A Community-based Study on the Relationship between Chronic Condition Status, Social Determinants of Health, and Health Behaviors among Detroit Residents

doi:10.21203/rs.3.rs-3107263/v1

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Research Article

A Community-based Study on the Relationship between Chronic Condition Status, Social Determinants of Health, and Health Behaviors among Detroit Residents

https://doi.org/10.21203/rs.3.rs-3107263/v1

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Compared to Michigan as a state, Detroit, the largest urban city in Michigan, has a substantially higher chronic condition burden. This study examined influential factors, including health beliefs, behavior tracking, and social determinants of health associated with Detroit residents' chronic condition status. Using a cross-sectional community-based study design, 394 Detroit residents were recruited from May 2019-August 2021 to complete a survey. To meet the study objectives, descriptive statistics and binary logistic regression analyses were conducted using STATA MP17. Over 45% of participants self-reported having a chronic condition. Participants reported housing, food, healthcare, and stress as their top social determinants of health. Participants with a chronic condition had significantly higher adjusted odds (AOR = 1.71, 95% CI: 1.01 to 2.89) of requesting assistance with intermediary than structural determinants. This is one of the first studies to describe Detroit residents' self-reported needs by their chronic condition status. Residents' social needs are multifaceted and associated with chronic condition status. Residents would benefit from interprofessional collaborations to address their top social determinants and promote lifestyle changes.

Detroit

social determinants of health

chronic conditions

health behavior tracking

health behavior

Twenty-two years ago, Detroit, the largest metropolitan area in Michigan, was negatively impacted by the 2001 economic crisis, which was then followed by the 2007 Great Recession [1]. These occurrences affected the city's economy and negatively impacted the city's physical and social environment. For instance, Detroit experienced an increase in crime, with one of the higher peak times in 2006, in which Detroit's crime rate was more than 4.29 times Michigan's rate and more than five times the U.S.'s crime rate [2].

Detroit has made substantial economic and social progress over the years [3, 4], including a projected increase in employment by 2027 [4]. However, residents' health remains a significant concern. Compared to Michigan as a state, Detroit residents' average mortality rate from 2019–2021 was substantially higher for heart conditions (205.5 vs. 321.1), stroke (44.0 vs. 48.7), and diabetes (83.5 vs. 102.8) per 100,000 age-adjusted population [5].

While chronic conditions contributed to the influx of mortality in recent years, a considerable number of Detroit residents' chronic conditions can be prevented by managing leading risk factors such as hypertension, diabetes, and being overweight/obese [6, 7]. Nevertheless, the 2020 data from the Michigan Department of Health and Human Services shows that compared to Michigan, a greater percentage of Detroit residents have non-ideal levels of these leading risk factors; hypertension (34.3% vs. 44.9%), diabetes (10.5% vs. 13.5%), obesity (31.4% vs. 38.8%), and perform inadequate physical activity (19.5% vs. 17.9%), respectively [8].

An extensive body of literature has shown that healthy lifestyle behaviors can significantly reduce the development of risk factors and chronic conditions' long-term adverse health effects [6, 7]. Moreover, cognitive factors such as health beliefs can influence the performance of healthy lifestyle behaviors [9, 10]. Previous research has demonstrated the association between health beliefs and the performance of specific health behaviors such as physical activity [11], a healthy diet [12], and health services use [13]. In addition to performing healthy behaviors, there are benefits to tracking them to increase awareness of current lifestyle and daily activities to foster cues to action among individuals with chronic conditions [14, 15]. Although research has aided in understanding Detroit residents' chronic condition status, no study has been performed to understand the relationship between residents' chronic condition status, health beliefs, and self-monitoring of their behaviors.

A growing body of literature also shows that social determinants of health can impact chronic condition status [16–18]. Specifically, a study among U.S. adults in 11 states and one territory found that those with cardiovascular and lung conditions had higher odds of housing or food insecurity [16]. Stress has also been identified as a social determinant [19, 20], and a bidirectional relationship has been found between stress and chronic conditions [21]. Research has also linked chronic conditions to healthcare access [16]. Therefore, social determinants of health may be attributable to Detroit residents' chronic condition status, and further research should be performed to examine this relationship.

