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Relationship between social determinants of health and processes and outcomes in adults with type 2 diabetes: validation of a conceptual framework. BMC Endocr Disord 2014 Oct 09;14:82 PMID: 25298071 PMCID: PMC4203970

Pubmed ID





BACKGROUND: The aim of this study was to empirically validate a conceptual framework and elucidate the pathways linking social determinants of health to outcomes in individuals with type 2 diabetes.

METHODS: 615 adults were recruited from adult primary care clinics in the southeastern United States. The model was estimated using path analysis to determine if socioeconomic (education, employment, income) and psychosocial (fatalism, self-efficacy, depression, diabetes distress, serious psychological distress, social support, and perceived stress) factors would independently predict glycemic control or be associated with mediator/moderators of self-care, access to care, and processes of care. Covariates were gender, age, race and health literacy.

RESULTS: The final model (chi2 (15) = 17.68, p = 0.28; RMSEA = 0.02, CFI = 0.99) showed lower glycemic control was directly associated with less hours worked (r = 0.13, p = 0.002), more fatalistic attitudes (r = -0.09, p = 0.03), more self-efficacy (r = -0.30, p < 0.001), and less diabetes distress (r = 0.12, p = 0.03), with the majority of total effects being direct. Significant paths associated self-care with diabetes distress (r = -0.14, p = 0.01) and perceived stress (r = -0.15, p = .001); access to care with income (r = 0.08, p = 0.03), diabetes distress (r = -0.21, p < 0.001) and social support (r = 0.08, p = 0.03); and processes of care with income (r = -0.11, p = 0.03), social support (r = 0.10, p = 0.04), and perceived stress (r = 0.10, p = 0.04). The paths explained 76% of the variance in the model.

CONCLUSIONS: Consistent with the conceptual framework, social determinants were associated with glycemic control through a direct association and mediators/moderators of self-care, access to care and processes of care. This study provides the first validation of a conceptual framework for the relationship between socioeconomic and psychological components of social determinants of health and diabetes outcomes.

Author List

Walker RJ, Gebregziabher M, Martin-Harris B, Egede LE


Leonard E. Egede MD Center Director, Chief, Professor in the Medicine department at Medical College of Wisconsin
Rebekah Walker PhD Assistant Professor in the Medicine department at Medical College of Wisconsin


2-s2.0-84988838005   24 Citations

MESH terms used to index this publication - Major topics in bold

Diabetes Mellitus, Type 2
Health Education
Health Knowledge, Attitudes, Practice
Health Literacy
Health Services Accessibility
Models, Theoretical
Outcome and Process Assessment (Health Care)
Patient Education as Topic
Self Care
Self Efficacy
Social Determinants of Health
Social Environment
Social Support
Southeastern United States
jenkins-FCD Prod-353 9ccd8489072cb19f5b9f808bb23ed672c582f41e