barriers to glycemic control among latina diabetics: a multi- method study m. diane mckee jeff...
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Barriers to Glycemic Control among Latina Diabetics: A Multi-
Method Study
M. Diane McKeeJeff Levine
Eliana KorinCharles Schwartz
Alison KaraszArthur Blank
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Background
Latinas with Diabetes Mellitus: Disproportionately affected by the illness Control less successful, even for patients receiving
primary careEfforts to improve care via Chronic Care Model:
Focus on systems to increase patient information for providers and self-management for patients
Attention to mental health largely focused on depressionImproving diabetic care may require a broader, integrated
approach targeting: Socio-cultural and family barriers Mental health barriers go beyond depression
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Specific Aims
For Latinas with well-controlled versus poorly-controlled diabetes:
• Obtain preliminary data about mental health variables, including mood disorders and abuse,
• Investigate the socio-cultural context of diabetes care with emphasis on barriers to successful management,
• Use quantitative and qualitative methods to explore family relationships and family stresses.
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Setting and Participants
Setting: 6 Bronx hospital-affiliated family medicine practices
Participants: Latina women with diabetes receiving primary care
Inclusion Criteria: at least 2 visits to site in the past year, and highest HgbA1C<7.5 (“well-controlled”) or > 9.5
(“poorly controlled”) self-identified Latina
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Recruitment
Potential participants identified by CIS (problematic) and diabetes collaborative database (much more useful)
Letter mailed signed by PCP Phone outreach to patient by research
team (!) First 20? participants invited to take
part in both qual and quant on separate days
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Qualitative-Objectives
To assist in designing effective interventions for Latina women with out-of-control diabetes, we explored:
Socio-cultural and family factors affecting diabetes care Health beliefs about diabetes: illness, prognosis,
treatment Diabetes in current life context: where diabetes “fits”
among competing priorities Mental health issues impeding care
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Qualitative Methods
Data Collection: In-depth qualitative interview (English or Spanish)
lasting 30-70 minutes (phone or in-person) Audio taped, transcribed verbatim, then translated
by professional translator
The Interview: Perceived overall health status and main health
concerns; Participant’s stories of how diabetes affects their
families; Descriptions of self-care activities and barriers; Prompts explored interaction with the health care
system, and family dynamics related to diabetes.
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Qualitative Analysis
Team reflexivity exercise completed before analysis Coding scheme developed and applied A set of psychological and contextual factors were
identified that were hypothesized to be associated with decreased ability to engage in diabetes self-care
Each narrative systematically re-examined to identify these these factors in relation to glycemic status
Variables hypothesized to be related to decreased ability to engage in self-care were found in individuals with good glycemic control
Narratives re-examined to identify strengths that might contribute to good glycemic control
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Themes
Latina Context Family legacy of diabetes Diabetic diet as culturally alien Tension between care for self versus others Socioeconomic limitationsMaladaptive Psychological Styles Fatalism Blurring of symptoms Treatment worse than the disease “Talking the talk” without “walking the walk” Psychiatric symptoms and disordersSources of Resilience Self-efficacy Family support and adaptation to diabetes
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Family Legacy of Diabetes
“….I’ve seen what it did to my parents…you know, my parents lost the eyesight, their kidneys failed, (they) were on dialysis…so…I had it in the back of my mind….”
“…we expected it (diabetes)…we knew our parents had it and died of it…we prepared ourselves that sooner or later we would get it…”
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Care for Others versus Self-Care
direct conflict between diabetes self-care, and the revered role as matriarch and caregiver
“….that’s the problem in my home…I’ve always been the tree trunk…the one helping (to keep) things together…”
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Diabetic Diet as Alien
diet at odds with culturally meaningful foods; in direct conflict with preparing and serving meals appealing
and nurturing to families
“….I’m used to eating a certain way. When you have diabetes you have to change your whole life around. You have to eat a certain way and it’s kind of hard. I mean being Hispanic I love rice and beans (laughs)…you know?….”
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Socio-Economic Limitations
“…Because you go to the supermarket, you buy things for the family, and…your diabetes is not on the dot in the budget”
“…Sometimes I don’t have (money). So how am I going to keep on a diet?”
