Beliefs about racism and health among African American women with diabetes: a qualitative study

Black-White Differences in The Effects of Parental Education on College Students' Beliefs about Racial Discrimination

Background

Racial discrimination remains a significant issue in the United States, particularly affecting Black individuals. Understanding how beliefs about the persistence of racial discrimination are shaped by race and parental education among college students is crucial for developing strategies to address these inequities.

Objectives

This study aims to examine the multiplicative effects of race and parental education on beliefs about the persistence of racial discrimination among Black and White college students. We hypothesize that Black students, particularly those with highly educated parents, will exhibit stronger beliefs in the persistence of racial discrimination as a significant issue compared to their White peers.

Methods

Data were drawn from the Higher Education Research Institute (HERI) study, which includes a national sample of Black and White young adults on college campuses across the United States. We conducted statistical analyses to explore the influence of race and parental education on students' beliefs about racial discrimination.

Results

Black students demonstrated stronger beliefs in the persistence of racial discrimination compared to White students. Additionally, students with higher parental education levels were more likely to recognize racial discrimination as a significant issue than those with lower parental education. The impact of parental education on these beliefs was more pronounced for Black students compared to White students.

Discussion

Black college students, especially those from higher SES backgrounds, exhibit a heightened awareness of racial discrimination due to their lived experiences and educational exposure. High SES Black individuals often face increased visibility and prejudice in predominantly White environments, further reinforcing their beliefs about the persistence of discrimination. These findings highlight the need for targeted interventions to support Black students in higher education and promote awareness of racial discrimination. Policy solutions should include comprehensive anti-discrimination policies, increased diversity and inclusion efforts, and educational curricula that address systemic racism and social justice. The cross-sectional nature of the data limits causality inference, and self-reported measures may be subject to bias. Despite these limitations, the study's large and diverse sample enhances the generalizability of the findings. Race and parental education have multiplicative effects on college students' beliefs about the persistence of racial discrimination. Black students, particularly those from high SES backgrounds, are more likely to perceive racial discrimination as a continuing problem. Addressing these disparities through targeted policies and interventions is essential for creating equitable and inclusive educational environments.

Perceived Interpersonal Racism in Relation to Incident Coronary Heart Disease Among Black Women

BACKGROUND

Racism is highly prevalent in the United States. Few data exist about whether perceived interpersonal racism is associated with risk of coronary heart disease (CHD).

METHODS

We followed 48 305 participants in the Black Women's Health Study through biennial mailed and Internet-based health questionnaires from 1997, when they provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer, until the end of 2019. We averaged participant responses to 5 validated questions about perceived interpersonal racism in everyday activities, such as "people act as if they think you are dishonest." We summed the positive responses to 3 questions about perceived racism in interactions that involved jobs, housing, and police; scores ranged from 0 (no to all) to 3 (yes to all). CHD cases were defined as nonfatal myocardial infarctions confirmed through medical records, fatal cases identified through the National Death Index, and self-reported revascularization events. We used Cox proportional hazard models adjusting for major confounders to estimate hazard ratios (HRs).

RESULTS

During 22 years of follow-up, we identified 1947 incident CHD cases. For women who reported experiences of racism in employment, housing, or involving the police relative to women who reported no such experiences, the age-adjusted HR for CHD was 1.35 (95% CI, 1.13-1.61; Ptrend=0.006), and the multivariable HR for CHD was 1.26 (95% CI, 1.05-1.51; Ptrend=0.05). For women in the highest quartile of perceived interpersonal racism in daily life relative to women in the lowest quartile, the age-adjusted HR for CHD was 1.25 (95% CI, 1.07-1.46; Ptrend=0.006). After multivariable adjustment, the HR was attenuated and no longer statistically significant.

CONCLUSIONS

Perceived experiences of interpersonal racism in employment, in housing, and with the police were associated with higher incidence of CHD among Black women, whereas perceived racism in everyday life was not associated with higher risk.

Improving adult behavioural weight management services for diverse UK Black Caribbean and Black African ethnic groups: a qualitative study of insights from potential service users and service providers

Background

A significantly higher proportion of UK Black ethnic adults live with overweight or obesity, compared to their White British counterparts. The role of obesity in excess infection rates and mortality from COVID-19 has increased the need to understand if weight management interventions are appropriate and effective for Black ethnic groups. There is a paucity of existing research on weight management services in Black populations, and whether anticipated or experienced institutional and interpersonal racism in the healthcare and more widely affects engagement in these services. Understanding the lived experience of target populations and views of service providers delivering programmes is essential for timely service improvement.

