"Give me some sugar!" the diabetes self-management activities of African-American primary caregiving grandmothers

An act of political warfare: Self-care prioritization strategies of older African-American women with type 2 diabetes

Type 2 diabetes mellitus (diabetes) is the eighth leading cause of death in the United States. Diabetes disproportionately affects older adults and people of color. For older African American women, diabetes is considered a public health crisis. African American women 55 and older face higher mortality rates and more severe diabetes-related complications compared to their White counterparts. Secondary conditions such as cardiovascular disease, stroke, dementia, diabetic neuropathy, amputations, renal failure and blindness provide further complications to what is considered a major health challenge in the African American community. Self-management strategies are key to optimizing health outcomes for diabetes; however, in general, prioritizing self-care has been especially difficult for women given their adherence to cultural scripts that dictate prioritization of other-care over self-care. This paper presents selected narratives of Black women from a large qualitative study funded by the National Institute on Aging, which examined the diabetes management strategies of older adults residing in an urban area of the mid-Atlantic region of the U.S. The Black women selected for this analysis, have chosen to prioritize the self in the face of competing responsibilities, and by doing so display active resistance to the traditional gender expectations imposed upon women in American culture. We use Black Feminist Perspective to center and contextualize the variation in health experiences of Black women in our sample. For healthcare providers it is important to understand the experiences of African American women and the social forces which influence - hinder and support - their strategies for prioritizing health.

SISTER (Sisters Inspiring Sisters to Engage in Relevant Diabetes Self-Care) Diabetes Study: Protocol for diabetes medical nutrition therapy randomized clinical trial among African American women

BACKGROUND

African American (AA) women with type 2 diabetes (T2D) carry disproportionate diabetes-related morbidity and mortality burdens. Diabetes medical nutrition therapy (MNT) improves glycemic, blood pressure, and cholesterol control, all critical in preventing and reducing diabetes complications. Yet, MNT does not address low motivation for dietary intake management, which is frequently reported among AA women with T2D living in the Southeastern US.

METHODS

A randomized controlled trial will be used to test the central hypothesis that diabetes MNT plus culturally-tailored motivational interviewing (MI) (diabetes MNT plus MI) is more effective than diabetes MNT alone (diabetes MNT). Two hundred ninety-one Southeastern AA women who are at risk for development and/or progression of T2D complications will be randomized to diabetes MNT plus MI or diabetes MNT. Both groups will include: 1) a 3-month active intervention period, consisting of group-based, nutritionist-facilitated MNT sessions; 2) a 3-month maintenance intervention period, including one group-based, nutritionist-facilitated maintenance support session; and 3) a 6-month inactive period. Culturally-adapted MI exercises will be integrated into the diabetes MNT plus MI group only. Primary (HbA1c) and secondary (systolic blood pressure, LDL cholesterol) outcomes will be assessed at baseline and 3, 6, and 12 months following the active intervention period.

DISCUSSION

The results from this study, called the SISTER (Sisters Inspiring Sisters to Engage in Relevant Diabetes Self-Care) Diabetes Study, are vital to the adoption and uptake of rigorously-tested MNT interventions that address motivation among AA women with T2D as a way to reduce their risk and/or progression of diabetes-related complications.

Caring in the recruitment of older African American adults with chronic health disease: An integrative review

OBJECTIVES

The aim of this integrative review is to accrue a comprehensive understanding of caring behavioral characteristics in the recruitment of older African-American adults into health-related research studies centered on chronic diseases.

METHODS

Combined methodologies, Whittemore & Knafl and Kable, Pich & Maslin-Prothero in accordance with preferred items for systematic reviews and meta-analysis, were used to guide the data collection and to report the findings. The data were analyzed based upon recruitment categorization and Kristen Swanson's middle-range theory of caring.

RESULTS

Ten out of 260 publications comprised the final sample. They were analyzed and then aggregated by chronic illnesses, recruitment activities, contact level, and Swanson's five caring behavioral concepts. Select cancers, diabetes, hypertension, and Alzheimer's disease were the chronic illness foci of eight publications. Cardiovascular disease and stroke were the focus of two publications. Only three studies utilized all five Swanson's caring concepts, and the frequently used concept throughout all 10 studies was enabling.

DISCUSSION

Recruitment approaches employed to accrue older African-American adults into chronic illness-related research studies necessitate proactive recruitment strategies that incorporate caring behaviors. Future researchers ought to develop multi-modality recruitment strategies to improve older African-American adults' representation.

