“IN SPITE OF THE SYSTEM”: A QUALITATIVE EXPLORATION OF HOW INNER-CITY AFRICAN AMERICAN ADULTS WITH TYPE 2 DIABETES NAVIGATE SOCIAL ENVIRONMENTAL BARRIERS TO HEALTH SELF-MANAGEMENT By PAULETTE ANN SAGE Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Dissertation Advisor: Brian Gran, PhD Department of Sociology CASE WESTERN RESERVE UNIVERSITY January, 2017 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the dissertation of Paulette Ann Sage candidate for the Doctor of Philosophy degree. Brian Gran, PhD Chair of Committee Gary Deimling, PhD Shari Bolen, MD, MPH Kurt Stange, MD, PhD September 12, 2016 *We also certify that written approval has been obtained for any proprietary material contained therein. 2 ACKNOWLEDGEMENTS I can no other answer make but thanks, and thanks, and ever thanks. William Shakespeare 3 TABLE OF CONTENTS Page LIST OF TABLES ............................................................................................................... 7 LIST OF FIGURES ............................................................................................................. 9 ABSTRACT ..................................................................................................................... 10 CHAPTER ONE: INTRODUCTION ..................................................................................... 12 Background and Statement of the Problem ....................................................... 12 Type 2 Diabetes and Overall Health Status ....................................................... 26 Purpose of the Study and Research Questions .................................................. 28 Sociological Significance and Contribution ......................................................... 30 CHAPTER TWO: THEORETICAL FRAMEWORK ................................................................ 34 Introduction ...................................................................................................... 34 Early Theorists and Conceptualizations of Structure and Agency ....................... 35 Cockerham’s (2005) Health Lifestyle Model, a Nexus of Structure, Agency, and Health ........................................................................................... 38 Theories and Models of Social Determinants of Health ...................................... 43 Brief Review of History of Social Determinants of Health (SDOH)/Social Ecological Model ............................................................................................... 45 Ecological Models of Health and Health Promotion ............................................ 54 Ecological/SDOH Models Informing Analysis and Coding Structure ........................................................................... 55 CHAPTER THREE: METHODOLOGY ................................................................................ 63 Introduction and Background ............................................................................ 63 Theoretical Framework ..................................................................................... 65 4 Qualitative Research Approach ......................................................................... 66 Strategy of Inquiry ............................................................................................. 67 Study Population ............................................................................................... 75 Data Collection and Procedures ........................................................................ 80 Data Analysis ..................................................................................................... 83 Role of Researcher ............................................................................................ 91 Study Quality ..................................................................................................... 95 Ethical Considerations ..................................................................................... 100 Study Limitations/Sample Size Considerations ................................................ 100 CHAPTER FOUR: Themes Derived from the Literature Review ..................................... 104 Introduction .................................................................................................... 104 Process, Search Strategies ............................................................................... 109 Results ............................................................................................................ 111 Terminology ........................................................................................ 111 Constructs, Definitions, Glossary ......................................................... 113 Health Disparities Among African Americans ....................................... 115 Growth and Multidisciplinary Nature of the Study of SDOH ................. 118 SDOH Variables (Barriers and/or Facilitators) Implicated in the Etiology and Treatment of Diabetes and Health in General ........ 120 CHAPTER FIVE: STUDY RESULTS ................................................................................... 172 Introduction .................................................................................................... 172 Social Determinants of Diabetes and General Health Management ................. 179 Economic factors as social determinants of health .............................. 179 Public policy-related issues as social determinants of health ............... 185 5 Work, occupation, career, school as social determinants of health ...... 194 Family as social determinant of health ................................................. 200 Physical environment as social determinant of health ......................... 216 Self-Management Barriers: Diet, Exercise, Medication Adherence, and Blood Sugar Monitoring ................ 219 Barriers to healthy eating ..................................................................... 220 Barriers to exercising ........................................................................... 223 Barriers to medication adherence ........................................................ 224 Barriers to blood glucose monitoring ................................................... 231 Self-Management Strategies: Diet, Exercise, Medication Adherence, and Blood Sugar Monitoring ............... 234 Strategies for diet control .................................................................... 234 Strategies for exercise management .................................................... 237 Strategies for managing blood glucose monitoring .............................. 240 Strategies for medication management ............................................... 243 Other Barriers to Health and Diabetes Self-Management ................................ 246 Chronic and acute comorbidities ......................................................... 246 Psychological and other barriers .......................................................... 252 Strategies for Diabetes Self-Management - “not elsewhere classified” ............ 257 Listening to, knowing my body ............................................................ 259 “Experimenting,” learning by trial and error ........................................ 260 Seeking information, becoming informed ............................................ 262 The influence of popular culture .......................................................... 262 Motivators/Facilitators of diabetes Self-Management ..................................... 270 The physician ....................................................................................... 271 Physician’s use of Electronic Medical Records system .......................... 277 Diabetes diagnosis ipso facto as motivator and facilitator ................... 285 Information, knowledge ...................................................................... 291 The Clinic .............................................................................................. 295 Other motivating and/or facilitating health self-management factors ..................................................................... 305 CHAPTER SIX. CONCLUSIONS, DISCUSSION, IMPLICATIONS ......................................... 316 APPENDIX ................................................................................................................... 360 REFERENCES ............................................................................................................... 373 6 LIST OF TABLES Page Table 1. Ecological model of health behavior ............................................................. 57 Table 2. Characteristics of constructivist vis à vis objectivist grounded theory ........................................................................................... 74 Table 3. Characteristics of sample .............................................................................. 78 Table 4. Practice site (Clinic) type 2 diabetes patient characteristics .......................... 79 Table 5. Initial process coding example ...................................................................... 88 Table 6. Sample/illustrative list of psychological, social, and physical environmental factors implicated in health and diabetes management ......................................................................... 127 Table 7. Macrosocial determinants of population health .........................................