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Self-management among patients living with diabetes in the United States Virgin Islands.
– Reported, April 02, 2012
Managing the emerging diabetes epidemic is a significant public health challenge in the United States Virgin Islands (USVI). The USVI, a territory of the U.S., is a culturally unique community: most residents are of African descent and represent a distinct ethnic group with lifestyle influences from both the U.S. mainland and other Caribbean islands. The prevalence of diabetes among African Caribbean people residing in the USVI is similar to that of African Americans on the U.S. mainland, at 1012%, but is double that of estimates for African Caribbean residents on neighboring islands.14 Understanding this disparity requires a multipronged exploration of several potential contributing factors. Insights into culturally-specific perspectives may inform intervention development, as in other settings.57 In particular, capturing patient self-management skills and diabetes knowledge is important, as recommended by the American Diabetes Associations (ADA) national guidelines.8 The impact of family and social support on self-management attitudes, behaviors, and glycemic control is another important factor that varies across patient culture and ethnicity.9,10 Given existing racial/ethnic differences in glycemic control,11 we sought to explore how culturally-influenced views on self-management might contribute to diabetes outcomes in the USVI.
Little is known about how the unique social and cultural context of the USVI influences self-management behaviors and attitudes. Factors such as ethnicity, knowledge about diabetes, and individual family and patient characteristics all affect these outcomes in other populations and can inform the selection and design of interventions to improve the ability of patients to manage their health successfully. Therefore, we used quantitative and qualitative methods to achieve the following research objectives: 1) identify patterns of self-management behaviors among patients with adult onset diabetes in the USVI; 2) examine the association between self-management behaviors, patient-level characteristics (i.e., level of education, diabetes knowledge, income, and social support), and the clinical outcome of glycosylated hemoglobin (A1c); and 3) characterize the impact of culture on self-management attitudes, knowledge, and behavior.
The mean age of the sample was 57.6 years (SD ± 11.74), range 26 to 80 years. Participants were fairly evenly distributed between St. Thomas/St. John and St. Croix and most were women. A slight majority of respondents (51%) was employed and the remaining participants were either retired or unemployed. Concerning the highest level of education achieved, 38% completed elementary schooling and 21% reported completing a college degree (associate, baccalaureate, or a masters degree). About 40% reported an annual individual income of less than $12,000 and only 8% indicated an annual income of at least $50,000.
All individuals identified one individual physician as their diabetes health care provider, with 83% stating that they had seen their physician for a diabetes-related visit within the last three months. Only 6% of participants did not have a physician encounter within the previous nine months. The majority of participants (55%) received care from private physicians; 45% identified government-operated clinics as their medical home. Study participants were asked to recall the content of their most recent physician visit by identifying topics that were discussed from a list of diabetes-relevant management issues. Responses revealed that while exercise, diet, diabetes medication regimen, fasting blood sugar, cholesterol levels, and foot care were discussed with at least half of the patients, only 19% of patients reported discussing A1c measurements with their physicians.
Gender was the only demographic characteristic that was significantly associated with the outcome variable, A1c. Male participants achieved significantly tighter glycemic control than women (Fishers Exact Test, p = 0.0271). Employment status, education, income, age, knowledge, and medical home type were not significantly associated with A1c.
We sought to explore and characterize patterns of self-management behavior among patients living with diabetes in the USVI. Several patterns of self-management knowledge, behaviors, and attitudes emerged across our diverse sample. The mean A1c measurement was within accepted parameters despite the overall poor performance on knowledge testing, and the low percentage of adherence to all four of the assessed self-management behaviors. Male participants were likely to have significantly lower A1c measurements than their female counterparts. Interestingly, the only self-management behavior associated with significant lowering of the A1c was following a diabetes-appropriate diet. The qualitative data identified several challenges to adhering to an appropriate diet such as the desire to maintain the cultural diet, the prohibitive cost of non-locally grown foods, stigma from family and co-workers, and poor communication with their primary providers. The provider relationship was also relevant to other self-management behaviors. Few participants (19%) reported having discussed A1c with their primary health care physicians, and approximately half of our sample recalled discussing other specific aspects of diabetes at their most recent visits. Participants more readily accepted and trusted disease management guidance provided by family members and friends, especially others living with diabetes, than recommendations made by their physicians. Although the vast majority of participants (77%) filled and took their prescription medications, many patients were comfortable adjusting medication dosage and frequency without notifying their medical providers. Participants also easily incorporated complementary and alternative therapies into their treatment regimen without physician consultation. Still, many participants were highly motivated by the fear of complications and stated they would welcome communication with their physicians if the medical home offered culturally-relevant resources such as diabetes education and nutrition counseling.
Our findings have several implications with direct and immediate relevance to the USVI. It is clear that health care providers should focus on creating an environment in which patients are invited to and feel comfortable sharing the modifications and alternative medications they may incorporate into their self-care plan. Frequent physician visits are not sufficient to achieve diabetic control and more attention can be paid to the content of patient interactions with their medical homes. Physicians can recognize the importance of peer group support and reinforcement and create opportunities for group interactions with diabetes educators within the office setting. Importantly, providers can routinely assess patient knowledge and understanding of diabetes and make culturally-relevant resources available. Recognizing the unique cultural influences affecting health outcomes in the U.S. territories is a critical step towards achieving health equity for all of the nations citizens.
Credits: Maxine A. Nunez, DrPH, RN, Hossein Yarandi, PhD, and Marcella Nunez-Smith, MD, MHS
More Information at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140693/?tool=pubmed
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