Socioeconomic Position and Health among Persons with Diabetes Mellitus: A Conceptual Framework and Review of the Literature

Abstract

FIGURE 1. Conceptual framework for the relation between socioeconomic position and health among persons with diabetes mellitus. Numbers and letters refer to pathways mentioned in the text.

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

“…It has been suggested that an accumulation of exposures to multiple unhealthy contextual factors may explain the deleterious health effects of unhealthy neighborhoods. 1,16,33,34 Although the models presented in the current study were adjusted for serious psychological distress, the fact that neighborhood safety was measured using a subjective, individual-level measure suggests that respondents rating their neighborhoods as unsafe are not only living in an unfavorable setting, but are perceiving neighborhood problems and being affected by them. The accumulated burden of these problems may diminish the importance of filling prescriptions or obtaining needed medical treatment promptly in light of competing demands.…”

“…Other mechanisms by which an unfavorable neighborhood environment may impact health behaviors have been proposed, including a lack of access to health-promoting resources, accumulated stress brought on by the presence of hazards in the neighborhood environment, and prevailing attitudes that de-emphasize the importance of health and health behaviors. 1,12,[16][17][18][19] Because the association between neighborhood safety and adherence persisted after adjustment for multiple potential barriers to accessing a pharmacy and paying for prescriptions, including income, insurance status, and access to transportation, the lower adherence observed in unsafe neighborhoods is likely attributable to factors in addition to access and finances. It has been suggested that an accumulation of exposures to multiple unhealthy contextual factors may explain the deleterious health effects of unhealthy neighborhoods.…”

“…[1][2][3] Although income, education, communication barriers, insurance status and access to quality medical care are important contributors to these disparities, much of the observed variation in glycemic control remains unexplained by these factors. 4,5 This suggests that, even among individuals who have access to medical care, contextual influences-i.e.…”

“…aspects of an individual's social and environmental life context that fall outside of the health care setting-may contribute to perpetuating health disparities. 1,[6][7][8][9][10] Given the widely-reported associations between contextual influences, particularly neighborhood characteristics 6,[11][12][13] , and health behaviors in general, it is plausible that unfavorable contextual influences promote poor diabetes outcomes by creating barriers to patient adherence to diabetes selfmanagement regimens.…”

Peer Coaching to Improve Diabetes Self-Management: Which Patients Benefit Most?

“…Both individuals from low socioeconomic status and from non-white racial/ethnic groups have poorer control 13 and higher diabetes related morbidity. 14,15 Individuals with poorer health literacy, lower levels of social support and more severe depression also have worse diabetes outcomes. [16][17][18][19] Additionally, the degree of diabetes control is positively associated with the better medication adherence and self-management.…”