The predominant paradigm used in chronic disease prevention and control rests on the traditional and hard-held belief that individuals are solely responsible for adopting and maintaining modifications in lifestyle practices.1-3 Lifestyle interventions have historically targeted individual-level risk factors such as body mass index, cholesterol, fasting glucose, hemoglobin Alc, triglycerides, and blood pressure.4-7 According to Dennis Raphael et al, "this dominant 'health behavior' paradigm takes little account of the increasing literature concerning the importance of the social determinants of health in population health in general and the incidence and management of diseases such as diabetes."2^(p10) Social determinants have been defined as factors (eg, socioeconomic status, housing, transportation, availability and accessibility of health care resources, and social support) in the social environment that either positively or negatively affect the health of individuals and communities.3

This commentary explores recent discourse regarding the limitations of linear approaches to addressing diabetes prevention and control typically reported in efficacy investigations. A brief discussion is provided regarding published recommendations around the need for more effectiveness studies that take into consideration characteristics of the setting in which interventions are delivered and evaluated. Thereafter, this commentary identifies social determinants of health that operate at the individual, family, community, and society levels for which both multilevel interventions and research are needed. The author offers a rationale for the use of public and economic policies and provides examples of how such policies can be used to intervene on social determinants of health.

Lifestyle and Disease Management Interventions in Diabetes

Findings from landmark diabetes complications and control trials,8,9 and more recently diabetes primary prevention health care (clinical) setting efficacy trials,10,11 have generated impressive results in lifestyle and disease management. These trials demonstrate that when patients are provided access to highly trained medical staff, tailored medical and educational interventions, and patient-provider follow-up, changes in clinical outcomes (eg, glycemic control, hemoglobin Alc, blood pressure) are positive. Such findings, while impressive, are generated under ideal institutional and financial circumstances that are typically not the reality of the everyday experiences of most patients living with diabetes and the health care settings charged with providing care to them.

Because there are few, if any, effectiveness trials to recommend diabetes management interventions tested under real-world conditions, there is still a predominate use of the stimulus-organism approach, which has as its guiding principle that educating individuals to improve patient knowledge will facilitate adoption of lifestyle practices.1 Such an approach facilitates the "blame the victim" mentality that after exposure to educational interventions, the individual should voluntarily choose to comply with dietary and physical activity recommendations.1 This approach ignores the role of the social and physical environments in which lifestyle practices are shaped and often constrained.4

The Efficaciousness vs Effectiveness Discussion

Typically, public health interventions patterned after clinical efficacy trials are not evaluated, and when evaluated have marginal success. According to Glasgow et al, "It should not be surprising when the results of an intervention are efficacious under a highly specific set of circumstances but fail to replicate across a wide variety of settings, conditions, and intervention agents in effectiveness research."11^(p263) They further state, "We need to embrace and study the complexity of the world, rather than attempting to ignore or reduce it by studying only isolated and often unrepresentative situations. We must move forward despite a current dependency on linear approaches and research methodologies to explain complex manifestations of population based disease management."11^(p264) This is particularly true for populations in the United States, for which diabetes has had a more significant cost financially and emotionally.2

Unfortunately, effectiveness research findings from this perspective are limited. Recommendations, however, regarding the need to conduct effectiveness research that seeks to understand how the setting in which interventions are delivered and what organizational support is needed to adopt successful interventions have been published elsewhere.11 Findings from effectiveness studies will provide program planners and health care administrators with valuable information regarding the generalizability of interventions to their unique settings, fiscal and human resources necessary to enroll participants, how variations in the delivery of interventions affect outcomes, and organizational commitments needed to adopt and deliver interventions.11

Some public health experts argue that responding to the rising incidence of diabetes among despaired populations in the United States for which diabetes has had a more significant cost financially and emotionally will also require a deeper understanding of the underlying social determinants of health. This understanding would also help identify radical public health strategies that recognize these determinants as opposed to ignoring them.12 This is particularly important as unhealthy behavior and lifestyle alone do not solely explain poor health outcomes among lower socioeconomic groups.13 Even if behavior is held constant, people of lower socioeconomic status are more likely to die prematurely than are people of higher socioeconomic status.13

