RESUMO
BACKGROUND: Social determinants of health (SDOH) refer to the social, economic, and psychosocial conditions that influence health. Lower levels of SDOH factors including income, education, and employment are associated with a higher prevalence of diabetes, poorer glycemic control, and increased diabetes-related mortality. Few studies have conducted a comprehensive evaluation of multiple SDOH factors in a population with type 2 diabetes mellitus (T2DM). OBJECTIVE: This study aimed to identify the range of SDOH challenges-including diabetes-related distress-that impact patients with insulin-dependent diabetes at an urban safety-net clinic using the 5-domain SDOH framework developed by the Healthy People 2020 initiative. METHODS: The pilot study used a cross-sectional, mixed methods approach. Participants were recruited from 3 programs within a general internal medicine clinic that provides ambulatory care for patients with uncontrolled T2DM. We administered an investigator-developed SDOH survey based on the Healthy People 2020 framework and the validated Diabetes Distress Scale (DDS), which assesses 4 domains of diabetes-related distress. One-on-one interviews were conducted to gain in-depth information about challenges. RESULTS: In total, 57 participants had an average hemoglobin A1c level of 11.0% (SD 2.6%). Overall, 92% (52/57) of participants had a barrier in at least one SDOH domain. SDOH challenges were most commonly reported in the domain of Health and Health Care (84%, 48/57), followed by Economic Stability (54%, n=31), Neighborhood and Built Environment (53%, n=30), Education and Health Literacy (47%, n=27), and Social and Community context (37%, n=21). The mean overall DDS score was 2.09 (SD 0.84), where scores of ≥2 indicate distress. Further, 79% (45/57) of participants had at least moderate diabetes-related distress in one of the 4 DDS domains. General themes that emerged from participant interviews included job interference with healthy behaviors, concerns about burdening others, challenges communicating with providers, and difficulty getting appointments in a timely manner. CONCLUSIONS: We found high levels of SDOH barriers across all 5 domains of the Center for Disease Control and Prevention's Healthy People 2020 framework, including significant levels of diabetes-related distress. Future programs to address SDOH barriers in patients with uncontrolled insulin-dependent diabetes should consider screening for and focusing on a wide range of challenges.
RESUMO
Lead concentrations in new enamel decorative paints were determined in three countries in different areas of the world where data were not previously available. The average total lead concentration of the enamel decorative paints purchased in Lebanon, Paraguay and Russia was 24,500ppm (ppm, dry weight), more than 270 times the current limit of 90ppm in Canada and in the United States. Sixty-three percent of these paints contained concentrations greater than 90ppm. Fifty-nine percent contained concentrations greater than 600ppm, the current limit in some countries. The maximum concentrations found were 236,000ppm in Lebanon, 169,000ppm in Paraguay and 52,900ppm in Russia. An average of 29% of the samples contained exceedingly high lead concentrations, >=10,000ppm. Five brands of paint were sampled in each of Lebanon and Paraguay and seven in Russia. Three colors from each brand were analyzed. For five of the six samples of the two brands in Lebanon with affiliations outside the country, the lead concentrations ranged from 1360ppm to 135,000ppm. In Lebanon the maximum concentration in the Egypt-affiliated brand (Sipes) was 135,000ppm and the maximum for the USA-affiliated brand (Dutch Boy) was 32,400ppm. Lead was not detected in any paints from the three of the four brands of paint purchased in Paraguay that had headquarters/affiliations in other countries (Brazil-Coralit), Germany (Suvinil) and USA (Novacor)). Two of the three paints from each of the other Paraguay brands contained high levels of lead with the maximum concentrations of 108,000 and 168,000ppm; one of these brands was manufactured under a license from ICI in the Netherlands. All of the paints purchased in Russia were from Russian brands and were manufactured in Russia. All three paints from one brand contained below detection levels of lead. The maximum levels of lead in the other six brands in Russia ranged from 3230 to 52,900ppm. The two brands with the highest lead concentration, TEKS and LAKRA, were produced by companies in the top three in market share.. Overall, lead concentrations were much higher in the colored paints such as red and yellow than in white paints. In each of the three countries a brand based in that country had a colored paint that either met a 90ppm limit or was close to meeting the limit-demonstrating that practical technology was available in each of these countries to produce low lead bright colored enamel decorative paints. Even though technology for producing paint without added lead existed in each of these countries, twenty-nine (29) percent of the paints analyzed contained exceedingly high concentrations (>=10,000ppm) of lead.