“…if I don’t have any control of what I have…I eat whatever is there”
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Blurring of Symptoms
Mixed physical and mental symptoms, often seen as all due to diabetes; leading to adoption of
maladaptive self-care strategies
“ …I have a sickness in my body that is called [fibromyalgia]..the thing is that when my body hurts me, I don’t know if (it) is the arthritis, depression, fibromyalgia… or diabetes, or my nerves. The thing is that I cannot say if it’s one more than the other, but the diabetes makes me feel bad and I get a lot of dizziness..”
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Treatment Worse than the Disease
“….Actually, when [my blood sugar] is high I’m OK. According to the doctors….my body is used to it. When they try to control it…it starts coming down…I have a problem. That’s when I start getting sick…they call it withdrawal…of the sugar….”
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Fatalism
“If I have AIDS, if I have cancer or diabetes…I already have it…If I like it I eat it. I tell [my family] give it (the candy) to me…if I am going to die, I’m going to die anyway…”
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“Talking the talk” without “walking the walk”
“(My health) has been fine in the past year, no problems. I watch what I eat and take my medication…I have to take care of myself …because...I’m completely in charge of my kids’ well-being…you gotta take care of yourself…because you have people to take care of…a very close friend…I nudge…we get on each others’ case…” [HgbA1C 12.7]
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Beyond Depression
Participants with a very wide range of psychiatric problems: Depression Thought Disorder Panic Disorder Generalized anxiety Fibromyalgia and other somatization Psychiatric and substance disorders in children,
partners, siblings, parents Bereavement: multiple, prolonged, complicated Chronic psychosis
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Sources of Resilience
Individual Resilience: Self-Efficacy
“I tend to be a type of person that I nip things in the bud. I don’t like to let it go…”
“Exercise. I do walk for an hour-that’s what helps contain it, because I can’t say I follow a great diet. cause I was working out I didn’t need the medication. You know people say oh I’m tired, I can’t go to the gym. When you go to the gym and all of that goes away. And it’s so good for you”
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Family Resilience
Family Resilience: Role Adaptation to Diabetes
“My family worries about me. They just want me to take care of myself…Oh (my partner) loves (to cook healthy foods)…I tell him what to do …now it’s different cooking and ingredients…”
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Qualitative Insights
Narratives with inner city Latinas illustrate major barriers that go far beyond knowledge and motivation and limit participation in self care activities
Barriers to glycemic control include• Contextual factors (limited resources, family stressors)• High burden of co-morbid mental illness • Maladaptive individual styles
Blurring of mental and physical symptoms, attributed to DM Lack of insight into actual self care Fatalistic thinking Belief that treatments is worse than the disease
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Qualitative Insights
Resilience of individuals with diabetes, and/or their families may mitigate success or failure of efforts to control diabetes
Interventions with Latina women should be sensitive to the unique Latina experience of diabetes• Fear and potential fatalism resulting from the family
legacy of diabetes• Conflict between the Latina role as matriarch and
caregiver, and the need for diabetic self-care• Include culturally sensitive implementation of the diabetic
diet
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Survey-Objectives
Measurable psycho-social predictors of glycemic control
Explore hypotheses related to socio-cultural context, family environment, and mental health
Post-hoc analyses to explore hypotheses generated by qualitative data
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Domains and Measures
