The purpose of this study was to explore self-reported diabetes management strategies, social determinants of health (SDOH), and barriers to care among people with diabetes receiving care in a safety-net setting to identify factors contributing to disparities in outcomes for Black and Hispanic adults and inform future interventions.
Methods
Sequential, explanatory, mixed methods study comprised a survey of adults with diabetes seen in primary care at a safety-net hospital in New England, followed by qualitative semistructured interviews with a subset of the Black and Hispanic respondents. Descriptive statistics, chi-square and t tests were used to analyze quantitative data. The health equity implementation framework was used to guide qualitative data collection and directed content analysis.
Results
A total of 496 respondents completed the survey; 48 Black and Hispanic adults participated in interviews. Diabetes-related distress was significantly higher among Black and Hispanic participants compared to White participants. Nutrition management use was significantly lower among Black and Hispanic participants. Qualitative findings suggest that SDOH and lack of education and support, specifically, nutrition and access to self-management resources, contributed to diabetes-related distress and prevented optimal self-management.
Conclusions
High rates of diabetes-related distress and low rates of nutrition management were identified in Black and Hispanic adults in a safety-net setting. Qualitative interviews demonstrated a relationship between adverse SDOH and lack of nutrition education with diabetes distress and challenges to self-management, potentially contributing to disparities in outcomes. Findings suggest that increased uptake of nutrition therapy and self-management education and support may be critical for improving diabetes outcomes and promoting health equity.
Get full access to this article
View all access options for this article.
References
1.
ChengYJKanayaAMAranetaMRG, et al. Prevalence of diabetes by race and ethnicity in the United States, 2011-2016. JAMA. 2019;322(24):2389-2398. doi:10.1001/jama.2019.19365
CanedoJRMillerSTSchlundtDFaddenMKSandersonM.Racial/ethnic disparities in diabetes quality of care: the role of healthcare access and socioeconomic status. J Racial Ethn Health Disparities. 2018;5(1):7-14. doi:10.1007/s40615-017-0343-x
4.
LeeWLloydJTGiuriceoKDayTShrankWRajkumarR.Systematic review and meta-analysis of patient race/ethnicity, socioeconomics, and quality for adult type 2 diabetes. Health Serv Res. 2020;55(5):741-772. doi:10.1111/1475-6773.13316
5.
WangLLiXWangZ, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US adults, 1999-2018. JAMA. 2021;326(8):704-716. doi:10.1001/jama.2021.9883
6.
ChiouTTsugawaYGoldmanDMyersonRKahnMRomleyJA.Trends in racial and ethnic disparities in diabetes-related complications, 1997–2017. J Gen Intern Med. 2020;35(3):950-951. doi:10.1007/s11606-019-05414-5
7.
SpanakisEKGoldenSH.Race/ethnic difference in diabetes and diabetic complications. Curr Diab Rep. 2013;13(6):814-823. doi:10.1007/s11892-013-0421-9
8.
EzzatvarYRamírez-VélezRIzquierdoMGarcía-HermosoA.Racial differences in all-cause mortality and future complications among people with diabetes: a systematic review and meta-analysis of data from more than 2.4 million individuals. Diabetologia. 2021;64(11):2389-2401. doi:10.1007/s00125-021-05552-2
9.
MathurRFarmerREEastwoodSVChaturvediNDouglasISmeethL.Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: a cohort study. PLoS Med. 2020;17(5):e1003106. doi:10.1371/journal.pmed.1003106
10.
AddalaAHanesSNaranjoDMaahsDMHoodKK.Provider implicit bias impacts pediatric type 1 diabetes technology recommendations in the United States: findings from the Gatekeeper Study. J Diabetes Sci Technol. 2021;15(5):1027-1033. doi:10.1177/19322968211006465
11.
SchmittABendigEBaumeisterHHermannsNKulzerB.Associations of depression and diabetes distress with self-management behavior and glycemic control. Health Psychol. 2020;40(2):113-124. doi:10.1037/hea0000964
12.
