Beyond the Prescription: How Pharmacists Address Social Barriers to Diabetes Care

Diabetes as defined by the American Diabetes Association (ADA) is “a group of metabolic disorders of carbohydrate metabolism in which glucose is both underutilized as an energy source and overproduced due to inappropriate gluconeogenesis and glycogenolysis, resulting in hyperglycemia.”¹ Diabetes is diagnosed based on hemoglobin A_1c (HbA_1c) or plasma glucose criteria. In 2021, the CDC estimated approximately 29.1 million people in the US have a formal diagnosis of diabetes.²

Diabetes has a significant impact on an individual’s health and society at large. In 2023, diabetes was estimated to be the seventh leading cause of death in the US.³ Complications from diabetes contribute to financial and resource strains on individual and community levels. Complications of diabetes include risk of stroke, heart attack, diabetic retinopathy, diabetic neuropathy, and nephropathy.⁴ Diabetes contributes to 39% of all end-stage renal disease (ESRD) cases.² In 2019 alone, approximately 60,000 individuals with diabetes developed ESRD.

Furthermore, in 2021, approximately 12% of emergency department visits had a diagnosis of diabetes listed. The estimated cost of diabetes in the US in 2022 was $413 billion, including direct and indirect costs: medical costs, lost productivity from work-related absences, and premature mortality. Overall, these data and trends show diabetes is a public health issue that is influenced by social determinants of health (SDoH).

SDoH is defined by the CDC as “nonmedical factors that affect health outcomes.”⁵ These encompass the “conditions in which people are born, grow, work, live, and age. SDoH also includes the broader forces and systems that shape everyday life conditions.”⁶ The 5 primary health indicators of SDoH are education access and quality, health care and quality, neighborhood and built environment, social and community context, and economic stability.

Healthy People 2030 identifies several health care-related goals to further public health, many of which are closely related to SDoH. Healthy People 2030 set 1 of its 5 overarching goals to “create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”⁶ Guidelines and policies have been updated to include assessing and addressing SDoH, including the ADA Standards of Care and the American Society of Health-System Pharmacists.^7,8 These key health indicators should be addressed to advance health equity.

Among adults with diagnosed diabetes, there are differences in populations affected across race, education levels, and socioeconomic status, as shown in Table 1² below. These findings highlight areas pharmacists can continue to work toward improved health outcomes. This literature review will further discuss SDoH and the role of pharmacists in assisting patients with diabetes specifically.

Education

Education access and quality are 1 of the 5 key health indicators of SDoH.⁶ It has many different aspects relating to attainment, language, and literacy.  Per Healthy People 2030, “People with higher levels of education are more likely to be healthier and live longer.”⁶ It is evident that education level has an impact on diabetes based on prevalence.² Adults with less than a high school education have higher prevalence rates compared with adults who have a high school education and more (13.3% in those with less than a high school education, 9.9% in those with a high school education, and 7% in those with more than a high school education).² These statistics show education has a role in influencing the risk of diabetes.

Bijlsma-Rutte et al performed a meta-analysis to assess for differences in HbA_1c levels between people with type 2 diabetes of different socioeconomic statuses.⁹ HbA_1c levels are commonly used to assess control of a patient’s diabetes, with higher levels indicating less control. The meta-analysis primarily focused on education, income, deprivation level (defined using a score that assesses unemployment rates), non–car ownership, non–home ownership, household overcrowding, and employment status (categorized as currently employed, retired, and unemployed). The analysis found a 0.26% higher mean HbA_1c level in people with the lowest education when compared to those with the highest education (95% CI, 0.09-0.43). A higher HbA_1c by 0.26% does not establish clinical significance overall, but it is still worthwhile to note that HbA_1c levels did appear to be more elevated among lower education levels when compared to higher education levels.

Of note, due to education levels having varying cutoff points for the studies, descriptive data were pooled into the highest and lowest categories for the meta-analysis. The researchers noted further study is needed to focus on socioeconomic-sensitive strategies to reduce HbA_1c levels in people with type 2 diabetes. This was the first systematic review to assess differences in HbA_1c levels for people with type 2 diabetes of different socioeconomic status.

