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Neighborhood focus central to Cities Changing Diabetes program in Houston
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HOUSTON — Beyond individuals, social, geographic and economic factors influence the risk for developing diabetes. By identifying specific factors on the local level, researchers are developing interventions to head off disease, according to two presenters at the American Association of Diabetes Educators annual meeting.
Faith Foreman-Hays, DrPH, MPH, BA, LVN, deputy assistant director of the Houston Health Department, and Stephen H. Linder, PhD, director of the Institute for Health Policy, and distinguished teaching professor in the department of management, policy and community health at UTHealth School of Public Health and associate director of the Health Policy Institute at Texas Medical Center, discussed their work with the Changing Cities Diabetes program in Houston.
For Linder, who conducts research shaping how the program operates, diabetes is a condition that can be prevented on a larger scale by looking beyond individual patients.
“There’s something about the neighborhoods that appears to determine whether or not people really get sick,” Linder said during the presentation. “If our mission is prevention —and that’s primary prevention and catching people before they get sick — then that’s putting in place the change that’s necessary for them to stay well and achieve the most that they can. We’ve got to understand how those neighborhood factors affect their path and put constraints on it.”
The neighborhood factor — along with economic standing and biological predisposition — make up what Linder described as “compositive vulnerability.”
To pinpoint neighborhoods in the Houston area that were more susceptible to diabetes, Linder accumulated data from residents of the region with a diabetes diagnosis and looked for commonalties among the neighborhoods in which they lived.
At the economic level, a lack of access to health care, difficulty maintaining financial security and living below the poverty line were factors that contributed to vulnerability.
At the biological level, Linder looked beyond the universally accepted indicators for diabetes and identified factors specific to Houston residents with diabetes. High blood pressure, age older than 45 years and BMI greater than 26.9 kg/m2 were characteristics of 80% of the Houston population with diabetes.
Based on 90-minute in-person interviews with individuals who lived in the neighborhoods considered most vulnerable and as well as the economic and biological factors, Linder identified four populations of interest.
Populations at risk
The first group, which Linder defined as “isolated skeptics,” were people who faced more economic difficulty and met the biological indicators of elevated diabetes risk. This population was more removed from their community and potentially distrusting of health care systems. Encouraging engagement at both the community and health care levels would be keys to successful preventive strategies in this population, according to Linder.
The second group included people who were not in immediate danger of developing diabetes, but due to financial insecurities, time constraints and other outside factors, were potentially set up for future disease. For this population, which were categorized as “financially pressured caregivers,” commuting stood out as a detriment for maintaining healthy practices.
“Commuting becomes a burden because the affordable housing, as in many urban centers, is on the outskirts,” Linder said. “People live out there, and they have to commute in, and they find that most of their discretionary time is spent in the car. There’s no time left for shopping carefully. There’s no time left for meal planning. There’s no time left for getting ... exercise or encouraging others in one’s family.”
Some of the older residents of these neighborhoods also emerged as a group that may require extra attention. These “concerned seniors” may not experience financial hardships, but they are already at higher risk due to their age, which may be compounded by a lack of health literacy, according to Linder, who further noted that major personal and community changes can contribute to the increased vulnerability for this population.
Lastly, Linder said that younger people may not be likely to develop diabetes in the near-term, but for the fourth group,“time-pressured young adults” in these neighborhoods, detrimental habits can develop that ultimately lead to heightened risk further down the line.
“These social determinants [are] working in the background against them, so when they weren’t 20 something anymore ... they started to develop symptoms,” Linder said. “Why? Because they didn’t attend to their health and develop the habits they needed.”
Cities Changing Diabetes Houston
Linder’s research in this area is just one of the many components utilized in Cities Changing Diabetes in Houston, which is the only city in the United States currently taking part in the global program.
More specifically, research makes up part of the mapping process of the program, Foreman-Hays explained, which focuses on identifying and quantifying the diabetes problem at a local level. From there, information is shared via multiple avenues, such as publications, conferences, meetings and other media.
Once the information has been disseminated, action is required, and that’s where the Cities Changing Diabetes program in Houston has begun to make real progress through what Foreman-Hays calls “action work groups.”
“This is where the work really takes place in Cities Changing Diabetes Houston,” Foreman-Hays said during the presentation. “The work group level is where the work takes place, and we have a lot of passionate folks in Houston who believe we can do anything.”
The program has produced five initiatives through a process that features a proposal system that Foreman-Hays likens to the television show “Shark Tank.” First, an emergency preparedness program that has been supported by the American Diabetes Association, AADE and Harris County Medical Society aims to improve diabetes care during natural disasters via pop-up clinics. Second, an employer worksite prevention initiative works with employers to emphasize prediabetes prevention strategies for employees. Third, the Houston Diabetes Resource Center is an online tool that individuals can use to access information about diabetes and related conditions and, in the future, directly connect with other people with diabetes and health works in their communities, according to Foreman-Hays. Fourth, the Faith and Diabetes program encompasses 41 participants across multiple religions and aims to strengthen diabetes care in these communities. Finally, a peer-support group makes diabetes education available for both English and Spanish speakers and includes a Facebook group.
Foreman-Hays attributes the overall program’s successes to a multitude of factors, including multi-sector coalitions, the work of patients and certified diabetes educators in the process, and financial support from Novo Nordisk.
Foreman-Hays’s and Linder’s work in Houston has not been done in isolation. As mentioned, the Cities Changing Diabetes program is globally focused, with 22 participating cities. Foreman-Hays said the total will grow by 28 in the next few years, adding Philadelphia among others. Meanwhile, Linder has collaborated and learned from fellow researchers who are conducting similar work in Vancouver and Mexico City.
Even though this program has a global reach, its focus remains on how differences in individual cities and communities can affect diabetes prevention and care.
“[This is] an action plea for you to consider not only social factors that affect your work and your ability to be effective, but a key that primary prevention entails — the power to change — and not everyone has that power. It’s not distributed equally across the population,” Linder said. “It starts in the neighborhoods, and so I encourage you all to not only look for opportunities to be active at the neighborhood level, but to consider that logic and how you deal with the patient populations.” – by Phil Neuffer
Reference:
Foreman-Hays, et al. GS01. Presented at: American Association of Diabetes Educators; Aug. 9-12, 2019; Houston.
Disclosures: Foreman-Hays reports no relevant financial disclosures. Linder reports he has received a research grant from Novo Nordisk.