Rebekah J. Walker

Associations between adverse childhood experiences, high-risk behaviors, and morbidity in adulthood

INTRODUCTION Adverse childhood experiences (ACEs) are associated with early mortality and morbidity. This study evaluated the association among ACEs, high-risk health behaviors, and comorbid conditions, as well as the independent effect of ACE components. METHODS Data were analyzed on 48,526 U.S. adults from five states in the 2011 Behavioral Risk Factor Surveillance System survey. Exposures included psychological, physical, and sexual forms of abuse as well as household dysfunction such as substance abuse, mental illness, violence, and incarceration. Main outcome measures included risky behaviors and morbidity measures, including binge drinking, heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by poor health, and use of special equipment because of disability. Multiple logistic regression assessed the independent relationship between ACE score categories and risky behaviors/comorbidities in adulthood, and assessed the independent relationship between individual ACE components and risky behaviors/comorbid conditions in adulthood controlling for covariates. RESULTS A total of 55.4% of respondents reported at least one ACE and 13.7% reported four or more ACEs. An ACE score ≥4 was associated with increased odds for binge drinking, heavy drinking, smoking, risky HIV behavior, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by health, and use of special equipment because of disability. In addition, the individual components had different effects on risky behavior and comorbidities. CONCLUSIONS In addition to having a cumulative effect, individual ACE components have differential relationships with risky behaviors, morbidity, and disability in adulthood after controlling for important confounders.

Glucose control in diabetes: the impact of racial differences on monitoring and outcomes.

Type 2 diabetes is the seventh leading cause of death in the US and is projected to increase in prevalence globally. Minorities are disproportionately affected by diabetes and data suggest that clinical outcomes consistently fall below American Diabetes Association recommendations. The purpose of this systematic review was to examine ethnic differences in self-monitoring and outcomes in adults with type 2 diabetes. Medline was searched for articles published between January 1990 and January 2012 by means of a reproducible strategy. Inclusion criteria included (1) published in English, (2) targeted African Americans, Hispanic, or Asian adults, ages 18+ years with type 2 diabetes, (3) cross-sectional, cohort, or intervention study, and (4) measured change in glycemic control, BP, lipids, or quality of life by race. Twenty-two papers met the inclusion criteria and were reviewed. Overall, significant racial differences and barriers were found in published studies in diabetes management as it pertains to self-monitoring and outcomes. African Americans tend to consistently exhibit worse outcomes and control when compared to other minority populations and non-Hispanic Whites. In conclusion, significant racial differences and barriers exist in diabetes management as it pertains to self-monitoring and outcomes when compared to non-Hispanic Whites. Explanatory and intervention studies are needed to determine the mechanisms and mediators of these differences and strategies to reduce these disparities. In addition, more research is needed to investigate the impact of racial differences in self-monitoring and outcomes on quality of life.

Diabetes Empowerment, Medication Adherence and Self-Care Behaviors in Adults with Type 2 Diabetes

BACKGROUND Evidence suggests that empowerment is an important factor to address everyday aspects of dealing with a chronic disease. This study evaluated the effect of diabetes empowerment on medication adherence and self-care behaviors in adults with type 2 diabetes. SUBJECTS AND METHODS Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure diabetes empowerment, medication adherence, diabetes knowledge, and diabetes self-care behaviors (including diet, physical activity, blood sugar testing, and foot care). Multiple linear regression was used to assess the independent effect of diabetes empowerment on medication adherence and self-care behaviors controlling for relevant covariates. RESULTS Eighty-three percent were non-Hispanic blacks, 69% were women, 22% were 65 years or older, 68% were not married, 26% had less than high school education, 60% were unemployed, 39% were uninsured, and 47% had a yearly income <

Independent effects of socioeconomic and psychological social determinants of health on self-care and outcomes in Type 2 diabetes

