Determinants of Health Behaviors in Adults with Diabetes

Presenter Name: Pei-Shu Ho, Ph.D

Institution: National Rehabilitation Hospital – Center for Health and Disability Research

Primary Research Interests: Health care outcomes, access to care, and employment for older adults with disabilities

INTRODUCTION

Previous studies have demonstrated that diabetes is associated with increased comorbidity (e. g., hypertension, heart disease, kidney problems, and stroke) and decreased functional health in the general population. Despite the increased prevalence of diabetes and diabetes-related comorbidity and functional limitations, no study has examined (1) how adults with diabetes and functional limitations differ from those without functional limitations, and (2) how personal characteristics are related to health behaviors in adults with diabetes and functional limitations.

RESEARCH OBJECTIVE/RESEARCH QUESTION

The purpose of this study was to examine the factors that are associated with health behaviors in adults with diabetes-related functional limitations. Three specific aims were:

To examine the characteristics of adults with diabetes and diabetes-related functional limitations; To examine the differences in personal characteristics and health behaviors between adults with and without functional limitations; and To examine factors that are associated with health behaviors in adults with diabetes and functional limitations.

METHODS

Study Design and Data Source

This study used a retrospective, cross-sectional design. The data used in this study came from Sample Adult and Person level files of the 2001 National Health Interview Survey (NHIS). The NHIS was conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). This survey collects information on the health of the civilian, non-institutionalized, household population of the United States.

Study Population

The target population was individuals who were 18 years old and older and resided in the community. The data included 2,285 cases representing an estimated 13,006,143 individuals with diabetes.

Statistical Analysis

For the analysis, the Sample Adult and Person level files were linked. The final annual weight was used in all the analyses in order to generalize to the national population. Descriptive, comparative, and multiple logistic regression analyses were conducted using SPSS software and SUDAAN. The Behavioral Model (Andersen, 1968 & 1995; Gelberg, Andersen, & Leake, 2000) was used as a theoretical framework to guide the analysis (Figure 1). The hypothesis was that individuals’ characteristics (e.g., socio-demographics, social structure, personal or community resources, and health conditions) are associated with their health behaviors.

Figure 1. The Behavioral Model

Population Characteristics Line Drawing. There are two lines: the top line has 5 categories horizontally. The bottom line of categories feed into each of the top categories. A list format has been used to describe the graphic. Note that categories A, B, and C have a box around them; D and E are excluded from the box. Each numbered item under a letter item is from the row below (arrows feed the lower information into the top categories). A. Predisposing 1. Demographics 2. Health beliefs 3. Social Structure B. Enabling 1. Personal / Family Resources 2. Community Resources C. Need 1. Perceived Health 2. Evaluated Health D. Health Behavior 1. Personal Practices 2. Health Services Use E. Outcomes 1. Health Status 2. Satisfaction with Care A. Predisposing B. Enabling C. Need

Overview of adults with diabetes.

Adults with diabetes

The overall prevalence rate of diabetes in adults was 6.4%. Most of them were Whites (77%), non-Hispanic (88%), married (61%), and between the ages of 45 and 64 (45%) with an average age of 59 years old. The rate of diabetes among both men and women was similar with a slightly higher rate in females (51%). Most of the adults with diabetes resided in the city (75%) and over 40% lived in the Southern region of the United States. Over half of the adults with diabetes were middle or high school graduates and close to one-third (31%) of them had a family annual income less than $20,000. The data also show that most of the adults with diabetes were obese (48%) and diagnosed with hypertension (63%); nearly one-fourth of them had trouble seeing even with glasses or lenses (24%). Most of the adults with diabetes had health insurance (92%). Over half of them were covered by private employer-based health insurance (54%). Over 40% of adults with diabetes were enrolled in Medicare and 12% in Medicaid.

The prevalence of diabetes also varied in different age, race, family income, and education groups. Overall, Blacks and adults between the ages of 65 and 74, with an annual family income less than $20,000, and an education of grade school or less had a higher rate of diabetes than did their counterparts.

Adults with diabetes-related functional limitations

Almost two-thirds of adults with diabetes had functional limitations (65%). Of people with functional limitations, one-third of them indicated that diabetes caused their difficulty with activities. Of adults with diabetes-related functional limitations, most of them were between the ages of 45 and 64 (49%), White (75%), non-Hispanic (90%), female (53%), married (54%), and middle or high school graduate (63%). This group also had a substantial number of individuals whose family annual income was less than $20,000 (43%). Over one-third of them had a health problem that required them to use special equipment (37%), such as a cane, wheelchair, a special bed, or a special telephone. Almost one-fifth of them were current smokers and close to one third of them were current drinkers. The percentage of health services utilization in adults with diabetes-related functional limitations was high. More than 40% of them had at least one hospital emergency room visit in the past year. At least half of them also had contacts with an eye doctor, a medical specialist, or a generalist, and had a flu vaccination in the past year. The majority took only diabetic pills (50%) for their diabetes. Over one-fifth took insulin (23%) or both insulin and diabetic pills (22%), and 5% did not take any medications for their diabetes. The finding also shows a relatively high percentage of non-working adults with diabetes-related functional limitations, particularly in adults between the ages of 45 and 64 whose non-participation rate was 49%.