One aspect of education that can have a major impact on diabetes management is health literacy, which is defined as “the degree to which people are able to find, understand, and use information and services to guide health-related decisions and actions for themselves and others.”¹⁰ Insufficient health literacy is estimated to be prevalent in 4.7% to 71.7% of individuals with type 2 diabetes.¹¹ A systematic review included 57 records, of which 26 studied the association of health literacy and glycemic targets, and 4 reviewed health literacy rates and diabetes complications. The systematic review concluded there is a direct association between levels of health literacy and disease control in type 2 diabetes. Of the 26 studies reviewed for health literacy and glycemic targets, 10 were found to have an inverse association of health literacy and HbA_1c. This suggests that patients with lower levels of health literacy were more frequently uncontrolled. This review also noted an inverse association with health literacy and the risk of complications of diabetes. This further aligns the data that shows lower education leads to increased HbA_1c, which can lead to an increase in diabetes complications.¹¹

Abdullah et al conducted a systematic review and found the prevalence of inadequate health literacy in the US in patients with type 2 diabetes to be 28.9% (95% CI, 20.4-37.3).¹² The definition of inadequate health literacy varied in this systematic review due to different health literacy measurement tools being used in the 13 studies included. This review also found that people with less than a high school education have a higher prevalence of limited health literacy, defined as any level of literacy below adequate health literacy (P=.009). These statistics emphasize the need for health literacy to be assessed in each patient with diabetes. Almost 1 in 3 patients in the US finds it difficult to self-manage their diabetes and to make daily health care decisions. Patients who have sufficient health literacy can benefit from understanding their health needs, reading and following directions, communicating needs with health care providers, and knowing when to seek help. Overall, education has a major impact on diabetes.

Pharmacists have a great opportunity and ability to help impact disparities seen in education and diabetes. Pharmacists are among the most accessible health care providers within communities and health systems, with the most accessibility in community pharmacies, increasing their ability to answer patient questions and provide counseling.¹³ Patients with lesser education may struggle with health literacy. When interacting with patients or dispensing medications, it is suggested to speak to patients at or below a 6th-grade level.¹⁴ Pharmacists can adjust medication directions to use patient friendly language, be specific, and provide clear instructions to assist patients with understanding their medications. Another way for pharmacists to help patients is to use demonstration products, when available, to show how to use different diabetic medications and supplies.

Healthy People 2030 has a goal to increase the proportion of adults whose health care provider checked their understanding of current or new medication therapies or disease states.⁶ Due to their accessibility and training, pharmacists can contribute to this goal, especially by utilizing a common practice called the teach-back method. The teach-back method is when a patient explains back the information a health care provider has just told them in their own words, measuring the patient’s level of understanding.¹⁵ There are many methods pharmacists can use to assist with the teach-back method. One example of this is called PictureRx, which can be used to provide patients with illustrated medication lists.¹⁶ This can assist patients who have limited literacy skills. These medication lists are illustrated and include name, dose/strength, frequency, purpose, and special instructions.

A county health system in Texas studied the impact of utilizing low health literacy flashcards and quick response (QR) education videos for heart failure, diabetes, and hypertension medications.¹⁷ The primary outcome was the difference in medication adherence 180 days after implementing the low health literacy flashcards and QR educational videos. Following the 180-day trial, patients in the intervention group had increased adherence (71% vs 44%, P=.0069).

Beyond this, pharmacists can facilitate educational sessions for patients regarding type 2 diabetes prevention or delay. The CDC provides a resource for these sessions in the Road to Health Toolkit.¹⁸ Furthermore, pharmacists can help close the gap by simplifying care plans for patients to reduce complexity, such as simplifying medication regimens in patients with polypharmacy, as recommended by the ADA.⁷ These are just some examples of what pharmacists can do to address education disparities in diabetes.

Overall, pharmacists can use different practices, like the teach-back method or patient-friendly language, to assist with addressing gaps seen in diabetes prevalence and management. These practices can help improve a patient’s quality of life and provide evidence-based diabetes care. In summary, pharmacists offer a unique perspective to addressing education and its major impact on diabetes and diabetes-related outcomes.

