Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

In amenable mortality--deaths avoidable through health care--progress in the US lags that of three European countries

We examined trends and patterns of amenable mortality-deaths that should not occur in the presence of timely and effective health care-in the United States compared to those in France, Germany, and the United Kingdom between 1999 and 2007. Americans under age sixty-five during this period had elevated rates of amenable mortality compared to their peers in Europe. For Americans over age sixty-five, declines in amenable mortality slowed relative to their peers in Europe. Overall, amenable mortality rates among men from 1999 to 2007 fell by only 18.5 percent in the United States compared to 36.9 percent in the United Kingdom. Among women, the rates fell by 17.5 percent and 31.9 percent, respectively. Although US men and women had the lowest mortality from treatable cancers among the four countries, deaths from circulatory conditions-chiefly cerebrovascular disease and hypertension-were the main reason amenable death rates remained relatively high in the United States. These findings strengthen the case for reforms that will enable all Americans to receive timely and effective health care.

What are patient factors associated with the quality of diabetes care?: results from the Korean National Health and Nutrition Examination Survey

BACKGROUND

Recently there has been a growing interest in healthcare quality control in Korea. We examined the association between patient factors and quality indicators of diabetic care among Korean adults with diabetes.

METHODS

We obtained a sample of 335 adults aged 20 or older diagnosed with diabetes from the 2005 Korean National Health and Nutrition Examination Survey. Patient factors were divided into two categories: socioeconomic position and health-related factors. Quality indicators for diabetes care were defined as receiving preventive care services for diabetes complications (e.g., fundus examination, microalbuminuria examination, diabetes education) and diabetes-related clinical outcomes (e.g., HbA1c, blood pressure, LDL-cholesterol). We performed multiple logistic regression analyses for each quality indicator.

RESULTS

We found that people with lower education levels or shorter duration of diabetes illness were less likely to receive preventive care services for diabetes complications. Women or people with longer duration of diabetes were less likely to reach the glycemic target. Obese diabetic patients were less likely to accomplish adequate control of blood pressure and LDL-cholesterol.

CONCLUSIONS

Several factors of patients with diabetes, such as education level, duration of illness, gender, and obesity grade are associated with the quality of diabetes care. These findings can help inform policy makers about subpopulations at risk in developing a public health strategy in the future.

Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study

OBJECTIVE

To assess the contribution of modifiable risk factors to social inequalities in the incidence of type 2 diabetes when these factors are measured at study baseline or repeatedly over follow-up and when long term exposure is accounted for.

DESIGN

Prospective cohort study with risk factors (health behaviours (smoking, alcohol consumption, diet, and physical activity), body mass index, and biological risk markers (systolic blood pressure, triglycerides and high density lipoprotein cholesterol)) measured four times and diabetes status assessed seven times between 1991-93 and 2007-09.

SETTING

Civil service departments in London (Whitehall II study).

PARTICIPANTS

7237 adults without diabetes (mean age 49.4 years; 2196 women).

MAIN OUTCOME MEASURES

Incidence of type 2 diabetes and contribution of risk factors to its association with socioeconomic status.

RESULTS

Over a mean follow-up of 14.2 years, 818 incident cases of diabetes were identified. Participants in the lowest occupational category had a 1.86-fold (hazard ratio 1.86, 95% confidence interval 1.48 to 2.32) greater risk of developing diabetes relative to those in the highest occupational category. Health behaviours and body mass index explained 33% (-1% to 78%) of this socioeconomic differential when risk factors were assessed at study baseline (attenuation of hazard ratio from 1.86 to 1.51), 36% (22% to 66%) when they were assessed repeatedly over the follow-up (attenuated hazard ratio 1.48), and 45% (28% to 75%) when long term exposure over the follow-up was accounted for (attenuated hazard ratio 1.41). With additional adjustment for biological risk markers, a total of 53% (29% to 88%) of the socioeconomic differential was explained (attenuated hazard ratio 1.35, 1.05 to 1.72).

CONCLUSIONS

Modifiable risk factors such as health behaviours and obesity, when measured repeatedly over time, explain almost half of the social inequalities in incidence of type 2 diabetes. This is more than was seen in previous studies based on single measurement of risk factors.

Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study

BACKGROUND

To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.

METHODS

Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.

RESULTS

A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell's c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.

CONCLUSIONS

The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.

Nature, nurture, or that fast food hamburger: media framing of diabetes in the New York Times from 2000 to 2010

Diabetes is a growing yet misunderstood health concern in the United States. This study examined the ways in which diabetes has been framed by the New York Times over the past decade. The public's perception of the causes and solutions to complex problems such as diabetes has significant implications for the way public policy interventions are viewed; therefore, understanding how diabetes is being framed in the media can be an important first step in shifting public opinion about ways to combat the disease. A content analysis of 239 articles published in the New York Times between 2000 and 2010 revealed that nearly one-third of articles failed to differentiate between type 1, type 2, and gestational diabetes, which may cause confusion given substantial differences in the root cause and treatment of each. An examination of frames used within each type of diabetes showed that the overall dominant frame across types was either a medical frame or a behavioral frame, with deficient use of a societal frame. The limited use of societal-level framing may make it difficult for the public to see the wider consequences of diabetes and decreases the likelihood of public support for policy solutions to combat the disease.