Differences in personal characteristics and health behaviors between adult diabetics with and without functional limitations.

Compared to diabetics without functional limitations, diabetics with functional limitations were more likely to be older, female, and not married. They had a higher percentage of middle/high school graduates as well as people with a family annual income below $20,000. Adults with functional limitations were also more likely than their counterparts to perceive themselves in fair or poor health. The rate of chronic medical conditions, such as hypertension, coronary heart disease, stroke, weak/failing kidneys, and poor vision, was also high in adults with functional limitations. Further, the group of people with functional limitations was more likely to require special equipment such as a cane, wheelchair, a special bed, or a special telephone because of a health problem.

Diabetics with functional limitations were less likely than their counterparts to engage in physical activities in their leisure time. Most of them suffered from a weight problem. At least half of them were obese or overweight. They were also more likely to use tobacco or alcohol compared to adults without functional limitations.

Diabetics with functional limitations tended to use more health services than did diabetics without functional limitations. For instance, the percentage of hospital emergency room visits, surgery, home care, and doctor’s office visits was higher in adults with functional limitations than their counterparts. Adult diabetics with functional limitations were also more likely than their counterparts to get a flu vaccination or a pneumonia vaccination, and to contact an eye doctor or a foot doctor. They also reported barriers to accessing timely medical care. For instance, the percentage of those requiring transportation to get medical care and needing resources for prescription medicine or eyeglasses was higher than that of adult diabetics without functional limitations.

Factors that are associated with health behaviors in adults with diabetes and functional limitations.

Health risk behaviors

Adult diabetics with functional limitations who were younger and not involved in religious activities had a greater chance of engaging in health risk behaviors (e.g., drinking and smoking) than their counterparts. In addition, those who were males, had higher education and income, and perceived themselves in good health had a greater chance of drinking.

Preventive care practices

The engagement in preventive health practices (e.g., exercise, flu shot) was associated with demographic characteristics, social structure, personal or family resources, and health care need. For instance, people, who were younger, had a higher education, perceived themselves in good health, and had been to group events in the past (e.g., went to a movie or sport event), had a greater chance of engaging in physical activities in their leisure time than did their counterparts. In addition, people, who were older, Black, and had smaller families, health insurance, and higher income, had a greater chance of having received a flu shot in the past 12 months than did their counterparts.

Health services utilization

The odds of contacting health care providers or using health services in adults with diabetes were also associated with demographic characteristics, social structure, personal or family resources, and health care need. For instance, people, who had smaller families, health insurance, and higher income, and resided in the city, had a greater chance of seeing or talking to an eye doctor (optometrist or ophthalmologist) in the past 12 months. In addition, individuals who were females, had not been to group events in the past, had low income, resided in the city, and perceived themselves in poor health had a greater chance of visiting a hospital emergency room in the past 12 months.

CONCLUSIONS

In summary, determinants of health behaviors in adults with diabetes and functional limitations are consistently associated with individual’s age, social structure, personal or community resources, and health care needs. In particular, adult diabetics with functional limitations are more likely to use health services and engage in health risk behaviors than adult diabetics without functional limitations are. Further, older working-age adults with diabetes-related functional limitations are less likely to work.

IMPLICATIONS

Research:

  1. Current research used cross-sectional data that did not allow us to examine the direct impact of health behaviors on health outcomes among adults with diabetes-related functional limitations. It is recommended that a prospective and longitudinal study be used in future research.

Policy:

  1. The findings show that older working-age adults (between the ages of 45 and 64 years old) with diabetes-related functional limitations had a very high non-employment rate. It is important to know how the implementation of the Ticket to Work and Work Incentives Improvement Act (TWWIIA) affects this population.

References

Andersen, R. M. (1995). Revisiting the behavior model and access to care: Does it matter? Journal of Health and Social Behavior, 36(1): 1-10.

Andersen, R. M. (1968). Behavior models of families’ use of health services. Research Series No. 15. Center for Health Administration Studies, University of Chicago.

Gelberg, L., Andersen, R. M., & Leake, B. D. (2000). The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people.