Facilitators and Inhibitors to Self-Maintenance for Type II Diabetics

Abstract: 

Self-maintenance of Type II diabetes requires an individual to engage in regular physical activity, consume a reasonably healthy diet, make regular visits to doctors or other health care providers, and take medications regularly, as well as consistently checking their blood sugar (ADA 2006; Reichenbach and Maish 2006). Not following these recommendations can result in other health complications in addition to diabetes. As a preliminary investigation into this phenomenon, a focus group was conducted with a local group of Type II diabetics. Through their discussion on issues that facilitate and inhibit their ability to adhere to self-maintenance practices, it has been determined that in spite of some social welfare programs there are structural issues that limit this population in being able to maintain their health with diabetes to the best of their ability. 

Table of Contents: 

    Introduction

    Self-maintenance of Type II diabetes requires an individual to engage in regular physical activity, consume a reasonably healthy diet, make regular visits to doctors or other health care providers, and take medications regularly, as well as consistently checking their blood sugar (ADA 2006; Reichenbach and Maish 2006). Not following these recommendations can result in other health complications in addition to diabetes. As a preliminary investigation into this phenomenon, a focus group was conducted with a local group of Type II diabetics. Through their discussion on issues that facilitate and inhibit their ability to adhere to self-maintenance practices, it has been determined that in spite of some social welfare programs there are structural issues that limit this population in being able to maintain their health with diabetes to the best of their ability.

    Background

    Currently there are 18 million people in the United States who are known to have Type II diabetes. According to a recent study entitled “The State of Diabetes Complications in America” released on April 10, 2007, through the American Association of Clinical Endocrinologists in association with members of diabetes complications consortium, of the 18 million people who currently have Type II diabetes 3 out of 5 of them have at least one other complication associated with diabetes, 1 out of 10 has 2 other complications, 1 out of 15 has 3 other complications, and 1 out of 13 has 4 or more complications. Refer to Figure 1. “Complications from poorly controlled diabetes drive up health care costs, not to mention costs in human suffering, in no small way” (Chaufan 2004:277).

    In 2006, the nation spent an estimated $22.9 billion on direct medical costs related to diabetes complications. Annual health care costs for a person with type 2 diabetes complications are about three times that of the average American without diagnosed diabetes. These complications…cost almost $10,000 per person each year. [ACCE 2007:para.1]

    Because of both the concern for human suffering and the economic implications of having such high rates of complications when it is possible to avoid, postpone, and reduce the onset of complications it is important to examine what is causing the obvious disconnect between self-maintenance behavior and maintaining a relatively good level of health. Reichenbach and Maish point out a

    …need to understand the experiment Type 2 diabetes and the contexts in which people grapple with self-care, food choices, treatment options and regimens, familial demands, shifting emotional ground and physical suffering so that, at a minimum, clients can speak to these constituents meaningfully, and optimally, so that they can design products or services in a way that truly meet diabetics’ needs. [Reichenbach and Maish 2006:5]

    These types of contexts and understanding of them will better enable health care professionals, clinicians, educators, and policy makers to see where to begin to implement changes that will enable individuals to maintain their health with type II diabetes.

    In order to gain an insight and foundation for which to conduct future research, I conducted a preliminary ethnographic study with a local population. The population that I studied consisted of participants of a monthly diabetes support and education class. This class is organized and provided by the local county health department. Every month participants receive a $10 food voucher to a local food store for attending. The class meets at a local recreation center that is located in an economically disadvantaged area of town. The class has been in existence for five years. The topic of each meeting covers a different aspect of self-maintenance. I contacted the class facilitator at the county health department and scheduled a focus group at their next monthly meeting.

    Research Question

    This preliminary study focuses on individual ability to maintain with diabetes. Specifically I wanted to know what facilitated or inhibited self-maintenance. The four major self-maintenance behaviors (consuming a healthy diet, taking medication, testing blood levels regularly, and engaging in regular physical activity) were the major foci of this study. By questioning a large and somewhat diverse group of people, it is my intention to gain foundational information that can guide future research avenues within the topic of self-maintenance.

    Analytical Framework

    The theoretical framework that I used to analyze and interpret the data produced by this study stemmed from a personal conviction that the amount and kinds of choices a person with Type II diabetes makes about self-maintenance largely depends on their life circumstances (Chaufan 2004).

