1. Clinical versus public health perspectives on diabetes (any public health issue) CharacteristicsClinical PerspectivePublic Health Perspective Problem definitionIndividual, lifestyle Community, public policy, environment TargetSelf-referred or recruited samples Populations and/or high-risk groups SettingMedical/specialized clinics Community environments (work, schools, primary care, home) ProviderTrained professionals Professionals, lay, automated (internet, 1-800 service) InterventionBrief counseling or intensive, multi-session Brief, low-cost, self-change focus Outcomemeasure: HgbA1C Measures: I feel that diabetes does not interfere with my life: I have access to affordable food; I have a supportive community for exercising Population of eligible individuals screened Small percentage Large percentage Cost-effectivenessLower Higher

2. Stages of change 1.Precontemplation: not thinking about change 2.Contemplation: unsure or ambivalent about change 3.Preparation: ready to initiate change in next four weeks 4.Action: taking steps toward the behavioral goal 5.Maintenance: trying to maintain change over the long term-at least 6 months

3. Social determinants of health 1.Social gradient: the poorest and most disadvantaged are especially affected. The poorest have the lowest diabetes control. Copays on medications leads to poorer diabetes control. 2.Stress: social and psychological environment impact diabetes control 3.Early life: importance of a good start in life 4.Unemployment: job security and satisfaction. Poor job security impacts diabetes control 5.Work environment: impacts on health and risk of disease. Lack of job control impacts diabetes control 6.Social support: positive role of friendship and social cohesion 7.Social exclusion: impact of social isolation and relative deprivation. Rapid community change can impact decrease social relations thus decreasing diabetes control. 8.Addictions: effects of tobacco, alcohol and other drugs 9.Food: access to reasonably priced nutritious food is a community issue and its lack leads to poorer diabetes control. 10.Transport: better public transport, reducing driving and encouraging healthier means (walking, cycling). Lack of culturally encouraged exercising leads to poorer diabetes control.