UN1VERSIlY OF HAWAJ'I UBRARY SELF-MANAGEMENT BY UNINSURED FILIPINO IMMIGRANTS WITH TYPE 2 DIABETES A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI'I IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN NURSING By Anne Reynolds Leake Dissertation Connnittee: lillian Inouye, Chairperson Amefil Agbayani Dianne N. Ishida Patricia W. Nishimoto Chen-Yen Wang Charles W. Mueller ABSTRACT Filipino Americans have a higher prevalence oftype 2 diabetes than the national average. Good self-management (SM) ofdiabetes is required for good outcomes. Uninsured Filipino immigrants face cultural and financial barriers to good outcomes. The purpose ofthis study was to describe self-management by uninsured Filipino immigrants with type 2 diabetes. Results from the study will reduce the risks ofcomplications by improving self-management education. Qualitative research on diabetes self-management [SM] and research on Filipinos and health were reviewed. Concept analysis ofSM using the Wilsonian method (Wilson, 1963) produced eight essential elements. An applied ethnography was conducted with 11 participant interviews and 100 hours of field observation over 10 months. Participants were two men and nine women, ages 57 to 74, attending a free diabetes clinic in federally funded community health center in urban Hawai'i. The explanatory model [EM] (Kleimnan, 1980) and a model for health disparities (Cooper, 2002), guided the study. Purposive sampling achieved a range ofparticipants across factors ofage, recent HgbA1c, years with diabetes, and years in Hawai'i. An inquiry audit by an external expert was done. Significant statements coded into four domains ofbarriers, the explanatory model, family and self-management behavior. Participants' EMs combined Western and naturalistic explanations, including avoiding a hot climate and use oflocal plants (bittermelon and noni) recommended by other Filipinos. All participants exercised and most used SM strategies ofcontrol and moderation. Four cultural themes were induced from the data: 1.) rice is more than just a starch; 2.) worry is a Filipino pastime; 3.) advice is a gift freely given and received; and 4.) the family is everything. Participants demonstrated five ofthe essential elements of SM but did not do as well with consulting health care team, problem solving and increasing self-efficacy. The family's group efficacy, as much as self-efficacy, influenced behavior change. Participants' SM compared favorably to other populations for behavioral change, emotional distress and support from family and friends. Implications for clinical practice were emphasis on group efficacy and reducing barriers to medical consultation. Further research to explore the concept ofworry was recommended. 111 TABLE OF CONTENTS Abstract iii List ofTables vi List ofFigures vii Chapter 1: Background and Significance 1 Background 1 Statement ofthe Problem 5 Purpose ofthe Study 6 Significance ofthe Study 6 Chapter 2: Literature Review 9 Chapter 3: Concept Analysis ofSelf-management.. 22 Model Cases 30 Contrary Cases 32 Related Cases 34 Borderline Cases 35 Chapter 4: Methodology 42 Conceptual Orientations 42 Design and Method 43 Sample and Setting 46 Data Collection 48 Data Analysis 52 Limitations 53 Chapter 5: Findings 56 Field Observations 56 Quantitative Data 70 Qualitative Data 71 The Domain ofBarriers 71 IV The Domain ofExplanatory Model 83 The Domain ofSelf-management.. 96 The Domain ofFamily 148 Cultural Themes 182 Chapter 6: Conclusions 190 Pinoy Self-Management.. 190 Comparisons with Findings from Literature Review 196 Recommendations for Future Research 208 Implications for Practice 210 Appendix A: Committee on Human Studies Application 236 Appendix B: Oral Briefing for Informed Consent.. 239 Appendix C: Semi-structured Interview Guide 241 Appendix D: Code Book, Code Tree 243 Appendix E: External Audit by Dr. Kathleen May 260 References , 269 v LIST OF TABLES 1. Eastern and Western Values 215 2. Self-management ofType 2 Diabetes 216 3. Studies ofFilipinos Related to Health and Migration 226 4. Factors for Purposive Sampling 229 5. Quantitative Data for Participants 230 6. Rank Ordering ofParticipants by Hgbalc and Ratio ofPositive to Negative Emotional Statements During Interview 231 7. Factors Influencing Self-management Behaviors 232 8. Domains and Categories with Code Counts 233 VI LIST OF FIGURES Figure Page I. Model ofHealth Disparities 235 VI! CHAPTER ONE: BACKGROUND AND SIGNIFICANCE Background Recent Filipino immigrants have faced more barriers to obtaining health services since 1996 with welfare reform at the federal level. Filipinos have become the second largest group ofimmigrants to the U.S. to date after Mexicans (Bonus, 2000). In their White Paper on the Health