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Latina patients' social support and self-efficacy managing Type 2 diabetes mellitus

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Title:
Latina patients' social support and self-efficacy managing Type 2 diabetes mellitus
Creator:
Geno Rasumussenm Cristy R. ( author )
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Denver, CO
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University of Colorado Denver
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English
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Subjects / Keywords:
Non-insulin-dependent diabetes ( lcsh )
Self-management (Psychology) ( lcsh )
Hispanic American women ( lcsh )
Self-efficacy ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Review:
Health disparities exist for Latinas who have a higher incidence of complications rom Type 2 Diabetes Mellitus (T2DM). Treatment of T2DM requires daily self-management. If not managed correctly, T2DM can lead to comorbidities including coronary heart disease. Barriers to self-management are complex and may be exacerbated by psychosocial factors. There is little research on psychosocial factors, including social support and self-efficacy, in relation to self-management of T2DM by Latinas. The Latina perspective on psychosocial factors is explored in this dissertation through an examination of family, health care, community, and cultural sources of social support and self-efficacy as they influence self-management of T2DM. Further, the influence of age, acculturation, and level of education is also explored. This study asks: What is the role of social support and self-efficacy in self-management of T2DM by Latinas? A qualitative data analysis on in-depth, semi-structured interviews is used to answer this question. The study population consisted of 33 self-reported Latinas between the ages of 42 and 70 who had just completed and were recruited from an intensive behavior change intervention, !Viva Bien!. Themes among the study's three concepts of self-management, self-efficacy, and social support emerged. Depression and denial were found to influence a pathway between self-efficacy and self-management. The study also found that knowledge and collective-efficacy influenced a pathway between social support and self-efficacy. Furthermore, collective-efficacy, awareness of disease, and continuity of social support were found to influence a pathway between social supports of self-management. Family and cultural social support were found to be the most important sources of social support for the study population. Findings also suggest that younger Latinas view health behaviors and prevention differently that older Latinas in the U.S. The study's findings support the need for additional research that explores psychosocial factors as they influence self-management behaviors for Latinas. Given that Latinas are at higher risk of developing T2DM, culturally tailored programs aimed at increasing social support and self-efficacy to prevent and manage the disease at a younger age for Latinas need to be developed. Research should explore collective-efficacy as a potential contributor to increasing and maintaining self-management behaviors in Latinas.
Thesis:
Thesis (Ph.D.)--University of Colorado Denver. Health and behavioral sciences
Bibliography:
Includes bibliographic references.
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Cristy R. Geno Rasmussun.

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|Auraria Library
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891657568 ( OCLC )
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Full Text
LATINA PATIENTS SOCIAL SUPPORT AND SELF-EFFICACY MANAGING TYPE 2
DIABETES MELLITUS
by
CRISTY R. GENO RASMUSSEN
B. S., University of Missouri Columbia, 1995
M.P.H., University of Northern Colorado, 1999
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
Health and Behavioral Sciences
2013


This thesis for the Doctor of Philosophy degree by
Cristy R. Geno Rasmussen
has been approved for the
Health and Behavioral Sciences Program
by
James Dearing, Dissertation Chair
Sara Yeatman, Examination Chair
Sharon Devine
Diane King
November 5, 2013
11


Geno Rasmussen, Cristy R. (Ph.D., Health and Behavioral Sciences)
Latina Patients Social Support and Self-efficacy Managing Type 2 Diabetes Mellitus
Thesis directed by Professor James W. Dearing
ABSTRACT
Health disparities exist for Latinas who have a higher incidence of complications
from Type 2 Diabetes Mellitus (T2DM). Treatment of T2DM requires daily self-
management. If not managed correctly, T2DM can lead to comorbidities including
coronary heart disease. Barriers to self-management are complex and may be
exacerbated by psychosocial factors. There is little research on psychosocial factors,
including social support and self-efficacy, in relation to self-management of T2DM by
Latinas. The Latina perspective on psychosocial factors is explored in this dissertation
through an examination of family, health care, community, and cultural sources of social
support and self-efficacy as they influence self-management of T2DM. Further, the
influence of age, acculturation, and level of education is also explored.
This study asks: What is the role of social support and self-efficacy in self-
management of T2DM by Latinas? A qualitative data analysis of in-depth, semi-
structured interviews is used to answer this question. The study population consisted of
33 self-reported Latinas between the ages of 42 and 70 who had just completed and
were recruited from an intensive behavior change intervention, jViva Bieni.
Themes among the studys three concepts of self-management, self-efficacy,
and social support emerged. Depression and denial were found to influence a pathway
between self-efficacy and self-management. The study also found that knowledge and
collective-efficacy influenced a pathway between social support and self-efficacy.
Furthermore, collective-efficacy, awareness of disease, and continuity of social support
iii


were found to influence a pathway between social support and self-management. Family
and cultural social support were found to be the most important sources of social support
for the study population. Findings also suggest that younger Latinas view health
behaviors and prevention differently than older Latinas in the U.S.
The studys findings support the need for additional research that explores
psychosocial factors as they influence self-management behaviors for Latinas. Given
that Latinas are at higher risk of developing T2DM, culturally tailored programs aimed at
increasing social support and self-efficacy to prevent and manage the disease at a
younger age for Latinas need to be developed. Research should explore collective-
efficacy as a potential contributor to increasing and maintaining self-management
behaviors in Latinas.
The form and content of this abstract are approved. I recommend its publication.
Approved: James W. Dearing
IV


DEDICATION
I dedicate this thesis to the important people in my life: especially my parents, Betty and
Bob, who helped me learn to be compassionate to others; my grandparents, Margie and
Bob, who helped me believe in myself; my husband, John, who continues to encourage
me to grow and love more than I ever knew possible; my smart, funny, and beautiful
children, Klara and Jack, for whom I am over the moon for and who are the light of my
life, and my sister, Michele, who is my constant rock.
I also wouldnt have finished if it had not been for my incredibly supportive friends:
especially Sara, Alyssa, Bre, Fabio, Diane, Amy, Amy Amy, Corina, David, Heike, Jen,
Barb, and Diego, who continued to believe in and push me to persevere amidst
adversity, heartache, and a very full and blessed plate in life. Finally, this work would
not exist if it had not been for the wonderful study participants who I am eternally grateful
to for sharing their stories, laughter, and wisdom with me.
Last, but not least, my sincere thanks and appreciation go to my advisor, James W.
Dearing, for his tremendous support, contribution, and spirited energy toward my
research. I also want to thank all the members of my committee for their thoughtful
guidance, participation, wisdom, mentorship, and shared knowledge. I am ever grateful
to each of you for your commitment to me and this important research.
v


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION TO THE HEALTH PROBLEM...................................1
Latino and Latina Health Status..............................5
Health Care............................................6
Health Disparities.....................................8
Self-Management of T2DM...............................12
Overview of the Dissertation................................13
II. SELF-MANAGEMENT OF DISEASE, SELF-EFFICACY, AND
SOCIAL SUPPORT..................................................... 16
Self-Management of Disease................................. 16
Socio-Ecologic Model........................................18
Self-Efficacy...............................................22
Social Support..............................................25
Family................................................27
Health Care...........................................29
Community.............................................30
Culture...............................................31
III. RESEARCH METHODS AND DESIGN ........................................34
Study Population............................................35
Research Setting............................................41
Sample Recruitment..........................................42
Data Collection.............................................43
Analytic Plan...............................................47
vi


IV. RESULTS AND INTERPRETATION OF SELF-MANAGEMENT,
SELF-EFFICACY, AND SOCIAL SUPPORT........................................51
The Concept of Self-Management..................................52
Medication...............................................53
Stress.................................................. 54
Healthy Eating Habits....................................56
Money....................................................58
Physical Activity........................................59
Social Support...........................................61
Knowledge, Awareness and Education.......................63
Collective-Efficacy......................................64
Continuity and Routine...................................65
The Concept of Self-Efficacy....................................66
Definition of Healthy....................................67
Denial...................................................69
Depression...............................................70
Increased Knowledge and Self-Management Behavior.........71
Collective-Efficacy......................................73
The Concept of Social Support.................................. 75
Family Themes............................................76
Health Care Themes...................................... 79
Community Themes.........................................80
Cultural Themes..........................................82
Potential Pathways Between Concepts.............................88
Potential Pathways: Social Support and Self-Efficacy.....89
vii


Summary of Social Support and Self-Efficacy.............95
Potential Pathways: Social Support and Self-Management.96
Family Social Support Source............................97
Health Care Social Support Source.......................99
Community Social Support Source.........................99
Cultural Social Support Source........................ 100
Summary of Social Support and Self-Management......... 101
Potential Pathways: Self-Efficacy and Self-Management..103
Summary of Self-Efficacy and Self-Management.......... 104
V. RESULTS AND INTERPRETATION OF AGE, ACCULTURATION,
AND LEVEL OF EDUCATION................................................ 106
Self-Management and Age.......................................106
Self-Management and Acculturation.............................110
Self-Management and Level of Education........................114
Self-Efficacy and Age.........................................117
Self-Efficacy and Acculturation.............................. 121
Self-Efficacy and Level of Education......................... 124
Social Support and Age........................................128
Social Support and Acculturation..............................131
Social Support and Level of Education........................ 133
Summary of Age, Acculturation, and Level of Education........ 136
VI. DISCUSSION AND CONCLUSION............................................ 141
Discussion....................................................141
Theoretical Implications...............................142
Intervention Implications.............................151
viii


Implications for the Patient Population of Latinas.... 153
Conclusion.................................................. 155
Limitations............................................157
Future Research........................................159
REFERENCES.................................................................. 162
APPENDIX
A: Interview Code Book Categories........................... 177
B: Modified ARSMA II Acculturation Measure...................181
C: Descriptive Characterization of Units of Analysis.........182
IX


LIST OF FIGURES
Figure
1.1 U.S. Census Data 2010: Percent Latinos 1960-2050.........................6
2.1 Socio-Ecologic Source-Of-Influence Model............................... 18
3.1 Research Methods........................................................35
4.1 Thematic Findings For Self-Management...................................53
4.2 Thematic Findings For Self-Efficacy.....................................67
4.3 Thematic Findings For Social Support....................................75
4.4 Potential Pathways Between Social Support And Self-Efficacy.............89
4.5 Potential Pathways Between Social Support And Self-Management...........97
4.6 Potential Pathways Between Self-Efficacy And Self-Management.......... 103
5.1 Thematic Findings For Self-Management And Age .........................107
5.2 Thematic Findings For Self-Management And Acculturation................111
5.3 Thematic Findings For Self-Management And Level of Education ......... 115
5.4 Thematic Findings For Self-Efficacy And Age............................118
5.5 Thematic Findings For Self-Efficacy And Acculturation..................121
5.6 Thematic Findings For Self-Efficacy And Level Of Education.............125
5.7 Thematic Findings For Social Support And Age.......................... 128
5.8 Thematic Findings For Social Support And Acculturation................ 131
5.9 Thematic Findings For Social Support And Level Of Education ...........134
6.1 Recursive Conceptual Pathways ........................................ 150
x


LIST OF TABLES
TABLE
3.1 Participant demographics................................................38-39
3.2 Descriptive characteristics of age, acculturation, and level of education. 40
3.3 Racial/Ethnic composition of the Denver Metropolitan population
and Kaiser Permanente Colorado membership..................................41
3.4 Exit interview questions...................................................47
xi


CHAPTER I
INTRODUCTION TO THE HEALTH PROBLEM
Diabetes is a devastating and debilitating chronic disease for Latinas in the
United States (U.S.). Although they represent a large collective of young women in the
U.S., Latinas are underrepresented in research literature. Compared to non-Hispanic
White women, Latinas have greater incidence of complications related to type 2 diabetes
mellitus (T2DM), including premature death from cardiovascular events, due to delayed
diagnosis and treatment (Cusi and Ocampo, 2011; Caballero, 2001). Family history,
age, and obesity are three main risk factors in the development of T2DM in Latinas
(American Diabetes Association, 2013; Copeland, Becker, Gottschalk, and Hale, 2005).
In addition, insulin resistance is a frequent comorbidity associated with obesity, and
generally precedes T2DM (Copeland, Becker, Gottschalk, and Hale, 2005). Further,
incidence of overweight and obese Latina children and adolescents are increasing in the
U.S., placing them at higher risk of developing gestational diabetes, a glucose
intolerance that begins in pregnancy and elevates risk of T2DM (Black, 2002). Research
that explores the broader socio-ecological context of diabetes in Latinas of all ages is
needed to better understand their health disparities.
There are two causes of T2DM; the first is when the body doesnt produce
enough insulin, and the second is when the body produces insulin, but the body does
not recognize it. Insulin resistance results because the body does not properly use the
insulin. Insulin is a hormone needed to effectively metabolize glucose, or sugars, which
fuels the body. Inadequate levels of insulin can lead to unstable blood sugar levels. A
commonly used marker to test for appropriate blood sugar levels and diabetes is
hemoglobin A1c. Hemoglobin A1c levels need to be stable and in a normal range
1


(Barrera, Strycker, MacKinnon, and Toobert, 2008; Barrera, Toobert, Angell, Glasgow,
and MacKinnon, 2006; American Diabetes Associate, 1997).
As it is often called adult-onset diabetes, T2DM generally develops in
adulthood. Age is a risk factor for T2DM as the disease usually develops after the age
of 45 (American Diabetes Association, 2013). However, T2DM is increasingly found in
younger adults and children as obesity rates are increasing in youth (Harron, Feltbower,
McKinney, Bodansky, Campbell, and Parslow, 2011). Furthermore, T2DM is more
prevalent among Latinas than non-Latino women (Copeland, Becker, Gottschalk, and
Hale, 2005; Rosenbloom, Joe, Young, Winter, 1999). Estimates are that Latino men and
women have lifetime prevalence rates of 45.4% and 52.5%, respectively, compared to
26.7% and 31.2% in non-Latino White men and women due to earlier onset (Narayan,
Boyle, Thompson, Sorensen, Williamson, 2003).
Left untreated, T2DM can be life threating. Uncontrolled diabetes can put
individuals at risk for developing other comorbid conditions, including coronary heart
disease, hypertension, retinopathy, nephropathy, neuropathy, and dyslipidemia
(Fortmann, Gallo, and Philis-Tsimikas, 2011). Common symptoms of T2DM include
increased thirst, urination, blurred vision, and hunger, which are due to high sugar levels
in the bloodstream caused by insufficient insulin (American Diabetes Association, 2013).
Conversely, when blood sugars are too low due to improper and poorly regulated diets,
symptomology includes fatigue and lethargy. Other frequent symptoms of diabetes
include the inability of sores to heal and recurrent infections. Regular blood sugar
monitoring to maintain glycemic control, a healthy diet, daily exercise, and sometimes
medications, including insulin therapy and other medications that help control blood
sugars, are needed to effectively treat T2DM.
2


The etiology of type 2 diabetes mellitus and treatment regimens to manage it are
generally agreed upon by medical practitioners; however, delayed diagnosis in younger
women, postponed treatment, and mismanagement by the patient increases poor health
outcomes for Latinas (Cusi and Ocampo, 2011). Successful management of T2DM
require active participation by the patient in maintaining health, and research
increasingly addresses the importance of psychosocial sources of influence as they
improve or inhibit self-management of disease. Research further states that different
cultural groups have varying perspectives on the role of two key psychosocial sources of
influence in particular, social support and self-efficacy, for T2DM management (Wen,
Shepherd, Parchman, 2004).
Self-efficacy is an individuals confidence or belief that she can do a specific
behavior or task (Bandura, 1986). Application of self-efficacy is important when
monitoring and maintaining blood glucose (A1c) levels for persons with diabetes
(Gherman, Schnur, Montgomery, Sassu, Veresiu, and David, 2011; Concha, Kravitz,
Chin, Kelley, Chavez, and Johnson, 2009; Krichbaum, Aarestad, and Buethe, 2003).
Higher self-efficacy specific to medication adherence, blood glucose (A1c) monitoring,
diet, physical activity, and other self-management tasks may help individuals with T2DM
in making the necessary behavior changes and maintaining them, whereas those with
lower self-efficacy may be less likely to adhere to good self-management regimens. It is
not surprising that high self-efficacy is related positively to good self-management of
diabetes (Gherman, Schnur, Montgomery, Sassu, Veresiu, and David, 2011; Krichbaum,
Aarestad, and Buethe, 2003; van de Laar and van der Bijl, 2001; Hurley and Shea,
1992; Padgett, 1991). However, what influences self-efficacy in self-management for
Latinas is not understood, and will be a purpose of this dissertation.
3


Social support is defined as assistance received from others that has the
potential to help the receiving individual. An understanding of social support can help
health providers and care givers tailor care to the specific needs of patients as well as
assist patients with increasing their own self-efficacy so that they can better manage
their disease (Morrow, Haidet, Skinner, and Naik, 2008). The present dissertations
emphasis is on different sources of social support and whom among Latinas those
sources affect.
Different sources of social support may affect self-efficacy to self-manage T2DM
by Latinas; however, little research exists on the Latina perspective on these issues.
There is some evidence exists that there may be a relationship between social support
and self-management of disease across U.S. populations (Albright, Parchman, and
Burge, 2001; Fisher, Chesla, Skaff, 2000; Boehm, Schlenk, Funnell, Powers, and Ronis,
1997; Glasgow and Toobert, 1988; Antonucci, 1985). However, sources of social
support may influence self-efficacy differently for Latinas than non-Latinas.
Understanding the influence social support has on self-efficacy and self-management of
T2DM could improve interventions and programs aimed at managing the disease for the
Latina population.
An important consideration in Latino culture is the role and norms of family:
namely, familism or the strong values related to the family and interpersonal
relationships with extended family. The traditional role of Latinas is as primary care
giver in the family, with the expectation that they will care for all other family members.
The paucity of literature on Latina self-management of disease suggests that research is
needed to improve the health of these women who traditionally care for others before
they care for themselves. The research questions driving the present dissertation are
aimed at understanding the role of two psychosocial factors, social support and self-
4


efficacy, in relation to self-management of T2DM by Latinas while looking through the
lens of familism. To date, the influence of social support on self-efficacy to manage
T2DM in Latinas has not been much examined in the literature, and research suggests
that there may be a direct effect of social support on self-management of disease
(Fisher, Chesla, Skaff, 2000; Boehm, Schlenk, Funnell, Powers, and Ronis, 1997;
Glasgow and Toobert, 1988; Antonucci, 1985). Further, self-efficacy literature shows a
direct influence on self-management of disease (Sarkar, Fisher, and Schillinger, 2006;
Aljasem, Peyrot, Wissow, and Rubin, 2001; McCaul, Glasgow, and Schafer, 1987).
However, it is unclear how different sources of support may effect self-efficacy, and in-
turn, self-management. Given the importance of familism in Latina culture, and the
significance of the care giver role in Latina culture, it is important to understand how
Latinas perceive social support. Understanding how different sources of social support in
the lives of Latinas influence their self-efficacy and T2DM self-management, and the
potential to use that knowledge to influence positive health outcomes for other Latinas
with similar conditions, are the primary goals of this research.
Latino and Latina Health Status
Hispanic Americans, or Latinos, will triple in number by 2050 in the U.S. They
are the fastest growing ethnic population in the country (Kirk, Passmore, Bell, Narayan,
DAgostino, Arcury, Quandt, 2008; U.S. Census Bureau 2006). The proportion of
Latinos will grow from 3.6% in 1960 to a projected 29% in 2050 (U.S. Census, 2010).
The National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK, 2008)
reported that Hispanics have a greater risk of developing T2DM than non-Hispanic
Whites. In addition, Hispanics are the fastest growing segment of the elderly population
and will have increased prevalence of T2DM as they continue to age (Rodriguez, Joynt,
5


Lopez, Saldana, and Jha, 2011). It is important to understand the prevalence and risk
factors associated with T2DM in this growing U.S. population.
Percentage of Latinos U.S. 1960 2050
U.S. Census 2010 Projections
35 -|-------------------------------------------------------
30----------------------------------------------------------
25----------------------------------------------------------
20------------------------------------------------------
15
10
5
0
1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Figure 1.1: U.S. Census Data 2010: Percent Latinos 1960-2050
Health Care
Latinos are less likely than non-Latinos to have regular medical benefits
(Maldonado and Farmer, 2006; Del Pinal and Singer, 1997). Disproportionately large
percentages of Latinos have low-wage jobs, less job stability, and more hazardous
working conditions than non-Hispanics, factors that negatively influence the likelihood of
having consistent medical benefits and health care options (Maldonado and Farmer,
2006). According to the Office of Minority Health (2011), approximately 30 percent of
Latinos under the age of 65 did not have health insurance in 2010, as compared to
11.7% of non-Hispanic Whites in the U.S. (OMH, 2011; Reschovsky, Hadley, and
Nichols, 2007; Aguirre-Molina, Molina, and Zambrana, 2001). Fortunately, the full
implementation of the Affordable Care Act (ACA) of 2010 is expected to reduce medical
6


insurance coverage disparities by 32 million by 2019, including 9 million Latinos
(Clemans-Cope, Kenney, Buettgens, Carroll, and Blavin, 2012). The extent to which the
law will actually impact insurance coverage for Latinos is likely to depend on effective
state policies and strategies that address barriers to enrollment, such as language, for
Latinos (Clemans-Cope, Kenney, Buettgens, Carroll, and Blavin, 2012).
For Latinos with insurance, quality and satisfaction of the health care received,
regardless of fee-for-service (FFS) or managed care plans (MCO), was rated as fair or
poor by one in four Latinos in a study conducted by the Kaiser Family Foundation and
the Commonwealth Foundation (Neuman, Schoen, and Rowland, 1999). In addition, the
study also found that monolingual, Spanish-speakers were almost twice as likely as
English-speaking patients to lack a regular health care provider. Further, even when
insurance and medical benefits are available, costs to the health care system are
increasing due to higher complication rates and poorer overall health outcomes in
Hispanics with T2DM (Rosal, White, Restrepo, Olendzki, Scavron, Sinagra, Ockene,
Thompson, Lemon, Candib, and Reed, 2009; Boyle, Honeycutt, Narayan, Hoerger,
Geiss, Chen, and Thompson, 2001).
These findings underscore the need for culturally appropriate T2DM prevention
and treatment programs for Latinas that consider the broader socio-cultural, economic,
and environmental context of their lives. Even when access-related factors are
accounted for, the quality of health care in the U.S. is considerably lower for racial and
ethnic minorities than for non-minorities (IOM, 2002). This gap is widened by not having
adequate culturally sensitive interventions and programs in the U.S. that address health
care issues and disparities of Latinos and Latinas.
7


Health Disparities
Studies that control for socioeconomic status (SES) in Latinos document reduced
disparities for some health outcomes, but not for T2DM; this research suggests that the
perceived protection offered to some within-SES-groups is not consistent within all
ethnic groups (Whitfield, Clark, and Anderson, 2002). Even when SES is controlled for,
it is not clear why T2DM Hispanics are more than twice as likely to have T2DM than their
non-Hispanic counterparts (CDC, 2011). The disease is the fifth leading cause of death
for Latinos, and the fourth leading cause of death in Latinas (Center of Health Statistics,
2001). The prevalence of T2DM among Latinas is almost twice that of non-Hispanic
White women (Kirk, Passmore, Bell, Narayan, DAgostino, Arcury, Quandt, 2008). In
addition, the age-adjusted prevalence of T2DM increased by 21% in Latinas from 1995-
2007 (CDC, 2011). However, the underlying factors that contribute to health disparities
and the higher prevalence of T2DM in Latinas are not understood.
While aggregate measures of Latino health that look at global health status of
Latinos are important, they do not help to understand the complexity of cultural and
contextual factors that impact health status and influence health disparities of Latina
subgroups (Amaro and de la Torre, 2002). For example, certain subgroups have higher
mortality and morbidity rates than others, and perceptions of health also vary among
Latino subgroups (Amaro and de la Torre, 2002). Further confounding health disparities
in Latinos, Latinas have a higher incidence of complications from diabetes relative to
Latino men and an increase in hypertension and high triglycerides (Flegal, Carroll,
Ogden, and Johnson, 2002; Maskarinec, Grandinetti, Matsurra, Sharma, Mau,
Henderson, and Kolonel, 2009). This higher incidence of complications from diabetes is
found in women compared to men worldwide, as T2DM undermines the protective
effects that women have against coronary heart disease (Black, 2002). With coronary
8


heart disease as the leading cause of death among women in the U.S., T2DM appears
to be a greater risk factor for U.S.-born Latinas who have a higher mortality from
coronary heart disease (Pandey, Labarthe, Goff, Chan, and Nichaman, 2001; Hunt,
Williams, Resendez, Hazuda, Hagberg, and Stern et al., 2002; Slater, Selzer, Dorbala,
Tormey, Vlachos, Wilensky, et al., 2003). Coronary heart disease (CHD) is a frequent
comorbidity that may result from diabetes, and controlling the risk factors of CHD
through self-management, including total cholesterol and blood pressure, are imperative
for Latinos to decrease cardiovascular disease (Ford, 2011). However, understanding
the risk factors for disease does not explain the cultural and contextual factors that
influence health disparities and may improve health outcomes for Latinos and Latinas.
The 2005 National Health Care Disparities Report found that Hispanics or
Latinos are the one major minority group in the U.S. for which health disparities are
increasing, not decreasing (AHRQ, 2005). There were more age-adjusted years of
potential life lost (or disability-adjusted life year, DALY, which is one year of healthy life
lost due to disease or health condition) before 75 years of age per 100,000 population
for Latinos compared to non-Hispanic Whites in 2001 (CDC, 2004). Specifically, years of
potential life lost by health condition for Latinos compared to non-Hispanic Whites in
2001 were higher for the following health conditions or diseases: T2DM (41% higher),
human immunodeficiency virus (168% higher), chronic liver disease and cirrhosis (62%
higher), stroke (18% higher), and homicide (128% higher); in 2000, there were higher
age-adjusted incidence for cervical (152%) and stomach cancers among Latinos (63%
more for males, and 150% more for females)(CDC, 2004). Higher rates of overweight
and obesity were also reported by Mexican Americans from 1999-2000 with obesity 32%
higher in Mexican Americans as compared to non-Hispanic Whites (CDC, 2004).
Obesity, which is a risk factor for diabetes, may lead to other co-morbidities including
9


diabetes-related complications such as coronary heart disease (CHD), hypertension,
high triglycerides, and abdominal body fat distribution (Vega, Rodriguez, and Gruskin,
2009; Kuczmarski, Flegal, Campbell, and Johnston, 1994). Further, the prevalence of
risk factors for CHD is higher among Latinas compared to non-Hispanic White women
and men, as well as Latino men (Cusi and Ocampo, 2001; CDC, 2004). Given the
abundant findings on increasing health disparities in the Latina population, research that
focuses on explaining these inequalities by examining cultural and contextual factors is
necessary and prudent to improve the health of Latinas in the U.S.
Socioeconomic factors (e.g., poverty, lack of education and employment, little or
no access to medical or preventive care that lead to delayed diagnosis and treatment),
and the social environment (e.g., racial/ethnic discrimination, environmental conditions in
neighborhoods and at work, limited social networks) can increase risks of chronic
disease and injury (Greenlund, Zheng, Keenan, et. al., 2004; Wen, Shepard, and
Parchman, 2004; Williams, Neighbors, and Jackson, 2003; Morales, Lara, Kington,
Valdez, and Escarce, 2002; Hoffman, Trevino, and Ray, 1990). For example, Hispanics
with access to health care show different patterns of care utilization than non-Hispanic
Whites, generally waiting longer for evaluation and thereby presenting with more
advanced disease and leading to poorer health outcomes (Gaskin, Arbelaez, Brown,
Petras, Wagner, and Cooper, 2007; Hargraves, Cunningham, and Hughes, 2001).
Further, research suggests that even with insurance there are organizational,
institutional, and structural barriers to health care access for Latinos leading to unequal
care and health disparities (Beach, Gary, Price, Robinson, Gozu, Palacio, et al., 2006;
Smedley, Stith, and Nelson, 2003). At the organizational level, lack of ethnic diversity
among health care professionals can also interfere with the delivery of quality care to
diverse patient populations that may require more or different types of health care
10


provider support. Patient reported satisfaction with the provider visit and quality of care
is rated higher among minority populations when racial concordance exists between the
provider and the patient (Escarce and Kapur, 2006; Saha, Komaromy, Koepsell, and
Bindman, 1999). This finding suggests the importance of cultural competence in the
patient-provider relationship. Furthermore, lack of interpreter services and inappropriate
health education materials (both linguistically and culturally) can challenge the success
and utilization of health services. Other institutional and structural factors that foster
health disparities also include inconvenient hours of operation and locations, including
distance to providers (Escarce and Kapur, 2006). In addition, difficult intake processes,
including long wait times for appointments can be barriers to care (DHHS, National
Hispanic/Latino Health Initiative, 1993). Having the opportunity to build relationships
with providers, especially Latino physicians, also helps individuals feel more comfortable
seeking out health care, which may reduce uncertainty around processes and systems
involved in accessing care; further encouraging patients to manage their care (Escarce
and Kapur, 2006). Understanding the socioeconomic factors and social environment as
they influence health disparities of Latinos and Latinos can help providers and
researchers to develop improved strategies to help reduce disease and improve health
outcomes.
To help encourage Latinos and Latinas to better manage their care and reduce
health disparities, several improvements can be made in the areas of informed medical
treatment, improved educational materials that are aimed at prevention and tailored to
health literacy levels, awareness of barriers and cultural context regarding health and
health care access, and a better understanding of and response to the social
determinants of health care for Latinas (CDC, 2011). One strategy to improve access
and quality of health care is to adapt successful, evidence-based interventions and
11


programs from one cultural group to another. Although research suggests that cultural
characteristics of the target group need to be incorporated into new interventions and
programs, often cultural factors are not prioritized (Elder, Ayala, Arredondo, Talavera,
McKenzie, Hoffman, Cuestas, Molina, and Patrick, 2013; Osuna, Barrera, Strycker,
Toobert, Glasgow, Geno, Almeida, Perdomo, King, and Doty, 2011; Zambrana, Dunkel-
Schetter, Scrimshaw, 1991). Programs grounded in data, theory, and methods that
were developed and evaluated with one cultural group and then implemented as is for
other cultural groups may save time and money but not retain their effectiveness. To
retain effectiveness program adopters should factor in culturally mediated behaviors,
norms, social support systems, and values through thoughtful intervention adaptation
(Dearing, Smith, Larson, and Estabrooks, 2013; Dearing, 2009; Brach, Fraser, and
Paez, 2005; Betancourt, Green, Carillo, and Park, 2005). By understanding the social
determinants of health care in the U.S., culturally competent interventions and programs
aimed at increasing disease self-management can be developed to reduce health
disparities for Latinos and Latinas.
Self-Management of T2DM
Improving culturally competent care and self-management interventions to help
Latinas manage diabetes is sorely needed. The role of self-management in controlling
T2DM cannot be understated. Self-management of T2DM is grounded in patient
understanding of their health condition and what is necessary to manage their care
(Harvey, Petkov, Misan, Warren, Fuller, Battersby, et al., 2008; Carbone, Rosal, Torres,
Goins, and Bremudez, 2007). The American Association of Diabetes Educators (AADE)
has identified seven self-care behaviors needed to effectively change behavior: eating a
healthy diet, being active, monitoring blood glucose levels, taking medication, problem
solving, reducing risks of complications (e.g., checking feet, regular eye check-ups,
12


preventive care), and using healthy coping skills (AADE, 2013). When used together,
these self-management behaviors significantly improve A1c levels, lower blood pressure
and cholesterol, and improve quality of life (Funnell, Brown, Childs, Haas, Hosey,
Jensen, Maryniuk, Peyrot, Piette, Reader, Siminerio.Weinger, and Weiss, 2008). In
addition, self-management and glycemic control decreases complications and
comorbidities from T2DM (Vincent, Clark, Zimmer, and Sanchez, 2006). Some research
suggests that Latinas have more difficulty with controlling glycemic or blood sugar levels
and do not have the same physiological response as non-Latinas (Brown, Garcia,
Kouzekanani, and Hanis, 2002). Family and cultural influences on self-management of
T2DM for Latinas are not understood. However, there is some research that suggests
family and cultural beliefs about self-management behaviors, including diet and physical
activity, may influence treatment regimens and contribute to poor glycemic control
(Vincent, Clark, Zimmer, and Sanchez, 2006; Brown, Garcia, Kouzekanani, and Hanis,
2002; Whittemore, 2000). Understanding the contextual and cultural barriers to health
care and disease management that Latinas face is important for influencing Latinas
ability to make and sustain the numerous behavior changes necessary for managing
T2DM.
Overview of the Dissertation
This dissertation focuses on the role of social support and self-efficacy in self-
management of T2DM by Latinas living in Denver, Colorado. My a priori assumption,
based on prior research, is that these psychosocial factors directly affect Latinas ability
to manage T2DM effectively. This study poses the following main research question
aimed at exploring the issues and concerns about family, health care, community, and
culture as they may affect my primary concepts of interest:
13


What is the role of social support and self-efficacy in self-management of T2DM for
Latinas?
Sub-questions include:
What is the comparative importance of sources of social support for
Latinas?
How does social support influence self-efficacy and self-management for
Latinas?
What is the importance of self-efficacy in self-management for Latinas?
In Chapter 11,1 review social science theory and prior research studies that
provide the conceptual basis for the dissertation. I use a socio-ecologic framework to
contextualize how self-management of disease, self-efficacy, and social support are
related and how they function in everyday lives. Behaviors of self-management of T2DM
and types and sources of social support are described. In Chapter 111,1 describe the
qualitative methods used in the study. A description of the study population, research
setting, study instruments, data collection techniques, and data-analysis are presented.
Chapter IV presents the results of thematic analysis. The analysis explores
participant perspectives on the psychosocial factors of self-efficacy and social support
and their relationship to disease self-management. Descriptive results, themes, and
relationships among themes are presented with the aid of verbatim text passages taken
from the interviews with participants. Indicators of implied pathways between social
support, self-efficacy, and self-management are analyzed, and the comparative
importance of sources of social support is explored as they relate to the studys research
questions. In Chapter V, analysis and explanatory interpretation is used to further
examine the potential pathways between the concepts of self-management, self-efficacy,
and social support as they are influenced by categories of age, acculturation, and level
14


of education. Age was selected given it is a risk factor of T2DM for Latinas and may
influence social support, self-efficacy, and self-management of T2DM. Acculturation and
level of education were also explored as they may play an important role in
understanding the influence psychosocial factors have on self-management of T2DM.
In conclusion, Chapter VI summarizes the studys key findings with an
interpretive emphasis on the concepts of social support, self-efficacy, and self-
management, and what the study results suggest for behavior change theory.
Limitations to this research are considered, as is the practical value of the present study
results to future intervention design for Latinas with T2DM.
15


CHAPTER II
SELF-MANAGEMENT OF DISEASE, SELF-EFFICACY AND SOCIAL SUPPORT
Theories of health behavior have traditionally focused on behavior change at the
individual level, and health behavior change interventions are often grounded in these
theories. Research over the past several years has emphasized the importance of
translating theoretical concepts into effective and practical interventions that are tailored
to diverse cultures. However, the extent to which cultural and contextual factors inform
development of interventions and medical care aimed at improving the health outcomes
of different populations varies. Furthermore, the context of an individuals psychosocial
environment as it influences self-management of disease varies within cultures, and has
not been targeted for some populations as a potential mechanism for affecting behavior
change. This is a limitation of some health behavior theory (Gallant, 2003).
Self-Management of Disease
Research on self-management of disease is generally framed by health theories
focused on the individuals knowledge, beliefs, and self-efficacy to manage disease.
Behavior change interventions and programs aimed at disease self-management are
grounded in theory to support how shared knowledge of disease management with the
patient will result in improved self-efficacy and self-management. Self-management of
disease is daily care aimed to control one's own disease, reduce or minimize impact to
personal health and functioning, and help oneself cope with the mental and psychosocial
sequelae of the disease (Gallant, 2003; Clark, Becker, Janz, Lorig, Rakowski, and
Anderson, 1991). Many individuals provide most of their own care, making them both
the primary care giver and recipient (Anderson, Funnell, Butler, Arnold, Fitzgerald, and
16


Feste, 1995). Lacking in the literature are the psychosocial factors from the Latina
patient's point of view that influence disease outcomes. For example, social and cultural
influences on self-management behaviors in Latinas are not understood and the applied
health theories may be culturally inadequate.
Daily self-management is mandatory for diseases such as diabetes. In addition
to a healthy diet and exercise, daily self-management of diabetes may include home
blood glucose testing, oral medications, and insulin injections. Daily self-care regimens
have been shown to improve quality of life, reduce mortality and morbidity, and reduce
health care costs (Gallagher, Viscoli, and Horwitz, 1993; Horwitz and Horwitz, 1993;
Horwitz, Viscoli, Berkman, Donaldson, Horwitz, Murray, et al., 1990). The importance of
self-management of T2DM cannot be overstated; research that explores how to improve
health outcomes of T2DM must factor into account barriers and facilitators of successful
self-management.
Latinas face a number of institutional, social, and structural barriers to T2DM self-
management (U.S. DHHS, 2000) as well as general socio-economic factors that can
make their lives challenging (Vega, Rodriguez, and Gruskin, 2009; Morales, Lara,
Kington, Valdez, and Escarce, 2002; Estrada, Trevino, and Ray, 1990). Reasons for
poor health are multifaceted and include culture (Caballero, 2001; Estrada, Trevino, and
Ray, 1990), biology (Burke, Williams, Gaskill, Hazuda, Haffner, and Stern, 1999), lack of
access to health care and high quality health care systems (Wen, Shepard, and
Parchman, 2004), lack of or limited English proficiency (Cusi and Ocampo, 2011; Pitkin
Derose and Baker, 2000), and little insurance coverage (Hoffman and Pohl, 2000;
Burke, Williams, Gaskill, Hazuda, Haffner, and Stern, 1999; Estrada, Trevino, and Ray,
1990; Solis, Marks, Garcia, and Shelton, 1990). The numbers of barriers to self-
management of T2DM for Latinas in the U.S. are abundant and negatively impact health
17


outcomes in this growing population; a further examination of these cultural and
contextual barriers is necessary.
Cultural Social
Support:
Traditional
Norms, Familism
Family Social
Support:
Immediate and
Extended Family
and Friends
Figure 2.1: Socio-Ecologic Sources-Of-Influence Model
Socio-Ecologic Model
A socio-ecological environment is a nested system of influences that can affect
individual perception and behavior. Self-management of T2DM is affected by three
important social-ecologic factors: (1) the health care system and its practitioners; (2)
community environments along with their social/civic institutions, and (3) family (Wen,
Shepherd, and Parchman, 2004). For the purpose of this dissertation, the socio-
ecological environment includes the individuals family, health care, community, and
culture. While other socio-ecological components such as the larger policy environment,
media, work, or educational institutions may also influence self-management behavior,
the focus here is on those elements that the literature has highlighted as most proximal
and salient to Latinas self-management of their T2DM. An illustrative model, which I
have based on several socio-ecological health models, was developed to explore the
relationships between social support, self-efficacy, and self-management factors (Figure
18


