Background: American Indians (AI) experience disparate prevalence, complications, and rates of death from diabetes compared to the general population. Diabetes self-management behaviors (DSMB) including healthy eating, physical activity, and medication adherence can improve glycemic control and prevent long-term complications. Prior studies, generally in non-AI populations, have suggested that distress negatively and resources positively impact DSMB participation, but have often studied influential determinants in isolation. In addition, the influence of contextual social-ecological determinants on personal determinants has been neglected. Aim: This work describes the frequency of DSMB and tested a proposed model, based upon Andersen’s Behavioral Model, to understand the relationships between appraisal of community distress and resources, personal distress and resources, and DSMB among a clinic sample of AI adults with type 2 diabetes. Method: A cross-sectional computer assisted personal interview survey was administered to a random sample of 194 AI adults with a recent diagnosis of type 2 diabetes using care at Indian Health Service facilities in one of five upper Midwest reservation communities. Survey items included measures of healthy eating, physical activity, medication adherence, personal distress, personal resources, appraisal of community distress, appraisal of community resources, and demographic variables. Relying on Andersen’s Behavioral Model as the conceptual framework, one model for each DSMB was tested using structural equation modeling. Results: The mean days per week of healthy eating and physical activity reported by participants were 2.93 and 2.95, respectively. Based upon the 4-item Morisky Medication Adherence scores 27.5% of the participants using medications met criteria for high and 20.5% for low adherence. The structural equation models for healthy eating and medication adherence displayed good fit and accounted for 60.4% and 29.6% of the variance in the DSMB, respectively. The model for physical activity did not fit the data and explained only 17% of the variance in physical activity. Personal resources and personal distress had strong direct relationships with healthy eating, while both gender and income had significant indirect relationships. Personal distress had a direct negative relationship with medication adherence, and both gender and education had indirect effects in this model. Indirect effects in each model were primarily due to paths through personal distress and personal resources. No significant direct or indirect paths were observed for appraisal of community distress or appraisal of community resources. Conclusion: Rates of healthy eating and medication adherence found in this study are somewhat lower than previous estimates in other Native and non-Native samples. The proposed models fit well for healthy eating and medication adherence, but not for physical activity. For individuals from these communities, physical activity behaviors are not explained by this model and may be induced by other mechanisms. Given the strength of the relationships in the models, personal distress and personal resources may influence DSMB. In addition, several demographic variables may exert indirect influence upon DSMB: female gender through a strong positive relationship with personal distress, and income and education through a strong positive relationship with personal resources. The failure of appraised community determinants in the model may indicate the use of poor measured indicators of the latent constructs. Implications: Facilitating and building personal resources and mitigating personal distress are potentially important clinical targets to improve healthy eating and medication adherence. Although appraised community level factors did not have relationships with DSMB, education and income had positive indirect effects. The community and contextual environment influence these demographic factors, thus future research may explore the possible distal relationship here. The findings also suggest that diabetes distress may act as a mediator between gender and DSMB.
University of Minnesota Ph.D. dissertation. August 2016. Major: Social and Administrative Pharmacy. Advisor: Melissa Walls. 1 computer file (PDF); x, 115 pages.
Understanding Diabetes Self-Management Behaviors among American Indian Adults.
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