Methods

A qualitative study using semi-structured interviews was conducted in June-October 2021 among 18 Black African and Black Caribbean men and women interested in losing weight and 10 weight management service providers.

Results

The results highlighted a positive view of life in the United Kingdom (UK), whether born in the UK or born abroad, but one which was marred by racism. Weight gain was attributed by participants to unhealthy behaviours and the environment, with improving appearance and preventing ill health key motivators for weight loss. Participants relied on self-help to address their overweight, with the role of primary care in weight management contested as a source of support. Anticipated or previously experienced racism in the health care system and more widely, accounted for some of the lack of engagement with services. Participants and service providers agreed on the lack of relevance of existing services to Black populations, including limited culturally tailored resources. Community based, ethnically matched, and flexibly delivered weight management services were suggested as ideal, and could form the basis of a set of recommendations for research and practice.

Conclusion

Cultural tailoring of existing services and new programmes, and cultural competency training are needed. These actions are required within systemic changes, such as interventions to address discrimination. Our qualitative insights form the basis for advancing further work and research to improve existing services to address the weight-related inequality faced by UK Black ethnic groups.

Perceived Interpersonal Racism and Incident Stroke Among US Black Women

Importance

Black individuals in the US experience stroke and stroke-related mortality at younger ages and more frequently than other racial groups. Studies examining the prospective association of interpersonal racism with stroke are lacking.

Objective

To examine the association of perceived interpersonal racism with incident stroke among US Black women.

Design, Setting, and Participants

The Black Women's Health Study, a prospective cohort study of 59 000 Black women from across the US, assessed the longitudinal association between perceived interpersonal racism and stroke incidence. Stroke-free participants were followed up from 1997 until onset of stroke, death, loss to follow-up, or the end of the study period (December 31, 2019). Cox models were used to estimate hazard ratios (HRs) and 95% CIs, adjusting for major confounders, including education, neighborhood socioeconomic environment, and cardiometabolic factors. Data analysis was performed from March 2021 until December 2022.

Exposure

On a questionnaire completed in 1997, participants reported experiences of racism in everyday life and when dealing with situations that involved employment, housing, and interactions with police.

Main Outcomes and Measures

Strokes were identified through self-report on biennial questionnaires, medical records adjudication, and linkage with the National Death Index.

Results

In 1997, 48 375 Black women (mean [SD] age, 41 [10] years) provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer. During the 22 years of follow-up, 1664 incident stroke cases were identified; among them, 550 were definite cases confirmed by neurologist review and/or National Death Index linkage. Multivariable HRs for reported experiences of racism in all 3 domains of employment, housing, and interactions with police vs no such experiences were 1.38 (95% CI, 1.14-1.67), a 38% increase, for all incident cases and 1.37 (95% CI, 1.00-1.88) for definite cases. For comparisons of women in the highest quartile of everyday interpersonal racism score vs women in the lowest quartile, multivariable HRs were 1.14 (95% CI, 0.97-1.35) for analyses that included all incident stroke and 1.09 (95% CI, 0.83-1.45) for analyses that included definite cases only.

Conclusions and Relevance

In this study, Black women who reported experiences of interpersonal racism in situations involving employment, housing, and interactions with police appeared to have an increased risk of stroke, even after accounting for demographic and vascular risk factors, suggesting that the high burden of racism experienced by Black US women may contribute to racial disparities in stroke incidence.

Participant and group facilitator perspectives on a novel culturally tailored diabetes self-management program for African Americans

Background

African Americans with type 2 diabetes experience disparities in their care and diabetes health-related outcomes. Diabetes self-management programs such as Healthy Living with Diabetes (HLWD) are important but do not account for the unique cultural experiences of African Americans. As well, a culturally tailored program focused on addressing sociocultural beliefs and providing race-congruent peer support, Peers LEAD (Peers Supporting Health Literacy, Self-Efficacy, Self-Advocacy, and Adherence) was implemented in two midwestern cities to improve medication adherence but does not include diabetes self-management topics included in HLWD. In attempt to fill the gaps from both HLWD and Peers LEAD, Peers EXCEL (Peers' Experience in Communicating and Engaging in Healthy Living) was designed to integrate both programs.

