The Role of Structural Racism on Disparities in Clinical Outcomes for Diabetes: A Mixed Methods Study

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Approximately 37.1 million adults 18 years or older (14.7% of all U.S. adults) are estimated to have diabetes, where 90-95% of cases are classified as type 2 diabetes mellitus (T2DM). Adults from racial/ethnic minority groups continue to be disproportionately impacted by higher morbidity and mortality and poor outcomes compared to Non-Hispanic White adults. The reasons for these disparities among population groups remain elusive; however, structural racism, defined as the laws, policies, institutional practices, and entrenched norms embedded within society that foster discrimination through mutually reinforcing inequitable systems, has been indicated as a root cause of inequities in health outcomes including those related to diabetes. One form of structural racism, historic redlining, known as the practice of denying resources to communities based on race, largely impacts neighborhoods populated by persons from racial and ethnic minority groups where diabetes is highly prevalent. It has led to social and economic disadvantage within hyper-segregated and under-resourced neighborhoods due to community disinvestment. Despite reportedly being banned decades ago, the relationship between historic redlining and contemporary diabetes outcomes has not been well- studied. Since current evidence supports an association between redlining and population health, this is a significant gap that needs to be addressed to reduce diabetes disparities. Preliminary data from our group shows people report that current studies do not account for their lived experiences or accommodate for the structural inequities they deal with that limits their ability to self-manage diabetes. Therefore, we propose to assess the role of structural racism, in the form of historic redlining, on diabetes disparities and how it impacts current-day clinical and behavioral outcomes, quality of life, and the neighborhood environment in 2,000 adults with T2DM. This study offers a unique opportunity to bridge a gap in knowledge within the field by using an experimental convergent mixed methods study design to understand the relationship between historic redlining and diabetes-related outcomes in adults with T2DM. Aim 1 will use qualitative research methods to explore beliefs and attitudes about historic redlining and its impact on diabetes self-management and outcomes. Aim 2 will use quantitative research methods to identify direct and indirect pathways through which historic redlining impacts diabetes- related outcomes (glycemic control, blood pressure control, lipid control, self-care behaviors (diet, physical activity, medication adherence, blood glucose monitoring), and quality of life) in adults with T2DM and investigate invariance by race/ethnicity and sex/gender in the relationship. Aim 3 will use hierarchical modeling to assess the impact of individual, interpersonal, and neighborhood level factors on individual level diabetes outcomes; to assess the contribution of historic redlining exposure toward noted neighborhood level associations; and to assess whether individual level associations are moderated by historic redlining exposure.