Association of Burden and Prevalence of Arthritis With Disparities in Social Risk Factors, Findings From 17 US States

Zachary D. Rethorn, PhD, DPT; Timothy J. Rethorn, DPT; Chad E. Cook, PhD, MBA; Jason A. Sharpe, PhD, DPT; S. Nicole Hastings, MD, MHS; Kelli D. Allen, PhD

Disclosures

Prev Chronic Dis. 2022;19(2):E08

Abstract and Introduction

Abstract

Introduction: Social risks previously have been associated with arthritis prevalence and costs. Although social risks often cluster among individuals, no studies have examined associations between multiple social risks within the same individual. Our objective was to determine the association between individual and multiple social risks and the prevalence and burden of arthritis by using a representative sample of adults in 17 US states.

Methods: Data are from the 2017 Behavioral Risk Factor Surveillance System. Respondents were 136,432 adults. Social risk factors were food insecurity, housing insecurity, financial insecurity, unsafe neighborhoods, and health care access hardship. Weighted χ ² and logistic regression analyses, controlling for demographic characteristics, measures of socioeconomic position, and other health conditions examined differences in arthritis prevalence and burden by social risk factor and by a social risk index created by summing the social risk factors.

Results: We observed a gradient in the prevalence and burden of arthritis. Compared with those reporting 0 social risk factors, respondents reporting 4 or more social risk factors were more likely to have arthritis (adjusted odds ratio [AOR], 1.92; 95% CI, 1.57–2.36) and report limited usual activities (AOR, 2.97; 95% CI, 2.20–4.02), limited work (AOR, 2.72; 95% CI, 2.06–3.60), limited social activities (AOR, 3.10; 95% CI, 2.26–4.26), and severe joint pain (AOR, 1.86; 95% CI, 1.44–2.41).

Conclusion: Incremental increases in the number of social risk factors were independently associated with higher odds of arthritis and its burden. Intervention efforts should address the social context of US adults to improve health outcomes.

Introduction

Approximately 1 in 4 US adults have medically diagnosed arthritis, which is the most common cause of disability in the US, with over $300 billion in costs in 2013.^[1,2] Although no cures exist for arthritic conditions, a number of biomedical and behavioral factors can modify the prevalence and burden of arthritis; these include obesity and physical activity.^[3] However, these traditionally measured factors fail to adequately explain patients' risk of developing arthritis and the burden of arthritis (ie, mortality, morbidity, or financial cost).

In recent years, public policy groups who engage in community health care and cost management have increasingly recognized the influence of health risks related to social context.^[4] Whereas clinical care pathways for arthritis commonly consider biological and psychological factors,^[5] social determinants of health (SDOH) are not routinely taken into account. SDOH are broadly defined as the conditions in which people are born, work, live, and play and include areas such as economic stability, education, social and community context, and the built environment.^[4] Social risk factors are individual-level adverse SDOH that can be identified through screening tools (eg, positive for housing insecurity), although social needs are social risks prioritized by patients (eg, request for housing assistance).^[6] Because arthritis is so prevalent and costly, it is essential that the influence of social risk factors on arthritis is better understood.

Studies have quantified the relative contribution of traditional biomedical factors and social influences such as education and income to the development and burden of arthritis.^[7] However, social risk factor variables do not routinely exist alone and may cluster cross-sectionally. Shifting from a single risk factor analysis to a more comprehensive perspective that seeks to understand the complexity of coexisting social risk factors may offer greater insight into the effect of the accumulation of influences on health.^[8] No studies to date, however, have examined the effect of multiple or coexisting social risk factors on arthritis prevalence and burden. Our aim was to explore the association between social risk factors and the prevalence and burden of arthritis individually and with a social risk index based on the total number of social risk factors reported. A social risk index is a composite statistic that measures changes in a representative group of systemic social issues, or a compounding measure that aggregates multiple indicators.^[9]