Physical and Psychological Health of African American Women Caregivers: Unmasking the Paradox

Existing evidence consistently shows that African American (AA) caregivers experience a health paradox; participants of AA ethnicity have commonly reported having worse physical health but better mental health related to caregiver burden when compared to other racial groups. However, inconsistencies exist in the literature regarding mental health outcomes for this population. In order to provide culturally appropriate, health-promoting interventions, it is imperative to identify accurately the impact of caregiving burden on the mental health of AAs. Fifteen reports of research on the influence of caregiver burden on health were reviewed to evaluate the legitimacy of the paradox (that may be better explained by the term, 'masking'). The appropriateness of two stress process models and the adequacy of comparative research versus culturally-focused studies for AA women caregivers were examined also.

The Relationships Between Diabetes Self-Care, Diabetes Time Management, and Diabetes Distress in Women With Type 2 Diabetes Mellitus

PURPOSE

The purpose of this study was to examine the relationships between and among diabetes self-care, diabetes time management, and diabetes distress in women with type 2 diabetes mellitus (T2DM).

METHODS

A descriptive correlational design with a total of 188 participants completed 3 valid and reliable instruments to measure the main study variables, the Diabetes Self-Management Questionnaire, the Diabetes Time Management Questionnaire, and the Diabetes Distress Scale, in an uncontrolled, natural setting using mix-mode surveys (electronic and paper). Survey responses were analyzed using several descriptive, bivariate, and multivariate analyses.

RESULTS

Diabetes time management was the strongest, statistically significant, unique contributor to explaining self-care. The regression model showed that diabetes time management demonstrated a large effect size and that diabetes distress demonstrated a small effect size.

CONCLUSIONS

The 2 predictor variables among diabetes self-care in women showed diabetes time management had a stronger effect size compared to diabetes distress. This is the first known study to measure the influence of diabetes time management on diabetes self-care and to examine the relationship between and among diabetes time management and diabetes distress. Diabetes time management, an understudied variable in individuals with T2DM, has the potential to be a contributor to improve patient outcomes.

Caregiver Status and Diet Quality in Community-Dwelling Adults

Objective: We investigated cross-sectional and longitudinal associations of diet quality with middle-aged caregiver status. Methods: Caregiving in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study (57.7% women, 62% African American (AA)) was measured at waves 3 (2009–2013) and 4 (2013–2017) (mean follow-up time 4.1 years). Diet quality was assessed by the Healthy Eating Index 2010 (HEI-2010) derived from two separate 24 h diet recalls. Multivariable ordinary least square regression was performed for cross-sectional analyses of the association of wave 4 caregiving with wave 4 HEI-2010. Wave 3 caregiving was examined both cross-sectionally and with annual rate of change in HEI using mixed-effects linear regression Models. Multivariable models were adjusted for age, sex, and poverty status. Results: Cross-sectional analyses at wave 4 demonstrate an inverse association of frequent caregiving (“Daily or Weekly” vs. “Never”) for grandchildren with HEI-2010 total score (i.e., lower diet quality) among Whites (β = −2.83 ± 1.19, p = 0.03, Model 2) and AAs (β = −1.84 ± 0.79, p = 0.02,). The “cross-sectional” analysis pertaining to grandchildren caregiving frequency suggested that frequent caregiving (i.e., “Daily or Weekly” vs. “Never” (β = −2.90 ± 1.17, p = 0.04)) only among Whites was inversely related to HEI-2010 total score. Total HEI-2010 score was also related to caring (Model 1), for the elderly over “5 years vs. Never” among Whites (−7.31 ± 3.54, p = 0.04, Model 2). Longitudinally, we found slight potential improvement in diet quality over time (“Daily or Weekly” vs. Never by TIME interaction: +0.88 ± 0.38, p = 0.02) with frequent caregiving among Whites, but not so among AAs. Conclusions: Frequent caring for grandchildren had an inverse relationship with the diet quality of White and AA urban middle-aged caregivers, while caring for elderly was inversely linked to diet quality among Whites only. Longitudinal studies should address the paucity of research on caregivers’ nutritional quality.

Health literacy enhanced intervention for inner-city African Americans with uncontrolled diabetes: a pilot study

Background

Disparities in diagnosis and control of type 2 diabetes mellitus are most evident in African Americans (AAs) with lower socioeconomic status. Health literacy is an important predictor of adequate self-management and control of diabetes. The purpose of this pilot study was to test the feasibility and preliminary efficacy of a health literacy-enhanced diabetes intervention, PLAN 4 Success (Prevention through Lifestyle intervention And Numeracy)-Diabetes, in inner-city, low-income AAs with uncontrolled type 2 diabetes.

Methods

Nineteen of 30 participants who completed the baseline survey received the study intervention which consisted of 4-week health literacy training and disease knowledge education followed by two home visits and monthly phone counseling for over 24 weeks.

