HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS by

Beverly A. Dow-Graffeo

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Health disparity is defined as: "...differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States." ~ (Medical College of Georgia, 2005)

"...differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation." ~ (Medical College of Georgia, 2005)

Cultural competency is:

"...the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self-awareness, knowledge of the patients culture, and adaptation of skills." ~ (Medical College of Georgia, 2005)

Diabetes mellitus (DM), a.k.a. type 2 diabetes, is a metabolic disorder of the pancreas, affecting carbohydrate, fat, and protein metabolism (Timby, 2009). It is a characterized by increased levels of glucose in the blood ( hypergl ycemia) resulting from defects in insulin secretion, insulin ac tion, or both (Smeltzer, 2008). This disease is reaching epidemic proportions in the United States (Timby, 2009). Some experts believe that diabetes in adults is one consequence

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

of metabolic syndrome, which includes obesity, especially in the abdominal area; high blood pressure; elevated trigl yceride, low -density lipoprotein (LDL), and blood glucose levels; and a l ow high-density lipoprotein (HDL) level. The World Health Organization predicts that, as a result of longer life expectancies, diabetes will affect 366 million people worldwide by 2030 (Smeltzer, 2008). At present, diabetes is the seventh cause of death in the United States (Smeltzer, 2008). Because of the chronic nature of diabetes, affected people experience many debilitating and life -threatening complications before death (Timby, 2009). Minority populations, and in particular, Black Americans, are disproportionately affected by diabetes (Smeltzer, 2008).

From 1980 through 2002, the age -adjusted prevalence of diabetes increased among all gender and race groups. This incidence was increased among Black Americans, Latinos, Native Americans, and Asian Americans (including Pacific Islanders) (Timby, 2009). It was highest among Black American women, and, overall, it was higher among Black Americans than Caucasians (Smeltzer, 2008). During this period, the age -adjusted prevalence of diabetes increased by 98% in Caucasian men, 54% in Caucasian women, and 66% in Black American men and women. From 1997 through 2002, the age -adjusted prevalence of diabetes among Hispanic men and women was similar to that among Black American men. Compared to Caucasians, Black Americans and members of other racial and ethnic groups (Native Americans and persons of Hispanic origin) are more likely to develop diabetes, are at greater risk for many of the complications, and have higher death rates secondary to diabetes (Smeltzer, 2008). The health disparities of
3

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

DM are so well noted that as a matter of fact, ethnicity (included with race) is listed as a risk factor for diabetes mellitus, especially for Black Americans, Hispanic Americans, Native Americans, Asian Americans, and Pacific Islanders (Smeltzer, 2008).

Black American adults are twice as likely as non-Hispanic white adults to have been diagnosed with diabetes by a physician (US Department of Health & Human Services, 2007) . In addition, they are more likely to suffer complications from diabetes, such as end-stage renal disease and lower extremity amputations (US Department of Health & Human Services, 2007). In 2006, Black American men were 2.2 times as likely to start treatment for end-stage renal disease related to diabetes, as compared to non-Hispanic white men (US Department of Health & Human Services, 2007) . Although Black Americans have the same or lower rate of high cholesterol as their non-Hispanic white counterparts, they are more likely to have high blood pressure (US Department of Health & Human Services, 2007) . In 2006, diabetic Black Americans were 1.5 times as likely as diabetic Whites to be hospitalized, and in 2006, Black Americans were 2.3 times as likely as non-Hispanic Whites to die from diabetes (US Department of Health & Human Services, 2007) .

Similarly, in people of similar age, the prevalence of type 2 diabetes is 1.6 times higher among Black Americans ( Hea l t h Educat i on & Beh avi or, 2006) . Type 2 diabetes, whose prevalence, as stated, has increased dramatically in recent years, places Black American women at extraordinary risk (H e al t h Educat i on & Be havi or, 2006) . Type 2 diabeteswhich, as stated, is linked to obesity and physical inactivity, accounts for 90% to 95% of diabetes cases, and most often appears in people older than 40has been diagnosed in an estimated 10% of

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Black American women (Heal t h Educ at i on & B ehavi or, 2006 ) . As more than 80% of Black American women older than 40 are categorized as either overweight or obese, in the absence of dramatic changes, this population will continue to be at great risk for type 2 diabetes in decades to come (H ea l t h Educat i on & Beh avi or, 2006) . Taken altogether, these statistics portray a state of emergency among Black Americans (He al t h Educat i on & Behavi o r, 2006) .