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Demographic Characteristics of Individuals from 17 States in the 2017 BRFSS Sample ^a
Characteristic	0 of 5 social risk factors^b (54.3%)	1 of 5 social risk factors^b(25.0%)	2 of 5 social risk factors^b(11.2%)	3 of 5 social risk factors^b (6.3%)	≥4 of 5 social risk factors^b(3.2%)	Sample totals (100%)
Age group, y
18–24	11.5	12.3	15.8	12.8	12.2	12.3
25–34	15.3	16.2	19.4	22.0	21.6	16.6
35–44	15.2	14.8	16.4	20.7	22.8	15.8
45–54	16.0	16.8	17.3	17.1	20.4	16.5
55–64	17.1	17.0	16.6	17.9	16.9	17.0
≥65	24.9	22.9	14.5	9.5	6.1	21.7
Sex
Male	51.0	47.3	45.5	41.4	41.3	48.5
Female	49.0	52.7	54.5	58.6	58.7	51.5
Married or partnered	61.7	52.7	43.4	41.0	36.1	55.3
Race or ethnicity
African American	10.0	13.0	18.7	20.3	22.7	12.8
Hispanic	7.6	12.2	16.0	15.8	15.4	10.5
Multiracial	1.0	1.3	1.7	2.1	2.6	1.3
Other	4.6	4.6	4.4	4.1	4.0	4.5
White	76.8	68.8	59.2	57.7	55.3	70.9
Household income, $
<15,000	4.4	9.3	18.8	24.1	29.0	9.4
15,000–24,999	10.1	20.5	27.9	35.2	34.4	17.1
25,000–34,999	8.0	13.5	15.2	13.7	14.2	10.8
35,000–49,999	13.0	15.4	14.7	12.4	11.2	13.7
≥50,000	64.5	41.3	23.4	14.6	11.2	49.0
Homeowners	77.4	67.9	53.9	46.0	40.3	69.1
Educational attainment
Less than high school graduation	7.8	14.1	18.9	20.9	21.8	11.9
High school diploma or GED	27.8	31.9	34.6	33.4	33.3	30.1
Some college	30.1	30.6	31.8	33.8	33.7	30.8
College degree	34.3	23.3	14.7	11.9	11.2	27.2
Employment status
Employed	60.3	55.3	51.5	49.6	51.3	57.1
Unemployed	3.5	5.9	8.9	12.7	14.6	5.6
Unable to work	3.4	31.5	13.9	18.5	14.1	7.1
Other	32.8	7.3	25.7	19.2	20.0	30.2
Census region
Midwest	24.6	24.0	23.6	23.4	22.5	24.2
Northeast	21.2	19.5	18.4	17.4	13.7	20.0
South	45.9	48.1	48.8	51.1	55.7	47.4
West	8.3	8.4	9.2	8.1	8.1	8.4
Has health insurance	93.6	88.0	81.4	76.4	69.7	90.0
Health conditions
Heart attack	3.8	5.0	5.7	6.3	7.4	4.6
Coronary heart disease	3.9	4.9	4.7	5.3	6.8	4.4
Stroke	2.6	3.7	4.9	5.6	6.8	3.4
Asthma	11.5	14.3	18.7	21.4	24.9	14.0
Skin cancer	7.8	6.5	4.5	3.9	2.9	6.7
Other cancer	7.2	7.4	6.3	6.9	9.3	7.2
COPD	5.0	7.4	10.7	13.0	16.7	7.1
Depression	13.5	20.0	26.8	41.1	47.2	19.4
Chronic kidney disease	2.3	3.1	3.9	5.2	5.5	3.0
Obesity	64.1	67.0	67.9	68.6	69.8	65.7
Multimorbidity (≥2 comorbidities)	30.9	38.0	44.0	52.5	58.7	36.4

Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; COPD, chronic obstructive pulmonary disease.
^aData are presented as weighted percentages of study participants.
^bSocial risk factors are 1) having arthritis, 2) limited activities, 3) limited work, 4) limited social activities, and 5) severe joint pain.

