The social determinants of the incidence and management of type 2 diabetes mellitus: are we prepared to rethink our questions and redirect our research activities?

Beyond the Nest: The Role of Financial Independence in Young Adult Health

BACKGROUND

This study aimed to examine the impact of neighborhood conditions and household material hardship experiences on young adult health outcomes, while also considering financial autonomy as a critical determinant of health.

METHOD

We employed a cross-sectional observational design with a diverse sample of young adults from a large urban university. Structural equation modeling was used to analyze the relationships between neighborhood conditions and material hardship with health outcomes by financial autonomy.

RESULTS

Material hardship and neighborhood conditions were significantly related to various health outcomes among young adults. Food insecurity emerged as a significant mediator linking neighborhood conditions to health including global physical health, cognitive functioning, and depression. Financially independent young adults showed stronger direct and indirect effects of neighborhood conditions on health compared to financially dependent counterparts.

CONCLUSION

This study underscores the complex interplay of neighborhood conditions, household material hardship, and financial autonomy in shaping young adult health. Our findings also suggest how the impact of SDOH on young adult health may have long-term effects later in life. Future research should consider these factors comprehensively to address disparities in emerging adult health.

Beyond the Body: Using Photovoice to Explore Social Determinants of Diabetes With South Asian Adolescents in the Peel Region of Ontario, Canada

OBJECTIVES

The higher prevalence of diabetes in the South Asian (SA) population living in Canada spans across generations and is often associated with individual risk factors while undermining the social determinants of health (SDOH). There is a scarcity of studies on the perspectives of SA adolescents with a family history of type 2 diabetes mellitus (T2DM). Learning directly from these adolescents can fill a major gap by providing insight on how the SDOH contribute to disproportionate rates of T2DM in SA immigrant communities.

METHODS

In this study, we used Photovoice, which is a community-based participatory research (CBPR) method that involves the use of photography to visually capture the challenges of diabetes prevention from the perspective of those with lived experiences. A group of 15 SA youth were recruited from an adolescent diabetes education program in the Peel Region of Ontario. The youth discussed their images and accompanied written narratives during focus groups.

RESULTS

Four themes emerged from the thematic analysis of the photographs and participant narratives that influence the manifestation of T2DM in SA communities: 1) immigration and resettlement stressors; 2) food insecurity; 3) unhealthy school environments; and 4) academic pressures.

CONCLUSIONS

Findings suggest the need to address T2DM as a response to unjust conditions and environments rather than as an epidemic entrenched in genetic predisposition, culture, and poor lifestyle choices.

Complications in Diabetes Mellitus: Social Determinants and Trends

Conditions that impact an individual's health are referred to as social determinants of health. Through a retrospective study (January 2017-February 2022) and statistical analysis, researchers looked at the relationship between social demands and type 2 diabetes mellitus (T2DM) diagnosis. All social demands, with the exception of childcare, were more typically documented in patients with T2DM. Prescription expense, conveyance, and health literacy were the domains with the greatest relationships. These results might help health systems and social service providers develop collaborations to help in certain areas.

A qualitative investigation of lived experiences of long-term health condition management with people who are food insecure

Background

As more people are living with one or more chronic health conditions, supporting patients to become activated, self-managers of their conditions has become a key health policy focus both in the UK and internationally. There is also growing evidence in the UK that those with long term health conditions have an increased risk of being food insecure. While international evidence indicates that food insecurity adversely affects individual’s health condition management capability, little is known about how those so affected manage their condition(s) in this context. An investigation of lived experience of health condition management was undertaken with food insecure people living in north east Scotland. The study aimed to explore the challenges facing food insecure people in terms of, i. their self-care condition management practices, and ii. disclosing and discussing the experience of managing their condition with a health care professional, and iii. Notions of the support they might wish to receive from them.

Methods

Twenty in-depth interviews were conducted with individuals attending a food bank and food pantry in north east Scotland. Interview audio recordings were fully transcribed and thematically analysed.

Results

Individuals reporting multiple physical and mental health conditions, took part in the study. Four main themes were identified i.e.: 1. food practices, trade-offs and compromises, that relate to economic constraints and lack of choice; 2. illness experiences and food as they relate to physical and mental ill-health; 3. (in) visibility of participants’ economic vulnerability within health care consultations; and 4. perceptions and expectations of the health care system.

