Type 2 diabetes distress among black U.S. Veterans: Development of a culturally sensitive diabetes self-management framework for a health coaching intervention

Abstract: Background and Purpose: Within the Department of Veterans Health Administration in the U.S., 1.1 million (32.3%) of the 3.4 million enrolled Veterans are living with type-2 diabetes, with a higher prevalence among Black Veterans. The daily burdens of managing diabetes and the risk of related complications can lead to low motivation, reduced self-efficacy, and mental distress related to diabetes. Studies indicate that 41-50% of people with type-2 diabetes experience some level of diabetes-related distress. This distress negatively affects the performance of self-management behaviors, leading to poor outcomes. Standardized self-care guidelines often fail to address the specific cultural needs of Black U.S. Veterans in managing type-2 diabetes. A systematic review was conducted to identify interventions components that may be adopted into standard care to support the cultural needs of Black Veterans. This dissertation aims to give Black U.S. Veterans a platform to share their experiences with diabetes distress and the influence of culture on their self-management. The purpose of this study was to gather perspectives on diabetes self-management and distress from 20 Black U.S. Veterans with type-2 diabetes. Methods: Twenty Black Veterans were recruited through Facebook advertisements and word-of-mouth referrals. Each participant engaged in a 60-minute virtual interview via Zoom or telephone. An audit trail was maintained in REDCap and Microsoft Excel to track interactions between the principal investigator (PI) and participants. A semi-structured interview guide, based on Social Cognitive Theory, was used to ask open-ended questions. Additionally, participants completed a demographic data form and the Diabetes Distress Scale-17. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist ensured the transparency and rigor of the interviews. Using Huberman and Miles’ postpositivist analysis method, qualitative data were coded, and memos and diagrams were created from field notes to understand the experiences of Black Veterans living with type-2 diabetes. Descriptive statistics were used to analyze demographic data and the Diabetes Distress Scale-17. Results: The sample included a significant proportion of women Veterans (45%). Participants identified as Black Caribbean (30%) or Black/African American (70%), with ages ranging from 19 to 63 years. Seven themes emerged from the qualitative interviews, highlighting factors critical to diabetes self-management success: 1) Knowledge; 2) Performing Diabetes Self-Management Behaviors; 3) Diabetes Self-management Support; 4) Perceived Self-Efficacy; 5) Behavioral Factors (facilitators and barriers); 6) Outcome Expectations; and 7) Environment. The average diabetes distress score was 3.8 (1.1), and the emotional burden score was 4.0 (1.1), indicating a moderate to serious level of distress. Incorporating cultural practices such as prayer and food preferences into diabetes self-management education was found to be beneficial. Conclusions: Diabetes distress is a significant issue for Black Veterans. The study identified cultural practices and preferences that impact diabetes self-management, providing valuable insights for practice. Future research should focus on developing culturally tailored programs for Black Veterans, integrating key components from the identified themes.

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