WalkerRJSmallsBLCampbellJAJoniLWilliamsSEgedeLE.Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review. Endocrine. 2014;47(1):29-48. doi:10.1007/s12020-014-0195-0
13.
Hill-BriggsFAdlerNEBerkowitzSA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2021;44(1):258-279. doi:10.2337/dci20-0053
14.
ElhusseinAAndersonABancksMP, et al. Racial/ethnic and socioeconomic disparities in the use of newer diabetes medications in the Look AHEAD study. Lancet Reg Health Am. 2022;6:100111. doi:10.1016/j.lana.2021.100111
15.
Lamprea-MontealegreJAMaddenETummalapalliSL, et al. Association of race and ethnicity with prescription of SGLT2 inhibitors and GLP1 receptor agonists among patients with type 2 diabetes in the veterans health administration system. JAMA. 2022;328(9):861-871. doi:10.1001/jama.2022.16191
16.
FosterNCBeckRWMillerKM, et al. State of type 1 diabetes management and outcomes from the T1D exchange in 2016–2018. Diabetes Technol Ther. 2019;21(2):66-72. doi:10.1089/dia.2018.0384
17.
Mosley-JohnsonEWalkerRJThakkarM, et al. Relationship between housing insecurity, diabetes processes of care, and self-care behaviors. BMC Health Serv Res. 2022;22(1):61. doi:10.1186/s12913-022-07468-7
18.
AsuzuCCWalkerRJWilliamsJSEgedeLE.Pathways for the relationship between diabetes distress, depression, fatalism, and glycemic control in adults with type 2 diabetes. J Diabetes Complications. 2017;31(1):169-174. doi:10.1016/j.jdiacomp.2016.09.013
RendleKASMaySGUyVTietbohlCKMangioneCMFroschDL.Persistent barriers and strategic practices: why (asking about) the everyday matters in diabetes care. Diabetes Educ. 2013;39(4):560-567. doi:10.1177/0145721713492218
22.
VestBMKahnLSDanzoA, et al. Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system. Chronic Illn. 2013;9(2):145-155.
23.
LeeLTWilligALAgneAALocherJLCherringtonAL.Challenges to healthy eating practices: a qualitative study of non-Hispanic Black men living with diabetes. Diabetes Educ. 2016;42(3):325-335. doi:10.1177/0145721716640904
24.
WolfRAMartynKKHawJSKimbleLP.Emerging adults with diabetes in safety-net care: self-management influences and patient-provider interactions. West J Nurs Res. 2023;45(8):680-687. doi:10.1177/01939459231172587
25.
Orr ChlebowyDHoodSLaJoieAS. Facilitators and barriers to self-management of type 2 diabetes among urban African American adults. Diabetes Educ. 2010;36(6):897-905.
26.
PollardSLZacharyDAWingertKBookerSSSurkanPJ.Family and community influences on diabetes-related dietary change in a low-income urban neighborhood. Diabetes Educ. 2014;40(4):462-469. doi:10.1177/0145721714527520.
27.
LevyNKParkASolisD, et al. Social determinants of health and diabetes-related distress in patients with insulin-dependent type 2 diabetes: cross-sectional, mixed methods approach. JMIR Form Res. 2022;6(10):e40164. doi:10.2196/40164
28.
StotzSARicksKAEisenstatSAWexlerDJBerkowitzSA.Opportunities for interventions that address socioeconomic barriers to type 2 diabetes management: patient perspectives. Sci Diabetes Self-Manag Care. 2021;47(2):153-163. doi:10.1177/0145721721998817
29.
GaskinDJHadleyJ.Population characteristics of markets of safety-net and non-safety-net hospitals. J Urban Health. 1999;76(3):351-370. doi:10.1007/BF02344959
30.
BuitronDeLa VegaPLosiSSprague MartinezL, et al. Implementing an EHR-based screening and referral system to address social determinants of health in primary care. Med Care. 2019;57(suppl 6 suppl 2):S133-S139. doi:10.1097/MLR.0000000000001057
31.
