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Unformatted text preview: Can patient self-management help explain the SES health gradient? Dana P. Goldman and James P. Smith* RAND, 1700 Main Street, Santa Monica, CA 90407 Edited by Robert M. Hauser, University of Wisconsin, Madison, WI, and approved June 14, 2002 (received for review February 12, 2002) 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 explanationbetter 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 surveysone cohort study and one randomized clinical trialthat are usually used exclusively by either biomedical or y and social scientists separately. For both ill- nesses, we find significant effects of adherence that are much stron- ger among patients with high SES. After controlling for other factors, more educated HIV 1 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 subse- quent 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. I n recent years, there has been renewed interest in why people of lower socioeconomic status (SES) have worse health outcomes. No matter which measures of SES (income, wealth, or education) are used, the evidence that this association is large and pervasive across a variety of health outcomes such as mortality or morbidity is abundant (1, 2). However, considerable debate remains about why the relation arises. The traditional argumentsthat the less well-to-do have access to less (3, 4) or lower quality (5) medical care or exhibit a stronger pattern of deleterious personal behaviors such as smoking and excess drinkingare seen as incomplete. Recently, some intriguing theories have arisen that emphasize long-term impacts of early childhood or even inter-uterine environmental factors (6, 7) or the cumulative effects of prolonged exposures to individual stressful events (8). Although these may be important reasons for part of the SES health relationship, we investigate here another mechanism: the ability of individuals across different SES...
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