Leveraging Social Needs Assessments to Eliminate Barriers to Diabetes Self-Management in a Vulnerable Population

Jennifer Odoi, Wei-Chen Lee, Hani Serag (), Monica Hernandez, Savannah Parks, Sarah B. Siddiqui, Laura C. Pinheiro, Randall Urban and Hanaa S. Sallam
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Jennifer Odoi: John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Wei-Chen Lee: Department of Family Medicine, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Hani Serag: Department of Population Health, Division of Global Partnerships, School of Public and Population Health (SPPH), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Monica Hernandez: MD Anderson Cancer Center, Houston, TX 77555, USA
Savannah Parks: Department of Patient Services, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Sarah B. Siddiqui: Department of Internal Medicine, Division of General Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Laura C. Pinheiro: Weill Cornell Medical College, New York City, NY 10021, USA
Randall Urban: John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
Hanaa S. Sallam: Department of Population Health, Division of Global Partnerships, School of Public and Population Health (SPPH), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA

IJERPH, 2025, vol. 22, issue 8, 1-11

Abstract: This article describes the design, methods, and baseline characteristics of the social needs assessment (SNA) of participants enrolled in an ongoing randomized clinical trial implementing a comprehensive approach to improving diabetes self-management and providing an intensive Diabetes Self-Management Education and Support (iDSMES) Program at St. Vincent’s House Clinic, a primary care practice serving resource-challenged diverse populations in Galveston, Texas. Standardized SNA was conducted to collect information on financial needs, psychosocial well-being, and other chronic health conditions. Based on their identified needs, participants were referred to non-medical existing community resources. A series of in-depth interviews were conducted with a subset of participants. A team member independently categorized these SNA narratives and aggregated them into two overarching groups: medical and social needs. Fifty-nine participants (with a mean age of 53 years and equal representation of men and women) completed an SNA. Most (71%) did not have health insurance. Among 12 potential social needs surveyed, the most frequently requested resources were occupational therapy (78%), utility assistance (73%), and food pantry services (71%). SNA provided data with the potential to address barriers that may hinder participation, retention, and outcomes in diabetes self-management. SNA findings may serve as tertiary prevention to mitigate diabetes-related complications and disparities.

Keywords: diabetes; intensive diabetes self-management education and support; iDSMES; Social Determinants of Health; social needs assessment; vulnerable population (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2025
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