Conclusions

This study, the first of its kind in the UK, indicated that participants’ health condition management aspirations were undermined by the experience of food insecurity, and that their health care consultations in were, on the whole, devoid of discussions of those challenges. As such, the study indicated practical and ethical implications for health care policy, practice and research associated with the risk of intervention-generated health inequalities that were suggested by this study. Better understanding is needed about the impact of household food insecurity on existing ill health, wellbeing and health care use across the UK.

Moving Diabetes Upstream: the Social Determinants of Diabetes Management and Control Among Immigrants in the US

PURPOSE OF REVIEW

Relative to the US-born population, immigrants are less likely to successfully manage and control their diabetes, leading to a host of diabetes-related complications. This review draws on the social determinants of health framework (SDoH) to summarize the multilevel factors that shape diabetes care and management among immigrants in the USA.

RECENT FINDINGS

While the diabetes literature is replete with research on individual-level risk factors and health behaviors, empirical literature linking the SDoH to diabetes management among immigrants is limited. However, housing precarity, food insecurity, poverty, uninsurance and underinsurance, and limited support for immigrants in healthcare systems are consistently shown to deter diabetes management and care. Immigrants with diabetes face a multitude of structural constraints to managing their diabetes. More research that theorizes the role of SDoH in diabetes management along with empirical qualitative and quantitative studies are needed. Interventions to address diabetes also require a more upstream approach in order to mitigate the drivers of diabetes disparities among immigrants.

Neighborhood Influences on Physical Activity Among Low-Income African American Adults With Type 2 Diabetes Mellitus

PURPOSE

The purpose of the study was to explore the influences of the neighborhood environment on physical activity (PA) among people living with type 2 diabetes mellitus (T2DM) in a community with limited resources.

METHODS

Participants were adults with T2DM and their family members or friends who help in the management of T2DM and who were living in a low-income African American (AA) community. Health care providers working in the neighborhood were also included. Using an emergent design, qualitative data were collected through 7 focus group discussions (N = 63) and 13 in-depth interviews. Verbatim transcriptions were analyzed via thematic coding to explore contextual factors that limit PA and meaning around neighborhood features that promote or discourage PA.

RESULTS

Levels of PA were strongly limited by neighborhood insecurity and a lack of recreational facilities in the neighborhood. People with T2DM and physical/mobility disabilities were more affected by the neighborhood environment than those without disabilities, particularly due to perceived safety concerns and social stigma. Despite socioeconomic inequalities within neighborhoods, participants showed resilience and made efforts to overcome social-environmental barriers to PA, applied various coping strategies, and received social support.

CONCLUSIONS

Results suggested that in an underserved neighborhood, individual barriers to physical activity were amplified by neighborhood-level factors such as crime, especially among individuals who have T2DM and disabilities. Socioeconomic inequalities should be addressed further to improve management of T2DM and its complications.

Increasing gaps in health inequalities related to non-communicable diseases in South Australia; implications towards behavioural risk factor surveillance systems to provide evidence for action

BACKGROUND

Although Australia is a country cited as having generally low health inequalities among different socioeconomic groups, inequalities have persisted. The aim of this analysis was to highlight how inequalities have evolved over a 13 years period in South Australia (SA).

METHODS

Since 2002, over 600 interviews per month have been undertaken with SA residents through a computer assisted telephone survey method (total 77,000+). Major risk factors and chronic diseases have been analyzed providing trends by two socio-economic variables: education and a proxy of income (ability to save).

RESULTS

While income and educational gaps are reducing over time in SA, those that remain in the lower socio-economic groups have a generally higher prevalence of risk factors and chronic diseases. The health disparity gap is still relevant, although at a different extent, for all the variables considered in our study, with most appearing to be stable if not increasing over time.

CONCLUSIONS

Surveillance can be a good source of information both to show the evolution of problems and to evaluate possible future interventions. Extensive effort is still required to "close the gap" of health inequalities in SA. More precisely targeted and properly implemented interventions are needed.