Income

Income level is a critical aspect of SDoH that can significantly shape a patient’s access to care for their diabetes.⁶ Income affects the built environment, food access, and access to affordable and quality health care.¹⁹ Income level can be assessed in different ways with regard to economic stability, such as a person’s own income, the income of the household, and the income level of the community. In 2024, there were 35.9 million people in poverty in the US, which is defined by comparing pretax financial income to a national poverty threshold adjusted by family composition.²⁰ This leads to many people being unable to afford things like healthy food, health care, housing, and reliable transportation.¹⁸ Diabetes disproportionally impacts adults who earn less income compared with those earning more, as seen in table 2.²

A systematic review and meta-analysis by Agardh et al assessed for associations between type 2 diabetes and socioeconomic positions by educational level, occupation, and income.²¹ The meta-analysis included 41 studies and divided income into low- and high-income groups, but it is important to note that low-income classifications vary due to differences in the countries of the studies included. Agardh et al found a 40% increased risk of type 2 diabetes in people with lower income levels (RR=1.4-, 95% CI: 1.04-1.88). The meta-analysis notes lower income may contribute to the development of type 2 diabetes due to the limited availability of healthy foods, lifestyle choices, and access to health care.

A study by Gaskin et al was performed to determine how neighborhood poverty and racial composition or race disparities impact diabetes prevalence.²² Gaskin et al used data from the 1999-2004 National Health and Nutrition Examination Survey and the 2000 US Census for the study. Poverty was measured in a ratio of household income to the federal poverty level and is based on the respondent’s household income and size. They noted individual poverty increased the likelihood of having diabetes in both Black and White populations. The study also found living in a poor neighborhood increased the odds of having diabetes. Gaskin et al noted poor neighborhoods may have less support for physical activity and healthy nutrition, which can impact the risk of diabetes.

HbA_1c and income levels have been widely investigated for an association. A random-effects meta-analysis reviewed 8 studies that looked at an association between income and HbA_1c levels.⁹ Income was sorted into highest and lowest income categories due to the varying differences between the studies included. The meta-analysis found people with the lowest income have a 0.20% higher HbA_1c level on average when compared to those who have the highest income level (95% CI, –0.05 to 0.46). This does not establish statistical significance but can contribute to clinical significance. A higher HbA_1c level can lead to increased risks of complications of diabetes, which can further increase costs. Bijlsma-Rutte et al concluded further research is needed regarding strategies to reduce HbA_1c levels in people with type 2 diabetes with lower socioeconomic status.

Many adults with diabetes are facing financial strain, whether they are uninsured or underinsured. Those who are underinsured may be facing more costs due to a high-deductible health plan. Patients often ration or do not take their medication, delay care, and/or forgo other expenditures to manage costs, which can lead to higher HbA_1c levels and an increase in diabetes distress.⁷ A national survey done in 2021 in the US found 18.6% of adults with type 1 diabetes and 15.8% of adults with type 2 diabetes who are treated with insulin are rationing insulin to decrease costs. The ADA notes that among people with chronic illness, “…two-thirds of those who reported not taking medications as prescribed due to cost-related barriers never shared this information with their physician.”² Patients without access to insulin can accumulate further costs, including complications, hospitalization, and even death.

Income has also been found to have an association with diabetes-related mortality. A study by Saydah and Lochner reviewed diabetes-related mortality for socioeconomic status groups in the US.²³ The study found having a family income below the federal poverty level doubled mortality rate compared with adults with the highest family incomes (RH=2.41; 95% CI, 2.05-2.84). Another study observed mortality rates and socioeconomic status in type 1 diabetes.²⁴ This study found lower levels of income are associated with a significantly higher mortality rate. These statistics show how lower income levels can increase diabetes-related mortality, reflecting on the impact of economic stability and diabetic-related outcomes.

Cost considerations regarding diabetes medication and supplies are a known barrier to diabetes care.⁷ As pharmacists, this can be a major area for action. Pharmacists can assist patients by using a coupon for prescriptions, using a co-payment card, or recommending a patient assistance program when available.²⁵ An article by Lelani et al provides different methods to assist patients with high prescription costs. The article notes the importance of clinicians being prepared to assist patients through these financial barriers to obtaining their prescriptions. A study by Bias et al observed the impact of pharmacist-led intervention using manufacturer patient assistance programs.²⁶ Bias et al found an HbA_1c reduction of 2.5% in the intervention group, while the control group had a reduction of 1.3% (5% CI, –3.95 to –1.61; P < .05). Pharmacists can also recommend medication changes when needed while keeping the patient and their resources in consideration.