    When history is factored into the equation, it appears that money, poor access to knowledge, and social connections have enabled those who are better off, in the past as well as today, to gather whatever resources are available at a particular time, place, and state of knowledge to secure conditions to stay healthy, and that individual pathways (i.e., individual risk factors) mediating the relationship are less important than the totality of socioeconomic location itself. [Chaufan, 2004:260]

    Using a political–economy theoretical approach, I examined the findings of this study, looking for societal and structural factors that might be limiting the choices that people have and their ability to completely adhere to self-maintenance recommendations. Much of the current theory on self-maintenance adherence as well as risk factors for type II diabetes focus on education and empowering individuals by giving the information needed to make smart choices. Empowerment, however, can only go so far when a person is limited by resources.

    Although initially I planned to analyze this research through a political–economy lens, my findings led me to question the role of agency as well. To what degree are individuals responsible for maintaining their health even in spite of political and economic factors that might make it more difficult for them to do so?

    Population

    I chose to examine the group I did because, having attended the class myself for a few months, it was an easy access population and there were extreme time constraints on this study. Also, many people have been attending for a year or more. Out of the 23 participants, 17 responded to a question about the length of time they had been attending the group. The range for length of attendance was from 14 months to 5 years, with an average of approximately 3 years. Based on this information, I consider this population to have a higher level of education about self-maintenance behaviors than the average person with Type II diabetes. This is important because one of the major avenues of help that is being pursued is that of education. Many people feel that individuals do not have the knowledge to make the healthful decisions that either puts them at risk for developing Type II diabetes or puts them at risk for developing other health complications by not properly maintaining their health while having diabetes (Chaufan 2004).

    Twenty-three people participated in the focus groups for this study. Ten of the participants were men and thirteen were women. The age range was from 26 years old to 75 years old. The mean age was approximately 60 years. The modal age was 72 with a median of 75. Normally it would be less than necessary to report the median and modal ages, however the 26 year old was an outlier, with the next youngest participant being 44 years old as well as the fact that the 26 year old was not actively engaged in the discussion.

    The population for this study was somewhat ethnically diverse. Participants who identified as African American represent 58 percent of the group with self-identified Caucasians and Hispanic/Latinos equally represented in the group with 21 percent each. Refer to Figure 2. Here it is important to note that although only 22 participants provided a response to the question about race and ethnicity, two individuals provided multiple responses, identifying as both Hispanic/Latino and as Caucasian. My findings are actually based on both the number of respondents (22) and the number of responses (24).

    The annual household income of participants ranged from less than $10,000 to $70,000. The majority of respondents, 74 percent, reported an annual income of between ten and thirty thousand dollars. Only 5 percent of respondents reported household incomes less than ten thousand dollars as well as an additional 5 percent reporting an annual income between thirty and fifty thousand dollars. The remaining 16 percent of the population reported an annual household income between fifty and seventy thousand dollars. Only 19 out of the 23 participants responded to this question. Refer to Figure 3. In order to understand the role that income and cost plays in the ability to maintain health, it was helpful to know the number of household members who are dependent on the income. The number of household members ranged from one to five, with an average of 2.35 members. Of the 20 people who responded to this question, 50 percen reported at two-member household. A single-person household was reported by 20 percent, 15 percent of participants reported having a three-member household, with 10 percent reporting a five-member household, and 5 percent reporting a four-member household. Refer to Figure 4.

    My first impression of the group of people who participated in this study was that they were an older population who appeared to be of the same socioeconomic level, which I would call upper-lower class to lower-middle class. Many of the participants seemed to have some trouble getting around either using a walker, cane, or walking with somewhat of a limp. Some of the group members appeared to be either overweight or obese. Dress was casual as was conversation and interaction.

    Methods

    The conclusions of this study are based on the findings of a focus group that was conducted with 23 people. The normal size of a focus group is between seven and ten participants. The anticipated sample size was between 30 and 40 people, based on the normal monthly attendance rates of the class. In view of this level of attendance, the original plan was to conduct three hour-long focus groups simultaneously in different rooms at the location where the group meets. Unfortunately, due to scheduling conflicts it was impossible to procure any additional rooms. I was left with the options of trying to conduct three small focus groups in a very large room that echoes or to tough it out and conduct one very large focus group. I chose to do that latter. By using five precariously placed digital recorders and seven note-takers assigned to concentrate on the conversation and physicality of a set number of individuals, I made it through. These circumstances created some limitations to my findings and conclusions, which will be discussed later on.

