MPH 520 Week 2 Social Determinants of a Public Health Problem Example

The Last Week of the Month: How Food Budgets, Income and Neighborhood Shape Type 2 Diabetes in a Colorado Steel Town

[Student Name]

University of Phoenix

MPH/520: Social and Behavioral Aspects of Public Health

Week 2 Assignment

[Instructor Name]

[Date]

The county health department, its clients and program data are composites written for a model paper; city estimates and research findings come from the sources cited.

A nurse at the diabetes clinic run by a composite health department in a southern Colorado steel town noticed a pattern. Her patients' calls about low blood sugar, and their emergency visits, came most often in the last days of the month. She asked her supervisor whether it might be about money. This paper uses her question to analyze the social determinants of type 2 diabetes in the community.

Defining Social Determinants

The phrase social determinants refers to everyday circumstances outside the clinic that decide how healthy people can be: what they earn and whether work is steady, how much schooling they had, whether they can buy enough food, where they live and how they get around, how safe their streets feel and whether they can see a clinician when needed.

The Local Picture

CDC estimates for Pueblo city, on which this composite community is modeled, put age-adjusted diagnosed diabetes among adults at 11.6% and obesity at 33.9%, and estimate that nearly one in five working-age adults has no health coverage, 19.5% (Centers for Disease Control and Prevention, 2025). Many residents work shifts in manufacturing, warehousing and health care, and median household income is well below the state's.

Fundamental Causes

Research on social determinants argues that behaviors like diet and exercise are shaped by deeper conditions. Braveman and Gottlieb's review argued that money, accumulated assets and schooling sit underneath a wide range of health outcomes, and laid out routes, some biological such as prolonged stress, by which these conditions get under the skin (Braveman & Gottlieb, 2014). Telling people to eat better does little when the problem is that the money is gone by the 25th.

Food Insecurity and Chronic Disease

Many of the clinic's patients cannot count on having enough to eat every day of the month. Among low-income adults in a national health survey, not having reliable access to enough food went along with laboratory or examination evidence of hypertension, and when a stricter definition of food insecurity was used, with more than twice the prevalence of laboratory-confirmed diabetes (Seligman et al., 2010).

The End of the Month

The nurse's observation has support in research. In California, admissions for hypoglycemia were more common among the low-income population than among high-income residents, and for low-income residents the risk of admission increased 27% in the last week of the month compared with the first, with no similar pattern among high-income residents (Seligman et al., 2014). When food runs out, people taking diabetes medicines may skip meals while still taking doses.

Pathway One: Food

Low income leads to cheaper, calorie-dense foods, irregular meals and, at month's end, skipped meals. For people with diabetes, this means swings in blood sugar and a harder time following nutrition advice.

Pathway Two: Stress

Financial strain and job insecurity cause chronic stress, which affects hormones that raise blood sugar and disrupts sleep, both linked to diabetes risk and control.

Pathway Three: Work

Shift work disrupts sleep and meal timing. Workers on rotating shifts at the mill and hospitals find it hard to attend daytime appointments, exercise regularly or eat consistently.

Pathway Four: Housing and Neighborhood

Some neighborhoods lack grocery stores with fresh food but have many fast-food outlets and convenience stores. Sidewalks and parks are fewer, and residents describe safety concerns about walking after dark.

Pathway Five: Access to Care

One in five working-age adults without insurance means delayed diagnosis, rationed medications and missed follow-up. Insulin and newer diabetes medicines are costly for the uninsured, so some patients stretch doses to make prescriptions last.

A Patient's Month

The nurse described one patient, a 54-year-old warehouse worker with diabetes, as typical. In the first week after payday, he bought groceries and took his medicines as prescribed. By the third week, money for food was short, and he ate one meal a day while still taking his full doses. Twice in a year he was brought to the emergency department with dangerously low blood sugar in the last days of the month, once from the loading dock at work. His story made the pathways visible to staff who had seen only the emergencies.

Why This Is Not About Willpower

Staff sometimes described patients like him as noncompliant. The analysis reframed the problem: he was following a plan designed for someone with a steady food supply. The plan, not the patient, needed to change, along with the conditions that emptied his refrigerator.

How the Pathways Interact

The pathways reinforce each other. A shift worker with diabetes, no insurance and an empty refrigerator at month's end faces multiple barriers at once. Addressing one pathway while ignoring others limits results.

What Clinic Data Showed

The clinic reviewed a year of calls and visits for hypoglycemia. Nearly half occurred in the last ten days of the month, and very few in the first week after benefit issuance. Patients receiving food assistance benefits reported running out before the next issuance date.

Implications: Screening for Social Needs

The clinic will screen every patient for food insecurity with a validated two-question tool and ask about housing, utilities and transportation.

Implications: Connecting to Benefits

Staff will help eligible patients enroll in food assistance, Medicaid and utility assistance, and the department will partner with the local food bank to offer diabetes-appropriate food boxes timed for the end of the month, when budgets run out.

Implications: Medication Safety

Clinicians will review medication plans for patients who report running out of food, adjusting regimens to reduce hypoglycemia risk when meals are uncertain.

Implications: Work

The department will work with the mill and the two hospitals, the largest employers, on shift-friendly clinic hours and workplace diabetes prevention.

Implications: Neighborhoods

The department will join city planning discussions on grocery access and safe walking routes in the neighborhoods with the highest diabetes rates.

Implications: Coverage

Enrollment assistance at clinics, community events and the food bank aims to reduce the uninsured share among patients.

Measuring Change

The clinic will track hypoglycemia calls and emergency visits by week of the month, the share of patients screened for food insecurity, the share connected to benefits and A1c levels among patients receiving food boxes, comparing the months before and after the changes.

Limits of the Analysis

City estimates are modeled, not measured, and the clinic's data come from its own patients. The California hypoglycemia pattern may not match Colorado precisely. The department will measure its own patterns before and after changes.

Conclusion

The nurse's question led to the causes behind the causes. Local estimates, a review identifying income and education as fundamental causes, national evidence linking food insecurity to chronic disease and research showing hypoglycemia admissions rising at month's end among low-income people explain why diabetes in this steel town is shaped by money, work, food and neighborhood. Public health's response must reach those conditions as well as the clinic.

References

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Centers for Disease Control and Prevention. (2025). PLACES: Place data (GIS friendly format), 2025 release [Data set]. data.cdc.gov. https://data.cdc.gov/d/vgc8-iyc4

Seligman, H. K., Bolger, A. F., Guzman, D., López, A., & Bibbins-Domingo, K. (2014). Exhaustion of food budgets at month's end and hospital admissions for hypoglycemia. Health Affairs, 33(1), 116-123. https://doi.org/10.1377/hlthaff.2013.0096

Seligman, H. K., Laraia, B. A., & Kushel, M. B. (2010). Food insecurity is associated with chronic disease among low-income NHANES participants. The Journal of Nutrition, 140(2), 304-310. https://doi.org/10.3945/jn.109.112573