Table 2. Relative Arthritis Prevalence and Burden by Individual Social Risk Factor and Social Risk Index ^a
Social risk	Total sample	Having arthritis	Limited activities	Limited work	Limited social activities	Severe joint pain
Social risk factor
Food insecurity	22.2	24.3^b	32.9^b	38.8^b	35.6^b	42.0^b
Housing insecurity	9.6	12.8^b	18.2^b	23.5^b	20.0^b	23.9^b
Financial insecurity	47.4	53.6^b	63.1^b	69.5^b	67.0^b	72.9^b
Unsafe neighborhood	5.6	6.8^b	8.8^b	10.2^b	9.5^b	11.2^b
Health care access hardship	13.0	14.4^b	20.0^b	24.5^b	21.2^b	23.8^b
Social risk index, No. (total number of social risk factors)
0	54.2	49.0^b	40.0^b	33.9^b	36.8^b	31.9^b
1	25.0	25.9	26.1	26.2	26.9^b	26.6
2	11.2	12.5^b	15.4^b	17.3^b	16.3^b	18.4^b
3	6.3	8.1^b	11.5^b	13.3^b	12.4^b	14.2^b
≥4	3.3	4.5^b	7.0^b	9.3^b	7.6^b	8.9^b

^aData are presented as weighted percentages of study participants.
^b P < .05.

Table 3. Adjusted Odds Ratios ^a for Arthritis Prevalence and Associated Burden by Social Risk
Social risk	Having arthritis	Limited activities	Limited work	Limited social activities	Severe joint pain
Social risk factor
Food insecurity	1.32 (1.20–1.45)	1.65 (1.43–1.91)	1.56 (1.36–1.79)	1.73 (1.50–2.00)	1.67 (1.44–1.93)
Housing insecurity	1.59 (1.41–1.80)	1.54 (1.28–1.86)	1.76 (1.48–2.09)	1.74 (1.44–2.12)	1.59 (1.33–1.89)
Financial insecurity	1.20 (1.11–1.29)	1.53 (1.37–1.71)	1.48 (1.31–1.66)	1.64 (1.47–1.83)	1.44 (1.26–1.64)
Unsafe neighborhood	1.38 (1.15–1.64)	1.37 (1.06–1.79)	1.42 (1.11–1.82)	1.37 (1.06–1.78)	1.34 (1.06–1.70)
Health care access hardship	1.48 (1.34–1.63)	2.00 (1.72–2.33)	1.97 (1.70–2.28)	2.33 (1.98–2.74)	1.71 (1.46–1.99)
Social risk index, No. (total number of social risk factors)
0	1.00 [Reference]	1.00 [Reference]	1.00 [Reference]	1.00 [Reference]	1.00 [Reference]
1	1.12 (1.05–1.20)	1.31 (1.18–1.46)	1.31 (1.17–1.47)	1.44 (1.29–1.60)	1.25 (1.10–1.43)
2	1.35 (1.21–1.50)	1.72 (1.47–2.02)	1.74 (1.49–2.04)	1.99 (1.69–2.33)	1.72 (1.46–2.02)
3	1.72 (1.50–1.98)	2.31 (1.85–2.89)	1.81 (1.49–2.20)	2.40 (1.89–3.04)	1.78 (1.45–2.18)
≥4	1.92 (1.57–2.36)	2.97 (2.20–4.02)	2.72 (2.06–3.60)	3.10 (2.26–4.26)	1.86 (1.44–2.41)

^aData are presented as weighted odds ratios (95% CI), adjusted for demographic characteristics (age, sex, race, ethnicity, marital status, and health insurance), socioeconomic position (educational attainment, income, current employment status, and home ownership), and health conditions (heart attack, coronary heart disease, stroke, asthma, skin cancer, other cancer, chronic obstructive pulmonary disease (COPD), depression, chronic kidney disease, obesity, and multimorbidity).