Association between Social Determinants of Health and Glycemic Control in an Inner City Primary Care Population



Social determinants of health, diabetes mellitus, type 2, Primary health care.


Background: Diabetes is among the 10 leading causes of death in the U.S. Effective disease management comprised of medical care, self-management education, and ongoing diabetes support is key to improving quality of life and reducing acute and long-term complications. Evidence suggests that social determinants of health acting through social support, neighborhood quality, and physical activity influence diabetes prevention, management, and outcomes. The Chronic Illness Resource Survey (CIRS) is a reliable and valid instrument for assessing support and resources for chronic disease management and is based on a multi-level socio-environmental model. We conducted this study to assess the relationship between social resources as estimated by CIRS subscales and glycemic control in our urban safety-net clinic to identify specific types of support that are associated with glycemic control. Methods: Adult patients (n= 104) with a diagnosis of type 2 diabetes were recruited from an academic urban safety-net clinic in Buffalo, New York. Eligible patients were approached during a regularly scheduled clinic appointment while waiting for their provider. Average hemoglobin A1c values were compared between subjects with values above and below the median for each CIRS subscale. The age and BMI-adjusted relative risks for having a hemoglobin A1c value >7% were also estimated for each subscale. Results: In this sample having established medical care, lower neighborhood support was associated with elevated A1c (OR: 3.10, 95% CI 1.39 to 6.90). Social determinants related to support from family and friends, community organizations, personal factors, and media and policy were not associated with A1c. Exploration of individual items in the neighborhood support subscale suggested that social interaction with neighbors were particularly associated with diabetes control. Conclusions: A higher level of neighborhood support and greater interaction with neighbors in patients from an inner city primary care clinic was associated with better glycemic control. Future research will evaluate how neighborhood support influences self-management behaviors, and how self-management behavior may be modified by increased social interactions with neighbors.

Author Biographies

Roberto O. Diaz Del Carpio, University at Buffalo

Division General Internal Medicine, Department of Medicine. Clinical Assistant Professor.

Scott H Stewart, University at Buffalo

Division General Internal Medicine, Department of Medicine. Associate Professor.


Centers for Disease Control and Prevention, National Diabetes Statistics Report: Estimates of Diabetes and Its

Burden in the United States, 2014. 2014, U.S. Department of Health and Human Services; 2014.: Atlanta, GA.

Huang, E.S., et al., Projecting the future diabetes population size and related costs for the U.S. Diabetes Care, 2009. 32(12): p. 2225-9.

American Diabetes Association, Economic costs of diabetes in the U.S. in 2012. Diabetes Care, 2013. 36(4): p. 1033-46.

Zhuo, X., P. Zhang, and T.J. Hoerger, Lifetime direct medical costs of treating type 2 diabetes and diabetic complications. Am J Prev Med, 2013. 45(3): p. 253-61.

American Diabetes Association, Standards of medical care in diabetes--2015: summary of revisions. Diabetes Care, 2015. 38 Suppl: p. S4.

van Dam, H.A., et al., Social support in diabetes: a systematic review of controlled intervention studies. Patient Educ Couns, 2005. 59(1): p. 1-12.

Tang, T.S., et al., Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes. Diabetes Educ, 2008. 34(2): p. 266-76.

Billimek, J. and D.H. Sorkin, Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes. J Gen Intern Med, 2012. 27(3): p. 292-6.

Marmot, M., Social determinants of health inequalities. Lancet, 2005. 365(9464): p. 1099-104.

Friel, S. and M.G. Marmot, Action on the social determinants of health and health inequities goes global. Annu Rev Public Health, 2011. 32: p. 225-36.

Solar, O.I., A, A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion

Paper 2 (Policy and Practice). 2010, World Health Organization: Geneva.

Walker, R.J., et al., Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling. Patient Educ Couns, 2015. 98(1): p. 34-40.

Walker, R.J., et al., Relationship between social determinants of health and processes and outcomes in adults with type 2 diabetes: validation of a conceptual framework. BMC Endocr Disord, 2014. 14: p. 82.

Selvin, E., et al., Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med, 2014. 160(8): p. 517-25.

Glasgow, R.E., et al., A social-ecologic approach to assessing support for disease self-management: the Chronic Illness Resources Survey. J Behav Med, 2000. 23(6): p. 559-83.

Brown, A.F., et al., Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev, 2004. 26: p. 63-77.

Brown, A.F., A. Ang, and A.R. Pebley, The relationship between neighborhood characteristics and self-rated health for adults with chronic conditions. Am J Public Health, 2007. 97(5): p. 926-32.

Gary, T.L., et al., Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care, 2008. 31(2): p. 273-8.

Smalls, B.L., et al., Effect of neighborhood factors on diabetes self-care behaviors in adults with type 2 diabetes. Diabetes Res Clin Pract, 2014. 106(3): p. 435-42.

Smalls, B.L., et al., Direct and indirect effects of neighborhood factors and self-care on glycemic control in adults with type 2 diabetes. J Diabetes Complications, 2015. 29(2): p. 186-91.

Christine, P.J., et al., Longitudinal Associations Between Neighborhood Physical and Social Environments and Incident Type 2 Diabetes Mellitus: The Multi-Ethnic Study of Atherosclerosis (MESA). JAMA Intern Med, 2015. 175(8): p. 1311-20.






Original Research