General Diabetes Knowledge and Compliance
Running Head: UNDERSTANDING DIABETES: AN EXAMINATION OF THE IMPACT OF
SOCIOECONOMIC STATUS
Understanding Diabetes: Examination of the impact Socioeconomic Status has on General
Diabetes Knowledge and Compliance
Ari Richelson
Argosy University/Chicago
2/23/09
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Abstract
There is a growing rate of diabetes diagnosis in the United States of America where 23.6
million individuals suffer from the disease and 1.6 million new cases are diagnosed every year.
The present research has examined how low SES individuals are more likely to engage in poor
symptom management and compliance behaviors. Furthermore, those individuals are also
typically inadequately educated about their illness, despite the evidence that indicates education
can improve symptom management in low income populations. The present study hypothesizes
that individuals with low SES levels will be less knowledgeable about their diagnosis of diabetes
than affluent individuals. Furthermore, the present study hypothesizes that individuals with low
SES levels will engage in less healthy symptom management and compliance behaviors than
affluent individuals.
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Introduction
Health and Income
There is increasing attention to the many adverse health factors associated with low
socioeconomic status in the United States and the world. Studies indicate that low SES is
associated with and is strongly predictive of health status in adulthood (Power, Manor and
Matthews, 1999). Socioeconomic disadvantage is associated with a large spectrum of risky
behaviors such as smoking, physical inactivity and eating habits that lead to obesity (Najman,
Toloo and Siskind, 2006). A study done by Power, Manor and Matthews (1999) indicated that
the longer individuals were exposed to low socioeconomic status conditions the more likely they
were to develop adverse health risks and problems in life. Studies have corroborated these
findings, such as research that was done in London which found that individuals living in lower
SES neighborhoods experienced poorer physical functioning than those living in higher SES
areas (Feldmen and Steptoe, 2004). Furthermore, those same individuals experienced poorer
psychological health as well such as lower levels of social cohesion, increased neighborhood
problems and a higher vigilance for threat (Feldmen and Steptoe, 2004). Such findings suggest
that long-term exposure to low SES conditions could negatively impact a person’s overall health.
Many studies have also indicated that higher SES is associated with healthier lifestyles,
supporting the notion that SES does impact health risks in a consistent direction. There appears
to be a clear advantage to individuals exposed to higher levels of socioeconomic status,
particularly when that advantage is measured over time (Wilson, Shuey and Elder Jr., 2004). A
study done in the European Union revealed that individuals with higher education were also
40%-90% more likely to engage in some form of exercise than those with lower levels of SES
(Martinez-Gonzalez et al., 2001). Based on these findings, further analysis would be helpful to
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understand how socioeconomic status affects the diagnosis and development of a specific illness,
such as diabetes.
Diabetes
There is a growing concern, particularly in the United States, related to the prevalence of
diabetes. More and more children and adults are being diagnosed with the disease despite
countless efforts to manage, treat and prevent its spread (NIH, 2006). There are currently 23.6
million children and adults suffering from diabetes in the United States alone, with an estimation
of about 57 million exhibiting symptoms of prediabetic presentations (ADA, 2007). In one
study, researchers found that sons of obese fathers and daughters of obese mothers are six and
ten times respectively more likely to be obese themselves when compared to leaner parents and
their children (Diabetes Forecast, 2009). This demonstrates how parental modeling in general
and education about dieting specifically can result in similar consequences for children that their
parents originally experienced.
As children and adults continue to engage in unhealthy lifestyle habits, more and more
cases of diabetes continue to occur each year. According to the American Diabetes Association
(2007), approximately 1.6 million new cases of diabetes are diagnosed every year. As the
number of diagnoses continues to escalate, growing concern for the disease increases as well,
particularly because of the many cases that go unnoticed and/or untreated. Many professionals
believe that half of the millions of adults exhibiting symptoms of Type II diabetes in the United
States are unaware that they have diabetes (Sangani, 2007). As a result, these individuals are
likely to have already sustained organ damage in one or more places (Sangani, 2007). Therefore,
it is likely that because those individuals are unaware of the meaning of their symptoms, they
will continue engaging in their regular health habits, which will exacerbate and perpetuate their
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disease (Sangani, 2007). These facts and results indicate the growing concern for diabetes in
America as well as the tendency for the disease to be poorly managed and treated. Therefore,
further analysis of what might be causing such an epidemic is warranted to try and understand
what factors might be contributing to the development of the disease.
