Barriers to Glycemic Control
among Latina Diabetics: A MultiMethod Study
M. Diane McKee
Jeff Levine
Eliana Korin
Charles Schwartz
Alison Karasz
Arthur Blank
Background
Latinas with Diabetes Mellitus:
 Disproportionately affected by the illness
 Control less successful, even for patients receiving
primary care
Efforts 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 depression
Improving diabetic care may require a broader, integrated
approach targeting:
 Socio-cultural and family barriers
 Mental health barriers go beyond depression
Specific Aims
For Latinas with well-controlled versus poorlycontrolled 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.
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
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
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
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.
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
Themes
Latina Context
 Family legacy of diabetes
 Diabetic diet as culturally alien
 Tension between care for self versus others
 Socioeconomic limitations
Maladaptive Psychological Styles
 Fatalism
 Blurring of symptoms
 Treatment worse than the disease
 “Talking the talk” without “walking the walk”
 Psychiatric symptoms and disorders
Sources of Resilience
 Self-efficacy
 Family support and adaptation to diabetes
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…”
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…”
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?….”
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”
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..”
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….”
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…”
“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]
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
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”
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…”
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
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
Survey-Objectives
Measurable psycho-social predictors of
glycemic control
Explore hypotheses related to sociocultural context, family environment,
and mental health
Post-hoc analyses to explore
hypotheses generated by qualitative
data
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)
Recruitment and Participation
Final quantitative sample n=102
320 invited by mail
197 unable to reach (62%)
21 refused (17%)
In-control (N = 62)
Out-Of-Co ntrol (N =40)
Freq
(PCT)
Freq
(PCT)
18
(29.03)
13
(32.50)
8th g rade or less
18
(29.51)
14
(35.90)
Some high schoo l but no t gradu ated
14
(22.95)
10
(25.64)
High schoo l gradu ate or GED
18
(29.51)
7
(17.95)
Some colle ge o r 2-yea r degr ee
9
(14.75)
7
(17.95)
4-year colle ge g radua te
2
(3.28)
1
(2.56)
Single
12
(20.34)
11
(28.21)
Married
15
(25.42)
9
(23.08)
Comm on law/civil un ion
3
(5.08)
2
(5.13)
Living wit h pa rtner
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)
Language spoken at home (N= 102 )
Engl is h
Highest grade compl eted (N= 100 )
Marital Status (N= 98)
In-control (N = 62)
Out-Of-Control (N =40)
Freq
(PCT)
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)
Out-Of-Control (N =40)
Mean (CI)
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
3.08
Average number of years in USA (for the
foreign –born) ( N = 79)
21.86 (18.08 –
25.64)
(2.51 – 3.43)
(2.42 - 3.74)
22.28 (17.42 – 27.13)
+ 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 SD
Standards for mean difference ES's according to Cohen (1988) are:
Small = .2SD; Medium = .5SD; Large .8SD
Table 5. Group differences of scales
Measure
Group
Out of control
Mean
(CI)
P-value
Parametric
+
P-value
Nonparametric++
Effect
size
In control
Mean
(CI)
Stanford Trust
86.34
(82.13 – 90.55)
85.05
91.49)
(78.62 –
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
31.15))
(18.33 –
38.01
48.08)
(27.94 –
0.02*
0.046*
-0.43
Cohesion
59.31
(56.81 – 61.82)
58.91
62.21)
(55.62 –
0.84
0.96
0.04
Conflict
41.11
(38.57 – 43.65)
42.97
46.79)
(39.16 –
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
29.92)
(21.67 –
0.73
0.75
-0.07
STOFHLA
26.43
(23.52 – 29.35)
27.42
31.40)
(23.44 –
0.69
0.56
-0.10
PAID
Higher score reflects greater distress
related to diabetes
Only scale with significant difference
between groups (p=.046)
• In-control
• Out-of-control
24.7 (18.3-31.2)
38.0 (27.9-48.1)
Pearson Correlation Coefficients
Prob > |r| under H0: Rho=0
Number of Observations
Stanford_Score100
Stanford_Score100
1.00
92
FamilismScore
FamilismScore
0.09
0.35
92
1.00
92
MdqScore
MdqScore
-0.23
0.03*
92
-0.29093
0.0049
92
1.00
92
PaidScore
PaidScore
-0.161
0.12
92
0.03
0.81
92
0.31
0.0029*
92
1.00
92
Cohesion
Cohesion
0.27
0.01*
88
0.32
0.0023*
88
-0.20
0.06
88
-0.38
0.0002*
88
1.00
88
Conflict
Conflict
-0.19
0.08
88
-0.29
0.01*
88
0.35
0.0009*
88
0.29
0.0071*
88
-0.40
<.0001*
88
1.00
88
Phq9Score
Phq9Score
-0.26
0.01*
92
-0.01
0.95
92
0.29
0.0042*
92
0.74
<.0001*
92
-0.34
0.0013*
88
0.09
0.37
88
1.00
92
RsssScore
RsssScore
0.12
0.25
92
0.02
0.82
92
0.07
0.53
92
0.20
0.05
92
0.05
0.66
88
-0.23
0.03*
88
0.26
0.01*
92
1.00
92
TOFHLA_ScoreN
TOFHLA_ScoreN
0.27
0.03*
70
-0.36
0.0020*
70
0.08
0.50
70
0.03
0.80
70
-0.072
0.56
67
-0.06
0.64
67
0.01
0.97
70
0.22
0.07
70
1.00
70
Mental Health
PHQ< PHQ>
10
10
 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)
In
control
46
Out of
control
26
16
(74.2%) (25.8%)
13
(66.7%) (33.3%)
Mental Health
MDQ
<7
 Bipolar (MDQ)
 Mean
 In
 Out
3.6 (3.6)
3.2 (3.2)
4.2 (4.1)
 Bipolar (MDQ>7)
 Chi-square=.01,
p=.02
MDQ
>7
In
Control
53
9
85.5% 14.5%
Out of
Control
25
14
64.1% 35.9%
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
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
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?
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?
study_group
Not a
problem
In control
39
62.90%
Out of
16
control
41.03%
Total
55
Chisq = 9.7, p-value = 0.04*
Mood_bc_DM(Mo od b c DM)
Minor
Moderate
Somewhat
problem
problem
serious problem
12
4
2
19.35%
6.45%
3.23%
5
6
5
12.82%
15.38%
12.82%
17
10
7
Total
Serious
problem
5
8.06%
7
17.95%
12
62
39
101
Resilience: Can we detect within scales?
Self-efficacy and optimism
Variable
study_group
N
Mean
Std Dev
Minimum
Maximum
pvalue*
Self efficacy (PAID
1,2,7,8,16,20)
In control
Out of control
62
39
5.5806
9.2564
6.5526
8.3563
0
0
24
24
0.02*
Optimisim –
Positive family
structure (FES 1,7,
15,17)
In control
Out of control
54
35
3.7963
3.7714
0.6553
0.7702
0
0
4
4
0.87
Optimism –
Positive outlook on
life (PAID 2,3,6,12)
In control
Out of control
62
39
6.0645
9.0513
5.6128
7.082
0
0
20
20
0.03*
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
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
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
The Chronic Care Model
Wagner EH et al., Improvingchroniccare.org
“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
Acknowledgements
 Nancy Bassett
 Eduardo LaCalle
 Nellie Fernando
 Jason Fletcher
 MMG and Bronx Lebanon
 DRTC!