2.1) and will be used to operationalize respondents socio-ecological environments
(Sallis, Owen and Fisher, 2008; Bronfenbrenner, 1999).
The present study explores family, health care, community, and cultural sources
of social support and their influence on self-efficacy to understand the extent to which
they are related to and affect self-management of disease. Literature suggests that
identifying and setting realistic goals around self-management of disease, including
problem solving and coping skills, may be influenced by the exercise of self-efficacy
(Senecal, Nouwen, and White, 2000; Strecher, Seijts, Kok, Latham, Glasgow, DeVillis,
Meertens, and Bulger, 1995). However, research suggests that family social support
influences on self-efficacy can both enable and hinder self-management behaviors (van
Dam, van der Horst, Knoops, Ryckman, Crebolder, and van den Borne, 2005; Hayes,
2001). Furthermore, health care and community level influences on self-efficacy may
positively and negatively affect adherence to self-management and treatment regimens
through the use of education and support networks aimed at self-care and disease
prevention (Coffman, 2008; Krichbaum, Aarestad, and Buethe, 2003). In addition, at the
cultural level, self-efficacy may be influenced by cultural norms and beliefs (Concha,
Kravitz, Chin, Kelley, Chavez, and Johnson, 2009). Exploration of these multi-level
influences of social support sources will lead to a greater understanding of self-efficacy
beliefs and how they impact self-management of disease. Having a clearer
understanding of the social support influences on self-efficacy will help to strengthen
interventions aimed at increased self-efficacy to achieve specific behavioral goals for
self-management.
Researchers from an array of disciplines have proposed that psychosocial and
physical environments have multiple direct impacts on health. Intrapersonal (biological,
psychological), interpersonal (social, norms), and environmental factors inform ones
19


health, well-being, and quality of life. Although multiple models and labels are used
under the general rubric of social-ecology models, they all address the multiple sources
of support and pathways that influence behavior. Socio-ecologic models are multifaceted
and include individual self-efficacy and how it is influenced by sources of social support
of multiple types. The socio-ecologic sources-of-influence model (presented above in
Figure 2.1) will be used for analysis in this dissertation to explore the multiple pathways
of psychosocial factors as they influence self-management of T2DM.
Sallis and colleagues (2008) propose four key principles of comprehensive socio-
ecologic models, which aim to understand the dynamic between individual behaviors
and the many biologic, social, and environmental factors that help determine these
behaviors. According to Sallis and colleagues, the first core principle in a comprehensive
socio-ecologic model examines intra- and interpersonal, community, organizational
(including health care), and policy levels and their influence on health behaviors. The
second core principle is the acknowledgement that there is a multidirectional interaction
across the various levels of influence. The third core principle is the understanding that
socio-ecologic models should be specific in their behavioral focus to identify the
influences. Finally, the fourth core principle is that to effectively change health behavior,
multi-level interventions need to be developed (Sallis, Owen and Fisher, 2008).
Furthermore, transdisciplinary research models frequently used in literature are
grounded in evidence-based research and practice across several disciplines (i.e.,
medicine, psychology, public health and social work) and aim to help explain the mosaic
of factors that impact health outcomes. The recent move to more transdisciplinary
models in health behavior research highlights the complexity of health behaviors and
health determinants and supports the use of socio-ecologic models. Theorists and
interventionists are in agreement about the importance of a socio-ecologic approach for
20


understanding and predicting how contextual factors affect sustainability of intervention
components and their effects (Scheirer and Dearing, 2011).
Drawing from both public health and psychology, socio-ecological models are
grounded in work of several scientists, including Uri Bronfenbrenners (1979)
examination of multi-level influences on behavior via synergistic systems and Albert
Banduras (1986) social cognitive theory, which looks at how behavior is influenced by
the environment (Bandura, 1997). In the late 1970s, Bronfenbrenner described this
relationship of the environment to individual behavior through a multi-level model:
Microsystems, the immediate social environment (e.g., family, home,
neighborhood)
Mesosystems, that create the link from the individuals immediate social
environment to other key settings (e.g., work, school)
Exosystems, that impact the individual indirectly (e.g., community groups)
Macrosystems, the culture of the larger social environment in which the
individual lives (e.g., media, societal norms, government).
Bronfenbrenners work was preceded by the Lalonde Report of 1974, A New
Perspective on the Health of Canadians, which proposed four key factors that affect
health: human biology, lifestyle, environment, and health care organizations (Lalonde,
1974). This evolution from human to social ecology schools of thought led the shift to a
broader understanding of the reciprocal relationship between a person and her
environment (Stokols, 1996). Furthermore, there was an expansion of the concept of
health; for the first time health was viewed holistically and had a comprehensive focus
on an individuals health, including physical, emotional, social, and spiritual well-being
(Surgeon Generals Report on Health Promotion and Disease Prevention, 1979).
Although focused primarily on an individuals responsibility toward their own health
21


behaviors, the 1979 Surgeon Generals Report on Health Promotion and Disease
Prevention began to capture a holistic view of health and literature began to explore
multi-level influences on health with more frequency. In 1986, the Surgeon Generals
Report was further supported at the first international conference on health promotion,
the Ottawa Charter for Health Promotion, which advocated an even greater influence on
health coming from socio-cultural and physical environmental factors (World Health
Organization, 1986). This new definition of health began commonly to include disease
prevention, health protection, and health promotion, with a focus on the roles of
individuals as well as groups and organizations to participate as active agents toward
healthy behaviors and creation of health policy. In addition, community health promotion
began to emphasize the collaborative efforts of both public and private institutions within
a community for enhancing the well-being of a population and, socio-ecologic models
began to explore multiple factors that influence health promotion and disease prevention
at the individual and group level.
The value of using a socio-ecologic approach to understand the many factors
that influence health is apparent; a socio-ecologic approach not only integrates behavior
change and environmental models of health promotion, but extends its focus to
comprehensively capture characteristics of the immediate and extended environment -
the individual, her self-efficacy, and her surroundings each of which must be in view in
order to fully understand reasons for an individuals health (Stokols, 1996).
Self-Efficacy
Stemming from Albert Banduras (1986) Social Cognitive Theory, self-efficacy is
an individuals belief or confidence that she is capable of beginning and completing a
behavior or task (Bandura, 1986). Self-efficacy is well-established as an important
mechanism for behavior change (Bandura, 1997). Social Cognitive Theory follows a
22


human agency perspective in which the individual chooses to act a certain way, and
may adjust or control her actions based on personal, social, and environmental feedback
(Bandura, 1986). This feedback affects beliefs or perceptions around capabilities, rather
than actual capabilities, and thereby helps predict actions (Bandura, 1997).
Self-efficacy is specific to task, must be built up over time, and may change
throughout the life span (Bandura, 1997). Ones beliefs in self-efficacy are determined by
four primary sources: (1) mastery experience or life experiences, and accomplishments,
(2) vicarious experience, or seeing similar individuals succeed in a task; i.e., social
modeling, (3) social persuasion or verbal persuasion from others, and (4) affective state,
or feelings, and self-appraisal of personal strengths and weaknesses, both emotional
and physiological (Bandura, 1997). The combination of these four primary sources is
effective at increasing perceived self-efficacy in an individual (Bandura, 1977). In
addition, Bandura suggests that a collective-efficacy captures the capability, shared skill
set and knowledge that a group uses to achieve a desired outcome. Related to, but
different from self-efficacy, collective-efficacy builds upon the personal agency for which
an individual is autonomous in her actions to expand interdependent efforts to achieve
outcomes when accomplishing them at the individual level is not possible or likely
(Bandura, 2000). Collective-efficacy is a groups shared belief in their confidence and
ability to complete a behavior or task, and research suggests that the inability to make
successful changes in health behaviors may signal a low self-efficacy at the individual or
group level (Bandura, 2000).
Self-efficacy has been shown to be an important factor in self-management of
disease (Krichbaum, Aarestad, and Buethe, 2003; Glasgow, Toobert, and Gillette, 2001;
Johnson, 1996). Since self-efficacy helps to predict individual level behavior, improved
self-efficacy can be expected to improve self-management of disease and, if self-efficacy
23


can be built up at a younger age, heightened self-efficacy may help prevent or delay
onset of diseases (Bandura 1997). Research suggests that high self-efficacy increases
self-management of disease, whereas lower self-efficacy decreases self-management of
disease (Krichbaum, Aarestad.and Buethe, 2003). Successful self-management and
adherence to medical treatment regimens or self-treatment plans can be explored
through analysis of self-efficacy, both at the individual level and collectively for Latinas.
At the individual level, beliefs about social cohesiveness and maintenance of social
norms impact the level of social cohesion and, ultimately, social engagement, that the
individual feels. Collectively, reflection of high self-efficacy may be seen within cultural
norms, including health knowledge, attitudes, and beliefs. The importance of familism in
Latina culture underscores the need to examine self- and collective-efficacy as both a
facilitator of and a barrier to effective disease self-management in Latinas.
Specifically, self-efficacy has been shown to be positively associated with
specific self-management behaviors aimed at controlling T2DM, including metabolic
control, self-care adherence, dietary self-care, and satisfaction with treatment in Latinos
and non-Latinos alike (King, Glasgow, Toobert, Strycker, Estabrooks, Osuna, and Faber,
2010; Trief, Eimicke, Shea, and Weinstock, 2009; Sarkar, Fisher, and Schillinger, 2006;
Krichbaum, Aarestad, and Buethe, 2003; Aljasem, Peyrot, Wissow, and Rubin, 2001;
Xu, Toobert, Savage, Pan and Whitmer, 2008; Skelly, Marshall, Haughey, Davis, and
Dunford, 1995; Kavanagh, Gooley, and Wilson, 1993). Stronger self-efficacy beliefs
concerning a specific behavior that is required for the continual self-management of
disease will result in maintenance of management behavior (Krichbaum, Aarestad, and
Buethe, 2003). Furthermore, self-efficacy influences the relationship between social
support and self-management (Bandura, 1997) and is a key driver predicting the extent
of control that an individual has in relation to her environment. However, individuals both
24


act upon their environment and are constrained by that environment and, it is not
understood how self- and collective-efficacy in self-management of T2DM in Latinas is
influenced or varies by sources of social support.
Social Support
Understanding the role of social support as it impacts self-efficacy and disease
self-management is important (Dale, Williams, and Bowyer, 2012; Funnell, 2010; Sarkar,
Fisher, and Schillinger, 2006). Research suggests that individuals with chronic disease
have improved quality of life and functional health status when they have positive social
support in their life (Gonzales, Haan, and Hinton, 2001). Furthermore, people with
diabetes perceive that they have better health when they have social support, or
assistance, received from others (Morrow, Haidet, Skinner, and Naik, 2008; Goodall and
Halford, 1991). However, the influence of types and sources of social support on self-
efficacy as it relates to self-management of disease is not understood as it varies by
culture.
Social support may come in multiple functional types, including emotional,
informational, appraisal, and tangible support as well as positive social interaction
(Sherbourne and Stewart, 1991). Emotional support includes nurturing, love, trust, and
caring, whereas informational support includes giving of advice (Langford, Bowsher,
Maloney, and Lillis, 1997). Appraisal support includes helping the individual understand
information and assisting the individual with coping strategies and resources (Langford,
Bowsher, Maloney, and Lillis, 1997). Tangible support is the provision of actual goods
and services, or actual helping behaviors. Research suggests that tangible or
informational types of social support can be detrimental when the support is viewed as
nagging about behaviors (van Dam, van der Horst, Knoops, Ryckman, Crebolder, and
van den Borne, 2005; Hayes, 2001; Boehm, Schlenk, Funnell, Powers, and Ronis, 1997;
25


Bogat, Sullivan, and Grober, 1993; Griffith, Field, and Lustmam, 1990; Kaplan, and
Hartwell, 1987; Kaplan, Chadwick, and Schimmel, 1985). However, it is not clear if
certain types of social support are viewed more positively or negatively in different
cultures. Understanding the significance of types of social support in different cultures
may help researchers and clinicians tailor care specific to patient needs.
Another important consideration includes the importance of sources and not just
types of social support as they impact self-efficacy and self-management of T2DM for
Latinas. Social support may come from multiple sources, including the family, health
care, community and culture. Self-efficacy may be stronger when social support is
available from multiple sources of family, health care, community and culture; together,
these sources support the individual through emotional, informational, appraisal, and
tangible means. On the other hand, strong self-efficacy may be protective of self-
management behaviors when social support is lacking. Understanding the importance of
sources of social support in the lives of Latinas can help researchers and clinicians
develop programs and interventions aimed at increasing self-efficacy and self-
management of T2DM.
My a priori assumption is that the relationship between social support and self-
management may be mediated by the individuals perceived self-efficacy to manage
disease. However, it is not clear how social support influences self-efficacy of disease
management in Latinas. The sources of social support that are most important in the
lives of Latinas may directly impact self-management behaviors. Cultural norms for
Latinas place a great emphasis on interpersonal relationships and on the role of women
in the family unit, and yet the significance and complexity of these relationships is not
understood (Barrera, Strycker, MacKinnon, and Toobert, 2008). The contextual and
cultural factors that influence the relationship between social support and self-
26


management may be highlighted by understanding the Latina womans role in the family
unit as it relates to self-management of disease.
Social support and self-efficacy are both key psychosocial factors affecting
self-management of disease (Nouwen, Balan, Ruggiero, Ford, Twisk, and White, 2011;
King, Glasgow, Toobert, Strycker, Estabrooks, Osuna, and Faber, 2010; Ingram, Torres,
Redondo, Bradford, and OToole, 2007; van Dam, van der Horst, Knoops, Ryckman,
Crebolder, and van den Borne, 2005; Krichbaum, Aarestad, and Buethe, 2003; Glasgow,
Toobert, and Gillette, 2001). However, the mechanism by which that relationship occurs
is not clearly understood. For example, the self-care activity of monitoring blood sugar
may be influenced by education provided by a physician; whereas diet restrictions may
be influenced more profoundly by family and friends who encourage or help facilitate
healthy dietary behaviors. Further, social support sources of influence may vary
according to the self-management regimen specific to the individual and her health
condition(s). The four sources of social support, including family, health care,
community, and culture will be further explored in this chapter.
Family
Positive support from family and friends can beneficially affect patient health
behaviors and outcomes (Rosland, Heisler, Choi, Silveira, and Piette, 2010; Zhang,
Norris, Gregg, and Beckles, 2007; Luttik, Jaarsma, Moser, Sanderman, and van
Veldhuisen, 2005; Gallant, 2003). Family is important in the lives of Latinas. One norm
in Latino families is that Latinas are care givers to the entire family; placing family health
and care before their own health (Wen, Shepherd, and Parchman, 2004; Hunt, Pugh,
and Valenzuela, 1998). Health care and medical decisions are often made only after
consulting the family and extended family that are considered a primary support group
for Latinas (Carteret, 2011; Wen, Shepherd, and Parchman, 2004; Hunt, Pugh, and
27


Valenzuela, 1998). Furthermore, if support from family and extended family is not
considered positive or adequate the Latina patient may not feel she has the self-efficacy
to make a health decision or behavior change.
Family social support is more important to Latinas than Latinos (Rosland, Heisler,
Choi, Silveira, and Piette, 2010; Jackson, 2006; Gallant and Dorn, 2001), however it is
not known if Latinas believe that they receive or need more family support than Latinos.
There is some evidence to suggest that high levels of social support offered by the
family are most closely related to self-management and increased self-efficacy
(Coffman, 2008; Dimatteo, 2004; DiMatteo and Robin, 2004; Glasgow, Toobert, and
Gillette, 2001). Conversely, low levels of social support from the family are related to
low levels of self-management (Tillotson, and Smith, 1996). Family involvement in self-
management of disease can also be experienced as negative, and increase barriers to
self-management (Rosland, Heisler, Choi, Silveira, and Piette, 2010; Jones, Utz,
Williams, et al, 2008; Carter-Edwards, Skelly, Cagles, and Appel, 2004). If an individual
feels that she is being nagged or excessively reminded about doing a self-management
behavior, such as taking her medicine or monitoring her blood sugar levels regularly, she
may feel guilty or criticized for not taking better care of herself. Family support that infers
insufficient self-management can hinder self-efficacy (Rosland, Heisler, Choi, Silveira,
and Piette, 2010). Latinas may feel frustrated and confused or thwarted in their efforts to
make healthful food choices by family involvement in determining the preparation or
ingredients used in meals (Rosland, Heisler, Choi, Silveira, and Piette, 2010; Cagle,
Appel, Skelly, and Carter-Edwards, 2002). Other family barriers that may influence self-
management include family members placing dietary constraints, such as demanding
that certain foods, like tortillas and beans, be made a traditional way that does not
support good self-management behaviors. Though research suggests that Latinas
28


value family social support more than Latinos, the importance of family social support
barriers as they impact self-efficacy and self-management of T2DM is not understood.
Health Care
At the organizational level, health care stands out in the literature as an important
source for supporting Latina health. Latino, Spanish-speaking patients report more
satisfaction with Spanish-speaking providers (Cooper-Patrick, Gallo, Gonzales, Thi Vu,
Powe, Nelson, and Ford, 1999). Given the dearth of Latino physicians in the U.S.,
communication barriers both linguistically and culturally affect the delivery of care, as
well as patient satisfaction with care. Literature has also shown the importance of
factoring health literacy into the development of health education materials in a culturally
competent manner (Shaw, Huebner, Armen,Orzech, and Vivian, 2008). There have
been initiatives in medical schools over the past two decades to teach cultural
competency to all physicians, residents and students (Carrillo, Green, and Betancourt,
1999; Culhane-Pera, Like, Lebensohn-Chialvo, and Loewe, 2000; Culhane-Pera, Reif,
Egli, Baker, and Kassekert, 1997). These educational efforts emphasize the patient-
clinician relationship and cultural discordance that may exist; potential bias in clinician
perceptions around lifestyle behaviors and disease risks in Latinos; the importance of
understanding the cultural orientation and health literacy of patients; and how to take
action to improve clinical conditions for people of different cultures.
Latinas often include family members and friends during medical visits with
providers (Coffman, 2008). There is the expectation of respect, or respeto, in Latin
American culture, which extends to health care encounters. In the health care setting,
respeto is the reciprocal nature of both patients and providers understandings of the
appropriate position of authority given to individuals. Physicians are generally viewed as
authority figures (Carteret, 2011). Latina patients may listen carefully and nod their head
29


when the provider is speaking, however this behavior may show respect to the provider
more than agreement about what the provider is suggesting for treatment. In Latin
American culture, positions of authority are hierarchical, and vary depending on the level
of importance placed on age, gender, title, social position, and economic status (Flores
and Vega, 1998). Similar to the level of respect the patient gives to the provider, the
patient also expects respect to be given to her and her family during health care visits.
This may include using titles of respect, such as Senora and Senorita (Carteret, 2011).
Family involvement in decision making around disease management and treatment is
greater for Hispanics than non-Hispanics (Coffman, 2008). When families are not
welcomed, disrespected, or excluded from the patient encounter with the physician and
care providers, the patient and his or her family may not feel supported and may not be
as receptive to the medical information given. The level of support offered to the patient
and her family during provider encounters could negatively impact health outcomes if the
patient feels lack of respect to her and her family.
Community
The community in which people live can have a significant impact on the social
support networks to which individuals are exposed. Possible community sources that
foster social engagement and social support, and affect health behaviors, include social
organizations and institutions (e.g., churches, community centers, recreation centers and
parks, libraries, educational facilities), businesses (e.g., grocery stores, banks, post
offices), and transportation services (e.g., bus, taxi, light rail, subway, shuttle) (Stahl,
Rutten, Nutbeam, Bauman, Kannas, Abel, Luschen, Rodriquez, Vinck, and van derZee,
2001). Community factors that have been shown to be protective of health for Latinos
include living in ethnically homogenous neighborhoods that include physical
characteristics of a built environment, such as sidewalks, porches, homes with
30


windows facing communal space, and other variables associated with promoting social
cohesion (i.e., that facilitate a sense of safety, trust and reciprocity among neighbors)
(Sampson, 2003); that promote outdoor activity (such as walking or gardening) and
foster social support (Aranda, Ray, Snih, Ottenbacher, and Markides, 2011; Gerstm
Nurabdam Eschbach, Sheffield, Peek, and Markides, 2011; Verbrugge and Jette, 1994).
Strong social support networks in the community have been associated with physical
activity and social cohesion (Stahl, Rutten, Nutbeam, Bauman, Kannas, Abel, Luschen,
Rodriquez, Vinck, and van derZee, 2001; Giles-Corti, and Donovan, 2002).
Environmental factors that may benefit communities include farmers markets and other
neighborhood activities that target Latino culture; promoting healthy food options as well
as opportunities for gathering and social engagement, which may increase social
support options for community members. Latinas represent the social hubs of the family
and the community they live in through the many roles they play as mothers, daughters,
wives, care takers and contributors to family income. Some research suggests that in
Latino communities there is a protective health factor associated with social cohesion,
and intergenerational support networks that include mothers and grandmothers, built
upon cultural traditions to protect health in the Latino community (Kawachi, Kennedy,
and Glass, 1999). However, it is not clear whether the importance of cultural traditions
and health behaviors varies according to generation, age.
Culture
Acculturation and cultural orientation influence how Latinas view diabetes (Rosal,
White, Restrepo, Olendzki, Scavron, Sinagra, Ockene, Thompson, Lemon, Candib, and
Reed, 2009; Kieffer, Willis, Arellano, and Guzman, 2003). Management and treatment
of disease can be informed by culture and ones cultural orientation, their norms and
beliefs, including how important it is to treat and manage T2DM. The influence of culture
31


as it supports and influences disease management may vary depending on how long
one has lived in the United States.
The concept of familism is prevalent in Latino culture. Familism, also sometimes
called familismo, is the norms and values inherently important to the Latino family
(Carteret, 2011; Wen, Shepherd, and Parchman, 2004; Hunt, Pugh, and Valenzuela,
1998). The concept of familism is important in the lives of Latinas who value the input
and opinions (i.e., informational, appraisal support) of their extended families, which may
include friends who are not biologically related, and may influence disease management.
In addition to the cultural norms and sense of familism inherent in Latino culture,
Spanish language variations, cultural traditions, including food preferences and exercise
habits, vary depending on culture of origin and ones acculturation (Rosal, White,
Restrepo, Olendski, Scavron, Sinagra, Ockene, Thompson, Lemon, Candib, and Reed,
2009). Literature shows that acculturation may play a large role in understanding self-
management of chronic disease in Latinos (Perez-Escamilla and Putnik, 2007; Balcazar,
Castro, and Krull, 1995).
Acculturation is defined as the individuals adoption process of customs, beliefs,
values, behavior and attitudes of a culture. Cultural orientation is the extent to which an
individual is influenced by and engages in cultural norms, customs, and traditions (Tsai
and Chentsova-Dutton, 2002). Measures of acculturation frequently use English
language proficiency or language spoken within the home as proxies for determining
level of acculturation.
Acculturation was originally viewed as a process by which immigrants changed
their behavior and attitudes toward those of the host society (Rogler, Cortes and
Malgady, 1991) and was grounded in a preconceived understanding of what constitutes
mainstream White American culture (Castillo, Conoley, and Brossart, 2004; Zane and
32


Mak, 2003). Sociologists viewed acculturation as loss of the original culture (Park,
1938). The cultural factors at play when one migrates to another country are likely
mediated by the social and structural context that surrounds the individual, and includes
community and structural variables such as where they live and available community
resources. And other cultural variables, such as living near others who have similar
cultural backgrounds and norms. There is a need for acculturation models that include
contextual and structural factors that influence acculturation. As more multidimensional
acculturation models come to fruition, increased awareness of underlying cultural bias
may surface and acculturation measures may be able to better assess the dynamic that
occurs as immigrants adopt behaviors and traits from another culture, or not (Chun,
Organista, and Marin, 2003). Further exploration of cultural social support and
acculturation as they influence behaviors and expectations around self-management is
necessary to better understand self-management of T2DM; this finding by Chun and his
colleagues suggests the need for further development of theories that help explain the
influence of cultural orientation and acculturation as it impacts health and disease
outcomes (Chun, Organista, and Marin, 2003).
33


CHAPTER III
RESEARCH METHODS AND DESIGN
This research project uses qualitative data collection and analysis to investigate
and understand the interrelationships between social support, self-efficacy, and self-
management of T2DM. In addition, age, acculturation, and level of education were also
explored to examine similarities and differences within these categories. A description of
the study population, research setting, study instrument, sample recruitment, data
collection techniques, and data-analyses are presented here.
My study used the conceptual socio-ecologic sources-of-influence model,
previously explained in chapter II (Figure 2.1), and led to questions (Table 3.4) that were
posed to study participants to answer my research questions. I used a one phase
exploratory study design. My study methods consisted of qualitative, in-depth, semi-
structured interviews and data analysis to explore sources of social support (family,
health care, community, and culture), self-efficacy, and self-management. A
methodological framework (Figure 3.1) facilitated the identification of themes in the
collected data, subsequent grouping of themes, and the present analysis, interpretation,
and recommendations as represented in the following chapters.
34


The following research methods were used to guide the project:
Figure 3.1: Research Methods
Study Population
The study population consisted of 33 self-reported Latinas (10 from Salud Family
Health Center, 23 from Kaiser Permanente between the ages of 42 and 70) who had
enrolled and had just participated for two years in a behavior change intervention, jViva
Bieni. The jViva Bien! intervention was based on a successful, comprehensive theory-
based program conducted in Oregon by the Oregon Research Institute called the
Mediterranean Lifestyle Program. That program had been shown to be effective in
improving biological, behavioral, psychological, and quality of life outcomes in Anglo
women with T2DM (Toobert, Glasgow, Strycker, Barrera, et al., 2003).
The aim of jViva Bien! (VB) was to reduce the risk of coronary heart disease
(CHD) for Latina women with T2DM by participating in a lifestyle behavior change
program that incorporated a healthy diet, physical activity, stress management, social
support, and smoking cessation. The VB study had a total of 280 Latinas enrolled
between early 2008 and late 2010 and was supported by a grant from the National
35


Heart, Lung, and Blood Institute (R01 HL0771120). Participants in the VB study
received care from 14 Kaiser Permanente Colorado medical clinics as well as a subset
of non-KPCO members who were recruited from the Salud Family Health Center in
Commerce City, Colorado.
The VB intervention began with a weekend retreat to introduce the lifestyle
behavior change program. The study intervention consisted of six months of weekly
four-hour meetings that were composed of one hour each of physical activity, stress
management, dinner and potluck (visited occasionally by the studys dietician or
physician to discuss diabetes self-management), and social support. After six months,
meetings became less frequent, averaging a meeting every other week, for another six
months, followed by monthly meetings for months 13-18, and every other month for the
last six months of the two-year intervention period. Because of the large time
commitment for the participants, reminder calls were placed weekly and family members
were invited to attend several meetings throughout the intervention period.
For the exit interviews, 40 women (10 women from each of four VB intervention
waves) were invited to participate; 33 interviews were completed with 7 participants
excluded due to incomplete interviews (failed to show for the interview or incoherent
recording). The 33 women who participated in the interviews used for this study
represented a combination of KPCO and Salud Family Health Center patients, with 8-9
participants from each of four jViva Bien! study waves. Demographics and
characteristics from the participants are in Table 3.1 and include level of acculturation,
level of education, employment status, income, living arrangement, primary language
spoken at home, marital or partner status, and health care system. Level of acculturation
was measured using a modified ARSMA II (Appendix B) measure to assess ethnic
identity, and participants were asked a series of questions that assessed whether they
36


viewed themselves as mostly Latino, somewhat Latino, mixed Latino and Anglo,
somewhat Anglo, or mostly Anglo. The ARSMA II is based on its predecessor, the
ARSMA, which is the most widely used acculturation measure for Latinos as an
assessment of national heritage, generational status, language use, social relationships,
cultural practices and other aspects of acculturation. The modified ARSMA included
questions regarding activities done in English or Spanish, including thinking in either
language. The reliability and validity of the ARSMA II have been established (Cuellar,
Arnold, Maldonado, 1995). Data from the acculturation survey measure were converted
to a five point scale based on how the ARSMA II scale categorizes levels of
acculturation, with Level 1 = most Latino, Level 2 = somewhat Latino, Level 3 = mixed
Latino and Anglo, Level 4= somewhat Anglo, and Level 5 = most Anglo (Cuellar, Arnold,
Maldonado, 1995). Participants were given the ARSMA II assessment individually at
one of the four centrally located KP medical clinics or the Salud health clinic. Data were
keypunched and verified for accuracy.
37


Table 3.1: Participant Demographics
Characteristic Total Sample (n=33) Number/(%)
Age range 42-51 52-61 62-70 33 (100) 9 (27.2) 12 (36.4) 12 (36.4)
Level of acculturation (ARSMA II) Most Latino Somewhat Latino Mix Latino / Anglo Somewhat Anglo Anglo 33 (100) 8 (24.2) 1 (3) 6 (18.2) 8 (24.2) 10 (30.3)
Level of education Grades 0-8 Grades 9-11 High School Some College College Graduate Post College Work Missing 33 (100) 4 (12.1) 4 (12.1) 10 (30.3) 8 (24.2) 5 (15.2) 1 (3) 1 (3)
Employment Student Self-employed Employed for wages Unemployed for less than 1 year Unemployed for more than 1 year Homemaker Retired Missing 33 (100) 0 (0) 2 (6.2) 12 (36.3) 0 (0) 1 (3) 5 (15.2) 12 (36.3) 1 (3)
Income $0-14,999 $15,000-29,999 $30,000-49,999 $50,000-69,999 $70,000-89,999 $90,000 or more Missing 33 (100) 5 (15.2) 9 (27.2) 6 (18.2) 4 (12.1) 3 (9.1) 4 (12.1) 2 (6)
Living arrangement Live with spouse or partner Live with spouse/partner and children Live with children only Live with parents or other relatives Live with unrelated roommates Live alone Missing 33 (100) 13 (39.4) 11 (33.4) 2 (6) 4 (12.1) 1 (3) 1 (3) 1 (3)
Primary language spoken in home Spanish English 33 (100) 7 (21.2) 26 (78.8)
Healthcare system Kaiser Permanente Salud Family Health Center 33 (100) 23 (69.7) 10 (30.3)
38


Characteristic Total Sample (n=33) Number/(%)
Marital/partner status 33 (100)
Married 21 (63.6)
Separated 0 (0)
Divorced 1 (3)
Widowed 2 (6)
Single 4 (12.1)
Single, involved inn intimate relationship 5 (15.2)
An overview of participant characteristics was further broken down by age,
acculturation, and level of education and is presented in Table 3.2. For the purpose of
thematic analysis throughout the results chapter, age range is coded into three
categories: (1) ages 42-51, (2) 52-61, and (3) 62-70. The age categories are used to
balance respondents arbitrarily into three groups according to younger to older
participants so that there was approximately the same number of participants in each
age group and are based on the age range of the study participants. Acculturation will
also be discussed using three categories including: (1) most/somewhat (M/S) Latino, (2)
mixed Latino/Anglo, and (3) most/somewhat (M/S) Anglo. For subgroup analysis
purposes respondents were categorized using the scores on the ARSMA II measure
(collapsing categories 1 and 2, and 4 and 5). Education level is also coded into three
categories, including: (1) less (<) than high school (N/A, grades 0-8, and grades 9-11),
(2) high school (high school graduate), and (3) more than (>) high school (some college,
college graduate, or post-graduate).
39


Table 3.2: Descriptive Characterization of Age, Acculturation, and Education Levels
Age Range Number Acculturation Number Education Number
(%) (%) Category (%)
42-51 9 (27.2) M/S Latino 4 (44.4) Latino/Anglo 2 (22.2) High School 1 (11.1)
M/S Anglo 3 (33.3) >High School 4 (44.4)
52-61 12 (36.4) M/S Latino 2 (16.7) Latino/Anglo 3 (25.0) High School 5 (41.7)
M/S Anglo 7 (58.3) >High School 5 (41.7)
62-70 12 (36.4) M/S Latino 3 (25.0) Latino/Anglo 1 (8.3) High School 4 (33.3)
M/S Anglo 8 (66.7) >High School 5 (41.7)
Acculturation Number Education Number Age Range Number
(%) Category (%) (%)
M/S Latino 9 (27.3) High School 2 (22.2) 52-61 2 (22.2)
>High School 0(0) 62-70 3 (33.3)
Latino/Anglo 6 (18.2) High School 1 (16.7) 52-61 3 (50.0)
>High School 5 (83.3) 62-70 1 (16.7)
M/S Anglo 18 (54.5) High School 7 (38.9) 52-61 7 (38.9)
>High School 9 (50.0) 62-70 8 (44.4)
Education Number Age Range Number Acculturatio Number
Category (%) (%) n (%)
< High School 9 (27.3) 42-51 4 (44.4) M/S Latino 7 (77.8)
52-61 2 (22.2) Latino/Anglo 0(0)
62-70 3 (33.3) M/S Anglo 2 (22.2)
High School 10 (30.3) 42-51 1 (10.0) M/S Latino 2 (20.0)
52-61 5 (50.0) Latino/Anglo 1 (10.0)
62-70 4 (40.0) M/S Anglo 7 (70.0)
>High School 14 (42.4) 42-51 3(21.4) M/S Latino 0(0)
52-61 6 (42.9) Latino/Anglo 5 (35.7)
62-70 5 (35.7) M/S Anglo 9 (64.3)
40


Research Setting
The exit interviews that comprise the dataset for this study were conducted at four
Kaiser Permanente Colorado (KPCO) health clinics, the Salud Family Health Center
(Commerce City), or at the participants home. The jViva Bien! program (VB),
interviews, and reanalysis of the VB data to address this dissertations research
questions were approved by Kaiser Permanente Colorados (KPCO) Institutional Review
Board (IRB). The University of Colorados IRB (COMIRB) subsequently ceded to
KPCOs IRB for approval of this study. KPCO provides integrated health care services
to approximately 17% of the population in the Denver-Boulder metropolitan area. The
Racial/Ethnic Composition of the Denver Metropolitan Population and Kaiser
Permanente Colorado membership.of the 550,000 KPCO members are representative of
the characteristics of the Denver Metropolitan population as presented in Table 3.3.
Table 3.3: Racial/Ethnic Composition of the Denver Metropolitan Population and
Kaiser Permanente Colorado Membership.
Race/Ethnicity Denver Metro (ACS 2006-2008 data) KPCO Membership (Qtr 4 2008)
White 68% 74%
Hispanic 21% 15%
African American 5% 5%
Asian American 3% 3%
Native American 1% 1%
Other or multi- racial 2% 2%
The Salud Family Health Center was established in 1970 as a migrant farmer
health center, and today provides integrated primary health care services to the
uninsured, regardless of age, sex, or disease status. Currently, there are nine
41


community health clinics and a mobile unit throughout north central and northeastern
Colorado. The Salud Family Health Centers, which are Federally Qualified Health
Centers (FQHC) are designed as safety net clinics to help reduce health disparities
and barriers to health care including ability to pay, language, and transportation.
The rationale for conducting this study with participants from two different health
care organizations, KPCO and Salud Family Health Center, was to obtain a more
diverse study sample by reaching women in VB without health insurance (all KPCO
members have health insurance), as well as to capture a wider range of experiences
with health and health care resources among participants.
Sample Recruitment
Convenience sampling was used to recruit the women. The women in this study
sample had volunteered to participate in jViva Bien! (VB) and then again volunteered,
and consented for a 60-90 minute interview that was conducted after the 24-month VB
intervention period. Interested individuals were called 2-4 weeks after completion of the
VB program and invited to participate in this study. The original purpose of the interviews
was to conduct exit interviews with the women to understand what they liked and didnt
like about the original VB program, and to better understand how they feel about social
support, health, and self-management of their disease. Participants were chosen based
on their willingness to talk openly about their health and their desire to participate in an
exit interview after the intervention. It is important to clarify that participants were
prompted to comment about jViva Bien!, and these results are reported because I have
used the findings to assess the extent that jViva Bien! influenced their answers to the
research questions; however, the dissertation is not an analysis of the jViva Bien!
program. This study is a reanalysis of jViva Bien! data to address this studys research
questions.
42


Data Collection
Interviews took place at four health clinics or at the participants home if
preferred by the interviewee. Participants were compensated for their time with a $25
gift certificate. Two interviewers were present for each interview, including this
investigator and a research specialist. A research assistant, when available, also
participated and took notes. Interviews were conducted in the participants preferred
language (8 Spanish, 25 English). In most cases, two recorders (digital and analogue)
were used. I facilitated the interviews whenever possible except for the Spanish
interviews, at which point the bilingual research specialist facilitated the interviews in
Spanish. Both the investigator and research specialist had Masters degrees, and the
research assistant had a Bachelors degree. All of the participating research staff were
trained in facilitating interviews, and practice interviews were carried out with study staff
to identify problems with the interview protocol and to refine it.
The collected data consisted of responses to the semi-structured, in-depth
interviews. The use of in-depth, semi-structured interviews with open-ended questions
enables the participant to explore her health experiences across social support sources
of influence, and draws on themes and personal stories that may be relevant to self-
management of disease. In-depth interviews have been used successfully to explore
health beliefs and practices in Latinas (Julliard, Viva, Delgado, Cruz, Kabak, and Sabers,
2008; Thornton, Kieffer, Salabarria-Pena, Odoms-Young, Willis, Kim, and Salinas,
2006). Other researchers have successfully used in-depth interviews for understanding
self-management behaviors in patients who have diabetes, cardiovascular disease and
other chronic health conditions (Coventry, Hays, Dickens, Bundy, Garrett, Cherrington,
and Chew-Graham, 2011; Collins, Bradley, OSullivan, and Perry, 2009).
43


The main research question, What is the role of social support and self-efficacy
in self-management of T2DM for Latinas? helped shape the additional sub-questions.
The interviewer began the interview with grand tour questions also grounded on
Kleinmans explanatory model (1978), aimed at having open ended questions guide the
interviewee through a discussion regarding disease management. Kleinmans model
emphasizes how patients bring their own ideas and perceptions of illness to the clinical
encounter; beliefs around severity, trajectory, and treatment can help inform how
patients experience illness (Kleinman, Eisenberg, and Good, 1978). Clarification probes
(Patton, 2002) were used to understand what interviewees meant by social support
since that concept can mean different things to different individuals and to encourage
interviewees to contribute more to the topic being discussed (Kleinman, 1998).
Interviews were guided and facilitated as an open-ended communication and a dialogue
was co-created by the interviewer and the interviewee (Crabtree and Miller, 1999).
Open-ended questions permitted an environment for the investigator to understand the
other persons perspective (Patton, 2002).
Memoing, which is a form of note taking, was also used as a method to capture
and record ideas, potential relationships, and thoughts as they occurred throughout the
interview (Glaser, 1992). In this case, the memoing technique includes notes and
conjecture or theorizing jotted down on paper during the interviews. For the purpose of
my study, memoing was used to draw attention to patient perceptions of important
factors individual, family, health care, community, and culture that may impede or
support exercising self-efficacy of self-management of disease. An example of memoing
follows:
Family traditions as activity", sharing aspect of these activities is a positive
mental and spiritual influence.
-Participant 8, pg. 12
44


Believed she could have prevented her diabetes had she known how to eat
differently, prevented it through diet.
-Participant 5, pg. 5
In addition, non-verbal communication was observed during the interviews and
notes on these observations were taken by the research specialist, which were later
reviewed by the investigator.
Once collected, interviews were transcribed. Each interview transcript was
verbatim, with the exception of involuntary phrases (e.g. filler words like uh, urn, you
know); or words that were repeated several times (e.g. I think, I did) unless it was felt it
would take away meaning or context from what was being said. After the initial
transcription, which constituted between 20 and 30 pages single spaced, the interview
was listened to again and compared to the transcription for accuracy. If the interview
was conducted in Spanish, the interview was then translated into English by the bilingual
research specialist and then back-translated by a different bilingual jViva Bien! staff
member for accuracy. Text was then entered into ATLAS.ti qualitative software
(ATLAS.ti, version 6) for coding and data analysis.
Thematic analysis of interviewee comments was conducted by this investigator
using ATLAS.ti and emerging pathways and relationships were further supported by the
use of coding. Thematic analysis is a method used to help code, organize, and describe
the principal patterns and ideas in the data (Boyatzis, 1998). For the purpose of my
study, structural coding was used to label text according to topic or domain of interest. A
code can be a word, phrase, or a mnemonic, that is assigned to text in order to organize
and interpret meaning. For example, the topic of cultural traditions was coded to
represent this domain, and sub-domains, of interest. One sub-domain for culture was
type of cultural influence with the specific code CT-TI created to label the text
accordingly throughout the interviews. A similar structural code was created for each
45


domain and sub-domains of analysis. Topics and domains of interest were coded by
sentence or paragraph that conveyed contextual information that captured key ideas.
A priori coding categories were used to develop a classification system for
identifying and categorizing patterns in the data that were plausibly related to the
research questions (Patton, 1990), and were further expanded upon to capture new
emerging themes during the coding process. I first coded for themes in the concept of
self-management of T2DM. Second, I reread the transcripts and coded for themes in
the concept of self-efficacy, and third, upon another reread of the transcripts, I coded for
themes in the concept of social support, including: family, health care, community, and
culture.
The exit interview guide and some examples of probing, open-ended questions,
which were relevant to this project, are included in the following table (Table 3.4). A
complete list of questions, probes and a priori codes can be found in Appendix A. In
addition, a descriptive characterization of the results, including the numbers of coded
interviews and specific thematic coding information, is provided in Appendix C. The
number of coded themes for each of the concepts is listed in Appendix C followed by the
significant, reoccurring thematic findings per concept, which represented positive and
negative attributes, and allowed me to answer the research questions.
46


