Self-Management of Type 2 Diabetes in Adult Haitian Immigrants: A Qualitative Study

Abstract

Introduction: A large body of literature exists on self-management of type 2 diabetes (T2D) in a variety of populations. However, research is limited on how Haitian immigrants self-manage their T2D despite a prevalence of 6.9% in Haiti. The purpose of this study was to explore and describe the lived experience of adult Haitian immigrants managing T2D living in the United States. Methodology: Moustakas’s phenomenological approach guided this qualitative study. Adult Haitian immigrants diagnosed with T2D for at least 1 year were interviewed. Individual interviews were audio-recorded, transcribed verbatim, uploaded into NVivo, and analyzed using Moustakas’s existential data analysis process. Results: We interviewed 16 participants (mean age 56;12 females; an average of 11 years living in the United States; mean hemoglobin A1c 8.1%). Four themes emerged: self-reliance, spirituality, nostalgia for home, and a desire for positive patient–provider relationships. Cultural influences and health beliefs may affect individual self-management of T2D in this population. Conclusions: These results may assist clinicians in identifying factors that contribute to suboptimal self-management in Haitian immigrants and help patients reach glycemic control. Culturally competent assessment and interventions for Haitian immigrants with T2D may not be provided without considering these four themes.

Keywords

diabetes health disparities transcultural health phenomenology qualitative migration

Introduction

Increases in diabetes-related complications and death in minority populations have been attributed to the individual’s inability to effectively self-manage the disease (Carey & Doherty, 2012; Golden et al., 2012; Rosenstock, Whitman, West, & Balkin, 2014). Diabetic Haitian immigrants living in the United States have unique migration experiences compared to other ethnic groups (Magny-Normilus, 2016; Ross, 2010). Little is known about the influence of Haitian immigrants’ self-management activities, health-related beliefs, and lived experience with type 2 diabetes (T2D).

In the United States, Haitians make up a large portion of the Black Diaspora, that is, 1.1 million and rising. In 2016, the prevalence of T2D in Haiti was 6.9%. (World Health Organization, 2016). Despite these facts, research is scarce that pertains to the health status of Haitian immigrants and Haitian Americans apart from those living with human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), and/or tuberculosis. Of the limited studies on chronic disease, only a few assessed factors influencing Haitian immigrants’ ability to self-manage their conditions (Moise, Conserve, Elewonibi, Francis, & BeLue, 2017; Sanon, Spigner, & McCullagh, 2016).

Haitian immigrants have traditionally been combined with African Americans (AAs) in diabetes research studies, but Haitian perceptions and beliefs about causes of disease may be different from those of other Black populations (Magny-Normilus, 2016; Moise et al., 2017; Purnell & Paulanka, 2008). Haitian immigrants often attribute health problems to religious factors and rely on family decision making to address health concerns (Magny-Normilus, 2016; Ross, 2010). Haitian immigrants’ beliefs about T2D are filtered through the lens of not only the American culture but of the Haitian culture as well.

The studies related to Haitian immigrants and diabetes have primarily used descriptive, quantitative designs (Huffman, Exebio, Vaccaro, Zarini, & Dixon, 2013; Vaccaro, Exebio, Zarini, & Huffman, 2014; Vimalananda, Rosenzweig, Cabral, David, & Lasser, 2011). In one study, Haitian immigrants were more likely than AAs to follow dietary recommendations when they were provided with medical advice on a healthy dietary regimen (Huffman et al., 2013). In another study, resilient cultural values were perceived to be valuable in the prevention and management of T2D (Moise et al., 2017). Diabetes self-management practices were higher in Haitian immigrants compared to AAs, yet Haitian immigrants had poorer glycemic control (Huffman et al., 2013). Family/friend support has been strongly associated with improved diabetes self-management in different ethnic groups, including Haitian immigrants (Vaccaro et al., 2014). Thus, varying levels of family/friend support and self-management strategies have been described, but no research is available on how family/friend support and self-management relationships developed over time and how culture may have led to the variations (Huffman et al., 2013; Vaccaro et al., 2014; Vimalananda et al., 2011).