The Ecological Theory
It can be argued that human functioning and behavior is influenced in a number of
different ways by different environmental circumstances and situations. Bronfenbrenner (1993),
the founder of the ecological theory, purported that development is an evolving process of
human-environment interaction. Bronfenbrenner (1986) discussed three different systemic levels
that he stated served as sources of external influence on those human-environment interactions.
These systems; the microsystem, mesosystem and the exosystem, are comprised of interrelated
dynamic capacities involving thoughts, feelings and actions (Bronfenbrenner, 1986). The
microsystem is the most basic system involving the activities, roles and relationships a person
experiences within their given context, which has specific physical and material characteristics
(Bronfenbrenner, 1979). A person has multiple microsystems which can consist of family life,
school life and/or social situations that have a direct impact on the person. The mesosystem is
one step beyond the person’s immediate behaviors and involves linkages between two or more
microsystem environments (Bronfenbrenner, 1979). The mesosystem illustrates how a person’s
family life can have a direct impact on their performance in school. Finally, the exosystem
involves the interactions between two or more systems, at least one of which does not involve
the person, but does indirectly affect that person through events and/or situations that the person
is somehow exposed to in the environment they live (Bronfenbrenner, 1993). Each of a person’s
systems has different properties that affect the other systems. Therefore, the normal functioning
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of a person can be directly or indirectly affected by the interaction of different systems, such as
family and school or illness and SES.
Some variables impacting the adequate functioning of a person are present within
multiple systems. Knowledge, for example, would be a variable impacting functionality of a
person’s thoughts, feelings and actions because of its presence within each system
(Bronfenbrenner, 1993). According to Bronfenbrenner (1993), development is promoted by
exploration of different aspects of the social and physical environment as well as how often the
person is encouraged to pursue increasingly complex activities. However, this is strongly
impacted by what is conveyed and done to the person by all those individuals that are directly or
indirectly influencing their growth (Bronfenbrenner, 1993). Furthermore, this growth can also
be impacted by conditions of their environment such as diet, quality of air, furnishings,
surrounding noise, threats to safety and education. Therefore, lacking positive interactions
between these environments can potentially thwart development (Bronfenbrenner, 1993). Such
stunting could then occur if insufficient environmental contexts, such as SES, leave the child at a
disadvantage to function efficiently. According to the ecological theory, increased stressors and
reduced functionality would likely result in less knowledge of an illness such as diabetes.
Socioeconomic Status and Diabetes
There is a significant amount of research related to socioeconomic status and prevalence
of disease. This research attempts to understand how socioeconomic status might be a
contributing factor in the prevalence of disease and why. A study done by Chilton, Hu and
Wallace (2006) was conducted with individuals in a low-income Hispanic population. It
concluded that these individuals were significantly more likely to engage in unhealthy eating and
exercise habits regardless of their diabetes diagnosis. Another study that included low income
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Caucasian participants reported that each individual had an incomplete and vague understanding
of their disease (Arcury, Skelly, Gesler and Dougherty 2005). Such evidence purports that
perhaps individuals with low income are more likely to have an inadequate understanding about
diabetes, regardless of how much education they have had.
Much of the evidence suggests that exposure to low SES is correlated with poor health,
especially in diabetes patients. Socioeconomic status has been accepted as being a determinant
to health in some examples; in a study done by the National Institute of Health (2006), there
appeared to be an association between low-income populations and a high prevalence of
diabetes. Some evidence suggests that low socioeconomic status and educational levels is a risk
factor for the development of diabetes (Kemper, Savage, Niederbaumer and Anthony, 2005). In
addition, diabetes has been found to be up to two times more prevalent in low-income
populations when compared to wealthy populations (NIH, 2006). This evidence suggests that
diabetes patients are more likely to be less educated, have lower incomes and come from families
that are in similar situations.
