Transcript Association of Socioeconomic and Age Group Status with

Association of Socioeconomic
and Age Group Status with Selfreported Health Outcomes of
Persons with SCD in Rural and
Urban Areas of North Carolina
AUTHORS/REFERENCE
 Aklaque Haque, PhD, Dept of Government and
Public Services - Sch. Of Social and Behavioral
Sciences, University of Alabama at Birmingham
 Joseph Telfair, DrPH, MSW/MPH, Sch. Of
Public Health, University of Alabama at
Birmingham
 Reference: Haque, A & Telfair, J (in press).
Socioeconomic distress and Health Status: The
Urban-Rural dichotomy of services utilization
for persons with SCD in NC. J. Rural Health
Thank You
 Individuals with SCD and their families
 Members of the Duke/UNC CSCC
 Staff of the Four NC SC Community-based
programs
 Duke/UNC CSCC Biometry Core
 David Redden CCC Biostatistical Core,
UAB
BACKGROUND
 Research addressing risk factors associated with
SCD - predominantly biomedical & bioclinical
 This research has led to reduced morbidity,
better treatment outcomes & raised awareness of
the need for comprehensive biomedical and
psychosocial treatment strategies
 This research has failed to consider impact of the
interaction of socioeconomic background and
geographic distribution has had on health care
delivery and medical outcomes
BACKGROUND: SCD IN NC
 NC SCD Consortium provides much of the
outreach, education, social, health and medical
care
 NC SCD Consortium:
 3 state level administrative and 9 (regional)
level Educator/Counselor
 5 major tertiary medical centers (only 2 serve
adults) for comprehensive care
 4 community-based centers
 Consortium survey suggested differential access
PURPOSE OF THE STUDY
 To gain an understanding of how access
& utilization of services may be affected
separately and interactively by age,
socioeconomic conditions, geographic
location, functional status, severity of
disease & distance to medical care
 To introduce Social Epidemiological
Methods to the study of issues impacting
persons with SCD
METHODS: PARTICIPANTS
 1189 [of 1298] adults and children with SCD at
intake (1991-1995)
 Served by the three medical centers in the
Duke/UNC CSCC (68%) of estimated SCD
population in NC, consent obtained
 Intake Qs information
 self-reported demographic, medical history,
psychological and social data
 objective physical exam, laboratory and medical
records
MAP 1
Sickle Cell Clients in Urban and Rural Areas
of North Carolina by Zip Code
ECU (Children)
Duke (Adult, Children)
UNC (Adult, Children)
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SCD Clients
1-4
5 - 11
12 - 20
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21 - 31
Zip Code
Urban
Rural
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Wilmington (Children)
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40
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MAP 2
Utlization of Services in Urban and Rural Areas,
North Carolina by Zip Code
UNC (Adult, Children)
Duke (Adult, Children)
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Utlization of Serives (%)
Low (0 - 30%)
Medium (50 - 90%)
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High (100 - 600%)
Zip Code
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Rural
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Wilmington (Children)
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100 Miles
N
METHODS: MEASURES
Community Distress Index(CDI)
 Based on Haque’s Econometric Model
 5 indicators of poor QOL based on 1990 U.S.
Census Indicators
 income (Black per capita income)
 education (% Black not beyond HS)
 poverty (% Black below poverty)
 unemployment (% Black unemployed)
 not in labor force (% Black not in labor force)
 Index Score(SUM) - Low, Medium, High distress
METHODS: MEASURES
SCD Interference Index (SCDII) - Child/Adult
 Based on Psychosocial Interference Scale
(Kramer & Nash, 1992)
 8 items for each (e.g., School/ Employment
attendance, school/employment performance,
household activities, etc.)
 Coding
 Interference - YES (1) NO (0)
 Amount of Interference - Rare (1) Somewhat
(2) A lot (3)
 Index Score(SUM) - None, Low, Medium, High
METHODS: MEASURES
Medical Problem Index (MPI)
 Index items based on anecdotal, clinical and
evidence-based research information
 Event groupings (most common) Problem (Acute Chest/Pneumo, Pain req Hosp)
 Condition (Ascep Nec Hips & Shoulders,
Gallstones, eye problems)
 Infection (osteomyelitis, pyelonephritis)
 Procedure (cholecystectomy & splenectomy)
 Index score(SUM) - none, low, medium, high
Results Ia
Correlation Coefficient for all Cases (n= 1189)
Index
CDI
MPI SCDII
CDI
--0.105 -.039
MPI
-0.105
-0.564**
SCDII
-0.038 0.564**
-Age
-0.114**0.691** 0.590**
Urb/Rurl 0.568**-0.091** 0.001
Age Urb/Rurl
-0.114 0.568**
0.691** -0.091**
0.590** .001
--0.067*
-0.067*
--
**Correlation is significant at the .01 level (2 tailed)
Results Ib
Correlation Coefficient for all
Controlling
for Client
Age
CDI
MPI
SCDII Urb/Rurl
CDI
--0.053 -0.016 0.560**
MPI
-0.053
-0.253** -0.054
SCDII
-0.016 0.253**
-0.019
Urb/Rurl
0.560** -0.054
0.019
-**Correlation is significant at the .01 level (2
tailed)
* Correlation is significant at the .05 level (2
tailed)
Results Ic
Controlling
for
Location
and Age
CDI
MPI
SCDII
CDI
MPI
SCDII
--0.028 -0.033
-0.028
-0.255**
-0.033* 0.255**
--
**Correlation is significant at the .01 level (2 tailed)
* Correlation is significant at the .05 level (2 tailed)
Results II
Correlation Coefficient* of Problem Indicators for Clients in
Distressed Areas (HGB SS type)
Age Category
Location/N
18 and Younger
Urban N = 17
Rural N = 95
18 - 34
Urban N = 10
Rural N = 34
34 and Above Urban N = 11
Rural N = 18
CDI
MPI
SCDII
0.20
0.24
0.10
0.14
0.09
0.14
0.64
0.77
0.42
0.56
0.49
0.40
0.44
0.24
0.71
0.74
0.73
0.78
*Modify: Sum of all problem indicators (community distress,
medical problem and interference) = Community Distress + Medical
Problems + Interference All coefficients are significant at 0.1 level.
CONCLUSIONS
 This study has allowed for the the investigation
of the observation that a wide disparity has been
observed in socioeconomic characteristics
among urban and rural persons with SCD in NC
 When controlling for age and location, the
significant relationships between indices persist.
 Specifically, rural clients of all ages live under
relatively more distressed economic conditions
than urban clients and younger clients are woreoff than older clients, yet for youngsters CDI is
not a contributing factor to higher interference
CONCLUSIONS
 Supports contention, youngsters with SCD, in NC
have, in general, have better familial and systems
level supports that may “buffer” physical and
social consequences
 For adults the supports are limited and
inadequate to compensate for hardships, especially
in rural areas
 By changing the policy to create a more equitable
of system of supports rural and age differentials
can be effectively addressed
 These findings have particular implications for
states with a 40% or greater rural population
Limitations of the Study
 The study uses zip code linked SES data as the
basis for determining CDI score areas, a very
good proxy measure, but may fully reflect the
individual level SES of the client
 Interference for children (not adolescents) is
generally reported by parents and guardians, a
good approach, but is limited by the parent’s
perception
 Current research is underway in Alabama
aimed at addressing these limitations and
improving on this study