Objective ~ These data represent a glaringly high and very obvious health disparity. The purpose of recognizing the existence of health disparities among target populations, it is hoped, is to address possible solutions for solving these problems because identifying disparities is a first step toward understanding what causes them and what can be done to reduce them (US Dept. of Health & Human Services, 2007). Among the health disparities experienced by Black Americans is the lack of care in and education about diabetes mellitus until it is too late to do anything about it. This is an appalling situation in this day and age when, if caught early enough and controlled, this illness does not have to progress, but can be delayed, prevented, or even reversed in some instances, rather than causing an early demise (CDC, 2009). So, although DM is a chronic illness, it doesnt have to be progressively and predictably fatal.

Assessment ~ There are many things that lead to health disparities; only a few of these considerations will be addressed in this essay and they are medical compliance, cultural competency, and gender (specifically the male gender). To better understand the root causes of this particular health disparity, we need to examine the social environment in which these chronic conditions persist (Heal t h Ed ucat i on & Behavi o r, 2006) .Since a patients medical compliance is usually linked to the patients
5

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

socioeconomic level, it has been found that the availability of goods and services is also linked to the patients ability to pay for them (Health Education & Behavior, 2006). Generally, the amount of residential segregation is a code (that consistently disadvantage Black Americans) for the quality of the public schools; the quality of, and access to, services (e.g., shopping, health care, property values, and the investments of the local government in creating a livable community); and police surveillance and protection, among other things (Health Education & Behavior, 2006). In the United States, communities that are primarily or exclusively inhabited

by Black Americans typically have lower assessed property values, and this is a concern because the property tax is the primary source of revenues for the school systems (Health Education & Behavior, 2006). The result has been that the children of families who can afford to live in middle- to upper-class housing developments and communities with relatively higher property taxes are privileged in their school resources and educational opportunities over their peers in lower income communities (Health Education & Behavior, 2006). When neighborhoods have a high concentration of Black families and poor school systems because of disproportionately low-tax properties and low political engagement, the quality of their sociocultural environment is often well below that found in comparable White communities (Health Education & Behavior, 2006). It has been found that in societies where there is more socioeconomic equality, there is less sickness and violence (Health Education & Behavior, 2006). Many of the biological processes that lead to illness are triggered by what we think and feel about our material and social circumstances (Health Education & Behavior, 2006). It is well documented that Black Americans are marginalized and undervalued in the United States (Health Education & Behavior, 2006). The internalization of such social oppression and repression can result in

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

feelings of hopelessness, powerlessness, and self-hatred among U.S. Blacks. This is believed to be a psychosocial link to health (Health Education & Behavior, 2006). An example of how a compromised social environment can lead to economic instability comes from certain changes in housing patterns that sometimes have their origin in the bigger economic picture (Health Education & Behavior, 2006). As prices for gasoline have risen, the return of White families to inner-city communities has risen, too, instead of remaining out in the suburbs, with the effect of dislocating Black families from their neighborhood roots (Health Education & Behavior, 2006). Because the White families are more affluent, they can afford to turn and flip

ghetto houses (bought cheaply), which were previously occupied by many generations of Blacks, into prime real estate (Health Education & Behavior, 2006). The power of this new urban

demographic to transform property, raise property values, and increase rates of property taxes results in better schools than those attended by the Black Americans who resided there previously (Health Education & Behavior, 2006). So, this gentrification of these communities is directly linked with the displacement of Black families and the destruction of their social networks and support systems (Health Education & Behavior, 2006).

In lower-class Black residential neighborhoods, the ratio of fast-food franchises and liquor stores far outnumber those in white residential neighborhoods. Consequently, the consumption of said food and beverages in Black communities is higher, toothis is well related to the aggressive marketing targeting tactics of these products to Black consumers (Health Education & Behavior, 2006). It seems that the more fast-food places and liquor stores that there are in these Black communities, the less there are nearby grocery store chains and farmers markets, which means fewer affordable options for consumption of fresh fruits and vegetable sources close to home
7

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

(Health Education & Behavior, 2006). This finding has huge implications regarding maintaining a healthy diet and the availability of grocery stores within close range related to eating fresh fruits, vegetables, and unprocessed foods (Health Education & Behavior, 2006). Increasing the ratio of food markets to fast-food restaurants and liquor stores in Black communities is a very possible and practical change that could reap improved health benefits for the future.