Another way to help can be assessing patients for food insecurity, as recommended by the ADA Standards of Care.⁷ The ADA Standards of Care note food prescription programs have been promising in underserved communities with food deserts. Patients with diabetes need secure places and refrigeration to store medications and supplies. The ADA Standards of Care also recommends that health care workers who care for patients with housing insecurity should be aware of resources available in their areas to assist patients.

Overall, patients with lower incomes are disproportionally impacted by diabetes and its complications when compared to patients with higher incomes. Higher prevalence rates, HbA_1c levels, and increased mortality show the impact of income on diabetes management. As pharmacists, there are many ways to help assist patients with this disparity while still providing evidence-based and quality health care.

Race and Ethnicity 

Race and ethnicity fall under the umbrella of social and community context as one of the key health indicators of SDoH.²⁷ Social and community context have many different aspects, including cohesion within a community, discrimination, workplace conditions, and incarceration. Disparities within the race and ethnicity aspect of social and community context have been observed in diabetes prevalence, management, and complications.

Diabetes disproportionally impacts people in the US by race and ethnicity, as seen in table 3.²⁸ Survey findings by Cheng et al found the prevalence of diagnosed and undiagnosed diabetes varied by race and ethnicity from 2011 to 2016.²⁸ Diabetes type was not available from this study. The survey had a sample size of 7575 adults in the US. Of those, 2266 had diagnosed diabetes, and 377 had undiagnosed diabetes. Cheng et al found the prevalence of total diabetes was 12.1% for non-Hispanic White (95% CI, 11%-13.4%), 20.4% for non-Hispanic Black (95% CI 18.8-22.1%), 22.1% for Hispanic (95% CI, 19.6%-24.7%), and 19.1% for non-Hispanic Asian adults (95% CI, 16%-22.1%). These statistics highlight the disparities seen in diabetes prevalence within race and ethnicity.

Diabetes management is impacted by race and ethnicity. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a class of medications recommended by the ADA for diabetes management.²⁹ The class has dual benefits for weight loss, atherosclerotic cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease. A study by Eberly et al evaluated discrepancies in the use of GLP-1 RA medications by race and ethnicity in patients with type 2 diabetes in the US through a retrospective cohort study. The study found GLP-1 RA use was lower among Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black (aOR 0.81; 95% CI, 0.79-0.83), and Hispanic (aOR, 0.91; 95% CI, 0.88-0.93) patients with type 2 diabetes. Asian, Black, and Hispanic patients, who are disproportionately affected by diabetes, are less likely to receive recommended classes of diabetes medications.

Elhussein et al studied the association of race and ethnicity with the initiation of newer diabetes medications like GLP-1 RAs, dipeptidyl peptidase-4 inhibitors (DPP-4I), and sodium glucose co-transporter 2 inhibitors (SGLT-2i).³⁰ The authors performed a secondary analysis of the Look AHEAD trial. The primary outcome was time to first use of a DPP-4I, GLP-1 RA, or SGLT-2i from April 28, 2005, to February 2020. The study noted all minority races and ethnicities had lower rates of newer medication initiations when compared to White patients, as shown in table 4³⁰ and noted (P=.019). These statistics show the impact of race and ethnicity on medication management in diabetes, specifically how non-White patients have less access to newer diabetes medications. This highlights the need to create equitable access to diabetes treatments.

Race and ethnicity also impact rates of prescribing of continuous glucose monitoring systems (CGMs) and continuous subcutaneous insulin infusion devices. A retrospective review by Wirunsawanya, Rizo, and Fantasia evaluated the use of CGMs and continuous subcutaneous insulin infusion in patients with type 1 diabetes, focusing on racial differences.³¹ The study found Caucasian and Asian groups have the highest rates of using diabetes technology when compared to African American and Hispanic groups. The study also noted use of diabetes technology is associated with lower HbA_1c levels. Many patients also find diabetes technology devices help ease the burden of diabetes and its management. Therefore, the impact of race and ethnicity causing disparities in the prescribing of diabetes technology can lead to further complications of diabetes management for some populations.

