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This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formattedPDF and full text (HTML) versions will be made available soon.
Individual-level socioeconomic status is associated with worse asthmamorbidity in patients with asthma
Respiratory Research2009, 10:125 doi:10.1186/1465-9921-10-125
Simon L Bacon ([email protected])Anne Bouchard ([email protected])Eric B Loucks ([email protected])Kim L Lavoie ([email protected])
ISSN 1465-9921
Article type Research
Submission date 5 July 2009
Acceptance date 17 December 2009
Respiratory Research
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]8/14/2019 Asma y estatus socieconmico
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Individual-levelsocioeconomicstatusisassociatedwithworseasthma
morbidityinpatientswithasthma
SimonL.Bacon1,2,3,AnneBouchard1,4,EricB.Loucks5,KimL.Lavoie1,2,4
1MontrealBehaviouralMedicineCentre,DivisionofChestMedicine,ResearchCenter,Hpitaldu
Sacr-CurdeMontralaUniversityofMontralaffiliatedhospital,5400GouinWest,Montral,
Qubec,H4J1C5,Canada
2DepartmentofExerciseScience,ConcordiaUniversity,7141SherbrookeSt.West,Montreal,
Quebec,H4B1R6,Canada
3MontrealBehaviouralMedicineCentre,ResearchCenter,MontrealHeartInstituteaUniversityof
Montralaffiliatedhospital,5000Belanger,Montreal,Quebec,H1T1C8,Canada
4DepartmentofPsychology,UniversityofQuebecatMontreal(UQAM),P.O.Box8888,Succursale
Center-Ville,Montreal,Quebec,H3C3P8,Canada
5DepartmentofCommunityHealth,EpidemiologySection,CenterforPopulationHealth&Clinical
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Abstract
Background
Lowsocioeconomicstatus(SES)hasbeenlinkedtohighermorbidityinpatientswithchronic
diseases,butmaybeparticularlyrelevanttoasthma,asasthmaticsoflowerSESmayhavehigher
exposurestoindoor(e.g.,cockroaches,tobaccosmoke)andoutdoor(e.g.,urbanpollution)
allergens,thusincreasingriskforexacerbations.
Methods
ThisstudyassessedassociationsbetweenadultSES(measuredaccordingtoeducationallevel)
andasthmamorbidity,includingasthmacontrol;asthma-relatedemergencyhealthserviceuse;
asthmaself-efficacy,andasthma-relatedqualityoflife,inaCanadiancohortof781adult
asthmatics.Allpatientsunderwentasociodemographicandmedicalhistoryinterviewand
pulmonaryfunctiontestingonthedayoftheirasthmaclinicvisit,andcompletedabatteryof
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independentofdiseaseseverity.ResultsareconsistentwithpreviousstudieslinkinglowerSESto
worseasthmainchildren,andaddasthmatothelistofchronicdiseasesaffectedbyindividual-
levelSES.
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Background
Asthmaisachronicdisorderoftheairwayscharacterizedbyreversibleandintermittentairway
obstruction,airwayinflammation,andhyper-reactivityoftheairwaysinresponsetoavarietyofstimuli
(e.g.,dust,animalhair,smoke,andairbornepollutants).Despiteimportantadvancesindiagnosisand
treatment,asthmaremainsoneofthemostprevalentchronicrespiratorydisorders,affecting7-10%of
theworldspopulation.Ratherthandecreasing,prevalenceratesofasthmaoverthepastthree
decadesareactuallyrisinginallage,sex,andracialgroupsinNorthAmerica[1].
Theglobalburdenofasthmaappearstoberelatedtopoorasthmacontrol,whichisassociated
withmorefrequentasthmasymptomatologyandbronchodilatoruse,worsepulmonaryfunction,
greateremergencyhealthserviceutilization,andgreaterfunctionalimpairment(absenteeism,
participationinsocialactivities)[2,3].InCanada,asthmaremainspoorlycontrolledinnearly60%
ofpatients,whichplacesanexcessburdenonthehealthcaresystem,andaccountsforbetween
250 300 deaths per year [4 5] Given that asthma can be well controlled for the vast majority of
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postalcodestodefinedeprivation)inadults[14,15],lessisknownaboutassociationsbetween
individual-levelSESandasthmainadults.