In summary, strong family/friend support, self-monitoring, and effective dietary and medical advice are associated with improved self-management, metabolic control, and clinical health outcomes in Haitian immigrants (Huffman et al., 2013; Vaccaro et al., 2014). However, Haitian immigrants had poorer metabolic control than comparable ethnic groups (Vaccaro et al., 2014; Vimalananda et al., 2011). Ineffective diabetes self-management among adult Haitian immigrants is a significant problem that requires further exploration. An etic rather than emic perspective dominated the literature. Research regarding lived experiences of adult Haitian immigrants managing their T2D is missing. Therefore, vital factors that may influence self-management of T2D in this population was not found. The purpose of this study was to explore and describe the lived experience of adult Haitian immigrants living in the United States who are self-managing their T2D to further understand the unique cultural factors influencing diabetes self-management. The specific aims of the study were (a) to explore the self-reported lived experiences of adult Haitian immigrants in managing their T2D and (b) to identify the challenges faced by this population in managing their disease so that health care providers can offer more effective diabetes care. The study was guided by this research question: What is the lived experience of adult Haitian immigrants who are self-managing their diabetes?

Method

Study Design

A phenomenological approach described by Moustakas (1994) guided this study. Moustakas’s approach was developed from the philosophical underpinning of the German philosopher Edmund Husserl, who was interested in discovering meanings and essences of knowledge. Phenomenology is described by Moustakas as a form of investigation that seeks to shed light on human experiences by exploring phenomena and how it is experienced and perceived by a person or group (Lester, 1999; Moustakas, 1994). Moustakas further postulated that the value of qualitative research is that the research captures the wholeness of experiences and aims to search for essences of experiences. Based on this view, an inseparable relationship exists between the experience and behavior of a phenomenon with the individual or group experiencing the phenomenon (Moustakas, 1994). The phenomenon in this study was the lived experience of adult Haitian immigrants who are self-managing T2D.

The primary researcher is a Haitian immigrant, a family nurse practitioner with several years of experience in diabetes care. Given the researcher’s background, all preconceived judgments were set aside through epoché during data collection and data analysis.

Sample Inclusion/Exclusion Criteria

The inclusion criteria were (a) adult Haitian immigrants, (b) 21 to 64 years of age, (c) T2D for at least 1 year, (d) living in the United States for more than a year, (e) willing and able to participate in an individual interview, and (f) able to speak Haitian Creole or English. Exclusion criteria were (a) non-Haitian immigrants; (b) a diagnosis of Type 1 diabetes; (c) the presence of diabetes-related complications such as blindness, stroke, myocardial infarction, or hemodialysis; (d) inability to comprehend, consent, and fully participate in the study; and (e) an age greater than 64 years (because of possibly different self-management needs due to coexisting chronic conditions).

Recruitment, Sampling, and Sample

Using purposive sampling, participants were recruited from an urban outpatient clinic in the northeastern United States. A list of adult Haitian immigrants with T2D was obtained through a medical record query that produced 133 potential participants. Of these, 60 were excluded because of their age (>64). Individuals who met the inclusion criteria were contacted and invited to meet to discuss participating in the study. Those meetings were held either at the clinical research center or in the potential participant’s residence.

Sixteen adult Haitian immigrants participated in the study. After interviews of 10 participants, the breadth and depth of data needed to reach saturation were achieved. However, due to the dearth of qualitative studies on the lived experience of this population, and because six more individuals wanted to participate, six more interviews were completed, which confirmed the initial analysis.

