Descriptions of Barriers to Self-Care by Persons with Comorbid Chronic Diseases

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