The Relationship Between County-Level Contextual Characteristics and Use of Diabetes Care Services

Abstract

Objectives To examine the relationship between county-level measures of social determinants and use of preventive care among US adults with diagnosed diabetes. To inform future diabetes prevention strategies. Methods Data are from the Behavioral Risk Factor Surveillance System (BRFSS) 2004 and 2005 surveys, the National Diabetes Surveillance System, and the Area Resource File. Use of diabetes care services was defined by self-reported receipt of 7 preventive care services. Our study sample included 46 806 respondents with self-reported diagnosed diabetes. Multilevel models were run to assess the association between county-level characteristics and receipt of each of the 7 preventive diabetes care service after controlling for characteristics of individuals. Results were considered significant if P < .05. Results Controlling for individual-level characteristics, our analyses showed that 7 of the 8 county-level factors examined were significantly associated with use of 1 or more preventive diabetes care services. For example, people with diabetes living in a county with a high uninsurance rate were less likely to have an influenza vaccination, visit a doctor for diabetes care, have an A1c test, or a foot examination; people with diabetes living in a county with a high physician density were more likely to have an A1c test, foot examination, or an eye examination; and people with diabetes living in a county with more people with less than high-school education were less likely to have influenza vaccination, pneumococcal vaccination, or self-care education (all P < .05). Conclusions Many of the county-level factors examined in this study were found to be significantly associated with use of preventive diabetes care services. County policy makers may need to consider local circumstances to address the disparities in use of these services.

Diabetes Self-Management Education Programs in Nonmetropolitan Counties — United States, 2016

“…The characteristics of persons with diagnosed diabetes in those counties could differ from the overall county population. Although previous studies of diabetes care services found an association between persons living in socially disadvantaged counties and lower use of diabetes education among persons with diagnosed diabetes, this report limited interpretations of findings to the county level ( 9 ).…”

“…Although the study in this report included only nonmetropolitan counties, the persons in nonmetropolitan counties without a DSME program were also less educated than those in nonmetropolitan counties with at least one DSME program. Previous national studies suggest an association between lower education levels and lower use of preventive care practices ( 9 ).…”

“…Health insurance coverage is considered a substantial expense for many persons in rural areas because the costs exceed 10% of after-tax household income ( 13 ). Previous studies suggest that lower insurance coverage rates at the county level in the United States contributes to underuse of diabetes preventive services by persons with a diagnosis of diabetes ( 9 ).…”

“…A complex array of individual, provider, and environmental factors influence access and use of DSME by persons with diabetes who live in rural communities, including insurance, education and income, literacy, transportation, poverty, and race/ethnicity. Anderson’s Behavioral Model for Health Services Use describes these as predisposing and enabling factors ( 8 , 9 ). Challenges also include establishing and sustaining DSME programs in rural communities ( 6 ).…”

The Brazilian Family Health Strategy and the management of intestinal parasitic infections

“…Alicea-Planas et al (2016) identified time constraints as a major barrier, especially to health education in community health clinics serving populations with multiple needs. Furthermore, this region presented low physician density which can strain health care quality, especially regarding disease prevention and health promotion (Luo et al, 2014). Luo et al (2014) found that in areas with greater disease burdens, health education (referred to as selfmanagement education) was less likely despite the positive effects of health education on self-care behaviors previously identified.…”