• Depression- PHQ• Bipolar- MDQ• Alcohol- CAGE, AUDIT• Abuse- Abuse Assessment Screen• Regimen Specific Social Support• Diabetes QOL- PAID• Family Cohesion and Conflict- FES
Familism• Physician Trust- Stanford• Health Literacy (STOFHLA)
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Recruitment and Participation
Final quantitative sample n=102
320 invited by mail 197 unable to reach (62%)21 refused (17%)
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In-control (N = 62)
Freq (PCT)
Out-Of-Control (N =40)
Freq (PCT)
Language spoken at home (N= 102 )
English 18 (29.03) 13 (32.50)
Highest grade completed (N= 100 )
8th grade or less 18 (29.51) 14 (35.90)
Some high school but not graduated 14 (22.95) 10 (25.64)
High school graduate or GED 18 (29.51) 7 (17.95)
Some college or 2-year degree 9 (14.75) 7 (17.95)
4-year college graduate 2 (3.28) 1 (2.56)
Marital Status (N= 98)
Single 12 (20.34) 11 (28.21)
Married 15 (25.42) 9 (23.08)
Common law/civil union 3 (5.08) 2 (5.13)
Living with partner 2 (3.39) 2 (5.13)
Separated 7 (11.86) 5 (12.82)
Divorced 8 (13.56) 6 (15.38)
Widowed 12 (20.34) 4 (10.26)
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In-control (N = 62)
Freq (PCT)
Out-Of-Control (N =40)
Freq (PCT)
Mexican/Mexican American 1 (3.23) 0 (0.00)
Puerto Rican 19 (61.29) 14 (82.35)
Dominican 7 (22.58) 2 (11.76)
Central American 1 (3.23) 1 (5.88)
South American 2 (6.45) 0 (0.00)
Other Hispanic 1 (3.23) 0 (0.00)
% Employed FT, PT (N = 96 ) 12 (20.69) 6 (15.79)
% Born in USA (N = 98 ) 10 (16.95) 10 (25.64)
In-control (N =62)
Mean (CI)
Out-Of-Control (N =40)
Mean (CI)
Mean Age (N =99 ) 53.95 (51.18 – 56.71)
52.19 (48.99- 55.39)
Average number of children (N=99 ) 2.97 (2.51 – 3.43) 3.08 (2.42 - 3.74)
Average number of years in USA (for the foreign –born) ( N = 79)
21.86 (18.08 – 25.64)
22.28 (17.42 – 27.13)
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Table 5. Group differences of scales
Measure Group P-valueParametric+
P-valueNon-parametric++
Effect size
In controlMean (CI)
Out of controlMean (CI)
Stanford Trust 86.34 (82.13 – 90.55) 85.05 (78.62 – 91.49) 0.73 0.57 0.06
MDQ 3.19 (2.37 – 4.02) 4.23 (2.91 – 5.55) 0.16 0.26 -0.26
Familism 8.38 (8.02 – 8.75) 8.65 (8.23 – 9.07) 0.35 0.35 -0.21
Paid 24.74 (18.33 – 31.15))
38.01 (27.94 – 48.08) 0.02* 0.046* -0.43
Cohesion 59.31 (56.81 – 61.82) 58.91 (55.62 – 62.21) 0.84 0.96 0.04
Conflict 41.11 (38.57 – 43.65) 42.97 (39.16 – 46.79) 0.39 0.56 -0.17
PHQ9 7.19 (5.41 – 8.98) 7.59 (5.21 – 9.97) 0.79 0.89 -0.05
RSSS 24.92 (21.86 – 27.98) 25.76 (21.67 – 29.92) 0.73 0.75 -0.07
STOFHLA 26.43 (23.52 – 29.35) 27.42 (23.44 – 31.40) 0.69 0.56 -0.10
+ t-test is used to obtain the parametric p-value++ Wilcoxon rank-sum test (equivalent to Mann- Whitney U-test) is used to obtain the non-parametric p-value#Effect Size (d) is computed based on out of control group SDStandards for mean difference ES's according to Cohen (1988) are:Small = .2SD; Medium = .5SD; Large .8SD
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PAID
Higher score reflects greater distress related to diabetes
Only scale with significant difference between groups (p=.046)
• In-control 24.7 (18.3-31.2)• Out-of-control 38.0 (27.9-48.1)
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Pearson Correlation Coefficients Prob > |r| under H0: Rho=0
Number of Observations Stanford_Score100 FamilismScore MdqScore PaidScore Cohesion Conflict Phq9Score RsssScore TOFHLA_ScoreN
Stanford_Score100 1.00 92
0.09 0.35 92
-0.23 0.03* 92
-0.161 0.12 92
0.27 0.01* 88
-0.19 0.08 88
-0.26 0.01* 92
0.12 0.25 92
0.27 0.03* 70
FamilismScore 1.00 92
-0.29093 0.0049 92
0.03 0.81 92
0.32 0.0023* 88
-0.29 0.01* 88
-0.01 0.95 92
0.02 0.82 92
-0.36 0.0020* 70
MdqScore 1.00 92
0.31 0.0029* 92
-0.20 0.06 88
0.35 0.0009* 88
0.29 0.0042* 92
0.07 0.53 92
0.08 0.50 70
PaidScore 1.00 92
-0.38 0.0002* 88
0.29 0.0071* 88
0.74 <.0001* 92
0.20 0.05 92
0.03 0.80 70
Cohesion 1.00 88
-0.40 <.0001* 88
-0.34 0.0013* 88
0.05 0.66 88
-0.072 0.56 67
Conflict 1.00 88
0.09 0.37 88
-0.23 0.03* 88
-0.06 0.64 67
Phq9Score 1.00 92
0.26 0.01* 92
0.01 0.97 70
RsssScore 1.00 92
0.22 0.07 70
TOFHLA_ScoreN 1.00 70
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Mental Health
Depression (PHQ-9) Mean All: 7.4 (7.1) Mean IN: 7.2
(7.0) Mean OUT:7.6 (7.4)
