Tratamiento de la Hipertensión Endocraneal

Chronic bronchitis has been found to be more consistently associated with low SEP, inadequate indoor environmental conditions and high medical resource consumption

(Cerveri et al., 2003; Ferre et al., 2012; Korad et al., 2013). Only a few studies have accessed the relationship between socio-demographic, indoor environmental factors, and chronic bronchitis in adults, but none of these studies examined mediation with predictor-mediator interaction effects.

6.3.1 Socio-demographic Factors

In the bivariate analysis, significant independent associations were observed between chronic bronchitis and female gender, increased age, blacks and other race groups, widowed/separated, non-high school graduates, retired, unable to work participants and those with annual income <$15000. The high proportion of chronic bronchitis observed among females compared to males in the current study is contrary to the findings of a general population study in France (Ferre et al., 2012). However, the high proportion of chronic bronchitis observed in females in the current study is not abnormal because a recent study by Konrad et al. (2013) identified a high probability of chronic bronchitis among females compared to males. As reported by Montnémery et al. (1998); Kongevinas et al. (1998) and Montnémery et al. (2001) individuals in low SEP measured by gender, age and employment status are at increased risk of bronchitis.

6.3.2 Indoor Environmental Factors

Previous studies have revealed that the increased risk of bronchitis is as a result inadequate indoor environmental conditions (Viegi et al., 1991; Bakke et al., 1991; Fishwick et al., 1997; Sunyer et al., 1998; Zock et al., 2001; Kurmi et al., 2010; Hu et al., 2010). More specifically, in the current study mold presence, smoking, second- hand smoke, mice, cockroach and occupational exposure were identified to be significantly related to the reporting of chronic bronchitis. Numerous studies have reported a link between occupational exposure, smoking status and increased risk of chronic bronchitis (Heederik et al., 1990; Sunyer et al., 1998; Montnemery et al., 1998;

Sethi and Rochester 2000; Zock et al., 2001; Rodriguez et al., 2014). Mold presence was consistently observed to be associated with chronic bronchitis for all three years. Although studies that access these relationships in adults are limited, a review by WHO (2009), concluded that there is sufficient evidence to document an association of dampness-related agents with respiratory infections, but evidence of an association with bronchitis was limited and only suggestive. However, a recent meta-analysis by Fisk et al. (2010) concluded that indoor dampness and mold are associated with substantial and statistically significant increases in both respiratory infections and bronchitis.

6.3.3 Healthcare Access

Medical cost was a significant predictor of increased risk of chronic bronchitis. Also, medical cost was identified as a mediator in the relationship between socio- demographic factors and chronic bronchitis which was consistent for all three years. In the U.S., medical cost is a significant barrier to adequate healthcare for individuals in low SEP measured by the level of education, employment characteristics and level of income (Monheit and Vistries 2000; Fiscella et al., 2003). Although studies that directly examined the effect of medical cost on the risk of respiratory diseases such as chronic bronchitis were lacking, Lurie and Dubowitz (2007) noted that disparities in health outcomes such as CLRD are directly related to healthcare access and that access to adequate healthcare is important because it leads to better health outcomes.

6.3.4 Mediation Test for Chronic Bronchitis

In the mediation analysis, mold presence, being a current or former smoker, smoking indoors, occupational exposure and medical cost completely or partially mediated the effects of age, marital status, education, employment and income on the reporting of chronic bronchitis. The findings revealed that gender, age, marital status, education, employment and income disparity in the reporting of chronic bronchitis is fully or

partially explained by, mold presence, being a current or former smoker, smoking indoors, occupational exposure and medical cost. Sunyer et al. (2006) and Ferre et al. (2012) identified lower social class, smoking, lower education, occupational exposure in men, home and outdoor No2 _{levels in women as significant risk factors for lower}

respiratory infection. The significant predictor-mediator interaction effects revealed that there is differential gender, age, education, employment and income effects of mold presence, pest infestation smoking status, smoking indoors, occupational exposure and medical cost on the reporting of chronic bronchitis. Females who reported smoking indoors and were former smokers were more likely to report chronic bronchitis. While increased odds of reporting chronic bronchitis were observed among participants with income <$15000 and $25000-$49999 who report cost as a barrier to medical care. When mold was present those with a household income of $25000-$49999 were more likely to report chronic bronchitis. Increased odd of reporting chronic bronchitis was observed for age groups 35 years or older who reported occupational exposure. Current or former smokers who were high school graduates and those with household income $25000- $49999 who were former smokers were more likely to report chronic bronchitis. As reported by Ferre et al. (2012), the relationship between increased risk of chronic bronchitis and SEP could be related to differential exposures to environmental or occupational air pollutants or environmental tobacco smoke. Lange et al. (2003), identified male gender, advanced age, smoking and occupational exposure as predictors of chronic bronchitis. According to Steenland et al. (2002) and Prescott et al. (2003), the increased risk of chronic bronchitis observed in men than women might be because men are more likely to have occupations where they were more likely to be exposed to occupational pollutants. Although the mediating process was not supported for gender, a significant effect was observed for females and chronic bronchitis.

The current findings from the mediation test revealed that the impact of gender, age, marital status, educational level, employment status and income level on the reporting of chronic bronchitis among ACBS respondents in the U.S. is influenced by mold, pest infestation, smoking status, smoking indoors, occupational exposure and medical cost. More specifically from the interaction effects females, above 35 years or older, non- high school graduates, retired with income <$50000 who reported mold presence, pest infestation, occupational exposure, cost as a barrier to care, smoke indoors and were current or former smokers were at increased risk of reporting chronic bronchitis. These findings are novel and contribute to knowledge in that this is the first study to use three different years of cross-sectional data based on social causation of health inequality framework to identify mediating indoor environmental factors and access to healthcare on the relationship between socio-demographic factors and chronic bronchitis with specific predictor-mediator interaction effects. Thus, highlighting the important risk factors that can be targeted by policymakers to reduce the burden of chronic bronchitis and improve the health outcomes among adults in the U.S.