Data Collection

Interviews were conducted between March and April 2017, each lasting 45 minutes on average. Participants were given the choice between Haitian Creole and English interviews; six opted for Haitian Creole. Eleven of the interviews were conducted at the participants’ residence. After the consent form was explained and signed by the participants, a semistructured interview guide was used during the face-to-face, audio-recorded, one-on-one interview. The interview guide had been developed according to the research question, the methodology, and the cultural dynamics with open-ended questions such as (a) “Can you tell me the story of when you were first diagnosed with T2D? (b) Tell me about a typical day in managing your T2D; and (c) What are your experiences after having and managing T2D? The semistructured interview guide included probing questions focusing on information about how the participant self-manages his/her T2D. After each interview, glycosylated hemoglobin A1c (HbA1C), weight, and height (all taken from medical records) were recorded in order to describe the level of overweight and obesity in the sample as it relates directly to T2D development (Eckel et al., 2011). The HbA1C level was recorded to document the participant’s level of engagement for descriptive purposes and to examine if the participant was aware of their levels as part of their self-management program. Immediately after each interview, field notes that described nonverbal cues and interpretation of initial findings were entered. A $20 gift card was given at the completion of the interview in appreciation of their participation.

Human Subject Protection

The university and study site institutional review boards approved the study. Signed consent, which described participant rights and how their privacy would be protected, was obtained, a copy of which the participant was given. Privacy and confidentiality were maintained through the use of assigned fictitious names. Study interviews, field notes, and transcriptions were kept in a password-protected cabinet.

Translation

To enable participants to select their language of preference, the scripts for telephone recruitment, demographic questions, consent form, semistructured interview guide, and description of the study were translated into Haitian Creole. The translation process followed the guidelines of Chávez and Canino (2005), including back translation. A study team member and a translation agency collaborated in translating the transcripts generated from the Haitian Creole interviews into English for coding. These procedures ensured that different cultural meanings were not lost in the literal translations of words.

Data Analysis

Demographic characteristics were summarized. The interviews were all transcribed verbatim. The interviews conducted in Haitian Creole were transcribed in Haitian Creole and then the process of translation indicated above was followed. Once all were translated into English, the demographic data, transcriptions, and field notes were uploaded into NVivo software 11, from Qualitative Solutions and Research, for data organization and analysis. Transcripts were read multiple times, and segmented text was assigned codes (referred to as nodes in NVivo). The data articulating common concepts were assigned to an appropriate node and then reviewed until data saturation was reached and no new data could be added to the nodes. During the iterative process, subcategories were created and then clustered under overarching themes (Creswell, 2013).

The four criteria suggested by Lincoln and Guba (1985) were used to assess trustworthiness: credibility, transferability, dependability, and confirmability. Credibility was assured by reflective journals, field notes, and verbatim transcripts. Confirmability was achieved by having a subset of participants (n = 4) verify the transcripts, which resulted in no changes to the data. One of the coauthors independently reviewed and analyzed a subset of transcripts to confirm the developing themes; themes were later reviewed and verified for consensus. Dependability was assured by using NVivo software that provided an audit trail. Transferability was supported by the in-depth or thick description of the 16 interviews.

Results

At the end of the interview sessions, most participants offered comments about the interview process such as “therapeutic, lively, positive, cordial,” which appeared to indicate that they felt they had been listened to and respected. During the interviews, the participants discussed their perceptions of and experiences with T2D. They understood that T2D is a complex medical issue. Meanings related to their experiences of living with and managing T2D emerged from the data in four themes: self-reliance, spirituality, nostalgia for home (Haiti), and the desire for positive patient–provider relationships.

Demographics

Participants had moved to the United States between 1974 and 2006, with an average of 11 years living in the United States (Table 1). Eighty-one percent reported that they were not able to meet financial obligations. Most reported that they were self-managing their diabetes, with limited family support. More than half were of normal weight (56%), 13% overweight, and 19% obese. Average HbA1C levels ranged from 5.80 to 15.00, with a mean of 8.1%. Only three participants knew and could accurately state their recent HbA1C levels, with 33% meeting the recommended guidelines for metabolic control (7.0 or below). A greater number were on oral medications (75%); 19% were also on insulin.

Table 1.

Participant Characteristics.

