Porque me tocó a mi? Mexican American diabetes patients' causal stories and their relationship to treatment behaviors

"No sufro, estoy bien/I am not suffering, so I am doing OK": A mixed method exploration of individual and network-level factors and Type 2 Diabetes Mellitus (T2DM) among Mexican American adults in New York City

INTRODUCTION

The prevalence of type 2 Diabetes Mellitus (T2DM) is 2-3 times greater among Mexican Americans than non-Latino whites, and Mexican Americans are more likely to develop T2DM at younger ages and experience higher rates of complications. Social networks might play a crucial role in both T2DM etiology and management through social support, access to resources, social engagement, and health behavioral norms.

OBJECTIVE

To quantitatively identify the social network features associated with glycated hemoglobin (HbA1c) in a community sample of Mexican immigrants residing in New York City, and to explore the extent to which these quantitative findings converge with qualitative narratives of their lived experiences.

METHODS

This study used a convergent mixed methods design. To collect personal network data, we used EgoWeb, and obtained 1,400 personal network ties from 81 participants. HbA1c readings were collected using dried blood spots and categorized according to the laboratory criteria of the American Diabetes Association. Additional survey data were collected using Qualtrics software. To investigate the significance of the network-level factors after accounting for the socioeconomic and demographic individual-level factors that the literature indicates to be associated with T2DM, we used a multiple regression model on quantitative data sources. For the qualitative portion of the study, we selected a subset of individuals who participated in the quantitative portion, which represented 500 personal network ties from 25 participants. We conducted in-depth interviews guided by the visualization of these ties to explore who was helpful or difficult in managing their health and health behaviors.

RESULTS

Individual-level indicators associated with lower HbA1c scores were body mass index (β = -0.07, p<0.05), and healthy eating index scores (β = -0.03, p<0.02). The network-level predictor associated with higher HbA1c levels was the percentage of diabetic alters in the network (β = 0.08, p <0.001, with a 25% increase in the percentages associated 2.0 change in HbA1c levels. The qualitative data highlighted that most of the diabetes-related information diffused through the social networks of our participants was related to dietary practices, such as reducing sugar and red meat consumption, eating out less, and reducing portion sizes. Notably, even among those with elevated levels and diabetes-related health complications, HbA1c was not considered a part of the lay descriptions of good health since they were not "suffering." Participants regarded doctors as the ultimate authority in diabetes care, even if they had supportive members in their personal networks.

CONCLUSION

Our study provides quantitative evidence for the significant role of diabetic network members in the etiology and management of T2DM among Mexican Americans. Our qualitative findings suggest important ley terms for T2DM management and the importance of physicians, which could be included in in future social networks studies seeking to diffuse diabetes-related health information for T2DM prevention and management efforts in this population.

What drives distress? Rethinking the roles of emotion and diagnosis among people with diabetes in Nairobi, Kenya

Type 2 diabetes mellitus is a condition that both results from and produces social and psychological suffering. As 'diabetes' increases among low income patients in poorer nations, new challenges arise that drive, co-occur, and result from the condition. In this article, we describe how social suffering produces diabetes by way of addressing the varied social, psychological, and biological factors that drive diabetes and are reflected in diabetes experiences among patients seeking care at a public hospital in Nairobi, Kenya. We recruited a non-probability sample to participate in a cross-sectional study of 100 patients (aged 35-65 years), where half of the participants sought care from a diabetes clinic and half sought care from the primary healthcare clinic. We obtained informed consent in writing, and collected life history narratives, surveys, anthropometrics, and biomarkers. This paper evaluates survey data using frequencies and regression tables. We found that social factors as opposed to disease factors were major drivers of psychological distress among those with and without diabetes. Psychological distress was associated with female gender and feelings of financial and personal insecurity. We also found insulin resistance was common among those undiagnosed with diabetes, suggesting that many seeking primary care for other health conditions did not receive a routine diabetes test (most likely because it is an out-of-pocket cost, or other competing social factors) and therefore delayed their diagnosis and care. Thus, social and economic factors may drive not only emotional distress among people with diabetes but also delayed care seeking, testing, and self-care as a result of cost and other social challenges.

Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis

Background

Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care.

Methods

Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley’s checklist for survey designs. A thematic synthesis was then conducted of the collected studies.

Results

Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians.

Conclusions

This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0753-2) contains supplementary material, which is available to authorized users.

Diabetes Cultural Beliefs and Traditional Medicine Use Among Health Center Patients in Oaxaca, Mexico

Type II diabetes mellitus is currently the leading cause of death in Mexico. Oaxaca is one of the poorest states in Mexico with the largest concentration of indigenous people in the country. Despite the alarming increase of diabetes rates in this region, little is known about the indigenous populations' cultural understandings and related practices for this chronic disease. This study examined diabetes cultural beliefs and traditional medicine use among a sample of 158 adults with and without diabetes in Oaxaca, Mexico. Individuals with and without diabetes did not differ in their traditional culture beliefs regarding diabetes in this study. Younger age (OR = 1.04) and stronger beliefs in punitive and mystical retribution (OR = 5.42) regarding diabetes causality increased the likelihood of using traditional medicine (p < .05). Findings may aid in the development of culturally tailored programs to address diabetes prevention and management efforts in the region.

