For multivariable statistical analyses we constructed non-conditional multiple logistic regression and multinomial logistic regression models. The variables included in these models were those significantly associated in the bivariate analysis and those considered to be relevant in literature. We incorporated the survey sampling design and sampling weights. In accordance with Spanish legislation, there is no need for Ethics Committee approval, since the database was obtained from the Spanish Ministry of Health, Social Services and Equality webpage, where it is publicly available.
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The data was provided to us and therefore analyzed anonymously. The study sample included 1, prevalence 7. The distribution of the study population by diabetes status and according to study variables is shown in Table 1. The diabetic population was significantly older than the non-diabetic The largest proportion of the diabetic sample The prevalence of chronic conditions was higher among persons with diabetes with The equivalent figures for those not suffering diabetes were More than half of the diabetic subjects The number of unhealthy lifestyles was slightly but significantly higher among those suffering diabetes.
When analyzed by type of preventive health practice we found that adherence among diabetic subjects varied by specific activity. As can be seen in Table 1 after adjusting by age and sex, when required, the adherence to blood and cholesterol measurements and influenza vaccination was significantly higher among those suffering diabetes. On the other hand cytology and dental checkup were lower. No significant differences were detected for mammography or FOBT.
The observed adherence to clinical preventive recommendations among diabetes patients according to study variables is shown in Table 2. Diabetic women showed higher adherence than men for BP measurement with no difference according to sex in any other practice. For BP, cholesterol checkups and influenza vaccine adherence increased with age. In mammography the highest uptake was found in the 50—59 years age group and for cytology and dental check up in the youngest group. Married or cohabiting diabetic patients showed higher uptakes for mammography, FOBT and dental checkup.
Educational level was positively and significantly associated with the uptake of cytology and dental care checkup. Immigrants reported lower adherence to mammography, cholesterol checkup and influenza vaccination. Suffering more chronic conditions was associated to higher adherence for all the preventive practices except mammography and cytology.
For dental care checkups the relationship was reversed, with lower uptake among those with more conditions. It was found that female non-smokers reported higher mammography uptake and for both sexes those who smoked had lower adherence to influenza vaccination. Diabetic patients who had consumed alcohol in the last week were less likely to have a BP checkup and obese subjects to have a dental care checkup.
The results of the multivariable analysis to identify independent predictors for each preventive clinical practice among diabetic patients are shown in Table 3. Diabetic women were more likely to undergo a mammography in the last two years if they were older, born in Spain and married or cohabiting.
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Being Spanish born increased the uptake of mammography by 2. Positive predictors for cytology tests included being younger and having a higher educational level.
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Diabetic women who had completed university studies were 2. A higher number of chronic conditions and visits to a GP increased the uptake of cholesterol checks.
Predictors of more dental care checkups included female sex OR 1. Table 4 shows the adjusted odds ratios obtained by multinomial logistic regression for levels of adherence to preventive clinical practices, as the dependent variable, according to study variables and number of unhealthy lifestyle behaviors. Within each level of adherence to preventive measures, we observed an adjusted OR for female sex of over 3. Educational level also showed a significant association with increasingly higher OR as the adherence level rose.
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This means that higher educational level is strongly associated with a higher adherence to preventive practices. A higher number of chronic conditions and number of physician visits increased the probability of having higher adherence in all the levels analyzed. Finally for each unhealthy lifestyle reported the probability of having a higher adherence level decreased. Our results suggest that the adherence to recommended clinical preventive practices among diabetic adults included in our study is suboptimal.
Current results suggest a possible improvement in the application of cardiovascular risk factor control protocols by primary health care professionals as has been described by other Spanish authors [ 35 — 37 ]. Studies conducted in other countries find adherence levels for these two preventive practices that are similar to ours [ 11 , 12 , 38 , 39 ]. We agree with Baillot et al who comments that it appears that BP and cholesterol monitoring have been systematically incorporated into routine clinical care [ 12 ].
In our study population we found that only This figure is remarkably lower than the Other studies conducted in Spain have detected a significant decrease in high risk groups, including diabetes patients, having an influenza vaccination after the H1N1 pandemic influenza [ 40 — 41 ].
Further studies are necessary to precisely identify reasons for non-compliance and barriers to influenza vaccination among people with diabetes. Meanwhile urgent strategies to improve seasonal vaccination uptake must be discussed and implemented [ 40 ]. Adults with diabetes experience an increased oral disease burden, but as found in several studies this may not translate into increased dental care service utilization [ 14 , 42 , 43 ].
Our study indicated that individuals with diabetes were less likely to visit a dentist in the last year than age-and-sex adjusted individuals without diabetes The use of dental care among Spanish people with diabetes is lower than those described in the US Chaudhari et al used data from the Washington Dental Service WDS study and found that patients with diabetes are less likely to use dental services than people without this disease. In the published literature dental care use is often governed by access factors such as income and dental insurance coverage [ 45 ]. Thus, lack of financial coverage could explain the poor uptake of this measure among the oldest and the lower educational level groups in our population, since dental exam is the only preventive activity not delivered by the Spanish National Health System.