BerkmanNDSheridanSLDonahueKE, et al. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. doi:10.7326/0003-4819-155-2-201107190-00005
32.
Institute of Medicine. Health Literacy: A Prescription to End Confusion. The National Academies Press; 2004. doi:10.17226/10883
33.
GuettermanTCFettersMDCreswellJW.Integrating quantitative and qualitative results in health science mixed methods research through joint displays. Ann Fam Med. 2015;13(6):554-561. doi:10.1370/afm.1865
BilliouxAVerlanderKAnthonySAlleyD.Standardized screening for health-related social needs in clinical settings: the accountable health communities screening tool. NAM Perspect. 2017;7(5). doi:10.31478/201705b
36.
McGuireBEMorrisonTGHermannsN, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66-69. doi:10.1007/s00125-009-1559-5
37.
PerrinNEBodicoatDHDaviesMJRobertsonNSnoekFJKhuntiK.Effectiveness of psychoeducational interventions for the treatment of diabetes-specific emotional distress and glycemic control in people with type 2 diabetes: a systematic review and meta-analysis. Prim Care Diabetes. 2019;13(6):556-567. doi:10.1016/j.pcd.2019.04.001
38.
WoodwardENMatthieuMMUchenduUSRogalSKirchnerJE.The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. Implement Sci. 2019;14(1):26. doi:10.1186/s13012-019-0917-5
39.
HarveyGKitsonA.PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016;11(1):33. doi:10.1186/s13012-016-0398-2
40.
HarrisPATaylorRThielkeRPayneJGonzalezNCondeJG.Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010
41.
HillCKnoxSThompsonBWilliamsEHessSLadanyN.Consensual qualitative research: an update. J Couns Psychol. 2005;52(2):196-205. doi:10.1037/0022-0167.52.2.196
42.
HsiehHFShannonSE.Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288. doi:10.1177/1049732305276687
43.
ArchibaldMM.Investigator triangulation: a collaborative strategy with potential for mixed methods research. J Mix Methods Res. 2016;10(3):228-250. doi:10.1177/1558689815570092
44.
ElsayedNAAleppoGArodaVR, et al. 5. Facilitating positive health behaviors and well-being to improve health outcomes: Standards of Care in Diabetes—2023. Diabetes Care. 2023;46(suppl 1):S68-S96. doi:10.2337/dc23-S005
45.
BekeleBBNegashSBogaleB, et al. Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: systematic review and meta-analysis of randomized controlled trials. Diabetes Metab Syndr Clin Res Rev. 2021;15(1):177-185. doi:10.1016/j.dsx.2020.12.030
46.
FranzMJMacLeodJEvertA, et al. Academy of nutrition and dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017;117(10):1659-1679. doi:10.1016/j.jand.2017.03.022
47.
StrawbridgeLMLloydJTMeadowARileyGFHowellBL.Use of Medicare’s diabetes self-management training benefit. Health Educ Behav. 2015;42(4):530-538. doi:10.1177/1090198115577378
48.
LiRShresthaSSLipmanR, et al; Centers for Disease Control and Prevention. Diabetes self-management education and training among privately insured persons with newly diagnosed diabetes—United States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2014;63(46):1045-1049.
49.
PerrinNEDaviesMJRobertsonNSnoekFJKhuntiK.The prevalence of diabetes-specific emotional distress in people with type 2 diabetes: a systematic review and meta-analysis. Diabet Med. 2017;34(11):1508-1520. doi:10.1111/dme.13448
50.
SilvermanJKriegerJKieferMHebertPRobinsonJNelsonK.The relationship between food insecurity and depression, diabetes distress, and medication adherence among low-income patients with poorly controlled diabetes. J Gen Intern Med. 2015;30(10):1476-1480. doi:10.1007/s11606-015-3351-1
51.
NaranjoDHesslerDMDeolRCheslaCA.Health and psychosocial outcomes in U.S. adult patients with diabetes from diverse ethnicities. Curr Diab Rep. 2012;12(6):729-738. doi:10.1007/s11892-012-0324-2
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