"My heart burns" - A qualitative study of perceptions and experiences of type 1 diabetes among children and youths in Tajikistan

Aims To explore and describe perceptions and experiences of living with type 1 Diabetes Mellitus among children/youths in Tajikistan. Methods Qualitative methods were employed. Participants were recruited through purposive and snowball samplings. Data were collected using a semi-structured interview guide with children/youths having diabetes, their parents as well as health professionals. Data were analyzed according to Malterud's systematic text condensation. Results Children/youths with diabetes (n = 18), their parents (n = 19) and endocrinologists (n = 4) were interviewed. Families described unique stories in which "emotional stress" and a spiritual "evil eye" were perceived as possible causes of diabetes. Life-threatening complications and maltreatment preceding diagnosis of diabetes were frequent. From manifestation of diabetes onwards, families struggled with systemic and cultural obstacles, causing stigma, discrimination, high school-drop-out rates, diabetic coma, chronic complications or death of the child/youth with diabetes. Conclusions Results of this qualitative study highlight the severity and complexity of challenges families living with a child/youth having diabetes in this low-income country face. Efforts to improve life expectancy and life quality are strongly needed and require addressing both systemic and cultural factors in order to accomplish sustainable impact.

Discovering successful strategies for diabetic self-management: a qualitative comparative study

OBJECTIVE

This project explored lifestyles of patients in good and poor control to identify naturally occurring practices and strategies that result in successful diabetes management.

RESEARCH DESIGN AND METHODS

Semistructured interviews with adult patients with type 2 diabetes explored diet, food preparation, physical activity, medication use and glucose monitoring. Patients (n=56) were classified into good (A1C <7.0%), fair (7.0%8.0%) control groups and matched across groups on diabetes duration (±5 years) and medication modality (none, oral, insulin±oral) to control for non-lifestyle factors. A qualitative comparative analysis identified practices that distinguished glycemic groups.

RESULTS

Good control patients were more likely to test their glucose two or more times a day and reduce their sodium intake, as well as increase fruits and vegetables and limit portion sizes, some attaining good control without exercise. Fair control patients discussed several dietary strategies including limiting sweets, drinking non-caloric beverages, reducing carbs, 'cheating' (eating only a few sweets/limiting carbs in one meal to have more in another meal) and tested their glucose once a day. Poor control patients were more likely to skip antidiabetic medications and not test their glucose.

CONCLUSIONS

Although clinical trials indicate most self-management practices have limited effectiveness over time, increased glucose monitoring is a valuable component in daily management. Research is needed on effectiveness of dietary strategies that emphasize sodium monitoring and allow some degree of cheating. Reoffering diabetes education classes and providing pill boxes as memory aids may help improve poor control.

An ethnographic study of salt use and humoral concepts in a Latino farm worker community in California's Central Valley

BACKGROUND

This article reports on the use of domestic or table salt for its perceived health effects and healing properties in a Latino farmworker community. It explores how contemporary salt usage beliefs can be seen to have roots in long-standing humoral theories of medicine and health.

METHODS

This qualitative investigation comprised 30 in-depth individual interviews and five focus groups conducted in Spanish with Mexican and Central American immigrants in one small city in California's Central Valley (N = 61 total participants). Interviews and focus groups were audiotaped, translated into English and transcribed. Several researchers independently and iteratively read transcripts, developed and applied codes, and engaged in thematic analysis.

RESULTS

Strongly emergent themes identified the importance of balance in health, and beliefs about the effects on salt on health. Valued for its culinary role, for bringing out the flavors in food, and used by people of all ages, salt use is part of a robust set of cultural practices. Salt was regularly mixed with foods in different combinations and ingested to restore balance, prevent disequilibrium or reduce vulnerability to diverse illnesses, promote rehydration, and address symptoms of exposure to extremes of temperature or physical or emotional stress. Statements made and practices engaged in by participants were highly suggestive of health and healing beliefs common to humoral belief systems based primarily on a hot-cold dichotomy in classifications of foods and healing behaviors. We evaluate these statements and practices in the context of the existing literature on historical and contemporary humoral beliefs in Latin American communities, in Mexico and Central America, and in the United States.

CONCLUSION

Humoral theory is a useful framework for understanding contemporary rural Latino migrant farmworkers' perceptions of the importance of salt for their health.

A Systematic Review of Research on Culturally Relevant Issues for Hispanics With Diabetes

Purpose

The purpose of this review is to provide a description of current research on culturally relevant issues among Hispanics subgroups with diabetes throughout the United States.

Methods

A search of 2655 abstracts was conducted using Medline, PubMed, and Psychlit. Sixty articles were identified, and 33 were reviewed.

Results

Most studies focused on Mexican Americans, and little is known about the unique and shared health beliefs of different Hispanics subgroups within the United States. Personal models of illness varied across groups and were influenced by levels of acculturation. Definitions and treatments for susto varied considerably: Puerto Ricans did not identify it as a cause of diabetes. Patients'thoughts about God and diabetes differed, and little is known about how these thoughts affect diabetes self-management. There is also limited research on Hispanics' use of curanderos (folk healers) for diabetes-related care, and only some participants reported using alternative treatments in conjunction with standard medical care. There is limited evidence that fatalistic thinking is unique to Hispanic culture, and its relationship to diabetes self-management remains unclear.

Conclusions

More research is needed to determine how cultural factors influence Hispanics' approaches to diabetes self-management. Clinicians and educators would benefit from exploring cultural belief systems with patients, as they may enhance the patient-provider relationship and serve as tools in identifying appropriate treatment strategies.

Decoding the Type 2 Diabetes Epidemic in Rural India

Type 2 diabetes mellitus is an escalating public health problem in India, associated with genetic susceptibility, dietary shift, and rapid lifestyle changes. Historically a disease of the urban elite, quantitative studies have recently confirmed rising prevalence rates among marginalized populations in rural India. To analyze the role of cultural and sociopolitical factors in diabetes onset and management, we employed in-depth interviews and focus groups within a rural community of Tamil Nadu. The objectives of the study were to understand sources and extent of health knowledge, diabetes explanatory models, and the impact of illness on individual, social, and familial roles. Several cultural, socioeconomic, and political factors appear to contribute to diabetes in rural regions of India, highlighting the need to address structural inequities and empower individuals to pursue health and well-being on their own terms.

