Educational disparities in health behaviors among patients with diabetes: The Translating Research into Action for Diabetes (TRIAD) Study

Andrew J. Karter, Mark R. Stevens, Arleen F. Brown, O. Kenrik Duru, Edward W. Gregg, Tiffany L. Gary, Gloria L. Beckles, Chien Wen Tseng, David G. Marrero, Beth Waitzfelder, William H. Herman, John D. Piette, Monika M. Safford, Susan L. Ettner

Research output: Contribution to journalArticle

Abstract

Background. Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods. This observational study was based on a cohort of 8,763 survey respondents drawn from ∼180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results. Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion. The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Original languageEnglish (US)
Article number308
JournalBMC Public Health
Volume7
DOIs
StatePublished - 2007

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Health Behavior
Education
Research
Health
Self Care
Foot
Logistic Models
Smoking
Self-Examination
Exercise
Blood Glucose Self-Monitoring
Foot Ulcer
Self-Help Groups
Managed Care Programs
Peripheral Nervous System Diseases
Disease Management
Health Education
Observational Studies
Cluster Analysis
Communication

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

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Educational disparities in health behaviors among patients with diabetes : The Translating Research into Action for Diabetes (TRIAD) Study. / Karter, Andrew J.; Stevens, Mark R.; Brown, Arleen F.; Duru, O. Kenrik; Gregg, Edward W.; Gary, Tiffany L.; Beckles, Gloria L.; Tseng, Chien Wen; Marrero, David G.; Waitzfelder, Beth; Herman, William H.; Piette, John D.; Safford, Monika M.; Ettner, Susan L.

In: BMC Public Health, Vol. 7, 308, 2007.

Research output: Contribution to journalArticle

Karter, AJ, Stevens, MR, Brown, AF, Duru, OK, Gregg, EW, Gary, TL, Beckles, GL, Tseng, CW, Marrero, DG, Waitzfelder, B, Herman, WH, Piette, JD, Safford, MM & Ettner, SL 2007, 'Educational disparities in health behaviors among patients with diabetes: The Translating Research into Action for Diabetes (TRIAD) Study', BMC Public Health, vol. 7, 308. https://doi.org/10.1186/1471-2458-7-308
Karter, Andrew J. ; Stevens, Mark R. ; Brown, Arleen F. ; Duru, O. Kenrik ; Gregg, Edward W. ; Gary, Tiffany L. ; Beckles, Gloria L. ; Tseng, Chien Wen ; Marrero, David G. ; Waitzfelder, Beth ; Herman, William H. ; Piette, John D. ; Safford, Monika M. ; Ettner, Susan L. / Educational disparities in health behaviors among patients with diabetes : The Translating Research into Action for Diabetes (TRIAD) Study. In: BMC Public Health. 2007 ; Vol. 7.
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abstract = "Background. Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods. This observational study was based on a cohort of 8,763 survey respondents drawn from ∼180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ({"}education{"}) and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results. Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion. The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.",
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AU - Brown, Arleen F.

AU - Duru, O. Kenrik

AU - Gregg, Edward W.

AU - Gary, Tiffany L.

AU - Beckles, Gloria L.

AU - Tseng, Chien Wen

AU - Marrero, David G.

AU - Waitzfelder, Beth

AU - Herman, William H.

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AU - Safford, Monika M.

AU - Ettner, Susan L.

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N2 - Background. Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods. This observational study was based on a cohort of 8,763 survey respondents drawn from ∼180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results. Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion. The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

AB - Background. Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods. This observational study was based on a cohort of 8,763 survey respondents drawn from ∼180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results. Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion. The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

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