Depression (PHQ>10) P=0.56 (Chi-Square)
PHQ<10
PHQ>10
In control
46 (74.2%)
16 (25.8%)
Out of control
26 (66.7%)
13 (33.3%)
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Mental Health
Bipolar (MDQ) Mean 3.6 (3.6) In 3.2 (3.2) Out 4.2 (4.1)
Bipolar (MDQ>7) Chi-square=.01,
p=.02
MDQ < 7
MDQ> 7
InControl
5385.5%
914.5%
Out ofControl
2564.1%
1435.9%
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Family conflict and cohesion
Overall, measures performed well in population (alphas .88 to .97)
Exception: FES Cohesion (.43) Conflict (.73)
Cohesion mean 8.1 (norm 6.9) Conflict mean 1.5 (norm 3.26) Not a predictor of glycemic control
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Additional Findings
Health Literacy Mean 26.8 (10.1) Lower than general population But adequate and no difference between groups
Abuse and substance use Much less common than anticipated Responses probably not valid But this problem is unusual and may be particular
to the population
Familism Highly endorsed but not discriminating
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Post-hoc Analyses
Role of blurring?
Is there quantitative evidence of the resilience factors we identified?
Why such high correlation between PHQ and PAID, yet only PAID discriminates glycemic control?
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Blurring
PAID: “Which of the following diabetes issues are currently a problem for you?” …
#7. Not knowing if your mood or feelings are related to your diabetes?
Mood_bc_DM(Mood bc DM)study_groupNot a
problemMinor
problemModerateproblem
Somewhatserious problem
Seriousproblem
Total
In control 3962.90%
1219.35%
46.45%
23.23%
58.06%
62
Out ofcontrol
1641.03%
512.82%
615.38%
512.82%
717.95%
39
Total 55 17 10 7 12 101Chisq = 9.7, p-value = 0.04*
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Resilience: Can we detect within scales?
Self-efficacy and optimism
Variable study_group N Mean Std Dev Minimum Maximum p-value*
In control 62 5.5806 6.5526 0 24 Self efficacy (PAID 1,2,7,8,16,20) Out of control 39 9.2564 8.3563 0 24 0.02*
In control 54 3.7963 0.6553 0 4 Optimisim –Positive family structure (FES 1,7, 15,17)
Out of control 35 3.7714 0.7702 0 4 0.87
In control 62 6.0645 5.6128 0 20 Optimism –
Positive outlook on life (PAID 2,3,6,12)
Out of control 39 9.0513 7.082 0 20 0.03*
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PAID vs PHQ
Created subscale with 7 PAID items most reflecting depression
Hypothesized these items would correlate even more strongly with the PHQ
“Depression items” of PAID no more closely correlated to PHQ than instrument as a whole
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Limitations
Preliminary study intended to generate hypotheses for more formal testing
Study did not control for intrinsic diabetic disease severity, i.e., subjects with mild disease may have done well and subjects with severe disease done badly, irrespective of other barriers
Findings only relevant to patients receiving regular primary medical care
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Limitations
Interviewing process used in study was less effective than intended in the following areas: where diabetes fits in to the hierarchy of multiple life
priorities impact of diabetes on and adaptations in the family individual patient suggestions for potent and
practical interventions to improve self-efficacy, family adaptability, other barriers specific to the patient/patient’s life circumstances
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The Chronic Care ModelWagner EH et al.,
Improvingchroniccare.org
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“Self-Management” in the Inner City Latina Context
Will need to reflect cultural meaning of diabetes, particularly the family heritage, and the personal meaning of a legacy of tragedy
Will need to consider specific dietary modifications
Will need to respect the woman’s aspirations to care for others rather than herself
Might not expect agreement on the importance of “control” of diabetes at the outset – or even for some time
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Acknowledgements
Nancy Bassett Eduardo LaCalle Nellie Fernando Jason Fletcher MMG and Bronx Lebanon DRTC!