Lower educational level is a predictor of incident type 2 diabetes in European countries: the EPIC-InterAct study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases worldwide. In high-income countries, low socioeconomic status seems to be related to a high incidence of T2DM, but very little is known about the intermediate factors of this relationship. Method We performed a case-cohort study in eight Western European countries nested in the EPIC study (n = 340, 234, 3.99 million person-years of follow-up). A random sub-cohort of 16,835 individuals and a total of 12,403 incident cases of T2DM were identified. Crude and multivariate-adjusted hazard ratios (HR) were estimated for each country and pooled across countries using meta-analytical methods. Age-, gender- and country-specific relative indices of inequality (RII) were used as the measure of educational level and RII tertiles were analysed.

RESULTS

Compared with participants with a high educational level (RII tertile 1), participants with a low educational level (RII tertile 3) had a higher risk of T2DM [HR: 1.77, 95% confidence interval (CI): 1.69-1.85; P-trend < 0.01]. The HRs adjusted for physical activity, smoking status and propensity score according to macronutrient intake were very similar to the crude HR (adjusted HR: 1.67, 95% CI: 1.52-1.83 in men; HR: 1.88, 95% CI: 1.73-2.05 in women). The HRs were attenuated only when they were further adjusted for BMI (BMI-adjusted HR: 1.36, 95% CI: 1.23-1.51 in men; HR: 1.32, 95% CI: 1.20-1.45 in women).

CONCLUSION

This study demonstrates the inequalities in the risk of T2DM in Western European countries, with an inverse relationship between educational level and risk of T2DM that is only partially explained by variations in BMI.

Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes

BACKGROUND

Few studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes.

OBJECTIVE

To assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens.

DESIGN

A cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status.

PARTICIPANTS

Adults with type 2 diabetes currently receiving medical treatment.

MAIN MEASURES

Patient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care).

KEY RESULTS

Self-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62).

CONCLUSIONS

Contextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.

Association between socioeconomic status and self-reported diabetes in India: a cross-sectional multilevel analysis

OBJECTIVES

To quantify the association between socioeconomic status (SES) and type 2 diabetes in India.

DESIGN

Nationally representative cross-sectional household survey.

SETTING

Urban and rural areas across 29 states in India.

PARTICIPANTS

168 135 survey respondents aged 18-49 years (women) and 18-54 years (men).

PRIMARY OUTCOME MEASURE

Self-reported diabetes status.

RESULTS

Markers of SES were social caste, household wealth and education. The overall prevalence of self-reported diabetes was 1.5%; this increased to 1.9% and 2.5% for those with the highest levels of education and household wealth, respectively. In multilevel logistic regression models (adjusted for age, gender, religion, marital status and place of residence), education (OR 1.87 for higher education vs no education) and household wealth (OR 4.04 for richest quintile vs poorest) were positively related to self-reported diabetes (p<0.0001). In a fully adjusted model including all socioeconomic variables and body mass index, household wealth emerged as positive and statistically significant with an OR for self-reported diabetes of 2.58 (95% credible interval (CrI): 1.99 to 3.40) for the richest quintile of household wealth versus the poorest. Nationally in India, a one-quintile increase in household wealth was associated with an OR of 1.31 (95% CrI 1.20 to 1.42) for self-reported diabetes. This association was consistent across states with the relationship found to be positive in 97% of states (28 of 29) and statistically significant in 69% (20 of 29 states).

CONCLUSIONS

The authors found that the highest SES groups in India appear to be at greatest risk for type 2 diabetes. This raises important policy implications for addressing the disease burdens among the poor versus those among the non-poor in the context of India, where >40% of the population is living in poverty.

'You get the quickest and the cheapest stuff you can': Food security issues among low-income earners living with diabetes

BACKGROUND

Diabetes prevalence is increasing worldwide. More than 800,000 Australians live with diabetes, and there are stark inequities in prevalence and clinical outcomes among Indigenous people and low socio-economic groups.

AIMS

This paper focuses on food security issues experienced by low-income earners living with type 2 diabetes in Perth, Western Australia. The results presented here are part of a broader qualitative study exploring the impact of socioeconomic disadvantage on diabetes.

METHOD

Data was collected through focus groups and semistructured interviews conducted from October 2008 to November 2009. The sample, comprising 38 participants ( Indigenous and non-Indigenous), was recruited from areas with high indices of socio-economic disadvantage in Perth. Deductive data analysis identified categories from an existing conceptual framework for the relationship between socio-economic position and diabetes health outcomes, while an inductive approach was adopted to identify new themes.

RESULTS

Participants had a good understanding of their dietary requirements. However, access to healthy food was not always realised, as many participants depended on others for food provision and meal preparation and had little control over their diets. Furthermore, the majority struggled to accommodate the price of healthy food within a limited budget.

CONCLUSION

In this study, low-income earners living with diabetes faced food security issues. Participants reported cost barriers, but also physical barriers relating to functional limitations and lack of transport. This study highlights that the socioeconomic circumstances in which vulnerable populations experience their disease need to be understood and addressed in order to reduce the inequities surrounding diabetes outcomes.

Screening for deprivation using the EPICES score: a tool for detecting patients at high risk of diabetic complications and poor quality of life

AIM

Deprivation has been linked to more complicated and uncontrolled diabetes. The validated Évaluation de la précarité et des inégalités de santé dans les centres d'examens de santé (EPICES; Evaluation of the Deprivation and Inequalities of Health in Healthcare Centres) score could help to identify such deprived patients. The present study evaluated the relationships between deprivation and prevalence of complications, uncontrolled diabetes and quality of life.