Demographic and spatial trends in diabetes-related virtual nursing examinations

Diabetes currently affects nearly 30 million Americans, but the distribution of cases is not uniform across all demographics or every state. In the course of their education, nurses learn how to become important conduits for information on diabetes management during their eventual interactions with patients. Exploring the status and trends of diabetes-related knowledge in nursing students is one method to explore the idea that one's community affects how one sees disease. However, they are not yet experts, which places them in a period of transition. This study used data mined from the Shadow Health Digital Clinical Experience™ virtual patient exams conducted by nursing students between the years of 2012 and 2015 to find any potential demographic or spatial trends within simulation performance results from nursing students who examined a virtual patient with self-managed diabetes. Findings of the analysis indicated that age and experience affected the way in which an examination was conducted, where older and more experienced nursing students asked 8% fewer examination questions, yet showed 32% more empathy and offered 76% more educational statements than their younger counterparts. Spatial trends were less pronounced, although deeper analysis revealed that students in states closer to the national mean for population rate with diabetes perform better, show more empathy, and offer more educational statements during examinations compared to states well above or well below the national mean. This suggests that targeted information may be preferable to "one-size-fits-all" public health awareness and education programs for diabetes programs used uniformly across the country.

Identifying and Strengthening the Structural Roots of Urban Health in Canada: Participatory Policy Research and the Urban Health Agenda

An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research and action agenda with four components: a) an emphasis on health promotion and the social determinants of health; b) community-based participatory research; and c) drawing on the lived experience of people to influence d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action on public policy.

The health of Saudi older adults; results from the Saudi National Survey for Elderly Health (SNSEH) 2006-2015

OBJECTIVES

To Describe the Saudi older adult (SOA) characteristics and Introduce the Saudi National Survey for Elderly Health (SNSEH).

METHODS

The SNSEH, a population-based nationally-representative survey, was used. Subjects were included in 2006-2007, using random-cluster sampling utilizing probability proportional to size approach, and followed-up to determine their vital status until June 2015. In the analyses, survey weights were incorporated. Parametric, non-parametric and logistic regression were used. Cox-proportional hazard regression was used to determine gender effects on mortality.

RESULTS

We included 2,946 SOA. The mean age was 70.1(SD = 0.3). Around, 70% were illiterate. Almost 50% had monthly income of 2500 (2007-Saudi-Riyals). The most reported diseases were hypertension, diabetes and joints pain. The most reported medications were over the counter, antidiabetics and antihypertensive. The nine-years age-adjusted death hazard was 42% higher in SOA males.

CONCLUSION

This is an introductory paper for a series of papers that describe SOA health. These efforts will help in guiding the development of a national healthcare model for SOA, evidence-based health policies and public intervention programs that address SOA health-related issues.

Developing and Implementing a Food Insecurity Screening Initiative for Adult Patients Living With Type 2 Diabetes

OBJECTIVES

Routine food insecurity screening is recommended in diabetes care to inform more tailored interventions that better support diabetes self-management among food-insecure patients. This pilot study explored the acceptability and feasibility of a food insecurity screening initiative within a diabetes care setting in Toronto.

METHODS

A systematic literature review informed the development of a food insecurity screening initiative to help health-care providers tailor diabetes management plans and better support food-insecure patients with type 2 diabetes. Interviews with 10 patients and a focus group with 15 care providers elicited feedback on the relevance and acceptance of the food insecurity screening questions and a care algorithm. Subsequently, 5 care providers at 4 sites implemented the screening initiative over 2 weeks, screening 33 patients. After implementation, 7 patients and 5 care providers were interviewed to assess the acceptability and feasibility of the screening initiative.

RESULTS

Our findings demonstrate that patients are willing to share their experiences of food insecurity, despite the sensitivity of this topic. Screening elicited information about how patients cope with food insecurity and how this affects their ability to self-manage diabetes. Care providers found this information helpful in directing their care and support for patients.

CONCLUSIONS

Using a standardized, respectful method of assessing food insecurity can better equip health-care providers to support food-insecure patients with diabetes self-management. Further evaluation of this initiative is needed to determine how food insecurity screening can affect patients' self-management and related health outcomes.

Lived experiences of women with co-existing BMI≥30 and Gestational Diabetes Mellitus

OBJECTIVE

to explore the lived experiences of women with co-existing maternal obesity (BMI ≥ 30) and Gestational Diabetes Mellitus (GDM) during pregnancy and the post-birth period (<3 months post-birth).