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This finding emphasizes the need to increase awareness and support for oral health care among diabetes patients. The adherence to breast and CRC screening tests in our study did not differ between those with and without diabetes.
Some, but not all, authors have reported that women with diabetes have lower uptake for mammography than women without diabetes [ 26 — 30 , 47 , 48 ]. Our results show very low adherence 8. Previous studies show lower uptake of FOBT among people with diabetes than in non-diabetic subjects, a result not found in our sample [ 26 — 28 ].
The lower adherence among diabetic women has been previously described in Spain and other countries [ 26 , 29 , 30 , 48 ]. A possible reason for lower uptake of cancer screening among people with diabetes is that diabetes management may compete with preventative healthcare because of their focus on clinical control of their diabetes and the perception that long-term disease prevention is less important 26, 29, 30, 48, 51].
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Physicians and patients tend to prioritize demands and to only deal with the most pressing or symptomatic problems, thus leading to clinical inertia [ 26 , 29 , 30 , 48 , 51 ]. Among adults with diabetes in our study, several factors have been found to be associated with a higher adherence to specific preventive practices and with a simultaneous uptake of a higher number of preventive practices.
Being married or cohabiting increased the adherence to mammography and dental care and was associated with being in a higher adherence group. These findings suggest that social support is important in order to engage in preventive activities. This support could be instrumental in the form of accompanying someone on a health visit or activity or emotional by discussing concerns around a condition and ongoing care.
As a consequence, improved health behaviors and a healthier lifestyle can be developed by the couple [ 52 ]. Consistent with existing literature, higher education was associated with the uptake of a greater number of preventive care, specifically cytology, influenza vaccination and dental care; this documents disparity in preventive care by educational status [ 9 , 15 , 29 , 30 , 31 , 48 , 53 ].
Educational level, imparts health related knowledge capacity, reflects access to resources including preventive health care, and determines health behaviors, which may explain our findings [ 15 , 29 , 30 ]. These results can imply that stronger public health efforts are needed to increase rates of preventive care uptake for those with lower education levels.
Diabetes patients with more comorbid chronic conditions and more frequent users of GP services were more likely to receive clinical preventive services. This is consistent with the findings in the literature that individuals with multiple conditions are more likely to receive necessary care because they are often seen by more than one provider, and that the primary care provider is now encouraged to not just treat a single disease or condition, but rather to treat the multiple comorbid conditions for overall health management.
Previous studies conducted in Spain and elsewhere have also found these associations [ 9 , 26 , 29 , 50 ]. The association between unhealthy lifestyles and the uptake of specific clinical preventive practices found in our sample showed no conclusive results. However, the multinomial models consistently showed that as the number of unhealthy lifestyles increased the probability of belonging to a group with a higher degree of adherence decreased. Clusters of unhealthy behavioral risk factors have been previously linked to lower uptake of clinical preventive services in both the general population and among diabetic patients in Spain [ 9 , 54 ].
This relationship is relevant since subjects at highest risk those with the greatest number of unhealthy behaviors are less likely to receive the recommended preventive care clinical practices even though they are the ones who would obtain the maximum benefit [ 9 , 54 ]. Improved diabetes management and uptake of preventive practices will result from complex interactions among factors at the patient level e. To increase the proportion of all people with diabetes who receive multiple preventive care services, system-level approaches, such as use of electronic medical records and patient registries, are needed to ensure equity of access and delivery of quality health care [ 10 ].
Further research is necessary and should include mixed methods—such as continued population-based surveillance of preventive care services and qualitative research methods—to determine the barriers to preventive practices [ 10 , 11 ]. We believe that our findings can help inform policy makers developing public health strategies around subpopulations at risk. Our study has several strengths. We used data from two successive, nationally representative surveys conducted in the Spanish population with diabetes, and were able to collect information for many socio-demographic characteristics and lifestyle behaviors which are not available in medical records.
We joined the two databases for the following reason i The two surveys use identical sampling and interviewing methods and the same questions. The institution which carried out both surveys is the National Statistics Institute INE that has conducted all the national surveys done in Spain since This institution guaranties the highest quality controls. So we think that the time effect, if any, would be of small magnitude; iii When we compared the distribution of the diabetic population between the two surveys no significant differences were found for socio-demographic variables or for the adherence to any of the clinical preventive practices analyzed between the diabetic patients in both surveys and; iv finally, we needed to join the two databases in order to obtain a large enough sample size to analyze some dependent variables, such as FOBT, or independent variables, such as educational level or nationality.
However there are some limitations to our study. First, since our study was based on a cross-sectional design, there was no information on the temporal relationship and therefore, causal associations were unable to be made. Second, the validity of the questions used to classify subjects as diabetic or nondiabetic should be evaluated.
Third, another possible limitation of health surveys is that the use of unvalidated self-reported data on unhealthy lifestyle behaviors and preventive care recommendation fulfillment could lead to possible biases, due to recall errors or to the tendency of individuals to give socially desirable responses within interviews [ 57 , 58 ]. Fourth, other relevant variables such as years since diabetes diagnosis, type of diabetes, insulin use or glycemic control are not collected by the surveys used and may act as confounding factors since some of them have been found to be associated with adherence [ 15 , 31 , 50 ].