METHODS

This prospective study was conducted in the diabetology department of a tertiary university hospital from November 2006 to July 2007. Patients with diabetes were divided into two groups, according to their deprivation status [non-deprived: EPICES score<30.17; deprived: EPICES score≥30.17 (56.5%)]. Diabetes control, complications and quality of life [Short Form Health Survey (SF-36)] were compared in the two groups.

RESULTS

Of a total of 102 patients, 97 completed all of the questionnaires: 18 had type 1 diabetes and 79 had type 2 diabetes, in a geographical area moderately affected by deprivation. No statistical relationship could be demonstrated between deprivation and HbA(1c). Deprived patients with diabetes presented with higher levels of fasting blood glucose, lower levels of LDL cholesterol and a significantly higher risk of obesity (P=0.0020). As for complications, microalbuminuria was linked to deprivation (P=0.03), but no associations with other complications were found. Quality of life was poorer for all physical, mental and social dimensions in deprived patients.

CONCLUSION

In this diabetic population, deprivation and glycaemic control were not associated. However, more deprived subjects with diabetes were at higher risk of renal disease. A deprived state was related to an altered quality of life as assessed by the SF-36 score.

Predictors of adherence with self-care guidelines among persons with type 2 diabetes: results from a logistic regression tree analysis

Type 2 diabetes is known to contribute to health disparities in the U.S. and failure to adhere to recommended self-care behaviors is a contributing factor. Intervention programs face difficulties as a result of patient diversity and limited resources. With data from the 2005 Behavioral Risk Factor Surveillance System, this study employs a logistic regression tree algorithm to identify characteristics of sub-populations with type 2 diabetes according to their reported frequency of adherence to four recommended diabetes self-care behaviors including blood glucose monitoring, foot examination, eye examination and HbA1c testing. Using Andersen's health behavior model, need factors appear to dominate the definition of which sub-groups were at greatest risk for low as well as high adherence. Findings demonstrate the utility of easily interpreted tree diagrams to design specific culturally appropriate intervention programs targeting sub-populations of diabetes patients who need to improve their self-care behaviors. Limitations and contributions of the study are discussed.

The socioeconomic gradient of diabetes prevalence, awareness, treatment, and control among African Americans in the Jackson Heart Study

PURPOSE

Little research has focused on the social patterning of diabetes among African Americans. We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans.

METHODS

Education, income and occupation were examined among 4,303 participants (2,726 women and 1,577 men). Poisson regression estimated relative probabilities (RP) of diabetes outcomes by SES.

RESULTS

The prevalence of diabetes was 19.6% in women and 15.9% in men. Diabetes awareness, treatment, and control were 90.0%, 86.8%, and 39.2% in women, respectively, and 88.2%, 84.4%, and 35.9% in men, respectively. In adjusted models, low-income men and women had greater probabilities of diabetes than high-income men and women (RP, 1.94; 95% confidence interval [CI], 1.28-2.92; and RP, 1.35; 95% CI, 1.04-1.74, respectively). Lack of awareness was associated with low education and low occupation in women (RP, 2.28; 95%CI 1.01-5.18; and RP, 2.62; 95% CI, 1.08-6.33, respectively) but not in men. Lack of treatment was associated with low education in women. Diabetes control was not patterned by SES.

CONCLUSIONS

Diabetes prevalence is patterned by SES, and awareness and treatment are patterned by SES in women but not men. Efforts to prevent diabetes in African Americans need to address the factors that place those of low SES at higher risk.

Hemoglobin A1c as a diagnostic tool: public health implications from an actor-network perspective

Public health arguments for collecting hemoglobin A1c (HbA1c) data, particularly in clinical settings, should be reframed to place more emphasis on nonmedical determinants of population health. We compare individual- with population-level interpretations of HbA1c titers. This comparison reveals that public health researchers need to pay close attention to diagnostic tests and their uses, including rhetorical uses. We also synthesize historical and current evidence to map out 2 possible scenarios for the future. In the first scenario, prevention efforts emphasize primary care and focus almost entirely downstream. The second scenario anticipates downstream interventions but also upstream interventions targeting environments. Our analysis adapts actor-network theory to strategic planning and forecasting in public health.

Variations in amenable mortality--trends in 16 high-income nations

BACKGROUND

There has been growing interest in the comparison of health system performance within and between countries, using a range of different indicators. This study examines trends in amenable mortality, as one measure of health system performance, in sixteen high-income countries.

METHODS

Amenable mortality was defined as premature death from causes that should not occur in the presence of timely and effective health care. We analysed age-standardised rates of amenable mortality under age 75 in 16 countries for 1997/1998 and 2006/2007.

RESULTS

Amenable mortality remains an important contributor to premature mortality in 16 high-income countries, accounting for 24% of deaths under age 75. Between 1997/1998 and 2006/2007, amenable mortality fell by between 20.5% in the US and 42.1% in Ireland (average decline: 31%). In 2007, amenable mortality in the US was almost twice that in France, which had the lowest levels.

CONCLUSIONS

Amenable mortality continues to fall across high-income nations although the USA is lagging increasingly behind other high income countries. Despite its many limitations, amenable mortality remains a useful indicator to monitor progress of nations.

Adherence to guidelines for youths with diabetes mellitus

OBJECTIVE

To describe demographic and clinical characteristics associated with self-reported receipt of tests and measurements recommended by the American Diabetes Association (ADA) for children and youths with diabetes.

METHODS

The study included 1514 SEARCH for Diabetes in Youth study participants who completed a survey about diabetes care received. Quality-of-care measures were based on ADA guidelines for eye examinations and glycohemoglobin (hemoglobin A1c [HbA1c]), lipid level, microalbuminuria, and blood pressure measurements, and a composite variable of these 5 indicators was created. Multivariate logistic regression models were used to assess the association of selected demographic and clinical characteristics with the reported receipt of all recommended tests and measurements according to age and diabetes type subgroups.