Methods

Our study explored the perceptions of African American participants and facilitators of the separate HLWD and Peers LEAD programs, on the proposed new Peers EXCEL program using focus groups and interviews. Findings were analyzed by research assistants trained in qualitative research using deductive and inductive open coding approaches.

Results

Participants described the lack of cultural fit of the current HLWD program for African American communities and proposed strategies to enhance Peers EXCEL's impact in African American communities. They shared the need to include topics such as the relationships between systemic racism and diabetes.

Conclusion

Participants' feedback of Peers EXCEL reveals the importance of including various community member perspectives in the design of new diabetes self-management programs tailored for African Americans.

Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

OBJECTIVE

To evaluate the evidence on the role of structural racism as an upstream factor impacting diabetes outcomes, identify current gaps, and recommend areas for future work.

RESEARCH DESIGN AND METHODS

A reproducible search of Medline and Ovid was used. Structural factors based on the World Health Organization social determinants of health framework (governance, macroeconomic policy, social policy, public policy, and cultural and societal values) had to be included as measured variables or contextual factors discussed as upstream influences. Outcomes included 1) hemoglobin A1c (HbA1c), 2) LDL, 3) BMI, 4) quality of life, 5) self-efficacy, 6) mortality, 7) years of life lost, and 8) self-care behaviors.

RESULTS

Thirteen articles were included for final synthesis. Ten studies focused on governance, two on social policies, one on public policies, and one on cultural and societal values. Results highlight significant associations between structural racism and poorer clinical outcomes (HbA1c and blood pressure), worse self-care behaviors (diet and physical activity), lower standards of care, higher mortality, and more years of life lost for adults with diabetes.

CONCLUSIONS

There is a paucity of work investigating the relationship between structural racism and diabetes outcomes. Five areas for future work include 1) more rigorous research on the relationship between structural racism, downstream social determinants, and health outcomes in diabetes, 2) policy assessments specific to diabetes outcomes, 3) research designed to examine pathways and mechanisms of influence, 4) intervention development to mitigate the impact of structural racism, and 5) tracking and monitoring of change over time.

Psychometric evaluation of a culturally adapted illness perception questionnaire for African Americans with type 2 diabetes

Background

Diabetes is burdensome to African Americans, who are twice as likely to be diagnosed, more likely to develop complications and are at a greater risk for death and disability than non-Hispanic whites. Medication adherence interventions are sometimes ineffective for African Americans because their unique illness perceptions are not adequately addressed. The Illness Perception Questionnaire-Revised (IPQ-R) that assesses illness perceptions has shown reliability and validity problems when used with African Americans. Thus, the study objective was to adapt the IPQ-R for African Americans and assess the validity and reliability of the culturally adapted questionnaire.

Methods

The parent study used an exploratory sequential mixed methods design, to explore African Americans’ illness perceptions qualitatively, used the results to adapt the IPQ-R, and tested the culturally adapted IPQ-R items quantitatively. In this paper, a preliminary culturally adapted IPQ-R refined based on the qualitative study, was administered to 170 middle-aged United States-based African Americans with type 2 diabetes in a face-to-face survey. Content, construct, convergent, and predictive validity, including reliability was examined. Pearson and item-total correlations, item analysis, exploratory factor analysis, multiple linear regression analysis, and test-retest were conducted.

Results

A revised culturally adapted IPQ-R was identified with a 9-factor structure and was distinct from the old factor structure of the original IPQ-R. The ‘consequences’ domain from the IPQ-R occurred as two factors (external and internal consequences) while the ‘emotional representations’ domain in the IPQ-R emerged as separate ‘present’ and ‘future’ emotional representation factors. Illness coherence’ was differently conceptualized as ‘illness interpretations’ to capture additional culturally adapted items within this domain. Most items had factor loadings greater than 0.4, with moderate factor score correlations. Necessity and concern beliefs in medicines significantly correlated with domains of the culturally adapted IPQ-R. Pearson’s correlation values were not greater than 0.7, indicating good convergent validity. The culturally adapted IPQ-R significantly predicted medication adherence. None of the correlation values were higher than 0.7 for the test-retest, indicating moderate reliability. Most domains of the culturally adapted IPQ-R had Cronbach’s alpha values higher than 0.7, indicating good internal consistency.

