How is neighborhood social disorganization associated with diabetes outcomes? A multilevel investigation of glycemic control and self-reported use of acute or emergency health care services

Abstract

BackgroundDiabetes management is influenced by a number of factors beyond the individual-level. This study examined how neighborhood social disorganization (i.e., neighborhoods characterized by high economic disadvantage, residential instability, and ethnic heterogeneity), is associated with diabetes-related outcomes.MethodsWe used a multilevel modeling approach to investigate the associations between census-tract neighborhood social disorganization, A1c, and self-reported use of acute or emergency health care services for a sample of 424 adults with type 2 diabetes.ResultsIndividuals living in neighborhoods with high social disorganization had higher A1c values than individuals living in neighborhoods with medium social disorganization (B = 0.39, p = 0.01). Individuals living in neighborhoods with high economic disadvantage had higher self-reported use of acute or emergency health care services than individuals living in neighborhoods with medium economic disadvantage (B = 0.60, p = 0.02).ConclusionsHigh neighborhood social disorganization was associated with higher A1c values and high neighborhood economic disadvantage was associated with greater self-reported use of acute or emergency health care services. Controlling for individual level variables diminished this effect for A1c, but not acute or emergency health care use. Comprehensive approaches to diabetes management should include attention to neighborhood context. Failure to do so may help explain the continuing disproportionate diabetes burden in many neighborhoods despite decades of attention to individual-level clinical care and education.Trial registrationFor this study, we used baseline data from a larger study investigating the impacts on patient-centered outcomes of three different approaches to self-monitoring of blood glucose among 450 adults with non-insulin dependent type 2 diabetes living in North Carolina. This study was registered as a clinical trial on 1/7/2014 (https://clinicaltrials.gov/ct2/show/NCT02033499).

The Longitudinal Influence of Social Determinants of Health on Glycemic Control in Elderly Adults With Diabetes

“…In addition, psychosocial factors, such as social support, health literacy, depression, and anxiety, have been associated with diabetes prevalence, adherence to selfmanagement recommendations, access to regular health care, and glycemic control (14)(15)(16)(17)(18)(19). Less evidence links the neighborhood environment to diabetes outcomes, although more recent analyses have indicated that there are possible relationships, for example through changes in access to supermarkets or improving community cohesion (20)(21)(22)(23)(24)(25).…”

Perceived Stress as a Pathway for the Relationship Between Neighborhood Factors and Glycemic Control in Adults With Diabetes

“…While existing evidence shows the relationship across various neighborhood factors and diabetes incidence and outcomes, 15,17,18,45 these results provide novel insights into the stress pathway through which specific neighborhood factors (specifically discrimination and crime) appear to negatively influence diabetes outcomes, namely, glycemic control. Prior work shows perceived discrimination impacts glycemic control directly through stress and indirectly through stress via self-care behaviors 29 among patients with diabetes.…”

“…Based on significant direct and indirect effects, this study suggests that neighborhood factors (particularly crime and discrimination) are indirectly associated with poorer glycemic control through higher levels of perceived stress, lower levels of self-efficacy, and completion of diabetes self-care behaviors. While existing evidence shows the relationship across various neighborhood factors and diabetes incidence and outcomes, 15,17,18,45 these results provide novel insights into the stress pathway through which specific neighborhood factors (specifically discrimination and crime) appear to negatively influence diabetes outcomes, namely, glycemic control. Prior work shows perceived discrimination impacts glycemic control directly through stress and indirectly through stress via self-care behaviors 29 among patients with diabetes.…”

Individual and Community Social Determinants of Health Associated With Diabetes Management in a Mexican American Population

“…Another possible interpretation might be that since the study populations are even more disadvantaged compared to the whole population in the study region, those disadvantaged individuals from wealthier census tracts may experience an increased level of depression and stress and in turn, had negative impacts on glycemic control. Finally, a previous study suggested people living in socioeconomically disadvantaged neighborhoods are more likely to use health care services than people from a more advantaged neighborhoods ( 35 ). Indeed, we saw that people from less advantaged communities on average participated in more classes (5.68 for first quartile of advantage index and 5.25 for fourth quartile of advantage index, Supplementary eTable 2 ) and stayed longer in the program (319 days for first quartile of advantage index and 295 days for fourth quartile of advantage index, Supplementary eTable 2 ).Therefore, a potentially higher engagement in the program among those living in more socioeconomically disadvantaged areas may have partially contributed greater HbA1C reduction in this group.…”