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Electronic letters published:
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Author's response
Role of socio-economic status in self-management of comorbid chronic illness
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Elizabeth A. Bayliss, Clinician Researcher Kaiser Permanente, Denver, CO
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I appreciate Dr. Chirayath’s perceptive comments on our recent article. There is no question that depression is of significant importance in the assessment of barriers to self- care for almost any coexisting medical condition and is, in itself, a comorbidity. The effect of depression on self-care is complex and depends not as much on a history of the diagnosis, but on the level of depressive symptoms at a given point in time: it is a disease with a fluctuating course and years may elapse between symptomatic episodes. Determining the effect of depression on self-care requires assessing the level of depressive symptoms at one or more points in time and correlating these with findings on the self-care process. Although low SES is linked to multiple other barriers to self-care, for the purposes of exploring this domain, it seems worthwhile to ‘split’ rather than ‘lump’ the potential downstream effects of disadvantage as they may also apply to less disadvantaged populations with multiple chronic medical conditions. Until we complete a more quantitative assessment of barriers to self-care with a more diverse population, it will not be clear whether lack of knowledge, low self-efficacy, lack of social support, etc. are accounted for primarily by low SES, or whether these areas also present barriers to the self-care process for persons in varying socioeconomic strata. There is no question that social factors affect not only barriers to the self-management of disease, but to the self-management of health as well. We would do well to remind ourselves of the well-worn (but very relevant) term ‘biopsychosocial ‘ assessment as we care for persons with multiple illnesses. Competing interests: None declared |
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Heidi T Chirayath, Assistant Professor of Sociology Bates College
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The article by Bayliss and colleagues in this issue of the Annals of Family Medicine provides excellent qualitative data regarding barriers to self care among patients with comorbid chronic illnesses. A sociological perspective raises two questions or comments regarding the findings of this research. Firstly, the authors note that the majority of respondents had a past or current diagnosis of depression. In fact, it is listed in Table 2 as the most common disease characteristic of respondents. This raises the question of what diseases are classified as comorbidities. Given the high prevalence of depression in patients with chronic illness, it calls into question the systematic omission of this illness from lists of comorbid conditions. Certainly, depression would qualify as a condition which compounds treatment for other illnesses, and one whose medications can have compounding effects on other treatments. As this study illustrates, the effects of depression on self-treatment for comorbid chronic illnesses is an exciting avenue for future study. Secondly, the authors indicate that the majority of study respondents have low incomes and are unemployed, but they fail to discuss this essential fact at the conclusion of their paper. One half of respondents indicated that financial constraints were a barrier to care, and I would argue that a number of other factors can be linked to the "disadvantage" of these patients. Specifically, research has linked patient socio- economic disadvantage to lack of knowledge about medical conditions, problems in communicating with providers, low self-efficacy, and low levels of social support. When acknowledging both the direct and indirect effects of poverty on self-care, it is clear that socioeconomic status is one of the predominant, if not leading, barriers to self-care among this population. Focus on structural barriers to medical care, including income, education, and employment and insurance status, provide social context to the daily battles faced by disadvantaged patients coping with multiple chronic illnesses. Competing interests: None declared |
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