Family Support in the Self-Management of Type 2 Diabetes Among Hispanics
For nurses treating a large number of Hispanic patients, it is an unfortunate reality that they will also encounter a large number of diabetics. Diabetes is one of the most persistent and apparent health disparities affecting Hispanic communities; they are nearly twice as likely to suffer from the disease than white non-Hispanics. Fortunately, Hispanic diabetics rarely face the fight against their disease alone, supported by strong family environments.
This study explored the impact of that family-patient dynamic among a small group of Hispanics who attend a diabetic support group meeting at First Christian Church in Marietta, Georgia. It included both diabetics and supportive non-diabetic family members.
All participants reported family as an important entity, which coincides with traditional values among Hispanic families that promote strong family ties and loyalty.1 Diabetic individuals in this study expressed their confidence toward family support, but the survey also found perceived cultural barriers to diabetes management might significantly affect adherence to following a diabetic diet. Handling social pressure and incorporating traditional foods into the diabetes meal plan are core cultural issues for many Hispanics.2
All subjects demonstrated some knowledge of diabetes and self-management, but both diabetics and non-diabetics revealed some misunderstandings regarding what causes the disease. Many participants expressed fatalistic attitudes, saying they believed that what happens in life is out of their control and in God’s hands. Fatalism (fatalismo) is frequently identified as a cultural perspective among Hispanics1 and an affecting factor in the health conditions of Hispanic patients with diabetes.3 Persons who adhere to fatalism may dismiss the idea that diabetes can be prevented or managed.
Project purpose and rationale
The purpose of this project was to better understand the beliefs, perceptions, and attitudes toward Type 2 diabetes among adult Hispanic individuals and their family members in a faith-based community and explore the impact that family members impose on a diabetic’s self-management of this disease.
To successfully manage Type 2 diabetes, individuals need to make a commitment to lifestyle changes such as healthy diet, physical activity, and preventive care in order to adhere to recommended treatment guidelines. These necessary changes can affect family members, which can circle back to the individual, as all family members are interdependent. Family plays a critical role in the health of each member,4 especially since healthy habits are often developed within the context of family.5
Current data indicates that the lifetime risk of developing Type 2 diabetes is greater for Hispanic men (54.5% risk) and Hispanic women (45.4% risk), compared to a 31.2% and a 26.7% risk among non-Hispanic white women and men, respectively.6 This alarmingly high risk rate among the Hispanic population is a public health concern, and even though evidence suggests that family psychosocial interventions can improve chronic illness outcomes, a number of authors have noted that research has so far neglected the role family plays in the management of Type 2 diabetes.7
Implementing the project
The intended sample size was 10 participants who have had Type 2 diabetes for at least one year from the WellStar Congregational Health Ministry and Kennesaw State University’s Project Initiative for Diabetes Education Advancement for Latinos (IDEAL), and one of their family members. With approval of the study from the Institutional Review Board at KSU, a student researcher collected data with support from a WellStar congregational nurse and Janice Long, Ph.D., R.N., an assistant professor of nursing at KSU and Director of Project IDEAL. In order to reach potential participants, the researchers attended diabetic support group meetings at the First Christian Church in Marietta, Georgia, and KSU Community Health Clinic MUST Ministries in September and October 2010. WellStar Congregational Health Ministry and KSU Project IDEAL facilitated the support groups for diabetic individuals and their family members.
At an August support group meeting at the First Christian Church, the WellStar congregational nurse made a verbal announcement to recruit the participants. Criteria for selection of participants were Hispanic adults 18 years or older, diagnosed with Type 2 diabetes for at least one year, and receiving family support to manage their disease. Those who met the inclusion criteria were asked to choose the family member who provided the most assistance in managing their disease (also 18 years or older) to participate in the survey as well.
Data was collected using instruments developed by the student researcher based on family support and diabetes literature, the investigator’s experience with Hispanic families with diabetes, and suggestions from nursing educators. Available to participants in English and Spanish, the surveys were the Diabetes Self-Management Questionnaire (DSMQ), Diabetes Family Support Questionnaire (DFSQ), and Demographic Profile. These three items were combined into two 43-item questionnaires, one for the diabetic and the other for the family member.