    After the focus group was completed the main recording was transcribed, and the other four were used for any side conversations or statements that were not picked up by the main recorder. These later recordings were transcribed as well. Once everything had been transcribed, the transcription was read through to pinpoint certain themes and ideas that were then turned into codes. The entire transcription was coded using the program Atlas Ti. The coded information was analyzed for implications and deeper meanings.

    Key Findings

    Due to the size of the focus group and time restraint I was under (less than an hour) it was difficult to get a wealth of knowledge or to go into much depth as different topics emerged. However, there were some key factors that were seen either as facilitators or inhibitors and some factors crossed categories depending on the person or the particular aspect of the factor being discussed.

    The major inhibitors to self-maintenance that were both discussed and implied were time and money. Participants referred to time as a problem in relation to all four of the major aspects of self-maintenance and always in reference to not having enough time. People stated not having enough time to eat “five or six times a day” or having the time to cook. When asked if they could have whatever it was they needed that would make self-maintenance easier, one gentleman said time. He stated not having time to take his medications because he had to “get up and get.” People also expressed difficulty finding time to exercise as well as expressed negative feelings toward having to test so often.

    Money as an inhibitor was also expressed in relation to all of the aspects of self-maintenance. Participants talked about difficulty being able to purchase medications and testing supplies. Difficulty being able to afford the recommended foods was also discussed. In addition people talked about the high price of gym memberships as inhibiting their ability to exercise.

    Other inhibitors that were briefly touched on were the complications and difficulty reading new electronic blood testers, how physical condition keeps people from being able to exercise or even stand long enough to cook a meal, negative experiences with doctors and other health care providers that led to a distrust of biomedicine, and attitudes toward self-maintenance also seemed to inhibit adherence. The most interesting inhibitors were factors related to the way that society has changed. Participants stated that food has fewer nutrients due to a lack of nutrients in the soil as well as expressing a negative opinion toward meat containing steroids and other additives. Changes in household dynamics over time were also discussed:

    It didn’t used to be that you had to have both people in the home working to provide a living so now that both husband and wife have to work there is more fast food because you don’t have time to or the energy when you get home to cook. You don’t even care, it’s like ‘Go pick up some hamburgers.’ Back when the mothers could stay home and take care of the kids and the father could bring the bacon home and everybody was fine we lived healthier, things were better, there was not the fast food…
    – Sheila, older female with neuropathy

    The facilitating factors were discussed with an equal amount of emphasis. However, two major factors stood out and those were access to information and attitude/outlook. Again this group had been meeting for some time and most members have been attending for over a year. This alone means that for the most part they have received a lot of information about how to healthfully maintain their diabetes. In addition, participants mentioned subscribing to diabetic newsletters, receiving good and up-to-date information from their doctor, and using the Internet as a source of information.

    Attitude/outlook was an important facilitator to some of the participants. These individuals were quick to offer advice and solutions based on personal behavior and experience to problems brought up by other group members.

    Some of the other facilitators that were discussed were technology in that a lot of the new testers make taking blood levels faster and easier, money was mentioned as a facilitator in the context of programs that cater to economically disadvantaged people with diabetes. Having good doctors and a good relationship with one’s doctor was also expressed as imperative to proper self-maintenance.

    Discussion

    The unorthodox size and recruitment of the focus group participants for this research places some limitations on the findings that are important to keep in mind. First of all, not all of the participants of the group were type II diabetics and some individuals did not actually have diabetes. One man stated being there to support his wife. The fact there was no requirement on the group or class meeting that participants have some form of diabetes, coupled with the food voucher provided to every participant, led me believe some people might have brought other family members in order to receive additional vouchers. The vouchers might also have been the cause of about half of the group members not actively engaging in the discussion. Although participation was entirely voluntary, by commandeering their normal monthly meeting, there were some people who were there for their voucher and had little to no interest in the activity of the focus group. I think it is important to note that the feeling of coercion was avoided by stating at the very beginning that anyone who did not want to participate was welcome to leave at any time without fear of any retribution. The large size also led to an inability to really get a group consensus, which is one of the main goals of a focus group.