DESIGN

A qualitative, sociological design was utilised. Data were collected using a series of sequential in-depth narrative interviews during pregnancy and post-birth and fieldnotes. Cross sectional thematic analysis of the data set was undertaken, alongside the construction/analysis of in-depth biographical longitudinal case profiles of individual participants.

SETTING

Participants were recruited from diabetic antenatal clinics at two NHS hospital trusts in the South West of England.

PARTICIPANTS

27 women with co-existing BMI ≥ 30 and GDM. Participants were predominantly of low socio-economic status (SES).

FINDINGS

Women were experiencing a number of social and economic stressors that compromised their ability to manage pregnancies complicated by maternal obesity and GDM, and make lifestyle changes.Women perceived themselves to be stigmatised by healthcare professionals and the general public due to their obese and gestational diabetic status.

KEY CONCLUSIONS

Women of low SES with maternal obesity and GDM perceived healthcare professionals' recommendations with respect to lifestyle change as unrealistic given their constrained social/material circumstances. Frequent references to weight/lifestyle change by different HCPs were seen as stigmatising and may be counterproductive.

IMPLICATIONS FOR PRACTICE

Women would like more collaborative care which acknowledges/addresses their personal and financial circumstances. Multidisciplinary teams should give consideration to how, by whom, and the frequency with which issues of weight/lifestyle change are being discussed in order to avoid women feeling stigmatised.

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines—epidemiology, sociology, political economy, and the human rights perspective—to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.

An expanded model of diabetes care based in an analysis and critique of current approaches

AIMS AND OBJECTIVES

To examine and critique various models guiding the care and education of people with diabetes, to develop more helpful and effective approaches to care. The focus is on relationships and communication between patients and healthcare providers.

BACKGROUND

Many patients are not adhering to the recommended treatments, hence it seems that effective diabetes care is difficult to achieve, particularly for patients of lower socio-economic status, who are disproportionately afflicted. The results are usually devastating, and lead to serious health complications that incisively diminish quality of life for patients with diabetes, frustrate healthcare providers and increase healthcare costs.

DESIGN

Critical review.

METHOD

This paper represents a critical review of various approaches to diabetes care and education. A CINAHL search with relevant key words was carried out and selected exemplary research studies and articles describing and/or evaluating the various approaches to diabetes care and management were examined. Particular attention was paid to how the paradigmatic underpinnings of these approaches construct patient - healthcare provider relationships.

CONCLUSION

The literature revealed that the traditional top-down approaches to care were largely ineffective, while collaborative approaches, based in respect and taking the whole persons and their unique situations into account, were found to be central to good care. Further, an integration of the different kinds of knowledge contained in the various approaches can complement and extend one another.

RELEVANCE TO CLINICAL PRACTICE

Avoiding devastating complications by improving the management of diabetes and overall quality of life of patients is a worthwhile goal. Therefore expanding diabetes care beyond the traditional bio-medical model to develop more effective approaches to care is of interest to all healthcare professionals working in this area.

Socioeconomic status and glycemic control in adult patients with type 2 diabetes: a mediation analysis

OBJECTIVE

The purpose of this study is to examine the contribution of health behaviors (self-management and coping), quality of care, and individual characteristics (depressive symptoms, self-efficacy, illness representations) as mediators in the relationship between socioeconomic status (SES) and glycemic control.

METHODS

A sample of 295 adult patients with type 2 diabetes was recruited at the end of a diabetes education course. Glycemic control was evaluated through glycosylated hemoglobin (HbA1c). Living in poverty and education level were used as indicators of SES.

RESULTS

Bootstrapping analysis showed that the significant effects of poverty and education level on HbA1c were mediated by avoidance coping and depressive symptoms. The representation that diabetes is unpredictable significantly mediated the relationship between living in poverty and HbA1c, while healthy diet mediated the relationship between education level and HbA1c.

CONCLUSIONS

To improve glycemic control among patients with low SES, professionals should regularly screen for depression, offering treatment when needed, and pay attention to patients' illness representations and coping strategies for handling stress related to their chronic disease. They should also support patients in improving their self-management skills for a healthy diet.