The literature demonstrates the importance of health beliefs, health tracking, and social determinants of health in chronic condition prevention and management. However, there is a limited understanding of the influence of these factors on Detroit residents' chronic condition status. To address the gaps in the literature regarding these social issues, this study aimed to examine the relationship between Detroit residents' health beliefs, behavior tracking, and social determinants of health and their chronic condition status.

Guiding Theory

The Social Cognitive Theory guided this study [22], which depicts that one's cognitive (e.g., health beliefs), behavioral (e.g., health tracking), and environmental (e.g., social determinants of health) factors can influence their performance of health behaviors. This study was also guided by the World Health Organizations' conceptual framework for addressing social determinants of health [23]. This framework categorizes social determinants as structural or intermediary to inform the development and implementation of actions to address determinants of health [23].

Research design and study population

For this cross-sectional community-based study, individuals who self-identified as 20 years or older and reported living in Detroit were recruited to participate. Non-English speaking individuals were excluded from the study. The study's sample size was determined based on the population of Detroit in 2019 (670,052) [24]. Using a 95% confidence level and a 5% margin of error, an optimum sample size was calculated to be 384 participants aged 20 years and older [25].

Data Collection

Data collection occurred from May 2019 through August 2021. Following approval from the institutional review board, a three-prong recruitment strategy was implemented. In May 2019, in-person data collection via tablets occurred across Detroit's seven districts at neighborhood block parties, fairs, parks, churches, libraries, senior centers, and local businesses. This strategy was undertaken to obtain a representative sample of Detroit residents (i.e., neighborhood residence, race/ethnicity, socioeconomic status, and age) while addressing internet, phone, and transportation barriers.

In-person data collection was paused in March 2020 due to Michigan's stay-at-home order during the COVID-19 pandemic. Data collection resumed in December 2020 through January 2021 via phone calls and email recruitment to neighborhood book clubs, businesses, local associations, community centers, and churches.

The study's flyer was also posted on social media accounts (i.e., Facebook, Reddit, and Craig's List) to enhance recruitment efforts. However, the three strategies (phone, email, and social media) drew limited participants (n = 6). Therefore, an incentive was incorporated from February 2021 to August 2021. An electronic $50 Visa gift card was given to the first person to complete the survey for the respective week. The incentive increased participation, resulting in a representative sample size of 394. Additional details on the study's design and methodology have been previously published [26].

Measures

The primary outcome of interest was the participants' chronic condition status (yes/no). This variable was developed by combining participants' reporting of hypertension or diabetes diagnosis, and determination of obesity status. Using measures from the Behavioral Risk Factor Surveillance System Questionnaire [BRFSS] [27], participants reported ever being told by a provider they have hypertension or diabetes (yes, no, yes but female told during pregnancy, or don't know).

The study had three main independent variables; health beliefs, health behavior tracking, and top social determinants of health. Per beliefs, participants reported strongly agree, agree, neither agree/disagree, disagree, or strongly disagree on behaviors (eating a balanced meal, exercising regularly, regular checkups when not sick, not smoking, not drinking alcohol, following medication regimens, adhering to food restrictions, and maintain a healthy weight) believed should occur to stay healthy [28]. Limited responses were identified; therefore, 'strongly agree' and 'agree' were combined to 'agree'. A similar modification was conducted for 'strongly disagree' and 'disagree' to 'disagree'.

Participants also reported tracking, not tracking, interested in tracking, or not applicable to monitoring their physical activity, fruit/vegetable intake, fish consumption, sugary beverage consumed, whole grain eaten, weight status, number of cigarettes smoked, and measuring blood pressure and sugar levels. Due to lower responses, 'do not track' and 'do not track/monitor but interested' responses were combined to create the response 'do not track/monitor'. The 'does not apply' responses were coded as missing because tracking these behaviors was not applicable.

Per the third primary independent variable, participants selected their top five social determinants of health they would like assistance addressing from a list of 21 determinants (housing, food, healthcare, stress, transportation, language, substance use, mental health, employment, education, personal safety, finances, family and community support, race/ethnicity, health literacy, physical activity, self-confidence, engagement in health/activation, sexual orientation, veteran status, or other). Participants were also able to select none of the determinants as an option. 'Other' and 'none' of the determinant responses were recoded as missing due to limited-to-no responses. For the regression analysis, the social determinants of health variables were recoded to intermediary or structural as defined by the World Health Organization's framework for social determinants of health [23].