Sample characteristics	M	SD	Range
Age (years)	55.63	6.5	40-63
Validated A1C levels^a	8.1	2.47	5.80-15.0
Body mass index	32.8	7.21	24.6-55.1
	N	%
Haiti origin
Port-au-Prince	6	37.6
Other (Cap-Haitien, Artibonite, Cayes, Jérémie, Port-De-Paix)	10	62.4
Education
High school	6	37.5
Some college	8	50.0
Other	2	12.5
Marital status
Single	2	12.5
Married	8	50.0
Divorced	6	37.5
Work
Full-time	11	68.8
Part-time	2	12.5
Disabled	3	18.8
Income meeting needs
Yes	3	18.8
No	13	81.3
Primary self-management
Spouse	2	12.5
Self	11	68.8
MD/nurse practitioner	1	6.3
Other	2	12.5
Comorbidities
Hypertension	15	93.8
Hyperlipidemia	1	6.3
Overweight/obese^a	5	12.5/18.8

A1C levels and recorded weight verified from patient records.

Self-Reliance

The participants demonstrated an attitude of self-reliance. Despite having strong family values, the majority exhibited independence in T2D self-management. The examples below describe their self-reliance: Julene, a 56-year-old woman who has managed her diabetes for over 10 years, noted, “I am the one that helps me. If I didn’t take this disease seriously, the disease would have taken my life.” Marthe, a 59-year-old woman, noted her self-reliant attitude as “I know my body. It’s all me. You know, in the U.S., family doesn’t have time for each other.” And John, a 62-year-old who has managed his diabetes for over two decades, stated, “Yes, support would have been helpful, but, at this point, I don’t really need a lot of help because I am still on my two feet and able to take care of myself.”

Although the majority of the participants have been living with T2D for at least 5 years, they varied in their self-management of blood glucose monitoring, choices of food, sedentary lifestyle, and administration of medications. Twelve of them shared that they occasionally monitor their blood glucose, had major variations in healthy eating and physical activities, and had issues adhering to prescribed medications. Most often, they checked blood glucose only when there were changes in symptoms such as feeling cold or clammy, experiencing headaches, or having polyuria.

Jacques, 61, reported,

To tell you the truth, nowadays, I only check my blood sugar when I don’t feel good. If I feel dizzy, or sense that the level is low, I eat more food, and if the level is higher, I eat very light and recheck my sugar a few hours later to see.

Kellie, also age 61, summarized her reflections as “Like, I make rice, I make sós pwa [bean sauce]. Based on what my blood sugar is, I will decide how much of the rice, sós pwa, and meat I eat.” In contrast, a few participants mentioned that they check their blood sugar regularly. For example, Sophia, who has been living in the United States for over 30 years and has managed her diabetes for 22 years noted, “I check my blood sugar to see what the level is. If it’s low, I therefore, don’t take insulin. I watch my menu, so if the blood sugar is really low, I don’t even take my Metformin.”

The majority of these participants stated that they had not received any formal diabetes education, which may have contributed to variations in effective self-management behaviors. According to Kolb and Lipman (2015), diabetes self-management education and support services are also underutilized in the general population.

Spirituality

The participants shared stories of their chronic disease as it related to religious/spiritual beliefs ingrained during their early years in Haiti. Despite strong feelings of self-reliance (internal locus of control), participants also expressed strong beliefs about the power of God (external locus of control) to help them manage their chronic illness. Spirituality was reported as a major source of strength in coping with and managing T2D. While a few commented that they prayed that God would take “it” (the disease) away from them, others indicated relief or comfort from God and described how God carried them through their daily management. Most regularly attended church services and social church gatherings as a source of support. In terms of self-management, the majority indicated caring for themselves with God as their primary support on a daily basis, even when family/relatives actively participated in their care.

Soimise, a 56-year-old woman who has lived in the United States for over 10 years, noted, “My faith in God keeps me going and I think whatever stress I have, I always find a way to let it go and let God control, and that has helped me with this disease.” Gretha, age 49, diagnosed within a few years of immigrating to the United States, noted,

What does God bring to my life? He brings a lot into my life. He has changed my life. He has given me relationships among my peers, and has helped me socialize, which relieves the stresses that come with this disease.

Jacques, 61, stated,

I mean, my faith is that, God is never late. I can be late, you can be late, but, He’s never late. For example, once I am done talking with you, I will take a shower and go to church. I am in a group at the church, and they help with my diabetes.