Thepurposeofthepresentstudywastoassessassociationsbetweenadultindividual-levelSES,
measuredaccordingtoeducationlevel,andseveralmeasuresofasthmamorbidityandhealth,
includinglevelsofasthmacontrol,emergencyhealthserviceuse,asthmaself-efficacy,andasthma-
relatedqualityoflifeinaCanadiancohortofasthmatics.ItwashypothesizedthatSESwouldbe
significantlyandnegativelyassociatedwiththesemeasuresofasthmamorbidityandhealth.
Methods
Studyparticipants
Atotalof781consecutiveadultswithphysician-diagnosedasthma(confirmedbychartevidenceofa
20%fallinforcedexpiratoryvolumein1second(FEV1)aftermethacholinechallengeand/or
bronchodilatorreversibilityinFEV1of>20%predicted[16])wererecruitedfromtheoutpatientasthma
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patientswereexcludedfromanalysesduetoincompleteormissingdata,yieldingafinalsampleof781
patients.ThisprojectwasapprovedbytheEthicsCommitteeofHpitalduSacr-CurdeMontral,
andwrittenconsentwasobtainedfromallparticipants.
StudyDesign
Thiscross-sectionalstudywasconductedaspartofalargerstudyevaluatingtheprevalenceand
impactofpsychiatricdisordersamongadultasthmatics[17].Briefly,patientswerescreenedto
determineeligibilityonthedayoftheirregularasthmaclinic.Allpatientsunderwenta
sociodemographicinterview(includingquestionsabouteducationalattainment),andamedical/asthma
historyinterview(includingassessmentsofheightandweightforthecalculationofbodymassindex,
BMI)followedbyabriefpsychiatricinterview(PrimaryCareEvaluationforMentalDisorders,PRIME-
MD)thatwasadministeredbyatrained,clinicalresearchassistant.SESwasmeasuredaccordingto
educationallevel(totalnumberofyearscompleted),whichisoneofthemostcommonmeasuresof
individual-levelSES[18].EducationalattainmentisfrequentlyusedasameasureofSES,becauseit
i t bl ti lik ti d i th t fl t t th lif F th
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QuestionnaireandPsychologicalMeasures
AsthmaControlQuestionnaire(ACQ):
TheACQ[20]isa7-itemself-reportquestionnairethatassesseslevelsofasthmacontrolinthelast
weekaccordingtostandardcriteriaspecifiedbyinternationalguidelines[2].Itemsareratedona7-
pointscale,where0indicatesgoodcontroland6indicatespoorcontrol,toyieldameanscoreoutof6.
Patientsareaskedtoreporttheirsymptoms,limitationsintheirdailyactivities,andbronchodilatoruse
inthelastweek.FEV1%predicted)wascalculatedfromthepulmonaryfunctiontest.TheACQhas
demonstratedexcellentmeasurementproperties,hasbeenvalidatedinCanadianFrench,andscores
of0.8indicatepoorlycontrolledasthma[21].Forthecurrentstudy,theinternalconsistencyofthe
questionnairewashigh(Cronbachs=.84).
AsthmaSelf-EfficacyScale(ASES):
TheASES[22]isan80-itemself-reportquestionnairethatassessesasthmaticsbeliefsorconfidence
intheirabilitytosuccessfullycontroloravoidanasthmaattackinavarietyofsituations.TheASESis
t d 5 i t l h 0 i di t fid d 4 i di t fid t t i ld
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PrimaryCareEvaluationofMentalDisorders(PRIME-MD):
ThePRIME-MD[26]assessestheprevalence(i.e.,presentornot)ofmood(majorandminor
depression,dysthymia)andanxiety(panicdisorders,generalizedanxietydisorder,otheranxiety
disorder)usingalgorithmsthatarebasedonDSM-IV.Ithasbeenshowntobeofcomparable
sensitivity,specificityandreliabilityaslongerstructuredinterviews,andtakesapproximately10to20
minutestoadministerandscore[26].
