Knowledge about Diabetes and Participation in Diabetes Training Courses: The Need for Improving Health Care for Diabetes Patients with Low SES

Abstract

The association between socioeconomic status (SES) and health is well known, and many determinants of these health inequalities have been studied. Concerning the role of health care, the results are conflicting, though. The study adds to this discussion by focussing on health care differences for people with type 2 diabetes. The analyses are based on a study conducted in Southern Germany (WHO MONICA study, Augsburg myocardial infarction registry). The sample consists of 378 type 2 diabetic patients, divided into two clearly distinct groups: one group (n = 210) from a MI registry with clinically confirmed myocardial infarction (MI), the other (n = 168) from a population based survey, characterised by the absence of a previous MI. Ten topics are differentiated in the assessment of diabetes knowledge (diet, weight control, etc.). The analyses show that knowledge about diabetes increases with increasing educational level. Concerning “very well informed about diet”, for example, the odds ratio for the high educational group is 3.45 (95 % CI: 1.34 - 8.86) as compared with the low educational group. This association is restricted to those diabetic persons with previous MI. For diet, the odds ratio for this subsample increases to 7.35 (p < 0.05). Similar results are seen for the other topics of diabetes knowledge. Also, diabetic persons with a low educational level participated in diabetes training courses least often, especially in the subsample with previous MI. Thus, taking the example of type 2 diabetes, the study adds to the evidence that the inverse care law is still present today in Germany.