Results

A retention rate of 58% was achieved at 24 weeks. All participants who completed the follow-up assessment at 24 weeks reported high satisfaction with the intervention. Participation in the PLAN 4 Success-Diabetes was associated with improved glucose control and psychological outcomes at 12 weeks but the positive trend was attenuated at 24 weeks.

Conclusions

The current intervention protocols were in general feasible and highly acceptable. The results support health literacy training as a promising component of interventions to promote glucose control among inner-city AAs. Some changes are suggested to optimize the protocols, before conducting a randomized controlled trial. Future interventions should consider addressing social determinants of health such as transportation as part of designing an intervention targeting low-income AAs with uncontrolled type 2 diabetes.

Trial registration

ClinicalTrials.gov, NCT03925948. Registered on 24 April 2019—retrospectively registered.

Factors Influencing Diabetes Self-Management Among Medically Underserved Patients With Type II Diabetes

In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.

The Diabetic Health of African American Grandmothers Raising their Grandchildren

PURPOSE

The purpose of this study is to compare the health of primary caregiving African American grandmothers with diabetes with African American women with diabetes who were not primary caregivers.

DESIGN

Using a comparative, descriptive, cross-sectional design, 34 African American primary caregiving grandmothers were compared with 34 non-caregiving women with diabetes mellitus; women aged 55-75 years were recruited for this study throughout the central Arkansas.

METHODS

To measure the overall health, data on blood pressure, body mass index measurements, HbA1c levels, total cholesterol, and urine protein and creatinine levels were collected from all the participants.

RESULTS

Statistically significant differences between the caregivers and non-caregivers groups in systolic pressure (t = -3.42, P = 0.001) and diastolic pressure (t = -3.790, P = 0.000) and urine protein (W = 294.00, P = 0.000) were noted. Additionally, a clinically significant difference in HbA1c was noted between groups.

CONCLUSION

Differences in systolic and diastolic pressures, urine protein, and clinically significant differences in HbA1c suggest that African American primary caregiving grandmothers with diabetes mellitus may have more difficulty in maintaining their diabetic health than non-caregiving African American women.

Chronic Pain in Older African American Grandparent Caregivers

African American grandparent caregiving is increasing, and evidence shows that grandparent caregiving influences health and its management. As older adults age, their potential of experiencing chronic pain increases, and this is profound given that physiological research shows that African Americans, aside from aging, may have a predisposition for developing chronic pain. Research shows older African Americans experience significant chronic pain, but few have discussed the implications of managing chronic pain in older African Americans who have added parental responsibility. Many older African Americans receive home healthcare services and there is a unique role for home healthcare clinicians in caring for this vulnerable population. This article discusses the impact of pain on caregiving, challenges in pain management, and practice and policy implications to assist home healthcare clinicians maintain the safety and protection of both the older grandparent and grandchildren.

Adaptive Challenges Rising from the Life Context of African-American Caregiving Grandmothers with Diabetes: A Pilot Study

To understand the challenges arising from the context within which diabetic African-American caregiving grandmothers self-manage their diabetes we used the Adaptive Leadership Framework. Additionally, challenges to retaining this population in a longitudinal study were examined. In this exploratory, longitudinal, qualitative pilot study, data were collected at five time-points over 18 months. We coded the data using content analysis and conducted the within-case and cross-case analyses using data matrices. Lack of awareness of available resources, represented a technical challenge within the life context of these grandmothers and the remaining three themes: family upheaval; priority setting (with subthemes of difficulty meeting basic needs and competing demands); and self-silencing and self-sacrifice represented adaptive challenges. The context of African-American grandmothers’ lives created primarily adaptive challenges that were complex and without immediate solutions. Research is needed to develop culturally and contextually appropriate interventions to help this vulnerable group develop capacity for adaptive work.

Renal Disease Risk Factors Among Risk Groups Comprised of African American Women With Type 2 Diabetes: A Secondary Analysis

PURPOSE

The purpose of this study was to explore and describe the prevalence of renal disease risk factors and the categorization of renal disease risk groups among African American women with type 2 diabetes mellitus (T2DM) who participated in a self-management and coping skills training intervention. We also explored and described the change in renal disease risk factors within and between risk groups, determining if participation in a culturally relevant coping skills training intervention decreased renal disease risk.

METHODS

This study was a secondary analysis of data from a longitudinal intervention study and included all 109 African American women with T2DM from the primary intervention study. This study examined the prevalence of 4 renal disease risk factors among the women at baseline via descriptive statistics, used cluster analysis to divide the women into risk groups and categorize the risk groups, and also measured the change in risk factors over time among risk groups via mixed modeling.

