Conclusions
Over the course of 2 years, we developed, tested, and validated the DISDOH. The DISDOH is a concise 16-item assessment that provides an overview of the ADA’s five critical SDoH factors influencing individuals with diabetes: socioeconomic status, neighborhood and physical environment, food environment, healthcare access, and social context. No similar measure exists presently. We established initial reliability and validity psychometric properties for the tool. As such, providers, patients, healthcare organizations, and other potential users may trust the interpretation of its results when assessing the SDoH vulnerability of individuals living with diabetes.
While psychometric properties should be established in tool creation processes, pragmatism must also be embraced to foster better uptake and implementation of these tools.16 Concise measures such as the DISDOH are associated with a reduction of respondent time burden and higher response rate. While intrinsic adverse factors may play a role, as noted earlier by Garg et al,17 many advocates for SDoH screening tools have argued18 that recognizing them is a step in the right direction for better healthcare delivery—a claim supported by strong evidence.19 Of important note, users of tools like the DISDOH must be prepared and equipped to have conversations addressing the vulnerabilities these tools uncover, ensuring meaningful engagement and effective interventions.
The DISDOH is one of the first concise, diabetes-specific SDoH measures that is designed to be both actionable and feasible for use in real-world settings, addressing a critical gap in diabetes care. Because of its psychometric properties, we are confident that the DISDOH tool is an effective screening option for those involved with caring for persons living with diabetes to foster more holistic health assessments and better health equity, and equip to better address the socially determined health outcomes associated with this chronic illness. To support practical implementation, we developed domain-specific and total score interpretation ranges that classify individuals into four levels of SDoH burden (high, moderate, minimal, and low), providing clear guidance for clinical decision-making. Lower DISDOH scores indicate a greater burden of SDoH that may hinder an individual’s ability to effectively manage their diabetes. In other words, individuals in the high SDoH burden category (lower DISDOH scores) are likely experiencing more SDoH challenges than those in the low SDoH burden category (higher DISDOH scores). These thresholds help identify individuals with elevated social needs and support the use of targeted referrals or interventions. Importantly, the DISDOH was developed in collaboration with programme facilitators to ensure that the questions focus on aspects of SDoH that providers or other care team members can help modify or improve—such as connecting individuals to food banks, support groups, or free clinics—making it a practical tool for driving tailored support and resource linkage.
A key strength of this study is the systematic and iterative nature of the development and validation. By incorporating feedback at various points and from various parties (diabetes care experts, programme facilitators, survey researchers, and individuals with diabetes), the DISDOH was refined to enhance its validity, reliability, and usability for clinical and community-based settings. The DISDOH has additional potential utility for researchers. Its concise format allows for efficient integration into large-scale data collection efforts, enabling the identification of social needs across different diabetes populations. Furthermore, the focus on modifiable domains supports targeted intervention planning and facilitates evaluation of programme impact on health equity and social risk reduction.
Limitations
Despite these strengths, several limitations should be noted. First, the majority of participants were recruited through structured programmes such as HED and Prolific, which may not fully capture the breadth of experiences across settings frequented by those living with diabetes. Future validation efforts should include larger and more demographically diverse populations, including individuals receiving care in different healthcare systems or participating in diabetes education programmes outside of structured interventions. Given that the SDoH impact varies across demographic groups, this broader sampling will be critical to enhance external validity and ensure the tool’s applicability across underrepresented populations. Another consideration is the reliance on self-reported diabetes data, which may introduce recall bias or social desirability bias in responses. In a similar vein, some individuals may find certain SDoH-related questions sensitive, which could impact response accuracy. The DISDOH was developed as a brief, pragmatic tool for assessing SDoH among individuals with diabetes. Given its short-form structure, certain domains (eg, food environment, social context) contain a limited number of items. As such, the DISDOH may not fully capture the breadth and complexity of each domain and should be considered a starting point if a more comprehensive understanding of an individual’s SDoH is required. It is recommended that implementations of tools like the DISDOH be accompanied by mechanisms that can help when issues or vulnerabilities arise. Future studies should consider evaluating the tool’s predictive validity and responsiveness to interventions aimed at addressing SDoH-related barriers to diabetes care and management. We are eager to collect longitudinal data to further assess DISDOH applicability and long-term impact.
Clinical applicability
This study reports on the development and validation of the 16-item DISDOH assessment. The DISDOH focuses on ADA’s five critical SDoH factors influencing individuals with diabetes: socioeconomic status, neighborhood and physical environment, food environment, healthcare access, and social context. Results support the validity and reliability of the measure in individuals with diabetes. By offering a concise, yet comprehensive, tool, the DISDOH reduces the burden of current SDoH assessments, making it more feasible for use in clinical settings. Healthcare providers may integrate the DISDOH into routine diabetes care to systematically identify and address social risk factors, personalize treatment plans, and enhance patient-centered interventions. The DISDOH could also inform policy and resource allocation to improve diabetes outcomes at both individual and population levels.
While the DISDOH shows promise as a feasible and actionable tool for use in clinical settings, we acknowledge that these conclusions are preliminary and based on psychometric validation rather than implementation data. Future research should examine the DISDOH’s integration into clinical workflows, including its compatibility with electronic health record systems and its potential to support value-based care initiatives. Pilot studies assessing provider uptake, usability, and impact on care planning and patient outcomes will be critical for determining its real-world utility. These next steps will help establish the DISDOH not only as a valid assessment tool, but also as a practical mechanism for addressing SDoH in routine diabetes care.
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