Association of Socioeconomic and Age Group Status with Self-

reported Health Outcomes of Persons with SCD in Rural and Urban Areas of North Carolina

AUTHORS/REFERENCEAklaque Haque, PhD, Dept of Government and

Public Services - Sch. Of Social and Behavioral Sciences, University of Alabama at Birmingham

Joseph Telfair, DrPH, MSW/MPH, Sch. Of Public Health, University of Alabama at Birmingham

Reference: Haque, A & Telfair, J (in press). Socioeconomic distress and Health Status: The Urban-Rural dichotomy of services utilization for persons with SCD in NC. J. Rural Health

Individuals with SCD and their familiesMembers of the Duke/UNC CSCCStaff of the Four NC SC Community-based

programsDuke/UNC CSCC Biometry CoreDavid Redden CCC Biostatistical Core,

UAB

Thank You

BACKGROUNDResearch addressing risk factors associated with SCD

- predominantly biomedical & bioclinicalThis research has led to reduced morbidity, better

treatment outcomes & raised awareness of the need for comprehensive biomedical and psychosocial treatment strategies

This research has failed to consider impact of the interaction of socioeconomic background and geographic distribution has had on health care delivery and medical outcomes

NC SCD Consortium provides much of the outreach, education, social, health and medical care

NC SCD Consortium:3 state level administrative and 9 (regional) level

Educator/Counselor5 major tertiary medical centers (only 2 serve

adults) for comprehensive care4 community-based centers

Consortium survey suggested differential access

BACKGROUND: SCD IN NC

PURPOSE OF THE STUDY

To gain an understanding of how access & utilization of services may be affected separately and interactively by age, socioeconomic conditions, geographic location, functional status, severity of disease & distance to medical care

To introduce Social Epidemiological Methods to the study of issues impacting persons with SCD

METHODS: PARTICIPANTS

1189 [of 1298] adults and children with SCD at intake (1991-1995)

Served by the three medical centers in the Duke/UNC CSCC (68%) of estimated SCD population in NC, consent obtained

Intake Qs informationself-reported demographic, medical history,

psychological and social dataobjective physical exam, laboratory and medical

records

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UNC (Adult, Children)Duke (Adult, Children) ECU (Children)

Wilmington (Children)

40 0 40 80 120 Miles

N

MAP 1Sickle Cell Clients in Urban and Rural Areas

of North Carolina by Zip Code

Zip CodeUrbanRural

SCD Clients# 1 - 4# 5 - 11# 12 - 20# 21 - 31

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UNC (Adult, Children) Duke (Adult, Children)

Wilmington (Children)

ECU (Children)

Zip CodeUrbanRural

Utlization of Serives (%)# Low (0 - 30%)# Medium (50 - 90%)# High (100 - 600%)

50 0 50 100 Miles

N

MAP 2Utlization of Services in Urban and Rural Areas,

North Carolina by Zip Code

METHODS: MEASURESCommunity Distress Index(CDI)

Based on Haque’s Econometric Model5 indicators of poor QOL based on 1990 U.S.

Census Indicators income (Black per capita income)education (% Black not beyond HS)poverty (% Black below poverty)unemployment (% Black unemployed)not in labor force (% Black not in labor force)

Index Score(SUM) - Low, Medium, High distress

METHODS: MEASURESSCD Interference Index (SCDII) - Child/Adult

Based on Psychosocial Interference Scale (Kramer & Nash, 1992)

8 items for each (e.g., School/ Employment attendance, school/employment performance, household activities, etc.)

Coding Interference - YES (1) NO (0)Amount of Interference - Rare (1) Somewhat (2)

A lot (3) Index Score(SUM) - None, Low, Medium, High

METHODS: MEASURESMedical Problem Index (MPI)

Index items based on anecdotal, clinical and evidence-based research information

Event groupings (most common)- Problem (Acute Chest/Pneumo, Pain req Hosp)Condition (Ascep Nec Hips & Shoulders,

Gallstones, eye problems)Infection (osteomyelitis, pyelonephritis)Procedure (cholecystectomy & splenectomy)

Index score(SUM) - none, low, medium, high

Index CDI MPI SCDII Age Urb/RurlCDI -- -0.105 -.039 -0.114 0.568**MPI -0.105 -- 0.564** 0.691** -0.091**SCDII -0.038 0.564** -- 0.590** .001 Age -0.114**0.691** 0.590** -- -0.067*Urb/Rurl 0.568**-0.091** 0.001 -0.067* --

Correlation Coefficient for all Cases (n= 1189)

**Correlation is significant at the .01 level (2 tailed)

Results Ia

Controlling for Client

Age CDI MPI SCDII Urb/RurlCDI -- -0.053 -0.016 0.560**MPI -0.053 -- 0.253** -0.054SCDII -0.016 0.253** -- 0.019Urb/Rurl 0.560** -0.054 0.019 --

Correlation Coefficient for all

**Correlation is significant at the .01 level (2 tailed)* Correlation is significant at the .05 level (2 tailed)

Results Ib

Results IcControlling

for Location and Age CDI MPI SCDII

CDI -- -0.028 -0.033MPI -0.028 -- 0.255**SCDII -0.033* 0.255** --

**Correlation is significant at the .01 level (2 tailed)* Correlation is significant at the .05 level (2 tailed)

Results II

Age Category Location/N CDI MPI SCDII

18 and YoungerUrban N = 17 0.20 0.64 0.44Rural N = 95 0.24 0.77 0.24

18 - 34 Urban N = 10 0.10 0.42 0.71Rural N = 34 0.14 0.56 0.74

34 and Above Urban N = 11 0.09 0.49 0.73Rural N = 18 0.14 0.40 0.78

Correlation Coefficient* of Problem Indicators for Clients in Distressed Areas (HGB SS type)

*Modify: Sum of all problem indicators (community distress, medical problem and interference) = Community Distress + Medical Problems + Interference All coefficients are significant at 0.1 level.

CONCLUSIONSThis study has allowed for the the investigation

of the observation that a wide disparity has been observed in socioeconomic characteristics among urban and rural persons with SCD in NC

When controlling for age and location, the significant relationships between indices persist.

Specifically, rural clients of all ages live under relatively more distressed economic conditions than urban clients and younger clients are wore-off than older clients, yet for youngsters CDI is not a contributing factor to higher interference

Supports contention, youngsters with SCD, in NC have, in general, have better familial and systems level supports that may “buffer” physical and social consequences

For adults the supports are limited and inadequate to compensate for hardships, especially in rural areas

By changing the policy to create a more equitable of system of supports rural and age differentials can be effectively addressed

These findings have particular implications for states with a 40% or greater rural population

CONCLUSIONS

Limitations of the StudyThe study uses zip code linked SES data as the

basis for determining CDI score areas, a very good proxy measure, but may fully reflect the individual level SES of the client

Interference for children (not adolescents) is generally reported by parents and guardians, a good approach, but is limited by the parent’s perception

Current research is underway in Alabama aimed at addressing these limitations and improving on this study