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Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults With Diabetes: Findings From the National Health Interview Survey

Patel, Minal R. PhD, MPH; Piette, John D. PhD; Resnicow, Kenneth PhD; Kowalski-Dobson, Theresa MPH; Heisler, Michele MD, MPA

doi: 10.1097/MLR.0000000000000565
Original Article

Background: Cost-related nonadherence (CRN) is prevalent among individuals with diabetes and can have significant negative health consequences. We examined health-related and non–health-related pressures and the use of cost-reducing strategies among the US adult population with and without diabetes that may impact CRN.

Methods: Data from the 2013 wave of National Health Interview Survey (n=34,557) were used to identify the independent impact of perceived financial stress, financial insecurity with health care, food insecurity, and cost-reducing strategies on CRN.

Results: Overall, 11% (n=4158) of adults reported diabetes; 14% with diabetes reported CRN, compared with 7% without diabetes. Greater perceived financial stress [prevalence ratio (PR)=1.07; 95% confidence interval (CI), 1.05–1.09], financial insecurity with health care (PR=1.6; 95% CI, 1.5–1.67), and food insecurity (PR=1.30; 95% CI, 1.2–1.4) were all associated with a greater likelihood of CRN. Asking the doctor for a lower cost medication was associated with a lower likelihood of CRN (PR=0.2; 95% CI, 0.2–0.3), and 27% with CRN reported this. Other cost-reducing behavioral strategies (using alternative therapies, buying prescriptions overseas) were associated with a greater likelihood of CRN.

Conclusions: Half of the adults with diabetes perceived financial stress, and one fifth reported financial insecurity with health care and food insecurity. Talking to a health care provider about low-cost options may be protective against CRN in some situations. Improving screening and communication to identify CRN and increase transparency of low-cost options patients are pursuing may help safeguard from the health consequences of cutting back on treatment.

Supplemental Digital Content is available in the text.

*Department of Health Behavior & Health Education, University of Michigan School of Public Health

Department of Internal Medicine and Health Behavior and Health Education, Ann Arbor, MI

This research used the Michigan Center for Diabetes Translational Research supported from grant number P30DK092926 from the National Institute of Diabetes and Digestive and Kidney Diseases. J.D.P. is a VA Senior Research Career Scientist.

The authors declare no conflict of interest.

Reprints: Minal R. Patel, PhD, MPH, Department of Health Behavior & Health Education, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029. E-mail:

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