Race and ethnicity-impacted disparities are also seen in diabetes complications. A study by Wang et al reviewed trends in the prevalence of diabetes and control of diabetic risk factors in the US from 1999 to 2000 and 2017 to 2018.³² Wang et al reviewed risk factors regarding individualized targets for HbA_1c, blood pressure levels less than 130/88 mm Hg, and low-density lipoprotein (LDL) levels less than 100 mg/dL with factors controlled [12.5% vs 20.6%; aOR, 0.60 (95% CI, 0.40-0.90)]. When reviewed individually, HbA_1c targets showed non-Hispanic Black adults were more likely to not be at goal when compared to non-Hispanic White adults [60.4% vs 68.3%; adjusted OR, 0.64 (95% CI, 0.53-0.77)]. It is important to maintain control of HbA_1c, blood pressure, and LDL levels due to the risk of major cardiovascular complications, like heart attack or stroke. Microvascular complications of diabetes include chronic kidney disease, retinopathy, and amputations. Chronic kidney disease (stages 1-4) is reported to have a higher prevalence in non-Hispanic Black adults, with 24.7% having stage 3 or 4, while 18.4% of White adults and 7.7% of Hispanic adults with diabetes have chronic kidney disease stage 3 or 4.² These statistics show how diabetic complications disproportionately impact adults in the US based on race and ethnicity.

Disparities in morbidity and mortality for diabetes can be seen in race and ethnicity. A retrospective cohort study by Clements et al aimed to confirm disparities in diabetes mortality rates.³³ The study found race impacts mortality in Medicare beneficiaries with type 2 diabetes. The results found Black, American Indian, and Alaska Natives have an increased risk of mortality compared to Whites. Additionally, Golden et al performed a review of contributions that race and ethnicity have on mortality in endocrine disorders.³⁷ The study found non-Hispanic Blacks have higher mortality rates and worse outcomes from diabetes.  Overall, this evidence showcases disparities in diabetes-related morbidity and mortality that can be caused by race and ethnicity.

Pharmacists have a large role in addressing the disparities seen in diabetes management with regard to race and ethnicity. The Joint Commission requires accredited organizations in ambulatory health care, behavioral health care, critical access hospitals, and hospital accreditation programs to collect race and ethnicity information and implement specific steps health care can take to reduce disparities.⁷ As pharmacists, it is important to identify gaps in these steps to improve patient care. Pharmacists can do this by making medication recommendations and implementing access programs when able for patients to have more accessibility to diabetes medications and technology.

Gerber et al performed a study to determine whether clinical pharmacists using mHealth tools can improve HbA_1c levels from 2017 to 2020.³⁴ The mHealth tools platform provided care with clinical pharmacists via a telehealth platform to review glucose levels and manage medications. The study found HbA_1c levels improved among African American and Latinx adults with type 2 diabetes. A study by Narain et al studied the impacts of primary care clinical pharmacists on cardiovascular risk factor control among Blacks with type 2 diabetes in a health care system.³⁵ The primary care clinical pharmacists reviewed labs and vital signs, performed medication reconciliations, used a standardized survey to assess barriers to medication adherence, and developed interventions to improve medication adherence. Narain et al. measured changes in HbA_1c and systolic blood pressure from before to after the first visit. A reduction in HbA_1c (-0.4%, P=.01) was found but no significant impact on systolic blood pressure was observed (-0.51 mm Hg, P =.74).

Additionally, Hassan et al performed a literature review on type 2 diabetes disparities by race and ethnicity in the US.³⁶ They noted many strategies that can be used to help address these disparities seen in type 2 diabetes. Hassan et al recommended practitioners at all levels be aware of implicit bias and address barriers to accessing quality health care. Some ways to address these barriers could be offering language assistance to individuals who have limited English proficiency, informing individuals of the availability of language services, and providing print and multimedia materials in languages in which the services are offered.³⁷ These are the Culturally and Linguistically Appropriate Services (CLAS) standards set by the US Department of Health and Human Services Office of Minority Health. Hassan et al noted policy makers need to recognize their role and abilities to make changes to policies that can help address these disparities by addressing social determinants of health, addressing institutional racism, and integrating social care into medical care.³⁶ The CLAS standards also recommend organizational government and leadership to promote health equity.³⁷