Understanding the structural influences of mainstream, largely White culture on Black American life is particularly important in any examination of health disparities (Health Education & Behavior, 2006). If health care providers have an understanding of cultural behaviors that are different from their own, they are better able to resist the tendency to associate other cultures in health with only negative assumptions about local customs and norms, to assume that these factors constitute a barrier to achieving changes in health behaviors (Health Education & Behavior, 2006). A negative representation of culture in health typically relegates behaviors related to that culture as unhealthy and behaviors to be overcome (Health Education & Behavior, 2006). Such a mind-set on the part of researchers and health practitioners working in Black communities has been particularly prevalent and counterproductive (Health Education & Behavior, 2006). An example of this bias is when health care providers/researchers have alleged that the presence of unhealthy cultural norms in a community have caused their programs to fail (Health Education & Behavior, 2006), when the truth is they themselves have failed to try to integrate healthy behaviors within the culture because they dont respect it. As health care providers in the U S are encountering patients from diverse backgrounds and nationalities, it is essential that they understand the unique perspectives and beliefs of the patient in order to enhance the quality of care they provide (Health Education & Behavior, 2006). The health care

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

providers cultural competency directly affects the way she effectively (or not) communicates with the patient about the things the patient needs to do in order to be medically compliant.

The problem of health care providers not having relevant skills to adequately communicate with diverse clients is important, but getting these skills is only one part of whats needed to address cultural insensitivity in particular and health promotion more broadly (Health Education & Behavior, 2006). Health care providers must also be savvy in the culture of gender. We are born male and female, but the process of becoming a man and masculine or a woman and feminine is constructed socially (Health Education & Behavior, 2006). So, some understanding of the social construction of gender identity as embedded in the study of relationships is also needed (Health Education & Behavior, 2006). The study of gender is more about the study of relationships (Health Education & Behavior, 2006). These relationships are those between men and women, men and men, and women and women, as well as their relationships with the entire society (Health Education & Behavior, 2006). The formation of gender identities begins at birth and is learned through many channels, including families and social networks, community and governmental institutions (Health Education & Behavior, 2006), and all of this is highlighted/reinforced through the all-prevalent media. Cultural constructs of manhood/manliness and womanhood and the supporting attitudes, beliefs, and behaviors that express gender identities, as well as the structural forces that align economic, educational, and other opportunities with gender, have a direct bearing on health outcomes (Health Education & Behavior, 2006), (but is far too long a discussion for this essay). Suffice it to say that when the relationship between gender and health is brought up, it commonly is focused on the empowerment of women (Health Education & Behavior, 2006). An example of this is in the

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

fight against HIV/AIDS, the goal of empowering women to put themselves and healthy behaviors first is completely justified. However, the question of empowerment of a woman without an examination of her social and cultural environments, particularly those concerning the status and health condition of the men in her social cultural contexts, is limited (Health Education & Behavior, 2006).

How gender influences health disparities, and how health care providers, by sensitively recognizing this, can be proactive in preventing these two things from blocking medical compliance is an enormous subject to address. Where race and gender intersect is also a critical context for examining the influence of identity (i.e., gender identity, ethnic identity, socioeconomic position, etc.) on health in the United States (Health Education & Behavior, 2006). The health status of Black American men must be considered because Black men experience a shorter life expectancy than any other racial or ethnic group, and they experience higher mortality in every age-group up to age 65 (Health Education & Behavior, 2006). The death rate for heart disease in Black men is one and one-half times greater than that experienced by Black women and two times greater than that of White men (Health Education & Behavior, 2006). Unintentional injuries and homicide also disproportionately affect Black men. (Health Education & Behavior, 2006). In addition, Black men bear a very great burden of HIV/AIDS, drug and alcohol abuse, strokes, type 2 diabetes, and other chronic illnesses (Health Education & Behavior, 2006). Contributing to these health disparities among Black men is what is described as the masculine mystique: The masculine mystique often indoctrinates men into ignoring an illness until it becomes disabling (Health Education & Behavior, 2006) According to this mystique:

10

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Men have traditionally been socialized that they should not cry ...they should be cavalier about certain things that affect them, that it is weak to show pain, and that it is cowardly to run from danger. They have also been encouraged to detach themselves psychologically from feelings of fatigue or discomfort that might prevent them from completing their tasks (Health Education & Behavior, 2006).

In addition, Black American men tend to fear hearing a diagnosis of disease or a poor prognosis and exhibit a lot of distrust for the health care industry (Health Education & Behavior, 2006). At the basic level of this political economy and racial inequality, Black American men have the highest rates of unemployment and therefore are less likely to have health insurance; are considerably overrepresented in the prison industrial complex (they comprise more than 60% of persons under correctional supervision); have higher exposures to toxic substances in their living and work environments; and are at higher risk of occupationally induced diseases, injuries, and death (Health Education & Behavior, 2006).