And Kellie, 61, said, “So, when diabetes wants to bother me, I pray to God, and He keeps me in the right path.”

Nostalgia for Home (Haiti)

Participants reflected on the cultural challenges that they faced in the United States. The differences in pace of life and environment between the two countries were viewed by many as a barrier to effective self-management. They indicated that a sedentary lifestyle, poor nutrition, and lack of necessary resources were obstacles related to the process of acculturation. Some examples include working multiple low-paying jobs, having to use cheaper/fast-food chains while supporting family members both here in the United States and in Haiti. The majority found Haiti’s food to be “natural” when compared to “heavily processed” foods in America. Their beliefs of which food choices are good for them were strongly influenced by their previous experiences. The differences in grocery shopping as well as their beliefs of what is “good” for them guided their self-management strategies. These differences may well be ongoing during their acculturation phases between Haiti and the United States, their newly adopted country.

Julene, 56, noted,

For example, someone who lives in the countryside can get and eat fresh ripe banana right from their banana tree. So, I might not have diabetes if I was still in Haiti as my food items would have been fresh. Things are different in America. Within a few months after we move here, most of us gain tons of weight.

Pierre, a 44-year-old who has lived in the United States for over 10 years, noted “The food in Haiti makes me feel good but the ones in the U.S. don’t always make me feel good. In Haiti, I know they say we’re poor, but our food is fresh.”

Daphney, age 57, shared,

In Haiti, we walk to school and back, we walk to meet our friends when we need to socialize, we walk to meetings, everything we walk to. We had more time to socialize with family and friends. We loved each other more, less stress.

John reported,

In Haiti, they use the word doctѐ féy/pansman [leaves doctor/dressings]. So, someone has a cut, they go to the garden and pick up the special leaves, they place the pansman, before you know it, the cut is healed. The leaves from Haiti have managed many diseases, even bad infections.

Desire for Positive Patient–Provider Relationships

When talking about their health care providers, most participants spoke of providers’ lack of recognition and understanding of the Haitian culture. Several reported a lack of cultural sensitivity on the part of their providers when delivering health-related information. Most participants desired better communication, more respect, compassion, listening, and a better understanding of their cultural differences. Notably, most were unable to recall their providers’ names even though they had seen those providers for years.

Kellie, 61, expressed her thoughts:

The approach is giving bad news. They don’t care how the news will affect you after hearing it. I would ask them to be more courteous, have more patience because sometimes the patients might not understand what they are saying. Try to understand the culture, the food we eat, and why some of us can’t stay away from eating it.

Odette, age 54, has managed her diabetes for over 15 years. She noted,

I was being yelled at. Here I am an adult with children and I’m being yelled at about something that’s affecting me. Not that the doctor is a mean person; it just came across like you’re being treated like a child that has not done her homework. So, that would keep me away from the doctor’s office.

John stated,

There should be a focus for providers to educate their patients more, spending a little more time explaining versus just prescribing. The team should always have Haitian providers so that the Haitian providers will be able to teach the Haitian patients and educate other providers about the Haitian culture. I believe that by working together, we can save a lot of Haitians.

Discussion

This qualitative study was the first to explore the lived experiences of self-management in adult Haitian immigrants with T2D. All participants had a clear understanding that T2D was a complex medical disease requiring careful attention. A recent study links disease acknowledgment with the development of self-management strategies (Tseng, Liao, Wen, & Chuang, 2017). Participants in our study expressed how life in the United States was challenging, how it negatively affected their choice of foods and their ability to exercise. As noted, their mean HbA1C was 8.1, indicating a suboptimal level of overall metabolic control. A reasonable HbA1C target goal for nonpregnant adults is <7.0% (American Diabetes Association, 2018), a target that the majority of participants did not meet.

