摘要：Objective. We assessed which of a broad range of determinants of health are most strongly associated with health-related quality of life (HRQL) among people with type 2 diabetes. Methods. Our analysis included respondents from the Canadian Community Health Survey Cycle 1.1 (2000–2001) who were aged 18 years and older and who were identified as having type 2 diabetes. We used regression analyses to assess the associations between the Health Utilities Index Mark 3 and determinants of health. Results. Comorbidities had the largest impact on HRQL, with stroke (−0.11; 95% confidence interval [CI] = −0.17, −0.06) and depression (−0.11; 95% CI = −0.15, −0.06) being associated with the largest deficits. Large differences in HRQL were observed for 2 markers of socioeconomic status: social assistance (−0.07; 95% CI=−0.12, −0.03) and food insecurity (−0.07; 95% CI=−0.10, −0.04). Stress, physical activity, and sense of belonging also were important determinants. Overall, 36% of the variance in the Health Utilities Index Mark 3 was explained. Conclusion. Social and environmental factors are important, but comorbidities have the largest impact on HRQL among people with type 2 diabetes. The health of a population is determined by a large number of factors. Specific medical conditions, such as diabetes, have a significant impact on health status. Diabetes affects approximately 5% of Canadians aged 20 years and older, and the prevalence increases with age. 1 Individuals aged 65 years and older account for 50% of diabetes cases but represent only 15% of the population. 1 Ninety percent of all diagnosed cases of diabetes are type 2 diabetes, which is associated with a substantial physical and emotional burden for individuals who have the disease and their families. 2 – 4 The health-related quality of life (HRQL) deficits reported by people with type 2 diabetes are generally attributed to the disease itself, its restrictive treatment regimens, and its associated comorbidities. 2 – 4 However, HRQL deficits associated with type 2 diabetes may be better explained in the context of a more holistic determinants of health framework, because population health is not solely associated with disease and treatment. 5 , 6 The general approach to studying factors associated with HRQL and type 2 diabetes, however, has tended to focus on demographic and clinical factors. 7 – 11 There has been less emphasis on individual lifestyle factors (e.g., stress), the social environment (e.g., social integration), and access to health care. Previous research has shown that demographic characteristics and clinical factors (e.g., complications and comorbidities, duration of diabetes, and insulin use) have an impact on HRQL associated with type 2 diabetes, and some heterogeneities of HRQL and the disease can be explained by these factors. 10 This is not surprising because a number of these variables are determinants of population health. 6 There are many frameworks that conceptualize the determinants of health and their causal associations, but because of the complexity of the specified associations, it is often difficult to use such frameworks analytically. Hertzman et al. 12 proposed a relatively simple conceptual scheme for organizing and analyzing the relative importance of individual-level determinants of health on the basis of a commonly used population health framework. 6 They categorized the determinants of health into 3 domains for analysis: stage of life cycle, subpopulation partitions, and sources of heterogeneity. The objectives of our analysis were to (1) assess the magnitude of HRQL deficits associated with determinants of health and type 2 diabetes, and (2) assess the contribution of Hertzman et al.’s domains to explaining the variance in HRQL associated with type 2 diabetes.
