Original article
Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients

https://doi.org/10.1016/j.jdiacomp.2007.11.003Get rights and content

Abstract

Objective

To examine ethnic and gender differences in psychosocial factors, e.g., social support and acceptance of the disease, knowledge levels, perceived difficulty in adherence behaviors, and diabetes outcome (glycemic control and quality of life) in Type 2 diabetic patients.

Methods

Data were collected via telephone interviews from 180 diabetic subjects (34% Hispanics, 27% Non-Hispanic whites, 18% African-Americans, and 20% Asian-Indians; 52% females) from 2 clinics. Hemoglobin A1c levels were obtained from patient charts.

Results

Significant ethnic and gender differences existed in acceptance of the disease, in receiving social support, disease knowledge, perceived difficulty in self-management behaviors, glycemic control, and quality of life among Type 2 diabetic patients; differences were more pronounced by gender than by ethnicity. In general, social support and acceptance of the disease were high. However, perceived difficulty in self-management behaviors varied by racial/ethnic groups with self-monitoring of blood glucose perceived as most difficult by Hispanic respondents, dietary management was most difficult for non-Hispanic whites, while physical activity was the most difficult for African-Americans. Hispanic respondents had greatest severity of the disease (poorest metabolic control).

Conclusions

Ethnic and gender variations exist in social support, acceptance of diabetes, quality of life, and adherence behaviors. The outcomes of diabetes care can be improved if practitioners factor these differences in tailoring diabetes education and supportive care for individuals with Type 2 diabetes.

Introduction

Diabetes disproportionately affects minorities and women (Beckles & Thompson-Reid, 2001, Centers for Disease Control, 2004, King et al., 1998). Among individuals over 20 years of age, African-Americans, Mexican-Americans, and Asian-Americans are two to three times more likely to have diabetes than non-Hispanic whites of similar age (Narayan et al., 2003). Further, more than half of the 18.2 million people diagnosed with diabetes are women. Minority women are two to four times more likely to be diagnosed with diabetes than non-Hispanic white women (Beckles et al., 2001). Lifetime risk for developing diabetes is also greater among females, with Hispanic females at greatest risk (one in two chances at birth) (Narayan et al., 2003). In addition, diabetes-related complications excessively burden minorities and women (Karter, 2002, Lavery et al., 2003, Saydah et al., 2002, Young et al., 2003). Because these complications, the complexity and demand of the condition of diabetes significantly impact their quality of life (Glasgow et al., 1997, Schlundt et al., 1994), the goal of Healthy People 2010 is to reduce the incidence and burden of diabetes for women by 35% and minorities by 56% (Keppel et al., 2004).

Development and progression of diabetic complications can be minimized with good glycemic control. Glycemic control is also important for maintaining higher quality of life and achieved by self-management behaviors. Perceived difficulty in adherence behaviors impacts self-management activities and is linked to poor blood glucose control and quality of life (Bonds et al., 2004). Although many factors influence diabetes management and its outcomes (Aalto & Uutela, 1997, Gentili et al., 2001, Glasgow et al., 1997, Karlsen & Bru, 2002, Kneckt et al., 2001, Koopmanschap, 2002, Lloyd et al., 1992, Lloyd et al., 1999, Mazze et al., 1984, Nouwen et al., 1997, Peyrot et al., 1999), this article focuses on psychosocial variables (acceptance of diabetes and social support), diabetes knowledge, perceived difficulty in adherence behaviors, and diabetes outcomes (glycemic control and quality of life). In health behavior and epidemiological research, gender and racial/ethnic categories are useful for generating and exploring hypotheses about factors that influence illness and injury, especially chronic diseases, and their relative effects and interactions for important medical outcomes. Hence, ethnicity and gender differences are explored as study variables to assist in tailoring the education and supportive care offered to diabetic patients (Taylor et al., 2003). Examining racial and ethnic differences in psychosocial factors and diabetes outcomes will provide important information for addressing culturally appropriate treatment and intervention programs to improve delivery of health services and eliminate health disparities. Although ethnic/gender differences in some psychosocial factors (e.g., social support), glycemic control, and quality of life have been examined among diabetic patients (Auslander et al., 1997, Bertera, 2003, LeMaster et al., 2006, Wee et al., 2006), studies that examine extensively ethnic and gender differences in social support, acceptance of diabetes, perceived difficulty in adherence behaviors, knowledge levels, glycemic control, and quality of life among individuals with Type 2 diabetes are currently unavailable.

Optimal outcomes require ongoing adaptation, monitoring, and adherence to self-management behaviors (Rubin & Peyrot, 1999). Diabetes management, however, can be demanding and intrusive, thus increasing the perceived burden and anxiety about the disease (Eiser & Tooke, 1995, Rubin & Peyrot, 1999, Watkins et al., 2000). In general, most individuals with diabetes feel restricted in amounts, types, and timing of food consumption; social functioning; and leisure activities (Goddijn et al., 1999, Mayou et al., 1990, Watkins et al., 2000). In addition, adherence to insulin regimens (if any) can be frustrating (Mayou et al., 1990). These perceived burdens and restrictions define a diabetic patient's quality of life. Gender differences are also observed with women having higher anxiety about the disease and its complications (Bonds et al., 2004). Women report greater difficulty in adhering to the diabetes regimen than men (Enzlin et al., 2002). Although men perceive diabetes management to be difficult, it has been less of a hindrance in their life and daily activities (Enzlin et al., 2002, Fitzgerald et al., 1995, Gafvels et al., 1993).