A study done by Best, Hayward and Hidajat (2005) supports these conclusions and
reported that the prevalence of diabetes was higher in participants with poorly educated fathers.
Diabetes was also found to be more common in urban indigenous Australian adults that were of a
lower socioeconomic status than higher SES participants (Cunningham et al., 2008). There are
some findings that purport some explanations for why diabetes patients are more prevalent in
lower SES populations. Lower education and income is associated with poorer understanding of
illness and the factors related to onset, such as diet, which frequently results in the growth of the
disease (Kemper, Savage, Niederbaumer and Anthony, 2005). An example of this was studied
by Cox, Carpenter, Bruce, Poole and Gaylord (2004), who concluded that only half of low
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income Virginia residents diagnosed with type II diabetes adhere to the recommended dietary
and exercise guidelines given to them by health professionals despite receiving adequate diabetes
education (Cox, Carpenter, Bruce, Poole and Gaylord, 2004). Kemper, Savage, Niederbaumer
and Anthony (2005) have also examined education and income among diabetes patients and
indicate that individuals with a completed high school education have more knowledge about
diabetes than those without a high school education. These substantial conclusions convey that
the amount of education provided to diabetes patients can be directly related to the level of
education completed by the patient. However, it also suggests that lower income individuals are
less likely to adhere to medical guidelines, indicating that socioeconomic status plays some role
in the prevalence of diabetes diagnosis. Based on these findings alone, it is unclear how much
SES is a factor and to what degree the level of socioeconomic status impacts a person’s
knowledge of the disease.
The present study was designed to understand more about socioeconomic status and how
it might correlate to a diagnosed person’s knowledge about diabetes. The data will be examining
knowledge of a diabetes patient and comparing that knowledge across a wide spectrum of
socioeconomic status ranging from high SES to low SES participants. By doing this, the present
intends to discover how much higher socioeconomic status might increase understanding of
diabetes and therefore increase medical, nutritional and exercise compliance of each patient.
This would also help to understand how much less compliant are lower SES diabetes patients
than high SES diabetes patients.
Hypotheses
The present study asks what impact socioeconomic status has on a person living with
diabetes. The corresponding hypotheses are therefore:
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(H1), the higher the socioeconomic status the better a person’s understanding (more knowledge)
of diabetes;
(H2), the higher the socioeconomic status the more knowledge about healthy dieting, exercise
and nutrition;
(H3), the higher the socioeconomic status the higher medical, dietary and exercise compliance
resulting in lower A1C levels;
Method
Participants
The proposed study will recruit approximately 100 persons with Type I diabetes based on
the results of the power analysis (Soper, 2004). Each participant must be at least 18 years of age
and able to write and speak English. Participants will be of different ethnic and racial
backgrounds with no bias toward one group or another. Participants will be assigned to one of
three groups based on their socioeconomic status. Roughly one third of the participants will be
characterized as having a low socioeconomic status, one third will have an average
socioeconomic status and the remaining third will have a high socioeconomic status.
Socioeconomic status includes occupation, income, wealth, education and place of residence
(United States Census Bureau, 2000). High socioeconomic status will consist of participants that
have an income in the upper-middle class range of $75,000 or more. Participants in this range
are typically highly educated with graduate degrees and have secured at the very least middle
management positions (Gilbert, 2002). Average socioeconomic status will consist of participants
that have an income in the lower middle class range of $30,000 and $75,000. Participants in this
range are typically college educated professionals and/or specialists proficiently trained in one
area of expertise with some degree of work autonomy (Thompson and Hickey, 2005). Low
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socioeconomic status will consist of participants with an income in the working class between
$16,000 and $30,000. Participants in this range are typically high school educated and have
occupations in blue collar, clerical positions with often low job security (Beeghley, 2004).