Covariates included sociodemographic characteristics adapted from the BRFSS questionnaire. These variables were age in years (≤ 19, 20–39,30–39, 50–59, 60–69, and 70+) and gender (male/female). The race/ethnicity variable (White, Black, American Indian or Alaska Native, Asian or Indian, Middle Eastern or North African Descent, Other, Mixed race, and Hispanic) was recategorized to White, Black, Hispanic, or Other to address limited responses. Similarly, income ($0 to $9,999, $10,000 to $14,999, $15,000 to $19,999, $20,000 to $34,999, $35,000 to $49,999, $50,000 to $74,999, $75,000 to $99,999, and $100,000 or higher) was recategorized to $19,999 or less, $20,000 to $34,999, $35,000 to $49,999, $50,000 to $64,999, $65,000 to $74,999, and $75,000 or higher to address limited responses. Additionally, education (less than 8 years, 8 years to 11 years, high school graduate/GED, some college, college graduate, or postgraduate) was recategorized to high school graduate/GED or less, some college, college graduate, and postgraduate to address low responses across categories.

The survey was reviewed by public health researchers external to the research team to ensure its clarity and relevance. The survey was also piloted among 55 Detroit residents before collection occurred. The piloted survey contained open-ended questions to collect participants' opinions on the overall length of the survey and the clarity of the questions. Individuals participating in the pilot were also given the contact information of the researchers involved in the study to answer any questions or concerns regarding the survey.

Statistical Analysis

Characteristics of the sample were described using descriptive statistics (frequencies and percentages). Chi-squared tests assessed the relationship between chronic condition status, social determinants of health, health belief, behavior tracking, and sociodemographics. Binary logistic regression models evaluated the association between chronic condition status and social determinants of health variables. The binary logistic regression was adjusted for the sociodemographic characteristics (race/ethnicity, age, and education). Statistical analyses were conducted using STATA MP17 [29]. A p-value of ≤ 0.05 was considered statistically significant.

Sample Characteristics

Among the 394 participants, 57.7% self-identified as female, 53.72% identified as black, and 61.63% identified as less than 40 years of age (Table 1). Majority of the participants identified as having some college education or more (83.02%) and having an annual household income of less than $50,000 (56.81%) (Table 1). Approximately 29% of the sample had been diagnosed with hypertension at least once in their life, 13.04% of the sample self-identified as being diagnosed with diabetes by their medical doctor, and nearly a third (35.28%) of the sample classified as obese (Table 2).

Table 1

Participants' Sociodemographics
Variable		n(%)
Detroit resident
	Yes	394(100.00)
Age
	20–29	152(38.87)
	30–39	89(22.76)
	40–49	51(13.04)
	50–59	45(11.51)
	60–69	38(9.72)
	70+	16(4.09)
Sex
	Male	162(42.30)
	Female	221(57.70)
Race/Ethnicity
	White	99(26.33)
	Black	202(53.72)
	Hispanic	37(9.84)
	Other	38(10.11)
Income level
	$19,999 or less	88(23.04)
	$20,000 to $49,999	129(33.77)
	$50,000 to $74,999	78(20.42)
	$75,000+	87(22.77)
Education level
	High school/GED or less	65(16.97)
	Some college	112(29.24)
	College graduate	132(34.46)
	Postgraduate	74(19.32)

Table 2

Descriptive statistics of Chronic Conditions and Social Determinants of Health
Variable		n(%)
Hypertension Diagnosis
	Yes	105(29.17)
	No	255(70.83)
Diabetes Diagnosis
	Yes	48(13.04)
	No	320(86.96)
Obese
	Yes	139(35.28)
	No	255(64.72)
Have Chronic Condition
	Yes	194(49.24)
	No	200(50.76)
Social Needs
	Housing	95(25.13)
	Food	89(23.54)
	Healthcare	29(7.67)
	Stress	76(20.11)
	Transportation	6(1.59)
	Language	2(0.53)
	Mental health	6(1.59)
	Employment	6(1.59)
	Education	3(0.79)
	Personal safety	1(0.26)
	Finances	11(2.91)
	Social support	1(0.26)
	Race/ethnicity	4(1.06)
	Engagement in health/activation	1(0.26)
	Self-confidence	2(0.53)
	Physical activity	8(2.12)
	Other	3(0.79)
	None of the above	35(9.26)

(Table 1 here)

There was almost an equal percentage of individuals who identified as having been diagnosed with one or more chronic conditions or not, with 49.24% of participants self-identifying as being diagnosed with one or more chronic conditions by a doctor before the study and 50.76% identifying as never being diagnosed (Table 2). Additionally, those self-identifying as black reported the highest prevalence of chronic disease (61.39%), with those identifying as Hispanic reporting the second highest (56.76%) (p < 0.001).

