer, circulatory and respiratory disease. Overall, 19% of Canadians were considered current daily smokers compared with 17% of Americans. The difference is partly due to the higher rate of daily smokers among women aged 65 and older in Canada (10%) compared with those aged 65 and older in the United States (6%).
Obesity is a major risk factor for several diseases including diabetes, hypertension and cardiovascular disease. Individuals with a Body Mass Index (BMI) of 30 or greater are considered obese by international standards (see Definitions). A significantly higher proportion of Americans were obese compared with Canadians (21% versus 15%). The differences between the two countries are primarily a result of the differences between American and Canadian women. One in five American women were obese compared with approximately one in eight Canadian women (21% versus 13%). There were no significant differences in the BMI distribution among males in the two countries.
Health status tends to be patterned by social position (measured by income or education levels) in most industrialized countries. This patterning tends to follow what has been called a “social gradient” such that health status deteriorates in a step-like fashion from higher to lower income or education category. As such, health status information from the JCUSH is analysed by income level to identify differences in the social disparities related to health between the two countries.
In both countries, those in the lower income groups were more likely to be in fair or poor health, to have severe mobility limitation, to smoke and to be obese. A higher proportion of those in the lower income groups reported poorer health in the United States than in Canada but there were no significant differences in the middle and high income groups between the two countries. For example, 31% of low income Americans reported that their health was fair or poor compared with 23% of low income Canadians. The gap between the lowest and highest income groups in the proportion of those with fair/poor health was 19 percentage points in Canada and 24 percentage points in the United States.
In addition, the disparity in severe mobility limitation between high and low income individuals was greater in the United States than Canada. The difference between the lowest and highest income groups in the proportions of individuals with severe mobility limitations was 19 percentage points in the United States and 13 percentage points in Canada.
For three of the five income groups, the obesity rate was higher among Americans than Canadians. Differences were most notable in the lowest income group where the obesity rate was 9 percentage points higher for the United States than Canada (27% versus 18%). The gradient between income groups was also steeper in the United States The differential in obesity rate between the lowest and highest income groups was more than double for the United States compared with Canada.
Differences between the two countries related to income were not found for current daily smoking behaviour. In both countries, the levels of such smoking behaviour were higher among those with lower incomes but there were no statistically significant differences in levels between the two countries by income group. In both Canada and the United States, the difference in current daily smoking rates between the lowest and highest income groups was approximately 13 percentage points.
A comparison of access to health care services between Canada and the United States is of particular interest given the health system differences between the two countries, most notably the role of public and private insurance. Canadians have universal access to publicly funded health care services, primarily physician and hospital services. In the United States, the majority of citizens require private insurance to cover the cost of medical care services; public insurance is provided for the poor (Medicaid) and for those over 65 years of age (Medicare). Given these differences, information on insurance status is included in the analyses of health care use.
Based on the results of JCUSH, approximately 11% of Americans do not have health insurance. Sixteen percent of Americans between 18 and 44 years of age were uninsured compared with 9% of Americans 45 to 64 years of age and 1% of those 65 years of age and older. One in four Americans (26%) in the lowest income quintile are uninsured, representing 36% of all uninsured individuals.
While the majority of individuals in both Canada and the United States reported having a regular medical doctor, the rate for Canada was 5 percentage points higher (85% versus 80%). The difference is mainly due to the significantly lower proportion of uninsured Americans with a regular medical doctor (43%). There was no difference between Canadians and insured Americans regarding access to a regular medical doctor.
The majority of Canadians and Americans had at least one contact with any medical doctor in the previous 12 months (83% versus 82%). Insured Americans were slightly more likely than Canadians to have contacted any doctor compared with Canadians (86% versus 83%). However, significantly fewer uninsured Americans contacted a doctor in the previous 12 months (61%).
Overall, patterns of contact with any doctor by self-reported health status were the same for Canada and the United States As expected, individuals in poorer health status were more likely to have contacted a medical doctor.
Mammograms are considered important for the early detection and treatment of breast cancer. There are two types of mammograms – diagnostic and screening. Diagnostic mammograms are requested by a physician when there is a suspicion of cancer. Screening mammograms are conducted to look for evidence of cancer when there are no other symptoms. The guidelines for the use of screening mammograms vary between the two countries. In Canada, screening mammograms are recommended for most women between the ages of 50 and 69 every two years.12 In the United States, The National Center for Chronic Disease Prevention and Health Promotion recommends that women between 40 and 74 years of age have a mammogram every one to two years.13 To ensure comparability, women aged 50 to 69 were selected to compare mammography use in the two countries.
Overall, the proportion of women who had a mammogram within the last 2 years was 82% in the United States and 74% in Canada. Over 60% of women aged 50 to 69 in the United States had a mammogram in the last 12 months compared with less than half (48%) in Canada. Conversely, one in four women aged 50 to 69 in Canada had a mammogram one to two years ago compared with 17% in the United States There was no difference between the two countries regarding the proportion of women aged 50 to 69 years who never had a mammogram.
Pharmaceuticals represent a significant portion of overall health care expenditures in both countries. In both Canada and the United States, most individuals depend on private insurance to cover the cost of prescribed medicines or they pay out of pocket. In Canada, the costs of prescribed medications for those aged 65 and over is partially covered by public insurance. Based on results from the JCUSH, most individuals aged 18 and over had private insurance for prescription medications in Canada (77%) and the United States (79%).
Overall, over half of respondents in both countries reported that they had taken a prescription medication in the past month. The reported use was higher among those 65 years of age and older than among younger respondents and higher among women than men regardless of age.
