The Impact of Addressing Social Needs on Diabetes Prevention and Treatment


November is American Diabetes Awareness Month! According to the Centers for Disease Control and Prevention (CDC), there are 1 in 10 Americans living with diabetes. That’s 37 million Americans diagnosed with diabetes and 90-95% are living with type 2 diabetes. When it comes to diabetes prevention and management, it’s important to raise awareness through culturally and linguistically appropriate education. However, education may not always be enough, as the social needs of those living with diabetes may be affecting their personal prevention and management. The social needs of people living with diabetes are often a result or construct of the social drivers of health (SDOH), which are the policies and systems in place that limit or restrict individuals from making healthier lifestyle/behavior changes. Identifying the social needs of individuals with diabetes can help us understand the root causes of social needs experienced by patients and address the upstream factors creating poor health outcomes.

Between 2016 and 2018, the National Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE®) Team conducted a cross-sectional observation study focused on patients living with diabetes and hypertension at Siouxland Community Health Center in Sioux City, Iowa. The study included 11,773 adults between 18 and 75 years old who were assessed using the PRAPARE® SDOH screening tool. Of those patients, 716 patients had diabetes only, 2,388 had hypertension only, 1,477 had both, and 7,192 had neither disease. 

The study found that those living with only diabetes were more likely to be people of color (35%), limited English proficient (39%), and have less than a high school education (72%). In addition, those living with only diabetes had the highest need for food (14%) and medicine/health care (16%). Those living with both diabetes and hypertension had the highest need for transportation (14%) and were more likely to be unemployed (55%) and uninsured (71%). 

This study supports previous research on SDOHs and health outcomes. For example, a study found that Mandarin speakers, in other words, limited English proficient community members, were more likely to have elevated HbA1c, or blood sugar, levels when compared to English speakers. Both studies suggest that SDOHs are linked to adverse health outcomes. Thus, it is important to address SDOHs directly. In the Moving to Opportunity program, community members who moved from neighborhoods with high-poverty to low-poverty ones also had lower blood sugar levels. Therefore, targeting SDOHs directly in prevention and/or treatment plans can lead to positive health outcomes. 

The type of services and programs that address SDOHs are non-clinical and social services called . ES workforce categories include case managers, community education specialists, community health workers, eligibility assistance workers, interpretation staff, outreach workers, and transportation staff. In the Association of Asian Pacific Community Health Organization’s study on ES, patients who utilized ES were more likely to have their blood sugar levels under control. ES can lead to better health outcomes, costs, access, and patient satisfaction

There are several benefits to utilizing ES and a social risk assessment tool like PRAPARE® together in a patient’s care. In upstate New York, PRAPARE® revealed that despite the number of public and supportive housing services available, housing was still a significant need. As a result, health center leadership staff advocated for more housing services using the PRAPARE® data in meetings with payers and foundations. In another case, providers at one health center in New York assumed that transportation was a concern for their patient population. But upon administering PRAPARE®, they discovered that a significant number of their patients were recently incarcerated. As a result, they are now planning more services to help these patients transition to civilian life, such as job training resources and legal services.  

When it comes to working diabetes prevention and treatment care, providers can support diabetes prevention and management treatment plans by taking a whole-person approach in care. As demonstrated by the examples provided above, using a social risk assessment tool and ES to address the immediate needs of a patient can improve the overall quality of life of a patient.

For further reading about the study, check out the Journal of the American Board of Family Medicine article and the PRAPARE® fact sheet on the study. We would also like to hear from you if you and your team are using PRAPARE® to address the social needs of people living with diabetes. Please submit your stories here and a member of the National PRAPARE® Team will reach out to learn more about your efforts to improve the health and well-being of individuals living with diabetes by using PRAPARE®.    

If you have any concerns and/or questions about the PRAPARE® assessment tool, please contact the National PRAPARE®  Team. You can also join us every third Monday at the Tiger Team workgroup to ask questions live and provide feedback. 

Authors: Kristine Cecile Alarcon, Gabrielle Peñaranda, and Rosy Chang Weir (Association for Asian Pacific Community Health Organizations/AAPCHO)