Participants will be limited to a diagnosis of Type I Diabetes to control for potential
confounds that might differ across Type I and Type II Diabetes diagnoses. Persons with Type I
Diabetes typically inherit risk factors from both parents and therefore are frequently afflicted at
younger ages through no environmental influences (ADA, 2007). Persons with Type II Diabetes
may inherit risk factors from parents however diagnoses of this type is also frequently the result
of environmental influences such as poor diet and exercise habits (ADA, 2007). Therefore, a
diagnosis of type I diabetes must have been given by the age of 16 or earlier for each participant.
The sampling for this study was considered to be a convenience sample.
Measures
Hollingshead Demographic Information Questionnaire (Hollingshead, 1975). This
measure will be given to gather demographic information such as socioeconomic status, parental
income and age of diagnosis. As indicated above, SES typically consists of five categories and
therefore this questionnaire will assess the variables relevant to the study, which are education,
occupation and income, in order to measure the socioeconomic status of each participant and
their family. This measure consists of nine questions and will take approximately 5-10 minutes
to complete.
Measurement of Diabetes Knowledge (DKN; Dunn, Bryson, Hoskins, Alford,
Handelsman and Turtle, 1984). The second measure was designed to measure a person’s general
knowledge about diabetes on three different forms in five different categories. The categories
are; basic physiology of diabetes including insulin action, hypoglycemia, food groups and food
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substitutions, sick day management and general diabetes care. This measure has three scales that
each have 15 questions on them and should take approximately 20 minutes to complete. The
Measurement of Diabetes Knowledge has been found to be a reliable and valid instrument. A
homogeneity analysis supported a unitary concept of 0.92. The internal reliability was 0.84, 0.83
and 0.85 respectively for the three forms of the instrument. It has had positive correlation results
regarding construct validity between education and DKN scores (0.41). The kind of knowledge
the scale measures best can be distinguished as practical and behavioral.
The Measurement of Diabetes Knowledge scale is a short and easily-administered
questionnaire, which was designed to allow measurement of knowledge for the purposes of
understanding relationships between knowledge, psychological factors, social factors, health
status and metabolic control. The philosophy behind those purposes was to determine patient
understanding of theoretical aspects of diabetes treatment in order to better manage their
symptoms. The present study will be attempting to elaborate on its purpose by comparing a
person’s understanding across different levels of socioeconomic status to see if there are any
discrepancies. This is a self-administered questionnaire scored by summing the correct
responses of the total number of responses for each subscale. Total scores range from 0-15 with
higher scores indicating better diabetes knowledge. A limitation of this measurement is that
there is little justification that knowledge can account for predicting patient outcomes.
Summary of Diabetes Self-Care Activities (SDSCA; Schafer, Glasgow, McCaul and
Dreher, 1983). Participants will be assessed for medical, dietary and exercise compliance in this
scale. This scale assesses each participant’s self-care regimens by asking questions pertaining to
diet, exercise, glucose testing and diabetes medication management. There are 12 items on this
scale and it should take approximately 10 minutes to complete. The Summary of Diabetes Self-
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Care Activities scale has been found to be a reliable and valid instrument. The average interitem correlations presented to assess internal consistency were high, typically exceeding 0.50.
Test-retest reliability over a six month interval was between 0.43-0.58. The instrument has “face
validity” because it only inquires about diabetes-related information, specifically about diabetes
regimen that most patients have daily recommended activities. Concurrent validity in self-care
measures was represented by high correlations between assessment scores measuring the same
characteristics in different procedures, which were self-monitoring, behavior inventories,
interview and reflectance meter measures. In adherence, concurrent validity correlations ranged
from 0.10 to 0.51. This is a self-administered questionnaire scored by converting the raw scores
to standard scores. The standardized scores are averaged to form a composite score for each
assessed behavior.
This instrument was developed to provide a measure that examines self-care practices in
different areas for clinical and research uses. Because of its brief nature, it gives clinicians and
researchers an advantage in time and practicality, indicating that this measure is recommended to
be used as a measure of change. It can be useful as a screening instrument to identify patients
who may experience difficulty as well as patient education. This measure is limited in that it
does not assess all aspects of adherence/self-care for adults. In addition, this measure had to rely
on correlations rather than structural coefficients to assess validity.