Conclusions

The results provide preliminary support for the validity of the culturally adapted IPQ-R in African Americans with diabetes, showing good construct, convergent and predictive validity, as well as reliability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13172-2.

Identifying and Reducing Disparities in Young Adults With Diabetes

This article outlines how social and health care determinants can affect young adults with diabetes. The authors provide a detailed description of each determinant's influence on diabetes self-management and offer solutions to help mitigate these harmful effects.

"All I know is that there is a lot of discrimination": Older African immigrants' experiences of discrimination in the United States

Discrimination is implicated in the disproportionate burden of disease and health disparities in racial/ethnic minorities. This qualitative descriptive study explored the experiences of discrimination and its impact on the health of older African immigrants. Semi-structured interviews were conducted with 15 participants. Three main themes and six sub-themes were identified. These included: (1) types of discrimination which were: (a) accent-based, (b) unfair treatment during routine activities, (c) experience with systems; (2) consequences of discrimination; and (3) surviving and thriving with discrimination: (a) "blind eye to it", (b) reacting to it, (c) avoiding it. These themes described common experiences of discrimination, current strategies used to deal with discrimination, and the impact of discrimination on this sample. Health care providers should be aware of discrimination experiences, how to assess for it, and identify when to refer patients to appropriate community resources that include mental health, employment, cultural groups and legal services.

Health Disparities in COVID-19: Addressing the Role of Social Determinants of Health in Immune System Dysfunction to Turn the Tide

It is evident that health disparities exist during the COVID-19 pandemic, a pandemic caused by the novel coronavirus SARS-CoV-2. Underlying reasons for COVID-19 health disparities are multi-factorial. However, social determinants, including those regarding socioeconomic status, social inequalities, health behaviors, and stress, may have implications on these disparities. Exposure to one or more of these social determinants is associated with heightened inflammatory responses, particularly increases in the cytokine interleukin-6 (IL-6), as well as immune system dysfunction. Thus, an amplified effect during COVID-19 could occur, potentially resulting in vulnerable patients experiencing an intensified cytokine storm due to a hyperactive and dysfunctional immune response. Further understanding how social determinants play a mechanistic role in COVID-19 disparities could potentially help reduce health disparities overall and in future pandemics.

Diabetes management at community health centers: Examining associations with patient and regional characteristics, efficiency, and staffing patterns

A major source of primary health care for millions of Americans, community health centers (CHCs) act as a key point of access for diabetes care. The ability of a CHC to deliver high quality care, that supports patients' management of their diabetes, may be impacted by the unique set of resources and constraints it faces, both in terms of characteristics of its patient population and aspects of operations. This study examines how patient and regional characteristics, staffing patterns, and efficiency were associated with diabetes management at CHCs (percentage of patients with uncontrolled diabetes, HbA1C > 9%). Data on a sample of 1229 CHCs came from multiple sources. CHC-level information was obtained from the Uniform Data System and regional-level information from the Behavioral Risk Factor Surveillance System and the US Census American Community Survey. A clustering methodology, latent class analysis, identified seven underlying staffing patterns at CHCs. Data envelopment analysis was performed to evaluate the efficiency of CHCs, relative to centers with similar staffing patterns. Finally, generalized linear models were used to examine the association between staffing patterns, efficiency, and patient and regional-level characteristics. Findings from this study have sociological, practical, and methodological implications. Findings highlight that the intersection of patient racial composition with regional racial composition is significant; diabetes control appears to be worse at CHCs serving racial minorities living in predominantly White areas. Findings suggest that CHCs that incorporate more behavioral health care into their staffing mix have lower rates of uncontrolled diabetes among their patients. Finally, greater efficiency in CHC operations is associated with better diabetes control among patients. By identifying sociodemographic and operational characteristics associated with better hemoglobin control among diabetes patients, the current study contributes to our understanding of both health care operations and health inequalities.

