Diabetes-Specific Tools Help Pharmacists Address Patients’ Social Determinants of Health


One in 5 American adults with diabetes don't know that they have the disease.

“Where a person is born, where they live, worship, age, grow, and discover” are the elements that make up the social determinants of health (SDOH), said Erin Pauling, PharmD, BCACP, during her session at the American Pharmacists Association 2022 Annual Meeting & Exposition.

Pauling, assistant dean for academic affairs at New York’s Binghamton University School of Pharmacy and Pharmaceutical Sciences, was joined by Megan Coleman, PharmD, BCPS, CPP, associate professor at Wingate University School of Pharmacy in Wingate, North Carolina.

Together, they pointed to 6 elements of SDOH developed by Healthy People 2030, an initiative of the United States Department of Health and Human Services that sets data-driven national objectives to improve health and well-being over the next decade.1

The 6 elements of SDOH include:

Education access and quality. That’s about a person’s ability to read, or not.

Healthcare access and quality. This is the ability of a person to access healthcare. “We think about our patients…their healthcare is really visiting urgent care and emergency room departments. But access to healthcare also [considers], ‘Does a person have a PCP?’” she said. The difference is preventative care, instead of care that’s reactive.

Neighborhood and built environment. Included in this category is access to healthy foods, she explained, while asking these questions: “What does that environment look like? Are there grocery stores, are there markets…[what about] the restaurants that are available?”

Environmental conditions. “Are there bike paths on the roads? Are there sidewalks such that you would be able to walk and get physical activity? Are there parks available?” asked Pauling. The quality of home structures, such as apartments, is another consideration under environmental conditions; heating issues and mold are also potential concerns.

Social and community context. This includes the ability to vote, access community gardens, the prevalence of discrimination, and rates of incarceration.

Economic stability. Employment, housing stability, food insecurity, and poverty are issues of concern in this area.

“Diabetes is the seventh leading cause of death in the United States and immensely prevalent,” she said. Although 37.3 million adults in the United States have diabetes, 1 in 5 don’t know they have it.2

But diabetes doesn’t affect all populations in the same way, Pauling explained, citing these statistics:

  • Eight percent of the homeless population in the United States has been diagnosed with diabetes.3
  • Up to 25% of patients prescribed insulin report cost-related underuse. That means often stretching out the use of insulin in a given month.4
  • 80 million US adults–or more than 4% of the population–have difficulty understanding healthcare information and navigating the healthcare environment.5

But diabetes-specific screening tools can help.

Pauling defined health literacy as a person’s ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.” This is important to keep in mind when trying to avoid using medical jargon and using layperson language, she explained.

But there’s also health numeracy. That’s the ability to understand and apply numbers in the context of acts of daily living and with disease management, said Pauling, who added that diabetes management has many numbers associated with it.

Diabetes is full of clinical terminology, such as A1C, fasting blood glucose, and postprandial blood glucose, she explained. This is further complicated by the fact that a patient may need further customization for their care plan, depending on other comorbidities.

Nutrition, physical activity, and medication are always issues of concern, and they’re largely the responsibility of patients, who may get confused about when they should take their insulin. “There are a lot of areas where social determinants of health may impact patients with diabetes,” she said.

Pauling highlighted 2 diabetes-specific screening tools available to pharmacists.

First is the Diabetes Numeracy Test, a 43-item test that uses word problems to understand a patient’s health literacy and health numeracy related to diabetes.

One word problem cited by Pauling: “Your blood sugar target is 80 to 130 milligrams per deciliter. Circle the values below that fall within that range.” This word problem helps identify the values that fall in the goal range, she explained.

And second is the Literacy Assessment for Diabetes, which includes a list of 60 diabetes-related terms. This tool assesses a patient’s ability to pronounce and read a list of terms such as bread, sugar, glucose, atherosclerosis, and ketoacidosis.

Pauling emphasized that using the screening tools isn’t enough; rather, addressing the problems encountered by connecting the patient with appropriate resources is key.


  1. Healthy People 2030. United States Department of Health and Human Services. Accessed April 6, 2022. https://health.gov/healthypeople
  2. Statistics about diabetes. American Diabetes Association. Updated February 4, 2022. Accessed April 6, 2022. https://www.diabetes.org/about-us/statistics/about-diabetes
  3. What is Diabetes? CDC. Reviewed December 16, 2021. Accessed April 6, 2022. https://www.cdc.gov/diabetes/basics/diabetes.html
  4. Herkert D, Vijayakumar P, Luo J, et al. Cost-related insulin underuse among patients with diabetes. JAMA Intern Med. 2019;179(1):112–114. doi:10.1001/jamainternmed.2018.5008
  5. Hickey KT, Masterson Creber RM, Reading M, et al. Low health literacy: Implications for managing cardiac patients in practice. Nurse Pract. 2018;43(8):49-55. doi:10.1097/01.NPR.0000541468.54290.49
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