Socioeconomic status of women with diabetes--United States, 2000.

Persons whose socioeconomic status is low have poorer health than other persons and are less likely to have adequate access to care or to receive high-quality clinical and prevention care services. In the United States, diabetes is a potentially debilitating disease that is increasing in prevalence; however, little is known about the socioeconomic status of persons with diabetes. Women account for approximately 52% of all persons aged > or = 20 years with diabetes. To assess the socioeconomic status of women with diabetes, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS), which indicated that the socioeconomic status of women with diabetes in 2000 was markedly lower than that of women without diabetes. Efforts should be focused to understand the impact of socioeconomic conditions on the health and quality of care of women with diabetes.

PERSONS WHOSE SOCIOECONOMIC STAtus is low have poorer health than other persons 1,2 and are less likely to have adequate access to care or to receive highquality clinical and prevention care services. 3 In the United States, diabetes is a potentially debilitating disease that is increasing in prevalence 4 ; however, little is known about the socioeconomic status of persons with diabetes. [5][6][7] Women account for approximately 52% of all persons aged Ն20 years with diabetes. 4 To assess the socioeconomic status of women with diabetes, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS), which indicated that the socioeconomic status of women with diabetes in 2000 was markedly lower than that of women without diabetes. Efforts should be focused to understand the impact of socioeconomic conditions on the health and quality of care of women with diabetes.
BRFSS is a state-based, random-digitdialed telephone survey of the noninstitutionalized U.S. population aged Ն18 years. In 2000, the median statespecific response rate was 48.9% (range: 28.8%-71.8%) (CDC, unpublished data, 2001). Persons with diabetes were identified if they answered "yes" to the question, "Have you ever been told by a doctor that you have diabetes?" Women who answered "no" and those who had been told they had diabetes only during pregnancy were considered not to have diabetes. Data on level of education and annual household income were used to assess socioeconomic status; marital status, size of household, and employment status were used as indicators of living arrangements; and household size was derived by adding the number of adults and number of children aged Յ17 years. A woman was classified as having low socioeconomic status if she did not complete high school or resided in a household with an annual income of Ͻ$25,000.
State-specific data were aggregated and weighted to reflect age, sex, and racial/ethnic distribution, and chisquare tests were used to test all univariate associations. Because many persons aged 18-24 years have not completed their education, socioeconomic status was evaluated only for women aged Ն25 years. Multivariate logistic regression analysis was used to examine the relation between having diabetes and not completing high school or living in a low-income household, with control made for age, race/ethnicity, and living arrangements. The models then were used to calculate adjusted percentages using the distributions of female respondents aged Ն25 years in the total population. All analyses were conducted using SASv8 software with SUDAAN to estimate standard errors.
Of the 109,680 women who participated in the 2000 BRFSS survey, 6,835 (6.3%) had been told by a doctor that they had diabetes (mean age at diagnosis: 48.8 years). Women with diabetes were more likely than women without diabetes to be aged Ն45 years; nonwhite; divorced, separated, or widowed; living alone; retired; or unable to work.
Overall for women aged 45-64 years. In each age group, percentages were lower for women without diabetes (32.9%, 19.7%, and 18.6%, respectively). After multivariate adjustment, the difference between women with and without diabetes remained significant.

