- 1. State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
My health outcome is outpatient diabetes control. Adherence to medications is my primary research interest and good adherence to diabetes medications has been well documented to improve diabetes control. There are many barriers to adherence from cost to difficulty giving injections to multiple times a day dosing. A second behavior in the control of diabetes is diet plays a role in the etiology, prevention and intervention of diabetes. Focusing on intervention, modifying caloric intake and carbohydrate intake can often dramatically improve diabetes control and in some instances even fully control the disease without the use of medications.
- 2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
Focusing on the impact of adherence to diabetes medications on outpatient diabetes control we are planning a study to examine the impact of a clinician decision on patient adherence to diabetes medications. We are conducting a study of older veterans using national VA data to examine the impact of changes made to diabetes medications during hospitalizations for unrelated conditions on subsequent adherence and diabetes clinical outcomes. Our hypothesis is that when inpatient clinicians make changes to outpatient regimens they may not be aware of important patient-specific contextual factors, such as history of barriers to adherence or history of intolerance to a drug. In addition, prospects for long-term adherence are often poor in the absence of buy-in from the patient and his or her outpatient clinician, and may be further reduced due to confusion from multiple medication changes during a hospitalization. Thus we will examine how adherence (as measured by proportion of days covered by filled prescriptions using pharmacy records) and measures of diabetes control (i.e. hemoglobin A1c) differ in a cohort of patients who experienced medication changes during hospitalization vs a matched cohort who did not experience a medication change. Due to our use of HER data, we have limited information on social factors but will include race/ethnicity, median income by zip code, and veteran priority scores which are a combined measure of eligibility for VA services based on income and service status. By adjusting for these factors we can examine if patient adherence after a diabetes medication regimen change is differentially effected in populations stratified by race/ethnicity or income.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
Health outcomes are rarely driven by a single upstream factor. Thus, it is important to continue to study how behaviors influence health outcomes as if we successfully target the most apparent social factor we are likely to uncover additional ways in which behaviors influence our outcome of interest. For example, if we know that adherence to diabetes medications is strongly influenced by income due to the high cost of diabetes medications and successfully implement an intervention which reduces the cost of medications – we may improve adherence partially. However, we are likely to then find additional barriers such as access to pharmacies that carry the medications (neighborhood) or educational disparities in diabetes control due to the need to follow complex insulin dosing instructions.