Interpreting Low-Income Latinas’ Amniocentesis Refusals

As with other medical care, low-income Latinas turn down prenatal genetics services, including amniocentesis, more than any other U.S. group. Amniocentesis is a medical procedure that provides information about a fetus‘ health. Virtually all conditions the test detects are untreatable other than by induced abortion. Because little is known about why Latinas accept or decline amniocentesis and the role ethnicity might play in their decision, we sought to address these issues. We first identify factors associated with amniocentesis acceptance and refusal in a group of Mexican-origin women. We then described the actions those who refused took after turning down the test and their explanations for their acts. We show that while study participants‘ ideas about what put their pregnancies at risk were often at odds with those of clinicians, their objectives were similar: to reduce risk and maintain hope in the face of uncertainty.

Retention of Minority Participants in Clinical Research Studies

Recruitment of minority participants for clinical research studies has been the topic of several analytical works. Yet retention of participants, most notably minority and underserved populations, is less reported and understood, even though these populations have elevated health risks. This article describes two related, intervention-based formative research projects in which researchers used treatment theory to address issues of recruitment and retention of minority women participants in an exercise program to reduce obesity. Treatment theory incorporates a model of health promotion that allows investigators to identify and control sources of extraneous variables. The authors’ research demonstrates that treatment theory can improve retention of minority women participants by considering critical inputs, mediating processes, and substantive participant characteristics in intervention design.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

A Qualitative Exploration of Motivation to Self-Manage and Styles of Self-Management amongst People Living with Type 2 Diabetes

The study examined the motives that people living with type 2 diabetes (T2D) had for self-managing their condition and ways they used to assess the success of their self-management efforts. Using semistructured interviews (N = 25), focus groups (3 × N = 12 participants), and open-ended questionnaires (N = 6), people living with and self-managing T2D were recruited from a community-based T2D participation group. Most participants were older (aged 60+) and lived in a socioeconomically deprived area in the United Kingdom. Data were analysed thematically using framework analysis. Patients' motives for self-management included (i) concern about the anticipative effects of T2D; (ii) wishing to "stay well"; (iii) maintaining independence; (iv) reducing the need for healthcare professionals; and (v) improving quality of life. Six self-management styles were found and pertained to self-managing: (i) through routinisation; (ii) as a burden; (iii) as maintenance; (iv) through delegation; (v) through comanagement; and (vi) through autonomy. Motivators for self-management shaped the criteria people used to judge the success of their self-management practices and influenced their self-management style. The findings show that styles of T2D self-management are mediated and moderated by sociocontextual issues. Healthcare professionals should take these into account when supporting people living with T2D.

Implementation of integrated care for type 2 diabetes: a protocol for mixed methods research

Introduction

While integrated care for diabetes mellitus type 2 has achieved good results in terms of intermediate clinical and process outcomes, the evidence-based knowledge on its implementation is scarce, and insights generalisable to other settings therefore remain limited.

Objective

This study protocol provides a description of the design and methodology of a mixed methods study on the implementation of integrated care for type 2 diabetes. The aim of the proposed research is to investigate the mechanisms by which and the context in which integrated care for type 2 diabetes has been implemented, which outcomes have been achieved and how the context and mechanisms have affected the outcomes.

Methods

This article describes a convergent parallel mixed methods research design, including a systematic literature review on the implementation of integrated care for type 2 diabetes as well as a case study on two Dutch best practices on integrated care for type 2 diabetes.

Discussion

The implementation of integrated care for diabetes type 2 is an under-researched area. Insights from this study could be applied to other settings as well as other chronic conditions to strengthen the evidence on the implementation of integrated care.

Works of Illness and the Challenges of Social Risk and the Specter of Pain in the Lived Experience of TMD

Temporomandibular Disorders (TMD) represent a particular form of chronic pain that, while not outwardly debilitating, profoundly impacts interactions as fundamental to human existence as smiling, laughing, speaking, eating, and intimacy. Our analysis, informed by an expanded "works of illness" assessment, draws attention to work surrounding social and physical risk. We refer to these as the work of stoicism and the work of vigilance and identify double binds created in contexts that call for both. Conflicting authorial stances in informants' narratives are shown to be essential in maintaining a positive identity in the face of illness. While earlier ethnographic studies report TMD sufferers' experience of stigma and search for diagnosis and legitimacy, we present a group of individuals who have accepted diagnosis at face value and soldier through pain as a fundamental aspect of their identity.

Patterns and Stability over Time of Older Adults' Diabetes-related Beliefs

OBJECTIVES

We sought to identify coherent profiles of diabetes beliefs within discrete domains (ie causes, symptoms, consequences, self management, and medical management), and delineate consistency of belief profiles over one month.

METHODS

Diabetes beliefs of rural-dwelling older adults were assessed with the Common Sense Model of Diabetes Inventory at baseline (N = 593) and one month later (N = 563).

RESULTS

A discrete number of belief patterns were identified in each belief domain using latent class analysis. Belief patterns varied by the extent to which more popular or folk notions of diabetes encroached on biomedical understandings of the disease. Belief patterns were generally stable over time.

CONCLUSIONS

A manageable number of belief patterns can be identified and used to strengthen patient-centered care and, potentially, enhance diabetes management.

Dietary beliefs and eating patterns influence metabolic health in type 2 diabetes: A clinic-based study in urban North India

BACKGROUND

Almost 15% of India's urban adult populace now lives with type 2 diabetes. This study aimed to characterize the eating patterns, knowledge, beliefs, and determinants of food choice, and assess associations with the metabolic health among urban Asian Indians with type 2 diabetes.