The Demographic Profile included questions on age, gender, ethnicity, country of origin, education status, income, marital status, household status, and length of stay in the United States. Diabetic specific questions included number of years with diabetes, mode of diabetic management, and health insurance. The four questions used to access acculturation level included language preference, language spoken at home, use of children as interpreters, and English-speaking ability. The 25 items for the DSMQ and DFSQ consisted of statements dealing with diabetes-related knowledge, self-management of the disease, family support behavior, perceived cultural barriers, acculturation, and depression. The student-developed questionnaires were not tested for reliability since the sample size was very small.
The last two items of the DSMQ and DFSQ were adapted from The Patient Health Questionnaire- 2 (PHQ-2) to screen for frequency of depressed mood over a two-week period. Researchers have suggested that when diabetes occurs concurrently with depression, diabetes management suffers, yet little is known about the effects of depression on diabetes self-efficacy.8
The 10–15 minute survey was translated to Spanish by a native speaker and tested on three native Spanish-speaking students from KSU. Persons completing the questionnaires were not asked for any personal identifying information. Each diabetic and family member was asked to complete a questionnaire independently during a support group meeting, while an interpreter was available for any needed translations.
The data was analyzed to calculate proportions, percentages, standard deviation, and mean. Because the sample data was small, internal consistency reliability and correlation were not deemed appropriate.
Evaluation and final project outcomes: diabetics
Eight diabetic individuals and six family members participated in the survey; not all family members were present at the support group meetings. All participants identified themselves as Hispanic, with length of time in the United States ranging from one year to 47 years. On average, diabetic patients were in their 60s, while the family members’ mean age was 47. The majority of the participants were married (71%). Only one participant lived alone; half lived with family or friends, and the rest with family or friends and children. About 86% of the participants preferred speaking Spanish, and all favored speaking it at home. The majority said they had an “average” English-speaking ability. Half of the family members had high school education or higher, while only 28.6% of the diabetic individuals had high school or additional education.
The diabetic participants had been diagnosed with diabetes for an average of almost 10 years (range: four to 21 years). Fifty percent reported they manage their diabetes with medication; slightly more than one-third controlled their diabetes with diet and exercise alone. Only one of the diabetic participants took insulin. More than half of the diabetic participants had health insurance. The diabetic participants were in agreement on most items dealing with self-management and family support behavior, and they felt family was an important entity. Furthermore, they agreed that family support is essential in motivating them to manage their diabetes. The diabetic participants reported feeling confident in their knowledge of testing blood glucose, taking diabetic medications as recommended, exercising, checking their feet, and following a diabetic meal plan. However, the diabetic individuals indicated they would feel selfish if changes in their diet and exercise patterns were different from the family’s routine.
One study shows that social support from family and friends was positively associated with testing blood glucose levels, following a diabetes meal plan, and checking feet, but was not significantly associated with other self-management behaviors.9 Nevertheless, the majority of the participants agreed that they received sufficient culturally specific education regarding a diabetic diet. (The fact that participants received such education can be associated with being a member of the diabetic support group for Hispanics at the First Christian Church.)
The majority of diabetic participants’ answers suggest that they had average knowledge of the following: normal blood glucose level, A1C goals for diabetic individuals, diabetes as a severe health problem, and the long term complications of diabetes. However, other research suggests that many Hispanic adults have limited knowledge about diabetes. Many participants also see their disease as a punishment from God (fatalismo) and feel they can do little to alter their fate, which may hinder Hispanic diabetic patients in successfully managing their disease.10 Participants’ answers about their knowledge of blood glucose levels were less confident when the diabetic individuals expressed these fatalistic beliefs.