Conclusion

Disparities in education access and quality, income level, and race and ethnicity are SDoH that make a major impact on diabetes and its management in the US. Pharmacists are well equipped to identify these discrepancies and assist with preventing the potential negative impact these SDoH can have in diabetes management. The following are highlights of how pharmacists can help mitigate the impact:

Education

• Speak to patients at or below a 6th-grade level
• Use patient-friendly language, be specific, and use clear instructions when interacting with patients
• Utilize the teach-back method
• Simplify care plans for patients

Income

• Reduce medication costs through prescription coupons, co-pay cards, or patient assistance programs
• Recommend medication changes that keep the patient and their resources in consideration
• Assess for food insecurity and be aware of what assistance is available in the area
• Be aware of resources for patients with housing insecurity

Race and Ethnicity

• Recognize implicit bias and be able to address barriers
• Identify gaps to improve patient care
• Support policy changes that promote health equity

REFERENCES

1. Diagnosis and classification of diabetes: standards of care in diabetes—2026. Diabetes Care. 2026;49(suppl_1):27-49. doi:10.2337/dc26-S002

2. National Diabetes Statistics Report. CDC. March 11, 2026. Accessed June 1, 2026. https://usdss.cdc.gov/diabetes/report.html

3. Deaths: leading causes for 2023. CDC. September 16, 2025. Accessed June 1, 2026. https://stacks.cdc.gov/view/cdc/174607

4. Diabetes complications. American Diabetes Association. Accessed June 1, 2026. https://diabetes.org/about-diabetes/complications

5. Social determinants of health. CDC. May 16, 2024. Accessed June 1, 2026. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html

6. Social determinants of health. Healthy People 2030. Accessed June 1, 2026. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

7. Improving care and promoting health in populations: standards of care in diabetes—2026. Diabetes Care. 2026;49(suppl_1):13-26. doi:10.2337/dc26-S001

8. Cameron G, Chandra RN, Ivey MF, et al. ASHP statement on the pharmacist’s role in public health. Am J Health Syst Pharm. 2021;79(5):388-399. doi:10.1093/ajhp/zxab338

9. Bijlsma-Rutte A, Rutters F, Elders PJM, Bot SDM, Nijpels G. Socio-economic status and HbA1c in type 2 diabetes: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2018;34(6):e3008. doi:10.1002/dmrr.3008

10. DSMES health literacy tool: addressing health literacy. CDC. July 26, 2024. Accessed June 1, 2026. https://www.cdc.gov/diabetes-toolkit/php/health-literacy-tool/addressing-health-literacy.html

11. de Carvalho AC, Silva MT, Treptow ILG, et al. Health literacy in patients with type 2 diabetes mellitus: a systematic review. Clinics (Sao Paulo). 2025;80:100774. doi:10.1016/j.clinsp.2025.100774

12. Abdullah A, Liew SM, Salim H, Ng CJ, Chinna K. Prevalence of limited health literacy among patients with type 2 diabetes mellitus: a systematic review. PLoS One. 2019;14(5):e0216402. doi:10.1371/journal.pone.0216402

13. Beating non-communicable diseases in the community: the contribution of pharmacists. International Pharmaceutical Federation. 2019. Accessed June 1, 2026. https://www.fip.org/files/fip/publications/NCDs/beating-ncds-in-the-community-the-contribution-of-pharmacists.pdf

14. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association Foundation. 2006. Accessed June 1, 2026. http://lib.ncfh.org/pdfs/6617.pdf

15. Talevski J, Shee AW, Rasmussen B, Kemp G, Beauchamp A. Teach-back: a systematic review of implementation and impacts. PLoS One. 2020;15(4):e0231350. doi:10.1371/journal.pone.0231350

16. Mohan A, Riley MB, Boyington D, Kripalani S. PictureRx: illustrated medication instructions for patients with limited health literacy. J Am Pharm Assoc (2003). 2012;52(5):e122-129. doi:10.1331/JAPHA.2012.11132

17. Yeung DL, Alvarez KS, Quinones ME, et al. Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc (2003). 2017;57(1):30-37. doi:10.1016/j.japh.2016.08.012