The literature supports the importance of self-reliance among some cultural groups. Page-Carruth, Windsor, and Clark (2014) found rural self-reliance identity to be compatible with diabetes self- management in Queensland, Australia. Self-reliance and self-management are thought to be essential to metabolic control. However, many questions remain about how self-reliance applies to minority populations. Self-reliance has not been previously reported as a value in the adult Haitian immigrant population, which makes it a novel finding in this study. While the literature has noted that the family has played a key role in chronic illness management, in this study, the individuals reported that they themselves were mainly in control of managing their disease (Abubakari et al., 2011; Dalton & Matteis, 2014; Huffman et al., 2013; Sanon et al., 2016; Vaccaro et al., 2014).

Turning to ineffective strategies in managing their disease may have resulted from a lack of knowledge about T2D pathophysiology and/or of self-management behaviors. In a recent study of diabetes management and prevention among Haitians in Philadelphia, participants gave accurate information about effective health practices, but the majority demonstrated poor metabolic control during clinic visits; thus, knowledge about behavior is not sufficient for incorporating behavior into life (Moise et al., 2017). Although, the settings of the two studies differ (church-based vs. urban outpatient clinic), the suboptimal metabolic control finding is similar to our study.

The locus of control (internal and external) may be an important concept to explore in diabetes self-management of the Haitian immigrant population. While participants expressed a strong internal locus of control in terms of being in charge of their daily decisions related to self-management, they also expressed a reliance on God as a spiritual source of external control to help manage their diabetes.

Additionally, the process of acculturation appeared to be somehow problematic for the majority of the participants, who continue to view food consumption and sedentary lifestyle in their adopted country as different from the practices in their motherland. Studies have shown that Haitian immigrants have a higher mean HbA1C than AAs and Cuban Americans, with causes related to ongoing acculturation issues (Moise et al., 2017; Vimalananda et al., 2011). Participants’ changes in lifestyle such as different diet and lack of exercise during acculturation may contribute to detrimental health concerns.

Participants described a lack of recognition and cultural understanding on the part of their health care providers and recommended a “desire for positive patient–provider relationships.” Increasing evidence shows that patient–provider relationships and providers’ beliefs, attitudes, and knowledge are key influences in patients effectively managing chronic diseases (Nam, Chesla, Stotts, Kroon, & Janson, 2011; Schulman-Green et al., 2012). The participants suggested that providers need to offer rationales for recommended treatments instead of telling patients “what to do.” Nam et al. (2011) also concurred that improved communication may be particularly important in the immigrant population. This may facilitate patients’ involvement in their self-management and result in improved clinical outcomes. In prior research, a lack of trust in health care professionals and systems related to the use of herbal medicines in HIV/AIDS and hypertension management among African Caribbean and Haitian patients has been reported (Higginbottom & Mathers, 2006).

Limitations, Implications for Practice, and Research

The study was limited to one geographic location and included only four men (25%). While the limited diversity in gender and geographic location in this study may not have identified the full realm of possible experiences in this population, the stories and shared experiences did provide a rich description of the phenomenon. Moustakas’s (1994) phenomenological approach was found to be very useful in guiding this research. Specifically, the approach provided in-depth steps in the data collection and analysis procedures that facilitated obtaining testimonies that reflected the essence of the participants’ experiences from their perspectives. Future qualitative studies are recommended to explore the phenomenon from a broader perspective in terms of gender, economic status, educational level, and geographic location. Despite these limitations, this study provides evidence of how cultural influences and health beliefs may affect individual self-management of T2D in this population. A need exists for health care providers to explore adult Haitian immigrants’ health beliefs, misconceptions, and approaches to diabetes self-management.

Other implications include identifying the preferred language (French or Creole) and having interpreters available, exploring the difficulties of adjusting diet and activity level to the U.S. culture, and modifying nutritional education to allow for cultural preferences. In addition, assessing and clarifying the perceived locus of disease control based on external (spirituality) versus internal (self-reliance) factors could lead to improved self-management and metabolic control in this population. Education can be provided regarding self-management behaviors (nutrition, medications, meaning of HbA1C, and interpretation of results from blood glucose testing) in a variety of targeted venues. However, assessment of basic financial needs is essential, as the majority of these study participants identified this issue as an unmet need. In addition, peer-led support groups in the community such as church-based interventions with peer supports and culturally competent professionals could be positively received, particularly when family members are not primary supports for self-management activities. Additional qualitative research is needed to assess cultural factors of Haitian immigrants in different regions of the United States, with a balanced gendered sample and inclusion of older Haitian immigrants who may have a greater reliance on family (Dalton & Matteis, 2014). Cross-sectional quantitative study designs could examine factors associated with self-management such as locus of control and social support. Longitudinal cohort study designs would add to the knowledge of causative factors related to successful T2D self-management over time.