    Using the information that participants provided about their annual household income and household size, I compared these to the U.S. Census Bureau’s 2006 Chart on Poverty Thresholds (U.S. Bureau of the Census 2006). Based on the 17 participants who provided a valid response to both the income and household size question, it is possible that 12 of them were living at or very near the government-defined poverty threshold. The poverty threshold ranges from approximately ten to twenty-five thousand dollars for households ranging from one to five members.

    It was assumed for the purpose of making this comparison that all household members were over 18 years of age. All respondents who fit the poverty threshold criteria had income between ten and thirty thousand dollars. However, it is fair to say that a large majority of the individuals who participated in this study are living either at or close to the government-defined poverty threshold. This comparison and what it implies provides substantial evidence that money really is an inhibitor for this population.

    Although, the issue of not having enough time was discussed in more depth, I think that cost was really the biggest inhibitor this group is facing. There were a few reasons why this might not have come out in the transcript. For one thing, only 19 out of 23 participants responded to an anonymous question asking for a range of their household income. In addition, when one participant mentioned having difficulty being able to afford to stay on her “diabetic diet,” I then asked the group if anyone else had trouble being able to afford the foods that they needed to eat. No one responded to this question. These two factors led me to believe that the issue of money and lack of it especially were sensitive issues that participants were reluctant to discuss.

    Money also was an issue for people who have complications, as some participants stated having. According to the ACCE report on the cost of diabetes complications,

    People with diabetes complications pay nearly $1,600 out of their own pockets for costs that are not reimbursed by insurance, such as co-payments and deductibles. This amount is significant, considering that according to the National Health Interview Survey, an estimated 40 percent of adults with diabetes reported a family income of less than $35,000 per year in 2005. [ACCE 2007:para.1]

    Time, which was discussed as both a facilitator and an inhibitor, is something that needs to be examined further. I wonder how many of the people in this group truly did not have the time to do all of the self-maintenance practices prescribed to them by their doctors and diabetes education. It seemed common for people to use time as a scapegoat for an inability to do something. It would be interesting to see to what extent this is the case in this population.

    Time as an inhibitor was interesting when discussed in conjunction with level of motivation. Did people who made the time have a higher level of motivation than those who did not make the time to adhere to recommendations for self-maintenance? How much did an individual’s personal level of motivation to follow self-maintenance principles affect their ability to do so? To what degree was a person responsible for the maintenance of their own health even in the face of societal and structural difficulties? It is true that being a lower income bracket can greatly reduce a person’s choices when it comes to health care. However, there is still a level of choice. This fact is exhibited by the individuals in the group who showed a willingness to do the best they could by catering recommendations to their own needs and lifestyle, even if they did not fit in with the exact recommendations of their doctors. These individuals seem to have the attitude that it is better to do something than nothing.

    This research provided me with a foundation on which to build future research. Although the results are not generalizable and are limited by the methods used, they are suggestive. By conducting this study, some key factors manifested that could help explain what keeps people from adhering to recommended self-maintenance behaviors and what kinds of things makes it easier for them to do this. There are problems that are outside of the individual’s control, but there are things that can be done. Again I will state that more research on this and other subjects needs to be done in order to really work toward a solution. It is my intention to conduct this type of research as a way to develop a holistic, effective method for enabling people to maintain their health with type II diabetes as a means to avoid the associated complications and improve the overall quality of life.

    Future Research

    I conducted this study as foundation research to guide future research in this topic. I now see that there are a myriad of directions that I could choose for further study. Generally, I would like to continue with similar exploratory research such as I did in this project. I would like to conduct focus groups with more homogenous populations and then compare the findings.

    I want to study varied ethnic groups but especially those that have the highest rates of type II diabetes, specifically African American, Hispanic/Latino, and Native American populations. Within each of these populations it will be necessary to understand their cultural conceptions of health, treatment, and self-maintenance. I also want to examine issues of self-maintenance among various age groups and groups of various socioeconomic and education levels. Seeing as how money and time were major inhibitors and these are very broad and vague concepts as they were discussed by this specific population, it is imperative to expand the scope of the findings. Conducting this scale of research will improve the generalizabiltiy of my conclusions and interpretations.

