Arthritis self-management education and provision of advice

Level of education was the only socioeconomic factor to have been explored in relation to access to arthritis self-management education (both structured and informal). Using data from the US National Health Interview Survey, Hootman et al. found that only 5% of those who did not complete high school had received arthritis education, compared with 12% of those with at least high school education. More recently, a large study in the US involving almost 30,000 people with arthritis found that those who did not complete high school had a lower likelihood of receiving self-management advice from a health professional, compared with college graduates (adjusted odds ratio (OR) 0.81, 95% confidence interval (CI) 0.69–0.95) . By contrast, a study by the developers of the Stanford self-management programmes found that level of education was unrelated to participation in arthritis self-management programmes in the San Francisco Bay area . However, this study sample is unlikely to be representative of the general population, with an average of 15 years of education and a self-management participation rate of over 42%.

In relation to informal self-management advice, one study found that people with higher education were significantly more likely to receive weight loss advice as a strategy for the management of their arthritis, compared with those who had not completed high school (adjusted ORs 1.19–1.69) . Other studies have reported no relationship between education and receipt of weight loss advice , regardless of whether or not adjustment was made for body mass index. On the other hand, people with arthritis were found to receive advice on physical activity for arthritis more frequently if they had completed at least high school (57% vs. 49% for those who did not complete high school) .

Primary care

There is no evidence to suggest that education level is associated with access to primary health care for arthritis. Two studies from the Netherlands involving people with RA found that education was not associated with the utilisation of general practitioner services . Similarly, a US-based survey of adults with self-reported OA and RA found that access to a primary health-care practitioner was not associated with education, after adjusting for other factors .

Two studies have investigated the association between income and access to primary health care, with contrasting findings. Hagglund et al. found that access to primary care was not associated with income, after adjusting for other factors. Conversely, an Italian population-based study, which included over 25,000 people with arthritis, found significant pro-rich income-related inequities in access to general practitioner services . Two related studies from the United Kingdom (UK) investigating access to knee and hip replacement surgery have found that deprivation (defined as receiving means-tested welfare benefits) was associated with reduced access to general practitioner services among people in need of joint replacement.

Few studies have investigated relationships between other socioeconomic factors and access to primary care. One study from the UK found that people employed in non-manual and manual occupations reported similar utilisation of primary care for knee OA . Similarly, insurance type (public vs. private) was not associated with utilisation of general practitioner services for arthritis in studies from the Netherlands or US .

Musculoskeletal specialist services

Although neither education nor insurance type was associated with use of rheumatology services among people with RA in studies from the Netherlands, there is evidence of a relationship between SES and access to specialist care in other countries. A Canadian study of people with arthritis and rheumatism found that individuals living in areas with a lower proportion of high school graduates reported less utilisation of musculoskeletal specialist services (rheumatologists, orthopaedic surgeons or general internal medicine specialists), after adjusting for other factors including local availability of specialists .

Other Canadian research found lower SES to be associated with a longer median time to consultation with a rheumatologist (adjusted hazard ratio (HR) 1.16, 95%CI 1.05–1.26) , and a subsequent qualitative study involving patients with inflammatory arthritis, health professionals and health-care administrators reported that lower SES was perceived to be a barrier for access to rheumatology specialists . Masseria et al. also reported significant pro-rich income-related inequity in access to specialist services in Italy and, most recently, a Canadian study found that the likelihood of consulting an orthopaedic surgeon for OA was greatest for patients in the highest SES quintile, compared with the lowest quintile (adjusted HR for males 1.42, 95%CI 1.27–1.58; 1.19, 95%CI 1.09–1.31 for females) .

Other SES factors have also been associated with delayed access to orthopaedic consultations among people in need of joint replacement surgery. Research involving people undergoing total hip replacement (THR) in England found that individuals whose health care was publicly funded were over 5 times more likely to wait more than 3 months for an orthopaedic outpatient appointment, compared to those with private funding (OR 5.28, 95%CI 4.22–6.59) . This study also reported that people who rented public housing were more likely to wait longer for an orthopaedic appointment, compared with people who owned their own home (OR for waiting >3 months 1.57, 95%CI 1.31–1.89).

Allied health services

Preliminary evidence suggests that lower education is associated with greater self-perceived need for physical and occupational therapy . At the same time, there is strong evidence to support a link between lower education and reduced access to allied health services. Research from the Netherlands involving people with RA has shown that individuals with a university education were twice as likely to use allied health services, compared with those who had a primary education or less (adjusted OR 2.1, 95%CI 1.1–4.0) . A later study involving the same population found even greater disparities in access to allied health services for those with the lowest level of education . A study from the US involving people with musculoskeletal conditions found that those who did not complete high school had a lower likelihood of receiving physical therapy (adjusted OR 0.72, 95%CI 0.61–0.86), compared with those who competed high school . In a study of people with RA in the US , those with less than college education were only half as likely to have used physical therapy services, compared with those who had higher education (adjusted OR 0.5, 95%CI 0.3–0.8).

In their study of people with RA, Iversen et al. found that the highest income group was twice as likely to receive physical therapy, compared with lower income groups (adjusted OR 2.0, 95%CI 1.2–3.1). However, no association between income or financial security and access to physical and occupational therapy was found in a US study . The relationship between health insurance status and access to allied health services is also unclear. Research from the Netherlands and US found no relationship between insurance type (private vs. public) and utilisation of allied health services for arthritis. However, in another US study, those who had public insurance (adjusted OR 0.66, 95%CI 0.55–0.80) or no health insurance (adjusted OR 0.57, 95%CI 0.43–0.74) were less likely to utilise physical therapy services than those who had private insurance . Similarly, a US study investigating referrals to physical therapy for musculoskeletal conditions found that primary care visits covered by Medicaid were significantly less likely to result in referral to physical therapy, compared with visits covered by private insurance . Insurance status did not affect referrals to physical therapy by orthopaedic surgeons in the same study.

Medication use

There is some evidence of disparities in access to medications for arthritis according to SES. Research from North America found that college graduates were more likely to receive tumour necrosis factor inhibitors (TNF-Is) for RA, compared with those who had secondary education or less (OR 1.33) . People with private insurance were also more likely to receive TNF-I therapy than those with Medicare or Medicaid cover (OR 1.22) . Lower SES and lower income have also been associated with lower use of disease-modifying antirheumatic drugs (DMARDs) for RA . No relationship was found between occupation category and use of paracetamol or non-steroidal anti-inflammatory medications in knee OA .

Complementary and alternative therapies

There is no clear pattern of SES disparities in access to complementary and alternative therapies. Although one US-based study involving people with OA, RA and fibromyalgia found that higher levels of education were associated with greater CAM use , other studies from the US , as well as those from Korea and Turkey have found no relationship between education and CAM use. Looking at income, some studies have reported an association between higher disposable income or higher annual household income and greater use of CAM among people with arthritis , while others have found a negative association or no relationship . A study of people with knee OA in the UK reported higher use of both glucosamine and chondroitin supplements by people in non-manual occupations, compared with those in manual jobs . The same study found no differences in the utilisation of chiropractic or osteopathy services between occupation groups . Two US studies have found that insurance type was not associated with CAM use .