Planning ~ Since diabetes is a self -managed disease that requires many strategies to keep it under control and a system of care to monitor the prevention and provide early treatment of complications, effort s should be directed to strategies that can be used to teach people with diabetes and a system in which care can be provided in a cost-effective way to reduce the occurrence of these costly complications (Smeltzer, 2008). Nurses are ideal professionals to provide this care; cultural competency and sensitivity in patient education is a key component of nursing practice (Smeltzer, 2008). Patients are often more comfortable with

11

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

nurses, and nurses spend more time with patients and have the expertise to teach them to manage their diabetes properly (Smeltzer, 2008). The provision of care in nurse-directed settings can contribute to keeping patients with diabetes healthy and free of complications (Smeltzer, 2008).

In order to overcome the disparities that initiate from gender identities like the masculine mystique, its extremely important to realize that behavior can be modified to be health promoting (Health Education & Behavior, 2006). Learned behavior can become unlearned, for example, nowadays there is an increasing shift in fathers who do the childrearing as more and more women are working outside of the home (Health Education & Behavior, 2006). To further exemplify this concept in action is that in response to the tendency of some men to internalize pain and endure suffering alone, support groups have emerged around the country for men confronting prostate cancer (Health Education & Behavior, 2006). These groups provide a safe space for men to talk openly about their concerns related to this disease and its effect on their personal, family, and occupational lives (Health Education & Behavior, 2006). This is just one area addressed in decreasing this disparity.

The Agency for Healthcare Research and Qualit y is AHRQ. AHRQ-funded research has demonstrated ways in which racial/ethnic disparities can be reduced (US Dept. of Health & Human Services, 2007). Strategies to prevent the onset of diabetes through diet and lifestyle changes require interventions that are culturally sensitive and population specific (US Dept. of Health & Human Services, 2007). Designing strategies for managing the disease and its complications to be culturally sensitive and targeted to specific populations may also be helpful (US Dept. of Health & Human Services, 2007). One such way is the Chronic Disease Self12

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Management Program (CDSMP) which is now being used by health organizations in 31 States and 9 countries (including diabetes treatment facilities) (US Dept. of Health & Human Services, 2007). The CDSMP could eventually have a significant impact on the health status and health care use of minority persons with diabetes. The CDSMP is comprised of community-based patient education programs in weekly learning sessions focusing on: nutritional change, adoption of exercise programs, use of medications and community resources, and health-related problem solving (US Dept. of Health & Human Services, 2007).

In an AHRQ-funded study, reporting on the effects of social support among Black-American adults with diabetes, it was found that Black Americans relied more heavily than Whites on informal social networks to meet their disease management needs. The social support consisted of help with the day-to-day management of diabetes including: help with diet supervision, medication assistance, general support, and blood sugar monitoring (US Dept. of Health & Human Services, 2007). The review found that social support is significantly associated with improved diabetes management among this population (US Dept. of Health & Human Services, 2007). Although research has not been done to show that this practice leads to better outcomes, it appears to be a promising practice (US Dept. of Health & Human Services, 2007).

Recent AHRQ studies continue to address the need for better disease management and improved quality of life for diabetics in minority populations (US Dept. of Health & Human Services, 2007). A culturally sensitive multimedia computer education program is being tested in a clinical setting where researchers are evaluating its impact on diabetes-related knowledge, attitudes, self-efficacy (the belief that what you do makes a difference), and self-care for Black American and Latino populations (US Dept. of Health & Human Services, 2007).

13

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Implementation ~ There definitely are things being done to ease the problem of health disparities. In 1999, then-President Bill Clinton launched the CDCs REACH 2010 program, as part of President Clintons initiative to eliminate health disparities in racial and ethnic communities. REACH is an acronym for Racial and Ethnic Approaches to Community Health (Health Education & Behavior, 2006). The goal of this program is to bridge race, gender, and power in community strategies intended to eliminate disparities in health care in 6 priority areas, including diabetes (Health Education & Behavior, 2006). REACH primarily targets Black

Americans, American Indians, Alaska Natives, Asian Americans, Hispanic Americans, and Pacific Islanders (Health Education & Behavior, 2006). Of their numerous successes, one will be summarized.