Factors Related to Medication Self-Management in African American Older Women

Individuals with multiple chronic diseases are often prescribed medications for each condition and thus must manage a drug regimen. Medication self-management is challenging for most individuals with chronic diseases, but it can be especially difficult for African American older women. This study investigated how medical mistrust, caregiver role strain, and other relevant variables may be associated with medication self-management behaviors (MSMB) among African American older women, and whether goal congruence and self-efficacy mediated the relationship between the predictor variables and MSMB. A sample of 116 African American older (age >50 years) women from central Milwaukee participated in this correlational, cross-sectional study. Although goal congruence and self-efficacy were not found to act as mediators, the main finding was that goal congruence, self-efficacy, and age predicted 30% of the variance in MSMB. The results suggest that it is essential to strengthen individual self-efficacy, determine the goals that individuals have for their medication regimen, and develop support mechanisms to help patients attain these goals to better manage chronic disease. [Res Gerontol Nurs. 2019; 12(2):71-79.].

Individual-, Community-, and Health System-Level Barriers to Optimal Type 2 Diabetes Care for Inner-City African Americans: An Integrative Review and Model Development

PURPOSE

The purpose of this integrative review is (1) to elucidate the unique barriers faced by inner-city African Americans for type 2 diabetes (T2DM) care; (2) to identify effective interventions/programs for optimal T2DM care at the individual, community, and health systems levels; and (3) to integrate 2 behavioral models and 1 social ecological model for framing interventions for inner-city African American to optimize T2DM care.

METHODS

PRISMA guidelines were followed to systematically search PubMed, PsychInfo, and CINAHL. Integration of models was based on underlying principles of social ecological models.

RESULTS

The search returned 1183 articles. Forty-six articles were synthesized after applying inclusion criteria. Multiple barriers for the individual level, community level, and health system level were identified. Major barriers include lack of knowledge, lack of social support, and self-management support. Interventions identified in this review show that among inner-city African Americans with T2DM, the focus is placed at the health systems level, with very limited focus toward addressing individual- and community-level barriers. Final synthesis includes development of a new integrated model that explains barriers to care across multiple levels.

CONCLUSIONS

These findings highlight the fragmentation that may be occurring between policy, research, and practice for achieving health equity and addressing health disparities for T2DM care among inner-city African Americans. The new model is an important step in the pursuit of equity in T2DM by specifying the complex barriers that occur across multiple levels. The application of this model using the 2017 National Standards for Diabetes-Self Management Education and Support are discussed.

Theories for Race and Gender Differences in Management of Social Identity-Related Stressors: a Systematic Review

Sociodemographic group-specific strategies for stress management may contribute to racial and gender disparities in health outcomes in the USA. We aimed to systematically review theoretical and empirical investigations of factors influencing variation in response to and management of identity-related stress among black and white Americans. OvidPsychInfo and PubMed databases were searched to identify eligible studies. Criteria were participant age of ≥ 18 years, conducted in the US sampling black or white participants, and published in English in a peer-reviewed journal. The final sample included 167 articles. Theories suggesting social status inequities as the primary contributor to disparate strategies employed by black and white women and men to manage social identity-related stress were most frequently tested and supported. Studies disproportionally focused on how women and black persons cope as targets of prejudice and discrimination rather than on how management strategies of men or white persons are affected as perpetrators. Finally, there was theoretical support for an interactive effect of race and gender on stress management, but empirical evidence was lacking, particularly among black men, white women, and white men. The literature could be strengthened through the use of prospective cohorts and nationally representative samples, as well as study designs accounting for potential within-race and within-gender variation in the effects of social identity-related stressors on coping. With greater consistency in methodology, future empirical studies may yield additional information regarding group differences in stress management pertinent to clarifying mechanisms for the health consequences of exposure to social inequity among black and white women and men.

Sociocultural Influences on African Americans' Representations of Type 2 Diabetes: A Qualitative Study

Objective

Illness representations, known as patients' beliefs and expectations about an illness, may be influenced by cultural beliefs and personal experiences. This study explored African Americans' perceptions of the sociocultural factors that influence their representations of diabetes.

Design

Six semi-structured focus groups.

Setting

Private space at a convenient site.

Participants

Forty African Americans, aged 45-60 years with type 2 diabetes for at least one year prior.

Results

Participants perceived that there was a race-mediated effect of how they developed diabetes because of poverty due to past slavery, racial discrimination by health care providers, and the stigma associated with diabetes within the African American community. Participants perceived that poverty influenced African Americans' unhealthy eating habits, which led to diabetes diagnosis among their ancestors and their development of the disease since it was hereditary. Participants also perceived that there was provider ill intention, ie, providers were purposefully making people sick, and their lack of education on diabetes from providers was done on purpose, as information on diabetes was withheld and not shared due to racial discrimination. Perceived stigma by the community led to African Americans' avoidance and denial of the disease, and subsequently the development of diabetes.

