title: Quantifying direct effects of social determinants of health on glycemic control in adults with type 2 diabetes.
abstract: BACKGROUND
  The aim of this study was to investigate if self-care is the pathway through which social determinants of health impact diabetes outcomes by analyzing the direct and indirect effects of socioeconomic and psychosocial factors on self-care and glycemic control.
  
  
  METHODS
  Six hundred fifteen adults were recruited from two primary care clinics in the southeastern United States. A series of confirmatory factor analyses identified the latent factors underlying social status, psychosocial determinants (psychological distress, self-efficacy, and social support), and self-care (diet, exercise, foot care, glucose testing, and medication adherence). Structured equation modeling investigated the relationship among social determinants, self-care and glycemic control.
  
  
  RESULTS
  Latent variables were created for diabetes self-care, psychological distress, self-efficacy, social support, and social status. The final model [χ(2)(275)=450.07, P<0.001, R(2)=99, root mean square error of approximation=0.03, comparative fit index=0.98] showed lower psychological distress (r=-0.13, P=0.012), higher social support (r=0.14, P=0.01), and higher self-efficacy (r=0.47, P<0.001) were significantly related to diabetes self-care. Lower psychological distress (r=0.10, P=0.03), lower social support (r=0.10, P=0.02), and higher self-efficacy (r=-0.37, P<0.001) were significantly related to lower glycemic control. When social determinants of health variables were included in the model, self-care was no longer significantly associated with glycemic control (r=0.01, P=0.83).
  
  
  CONCLUSIONS
  This study suggests a direct relationship between psychosocial determinants of health and glycemic control. Although associated with self-care, the relationship between social determinants of health and glycemic control is not mediated by self-care. Development of interventions should take psychosocial factors into account as independent influences on diabetes outcomes, rather than as indirect influences via self-care behavior.
authors.affiliation: 1 Health Equity and Rural Outreach Innovation Center, Charleston Veterans Affairs Health Services Research and Development Service Center of Innovation, Ralph H. Johnson Veterans Administration Medical Center , Charleston, South Carolina.
authors.forename: Rebekah J
authors.initials: RJ
authors.lastname: Walker
authors.forename: Mulugeta
authors.initials: M
authors.lastname: Gebregziabher
authors.forename: Bonnie
authors.initials: B
authors.lastname: Martin-Harris
authors.forename: Leonard E
authors.initials: LE
authors.lastname: Egede
mesh_terms: D000328:Adult; D001786:Blood Glucose / Q000378:metabolism*; D015190:Blood Glucose Self-Monitoring; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000453:epidemiology*; D015444:Exercise; D005247:Feeding Behavior; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D012648:Self Care / Q000706:statistics & numerical data*; D064890:Social Determinants of Health / Q000706:statistics & numerical data*; D012944:Social Support; D015144:Southeastern United States / Q000453:epidemiology; D016903:Drug Monitoring
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human