Diabetes and Social Determinants of Health

Several organizational, economic, and social determinants, while less researched, have been postulated to influence the pathways through which chronic diseases such as diabetes are produced and managed. Examples include health care organizational characteristics (eg, health care provider practices, provision and degree of appropriate diabetes education, use of patient reminder systems, health care provider training, cultural competencies of medical staff),14 diabetes-related health care costs,15 family involvement,16 social support,17 and other factors such as housing, racism, availability and accessibility to healthy foods, and transportation.18

Intuitively, these factors would appear as obvious determinants of health. They are often mentioned as determinants of health in published reports of clinical efficacy trials.19-20 These determinants however are seldom studied in any rigorous manner given that these factors operate at the level of the individual, family, community, and society and are difficult to measure in a scientifically defensible manner. Even when interventions are conceptualized at multiple levels, the measurement techniques that are employed often rely only on individual-level outcomes for evaluation because of a lack of familiarity with techniques at other levels of analysis.21

Although difficult, emerging work in social epidemiology offers hope into applying special statistical techniques in multilevel analysis that can where possible establish links between health outcomes among individuals who share similar economic, social, and geographic characteristics.21 Appropriate use of multilevel statistical modeling will help the public health field better understand empirically how organizational, economic, and other factors as described earlier influence health in poor communities. This type of analysis would underscore the complex relationship between socioeconomic status and health inequalities. Residents in poor communities tend to experience higher crime rates, substandard housing, minimal or no medical services, and limited recreational facilities and stores offering healthier foods.13,21 These environmental conditions substantially impede opportunities to engage in appropriate lifestyle behaviors.13,21

Furthermore, this helps to emphasize that relying primarily on the use of lifestyle interventions whether proven efficacious or effective will not help the field of public health to embrace complexity as mentioned by Glasgow et al.11 Embracing this complexity will allow the field of public health to identify opportunities to intervene at multiple levels. However, to do this will require innovation, progressive thinking, courage, and a desire to participate in a needed paradigm shift in public health.

Public and Economic Policies to Intervene on Social Determinants of Health

Policy experts maintain that public and economic policies are needed in order to intervene on the effects socioeconomic inequalities places on poor, racial minority and rural geographic populations in the United States.22 Ruger22 suggests the integrative use of what she describes as horizontal and vertical public and economic policies to intervene on these effects. Horizontal public policies encourage the use of comprehensive disease-specific interventions to improve health. In this instance, interventions targeted at improving patient and provider interactions (eg, communication, shared decision making, delivery of diabetes care preventive services),23 psychological functioning (eg, group psychotherapy, family and social support),24 and promising environmental support interventions16 (eg, availability and accessibility to safe places to exercise, affordable transportation, healthy foods, and safe places to exercise) are utilized simultaneously whenever possible.

Vertical public policies according to Jennifer Ruger targets, for example, improved economic, cultural, and social conditions that include employment, political, and civic opportunities. At present, traditional partnerships have included health care providers, universities, media, and health care, community-based, professional, and faith-based organizations. Reported results of these partnerships include distributing educational materials, conducting localized health events, and distributing media (eg, public service announcement).25

The use of vertical public policies takes these partnerships one step further by encouraging linkages with new or reinvented partnerships that are seldom pursued. For example, agencies who have as their primary function the dissemination of diabetes education materials can work with agencies whose purpose is to utilize market-based approaches to expand employment opportunities.22 Other agencies whose primary focus is on education, recreation, transportation, and housing can also play a role in the identification of social, economic, and public policies that may have beneficial improvements on health. Institutional policies, for example, could help eliminate unhealthy snacks in public facilities. Community or municipal-driven public policies could respond to challenges in the availability of healthy food by enhancing transportation systems to improve access.

Conclusion

Public health experts acknowledge that diabetes is serious, common, and costly.26 It has been projected that the burden of diabetes will increase over the next decade despite advances in our understanding of its treatment. Responding to this emerging pandemic will require a variety of interventions operating simultaneously at the level of the individual, family, community, and society.6,27 To date, public health has relied on disease management findings derived from linearly driven research that does not often consider social determinants of health. The public health field should look for opportunities to work collaboratively with other agencies that have as their primary interest the identification and implementation of public and economic policies to intervene on social determinants of health.

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