Conclusions

To enhance disease management for African Americans with diabetes, it is important to focus on the sociocultural context of how African Americans view their world that may be influenced by their knowledge of negative historical circumstances and their current provider relationship, which, in turn, may be reflected in their perceptions of diabetes.

Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis

Objectives Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization. Methods A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge. Results Due to the central role of food in social life, dietary change affects all aspects of a person's life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges. Discussion A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.

Self-reported discrimination, diabetes distress, and continuous blood glucose in women with type 2 diabetes

We investigated whether self-reported racial discrimination was associated with continuous glucose levels and variability in individuals with diabetes, and whether diabetes distress mediated these associations. Seventy-four Black and White women with type 2 diabetes completed the Experience of Discrimination scale, a measure of lifetime racial discrimination, and the Problem Areas in Diabetes, a measure of diabetes distress. Participants wore a continuous glucose monitor for 24 h after 8 h of fasting, a standard meal, and a 4-h run in period. Higher discrimination predicted higher continuous mean glucose and higher standard deviation of glucose. For both mean and standard deviation of glucose, a race × discrimination interaction indicated a stronger relationship between discrimination and glucose for Whites than for Blacks. Diabetes distress mediated the discrimination-mean glucose relationship. Whites who report discrimination may be uniquely sensitive to distress. These preliminary findings suggest that racial discrimination adversely affects glucose control in women with diabetes, and does so indirectly through diabetes distress. Diabetes distress may be an important therapeutic target to reduce the ill effects of racial discrimination in persons with diabetes.

Self-Care Disparities Among Adults with Type 2 Diabetes in the USA

Suboptimal glycemic control is more common among non-Hispanic Blacks (NHBs) and Hispanics than non-Hispanic Whites (NHWs). Disparities in the performance of self-care behaviors may contribute to this. To synthesize knowledge on current self-care disparities, we reviewed studies from January 2011-March 2016 that included NHWs, NHBs, and Hispanics with type 2 diabetes in the USA. Self-care behaviors included diet, exercise, medications, self-monitoring of blood glucose (SMBG), self-foot exams, and not smoking. Of 1241 articles identified in PubMed, 25 met our inclusion criteria. These studies report consistent disparities in medication adherence. Surprisingly, we found consistent evidence of no disparities in exercise and some evidence of reverse disparities: compared to NHWs, Hispanics had healthier diets and NHBs had more regular SMBG. Consistent use of validated measures could further inform disparities in diet and exercise. Additional research is needed to test for disparities in self-foot exams, not smoking, and diabetes-specific problem solving and coping.

Normalizing diabetes in Delhi: a qualitative study of health and health care

The Type 2 diabetes epidemic in India poses challenges to the health system. Yet little is known about how urban Indians view treatment and self-care. Such views are important within the pluralistic healthcare landscape of India, bringing together allopathic and non-allopathic (or traditional) paradigms and practices. We used in-depth qualitative interviews to examine how people living with diabetes in India selectively engage with allopathic and non-allopathic Indian care paradigms. We propose a 'discourse marketplace' model that demonstrates competing ways in which people frame diabetes care-seeking in India's medical pluralism, which includes allopathic and traditional systems of care. Four major domains emerged from grounded theory analysis: (1) normalization of diabetes in social interactions; (2) stigma; (3) stress; and (4) decision-making with regard to diabetes treatment. We found that participants selectively engaged with aspects of allopathic and non-allopathic Indian illness paradigms to build personalized illness meanings and care plans that served psychological, physical, and social needs. Participants constructed illness narratives that emphasized the social-communal experience of diabetes and, as a result, reported less stigma and stress due to diabetes. These data suggest that the pro-social construction of diabetes in India is both helpful and harmful for patients - it provides psychological comfort, but also lessens the impetus for prevention and self-care. Clarifying the social constructions of diabetes and chronic disease in India and other medically pluralistic contexts is a crucial first step to designing locally situated treatment schemes.

