标题：Healthy Eating and Exercising to Reduce Diabetes: Exploring the Potential of Social Determinants of Health Frameworks Within the Context of Community-Based Participatory Diabetes Prevention
摘要：Objectives. We examined a community-based participatory diabetes intervention to identify facilitators of and barriers to sustained community efforts to address social factors that contribute to health. Methods. We conducted a case study description and analysis of the Healthy Eating and Exercising to Reduce Diabetes project in the theoretical context of a conceptual model of social determinants of health. Results. We identified several barriers to and facilitators of analysis of social determinants of a community-identified disease priority (in this case, diabetes). Barriers included prevailing conceptual models, which emphasize health behavioral and biomedical paradigms that exclude social determinants of health. Facilitating factors included (1) opportunities to link individual health concerns to social contexts and (2) availability of support from diverse partners with a range of complementary resources. Conclusions. Partnerships that offer community members tangible resources with which to manage existing health concerns and that integrate an analysis of social determinants of health can facilitate sustained engagement of community members and health professionals in multilevel efforts to address health disparities. Diabetes disproportionately affects African Americans and is an important contributor to African Americans’ excess morbidity and mortality. 1– 3 In 2000 in the predominantly African American city of Detroit, approximately 71540 (1 in 10) African Americans had been diagnosed with diabetes. 4 Detroit residents experience higher mortality rates (deaths per 100 000) from diabetes-related causes than do Michigan residents overall, in every age group (Table 1 ▶ ). Age-adjusted diabetes mortality rates are substantially higher in Detroit (29.1 per 100 000) than in nearby (wealthier and predominantly White) Oak-land County (21.4 per 100 000) or the nation as a whole (24.9 per 100 000). 4 TABLE 1— Diabetes-Related Mortality Rates (3-Year Average) for Detroit and Michigan, by Age: 2000–2002 3-Year Averagea Detroit Michigan Age, y < 50 9.3 ±1.3 5.4 ±0.3 50–74 227.2 ±13.0 144.9 ±2.9 ≥75 785.1 ±46.7 749.2 ±12.7 Total 104.9 ±4.0 81.3 ±1.0 Open in a separate window Source. Adapted from Michigan Department of Community Health. 4 aRates are deaths per 100 000. African American women are more likely than White men, White women, and African American men to be overweight and to have limited participation in physical activity: both overweight and limited activity contribute to the likelihood of developing type 2 diabetes. According to the most recent National Health and Nutrition Examination Survey data (1990–2002), 77% of African American women are overweight and 50% are obese; for African American men, the percentages were 61% and 28%, respectively. 5 Among African American women overall, 40% reported no leisure-time physical activity, and only 4% of African American women aged 20–39 years reported vigorous leisure-time physical activity. 6– 8 Results from the East Side Village Health Worker Partnership survey, 9 a 2001 random-sample survey (n = 365) of women older than 18 years residing in Detroit’s predominantly African American East Side, are reported in Table 2 ▶ . These results indicate that 15% of women reported engaging in moderate activity, and just 5% reported engaging in strenuous activity for at least 30 minutes per day. Furthermore, 23% of respondents in this Detroit study reported consuming 5 or more servings of fruits and vegetables per day, a finding similar to national estimates for African Americans in 2003 (23.6%). 10, 11 Although research efforts have focused on behavioral risk factors as the source of chronic health conditions, individual behaviors are influenced by local contexts and the historical, social, and political forces that shape those contexts. TABLE 2— Percentage of African American Women Residing in Detroit’s East Side Neighborhood and Reporting ≥30 Minutes per Day of Moderate Physical Activity and Strenuous Physical Activity and Consumption of ≥5 Fruits and Vegetables per Day, by Age Group: Healthy Eating and Exercising to Reduce Diabetes, 2001 ≥30 Minutes of Moderate Physical Activity per Day ≥30 Minutes of Strenuous Physical Activity per Day Consumption of ≥5 Fruits and Vegetables per Day Age, y 18–39 12.5 3.7 20.6 40–59 18.8 5.5 21.2 ≥60 13.0 7.4 28.4 Total 15.1 5.2 22.6 Open in a separate window Note. Results reported are from the ESVHWP survey conducted on Detroit’s East Side in 2001. For a description of survey sample and methods, see Schulz et al. 9 and Zenk et al. 10 Social and economic factors are linked to health and well-being, and inequalities in social and economic conditions contribute to inequalities in health. 7, 12– 15 Social determinants of health include contextual factors such as features of neighborhoods or communities (income distribution, segregation), as well as individual factors (social support, disrespect). 16 Conceptualizing diabetes in terms of social determinants of health broadens the scope of factors to be considered beyond individual factors like dietary intake or physical activity. These models’ emphasis on social factors suggests that research and intervention efforts must include attention to social and economic policies, social and physical environments, and the implications of these policies and environments for behaviors, social interactions, and biological indicators of health. 17– 21 For example, the availability of healthy foods influences individual dietary choices, 22– 24 as do public policies that subsidize production of some food products (e.g., corn syrup). 25, 26 Understanding relationships among social, economic, and biological factors enables practitioners to consider the implications of intervening at various points in these processes. It is particularly important to focus on social determinants of health if we are to understand and address racial and socioeconomic disparities in health in the United States. 19, 27– 30 Although findings of racial health disparities are reduced substantially when socioeconomic status is accounted for, some racial differences in health remain. For example, African American–White differences in the prevalence of obesity (a risk factor for diabetes) persist at every socioeconomic level: African American women are more likely than White women to experience obesity, regardless of income level, and disparities by income are smaller for African American women than for White women. 31 Such persistent disparities have led researchers to examine the contribution of racism—including race-based residential segregation—to health disparities. 30 In our study, we applied a conceptual model of social determinants of vulnerability to diabetes that was adapted from more general models that posited race-based residential segregation as a fundamental social determinant of health disparities. 32, 33 Our model suggests that race-based residential segregation contributes to spatial concentrations of wealth and poverty. These concentrations, in turn, affect aspects of the social environment (e.g., workplace conditions, community social relations) and of the physical, built environment (parks, retail stores, presence or condition of sidewalks) that affect health directly (by influencing risk of injury) or indirectly (via effects on proximate factors such as available foods, which in turn influence dietary practices). Applying this model to racial disparities in diabetes allows us to postulate links between the disproportionate impoverishment of predominantly African American neighborhoods and the extent to which conditions in wealthy and poor neighborhoods facilitate or discourage healthy lifestyles. For example, residents of poor neighborhoods have fewer safe places in which to exercise and more limited access to high-quality food and are more likely to report functional limitations and physical health problems compared with residents of wealthier neighborhoods. 11, 34– 38 In the Detroit area, Zenk et al. 39 found that a predominately African American community with limited economic resources had considerably fewer large grocery stores and significantly lower-quality fresh produce available at retail outlets compared with a racially heterogeneous middle-income community. Previous research has linked food quality to decisions to purchase fresh produce 40, 41 and supermarket proximity to consumption of fruits and vegetables. 42 Thus, residents of the predominantly African American community in our study may experience a heightened risk of diabetes because of reduced access to high-quality fresh produce.