RESULTS

Overall, 95% of the participants reported having their blood pressure checked at all or most visits, 88% had lipid levels measured, 83% had kidney function tested, 68% underwent HbA1c testing, and 66% underwent an eye examination, in accordance with ADA recommendations. Participants aged 18 years or older, particularly those with type 2 diabetes, tended to have fewer tests of all kinds performed. Age and family income emerged as important correlates of overall quality of care in multivariate models; older age and lower income were associated with not meeting guidelines.

CONCLUSIONS

Although there was relatively good adherence to ADA-recommended guidelines for most indicators, efforts are needed to improve rates of HbA1c testing and eye examinations, particularly among older youths.

Neighborhood environment and health status and mortality among veterans

BACKGROUND

The VHA is the largest integrated US health system and is increasingly moving care into the communities where veterans reside. Veterans who utilize the VA for their care have worse health status than the general population. However, there is limited evidence about the association of neighborhood environment and health outcomes among veterans.

OBJECTIVES

The primary aim of this study is to assess the relative contribution of neighborhood environment, health system, and individual characteristics to health status and mortality of veterans.

METHODS

Information on personal socio-economic indicators, existing medical conditions and health status were obtained from baseline data from a multi-site, randomized trial of primary care patients (n = 15,889). The physical component scale (PCS) and mental component scale (MCS) summarized health status. Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized the neighborhood socio-economic environment and walkability. Data were analyzed with multilevel hierarchical models. Analyses of health status were cross-sectional. Mortality analyses were longitudinal as participants were followed for an average of 722.5 days to ascertain vital status.

RESULTS

Neighborhood SES was associated with PCS and MCS scores, controlling for individual socio-economic status, self-reported co-morbid disease, smoking status, and health care access. In the lowest versus highest quartiles of neighborhood SES, adjusted PCS scores were 34.4 vs. 35.4 (p < 0.05) and adjusted MCS scores were 46.2 versus 47.0 (p < 0.05). PCS score was also significantly associated with neighborhood walkability (p < 0.05). Mortality was lower for veterans living in neighborhoods with the highest decile neighborhood SES (HR 0.78, highest vs. lowest decile 95% CI 0.63, 0.97).

CONCLUSIONS

Veterans living in lower SES neighborhoods have poorer health status and a higher risk of mortality, independent of individual characteristics and health care access. Neighborhood walkability was associated with higher PCS scores.

Quality of life in people with type 2 diabetes in relation to deprivation, gender, and age in a new community-based model of care

Objectives. To evaluate changes in health related quality of life (HRQL) for individuals with Type 2 diabetes following the introduction of a new community-based model of care. Methods. A survey method was used in which HRQL, Problems Areas In Diabetes (PAID) and demographics were assessed before and 18 months after introducing the new service. Results. Overall HRQL and PAID scores were lower than published levels in individuals with diabetes but remained stable during the transition to the new model of care except for the bodily pain domain and deteriorating PAID scores for older patients. Four domains of SF36 health showed deterioration in the highest socio-economic groups. Deterioration was also observed in males, most notably mental health, in patients aged 54 years or less, 75 years or more and patients from socio-economic groups 1 and 2. HRQL was lowest at baseline and follow-up in socio-economic groups 6 & 7. Low levels of distress in patients across all deprivation categories was observed but remained stable over the transition. Conclusions. HRQL and distress associated with diabetes remained stable following the introduction of the new community-based model of care except for deterioration in the bodily pain domain and deteriorating PAID scores for older patients. Relevance for Practice. (i) Health related quality of life assessment is practical and acceptable to patients. (ii) In clinical governance terms it is good practice to monitor the impact of change in service delivery on the health of the patients in your care. (iii) Screening with health related quality of life tools such as generic and disease specific tools could help identify health problems otherwise undetected within current clinical care. Systematic identification of the most vulnerable groups with Type 2 diabetes should allow care to be better targeted.

Is diabetes-specific health literacy associated with diabetes-related outcomes in older adults?

BACKGROUND

 The present study examined the association between a measure of diabetes-specific health literacy and three different Type 2 diabetes outcome indicators in a national sample of older adults.

METHODS

Data were taken from the Health and Retirement Study (HRS) 2003 Diabetes module and the HRS 2002 core wave. Analysis was performed on data from 1318 respondents aged 42-96 years [mean (±SD) 67.96 ± 8.65 years] who submitted responses on all relevant independent variable measures along with an HbA1c test kit. The index of diabetes-specific health literacy was constructed from responses to 10 diabetes self-care regimen items (α = 0.927).

RESULTS

Using a multivariate regression strategy to analyze weighted data, the diabetes-specific health literacy index was significantly and positively associated with self-graded assessment of diabetes self-care (R2 = 0.231). However, diabetes-specific health literacy was not independently associated with the HbA1c level or the average number of days five recommended self-management behaviors were practiced each week.

CONCLUSIONS

 No previous single study has focused on the relationship between diabetes-specific health literacy and multiple diabetes-related outcomes. The direct association of diabetes-specific health literacy with patients' assessment of their self-care practice acumen is useful information for the design of effective patient intervention and/or communication strategies. Health literacy is a broad, multidimensional construct that bridges basic literacy skills and various health and illness contexts. Because it is so important to adults engaged in the self-management of chronic illness, indicators of disease-specific knowledge and/or understanding should be included in efforts to measure health literacy.