(Table 2 here)

Health Beliefs and Behavior Tracking among Chronically Ill

Of the participants with a chronic condition who believed that having regular checkups even when they are not sick is important, 35.11% do not track their blood pressure (p < 0.05) (Table 3). Over a third (41.6%; p < 0.05) of participants with a chronic condition that agreed exercising regularly is an important part of maintaining good health do not track their activity levels. Moreover, of the participants with a chronic condition who agree that eating well-balanced meals is important to maintain health, 43.80% (p < 0.005) do not track their fruit and vegetable intake, and the vast majority do not track their grain intake (57.55%; p < 0.05).

(Table 3 here)

Social Determinants of Health Needs

Participants top reported social determinants of health needs were housing (25.13%), access to food (23.54%), access to healthcare (7.67%), and stress (20.11%) (Table 2). A significant relationship was found between race/ethnicity and reporting stress, with about one-third (36.67%) of White, 17.34% of Black, 11.43% of Hispanic, and 22.86% of Other participants reporting it as a top need (p < 0.005) (Table 4). There was also a significant relationship seen between education and reporting housing as a top need, with those with a high school education/GED or less (40.98%) and have some college education (36.63%) reporting it more frequently than those with a college degree (18.58%) or postgraduate degree (17.46%) (p < 0.005) [Table 4].

The majority of the race/ethnicity groups (White: 81.11%, Black: 57.23%, Hispanic: 60.00%; and Other: 65.71%) reported intermediary than structural determinants (p < 0.005) as their top needs. Higher education level (college graduate: 73.45%; postgraduate: 77.78%) participants were more likely to report intermediary determinants than those with a lower education level (p < 0.001) [Table 4].

(Table 4 here)

Chronic Conditions and Social Determinants of Health Needs

The binary logistic regression analyses identified a significant relationship between chronic condition status and social determinants of health needs (Table 5). Participants who reported having a chronic condition had higher adjusted odds of reporting intermediary determinants as their top needs than structural determinants (AOR = 1.71; 95% CI: 1.01 to 2.89).

Table 5

Association between Chronic Condition Status and Intermediary/Structural Social Determinants of Health†
Variable	Odds ratio	95% CI
Social determinant of health
Structural (reference)
Intermediary	1.71*	(1.01, 2.89)
^†The model was controlled for age, race/ethnicity, sex, and education level.

(Table 5 here)

Statistics show Detroit residents have a substantially higher mortality rate from preventable chronic conditions than Michigan as a state. Therefore, this study conducted a holistic assessment of residents' health beliefs, behavior tracking, and social determinants of health needs to understand further the underlying factors of residents' ubiquitous chronic conditions. Among participants with chronic conditions, a substantial number reported firmer beliefs in partaking in healthy behaviors; however, 35% or more of participants do not monitor their blood pressure, physical activity, or critical aspects of their diet. This finding is consistent with research demonstrating adults' perception of the importance of performing healthy behaviors [11, 12], but despite their beliefs, variations in self-monitoring activities have been documented [15].

Participants' social determinants of health may play a role in the identified disconnect between their beliefs and self-monitoring behaviors. Across all participants, the top three most reported social determinants of health needs were housing, food, and stress. However, participants with a chronic condition were more likely to request assistance with intermediary determinants. This relationship was further supported by the results of the regression analyses in which participants who self-reported having a chronic condition had significantly higher adjusted odds of stating they needed assistance addressing an intermediary determinant of health compared to structural determinants.