The influence of socioeconomic status on future risk for developing Type 2 diabetes in the Canadian population between 2011 and 2022: differential associations by sex

BACKGROUND

Articulating future risk of diabetes at the population level can inform prevention strategies. While previous studies have characterized diabetes burden according to socioeconomic status (SES), none have studied future risk.

METHODS

We quantified the influence of multiple constructs of SES on future diabetes risk using the Diabetes Population Risk Tool (DPoRT), a validated risk prediction algorithm that generates 10-year rates of new diabetes cases. We applied DPoRT to adults aged 30-64 in the 2011-2012 Canadian Community Health Survey (n = 65,372) and calculated risk for 2021-22. A multi-category outcome was created classifying risk as low (≤5%), moderate (greater than 5% and less than 20%), and high (≥20%), then assessed the impact of individual-level SES indicators, and area-level measures of marginalization on being moderate or high risk using multinomial logistic regression, stratified by sex.

RESULTS

We found nuanced profiles of social determinants by sex, where women are more sensitive to social context. Women living in households where highest educational attainment was less than secondary school were at greater risk [odds ratio (OR) of high compared to low diabetes risk 3.10, 95% confidence interval (CI) 2.19-4.40, p < 0.0001). The same relationship was less pronounced for males (OR 2.17, 95% CI 1.42-3.32, p = 0.0004). Lower household income and being food insecure predicted high future diabetes risk for women (OR 1.37, 95% CI 1.01-1.86, p = 0.0418 comparing quintile 1 to quintile 5; OR 2.64, 95% CI 1.78-3.92, p < 0.0001 comparing severely food insecure to food secure), but not men (OR 1.15, 95% CI 0.84-1.57, p = 0.3818 and OR 1.22, 95% CI 0.71-2.10, p = 0.4815). At the area-level, material deprivation was significantly associated with increased future risk comparing the most to the least deprived (OR females 2.39, 95% CI 1.77-3.23; OR males 1.61, 95% CI 1.22-2.14). Additionally, a strong protective effect was observed for women living in ethnically dense areas (OR 0.75, 95% CI 0.63-0.89, p = 0.0011) which was not as pronounced for men (OR 0.95, 95% CI 0.76-1.18, p = 0.6351).

CONCLUSIONS

This study characterized socio-contextual predictors for future diabetes risk, showing sex-specific effects. Diabetes prevention must consider factors beyond individual-level behavioral lifestyle change and actively take steps to mitigate the adverse impacts of socio-contextual factors.

Challenges of Diabetes Self-Management in Adults Affected by Food Insecurity in a Large Urban Centre of Ontario, Canada

Objective. To explore how food insecurity affects individuals' ability to manage their diabetes, as narrated by participants living in a large, culturally diverse urban centre. Design. Qualitative study comprising of in-depth interviews, using a semistructured interview guide. Setting. Participants were recruited from the local community, three community health centres, and a community-based diabetes education centre servicing a low-income population in Toronto, Ontario, Canada. Participants. Twenty-one English-speaking adults with a diagnosis of diabetes and having experienced food insecurity in the past year (based on three screening questions). Method. Using six phases of analysis, we used qualitative, deductive thematic analysis to transcribe, code, and analyze participant interviews. Main Findings. Three themes emerged from our analysis of participants' experiences of living with food insecurity and diabetes: (1) barriers to accessing and preparing food, (2) social isolation, and (3) enhancing agency and resilience. Conclusion. Food insecurity appears to negatively impact diabetes self-management. Healthcare professionals need to be cognizant of resources, skills, and supports appropriate for people with diabetes affected by food insecurity. Study findings suggest foci for enhancing diabetes self-management support.

Relationship between socioeconomic status and type 2 diabetes: results from Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2012

OBJECTIVE

To examine the relationship between socioeconomic status (SES) and type 2 diabetes using the Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2012.

DESIGN

A pooled sample cross-sectional study.

SETTING

A nationally representative population survey data.

PARTICIPANTS

A total of 14,330 individuals who participated in the KNHANES 2010-2012 were included in our analysis.

PRIMARY OUTCOME

Prevalence of type 2 diabetes.