MATERIALS AND METHODS

A cross-sectional study of 258 individuals (mean age 55.7 ± 10 years; body mass index 27.1 ± 4.8 kg/m(2); diabetes duration 10.1 ± 6.5 years) attending two out-patient clinics in New Delhi, India. Food-related information was collected during a semi-structured interview. Clinical, anthropometric, and biochemical data were recorded.

RESULTS

Beliefs related to health and diabetes played a role determining food choice and dietary patterns; erroneous views were associated with the poor food choices and greater metabolic perturbations. Average consumption of fruits/vegetables was low. Intakes were positively associated with intentions to manage diabetes; inversely associated with the waist circumference and negatively correlated with one's degree of personal responsibility for food choice. Household saturated fat usage was common. High fat intakes were positively associated with the taste preference, ratings of perceived "health-value;" waist circumference, glycosylated haemoglobin percentage (HbA1c%) and lipids.

CONCLUSIONS

Strategies to enhance diabetes control among Asian Indians are required and should encourage fruit/vegetable intake, personal accountability, and consider individual beliefs and preferences. Greater emphasis and resources directed to regular dietary and behavioral counseling may assist.

Living with diabetes on Buffalo, New York's culturally diverse West Side

OBJECTIVES

This study explores the perceptions, attitudes, and beliefs that inform how people live with diabetes in a high poverty, ethnically diverse neighborhood with a growing population of refugees. The specific research objective was to examine participants' explanations of how their diabetes began, understandings about the illness, description of symptoms, as well as physical and emotional reactions to the diagnosis.

METHODS

Qualitative design using semi-structured interviews. The transcripts were analyzed using an immersion-crystallization approach.

RESULTS

Thirty four individuals diagnosed with diabetes for at least 1 year participated. The sample included 14 refugees (from Somalia, Sudan, Burma, or Cuba), eight Puerto Ricans, six non-Hispanic Caucasians, six African-Americans, and two Native Americans. Three broad themes were identified across ethnic groups: (a) the diagnosis of diabetes was unexpected; (b) emotional responses to diabetes were similar to Kubler-Ross's stages of grief; (c) patients' understanding of diabetes focused on symptoms and diet.

CONCLUSIONS

Patients were frequently stunned by the diagnosis of diabetes, and expressed emotions associated with the stages of grief including denial, anger, bargaining, depression, and acceptance. Our findings suggest that clinicians might consider addressing the patients' emotions or grief reaction as an early priority to promote acceptance as a first step to self-management.

Stress and diabetes in socioeconomic context: a qualitative study of urban Indians

Type 2 diabetes has escalated in urban India in the past two decades. Historically a disease of the affluent, recent epidemiological evidence indicates rising diabetes incidence and prevalence in urban India's middle class and working poor. Although there is substantial qualitative data about people with diabetes from high-income countries, scant resources provide insight into diabetes experiences among those in India, and lower-income groups specifically. In this article, we use individual-level analysis of illness narratives to understand how people experience and understand diabetes across income groups in Delhi, India. We conducted in-depth qualitative interviews and administered the Hopkins Symptoms Check-List (HSCL-25) to evaluate depression among 59 people with diabetes in northeast Delhi between December 2011 and February 2012. We analyzed their responses to: 1) what caused your diabetes?; 2) what do you find most stressful in your daily life?; and 3) where do you seek diabetes care? We found few people held diabetes beliefs that were congruent with socio-spiritual or biomedical explanatory models, and higher income participants commonly cited "tension" as a contributor to diabetes. Stress associated with children's futures, financial security, and family dynamics were most commonly reported, but how these subjective stresses were realized in people's lives varied across income groups. Depression was most common among the poorest income group (55%) but was also reported among middle- (38%) and high-income (29%) participants. One-quarter of respondents reported diabetes distress, but only those from the low-income community reported co-occurring depression and these respondents often revealed poor access to diabetes care. These data suggest that lower-income populations not only have higher rates of depression but also may be more likely to delay health care and therefore develop diabetes complications. This research has many implications for public health care in India as diabetes prevalence shifts to affect lower income groups who concurrently experience higher rates of depression and poorer access to medical care.

Diabetes and Culture

Diabetes and its many manifestations articulate well with the four-field approach in anthropology, providing an almost seamless example of the relationship between human biology, behavior, society, and culture in both the past and the present tense. In general, publications on diabetes and culture echo Enlightenment philosophies on change and progress that posit the increasing prevalence of diabetes as a “crisis in human relations” ( Bendix 1967 , p. 302) for which culture plays a significant role. The undermining of racial approaches due to what now appears to be diabetes-without-borders has also directed anthropological research into the contingent temporal frameworks of history. The recent attention to society and the social production of the disease may portend the end of culture in research on diabetes and culture.

Explanatory models of diabetes in the U.S. and Mexico: the patient-provider gap and cultural competence

Successful management of type 2 diabetes requires support and collaboration between diabetic patients, their health care providers, family and community. Using data collected in 1994-2001, we describe illness beliefs of physicians, patients, and representative samples of community members in the US and Mexico. We test whether differences in conceptualizations of diabetes are greater across national and linguistic boundaries or between physicians and lay groups. Interviews were conducted in southern Texas on the Mexican border and in Guadalajara, Mexico. Culturally appropriate interview materials were developed with a mixed-methods approach. Qualitative interviews elicited beliefs about causes, risks, symptoms, and treatments for diabetes and salient themes were incorporated into structured interviews. A cultural consensus analysis was used to verify salient themes within each of the six samples. The consistency in responses in each of the six samples indicated a shared core of beliefs that transcended individual variations. The greatest differences occurred between physician and lay samples; patient and community models were more similar to one another than to the physician models. Differences between physicians and patients may affect optimal management of diabetes, but these differences do not appear to be simply a function of differences in national culture and language, as the largest differences occurred in Mexico. This suggests that rather than cultural competence per se, formal educational levels and class differences may also play an important role in patient understanding and the gap in patient-provider understanding.