Table 3.4 Exit Interview Questions
Family Dynamics (e.g. immediate, extended, living arrangement)
Question: Tell me about your family and extended family.
Probing questions: What relationships do you have in your life that influence your health and health behaviors? How do you feel your spouse, partner and/or children feel about your health and their own health? Do you feel you can successfully manage your health?
Health Care (e.g. types, quality, cost, access)
Question: Tell me about your health care and health care systems.
Probing questions: What forms of health care (mental, physical, complementary) do you have access to? What are all of the ways you are taking care of yourself? How much do you have to pay to access these forms of health care? How good is the quality of the care you receive? Are there other types of health care that you use (e.g. complementary and alternative medicine, home remedies)?
Community (e.g. access, characteristics, resources)
Question: Tell me about your community support network(s).
Probing questions: Do you have things (people, places) in your community where you feel support or lack of support around your health and health habits? Family? Friends? Church? What types of support (social, physical, mental) do you receive from your family, friends, co-workers and community members? What support do you feel you have within your community (neighbors, peers, business, organization)? Does this support influence your health?
Culture (e.g. traditions, societal and familial norms)
Question: Tell me about your culture and cultural traditions.
Probing questions: What cultural traditions do you have in your life that influences your health (e.g. foods, celebrations, activities, family customs, and daily rituals)? How do these cultural traditions influence your health (think of the activities you do, the foods you eat, and how you take care of yourself)? What does a healthy person look like to you?
Analytic Plan
Initial analysis included review of transcripts and memos that accompanied each
participant interview. A priori categories of themes and topics were assigned to the raw
data to help substantiate the coding process. Data analysis used analytical induction to
47


identify emerging themes, interpretations of study relationships, and categories about
participants lived experiences with self-management of T2DM (Berg, 2004; Patton,
2002; Glaser and Strauss, 1967).
Once I had completed coding the interviews according to the three concepts of
self-management, self-efficacy, and social support, emerging codes had formed and I
began to sort the codes into pathways between the three concepts of self-management,
self-efficacy, and social support. The text was coded by the investigator for reoccurring
themes of psychosocial factors, including positive and negative attributes, and their
relationship to self-management of T2DM. The emerging and reoccurring themes were
used in the development of a thematic framework to organize findings. Comparisons
among the study participants were made based on importance of social support sources
of influence over self-management. Families of themes emerged, and thematic
categories were adjusted accordingly. Thematic results from the interview data analysis
include quotes pulled from the data that were most interesting, reflective, and indicative
of the theme in question or were most typical of the participants viewpoints.
As pathways begun to form between the concepts, I wanted to explore further if
there were any relationships between the concepts dependent on age, acculturation,
and level of education. I then grouped the transcripts into three sets of data depending
on age range, acculturation level, or education level. Each set of transcripts was then
reread to pull out common themes depending on the category of interest; namely, each
concept (self-management, self-efficacy, and social support) was coded according to
age category, acculturation level, and level of education.
Thematic results were drawn from the data to inform the relationships among the
primary concepts of self-management, self-efficacy, and social support. Primary social
support themes in the areas of family, health care, community, and culture were
48


examined to determine which area of social support is most important to the study
participants. Themes representing influences on self-efficacy were identified. Self-
management themes were identified in relationship to positive and negative attributes.
Thematic results were analyzed and synthesized to inform conceptual theoretical and
practical implications for the Latina patient population. In addition, age, acculturation,
and level of education were explored in relation to the three concepts of self-
management, self-efficacy, and social support to look for similarities and differences
within each category, as they inform implications for the health of Latinas.
A deductive approach was taken to look at the broad concepts of self-
management, self-efficacy and social support as they interrelate and are informed by
specific themes found throughout the interviews. Once interviews were entered and
coded in ATLAS.ti, according to the constant comparative method (Berg, 2004; Patton,
2002), cross-case analysis of the 33 interviews was conducted to group themes of
psychosocial factors across answers of similar questions. An inductive approach was
taken to look for specific and broad patterns across the interviews and a priori codes to
theorize about relationships between the concepts of self-management, self-efficacy and
social support of T2DM (Patton, 2002). The constant comparison method is a process
that uses inductive category coding to concurrent comparison of relationships as they
appear throughout the analysis (Lincoln and Guba, 1985; Goetz and LeCompte, 1981).
Themes of psychosocial factors were explored for their relationships to self-management
of T2DM and variations were refined to move from individual concepts to theorizing
(Tashakkori and Teddlie, 2003; Patton, 2002).
Determining the validity of a studys qualitative data is defined as the extent to
which the phenomenon of interest is credible according to the perspective of the
interviewee, and adequately captured and reflected in the data about them that has been
49


recorded (Trochim, 2001; Patton, 2002). Methodological triangulation was used to verify
captured themes and codes by using memoing, observations, notes, and clarification
probes to support the interpretation of the in-depth interview data. Methodological
triangulation is a common technique used in qualitative research to help validate results
through the use of multiple methods to collect and understand data (Denzin, 2006). In
addition, respondent validation was another technique used during the interviews to
check for credibility and accuracy in interpretation (Yanow and Schwartz-Shea, 2006).
Information was frequently restated or summarized as I understood the participant for
clarification and accuracy of data collection. Analytical triangulation of data continued
until saturation occurred; namely, no new themes emerged.
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CHAPTER IV
RESULTS AND INTERPRETATION OF SELF-MANAGEMENT, SELF-EFFICACY,
AND SOCIAL SUPPORT
Results are organized by the three main concepts of self-management, self-
efficacy, and social support. In this chapter, results are grouped as themes under each
concept. Themes are used in several ways to enable my analysis of the three concepts.
First, themes may have a positive or negative valence embedded that relates positively
or negatively to a concept. For example, denial (a theme) can negatively affect one's
sense of self-efficacy. Second, taken together themes can represent concepts. For
example, perceptions of family, health care, community, and culture culminate to a
generalized but individual sense of social support. Third, my analysis of themes enables
a theoretical assessment of relationships among concepts. For example, it is through
thematic analysis that I am able to draw interpretations about the nature of self-efficacy
in relation to self-management behavior.
The themes noted throughout this chapter are most revealing of the participants
ideas throughout all of the interviews. Sub-sections in this chapter will present thematic
results related to the concepts of self-management, self-efficacy, and social support as
they inform the main research question: What is the role of social support and self-
efficacy in self-management of T2DM by Latinas? To answer this question, first I will
summarize how the participants talked about self-management, including negative and
positive themes that emerged in relation to self-management of T2DM. Second, I will
summarize how the participants spoke about self-efficacy, including themes that
positively and negatively affected participants self-efficacy. Third, I will summarize
thematic findings of how the participants talked about sources of social support in the
areas of family, health care, community, and culture. I will also explore what sources of
51


social support seemed to matter most to the participants, in an effort to answer the first
research sub-question: What is the comparative importance of sources of social support
for Latinas?
The last section in this chapter will examine the potential pathways between the
three concepts of self-management, self-efficacy, and social support. The interpretation
of these pathways will address the dissertations second research sub-question: How
does social support influence self-efficacy and self-management for Latinas? In
addition, social support thematic results will be reviewed as they relate to self-efficacy
themes, including an explanation of the implied pathways between social support and
self-efficacy. Next, the themes that constitute social support will be examined as they
affect self-management of disease. Lastly, I will answer the final research sub-question:
What is the importance of self-efficacy in self-management for Latinas? The themes that
constitute self-efficacy will be explored as they inform pathways to self-management.
The Concept of Self-Management
Throughout the interviews, participants were asked to clarify their comments and
statements around specific T2DM self-management behaviors, including what behaviors
were easier and/or harder for them to complete in the primary areas of medication
adherence and blood sugar monitoring, eating a healthy diet, and engaging in regular
physical activity. Four themes were identified from the interviews as negative in relation
to self-management: medication, stress, healthy eating habits, and money. Throughout
the interviews, two themes overlapped as both negative and positive in relation to self-
management of T2DM:physical activity and social support. Finally, three themes
emerged as positive in relation to self-management of T2DM: knowledge and education,
collective-efficacy, and continuity and routines. Thematic results for self-management
are presented in Figure 4.1.
52


-/+
Medication, Stress
Healthy Eating
Habits, Money
Knowledge,
Awareness, &
Education,
Collective-Efficacy,
Continuity & Routine
Self-
Management

Figure 4.1: Thematic Findings For Self-Management
Medication
Nine of the participants (n=9) in this study reported concern over taking
medication, though not necessarily medication associated with their diabetes control. In
addition, four of the nine participants commented that they consider taking any
medication bad for their health and believe that taking medicine can be more damaging
to treatment of their T2DM than not taking prescription medication. Further, several of
these participants made comments suggesting that taking too many medications may
lead to other health ailments, which was also of concern. Thematic findings suggest a
general distrust of medications, including diabetes medication as well as other
medications, for selves and others.
I really want to get off of these pills. I find theyre damaging me more....Cause
there are a lot of people out there sick because of medications; so many
medications. Some are taking 13 to 19 a day. And I feel theyre number one
killers.
-Participant 13, pg. 21
53


Many other participants echoed this feeling. In addition, several participants suggested
that if an individual is able to wean off medications they will be healthier, and feel
healthier overall.
(Healthy) means, first of all, that I can maintain my staying away from taking
medicines. Stay away from, if possible, taking medication. Cause it has side
effects. To me it causes other problems too sometimes."
-Participant 2, pg. 19
Several of the participants voiced concerns over family and friends taking
medication, noting worries that taking medicine contributes to poorer health outcomes
for their families and loved ones. In addition, four of the participants specifically
commented that monitoring their A1c levels, as part of their medication adherence
regimen was very difficult for them to do consistently, and was a struggle given their
negative views on medication.
Stress
Stress was consistently brought up as a negative theme in relation to self-
management of T2DM (n=9). Several of the participants noted that feelings of stress
negatively contribute to their T2DM disease management as it overshadows their ability
to be successful in daily management behaviors. Frequent stressors noted throughout
the interviews included worrying about their diabetes and other comorbidities or health
ailments such as being obese or overweight.
But its the hidden things that happen to you like the liver and kidneys. Things
like that. If you let them get to a certain point, theyre not going to get any better,
and theyre going to kill you.
-Participant 13, pg. 37
Eight of the nine participants commented that they experience stress over the
effects that T2DM has on their bodys organs, with two participants suggesting that
stress contributes to a sense of fatalism or lack of control of their T2DM, which thereby
contributes to poorer management of disease.
54


Diabetes eats everything, our entire system. Everything, everything, the heart
goes, the kidneys go.
-Participant 26, pg. 13
Further, having more than one health issue contributes to the participants feeling
stressed and, thereby, out of balance when disease is not effectively managed. The
concept of balance and having a balanced life was considered important to five of the
participants when they were asked to think about what it means to be healthy. In
addition, the notion of rushing around in American culture was also voiced by a few
participants (n=4) as a similar concern as it contributes symbolically to an individual
being out of balance in life, and therefore being in less than optimal health.
Healthy means having a balanced life."
-Participant 30, pg. 32
A few participants (n=4) tied stress to being a Latina in the U.S., including how
they feel they are viewed as culturally different, including cultural expectations.
I guess in some ways part of my experience as a Latino is that I feel like I
experience a kind of stress that is similar across all of us.my stress isnt just
mine. So, for instance, if my nephews having trouble with his children, that
affects me. I worry about that. Its not like, Oh well, thats my nephew, its his
family, hell figure it out. It doesnt work like that for us.
-Participant 30, pgs. 25 & 29
Furthermore, four of the participants commented that they had no or little
experience with incorporating stress management activities into their life (e.g., yoga,
meditation). Two participants noted that they were unsure of how the practice of stress
management would benefit their health or whether it is viewed as appropriate in their
culture to engage in stress management activities, including yoga, given their religious
faith and that they didnt want the practice of yoga or other stress management
techniques to be viewed culturally as being sacrilegious. Another theme that a few
participants mentioned (n=4) around stress and stress management was that men, in
general, do not stress as much as women do.
55


A few participants (n=4) commented that they worried high stress levels leads to
negative thinking, which poorly impacts their physiologic markers (e.g., A1c, blood
pressure), and, subsequently, contributes negatively to self-management of T2DM.
The only barrier, the only thing thats detrimental is my negative thinking. You
know, there is nothing else stopping me.
-Participant 29, pg. 18
The theme of stress was pervasive throughout the interviews, and participants
spoke in detail about the importance of it with regard to how it negatively influenced their
ability to self-manage diabetes.
Healthy Eating Habits
Eating a healthy diet was reported as a negative theme in relation to self-
management of T2DM, with nine of the participants stating that they feel eating the right
diet is the most important and the most difficult factor when working to manage their
T2DM. Further, six of the participants feel eating a healthy diet is the most difficult self-
management behavior.
A lot of people are very ignorant about what you eat that isnt sugar thats going
to turn into sugar. I was one of those. I never ate sugar, I never drank pop, I
never, I didnt eat that kind of stuff. But, I was eating a lot of breads and pastas
that do turn to sugar. And a lot of people were very ignorant about that because
of the culture. They eat the way their parents eat, and they cook that way, and
they just keep passing it down. To when they were diabetic they didnt know how
to get off that merry-go-round. And from what I could see a lot of these gals really
did learn a lot. And I know I did.
-Participant 13, pg. 26
Several of the participants commented that food preparation made good dietary
behaviors difficult for them due to the need to think differently about how they prepare
foods in more healthy ways, which may be very different from how they were taught as
children (e.g., using olive or canola oil in place of the traditional lard when preparing
beans, and cooking fish or chicken over traditional red meat). Several participants
commented that as children their food was prepared at home by their mother or
56


grandmother, and there were expectations to eat the available foods. Further,
vegetables and fruit were not always readily available.
All the food that my mom made, she made it at home. And no, I remember that
we didnt eat a lot of vegetables, almost always what we ate was the normal-
rice, potatoes, beans."
-Participant 16, pg. 11
As a child, we hardly ate fruit, vegetables. Thats the way the diet was, beans,
soup, beans, potatoes, tortillas, bread, a lot of bread with milk, a lot of bread."
-Participant 15, pg. 3
Two participants (n=2) noted that classes frequently offered to new diabetics
through health care providers and organizations are quickly presented and are not
tailored to Latinas. Further, several participants commented that the information
regarding how to eat and/or cook as needed to manage their diabetes did not take into
account their methods of cooking or include common foods they and their families eat.
Two of the participants commented that the timing of diabetes-specific dietary
information was often premature. They did not understand or accept what they were
being asked to do around dietary changes, as they were still trying to come to terms with
having the disease in the first place.
I was like, What the hell is she talking about?" Shes got all these boxes and the
cans of soup and Im looking at it and going I dont cook like that." Cause I cook
like my mom, from scratch. We dont use that kind of stuff. So Im looking at her
and Im going, Well, wheres the tortillas, wheres the beans, wheres the...? You
aint got anything in there that I eat. Im sorry. I dont eat that stuff.
-Participant 31, pg. 24
The theme of eating healthfully was also frequently discussed when the
participants spoke about the jViva Bien! program and, the programs expectations
around how the participants ate during the meetings at the potluck, which was a
component of the program. For example, one of the initial exercises that the participants
did during the jViva Bien! program was to meet with the Latina dietician to discuss how
to clean out their cupboards at home and throw away foods that were unhealthy for them
57


to eat. The program dietician did an exercise with the participants where she had a table
of frequently consumed Latin foods (e.g., lard, tortillas, beans, chicharrones). During
this exercise, the dietician asked the women what they thought they should throw out,
and the women proceeded to throw items into the trash can provided. Five participants
discussed this exercise during the exit interviews when they were reflecting on how it is
hard for them to eat healthy. Specifically, participants expressed disgust when the
bacon was thrown away into the trash. These participants conveyed their concern over
throwing away perfectly good food that they and their family liked; throwing away food is
a waste of food and money. This example illustrates how the participants really enjoy
and feel a sense of expectation eating certain foods using traditional methods of
preparation.
Money
Financial issues affect self-management. Many of the study participants (n=10)
reported that money has always been a significant consideration when managing
disease in terms of being able to afford medications, healthy foods (vegetables and
fruits), physical activity resources (e.g., inability to pay for recreation center
memberships consistently, and unsafe walking environments), and other resources (e.g.,
insurance, living environments) to be successful in their daily management regime.
Its hard to stay focused on my eating healthy because I cant afford a lot of the
vegetables and produce out there.
-Participant 2, pg. 11
Four (n=4) of the participants also discussed concerns over money and access to
food when they were children, which influences how they manage their health as adults.
So they (parents) didnt think of eating healthy. They just thought, eat, provide a
meal for your family whatever you can provide.
-Participant 28, pg. 14
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Some of the participants (n=7) commented that they live on a monthly fixed
income, noting that there are months when they are unable to afford their medications
(and have to use available funds to pay rent, buy food, and pay bills first). Other
participants noted that they cannot regularly afford fresh fruits and vegetables, and/or
cannot take classes at recreation centers or participate in educational programs offered
in the community simply because they cannot afford it on a regular basis.
In addition, money was mentioned by a few participants (n = 3) who have higher
incomes in terms of how they often give money to family or friends who are in need and
that they see this as an important means of support to offer when they can afford it.
Physical Activity
Physical activity was viewed as both positive and negative in relation to self-
management of disease. Several of the participants (n=6) reported that physical activity
was generally easier than other self-management behaviors for them to complete toward
managing their diabetes. Swimming at recreation centers (n=7) and walking (n=12) were
most frequently discussed as favorite exercises among the participants.
Several participants (n=5) also noted that once a physical activity or exercise
became a daily or consistent routine they usually found it easier to maintain the routine,
commenting that the health effects were immediate and positive in most cases.
I probably have more energy (after VB). I can do more things. Because it used
to be that Oh yeah, Im gonna paint the kitchen. And then I start thinking, Oh,
maybe I cant do this. Where now, we had our garage insulated, so I thought
Im going to paint this garage. And by golly, I did, even though I was on a ten
foot ladder you know doing the ceiling and stuff. I got it done, and it looks good.
Or maybe before I went to this class (VB), I couldnt because you know the mind
was thinking I could do it, but the body wouldnt let me. But now that I am
exercising and stuff, I have more strength and more, you know, I can do more
than what I did before.
-Participant 23, pg. 26
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However, getting into the initial routine of doing physical activity and exercise
was often hard. Many participants also reported physical limitations frequently kept them
from doing activities they would prefer to do.
Well, I used to go dancing a lot, before, but now with my legs I cant do that. I
just think, Im grateful that I can just do my housework and go for walks, and do
my chores...like with yoga, I cant really get down on my knees, and bend a lot. I
wish I could. But with these knees, its hard for me to get down. Even doing
housework is a chore.
-Participant 21, pg. 24
When asked about physical activity behaviors, three of the participants also
commented that they were raised as young ladies not to put their legs into the air, and
that physical activity was not necessarily encouraged by their parents or family when
they were growing up.
As a Latina woman you didnt really exercise. Oh no. You know, my age group.
Im 52. We really didnt. You didnt go to aerobics or anything like that. Say as a
20 year old. We really didnt. Should have, but we didnt. I think we were more
embarrassed of throwing our legs up in the air and doing whatever....we didnt
do that.
-Participant 23, pg. 33
The example of not putting legs into the air was an interesting finding that
speaks to the cultural norm that many of the women expressed regarding exercise
habits and expectations that were placed on them as young Latinas. Participants who
expressed this theme were aware that exercise was good for their health and for
managing diabetes. However, these participants spoke about how exercise was not
something that they were encouraged to do as younger girls. This finding supports
exploring the cultural shift in younger Latinas with regard to preferred exercise habits
and norms around physical activity as it contributes to prevention and self-management
of disease.
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Social Support
Social support also emerged as both positive and negative in relation to self-
management of T2DM. The theme of social support primarily touched on three types of
social support, including emotional (caring for and being cared for), informational
(advice), and tangible (help offered) support. Participants did not specifically distinguish
between sources of social support. Seven participants commented that social support
was the most important contributor to self-management of T2DM. Twelve participants
(n=12) suggested that social support could be both positive and negative as it impacts
self-management of T2DM. Further, social support, given to others in relation to caring
for others and being respectful, was frequently discussed as being both positive and
negative as it contributed to self-management of disease. The participants frequently
discussed taking care of others and how this made them feel good about themselves.
However, many of the participants (n=8) recognized that they often failed to take good
care of themselves because they prioritize taking care of others.
As a Hispanic woman I know I am the heart of my whole family. And my mom
was the heart of our family, and my grandma was the heart of her family. And, we
play a very important role in our families. Being a Hispanic woman theres a lot of
respect. And you have to live up to that respect that people give you. And that
has to do with everything.
-Participant 20, pg. 19
I dont think my family is concerned whatsoever (about my health) because I
never talk about it. They are always looking to me because I am a care giver. I
think they look to me to do things all of the time, and Im not a complainer. I just
dont go around saying I have diabetes, I have this or that. And I dont even think
that half of the time they think that I have it, you know, and then theyre
encouraged when I tell them Ive made so much progress in my health care and
my results that I even dont think theyre right. Its just a way of living, and you
learn to live with it, and you do the best you can.
-Participant 4, pg. 16
I think that most of the women in my moms, in my family, are the care givers. To
the point that they put their own health needs on the back burner. I know that
was definitely the case in my moms life. I kind of do some of that now. I always
watch out for everyone else and kind of say Im okay.
-Participant 6, pg. 9
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The concept of loneliness also emerged out of the discussions around social
support as it influences self-management of T2DM. Four participants commented that
loneliness is an issue that stems from a lack of social support and negatively contributes
to successfully managing disease. Other participants discussed the recognition of not
feeling lonely in their disease after they had met people with similar concerns who also
shared a sense of commonality through social support.
But to know that when you talk to somebody else they feel the same way you
do, they have the same concerns, theyre worried about their health, and how
they eat and everything. So its like ok, youre not alone. I think that is great.
Because sometimes you do feel, you might feel, Oh gosh, Im the only one like
this or Im the only one that feels like this. And then you find out You know
what, they all have the same concerns too.
-Participant 17, pg. 56
Laziness was another concept in the area of social support that four participants
spoke of negatively; namely, how little or no social support made it easier for them to be
lazy regarding self-management behaviors.
When asked what has helped one participant manage herT2DM, she simply
replied, That I see you one thousand times (Participant 32, pg. 32). Throughout her
interview, this participant spoke to the increase in social support both from the jViva
Bien! meeting leaders and the participants in the program; this support was influential on
how she now views the importance of her self-management behaviors. Nine of the
participants reported that participating in a social support group around self-
management of disease became the easiest way for them to improve their self-care
behaviors.
. .the friendships that I make with these people that I work out with. That has
helped me in the working out part too. Because I look forward to seeing them. So
you want to go, even if you dont feel really excited about doing weights today.
Its still kind of nice.
-Participant 28, pg. 36
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Participants expressed the importance of feeling a part of a collective group and
several spoke about the enjoyment they found when participating in social group settings
Knowledge, Awareness, and Education
Knowledge, awareness or sabiduria, and education were three of the most
commonly reported positive themes in relation to self-management of T2DM for the
participants, with 14 of the participants reporting that knowledge learned in the jViva
Bien! program gave them increased awareness of how to manage their disease and they
felt as though they woke up. Education consistently came out of the interviews as
being a key factor to improved self-management of T2DM, with a couple of the study
participants stating that the education they gained in jViva Bien! saved them.
It was like, it was like a life raft for me. I was drowning and everything. And / Viva
Bien! came along and I felt like I was being saved."
-Participant 5, pg. 11
Many participants (n=17) reported increased education and understanding of
their disease helped them feel their diabetes was more manageable than before the
education; namely, increased education improved perceived self-efficacy. Several
participants (n=8) also commented that having family members (usually the mother) who
have or had diabetes, and seeing what they go or went through when they fail to take
care of themselves, made a significant impact on how they manage their disease.
And then my brother got it (diabetes) when he was eighteen. Died at thirty. So,
its a different change. And then with me getting educated about it makes me feel
good because the other ones aint, you know? Weve all got it, but one of us."
-Participant 1, pg. 11
Twelve of the study participants also commented that when they learned
additional information regarding self-management behaviors around T2DM this
information also benefited their family and other friends, directly.
Four of the study participants noted that they used the internet and other media
(magazines, newspaper) to find information around self-management of T2DM. In
63


addition, a few of the participants commented that they watched television programs that
focused on health information, commenting that they shared the information they learned
through these programs with family and loved ones.
The importance of knowledge and education as it increased awareness was a
persistent theme throughout the interviews; there was a sense of pride and
empowerment from the participants who expressed that they felt proud to be able to
share their knowledge with loved ones and family.
Collective-Efficacy
When participants were asked about their ability to self-manage their disease,
the theme of collective-efficacy was pervasive as many participants (n=12) discussed
the positive aspect of working and learning with others to take better care of their health.
We had a lot of the ladies there are from Mexico, you had people from Puerto
Rico, Brazil. That was all Latino people, the women, and we all got to focus and
knowing our ways and stuff. You get to learn their cultures, our cultures, the way
we are, but were all Latinas. And thats what was good about it.
-Participant 6, pg. 15
Participants expressed the importance of eating a healthy diet and participating
in regular physical activity; sharing self-management responsibilities with others who had
similar disease management regimes seemed to resonate with the participants and
increased adherence for many of the participants who commented that they felt more
capable of doing certain behaviors when there was a collective effort.
I think we need to learn how to drink more water, eat healthier and work with
each other. Everyone needs to work with each other on all of this stuff, cause its
hard. Its hard to by yourself. You cant do it by yourself.
-Participant 2, pg. 3
The importance of family in Latina culture highlights this finding; namely, familism
is reinforced through the collective-efficacy of a group and nurtures empowerment to
manage disease more proactively. In addition, there seemed to be a reciprocal
relationship between the participants who participated in the jViva Bien! program.
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One learns from everybody else and everybody learns from one.
-Participant 9, pg. 26
Namely, the collective effort at the community level fostered a sense of
accountability to others and enablement to improve self-management behaviors.
Continuity and Routines
The theme of continuity and routine of self-management behaviors emerged as a
positive theme of facilitating self-management of disease (n=7). As one participant
succinctly noted, behavior change takes time so I can finally get it in to my head
(Participant 8, pg.60).
I liked when we were meeting once a week (for / Viva Bieni). I think that could
have been extended. Because you know what when you first start out, youre
asking people to commit to something and a lot of people didnt get into a rhythm.
And then as soon as we got into the rhythm at the end, it changed by decreasing
the times that we would get together. I found the last three months of this
program to be kind of a waste. They were, cuz they were once a month and
people werent coming and a lot of people lost interest. And I myself was one of
them. It seemed like people had moved on. They werent really interested in
finishing the study. So that to me was kind of a downer.
-Participant 6, pg. 16
The routine of the jViva Bien! program was discussed during the interviews, as
thirteen participants (n=13) commented it helped them feel more accountable to each
other, as they learned what the program leaders and participants expected of them
during the two year intervention. A couple of participants commented that they felt
looked up to during the program, and wanted to be seen as role models for other
participants. Further, seven participants (n=7) suggested that the continuity in the
meetings and the programs overall expectations in the areas of physical activity, diet,
stress management and social support helped facilitate good self-management
behaviors even when they were not at the actual VB meetings.
...difficult in the beginning. But they become easy as you practice and go on.
Just a continuation. It becomes a habit, instead of a bad habit its replaced with a
good habit.
-Participant 29, pg. 26
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Conversely, when the program ended several of the participants (n=6) reported
that it was harder to keep up self-management behaviors, with one participant stating
that she was devastated when the program ended. Three of the participants reported
being considerably depressed when the program was over.
Oh, I was devastated. I thought, Im not going to see these people anymore.
And I thought Oh, I could call them. But I never did call them. So that doesnt
work. It doesnt work unless you work.
-Participant 20, pg. 30
I didnt have any connections with anybody (after the program ended). I kind of
went to the wayside you know? But then I had to get myself together and say,
No, no. This is not who you are. This is not what jViva Bien! wants for you. They
taught you to do all the good that you need to do. And you need to continue
doing it. And so then that attitude changed. I started doing things on my own,
and trying to help myself get healthy.
-Participant 20, pg. 20
The theme of consistency and routine was present when the participants
expressed the importance of self-management behaviors. For example, physical activity
routines and consistency around having access to healthy foods, health care, and social
support groups were widespread themes throughout the interviews.
The Concept of Self-Efficacy
Self-efficacy was measured by the participants responses to interview questions
that inquired about her confidence and perceived ability to manage diabetes through the
primary behaviors of medication adherence and A1c monitoring, diet, and physical
activity. In addition, each participant was asked what they feel a healthy individual looks
like, and whether or not she, herself, feels that she is healthy. The intention behind this
question was to better understand the context of health as the participants viewed it. The
participants answers to this question also helped inform perceptions of self-efficacy, and
are therefore discussed in this section as they negatively or positively contributed to the
concept of perceived self-efficacy. Two themes emerged as negatively influencing self-
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efficacy for T2DM self-management: denial and depression. The themes of increased
self-management behaviors that came from learning new skills and increasing ones
knowledge and the sense of collective-efficacy emerged as positively influencing self-
efficacy for T2DM disease management. Thematic results for self-efficacy are
presented in Figure 4.2.
-/+
Definition of a
Healthy Person
Denial, Depression

Self-Efficacy

Increased
Knowledge & Self-
Management
Behaviors,
Collective-Efficacy
Figure 4.2: Thematic Findings For Self-Efficacy
Definition of Healthy
The majority of the participants (n=23) commented that if an individual is
healthy, then she is confident that she can carry out good self-management behaviors
toward managing T2DM. This definition of healthy, as either positive or negative was
indicative of the individuals perceived self-efficacy; whereas being healthy means being
confident you can do healthy things, and when you do them it reinforces your
confidence.
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But when I get up I feel good, my backs not hurting, I can move. To know that I
can do things and do them without fear that Im not able to. To know that I can
still go and try it. That it doesnt limit me in some of the things that I can try. I did
my trip a couple of weeks ago I went to Hawaii and I hadnt been in so
long....and nobody wanted to go to Diamond Head, And I said, you know what,
theres no reason I cant go. So I got up and I felt good. When I got back I felt
good. I walked all the way up there and I thought, You know what, Im so proud
of myself...Being healthy means, its all part of everything now... I feel like Ive
got to this point and Ive got to keep going. I dont want to go back where I was. I
feel better. My attitude. My daughter said too, You know mom, it seems like
youre happier, and youve got a purpose in life. Youre taking care of you.And I
said well, thats it. Ive got to take care of me.
-Participant 17, pgs. 39, 41
Many of the participants (n=9) reported that they feel healthy individuals are
generally happy and have a positive attitude in life, and suggested that they feel attitude
causes health or sickness.
And you see them, theyre happy, theyre wanted to help people, then you know
that theyre healthy. But if somebody is laying around and just not wanting to do
anything, well then you know that somethings wrong. Or theyre depressed.
Some people when theyre not healthy they always depressed. Theyre not
happy people.
-Participant 27, pg. 20
People who complain a lot and dont like themselves, or dont feel good about
themselves, they usually arent healthy.
-Participant 12, pg. 13
There were several other common indicators of health and how healthy
individuals are perceived, which participants spoke of. A few of the participants (n=4)
commented that healthy women have good skin, and several (n=5) participants also
said that being skinny is not considered healthy in Latin culture. Another common
response for a healthy person is an individual who is educated (n=5), and a few
participants (n=4) alluded that they felt if one was taking care of herself (and managing
her diabetes), even when they have a chronic disease or comorbid conditions, then they
are healthy. Another indicator of being healthy, as discussed later in this section as it
relates to increased self-management, includes taking the time to get ready or fix up;
wearing nice clothes, going to the salon, and getting out of the house.
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. .because you have to get up and get ready. And once you get up and get
ready, youre out of the house. And once you are out of the house, you are
moving all the time. Walking.
-Participant 19, pg. 18
I think that if theyre truly healthy you would see that they would have like a
glow. I mean their face, their complexion would be good.
-Participant 31, pg. 21
He (son) has his disease under control, but when you have your disease under
control you are also healthy.
-Participant 22, pg. 40
Denial
Nine of the participants (n=9) commented that they or others they know who
have T2DM are in, or were previously in, denial of their condition; believing that they are
not truly sick or when they found out they were sick they did not want to change
behaviors to help manage the disease. This sense of denial, therefore, was seen as
negative in the relation to self-efficacy for many of the participants.
You have to be brutally honest about what could happen to you. And a lot of
people dont hear that and they dont see it because theyre feeling good. And a
lot of people have not been around people that have diabetes. Like I wouldnt
have been as in tune to it had my mother not suffered the way she did.
-Participant 13, pg. 38
Hes (my husband) a diabetic, and hes mostly in denial about his diabetes. And
because of that, its very difficult for me to try and stay on any kind of plan, or
way of life. My husbands an engineer so hes very logical. Most things he can
fix..when he cant fix something, it very much stresses him out. And he cant
fix his diabetes, and he cant fix mine. Because of that he tries to just ignore that
he has it. And doesnt want to fix it. And not being able to do it together,
supporting each other, has been a real problem.
-Participant 5, pgs. 4-5
There is literature to support an expectation of altruism is common in Latinas who
are viewed as the matriarchs of the family (Mouldon M, Melkus GD, Cagganello, 2006;
Oomen JS, Owen LJ, Suggs; 1999; Upton RB, Losey LM, Giachello A, Mendez J,
Girotti, 1998). Denial seemed to be a predecessor to depression for some of the women
who, after accepting that they had T2DM, became depressed when they did not feel they
69


