Understanding Social Determinants and Their Impact on Health Care for People with Diabetes

    • September 30, 2008

The Problem: Clinicians now recognize that social determinants—such as easy access to medications and medical care, places to exercise and healthy foods—play important roles in a person's health. How, then, do social determinants specifically impact low-income individuals with chronic health conditions such as diabetes?

Grantee Background: Growing up in New York and then Los Angeles, Jamaican-born Arleen F. Brown, MD, PhD, understood early on about health care disparities. Her family lived about a mile from Children's Hospital Los Angeles, but she recalls taking three buses to travel instead to the county hospital when her family needed medical care. "My parents had no idea how to access the health care system nearby, and there wasn't anyone to help them," Brown recalls. "As immigrants, you don't understand how the health care system works and the resources weren't there to guide them. Those types of things informed my interest in medicine."

After high school in Los Angeles, Brown attended Harvard University, graduating with honors. She was then drawn back to California, and attended medical school at the University of California, San Francisco (UCSF), from 1988 to 1992, where her advisor, a specialist in underserved populations, introduced her to others interested in health services research.

While completing her training in primary care internal medicine, Brown also became interested in two of Robert Wood Johnson Foundation's special programs—the Robert Wood Johnson Foundation Clinical Scholars Program and the Harold Amos Medical Faculty Development Program. First she became a clinical scholar (1996 to 1998). She focused on adults with diabetes and the health care services they received while pursuing her Ph.D. in health services from UCLA. She was selected as a Harold Amos scholar and from 1999 to 2004, she used her grants to study the use of neighborhood services among Medicare beneficiaries with diabetes.

Brown's interest in diabetes was more than professional. Both of her parents were diagnosed with the disease, and it changed their lives. Overnight, they became patients who needed to take medication, monitor what they ate and change their lifestyle.

Through the Harold Amos program, Brown concentrated on trying to understand the factors that contribute to improved diabetes care and better self-care. "I'm interested in individual level factors and their interplay with community characteristics and the health care system," she explains. "Does age, race, ethnicity play a role? What about language, and the ability to engage the health care system? Does the type of care you get-managed care, community clinic or a private doctor's office? Are some environments or communities more diabetic-genic? What role does a sedentary or an active lifestyle play? Are there places to network and exercise? What drives the complex interplay of the health care system and neighborhood effects?"

Brown's research in the Translating Research into Action for Diabetes (TRIAD) study confirmed that race and ethnicity definitely play a role in the risk for diabetes and for poor outcomes among those with diabetes. But what she calls "individual level factors" are sometimes attenuated in areas where patients have easier access to care, while some individuals are at risk for poor diabetes control and poor quality care. "One of the critical things that we saw was that in managed care, you sometimes see less of an effect of race and socioeconomic status. If you raised the floor by increasing access to evidence-based care, you are potentially improving care for everybody," she says. That said, Brown found poorer outcomes among African Americans despite the equalization of process. "What then are the factors that are associated with poor outcomes, despite comparable processes?"

Brown gave particular attention to what she called "neighborhood" effects. By analyzing different neighborhoods, she discovered that people with diabetes and other chronic conditions who lived in more disadvantaged environments had poorer health status and higher risk for heart disease. In other research, she found that residents of areas with fewer supermarkets and areas with more convenience stores had poorer health status and higher rates of obesity. "We need to think about this as more than an issue of will power and patient control, and think about our role as a society to encourage self-management," she says.

One of the highlights of Brown's work as a Harold Amos scholar was the development of official guidelines for individuals over 65 with diabetes. Endorsed by the American Geriatrics Society, Guidelines for Improving the Care of the Older Person with Diabetes Mellitus, are the first to specifically factor in patient preferences, functional status and the need to control a patient's blood sugar.

Today, Brown continues her research into chronic diseases like diabetes, building on findings she observed during her time as a Harold Amos scholar-namely, the importance of making changes in neighborhoods by working with existing groups. In South Los Angeles, Brown is working with local groups, many of which have established programs to identify community resources for healthier eating or increasing physical activity. The programs include walking groups, neighborhood programs to encourage owners of small markets to stock healthy foods so that residents have easy access to them, and nutrition empowerment groups that help residents purchase and prepare healthier foods. The organizations "are making grocers aware that people want healthier options available locally and this awareness is a critical first step in changing access to healthy foods," says Brown. "What components of the neighborhood are critical to chronic disease management? In addition to high quality health care, those with chronic conditions need proper food, places to exercise, access to pharmacies. It's really thinking about what are the barriers to chronic disease self-management, in fundamental and concrete areas."

RWJF Perspective: The Harold Amos Program is one of RWJF's oldest programs, having started in 1983 as the Minority Faculty Development Program. It was renamed in 2004 to honor the first African American to chair a department at Harvard Medical School; he was also a former director of the program. The program provides four-year postdoctoral research awards to historically disadvantaged physicians who are committed to developing careers in academic medicine.

"One of the assumptions of the program," says J.A. Grisso, MD, MSc, a senior program officer at RWJF, "is that if you give leadership opportunities to individuals from underrepresented and disadvantaged groups that they, in their career trajectories, are more likely to take on the issues that are particularly important to vulnerable populations. That has been true for the Harold Amos Faculty Development Program. Individuals who could be outstanding scholars in any world and for any issue have very often chosen to address these important issues that we care about at RWJF.

"This is a long-standing program that is very forward-thinking," says Grisso. "It has uniquely engaged individuals who do basic science research as well as those who do health services research and clinical research. People who are completely basic science-oriented are now getting trained in or exposed to epidemiology and public health and then are starting to talk about the social issues as they might affect biological systems. They are asking questions that are unique in my experience with basic science."