Diabetes Self-Management Education for Special Populations: The Social Determinants of Health Matter

We read with interest the article by Adjei Boakye et al ¹ on the sociodemographic factors associated with engagement in diabetes self-management education (DSME) among persons with diabetes. The authors astutely examined sociodemographic characteristics such as age, sex, race/ethnicity, and socioeconomic status indicators among persons with self-reported diabetes in a contemporary, nationally representative sample of 84 179 adults in the Behavioral Risk Factor Surveillance System. Recent studies support their findings of limited DSME among populations with distinct sociodemographic characteristics, namely persons who are socially disadvantaged. ² The interplay of socioeconomic status, race/ethnicity, and cultural beliefs and norms influences patient-level diabetes self-management in these groups. ³ Although imperative, imparting knowledge to patients may not be sufficient for successful diabetes self-management. Thus, incorporation of other factors and support mechanisms beyond didactic education is necessary. Health care providers and experts in DSME agree that transformation of our current programs at the individual and systems levels with a focus on prioritizing the social determinants of health is warranted. ⁴

In the study by Adjei Boakye et al, a broadened scope of examined sociodemographic factors may provide a more comprehensive landscape of the psychosocial factors or social determinants of health ⁵ influencing DSME engagement, health behaviors, and practices of persons with diabetes. These often-underappreciated factors include, but are not limited to, religion/spirituality, health beliefs, social cohesion, emotional states and distress, neighborhood safety, food insecurity, access to healthy foods, and health literacy. This complex milieu of factors can either negatively or positively influence one’s ability to engage in healthy lifestyle practices, such as self-management of chronic disease. We wholeheartedly agree with the authors’ suggestions that community education programs in varying forms (digital, face-to-face, group-based) may foster enhanced participation in DSME by special populations that have challenges to participating in DSME, such as persons who are elderly, uninsured, low income, less educated, and of Hispanic ethnicity. However, a better understanding of the psychosocial influences on engagement in DSME through the use of validated instruments in diverse populations may provide an evidence base for determining components that are essential for inclusion in DSME programs. In addition, qualitative studies examining the lived experiences of persons with diabetes in managing their disease would further complement empirical findings.

In turn, these studies could yield data necessary to redesign or revamp existing programs to more patient-centric resources supporting sustained diabetes self-management—the cornerstone to improved health outcomes. Future studies should also investigate the effectiveness of integrating health care navigators or community health workers to better address the unique challenges and needs of older and socioeconomically disadvantaged patients. In the absence of these studies, our current DSME programs may not have a true and lasting impact on diabetes outcomes in populations that need them the most.