The only significant difference between the two countries was among those 45 to 64 years of age. Overall, 68% of Americans in this age group reported prescription medication use compared with 61% of Canadians. The difference was true for both men (63% versus 55%) and women (74% versus 66%).
Dental services are another example where individuals in both countries depend on private insurance. Results from the JCUSH indicate that 62% of individuals in both Canada and the United States have private dental insurance.
Overall, the majority of respondents in both countries indicated that they had visited a dentist in the past year (63% in both countries). Less than 3% indicated that they had never been to the dentist.
The use of dental services by insurance status was similar in the two countries. In both countries, over 70% of individuals with dental insurance visited the dentist in the past 12 months compared with 47% among those without insurance. A slightly higher proportion of uninsured Canadians had not visited a dentist in the last 5 years (17%) compared with uninsured Americans (14%).
Unmet health care needs provide a measure of access to health care services that focuses on individuals’ experiences accessing care. Individuals were asked whether there was a time in the previous 12 months that they felt they needed health care services but did not receive them.
Overall, slightly more Americans than Canadians reported an unmet health care need (13% versus 11%) The difference was much higher when Canadians were compared with uninsured Americans (11% versus 40%). There was no significant difference in unmet health care needs between Canadians and insured Americans (11% versus 10%).
When asked about the reasons for having an unmet health care need, most Canadians who experienced an unmet health care need reported that long waiting times for care was the primary barrier (32%) while most Americans cited cost (53%). Cost was the primary barrier cited in the United States regardless of insurance status.
In both countries, those with lower incomes experienced higher levels of unmet needs compared with those with higher incomes. However, significantly more Americans in the lowest income quintile reported an unmet health care need than low income Canadians (27% versus 17%). There was no difference in the rate of unmet health care needs among those with higher incomes. The gap in unmet health care needs between the highest and lowest income group was significantly higher in the United States (17 percentage points) compared with Canada (8 percentage points).
Respondents were asked to rate the quality of their health care services during the past 12 months as well as the quality of care they received during their most recent visit to their family doctor or other medical doctor (response categories were “excellent”, “good”, “fair” or “poor”). Americans were more likely than Canadians to report that the quality of their health care services in general was “excellent” (42% versus 39%). Canadians were more likely to report that the quality was “fair” (12% versus 10%). These differences remained when Canadians were compared with insured Americans. Uninsured Americans, however, were less likely than Canadians to report that the quality of their health care services was “excellent” (28%) and more likely to report that it was “fair” (20%) or “poor” (8%).
Canadians and Americans were similar regarding their more specific assessment of the quality of care they had received during their last doctor visit. Nearly 60% of Canadians and insured Americans indicated that the quality was “excellent”.
Respondents were also asked to rate their satisfaction with their health care services during the past 12 months as well as their satisfaction with physician services during their most recent visit (response categories were “very satisfied”, “somewhat satisfied”, “neither satisfied nor dissatisfied”, “somewhat dissatisfied”, or “very dissatisfied”).
When asked about their satisfaction with health care services in general, more Americans than Canadians reported that they were “very satisfied” (53% versus 44%). Canadians were more likely to indicate that they were “somewhat satisfied” (43% versus 37%). These differences remained when Canadians were compared with insured Americans.
Canadians were in fact more similar to uninsured Americans regarding satisfaction with care. The only significant difference between Canadians and uninsured Americans was the proportion reporting that they were “very dissatisfied” with their health care services: 9% of uninsured Americans and 3% of Canadians said they were “very dissatisfied”.
When asked specifically about satisfaction with physician services, insured Americans were more likely than Canadians to report that they were “very satisfied” (68% versus 64%).
The JCUSH represents a unique population health survey conducted jointly by two national statistical agencies, Statistics Canada and the United States National Center for Health Statistics. The use of a common questionnaire and identical data collection and processing methods provides highly comparable data. As a result, the findings from JCUSH provide valuable insights regarding similarities and differences between Canada and the United States in a manner not previously possible.
Overall, the health status of Canadians and Americans is generally similar with most individuals in both countries reporting that they are in good, very good or excellent health. More Americans, however, reported being at either end of the health status spectrum - in excellent health and in fair and poor health - compared with Canadians. This was particularly true among women. This may be associated with the higher rate of highly severe mobility limitation and obesity among American women. There were relatively few differences between men.
Canadians and Americans were similar regarding access to health care services provided under similar funding models. In the case of dental services, for example, where most depend on private insurance, access was similar in the two countries.
Canadians and Americans differed overall, however, regarding access to health care services provided under different insurance models such as those covering physician services. While Canadians are similar to insured Americans regarding access to a regular medical doctor and regarding unmet health care needs, they face significantly less barriers to care when compared with uninsured Americans.
The greatest differences between the two countries are related to differentials by income in health. While there has been solid evidence for some time of the social gradient in health status in both Canada and the United States,14 this is the first time that we have been able to examine the question of whether there are systematic differences in health status by social position in the two countries. One of the important findings of this survey is that Americans in the poorest income quintile report fair or poor health, obesity and severe mobility impairment more frequently than their Canadian counterparts. At the other end of the income spectrum, there are no systematic differences in the reporting of fair or poor health or mobility impairment among the most affluent households on either side of the border.
This report represents a first look at the results from the JCUSH. While it highlights a range of similarities and differences between the two countries, additional in-depth analyses are required to better understand these results, particularly in those areas where Canadians and Americans differ. Researchers from both Statistics Canada and the United States National Center for Health Statistics will be using the JCUSH data to conduct further analyses in key areas over the coming months.
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