RESULTS

The relationship between SES and type 2 diabetes was assessed using logistic regression after adjusting for covariates including age, gender, marital status, region, body mass index, physical activity, smoking and high-risk drinking behaviour. After adjustment for covariates, our results indicated that individuals with the lowest income were more likely to have type 2 diabetes than those with the highest income (OR 1.35; 95% CI 1.08 to 1.72). In addition, lower educational attainment was an independent factor for a higher prevalence of type 2 diabetes in Korea.

CONCLUSIONS

These findings suggest the need for developing a health policy to ameliorate socioeconomic inequalities, in particular income and education-related disparities in type 2 diabetes, along with risk factors at the individual level. In addition, future investigations of type 2 diabetes among Koreans should pay more attention to the social determinants of diabetes in order to understand the various causes of the condition.

Self-management, health service use and information seeking for diabetes care among Black Caribbean immigrants in Toronto

OBJECTIVE

The objective of this research was to explore self-management practices and the use of diabetes information and care among Black-Caribbean immigrants with type 2 diabetes.

METHOD

The study population included Black-Caribbean immigrants and Canadian-born participants between the ages of 35 to 64 years with type 2 diabetes. Study participants were recruited from community health centres (CHCs), diabetes education centres, hospital-based diabetes clinics, the Canadian Diabetes Association and immigrant-serving organizations. A structured questionnaire was used to collect demographics and information related to diabetes status, self-management practices and the use of diabetes information and care.

RESULTS

Interviews were conducted with 48 Black-Caribbean immigrants and 54 Canadian-born participants with type 2 diabetes. Black-Caribbean immigrants were significantly more likely than the Canadian-born group to engage in recommended diabetes self-management practices (i.e. reduced fat diet, reduced carbohydrate diet, non-smoking and regular physical activity) and receive regular A1C and eye screening by a health professional. Black-Caribbean immigrant participants were significantly more likely to report receiving diabetes information and care through a community health centre (CHC) and nurses and dieticians than their Canadian-born counterparts.

CONCLUSIONS

CHCs and allied health professionals play an important role in the management of diabetes in the Black-Caribbean immigrant community and may contribute to this group's favourable diabetes self-management profile and access to information and care. Additional research is necessary to confirm whether these findings are generalizable to the Black-Caribbean community in general (i.e. immigrant and non-immigrant) and to determine whether the use of CHCs and/or allied health professionals is associated with favourable outcomes in the Black-Caribbean immigrant community as well as others.

Regional primary care team to deliver best-practice diabetes care: a needs-driven health workforce model reflecting a biopsychosocial construct of health

OBJECTIVE

Best-practice diabetes care can reduce the burden of diabetes and associated health care costs. But this requires access to a multidisciplinary team with the right skill mix. We applied a needs-driven evidence-based health workforce model to describe the primary care team required to support best-practice diabetes care, paying particular attention to diverse clinic populations.

RESEARCH DESIGN AND METHODS

Care protocols, by number and duration of consultations, were derived for twenty distinct competencies based on clinical practice guidelines and structured input from a multidisciplinary clinical panel. This was combined with a previously estimated population profile of persons across 26 patient attributes (i.e., type of diabetes, complications, and threats to self-care) to estimate clinician contact hours by competency required to deliver best-practice care in the study region.

RESULTS

A primary care team of 22.1 full-time-equivalent (FTE) positions was needed to deliver best-practice primary care to a catchment of 1,000 persons with diabetes with the attributes of the Australian population. Competencies requiring greatest contact time were psychosocial issues and dietary advice at 3.5 and 3.3 FTE, respectively (1 FTE/~300 persons); home (district) nursing at 3.2 FTE; and diabetes education at 2.8 FTE. The annual cost of delivering care was estimated at just over 2,000 Australian dollars (~2,090 USD) (2012) per person with diabetes.

CONCLUSIONS

A needs-driven approach to primary care service planning identified a wider range of competencies in the diabetes primary and community care team than typically described. Access to psychosocial competences as well as medical management is required if clinical targets are to be met, especially in disadvantaged groups.