In South Carolina, coordinated by the Medical University of South Carolina, and implemented in Black American communities in the town of Georgetown and the city of Charleston (Health Education & Behavior, 2006), the community coalitions worked to improve diabetes care and control for more than 12,000 Black people with diabetes. Some of their strategies included: walk-and-talk groups (socially promoting exercise) providing diabetes medicines and supplies (promoting medical compliance) creating learning environments where health professionals and people with diabetes learn together (these strategies are relevant in a discourse of race and power) (Health Education & Behavior, 2006) The impact and legacy of centuries of slavery and social inequality have not been erased from Black American communities particularly in the South (Health Education & Behavior, 2006). The health education programs sponsored by the REACH 2010 program in South Carolina not only build skills in diabetes self-management but also teach adults the process of learning which
14

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

is transferable to other areas of their lives (Health Education & Behavior, 2006). In other words, the health education programs become a source of continuing education for adults who have historically not had access to the same health information as their White counterparts (Health Education & Behavior, 2006). In addition, having opportunities to interact with health care providers outside of the hierarchical structure of the clinical setting has been instrumental in demystifying the position of power held by physicians and is teaching adults with type 2 diabetes their entitlements to a particular quality of health care that has historically been withheld from them (Health Education & Behavior, 2006). Lastly, Black people are learning that despite what they have observed and construed to be inevitable outcomes of type 2 diabetes, such as end stage renal disease and lower-extremity amputations, there are proven strategies to prevent these devastating outcomes, and these strategies are available and accessible to them (Health Education & Behavior, 2006). Hopelessness and fear are being eliminated, and REACH 2010 is documenting impressive health repercussions (Health Education & Behavior, 2006).

Evaluation ~ Just 2 years after the program began, Black people in Charleston and Georgetown, South Carolina, are more physically active, they are being offered healthier foods at group activities, and they are getting better diabetes care and control (Health Education & Behavior, 2006). In addition, what has been particularly noteworthy about this program is that Black Americans are now receiving the recommended care for preventing complication of diabetes, such as testing for hemoglobin A1C values or blood sugar concentrations, lipid profiles, and kidney function, and they are getting dilated-eye exams annually (Health Education & Behavior, 2006). Participants are also having their blood pressures monitored regularly (Health Education & Behavior, 2006). The initial 21% disparity in hemoglobin A1C testing between Black

15

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

Americans and Whites has been virtually eliminated in these two communities (Health Education & Behavior, 2006).

Recognizing that there are definite health disparities in Black Americans with DM is an important first step in eliminating them (Health Education & Behavior, 2006). There is still a long way to go to eliminate all of the disparities involved with DM, but as health care providers the route to eliminating them is to become more culturally sensitive and aware in order to communicate with patients so as to increase their medical compliancy, to be competently aware of gender factors when dealing with this special population, and to remember our American history so that mistakes of the past are not repeated. In helping to decrease health disparities in patients with DM, it is hoped that in reaching out to one, many will be influenced.

16

HEALTH DISPARITIES AMONG BLACK AMERICANS WITH DIABETES MELLITUS

Beverly A. Dow-Graffeo

References Centers for Disease Control and Prevention, (2009). Power to prevent: helping african americans prevent type 2 diabetes Retrieved Novem be r 21, 2010 from http://www.cdc.gov/Features/DiabetesPrevention/ Definition of health disparities. (2005). Unpublished manusc ript, Health Disparities Unit, M edical College of Georgia, Georgia. Retrieved Novem b er 1, 2 0 1 0 from http://fammed.mcg.edu/hdu/HDU_HDdefinition.htm Definition of cultural competency. (2005). Unpublished manusc ript, Health Disparities Unit, M edical College of Georgia, Georgia. Retrieved Novem b er 1, 2 0 1 0 from http://fammed.mcg.edu/hdu/HDU_HDdefinition.htm Heal t h Educat i on & Behavi o r, (2006). El i mi nat i ng heal t h di spari t i es i n t he af r i can american population: the interface of culture, gender, and power. R et ri eved Novem ber 1 9, 2010 from ht t p: / / cret scm hd.ps ych.ucl a.edu/ h eal t hfa i r/ P DF%20art i cl es % 20for%20f act % 20s heet %20l i nki ng/ El i m _heal t hdi spari t i es_AAs.pdf Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2008). Brunner & Suddarths textbook of medicalsurgical nursing, eleventh edition. Philadelphia: Lippincott, Williams & Wilkins. Timby, B. (2009) Fundamental nursing skills and concepts, ninth edition. Wolters Kluwer. Health/ Lippincott William and Wilkins. US Department o Health & Human Services, Agency for Healthcare Research and Qualit y. (2007). Diabetes disparities among racial and ethnic minorities Retrieved Oct ob er 2 9, 2010 from http://www.ahrq.gov/research/diabdisp.htm

17