Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

OBJECTIVE To evaluate the evidence on the role of structural racism as an upstream factor impacting diabetes outcomes, identify current gaps, and recommend areas for future work. RESEARCH DESIGN AND METHODS A reproducible search of Medline and Ovid was used. Structural factors based on the World Health Organization social determinants of health framework (gover-nance, macroeconomic policy, social policy, public policy, and cultural and socie-tal values) had to be included as measured variables or contextual factors discussed as upstream influences. Outcomes included 1) hemoglobin A_1c (HbA_1c), 2) LDL, 3) BMI, 4) quality of life, 5) self-efficacy, 6) mortality, 7) years of life lost, and 8) self-care behaviors. RESULTS Thirteen articles were included for final synthesis. Ten studies focused on gover-nance, two on social policies, one on public policies, and one on cultural and soci-etal values. Results highlight significant associations between structural racism and poorer clinical outcomes (HbA_1c and blood pressure), worse self-care behav-iors (diet and physical activity), lower standards of care, higher mortality, and more years of life lost for adults with diabetes. CONCLUSIONS There is a paucity of work investigating the relationship between structural racism and diabetes outcomes. Five areas for future work include 1) more rigorous research on the relationship between structural racism, downstream social deter-minants, and health outcomes in diabetes, 2) policy assessments specific to diabetes outcomes, 3) research designed to examine pathways and mechanisms of influence, 4) intervention development to mitigate the impact of structural rac-ism, and 5) tracking and monitoring of change over time.