Adolescence as a gateway to adult health outcomes

Adolescence has long been regarded as a transition from childhood to adulthood. More recently it is become a concern of those wishing to avoid adverse health outcomes during middle and late adulthood. Most of this effort has been focused on behavioural risk factors such as tobacco and excessive alcohol use, physical exercise habits, dietary habits, as well as sexual and injury-related behaviours. The concern is that these habits are established during adolescence, continue into adulthood, and come to constitute ongoing risk factors for adverse health outcomes during middle and late adulthood. There is good reason to criticize this approach. These behaviours are themselves shaped by adolescents' living and working conditions and even then constitute a small proportion of the variance predicting adverse health outcomes during adulthood. More complex models of how adolescence serves as a gateway to adult health outcomes are presented. These are the socio-environmental, public policy, and political economy approaches. The argument is made that adolescence is a period during which public policy plays an especially important role in predicting future health outcomes. Yet, these public policies influence health all across the life span with adolescence providing only one of many important periods during which public policy shapes health prospects during middle and later adulthood. Ultimately one should consider a range of approaches ranging from the behavioural to the political to examine how adolescence serves as a gateway towards future adult prospects. An Adolescent Gateway Towards Adult Health Model is provided to assist in this process.

Patient attributes warranting consideration in clinical practice guidelines, health workforce planning and policy

Background

In order for clinical practice guidelines (CPGs) to meet their broad objective of enhancing the quality of care and supporting improved patient outcomes, they must address the needs of diverse patient populations. We set out to explore the patient attributes that are likely to demand a unique approach to the management of chronic disease, and which are crucial if evidence or services planning is to reflect clinic populations. These were incorporated into a new conceptual framework; using diabetes mellitus as an exemplar.

Methods

The patient attributes that informed the framework were identified from CPGs, the diabetes literature, an expert academic panel, and two cross-disciplinary panels; and agreed upon using a modified nominal group technique.

Results

Full consensus was reached on twenty-four attributes. These factors fell into one of three themes: (1) type/stage of disease, (2) morbid events, and (3) factors impacting on capacity to self-care. These three themes were incorporated in a convenient way in the workforce evidence-based (WEB) model.

Conclusions

While biomedical factors are frequently recognised in published clinical practice guidelines, little attention is given to attributes influencing a person's capacity to self-care. Paying explicit attention to predictable threats to effective self-care in clinical practice guidelines, by drawing on the WEB model, may assist in refinements that would address observed disparities in health outcomes across socio-economic groups. The WEB model also provides a framework to inform clinical training, and health services and workforce planning and research; including the assessment of healthcare needs, and the allocation of healthcare resources.

Urban area disadvantage and under-5 mortality in Nigeria: the effect of rapid urbanization

BACKGROUND

Living in socioeconomically disadvantaged areas is associated with increased -childhood mortality risks. As city living becomes the predominant social context in low- and middle-income countries, the resulting rapid urbanization together with the poor economic circumstances of these countries greatly increases the risks of mortality for children < 5 years of age (under-5 mortality).

OBJECTIVE

In this study we examined the trends in urban population growth and urban under-5 mortality between 1983 and 2003 in Nigeria. We assessed whether urban area socioeconomic dis-advantage has an impact on under-5 mortality.

METHODS

Urban under-5 mortality rates were directly estimated from the 1990, 1999, and 2003 Nigeria Demographic and Health Surveys. Multilevel logistic regression analysis was performed on data for 2,118 children nested within data for 1,350 mothers, who were in turn nested within data for 165 communities.

RESULTS

Urban under-5 mortality increased as urban population steadily increased between 1983 and 2003. Urban area disadvantage was significantly associated with under-5 mortality after adjusting for individual child- and mother-level demographic and socioeconomic characteristics.

CONCLUSIONS

Significant relative risks of under-5 deaths at both individual and community levels underscore the need for interventions tailored toward community- and individual-level interventions. We stress the need for further studies on community-level determinants of under-5 mortality in disadvantaged urban areas.

Getting serious about the social determinants of health: new directions for public health workers

International interest in the social determinants of health and their public policy antecedents is increasing. Despite evidence that as compared to other wealthy nations Canada presents a mediocre population health profile and public policy environments increasingly less supportive of health, the Canadian public health gaze is firmly - and narrowly - focused on lifestyle issues of diet, physical activity and tobacco use. Much of this has to do with Canada being identified as being driven by a liberal political economy, a situation shared with a cluster of other developed nations. Reasons for Canada's neglect of structural and public policy issues are explored and ways by which public health workers in Canada and elsewhere can help to shift policymakers and the general public's understandings of the determinants of health are outlined.