Beyond beliefs: risk assessment technologies shaping patients' experiences of heart disease prevention

Social science research on lifestyle-related diseases typically focuses on patients' understandings and beliefs and takes the clinical risk for granted. We interviewed 30 healthy UK patients at high risk of heart disease, recruited from a family history trial at 2 weeks and 6 months after a discussion with a clinician about their risk, lifestyle and medications. The participants took four different paths: (i) pharmaceutical (most common, risk reduction with cholesterol lowering statins), (ii) mixed (statins and behaviour change), (iii) behavioural (behaviour change, focus on wellbeing) and (iv) 'lost' (no prevention, difficult social/personal circumstances). Drawing on Berg we argue that coronary heart disease (CHD) risk assessment technologies are formal tools that generate, rather than represent, high risk in a way that patients often experience lifestyle change as futile, because it rarely reduces their cholesterol to targets defined by the tools. We suggest social scientists studying incipient or 'proto-diseases', such as CHD risk, should not only focus on understandings but also investigate the technologies (and the associated guidelines, policies, clinical practice and pharmaceutical industry operations) that generate incipient diseases and patients' experiences of them. However, technologies do not determine experience and we also discuss elements that direct patients down other than the pharmaceutical path.

Pushing the envelope for cultural appropriateness: does evidence support cultural tailoring in type 2 diabetes interventions for Mexican American adults?

PURPOSE

This study explores the potential utility of a culturally tailored diabetes management intervention approach by testing associations between acculturation and diabetes-related beliefs among Mexican-American adults with type 2 diabetes.

METHODS

Data from 288 Mexican-American adults with type 2 diabetes were obtained via a bilingual, telephone-administered survey. Participants were drawn from a stratified, random sample designed to obtain maximum variability in acculturation. The survey assessed diabetes-related beliefs, intervention preferences, and the following three acculturation constructs from the Hazuda acculturation and assimilation scales: Spanish use, value for preserving Mexican culture, and interaction with Mexican Americans.

RESULTS

Only one outcome-preference for a program for Mexican Americans-was associated with all three acculturation variables. Spanish use was positively associated with belief in susto as a cause of diabetes, preference for expert-driven health guidance, and involvement of others in taking care of diabetes. Value for preserving Mexican culture was related to a more holistic view of health, as evidenced by an increased likelihood of consulting a curandero, use of prayer, and interest in a diabetes program with religious content. Value for cultural preservation was also related to higher suspicion of free diabetes programs. Interaction with Mexican Americans was associated with a belief that insulin causes blindness.

CONCLUSION

Findings from this study suggest distinct relationships between acculturation constructs and diabetes-related beliefs and preferences, thus arguing against the use of a single acculturation construct to determine diabetes intervention design. Cultural tailoring may enhance the cultural appropriateness and ultimate effectiveness of diabetes interventions for Mexican American adults.

Aspectos da identidade na experiência da deficiência física: um olhar socioantropológico

O artigo analisa a experiência da deficiência física enfocando a identidade das pessoas, discutindo-a pelas categorias "ser e sentir-se deficiente" e "estigma", balizadas pelo autoconceito como construção sociocultural, atualizadas cotidianamente e inscritas em uma trajetória singular. Trata-se de pesquisa qualitativa de cunho socioantropológico fundamentada na fenomenologia. Foram entrevistados oito homens e cinco mulheres com deficiência física adquirida, guiando-se por roteiro semiestruturado, cujos dados foram submetidos à análise temática. Ser e sentir-se deficiente comporta uma ambiguidade diante do conceito reducionista que orienta o sistema legitimador dessa condição, confrontado com um significado mais englobante expresso no desempenho cotidiano. Reafirma-se a identidade como autoconceito (re)construído nas interações subjetivas e intersubjetivas, não descolada de uma biografia histórica, cultural e socialmente contextualizada.

Illness Beliefs Regarding the Causes of Diabetes among Latino College Students

This study examined the validity of the Klonoff and Landrine (1994) illness-belief scale when applied to Latino college students (n=156; 34% male, 66% female) at high-risk for future diabetes onset. Principal factor analysis yielded four significant factors - emotional, folk-beliefs, punitive, gene/hereditary - which accounted for 64.5% of variance and provided a culturally-relevant Latino perspective of the causes of diabetes. Additional analyses by age, gender, immigrant status and psychological acculturation revealed significant differences by age on the emotional and folk illness factors and a negative correlation between assimilation and endorsement of the emotional factor. The implication of these four illness factors for predicting health-related behaviors and health-outcomes among young Latinos was discussed as were recommendations for future research.

Subjective control and health among Mexican-origin elders in Mexico and the United States: structural considerations in comparative research

OBJECTIVES

This study examines the joint impact of psychological and structural factors on Mexican and Mexican American elders' sense of personal control over important aspects of their lives and health in Mexico and the United States.

METHODS

We employ the Mexican Health and Aging Study (MHAS) and the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) to explore patterns of association among structural factors, personal characteristics, indicators of material and physical vulnerability, and expressed locus of control.

RESULTS

The results suggest that an older individual's sense of personal control over important aspects of his or her life, including health, reflects real material and social resources in addition to individual predispositions. In Mexico, only the most privileged segment of the population has health insurance, and coverage increases one's sense of personal control. In the United States, on the other hand, Medicare guarantees basic coverage to the vast majority of Mexican Americans over 65, reducing its impact on one's sense of control.

DISCUSSION

Psychological characteristics affect older individuals' sense of personal control over aspects of their health, but the effects are mediated by the economic and health services context in which they are expressed.