Income, wealth and risk of diabetes among older adults: cohort study using the English longitudinal study of ageing

BACKGROUND

Socio-economic status has been associated with diabetes in cross-sectional studies. This study aimed to evaluate associations of household income and wealth with both prevalent and incident diabetes among older adults in the UK. It also evaluated the association between obesity and socio-economic status.

METHODS

A cohort of people aged ≥50 years was selected from the English Longitudinal Study of Ageing. The relation of prevalent and incident self-reported physician diagnosed diabetes to household income and wealth was evaluated in logistic regression models adjusting for education, social class, housing tenure, age, ethnicity, marital status, body mass index (BMI), smoking, alcohol use and physical activity stratified by sex. The relation of prevalent obesity to household income and wealth was also evaluated using logistic regression models.

RESULTS

There were 9053 participants (4021 men and 5032 women) including 721 (8.0%) with diabetes at baseline. Among 8332 participants initially free from diabetes, 246 (3.0%) were diagnosed with diabetes during ∼4 years follow-up. The adjusted odds ratio for prevalent diabetes in the lowest quintile of wealth compared with the highest was 1.56 for men and 2.08 for women. Incident diabetes was associated with lower wealth (P for trend 0.05 for men and 0.004 for women) after adjusting for socio-economic and demographic factors, but attenuated after further adjustment for lifestyle and BMI. Prevalent obesity was significantly associated with lower wealth in women but not in men.

CONCLUSION

Lower wealth, but not income, may be associated with prevalent and incident diabetes among older adults in UK.

Effect of socioeconomic status on mortality among people with type 2 diabetes: a study from the Scottish Diabetes Research Network Epidemiology Group

OBJECTIVE

The study objective was to describe the effect of socioeconomic status (SES) on mortality among people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We used a population-based national electronic diabetes database for 35- to 84-year-olds in Scotland for 2001-2007 linked to mortality records. SES was derived from an area-based measure with Q5 and Q1 representing the most deprived and affluent quintiles, respectively. Poisson regression was used to estimate relative risks (RRs) for mortality among people with type 2 diabetes compared with the population without diabetes stratified by age (35-64 and 65-84 years), sex, duration of diabetes (< 2 and ≥ 2 years), and SES.

RESULTS

Complete data were available for 210,994 eligible individuals (99.4%), and there were 33,842 deaths. Absolute mortality from all causes among people with type 2 diabetes increased with increasing age and socioeconomic deprivation and was higher for men than women. RR for mortality associated with type 2 diabetes was highest for women aged 35-64 years in Q1 with diabetes duration < 2 years at 4.83 (95% CI 3.15-7.40) and lowest for men aged 65-84 years in Q5 with diabetes duration ≥ 2 years at 1.13 (1.03-1.24).

CONCLUSIONS

SES modifies the association between type 2 diabetes and mortality so that RR for mortality is lower among more deprived populations. Age, sex, and duration of diabetes also interact with type 2 diabetes to influence RR of mortality. Differences in prevalence of comorbidities may explain these findings.

Health insurance doesn't seem to discourage prevention among diabetes patients in Colombia

In the South American nation of Colombia, as elsewhere, patients with type 2 diabetes often avoid care that could prevent their condition from worsening. Availability of health insurance may play a role in explaining this behavior. Some patients with diabetes skip preventive measures because they have insurance and calculate that they can access curative services later in life. Insurers may limit preventive services coverage because they can't be assured of sharing in the eventual savings that emerge when a chronic condition such as diabetes is managed properly. Our analysis of a nationally representative sample of Colombians who have type 2 diabetes and who pay premiums into the country's "contributory" insurance program, found no evidence that insurance influences those individuals to avoid preventive services. The evidence is less clear for those participating in a different, fully subsidized insurance program, who-despite the availability of preventive care-are no more likely to seek preventive visits than are uninsured patients. We propose controlled experiments to identify and measure the true causal effects of insurance on prevention and, more broadly, steps to increase patients' understanding of the benefits of prevention.

Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis, the first to our knowledge, summarizing and quantifying the published evidence on associations between type 2 diabetes incidence and socio-economic position (SEP) (measured by educational level, occupation and income) worldwide and when sub-divided into high-, middle- and low-income countries.

METHODS

Relevant case-control and cohort studies published between 1966 and January 2010 were searched in PubMed and EMBASE using the keywords: diabetes vs educational level, occupation or income. All identified citations were screened by one author, and two authors independently evaluated and extracted data from relevant publications. Risk estimates from individual studies were pooled using random-effects models quantifying the associations.

RESULTS

Out of 5120 citations, 23 studies, including 41 measures of association, were found to be relevant. Compared with high educational level, occupation and income, low levels of these determinants were associated with an overall increased risk of type 2 diabetes; [relative risk (RR) = 1.41, 95% confidence interval (CI): 1.28-1.51], (RR = 1.31, 95% CI: 1.09-1.57) and (RR = 1.40, 95% CI: 1.04-1.88), respectively. The increased risks were independent of the income levels of countries, although based on limited data in middle- and low-income countries.

CONCLUSIONS

The risk of getting type 2 diabetes was associated with low SEP in high-, middle- and low-income countries and overall. The strength of the associations was consistent in high-income countries, whereas there is a strong need for further investigation in middle- and low-income countries.

