Can patient self-management help explain the SES health gradient?
Can patient self-management help explain the SES health gradient?
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DOI：
10.1073/pnas.162086599
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发表时间：
2002-08-06
影响因子：
11.1
通讯作者：
Smith, JP
中科院分区：
文献类型：
--
作者：
Goldman, DP;Smith, JP
不同的社会经济地位(SES)在健康结果上有很大的差异，这不能用传统的论点来完全解释，例如获得护理或不良的健康行为。我们考虑了一种不同的解释--受过更多教育的人更好地自我管理疾病。我们通过教育检查糖尿病和艾滋病毒两种疾病患者治疗依从性的差异，然后评估差异依从性对健康状况的后续影响。这项研究的一个独特部分是，对于糖尿病，我们结合了两项不同的调查-一项队列研究和一项随机临床试验-通常由生物医学或/和社会科学家单独使用。对于这两种疾病，我们发现坚持治疗的显著效果在SES高的患者中要强得多。在控制了其他因素后，受过更多教育的HIV+患者更有可能坚持治疗，这种坚持使他们在自我报告的总体健康状况方面有所改善。同样，在糖尿病患者中，受教育程度较低的人更有可能更换治疗，这导致总体健康状况恶化。在随机试验环境中，强化治疗方案弥补了不良的依从性，使受教育程度较低的人在血糖控制方面有了更好的改善。在两种不同的慢性病中，维持更好的健康养生方案的能力是随后健康结果的一个重要独立决定因素。这一发现在临床试验和基于人群的环境中是可靠的。由于这种能力因受教育程度的不同而不同，自我维持能力是导致SES在健康结果上的陡峭梯度的一个重要原因。
There are large differences in health outcomes by socioeconomic status (SES) that cannot be explained fully by traditional arguments, such as access to care or poor health behaviors. We consider a different explanation-better self-management of disease by the more educated. We examine differences by education in treatment adherence among patients with two illnesses, diabetes and HIV, and then assess the subsequent impact of differential adherence on health status. One unique component of this research is that for diabetes we combine two different surveys-one cohort study and one randomized clinical trial-that are usually used exclusively by either biomedical or/and social scientists separately. For both illnesses, we find significant effects of adherence that are much stronger among patients with high SES. After controlling for other factors, more educated HIV+ patients are more likely to adhere to therapy, and this adherence made them experience improvements in their self-reported general health. Similarly, among diabetics, the less educated were much more likely to switch treatment, which led to worsening general health. In the randomized trial setting, intensive treatment regimens that compensated for poor adherence led to better improvements in glycemic control for the less educated. Among two distinct chronic illnesses, the ability to maintain a better health regimen is an important independent determinant of subsequent health outcomes. This finding is robust across clinical trial and population-based settings. Because this ability varies by schooling, self-maintenance is an important reason for the steep SES gradient in health outcomes.