Assessing Diabetes Dietary Goals and Self-Management Based on In-Depth Interviews With Latino and Caucasian Clients With Type 2 Diabetes

Latino ( n = 10) and Caucasian ( n = 8) clients with type 2 diabetes receiving care at a community health clinic participated in individual in-depth interviews assessing diabetes dietary self-management goal behaviors. Themes from interviews were identified using content analysis, which revealed current and future goals, influencing factors, and motivators and barriers to dietary modification for diabetes management. Implications for practice include simplifying goal setting to those goals with the greatest potential clinical impact or the greatest significance to the patient, in a socially supportive environment. Results contribute to future survey development and understanding how to optimize diabetes education for these populations.

Cultural values and political economic contexts of diabetes among low-income Mexican Americans

PURPOSE

To explore the political and economic dimensions of diabetes self-management for Mexican American adults.

DESIGN

Critical ethnographic analysis of focus group data from caregivers and adults with diabetes.

FINDINGS

Three themes were identified: diabetes self-management is tied to other mental and bodily states, family and neighborhood environments cause stress and prevent diabetes solutions, and hassles of the health care environment subvert self-management.

DISCUSSION

Cultural constructs about diabetes merge with social-political forces in explaining diabetes.

IMPLICATIONS

Cultural competence in diabetes care requires attention to the political economy of the disease and advocacy for healthful political and economic change.

"Worried all the time'': distress and the circumstances of everyday life among immigrant Australians with type 2 diabetes

People with diabetes commonly experience emotional distress and are often diagnosed with depression. To explore lay accounts of the conditions and social aspects of their co-occurrence, we draw on qualitative research conducted in metropolitan Melbourne, Australia. Data derive from in-depth interviews with men and women from Greek, Chinese, Indian and Pacific Island communities, all of which have a higher than average incidence of type 2 diabetes mellitus. Participants generally saw stress as a precursor to diabetes, influencing their ability to control symptoms. Yet they also emphasized that life adversities, trauma, disruption, and multiple losses caused distress and depression. Participants regarded diabetes as an illness that interrupted their ability to carry out everyday living tasks. This contributed to their social isolation and unsettled self-identity, resulting in feelings of personal inadequacy, loss and further distress. These themes were common across immigrant groups.

Diabetes self-care among a multiethnic sample of older adults

Type 2 diabetes constitutes a leading and increasing cause of morbidity and mortality among older adults, particularly African Americans, Native Americans, Mexican Americans, and rural dwellers. To understand diabetes self-care, an essential determinant of diabetic and overall health outcomes, 80 middle aged and older adults from these four disproportionately affected racial/ethnic/residential groups engaged in in-depth interviews, focusing on approaches to and explanations for diabetes self-care. Certain self-care activities (medication-taking, diet, foot care) were performed regularly while others (blood glucose monitoring, exercise) were practiced less frequently. Despite research suggestions to the contrary, only one in four elders used unconventional diabetes therapies, and only one-third listed someone other than a health care provider as a primary information source. Few self-care differences emerged according to race/ethnicity/residence, perhaps because of the influential and common circumstance of low income. Thematic analyses suggest that inadequate resources, perceived efficacy of medication, great respect for biomedical authority, and lack of familiarity with and concerns about unconventional therapies are influential in establishing these patterns of self-care. We discuss the similarity of self-care practices and perspectives irrespective of race/ethnicity/residence and the predominance of biomedical acceptability.

Positive experiences of type 2 diabetes in Japanese patients: An exploratory qualitative study

BACKGROUND

Previous research on self-management in people with diabetes mellitus mostly focused on the negative aspects of the disease, such as depression, lack of support, and psychological stress.

OBJECTIVES

The purpose of this study was to explore the existence of positive experiences in people with type 2 diabetes. 'Positive experience' is operationally defined as positive thoughts or good feelings in coping with diabetes expressed by the participants.

DESIGN

An exploratory qualitative design using constant comparative method.

METHOD

Convenience sampling was used to recruit participants receiving care in two hospitals in Kansai area, Japan. The following eligibility criteria were used: (1) individuals diagnosed with type 2 diabetes; (2) individuals capable of conversing in Japanese; and (3) individuals receiving care at either setting. Data collection and data analysis were conducted concurrently. Each verbatim transcript was read several times, and the data were coded line by line. Codes were constantly compared with each other for similarity and dissimilarity and were grouped to form categories.

RESULTS

Ten patients from the outpatient department and seven patients from the inpatient education program were interviewed between June and December in 2002. All the participants expressed positive experience in coping with diabetes. Three categories emerged from repeated coding: (1) positive appraisal; (2) diversion; and (3) bonding.

CONCLUSION

A tentative model of coping from the patient's perspective was proposed for a future research. Asking the patient about positive experience with their illness is important to elicit positive thoughts and experience.

Ethnic differences in outcomes of diabetes care and the role of self-management behavior

OBJECTIVE

Ethnic differences in outcomes of outpatient diabetic care and the role of self-management behavior and its determinants in explaining observed differences.

METHODS

Face-to-face interviews were held with 102 Turkish or Moroccan, and 102 native Dutch diabetic patients to measure self-management behavior and determinants of self-management (as derived from the Attitudes-Social support self-Efficacy model, and Personal Models and Barriers). A medical record review was conducted to measure ethnic differences in outcomes of diabetes care. Data were analyzed using multiple linear regression.

RESULTS

Outcomes differed significantly with ethnic minorities having higher levels of lipids (risk difference=RD=0.7%; CI: 0.3-1.2) and HbA1c (RD=0.9%; CI: 0.4-1.4) than native Dutch patients. Differences in self-management could not explain the ethnic differences in outcomes. Self-efficacy explained 18% of the ethnic differences in HbA1c. Beliefs about seriousness of diabetes and social support regarding diabetes management together explained 47% of the ethnic differences in lipids.

CONCLUSION

This study provides evidence for ethnic differences in outcomes of diabetes care. Self-efficacy is the most important determinant in explaining the differences in HbA1c.