Regarding perceived cultural barriers, the diabetic participants were mostly in agreement in suggesting that family support can also undermine individuals’ efforts to control their disease. Diabetic participants found it most difficult to stick with a diet different from their family diet; moreover, the survey depicts that their needs are secondary to the family’s needs. Fifty percent of the diabetic participants strongly agreed that their dietary restrictions conflicted with their food preferences. The majority (87.5%) of the diabetic participants were females. A Hispanic woman may be considered “self-indulgent” if she changes the family diet to support her diabetes meal plan; this negative perception could possibly contribute to poorer glycemic control.2 Another factor affecting home-based diabetic care, depression is two times more prevalent among persons with Type 2 diabetes and is more common among Hispanics than among non-Hispanics with the same condition.11 The PHQ-2 is used as the initial screening test for major depressive episodes in this study. The probability of a major depressive disorder among the diabetic individuals, on average, is 18%, and the probability of any depressive disorder, on average, is 36%. All the diabetic participants who at least identified one depressive symptom on the PHQ-2 strongly agreed that it is difficult for them to stick to a diet different from their family’s diet; these diabetic participants were all female. Eighty percent also indicated that they manage their diabetes with diet and exercise alone.
In 2004, the World Health Organization declared depression the second leading cause of disability among all health problems.12 In this study, diabetic individuals were more likely to be at risk of a depressive disorder than nondiabetic family members. This could reflect the fact that cultural barriers in management of diabetes might affect the relationship between family function and depression. The belief that Hispanic women seem “self-indulgent” when they change the family diet to support a diabetic meal plan may contribute to higher rates of depression among Hispanic women with diabetes. This is important to note since individuals with Type 2 diabetes who experience co-morbid depression manage their diabetes less effectively.12
Evaluation and final project outcomes: non-diabetics
Non-diabetic family members were in agreement on most items dealing with diabetes- related knowledge, self-management, family support behavior, and acculturation. All family members strongly agreed on these statements: family is important, they know how often their family member with diabetes checks his/her feet for wounds, and they get sufficient culturally specific education on the diabetic diet. Comfort with diabetes-related knowledge was also high. Most of the subjects said they believed that they knew normal blood glucose levels, understood that diabetes is a severe health problem, and were aware of the long-term complications of the disease. However, the knowledge level of the family members regarding A1C goals was lower, and many also held fatalistic beliefs.
Nearly every non-diabetic said they thought they knew how their diabetic family member managed his/her disease. When the non-diabetics were asked about their diabetic family member’s exercise habits, the answers were slightly less confident. The survey also indicated that most non-diabetic family members strongly agree that they are supportive in managing diabetes. Nevertheless, 40% of family members said diabetes had changed their relationships with their families.
Regarding non-diabetic family members’ perceptions of cultural barriers, 60% indicated that the dietary restrictions of their diabetic family member conflicted with their food preference. One corroborating study shows that family members can be confused and frustrated when trying to modify a typical Hispanic diet.2 Based on the PHQ-2, the probability of a major depressive disorder among family members is, on average, about 8%, and the probability of any depressive disorder is, on average, 15%.
Implementing project findings
On a local level, these research findings will be shared with support group leaders to examine and improve the current services offered to diabetic individuals and their family members by WellStar Congregational Health Ministry and Kennesaw State University’s Project IDEAL.
In a greater health care context, cultural and familial roles can either strengthen or undermine individuals’ efforts to control their diabetes. Factors affecting attitudes and behaviors toward self-management of diabetes, in this study, are rooted in Hispanic culture, such as fatalism (fatalismo) and traditional diet. Fatalism among Hispanics may require innovative program intervention, education, and motivation strategies for successful self-management of diabetes.
Nurses in faith-based community settings may need to assess for spiritual health to identify beliefs that can play a role in either preventing disease or identifying individuals that may be victims of their own beliefs. Community faith-based diabetic support groups can negotiate cultural barriers to achieve empowerment and feelings of self-efficacy.
