This study was conducted to better understand how older African Americans with diabetes view their illness, and to develop a conceptual framework for approaching their care.
METHODS
Researchers conducted interviews of 19 African American patients 65 years or older who attended clinics at an urban academic medical center. The mean age of the patients was 73 years, 58% were female, 63% had a complication from diabetes, and 58% were taking insulin. Patients were asked open-ended questions about how diabetes affected their lives and their attitudes toward treatment. Data were analyzed through a grounded-theory perspective.
RESULTS
Patients showed variation in the degree to which they believed that diabetes affected their lives and how aggressive they wished treatment to be. Themes included issues of quality of life, health beliefs, and the social context. Paradoxical, contradictory statements were common, expressing ambivalence and uncertainty regarding the effect of the illness and the treatment.
CONCLUSIONS
Wide variation exists in the attitudes of older African Americans toward their diabetes and treatment. Patients frequently expressed ambivalence toward the care of their illness. Providers should explore these issues and help patients resolve their ambivalence if patient preferences are to be respected in the overall treatment plan.
References
1.
1. Lunt H. Diabetes mellitus in older patients: is tight blood glucose control warranted?Drugs Aging. 1996;8:401-407.
2.
2. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non-insulin-dependent diabetes. In: Harris Ml, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, eds. Diabetes in America. 2nd ed.Washington, DC: US Government Printing Office; 1995:47-67. NIH publication 95-1468.
3.
3. Vijan S, Stevens DL, Herman WH, Funnell MM, Standiford CJ. Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus: putting evidence into practice. J Gen Intern Med. 1997;12:567-580.
4.
4. American Diabetes Association. Clinical practice recommendations 1999. Diabetes Care. 1999;22(suppl 1):S33-S33.
5.
5. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.
6.
6. UK Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853.
7.
7. Welch HG, Albertsen PC, Nease RF, Bubolz TA, Wasson JH. Estimating treatment benefits for the elderly: the effect of competing risks. Ann Intern Med. 1996;124:577-584.
8.
8. Gavin JR III. Diabetes in minorities: reflections on the medical dilemma and the healthcare crisis. Trans Am Clin Climatological Assoc. 1995;107:213-225.
9.
9. Chin MH, Zhang JX, Merrell K. Diabetes in the African-American Medicare population: morbidity, quality of care, and resource utilization. Diabetes Care. 1998;21:1090-1095.
10.
10. Tull ES, Roseman JM. Diabetes in African Americans. In: Harris Ml, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, eds. Diabetes in America. 2nd ed.Washington, DC: US Government Printing Office; 1995:613-629. NIH publication 95-1468.
11.
11. Schoenberg NE, Amey CH, Coward RT. Stories of meaning: lay perspectives on the origin and management of noninsulin dependent diabetes mellitus among older women in the United States. Soc Sci Med. 1998;47:2113-2125.
12.
12. Reid BV. "It's like you're down on a bed of affliction": aging and diabetes among black Americans. Soc Sci Med. 1992;34:1317-1323.
13.
13. Polly RK. Diabetes health beliefs, self-care behaviors, and glycemic control among older adults with non-insulin-dependent diabetes mellitus. Diabetes Educ. 1992;18:321-327.
14.
14. Tu KS. An assessment of diabetes self-care barriers in older adults. J Community Health Nurs. 1993;10:113-118.
15.
15. Glasgow RE, Toobert DJ, Hampson SE, Brown JE, Lewinsohn PM, Donnelly J. Improving self-care among older patients with type II diabetes: The "Sixty Something..." Study. Patient Educ Couns. 1992;19:61-74.
16.
16. Maillet NA, Melkus GD, Spollett G. Using focus groups to characterize the health beliefs and practices of black women with non-insulin-dependent diabetes. Diabetes Educ. 1996;22:39-46.
17.
17. Anderson RM, Barr PA, Edwards GJ, Funnell MM, Fitzgerald JT, Wisdom K. Using focus groups to identify psychosocial issues of urban black individuals with diabetes. Diabetes Educ. 1996;22:28-33.
18.
18. Feudtner C. Patients' stories and clinical care: uniting the unique and the universal?J Gen Intern Med. 1998;13:846-849.
19.
19. Medicode. The International Classification of Diseases. 9th revision. Clinical Modification. 5th ed.Salt Lake City, Utah: Medicode Publications; 1995.
20.
20. Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, Calif: Sage Publications; 1990.
21.
21. Charmaz K. 'Discovering' chronic illness: using grounded theory. Soc Sci Med. 1990;30:1161-1172.
22.
22. Gilovich T, Medvec VH. The experience of regret: what, when, and why. Psychological Rev. 1995;102:379-395.
23.
23. Charmaz K. The social construction of self-pity in the chronically ill. Stud Symbolic Interact. 1980;3:123-145.
24.
