The Role of Neighborhood Deprivation on Diabetes Outcomes: A Mixed Methods Study

PROJECT SUMMARY/ABSTRACT Approximately 38.1 million adults 18 years or older (14.7% of all U.S. adults) are estimated to have diabetes, where 90-95% of cases are classified as type 2 diabetes mellitus (T2DM). In public and population health, it is well-known that the prevalence of diabetes and its complications are not borne equally across society, with individuals living in more impoverished and disadvantaged neighborhoods being more likely to receive a diabetes diagnosis, experience complications of diabetes, and die prematurely because of suboptimal diabetes self-management. Individuals from disadvantaged neighborhoods are more likely to experience diabetes-related hospitalizations; 30-day re-admissions and death after discharge; and substantially higher overall healthcare costs. Neighborhoods of residence have been associated with diabetes management and control; associated morbidity including chronic conditions such as hypertension, obesity, and stroke, and others along the spectrum of the cardiovascular-kidney-metabolic syndrome; and chronic disease mortality. However, the primary mechanisms which dictate the pathways between neighborhood disadvantage and health outcomes remain elusive among adults with diabetes. This is a significant gap that needs to be addressed to improve population-level diabetes outcomes. The Area Deprivation Index (ADI) is a measure constructed to provide the relative degree of neighborhood deprivation, or socioeconomic disadvantage by census block group at the neighborhood level, that has been associated with diabetes prevalence and outcomes. It shows that individuals residing in communities and neighborhoods with the highest socioeconomic disadvantage have increased social risks and the poorest health outcomes. The gap in evidence between neighborhood deprivation and diabetes-related health outcomes warrants further investigation to inform targeted interventions and the allocation of resources to improve glycemic control, reduce the burden of adverse outcomes, lessen exposures to social risk factors, and ultimately, decrease the economic costs associated with diabetes management and treatment for individuals and society. Therefore, we propose to assess the pathways by which neighborhood disadvantage adversely impacts clinical and behavioral outcomes and quality of life among 2,000 adults with T2DM. This study offers a unique opportunity to bridge a gap in knowledge within the field by using an experimental convergent mixed methods study design to understand the relationship between neighborhood disadvantage/deprivation and diabetes-related outcomes in adults with T2DM. Aim 1 will use qualitative research methods to explore neighborhood-associated barriers and facilitators to diabetes self-management and their impact on outcomes. Aim 2 will use quantitative research methods to examine the direct and indirect effects of neighborhood disadvantage/deprivation on diabetes-related clinical outcomes (glycemic control, blood pressure control, lipid control); self-care behaviors (diet, physical activity, medication adherence, blood glucose monitoring); and quality of life in adults with T2DM. Aim 3 will use hierarchical modeling to assess the impact of individual, interpersonal, and neighborhood level factors on individual level diabetes outcomes and whether individual level associations are mediated or moderated by exposure to neighborhood deprivation.