Table 4.

Social determinants of health and themes in the Diabetes Distress Scale identified during semistructured interviews.

Social determinants of health domain and themes			Example quotes
Economic Instability
	Difficulty affording health-related needs	“Sometimes the way you eat is based on survival because it’s like $10 for a salad right? But it’s like $5 for a steak sandwich. So it’s like when you making financial choices and you trying to eat based on your budget. It conflicts because you know that you can’t have a Philly cheesesteak because of your diabetes but then again, you gotta eat something…So it’s about survival then.” (M117) “My income is not enough. I have rent, food, everything, so I just cannot pay for the medical visit.” (M109)
	Job interferes with healthy behavior	“I just don’t have the time [to exercise]. I work 11-12 hours daily, every day. I come home tired, I take a shower and go to sleep.” (M123) Interviewer: What are some challenges you have in being able to see your doctor for your diabetes? “Financially, permission from work, sometimes I don’t have money. It’s all together.” (M114)
Social and Community Context
	Limited or no support for diabetes-related health	“I had some family staying with me and because the type of food [they were cooking], I think it contributed to [my blood sugar getting out of control].” (M109) “Sometimes, people [don’t] understand diabetic people. Sometimes, I’m visit my friend, she’s having a birthday and gives me cake. Sometimes [she says], ‘You eat, you eat.’…Sometimes, people [don’t] understand.” (M105)
	Loved ones with diabetes are supportive of diabetes-related health	“If I feel a concern, I would just always talk to my father, because he’s been with diabetes and he’ll give me an example [of what to do]… ‘cause he’s been through the same thing.” (M106) “I get a call from my cousin every day, so sometimes she’ll ask me if I did check my sugar.” (M107)
	Participant feels an emotional toll associated with having diabetes	“You know you’re supposed to be doing better but it’s like, you know, how can you? It does put you in a—um, a clouded mental space. […] Like ,you know you be beat. You don’t wanna beat yourself up but it’s like, how do you make better choices?” Interviewer: What is the emotion you feel the most often when you struggle with your diabetes? “Frustration and sadness.” (M104)
	Participant does not want to burden others	“I have got plenty of [family], but, you know, sometimes everybody has their own thing to do. You don’t want to burden nobody with your things so try to get your thing over by yourself.” (M118)
Neighborhood and Built Environment
	Environmental exposure to unhealthy food	“[It’s harder] when watching TV and sometimes when commercials come on with food…psychologically it makes me hungry and I start eating the wrong things when I see commercials.” (M119)
	Limited access to healthy food in the neighborhood	Interviewer: What are some reasons that you find eating healthy challenging? “It’s just finding a place to buy the vegetables.” (M108)
Education and Health Literacy
	Challenges communicating with providers	“There are some words I still do not know. It might [help if my doctor would] explain things more slowly or that is when he speak sometimes talking is very fast and very cold, indifferent.” (M116)
	Language discordance	“The diabetes doctor for example speaks not an ounce of Spanish. But she also doesn’t use the translator phone.” (M135)
Health and Health Care
	Cannot get appointments in a timely manner	“I haven’t seen my primary in five months, so that’s half a year gone by there. You call and there’s no appointments available.” (M130)
	Disorganization of the health care system	“They shouldn’t be giving me appointments that are too close together, because then I might miss one or literally run from one appointment to the next and get late. 15 minutes late, they don’t want to see you. I’ve seen people get frustrated…extremely to the point where they’re yelling and screaming.” (M130)