CDC Editorial Note:
The findings in this report indicate that the socioeconomic status of women with diabetes is lower than that of women without diabetes and confirm the findings of the 1989 National Health Interview Survey (NHIS). 5 In 2000, at least one in four women with diabetes aged Ն25 years had a low level of formal education, and 40% lived in low-income households. Women with diabetes were more likely to have a low socioeconomic status independent of living arrangements (i.e., marital status, size of household, and employment status). Attaining a higher educational level might influence decision-making, and persons with a higher income might have better FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION access to health care, higher living standards, and other material benefits that have a positive impact on health. Although socioeconomic status might be influenced adversely by factors related to having diabetes (e.g., being unemployed or retiring early), most women with diabetes in this survey were diagnosed long after they had completed their education. BRFSS estimates suggest that the low socioeconomic status of many women with diabetes might compromise their ability to benefit from treatments that might reduce their risks for complications and premature death. Programs designed to meet the needs of women with diabetes should take socioeconomic status into account to assure that women benefit from the interventions. Performance should be carefully evaluated to assess program effectiveness and identify areas for improvement.
The findings in this report are subject to at least three limitations. First, the low median response rate suggests the potential for participation bias. Second, all data were self-reported and might be subject to recall bias. Finally, the level of low socioeconomic status (i.e., household income Ͻ$25,000) among women with diabetes might be under-estimated because 21% of women with diabetes declined to state their income; these nonrespondents were more likely to be elderly, Hispanic, widowed, retired, or not to have completed high school (i.e., to belong to groups that are frequently low income).
CDC has initiated activities that focus on the needs of women with diabetes. CDC's Diabetes and Women's Health Across the Life Stages: A Public Health Perspective analyzes the epidemiologic, social, and environmental dimensions of women and diabetes and discusses public health implications. 8 CDC, the American Diabetes Association, the American Public Health Association, and the Association of State and Territorial Health Officials are developing a National Public Health Action Plan for Diabetes and Women. CDC is sponsoring Translating Research into Action for Diabetes (TRIAD), a 5-year prospective study of the quality of diabetes care, costs, and outcomes in managed-care settings that will examine the effects of socioeconomic status on health and quality of care. Finally, CDC is encouraging increased focus on women with diabetes through the National Diabetes Education Program, a collaborative effort with the National Institutes of Health to promote early diagnosis and improvement of the treatment and outcomes for persons with diabetes (available at http:// www.cdc.gov/diabetes/projects/ndeps .htm); Racial and Ethnic Approaches to Community Health (REACH) 2010, a program aimed at eliminating disparities in the health status of ethnic minorities (available at http://www.cdc.gov /reach2010), and state-based diabetes control programs.
The low socioeconomic status of many women with diabetes poses challenges to public health practitioners. As the prevalence of diabetes continues to increase, continued and creative efforts will be needed to gain greater understanding of how socioeconomic status affects the health of women with diabetes.
This report is based on data contributed by state BRFSS coordinators.  2 Older women, persons with less education or lower income, persons unable to work, and those who were overweight or who had diabetes or high blood pressure reported more days for which they were physically or mentally unhealthy during the 30 days preceding the survey. Interventions designed to reach these vulnerable, demographic, socioeconomic, and behavioral risk groups might help adults in Puerto Rico increase their quality and years of healthy life and eliminate health disparities.

REFERENCES
BRFSS is an ongoing, random-digitdialed telephone survey of the noninstitutionalized civilian population aged Ն18 years that is conducted in the 50 U.S. states, the District of Columbia, and Puerto Rico. Data were weighted to reflect the age and sex distribution of Puerto Rico's estimated population during each survey year. In Puerto Rico, a Spanish-language version of the English-language BRFSS survey was administered. 2 HRQOL items included self-rated health status (i.e., excellent, very good, good, fair, or poor) and the number of days during the 30 days preceding the survey when physical health (i.e., physical illness or injury) or mental health (i.e., stress, depression, or FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION emotional problems) was not good and usual activity (i.e., self-care, work, or recreation) was limited as a result of poor physical or mental health. Unhealthy days were defined as the total number of days for which the respondent reported feeling either physically or mentally unhealthy, up to a maximum of 30 days per respondent. Means and 95% confidence intervals (CIs) were calculated using SUDAAN to account for the complex BRFSS survey design.
During 1996-2000, a total of 13,686 adults in Puerto Rico participated in BRFSS. The average response rate was 91.8% (range: 89.4%-93.2%). * An estimated 34% (95% CI=33.1%-35.0%) of adults in Puerto Rico reported fair or poor health. Levels of self-rated health in adults in Puerto Rico did not differ by sex. On average, adults with fair or poor health reported substantially more days for which they were either physically or mentally unhealthy or limited in activity than those whose health status was good, very good, or excellent. Among persons rating their health status as fair or poor, younger adults were more likely than older adults to report mentally unhealthy days.
Men aged 18-44 years living in the island's metropolitan or eastern regions reported the fewest (2.9) unhealthy days, and women aged Ն65 years living in the northern region reported the most (9.8) unhealthy days. The number of self-reported unhealthy days peaked in 1998 and 1999 but did not change substantially. Overall, the mean number of activity limitation days was substantially higher during 1998-2000 (2.7 days; 95% CI = 2.5-2.9) than during 1996-1997 (1.7 days; 95% CI=1.5-1.9). The number of unhealthy days reported was significantly higher for women aged 18-44 years, 45-64 years, and Ն65 years than for men in the same three age groups by 1.4 days, 1.7 days, and 2.2 days, respectively.
Fewer unhealthy days were reported by respondents with higher education, income, and employment levels than less educated, poorer, and unemployed respondents. By educational attainment, mean unhealthy days ranged from 2.7 days for men aged 18-44 years with a high school education to 9.5 days for women aged Ն65 years who did not complete high school. By household income, the lowest mean for unhealthy days was 1.9 days for men aged 18-44 years with household incomes of $35,000-$49,999; the highest mean for unhealthy days was 9.4 days for women aged Ն65 years with incomes Ͻ$15,000 per year. By employment status, the lowest mean (1.7 days) was for self-employed men aged Ն65 years, and the highest (16.1 days) was for women aged 45-64 years who were unable to work.
Respondents who exercised during the month preceding the survey or who had never smoked cigarettes reported fewer unhealthy days than those who did not exercise or who had smoked. Those with normal body mass index (BMI) usually had fewer unhealthy days than those who were obese (BMI [kg/m 2 ] Ն30). Persons in all age groups with diabetes had significantly more unhealthy days than those without diabetes. Persons who had been told two or more times by a health-care provider that they had high blood pressure reported significantly more unhealthy days in all age groups than those who not been told they had high blood pressure. Those who could not afford to see a health-care provider reported more unhealthy days than those who could afford to see one, but the 9% without health-care coverage had about the same mean number of unhealthy days as those with healthcare coverage.