The three most commonly requested intermediary determinants among participants with chronic conditions were healthcare, stress, and food. Healthcare was the third most commonly reported need and aligned with national-level data on healthcare utilization challenges among adults with chronic conditions [10]. Although no studies have examined Detroit residents' healthcare needs by their chronic condition status, previous research has reported Detroit residents experiencing barriers to accessing care due to cost; unable to afford their copays or having no health insurance [30]. Consequently, the report indicated residents were more likely to use the emergency room as a usual source of care [30]. Detroit participants' request for assistance with healthcare has implications for chronic condition prevention and management. Specifically, the underutilization of primary and specialty healthcare services is potentially a missed opportunity for residents to understand their condition and obtain counseling on partaking in healthy behaviors [7, 10].

Stress was the second most common social determinant of health participants with a chronic condition stated they needed assistance with. While limited studies have been conducted on the overall stress level of Detroit residents, Geronimus and colleagues' research suggests that Detroit residents' stress may be linked to their concern about physical environmental threats within their neighborhoods [35]. This concern may stem from the quality of housing and neighborhood characteristics that resulted after the earlier economic recessions [1–3].

Research has also been conducted on stressors among specific Detroit populations. Chronic stress was reported among African American female Detroiters [31]. Their chronic stress was associated with the performance of unhealthy dietary behaviors [31] that can affect their food and nutritional intake monitoring.

Additionally, research suggests that Detroit residents have a high financial stress level [32]. A survey conducted among Detroit residents by Hope Starts reported residents' childcare access as a financial stress [32]. Residents' financial stress may be associated with the city's poverty level. In 2018, Detroit was identified as having one of the highest poverty levels in the state and a lower annual median income ($29,481) [33]. A growing body of literature delineates the impact of stress on chronic condition prevention and management [21]. Therefore, further studies should be conducted to understand better the leading stressors of Detroit residents with chronic conditions. These findings can inform the identification of appropriate interventions.

Participants with chronic conditions reported food as their top social determinants of health needs, which aligns with previous research that stated in 2020, nearly 69% of Detroit residents said they were food insecure, a 7% increase from 2019 [34]. Moreover, these findings support the 2018 Detroit Community Needs Assessment outcomes, in which grocery stores were the highest need reported by residents [35]. Research suggests that Detroit residents' food insecurity arises from a lack of transportation to stores and markets, inadequate time to purchase food, and a limited income [34]. Residents' inconsistent access to food can create barriers to selecting healthy food choices [34], which may deter them from engaging in healthy dietary patterns or monitoring their food intake.

Several limitations of this study should be noted. The survey examined residents' monitoring of their health behaviors but did not measure their actual behaviors, such as consuming a healthy diet. These residents may partake in healthy behaviors but do not track them. Additionally, participants self-reported their chronic conditions, which could result in an under- or over-estimation of the prevalence of their chronic conditions. Furthermore, an extensive list of chronic conditions was not collected, which can also result in underestimating residents' chronic condition status. In conducting a cross-sectional study, a causal relationship cannot be determined between residents' health beliefs, behaviors, and social determinants of health.

This study addressed a gap in the literature on the relationship between Detroit residents' chronic condition status and their health beliefs, behavior tracking, and social determinants of health. Furthermore, the study's results depict healthcare, food, and stress as intermediary determinants that residents with chronic conditions would benefit from receiving assistance with. A substantial number of programs are provided to Detroit residents to assist them with their social needs. However, target interventions are warranted for residents with a chronic condition. Specifically, programs are needed to increase their healthcare utilization, engage them in healthy dietary patterns, and monitor their behaviors. Residents would also benefit from programs that aid them in coping with their stress while managing their chronic condition. With the known implications of financial status (i.e., higher poverty level) on chronic conditions, and on participants’ top requested intermediary determinants (healthcare, food, and stress), policies and programs should be implemented to improve residents’ financial status.

Note

CI = confidence interval

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Tables 3-4 is available in the Supplementary Files section.

Table34.docx

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You are reading this latest preprint version

A Community-based Study on the Relationship between Chronic Condition Status, Social Determinants of Health, and Health Behaviors among Detroit Residents

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Version 1

Abstract

Introduction

Methods

Guiding Theory

Research design and study population

Data Collection

Measures

Statistical Analysis

Results

Sample Characteristics

Health Beliefs and Behavior Tracking among Chronically Ill

Social Determinants of Health Needs

Chronic Conditions and Social Determinants of Health Needs

Discussion

Declarations

Note

References

Tables

Supplementary Files

Status:

Version 1