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

Patel, Minal R.; Piette, John D.; Resnicow, Kenneth; Kowalski-Dobson, Theresa; Heisler, Michele

doi:10.1097/mlr.0000000000000565

Cited by 143Medication Adherence and ComplianceFood Security and Health in Diverse PopulationsEconomic and Financial Impacts of Cancer

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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Patel, Minal R., Piette, John D., Resnicow, Kenneth, Kowalski-Dobson, Theresa, Heisler, Michele·2016·Medical Care

DOI 10.1097/mlr.0000000000000565PMC PMC4945373

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Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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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High out-of-pocket drug costs are identified as a factor that limits initiation of and adherence to prescribed glucose lowering therapies.
“High out-of-pocket (OOP) drug costs are identified as a factor that limit initiation of and adherence to prescribed glucose lowering therapies.8,9,10,11,12”
From Evaluation of Out-of-Pocket Costs and Treatment Intensification With an SGLT2 Inhibitor or GLP-1 RA in Patients With Type 2 Diabetes and Cardiovascular Disease (2023) · cites this paper as [9]
The Introduction identifies lack of affordability as a reason for nonadherence, and Methods > Measures defines cost-related nonadherence to include skipping doses, taking less medicine, and delaying a prescription fill to save money. The study concerns adults with diabetes, but these measures do not distinguish glucose-lowering drugs from other medications or establish that costs prevent initiation of glucose-lowering therapy. No page numbers are available in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Cost-reducing strategies may improve medication-taking behavior in some cases.
“Medication costs can be a major source of stress for people with diabetes and contribute to worse medication-taking behavior (197); cost-reducing strategies may improve medication-taking behavior in some cases (198).”
From 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2025 (2025) · cites this paper as [198]
The Results (page unavailable) associate asking a doctor for a lower-cost medication with less cost-related nonadherence among adults with diabetes. But the Discussion (page unavailable) says the cross-sectional data cannot establish whether cost-reducing strategies improve adherence; other strategies were associated with more nonadherence. (LLM, conf=0.85)
Experimental — accuracy not yet measured
Social determinants have been linked to nonadherence.
“Social determinants have also been linked to nonadherence, and a recent study using data from the National Health Interview Survey found that half of the adults with diabetes perceived financial stress, while one-fifth reported financial insecurity and food insecurity [30].”
From Impact of Social Determinants of Health and Demographics on Refill Requests by Medicare Patients Using a Conversational Artificial Intelligence Text Messaging Solution: Cross-Sectional Study (2019) · cites this paper as [30]
In a recent National Health Interview Survey study, half of adults with diabetes perceived financial stress, while one-fifth reported financial insecurity and food insecurity.
“Social determinants have also been linked to nonadherence, and a recent study using data from the National Health Interview Survey found that half of the adults with diabetes perceived financial stress, while one-fifth reported financial insecurity and food insecurity [30].”
From Impact of Social Determinants of Health and Demographics on Refill Requests by Medicare Patients Using a Conversational Artificial Intelligence Text Messaging Solution: Cross-Sectional Study (2019) · cites this paper as [30]
In a study of patients with chronic disease, two-thirds of those who reported not taking medications as prescribed due to cost never shared this with their physician.
“In a study of patients with chronic disease, two-thirds of those who reported not taking medications as prescribed due to cost never shared this with their physician [30,31].”
From Impact of Social Determinants of Health and Demographics on Refill Requests by Medicare Patients Using a Conversational Artificial Intelligence Text Messaging Solution: Cross-Sectional Study (2019) · cites this paper as [30]

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Factors beyond finances
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Authors: Patel, M. R., Piette, J. D., Resnicow, K., Kowalski-Dobson, T., & Heisler, M.
Affiliations: University of Michigan (US)
Department of Health Behavior & Health Education, University of Michigan School of Public Health
Corresponding author: Patel, Minal R.
Piette, John D.
Kowalski-Dobson, Theresa
ORCID: Patel, Minal R.
Piette, John D.
Kowalski-Dobson, Theresa
Heisler, Michele
Venue: Medical Care
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2016-08
Volume: 54
Issue: 8
Pages: 796-803
ISSN: 0025-7079 (ISSN-L)
DOI: 10.1097/mlr.0000000000000565
PMC: PMC4945373
OpenAlex: W2408160586
Cited by: 143
References: 27
Citations by year: 2026: 11 · 2025: 17 · 2024: 16 · 2023: 17 · 2022: 17 · 2021: 19 · 2020: 18 · 2019: 10 · 2018: 10 · 2017: 5 · 2016: 3
FWCI: 11.38
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: Medical Care (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092926)
Topics: Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
Health Sciences › Health Professions › General Health Professions › Food Security and Health in Diverse Populations
Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Economic and Financial Impacts of Cancer
Keywords: cost-related nonadherence, diabetes mellitus, social determinants of health, financial stress, financial insecurity, food insecurity, low-cost medication, complementary and alternative medicine, medication adherence
MeSH terms: Cost Control, Cross-Sectional Studies, Diabetes Mellitus, Female, Health Surveys, Humans, Insurance, Health, Male, Middle Aged, Patient Compliance, Self Care, Insurance Coverage, Social Determinants of Health

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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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