CDC Editorial Note:
The findings in this report indicate that there are substantial differences in HRQOL among subgroups in Puerto Rico. Socioeconomic and health indicators for Puerto Rico have improved substantially since 1970 as economic development has transformed a primarily agricultural economy to one based on manufacturing and services. 3 Since 1993, Puerto Rico also has privatized public health facilities and instituted managed competition to extend health insurance coverage to the uninsured. However, the continued low per capita income in Puerto Rico adversely affects Puerto Ricans' mental and physical health and their overall quality of life. 3 The findings in this report reflect the impact of lower socioeconomic status on HRQOL. In some cases, low HRQOL might affect socioeconomic status (e.g., by reducing one's productivity and associated earnings).
Puerto Rican adults reported having fewer unhealthy days but substantially worse self-rated health than U.S. adults. 2,4 Lower self-reported health status among Puerto Ricans, both those living in Puerto Rico and those living on the U.S. mainland, has in part been attributed to somatization (i.e., reported physical symptoms in the absence of physical pathology as a method of expressing psychosocial problems), 5 the stresses of acculturation (6), or ataque de nervios (a culturally meaningful expression addressing the experience of suffering either personal or social loss). 7 Persons with fair or poor health status reported more days for which they were physically and/or mentally unhealthy or limited in activity than did persons whose health status was good, very good, or excellent. This supports the construct validity of the HRQOL measures in the Puerto Rican population: the two constructs-self-rated health and reported unhealthy dayswere associated in a consistent and expected manner. 8 The findings in this report are subject to at least four limitations. First, households without telephones and those with only cellular phones were excluded from the sampling frame. 2 Second, BRFSS excludes an unknown number of persons in institutions and all persons aged Ͻ18 years. Third, BRFSS might underrepresent those with a severe impairment because time and functional capacity are required to participate in BRFSS. Finally, the reasons why persons reported worse health status are unclear because BRFSS does not FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION assess the effects of cultural expressions of distress, acculturative stress, or other sociocultural and environmental factors that influence health.
The results of this analysis indicate that the Spanish-language HRQOL questions might be useful for other Spanish-speaking groups in the U.S. and in other Spanish-speaking countries. Differences in HRQOL in demographic, socioeconomic, and behavioral risk subgroups in Puerto Rico reflect the influence of individual biology and behavior, as well as social and environmental factors, on HRQOL. 9 Policy makers can track HRQOL to identify groups with unmet health needs. 10 Public health interventions designed to reach vulnerable demographic, socioeconomic, and behavioral risk groups with poor HRQOL might help adults in Puerto Rico to increase their quality and years of healthy life and eliminate health disparities. 9