European Journal of Cardiovascular Medicine

Atopic dermatitis (AD), a chronic inflammatory skin condition characterized by itching, erythema, and dryness, is a global health concern, particularly among individuals in industrialized nations. The disease is marked by periods of exacerbation and remission, requiring long-term management to control symptoms and prevent flare-ups. While the physical manifestations of moderate-to-severe AD are significant, the psychological, social, and financial impacts on affected individuals are often underappreciated. For patients with moderate-to-severe AD, adherence to treatment regimens, which may include topical therapies, phototherapy, and systemic immunosuppressive agents, is critical for effective management and improvement in quality of life [1].Despite the availability of various treatment options, studies have consistently shown that treatment adherence among patients with AD is suboptimal [2]. Non-adherence to prescribed therapies is a widespread issue that can result in poor disease control, frequent flare-ups, and a greater need for more intensive and costly interventions. However, treatment adherence is not solely dependent on the clinical effectiveness of medications or the patient's motivation [3]. The impact of socioeconomic factors on adherence is gaining increasing attention in recent research, as it has become clear that a patient's social, economic, and environmental circumstances can significantly influence their ability to follow prescribed treatment regimens. These factors can create barriers to care, limit access to medications, and contribute to misunderstandings about the importance of consistent treatment, ultimately worsening disease outcomes [4]. Several socioeconomic factors are thought to contribute to treatment non-adherence in patients with AD. For example, patients from lower socioeconomic backgrounds may face financial challenges that prevent them from purchasing necessary medications, attending follow-up appointments, or accessing specialized dermatological care [5]. The costs associated with long-term therapy, especially for those requiring systemic immunosuppressants, can be prohibitive, even in high-income countries where insurance coverage may vary. Financial strain can also lead to the delay of treatment initiation or the discontinuation of therapy altogether when symptoms appear to improve or when out-of-pocket expenses become unsustainable [6]. Moreover, lower educational attainment is another socioeconomic factor that can negatively impact treatment adherence. Patients with limited health literacy may struggle to understand medical instructions or the importance of adhering to complex treatment regimens. This is particularly concerning in moderate-to-severe AD, where treatment often involves multiple steps and ongoing adjustments depending on disease activity [7]. Misunderstandings about the correct application of medications, such as the frequency of use or the duration of therapy, can hinder the efficacy of the treatment and result in poor disease control. Furthermore, cultural factors, including mistrust of healthcare providers or traditional beliefs about medical care, may also influence adherence, particularly in certain communities. This can be further exacerbated by the psychological burden of living with a visible, chronic condition, where stress and depression may lead to a disregard for prescribed treatments. Access to healthcare services is another critical determinant of adherence in AD patients [8]. In resource-limited settings, where healthcare infrastructure may be inadequate or unevenly distributed, patients may have difficulty accessing specialist care. Lack of transportation, long waiting times, and low availability of medications are common barriers [9]. The chronic nature of AD, along with its visible symptoms, can contribute to a cycle of low self-esteem, social isolation, and decreased motivation to manage the condition effectively. Mental health disorders, particularly those common among low-income groups, can lead to poorer adherence to treatment plans, as individuals may prioritize other aspects of their well-being over managing their skin condition [10-12]. This study, conducted at a tertiary care teaching hospital, seeks to explore the influence of socioeconomic factors on treatment adherence in patients with moderate-to-severe AD.

This study is a cross-sectional analytical study conducted at a tertiary care teaching hospital. It aims to evaluate the impact of socioeconomic factors on treatment adherence in patients with moderate-to-severe atopic dermatitis (AD). Data were collected from 120 participants. Inclusion Criteria 1. Patients aged 18 years or older 2. Diagnosed with moderate-to-severe atopic dermatitis as per the Hanifin and Rajka criteria 3. Receiving treatment for AD (topical or systemic therapy) 4. Patients who have been under treatment for at least 3 months prior to participation 5. Willing to provide informed consent for participation in the study Exclusion Criteria 1. Patients with severe comorbidities that affect their ability to participate (e.g., terminal cancer, severe psychiatric disorders) 2. Pregnant or lactating women 3. Patients who are unable to communicate or understand the study protocol due to language barriers or cognitive impairments 4. Patients with a history of non-compliance unrelated to socioeconomic factors 5. Patients who are not on any prescribed treatment for atopic dermatitis Data Collection Data will be collected through patient interviews, medical records, and self-reported questionnaires. The patients will be asked about their treatment adherence patterns, socioeconomic status (including income level, education, employment status, and insurance coverage), and psychological well-being (using validated tools such as the Hospital Anxiety and Depression Scale). Additionally, clinical data, such as disease severity, treatment type, and duration of the condition, will be gathered from medical records. Statistical Analysis Data analysis will be performed using SPSS version 17. Descriptive statistics will be used to summarize patient demographics and clinical characteristics, with mean ± standard deviation for continuous variables and frequencies with percentages for categorical variables. To assess the relationship between socioeconomic factors and treatment adherence, chi-square tests will be used for categorical variables, and t-tests will be used for continuous variables. Multivariate logistic regression will be conducted to identify significant predictors of non-adherence, adjusting for confounding variables such as age, gender, and disease severity. A p-value of <0.05 will be considered statistically significant.

The baseline demographic and clinical characteristics of the study participants show that the mean age of the patients was 42.6 years, with a standard deviation of 14.2 years, indicating a relatively broad age range among the subjects. The gender distribution was skewed towards males, with 58.3% of the sample being male. Regarding socioeconomic status, the majority of participants came from middle-income backgrounds (41.7%), followed by low-income (37.5%) and high-income (20.8%) groups. Educationally, 45.8% of participants had primary or lower education, 29.2% had secondary/high school education, and 25% had a university degree.

