3.0.0.0 TAI­LOR­ING TREAT­MENT FOR SO­CIAL CON­TEXT

3.1.0.0 Overview

Rec­om­men­da­tions

1.5 Pro­viders should as­sess so­cial con­text, in­clud­ing po­ten­tial food in­se­ cu­ri­ty, hous­ing sta­bil­i­ty, and finan­cial bar­ri­ers, and apply that in­for­ma­tion to treat­ment de­ci­sions. A

1.6 Refer pa­tients to local com­mu­ni­ty re­sources when avail­able. B

1.7 Pro­vide pa­tients with self man­age­ment sup­port from lay health coach­es, nav­i­ga­tors, or com­mu­ni­ty health work­ers when avail­able. A

Health in­equities re­lat­ed to di­a­betes and its com­pli­ca­tions are well doc­u­ment­ed and are heav­i­ly influenced by so­cial de­ter­mi­nants of health (58-62). So­cial de­ter­mi­nants of health are defined as the eco­nom­ic, en­vi­ron­men­tal, po­lit­i­cal, and so­cial con­di­tions in which peo­ple live and are re­spon­si­ble for a major part of health inequal­i­ty world­wide (63). The ADA rec­og­nizes the as­so­ci­a­tion be­tween so­cial and en­vi­ron­men­tal fac­tors and the pre­ven­tion and treat­ment of di­a­betes and has is­sued a call for re­search that seeks to bet­ter un­der­stand how these so­cial de­ter­mi­nants influence be­hav­iors and how the re­la­tion­ships be­tween these vari­ables might be modified for the pre­ven­tion and man­age­ment of di­a­betes (64). While a com­pre­hen­sive strat­e­gy to re­duce di­a­betes-‍re­lat­ed health in­equities in pop­u­la­tions has not been for­mally stud­ied, gen­er­al rec­om­men­da­tions from other chron­ic dis­ease mod­els can be drawn upon to in­form sys­tems-‍level strate­gies in di­a­betes. For ex­am­ple, the Na­tion­al Acade­my of Medicine has pub­lished a frame­work for ed­u­cat­ing health care pro­fes­sion­als on the im­por­tance of so­cial de­ter­mi­nants of health (65). Fur­ther­more, there are re­sources avail­able for the in­clu­sion of stan­dard­ized so­ciode­mo­graph­ic vari­ables in elec­tron­ic med­i­cal records to fa­cil­i­tate the mea­sure­ment of health in­equities as well as the im­pact of in­ter­ven­tions de­signed to re­duce those in­equities (66-68).

So­cial de­ter­mi­nants of health are not al­ways rec­og­nized and often go undis­cussed in the clin­i­cal en­counter (61). A study by Piette et al. (69) found that among pa­tients with chron­ic ill­ness­es, two-‍thirds of those who re­ported not tak­ing med­i­ca­tions as pre­scribed due to cost never shared this with their physi­cian. In a more re­cent study using data from the Na­tion­al Health In­ter­view Sur­vey (NHIS), Patel et al. (61) found that half of adults with di­a­betes re­ported finan­cial stress and one-fifth re­ported food in­se­cu­ri­ty (FI). One pop­u­la­tion in which such is­sues must be con­sid­ered is older adults, where so­cial difficul­ties may im­pair their qual­i­ty of life and in­crease their risk of func­tion­al de­pen­den­cy (70) (see Sec­tion 12 “Older Adults” for a de­tailed dis­cus­sion of so­cial con­sid­er­a­tions in older adults). Cre­at­ing sys­tems-‍level mech­a­nisms to screen for so­cial de­ter­mi­nants of health may help over­come struc­tural bar­ri­ers and com­mu­ni­ca­tion gaps be­tween pa­tients and pro­viders (61). In ad­di­tion, brief, val­i­dat­ed screen­ing tools for some so­cial de­ter­mi­nants of health exist and could fa­cil­i­tate dis­cus­sion around fac­tors that significant­ly im­pact treat­ment dur­ing the clin­i­cal en­counter. Below is a dis­cus­sion of as­sessment and treat­ment con­sid­er­a­tions in the con­text of FI, home­less­ness, and lim­it­ed En­glish proficien­cy/low lit­er­acy.