Unmet healthcare need, gender, and health inequalities in Canada

Unmet healthcare need should be rare in nations with a universally accessible publicly funded healthcare system such as Canada. This however is not the case. This study examines the extent to which predictors of such need are consistent with various paradigmatic approaches (e.g., structural-critical, social capital, social support, and lifestyle) that consider such issues. Analyses of data from a probability sample of 2536 urban residents in British Columbia specified the relationship of unmet need with socioeconomic issues such as income, gender, and housing tenure, community issues such as social networks and social support, and traditional lifestyle or behavioural risk factors. The structural-critical model concerned with socio-demographics provided the most parsimonious explanation for having an unmet healthcare need. Consistent with a structural-critical approach, gender was found to be a reliable predictor of having an unmet health need in each of the models tested. Increasing federal transfers to healthcare and providing childcare and other community supports that are of special value for women may help to reduce unmet healthcare need.

Development of the role of public health nurses in addressing child and family poverty: a framework for action

AIM

The purpose of this paper is to invite dialogue about how public health nurses could best address child and family poverty. Their current role is reviewed and a framework for expanding this role is presented.

BACKGROUND

The negative health consequences of poverty for children are well-documented worldwide. The high levels of children living in poverty in wealthy industrialized countries such as Canada should be of concern to the health sector. What role(s) can public health nurses play in addressing child and family poverty?

METHOD

A review of scholarly literature from Canada, the United States of America and the United Kingdom was conducted to ascertain support for public health nurses' roles in reducing poverty and its effects. We then reviewed professional standards and competencies for nursing practice in Canada. The data were collected between 2005 and 2006.

FINDINGS

Numerous nursing scholars have called for public health nurses to address the causes and consequences of poverty through policy advocacy. However, this role was less likely to be identified in professional standards and competencies, and we found little empirical evidence documenting Canadian public health nurses' efforts to engage in this role. Public health nurses' roles in relation to poverty focus primarily on assisting families living in poverty to access appropriate services rather than directing efforts at the policy level. Factors associated with this limited involvement are identified. We suggest that the conceptual framework developed by Blackburn in the United Kingdom offers direction for a more fully developed public health nursing role. Prerequisites to engaging in the strategies articulated in the framework are discussed.

CONCLUSION

Given more organizational support and enhanced knowledge and skills, public health nurses could be playing a greater role in working with others to make child and family poverty history.

Intervening on the social determinants of cardiovascular disease and diabetes

Heart disease, cerebrovascular diseases, and type 2 diabetes ranked first, third, and sixth, respectively, among the leading causes of death and disability in the United States in 2000. Racial and ethnic communities (i.e., African Americans, Hispanic-Latino Americans, Native Americans and Alaska Natives, and Asian Americans and Pacific Islanders) disproportionately suffer from these chronic conditions. Traditional behavior change strategies have had some positive, but limited effects and will not likely be sufficient to eliminate these health disparities at the population level. In this commentary, the authors argue for greater intervention research directed at the social determinants of cardiovascular disease and diabetes if we are to reverse current trends in chronic disease prevalence in communities of color. The authors also call for new research questions and study designs that will increase our understanding of the social, policy, and historic context in which disparities are created as a necessary first step in developing interventions aimed at social-contextual and psychosocial risk factors. Promising programs supported by the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health (REACH 2010) program and the Division of Diabetes Translation are highlighted.

Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation

The research identified gaps in Canadian knowledge and research activity concerning the roles that income and its distribution play in Canadians' population health. 241 Canadian research studies on income and health were considered along eight taxonomies: conceptualization of income or its proxies; theoretical underpinnings; income distribution measures; health measures; who/what was studied, pathways mediating between income and health; complexity of these pathways; research design; and presence of policy implications. The study identified the following areas of weakness: (a) poor conceptualization of income and the means by which it influences health; (b) lack of longitudinal studies of the impact of income-related issues upon health across the life-span; (c) lack of linked data bases that allow complex analyses of how income and related issues contribute to health and well-being, and (d) little inter-disciplinary work in identifying pathways mediating the income and health relationship. Advances in health policy to address the health effects of income and its distribution requires a research infrastructure that draws upon recent theoretical developments in the area and is able to access data sources to test these advanced conceptualizations.