PRACTICE IMPLICATIONS

For diabetes practice this suggests that strengthening patients' self-efficacy may improve the control of HbA1c and may result in a decrease of ethnic differences. The relationship between behavioral determinants like seriousness and social support and outcomes of diabetes care was differential by ethnic group, implying that caution is required when applying behavioral models to different ethnic groups.

Disparities in A1C levels between Hispanic and non-Hispanic white adults with diabetes: a meta-analysis

OBJECTIVE

Hispanics have higher rates of diabetes and diabetes-related complications than do non-Hispanic whites. A meta-analysis was conducted to estimate the difference between the mean values of A1C for these two groups.

RESEARCH DESIGN AND METHODS

We executed a PubMed search of articles published from 1993 through July 2007. Data sources included PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for Hispanics and non-Hispanic whites with diabetes were included. Studies were excluded if they included individuals <18 years of age or patients with pre-diabetes or gestational diabetes.

RESULTS

A total of 495 studies were reviewed, of which 73 contained data on A1C for Hispanics and non-Hispanic whites, and 11 met the inclusion criteria. Meta-analysis revealed a statistically significant mean difference (P < 0.0001) of -0.46 (95% CI -0.63 to -0.33), correlating to an approximately 0.5% higher A1C for Hispanics. Grouping studies by design (cross-sectional or cohort), method of data collection for A1C (chart review or blood sampling), and care type (managed or nonmanaged) yielded similar results.

CONCLUSIONS

In this meta-analysis, A1C was approximately 0.5% higher in Hispanic patients with diabetes than in non-Hispanic patients. Understanding the reasons for this disparity should be a focus for future research.

Hispanic adults? beliefs about type 2 diabetes: Clinical implications

PURPOSE

This integrative literature review focused on Hispanic adults' beliefs about type 2 diabetes. Type 2 diabetes is a progressive, chronic illness with the potential for debilitating complications that disproportionately affect Hispanic adults. By understanding Hispanic adults' beliefs about type 2 diabetes, health professionals will be able to offer more culturally competent health care.

DATA SOURCES

Published research reports on Hispanic adults' beliefs about type 2 diabetes were obtained using multiple computerized databases and by searching reference lists of published reports. A total of 15 research reports comprised this review.

CONCLUSION

While there was some variance among Hispanic subgroups, in general, Hispanic adults' understanding of the etiology of diabetes was an integration of biomedical causes such as heredity and traditional or folk beliefs such as susto, which is the concept of strong emotions. Hispanic adults believed that diabetes is a serious illness and that they could identify many of the symptoms of diabetes. They identified both biomedical and herbal treatments for diabetes. Negative attitudes toward insulin were common. Religious beliefs also factored into Hispanic adult's explanatory models of type 2 diabetes.

IMPLICATIONS FOR PRACTICE

Hispanic adults have a fairly cohesive explanatory model of diabetes. Healthcare professionals can use this information as a starting point to discuss each individual patient's explanatory model of illness, clarify misconceptions, and develop an individualized plan of care.

Contextualising accounts of illness: notions of responsibility and blame in white and South Asian respondents' accounts of diabetes causation

We undertook a secondary analysis of in-depth interviews with white (n = 32) and Pakistani and Indian (n = 32) respondents who had type 2 diabetes, which explored their perceptions and understandings of disease causation. We observed subtle, but important, differences in the ways in which these respondent groups attributed responsibility and blame for developing the disease. Whereas Pakistani and Indian respondents tended to externalise responsibility, highlighting their life circumstances in general and/or their experiences of migrating to Britain in accounting for their diabetes (or the behaviours they saw as giving rise to it), white respondents, by contrast, tended to emphasise the role of their own lifestyle 'choices' and 'personal failings'. In seeking to understand these differences, we argue for a conceptual and analytical approach which embraces both micro- (i.e. everyday) and macro- (i.e. cultural) contextual factors and experiences. In so doing, we provide a critique of social scientific studies of lay accounts/understandings of health and illness. We suggest that greater attention needs to be paid to the research encounter (that is, to who is looking at whom and in what circumstances) to understand the different kinds of contexts researchers have highlighted in presenting and interpreting their data.

“Diabetes is my companion”: Lifestyle and self-management among good and poor control Mexican diabetic patients

This paper identifies naturally occurring lifestyle and self-care practices in managing type 2 diabetes mellitus that are associated with good glycemic control. In-depth, qualitative interviews were conducted in Guadalajara, Mexico, with 31 matched pairs of good and poor control diabetic patients (n=62), who were matched on their duration of disease and use of medications. While many themes were listed by both groups, a comparison of the responses indicated that themes of daily exercise with a preference for walking, eating beef and milk rather than chicken and fish, economic issues, and emotional issues distinguished poor-control patients. Good-control patients were more likely to have a negative reaction to their initial diagnosis, take a more comprehensive approach to control, eat only two meals a day (plus snacks), use noncaloric beverages to satisfy desires for more food, and know what their blood sugar levels should be.

Sociodemographic factors and self-management practices related to type 2 diabetes among Hispanics and non-Hispanic whites in a rural setting

CONTEXT

Hispanics in the United States have a higher prevalence of non-insulin-dependent diabetes mellitus (type 2 diabetes) and experience more complications for the disease than non-Hispanic whites. Differences in medical management or self-management practices may, in part, explain the relative high risk for diabetes complications among Hispanics.

PURPOSE

Using data from a community-randomized intervention study on cancer prevention, we examined the medical management and self-management practices of Hispanics and non-Hispanic whites who have diabetes.

METHODS

Locally hired bilingual personnel conducted in-person interviews of a random selection of 1,863 adults in 20 communities in the Yakima Valley of eastern Washington State.

