Addressing Social and Structural Health Inequities in Diabetes Care
Coverage of the American Diabetes Association (ADA) Scientific Sessions is brought to you by the ADA x BT1 Collab.
Speakers for this session, “Diabetes Through a Health Equity Lens,” included:
- Joshua Joseph, MD, MPH, FAHA, The Ohio State University Wexner Medical Center
- Marshall Chin, MD, PHD, University of Chicago
This article focuses on research presented by Dr. Joshua Joseph.
Racial and ethnic minorities face health inequities in the United States. It’s well-known that African Americans, Asian Americans and Native Americans face higher rates of diabetes than white Americans. These populations also have less access to diabetes education, management tools and technology which contributes to overall higher blood sugar levels and increased rates of complications.
Experts discussed the potential factors that influence these alarming shortcomings in healthcare for underserved populations.
The rate of diabetes ranges significantly across groups in the United States
- African Americans have the highest rate of diabetes (diagnosed and undiagnosed): 17.4 percent
- White nonhispanic Americans have the lowest rate of all racial and ethnic groups: 13.6 percent
- Rural-urban disparities also exist. Rural populations are twice as likely to die of diabetes-related causes
Data also shows that diabetes-related indicators aren’t improving.
- The rate of new diabetes diagnoses is not declining for minority groups in the U.S.
- Data indicate effective diabetes management peaked from 2007 to 2010 and has declined since.
What are the roots of diabetes inequities?
Historical discrimination and racism tracing back to slavery and the post-civil war era are part of the bedrock of lasting health inequities. Contributors include:
- Rise of eugenics theory: The idea of improving the human species by selectively reproduction
- Closing of medical schools training Black physicians in the 19th and 20th centuries
- Medical experimentation on vulnerable groups
These events in history have a lasting effect on communities’ trust in the medical establishment, and led healthcare providers to develop biases towards minority patients. These events also created language and communication barriers between minority populations and the healthcare industry.
The cumulative result in the healthcare context is poor access to care, decreased quality of care, decreased communication between patient and provider and lower health education.
Social conditions and policies also lead to inequitable care. Some contributors include:
- Redlining and predatory lending restricted the ability to buy homes for people in certain neighborhoods.
- Far less money was invested in infrastructure within minority communities, such as schools, housing, roads, transportation, businesses, etc..
- Discrimination in access to jobs with high-quality health insurance
These factors facilitate structural and institutional racism. Seemingly simple deficiencies—like fewer sidewalks, parks and open spaces and less affordable food and stable housing are all devastating consequences of structural racism.
The cumulative effect impacts the overall health of these populations, seen through increased stress, blood pressure, obesity, cholesterol and blood glucose.
Potential solutions to inequities in diabetes care and treatment
- Target multiple patient barriers rather than a single solution
- Tailor intervention methods to specific cultures
- Use multidisciplinary teams: doctors, social workers, psychologists, etc.
- Employ interactive, skill-based patient training rather than passive learning approaches
- Using patient navigators or community health workers (CHW)
- Involve the family and community in interventions
Addressing “Tech-quity”
- There is a crisis of equity in minority groups’ access to diabetes technology.
- Change the distribution locations of continuous glucose monitors (CGM) to community centers for easier access.
- Bring clinical health workers in for patient training and education.
- The goal is to support long-term CGM use
The social determinants of health (SDOH) play a big role in a person’s ability to manage their health. Influential SDOH include:
- Food insecurity
- Unsafe or overcrowded housing
- Exposure to toxins
- Income inequality
- Unemployment
- Poor access to high-quality healthcare services
- Education
Addressing social determinants can include screening individuals to address social needs, linking them with community workers and bolstering community engagement.
Example: The Mid-Ohio Farmacy
Individuals who screen positive for food insecurity are referred by a provider for a Pharmacy Rx ID card for access to fresh produce for themselves and their families on a weekly basis instead of monthly. Participants have more access to healthy foods and ingredients, leading to positive changes in diet and behaviors around food.
Community Health Workers
Community health workers are frontline public health workers who are also trusted members of the community that have a deep knowledge of the community they serve. High-intensity contact with a CHW has repeatedly been shown to lower A1c.
Person-centered care models improve diabetes self-management
Patient-centered care models focus on engagement over outreach.
“It’s really important to break down the four walls of the healthcare system, to not think about outreach, which is short term, ‘What can I do for you?’ and transactional, but to think about engagement, which is long term. ‘What can we accomplish together?’ and relational,” Joseph said. “Community outreach does not equal community engagement. We should aim for true engagement.”
Some examples of patient-centered care programs include:
- Community-based cooking instruction
- The curriculum includes an interactive grocery store tour, hands-on cooking instruction and education on diabetes self-management
- Exercise is medicine, an 11-week provider prescribed program that engages a personal trainer and fitness education
- “Our goal with this program was to increase physical activity. What we saw was that exercise increased by about 64 minutes a week. Mental and physical quality of life increased, weight was reduced, waist circumference decreased, we saw improvements in blood pressure, as well as mental health outcomes which are critically important and including depressive symptoms and perceive stress,” Joseph said.
- Growing and Growth Collective
- Growing, harvesting and cooking education with community-grown vegetables
The patient-centered care frameworks supported by Joseph’s research illustrate a social-ecological framework. This approach acknowledges the true factors that contribute to a patient’s ability to successfully manage diabetes. By going beyond the basic 15-minute appointment in the clinic, he and his team are addressing significant community and policy issues that affect a patient’s immediate and long-term diabetes health.
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