Life-course socioeconomic position and type 2 diabetes mellitus: The Framingham Offspring Study

Evidence is lacking on whether the duration and timing of low socioeconomic position (SEP) across a person's life course may be associated with incidence of type 2 diabetes mellitus (T2D). The authors' objectives were to investigate associations between cumulative SEP and the incidence of T2D in the Framingham Offspring Study (n = 1,893; 52% women; mean baseline age = 34 years). Pooled logistic regression analyses demonstrated that age-adjusted cumulative SEP was associated with T2D in women (for low vs. high cumulative SEP, odds ratio (OR) = 1.92, 95% confidence interval (CI): 1.08, 3.42). Age-adjusted analyses for young-adulthood SEP (7.85 for ≤12 vs. >16 years of education, OR = 2.84, 95% CI: 1.03), active professional life SEP (for laborer vs. professional/executive/supervisory/technical occupations, OR = 2.40, 95% CI: 1.05, 5.47), and social-mobility frameworks (for declining life-course SEP, OR = 2.99, 95% CI: 1.39, 6.44; for stable low vs. stable high life-course SEP, OR = 1.85, 95% CI: 1.02, 3.35) all demonstrated associations between low SEP and T2D incidence in women. No association was observed between childhood SEP and T2D in women for father's education (some high school or less vs. any postsecondary education, OR = 1.26, 95% CI: 0.72, 2.22). In men, there was little evidence of associations between life-course SEP and T2D incidence. These findings suggest that cumulative SEP is inversely associated with incidence of T2D in women, and that this association may be primarily due to the women's educational levels and occupations.

Images of illness: how causal claims and racial associations influence public preferences toward diabetes research spending

Despite the salience of health disparities in media and policy discourse, little previous research has investigated if imagery associating an illness with a certain racial group influences public perceptions. This study evaluated the influence of the media's presentation of the causes of type 2 diabetes and its implicit racial associations on attitudes toward people with diabetes and preferences toward research spending. Survey participants who viewed an article on genetic causation or social determinants of diabetes were more likely to support increased government spending on research than those viewing an article with no causal language, while participants viewing an article on behavioral choices were more likely to attribute negative stereotypes to people with diabetes. Participants who viewed a photo of a black woman accompanying the article were less likely to endorse negative stereotypes than those viewing a photo of a white woman, but those who viewed a photo of a glucose-testing device expressed the lowest negative stereotypes. The effect of social determinants language was significantly different for blacks and whites, lowering stereotypes only among blacks. Emphasizing the behavioral causes of diabetes, as is common in media coverage, may perpetuate negative stereotypes. While drawing attention to the social determinants that shape these behaviors could mitigate stereotypes, this strategy is unlikely to influence the public uniformly.

The relationship between socioeconomic deprivation and metabolic/cardiovascular risk factors in a cohort of patients with type 2 diabetes mellitus

AIM

There is conflicting information on the impact of socioeconomic deprivation on outcomes in diabetes. Our aim was to study the relationship between socioeconomic deprivation and clinical outcome indicators in a patient cohort with type 2 diabetes mellitus [T2DM].

METHODS

We recruited a random sample of 446 patients with T2DM [57% male] stratified by Income Deprivation Measure. Data on patient specific socioeconomic status, educational attainment, behaviour and attitudes were gathered by patient interview. Data analysis was by logistic and linear regression with correction for age, gender and duration of diabetes.

RESULTS

The study cohort showed high levels of deprivation with 80% reporting a household annual income of <£20,000 and 69.5% having no formal educational qualification. The cohort was actively managed with high usage of lipid lowering [90.1%], antihypertensive [80.6%] and antiplatelet agents [78%] and correspondingly good control of modifiable risk factors: HbA1c 7.6 [1.4]%, systolic blood pressure 134.2 [20.6], diastolic blood pressure 72.7 [11.2]mmHg, total cholesterol 4.0 [0.9]mmol/L. Socioeconomic disadvantage was strongly related to measures of integration and attitude to diabetes. Despite this there were no significant or consistent relationships between Income Deprivation Measure/self-reported annual household income/educational attainment on metabolic or cardiovascular risk factors.

CONCLUSIONS

Successful management of modifiable risk factors can be achieved in a way that is independent of socioeconomic position.

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

Impact of early psychosocial factors (childhood socioeconomic factors and adversities) on future risk of type 2 diabetes, metabolic disturbances and obesity: a systematic review

Background

Psychological factors and socioeconomic status (SES) have a notable impact on health disparities, including type 2 diabetes risk. However, the link between childhood psychosocial factors, such as childhood adversities or parental SES, and metabolic disturbances is less well established. In addition, the lifetime perspective including adult socioeconomic factors remains of further interest.

We carried out a systematic review with the main question if there is evidence in population- or community-based studies that childhood adversities (like neglect, traumata and deprivation) have considerable impact on type 2 diabetes incidence and other metabolic disturbances. Also, parental SES was included in the search as risk factor for both, diabetes and adverse childhood experiences. Finally, we assumed that obesity might be a mediator for the association of childhood adversities with diabetes incidence. Therefore, we carried out a second review on obesity, applying a similar search strategy.

Methods

Two systematic reviews were carried out. Longitudinal, population- or community-based studies were included if they contained data on psychosocial factors in childhood and either diabetes incidence or obesity risk.

Results

We included ten studies comprising a total of 200,381 individuals. Eight out of ten studies indicated that low parental status was associated with type 2 diabetes incidence or the development of metabolic abnormalities. Adjustment for adult SES and obesity tended to attenuate the childhood SES-attributable risk but the association remained. For obesity, eleven studies were included with a total sample size of 70,420 participants. Four out of eleven studies observed an independent association of low childhood SES on the risk for overweight and obesity later in life.