24. Testa MA, Simonson DC. Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: a randomized, controlled doubleblind trial. JAMA. 1998;280:1490-1496.
25.
25. Petterson T, Lee P, Hollis S. Young B. Newton P, Dornan T. Well-being and treatment satisfaction in older people with diabetes. Diabetes Care. 1998;21:930-935.
26.
26. Van Der Does FEE, De Neeling JND, Snoek FJ, et al. Randomized study of two different target levels of glycemic control within the acceptable range in type 2 diabetes. Diabetes Care. 1998;21:2085-2093.
27.
27. Brangman SA. African-American elders: implications for health care providers. Clin Geriatr Med. 1995;11:15-23.
28.
28. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;1:1-47.
29.
29. Harris R, Skyler J, Linn MW, Pollack L, Tewksbury D. Relationship between the health belief model and compliance as a basis for intervention in diabetes mellitus. Pediatr Adolesc Endocrinol. 1982;10:123-132.
30.
30. Cerkoney KAB, Hart LK. The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care. 1980;3:594-598.
31.
31. Wooldridge KL, Wallston KA, Graber AL, Brown AW, Davidson P. The relationship between health beliefs, adherence, and metabolic control of diabetes. Diabetes Educ. 1992;18:495-500.
32.
32. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol. 1992;47:1102-1113.
33.
33. Sidell NL. Adult adjustment to chronic illness: a review of the literature. Health Soc Work. 1997;22:5-11.
34.
34. McCord EC, Brandenburg C. Beliefs and attitudes of persons with diabetes. Fam Med. 1995;27:267-271.
35.
35. Barnard D. The personal meaning of illness: client-centered dimensions of medicine and health care. In: Levant RF, Shlien JM, eds. Client-Centered Therapy and the Person Centered Approach: New Directions in Theory, Research, and Practice. New York: Praeger; 1984:337-351.
36.
36. Radley A, Green R. Illness as adjustment: a methodology and conceptual framework. Sociol Health Illness. 1987;9:179-207.
37.
37. Hopper S. Diabetes as a stigmatized condition: the case of low-income clinic patients in the United States. Soc Sci Med. 1981;15B:11-19.
38.
38. Segall A. The sick role concept: understanding illness behavior. J Health Soc Behav. 1976;17:163-170.
39.
39. Williams GH, Wood PHN. Coming to terms with chronic illness: the negotiation of autonomy in rheumatoid arthritis. Int Disability Stud. 1988;10:128-133.
40.
40. Mitchell GJ. Living with diabetes: how understanding expands theory for professional practice. Can J Diabetes Care. 1998;22:30-37.
41.
41. Charmaz K. Loss of self: a fundamental form of suffering in the chronically ill. Sociol Health Illness. 1983;5:168-195.
42.
42. Kelleher D. Coming to terms with diabetes: coping strategies and non-compliance. In: Anderson R, Bury M, eds. Living with Chronic Illness. London: Unwin Hyman; 1988:137-155.
43.
43. Charmaz K. Good days, bad days: the self in chronic illness and time. New Brunswick, NJ: Rutgers University Press; 1991.
44.
44. Maines DR. Time and biography in diabetic experience. Mid-Am Rev Sociol. 1983;8:104-117.
45.
45. Peyrot M, McMurry JF, Hedges R. Living with diabetes: the role of personal and professional knowledge in symptom and regimen management. Res Sociol Health Care. 1987;6:107-146.
46.
46. Taylor RJ, Thornton MC, Chatters LM. Black Americans' perceptions of the sociohistorical role of the church. J Black Stud. 1987;18:123-138.
47.
47. Krause N, Tran TV. Stress and religious involvement among older blacks. J Gerontol Soc Sci. 1989;44:S4-S13.
48.
48. Ellison CG. Religious involvement and self-perception among black Americans. Soc Forces. 1993;71:1027-1055.
49.
49. Chatters LM, Taylor RJ. Life problems and coping strategies of older black adults. Soc Work. 1989;34:313-319.
50.
50. Neighbors HW, Jackson JS, Bowman PJ, Gurin G. Stress, coping, and black mental health: preliminary findings from a national study. Prev Hum Serv. 1982;2:5-29.
51.
51. McNabb W, Quinn M, Kerver J, Cook S, Karrison T. The PATHWAYS churchbased weight-loss program for urban African-American women at risk for diabetes. Diabetes Care. 1997;20:1518-1523.
52.
52. Cohen MZ, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med. 1994;38:59-66.
53.
53. Golin CE, DiMatteo MR, Gelberg L. The role of patient participation in the doctor visit: implications for adherence to diabetes care. Diabetes Care. 1996;19:1153-1164.
54.
54. American Diabetes Association. Position statement. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 1998;21:2180-2184.
