The Social Determinants of Health and Type 2 Diabetes Management
Diabetes is a chronic disease that requires ongoing self-management. Despite one’s best efforts, diabetes control may falter. A patient with suboptimal glycemic control (i.e., an elevated A1C) may be unfairly labeled as non-compliant.
What is important for all of us to recognize is that diabetes control is much more than taking medication and going to the doctor. When helping a person with diabetes, it is important to consider the Social Determinants of Health (SDoH) and how these factors impact diabetes management, control, outcomes.
What does Social Determinants of Health (SDoH) mean?
“The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks.”1 Combined, the SDoH accounts for nearly 50 to 60 percent of health outcomes. While just 20 percent of health outcomes are tied to medical care.2
Healthy People 2030 has divided the SDoH into 5 categories:3
1. Education access and quality
This category includes early childhood education, literacy, graduating from high school, and overall level of educational attainment. There is a connection between one’s educational attainment and health and well-being. For example, a lower level of education is associated with having a higher A1C, while achieving a college education is protective against developing type 2 diabetes.
2. Healthcare access and quality
This category includes having access to quality healthcare that is affordable, having health insurance coverage, and understanding basic health information (i.e., health literacy).
An individual who has health insurance is more likely to have access to diabetes screenings and care. This is of vital importance because timely interventions may reduce the risk of chronic diabetes complications. A person’s education level also influences their health insurance status. For example, if someone has a lower education level, they may not have the employment opportunities that provide health insurance coverage.
Additionally, the cost of diabetes medications and supplies can be an immense expense, leaving an individual with diabetes without health insurance coverage to decide what medications/supplies they can go without.
In certain areas such as low-income inner cities and remote rural areas, there is often a lack of healthcare providers, limiting access to healthcare. As a consequence, care may be absent or inadequate, potentially worsening long-term conditions associated with diabetes.
3. Economic stability
This category includes issues of poverty, employment, food security, and housing stability. There is a connection between one’s financial resources and their health. For example, individuals with a lower income level have an increased prevalence of diabetes compared to those with higher incomes.
Approximately 20 percent of patients with diabetes have reported food insecurity which is a risk factor for poor diabetes management. For a family living in a food-insecure household, financial resources may need to pay for food with a little leftover for payment of diabetes medications and supplies.
4. Social and community context
This category includes the relationships and interactions people have within the community (i.e., family, friends, neighbors, co-workers) surrounding them, all of which can have a major impact on one’s health and well-being.
An individual living in a neighborhood with high social cohesion (having strong relationships with community members) has been associated with a 22 percent decrease in the incidence of type 2 diabetes. The greater the amount of social support a person with diabetes has, the greater their glycemic control and quality of life.2 While, a lack of social support has been linked with an increase in diabetes-related complications and mortality.2
5. Neighborhood and built environment
There is a connection between where one lives and their health and well-being. This category addresses quality of housing, access to healthy foods, air quality, safe water, transportation, and neighborhood crime.
A person living in unstable housing is more likely to face difficulty in engaging in diabetes self-care and self-management, have a harder time affording medications and supplies and have limited access to healthy foods.2 Unstable housing may be the key barrier to achieving diabetes care among low-income individuals.
A person living in an area of high crime may not feel safe leaving their home for a routine appointment or may also not feel comfortable going outside for physical activity.
If a person lives in a food desert with limited access to healthy food choices, they are left choosing less nutrient-dense foods that may negatively impact their diabetes management.
The overall impact on diabetes management
As you can see, all 5 categories of the SDoH are intertwined and can negatively impact diabetes control. Each one has the ability to affect patients’ adherence, the effectiveness of a treatment plan, and overall health outcomes.4
To make forward progress, we must recognize that for diabetes outcomes to be improved, the SDoH needs to be considered in diabetes management. All future healthcare providers (and current healthcare providers) need training on the SDoH and how they influence diabetes management.
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