could manage it effectively. Ten of the participants (n=10) spoke about the confidence
they had in managing their disease when they finally accepted their disease and began
to learn about it through education and increased knowledge. The interaction between
knowledge and acceptance led to a change in behavior, which contributed to a sense of
increased self-efficacy for several participants. Prior to accepting that they had T2DM,
several participants suggested that they didnt believe they needed to make changes,
regardless of whether or not they could make changes to improve their health.
I, just watching other people, learning from them, and seeing, and thats why I
say I need to get up and try to figure out something, and do something".
-Participant 2, pg. 16
As they began to accept their disease, they watched and learned through others
who were in similar health states and who had similar lives; learning and changing their
own behaviors through vicarious experiences that influenced their own self-efficacy.
Depression
Feelings of depression reduced self-efficacy for a large number of
participants (n=11). Several participants shared how they had struggled throughout life
with bouts of depression, and many considered their mental health providers a primary
care giver (n=5). Several participants suggested that their ongoing depression
contributed initially to how they viewed their diagnosis and management of T2DM.
Instead of going to the little classes that didnt even make sense to me, to really,
they wanted you to learn everything in two hours. First of all, its Greek to you to
begin with. And then youre expected to learn how to cook in two hours? I dont
think so. Thats maybe what they talk about, is your food, and your food charts,
and what you should be eating, and how many of this and how many of that. Im
like, Oh sheesh. I have to be calculating all this stuff?" And they delude you,
because first of all your hearts not in it. Youre depressed at being diabetic. So
yea, that what I would say that would be the best time to get people on the right
track. Is right then and there. Youre diabetic now, this is what its all about.
-Participant 28, pg. 46
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Depression was expressed by several participants as influencing their beliefs
about diabetes and the confidence they had to manage their disease. Several
participants suggested depression masked their disease, thereby hindering what was
needed to manage it. Several participants commented that participation in jViva Bien!
helped bring them out of a depressive state, and gave them new skills to help manage
diabetes and depression. Further, participants suggested that involvement in jViva Bien!
encouraged them to make behavior changes and to participate consistently throughout
the program because they didnt want to disappoint the other participants or meeting
leaders.
Increased Knowledge and Self-Management Behaviors
Eight participants (n=8) suggested an increase in knowledge of self-management
behaviors increased perceptions of self-efficacy to manage their T2DM and take better
care of their health. Several of the participants commented that they learned new skills
from watching other participants in the jViva Bien! program, suggesting that it was
important to observe other Latinas doing behaviors successfully, which helped increase
their own self-efficacy to believe that behavior change was possible for themselves.
And I go I never had nothing like this (VB), never experienced anything. She
(the VB social support leader) goes Well, how do you feel now? I go, I feel ok, I
feel ok. I feel even better. Like what Im doing is gonna be the best thing for
myself. It was all right there in our hands.
-Participant 2, pg. 31
Taking care of ones appearance also emerged as a theme in relation to self-
efficacy for self-management behaviors with several of the participants (n=5) observing
that when they take better care of themselves, including wearing make-up, dressing
nicely, and having their hair done, they feel more capable of managing their disease and
feel more empowered to take care of their health.
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Later (after participating in VB) I even liked fixing myself up more, I liked
changing my clothes more, and it was affecting me. Also I didnt know what to do
because I saw that with time I was limiting myself, I didnt want that.
-Participant 22, pg. 18
Participants (n=7) who reported they did not have to ask for permission from their
husbands or partners to participate in self-management behaviors (e.g., attending the
jViva Bien! program, attending community physical activity and recreation classes,
cooking healthy meals for the entire family), had more feelings of empowerment to
successfully carry out self-management behaviors. Several of these same participants
also suggested that they felt more confident to do additional self-management
behaviors, including trying new classes, seeking out more health resources, and sharing
their knowledge with others who have diabetes.
I didnt ask permission from my husband. ...any maybe it was an advantage for
me, that I deserved, I asked permission for everything from him. I knew he
wouldnt give me permission; he wouldnt have even taken me, or even let me
come.....In conjunction with my illness, my lifestyle, I feel better, because the
way I felt with the support I felt that what I did (participating in VB) wasnt wrong,
especially for me -for the rest, who knows but for me it wasnt bad because
one learns things, one learns how to live. For me when I talk to people like you
two, I learn things. I learn that I need to be me. Its bad what I have lost, no? That
is why, I think, I tell him.
-Participant 22, pg. 16-17
Participants (n=7) who felt they have more self-efficacy to carry out self-
management behaviors were more apt to see diabetes and other health conditions
(including depression) in terms of problem solving ways to treat their health conditions,
with less focus on causes of the medical condition or ailment.
Id spent a lot of time thinking about what causes some of my depression and
working with that. What Id never done was work through the problem and come
up with solutions for dealing with it. And that helped a lot.
-Participant 5, pg. 17
Now I am taking the problem seriously, and I know the problem that I have.
Because I never thought that diabetes was an illness, I for me, I would say, No,
Im not sick. I didnt assimilate it; I hadnt assimilated how much of a problem it
was, eh.
-Participant 8, pg. 27
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Participants suggested that the increase in self-management behaviors was
related to learning new skills and increased knowledge that helped increase self-efficacy
in this Latina population. Findings suggest that the increase in knowledge could be
more essential for increasing self-efficacy in Latinas who may not be aware of the
importance of self-management behaviors because of cultural biases.
Collective-Efficacy
When the participants were asked about their confidence and ability to manage
their disease, most of the participants spoke about a sense of collective-efficacy with
regard to how confident they felt about being able to make changes toward managing
their disease when they felt a part of a similar group. Participants expressed a sense of
collective-efficacy that they felt when they participated in community and cultural
activities, although many of them commented that they had not previously thought about
the significance of being part of a group until they had participated in jViva Bienl.
(In relation to participating in a social support group) We were all united because
we wanted to improve our health, that helped me a lot to be more open, to have
more self-confidence. Because before no.
-Participant 8, pg. 36
I need the support of somebody that I know being there with me. I think thats
what made jViva Bien! good because its more of a personalized thing where
people get to know each other.
-Participant 3, pg. 6
Four participants out of the total (n=33) specifically commented that they feel
their ability to manage their disease is more individualistic, and dependent on their
behaviors, even when they also spoke to the importance of family and community.
l just have to work on this myself, its me thats got to make this happen.
-Participant 2, pg. 9
Ive got to take care of myself, I think. Overall, its up to you, nobody else.
-Participant 21, pg. 21
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The concept of collective-efficacy was pervasive throughout the interviews, as
the participants spoke to their sense of being part of their family, community, and culture
as a Latina. One participant also spoke about the sense of collective-efficacy over
individualism for Latinos in general, and voiced concern over feeling that Latinos are
viewed differently than non-Latinos.
I really think the world is divided into two kinds of people. People who believe in
an individual perspective, and people who have a collectivist perspective. In the
United States the predominant culture is individualism. But in Latinos its really
predominantly collectivism. So theres a way that we care for each other that
feels different. So, I think thats part of it. I think its also the experience, whether
its recognized by people or not. Its not part of the culture, but part of the
domination thats happened to Latinos in the United States that we all (Latinos)
experience. Like being followed in a museum. Like the whole way that we get
treated by the police or our bosses. See thats not part of our culture, but thats
part of the reaction to our culture.
-Participant 20, pg. 25
This sense of collective-efficacy throughout the interviews speaks to the concept
of combined accountability that many of the participants spoke of with regard to their
participation in the jViva Bien! program. The expectations in the jViva Bien! program
were given great consideration by the participants as many viewed this role as a
continuation of care giving to the other program participants, and as part of their role of
care giver in the community, just as it had been for their parents.
Everybody knows everybody, and everybodys like, you know, family. You dont
have to ask if you could go in the fridge. Everybody feeds you. And of course
back in those days adults disciplined everybody, all the kids. I mean you didnt
just get in trouble with your mom and dad, you got in trouble with the whole
neighborhood if you did something bad. Its just more communal.
-Participant 31, pg. 18
Participants frequently spoke about how they would try and help other program
participants during the program, regardless of whether or not these problems were
related to self-management of T2DM.
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The Concept of Social Support
The social support sources of influence examined in this study included family,
health care, community, and culture. Participants were asked to clarify their statements
regarding social support sources of influence that are important to them when they think
about family, health care, community, and culture. Clarification probes proved useful to
elicit the specific aspects of each source of social support and what was of importance to
them in those areas. An important finding was that knowledge and awareness was found
in each domain of social support, as discussed in greater detail below. Additional
thematic results for each social support level of influence are discussed in this section.
Social support themes are presented in Figure 4.3.
Care Giver
Knowledge/
Awareness
Nagging
Unhealthy Behaviors
Collective-Efficacy
U.S. Lifestyle
Generational
Differences
Faith
Familism
Knowledge/
V Awareness
Physicians who
Listen
Alternative Care
Insurance and
Access to Care
Knowledge/
Awareness
Identify with other
Diabetics
Knowledge/
Awareness
Organizations
Discrimination
Figure 4.3: Thematic Findings For Social Support
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Family Themes
Family was discussed in terms of the participants views on family influence over
health as it relates to both current and historic health behaviors and disease
management. Participants were asked what relationships do you have in your life that
influence your health and health behaviors? A large number of the participants spoke
of their primary focus on others as the primary care giver in the home (n=11), noting that
this is considered both a good and bad thing. The role of care giver is one who instills
knowledge and awareness, or sabiduria, which instills wisdom to the family. The theme
of being a primary care giver was the most repeated theme in the area of family social
support. Participants expressed having an expectation of trust in the family with regard
to health matters, including having the support needed to manage their health
effectively; namely, family is protective of health. Further, the notion of reciprocation
was brought up by several participants as being a good thing that further encourages
healthy behaviors by both giving social support and receiving social support; notably,
both are to be expected in Latina culture. However, interview findings suggest that
participants felt that it was often easier to give support than to receive support from
others. Sharing of wisdom, or sabiduria, with family and friends was often spoke to with
regard to the awareness that came from participants accepting disease and the desire
that came from wanting to care for others by helping them gain awareness too, about
their own disease. Many of the participants spoke about how their family members and
friends also suffered from diabetes, and how they as care givers felt it was their
responsibility to share knowledge and learned awareness to help others.
Three participants brought up nagging in relationship to self-management in a
positive light, with one participant commenting that even though her granddaughter
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nags her to take her medicine and eat a certain way, she still views this nagging as
favorable:
Sometimes its a pain in the butt, but I wouldnt do it if they didnt bug me.
-Participant 21, pg. 9
Well if they (the family) see that Im run down or something, theyll get on my
back. Theyll make me stop eating, or slow down on my eating. Theyll tell me,
you know, that Ive got to watch my sugars.
-Participant 28, pg. 44
Seven participants (n=7) commented that there are several unhealthy behaviors
(e.g., poor diet, smoking, no physical activity) in their home environment, which
negatively influence their self-management behaviors. Other participants (n=3)
commented that even when family is supportive in one way, such as tangible support
through helping do chores and reminders to take medication or blood sugar levels, they
may also be unsupportive in other ways. For example, the foods family members may
choose to bring in to the home can frequently be unhealthy, and what little physical
activity family members offer to do (e.g., occasional walks after work, infrequent
opportunities and willingness to exercise together on a regular basis) with the participant
can be discouraging at times.
He doesnt have any of the issues that I have. So he doesnt have to be
concerned about his eating habits and so hes not very supportive there.
-Participant 28, pg. 32
One participant spoke to the extreme lack of support she has at home with her
mother and siblings, commenting that when she makes healthy foods her mother
encourages the other family members not to eat it because it wont taste good, even
though she, the mother, has not tried the food because it was food not made the using
the traditional methods or ingredients.
My mother says, Dont go eating that trash that was made by your- just look at
it, how ugly it tastes.
-Participant 8, pg. 19
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Two participants commented that they feel social support from the family is more
important when you get older.
I think its (social support) especially important when youre home all the time, as
a retiree Im home so much of the time. So at that point I think the social
becomes important. Its not like when youre working or when youre raising kids.
Youre always busy with kids or youre always busy with the job. Youre so busy
that you dont miss the social. In other words, youre giving it some help. But I
think as we get older and thats when the social becomes real important to
people, including me.
-Participant 28, pg. 37
Several participants (n=5) also discussed the support their husband or partners
give them and how it could be both positive and negative at times.
Shes (partner) super supportive in (exercise). She probably wishes I would eat
different. She is actually the first one to say Have you had enough to eat? Its
very sweet because I dont feel like shes pushing it on. Thats different than
Have more to eat.
-Participant 30, pg. 46
Three of the participants noted that their husbands do not support them eating
healthier foods, and want them to prepare foods a certain way. Other participants (n=4)
feel that they have no support from their husband or partner. The theme of denial may
also factor into lack of support from family members. Several participants commented
that loved ones were also in denial about their own disease; a finding that may have
social support implications given family members who are in denial of their own disease
may be unable to provide support, further undermining self-management and self-
efficacy. Further, three participants reported that they have some, but not sufficient or
real support at home.
Participants were also asked to discuss their source of family social support
when they were growing up as it pertained to their health. About half of the participants
reported a healthy childhood, and about half reported having an unhealthy childhood.
Similarly, several participants reported fruits and vegetables being a part of their diet
growing up, whereas several reported that fruits and vegetables were limited throughout
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childhood primarily due to financial constraints, including not having enough money to
buy them.
Health Care Themes
Participants were initially asked How do you take care of yourself to begin the
exploration of social support in the area of health care. This question led the health care
social support discussion for each of the 33 interviews, and the participants were probed
to explain types of and access to health care as well as costs and resources for health
care.
Participants were asked do you like your doctor(s)? The vast majority of
individuals who had Kaiser Permanente insurance (n=23) commented that they did like
their primary physician, however a large concern with their physician visits was that
there was not enough time to talk with him or her as the allocated visit time was usually
no more than 20 minutes per encounter. Poor communication with physicians was a
concern of three Kaiser Permanente provider participants, who felt that their provider did
not understand them and their needs.
You know, doctors are not very communicative, and they always have an
allotted time for each patient. Its not like, like if it would be more personalized.
They, like they say, they give you the medicine, and if you want to take it, you
take it.
-Participant 16, pg. 19
Eight of the participants commented they feel the most support from their physicians
when they are patient, good listeners, and understand their needs. The theme of having
a doctor who was a good listener and who shared relevant, understandable information
was the most repeated theme in the area of health care social support. Further,
participants spoke about the importance of having a physician that could be trusted to
help instill knowledge and increase awareness about disease self-management.
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We (my doctor and I) have established a long term relationship. I trust her
implicitly. She gives me really good directions and suggestions.
-Participant 5, pg. 1
I think that makes a good doctor- somebody who can see you as a person and
not just a patient.
-Participant 21, pg. 2
Several participants feel that the alternative care they have access to, including
massage, chiropractors, and other physicians (generally located in Mexico) are
supportive of their health.
I trust him (doctor in Mexico) a lot. I explain myself in depth, since he speaks
Spanish. I explain in depth about everything that I am feeling and how I feel.
Thats the main thing.
-Participant 25, pg. 3
Home remedies were mentioned by six of the participants as being supportive of
overall health management as they informed their view of health care. One health
remedy was brought up by four of the participants (n=4) as a method their mother or
grandmother used to help fight fevers when they were young:
When we have fevers, she would put potatoes, sliced potatoes, and dip them in
vinegar and baking soda. And she would tie it around my head with a rag and
she would put some of that on the top of my head and my feet and my hands.
And it worked.
-Participant 33, pg. 6
Five of the participants reported not having any health insurance growing up, and
health treatments were done at home by the parents or family members.
When we were kids we never went to the doctor. I mean we had to have a fever
for like over a 100 for three days, or whatever, before our parents would take us.
So, I learned a lot of medicines from my mother and a lot of techniques of how,
you know, if youre feeling constipated and you take a little castor oil. And I still
believe in all those little old remedies.
-Participant 16, pg. 41
Community Themes
Interview questions regarding community resources and social support were
initially framed by asking the participants to tell me about your community support
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networks when it comes to your health. Participants commonly reported community
organizations, businesses, or institutions that they participated in, including: church
(n=6), gyms or recreation centers (n=5), and peer groups (n=3) that they would meet
with out in the community as being common activities that helped support their health
and self-management of T2DM through shared knowledge and stories. Having a sense
of collective-efficacy through participation in community activities was mentioned several
times and participants spoke to an increased awareness and acceptance toward their
disease that came from learning from other women who they could identify with.
Weather (n=4) and transportation (n=5) were frequent concerns when going out
into the community to attend activities. One woman reported that she had recently gotten
a treadmill for her to walk on when the weather was poor. Four participants commented
that they felt a lack of knowledge around availability of community resources and the
type of community resources (e.g., educational classes, exercise programs) that were
available to them prior to participating in jViva Bienl.
Theres so much out there that you dont take advantage of. Its all available.
You just do it, and you just have to make a practice of it.
-Participant 17, pg. 51-52
However, there were a couple of participants who also voiced that even though
they are aware of community organizations and activities in the community that are
available to them (sometimes for free) they did not attend or try them out.
My sons would invite me, but I never went. I had never been inside. My sons
would take me and I would pick them up. Of course, it never occurred to me to go
inside.
-Participant 22, pg. 14
Several participants commented that once they participated in jViva Bien! they
felt more confident to seek out community services and resources. One participant
commented that she does not feel a part of her community, primarily due to language
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barriers and her neighborhood demographics. In addition, the notion of not feeling
accepted came out during the interviews for a couple of the other participants.
Well, my family always accepts me just the way I am. But other people dont.
They dont have to accept you the way you are. They can say, I dont like her
because shes fat....and they are always rejecting. Its just human nature to reject
people.
-Participant 20, pg. 28
In addition, a few participants (n=5) commented that they feel discrimination is
still prevalent in their communities. Three participants brought up the concept of stigma,
and having to try harder as a Latina.
Because you are Hispanic, you had to try harder. And you really had to go to
school. And you couldnt let that be part of why you didnt do well.
-Participant 17, pg. 29
Nine of the participants commented that they identify with other diabetics when
they meet them in the community at health programs or classes. The theme of meeting
and identifying with other individuals in the community, who have similar health issues
and lives, was the most repeated theme in the area of community social support.
I think having interaction with people that feel the same way you do, or
understand you. Again, all people that went to / Viva Bienl, they all had diabetes.
So they understood, they understood a lot of things about you.
-Participant 3, pg. 24
Cultural Themes
The participants were asked to tell me about your cultural traditions and how
they influence your health. Five of the participants commented that as Latina women
they are expected to stay at home, cook, and have babies; cultural expectations that
were instilled as children, and informed their development and knowledge base growing
up as Latinas.
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I think its just a cultural influence that they have. They believe that they should
just stay home. And not go out and exercise. Staying in their house, the dietary
aspect, and just the way theyre looked at by their husbands. Theyre expected to
do all this. They say, My husband, he will kill me if I dont have supper ready for
him. And I must have his gorditas just the way he likes it.And if she tries to
change it even a little bit, she usually gets a lot of flack from her (man). But what
they dont realize is the husbands go out and work hard for their eight and ten
hours a day, but she sits at home and cooks and does very little as far as activity.
She wouldnt have to do much, you tell them lets go walking, half an hour a
day. You would be amazed what you can do. So it just takes a little bit of outside
influence to get them to do that. But, yet a lot of them will do it in secrecy without
telling their husbands.
-Participant 12, pg. 11
Sometimes were homebodies, we dont go out a lot.
-Participant 18, pg. 20
Two of the participants commented that Latinas are not supposed to exercise,
and referenced their culture as encouraging women not to put their legs up.
We were joking that (the other study participant) has her legs up in the air
(during yoga). She wouldnt have done that as a younger girl. She wouldnt have.
We didnt do that.
-Participant 21, pg. 15
The primary issue around cultural support for nine of the participants is the
concept of diet, and expectations around food, specifically around cooking from scratch
and being expected to use certain recipes that are unhealthy. The theme of dietary
expectations was the most repeated theme in the area of cultural social support.
They hate to part with tradition. And I see that a lot, when I visit my husbands
family and all that too, you know. Everybodys still in that mode, where we have
to do things the way they were done before. Instead of thinking, Well, lets do it
the healthy way. Were not thinking that way...were still carrying on the
traditions, even if the traditions may not be healthy for us.
-Participant 28, pg. 15
A few (n=4) of the participants also discussed that food is expected to be
presented to family, friends, and guests in general, and the over emphasis of food in the
culture can be viewed both as a positive and negative support to health; positive in that
this cultural expectation encourages social engagement, but negative in that it
encourages or supports eating of unhealthy foods.
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You know (Latinos are) more sedentary. ...watching TV more, being family
oriented, not taking time to exercise, not monitoring your food, especially during
cultural events, during family things, you know we do have a lot of family
gatherings.....
-Participant 24, pg. 9
In regard to the dietary component of the jViva Bien! program, several of the
participants commented that having a Latina dietician, who was part of the study team,
was beneficial as she, the dietician, would bring Latin-inspired recipes and foods for the
participants to try. For example, instead of using the traditional lard to make refried bean,
the participants were taught to use healthier olive or canola oil, and instead of eating red
meat the participants were encouraged to experiment with chicken and fish in place of
the more traditional red meats commonly used in Latin American cooking. With the diet
being a major concern for most of the participants, the influence of culture on meal
preparation was a common theme that emerged. One woman commented that having a
cultural flavor to food preparation made the diet component of the program more
successful for her.
I just think that because they did it the Latina way, the Spanish way, the Mexican
way, where they were doing both languages. That was really an A+ for me.
Cause if we would have done it the Anglo way and we would have just had rice
and potatoes, green beans, a piece of meat, a piece of wheat bread. We would
have still learned, but with us having our green chilies, our salsa, our chips the
way we can eat them or nopales, which I would like to cook but I have forgotten
about them. Stuff like that. Black beans, I mean, you know. We dont do that kind
of food all the time. But if I know that its healthy for us, and I have it there, Ill
cook it.
-Participant 19, pg. 43
Another cultural support domain that a few participants discussed (n=3) was
around the U.S. culture being too hectic and fast paced, with a negative reliance on
convenience. A couple of participants spoke to convenient foods, for example, as
being a potential factor toward laziness. Several of the participants (n=5) also discussed
the positive aspect of their culture with regard to social activities and expectations.
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I, for example, am not accustomed to live, like here, right. That everything you
buy is already made. No, everything I do is in my house. Only on Sundays, and
that sometimes we go out to eat or we buy food. I do everything because no, so
laziness doesnt influence.
-Participant 25, pg. 6
Well we, I think our family, being a Hispanic, we are very family oriented. We
have lots of celebrations, were always looking fora reason to celebrate. We love
music. We love dancing. We do a lot of that, we do a lot of celebrating like for
holidays, for birthdays, for anniversaries. Its just a ....cause its positive, I think.
Just being around people, laughter, and reminiscing on old time....and I think that
is good for your health.
-Participant 4, pgs. 13-14
Further, the cultural foundations of many home remedies was also spoken to as
being a positive support to many of the participants (n=6).
A number of the participants (n=8) spoke about the changing culture with regard
to health and health behaviors, and their role in this change.
Well, it (VB) helped me in the manner that I am focusing more on my children,
how they eat.
-Participant 16, pg. 23
The older generation of Latinas is seeing a cultural shift in expectations around
exercise, diet, communications (with physicians, health care providers, and family), and
education.
In some ways I think Hispanic women have come a long way. Cause like I said, I
dont remember my mom doing any kind of exercise.
-Participant 6, pg. 15
...and of course some of the food that we eat are probably loaded with fat. They
didnt think of it that way, they just thought of it as a good meal for the family. I
think they lacked the education. I think that was the bottom line, they lacked
education. To think, whats good for our children? They thought having a meal
was good for their children, it didnt matter what the meal was.
-Participant 28, pg. 14
Oh we could have learned to eat the right foods before, before we got sick,
before we actually had diabetes. And I know thats hard. Its hard to keep eating
chicken, wheat bread, cause you get tired of it. I know with my culture we like to
fry a lot of foods and its tastier. When you have to change to olive oil and the
other oils and stuff..
-Participant 19, pg. 9
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The shift in cultural expectations is important as it relates to the changing needs
of Latinas who have T2DM; namely, it may be important to distinguish generational
preferences and expectations when developing behavior change interventions.
Two participants commented that their culture was different from many other
Latinas they met, and that there were differences between the various Hispanic cultures
that were significant depending on where the other person was from (Central or South
America compared to the U.S.) or whether they spoke Spanish or not; namely, not all
Latinas are the same.
I think theres a cultural differences even between American Hispanics and
Mexican Hispanics. And I think thats going to be there for a while until we get
used to each other and accepting of each other.
-Participant 6, pg. 14
Of the study participants, only one woman commented that for her a language
barrier was a significant reason that she did not do more activities in the community,
suggesting that language negatively influenced social support, which thereby negatively
influenced her self-management of T2DM directly.
I am surrounded by two parks. I have a gym, about four, five streets from my
house. And yet, I dont go. I dont go because, well, they only speak English.
Who am I going to talk to? Who can I relate to?
-Participant 25, pg. 14
However, upon participation in jViva Bien! the same woman reported that she started to
do more for herself, even though she viewed herself as having a language barrier.
Well, like Im saying, to me it (VB) was very helpful. Mainly to get out of my
routine. And later, well, to learn how to eat, to learn how to cook, to learn to
communicate with each other and others about diseases, right. Because many
times complications come with diabetes and we ignore them. We think they are
normal, or like that, right. And yet, talking with other people about whats
happening with them, what they are feeling and all that, well, already for one too,
it already helps one like a compliment, right, for ones disease.
-Participant 25, pg. 16
Ten participants reported that faith in God was important in their cultural
traditions, and many participants view their faith as having a significant, positive impact
86


on their health as a support system. Participants expressed spirituality and faith as an
intrinsic social support system, which many participants in jViva Bien! shared with each
other.
. .and I spoke to her (another participant) one day, you know, at length and I
admitted to her that I was depressed. And she says, Well, pray. Ill pray for you
and you start praying. So I thought there was somebody in my corner, you know.
And that started lifting.
-Participant 14, pg. 47
Along these same lines, the concept of fatalism was also brought up three of the
participants (n=3) who have felt their health is out of their control (i.e., in Gods hands)
even when support systems, especially their faith, are in place.
..one of the pieces is that way that we understand dualism, what do you call
that when youre like oh well, its us to God? (fatalism), and I totally.. .that is
probably some of the things that have prohibited my health behaviors from
getting better. ..if I ignore it, it doesnt exist, Its out of my hands.
-Participant 30, pg. 30
Another common theme around cultural support was the importance of being
around other Latinas who had similar health concerns and family life. This sense of
familism was important to the participants. Six participants commented that identifying
with other Latinas helped build trust, faster, and helped them feel more supported and
open to learning new ways of accepting and managing their T2DM.
I was very excited because I thought that the fact that I was going to be around
other Hispanics was good for me, because I think its kind of a cultural thing.
-Participant 4, pg. 17
Similarly, twelve participants also expressed the importance of feeling a part of a
group who understood and supported each other and how the collective effort of the
group helped them feel empowered to make changes for themselves as the learned
from others and became more aware of how they could better manage their disease.
The importance of familism was also prevalent, as participants commented that their
health does not just affect them, but also that of their families, extended families, and
87


friends. For example, the sense of accountability that many of the participants had to
each other and their jViva Bien! support groups illustrated the importance of collective-
efficacy to the participants. The participants spoke about the importance of sharing skills
and knowledge that helped them achieve behaviors at the individual and group level.
The sense of collective-efficacy was pervasive throughout the interviews as participants
expressed the importance of familism in their culture and working together to achieve
desired outcomes.
Potential Pathways Between Concepts
Potential pathways between self-management, self-efficacy, and social support
are explored next in this chapter, including interpretation of how identified themes are
related to one another. Taken together, the identified, categorized themes represent
the studys concepts. My analysis of themes enabled a theoretical assessment of
relationships among concepts as they were moderated by linking themes, which
influenced the strength between the concepts, and allowed me to draw interpretations
about sources of social support and self-efficacy in relation to self-management.
Potential pathways that may inform the relationship between the three concepts
of social support, self-efficacy, and self-management are suggested by similar themes
found in multiple concepts and where the more frequent themes were reported
throughout the coding process. Themes identified as most important by participants
within each concept suggests potential pathways that should be explored between the
three concepts. Interpretation of study pathways informed my understanding of
participants lived experiences with T2DM. Previously discussed social support thematic
results will be reviewed as they relate to self-efficacy themes, including an explanation of
the potential pathways between social support and self-efficacy. Next, the themes that
constitute social support will be examined as they may affect self-management of
88


disease. Finally, the themes that constitute self-efficacy will be explored as they inform
potential pathways to self-management.
Potential Pathways: Social Support and Self-Efficacy
The themes that were present in both social support and self-efficacy concepts
were knowledge and collective-efficacy. Findings suggest that increased knowledge and
collective-efficacy, which are informed by social support, fostered individual self-efficacy
for the participants, which in turn encouraged additional social support through increased
knowledge and collective-efficacy as shown in Figure 4.4. The reciprocity of the implied
pathway between social support and self-efficacy suggests a complexity of the
interrelatedness of the two concepts, and denotes a cyclical dynamic between social
support and self-efficacy.
Figure 4.4: Potential Pathways Between Social Support And Self-Efficacy
The theme of knowledge was relevant to both social support and self-efficacy.
Participants expressed the importance of being the primary care giver at home
(responsible for modeling and instilling knowledge), learning from her physician and
providers, identifying and sharing with other diabetics, and learning from other Latinas
and other cultures; namely, knowledge having an increased awareness was present in
all sources of social support as influencing participant self-efficacy. Increased
knowledge led to an increase in self-efficacy for the participants who believed that
behavior change could be made through the exercise of mastery experiences, vicarious
experiences, social persuasion, and affective states. This effect is not surprising given
Banduras model of self-efficacy. However, I identified a distinction between learned
knowledge and applied knowledge. Learned knowledge denotes information the
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Full Text

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EFFICACY M ANAGING TYPE 2 DIABETES MELLITUS by CRISTY R. GENO RASMUSSEN B. S. University of Missouri Columbia, 1995 M.P.H., University of Northern Colorado, 1999 A thesis submitted to the Facult y of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences 2013

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ii This thesis for the Doctor of Philosophy degree by Cristy R. Geno Rasmussen has been approved for the Health and Behavioral Sciences Program by James Dearing Dissertation Chair Sara Yeatman, Examination Chair Sharon Devine Diane King November 5, 2013

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iii Geno R a smussen, Cristy R. (Ph.D., Health and Behavioral Sciences) efficacy Managing Type 2 Diabetes Mellitus Thesis directed by Professor James W. Dearing ABSTRACT Health disparities exist for Latinas who have a higher incidence of complications from Ty pe 2 Diabetes Mellitus (T2DM). Treat ment of T2DM requires daily se lf management If not managed correctly, T2DM can lead to comorbidities including coronary heart disease. Barriers to self m anagement are complex and may be exacerbated by psychosocial f actors. There is little research on psychosocial factors, including social support and se lf efficacy, in relation to self management of T2DM by Latinas. T he Latina per spective on psychosocial factors is explored in this dissertation through an examination of family, health care, community, and cultural sources of social support and self efficacy as they in fluence self management of T2DM. Further, the influence of age, acculturation, and level o f education is also explored. Th is study asks : What is the role of social support and self efficacy in self management of T2DM by Latinas? A qualitative data analysis of in depth, semi structured int erviews is used to answer t his question The study popu lation consisted of 33 self reported Latinas between the ages o f 42 and 70 who had just completed and were recruited from a n intensive behavior c hange intervention, ¡ Viva Bien! T hemes among the three concepts of self management, self efficacy, an d social support emerged. D epression and denial were found to influence a p athway between self efficacy and self m anagement. T he study also found that knowledge an d collective efficacy influenced a pathway between social support and self efficacy. Furthe rmore c ollective efficacy, awareness of disease and continuity of social support

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iv were found to influence a pathway between social support and self management. F amily and cultural social support were found to be the most important sources of social suppor t for the study population F indings also suggest that younger Latinas view health behaviors and prevention differently than older Latinas in the U.S. that explo res psychosocial factors as they influence self management behaviors fo r Latinas. Given that Latinas are at higher risk of developing T2DM, c ulturally tailored p rograms aimed at increasing social support and self efficacy to prev ent and manage the disease at a younger age for Latinas need to be developed. Research should explore collective efficacy as a potential contributor to increasing and mainta ining self management behaviors in Latinas. The form and content of this abstract are approved I recommend its publication. Approved: J ames W. Dearing

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v DEDICATION I dedicate this thesis to th e important people in my life: especially m y parents, Betty and Bob, who helped me learn to be compassionate to others; my grandparents, Margie and Bob, who helped me belie ve in myself; my husband, John, who continues to encourage me to grow and love more than I ever knew possible; my smart, funny, and beautiful children, Klara and Jack for whom I am over the moon for and who are the light of my life and my sister, Michele who is my constant rock. friends: especially Sara, Alyssa, Bre, Fabio, Diane, Amy, Amy Amy, Corina, David, Heike, Jen, Barb, and Diego, who continued to believe in and push m e to persevere amidst adversi ty, heartache, and a very full and blessed plate in life. Finally, this work would not exist if it had not been for the wonderful study participants who I am eternally grateful to for sharing their stories laughter, and wisdo m with me. Last, but not least, m y sincere thanks and appreciation go to my advisor, James W. Dearing, for his tremendous support, contribution, and spirited energy toward my research. I also want to thank all the members of my committee for their though tful guidance, participatio n, wisdom, mentorship, and shared knowledge. I am ever grateful to each of you for your commitment to me and this important research.

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vi TABLE OF CONTENTS CHAPTER I. INTRODUCTION TO THE HEALTH PROBLEM 1 Latino and Latina Health 5 Health Care 6 He alth Dispariti 8 Self Management of Overview of the Dissertation 1 3 II. SELF MANAGEMENT OF DISEASE, SELF EFFICACY, AND SOCIAL SUPPORT 1 6 Self Manageme 1 6 Socio Ecologic Model ... 18 Self E fficacy .. 2 2 Soc ial Support 25 Family 27 Heal th Care 29 Community 30 3 1 III. RESE ARCH METHODS AND DESIGN ....... 3 4 Stud y Pop ulation 35 Research Se 41 Sample Rec ruitment.. 42 Data Collec tion... ..... 43 Analytic P lan. 47

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vii IV. RESULTS AND INTERPRETATION OF S ELF MANAGEMENT, SELF .. 51 The Concept of Self 52 53 54 56 58 59 61 Knowledge, Awareness and Education 63 Collective Efficacy .. 64 .. 65 The Concept of Self Ef ficacy 66 Definition of Healthy 67 De ni al .. .. 69 Dep re .. Increased Knowledge an d Self Management Behavi or.. ..71 Collective ... The Concept of Socia l Support Fam il Health Care Themes .. Comm unity Themes. Cultur al Themes. P otential P 88 P otential P athways: S ocial Support and Self Efficacy 89

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viii Summary of Social Suppo rt and Self .. 95 P otential Pathways: Social Support and Self Manage ment .. 96 Family Social Support Source 97 Health Care Social Support Source 99 Community Soci 99 Cultural Soc .. 100 Summary of So cial Supp ort and Self 101 Potential Pathways: Self Ef ficacy and Self 103 Summary of Self Effic acy and Self .... 104 V. RESULTS AND INTERPRETATION OF AGE, ACCULTURATION, .. Self Mana Self Management and Ac Self Management and Level of Educ Self Effi cacy and Age 117 Self Efficacy Self Efficacy and Level of Education Social Su .. Social Support Social Support an Summary of Age, Accultur ation, and Le VI. Theoretical 142 Intervention I mplications .. .. .. 151

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ix Implica t ions for the Patient Population of Latinas 153 Conc lusion 7 Future REFERENCES 16 2 APPENDIX A: Interview Code Book Categories 77 B: Modi fied ARSMA II Acculturation Measure ... 1 81 C: Descriptive Characterization of Units of A 82

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x LIST OF FIGURES Figure 1.1 U.S. Census Data 2010: Pe rc ent Latinos 1960 2.1 Socio Ecologic Source Of 3.1 35 4.1 Thematic Findings For Self 53 4.2 Thematic Finding s For Self 67 4.3 Thema 4.4 Potential Pathways Between Social S upport And Self .. 89 4.5 Potential Pathways Between Social Support And Self Management ............ .... 97 4.6 Potential Pathways Between Self Efficacy And Self Manage 103 5.1 Themat i c Findings For Self Management A nd Age .. 107 5.2 Th emati c Findings For Self Management And Acculturation 111 5.3 Thematic Fi nding s For Self Management A nd Level of Education 115 5.4 Thema tic Findings For Self Efficacy A 5.5 Thematic Findings For Self Efficacy A nd Acculturation........ ............................ 121 5.6 Thema tic Findings For Sel f Efficacy A nd Level O 5.7 Thematic Findings For Social Support And Age 128 5.8 Thematic Findings For Social Support 131 5.9 Thematic Findings For Social Support A nd Level Of Education 4 6.1 Recursive Concep tual Pathways

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xi LIST OF TABLES TABLE 3.1 38 39 3.2 Descriptive characteristics of age, acculturation, and level of education 40 3.3 Racial/Ethnic composition of the Denver Me tropolitan population and Kaiser Permanente Colorado membership .. ... .... 41 3.4 Exit intervi ew questions .. .... .. .. ..... 4 7

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1 CHAPTER I INTRODUCTION TO THE HEALTH PROBLEM Diabetes is a d evastating and debilitating chronic disease for Latinas in the U nited S tates (U.S.) Alt hough they represent a larg e collective of young women in the U.S., Latinas are underrepresented in r esearch literature. C ompared to non Hispanic White women, Latinas have greater incidence of complications related to type 2 diabetes mellitus (T2DM) including premature death from cardiovascular events, due to delayed diagnosis and treatment (Cusi and Oca mpo, 2011; Caballero, 2001). Family history age, and obesity are three main risk factors in the development of T2DM in Latinas ( American Diabetes Association, 2013; Copeland, Becker, Gottschalk, and Hale, 2005 ). In addition, insulin resistance is a freq uent comorbidity associated with obesity, and generally precedes T2DM (Copeland, Becker, Gottschalk, and Hale, 2005). Further, incidence of overweight and obese Latina children and adolescents are increasing in the U.S., placing them at higher risk of deve loping gestational diabetes, a glucose intolerance that begins in pregnancy and elevates risk of T2DM (Black, 2002). Research that explores the broader socio ecological context of diabetes in Latinas of all ages is needed to better understand the ir health disparities There are two causes of T2DM; the first is when enough insulin and the second is when the body produces insulin, but the bod y does not recognize it. Insulin resistance results because the body does not properly use t he insulin. Insulin is a hormone needed to effectively metabolize glucose, or sugars, which fuel s the body Inadequate levels of insulin can lead to unstable blood sugar levels. A commonly used m arker to test for appropriate blood sugar levels and diabet es is hemoglobin A1c Hemoglobin A1c levels need to be stable and in a normal range

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2 (Barrera, Strycker, MacKinnon, and Toobert, 2008; Barrera, Toobert, Angell, Glasgow, and MacKinnon, 2006 ; American Diabetes Associate, 1997 ). As it is o adulthood. Age is a risk factor for T2DM as the disease usually develops after the age of 45 (American Diabetes Association, 2013). However, T2DM is increasingly found in younger adults and children as obesity rates are increasing in youth (Harron, Feltbower, McKinney, Bodansky, Campbell, and Parslow, 2011). Furthermore, T2DM is more prevalent among Latinas than non Latino women (Copeland, Becker, Gottschalk, and Hale, 2005; Rosenbloom, Joe, Young, Winter, 199 9). Estimates are that Latino men and women have lifetime prevalence rates of 45.4% and 52.5%, respectively, compared to 26.7% and 31.2% in non Latino W hite men and women due to earlier onset (Narayan, Boyle, Thompson, Sorensen, Williamson, 2003). Left unt reated, T2DM can be life threating. Uncontrolled diabetes can put individuals at risk for developing other comorbid conditions, including coronary heart disease, hypertension, retinopathy, nephropathy, neuropathy, and dyslipidemia ( Fortman n Gallo, and Phi lis Tsimikas, 2011). Common s ymptoms of T2DM include increased thirst, urination, blurred vision, and h unger, which are due to high sugar levels in the bloodstream caused by insufficient insulin (American Diabetes Association, 2013). Conversely, when blood sugars are too low due to improper and poorly regulated diets symptomology includes fatigue and lethargy. Other frequent symptoms of diabetes include the inabilit y of sores to heal and recurrent infections. Regular blood sugar monitoring to maintain gl ycemic control a healthy diet, daily exercise, and sometimes medications, including insulin therapy and other medications that help control blood sugars are needed to effectively treat T2DM.

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3 The etiol ogy of type 2 diabetes mellitus and treatment regimen s to manage it are generally agreed upon by medical practitioners; however, delayed diagnosis in younger women postponed treatment, and mismanagement by the patient increases poor health outcomes for Latinas (Cusi and Ocampo, 2011). Successful management of T2DM require active participation by the patient in maintaining health, and research increasingly addresses the i mportance of psychosocial sources of influence as they improve or inhibit self management of disease. Research further states that different cultural groups have varying perspectives on the role of two key psychosocial sources of influence in particular, social support and self efficacy for T2DM management (Wen, Shepherd, Parchman, 2004). Self efficacy that she can do a specific behavior or task (Bandura, 1986). A pplication of self efficacy is important when monitoring and maintaining blood glucose (A1c) levels for persons with diabetes (Gherman, Schnur, Montgomery, Sassu, Veresiu, and David, 2011; Con cha, Kravitz, Chin, Kelley, Chavez, and Johnson, 2009; Krichbaum, Aarestad, and Buethe, 2003). Higher self efficacy specific to medication adherence, blood glucose (A1c) monitoring, diet, physical activity and other self management tasks may help individu als with T2DM in making the necessary behavior changes and maintaining them whereas those with low er self efficacy may be less likely to adhere to good self management regimens It is not surprising that h igh self efficacy is related positively to good se lf management of diabetes (Gherman, Schnur, Montgomery, Sassu, Veresiu, and David, 2011; Krichbaum, Aarestad, and Buethe, 2003; van de Laar and van der Bijl, 2001; Hurley and Shea, 1992; Padgett, 1991). However, w hat influences self efficacy in self manag ement for Latinas is not understood and will be a purpose of this dissertation.

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4 Social support is defined as assistance received from others that has the potential to help the receiving individual. An understanding of social support can help health provi ders and care givers tailor care to the specific needs of patient s as well as assist patient s with increasing their own self efficacy so that they can better manage their disease (Morrow, Haidet, Skinner, and Naik, 2008). emphasi s is on different sources of social support and who m among Latinas those sources affect. Different sources of social support may affect self efficacy to self manage T2DM by Latinas; h owever, l ittle research exists on the Lat in a perspective on these issue s. There is some evidence exists that there may be a relationship between social support and self management of disease across U.S. populations ( Albright, Parchman, and Burge, 2001; Fisher, Chesla, Skaff, 2000; Boehm, Schlenk, Funnell, Powers, and Ronis, 1 997; Glasgow and Toobert, 1988; Antonucci, 1985). However, sources of social support may influence self efficacy differently for Latinas than non Latinas. Understanding the influence social support has on self efficacy and self management of T2DM could i mprove interventions and programs aimed at managing the disease for the Latina population. An important consideration in Latino culture is the role and norms of family: namely, familism or the strong values related to the family and interpersonal relations h ips with extended family. The traditional role of Latinas is as primary care giver in the family, with the expectation that they will care for all other family members. T he paucity of literature on Lat ina self management of disease suggests that researc h is needed to improve the health of these wo men who traditionally care for others before they care for themselves The research question s dri ving the present dissertation are aimed at understanding the role of two psychosocial factors, social support and self

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5 efficacy in relation to se lf management of T2DM by Latinas while looking through the lens of familism. To date, the influence of social support on self efficacy to manage T2DM in Latinas has not been m uch examined in the literature, and research sugg ests that there may be a direct effect of s ocial support on self management of disease (Fisher, Chesla, Skaff, 2000; Boehm, Schlenk, Funnell, Powers, and Ronis, 1997; Glasgow and Toobert, 1988; Antonucci, 1985) Further, self efficacy literature shows a di rect influence on self management of disease (Sarkar, Fisher, and Schillinger, 2006; Aljasem, Peyrot, Wissow, and Rubin, 2001; McCaul, Glasgow, and Schafer, 1987) However, it is un clear how different sources of support may effect self efficacy, and in tur n, self management. Given the importance of familism in Lati na culture, and the significance of the care giver role in Latina culture, it is important to understand how Latinas perce ive social sup port Understanding how different sources of social support in the lives of Latinas influence their self efficacy and T2DM self management, and the potential to use that knowledge to influence positive health outcomes for other Latinas with similar conditions, are the primary goals of this research. Latino and Lat ina Health Status Hispanic Americans, or Latinos, will triple in number by 2050 in the U.S. They are the fastest growing ethnic population in the country (Kirk, Passmore, Bell, Narayan, ortion of Latinos will grow from 3.6% in 1960 to a projected 29% in 2050 (U.S. Census, 2010). The National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK, 2008) reported that Hispanics have a greater risk of developing T2DM than non Hispanic Whites. In addition, Hispanics are t he fastest growing segment of the elderly population and will have increased prevalence of T2DM as they continue to age ( Rodriguez, Joynt

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6 Lopez Saldana and Jha 2011 ). It is impor tant to understand the prevalence an d risk factors associated with T2DM in th is growing U.S. population. Figure 1.1: U.S. Census Data 2010: Percent Latinos 1960 2050 Health Care Latinos are less likely than non Latinos to have regular medical benefits ( Maldonado and Farmer, 2006; Del Pinal and Singer, 1997). Disproportionately large percentages of Latinos have low wage jobs, less job stability, and more hazardous working conditions than non Hispanics factors that negatively influence the likelihood of having con sistent medical benefits and health care options (Maldonado and Farmer, 2006). According to the Office of Minority Health (2011), a pproximately 3 0 percent of Latinos under the age of 65 d id not have health insurance in 2010, as compared to 11.7% of non Hi spanic Whites in the U.S. ( OMH, 2011; Reschovsky, Hadley, and Nichols, 2007; Aguirre Molina, Molina, and Zambrana, 2001) Fortunately, the full implementation of the Affordable Care Act (ACA) of 2010 is expected to reduce medical

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7 insurance coverage dispari ties by 32 million by 2019, including 9 million Latinos (Clemans Cope, Kenney, Buettgens, Carroll, and Blavin, 2012). The extent to which the law will actua lly impact insurance coverage for Latinos is likely to depend on effective state policies and strate gies that address barriers to enrollment, such as language, for Latinos (Clemans Cope, Kenney, Buettgens, Carroll, and Blavin, 2012). For Latinos with insurance, quality and satisfaction of the health care received, regardless of fee for service (FFS) the Commonwealth Foundation (Neuman, Schoen, and Rowland,1999). In addition, the study also found that monolingual, Spanish speakers were almost twice as likely as English speaking patients to lack a regular health care provider. Further, even when insurance and medical benefits are available, c osts to the health care system are increasing due to higher complication rat es and poorer overall health outcomes in Hispanics with T2DM (Rosal, White, Restrepo, Olendzki, Scavron, Sinagra, Ockene, Thompson, Lemon, Candib, and Reed, 2009; Boyle, Honeycutt, Narayan, Hoerger, Geiss, Chen, and Thompson, 2001). These findings undersco re the need for culturally appropriate T2DM prevention and treatment programs for Latinas that consider the broader socio cultural, economic, and environmental context of their lives Even when access related factors are accounted for, the quality of heal th care in the U.S. is considerably lower for racial and ethnic minorities than for non minorities (IOM, 2002). Th is gap is widened by not having adequate culturally sensitive interventions and programs in the U.S. that address health care issues and disp arities of Latinos and Latinas.