Status ofFilipino Americans and Recommendations for Research, dela Cruz et al. (2002) searched the literature in Medline and CINAHL in each ofthe 28 focus areas for Healthy People 2010. Focus areas were far reaching and included specific illnesses (e.g. cancer, chronic kidney disease, diabetes), population subsets (e.g. maternal/child health, occupational safety), and risk factors (e.g. physical activity and fitness, tobacco use). Only 48 studies were found, which focused primarily on cancer and mental health. There were five studies relating to cardiovascular disease and stroke, with Filipino Americans having the highest rates ofhypertension compared to other Asian and Pacific Islanders (AAPIs) (Klatsky, 1991; Klatsky, 1995) and with rates close to those for African-Americans. Type 2 diabetes has been a common problem for Filipino Americans with serious complications ifinadequately treated. The Filipina Women's Health Study was conducted to measure the rates ofdiabetes, heart disease, hypertension and osteoporosis among 454 Filipinas ages 50 and older in San Diego County (Araneta, 2002). One in three Filipinas had diabetes, compared to one in II Caucasian women. Ofthose Filipinas with diabetes, 90% were not obese, and 60% did not know they had diabetes. Little is I known about how Filipinos take care oftheir diabetes. Only two studies from the literature reviewed in the White Paper were about diabetes, and both ofthose related to gestational diabetes. DelaCruz et al. (2002) concluded that the paucity ofinformation about the health problems ofFilipinos was a barrier to the design ofculturally appropriate interventions to promote health behaviors. Forty years ago, Sloan found an age-adjusted prevalence ofdiabetes for Filipinos living in Hawai'i to be three times that for whites (Sloan, 1963). In Hawai'i, preliminary results ofthe Native Hawaiian Health Survey show a 12% prevalence rate oftype 2 diabetes for Filipinos, about twice the national average (Tom, 2001). In the 2000 State of Hawaii Behavioral Risk Factor Surveillance System (BRFSS), 6.0% ofthe 295 Filipinos surveyed had been told by a doctor that they had diabetes (Hawaii DOH, 2000). This prevalence exceeded the state average of5.2% for all ethnic groups surveyed in the 2000 BRFSS and surpassed all ethnic groups except Japanese at 8.6%. The different prevalence levels reported in these three surveys methods revealed the lack ofknowledge about prevalence ofdiabetes for Filipinos in Hawai'i. The complications oftype 2 diabetes (nephropathy, neuropathy, cardiovascular disease, and retinopathy) have been the contributors to morbidity and mortality. Filipinos with diabetes were less likely to have received an eye exam with dilated pupils during the past year at a rate ofonly 68.8% for Filipinos vs. the 81.0% state average (Hawaii DOH, 2000). Filipinos were also less likely to have taken a class in managing diabetes at a rate of40.5% for Filipinos vs. the 45.9% state average (Hawaii DOH, 2000). With already higher prevalence ofhypertension among Filipinos (NHLBI, 2000), good control of 2 diabetes is essential to preventing complications. Self-management ofdiabetes is the cornerstone ofgood control (Glasgow et aI., 1999; Norris, Englegau, & Narayan, 2001). Immigration and Welfare Reform The 1990 Immigration Act doubled the 1965 employment quota for Filipinos possessing needed job skills in the U.S. and has facilitated bringing in spouses and children ofpermanent immigrants (posadas, 1999). Many older Filipinos also immigrated under exempt, family-sponsored preferences following their adult children to become surrogate parents and homemakers for their grandchildren to allow both parents to work (McBride, 1996). With federal welfare reform, immigrants entering the U.S. after August 22, 1996 were no longer eligible to enroll in Medicaid or to qualify for Supplemental Security Income (S.S.L) and its associated Medicare coverage until they have accrued five years ofresidency. Sponsors ofimmigrants became responsible for the immigrant's medical bills. With a strong desire for family reunification (Abenoja, 1997), Filipinos strive to remain debt-free and to maintain a strong credit rating to be able to petition their relatives to come to the U.S. (Personal communication with Marissa delaCruz, R.N., 2002). Uninsured Filipino immigrants in need ofmedical services may be able to access low­ cost services at community health centers across the U.S. Federally qualified health centers have charged patients according to a sliding fee scale and have been able to write offbad debt because offederal, state, or private funding. However, patients still receive bills which could eventually go to a collection agency. Fear ofdebt has been a particular bamer to