Socioeconomic status and glycemic control in adult patients with type 2 diabetes: a mediation analysis

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Abstract

Objective

The purpose of this study is to examine the contribution of health behaviors (self-management and coping), quality of care, and individual characteristics (depressive symptoms, self-efficacy, illness representations) as mediators in the relationship between socioeconomic status (SES) and glycemic control.

Methods

A sample of 295 adult patients with type 2 diabetes was recruited at the end of a diabetes education course. Glycemic control was evaluated through glycosylated hemoglobin (HbA _1c). Living in poverty and education level were used as indicators of SES.

Results

Bootstrapping analysis showed that the significant effects of poverty and education level on HbA _1c were mediated by avoidance coping and depressive symptoms. The representation that diabetes is unpredictable significantly mediated the relationship between living in poverty and HbA _1c, while healthy diet mediated the relationship between education level and HbA _1c.

Conclusions

To improve glycemic control among patients with low SES, professionals should regularly screen for depression, offering treatment when needed, and pay attention to patients' illness representations and coping strategies for handling stress related to their chronic disease. They should also support patients in improving their self-management skills for a healthy diet.

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Most cited references 63

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Development and validation of the Patient Assessment of Chronic Illness Care (PACIC).

Russell E. Glasgow, Edward H Wagner, Judith Schaefer … (2005)

There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model-measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support. A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied. Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC. The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32-0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation. The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.

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U.S. disparities in health: descriptions, causes, and mechanisms.

Nancy E Adler, David Rehkopf (2008)

Eliminating health disparities is a fundamental, though not always explicit, goal of public health research and practice. There is a burgeoning literature in this area, but a number of unresolved issues remain. These include the definition of what constitutes a disparity, the relationship of different bases of disadvantage, the ability to attribute cause from association, and the establishment of the mechanisms by which social disadvantage affects biological processes that get into the body, resulting in disease. We examine current definitions and empirical research on health disparities, particularly disparities associated with race/ethnicity and socioeconomic status, and discuss data structures and analytic strategies that allow causal inference about the health impacts of these and associated factors. We show that although health is consistently worse for individuals with few resources and for blacks as compared with whites, the extent of health disparities varies by outcome, time, and geographic location within the United States. Empirical work also demonstrates the importance of a joint consideration of race/ethnicity and social class. Finally, we discuss potential pathways, including exposure to chronic stress and resulting psychosocial and physiological responses to stress, that serve as mechanisms by which social disadvantage results in health disparities.

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Relationship of depression and diabetes self-care, medication adherence, and preventive care.

Elizabeth Lin, Wayne J Katon, Michael Von Korff … (2004)

We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open Diabetes Res Care

Journal ID (iso-abbrev): BMJ Open Diabetes Res Care

Journal ID (hwp): bmjdrc

Journal ID (publisher-id): bmjdrc

Title: BMJ Open Diabetes Research & Care

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2052-4897

Publication date Collection: 2016

Publication date (Electronic): 11 May 2016

Volume: 4

Issue: 1

Electronic Location Identifier: e000184

Affiliations

[1 ]Department of Psychology, Université du Québec à Montréal , Montréal, Québec, Canada

[2 ]CRCHUM , Montréal, Québec, Canada

[3 ]Department of Family and Emergency Medicine, Université de Montréal , Montréal, Québec, Canada

[4 ]Faculty of Nursing, Université de Montréal , Montréal, Québec, Canada

[5 ]Department of Psychiatry, Université de Montréal , Montréal, Québec, Canada

[6 ]Department of Medicine, Université de Montréal , Montréal, Québec, Canada

[7 ]PERFORM Centre, Concordia University , Montréal, Québec, Canada

[8 ]Institut Universitaire de Gériatrie de Montréal , Montréal, Québec, Canada

[9 ]Department of Social and Preventive Medicine, School of Public Health, Université de Montréal , Montréal, Québec, Canada

Author notes

[Correspondence to ] Dr Janie Houle; houle.janie@ 123456uqam.ca

Article

Publisher ID: bmjdrc-2015-000184

DOI: 10.1136/bmjdrc-2015-000184

PMC ID: 4873951

PubMed ID: 27239316

SO-VID: 911a6a28-35ec-46f8-bf82-33330b824e32

Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 14 December 2015

Date revision received : 27 February 2016

Date accepted : 22 March 2016

Funding

Funded by: Canadian Institutes of Health Research, http://dx.doi.org/10.13039/501100000024;

Socioeconomic status and glycemic control in adult patients with type 2 diabetes: a mediation analysis

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Abstract

Objective

Methods

Results

Conclusions

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UCL: UN SDG 01 No Poverty

Most cited references 63

Development and validation of the Patient Assessment of Chronic Illness Care (PACIC).

U.S. disparities in health: descriptions, causes, and mechanisms.

Relationship of depression and diabetes self-care, medication adherence, and preventive care.

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