Barriers and Facilitators of Linkage to and Engagement in HIV Care Among HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study

Linking and engaging HIV-positive patients in care is the key bridging step to glean the documented health and prevention advantages of antiretroviral therapy (ART). In China, HIV transmission among men who have sex with men (MSM) is surging, yet many HIV-positive MSM do not use HIV care services. We conducted a qualitative study in order to help positive interventions to promote linkage-to-care in this key population. Four focus group discussions (FGD) were held among HIV-positive MSM in Beijing, China, to ascertain knowledge, beliefs, attitudes, and practices related to HIV care. FGD participates highlighted six major barriers of linkage to/engagement in HIV care: (1) perceived discrimination from health care workers; (2) lack of guidance and follow-up; (3) clinic time or location inconvenience; (4) privacy disclosure concerns; (5) psychological burden of committing to HIV care; and (6) concerns about treatment. Five major sub-themes emerged from discussions on the facilitators of linkage to/engagement in care: (1) peer referral and accompaniment; (2) free HIV care; (3) advocacy from HIV-positive MSM counselors; (4) extended involvement for linking MSM to care; and (5) standardization of HIV care (i.e., reliable high quality care regardless of venue). An understanding of the barriers and facilitators that may impact the access to HIV care is essential for improving the continuum of care for MSM in China. Findings from our study provide research and policy guidance for how current HIV prevention and care interventions can be enhanced to link and engage HIV-positive MSM in HIV care.

Qualitative Assessment of Barriers and Facilitators of Access to HIV Testing Among Men Who Have Sex with Men in China

Diagnosis of HIV is the entry point into the continuum of HIV care; a well-recognized necessary condition for the ultimate prevention of onward transmission. In China, HIV testing rates among men who have sex with men (MSM) are low compared to other high risk subgroups, yet experiences with HIV testing among MSM in China are not well understood. To address this gap and prepare for intervention development to promote HIV testing and rapid linkage to treatment, six focus groups (FGs) were conducted with MSM in Beijing (40 HIV-positive MSM participated in one of four FGs and 20 HIV-negative or status unknown MSM participated in one of two FGs). Major themes reported as challenges to HIV testing included stigma and discrimination related to HIV and homosexuality, limited HIV knowledge, inconvenient clinic times, not knowing where to get a free test, fear of positive diagnosis or nosocomial infection, perceived low service quality, and concerns/doubts about HIV services. Key facilitators included compensation, peer support, professionalism, comfortable testing locations, rapid testing, referral and support after diagnosis, heightened sense of risk through engagement in high-risk behaviors, sense of responsibility to protect self, family and partner support, and publicity via social media. Themes and recommendations were generally consistent across HIV-positive and negative/status unknown groups, although examples of enacted stigma were more prevalent in the HIV-positive groups. Findings from our study provide policy suggestions for how to bolster current HIV prevention intervention efforts to enhance 'test-and-treat' strategies for Chinese MSM.

Differential effect of race, education, gender, and language discrimination on glycemic control in adults with type 2 diabetes

BACKGROUND

Discrimination has been linked to negative health outcomes, but little research has investigated different types of discrimination to determine if some have a greater impact on outcomes. We examined the differential effect of discrimination based on race, level of education, gender, and language on glycemic control in adults with type 2 diabetes.

PATIENTS AND METHODS

Six hundred two patients with type 2 diabetes from two adult primary care clinics in the southeastern United States completed validated questionnaires. Questions included perceived discrimination because of race/ethnicity, level of education, sex/gender, or language. A multiple linear regression model assessed the differential effect of each type of perceived discrimination on glycemic control while adjusting for relevant covariates, including race, site, gender, marital status, duration of diabetes, number of years in school, number of hours worked per week, income, and health status.

RESULTS

The mean age was 61.5 years, and the mean duration of diabetes was 12.3 years. Of the sample, 61.6% were men, and 64.9% were non-Hispanic black. In adjusted models, education discrimination remained significantly associated with glycemic control (β=0.47; 95% confidence interval, 0.03, 0.92). Race, gender and language discrimination were not significantly associated with poor glycemic control in either unadjusted or adjusted analyses.

CONCLUSIONS

Discrimination based on education was found to be significantly associated with poor glycemic control. The findings suggest that education discrimination may be an important social determinant to consider when providing care to patients with type 2 diabetes and should be assessed separate from other types of discrimination, such as that based on race.