The treatment adherence data show a 50/50 split between adherent and non-adherent patients. Among those who were non-adherent, financial constraints were the most common reason, cited by 50% of these patients. Other factors included forgetfulness (25%), lack of understanding of the treatment regimen (16.7%), and lack of motivation (8.3%).

A large proportion of low-income patients (58.3%) were non-adherent, while only 16.7% were adherent. In contrast, the majority of middle-income patients (58.3%) were adherent, with a significantly smaller proportion (25%) being non-adherent. High-income patients showed a more balanced adherence pattern, with 25% adherent and 16.7% non-adherent, though this difference was not statistically significant. The results suggest that patients from lower socioeconomic backgrounds are at a higher risk of non-adherence, largely due to financial constraints.

The association between education level and treatment adherence revealed that patients with a primary education or below had the lowest adherence rates, with 66.7% being non-adherent. Conversely, patients with higher levels of education, particularly those with secondary or high school education (41.7% adherence), showed better adherence rates.

Table 1: Baseline Demographic and Clinical Characteristics of Patients (N = 120)

Table 2: Treatment Adherence Among Patients with Moderate-to-Severe AD (N = 120)

Table 3: Association Between Socioeconomic Status and Treatment Adherence (N = 120)

Table 4: Impact of Education Level on Treatment Adherence (N = 120)

A significant portion of non-adherent patients reported symptoms of anxiety (75%) and depression (66.7%), while only 33.3% of adherent patients had anxiety and 25% had depression. This highlights the psychological burden associated with non-adherence, as those with anxiety and depression are less likely to follow their treatment regimens. Conversely, patients with no psychological issues showed much higher adherence rates (41.7% adherent compared to 8.3% non-adherent).

Table 5: Psychological Factors and Treatment Adherence (N = 120)

The findings of this study underscore the significant role socioeconomic factors play in treatment adherence for patients with moderate-to-severe atopic dermatitis (AD). Our results indicate that adherence to prescribed treatment regimens is not only influenced by clinical and psychological factors but is also deeply intertwined with socioeconomic determinants such as income, education level, and psychological well-being. This highlights the importance of addressing these factors in the management of AD, especially in settings where resources may be limited.  A major finding of this study is the strong association between lower socioeconomic status and poor treatment adherence. As observed in Table 3, patients from low-income backgrounds were disproportionately non-adherent (58.3%), compared to those from middle and high-income backgrounds. This aligns with previous research that has shown that financial barriers, including the inability to afford medications and follow-up care, are major contributors to non-adherence among chronic disease patients, including those with dermatological conditions. The educational background of patients was also a significant determinant of treatment adherence [13]. Patients with lower educational attainment (primary or below) had the highest rate of non-adherence (66.7%) as shown in Table 4. This suggests that health literacy, which is often associated with educational attainment, may play a crucial role in ensuring proper treatment adherence. Previous studies have consistently highlighted that patients with higher education levels tend to have a better understanding of their condition, the importance of adhering to treatment regimens, and the potential consequences of non-compliance. The psychological well-being of patients also had a marked impact on treatment adherence [14]. As shown in Table 5, a substantial proportion of non-adherent patients reported symptoms of anxiety (75%) and depression (66.7%), which significantly impacted their ability to follow through with treatment plans. The psychological burden of managing a chronic condition like AD, particularly one with visible symptoms, can contribute to a cycle of stress, low self-esteem, and a lack of motivation to follow prescribed treatments [15]. Previous research has demonstrated that individuals with mental health issues, particularly anxiety and depression, are more likely to experience difficulties in managing chronic conditions, including dermatological diseases like AD [16]. The findings from this study suggest that healthcare providers should not only focus on the clinical aspects of AD but also consider the broader socioeconomic and psychological factors that affect treatment adherence. Interventions aimed at improving adherence could include financial assistance programs to help patients access necessary medications and therapies, as well as educational initiatives to enhance health literacy, especially in lower-income and less-educated populations [17-19]. Additionally, psychological support services could be implemented to address the mental health challenges that many patients face when managing chronic skin conditions. This study has some limitations that should be addressed in future research [20,21]. The cross-sectional design limits the ability to establish causality between socioeconomic factors and treatment adherence. A longitudinal study would provide a more comprehensive understanding of how socioeconomic factors impact treatment adherence over time. Additionally, the study was conducted at a single tertiary care center, which may limit the generalizability of the findings to other populations. Future research could include a more diverse sample, encompassing different geographic regions and healthcare systems to assess the broader applicability of these results. Moreover, the role of other socioeconomic factors, such as employment status and insurance coverage, could be explored in greater depth in future studies.

Socioeconomic status plays a crucial role in influencing the risk, severity, management, and quality of life of individuals with atopic dermatitis in India. While higher socioeconomic status may increase susceptibility through lifestyle and environmental factors, lower socioeconomic status often leads to greater disease severity due to poor living conditions, limited healthcare access, and lack of awareness. In conclusion, this study emphasizes the significant impact of socioeconomic factors such as income, education level, and psychological well-being on treatment adherence in patients with moderate-to-severe atopic dermatitis. Our findings reveal that patients from lower socioeconomic backgrounds, particularly those with lower income and education levels, exhibit poorer adherence to prescribed treatment regimens. Psychological factors, including anxiety and depression, further exacerbate non-adherence, underscoring the complex relationship between socioeconomic status, mental health, and disease management.

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