10,000. Empowerment had significant correlations with medication adherence (r=0.17, P<0.003), diabetes knowledge (r=0.16, P=0.007), diet (r=0.24, P<0.001), exercise (r=0.25, P<0.001), blood sugar testing (r=0.12, P=0.043), and foot care (r=0.18, P=0.002). In the regression model, diabetes empowerment was significantly associated with medication adherence (β=-0.04, P=0.001), diabetes knowledge (β=0.09, P=0.012), diet (β=0.09, P<0.001), exercise (β=0.10, P<0.001), blood sugar testing (β=0.07, P=0.016), and foot care (β=0.08, P=0.001). CONCLUSIONS In this sample, diabetes empowerment was related to better diabetes knowledge, medication adherence and improved self-care behaviors. Emphasis on empowerment and self-efficacy is relevant to improve outcomes in the management of diabetes.

Associations between Coping, Diabetes Knowledge, Medication Adherence, and Self-Care Behaviors in Adults with Type 2 Diabetes

OBJECTIVE The purpose of this study was to investigate the independent effects of socioeconomic and psychological social determinants of health on diabetes knowledge, self-care, diabetes outcomes and quality of life. RESEARCH DESIGN AND METHODS Cross-sectional sample of 615 adults from two adult primary care clinics in the southeastern United States. Primary outcome variables were diabetes knowledge, self-care behaviors (diet, exercise, medication adherence, blood sugar testing, foot care) and diabetes outcomes (HbA1c, low-density lipoprotein, blood pressure, physical component summary score of SF12 quality of life, mental component summary score of SF12 quality of life). Covariates included age, sex, race/ethnicity, marital status, health literacy and comorbidity. Linear regression models were used to assess independent associations controlling for covariates. RESULTS In final adjusted models, significant associations for HbA1c included education [β = -0.72, 95% confidence interval (CI): -1.36 to -0.08], income (β = -0.66, CI: -1.30 to -0.16), self-efficacy (β = -0.12, CI: -0.15 to -0.08) and diabetes distress (β = 0.43, CI: 0.14 to 0.72). Significant associations for self-care included medication adherence with diabetes distress (β = -0.58, CI: -0.91 to -0.25) and perceived stress (β = -0.12, CI: -0.18 to -0.05) and exercise with depression (β = -0.06, CI: -0.10 to -0.01) and self-efficacy (β = 0.06, CI: 0.01 to 0.10). Significant associations for quality of life included depression (β = -0.08, CI: -0.12 to -0.03), serious psychological distress (β = -0.09, CI: -0.12 to -0.05), social support (β = 0.01, CI: 0.001 to 0.02) and perceived stress (β = -0.12, CI: -0.19 to -0.06). CONCLUSIONS Social determinants of health were significantly associated with diabetes self-care and outcomes with socioeconomic factors being most often associated with diabetes outcomes and psychological factors, specifically self-efficacy and perceived stress being most often associated with self-care and quality of life.

Relationship between social determinants of health and processes and outcomes in adults with type 2 diabetes: validation of a conceptual framework

BACKGROUND Few studies have examined the emotional approach to coping on diabetes outcomes. This study examined the relationship between emotional coping and diabetes knowledge, medication adherence and self-care behaviors in adults with type 2 diabetes. METHODS Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure coping, medication adherence, diabetes knowledge and diabetes self-care behaviors (including diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of coping through emotional approach on medication adherence and self-care behaviors while controlling for relevant covariates. RESULTS Significant correlations were observed between emotional coping [as measured by emotional expression (EE) and emotional processing (EP)] and self-care behaviors. In the linear regression model, EP was significantly associated with medication adherence [β -0.17, 95% confidence interval (CI) -0.32 to -0.015], diabetes knowledge (β 0.76, 95% CI 0.29 to 1.24), diet (β 0.52, 95% CI 0.24 to 0.81), exercise (β 0.51, 95% CI 0.19 to 0.82), blood sugar testing (β 0.54, 95% CI 0.16 to 0.91) and foot care (β 0.32, 95% CI -0.02 to 0.67). On the other hand, EE was associated with diet (β 0.38, 95% CI 0.13 to 0.64), exercise (β 0.54, 95% CI 0.27 to 0.82), blood sugar testing (β 0.42, 95% CI 0.09 to 0.76) and foot care (β 0.36, 95% CI 0.06 to 0.66), but it was not associated with diabetes knowledge. CONCLUSION These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.

Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes

BackgroundThe aim of this study was to empirically validate a conceptual framework and elucidate the pathways linking social determinants of health to outcomes in individuals with type 2 diabetes.Methods615 adults were recruited from adult primary care clinics in the southeastern United States. The model was estimated using path analysis to determine if socioeconomic (education, employment, income) and psychosocial (fatalism, self-efficacy, depression, diabetes distress, serious psychological distress, social support, and perceived stress) factors would independently predict glycemic control or be associated with mediator/moderators of self-care, access to care, and processes of care. Covariates were gender, age, race and health literacy.ResultsThe final model (chi2 (15) = 17.68, p = 0.28; RMSEA = 0.02, CFI = 0.99) showed lower glycemic control was directly associated with less hours worked (r = 0.13, p = 0.002), more fatalistic attitudes (r = −0.09, p = 0.03), more self-efficacy (r = −0.30, p < 0.001), and less diabetes distress (r = 0.12, p = 0.03), with the majority of total effects being direct. Significant paths associated self-care with diabetes distress (r = −0.14, p = 0.01) and perceived stress (r = −0.15, p = .001); access to care with income (r = 0.08, p = 0.03), diabetes distress (r = −0.21, p < 0.001) and social support (r = 0.08, p = 0.03); and processes of care with income (r = −0.11, p = 0.03), social support (r = 0.10, p = 0.04), and perceived stress (r = 0.10, p = 0.04). The paths explained 76% of the variance in the model.ConclusionsConsistent with the conceptual framework, social determinants were associated with glycemic control through a direct association and mediators/moderators of self-care, access to care and processes of care. This study provides the first validation of a conceptual framework for the relationship between socioeconomic and psychological components of social determinants of health and diabetes outcomes.

Trends in Costs of Depression in Adults with Diabetes in the United States: Medical Expenditure Panel Survey, 2004-2011.

Background: There is strong evidence that race, ethnicity and social determinants of health significantly influence outcomes for patients with diabetes. A better understanding of the mechanisms of these relationships or associations would improve development of cost‐effective, culturally tailored programs for patients with diabetes. Methods: This article reviews the current state of the literature on the influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes for diabetes, with particular emphasis on the rural South to give an overview of the state of the literature. Results: The literature review shows that racial or ethnic differences in the clinical outcomes for diabetes, including glycemic, blood pressure (BP) and lipid control, continue to persist. In addition, the literature review shows that the role of social determinants of health on outcomes, and the possible role these determinants play in disparities have largely been ignored. Psychosocial factors, such as self‐efficacy, depression, social support and perceived stress, show consistent associations with self‐care, quality of life and glycemic control. Neighborhood factors, such as food insecurity, social cohesion and neighborhood esthetics have been associated with glycemic control. Perceived discrimination has also been associated with self‐care and the psychological component of quality of life. Conclusion: Healthcare professionals need to be skilled in assessing social determinants of health and taking them into consideration in clinical care. In addition, more research is needed to identify the separate and combined influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes in diabetes, especially in the South, where the burden of disease is particularly high.

Quantifying direct effects of social determinants of health on glycemic control in adults with type 2 diabetes.

ObjectiveTo investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression.Research Design and MethodsData from the 2004–2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004–2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, income level, and comorbidities.ResultsBased on a national sample of adults with diabetes (unweighted sample of 15,548, weighted sample of 17,465,579), 10.2 % had unrecognized depression, 13.6 % had asymptomatic depression, and 8.9 % had symptomatic depression. In the pooled sample, after adjusting for covariates, the incremental cost of unrecognized depression was

Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling

2872 (95 % CI 1660–4084), asymptomatic depression increased by