    It would also be interesting to peruse more specific and in-depth research topics. I would like to examine the topics of level of motivation to adhere to self-maintenance practices as well as in-depth investigation into the role of time in relation to self-maintenance. The methods I would like to use to pursue these two topics will be semi-structured, open-ended interviews about self-maintenance adherence recalls followed by participant observation to determine if the two coincide. I would also like to conduct interviews with doctors, health care workers, and diabetes educators to get the perspectives of the other side of diabetes treatment.

    Of course I also need to do more research into the literature on this subject as well as those that I plan to investigate in the future.

    Personal Reflections

    The experience of conducting my first ethnographic research project was many things. First of all, it was a learning experience. Designing and executing this project from start to finish helped me to learn so very much about the ethnographic process. I learned how to choose which methods best suit which type of research. One of the most valuable skills I gained is how to wade through the tedium of an IRB application and approval process.

    The major field work lesson I learned was that things do not always go according to plan; in fact I have been led to believe that they rarely do, and good anthropologists do the best they can with the given situation. Secondly, this experience encompassed a lot of life lessons for me, most importantly the recognition and subsequent acceptance of my personal biases. I have come to realize that it is next to impossible to be completely impartial but that it is important to do your best to not let bias cloud your judgment and analysis of data. Of all the things I learned and discovered about myself, the deepest and most powerful was learning to have confidence in myself and my knowledge, skills, and abilities.

    Before conducting my focus group, I had a small anxiety attack from thinking that this was my test and if I did not make the mark I would not be allowed to continue as an anthropologist. I had the insane notion that I would be blacklisted from all graduate programs. By taking the time to think it out and to examine my life I realized that anthropology is who I am and that it would have been and will be something that I do for the rest of my life in spite of the degrees or validation I have. I learned that for me anthropology is as second nature as breathing.

    The field of anthropology and my training in anthropological methods and theory brought to this study what it does to most others done by anthropologists and that is holism. Very few other disciplines that I have come into contact with examine the whole picture to the degree that anthropology does. These dedications to the holistic examination of humanity helps, especially in applied anthropology, reach more effective solutions to social problems. Personally anthropology brought to this research a realization that I had bias and an acceptance of that bias, as well as the ability, obligation really, to examine not only what participants said but also to dig deeper and look for hidden meanings.

    Bibliography

    • American Association of Clinical Endocrinologists (AACE). 2007 State of Diabetes Complications in America. Electronic document, http://www.stateofdiabetes.com, accessed April 26.
    • American Diabetes Association. 2006 Diabetes Overview: Type II Diabetes. Electronic document, http://www.diabetes.org, accessed April 9.
    • Chaufan, Claudia. 2004 Sugar Blues: A Social Anatomy of the Diabetes Epidemic in the United States. In Unhealthy Health Policy: A Critical Anthropological Examination. Arachu Castro and Merrill Singer, eds. Pp. 257–274. Walnut Creek: Altamira Press.
    • Reichenbach, Lisa, and Amy Maish. 2006 "Larger Than Life: Personal and Social Transitions within Type 2 diabetes." EPIC:4–18.
    • U.S. Census Bureau. 2006 Poverty Thresholds Chart. Electronic document, http://www.census.gov/hhes/www/poverty/data/threshld/, accessed July 26, 2007.

    Figure 1: Percent of Focus Group Participants with 1-4+ Diabetes Complications

    Figure 1. Percent of Focus Group Participants with 1-4+ Diabetes Complications

    Figure 2: Percent of Focus Group Participants Who Were African American, Hispanic/Latino, or Caucasian

    Figure 2. Percent of Focus Group Participants Who Were African American, Hispanic/Latino, or Caucasian

    Figure 3: Percent of Focus Group Participants Within Household Income Categories

    Figure 3. Percent of Focus Group Participants Within Household Income Categories

    Figure 4: Percent of Focus Group Participants in Households Sized 1-5+ Members

    Figure 4. Percent of Focus Group Participants in Households Sized 1-5+ Members