Procedure and Design
Recruitment was calculated by power analysis consisting of statistical power of 0.8, alpha
size of 0.05 and an effect size of 0.15. This effect size is considered to be medium size for a
multiple regression analysis. The procedures will consist of advertising the present study
through the American Diabetes Association’s numerous events held weekly, dialysis treatment
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centers, diabetes support groups, graduate schools and local hospitals (See Appendix B). The
above locations will be contacted and a request will be made to allow flyers to be placed within
the facility. The administration of each facility will be contacted for approval and if necessary,
the institutional review board of that facility will review and then approve participation as well.
The flyer will consist of a description of the study and encouraging feedback so that potential
participants will have a general explanation as to why they are participating. In addition, an
explanation about monetary incentive will be included in the flyer to provide motivation to
participate. Each participant will receive ten dollars upon completion of the survey’s, which will
be distributed via mail in the form of a ten dollar visa gift card. A telephone number and address
will be obtained during the initial screening procedure so the reward can be mailed to each
participant. In addition, each participant will be reminded that this information will only be used
to award them the incentive and will be immediately destroyed once the gift card has been
mailed.
Each participant will be informed that all identifying information will be kept
confidential on a spread sheet and will be number coded to ensure blind scoring so scorers will
remain unbiased. All information on the spread sheet will be password sensitive so that only
researchers involved in the present study will have access to the private information. Every
questionnaire completed by each participant will be kept in a locked drawer that will only be
accessible by those researchers with access to the key. Furthermore, each participant will be
reminded that upon completion of the study, all identifying and confidential information will be
destroyed. Participants will be instructed to complete each survey on
WWW.SurveyMonkey.Com after they have agreed to assist in the study to eliminate any
potential problems with obtaining transportation.
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Individuals interested in participating will be able to contact the research team by phone
number and/or email, which will be written on the flyer. Upon receipt of an individual’s desire
to participate, a screening procedure will be implemented consisting of a few general questions
to ensure that the participant meets the criteria needed to engage in the study (See Appendix C).
These questions will consist of meeting demographic requirements ensuring each participant
meets the appropriate age specifications, has been diagnosed with Type I Diabetes and at the
requested age range as well. After the decision has been made to participate, each individual will
be provided with the consent form, which will be signed and returned to the principal
investigator (See Appendix A). If participants do not have access to the internet and/or and
email account, arrangements will be made to provide them with the questionnaires via mail or in
person. Subsequent to signing the consent, administration of the selected questionnaires will
commence. Participants will complete all questionnaires at the same time. They will be
instructed to complete these questionnaires honestly and without any assistance from outside
resources. Upon completion of the questionnaires, the participant will be thanked for their
participation and given debriefing feedback. The feedback will be regarding what will happen
as a result of the information they provided, what they can do if they are experiencing any
discomfort as a result of the study as well as how long they can expect the study to take before it
is completed. If any participant does request additional help due to adverse feelings as a result of
participation, they will be given referrals to mental health professionals that can assist them.
The study will be a quantitative design meaning a correlation of the above variables will
be carefully controlled and statistically analyzed to determine if a meaningful relationship exists.
The stated measurements will be scored and analyzed to determine if statistical significance is
present and therefore meaningful correlations are present. The analysis of the data will be done
A Comparison Study of Diabetic Patient’s Personal Knowledge
with a linear regression model and will be analyzed using the Statistical Package for the Social
Sciences (SPSS 17.0).