Conclusions

Taken together, there is evidence that childhood SES is associated with type 2 diabetes and obesity in later life. The database on the role of psychological factors such as traumata and childhood adversities for the future risk of type 2 diabetes or obesity is too small to draw conclusions. Thus, more population-based longitudinal studies and international standards to assess psychosocial factors are needed to clarify the mechanisms leading to the observed health disparities.

Increasing socio-economic inequality in type 2 diabetes prevalence--repeated cross-sectional surveys in England 1994-2006

BACKGROUND

This study aimed to evaluate the association of rising type 2 diabetes prevalence with socio-economic inequality in diabetes.

METHODS

Data from the Health Survey for England were analysed for 1994, 1998, 2003 and 2006. This is a nationally representative annual survey of private households. Data for 41,643 individuals aged ≥35 years were included. The prevalence of self-reported diabetes diagnosed by a doctor was analysed in relation to household income, occupational social class and educational qualifications. Data were standardized for age using the European Standard Population for reference.

RESULTS

Prevalence of diagnosed diabetes increased in men from 3.74% in 1994 to 7.25% in 2006, and in women from 2.28% to 4.88%. In 1994, there were no associations between social class or educational level and diabetes prevalence evident. In 2006, there was evidence of a negative association in women [prevalence ratio for social class (IV + V vs. I) = 4.54, P-value for trend = 0.005; prevalence ratio for educational level ('none' vs. 'A-levels') = 1.96, P-value for trend = 0.001]. The Slope Index of Inequality (SII) for social class in women increased from -1.65 in 1994 to -4.95 [95% Confidence Interval (95% CI -8.52 to -1.38)] in 2006 and for level of education from -1.39 to -6.48 (95% CI -9.03 to -3.93). In men, diabetes prevalence was not associated with social class or level of education.

CONCLUSION

Increasing prevalence of type 2 diabetes has been associated with an increase of socio-economic inequality in women. There was no socio-economic gradient observed in men.

Who can respond to treatment? Identifying patient characteristics related to heterogeneity of treatment effects

BACKGROUND

Interest in comparative effectiveness research and the rising number of negative or "small effect" trials have stimulated research into differential response to treatment among subgroups of patients.

OBJECTIVE

To develop and test the Potential for Benefit Scale (PBS), a composite measure to identify subgroups of patients with differential potential for response to treatment, using diabetes as a model.

DESIGN

Cross-sectional and longitudinal cohort study.

SUBJECTS AND SETTING

Type 2 diabetes patients (n = 1361) were identified from 7 outpatient clinics serving a diverse population. Of these, 611 completed a 1-year follow-up.

MEASURES

To represent patients' health status, we used the Total Illness Burden Index, the Physical Function Index of the SF-36, the Center for Epidemiologic Studies Depression Scale, and the Diabetes Burden Scale. To represent personality characteristics related to health, we used the Provider-Dependent Health Care Orientation scale. We assessed the contribution of these measures to a composite scale of patients' potential for treatment response in terms of self-reported medication adherence and glycemic control.

RESULTS

Principal components analysis confirmed associations among these measures. The internal consistency reliability of the PBS was adequate (Cronbach alpha = 0.65). Patients in the lowest versus highest quartile of the PBS reported poorer adherence (18% vs. 55%, P < 0.001) and poorer glycemic control at baseline (mean hemoglobin A1c values: 7.75 vs. 7.39, P < 0.001). Those in the highest quartile of the PBS also were more likely to reach target values for glycemic control (HbA1c <7%) at 1-year follow-up, (adjusted OR = 1.61, P < 0.05).

CONCLUSIONS

The PBS, a composite scale, may be helpful in identifying patients with differential potential for response to treatment.

Educational disparities in mortality among adults with diabetes in the U.S

OBJECTIVE

To measure relative and absolute educational disparities in mortality among U.S. adults with diabetes and to compare their magnitude with disparities observed within the nondiabetic population.

RESEARCH DESIGN AND METHODS

A total of 85,867 individuals (5,007 with diabetes), aged 35-84 years, who participated in the National Health Interview Survey from 1986 to 1996 were followed for mortality through 31 December 2002. Relative and absolute educational disparities in all-cause, cardiovascular disease (CVD), and non-CVD mortality were measured.

RESULTS

In relative terms, the risk of all-cause mortality was 28% higher in diabetic adults with the lowest versus the highest position on the educational scale (relative index of inequality 1.28 [95% CI 1.08-1.53]). This inverse relationship reflected marked disparities in CVD mortality and was found in all age, sex, and race/ethnicity groups except Hispanics. Although substantial, this relative educational gradient in mortality among adults with diabetes was smaller than in the nondiabetic population. In absolute terms, diabetic adults with the lowest position on the educational scale suffered 503 excess deaths per 10,000 person-years of follow-up compared with those with the highest position. These absolute disparities were stronger than in the nondiabetic population. The results were even more striking for CVD mortality.

CONCLUSIONS

The risk of mortality differs substantially according to educational level among individuals with diabetes in the U.S. Although relative educational disparities in mortality are weaker in adults with versus without diabetes, their absolute impact is greater and translates into a major mortality burden.

