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Med Care. 2016 Aug;54(8):796-803. doi: 10.1097/MLR.0000000000000565.

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

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*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.



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.


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.


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.


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.

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