Analyses
Thoughmainanalyseswereconductedusingbothcontinuousanddichotomousmeasuresof
education,sociodemographic,andmedical/asthmahistorycharacteristicswerepresentedasa
functionoflow(
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Results
Samplecharacteristics
Thefinalsampleof781patientsincluded467(60%)womenwithamean(SD)ageof48.5(14.3)
years.Themean(SD)durationofasthmaforsamplewas18.6(15.2)yearsand71%(n=555)were
atopic.Themean(SD)educationallevelwas12.9(3.6)years(range2-23years)ofschooling.Mean
sample(SD)[range]forACQ,ASESandAQLQscoreswere1.6(1.1)[0.0-6.0],222.3(66.1)[13.3-
320],and5.1(1.2)[1.5-7.0]respectively.Atotalof184(24%)ofthesamplereportedamean(SD)
[range]of2.1(2.0)[1-15]emergencyhealthservicevisitsinthelastyear.Mean(SD)pulmonary
function(%FEV1,%FVC,FEV1/FVC)forthesamplewas78.9(21.8),89.5(19.6),and72.4(14.4)
respectively.
Demographicandmedical/asthmahistorycharacteristics
Demographicandmedical/asthmahistorycharacteristicsasafunctionoflow(
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Inaddition,therewasanapproximate30%reductionintheafteradjustingforcovariates,suggesting
thesevariablesaccountedforsomebutnotalloftheassociationstrength..Therewereno
associationsbetweenSESandAQLQscores.PoissonregressionrevealedthatlowerSESwas
associatedwithgreateremergencyhealthserviceuse,independentofage,sex,asthmaseverity
(estimate=-0.07,SE=0.02,95%CI=-0.10--0.03),andalladditionalcovariates(estimate=-0.05,SE
=0.02,95%CI=-0.09--0.01),withaminimalchangeintheestimate.Logisticregressionanalyses
revealedthatpatientswith
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Thesefindingsareconsistentwithpreviousstudiesfindingsignificantassociationsbetweenlower
childhoodSESandworseasthmamorbidity,includingincreasedprevalenceofasthmaandsevere
asthma[12,13],andincreasedriskofemergencydepartmentvisitsandhospitalizationsforasthma
[29,30].ThesefindingsarealsoinlinewithpreviousstudieslinkinglowerSES(assessedusingarea-
levelandindividual-levelmeasures)toworseasthmamorbidityinadults,includingincreased
prevalenceofasthma[31],greaterasthmasymptomatology[32],andincreasedasthmarelated
hospitalisations[33].However,thisstudyis,toourknowledge,thefirsttoassesstheimpactof
individual-levelSESonmultiplemeasuresofasthmamorbidityinsuchalargeCanadiancohortof
adultasthmatics.AlthoughLyndetal.[34]examinedthelinkbetweenbothindividualandarea-level
measuresofSESandasthmainaCanadiansample,theirsamplesizewasmodest(n=202),andtheir
analysesfocusedonlinksbetweenSESandshort-actingbronchodilatoruseasaproxymeasureof
asthmacontrol.Theirfindingsarestillconsistentwiththoseofourstudy,thoughwewereableto
extendtheirfindingsbyshowingthatasthmaticsoflowerSEShaveworseasthmacontrolaccordingto
theACQandemergencyhealthserviceuse.
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studydidnotcollectdataonmedicationadherence,buttheresultswereindependentofasthma
severity,whichisprimarilyderivedfromtheprescribeddosageofinhaledcorticosteroids.Furthermore,
apreviousstudyhasshownthatSESwasrelatedtoACQscoresindependentofcorticosteroiduse
[40].Thereisalsoevidencethattheunderlyingphysiologicalprocessesseeninasthmaareinfluenced
bySES,whereheightenedinflammatoryresponsestosimilardosesofantigenchallengehavebeen
showninpatientswithlowversushighSES[41,42],whichmaybeaconsequenceoflowSES
individualsoverexpressinggenesregulatingtheirinflammatoryprocesses[43].However,itshouldbe
notedthatthesefindingsaredrawnfromdatainchildrenandneedstobereplicatedinadultsamples.