Participants can be encouraged with alternative methods of preparing traditional Hispanic meals, modifying their typical diet, and involving both diabetic individuals and their family members in the transition. It is also important to note the link between depression and diabetic management, which demonstrates that depression and thus ineffective diabetic self-management can be prevented. Ultimately, patient- and family-centered culturally competent diabetes programs can enable Hispanic diabetics to make beneficial lifestyle changes.
- Garcia, F. C. (1995). “Mexican American Values in the American Southwest.” Southwest Hispanic Research Institute. Working Paper Series. Albuquerque, New Mexico: University of New Mexico.
- Early, K., Shultz, J., and Corbett, C. (2009). “Assessing Diabetes Dietary Goals and Self-Management Based on In-Depth Interviews with Latino and Caucasian Clients with Type 2 Diabetes.” Journal of Transcultural Nursing, 20, 371-381.
- Caban, A., and Walker, E. A. (2006). “A Systematic Review of Research on Culturally Relevant Issues for Hispanics with Diabetes.” The Diabetes Educator, 32(4), 584–595. Retrieved from http://tde.sagepub.com.
- Allender, J., Rector, C., and Warner, K. (2010). Community Health Nursing: Promoting and Protecting the Public Health, Philadelphia, PA: Lippincott Williams & Wilkins.
- Campbell, T. L. (2006). “Improving Health Through Family Interventions.” Handbook of Families & Health: Interdisciplinary Perspectives (D. R. Crane and E. S. Marshall, eds), Thousand Oaks, CA: Sage Publications. 379–395.
- Centers for Disease Control and Prevention. (2010). “Prevalence of Diabetes Among Hispanics in Six U.S. Geographic Locations.” Retrieved from http://www.cdc.gov/diabetes/pubs/factsheets/hispanic.htm.
- Keogh, K., White, P., Smith, S., McGilloway, S., O’Dowd, T., and Gibney, J. (2007). “Changing Illness Perceptions in Patients with Poorly Controlled Type 2 Diabetes, a Randomized Controlled Trial of a Family-Based Intervention: Protocol and Pilot Study.” BMC Family Practice, 8, 36–10.
- Coffman, M. (2008). “Effects of Tangible Social Support and Depression on Diabetes Self- Efficacy.” Journal of Gerontological Nursing, 34(4), 32–39. Retrieved from http://www.slackinc.com.
- Rosland, A., Kieffer, E., Israel, B., Cofield, M., Palmisano, G., Sinco, B., et al. (2008). “When is Social Support Important? The Association of Family Support and Professional Support with Specific Diabetes Self-Management Behaviors.” Journal of General Internal Medicine, 23(12), 1992–1999.
- Campos, C. (2007). “Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes.” Southern Medical Journal, 100(8), 812–520. Retrieved from www.sma.org.
- World Health Organization. (2004). “WHO Initiative on Depression in Public Health.”
- Fortmann, A. L., Gallo, L. C., Walker, C., and Philis-Tsimikas, A. (2010). “Support for Disease Management, Depression, Self-Care, and Clinical Indicators Among Hispanics with Type 2 Diabetes in San Diego County, United States of America.” Journal of Public Health, 28(3), 230–4. Retrieved from http://www.springer.com/medicine/health+informatics?SGWID=0-10062-0-0-0.
- Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., et al. (2010). “Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population.” Annals of Family Medicine, 8(4), 348–353.
- Miranda, A., Bilot, J., Peluso, P., Berman, K., and Van Meek, L. (2006). “Latino Families: The Relevance of the Connection Among Acculturation, Family Dynamics, and Health for Family Counseling Research and Practice.” Family Journal, 14(3), 268–273.
- Snyder, L. (2008). “Insights for Creating Culturally Competent Health Care Programs in the Latino Community.” Diversity Factor, 16(1), 35-41. Retrieved from http://diversityfactor.rutgers.edu
- Smokowski, P., Rose, R., and Bacallao, M. (2008). “Acculturation and Latino Family Processes: How Cultural Involvement, Biculturalism, and Acculturation Gaps Influence Family Dynamics.” Family Relations, 57(3), 295-308.