Development and validation of a questionnaire to assess carbohydrate and insulin-dosing knowledge in youth with type 1 diabetes

OBJECTIVE The American Diabetes Association advocates insulin regimens for youth with type 1 diabetes that involve adjusting insulin dose based on carbohydrate intake and blood glucose level. Implementing these regimens requires knowledge about carbohydrate content of foods and subsequent calculations of insulin dose, skills that may be difficult to gauge in practice. Therefore, we sought to develop and validate a questionnaire, the PedCarbQuiz (PCQ), to assess carbohydrate and insulin-dosing knowledge in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS After development by an expert panel, the PCQ was administered to 75 youth with type 1 diabetes or their parents. Reliability was assessed by Cronbach alpha and split-half testing. To assess validity, scores were correlated with A1C, expert assessments, parent educational level, and complexity of insulin regimen. RESULTS PCQ mean score was 87 +/- 9.7% (range 42-98%). Cronbach alpha was 0.88, and correlation of split halves was 0.59 (P < 0.0001). Higher PCQ scores correlated significantly with lower A1C (r = -0.29, P = 0.01) and expert assessments (r = 0.56, P < 0.001). Scores were significantly higher in parents with college degrees than in those without (P = 0.01) and in participants with more complex insulin regimens (P = 0.003). CONCLUSIONS The PCQ is a novel, easily administered instrument to assess knowledge about carbohydrates and insulin dosing calculations. Initial analyses support the reliability and validity of the PCQ.

Childhood cognition and risk factors for cardiovascular disease in midadulthood: the 1958 British Birth Cohort Study

OBJECTIVES

We sought to establish whether associations between childhood cognition and risk factors for cardiovascular disease in adulthood are explained by common causes, or adult social position or health behavior.

METHODS

We analyzed associations between cognition at age 11 and cardiovascular disease risk factors at age 45 in the 1958 British birth cohort (n=9377), with and without adjustment for covariates.

RESULTS

General ability was inversely associated with systolic and diastolic blood pressure, glycosylated hemoglobin, triglycerides (in women), body mass index, and waist circumference. Systolic blood pressure decreased by 0.47 mm Hg (95% confidence interval [CI]=-0.90, -0.05) for a 1-standard-deviation increase in ability. Separate adjustment for social class at birth, education level by adulthood, adult social class, and health behaviors reduced the associations respectively by 14% to 34%, 36% to 50%, 14% to 36%, and 24% to 73%. Full adjustment reduced associations between ability and risk factors at age 45 years by 43% to 92%, abolishing all associations.

CONCLUSIONS

Increments across the distribution of childhood cognition are associated with improvements in cardiovascular risk profile in midlife, with associations primarily mediated through adult health behavior and social destinations.

Characteristics of insured patients with persistent gaps in diabetes care services: the Translating Research into Action for Diabetes (TRIAD) study

BACKGROUND

Although preventing diabetes complications requires long-term management, little is known about which patients persistently fail to get recommended care.

OBJECTIVE

To determine the frequency and correlates of persistent, long-term gaps in diabetes care.

METHOD

: The study population included 8392 patients with diabetes. Patient surveys and medical records from 10 health plans over 3 years provided data on socioeconomic characteristics, access to care, social support, and mental and physical health, and diabetes preventive care services. We defined a "persistent gap" as a participant's missing a preventive care service for the entire 3 years. Services considered included hemoglobin A1c, cholesterol, and albuminuria tests, and foot and dilated eye examinations.

RESULTS

Thirty percent of participants had at least 1 persistent gap. The most common gaps were lipid testing (11.6%), microalbuminuria testing (9.7%), and eye examinations (9.0%). Persistent gaps were 18% to 42% higher for young patients, lean persons, those with low income, employed persons, smokers, those with diabetes less than 5 years, and patients with none or 1 comorbid conditions. Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with gaps in care.

CONCLUSIONS

Persistent gaps in diabetes care are common even among insured patients. Patients with lower income, younger age, fewer years of diabetes, having fewer comorbidities, taking fewer medications, and poor health behaviors are vulnerable to persistent gaps in care and a group who warrant targeted interventions to improve preventive diabetes care.

Individual-level socioeconomic status is associated with worse asthma morbidity in patients with asthma

BACKGROUND

Low socioeconomic status (SES) has been linked to higher morbidity in patients with chronic diseases, but may be particularly relevant to asthma, as asthmatics of lower SES may have higher exposures to indoor (e.g., cockroaches, tobacco smoke) and outdoor (e.g., urban pollution) allergens, thus increasing risk for exacerbations.

METHODS

This study assessed associations between adult SES (measured according to educational level) and asthma morbidity, including asthma control; asthma-related emergency health service use; asthma self-efficacy, and asthma-related quality of life, in a Canadian cohort of 781 adult asthmatics. All patients underwent a sociodemographic and medical history interview and pulmonary function testing on the day of their asthma clinic visit, and completed a battery of questionnaires (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire, and Asthma Self-Efficacy Scale). General Linear Models assessed associations between SES and each morbidity measure.

RESULTS

Lower SES was associated with worse asthma control (F = 11.63, p < .001), greater emergency health service use (F = 5.09, p = .024), and worse asthma self-efficacy (F = 12.04, p < .01), independent of covariates. Logistic regression analyses revealed that patients with <12 years of education were 55% more likely to report an asthma-related emergency health service visit in the last year (OR = 1.55, 95%CI = 1.05-2.27). Lower SES was not related to worse asthma-related quality of life.

CONCLUSIONS

Results suggest that lower SES (measured according to education level), is associated with several indices of worse asthma morbidity, particularly worse asthma control, in adult asthmatics independent of disease severity. Results are consistent with previous studies linking lower SES to worse asthma in children, and add asthma to the list of chronic diseases affected by individual-level SES.