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8 Health Disparities S tudies that control for socioeconomic status ( SES ) in Latinos document reduced disparities for some health outcomes, but not for T2DM; this research suggests that the e within SES groups is not consistent within all ethnic groups (Whitfield, Clark, and Anderson, 2002). Even when SES is controlled for, i t is not clear why T2DM Hispanics are more than twice as likely to have T2DM than their non Hispanic counterparts (CDC 2011). The disease is the fifth leading cause of death for Latinos, and the fourth leading cause of death in Latinas (Center of Health Statistics, 2001). The prevalence of T2DM among Latinas is almost twice that of non Hispanic White women (Kirk, Passmo In addition, t he age adjusted prevalence of T2DM increased by 21% in Latinas from 1995 2007 (CDC, 2011). However, t he underlying factors that contribute to health disparities and the higher prevalence of T2DM in Latinas are not understood. W hile aggregate measures of Latino health that look at global health status of Latinos are important, they do not help to understand the complexity of cultural and contextual factors that impact health status and in fluence health disparities of Latina subgroups (Amaro and de la Torre, 2002). For example, certain subgroups have higher mortality and morbidity rates than others, and perceptions of health also vary among Latino subgroups (Amaro and de la Torre, 2002). Further confounding health disparities in Latinos, Latinas have a higher incidence of complications from diabe tes relative to Latino men and an increase in hypertension and high triglycerides (Flegal, Carroll, Ogden, and Johnson, 2002; Maskarinec, Grandine tti, Matsurra, Sharma, Mau, Henderson, and Kolonel, 2009). This higher incidence of complications from dia betes is found in women compared to men worldwide, as T2DM undermines the protective effects that women have against coronary heart disease (Black, 2 002). With coronary

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9 heart disease as the leading cause of death among women in the U.S., T2DM appears to be a greater risk factor for U.S. born Latinas who have a higher mortality from coronary heart disease (Pandey, Labarthe, Goff, Chan, and Nichaman, 20 01; Hunt, Williams, Resendez, Hazuda, Hagberg, and Stern et al. 2002; Slater, Selzer, Dorbala, Tormey, Vlachos, Wilensky, et al., 2003). Coronary heart disease (CHD) is a frequent comorbidity that may result from diabetes, and controlling the risk factor s of CHD through self management, including total cholesterol and blood pressure, are imperative for Latinos to decrease cardiovascular disease (Ford, 2011). However, understanding the risk factors for disease does not explain the cultural and contextual factors that influence health disparities and may improve health outcomes for Latinos and Latinas. The 2005 National Health C are Disparities Report found that Hispanics or Latinos are the one major minority group in the U.S. for which health disparities a re increasing, not decreasing (AHRQ, 2005). There were more age adjusted years of potential life lost (or disability lost due to disease or health condition) before 75 years of age per 100,000 population for Latinos compared to non Hispanic W hites in 2001 (CDC, 2004). Specifically, years of potential life lost by health condition for Latinos compared to non Hispanic W hites in 2001 were higher for the following health condition s or disease s : T2DM (41% higher), human immunodeficiency virus (168% higher), chronic liver disease and cirrhosis (62% higher), stroke (18% higher), and homicide (128% higher); in 2000, there were higher age adjusted incidence for cervical (152%) and stomach cancers among La tinos (63% more for males, and 150% more for females)(CDC, 2004). Higher rates of overweight and obesity were also reported by Mexican Americans from 1999 2000 with obesity 32% higher in Mexican Americans as compared to non Hispanic W hites (CDC, 2004). Ob esity which is a risk factor for diabetes, may lead to other co mor bidities including

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10 diabetes related complications such as coronary heart disease (CHD), hypertension, high triglycerides, and abdominal body fat distribution (Vega, Rodriguez, and Gruskin, 2009; Kuczmarski, Flegal, Campbell, and Johnston, 1994). Further, t he p revalence of ris k factors for CHD is higher among Latina s compared to non Hispanic W hite wo men and men, as well as Latino men (Cusi and Ocampo, 2001; CDC, 2004). Given the abundant f indings on increasing health disparities in the Latina population research that focuses on explaining these inequalities by examining cultural and contextual f actors is necessary and prudent to improve the health of Latinas in the U.S. Socioeconomic facto rs (e.g., poverty, lack of education and employment, little or no access to medical or preventive care that lead to delayed diagnosis and treatment ), and the social environment (e.g., racial/ethnic discrimination, environmental conditions in neighborhoods and at work, limited social networks) can increase risks of chronic disease and injury (Greenlund, Zheng, Keenan, et. al., 2004; Wen, Shepard, and Parchman, 2004; Williams, Neighbors, and Jackson, 2003; Morales, Lara, Kington, Valdez, and Escarce, 2002 ; Ho ffman, Trevino, and Ray, 1990 ). For example Hispanics with access to health care show different patterns of care utilization than non Hispanic Whites, generally waiting longer for evaluation and thereby presenting with more advanced disease and leading t o poorer health outcomes ( Gaskin, Arbelaez, Brown, Petras, Wagner, and Cooper, 2007; Hargraves, Cunningham, and Hughes, 2001 ) Further, r esearch suggests that even with insurance there are organizational, institutional, and structural barriers to health ca re access for Latinos leading to unequal care and health disparities (Beach, Gary, Price, Robinson, Gozu, Palacio, et al., 2006; Smedley, Stith, and Nelson, 2003). At the organizational level, lack of ethnic diversity among health care professionals can a lso interfere with the delivery of quality care to diverse patient populations that may require more or different types of health care

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11 provider support. Patient reported satisfaction with the provider visit and quality of care is rated higher among minori ty populations when racial concordance exists between the provider and the patient (Escarce and Kapur, 2006; Saha, Komaromy, Koepsell, and Bindman, 1999). This finding suggests the importance of cultural competence in the patient provider relationship. F urthermore, l ack of interpreter services and inappropriate health education materials (both linguistic ally and culturally) can challenge the success and utilization of health services. Other institutional and structural factors that foster health disparit ies also include inconvenient hours of operation and locations, including distance to providers (Escarce and Kapur, 2006). In addition, difficult intake processes, including long wait times for appointments can be barriers to care (DHHS, National Hispanic /Latino Health Initiative, 1993). Having the opportunity to build relationships with providers, especially Latino physicians, also helps individuals feel more comfortable seeking out health care, which may reduce uncertainty around processes and systems i nvolved in accessing care; further encouraging patients to manage their care (Escarce and Kapur, 2006). Understanding the socioeconomic factors and social environment as they influence health disparities of Latinos and Latinos can help providers and resea rchers to develop improved strategies to help reduce disease and improve health outcomes. To help encourage Latinos and Latinas to better manage their care and reduce health disparities several improvement s can be made in the areas of i nformed medical tr eatment, improved educational materials that are aimed at prevention and tailored to health literacy levels, awareness of barriers and cultural context regarding health and health care access, and a better understanding of and response to the social determ inants of he alth care for Latinas (CDC, 2011). One strategy to improve access and quality of health care is to adapt successful, evidence based interventions and

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12 programs from one cultural group to another. Although research suggests that cultural chara cteristics of the target group need to be incorporated into new intervention s and programs, often cultural factors are not prioritized (Elder, Ayala, Arredondo, Talavera, McKenzie, Hoffman, Cuestas, Molina, and Patrick, 2013; Os una, Barrera, Strycker, Toob ert, Glasgow, Geno, Almeida, Perdomo, King, and Doty, 2011; Zambrana, Dunkel Schetter, Scrimshaw, 1991). Programs grounded in data, theory, and methods that were developed and evaluated with one cultural group and then implemented as is for other cultur al groups may save time and money but not retain their effectiveness. To retain effectiveness program adopters should factor in culturally mediated behaviors, norms, social support systems, and values through thoughtful intervention adaptation (Dearing, Sm ith, Larson, and Estabrooks, 2013; Dearing, 2009; Brach, Fraser, and Paez, 2005; Betancourt, Green, Carillo, and Park, 2005). By understanding the social determinants of health care in the U.S., culturally competent interventions and programs aimed at inc reasing disease self management can be developed to reduce health disparities for Latinos and Latinas. S elf Management of T2DM Improving culturally competent care and self management interventions to help Latinas manage diabetes is sorely needed. The role of self management in controlling T2DM cannot be understated. Self manage ment of T2DM is grounded in patient understanding of their health condition and what is necessary to manage their care (Harvey, Petkov, Misan, Warren, Fuller, Battersby, et al., 2008 ; Carbone, Rosal, Torres, Goins, and Bremudez, 2007 ). The American Association of Diabetes Educators (AADE) has identified seven self care behaviors needed to effectively change behavior: eating a healthy diet being active, monitoring blood glucose level s taking medication, problem solving, reducing risks of complications (e.g., checking feet, regular eye check ups,

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13 preventive care) and using healthy coping skills ( AADE, 2013). When used together, these self management behaviors significantly improve A1 c levels, lower blood pressure and cholesterol, and improv e quality of life (Funnell, Brown, Childs, Haas, Hosey, Jensen, Maryniuk, Peyrot, Piette, Reader, Siminerio,Weinger, and Weiss, 2008). In addition, self management and glycemic control decreases c omplications and comorbidities from T2DM (Vincent, Clark, Zimmer, and Sanchez, 2006). Some research suggests that Latinas have more difficulty with controlling glycemic or blood sugar levels and do not have the same physiological response as non Latinas (B rown, Garcia, Kouzekan a ni, and Hanis, 2002). Family and cultural influences on self m anagement of T2DM for Latinas are not understood. However, there is some research that suggests family and cultural beliefs about self management behaviors, including diet and physical activity, may influence treatment regimens and contribute to poor glycemic control (Vincent, Clark, Zimmer, and Sanchez, 2006; Brown, Garcia, Kouzekanani, and H anis, 2002; Whittemore, 2000). Understanding the contextual and cultural barriers to health care and disease management t hat Latinas face is important for ability to make and sustain the numerous behavior changes necessary for managing T2DM. Overview of the Dissertation This dissertation focuses on the role of socia l support and self efficacy in self management of T2DM by Latinas living in Denver, Colorado. My a priori assumption based on prior research, is that these psychosocial factors directly affect Latina to manage T2DM effectively This study poses the following main research question aimed at exploring the issues and concerns about family, health care, community, and culture as they may affect my primary concepts of interest:

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14 What is the role of social support and self efficacy in self management of T2DM for Latinas? Sub questions include: What is the comparative importance of sources of social support for Latinas? How does social support influence self efficacy and self management for Latinas? What is the importance of self efficacy in self man agement for Latinas? In Chapter II I review social science theory and prio r research studies that provide the conceptual basis for the dissertation. I use a socio ecologic framework to contextualize how self management of disease self efficacy and so cial support are related and how they function in everyday lives. Behaviors of self management of T2DM and types and sources of social support are described. In Chapter III I describe the qualitative methods used in the study. A description of the study p opulation, research setting, study instruments, data collection techniques, and data analysis are presented. Chapter IV presents the results of thematic analysis The analysis explores participant perspectives on the psychosocial factors of self efficacy and social support and their relationship to disease self management. Descriptive results, t h emes, and relationships among themes are presented with the aid of verbatim text passages taken from the interviews with participants. Ind icators of implied path ways between social support, self efficacy, and self management are analyzed, and the comparative importance of source s of social support is explored questions. In C hapter V analysis and explanatory interpretation i s u sed to further examine the potential p athways between the concepts of self management, self efficacy, and social support as they are influenced by categories of age, acculturation, and level

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15 of education Age was selected given it is a risk factor of T 2DM for Latinas and may influence social support, self efficacy, and self management of T2DM. Acculturation and level of education were also explored as they may play an important role in understanding the influence psychosocial factors have on self manag ement of T2DM. In conclusion, C hapter VI summarizes with an interpretive emphasis on the concepts of social support, self efficacy, and self management, and what the study results suggest for behavior change theory. Limitations to this research are considered, as is the practical value of the present study results to future intervention design for Latinas with T2DM.

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16 CHAPTER II SELF MANAGEMENT OF DISEASE SELF EFFICACY AND SOCIAL SUPPORT Theories of health behavior have traditionally focused on behavior change at the individual level and health behavior change interventions are often grounded in these theories Research over the past several years has emphasized the importance of translating theoretical concepts in to effective and practical interventions that are tailored to diverse cultures. However, the extent to which cultural and contextual fac tors inform development of interventions and medical care aimed at improving the health outcomes of different population s varies. Furthermore, t he context of an environment as it influences self management of disease var ies within culture s, and h as not been targeted for some populations as a potential mechanism for affecting be havior change. This is a limitation of some health behavior theory (Gallant, 2003). Self Management of Disease Research on self management of disease is generally framed by health theories efficacy to manage disease. Behavior change interventions and programs aimed at disease self management are grounded in theory to support how shared knowledge of disease management with the patient will result in improved self efficacy and self management. Self management of disease is daily care aimed to control one's own disease, reduce or minimize impact to personal health and functioning, and help oneself cope with the mental and psychosocial sequelae of the disease (Gallant, 2003; Clark, Becker, Janz, Lorig, Rakowski, and Anderson, 1991). Many ind ividuals provide most of their own care, making them both the prima ry care giver and recipient (And e r son, Funnel l Butler, Arnold, Fitzgerald, and

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17 Feste, 1995). Lacking in the literature are the psychosocial factors from the L atina patient's point of view that influence disease outcomes. For example, social and cultural influences on self management behaviors in Latinas are not understood and the applied health theories may be culturally inadequate. Daily sel f management is mandatory for diseases such as diabetes. In addition to a healthy diet and exercise, daily self management of diabetes may include home blood glucose testing, oral medications, and in sulin injections. Daily self care regimens have been show n to improve quality of life, reduce mortality and morbidity, and reduce health care costs (Gallagher, Viscoli, and Horwitz, 1993; Horwitz and Horwitz, 1993; Horwitz, Viscoli, Berkman, Donaldson, Horwitz, Murray, et al., 1990). The importance of self manag ement of T2DM cannot be overstated; research that explores how to improve health outcomes of T2DM must factor into account barriers and facilitators of successful self management. L at inas face a number of institutional, social and structural barriers to T 2DM self management (U S DHHS, 2000) as well as general socio economic factors that can make their lives challenging (Vega, Rodriguez, and Gruskin, 2009; Morales, Lara, Kington, Valdez, and Escarce, 2002; Estrada, Trevino, and Ray 1990 ) R easons for poo r health are multifaceted and include culture (Caballero, 2001; Estrada, Trevino and Ray 1990 ), biolog y (Burke, Williams, Gaskill, Hazuda, Haffner, and Stern 1999 ), lack of access to health care and high quality health care system s (Wen, Shepard, and Pa rchman, 2004), lack of or limited English proficiency (Cusi and Ocampo, 2011; Pitkin Derose and Bak er, 2000), and little insurance coverage (Hoffman and Pohl, 2000; Burke, Williams, Gaskill, Hazuda, Haffner, and Stern, 1999; Estrada, Trevino, and Ray 1990 ; Solis, Marks, Garcia, and Shelton, 1990 ). The number s o f barriers to self management of T2DM for Latinas in the U.S. are abundant and negatively impact health

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18 outcomes in this growing population; a further examination of these cultural and contextual ba rriers is necessary. Figure 2.1: Socio Ecologic Sources Of Influence Model Socio Ecologic Model A socio ecological environment is a nested system of influences that can affect individual perception and behavior. Self manage ment of T2DM is affected by three important social ecologic factors: (1) the health care system and its practitioners; (2) community environments along with their social/civic institutions, and (3) family (Wen, Shepherd, and Parchman, 2004). For the purpos e of this dissertation, the socio ecological environment includes the health care, community, and culture. While other socio ecological components such as the larger policy environment, media, work or educational institutions may also influence self management behavior, the focus here is on those elements that the literature has highlighted as most proximal and salient to management of their T2DM. An illustrative model which I have ba sed on several socio ecological heal th models was developed to explore the relationships between social support, self efficacy, and self management factors (Figure

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19 2.1) and ecological environments (Sallis, Owen and Fisher, 2008; Bronfenbrenn er, 1999) The present study explores family, health care, community, and cultural sources of social support and their influence on self efficacy to understand the extent to which they are related to and affect self management of disease. Literature sug gests that identifying and setting realistic goals around self management of disease, including problem solving and coping skills, may be influenced by the exercise of self efficacy (Senecal, Nouwen, and White, 2000; Strecher, Seijts, Kok, Latham, Glasgow, DeVillis, Meertens, and Bulger, 1995). However, research suggests that family social support influences on self efficacy can both enable and hinder self management behaviors (van Dam, van der Horst, Knoops, Ryckman, Crebolder, and van den Borne, 2005; Hay es, 2001). Furthermore, health care and community level influences on self efficacy may positively and negatively affect adherence to self management and treatment regimens through the use of education and support networks aimed at self care and disease pr evention (Coffman, 2008; Krichbaum, Aarestad, and Buethe, 2003). In addition, at the cultural level, self efficacy may be influenced by cultural norms and beliefs (Concha, Kravitz, Chin, Kelley, Chavez, and Johnson, 2009). Exploration of these multi level influences of social support sources will lead to a greater understanding of self efficacy beliefs and how they impact self management of disease. Having a clearer understanding of the social support influences on self efficacy will help to strengthen int erventions aimed at increased self efficacy to achieve specific behavioral goals for self management. Researchers from an array of disciplines have proposed that psychosocial and physical environment s h ave multiple direct i mpact s on health. Intrapersonal (biological, psychological), interpersonal (social,

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20 health, well being, and quality of life. Although multiple models and labels are used under the general rubric of social ecology models, they all address t he multiple sources of support and pathways that influence behavior. S ocio ecologic models are multifaceted and include individual self efficacy and how it is influenced by sources of social support of multiple types The socio ecologic sources of influen ce model (presented above in Figure 2.1) will be used for analysis in this dissertation to explore the multiple pathways of psychosocial factors as they influence self management of T2DM. Sallis and colleagues (2008) propose four key principles of comprehe nsive socio ecologic models, which aim to understand the dynamic between individual behaviors and the many biologic, social, and environmental factors that help determine these behaviors. According to Sallis and colleagues, t he first core principle in a co mprehensive socio ecologic model examines intra and interpersonal, community, organizational (including health care) and policy levels and their influence on health behaviors. The second core principle is the acknowledgement that there is a multidirectio nal interaction across the va rious levels of influence The third core principle is the understanding that socio ecologic models should be specific in their behavioral focus to identify the i nfluences. Finally, t he fourth core principle is that to effectiv ely change health behavior, multi level interventions need to be developed (Sallis, Owen and Fisher, 2008). Furthermore, transdisciplinary research models frequently used in literature are grounded in evidence based research and practice across several dis ciplines (i.e., medicine, psychology, public health and social work) and aim to help explain the mosaic of factors that impact health outcomes. The recent move to more transdisciplinary models in health behavior research highlights the complexity of healt h behaviors and health determinants and supports the use of socio ecologic models Theorists and interventionists are in agreement about the importance of a socio ecologic approach for

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21 understanding and predicting how contextual factors affect sustainabili ty of intervention components and their effects (Scheirer and Dearing, 2011). Drawing from both pub lic health and psychology, socio ecological models are grounded in work of several scientists, including Uri examin ation of multi le vel influences on behavior via synergistic systems and Albert ry, which looks at how behavior is influenced by the environment ( Bandura, 1997). In the late 197 relatio nship of the en vironment to individual behavior through a multi level model : M icrosystems the immediate social environment (e.g., family, home, neighborhood) M esosystems social environment to other key settings (e.g. work, school) E xosystems that impact the individual indirectly (e.g., communit y groups) M acrosystems, the culture of the larger social environment in which the individual lives (e.g., medi a, societal norms, government). Bro n ed by t he Lalonde R eport of 1974, A New Perspective on the Health of Canadians which proposed four key factors that affect health : human biology, lifestyle, environment, and health care organizations (Lalonde, 1974). This evolution from human to social ec ology schools of thought led the shift to a broader understanding of the reciprocal relationship between a person and her environment (Stokols, 1996) Furthermore, there was an expansion of the concept of health; for the first time health was viewed holis tically and had a comprehensive focus being Alt ponsibility toward their own health

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22 behaviors, the 1979 Prevention began to capture a holistic view of health and literature began to explore multi level influences on health with more frequency I n 1986, t he Report was further supported a t the first international conference on health promotion, the Ottawa C harter for Health Promotion which advocated an even greater influence on health coming from socio cultural and physical envir onmental factors (World Health Organization, 1986). T his new definition of health began commonly to include disease prevention, health protect ion, and health promotion, with a focus on the role s of individuals as well as groups and organizations to partic ipate as active agents toward healthy behaviors and creation of health policy. In addition, c ommunity health promotion began to emphasize the collaborative efforts of both public and private institutions within a community for enhancing the well being of a population and, s ocio ecologic models began to explore multiple factors that influence health promotion and disease prevention at the individual and group level The value of using a socio ecologic approach to understand the many factors that influence health is apparent; a s oci o ecologic approach not only integrate s behavior change and environmental models of health promotion, but extends its focus to comprehensively capture characteristics of the immediate and extended environment the individual he r self efficacy, and her surroundings each of which must be in view in order to fully unde Self E fficacy Stemming from Al bert self efficacy is an indivi that she is capable of beginning and completing a behavior or task (Bandura, 1986 ). S elf efficacy is well established as an important mechanism for behavior change (Bandura, 1997). Social Cognitive Theory follows a

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23 may adjust or control her actions based on personal, social, and environmental feedback (Bandura, 1986). This feedback affects beliefs or perceptions around capabilities, rather than actual capabilities, and thereby helps predict actions (Bandura, 1997). S elf efficacy is specific to task, must be built up over time, and may ch ange throughout the life span ( Bandura, 1997). b eliefs in self efficacy are deter mined by four primary s ources: ( 1) mastery experience or life experiences and accomplishments ( 2) vicarious experience or seeing similar individuals succeed in a task ; i.e., social modeling ( 3) social persuasion or verbal persuasion from others and ( 4) affective state or feelings and self appraisal of personal strengths and weaknesses both emotional and physiological (Bandura, 199 7 ). T he combination of these four primary sources is effective at increasing perceived self efficacy in an individual (Bandura, 1977). In addi tion, Bandura suggests that a collective efficacy captures the capability, shared skill set and knowledge that a group uses to achieve a desired outcome. Related to but different from self efficacy, collective efficacy builds upon the personal agency for which an individual is autonomous in her actions to expand interdependent efforts to achieve outcomes when accomplishing them at the individual level is not poss ible or likely (Bandura, 2000). C ollective ence and ability to complete a be havior or task, and research suggests that the i nability to make successful changes in health behaviors may signal a low self efficacy at the individual or group level (Bandura, 2000) Self efficacy has been shown to be a n important factor in self management of disease (Krichbaum, Aarestad, and Buethe, 2003 ; Glasgow, Toobert, and Gillette, 2001; Johnson, 1996). Since s elf efficacy helps to predict individual level behavior improved self efficacy can be expected to improve self management of disease and, if self efficacy

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24 can be built up at a younger age, heighten ed self efficacy may help prevent or delay onset of diseases (Bandura 1997). Research suggests that high self efficacy increases self management of disease, whereas lower self efficacy decreases self management of disease (Krichbaum, Aarestad,and Buethe, 2003). Successful self management and adherence to medical treatment regimens or self treatment plans can be explored through analysis of self efficacy, both at the individual level and collectively for Latinas. At the individual level, beliefs about social cohesiveness and maintenance of social norms impact the level of social cohesion and, ultimately, social engagement, that the individual feels. Collectively, ref lection of high self efficacy may be seen within cultural norms including health knowledge, attitudes, and beliefs T he importance of familism in Latina culture underscores the need to examine self and collective efficacy as both a facilitator of and a barrier to effective disease self management in Latinas. Specifically, self efficacy has been shown to be positively associated with specific self management behaviors aimed at controlling T2DM, including metabolic control, self care adherence, dietary sel f care, and satisfaction with treatment in Latinos and non Latinos alike (King, Glasgow, Toobert, St r ycker, Estabrooks, Osuna, and Faber, 2010; Trief, Eimicke, Shea, and Weinstock, 2009; Sarkar, Fisher, and Schillinger, 2006; Krichbaum, Aarestad, and Bueth e, 2003; Aljasem, Peyrot, Wissow, and Rubin, 2001; Xu, Toobert, Savage, Pan and Whitmer, 2008; Skelly, Marshall, Haughey, Davis, and Dunford, 1995; Kavanagh, Gooley, and Wilson, 1993). Stronger self efficacy beliefs concerning a specific behavior that is required for the continual self management of disease will result in maintenance of management behavior (Krichbaum, Aarestad, and Buethe, 2003). Furthermore, self efficacy influences the relationship between social support and self management (Bandura, 199 7) and is a key driver predicting the extent of control that an individual has in relation to her environment. However, individuals both

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25 act upon their environment and are constrained by that environment and, it is not understood how self and collective efficacy in self management of T2DM in Latina s is influenced or varies by sources of social support Social Support Understanding the role of social support as it impacts self efficacy and disease self management is important (Dale, Williams, and Bowyer, 2 012; Funnell, 2010; Sarkar, Fisher, and Schillinger, 2006 ). Research suggests that i ndividuals with chronic disease have improved quality of life and functional health status when they have positive social support in their life (Gonzales, Haan, and Hinton 2001). Furthermore, people with diabetes perceive that they have better health when they have social support, or assistance, received from others (Morrow, Haidet, Skinner, and Naik, 2008; Goodall and Halford, 1991). However, the influence of types and sources of social support on self efficacy as it relates to self management of disease is not understood as it varies by culture Social support may c ome in multiple functional types including emotional, informational, appraisal, and tangible support as well as positive social interaction (Sherbourne and Stewart, 1991). Emotional support includes nurtur ing, love, trust, and caring whereas informational suppo rt includes giving of advice (Langford, Bowsher, Maloney, and Lillis, 1997). Appraisal support inc ludes helping the in dividual understand information and assisting the individual with coping strategies and resources (Langford, Bowsher, Maloney, and Lillis, 1997). Tangible support is the provision of actual goods and services, or actual helping behavior s. Research suggests that tangible or informational types of social support can be detrimental when the support is viewed as nagging about behaviors (van Dam, van der Horst, Knoops, Ryckman, Crebolder, and van den Borne, 2005; Hayes, 2001; Boehm, Schlenk, Funnell, Powers, and Ronis, 1997;

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26 Bogat, Sullivan, and Grober, 1993; Griffith, Field, and Lustmam, 1990; Kaplan, and Hartwell, 1987; Kaplan, Chadwick, and Schimmel, 1985) However, it is not clear if certain types of social support are viewed more positive ly or negatively in different cultures. Understanding the significance of types of social support in different cultures may help resear chers and clinicians tailor care specific to patient needs Anoth er important consideration includes the importance of s ources and not just types of soci al support as they impact self efficacy and self management of T2DM for Latinas. Social support may come from multiple sources, including the family, health care, community and culture. S elf efficacy may be stronger wh en social support is available from multiple sources of family, health care, community and culture ; together these sources support the individual through emotional, informational, appraisal, and tangible means. On the other hand, strong self efficacy may be protective of self management behaviors when social support is lacking. Understanding the importance of sources of social support in the lives of Latinas can help researchers and clinicians develop programs and interventions aimed at increasing self eff icacy and self management of T2DM. My a priori assumption is that t he relationship between social support and self management may be mediated efficacy to manage disease. However, it is not clear how social suppor t influe nce s self efficacy of disease management in Latinas. The sources of social support that are most important in the lives of Latinas may directly impact self management behaviors. Cultural norms for Latinas place a great emphasis on interpersonal relationsh ips and on the role of women in the family unit, and yet the significance and complexity of these relationships is not understood (Barrera, Strycker, MacKinnon, and Toobert, 2008). The contextual and cultural factors that influence the relationship betwee n social support and self

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27 management may be highlighted by understand ing unit as it relates to self management of disease. Social support and self efficacy are both key psychosocial factors affecting sel f management of disease (Nouwen, Balan, Ruggiero, Ford, Twisk, and White, 2011; King, Glasgow, Toobert, Strycker, Estabrooks, Osuna, and Faber, 2010; Ingram, Torres, Crebolder, and van den Borne, 2005; Krichbaum, Aarestad, and Buethe, 2003; Glasgow, Toobert, and Gillette, 2001). However, the mechanism by which that relationship occurs is not clearly understood. For example, the self care activity of monitoring blood sugar may be influenced by education provided by a physician; whereas diet restrictions may be influenced more profoundly by family and friends who encourage or help facilitate healthy dietary behaviors. Further, social support sources of influence may vary according t o the self management regime n specific to the individual and her health condition(s). The four sources of social support, including family, health care, community, and culture will be further explored in this chapter. Family Positive support from family an d friends can beneficially affect patient health behaviors and outcomes (Rosland, Heisler, Choi, Silveira, and Piette, 2010; Zhang, Norris, Gregg, and Beckles, 2007; Luttik, Jaarsma, Moser, Sanderman, and van Veldhuisen, 2005; Gallant, 2003). Family is im portant in the lives of Latinas. One norm in Latino families is that Latinas are care givers to the entire family; placing family health and care before their own health (Wen, Shepherd, and Parchman, 2004; Hunt, Pugh, and Valenzuela, 1998). Health care a nd medical decisions are often made only after consulting the family and extended family that are considered a primary support group for Latinas (Carteret, 2011; Wen, Shepherd, and Parchman, 2004; Hunt, Pugh, and

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28 Valenzuela, 1998). Furthermore, if support from family and extended family is not considered positive or adequate the Latina patient may not feel she has the self efficacy to make a health decision or behavior change. Family social support is more important to Latina s than Latinos (Rosland, Heisl er, Choi, Silveira, and Piette, 2010; Jackson, 2006; Gallant and Dorn, 2001), however it is not known if Latinas believe that they receive or need more family support than Latinos. There is some evidence to suggest that high levels of social support offere d by the family are most closely related to self management and increased self efficacy (Coffman, 2008; Dimatteo, 2004; DiMatteo and Robin, 2004; Glasgow, Toobert, and Gillette, 2001). Conversely, low levels of social support from the family are related t o low levels of self management (Tillotson, and Smith, 1996). Family involvement in self management of disease can also be experienced as negative, and increase barriers to self management (Rosland, Heisler, Choi, Silveira, and Piette, 2010; Jones, Utz, W illiams, et al, 2008; Carter Edwards, Skelly, Cagles, and Appel, 2004). If an individual feels that she is being nagged or excessively reminded about doing a self management behavior, such as taking her medicine or monitoring her blo od sugar levels regular ly, she may feel guilty or criticized for not taking better care of herself. Family support that infers insufficient self managemen t can hinder self efficacy (Ros land, Heisler, Choi, Silveira, and Piette, 2010). Latinas may feel frustrated and confused or thwarted in their efforts to make healthful food choices by family involvement in determining the preparation or ingredients used in meals ( Ros land, Heisler, Choi, Silveira, and Piette, 2010; Cagle, Appel, Skelly, and Carter Edwards, 2002). Other family b arriers that may influence self management include family members placing dietary constraints, such as demanding that certain foods, like tortillas and beans, be made a traditional way that does not support good self management behaviors Though research suggests that Latinas

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29 value family social support more than Latinos, the importance of family social support barriers as they impact self efficacy and self management of T2DM is not understood. Health C are At the organizational level, health care stands out in the l iterature as an important source for supporting Latina health. Latino, Spanish speaking patients report more satisfaction with Spanish speaking providers (Cooper Patrick, Gallo, Gonzales, Thi Vu, Powe, Nelson, and Ford, 1999). Given the dearth of Latino physicians in the U.S., communication barriers both linguistically and culturally affect the delivery of care, as well as patient satisfaction with care. Literature has also shown the importance of factoring health literacy into the developm ent of health education materials in a culturally competent manner (Shaw, Huebner, Armen,Orzech, and Vivian, 2008). There ha ve been initiatives in medical schools over the past two decades to teach cultural competency to all physicians, residents and stude nts (Carrillo, Green, and Betancourt, 1999; Culhane Pera, Like, Lebensohn Chialvo, and Loewe, 2000; Culhane Pera, Reif, Egli, Baker, and Kassekert, 1997). These educational efforts emphasize the patient clinician relationship and cultural discordance that may exist ; potential bias in clinician perception s around lifestyle behaviors and disease risks in Latinos ; the importance of understanding the cultur al orientation and health literacy of patients ; and how to take action to improve clinical conditions for people of different cultures Latin a s often include family members and friends during me dical visits with providers (Coffman, 2008). There is the expectation of respect, or respeto in Latin American culture, which extends to health care encounters. In t he health care setting, respeto is appropriate position of authority given to individuals. P hysicians are generally viewed as authority figures (Carteret, 2011). Latina patients m ay listen carefully and nod their head

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30 when the provider is speaking, however this behavior may show respect to the provider more than agreement about what the provider is suggesting for treatment. In Latin American culture, positions of authority are hier archical, and vary depending on the level of importance placed on age, gender, title, social position, and economic status (Flores and Vega, 1998). Similar to the level of respect the patient gives to the provider, the patient also expects respect to be gi ven to her and her family during health care visits. This may include using titles of respect, such as Seora and Seorita (Carteret, 2011). F amily involvement in decision making around disease management and treatment is greater for H ispanics than non His panics (Coffman, 2008 ). When families are not welcomed disrespected, or excluded from the patient encounter with the physician and care providers, the patient and his or her family may not feel supported and may not be as receptive to the medical informat ion given. The level of support offered to the patient and her family during provider encounters could negatively impact health outcomes if the patient feels lack of respect to her and her family Community The community in which people live can have a si gnificant impact on the social support networks to which individuals are expose d. Possible community sources that foster social engagement and social support, and affect health behaviors, include social organizations and institutions (e.g. churches, c ommu nity centers recreation centers and parks, libraries, educational facilities), businesses (e.g. grocery stores, banks, post office s ), and transportation services ( e.g. bus, taxi, light rail, subway, shuttle) (Stahl, Rutten, Nutbeam, Bauman, Kannas, Abel Luschen, Rodriquez, Vinck, and van der Zee, 2001). Community factors that have been shown to be protective of health for Latinos include living in ethnic al ly homogenous neighborhoods that include physical s sidewalks, porches, homes with

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31 windows facing communal space and other variables associated with promoting social cohesion (i.e., that facilitate a sense of safety, trust and reciprocity among neighbors ) (Sampson 2003 ); that promote outdoor activity (s uch as walking or gardening) and foster social support (Aranda, Ray, Snih, Ottenbacher, and Markides, 2011; Gerstm Nurabdam Eschbach, Sheffield, Peek, and Markide s, 2011; Verbrugge and Jette, 1994). Strong social support networks in the community have been associated with physical activity and social cohesion (Stahl, Rutten, Nutbeam, Bauman, Kannas, Abel, Luschen, Rodriquez, Vinck, and van der Zee, 2001; Giles Corti, and Donovan, 2002). Environmental factors that may benefit communiti es include farmers mark ets and other neighborhood activities that target Latino culture ; promoting healthy food options as well as opportunities for gathering and social engagement, which may increase social support options for community members. Latinas represent the social hub s of the family and the community they live in th rough the many roles they play as mothers, daughters, wives, care takers and contributors to family income. Some research suggests that in Latino communities there is a protective health factor associated wi th social cohesion and intergenerational support networks that include mothers and grandmothers, buil t upon cultural traditions to protect health in the Latino community (Kawachi, Kennedy, and Glass, 1999). However, it is not clear whether the importance of cultural traditions and health behaviors var ies according to generation, age. Cultur e A cculturation and cultural orientation influence how Latinas view diabetes (Rosal, White, Restrepo, Olendzki, Scavron, Sinagra, Ockene, Thompson, Lemon, Candib, and Re ed, 2009; Kieffer, Willis, Arellano, and Guzman, 2003). Management and treatment their norms and beliefs, including how important it is to treat and manage T 2DM. The influence of cultur e

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32 as it supports and influences disease management may vary depending on how long one has lived in the United States. The concept of familism is prevalent in Latino culture. Familism also sometimes called familismo is the norms and values inherently im portant to the Latino family (Carteret, 2011; Wen, Shepherd, and Parchman, 2004; Hunt, Pugh, and Valenzuela, 1998). The concept of familism is important in the lives of Latinas who value the input and opinions (i.e., informational, appraisal support) of th eir extended families, which may include friends who are not biologically related, and may influence disease management. In addition to the cultural norms and sense of familism inherent in Latino culture, Spanish la nguage variations cultural traditions, i ncluding food preferences and exercise Restrepo, Olendski, Scavron, Sinagra, Ockene, Thompson, Lemon, Candib, and Reed, 2009). Literature shows that acculturation may play a large role in understanding self management of chronic disease in Latinos (Perez Escamilla and Putnik, 2007; Balcazar, Castro, and Krull, 1995). Acculturation is defined as the individual adoption process of customs, beliefs, values, b ehavior and attit udes of a cu lture. C ultural orientation is the extent to which an individual is influenced by and engages in cultural norms, customs, and traditions (Tsai and Chentsova Dutton, 2002). M easures of acculturation frequently use English language proficiency or language spoken within the home as proxies for determining level of acculturation. Acculturation was o Cortes and Malgady, 19 91) and was grounded in a preconceived understanding of what constitutes W

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33 Mak, 2003). Sociologists viewed acculturation as loss of the original culture (Park, 1938). T he cultural factors at play when one migrates to another country are likely mediated by the social and structur al context that surrounds the individual, and includes community and structural variables such as where they live and available community resources. And other cultural variables, such as living near others who have similar cultural backgrounds and norms. There is a need for acculturation models that include contextual and structural factors that influence acculturation. As more multidimensional acc ulturation models come to fruition, increased awareness of underlying cultural bias may surface and acculturation measures may be able to better assess the dynamic that occurs as immigrants adopt behaviors and traits from another culture, or not (Chun, Org anista, and Marin, 2003) F urther exploration of cultural social support and acculturation as they influence behaviors and expectations around self management is necessary to better understand self management of T2DM; this finding by Chun and his colleagu es suggests the need for further development of theories that help explain the influence of cultural orientation and acculturation as it impacts health and disease outcomes (Chun, Organista, and Marin, 2003)

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34 CHAPTER III RESEARCH METHODS AND DESIG N This research project uses qualitative data collection and analysis to investigate and understand the interrelationships between social support, self efficacy and self management of T2DM In addition, age, acculturation, and level of education were al so explored to examine similarities and diff erences within these categories A description of the study population, research setting, study instrument, sample recruitment, data collection techniques, and data anal yses are presented here. My study used th e conceptual socio ecologic sources of influence model previously explained in chapter II (Figure 2.1) and led to questions (Table 3.4) that were posed to study participants to answer my research questions I used a one phase exploratory study design. M y study methods consisted of qualitative, in depth, semi structured interviews and data analysis to explore sources of social suppor t (family, health care, community, and culture), self efficacy, and self management A methodological framework (Figure 3.1 ) facilitated the identification of themes in the collected data subsequent grouping of themes, and the present analysis, interpretation, and reco mmendations as represented in the following chapters

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35 The following research methods were used to guide the project : Figure 3.1 : Research Methods Study Population The study population consisted of 33 self reporte d Latinas (10 from Salud Family Health Center, 23 from Kaiser Permanente between the ages of 42 and 70 ) who had enroll ed and had just participated for two years in a behavior change intervention, ¡Viva Bien!. The ¡Viva Bien! intervention was based on a successful, comprehensive theory based program conducted in Oregon by the Oregon Research Institute called the Mediterran ean Lifestyle Program. That program had been shown to be effective in improving biological, behavioral, psychological, and quality of life outcomes in Anglo women with T2DM (Toobert, Glasgow, Strycker, Barrera, et al. 2003). The aim of ¡Viva Bien! (VB) was to reduce the risk of coronary heart disease (CHD) for Latina women with T2DM by participating in a lifestyle behavior change program that incorporated a healthy diet, physical activity, stress management, social support, and smoking cessation. T he VB study had a total of 280 Latinas enrolled between early 2008 and late 2010 and was supported by a grant from the National Develop r ecommendations based on findings and results Conduct a qualitative secondary data analysis of in depth, semi structu red interviews to explore sources of social support influence, including family, health care, community, and culture, and self efficacy, in relation to self management of T2DM in Latinas. Identify themes of psychosocial factors. Explore the relationships and pathways between social support and self efficacy as they contribute to self management of disease, including an investigation of age, acculturation, and level of educ ation.