Conclusions

In this study, the lived experiences of 16 adult Haitian immigrants were examined in relation to their self-management of T2D. Because management of the disease requires lifestyle modifications with respect to diet and physical activity in particular, self-management was reported to be an ongoing challenge, with evidence of suboptimal metabolic control. Over time, the participants had learned to cope by relying primarily on themselves to manage their diabetes, while acknowledging help from their faith in God. Haitian immigrants in this study acknowledged a lack of cultural sensitivity by their medical providers in health care encounters. Their yearning for home was also expressed, ironically revealing their belief that they left a country that had a lifestyle different from than the United States. The study findings create a foundation for culturally congruent T2D care that could improve health outcomes in the Haitian community. Future research is recommended to examine factors that support self-management in Haitian immigrants who have a high prevalence of T2D.

Footnotes

Acknowledgements

The authors would like to acknowledge Robin Whittemore, PhD, APRN, FAAN; Wilanda Gabriel, BA; Ainat Koren RN, PhD; and Marie-Louise Jean-Baptiste, MD. The authors would also like to thank the dedicated participants who participated in the study. They graciously welcomed the primary researcher into their busy lives and homes to help us understand their lived experience with type 2 diabetes.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Sigma Theta Tau International, Pi Epsilon-At-Large, and Eta Omega Chapters. This study was conducted with support from Harvard Catalyst/The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers. This work was further supported by National Institute of Nursing Research of the National Institutes of Health under Award No. T32NR008346.

ORCID iD

Cherlie Magny-Normilus

References

Abubakari

Jones

M. C.

Lauder

Kirk

Anderson

Devendra

(2011). Associations between knowledge, illness perceptions, self-management and metabolic control of type 2 diabetes among African and European-origin patients. Journal of Nursing and Healthcare of Chronic Illness, 3, 245-256. doi:10.1111/j.1752-9824.2011.01098.x

American Diabetes Association. (2018). Glycemic targets: Standards of medical care in diabetes. Diabetes Care, 41(Suppl. 1), S55-S64. doi:10.2337/dc18-S006

Carey

Doherty

(2012). Supporting successful self-management in diabetes. Diabetes & Primary Care, 14(5), 297-306.

Chávez

L. M.

Canino

(2005). Toolkit on translating and adapting instruments. Retrieved from www.hsri.org/files/uploads/publications/PN54_Translating_and_Adapting.pdf

Creswell

J. W.

(2013). Qualitative inquiry & research design (3rd ed.). Thousand Oaks, CA: Sage.

Dalton

J. M.

Matteis

(2014). The effect of family relationships and family support on diabetes self-care activities of older adults: A pilot study. Self-Care, Dependent-Care & Nursing, 21(1), 12-22.

Eckel

R. H.

Kahn

S. E.

Ferrannini

Goldfine

A. B.

Nathan

D. M.

Schwartz

M. W.

. . . Smith

S. R.

(2011). Obesity and type 2 diabetes: What can be unified and what needs to be individualized? Diabetes Care, 34, 1424-1430.

Golden

S. H.

Brown

Cauley

J. A.

Chin

M. H.

Gary-Webb

T. L.

Kim

. . . Anton

(2012). Health disparities in endocrine disorders: Biological, clinical, and nonclinical factors—An endocrine Society scientific statement. Journal of Clinical Endocrinology & Metabolism, 97(9), E1579-E1639. doi:10.1210/jc.2012-2043

Higginbottom

Mathers

(2006). The use of herbal remedies to promote general well- being by individuals of African-Caribbean origin in England. Diversity in Health and Social Care, 3(2), 99-110.

10.