Key words

Diabetes mellitus - health care - health inequalities

References

• 1 Beckles G, Engelgau M, Narayan K, Herman W, Aubert R, Williamson D. Population-based assessment of the level of care among adults with diabetes in the U.S.  Diabetes Care. 1998;  21 1432-1438
• 2 Britton A, Shipley M, Marmot M, Hemingway H. Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective Cohort Study.  BMJ. 2004;  329 318-323
• 3 Brown A, Ettner S, Piette J, Weinberger M, Gregg E, Shapiro M, Karter A, Safford M, Waitzfelder B, Prata P, Beckles G. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature.  Epidemiol Rev. 2004;  26 63-77
• 4 Brunner E, Marmot M, Nanchahal K, Shipley M, Stansfield S, Juneja M, Alberti K. Social inequality in coronary risk: central obesity and the metabolic syndrome. Evidence from the Whitehall II Study.  Diabetologia. 1997;  40 1341-1349
• 5 Chaturvedi N, Jarrett J, Shipley M, Fuller J. Socioeconomic gradient in morbidity and mortality in people with diabetes: cohort study findings from the Whitehall Study and the WHO Multinational Study of Vascular Disease in Diabetes.  BMJ. 1998;  316 100-106
• 6 Chen A, Escarce J. Quantifying income-related inequality in healthcare delivery in the United States.  Med Care. 2004;  42 38-47
• 7 Coonrod B, Betschart J, Harris M. Frequency and determinants of diabetes patient education among adults in the U.S. population.  Diabetes Care. 1994;  17 852-858
• 8 Diabetes Control and Complications Trial Research Group . Effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  New Engl J Med. 1993;  329 977-986
• 9 Forssas E, Keskimäki I, Reunanen A, Koskinen S. Widening socioeconomic mortality disparity among diabetic people in Finland.  Eur J Public Health. 2003;  13 38-43
• 10 Graham H. Social determinants and their unequal distribution: clarifying policy understandings.  Milbank Q. 2004;  82 101-124
• 11 Häring H, Joost H, Laube H, Matthaei S, Meissner H, Panten U, Schernthaner G. Antihyperglykämische Therapie des Diabetes mellitus Typ 2. Evidenzbasierte Diabetes-Leitlinie DDG. Scherbaum WA, Landgraf R (Hrsg).  Diabetes und Stoffwechsel. 2003;  12, Suppl. 2
• 12 Helmert U, Janka H, Strube H. Epidemiologische Befunde zur Häufigkeit des Diabetes mellitus in der Bundesrepublik Deutschland 1984 - 1991.  Diabetes und Stoffwechsel. 1994;  3 271-277
• 13 Hense H, Filipiak B, Döring A, Stieber J, Liese A, Keil U. Ten-year trends of cardiovascular risk factors in the MONICA Augsburg region in Southern Germany. Results from the 1984/85, 1989/90, and 1994/95 surveys.  CVD Prevention. 1998;  1 318-327
• 14 Keil U, Kuulasmaa K. WHO MONICA project: risk factors.  Int J Epidemiol. 1989;  18 S46-S55
• 15 Kleinbaum D, Kupper L, Muller K. Applied regression analysis and other multivariable methods. Boston; PWS-KENT Publishing Company 1988
• 16 Knopf H, Ellert U, Melchert H. Sozialschicht und Gesundheit.  Gesundheitswesen. 1999;  61 S169-S177
• 17 Löwel H, Lewis M, Hörmann A, Keil U. Case finding, data quality analysis, and comparability of myocardial infarction registries. Results of a Southern German register study.  J Clin Epidemiol. 1991;  44 249-260
• 18 Löwel H, Koenig W, Engel S, Hörmann A, Keil U. The impact of diabetes mellitus on survival after myocardial infarction: can it be modified by drug treatment? Results of a population-based myocardial infarction register follow-up study.  Diabetologia. 2000;  43 218-226
• 19 Mackenbach J. An analysis of the role of health care in reducing socioeconomic inequalities in health: the case of The Netherlands.  Int J Health Serv. 2003;  33 523-541
• 20 Mackenbach J, Bos V, Andersen O, Cardano M, Costa G, Harding S, Reid A, Hemström Ö, Valkonen T, Kunst A. Widening socioeconomic inequalities in mortality in six Western European countries.  Int J Epidemiol. 2003;  32 830-837
• 21 Mackenbach J, Bakker M. Tackling socioeconomic inequalities in health: analysis of European experiences.  Lancet. 2003;  362 1409-1414
• 22 McAlister F, Murphy N, Simpson C, Stewart S, MacIntyre K, Kirkpatrick M, Chalmers J, Redpath A, Capewell S, McMurray J. Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study.  BMJ. 2004;  328 1110-1113
• 23 McCall D, Sauaia A, Hamman R, Reusch J, Barton P. Are low-income elderly patients at risk for poor diabetes care?.  Diabetes Care. 2004;  27 1060-1065
• 24 Mielck A, Reitmeir P, Wjst M. Severity of childhood asthma by socioeconomic status.  Int J Epidemiol. 1996;  25 388-393
• 25 Mielck A. Soziale Ungleichheit und Gesundheit: Empirische Ergebnisse, Erklärungsansätze, Interventionsmöglichkeiten. Bern; Verlag Hans Huber 2000
• 26 Mühlhauser I, Overmann H, Bender R, Bott U, Jörgens V, Trautner C, Siegrist J, Berger M. Social status and the quality of care for adult people with type 1 (insulin dependent) diabetes mellitus - a population based study.  Diabetologia. 1998;  41 1139-1150
• 27 Mühlhauser I, Overmann H, Bender R, Jorgens V, Berger M. Predictors of mortality and end-stage diabetic complications in patients with type 1 diabetes mellitus on intensified insulin therapy.  Diabet Med. 2000;  17 727-734
• 28 Mühlhauser I, Berger M. Patient education - evaluation of a complex intervention.  Diabetologia. 2002;  45 1723-1733
• 29 Nilsson P, Johansson S, Sundquist J. Low educational status is a risk factor for mortality among diabetic people.  Diabet Med. 1998;  15 213-219
• 30 Rathmann W, Giani G, Mielck A. Cardiovascular risk factors in newly diagnosed abnormal glucose tolerance: comparison of 1997 ADA and 1985 WHO criteria (letter).  Diabetologia. 1999;  42 1268-1269
• 31 Rathmann W, Icks A, Haastert B, Giani G, Löwel H, Mielck A. Undiagnosed diabetes mellitus among patients with prior myocardial infarction.  Zeitschrift für Kardiologie. 2002;  91 620-625
• 32 Rathmann W, Haastert B, Icks A, Giani G, Holle R, Meisinger C, Mielck A. Association of socioeconomic status with undiagnosed diabetes mellitus and impaired glucose tolerance in a population-based sample. The KORA Survey 2000.  Eur J Public Health. 2005;  15 627-633
• 33 Siegrist J, Marmot M. Health inequalities and the psychosocial environment - two scientific challenges.  Soc Sci Med. 2004;  58 1463-1473
• 34 Tudor Hart J. The inverse care law.  Lancet. 1971;  1 405-412
• 35 UK Prospective Diabetes Study GROUP . Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).  Lancet. 1998 a;  352 837-853
• 36 UK Prospective Diabetes Study GROUP . Tight blood pressure control and risk of macrovascular and microvascular complications in patients with type 2 diabetes (UKPDS 38).  BMJ. 1998 b;  317 713-720
• 37 Unwin N, Binns D, Elliott K, Kelly W. The relationship between cardiovascular risk factors and socioeconomic status in people with diabetes.  Diabet Med. 1996;  13 72-79
• 38 van der Meer J, Mackenbach J. The care and course of diabetes: differences according to level of education.  Health Policy. 1999;  46 127-141
• 39 Watt G. The inverse care law today.  Lancet. 2002;  360 252-254
• 40 WHO Regional Office for Europe (ed). Social determinants of health. The solid facts. 2nd ed. Copenhagen; 2003