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36 Heart, Lung, and Blood Institute (R01 HL0771120). Participants in the VB study received care from 14 Kaiser Permanente Colorado medi cal clinics as well as a subset of non KPCO members who were recruited from the Salud Family Health Center in Commerce City, Colorado. The VB intervention began with a weekend retreat to introduce the lifestyle behavior change program. The study intervent ion consisted of six months of weekly four hour meetings that were composed of one hour each of physical activity, stress physician to discuss diabetes self management), and s ocial support. After six months, meetings became less frequent, averaging a meeting every other week, for another six months, followed by monthly meetings for months 13 18, and every other month for the last six months of the two year intervention period. Because of the large time commitment for the participants, reminder calls were placed weekly and family members were invited to attend several meetings throughout the intervention period. For the exit interviews, 40 women (10 women from each of four VB intervention waves) were invited to participate; 33 i nterviews were completed with 7 participants excluded due to incomplete interviews (failed to show for the interview or incoherent recording). The 33 women who participated in the interviews used for th is study represented a combination of KPCO and Salud Family Health Center patients, with 8 9 participants from each of four ¡Viva Bien! study waves. Demographics and characteristics from the participants are in Table 3.1 and include level of acculturation level of education, employment status, incom e, living arrangement, primary language spoken at home, marital or partner status, and health care system. Level of acculturation was measured using a modified ARSMA II (Appendix B) measure to assess ethnic ide ntity, and participants were asked a series of questions that assessed whether they

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37 viewed themselves as mostly Latino, somewhat Latino, mixed Latino and Anglo, somewhat Anglo, or mostly Anglo The ARSMA II is b ased on its predecessor, the ARSMA, which is the most widely used accul turation measure for Latinos as an assessment of national heritage, generational status, language use, social relationships, cultural practices and other aspects of acculturation. The modified ARSMA included questions regarding a ctivities done in English or Spanish, including thinking in either language. The reliability and validity of the ARSMA II have been esta blished (Cuellar, Arnold, Maldonado 1995). Data from the acculturation survey measure were converted to a five point s cale based on how the ARSMA II scale categorizes levels of acculturation with Level 1 = most Latino, Level 2 = somewhat Latino, Level 3 = mixed Latino and Anglo, Level 4= somewhat Anglo, and Level 5 = most An glo (Cuellar, Arnold, Maldonado, 1995) Partic ipants were given the ARSMA II assessment individually at one of the four centrally located KP medical clinics or the Salud h ealth clinic. Data were keypunched and verified for accuracy.

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38 Table 3.1: Participant Demographics Characteristic Tot al Sample (n=33) Number/(%) Age range 42 51 52 61 62 70 33 (100) 9 (27.2) 12 (36.4) 12 (36.4) Level of acculturation (ARSMA II) Most Latino Somewhat Latino Mix Latino / Anglo Somewhat Anglo Anglo 33 (100) 8 (24.2) 1 (3) 6 (18.2) 8 (24.2) 10 (30.3) Level of education Grades 0 8 Grades 9 11 High School Some College College Graduate Post College Work Missing 3 3 ( 100 ) 4 (12.1 ) 4 (12.1 ) 10 (30.3 ) 8 (24.2 ) 5 (15.2 ) 1 (3 ) 1 (3) Employme nt Student Self employed Employed for wages Unemployed for less than 1 year Unemployed for more than 1 year Homemaker Retired Missing 3 3 ( 100 ) 0 (0) 2 (6.2) 12 (36.3 ) 0 (0) 1 (3 ) 5 (15.2 ) 12 (36.3 ) 1 (3) Income $0 14,999 $15,000 29,999 $30,000 49,999 $50,000 69,999 $70,000 89,999 $90,000 or more Missing 3 3 ( 100 ) 5 (15.2 ) 9 (27.2 ) 6 (18.2 ) 4 (12.1 ) 3 (9.1 ) 4 (12.1 ) 2 (6) Living arrangement Live with spouse or partner Live with spouse/partner and children Live with children only Live with parents or other relatives Live with unrelated roommates Live alone Missing 3 3 ( 100 ) 13 (39.4 ) 11 (33.4 ) 2 (6 ) 4 (12.1 ) 1 (3 ) 1 (3 ) 1 (3) Primary language spoken in home Spanish English 33 (100) 7 (21.2) 26 (78 .8) Healthcare system Kaiser Permanente Salud Family Health Center 33 (100) 23 (69.7) 10 (30.3)

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39 Characteristic Total Sample (n=33) Number/(%) Marital/partner status Married Separated Divorced Widowed Single Single, involved inn intimate re lationship 33 (100) 21 (63.6) 0 (0) 1 (3) 2 (6) 4 (12.1) 5 (15.2) An overview of participant characteristics was further broken down by age, acculturation, and level of education and is presented in Table 3.2 For the purpose of thematic analy sis throughout the results chapter, age range is coded into three categories: (1) ages 42 51, (2) 52 61, and (3) 62 70. The age categories are used to balance respondents arbitrarily into three groups according to younger to older participants so that ther e was approximately the same number of participants in each age group and are based on the age range of the study participants Acculturation will also be discussed using three categories including: (1) most/somewhat (M/S) Latino, (2) mix ed Latino/Anglo, and (3) most/somewhat (M/S) Anglo. For subgroup analysis purposes respondents were categorized using the scores on the ARSMA II measure (collapsing categories 1 and 2, and 4 and 5). Education level is also coded into three categories, including: (1) less (<) than high school (N/A, grades 0 8, and grades 9 11), (2) high school (high school graduate), and (3) more than (>) high school (some college, college graduate, or post graduate).

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40 Table 3.2 : Descriptive Characterization of Age, Acculturatio n, and Education Levels Age Range Number (%) Acculturation Number (%) Education Category Number (%) 42 51 9 (27.2) M/S Latino Latino/Anglo M/S Anglo 4 (44.4) 2 (22.2) 3 (33.3) High School 4 (44.4) 1 (11. 1) 4 (44.4) 52 61 12 (36.4) M/S Latino Latino/Anglo M/S Anglo 2 (16.7) 3 (25.0) 7 (58.3) High School 2 (16.6) 5 (41.7) 5 (41.7) 62 70 12 (36.4) M/S Latino Latino/Anglo M/S Anglo 3 (25.0) 1 (8 .3) 8 (66.7) High School 3 (25.0) 4 (33.3) 5 (41.7) Acculturation Number (%) Education Category Number (%) Age Range Number (%) M/S Latino 9 (27.3) High School 7 (77.8) 2 (22.2) 0 (0) 42 51 52 61 62 70 4 (44.4) 2 (22.2) 3 (33.3) Latino/Anglo 6 (18.2) High School 0 (0) 1 (16.7) 5 (83.3) 42 51 52 61 62 70 2 (33.3) 3 (50.0) 1 (16.7) M/S Anglo 18 (54.5) High School 2 (11.1) 7 (38.9) 9 (50.0) 42 51 52 61 62 70 3 (16.7) 7 (38.9) 8 (44.4) Education Category Number (%) Age Range Number (%) Acculturatio n Number (%) < High School 9 (27.3) 42 51 52 61 62 70 4 (44.4) 2 (22.2) 3 (33.3) M/S Latino Latino/ Anglo M/S Anglo 7 (77.8) 0 (0) 2 (22.2) High School 10 (30.3) 42 51 52 61 62 70 1 (10.0) 5 (50.0) 4 (40.0) M/S Latino Latino/Anglo M/S Anglo 2 (20.0) 1 (10.0) 7 (70.0) >High School 14 (42.4) 42 51 52 61 62 70 3 (21.4) 6 (42.9) 5 (35.7) M/S Latino Latino/Anglo M/S Anglo 0 (0) 5 (35.7) 9 (64.3)

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41 Research Setting The exit interviews that comprise the dataset for this study were conducted at four Kaiser Permanente Col orado (KPCO) health clinics, the Salud Family Health Cente r (Commerce City) The ¡Viva Bien! program (VB), interviews, a nd reanalysis of the VB questions were approved by Kaiser Permanente (KPCO) Institutional Review Board (IRB KPCO provides integrated health care services to approximately 17% of the population in the Denver Boulder metropolitan area. The R acial/Ethnic C om position of the Denver Metropolitan P opulation and Kaiser Permanente Colorado m embership. of the 550,000 KPCO members are representative of the characteristics of the Denver Metropolitan population as presented in Table 3.3 Table 3.3 : Racial/Ethnic C omp osition of the Denver Metropolitan P opulation and Kaiser Permanente Colorado M embership. Race/Ethnicity Denver Metro (ACS 2006 2008 data) KPCO Membership (Qtr 4 2008) White 68% 74% Hispanic 21% 15% African American 5% 5% Asian American 3% 3% Native A merican 1% 1% Other or multi racial 2% 2% The Salud Family Health Center was established in 1970 as a migrant farmer health center, and today provides integrated primary health care services to the uninsured, regardless of age, sex, or disease status Currently, there are nine

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42 community health clinics and a mobile unit throughout north central and northeastern Colorado. The Salud Family Health Centers which are Federally Qualified Health Centers (FQHC) are designed to help redu ce health disparities and barriers to health care including ability to pay, language, and transportation. The rationale for conducting this study with participants from two different health care organizations, KPCO and Salud Family Health Center, was to o btain a more diverse study sample by reaching women in VB without health insurance (all KPCO members have health insurance), as well as to capture a wider range of experiences with health and health care resources among participants. Sample Recruitment Co nvenience sampling was used to recruit the women. The women in this study sample had volunteered to participate in ¡Viva Bien! (VB) and then again volunteered, and consented fo r a 60 90 minute interview that was conducted after the 24 month VB intervention period Interested individuals were calle d 2 4 weeks after completion of the VB program and invited to participate in this study The original purpose of the interviews t lik e about the original VB program, and to better understand how they feel about social support, health, and self management of their disease. Participants were chosen based on their willingness to talk openly about their health and their desire to parti cipate in an exit interview after the intervention. It is important to clarify that participants were prompted to comment about ¡Viva Bien!, and these results are reported because I have used the findings to assess the extent that ¡Viva Bien! influenced th eir answers to the research questions; however, the dissertation is not an analysis of the ¡Viva Bien! program. questions.

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43 Data Collection Interviews took place at fou r healt h clinics preferred by the interviewee Participants were compensated for their time with a $25 gift certificate. Two interviewers were present for each interview including this investigator and a research specialist. A r esearch assistant, when available, also participated and took notes. Interviews we re conducted in the participant s preferred language ( 8 Spanish, 25 English) In most cases, two recorders (digital and analogu e) were used I facilitated the interviews whe never possible except for the Spanish interviews, at which point the bilingual research specialist facilitated the interviews in Spanish. Both the investigator and research specialist had Masters degrees, and the research assistant All of the participating research staff were trained in facil itating interviews, and practice interviews were carried out with study staff to identify problems with the interview protocol and to refine it. The collected data consisted of responses to the semi structured, in depth interviews. The use of in depth, semi structured interviews with open ended questions enables the participant to explore her health experien ces across social support sources of influence, and draws on themes and personal stor ies that may be relevant to self management of disease. In depth interviews have been used successfully to explore health beliefs and practices in Latinas (Julliard, Viva, Delgado, Cruz, Kabak, and Sabers, 2008; Thornton, Kieffer, Salabarria Pena, Odoms Yo ung, Willis, Kim, and Salinas, 2006). Other researchers have successfully used i n depth interviews for understanding self management behaviors in patients who have diabetes, cardiovascular disease and other chronic health conditions (Coventry, Hays, Dicke ns, Bundy, Garrett, Cherrington, and Chew

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44 efficacy in self ditional sub questions. interviewee through a discussion regarding disease management. model emphasizes how patients bring their own ideas and perceptions of illness to the clinical encounter; beliefs around severity, trajectory, and treatment can help inform how Clarificat ion probes (Patton, 2002) were used to understand what interviewees meant by social support since that concept can mean different things to different individuals and to encourage interviewees to contribute more to the topic being discussed (Kleinman, 1998) Interviews were guided and facilitated as an open ended com munication and a dialogue was co created by the interviewer and the interviewee (Crabtree an d Miller, 1999). O pen ended questions permit ted an environment for the investigator to understand the M emoing, which is a form of note taking, was also used as a method to capture and record ideas, potential relationships, and thoughts as they occur red throughout the interview (Glaser, 1992). In this case, the m emoing technique includes notes and conjecture or theorizing jotted down on paper during the interviews. For the purpose of my study, memoing was used to draw attention to patient perceptions of important factors individual, family, health care communi ty, and culture that may impede or support exercising self efficacy of self management of disease. An example of memoing follows: Partic ipant 8, pg. 12

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45 Participant 5, pg. 5 In addition, non verbal communication was observed during the interviews and notes on these observati ons were taken by the research specialist which were lat er reviewed by the investigator. Once collected, interviews were transcribed. Each interview transcript was verbatim, with the exception of involuntary phrases (e.g. filler words like uh, um, you kn ow); or words that were repeated several times (e.g. I think, I did) unless it was felt it would take away meaning or context from what was being said. After the initial transcription, which constituted between 20 and 30 pages single spaced, the interview was listened to again and compared to the transcription for accuracy. If the interview was conducted in Spanish, the interview was then translated into English by the bilingual research specialist and then back translated by a different bilingual ¡Viva Bi en! staff member for accuracy. Text was then entered into ATLAS.ti qualitative software (ATLAS.ti, version 6) for coding and data analysis. Thematic analysis of interviewee comments was conducted by this investiga tor using ATLAS.ti and emerging pathways and relationships were further supported by the use of coding. Thematic analysis is a method used to help code, organize, and describe the principal patterns and ideas in the data (Boyatzis, 1998 ). For the purpose of my study, structural coding was used to label text according to topic or domain of interest. A code can be a word, phrase, or a mnemonic, that is assigned to text in order to organize and interpret meaning. For example, the topic of cultural traditions was coded to represent this domain, and sub domains, of interest. One su b domain for culture was type of cultural influence accordingly throughout the interviews. A similar structural code was created for each

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46 domain and sub domains of an alysis. Topics and domains of interest were coded by sentence or paragraph that conveyed contextual information that captured key ide as. A priori coding categories were used to develop a classification system for identifying and categorizing patterns in the data that were plausibly related to the research question s (P atton, 1990) and were further expanded upon to capture new emerging themes during the coding process. I first coded for themes in the concept of self management of T2DM. Second, I reread t he transcripts and coded for themes in the concept of self efficacy, and third upon another reread of the transcripts, I coded for themes in the concept of social support including: family, health care, community, and culture. The exit interview guide and some examples of probing, open ended questions which were relevant to this project, are included i n the following table (Table 3.4 ). A complete list of questions, probes and a priori codes can be found in Appendix A In addition, a descriptive charact erization of the results, including the numbers of coded interviews and specific thematic coding information, is provided in Appendix C. The number of coded themes for each of the concepts is listed in Appendix C followed by the significant, reoccurring th ematic findings per concept, which represented positive and negative attributes, and allowed me to answer the research questions.

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47 Table 3.4 Exit Interview Questions Family Dynamics (e.g. immediate, extended living arrangement ) Question: Tell me about your family and extended family Probing questions: What relationships do you have in your life that influence your health and health behaviors? How do you feel your spouse, partner and/or children feel about your health and their own health? Do yo u feel you can successfully manage your health? Health C are (e.g. types, quality, cost, access) Question: Tell me about your health care and health care systems Probing questions: What forms of health care (mental, physical, complementary) do you ha ve access to? What are all of the ways you are taking care of yourself? How much do you have to pay to access these forms of health care ? How good is the quality of the care you receive? Are there other types of health care that you use (e.g. complementary and alternative medicine, home remedies)? Community (e.g. access, characteristics resources ) Question: Tell me about your community support network (s) Probing questions: Do you have t h ings (people, places) in your community where you feel support or lack of support around your health and health habits? Family? Friends? Church? What types of support (social, physical, mental) do you receive from your family, friends, co workers and community members? What support do you feel you have within your co mmu nity ( neighbors, peers business, organization)? D oes this support influence your health? Culture (e.g. traditions, societal and familial norms ) Question: Tell me about your culture and cultural traditions. Probing questions: What cultural traditions do you have in your life that influences your health (e.g. foods, celebrations, activities, family customs, and daily rituals)? How do these cultural traditions influence your health (think of the activities you do, the foods you eat, and how you take car e of yourself)? What does a healthy person look like to you? Analytic Plan Initial a nalysis included review of transcripts and memos that accompanied each participant interview. A priori categories of themes and topics were assigned to the raw data to h elp substantiate the coding process D ata analysis used analytical induction to

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48 identify emerging themes, interpretations of study relationships, and categories about management of T2DM (Berg, 2004; Patton, 2002; G laser and Strauss, 1967). Once I had completed coding the interviews according to the three concepts of self management, self efficacy, and social support, emerging codes had formed and I began to sort the codes into pathways between the three concepts of self management, self efficacy, and social support. The text was coded by the investigator for r eoccurring themes of psychosocial factors including positive and negative attributes, and their relationship to self management of T 2DM. The emerging and reo ccurring themes were used in the development of a thematic framework to organize findings. Comparisons among the study participants were made based on importance of s ocial support sources of influence over self management. Families of themes emerged, and thematic categories were adjusted accordingly. Thematic results from the interview data analysis include quotes pulled from the data that were most interesting, reflective, and indicative viewpoints. As pathways begun to form between the concepts, I wanted to explore further if there were any relationships between the concepts dependent on age, acculturation, and level of education. I then grouped the transcripts into three sets of data de pending on age range, acculturation level, or education level. Each set of transcripts was then reread to pull out common themes depending on the category of interest; namely, each concept (self management, self efficacy, and social support) was coded acc ording to age category, acculturation level, and level of education. Thematic results were drawn from the data to inform the relationships among the primary concepts of self management, self efficacy, and social support. Primary social support themes in the areas of family, health care, community, and culture were

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49 examined to determine which area of social support is most important to the study participants. Themes representing influences on self efficacy were identified Self management themes were ide ntified in relationship to positive and negative attributes. T hematic results were analyzed and synthesized to inform conceptual theoretical and practical implications for the Latina patient population In addition, age, acculturation, and level of educati on were explored in relation to the three concepts of self management, self efficacy, and social support to look for similarities and d ifferences within each category, as they inform implications for the health of Latinas. A deductive approach was taken to look at the broad concepts of self management, self efficacy and social support as they interrelate and are informed by specific themes found throughout the interviews Once i nterviews were entered and coded in ATLAS.ti according to the constant comparat ive me thod (Berg, 2004; Patton, 2002), cross case analysis of the 33 interviews was conducted to group themes of psychosocial factors across answers of similar questions. An inductive approach was taken to look for specific and broad patterns across the i nterviews and a priori codes to theorize about relationships betwee n the concepts of self management, self efficacy and social support of T2DM (Patton, 2002). The constant comparison method is a process that uses inductive category coding to concurrent co mparison of relationships as they appear throughout the analysis (Lincoln and Guba, 1985; Goetz and LeCompte, 1981). Themes of psychosocial factors were explored for their relationshi ps to self management of T2DM and variations were refined to move from i ndividual concepts to theorizing (Tashakkori and Teddlie, 2003; Patton, 2002). which the phenomenon of interest is credible according to the perspective of the interviewee, and adequately captured and reflected in the data about them that has been

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50 recorded ( Trochim, 2001; Patton, 2002). M ethodological triangulation was used to verify captured themes and codes by using memoing, observations, notes, and clarification probes to support the interpretation of the in depth interview data. Methodological triangulation is a common technique used in qualitative research to help validate results through the use of multiple methods to collect and understand data (Denzin, 2006). In add ition, respondent validation was another technique used during the interviews to check for credibility and accuracy in interpretation (Yanow and Schwart z Shea, 2006). Information was frequently restate d or summarized as I understood the participant for cl arification and accuracy of data collection. A nalytical triangulation of data continued until saturation occurred ; name ly, no new themes emerged.

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51 CHAPTER IV RESULTS AND INTERPRETATION OF SELF MANAGEMENT, SELF EFFICACY, AND SOCIAL SUPPORT Results are organized by the three main concepts of self management self efficacy, and social support In this chapter, results are grouped as themes under each concept. Themes are used in several ways to enable my analysis of the three concepts. First, themes may have a positive or negative valence embedded that relates positively or negatively to a concept. For example, denial (a theme) can negatively affect one's sense of self efficacy. Second, taken together themes can represent concepts. For exampl e, perceptions of family, health care, community, and culture culminate to a generalized but individual sense of social support. Third, my analysis of themes enables a theoretical assessment of relationships among concepts. For example, it is through thema tic analysis that I am able to draw interpretations about the nature of self efficacy in relation to self management behavior. The themes noted throughout this chapter are most revealing of the ideas throughout all of the interviews. Sub sect ions in this chapter will present thematic results related to the concepts of self management, self efficacy, and social sup port as they inf orm the main research question: What is the role of social support and self efficacy in self management of T2DM by L atinas? To answer this question, first I will summarize how the participants talked about self management, including negative and positive themes that emerged in relation to self management of T2DM. Second I will summarize how the part icipants spoke abo ut self efficacy, including themes that positively and negatively affected participants self effic acy. Third I will summarize thematic findings of how the participants talked about sources of social support in the areas of family, health care, community, and culture I will also explore what sources of

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52 social support seemed to matter most to the participants, in an effort to answer the first research sub question: What is th e comparative importance of s ources of social support for Latinas? The last sec tion in this chapter will examine the potential pathways between the three concepts of self management, self efficacy, and social support. The interpretation question: How does social su pport influence self efficacy and self management for Latinas? In addition social support thematic results will be reviewed as they relate to self efficacy themes, including an explanation of the implied pathways between social support and self efficacy. Next, the themes that constitute social support will be examined as they affect self management of disease. Lastly, I will answer the final research sub question: What is the importance of self efficacy in self management for Latinas? The themes that co nstitute self efficacy will be explored as they inform pathways to self management. The Concept of Self Management Throughout the interviews, participants were asked to clarify their comments and statements around specific T2DM self management behavior s, including what behaviors were easier and/or harder for them to complete in the primary areas of medication adherence and blood sugar monitoring, eating a healthy diet, and engaging in regular physical activity. Four themes were identified from the inte rviews as negative in relation to self managem ent: medication, stress, healthy eating habits and money. Throughout the interviews, two themes overlapped as both negative and positive in relation to self management of T2DM : physical activity and social sup port. Finally, three themes emerged as positive in relation to self management of T2DM : knowledge and educa tion, collective efficacy, and continuity and routine s. Thematic results for self management are presented in Figure 4.1.

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53 Figure 4.1: Thematic Fi ndings For Self Management Medication Nine of the participants (n=9) in this study reported concern over taking medication, though not necessarily medication associa ted with their diabetes control. In addition, f ou r of the nine participants commented that they consider taking any medication bad for their health and believe that taking medicine can be more damaging to treatment of their T2DM than not taking prescription medication. Further, several of these participants made comments suggesting that taking too many medications may lead to other health ailments, which was also of concern. Thematic findings suggest a general distrust of medications, including diabetes medication as well as other medications, for selves and others. there are a lot of people out there sick because of medications; so many Participant 13, pg. 21

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54 Many other participan ts echoed this feeling. In addition, several participants suggested that if an individual is able to wean off medications they will be healthier, and feel healthier overall. medicines. Stay away from, if possible, taking medication. Cause it has side Participant 2, pg 19 Several of the participants voiced concerns over family and frie nds taking medication, noting wor ries that taking medicine contributes to poorer health outcomes for their families and loved ones. In addition, four of the participants specifically commented that monitoring their A1c levels, as part of their medication adherence regimen was very diffic ult for them to do consistently, and was a struggle given their negative views on medication. Stress Stress was consistently brought up as a negative theme in relation to self management of T2DM (n=9) Several of the participants noted that feelings of st ress negatively contribute to their T2DM disease management as it overshadows their ability to be successful in daily management behaviors. Frequent stressors noted throughout the interviews included worrying about their diabetes and other comorbidities or health ailments such as being obese or overweight. Participant 13, pg. 37 Eight of the nine participants commented that they experience stress over the stress contributes to a sense of fatalism or lack of control of thei r T2DM, which thereby contributes to poorer management of disease.

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55 Diabetes eats everything, our entire system. Everything, everything, the heart Parti cipant 26, pg. 13 Further, having more than one he alth issue contributes to th e participants feeling stressed and thereby, concept of balance and having a balanced life was considered important to five of the participants when they were asked to think about what it means to be healthy. In participants (n=4) as a similar concern as it contributes symbolically to an individual being out of balance in life, and therefore being in less than optimal health. Participant 30, pg. 32 A few participants (n=4) tied stress to being a Latina in the U.S., including how they feel the y are viewed as culturally different, including cultural expectations experience a kind of stress that is similar across all of us m mine. So, for instance, us. Participant 30, pgs. 25 & 29 F urthermor e, f our of the participants commented that they had no or little experience with incorporating stress management activities into their life (e.g., yoga, meditation). Two participants noted that they were unsure of how the practice of stress management wou ld benefit their health or whether it is viewed as appropriate in their culture to enga ge in stress management activities including yoga, gi ven their religious techniques to b e viewed culturally as being sacrilegious. Another theme that a few participants mentioned (n=4) around stress and stress management was that men, in general, do not stress as much as women do.

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56 A few participants (n=4) commented that they worried high str ess levels leads to negative thinking, which poorly impacts their physiologic markers (e.g., A1c, blood pressure), and, subsequently, contributes negatively to self management of T2DM. inking. You Participant 29, pg. 18 The theme of stress was pervasive throughout the interviews, and participants spoke in detail about the importance of it with regard to how it negatively influenced thei r ability to self manage diabetes. Healthy Eating Habits Eating a healthy diet wa s reported as a negative theme in relation to self management of T2DM, with nine of the participants stating that they feel eating the right diet is the most important an d the most difficult factor when working to manag e their T2DM. Further, six of the pa rticipants feel eating a healthy diet is the most difficult self management behavior. to turn into sugar. I was one of those. I never ate sugar, I never drank pop, I that do turn to sugar. And a lot of people were very ignorant about that because of the cul ture. They eat the way their parents eat, and they cook that way, and to get off that merry go round. And from what I could see a lot of these gals really did learn a lot. And Participant 13, pg. 26 Several of the participants commented that food preparation made good dietary behaviors difficult for them due to the need to think differently about how they prepare foods in more healthy ways, which may be very dif ferent from how they were taught as children (e.g., using olive or canola oil in place of the traditional lard when preparing beans, and cooking fish or chicken over traditional red meat). Several participants commented that as children their food was prep ared at home by their mother or

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57 grandmother, and there were expectations to eat the available foods. Further, vegetables and fruit were not always readily available. All the food that my mom made, she made it at home. And no, I remember that a lot of vegetables, almost always what we ate was the normal Participant 16, pg. 11 soup, beans, potatoes, tortillas, bread, a lot of bread with milk Participant 15, pg. 3 Two participants (n=2) noted that classes frequently offered to new diabetics through health care providers and organizations are quickly presented and are not ta ilored to Latinas Further, several participa nts commented that the inf ormation regarding how to eat and/or cook as needed to manage their diabetes did not take into account their methods of cooking or include common foods they and their families eat. Two of the participants commented that the timing of diabetes specific dietary information was often premature. T hey did not understand or accept what they were being asked to do around dietary changes, as they were still trying to come to terms with having the disease in the first place. n g at her Participant 31, pg. 24 The theme of eating health full y was also frequently discussed when the participants spoke about the ¡Viva Bien! program and the expectations around how the participants ate during the meetings at the potluck, which was a component of the program For example, one of the initial exercises that the participants did during the ¡Viva Bi en! program was to meet with the Latina dietician to discuss how to clean out their cupboards at home an d throw away foods that were unhealthy for them

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58 to eat. The program dietician did an exercise with the participants where she had a table of frequently consumed Latin foods (e.g., lard, tortillas, beans, chicha rrones). During this exercise, the dietician asked the women what they thought they should throw out, and the women proceeded to throw items i nto the trash can provided. Five participants discusse d this exercise during the exit interviews when they were reflecting on how it is hard for them to eat healthy. Specifically participants expressed disgust when the bacon was thrown away into t he trash. These participants conveyed their concern over thr owing away perfectly good food that they and thei r family liked; throwing away food is a waste o f food and money This example illustrates how the participants really enjoy and feel a sense of expectation eating certain foods using traditional methods of preparation. Money Financial issues affect self manage ment Many of the study participants (n=10) reported that money has always been a significant consideration when managing disease in terms of being able to afford medications, healthy foods (vegetab les and fruits), physical activity resources (e.g., inability to pay for recreation center memberships consistently, and unsafe walking environments), and other resources (e.g., insurance, living environments) to be successful in their daily management reg ime. Participant 2, pg. 11 Four (n=4) of the participants also discussed concerns over money and access t o food when they were childre n, which influences how they manage their health as adults. meal for your family Participant 28, pg. 14

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59 Some of the participants (n=7) comme nted that they live on a monthly fixed income, noting that there are months when they are unable to afford their medications (and have to use available funds to pay rent, buy food, and pay bills first). Other participants noted that they cannot regularly a fford fresh fruits and vegetables, and/or cannot take classes at recreation centers or participate in educational programs offered in the community simply because they cannot afford it on a regular basis. In addition, money was mentioned by a few partici pants (n = 3) who have high er incomes in terms of how they often give money to family or friends who are in need and that they see this as an important means of support to offer when they can afford it. Physical Activity Physical activity was viewed as both positive and negative in relation to self management of disease. Several of the participants (n=6) reported that physical activity was generally easier than other self management behaviors for them to complete toward managing their diabetes. Swimming at recreation centers (n=7) and walking (n=12) were most frequently discussed as favorite exercises among the participants. Several participants (n=5) also noted that once a physical activity or exercise became a daily or consistent routine they usually fo und it easier to maintain the r outine, commenting that the health effects were immed iate and positive in most cases. robably have more energy (after VB ). I can do more things. Because it used foot ladder you know doing the ceiling and stuff. I got it done, and it lo oks good. exercising and stuff, I have more strength and more, you know, I can do more than what I Participant 23, pg. 26

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60 However, getting into the initial routine of doing physical activity and exercise was often hard. Many participants also reported physical limitations frequently kept them from doing activities they would prefer to d o. d a lot. I wish I Participant 27, pg. 24 When asked about physical activity behaviors, three of the participants also that physical activity was not necessarily encouraged by their parents or family when they were growing up. to aerobics or anything like that. Say as a Participant 23, pg. 33 speaks to the cultural norm that many of the women expressed regarding exercise habits and expectations that were placed on them as young Latinas Participant s who expressed this theme were awar e that exercise was good for their health and for managing diabetes H owever these participants spoke about how exercise was not something that they were encouraged to do as younger girls. This finding supports exploring the cultural shift in younger La tinas with regard to preferred exercise habits and norms around physical activity as it contributes to prevention and self management of disease.

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61 Social Support Social support also emerged as both positive and negative in relation to self management of T2DM. The theme of social support prim arily touched on three t y pes of social support, including emotional (caring for and being cared for), informational (advice ), and tangi ble ( help offered ) support Participants did not specifically distinguish between sources of social support. Seven participants commented that social support was the most important contributor to self management of T2DM. Twelve participants (n=12) suggested that social support could be both positive and negative as it impacts self man agement of T2DM. Further, social support, given to others in relation to caring for others and being respectful, was frequently discussed as being both positive and negative as it contributed to self management of disease. The participants frequently disc ussed taking care of others and how this made them feel good about themselves. However, many of the participants (n=8) recognized that they often failed to take good care of themselves because they prioritize taking care of others. I know I am the heart of my whole family. And my mom was the heart of our family, and my grandma was the heart of her family. And, we respect. And you have to live up to th at respect that people give you. And that Participant 20, pg. 19 never talk about it. They are always looking to me because I am a care giver. I thin encouraged whe Participant 4, pg. 16 givers. To the point that they put their own health needs on the back burner. I know that watch out for everyone else and kind of say Participant 6, pg. 9

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62 The concept of loneliness also emerged out of the discussions around social support as it influences self management of T2DM. Four participants commented that loneliness is an issue that stems from a lack of social suppo rt and negatively contributes to successfully managing disease. Other participants discussed the recognition of not feeling lonely in their disease after they had met people with similar concerns who also shared a sense of commonality through social suppor t. they eat and everything. S I think that is great. Because som etimes you do feel, you might fe Participant 17, pg. 56 Laziness was another concept in the area of s ocial support that four participants spoke of negatively; namely, how little or no social support made it easier for them to be management behaviors. When asked what has helped one participant manage her T2DM, she simply at I see you one thousand t imes 32). Throughout her interview, this participa nt spoke to t he increase in social support both from the ¡Viva Bien! meeting lea ders and the participants in the program; this support was influential on how she now views the importance of her self management behaviors. Nine of the participants reported that participating in a social support group around self management o f disease became the easiest way for them to improve their self care behaviors. iendships that I make with these people that I work out with. That has helped me in the working out part too. Because I look forward to seeing them. So today. Participant 28, pg. 36

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63 P articipants expressed the importance of feeling a part of a collective group and several spoke about the enjoyment they found when participating in social group settings Knowledge, Awareness and Education Knowledge, awareness or sabidura and education were three of the most commonly reported positive themes in relation to self management of T2DM for the participants, with 14 of the participants reporting that knowledge learned in the ¡Viva Bien! program gave them increased a wareness of how to manage their disease and they being a key factor to improved self management of T2DM, with a couple of the study participants stating that the education Participant 5, pg. 11 Many participants (n=17) reported increased educat ion and understanding of their disease helped them feel the ir diabetes was more manageable than before the education ; namely, increased education improved perceived self efficacy Several participants (n=8) also commented that having family members (usual ly the mother) who have or had diabetes, and seeing what they go or went through when they fail to take care of themselves, made a significant impact on how they manage their disease. irty. So, Participant 7, pg. 11 Twelve of the study participants also commented that when the y learned additional information regarding self management behaviors around T2DM this information also benefited their family and other friends, directly. Four of the study participants noted that they used the internet and other media (magazines, newspap er) to find information around self management of T2DM. In

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64 addition, a few of the participants commented that they watched television programs that focused on health information, commenting that they shared the information they learned through these progra ms with family and loved ones. The importance of knowledge and education as it increased awareness was a persistent theme throughout the interviews; there was a sense of pride and empowerment from the participants who expressed that they felt proud to be a ble to share their knowledge with loved ones and family. Collective Efficacy When participants were asked about their ability to self manage their disease, the theme of collective efficacy was pervasive as many participants (n=12) discussed the positive aspect of wo rking and learning with others to take better care of their health. Rico, Brazil. That was all Latino people, the women, and we all got to focus and knowing our way s and stuff. You get to learn their cultures, our cultures, the way Participant 6, pg. 15 Participants expressed the importance of eating a healthy diet and participating in regular physi cal activity; sharing self management responsibilities with others who had similar disease management regimes seemed to resonate with the participants and increased adherence for many of the participants who commented that they felt more capable of doing c ertain behaviors when there was a collective effort. each other. Everyone needs to work with each other on all of this stuff, cause its Participant 2, pg. 3 The importance of family in Latina culture highlights this finding; namely, famil ism is reinforced through the collective efficacy of a group and nurtures empowerment to manage disease more proactive ly. In addition, there seemed to be a reciprocal relationship between the participants who participa ted in the ¡Viva Bien! program.

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65 Participant 9, pg. 26 N amely, the collective effort at the community level fostered a sense of accountability to others and enablement to improve self management behaviors. Continuity and Routine s T he theme of continuity and routine of self management behaviors emerged as a positive theme of facilit ating self management of disease (n=7). As one participant (Participant 8, pg.60). have b And then as soon as we got into the rhythm at the end, it changed by decreasing the times that we would get together. I found the last three months of this program to be kind of a waste. They were, cuz they were once a month and them. It seemed like people had moved on. They wer Participant 6, pg. 16 The routine of the ¡Viva Bien! program was discussed d uring the interviews, as thirteen participants (n=13) commented it helped them feel more accou ntable to each other, as they learned what the program leaders and participants expected of them during the two year intervention. A couple of participants commented that they felt looked up to during the program, and wanted to be seen as role models for o ther participants. Further, seven participants (n=7 ) suggested that the continuity in the stress management and social support helped facilitate good self management b ehaviors even when they were not at the actual VB meetings. Participant 29, p g. 26

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66 Conversely, when the program ended several of the participants (n=6) reported that it was harder to keep up self management behaviors, with one participant stating Three of the participants reported being considerably depressed when the program was over. Participant 20, pg. 30 went to the wayside you know? But then I had to get myself together and say, r you. They taught you to do all the good that you need to do. And you need to continue Participant 20, pg. 20 The theme of consistenc y and routine was present when the participants expressed the importance of self management behaviors. For example, physical activity routines and consistency around having access to healthy foods, health care, and social support groups were widespread th emes throughout the interviews. The Concept of Self Efficacy Self estions that inquired about her confidence and perceived ability to manage diabetes through the primary behaviors of me dication adherence and A1c monitoring, diet, and physical activ ity. In addition, each participant was asked what they feel a healthy individual looks like, and whether or not she, herself, feels that she is healthy. The intention behind this question was to better understand the context of health as the participants viewed it. The efficacy, and are therefore discussed in this section as they negatively or positively contributed to the concept of perceived self efficacy. Two themes emerged as negatively influencing sel f

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67 efficacy for T2DM self management: denial and depression. The themes of increased self management behaviors that came from learning new skills and increasing one knowledge and t he sense of collective efficacy emerged as positive ly influencing self efficacy for T2DM disease management. Thematic results for self effi cacy are presented in Figure 4.2 Figure 4.2 : Thematic Findings For Self Efficacy Definition of Healthy The majority of the participants (n=23) commented that if an indivi dual is then she is confident that she can carry out good self management behaviors toward managing T2DM. This definition of healthy, as either positive or negative was indicative self efficacy ; whereas being healthy means being confident you can do healthy things, and when you do them it reinforces your confidence.