OneadditionalfindingthatwarrantsdiscussionisthatasthmaticsoflowerSESwerelesslikelytobe
atopic(i.e.,haveallergicasthma)thanasthmaticsofhigherSES.Althoughthiswasnottheprimary
aimoftheanalyses,thisfindingisconsistentwithseveralstudieslinkinglowerSEStolowerincidence
ofallergicasthma[31,32,44,45].Althoughcontroversial,ithasbeensuggestedthatthisrelationship
maybeduetothehygienehypothesis,whichproposesthatthedevelopmentofatopicasthmaand
ll b t d i t l d l hildh d t i t ti l t
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berelatedtoissuesassociatedwiththenatureofthepopulationsassessedandtostudydesign.For
example,Blancetal.[14]recruitedpatientsfrommultipleclinicsviaphysicianreferral,aswellasusing
random-digittelephonerecruitment;whereaswerecruitedconsecutivepatientsfromasingletertiary-
careclinicwhereasthmaisgenerallymoresevereandthusmayreducevariabilityinqualityoflife
measures.TheApteretal.[48]studyfoundthattherelationshipbetweenSESandqualityoflifewas
highlyconfoundedbyrace/ethnicity,withnon-CaucasianshavinglowerSESandpoorerqualityoflife.
WhiletheApteretal.studyconsistedofnearly60%ofnon-Caucasians,thecurrentstudyhasless
than10%non-Caucasions,suggestingthattheresultsreportedbyApteretal.mayhavebeendriven
byrace/ethnicityratherthanSES[49].Inaddition,thesignificantassociationbetweenSESandworse
asthma-specificqualityoflifeinBlancetal.sstudywasobservedusingadifferentmeasureofSES
(i.e.,area-level),andadifferentqualityoflifescale(i.e.,MarksAsthmaQualityofLifeQuestionnaire)
thanthoseusedinthepresentstudy.Assuch,thedisparatefindingsbetweenthesetwostudiesmay
beattributabletothespecificchoiceofmeasures.Furtherreplicationstudiesareneededtoshed
morelightontheassociationbetweenSESandasthma-relatedqualityoflifeinadultsamples.
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thatareassociatedwithSESthatmayhavepartiallyaccountedforourfindingssuchasactual
exposurelevelstoallergens,irritants,andpollutants,andlivingconditions(i.e.,overcrowding)which
mayhaveincreasedtheriskofrespiratoryinfectionsthatconferriskforworseasthmamorbidity[32].
Despitetheselimitations,theresultsofthepresentstudycomplementandstrengthenpreviousreports
byincludingalargecohortofadultasthmaticswithobjectivelyconfirmedphysician-diagnosedasthma
andatopy,andthemeasurementofarangeofasthmamorbidityandhealthmeasuresthatincluded
self-reportedsymptomsandobjectivelymeasuredemergencyhealthserviceutilizationthatwas
verifiedbychartreview.Duetotherangeanddepthofourassessments,wewerealsoabletocontrol
foranumberofpotentialconfounders,includingsmokingstatus,BMI,psychiatriccomorbidity,and
asthmaseverity,whichatteststotherobustnessofthefindings.
Conclusions
Insummary,thisstudyfoundevidenceforanassociationbetweeneducationlevel(whichisindicative
f SES) d th bidit d h lth i l t ti l f C di d lt ith
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Authors'contributions
SLBco-wrotethemanuscript,conductedallstatisticaldataanalyses,andobtainedfundingforthe
study.ABcollectedprimarydataandhelpeddeveloptheconceptualidea.EBLhelpeddevelopthe
conceptualframeworkandprovidedcriticalfeedbackonmanuscriptdrafts.KLLconceivedofthe
study,participatedinitsdesignandcoordination,obtainedfundingforthestudy,andco-wrotethe
manuscript.Allauthorsreadandapprovedthefinalmanuscript.
Acknowledgements
TheauthorsthankGuillaumeLacoste,BA,forhisinvaluableassistancewithdatacollection.
FundingsupportforthisstudywasprovidedbysalaryawardsfromtheFondsdelarechercheen
santduQubec(FRSQ)(SLB&KLL)andtheCanadianInstitutesofHealthNewInvestigator
Award(CIHR)(SLB&EBL),grantsupportfromtheFRSQ(SLB&KLL)andtheMichelAuger
FoundationofHpitalduSacr-CoeurdeMontral(KLL),andscholarshipsupportfromFRSQand
th S i l S i d H iti R h C il (SSHRC) (AB)
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Tables
Table1:Demographicandmedical/asthmacharacteristicspresentedasafunctionofhigh
versuslowSES
Low(
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-22-
Table2:Associationbetweeneducationalattainmentandasthmamorbidityvariables (GLM)
modeladjustment
age,sex,asthmaseverity age,sex,asthmaseverity,BMI,smoking,andpsychiatric
disorder
(SE) F p (SE) F p
ACQ -0.041(0.011) 14.12