Behavioral reactivity to acute stress among Black and White women with type 2 diabetes: The roles of income and racial discrimination

This study investigated relationships of income and self-reported racial discrimination to diabetes health behaviors following an acute stressor. A total of 77 diabetic women (51% Black, 49% White) completed a laboratory public speaking stressor. That evening, participants reported same-day eating, alcohol consumption, and medication adherence; physical activity was measured with actigraphy, and the next morning participants reported sleep quality. Measures were repeated on a counterbalanced control day. There was no mean level difference in health behaviors between stressor and control days. On stressor day, lower income predicted lower physical activity, sleep quality, and medication adherence, and higher racial discrimination predicted more eating and alcohol consumed, even after accounting confounders including race and control day behaviors.

Stressors may compromise medication adherence among adults with diabetes and low socioeconomic status

Studies examining the impact of stressors on diabetes self-care have focused on a single stressor or have been largely qualitative. Therefore, we assessed the stressors experienced by a high-risk population with type 2 diabetes, and tested whether having more stressors was associated with less adherence to multiple self-care behaviors. Participants were recruited from a Federally Qualified Health Center and 192 completed a stressors checklist. Experiencing more stressors was associated with less adherence to diet recommendations and medications among participants who were trying to be adherent, but was not associated with adherence to other self-care behaviors. Because having more stressors was also associated with more depressive symptoms, we further adjusted for depressive symptoms. Stressors remained associated with less adherence to medications, but not to diet recommendations. For adults engaged in adherence, experiencing an accumulation of stressors presents barriers to adherence that are distinct from associated depressive symptoms.

The association of depression and perceived stress with beta cell function between African and Haitian Americans with and without type 2 diabetes

Background:

Diabetes and diabetes-related complications are major causes of morbidity and mortality in the United States. Depressive symptoms and perceived stress have been identified as possible risk factors for beta cell dysfunction and diabetes. The purpose of this study was to assess associations between depression symptoms and perceived stress with beta cell function between African and Haitian Americans with and without type 2 diabetes.

Participants and Methods:

Informed consent and data were available for 462 participants (231 African Americans and 231 Haitian Americans) for this cross-sectional study. A demographic questionnaire developed by the Primary Investigator was used to collect information regarding age, gender, smoking, and ethnicity. Diabetes status was determined by self-report and confirmed by fasting blood glucose. Anthropometrics (weight, and height and waist circumference) and vital signs (blood pressure) were taken. Blood samples were drawn after 8 – 10 hours over-night fasting to measure lipid panel, fasting plasma glucose and serum insulin concentrations. The homeostatic model assessment, version 2 (HOMA2) computer model was used to calculate beta cell function. Depression was assessed using the Beck Depression Inventory-II (BDI-II) and stress levels were assessed using the Perceived Stress Scale (PSS).

Results:

Moderate to severe depressive symptoms were more likely for persons with diabetes (p = 0.030). There were no differences in perceived stress between ethnicity and diabetes status (p = 0.283). General linear models for participants with and without type 2 diabetes using beta cell function as the dependent variable showed no association with depressive symptoms and perceived stress; however, Haitian Americans had significantly lower beta cell function than African Americans both with and without diabetes and adjusting for age, gender, waist circumference and smoking. Further research is needed to compare these risk factors in other race/ethnic groups.

The relationship between coping styles in response to unfair treatment and understanding of diabetes self-care

PURPOSE

This study examined the relationship between coping style and understanding of diabetes self-care among African American and white elders in a southern Medicare-managed care plan.

METHODS

Participants were identified through a diabetes-related pharmacy claim or ICD-9 code and completed a computer-assisted telephone survey in 2006-2007. Understanding of diabetes self-care was assessed using the Diabetes Care Profile Understanding (DCP-U) scale. Coping styles were classified as active (talk about it/take action) or passive (keep it to yourself). Linear regression was used to estimate the associations between coping style with the DCP-U, adjusting for age, sex, education, and comorbidities. Based on the conceptual model, 4 separate categories were established for African American and white participants who displayed active and passive coping styles.

RESULTS

Of 1420 participants, the mean age was 73 years, 46% were African American, and 63% were female. Most respondents (77%) exhibited active coping in response to unfair treatment. For African American participants in the study, active coping was associated with higher adjusted mean DCP-U scores when compared to participants with a passive coping style. No difference in DCP-U score was noted among white participants on the basis of coping style.

CONCLUSIONS

Active coping was more strongly associated with understanding of diabetes self-care among older African Americans than whites. Future research on coping styles may give new insights into reducing diabetes disparities among racial/ethnic minorities.