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68 that I and nobody wanted to go to Diamond Head, And I said, you know what, of myself Being healthy Participant 17, pgs. 39, 41 Many of the participants (n=9) reported that they feel healthy individuals are generally happy and have a positive attitu de in life and suggested that they feel attitude anything, well happy people. Participant 27, pg. 20 themse Participant 12, pg. 13 There were several other common indicators of health and how healthy individuals are perceived, which participants spoke of. A few of the participants (n=4) said that being skinny is not considered healthy in Latin culture. Another common response for a healthy person is an individual who is educated (n=5), and a few participants (n=4) alluded that they felt if one was taking care of herself (and managing her diabetes), even when they have a chronic disease or comorbid conditions, then they are healthy. Another indicator of being healthy, as discussed later in this section as it relates to increased self management, includes wearing nice clothes, going to the salon, and getting out of the house.

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69 he house, you are Participant 19, pg. 18 Participant 31, pg. 27 He (son) has his disease under control, but when you have your disease under Participant 22, pg. 40 Denial Nine of the participants (n=9) commented that they or others they know who have T2DM are in, or were previously in, denial of their condition; believing that they are not truly sick or when they found out they were sick they did not want to change behaviors to help manage the disease. This sense of denial, therefore, was seen as negati ve in the relation to self efficacy for many o f the participants. t Participant 13, pg. 38 lan, or he supporting each other has been a real problem Participant 5, pgs. 4 5 There is literature to support an expectation of altruism is common in Latinas who are viewed as the matria rchs of the family (Mouldon M, Melkus GD, Cagganello, 2006; Oomen JS Owen LJ Suggs; 1999; Lipton RB, Losey LM, Giachello A, Mendez J, Girotti, 1998). Denial seemed to be a predecessor to depression for some of the women who, after accepting that they had T2DM, became depressed when they did not feel they

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70 could manage it effectively. Ten of the participants (n=10) spoke about the confidence they had in managing their disease when they finally accepted their disease and began to learn about it through educ ation and increased knowledg e. The interaction between knowledge and acceptance led to a change in behavior which contributed to a sense of increased self efficacy for several participants. Prior to accepting that they had T2DM, several participants sugge regardless of whether or not they could make changes to improve their health. say I need to get up and try to figu Participant 2, pg. 16 A s they began to accept their disease, they watched and learned through others who were in similar health states and who had similar lives; learning and changing their own behaviors throug h vicarious experiences that influenced their own self efficacy. Depression Feelings of Feelings of depression reduced self efficacy for a large numbe r of participants (n=11). Several participants shared how they had struggled throughout life with bouts of depression, and many considered their mental health providers a primary care giver (n=5). Several participants suggested that their ongoing depression contributed initially to how they viewed their diagnosis and management of T2DM. your food, and your food charts, e you, because first of all your heart being diabetic. So yea, that what I would say that would be the best time to get people on the right Participant 28, pg. 46

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71 Depression was exp ressed by several particip ants as influencing their bel iefs about diabetes and the confidence they had to manage their disease. Several participants suggested depression masked their disease, thereby hindering what was needed to manage it. Several participants commented that partic ipation in ¡Viva Bien! helped bring them out of a depressive state, and gave them new skills to help manage diabetes and depression. Further, participants suggested that involvement in ¡Viva Bien! encouraged them to make behavior changes and to participate consistently throughout leaders. Increased Knowledge and Self Management Behaviors Eight participants (n=8) suggested an increase in knowledge of self management behavi ors increased perceptions of self efficacy to manage their T2DM and take better care of their health. Several of the participants commented that they learned new skills from watching other participants in the ¡Viva Bien! program, suggesting that it was imp ortant to observe other Latinas doing behaviors successfully, which helped increase their own self efficacy to believe that behavior change was possible for themselves. (the VB Participant 2, pg. 31 ance also emerged as a theme in relation to self efficacy for self management behaviors with several of the participants (n=5) observing that when they take better care of themselves, including wearing make up, dressing nicely, and having their hair done, they feel more capable of managing their disease and feel more empowered to take care of their health.

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72 to do Participant 22, pg. 18 Participants (n=7) who reported they did not have to ask for permission from their husbands or partners to participate in self management behaviors (e. g., attending the ¡Viva Bien! program, attending community physical activity and recreation classes, cooking healthy meals for the entire family), had more feelings of empowerment to successfully carry out self management behaviors. Several of these same p articipants also suggested that they felt more confiden t to do additional self management behaviors, including trying new class es, seeking out more health resources, and sharing their knowledge with others who have diabetes. me, that I deserved, I asked permission for everything from him. I knew he come. el better, because the especially for me for the rest, who knows one learns things, one learns how to live. For me when I talk to peo ple like you Participant 22, pg. 16 17 Participants (n=7) who felt they have more self efficacy to carry out self management behaviors were more apt to see diabetes and other health conditions (including depression) in terms of problem solving ways to treat their health conditions, with less focus on causes of the medical condition or ailment. causes some of my depression and Participant 5, pg. 17 blem that I have. Participant 8, pg. 27

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73 Participants suggested that the incre ase in self management behaviors was related to learning new skills and increased knowledge that helped increase self efficacy in this Latina population Finding s suggest that the increase in knowledge could be more essential for increasing self efficacy in Latinas who may not be aware of the importance of self management behaviors because of cultural biases. Collective Efficacy When the participants were asked about their confidence and ability to manage their disease, most of the p articipants spoke abou t a sense of collective efficacy with regard to how confident they felt about being able to make changes toward managing their disease when they felt a part of a similar group. Participants expressed a sense of collective efficacy that they felt when they participated in community and cultural activities although many of them commented that they had not previously thought about the significance of being part of a group until they had participated in ¡Viva Bien!. support group) We were all united because we wanted to improve our health, that helped me a lot to be more open, to have more self Participant 8, pg. 36 Participant 3, pg. 6 Four participants out of the total (n=33) specifically commented that they feel their ability to manage their disea se is more individualistic, and dependent on their behaviors, even when they also spoke to the importance of family and community. Participant 2, pg. 9 Participant 21, pg. 27

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74 The concept of collective efficacy was pervasive throughout the interviews, as the participants spoke to their sense of being part of their family, community, and culture as a Latin a. One participant also spoke about the sense of collective efficacy over individualism for Latinos in general, and voiced concern over feeling that Latinos are viewed differently than non Latinos. nds of people. People who believ e in an individual perspective, and people who have a collectivist perspective. In the care for each other that at we all (Latinos) experience. Like being followed in a museum. Like the whole way that we get treated by the polic Participant 20, pg. 25 This sense of collective efficacy throughout the interviews speaks to the concept participation in the ¡Viva Bien! program. The expectations in the ¡Viva Bien! program were given g reat consideration by the participants as many viewed this role as a continuation of care giving to the other program participants, and as part of their role of care giver in the community, just as it had been for their parents. have to ask if you could go in the fridge. Everybody feeds you. And of course just get in trouble with your mom and dad, yo u got in trouble with the whole Participant 31, pg. 18 Participants frequently spoke about how they would try and help other program participants during the program, regardless of whether o r not these problems were related to self management of T2DM.

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75 The Concept of Social Support The s ocial support sources of influence examined in this study included family, health care, community, and culture. Participants were asked to clarify their sta tement s regarding social support sources of influence that are important to them when they think about family, health care, community, and culture Clarificat ion probes proved useful to elicit the specific aspects of each source of social support and what was of importan ce to them in those areas. An important finding was that knowledge and awareness was found in each domain of social support, as discussed in greater detail below. Additional t hematic results for each social support level of influence are di scussed in this section. Social support themes are presented in Figure 4.3 Figure 4.3 : Thematic Findings For Social Support

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76 Family Themes health as it relates to both current and historic health behaviors and disease influence your he large num ber of the participants spoke of their primary focus on others as the primary care giver in the home (n=11), noting that this is considered both a good and bad thing. The role of care giver is one who instills knowledge and awareness, or sabidura which instills wisdom to the family. The theme of being a primary c are giver was the most repeated theme in the area of family social support. Participants expressed having an expectation of trust in the family with regard to health matters, including having the support needed to manage their health effectively; namely, f amily is protective of health. Further, the notion of reciprocation was brought up by several participants as being a good thing that further encourages healthy behaviors by both giving social support and receiving social support; notably, both are to be expected in Latina culture. However, int erview findings suggest that participants felt that it was often easier to give support than to receive support from others. Sharing of wisdom, or sabidura with family and friends was often spoke to with regard to that came from wanting to care for others by helping them gain awareness too, about their own disease. Many of the participants spoke about how their family members and friends also suffered from diabetes, and how they as care givers felt it was their responsibility to share knowledge and learned awareness to help others management in a positive light, with one part icipant commenting that even though her granddaughter

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77 favorable: Participant 21, pg. 9 Participant 28, pg. 44 Seven participants (n=7) commented that there are several unhealthy behaviors (e.g., poor diet, smoking, no physical activity) in their home environment, which negatively influence their self management behaviors. Other participants (n=3) commented that even when family is suppor tive in one way, such as tangible support through helping do chores and reminders to take medication or blood sugar levels, they may also be unsupportive in other ways. For example, the foods family members may choose to bring in to the home can frequently be unhealthy, and what little physical activity family members offer to do (e.g., occasional walks after work, infrequent opportunities and willingness to exercise together on a regular basis) with the participant can be discouraging at times. Participant 28, pg. 32 One participant spoke to the extreme lack of support she has at home with her mother and siblin gs, commenting that when she makes healthy foods her mother encourages the other family members not though she, the mother, has not tried the food because it was food not made the using the traditional methods or ingredients. just look at Participant 8, pg. 19

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78 Two participants commented that they feel social support from the family is more important when you get older. Partic ipant 28, pg. 37 Several participants (n=5) also discussed the support their husband or partners give them and how it could be both positive and negative at times. different Participant 30, pg. 46 Three of the participants noted that their husbands do no t support them eating healthier foods, and want them to prepare foods a certain way. Other participants (n=4) feel that they have no support from their husband or partner. The theme of denial may also factor into lack of support from family members. Sever al participants commented that loved ones were also in denial about their own disease; a finding that may have social support implications given family members who are in denial of their own disease may be unable to provide support, further undermining sel f management and self efficacy. Further, three participants reported that they have some, but not sufficient or Participants were also asked to discuss their source of family social support when they were growing up as it pertained to their health. About half of the participants reported a healthy childhood, and about half reported having an unhealthy childhood. Similarly, several participants reported fruits and vegetables being a part of their diet growing up, whereas several repo rted that fruits and ve getables were limited throughout

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79 childhood primarily due to financial constraints including not having enough money to buy them Health Care Themes do exploration of social support in the area of health care. This question le d the health care social support discussion for each of the 33 interviews, and the participants were probed to explain types of and access to health care as well as costs and resour ces for health care. of individuals who had Kaiser Permanente insurance (n=23) commented that they did like their primary physician, however a large concern with their physician vis its was that there was not enough time to talk with him or her as the allocated visit time was usually no more than 20 minutes per encounter. Poor communication with physicians was a concern of three Kaiser Permanente provider participants, who felt that t heir provider did not understand them and their needs. They, like they say, they give you the me dicine, and if you want to take it, you Participant 16, pg. 19 Eight o f the participants commented they feel the most support from their physicians when they are patient, good listeners, and understand their needs. The theme of having a doctor who was a good listener and who shared relevant, understandable information was the most repeated theme in the area of health care social support. Further, participants spoke about the importance of having a physician that could be trusted to help instill knowledge and increase awareness about disease self management.

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80 Participant 5, pg. 1 od doctor somebody who can see you as a person and Participant 21, pg. 2 Several participants feel that the alternative care they have access to, including massage, chiropractors, and other physicians (generally located in Mexico) are supportive of their health. Spanish. I explain in depth about everything that I am feeling and how I feel. Participant 25, pg. 3 Home remedie s were mentioned by six of the participants as being supportive of overall health management as they informed th eir view of health care One health remedy was brought up by four of the participants (n=4) as a method their mother or grandmother used to help fight fevers when they were young: vinegar and baking soda. And she would tie it around my head with a rag and she would put some of that on the top of my head and my feet and my hands. Participant 33, pg. 6 Five of the participants reported not having any health insurance growing up, and health treatments were done at home by the parents or family members. an we had to have a fever for like over a 100 for three days, or whatever, before our parents would take us. So, I learned a lot of medicines from my mother and a lot of techniques of how, r oil. And I still Participant 16, pg. 41 Community Themes Interview questions regarding community resources and social support were support

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81 organizations, businesses, or institutions that they participated in, including: church (n=6), gyms or recreation centers (n=5), and peer groups (n=3) that they woul d meet with out in the community as being common activities that helped support their health and self management of T2DM through shared knowledge and stories. Having a sense of collective efficacy through participation in community activities was mentioned several times and participants spoke to an increased awareness and acceptance toward their disease that came from learning from other women who they could identify with. Weather (n=4) and transportation (n=5) were freq uent concerns when going out in to th e community to attend activities. One woman reported that she had recently gotten a treadmill for her to walk on when the weather was poor. Four participants commented that they felt a lack of knowledge around availability of community resources and the ty pe of community resources (e.g., educational classes, exercise programs) that were available to them prior to participating in ¡Viva Bien!. You just do it, and you just have Participant 17, pg. 51 52 However, there were a couple of participants who also voiced that even though they are aware of community organizations and activities in the community that are available to them (sometimes for free) they did not attend or try them out. would take me and I would pick them up. Of course, it never occurred to me to go Participant 22, pg. 14 Several participants commen ted that once they participated in ¡Viva Bien! they felt more confident to seek out community services and resources One participant commented that she does not feel a part of her community, primarily due to language

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82 barriers and her neighborhood demogra phics. In addition, the notion of not feeling accepted came out during the interviews for a couple of the other participants. Participant 20, pg. 28 In addition, a few participants (n=5) commented that they feel discrimination is still prevalent in their comm unities. Three participants brought up the concept of stigma, Par ticipant 17, pg. 29 Nine of the participants commented that they identify with other diabetics when they meet them in the community at health programs or classes. The theme of meeting and identifying with other individuals in the community, who have simil ar health issues and lives, was the most repeated theme in the area of community social support. understand you. Again, all people that went to ¡Viva Bien!, they all had diabetes. So Participant 3, pg. 24 Cultural Themes Five of the participants commented that as L atina women they are expected to stay at home, cook, and have babies; cultural expectations that were instilled as children, and informed their development and knowledge base growing up as Latinas.

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83 They believe that they should just stay home. And not go out and exercise. Staying in their house, the dietary t have supper ready for change it even a little bit, she usually gets a lot of flack from her (man). But what eight and ten hours a day, but she sits at home and cooks and does very little as far as activity. tside influence to get them to do that. But, yet a lot of them will do it in secrecy without Participant 12, pg. 11 Participant 18, pg. 20 Two of the participants commented that Latinas are not supposed to exercise, and referenced their culture as encouraging women not to put their legs up. Participant 21, pg. 15 The primary issue around cultural support for nine of the participants is the concept of diet, and expectations around food, specifically around cooking from scratch and being ex pected to use certain recipes that are unhealthy. The theme of dietary expectations was the most repeated theme in the area of cultural social support. family and all that t to do thin g traditions, even if the traditions may Participant 28, pg. 15 A few (n=4) of the participants also discussed that food is expected to be presented to family, friends, and guests in general, and the over emphasis of food in the culture can be viewed both as a positive and negative support to health; positive in that this cultural expectation encourages social engagement, but negative in that it encourages or supports eating of unhealthy foods.

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84 orien ted, not taking time to exercise, not monitoring your food, especially during cultural events, during family things, you know we do hav e a lot of family Participant 24, pg. 9 In regard to the dietary component of the ¡Viva Bien! program, several of the participants commented that having a Latina dietician, who was part of the study team, was beneficial as she, the dietician, would bring Latin inspired recipes and foods for the participants to try. For example, instead of using the traditio nal lard to make refried bean, the participants were taught to use healthier olive or canola oil, and instead of eating red meat the participants were encouraged to experiment with chicken and fish in place of the more traditional red meats commonly used i n Latin American cooking. With the diet being a major concern for most of the participants, the influence of culture on meal preparation was a common theme that emerged. One woman commented that having a cultural flavor to food preparation made the diet co mponent of the program more successful for her. way, where they were doing both languages. That was really an A+ for me. Cause if we would have done it the Anglo way and we would have just had rice and potatoes, green beans, a piece of meat, a piece of wheat bread. We would have still learned, but with us having our green chilies, our salsa, our chips the way we can eat them or nopales, which I would like to cook but I have forgotten Participant 19, pg. 43 Another cultural support domain that a f ew participants discussed (n=3) was reliance on participant s spoke to convenient foods, for example, as being a p otential factor toward laziness. Several of the participants (n=5) also discussed the positive aspect of their culture with regard to social activities and expectations.

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85 buy is already made. No, everything I do is in my house. Only on Sundays, and that sometimes we go out to eat or we buy food. I d o everything because no, so Participant 25, pg. 6 have lot music. We love dancing. We do a lot of that, we do a lot of celebrating like for Just being a Participant 4, pgs. 13 14 Further, the cultural foundations of many home remedies was also spoken to as being a positive support to many of the participants ( n=6). A number of the participants (n=8) spoke about the changing culture with regard to health and health behaviors, and their role in this change. Participant 16, pg. 23 T he older generation of Latinas is seeing a cultural shift in expectations around exercise, diet, communications (with physicians, health care providers, and family), and education. use like I said, I Participant 6, pg.15 nd of course some of the food that we eat are probably loaded with fat. They I think they lacked the education. I think that was the bottom line, they lacked Participant 28, pg. 14 e could have learned to eat the right foods before, before we got sick, chicken, wheat bread, cause you get tired of it. I know with my culture we like to fry a lot of foods Participant 19, pg. 9

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86 The shift in cultural expectations is important as it relates to the changing needs of Latinas who have T2DM; namely, it may be important to di stinguish generational preferences and expectations when developing behavior change interventions. Two participants commented that their culture was different from many other Latinas they met, and that there were differences between the various Hispanic c ultures that were significant depending on where the other person was from (Central or South America compared to the U.S.) or whether they spoke Spanish or no t; namely, not all erican Hispanics and Participant 6, pg. 14 Of the study participants, only one woman commented that for her a language barri er was a significant reason that she did not do more activities in the community, suggesting that language negatively influenced social support, which thereby negatively influenced her self management of T2DM directly. a gym, about four, five streets from my Who am I going to talk to? Who can I relate to? Participant 25, pg. 14 However, upon participation in ¡Viva Bien! the same woman repor ted that she started to do more for herself, even though she viewed herself as having a language barrier. routine. And later, well, to learn how to eat, to learn how to cook, t o learn to communicate with each other and others about diseases, right. Because many times complications come with diabetes and we ignore them. We think they are happening with them, what they are feeling and all that, well, already for one too, Participant 25, pg. 16 Ten participants reported that faith in God was import ant in their cultural traditions, and man y participants view their faith as having a significant, positive impact

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87 on their health as a support system. Participant s expressed spirituality and faith as an intrinsic social support system, which many participants in ¡Viva Bien! shared with each other And that star Participant 14, pg. 47 Along these same lines, the concept of fatali sm was also brought up three of the participants (n=3) even when support systems, especially th eir faith, are in place. probably some of the things that have prohibited my health behaviors fr om getting better Participant 30, pg. 30 Another common theme around cultural support was the importance of being around other Latinas who had similar health concerns and family life. This sense of familism was important to the participants. Six participants commented that identifying with other Latinas helped build trust, faster, and helped them feel more supported and open to learning new ways of accepting and managing their T2DM. xcited because I thought that the fact that I was going to be around Participant 4, pg. 17 Similarly, twelve participants also expressed the importance of feeling a part of a group who understood and supported each other and how the collective effort of the group helped them feel empowered to make changes for themselves as the learned from others and became more aware of how they could better manage their disease T he importa nce of familism was also preval ent as participants commented that their health does not just affect them, but also that of their families, extended families, and

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88 friends. For example, the sense of accountability that many of the participants had to each o ther and their ¡Viva Bien! support groups illustrate d the importance of collective efficacy to the participants. The participants spoke about the importance of sharing skills and knowledge that helped them achieve behaviors at the individual and group lev el. The sense of collective efficacy was pervasive throughout the interviews as participants expressed the importance of familism in their culture an d working together to achieve desired outcome s P otential P athways Between Concepts P otential p athways be tween self management, self efficacy, and social support are explored next in this chapter, including interpretation of how identified themes are related to one another. Taken together, the identified, categorized themes represent M y analysis of themes enabled a theoretical assessment of relationships among concepts as they were moderated by linking themes, which influenced the strength between the concepts and a llowed me to draw interpretations about sources of social support and self efficacy in relat ion to self management P otential p athways that may inform the relationship between the three concepts of social support, self efficacy, and self management are suggested by similar themes found in multiple concepts and w h ere the mor e frequent themes were reporte d throughout the coding process. T hemes identified as most important by participants within each concept suggest s potential pathways that should be explored between the three concepts. Interpretation of study pathways informe d my understanding of lived experiences with T2DM. P reviously discussed social support thematic results will be reviewed as they relate to self efficacy themes, including an explanation of the potential pathways between social support and se lf efficacy. Next, the themes that constitute social support will be examined as they may affect self management of

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89 disease. Finally, t he themes that constitute self efficacy will be explored as they inform potential pathways to self management. P otential P athways: Social Support and Self Efficacy The themes that were present in both social support and self efficacy concepts were knowledge and collective efficacy. Findings suggest that increased knowledge and collective efficacy, which are informed by social support, fostered individual self efficacy for the participants, which in turn encouraged additional social support through increased knowledge and collective efficacy as shown in Figure 4.4 The reciprocity of the implied pathway between social s upport and self efficacy suggests a complexity of the interrelatedness of the two concepts, and denotes a cyclical dynamic between social support and self efficacy. Figure 4.4 : Potential Pathways Between Social Support A nd Self Efficacy The theme of kn owledge was relevant to both social support and self efficacy. Participants expressed the importance of being the primary care giver at home (responsible for modeling and instilling knowledge), learning from her physician and providers, identifying and sh aring with other diabetics, and learning from oth er Latinas and other cultures; namely, knowledge having an increased awareness was present in all sources of social su pport as influencing participant self ef ficacy. Increased knowledge le d to an increase i n self efficacy for the participa nts who believed that behavior change could be made through the exercise of mastery experiences, vicarious experiences, social persuasion, and affective states. This effect is not surprising given ef ficacy. However, I identified a distinction between learned knowledge and applied knowledge. Learned knowledge denotes information the Knowledge and Collective Efficacy Self Efficacy Social Support

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90 participant became aware of, whereas applied knowledge was taking the learned information and applying it to a behavior or action. For example, the participants frequently spoke to how they learned self management skills from their physician, peers, and educational materials, however these lessons were not always applied to actual behaviors until they saw others model the behaviors successfully and/or successfully practiced the behaviors themselves; namely, mastery and vicarious experiences helped increase self efficacy. The increase in applied knowledge influenced the participants to now know what to do. This increase in k nowledge about how to engage in new behaviors, such as increasing physical activity, changing dietary methods of cooking, and finding alternative social support systems in the community, suggested that the participants felt newly efficacious to try new beh aviors. The change in knowledge around diabetes and prevention of disease was also discussed by several participants as it impacts new generations of family members, and how they feel there is a cultural shift in Latin cultural expectations and health beha viors, specifically in the area of being more aware of disease prevention and health promotion. This shift in Latin cultural expectations resonated with the participants who spoke to how this change in new generations of Latinas motivated them to change th eir own health behaviors and helped to increase their own self efficacy to make positive changes for themselves. collective efficacy found through learning and identifying with others throughout the community (among Latinas, with oth er diabetics, and between other non Hispanic cultures) who share similar concerns, and have similar medical conditions. C ollective efficacy encompassed cultural expectations, norms, familism, and in fluenced the

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91 or should not do certain behaviors such as eat certain foods, do certain exercises, or take medications. Further, t efficacy as confidence to start and com plete a behavior or task is built up over time through mastery and vicarious experiences, social persuasion, and affective states or feelings are often experienced at the community level through participation in activities with others (Bandura, 1997) Thi s study suggests that a feeling of greater self efficacy may be strongly influenced by a perception of greater collective efficacy for Latinas ; a normative effect. This notion of learning from others, and in different environments such as through community settings, organizational activities, and educational sessions, was repeated throughout the interviews, with most of the participants relating it to their cultural identity as a Latina and the importance of socializing. For example, the collective efficac y discovered in ¡Viva Bien! fostered expectations and encouraged success toward desired outcomes for the participants. Social support was positively influenced through increased collective efficacy through ¡Viva Bien! as participants were influenced by th capabilities as a whole, and were thereby influenced as individuals. Findings suggest that for Latinas the influence of collective efficacy may increase the level of self efficacy and may be important to increase self management of T2DM Participant 10, pg. 12 nd, like the diabetes, or whatever, it makes of women have shared those same symptoms with you, so you kind of feel like you might be able to partake of some of the thi Participant 6, pg. 11

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92 off that I was. And I thought, you know here I am feeling sorry for myself, and so and she has such a greater prob lem. But then when I saw them, how they were overweight and they really could do and doing more things. More physical activities, swimming, in other words, I made it a part of my Participant 12, pg. 9 The nature of the relationship between themes of culture and family as they influence self efficacy of t he participants is explored below. At the cultural level, participants expressed how traditional expectations are that they stay at home, cook, and take care of the children, and that exercise is not something that they were encouraged to do. In addition, there are expectations around availability of types of foods and meal preparations that are considered important in Latin culture. These aspects of cultural social support and non support influence beliefs and perceptions that participants have regarding how capable they are of engaging in self management. Further, cultural influences impact the knowledge, attitudes, and beliefs participants have around certain behaviors. As many participants commented, the role of care giver was a common family theme. The participants often spoke to how they feel both obligated and/or pressured to take care of others, as well as find great satisfaction in takin g care of others. This expectation of care giver roles in the family and in the community and culture may also influence the levels of perceived social support. This finding is similar to other research findings that show how role expectations for women, in general, can lead to strain and overload (del Mar Garcia Calvente, Mateo Rodriguez, and Maroto Navarro, 2004 ; Burnette, 1999; Hurtado, 1995) The expectation of care giver role may therefore negatively influence participant self efficacy toward managing T2DM. For example, when participants spoke to the role

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93 of care giver, regardless of viewing it positively or negatively, the notion of giving to others first was pervasive throughout the interviews. Several participants commented during their interviews that they often chose to do for others before doing for themselves, acknowledging that they are not taking care of themselves first. Several participants said that once they realized they had some control over T2DM, and had learned how to better manage their disease, they realized that they were doing the best thing for their families by taking care of themselves first. This theme c ame out prominently in the interviews; namely, participants became comfortable in accepting support from others and focused more on themselves. Participants learned how to ask for and receive support. The perception of collective ef fica cy also surfaced from participation in the ¡Viva Bien! study, as the women felt accountable to others to achieve individual and group outcomes. P articipants in the ¡Viva Bien! study began to value taking care of themselves as they cared for others; namely, when participants had learned to build confidence and skills as a group, individual self efficacy was promoted at home and influenced the way the participants acted as care givers. One woman once she learned how to manage her disease, she started to change her beliefs around how much control she could have over her disease. This change in perspective suggested an increase in personal expectations of her behaviors and thereby self efficacy, w hich was similar for many of the participants; once they gained the kn owledge and support from others they felt more empowered Feeling empowered enabled participants to change. In addition, there seemed to be a shift in how participants viewed taking ca re of themselves from when they started the ¡Viva Bien! program until when it ended two years later. For example, a few of the participants mentioned how at the beginning of the program it was difficult to attend the weekly meetings. Once they realized wh at the

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94 program was about, and how it could benefit them, they really wanted, and eventually needed, to attend. Several participants also spoke to how learning information about diabetes through the social support they received helped them realize that they could make necessary changes to improve their health and manage their T2DM more effectively. Participant, 10, pg. 48 matter what. And I probably would have tried, I did finally later, cuz I told my husband Participant 2, pg. 40 confidence, my self esteem went way up, a lot concerned about that because that is what self esteem does to a person. Participant 8, pg. 39 H aving increased knowledge about T2DM self management not only helped the study participants feel accepted, make healthy changes, and believe that they could make necessary changes, it encouraged them to feel that as care givers in society they had to give the same care to others that they were now giving to themselves, as a role model. The concept of care giver seemed to shift from primarily giving to others, to learning to take better care of themself, with participants speaking to how they brought their n ew knowledge and information back to their families and communities in a greater capacity. Increased education improved self efficacy for many ¡Viva Bien! participants. inferi as a matter of fact, I kind of felt kind of looked up to. Cause showed me that, that I had to be a role model. Not only for my family, but for other people Participant 20, pgs. 28 29

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95 H ealth care as a source of social support was not found to be as significant of a contributing factor to self efficacy with few comments from participants. However, the importance of having a needs and interests was found to be an important factor, which influenced the efficacy beliefs. Through the support offered by the physician and other health care provide rs, participants had more confidence to make changes when they felt empowered to help make those decisions. Although there does not seem to be a direct influence on self efficacy of the patient at the health care level, thematic results suggests that succe ssful communication is key regarding health care information that is relevant and understood by the patients. Summary of Social Support and Self Efficacy Participants expressed the importance of two the mes that influenced the potential pathway between so cial support and self efficacy: knowledge and collective efficacy. These two concepts emerged as important elements in establishing the relationship between social support and self efficacy, and helped influence the exercise of self efficacy. Participants awareness knowledge found throu gh the four social support sources but primarily as gained through ¡Viva Bien!. Participants expressed an increased confidence and self efficacy that came from knowledge, and a new aw areness, to make needed behavior changes to take better care of their T2DM and health, in general. Explanatory interpretation reveals that social persuasion and vicarious experiences in areas of social support, especially that of family and culture, are i mportant considerations when exercising self efficacy to self manage T2DM, and may operate both at the individual and collective levels. Increased social support promoted both knowledge and collective efficacy, which promoted self efficacy that allowed

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96 par ticipants to better fulfill both their self management of disease, and still be care giver for the family. Participants expressed how family and cultural expectations influenced their perceptions, attitudes, knowledge and beliefs around appropriate behavi ors, both positively and negatively. For example, in addition to being the care giver to the family, participants expressed the extended familial role and expectations as they impact community and cultural social support; namely, the notion of giving to o thers first was pervasive. Only when the participant recognized having some control over her disease, did she change her focus from others first to putting herself first (or equal to) others; recognizing that if she took better care of herself, including allowing herself to be supported, she could then continue to take good care of others. Potential Pathways: Social Support and Self Management The themes relevant to both social support and self management were collective efficacy, awareness, and continuit y/routine. Initial interpretat ion suggests that the four sources of social support directly influenced self management of T2DM. Themes that were coded as negatively or positively related to self managemen t were related to all four sources of social suppo rt: family, health care, community, and culture. Explanation of these relationships suggests that social support can help facilitate or hinder self management of T2DM. Potential pathways exist between social support and self m anagement as shown in Figure 4.5

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97 Figure 4.5 : Potential Pathways Between Social S upport A nd Self Management The greatest associations between themes were with family social support and cultural social support as they influenced self management of T2DM for the participants. T his finding is not surprising given the significance of family and culture to Latinas. What was surprising, however, was the significance of cultural attributes that could be viewed both positively and negatively given varied expectations and norms of beha viors (e.g., diet and cooking methods, physical activity, and stress management practices ) These findings are further described below. Family Social Support Source Family social support influence d participant both positively and negatively self managemen t in the areas of stress (stressful situations in the home, including family dynamics and pressure to be the care giver), healthy eating hab its (family expectations to have certain foods prepared in a certain manner and to be offered to family and guests a bundantly), financial concerns (family financial constraints due to poor wages, Collective Efficacy Awareness Continuity Collective Efficacy Awareness Contin uity Collective Efficacy Awareness Continuity Collective Efficacy Awareness Continuity

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98 living on a fixed income, or poor job prospects; sometimes due to health concerns and age), physical activity (inability to perform certain physical activities or behaviors due to poor health or lack of time due to family expectations), knowledge (information and education encouraged increased self management to participants and their families) and continuity (family routines, including walking after dinner, and other family act ivities that were consistent). The participants expressed a comprehensive view of care giving that expanded beyond the immediate family to the community Literature shows that women in general are care givers to their families however there is some resear ch that suggests that the care giver role is more prominent for Latinas than for non Latina women ( Phillips Torres de Ardon Komnenich et al 2000; Clark and Huttlinger 1998; John Resendiz and De Vargas, 1997 ). The care giver role was seen as both a benefit and hindrance to self managemen t for many of the participants. For example, participants frequently spoke about how helping others made them feel good about themse lves, something they valued, but also how giving to others placed their ow n needs se cond The notion of the mother being the heart of the family, as care giver, and how this expectation informs family member expectations of the mother may also influence how the concept of denial is sustained for some of the participants; namely, when the participant feels the pressure to be the care giver, and the family has that expectation, the family may also be in denial denial of the participant to recognize her dis of the illness. The importance of understanding the significance of the care giver role for Latinas may be more pronounced compared to non Latina American women given these cultural expectations by Latinos.

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99 H ealth Care Social Support Source The influence of h ealth care sources of social support on self management were present in themes of stress (e.g ., not having access to alternative methods of care such as massage and not having enough time with the physici an to talk about issues ) and consistency ( e.g., having to switch providers ). Most of the participants, regardless of whether they were from Kaiser Permanente or the Salud Family Health Center, expressed satisfaction with t heir health care providers. Parti cipants expressed how important good communications is regarding health care social support as it can influence self management of T2DM; namely, a good physician is one who listens, is patient, and takes time to understand the patient and her history. Co mmunity Social Support Source Perceptions of social support from the community and how those influenced self management were present in themes of stress (discrimination, racism, and language barriers in the community), physical activity (local recreation c enters and parks fostered exer cise), knowledge (increased awareness to self management behaviors through education and information in the media and through community organizations, institutions, and activities), and continuity (availability of community re sources that encouraged self management behaviors, including famers markets, parks, free health clinics, diabetes workshops, and social support groups). S o me of the participants expressed loneliness even when they participated in community activities, s uch as going to church, visiting recreation centers, and attending celebrations or gatherings, which was a surprising finding. This finding suggests that being lonely, even when active in the community, may foster depression that negatively influences self management behaviors Participants expressed the importance of both connecting with others who had T2DM and who were Latinas like them. A shared

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100 connectedness of both having similar health concerns and understanding the cultural underpinnings of being a L atina seemed to resonate with many of the participants who expressed the significance of the ¡Viva Bien! study. Cultural Social Support Source Cultural sources of social support influenced participant views around self management in the areas of medicati on (beliefs that medication is bad for oneself and others), stress (cultural expectations and pressures), healthy eating habits (cultural around importance of family engagement and social activities). There was a negative relationship between cultural expectations and self management behaviors for many of the participants w ho expressed concern over changing behaviors that were considered culturally the norm. For example, when the participants learned how to cook using healthier cooking methods than what they had learned when they were children, several of the participants ex pressed feelings of guilt and insufficiency that they then felt from family and friends. An interesting finding in this area was around the issue of convenience that many of the participants spoke to as a negative aspect of American culture; namely, the U. S. culture is very hectic, fast paced, and encourages convenient, fast foods. Many of the participants spoke of the importance of cooking from scratch, and not purchasing convenient foods for their families, which in turn may be an opportunity for research ers and clinicians to explore regarding how to build on cultural expectations around cooking from scratch. Family based interventions and programs could be tailored to Latin diets, which would modify existing recipes and food preparation strategies and m ethods, and focus on increasing family knowledge around using more healthful ingredients and recipes.

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101 Another example of cultural dissonance from the ¡Viva Bien! study was during the stress management component of the study meetings, as several women expre ssed initially being uncomfortable doing yoga as they did not know if it was either culturally or spiritually, given their faith, appropriate to engage in. Ultimately, some of the ¡Viva Bien! participants opted not to do the stress management component at all, and used the time to walk, meditate, or talk with other participants who were also uncomfortable doing the stress management activity. The use of meditation as a form of stress management seemed relevant to all of the study participants, and may be a n important part of the Latina lifestyle worth considering as a contributor to managing stress. Summary of Social Support and Self Management Three overarching themes characterize these results about potential pathways between social support and self mana gement: (1) collective efficacy, (2) awareness, and (3) continuity/routine. The meaning of family, and a perceived collective efficacy, was recognized by participants in the home, within community, and through their culture as having significan ce and wa s brought up several times throughout the interviews with regard to how social s upport groups often become proxy for an extended family and helped reduce loneliness. This sense of collective efficacy is different from family, health care, community or cult ural social support Namely, collectiv e efforts and cultural beliefs at the group level seemed to help participants feel more confident in their own self management behaviors and also encouraged accountability to others. The collective perspective of Latin a culture (e.g. familism, care giver roles) helps to explain the need for collective efficacy for Latinas which seemed to be a process not an event. There was a sense of wisdom, or sabidura that came from a sense of collective empowerment For example, p articipants expressed the significance of the feeling part

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102 of an extended family and a sense of empowerment that came with feeling a part of a group, and the collective efficacy that ¡Viva Bien! instilled in them which helped them with their self managem ent behaviors that they picked my name and the three of us, we all Participant 1, pg. 32 The theme of awareness around self management behaviors was repeated throughou t the interviews and was tied to social support. Awareness was often gained through community and cultural levels of influence when the individual began to understand and accept what needed to be done for them to improve their disease management through t he form of education, information, and learned self management behaviors. These pathways appeared to foster additional social support influence and had a synergistic effect toward increased self management behaviors for the participants. Participant 6, pg. 13 The concept of continuity and routine was associated positively with a self participant was too keen on. For example, the continuity of social support offered through the ¡Viva Bie n! program helped build the behavioral systems that could be sustained through on going support and routines. Partic ipant 6, pg. 6 teaches you that you are wrong, that you have to gauge yourself, that you have Participant 9, pg. 30

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103 In summary, explanation o f these relationships supports research that shows sources of social support can help facilitate or hinder self management of T2DM and that collective efficacy, increased knowledge, and continuity of services and resources is especially important for Lat inas. Potential Pa thways: Self Efficacy and Self Management The themes that were present in both self efficacy and self management concepts were depression and denial. Finding s suggest that there is a reciprocal relationship between self efficacy and se lf management, which may be influenced by depression and denial, as shown in the figure below (Figure 4.6 ). Figure 4.6 : Potential Pathways Between Self Effi cacy A nd Self Management In general, depression was negatively related to self efficacy and self management. For several participants depression was an important factor in their ability to successfully manage their disease and was negative in relation self efficacy. The relationship between self efficacy and self management was inhibited by dep ression. Participants reported that when depressed, they felt less capable of doing things such as exercise, eating well, or taking their medications on time. Participants expressed decrease d feelings of confidence around m anaging their T2DM when depressed As previously discussed, denial was seen as a negative influence on self efficacy for many of the participants, with several participants commenting that they were in denial about having T2DM some for extended periods of time. Several participants sug gested that they either did not want to accept the diagnosis of T2DM nor did they want to tell their families that they had the disease as to not worry them as they were Self Efficacy Self Management Depression and Denial

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104 matriarch of the family and expected to be the care giver This finding suggests that there are cultural biases that influence self efficacy, and may lead to barriers to self management. When in the state of denial, most participants suggested that they did nothing to manage their diabetes, and many worry that this denial and delay may have made their disease worse in the long term than it needed to be. Summary of Self Efficacy and Self Management The themes of depression and denial, especially when combined, hinder self efficacy for some of the participants who could not or did not wa nt to improve self management behaviors. Several participants spoke about how getting through their depression and coming to terms with their disease empowered them to learn new skills around managing their T2DM, and increased their beliefs that they could effectively manage their condition. The participants suggested that this increase in knowledge empowered them, and others they know, to have different behaviors, and increased self efficacy or beliefs that they could do different behaviors to help manage their T2DM, and improve their health. Participant 10, pg. 19 for me, when they talked about diabetes, I anything to control it, knowing that I was already taking medicine for diabetes. So support. And when I entered Viva Bien, it changed everything for me, Participant 16, pg. 17 Two positive influences on self efficacy are increased self management behaviors and collective efficacy. This unexpected finding suggests that increased self management behaviors and increased collective efficacy increased self efficacy for

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105 many of the participants in a reciprocal relationship; namely, seeing other ¡Viva Bien! participants successfully make changes in a group settin g helped other participants believe that they were able to make successful changes too. then I even though I was on a ten foot ladder you know doing the ceiling and stuff, I got it done. And it lo know I can do more than what I did Participant 23, pg. 26 Similarly, many of the participants reported increased social support at home when they had increased self efficacy around managing their T2DM. felt Participant 15, pg. 16 This finding supports a reciprocal relationship between self efficacy and self management ; namely, increased self efficacy increases self management and increased s elf management increases self efficacy. In summary, the influence of depression and denial on the relationship between self efficacy and self management were found to negatively influence self management behavioral outcomes for the participants. However, w hen participants were able to get out of their depression and overcame feelings of denial regarding their disease, self management behaviors increased due to an interest in learning how to better manage their disease, which in turn f ostered increase self e fficacy.