15
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Appendix A
Participant Consent Form
Consent Form
I__________________________ hereby give my consent for my participation in the research
study entitled, “Understanding Diabetes: Examination of the impact Socioeconomic Status has
on General Diabetes Knowledge and Compliance” This project will be conducted by Ari
Richelson under the supervision of David VanDyke, Ph.D. and Argosy University-Illinois
School of Professional Psychology/Chicago campus. There will be approximately 100
participants recruited for this study for the purposes of understanding how socioeconomic status
impacts knowledge and compliance of persons with diabetes. The present study is also to satisfy
the clinical research project (dissertation) portion of Argosy University’s doctoral program
requirements and is partly for educational purposes. I understand the only requirement of the
study is to complete three self-administered questionnaires which will last about 20-30 minutes.
I understand that the results of this study will be coded in such a way that my identity will
be completely protected and that all information disclosed will be kept strictly confidential. The
data collected will be destroyed subsequent to the completion of the project within five years. I
understand that this study will involve answering personal questions relative to my medical
history, demographics and personal values. I understand that I might experience adverse
feelings due to disclosure of personal information although this is a small possibility and that if
needed, a referral for help can be given at any time.
I understand that the present study is designed to examine the diabetes illness and the
effects it may have. The results of this study may be published or otherwise reported to other
scientific professionals but my identity will remain confidential. In addition, I understand that
the benefit of my participation in this study for the professional community will be to provide
data to the medical field in the area of diabetes research. Furthermore, I also understand that I
can personally benefit from this study by learning valuable information about my disease.
I understand that my participation is voluntary and that there is no penalty for early
withdrawal or requirement to continue throughout the entire study. Furthermore, I understand I
can refuse to answer any question on each survey. I also understand that each participant will be
provided with monetary compensation of $10 for participation. I understand that I have the right
to refuse participation at any time however, upon doing so, I will not receive compensation.
I understand that this research study has been reviewed and approved by the Institutional
Review Board, American School of Professional Psychology (formerly Illinois School of
Professional Psychology) at Argosy University, Chicago. For research related problems or
questions regarding participants’ rights, I understand that I may contact the Institutional Review
Board through Dr. David VanDyke, IRB chair, at 312-777-7600 ext. 7699 or by email at
DVanDyke@argosy.edu. Any additional questions or concerns can be addressed by Ari
Richelson, the primary researcher, at 708-990-3884 or by email at arichels@stu.argosy.edu.
Signature_______________________________ Date ________________________
Witness________________________________
Date ________________________
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Appendix B
Flyer advertising study for recruitment
Participants wanted for Research Study
Examining Effects of Socioeconomic
Status on Type I Diabetes
$10 Monetary incentive will be offered for every participant interested in
helping.
Argosy University/American School of Professional Psychology


Doctoral student in clinical psychology program at Argosy University looking for
men and/or women aged 18 or older to participate in research study.
Study is looking for Persons with Type I Diabetes to examine the potential effects of
socioeconomic status on this disease.
Monetary compensation will be provided for participation. Compensation of $10 will be
given to each participant. Participants will be asked several questions during an initial
phone conversation to determine eligibility for this study. Subsequently, each participant
will be asked to complete the survey on their own. It will take approximately 20-30
minutes to complete three questionnaires. PARTICIPANTS ARE KINDLY ASKED TO
HONESTLY COMPLETE EACH SURVEY ENTIRELY ON THEIR OWN, WITHOUT
THE USE OF ANY RESOURCES OR HELP
Participants would not be eligible for this study if:
 They are under the age of 18
 Diagnosed with Type II Diabetes
 Diagnosed at age 16 or later with Type I Diabetes
 They have never been diagnosed with Type I Diabetes
To learn more about this research, please contact:
Ari Richelson - 708-990-3884
or
ARichels@stu.argosy.edu
This research is conducted under the direction of Dr. David VanDyke, Argosy University
A Comparison Study of Diabetic Patient’s Personal Knowledge
22
Appendix C
Preliminary questions asked of prospective participants during initial inquiry
1.
2.
3.
4.
5.
6.
Have you been diagnosed with Type I Diabetes, Type II diabetes, or neither?
At what age were you diagnosed?
How old are you?
Approximately how much money did your mother earn when you were living with them?
Approximately how much money did your father earn when you were living with them?
If you live outside of Chicago, approximately how many miles outside the city do you
live?