Open Access Highly Accessed Research article

Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

Andrew J Karter12*, Mark R Stevens3, Arleen F Brown4, O Kenrik Duru4, Edward W Gregg3, Tiffany L Gary5, Gloria L Beckles3, Chien-Wen Tseng67, David G Marrero8, Beth Waitzfelder6, William H Herman9, John D Piette10, Monika M Safford11 and Susan L Ettner4

Author Affiliations

1 Division of Research, Kaiser Permanente, Oakland, CA, USA

2 Affiliate Professor, Dept. of Epidemiology, School of Public Health & Community Health, University of Washington, USA

3 Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA

4 Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

5 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

6 Pacific Health Research Institute, Honolulu, HI, USA

7 Dept. of Family Medicine and Community Health, University of Hawaii, Honolulu, HI, USA

8 Indiana University Diabetes Research and Training Center, Indianapolis, IN, USA

9 Div. of Metabolism, Endocrinology & Diabetes, Dept. of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, MI, USA

10 Ann Arbor VAMC and University of Michigan, Ann Arbor, MI, USA

11 Deep South Center on Effectiveness at Birmingham VA Medical Center and Department of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

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BMC Public Health 2007, 7:308  doi:10.1186/1471-2458-7-308

Published: 29 October 2007



Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors.


This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans.


Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25–44, modest for those ages 45–64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings.


The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.