THE SOCIAL DETERMINANTS OF HEALTH OUTCOMES IN TYPE 1 DIABETES MELLITUS

Author: Kathleen Hill

Hill, Kathleen, 2017 THE SOCIAL DETERMINANTS OF HEALTH OUTCOMES IN TYPE 1 DIABETES MELLITUS, Flinders University, School of Health Sciences

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Abstract

BACKGROUND Type 1 Diabetes Mellitus (T1DM) is a chronic condition that requires a lifetime of diligent self-management to avoid complications. Living with T1DM is a considerable challenge and the inability to follow a prescribed regimen is often termed non-compliance, which fails to acknowledge that the barriers to glycaemic control may be insurmountable. Social determinants of health are aspects of an individual’s unique social environment that can affect their capacity for health, decision making and engagement with health care services. Individuals who are burdened by socioeconomic disadvantage may have particular difficulty navigating the health care system and are at risk of disengaging from health care services and the silent development of severe complications. AIM AND OBJECTIVES This thesis explores the structural determinants, social context and lived experience of T1DM into adulthood to understand influences on patterns of self-care, engagement with and trust in health care services, and health outcomes. METHODS Study one is an examination of the national data on end stage renal disease due to T1DM and study two is a retrospective cohort study of patterns of care and health outcomes of over 1000 individuals with T1DM. Study three is a deep qualitative exploration describing the lived experience of T1DM and barriers preventing access to health care for young people returning to care after developing serious complications. RESULTS T1DM prevalence in Australia follows an inverse gradient with higher socioeconomic deciles having an overall lower population prevalence of T1DM (correlation coefficient –.397, p<.001). Males with T1DM were more likely to develop end stage renal disease (ESRD) particularly if they are of low socioeconomic status (SES) (RR 1.20, CI 1.002–1.459). Engagement with endocrinology services decreased with increasing age, with high attendance only seen in childhood. Median HbA1c is 8.4%, however almost 40% are in a high-risk category of 9% or above. A recurrent theme in the qualitative data was the tension between fear of hypoglycaemia and fear of complications, leaving participants debating their options and inducing diabetes distress. Adverse early childhood environments led to subsequent difficulties in establishing close attachment relationships in adulthood and diminished social support. Participants with low social support reported struggling to manage diabetes on their own, combative relationships with health care providers, disengagement from health care for many years and the subsequent silent development of severe complications at a comparatively young age. CONCLUSION Several social determinants of health were found to be associated with poorer outcomes in T1DM and an understanding of these ‘at risk’ groups has the potential to inform clinical practice in relation to increased service provision and a more tailored approach to reduce inequities. These broader structural influences on health are beyond individual control and understanding this will enable tailoring of care to each individual and neutralising the perception of blame. This is vital to building a strong and trusting relationship with young people that will endure over time to ensure surveillance for the presence and progression of diabetes complications.

Keywords: Type 1 diabetes, Social Determinant, Socioeconomic, Diabetes, renal disease, Australia
Subject: Health Sciences thesis

Thesis type: Doctor of Philosophy
Completed: 2017
School: School of Health Sciences
Supervisor: Professor Paul Ward