Pediatric endocrinologist Nana-Hawa Yayah Jones, MD, is passionate about addressing health inequities affecting children with Type 1 diabetes. Here, she discusses the endocrine team’s efforts to improve outcomes through targeted interventions.

How would you characterize health inequities facing some children with Type 1 diabetes?

In 2021, I co-authored a retrospective, population-based cohort study based on data from the Cincinnati Children’s electronic medical record to identify which social determinants of health were associated with diabetic ketoacidosis (DKA) hospitalization among children with Type 1 diabetes. Our study showed that identifying as Black, living in high-poverty areas, or having public insurance were each associated with a higher likelihood of being admitted to the hospital for DKA. 

However, when we examined these exposures together in a multivariable model, we found that race was no longer significant. So it’s not about being Black; it’s about the social determinants of health—including poverty and being on public insurance—that disproportionally affect Black patients.

Locally, Black patients are admitted to the hospital two to three times more than their white peers for DKA, and their hemoglobin A1C is two to three points higher. Health disparities like these are not unique to our clinic—we see them throughout this country and in many different disease populations.

What’s an example of how social determinants of health affect Type 1 diabetes outcomes?

Children who live in poverty or are on public health insurance are less likely than other children to use diabetes management technology such as continuous glucose monitors (CGMs) and insulin pumps. The reasons are complex. One is provider bias—nationally, diabetes specialists are less likely to offer Black and Hispanic patients these technologies. Another is that families often obtain CGMs through durable medical equipment providers, which creates logistical challenges related to prior authorizations, order processing, consent and delivery. A parent might not be able to manage these details if they are worried about personal safety, food and shelter.

Then there’s the complexity of training families to use diabetes technology. A single parent working 9 to 5 might lose pay if required to participate in a half-day class or might not have reliable transportation to and from the hospital, especially when training may be over multiple days. Training materials also might not be written in a way a parent can easily understand.

What is Cincinnati Children’s doing to reduce equity gaps for children with Type 1 diabetes?

Our team has rolled out several targeted interventions. For example, we provide a “social determinants of health screening” for all patients with diabetes. The screening includes questions about food security, mental health, transportation, access to insulin and supplies, and other concerns. This helps us see what a family really needs rather than making assumptions.

We also hired a diabetes navigator to connect with high-risk patients between clinic appointments. This navigator addresses specific diabetes issues related to prescriptions, devices, emergency care plans, etc. And we have a partnership with Greater Cincinnati Legal Aid, whose lawyers are available to address housing security and stability.

The endocrine team also is part of the Cincinnati Children’s Health Equity Network (HEN). HEN brings together clinical teams throughout the hospital to improve outcomes and eliminate health disparities related to race, ethnicity and socioeconomic status. We share our data, ideas and achievements as we develop more effective solutions for at-risk children, some of whom are dealing with multiple health issues.

What are you learning through this process?

Clinicians can’t just solve problems from inside the hospital walls. That’s why we engage community leaders, parents, teachers, and schools as we develop interventions. We’re asking parents, “what do you need for your child to be successful?” We’re asking school nurses, “do you need additional training to care for kids with Type 1 diabetes?” This is new in the diabetes world—it’s new for all providers; moving from telling patients how to care for themselves to asking patients, “how can we best care for you?”