Acceptance and knowledge of diabetes along with social support from family and friends contribute to better glycemic control and quality of life (McDonald et al., 2002). Acceptance, conceptualized as the opposite of denial (Dion, 1990), promotes positive coping behaviors, lifestyle modifications, self-motivated management behaviors, and disease control (Garay-Sevilla et al., 1999, Richardson et al., 2001, Schussler, 1992). Furthermore, acceptance of the disease influences a patient's desire to gain knowledge about the disease, medication regimen, and self-regulatory behaviors (Adams et al., 1997).

Proper knowledge of diabetes, its management, and complications decrease the risk of short-and long-term complications (Colleran et al., 2003, Speight & Bradely, 2001). A minimum level of knowledge is required for good diabetes management (Norris et al., 2001, Speight & Bradely, 2001). Although knowledge alone is not sufficient to establish healthy lifestyle choices (Simmons et al., 2004), knowledge in conjunction with social support and/or acceptance, however, may significantly influence management behaviors, glycemic control, and quality of life (Coates & Boore, 1996, Speight & Bradely, 2001).

Social support obtained through patient networking, family members, and experts (doctors, nurses) provides encouragement, information, and emotional support and reduces the stress associated with diabetes (Rubin & Peyrot, 1999, Tillotson & Smith, 1996, Toljamo & Hentinen, 2001a, Toljamo & Hentinen, 2001b, Williams & Bond, 2002). While inadequate social support has shown to adversely affect the motivation levels of patients and in turn reduce their effort to stay actively involved in diabetes self-management (Nouwen et al., 1997), a supportive environment encourages behavioral adherence for optimizing health, glycemic control, and quality of life (Aalto et al., 1997, Fukunishi et al., 1998, Garay-Sevila et al., 1995, Hanestad & Albrektsen, 1991, Kvam & Lyons, 1991, Tillotson & Smith, 1996, Toljamo & Hentinen, 2001a, Toljamo & Hentinen, 2001b). Social support, in turn, impacts differently in men and women. It improves glycemic control among women but not among men (Heitzman & Kaplan, 1984). Furthermore, men perceive that they receive the greatest amount of support from family, particularly their spouse, while women report receiving greater support from friends (Kvam & Lyons, 1991).

There are numerous factors that are associated with disparities in diabetes management and outcomes including sociocultural factors, the access to/quality of care, and psychosocial variables. Although psychosocial factors are linked to adherence behaviors, glycemic control, and lower quality of life (Hanestad & Albrektsen, 1991, Toljamo & Hentinen, 2001a), gender and ethnic differences in these factors have not been studied formally. Hence, the purpose of this study is to examine gender and ethnic differences in diabetes outcomes (glycemic control and quality of life), psychosocial predictors (acceptance of the disease and social support), knowledge, and perceived difficulty in self-management behaviors among Type 2 diabetic patients. Such comparative assessments are important in identifying disparities in diabetes management so that targeted efforts can be undertaken to improve diabetes care and eventually help reduce the disease burden on vulnerable populations.

Section snippets

Design and sample

This study utilized a cross-sectional design and a clinic-based convenience sample of 180 Type 2 diabetic patients from two health clinics in Bryan and College Station, TX. The sample represented four racial/ethnic groups: Non-Hispanic whites, African-Americans, Asian-Indians, and Hispanics. Asian-Indians, the third largest Asian group in the United States, were selected due to a higher prevalence of diabetes among them as compared to the general US population (Mohanty et al., 2005,

Knowledge

Ten questions, based on the American Diabetes Association's information regarding Type 2 diabetes, were used to assess participants' knowledge about diabetes. Response options included “true,” “false,” and “unsure.” The questions were summed for a total knowledge score, and a higher score indicated greater diabetes knowledge. Cronbach's α for the knowledge scale was .754.

Acceptance

The 20-item Revised Ideas About Diabetes (IAD-R) scale measured acceptance of diabetes (Dion, 1990). The IAD-R measures 3

Results

The sample composed of 180 Type 2 diabetic patients with a mean age of 54.8 years (S.D.=11.9; range, 24–81 years) and mean age of onset of diabetes at 45.9 years (S.D.=12.7) (Table 1). Approximately one third of the participants (34%) were Hispanics, 18% were African-American, 27% were non-Hispanic white, and 20% were Asian-Indian. The majority of the respondents were female (52%), married (65%), and had a high school diploma (55%). Of those who were high school graduates, 70% indicated they

Discussion

The most noteworthy findings of this study is the presence of significant racial/ethnic differences in perceived difficulty in self-management behaviors, acceptance of diabetes, knowledge levels, and quality of life among Type 2 diabetic patients. Perceived difficulty in adherence behaviors varied by the respondent's ethnicity and has implications for developing culturally appropriate diabetes management programs—SMBG was perceived to be most difficult among Hispanics, dietary management among

Conclusion

The results highlight significant ethnic and gender differences in psychosocial factors, self-management behaviors, and quality of life indicators among Type 2 diabetic patients that will aid practitioners to tailor diabetes education and supportive care in a more culturally appropriate manner. Asian-Indian respondents had the most positive outlook and good glycemic control; African-Americans were most inhibited by their disease and perceived physical activity as the most difficult

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