Course of Health Status among Chronically Ill Persons: Differentials According to Level of Education

doi:10.1016/S0895-4356(97)00267-9

Journal of Clinical Epidemiology

Volume 51, Issue 3, February 1998, Pages 171-179

https://doi.org/10.1016/S0895-4356(97)00267-9 Get rights and content

Abstract

This article describes socioeconomic differences in the time course of several health indicators, encompassing perceived health and disabilities, among a population sample of persons reporting one or more chronic conditions. Data covering the period 1991–1993, were obtained from a Dutch follow-up study. Educational differences in the course of health status were estimated by ordinary least squares regression. The course of almost all health status measures was statistically significantly less favorable (p < 0.05) for those with a low educational level compared to those with higher vocational training or a university degree, adjusting for age, sex, and marital status. After additional adjustment for health status in 1991, significant differences remained for perceived general health, long-term disabilities, and two subscales of the Nottingham Health Profile. These findings imply that socioeconomic differences in prevalence of health problems are not only attributable to differences in incidence of diseases by socioeconomic status, but also to a differential course of existing health problems. Implications for health care delivery are discussed.

Introduction

Chronic diseases develop differently between groups of people. One of the characteristics which are associated with a differential course of chronic disease is socioeconomic status. Survival studies on cancer [1], ischemic heart disease [2], and asthma [3]demonstrate a lower survival among people with a low socioeconomic status than among people high in the social hierarchy. These survival studies suggest that health status develops more unfavorably among sick people when their socioeconomic status is lower. Indeed, in addition to incidence, the differential course of chronic disease by socioeconomic status may also contribute to the explanation of socioeconomic differences in the prevalence of health problems.

With the exception of mortality and survival, the course of chronic disease in different socioeconomic groups has received remarkably little attention. If “more people live with chronic conditions than die from them” [4], differential development of the burden of disease across social groups is relevant for medical care: the types of health problems involved and the socioeconomic groups where health declines fastest or recovery is slowest should be known to adequately plan health care delivery and manage patient care.

In this article we report differences according to level of education in the course of several aspects of health status over the period 1991–1993 among a Dutch population sample of persons who reported one or more chronic conditions. We describe differences according to educational level in the course of health status, operationalized as the mean change per educational group. As an unfavorable course of health status is more likely with a history of health problems (comorbidity, for instance), and as such a history will be unevenly distributed among socioeconomic groups, health status at the beginning of the study may be an important predictor of its very course. We take this factor into account when studying socioeconomic differentials in the course of health status.

Section snippets

Study Population

Source of the data is the Longitudinal Study on Socio-Economic Differences in Utilization of Health Services (LS-SEDUHS). The LS-SEDUHS is part of the GLOBE study, a longitudinal study that started in 1991 in the south east of the Netherlands, aimed at explaining socioeconomic inequalities in health. The design and objective of the GLOBE study have been described in detail elsewhere [5]. The cohort of the GLOBE study is based on a sample of noninstitutionalized Dutch nationals aged 15–74 years.

Results

Table 3 shows the mean difference of each health status measure between 1991 and 1993, for the total study population and stratified by health score in 1991. The items of the NHP were summarized in one score. Health status hardly seems to change between 1991 and 1993 when crude figures for the whole group are considered. Although the individual difference in perceived general health may vary between +4 (maximum improvement between 1991 and 1993) and −4 (maximum deterioration between 1991 and

Discussion

In a chronically ill population we have demonstrated a more unfavorable course of several aspects of general health status over a 2-year period in those with a lower educational attainment compared to a reference category of respondents with university level or higher vocational training, while controlling for age, sex, and marital status. Of four over-represented chronic conditions—asthma/COPD, heart disease, diabetes, and severe low back trouble—data about severity and year of onset were

Acknowledgements

This project was supported by a grant from the Health Insurance Council (Ziekenfondsraad). It is part of the GLOBE-study (Gezondheid en Levens-Omstandigheden Bevolking Eindhoven en omstreken), a large-scale research project on health and living conditions of the population of Eindhoven and surroundings. The GLOBE-study is conducted by the Department of Public Health, Erasmus University Rotterdam, in collaboration with the Community Health Services of the city of Eindhoven, the region of

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None.

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Original ArticlesCourse of Health Status among Chronically Ill Persons: Differentials According to Level of Education

Abstract

Introduction

Section snippets

Study Population

Results

Discussion

Acknowledgements

Eur J Cancer

Am J Med

Soc Sci Med

Soc Sci Med

Applied Ergonomics

J Clin Nutr

Health Policy

Soc Sci Med

Soc Sci Med

Soc Sci Med

Incidence and prognosis of ischaemic heart disease with respect to marital status and social class. A national record linkage study

J Epidemiol Community Health

Netherlands Health Interview Survey 1981–1991

Measuring Health Status

Original Articles
Course of Health Status among Chronically Ill Persons: Differentials According to Level of Education