Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes



Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population.


A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c.


In the final adjusted model across all four approaches, individual-level factors like age (β = − 0.05; p < 0.001); having 1–3 comorbidities (β = − 2.03; p < 0.05), and having 4–9 comorbidities (β = − 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (β = 0.58; p < 0.05), being married (β = 1.16; p = 0.001), and being overweight/obese (β = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control.


Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.

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Fig. 1

Data Availability

Data used for this study is available upon request from LEE.


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The authors would like to acknowledge that efforts for this study were partially supported by National Institute of Diabetes and Digestive Kidney Disease (K24DK093699, R01DK118038, R01DK120861, PI: Egede), National Institute for Minority Health and Health Disparities (R01MD013826, PI: Egede/Walker), and American Diabetes Association (1–19-JDF-075, PI: Walker). Funding organizations had no role in the analysis, interpretation of data, or writing of the manuscript.

Author information




LEE obtained funding for the study. LEE, RJW, and JAC designed the study. LEE and JAC acquired and analyzed the data. JAC drafted the article. RJW, JAC, AY, REW, LW, YW, and LEE critically revised the manuscript for intellectual content. All authors approved the final manuscript.

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Correspondence to Leonard E. Egede.

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Campbell, J.A., Yan, A., Walker, R.E. et al. Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes. J. Racial and Ethnic Health Disparities (2020).

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  • Diabetes
  • Individual
  • Community
  • Health system
  • Inner-city African American
  • Social determinants of health