Huffman

F. G.

Exebio

J. C.

Vaccaro

J. A.

Zarini

G. G

Dixon

(2013). Effect of medical advice for diet on diabetes self-management and glycemic control for Haitian and African Americans with type 2 diabetes. Food and Nutrition Sciences, 4, 1094-1101. doi:10.4236/fns.2013.411142

11.

Kolb

L. E.

Lipman

R. D.

(2015). Under-utilization of diabetes self-management education: Ideas on why and some suggested solutions. American Association of Diabetes Educators in Practice, 3(4), 10-17. doi.org/10.1177/23251603315576338

12.

Lester

(1999). An introduction to phenomenological research. Taunton, England: Stan Lester Developments. Retrieved from www.sld.demon.co.uk/resmethy.pdf

13.

Lincoln

Y. S.

Guba

E. G.

(1985). Naturalistic inquiry. Beverly Hills, CA: Sage.

14.

Magny-Normilus

(2016). Self-management of type 2 diabetes in the context of adult Haitian immigrant culture: A concept analysis (Unpublished manuscript). University of Massachusetts, Lowell.

15.

Moise

R. K.

Conserve

D. F.

Elewonibi

Francis

L. A.

BeLue

(2017). Diabetes knowledge, management, and prevention among Haitian immigrants in Philadelphia. Diabetes Educator, 43, 341-347. doi:10.1177/014572117715418

16.

Moustakas

(1994). Phenomenological research methods. Thousand Oaks, CA: Sage.

17.

Nam

Chesla

Stotts

Kroon

Janson

S. L.

(2011). Barriers to diabetes management: Patient and provider factors. Diabetes Research and Clinical Practice, 93, 1-9.

18.

Page-Carruth

Windsor

Clark

(2014). Rural self-reliance: The impact on health experiences of people living with type II diabetes in rural Queensland, Australia. International Journal of Qualitative Studies on Health & Well-Being, 9, 24182. doi:10.3402/qhw.v9.24182

19.

Purnell

L. D.

Paulanka

B. J.

(2008). Transcultural health care. A cultural competent approach (3rd ed.). Philadelphia, PA: E. A. Davis.

20.

Rosenstock

Whitman

West

J. F.

Balkin

(2014). Racial disparities in diabetes mortality in 50 most populous U.S. cities. Journal of Urban Health, 91, 873-885. doi:10.1007/s11524-013-9861-4

21.

Ross

(2010). Suddenly anything is possible: Background on Haiti & Haitian health culture. Retrieved from www.in.gov/isdh/files/cultural_primer_on_Haiti.pdf

22.

Sanon

M. A.

Spigner

McCullagh

M. C.

(2016). Transnationalism and hypertension self-management among Haitian immigrants. Journal of Transcultural Nursing, 27, 147-156. doi:10.117711043659614543476

23.

Schulman-Green

Jaser

Martin

Alonzo

Grey

McCorkle

. . . Whittemore

(2012). Processes of self-management in chronic illness. Journal of Nursing Scholarship, 44, 136-144. doi:10.1111/j.1547-5069.2012.01444.x

24.

Tseng

H. M.

Liao

S. F.

Wen

Y. P.

Chuang

Y. J.

(2017). Stages of change concept of the transtheoretical model of health eating links health literacy and diabetes knowledge to glycemic control in people with type 2 diabetes. Primary Care Diabetes, 11, 29-36.

25.

Vaccaro

J. A.

Exebio

J. C.

Zarini

G. G.

Huffman

F. G.

(2014). The role of family/friend social support in diabetes self-management for minorities with type 2 diabetes. Journal of Nutrition and Health, 2(1), 1-9.

26.

Vimalananda

V. G.

Rosenzweig

J. L.

Cabral

H. J.

David

M. M

Lasser

K. E.

(2011). Comparison of diabetes control among Haitians, African Americans, and non-Hispanic Whites in an urban safety-net hospital. Diabetes Care, 34(1), 58-60. doi:10.2337/dc10-1387

27.

World Health Organization. (2016). Diabetes country profiles 2016. Retrieved from www.who.int/diabetes/country-profiles/en/#H