18. Road to health toolkit. CDC. May 15, 2024. Accessed June 1, 2026. https://www.cdc.gov/diabetes/php/toolkits/road-to-health.html

19. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2020;44(1):258-279. doi:10.2337/dci20.0053

20. Poverty in the United States in 2024. Congressional Research Service. February 11, 2026. Accessed June 1, 2026. https://www.congress.gov/crs_external_products/R/PDF/R48854/R48854.1.pdf

21. Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol. 2011;40(3):804-818. doi:10.1093/ije/dyr029

22. Gaskin DJ, Thorpe RJ Jr, McGinty EE, et al. Disparities in diabetes: the nexus of race, poverty, and place. Am J Public Health. 2014;104(11):2147-2155. doi:10.2105/AJPH.2013.301420

23. Saydah S, Lochner K. Socioeconomic status and risk of diabetes-related mortality in the US. Public Health Rep. 2010;125(3):377-388. doi:10.1177/003335491012500306

24. Scott A, Chambers D, Goyder E, O’Cathain A. Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: a systematic review. PLoS One. 2017;12(5):e0177210. doi:10.1371/journal.pone.0177210

25. Lalani HS, Hwang CS, Kesselheim AS, Rome BN. Strategies to help patients navigate high prescription drug costs. JAMA. 2024;332(20):1741-1749. doi:10.1001/jama.2024.17275

26. Bias AA, Hiday RA, Kline MM. Impact of pharmacist intervention to improve medication access for patients with diabetes. J Am Pharm Assoc (2003). 2023;63(4S):25-30. doi:10.1016/j.japh.2022.12.021

27. Social and community context. CDC. March 27, 2023. Accessed June 1, 2026. https://www.cdc.gov/prepyourhealth/discussionguides/community.htm

28. Cheng YJ, Kanaya AM, Araneta MRG, et al. Prevalence of diabetes by race and ethnicity in the United States, 2011-2016. JAMA. 2019;322(24):2389-2398. doi:10.1001/jama.2019.19365

29. Eberly LA, Yang L, Essien UR, et al. Racial, ethnic, and socioeconomic inequities in glucagon-like peptide-1 receptor agonist use among patients with diabetes in the US. JAMA Health Forum. 2021;2(12):e214182. doi:10.1001/jamahealthforum.2021.4182

30. Elhussein A, Anderson A, Bancks MP, et al. Racial/ethnic and socioeconomic disparities in the use of newer diabetes medications in the Look AHEAD study. Lancet Reg Health Am. 2022;6:100111. doi:10.1016/j.lana.2021.100111

31. Wirunsawanya K, Rizo I, Fantasia K. OR30-03 racial differences in technology use among type 1 diabetes in a safety-net hospital. J Endocr Soc. 2020;4(Suppl_1):OR30-03. doi:10.1210/jendso/bvaa046.1382

32. Wang L, Li X, Wang Z, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US adults, 1999-2018. JAMA. 2021;326(8):1-13. doi:10.1001/jama.2021.9883

33. Clements JM, West BT, Yaker Z, et al. Disparities in diabetes-related multiple chronic conditions and mortality: the influence of race. Diabetes Res Clin Pract. 2020;159:107894. doi:10.1016/j.diabres.2019.107984

34. Gerber BS, Biggers A, Tilton JJ, et al. Mobile health intervention in patients with type 2 diabetes: a randomized clinical trial. JAMA Netw Open. 2023;6(9):e2333629. doi:10.1001/jamanetworkopen.2023.33629

35. Narain JDC, Doppee D, Li N, et al. An effectiveness evaluation of a primary care-embedded clinical pharmacist-led intervention among Blacks with diabetes. J Gen Intern Med. 2020;35(9):2569-2575. doi:10.1007/s11606-020-05750-0

36. Hassan S, Gujral UP, Quarells RC, et al. Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward. Lancet Diabetes Endocrinol. 2023;11(7):509-524. doi:10.1016/S2213-8575(23)00129-8

37. Caballero AE, ElSayed NA, Golden SH, Bannuru RR, Gregg B. Implicit or unconscious bias in diabetes care. Clin Diabetes. 2024;42(2):308-313. doi:10.2337/cd23-0048