The Role of the Community Environment in Managing Diabetes Risk
What can health care professionals do for patients who live in communities where it’s hard to follow standard diabetes-related advice to eat healthy, get exercise, and manage stress?
In this fourth and final post in our Social Determinants of Health series, Earle C. Chambers, PhD, MPH, explains how the communities where patients live strongly influence their ability to manage diabetes-related risk. He also points to the actions that health care systems and individual health care professionals can take to help patients access the resources they need to manage their health.
Q: You’re a social epidemiologist working at the intersection with social medicine. What do these terms mean?
A: Social medicine recognizes, as part of clinical care, the social context in which people live. It acknowledges that patients, in their ability to realize health and well-being, are influenced to a large degree by the social and economic context and conditions in which they live. As a social epidemiologist, I examine the health patterns of communities within their social and economic contexts. I do that by studying the social determinants of health, which if you use the World Health Organization definition, are the conditions in which people are born, grow, live, work, and age—the wider set of forces and systems that shape the conditions of our daily lives. For me, part of what makes social epidemiology and social medicine important is that they’re rooted in social activism. There is an urgency to the work.
Q: What are the links between the social and economic conditions of a community and health in that community?
A: Let me explain by way of a study that I’m currently working on. The National Diabetes Prevention Program (DPP) from the Centers for Disease Control and Prevention aims to prevent the progression to type 2 diabetes among people at high risk by encouraging a healthy diet, physical activity, and stress reduction—the kinds of behaviors we know are related to weight loss. According to the data, men are less likely to participate in the program, especially men of color. So we designed a DPP, the Power Up for Health initiative, tailored to men of color with prediabetes living in the Bronx. This program is designed to engage men by having male groups, male coaches, and a space where men of color can interact with other men.
But we also recognize that there are economic and social conditions that make it very difficult for these men to put a primary focus on healthy behaviors. If you think through a socioecological lens, it is clear that individual behaviors are nested within larger spheres of influence like families, neighborhoods, and cities. Therefore, it’s important that there be few barriers to healthy living, in order for people to prioritize healthy behaviors within their spheres of influence.
We know that residents in low-income communities have a larger burden of social conditions that make healthy behaviors difficult to maintain. For example, low-income neighborhoods and Black neighborhoods tend to have less access to healthy food and less access to safe places for leisure and recreational activity.
Low-income neighborhoods and neighborhoods of high poverty also offer less stable housing. It’s very difficult to focus on eating healthy foods, exercising more, and reducing psychosocial stress, if you’re not living in stable housing. So, prioritizing healthy behaviors, consistent with what we’re asking patients to do within the Diabetes Prevention Program, requires more than just willpower. You need to live in places that make doing those healthy things possible.
Q: How are the social and economic conditions of a community related to the primary care that’s available in that community?
A: Some studies show that our lower-income neighborhoods tend to have less overall access to health care. There are barriers for the people to get to primary care, whether it be lack of proximity to health care facilities, lack of transportation, or competing basic need priorities. In addition, there are other neighborhood conditions that are important to overall wellness that are also limited in lower-income neighborhoods, like access to healthy food, more walkable spaces, and places for physical activity.
Q: How does racism against communities affect wellness?
A: The distribution of resources that help people maintain health is not equitable. They have been allocated based on race, with policies that have denied Black communities and other communities of color access to resources for health and well-being. It’s important to think about why resources are where they are, and the kinds of policies that influence what is available where, and to whom. It’s a history related to race.
Maybe you have heard about the redlining policies begun in the 1930s that racially segregated large U.S. cities by denying federally backed mortgage loans in Black neighborhoods. By racially segregating neighborhoods in this way, it was much easier for other economic institutions to neglect these areas for investment. Decades later, we still see the results of this lack of investment in the form of less access to healthy resources such as parks and grocery stores in those communities. Today, exclusionary zoning practices also redline by making it difficult for multi-unit affordable housing to be built in more affluent suburban communities. This kind of zoning cuts off the people living in the more impoverished areas from living in neighborhoods where there are more resources available for optimal health and well-being.
In addition, the socioeconomic disparities that we see in health outcomes can be tied to race-based discrimination, including in our health care institutions. An important goal is working to overcome systemic racism by making these institutions more multicultural, with full participation by members of all racial and ethnic groups. Prioritizing an awareness of the social determinants of health and measuring determinants through the clinical setting aligns our activities with an overall commitment to transform our health care institutions into anti-racist institutions. This is the work that we actively need to do now.
Q: How can the clinical setting reduce health inequities?
A: It’s important to measure the social needs of our patient population. These data can be used to identify where resources are needed, to inform interventions, and to advocate along with community partners for community- and policy-level changes needed to improve health. Each health care system may have a different way of determining when and how these are measured, if at all—there’s no gold standard for how we measure social needs in the clinical setting. But we know the major content areas that should be incorporated in that assessment and conducted in a systematic way. Many health systems have electronic health record platforms that are capable of collecting these data.
Q: What can health care professionals do when they learn that patients have barriers preventing them from taking care of their health in the way that the Diabetes Prevention Program recommends?
A: Let’s take an example, like food insecurity, which means not getting enough of the food you need. If patients report that they’re having food insecurity issues, the first step could be trying to connect them to resources, such as government food programs, food pantries, or other community partners that address that kind of need. Having a robust referral system and the infrastructure to connect patients with these services is important. At Montefiore Health System, we are working diligently in this area using community health workers as part of the health care team to help our patients.
In my work and the work in our department, we examine individual-level behavior changes among populations that we know to be vulnerable. But this research also acknowledges the upstream, community-level social determinants that influence those health behaviors and make changing them difficult. So, to inform solutions, this requires measuring what those upstream variables are for our patient population. I also think that an important agenda in our research portfolio should be to include studies that speak to policy in order to address health disparities and create a more equitable society when it comes to health care delivery.
How are patients’ social needs measured in your clinical practice? Tell us in the comments.