FINDINGS

A total of 70 Hispanics (11% age-adjusted prevalence) and 87 non-Hispanic whites (7.3% age-adjusted prevalence) reported having type 2 diabetes. Hispanics with a high level of acculturation were slightly more likely to have diabetes, compared to those with a low level of acculturation, though the association was nonsignificant. Hispanics were significantly less likely than non-Hispanic whites to treat their diabetes with diet and exercise (36% vs 61.3%; P < or = .001). Annual eye examinations were less commonly reported among Hispanics (48.9%) than among non-Hispanic whites (72.7%).

CONCLUSIONS

Our data indicate that Hispanics engage less frequently in self-management practices to control diabetes than non-Hispanic whites.

“We are out of balance here”: a Hmong Cultural Model of Diabetes

A Hmong cultural model of type 2 diabetes has not been described. We analyzed 20 group discussions during 21 group visits over 1 year with 39 Hmong adults with type 2 diabetes in order to describe a model that underlines their discussions. These Hmong adults attribute their diabetes to their refugee experience. They do not fit with the food, activity, weather, or community in the United States. Consuming sugar, salt, fat, and chemicals and then not sweating them out of the body, combined with emotional losses of being refugees, the participants feel they are out of balance. And being out of balance, they develop diabetes. The participants interpret biomedical information, community experiences, and personal sensations of diabetes in terms of a traditional health model of balance and in the context of refugee loss of place. Throughout their discussions, the shared suffering of their personal experiences of diabetes was evident. This cultural model may help providers implement diabetes treatment and prevention programs.

Vulnerable Populations with Diabetes Mellitus

This review of the literature on vulnerable populations with diabetes identifies trends, summarizes major findings, and recommends strategies to fill gaps in the state of the science. For the purposes of this article "vulnerable populations" refers to members of diverse racial and ethnic groups, people of low-income, and those who live in rural and medically underserved areas.

Understanding patient experiences with goal setting for diabetes self-management after diabetes education

Diabetes educators need to understand self-care experiences of patients with diabetes in the early stage after diagnosis and education. A survey assessed patient-generated measures of experiences with goals (self-care behaviors) after diabetes education among patients with type 2 diabetes (N = 97) between 6 months and 1.5 years since diagnosis. Most patients set goals during diabetes education and thought that the goals were useful. There is evidence suggesting that patients experiencing difficulty with traditional self-care behaviors may use approaches to evaluate their diabetes control that are not encouraged in diabetes education, such as monitoring their physical and emotional feelings. Implications for diabetes education and counseling practices are suggested.

Idiosyncratic personal explanations for blood glucose events are associated with poorer self-management and glycemic control in adult patients with long-standing type 1 diabetes

OBJECTIVE

To examine whether spontaneous causal attributions for blood glucose events were associated with blood glucose control (HbA(1c) [A1C]), self-management, and adjustment to diabetes.

RESEARCH DESIGN AND METHODS

A total of 62 adults (31 female) with type 1 diabetes, recruited from a diabetes specialist clinic, with a mean age of 42.3 years and a mean illness duration of 19.6 years, were interviewed about the onset, history, course, and management of their diabetes. Spontaneous causal attributions for fluctuations in blood glucose level were extracted from the interviews and coded in accordance with the Leeds Attributional Coding System. Participants completed questionnaire measures of anxiety, depression, and appraisal of diabetes. Glycemic control (A1C) at the time of interview and 1 year later was extracted from notes.

RESULTS

Participants who made proportionally more personal, or idiosyncratic, explanations for blood glucose fluctuations or events (such as hypoglycemic episodes) had higher A1C levels at time 1 and 1 year later and were judged to manage their diabetes less well. Furthermore, the association between personal attributions and A1C was partly accounted for by self-management behavior. Participants who made personal and stable attributions appraised their diabetes more negatively.

CONCLUSIONS

Clinicians should be sensitive to patients' causal explanations for blood glucose events. Helping patients consider alternative explanations may produce benefits in terms of better management and control of diabetes.

Our lives were healthier before: focus groups with African American, American Indian, Hispanic/Latino, and Hmong people with diabetes

Focus groups were conducted to explore health-related beliefs and experiences of African American, Hispanic/Latino, American Indian, and Hmong people with diabetes and engage community members in improving diabetes care and education for these populations. Eighty participants attended 12 focus groups, 3 per population. Major themes were loss of health attributed to modern American lifestyles, lack of confidence in the medical system, and the importance of spirituality. Participants recommended improvements in the areas of health care, diabetes education, social support, and community action. Their recommendations emphasize the importance of respectful, knowledgeable health care providers; culturally responsive diabetes education for people with diabetes and their families; and broad-based community action. These recommendations align with current public health priorities and medical knowledge. It is proposed that healthy traditions from diverse populations can be leveraged to improve the health of all people with diabetes.

'I can't do any serious exercise': barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 diabetes

Type 2 diabetes is at least 4 times more common among British South Asians than in the general population. South Asians also have a higher risk of diabetic complications, a situation which has been linked to low levels of physical activity observed amongst this group. Little is known about the factors and considerations which prohibit and/or facilitate physical activity amongst South Asians. This qualitative study explored Pakistani (n = 23) and Indian (n = 9) patients' perceptions and experiences of undertaking physical activity as part of their diabetes care. Although respondents reported an awareness of the need to undertake physical activity, few had put this lifestyle advice into practice. For many, practical considerations, such as lack of time, were interwoven with cultural norms and social expectations. Whilst respondents reported health problems which could make physical activity difficult, these were reinforced by their perceptions and understandings of their diabetes, and its impact upon their future health. Education may play a role in physical activity promotion; however, health promoters may need to work with, rather than against, cultural norms and individual perceptions. We recommend a realistic and culturally sensitive approach, which identifies and capitalizes on the kinds of activities patients already do in their everyday lives.