RESULTS

A majority of the women had a hemoglobin A1C ≥7% (62.39%) and were obese (75.93%). The high-risk cluster displayed clinically significant declines in mean systolic blood pressure, triglycerides, and A1C in both the control and intervention groups, and the intervention was more effective in reducing triglycerides and A1C levels among high-risk participants than low-risk. Overall, the control, high-risk group exhibited the largest declines in systolic blood pressure, triglycerides, and A1C.

CONCLUSIONS

This study displays the importance of acknowledging African American women with type 2 diabetes mellitus (T2DM) at high risk for renal disease in health care settings, which is often overlooked, and realizing that renal disease risk reduction is obtainable.

Whose stress is making me sick? Network-stress and emotional distress in African-American women

Research on stress-related health outcomes in African-American women often neglects "network-stress": stress related to events that occur to family, friends, or loved ones. Data from the African-American Women's Well-Being Study were analyzed to examine self-stress and network-stress for occurrence, perceived stressfulness, and association with symptoms of psychological distress. Women reported a higher number of network-stress events compared with self-stress events. Occurrences of network-stress were perceived as undesirable and bothersome as self-stress. Both types of stress were significantly associated with psychological distress symptoms. Including network-stress may provide a more complete picture of the stress experiences of African-American women.

The "invisible caregiver": multicaregiving among diabetic African-American grandmothers

PURPOSE

To explore the multicaregiving roles African-American grandmothers assume while self-managing their diabetes.

DESIGN & METHODS

This longitudinal, qualitative pilot study explored the challenges of self-managing diabetes among six African-American caregiving grandmothers. Data were collected at 5 times points across 18 months. Content analysis, guided by the Adaptive Leadership framework, was conducted using data matrices to facilitate within-case and cross-case analyses.

RESULTS

Although participants initially stated they cared only for grandchildren, all had additional caregiving responsibilities. Four themes emerged which illustrated how African-American caregiving grandmothers put the care of dependent children, extended family and community before themselves. Using the Adaptive Leadership framework, technical and adaptive challenges arising from multicaregiving were described as barriers to diabetes self-management.

IMPLICATIONS

When assisting these women to self-manage their diabetes, clinicians must assess challenges arising from multicaregiving. This might require developing collaborative work relationships with the client to develop meaningful and attainable goals.

Dietary challenges of managing type 2 diabetes in African-American women

The purpose of this qualitative study was to explore the challenge of self-management of diet in African-American women living with type 2 diabetes. Specifically, the women were asked to talk about dietary challenges of managing diabetes in the context of their personal lifestyle factors, such as daily routines, family responsibilities, and individual needs. Using a phenomenological approach, a descriptive, exploratory design was implemented using four facilitated focus groups. A convenience sample of 24 African-American women was recruited from a family practice center in the midwest. Data from each of the four focus groups were audiotaped and transcribed verbatim. Themes were compared and contrasted within and across each of the four focus groups until consensus was reached. Four themes were identified: frequent difficulties in changing dietary habits, need for individual guidance, support, and misinformation gaps. Overall, the participants expressed the need for more attention to the personal lifestyle factors they viewed as obstacles to managing diabetes.

Empowerment: a framework to develop advocacy in african american grandmothers providing care for their grandchildren

Purpose. Based on a review of the literature, this paper presents a unique and innovative model that offers an empowerment framework, which may be used to develop advocacy in African American (AA) grandmother caregivers. This proposed framework centers on education as a catalyst to the empowerment process in these grandmothers. Application of this model has potential to guide the practice of healthcare providers as they assist these caregivers in managing their own lives. Methodology. Various empowerment definitions and research were used to develop this empowerment framework. Discussion. This framework offers an empowerment education program for AA grandmothers providing care for their grandchildren on topics that they feel are necessary to appropriately care for themselves and their grandchildren. Outcomes of this empowerment education are to develop skills within these grandmothers so that they will be able to advocate for themselves, their grandchildren, and others within their communities. This education will ultimately produce skillful AA grandmothers who will develop abilities to empower themselves and other AA grandmothers who are in similar circumstances.

Cushioning, weathering, place, and community in rural grandmother-mothering

Place influences rural women's health when distance and lack of anonymity contribute to a reluctance to seek care. A qualitative design was used to explore relationships between place and the health of rural grandmothers raising grandchildren. The study generated findings concerning theory related to perceptual experience of rurality, identifying "Cushioning," as a basic social concept and "Weathering," "Paradoxical Place," and "Community Mothering" as subconcepts. Physical and mental wear and tear, distance, isolation and unraveling community mothering undermined "Cushioning" and reflected in self-health neglect narratives. Findings underscore the importance of place to the health of rural women raising grandchildren.