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106 CHAPTER V RESULTS AND INTERPRETATION OF AGE, ACCULTURATION AND LEVEL OF EDUCATION The complexity of t hematic findings according to age, acculturation, and level of education categories are explored in this chapter as they contributed negati vely or positively to the concept s and interrelatedness of self management self efficacy, and social support. Similar to the last chapter, results are grouped as themes under each concept, including self management, self efficacy, and social support. For example, similarities and differences of self management themes discussed in chapter IV were further examined according to participant age using the three age categories ( 42 51, 52 61, and 62 70). Next, self management themes were examined according to pa rticipant acculturation level, using the three acculturation categories (M/S Latino, Mixed Latino/Anglo, and M/S Anglo) Finally, s elf management themes were examined according to participant level of education using the three education categories (< high school, high school, > high school). The concepts of self efficacy and social sup port follow in a similar manner with an examination of the influence of participant categories as they relate to age, acculturation and level of education. The last section of this chapter summarizes similarities and differences in the relationship of age, acculturation and level of education according to the three concepts of self management, self efficacy, and social support to help interpret study findings. Self Managem ent and Age Thematic results for the concept of self management and age ca tegory are presented in Figure 5.1

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107 Figure 5.1 : Thematic Findings For Self Management And Age Participants in the youngest age range of 42 51 (n=9) had similar thematic findings r egarding dietary self management behaviors primarily with regard to how eating a healthy diet was frequently a challenge for them. Many of the participants in this age range also expressed stress as an on going challenge that they struggled with that inf luenced their self management behaviors (6/9). Seven participants between the ages of 42 51 (7/9) expressed how they feel the younger generation of Latinas view diet and physical activity behaviors differently than they did when they were the same age, su ggesting that there has been a cultural shift in how younger Latinas view health more proactively. In addition, six of the nine participants in the age range of 42 51 commented di etary habits, suggesting the importance of prevention.

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108 at a younger age I think than I ever was. So hopefully, she can do something about that prevention. So I think maybe their o, maybe that will finally get into Participant 31, pg. 31 Other thematic areas in self management that participants in the age range of 42 51 commonly spoke to were around the shift in physical activity and how they were enjoying it more and were encouraged by their children to participate more in exercising. A few of the participants (3/9) spoke specifically to how their children encouraged them to participate at recreation centers with them, but one younger partici pant also was a repeated theme throughout the interviews regardless of age. These younger participants had more quotes regarding self management of their disease as it im pacted and disease prevention in their children, and was likely due to the fact that many of these women had children still living at home. The importance of sharing k nowledge and wisdom toward improved family health seemed to be an important motivator for the own self management of T2DM. Participants in the middle age range of 52 61 had several common themes in the area of self management, including a gre ater number of comments around the importance of physical activity (9/12). In addition, several participants spoke to how nted that they often had significant pain issues that interfered with daily exercise and activity routines. Several of the middle aged participants (6/12) also discussed medication has being bad for them and for others, with several stating they were tryi ng to wean off of their medications.

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109 Participant 5, pg.9 Other common themes in the area of self management for participants aged 52 61 were around the importance of passing information and knowledge to their children to increase good self management behaviors, with 5/12 participants mentioning the importance of prevention. Several middle aged participants (7/12) also commented on the valu e of support systems with other Latinas who have diabetes as being a good influence on how they manage their disease, including comments regarding the importance of the continuity of social support from participation in the ¡Viva Bien! program. Participant s in the higher age range (ages 62 70 n=12 ) had common themes in the area of self management with social support seeming more important for the higher aged participants than for the younger participants. Several participants (8/12) expressed the desire an d need for more social support to help them manage their disease successfully as they got older. The types of support participants mentioned included references to tangible, emotional, and informational support. Similar to the middle aged participant gro up, p articipants in this higher age range also spoke to physical limitations now that they were older, which decreased the amount of physical activity and exercise they could do on a regular basis. Several higher aged participants (5/12) also expressed fee lings of loneliness, which negatively influenced self management by not feeling they had the support they needed to successfully manage their disease. Some of the participants (4/12) in the older age range also spoke to the importance of continuing cultur al traditions with regard to dietary practices, which was seen both positively, as food customs encouraged social activities, and negatively, given

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110 how the traditional Latin foods are often expected at gatherings and prepared using unhealthy ingredients. Participant 30, pg. 29 The influence of knowledge and education was not as prevalent in the qu otes with the older aged participants, and more significance was placed on the value of on going social support. Similarities between self management and the younger age (42 51) and middle age (52 61) categories included the importance of physical activit y, prevention, and influencing the health of others. This finding was not surprising given the number of participants who expressed a shift in how younger generations of Latinas viewed health differently than they had when they were younger. Participants expressed the need to increase awareness of T2DM prevention in younger Latinas to help empower new generations to be more proactive in their health. Participants in the middle (52 61) and higher age (62 70) categories expressed similar concerns over physi cal limitations as it in fluenced their self management. The older participants also expressed more concern over consistency of social support, which was a finding in the older age category (62 70) for the concepts of self efficacy and social support as we ll. This finding illuminates the importance of social support for older Latinas who have T2DM. Self Management and Acculturation Thematic results for the concept of self management and acculturation cate gory are presented in Figure 5.2

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111 Figu re 5.2 : The matic Findings For Self Management And Acculturation Participants (n=9) in the lower acculturation category of most or somewhat Latino (M/S Latino) had several common themes regarding self management of their T2DM. Several participants who were less accul turated (5/9) spoke about concerns they had over money and finances as it impacts self management behaviors. For example, paying for medicine, health care, and food were frequent concerns mentioned during the interviews for the less acculturated participan ts. Several of the lower acculturated participants (5/9) also expressed how they were not encouraged to exercise when they were growing up, and that this made it harder for them t o exercise or do physical activity on a daily basis as part of their self ma nagement. The concept of family was very prevalent in the comments regarding self management, including the importance of extended family being involved in self management. For example, several participants spoke about how they were more apt to carry out self management behaviors (e.g., exercise, eating health fully and monitoring their blood sugars) when they were encouraged by family and loved ones to do so. The notion of collective efficacy from

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112 participation in the ¡Viva Bien! program was also suggest ed from less acculturated participants; namely, participants felt more empowered to manage their disease more g was the group meetings. I really enjoyed ever ything that we did in there, and how we spoke to each other and helped each other. But I think the best thing was the whole, the whole meeting. It was structured in such a way exercise, but all the things that (the physical activity teacher) brought us, she just kind of moved us, kept moving us, kept moving us in the direction we needed to th at surprised me t he group is what made the difference with everything. We Participant 5, pg. 22 & 25 The middle acculturated participants (Latino/Anglo) also had some thematic simila rities. It is worth noting that only six of the total sample (n=33) reported that they were a mix of both Latino and Anglo, and most participants in the study (n=18) reported that they were more acculturated (most or somewhat Anglo) according to the ARSMA II scale It may be that participants in the study wanted to identify more with one or the other (Latino or Anglo) for purpose of feeling part of a group. Interestingly, the mid acculturated participants reported more comments throughout the interviews on the importance of cooking from scratch (4/6). The importance of food preparation and types of traditional foods were common theme s for the middle acculturated participants, and healthy eating habits were a frequent concern as they impacted self management. The mid acculturated participants may have discussed scratch cooking more than the other two acculturation groups as they see the value of cooking traditional foods as an important part of their culture to retain as they become more acculturated Other s imilarities regarding self management of T2DM were around increasing knowledge to manage their disease.

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113 e t necessarily make the changes. I am aware that I am making choi ces now, a s opposed t o not Participant 6, pg. 12 Several of the participants (4/6) expressed value in the education and knowledge they gained by participating in the ¡Viva Bien! program, commenting that the collective effort of the group was important as they felt supported in each component of the program (diet, physical activity, stress management and social support), which made their efforts to improve self management easier as they were learning together and encouraging each other (collec tive efficacy) to tackle multiple self management skills suggesting behavior change at a group level. The more acculturated participants (n=18), most or somewhat Anglo according to the ARSMA II scale had similar themes throughout the interview in the area of self management. The importance of continuity and routine (e.g., regular physical activity, on going social support activities), was a common theme that participants (6/18) spoke to with regard to how they managed their T2DM. t groups, but the way ¡Viva Bien! was presented to us, it was easier for me. It seemed like it was easier to make friends with the staff, get to know them. It was a routine more, so you got to know people more, you got as easier to open up to people when you Participant 3, pg. 22 In addition, several more acculturated participants (8/18) also spoke to the importance of social support in their lives as it impacts self management (e.g., tangible suppo rt from loved ones and family to help do physical tasks, informational support from physicians, care givers, and educational programs such as ¡Viva Bien!, and emotional support as gained through close social support networks). It is worth noting that four of these individuals spoke to having social support as a need they had as a Latina; meeting other Latinas who had similar health conditions and life circumstances helped them build

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114 trust more easi ly and manage their disease better when they felt they were working together to positively change their health behaviors. In addition, four other s spoke about social support influencing their self management. However, these individuals appeared to view the influence of social support more individually, and less c ollectively, with comments around how they needed and valued social support to learn new self management skills, but that it was ultimately up to them as individuals to manage their disease successfully. Nonetheless, the issue of trust was discussed when these participants, who expressed more individualism, commented that they were responsible for self management; with three out of four suggesting that the collective support of the ¡Viva Bien! group helped them feel more empowered to manage their disease m ore proactively. Both individual and collective efficacy seemed to resonate within the group of more acculturated participants. The collective efficacy of the ¡Viva Bien! group for all study participants, regardless of acculturation category seemed to be nefit the increased self management behaviors of both the participants who viewed their health more indi vidually or more collectively. The importance of family in Latina culture underscores this finding; namely, familism and the care giver role are suppor ted through the col lective efficacy of a group and fosters empowerment to manage disease more proactively. Self Management and Level of Education Thematic results for the concept of self management and level of education cate gory are presented in Figure 5 .3

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115 Figure 5.3 : Thematic Findings For Self Management And Education Participants who had less than a high school degree (n = 9) had similar thematic findings in the area of self management regarding needing more positive support systems to help them ma nage their disease better, with a couple of the participants commenting that they felt little or no support from their husbands at home. Participant 13, pg. 38 For example, both of these participants spoke about how it was at first difficult to attend the ¡Viva Bien! program meetings as they did not feel that their husbands supported them to participate for themselves, suggesting that they were made to f eel selfish for wanting to attend. In addition, one of these participants talked about how she initially prepared two meals for dinner; one for her and one for her husband, but she eventually stopped doing this. In addition, three of the less educated part icipants also spoke to the importance of routine for them with regard to self management of T2DM, commenting that when they were able to get into a consistent routine around physical

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116 activity and eating a healthy diet it became easier to maintain the behav iors. Further, five of these participants suggested that the routine of ¡Viva Bien! was an important factor in helping the women feel that they could manage their disease more effectively as it became an expectation that they had for themselves, as well ha s others had for them (i.e., family members, program staff, participants). Several high school educated participants (4/10) discussed patient provider relationships and the importance of having a doctor who listened and cared about partnering in health ca re decisions. Three of the participants also spoke about health care information they received from television programs, such as Dr. Oz which helped them learn how to effectively manage their disease. Another theme for a few (3/10) of the participants who graduated from high school included stress, specifically around how they felt they were often rushing around and had hectic, busy schedules. important to do things that are relaxing. Like just going to the movies, or not just Parti cipant 10, pg. 31 Several of the high school educated participants (6/10) also spoke to how taking care of others was something that gave them support to take better care of themselves, suggesting a reciprocal relationship. Fourteen of the study partici pants had a higher education (some college, college graduate, or post graduate). About half (6/14) of the higher educated participants suggested that eating a healthy diet was one of the more difficult areas of self management for them and that they strugg led to maintain a healthy diet routine. A few of the participants (4/14) who commented that as young children they were encouraged not to speak Spanish, or not to speak it out in public, as it would be looked down upon. In addition, a few participants (3

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117 education. Half of the higher educated participants (7/14) also commented that they viewed taking care of and helping ot hers as a means to taking care of themselves, as they give and receive support and keep busy doing so. (in the U.S.) Til we got Participant 2, pg. 34 There was a similar finding of the importance of taking care of others in both the high school educated and higher educated categories. However, educatio n and self management did not have other salient relationships. The reciprocal relationship that many of the participants discussed with regard to caring for others and caring for themselves, suggests an important insight that may help Latinas be more proa ctive in self management of T2DM. The value Latinas place on caring for others can be reinforced by encouraging proactive self management behaviors; namely, p articipants may self manage their diseas e better as they desire to be able to h elp others. Self E fficacy and Age Thematic results for the concept of self efficacy and age cate gory are presented in Figure 5.4

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118 Figure 5.4 : Thematic Findings For Self Efficacy And Age Several participants in the age range of 42 51 expressed having depression as a negati ve influence on their self efficacy (6/9). The theme of awareness was also prevalent in many of the interviews of younger participants (4/9) who spoke about how they became aware and accepting of their disease, which helped build confidence for them to mak e changes and learn what they needed to do to stay healthy. that you can get it. It should be easier to prevent it because then you can watch tter not indulge so much in sweets and all Participant 12, pg. 16 Further, participants suggested that until they accepted that they had diabetes, nts discussed different situations that helped build awareness for them, with the two most prevalent including (i) having a family member who became very ill or died from diabetes and (ii) participating in the ¡Viva Bien! program, which presented understan dable information in multiple ways, in several areas (diet, physical activity, stress management, social

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119 support), over a two year period and helped teach how to take steps to manage T2DM effectively. The concept of awareness seemed to be fostered in many of the participants through multiple pathways, including increased knowledge and self management behaviors, and also supported by the fact that many participants had been depressed, but had changed their perception of their disease and began to manage it differently. Depressed patients expressed how their depressive state held them back from believing they could manage their disease successfully, and that staying in a state of denial helped support the lack of awareness they had around needing to make beha vior change. Pa rticipants in the age range of 42 51 also commented that they encouraged their children to have better health behaviors than they had. In addition many of the participants suggested that they were supported by their children to sustain hea lthy behaviors (e.g., exercise regularly, eat a healthier diet, stay more positive, take better care of their health). This dynamic, reciprocal relationship between the mothers and their children suggested increased self efficacy for both the mother and he r children to have improved health behaviors, and may have an influence over depression and/or denial of disease Seven of the participants in the middle age range of 52 61 (n=12) expressed having issues of denial, which negatively influenced self efficacy when it came to recognizing and accepting their T2DM Similar to the younger participants, several participants expressed how being in denial of their disease stifled their self efficacy to self management of the disease, suggesting that if they had bee n more aware of their disease and that it could be managed then they would currently be in better health. Parti cipant 4, pg. 20

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120 Several middle age range participants expressed how the younger generation of Latinas are more aware of health issues (n=6), and many of these participants (n=5) expressed the significance of prevention of T2DM and how important it is to teach prevention to younger generations. This finding suggests that there may be a shift in how younger Latinas define what a healthy person should look like. Further, participants in the middle age range suggested that younger Latinas have more knowledge than they did when they were younger An increased knowledge and awareness may help younger Latinas may be able to develop more self efficacy to have better health behaviors. Participants in the older age range of 62 70 had themes emerge in the areas of depression and loneliness, suggesting that these two factors negatively influenced participant self efficacy to manage their disease, as they were less likely to want to be proactive in improving their health, and were less motivated to want to take care of themselves. Participant 13, pg. 32 This finding suggests that the concept of loneliness impacted how the participants viewed the im por tance of self efficacy. A few participants commented that themselves when they were lonely and depressed However, several of the older participants spoke about how i ncreased social support and the collective efficacy that came from participation in the ¡Viva Bien! program influenced their perception of self efficacy and, thereby increased self management behaviors. Several of the older participants (7/12) spoke about how their participation in the ¡Viva Bien! program helped them learn new skills but, more importantly, helped build social support bonds with other participants. The social support component of the program was noted as the most

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121 important component of the p rogram as it influenced their self efficacy to improve self management behaviors and helped reduce depression for many of the participants. There was a similar ity between the younger age (42 51) and middle age (52 61) categories rega rding knowledge as it influenced self efficacy. This finding supports the importance of knowledge for Latinas with T2DM, as knowledge increases awareness, and accentuates the role of education that must be culturally appropriate and factors in health literacy levels. Further, d enial or depression was present regard less of age category. This finding highlights the importance of u nderstandin g where denial or depression are present in Latinas with T2DM to help health care providers and researchers alike develop education, care p ractices and interventions that addre ss these critical issues toward increased self efficacy. Self Efficacy and Acculturation Thematic results for the concept of self efficacy and acculturation cate gory are presented in Figure 5.5 Figure 5.5 : Themati c Findings For Self Efficacy And Acculturation

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122 Several common themes emerged from the less acculturated participants (M/S Latino), with 5/9 participants expressing an increase in self confidence and self efficacy in the area of self management due to their participation in the ¡Viva Bien! program, with several of the participants (4/9) commenting that they had been in denial about their disease prior to participating in the program. Interestingly, some of the lower acculturated participants (4/9) spoke abo ut how individuals with negative attitudes were frequently sick, or made themselves sick by being negative. Participant 8, pg. 24 few less acculturated participants (3/9), and the participants spoke to how it made them feel better to fix themselves up (e.g. get hair done, go to the salon, dress up nicely), and that it improved their confidence when they took the time to spend time on their appearance. In addition, several of these participants (4/9) also felt that being skinny was viewed as unhealthy and could be viewed as a negative characteristic for a Latina. Participant 22, pg. 37 One participant seemed to struggle with her perception of weight as it influenced her self efficacy. This participant viewed her weight, which was slightly overweight, as bad and considered herself to be unhealthy, and suggested she did a poor job of self management of her T2DM. However, thi s same participant also spoke of her sister, who was also overweight, as being healthy because she was positive, and looked good. Another participant commented similarly that sh overweight, but then subsequently made another comment that suggested being skinny was ugly. These findings suggest varied perceptions regarding what a healthy weight is and how it is viewed by some of the less accultura ted participants.

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123 Several mixed Latino/Anglo participants commented that they struggled with manage their depression, suggesting it was an on going battle and influenc ed their self efficacy to manage their disease successfully. It is also worth noting that generational changes were discussed frequently within the mixed Latino/Anglo participants (4/6) regarding self management, as the participants spoke about how there w as an increase in knowledge that was being transferred to younger generations of Latinas, and that there was a new awareness around prevention of disease that seemed to positively influence self efficacy in the younger Latinas. Further, mixed Latino/Anglo participants also spoke to the importance of increased knowledge and education as it influenced their self management behaviors, and suggested that the more information they learned about how to manage their disease, the more confident they were that they could have improved health behaviors and problem solve Participant 30, pg. 56 The more acculturated participants, those who identified as most or somewhat Anglo (n=18), had similar themes regarding self efficacy in the area of collective efficacy (7/18) and the importance of learning from other Latinas and other diabetics. This f inding suggests that the vicarious exp eriences, or role modeling, of learning from others is important to helping individuals apply learned knowledge, so that they believe they can make the suggested changes to health behaviors. Further, several participants (5/18) discussed how they valued t he ¡Viva Bien! program and suggested that they all learned new skills within multiple areas (diet, physical activity, stress management, and social support), and that it was a collective effort, across many topics, that helped them

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124 successfully change thei r behaviors. Participants also expressed concern when they were no longer involved in group activities that supported on going health behaviors. I was stressed, and I was Participant 30, pg. 55 These comments suggest the importance of collective efficacy across mu ltiple topic areas, which may increase the improvement of self efficacy. A few of the more acculturated participants (3/18) also spoke to how the ¡Viva Bien! program would have been good for other women, and not just for Latinas, with two of the women als o commenting that they do not necessarily feel a strong attachment to being Latina. Further, more acculturated participants also commented more frequently that a healthy person is one who educated (5/18), suggesting that they see an association with educat ion and health. There was a similar finding between self efficacy and acculturation for the mixed Latino/Anglo and M/S Anglo category regarding the importance of education. This finding further supports the importance of knowledge and education as they r elate to self efficacy. Findings also suggest the importance of collective efficacy, and learning with and from other Latinas, including younger generations. There were no other similarities between acculturation categories and self efficacy in this study population. Self Efficacy and Level of Education Thematic results for the concept of self efficacy and level of education cate gory are presented in Figure 5.6

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125 Figure 5.6 : Thematic Findings For Self Efficacy And Level Of Education Several of the partic ipants who had less than a high school degree (4/9), reported more comments around how they felt they had lower self efficacy or self confidence before participating in the ¡Viva Bien! program, with comments suggesting that they believed they were capable of making behavior changes that they previously did not think possible. In addition, a few of the participants (3/9) also suggested that they felt empowered or more confident upon completion of the program to know what they needed to help them sustain the changes they had made (e.g., support systems that needed to be in place, daily routines). Along this same theme, three of the lower when they started feeling better abou t themselves. In addition, a few of the participants (3/9) who were less educated discussed how they had become depressed upon learning that they had T2DM, and five of the participants also commented that they were in denial about their health condition prior to participation in the ¡Viva Bien! program. The theme of denial and depression was

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126 prevalent across the interviews regardless of level of education, however the less educated participants suggested that self efficacy increased more (compared to t he other two education levels) upon participation in the ¡Viva Bien! program, with more comments suggesting they felt more confidence to manage their disease now that they had learned that it was manageable. Several of the participants had suggested that t hey had been in denial prior to ¡Viva Bien! because they had felt their T2DM was unmanageable and that it could not be controlled. still feel good. You know how people keep I de al with it now (since participation in ¡Viva Bien!) Participant 11, pg. 19 Several participants who graduated from high school (n=10) had similar themes in the area of self efficacy including the importance of knowledge and learning new self management behaviors (6/10), with several of the participants (5/10) speaking about how they shared what they learned with their family members in order to help the health of their loved ones. about diabetes has done to her (sister), she has diabetes for 18 years, 19 years of I tell you, it has already absorbed her United S olive, not even canola, pur e lard with the years that she has of having diabetes Participant 8, pg. 54 Many participants who were high school educated (6/10) also expressed the importance of family involvement in their self management, with comments that suggested the participants felt empowered when their family members were supportive

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127 and engaged in their lives and health care decisions. These finding suggests an increased self efficacy when participants felt family support to carry out self management behaviors. In addition, the high school educated participants placed more emphasis than the two other education cohorts on sharing their knowledge and behaviors with family and loved ones. The higher educated participants (some college, college graduate, or post graduate) also had similar themes throughout the interviews. A few of the se par ticipants (4/14) who were higher educated made comments around problem solving and how staying positive helped them feel better about their health (6/14). what I l Participant 14, pg. 32 Several participants expressed how they tried to help themselves by thinking about new ways to improve their health behaviors, and were mindful of what had worked in the past (suggesting the importance of ro utines). Several of the higher educated participants (5/14) also suggested they were proud of themselves for taking care of their diabetes, and learning to manage their disease more effectively with comments regarding how they felt good about positive hea lth changes, and improvements in self management behaviors. In addition, several participants (4/14) commented that when they learned how they compared physically to others who were in worse health, it put things into a new perspective and helped them real ize how they could be worse; namely, it helped them feel that they could make changes to take even better care of themselves. Findings suggest that higher educated participants had less depression and denial, with comments supporting that increased educati on helps increase self efficacy. Regardless of education, there was an underlying theme of increased self efficacy that came from increased knowledge, and sharing of that knowledge with

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128 others, around managing their T2DM. However, participants in the high er educated category expressed more comments regarding higher self efficacy (e.g., proud o f self, able to problem solve) and the importance of education. This finding supports the use of lay health leaders, or promotoras with higher education to help fac ilitate group interventions and programs that foster increased individual and collective efficacy toward improved self management behaviors of T2DM Social Support and Age Thematic results for the concept of social support and age catego ry are presented i n Figure 5.7. Figure 5.7 : Thematic Findings For Social Support And Age Participants in the age range of 42 51 expressed similar themes throughout the interviews with regard to the influence of sources of social support. Participants in the younger age r ange expressed concern over unhealthy behaviors, primarily dietary concerns that they experienced at home with family members (e.g., expectations to cook certain foods in certain ways), and discussed the importance of being a care giver to

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129 their families ( many of the participants had children living with them at home), and the expectations they had to carry out this role. always expected to always have good food, Mexican food. Anybody comes to your house, you want Participant 32, pg. 27 In addition, several of the younger participants (6/9) spoke about how they feel they are more aware of important health i nformation and behaviors that they want to share with their family members, with two participants expressing that they felt their family members knew very little about good dietary habits. Findings suggest that the younger participants placed more emphasis on family expectations, and family social support was given greater consideration for the younger cohort. Participants (5/12) in the middle age range of 52 61 expressed similar concerns as the younger participants with regard to the importance of influen ce and responsibility to the younger generation of Latinos. For example, several participants in the middle age cohort spoke to how important it is to be supportive and share health information with their children to encourage better health habits and, ul timately, support better health outcomes. Some of the participants in this age range discussed expectations at home to prepare foods certain ways, however many of the participants did not have children living with them and it did not seem to be as signifi cant as an issue as it was for the younger participants. Some of the middle age range participants (4/12) also discussed how they value the support of other Latinas with similar health conditions and how they like learning from each other. Several of the participants (7/12) in the older age range of 62 70 expressed the importance of social support activities and participation in community organizations, with

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130 some of the participants (4/12) commenting that they were lonely, or knew others who were lonely. get to sociali Participant 31, pg. 23 Two of the participants in the ol der age range also stated that they felt they needed more social support as they got older. In addition, several participants (5/12) in the older age range also discussed the importance of having a good relationship with their health care provider, includi ng how they needed more support from their health care providers, frequently because they had more health ailments. Participant 28, pg. 28 A few of the participants (4/12) commented that they liked the ¡Viva Bien! program as it was like an exten ded family for them. There were similar findings in the younger (42 51) and middle age (52 61) categories regarding the importance of younger generations of Latinas and shared knowledge. Interestingly, the importance of social support sources varied acco rding to age category, with younger participants (42 51) expressing the importance of family social support over others sources of social support; a finding that is not surprising as many of these participants had family members and children at home that t hey cared for. The middle aged participants (52 61) also had a similar finding regarding the importance of social support, but suggested that cultural social support was most important to them. Similar to the other participants, social support was them e for participants in the older

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131 category (62 70) who expressed the importance of community and health care social support sources. This finding is not surprising given that the older participants expressed more loneliness and health ailments, which would s peak to the need for more support from community and health care providers. Social Support and Acculturation Thematic results for the concept of social support and acculturation ca tegory are presented in Figure 5.8 Figure 5.8 : Thematic Findings For So cial Support And Acculturation The lower acculturated participants (most or somewhat Latino), expressed the importance of family and faith in God, with several of the participants speaking about how their faith is a type of support for them (6/9). Family w as a primary support for participants w ho were less acculturated. S everal participants commented that it was nice to feel ac cepted in a community and encouraged in a group setting (collective efficacy) when they participated in the ¡Viva Bien! study (4/9) Participants also

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132 expressed the important of getting to know other Lati nas who shared similar cultural values. Participant 4, pg. 17 The concept of family was also mentioned in a few of the interviews with regard to feeling a part of a family in the ¡Viva Bien! program. Two lower acculturated participants commented that they had a hard time ad apting culturally, and another two commented that they struggled with loneliness. The mixed Latino/Anglo participants had common themes in the social support area regarding the importance of socialization, regardless of what type of social support, with 4 /6 participants discussing how they value social activities in general. In addition, a few mixed Latino/Anglo participants (3/6) also spoke about how they value their role as care giver to their families and communities at large. a lot of fulfillment to me Participant 4, pg. 13 An interesting finding from the mixed Latino/Anglo participants was that a couple of the participants (2/6) spoke about cultural differences bet ween Mexican Americans and Mexicans, commenting that there were differences between the two with regard to how they view social support. The more acculturated participants also had similar themes in the area of social support sources with several of the participants (8/18) speaking to the importance of continuity of social support from family, community, and culture; namely, ongoing support systems were important.

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133 And then having the same people, they came and talked, all the differ ent sections, was great. To see, to build the bond with everybody. I think that was great. There was consistency, because you got to know, it was like a family. I think that for me, when it (¡Viva Bien) was over it was like ok, it was like a chapter in your life. It was al you have to look at it as a positive It Participant 17, pg. 57 Several participants (7/18) who were more acculturated also spoke to the value in reaching out to and helping others, and the significance of a collective effort through programs like ¡Viva Bien! (collective efficacy), which made it easier for them to manage their disease and take better care of themselves. Similarities between the three acculturation categories included the importance of family social support and collective efforts; namely, collective efficacy to support each other to make positive behavior changes to manage their T2DM. Participants regardless of accult uration category expressed the importance of collective efficacy in sources of social support to help them manage their T2DM. This finding supports the role collective efficacy for increasing self efficacy for Latinas. Social Support and Level of Educa tion Thematic results for the concept of social support and level of education categ ory are presented in Figure 5.9

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134 Figure 5.9 : Thematic Findings For Social Support And Level Of Education The majority of lower educated participants (8/9) discussed the i mportance of learning from other Latinas and/or other diabetics, and three of the participants commented that they enjoyed learning English when their primary language was Spanish. at one having all this illness and you find out that you are not, and you get to talk to Participant 24, pg. 27 In addition, lower educated participants also spoke to how they valued the opportunity to meet with others in a social support setting, and for some (4/9) it was the first time they had participated in a group setting, such as the ¡Viva Bien! program. Common themes of the high school educated participants (n=10), included having a strong faith that gave them support (6/10) to better manage their T2DM. In addition, several of the participants who graduated from high school also spoke about the importance of social time (5/6) through f amily and community activities.

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135 went today and it was really nice cause I knew a lot of people there and it was kinds of things really Participant 28, pg. 36 A few of the participants (3/10) also mentioned how they grew up in neighborhoods with many Latinos, which supported their family and family values and how this was important to them The higher e ducated participants (some college, college graduate, post graduate), had several participants (7/14) who spoke about helping take care of others as a means of supporting themselves to take better care of themselves. The notion of helping others, and keep ing busy doing it, was a common theme for higher educated participants. A few of the higher educated participants (3/14) also spoke about how they had felt discriminated against and how racism had a ffected them over their lives, including how they felt a sense of accountability to their families to be successful. Participant 30, pg. 30 Another re occurring theme was laziness, with some of the women (5/14) suggesting that they feel their culture does not support their health as Latinos are often sedentary. mind is ex ercising, running a marathon, running the bikes, doing this and doing that. And I think for us, I think because we have so much to do at home, and Participant 19, pg. 36 Several of the higher educated participants (5/14) also spoke about how they felt it was easier to build trust with other Latinas, and expressed a sense of collective

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136 efficacy that helped them feel supported when they got to know other Latinas with similar health an d family situations. Similarities between the levels of education categories included the importance of learning from, supporting and being supported by, and building trust with other Latinas. This finding supports t he sense of collectivism that appears vital to bu ilding self efficacy in Latinas regardless of level of education. Summary of Age, Acculturation, and Level of Education W ith regard to age, findings suggests that the younger participants were more successful doing physical activity than the other two age cohorts, primarily due to having fewer health ailments and more support at home from family members. However, the younger participants also expressed more stress, which seemed to be related to caregiving expectations and pressures at home (i. e., due to having children who still lived in the home). Participants who were younger made more comments around fostering healthy behaviors in their children, and also suggested that they received reciprocation from their children who often encouraged th em to take better care of themselves. The younger participants also made more comments on self management of their T2DM, and seemed to be more aware of how the y viewed health differently than they had when they were a child. In comparison, middle aged participants spoke about the importance of prevention for their children and how they also felt a responsibility to foster heal thy behaviors in their family. In addition, t he se participants expressed having more physical limitations than the young er aged p articipants. M iddle aged participants also recognized that the younger generation of Latinas may be more aware of good health behaviors. The middle aged participants also expressed the importance of social support from other Latinas, and had more comments regarding denial of their disease. Unlike the younger

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1 37 participants, findings from the middle and older aged participants suggested that social support was more important as one gets older. Further, findings suggest that social support increases self effi cacy through collective efficacy, with several middle aged participants commenting that they valued learning from other Latinas with similar issues through the ¡Viva Bien! program. The older participants had m ore depression, loneliness, and more physical limitations These participants also expressed a greater need for social support of various types (tangible, emotional, informational) including the importance of extended families now tha t their children and other family members no longer lived with th em. The older participants also suggested that the collective efficacy generated in the ¡Viva Bien! program was important to them as it addressed their needs for increased social support, but also helped them learn from other Latinas in various areas (diet physical activity, stress management, and social support). Findings suggest that the continuity of the ¡Viva Bien! program, and the support throughout each component of the program, helped the older participants feel supported, which was most important t o them and helped them want to take better care of their health. With regard to the influence of acculturation, findings suggest that the less acculturated participants have less self efficacy than the middle or more accu lturated participants, with a grea ter number of themes suggesting difficulty adapting to their newer culture, and difficulty getting into routines. The less acculturated participants, however, also had findings that support how increased self management skills can help build self efficacy, and confidence, to manage disease more effectively. The middle acculturated participants expressed comments regarding the importance of knowledge, and generational changes, than the other participants. However, the middle acculturated participants also h ad findings around the importance

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138 of traditions, such as cooking from scratch, and being the care giver who passes down traditions. There seemed to be a dichotomy for these participants who recognized differences between cultural groups, and recognized how hard it can be to remain healthy when they both want to keep with traditions and learn how to take better care of their health. Findings suggest a need for increased social support to help individuals who are learning new cultural ways, while retaining i mportant cultural traditions and values that matter to them, in order to help build trust and to share knowledge and information that is understandable and appropriate. The more acculturated participants had findings that suggested they have higher levels of self efficacy (e.g., pride, problem solving skills), which seemed to be supported by a greater appreciation of education as it informed better health practices. Further, the more acculturated participants had more positive comments around routine, soci al support activities and the importance of reaching out to others to share knowledge and learn from one another. Findings from these participants suggests that the more acculturated participants view collective efficacy as a means to increasing self effic acy in a greater capacity; namely, it helps build trust sooner, and the more sharing that individuals do, the more they learn and increase their own skills awareness, and knowledge base to help manage their T2DM better. With regard to the level of educati on, participants who had less than a high school education expressed the importance of learning from others, and valuing group activities to help learn new skills. In addition, several of these participants said they needed more support and more continuity of routines to be successful in their self management. There was also a higher level of less educated participants who expressed both depression when they learned they had T2DM, and also denial of T2DM prior to participating in ¡Viva Bien! Interestingly, several of the less educated

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139 participants also commented that they felt it was good to learn more English (many of them were monolingual Spanish speakers), and that the increased communication with English and other Latinas who had T2DM, helped them learn to manage their disease more effectively. This finding suggests that perhaps learning English increased self efficacy to improve self management of their disease. P articipants who had graduated from high school expressed more comments around knowledge an d education than the less educated participants, and also spoke more about health care and learning about health. Interestingly, the high school educated participants commented more about family and faith values tha n those educat ed at other levels, suggest ing that they wanted to improve their health, leaned on their faith to help support them, and felt responsibility to share knowledge with their family and loved ones. The higher educated participants expressed more self efficacy to change their health be haviors and spoke more frequently about how they believed in themselves, tried to stay positive about their health, and problem solved issues. These participants also expressed the importance of helping others as means to help manage their own health. Find ings suggest that the higher educated participants also placed more pressure on themselves to be successful, including having better health outcomes. not being lazy, staying positive also seemed to place more press ure on cultural expectations for some of the participants, with several speaking about how they struggled with their diets, as certain food preparations and types of foods were expected at social and family gatherings, and other comments that suggested the ir culture had both positive (strong family ties, frequent celebrations and social gatherings, extended family support), and negative attributes (worry over being lazy, language difference, racism, and general feelings that they had to do better than

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140 othe rs). This finding may warrant additional studies that helps tease out how higher educated Latinas perceive self efficacy, hence successful self management, as compared to less educated Latinas.

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141 CHAPTER VI DISCUSSION AND CONCLUSION D iscussion T here were two major finding s in my research, including having a sen se of collective efficacy and the importance of knowledge and awareness, or sabidura My findings suggest that Latinas place a greater emphasis on collective efficacy as it pos itiv ely influences self efficacy as well as knowledge and awareness, or sabidur a toward self management of T2DM. Having a sense of collective efficacy, and a shared belief that participants could make successful self mana gement of T2DM behavior changes together, also informed t he increase of individual awareness and acceptance around T2DM When a sense of collective efficacy was hi gher, participants expressed an increase in disease awareness, personal self efficacy and sel f management behaviors as the y were reinforced through social persuasion, master y of repeated activities and vicarious experiences with others. There was a sense of wisdom, or sabidur a that came from a sense of collective empowerment. Furthermore, the importance of culture and fami ly sources of social support, including having a sense of familism, was accentuated by the significance of collective efficacy as it influenced self management of T2DM in the study population; having a sense of collective efficacy as it was informed by the ir cultural beliefs and norms, fostered increased knowledge and awareness to support self managem ent of T2DM in the participants and suggests that interventions and programs aimed at increasing collective efficacy may be beneficial for Latinas to make beha vior change. In addition, an increase in knowledge and awareness was reported by participants as being important factors that positively influenced sources of social support with regard to T2DM self management.

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142 With increased knowledge and awareness, par ticipants had greater self efficacy toward specific T2DM self management behaviors and reported less denial of disease and associated depression. When depresse d and or in denial about their T 2DM, particip ants had lower perceptions of self efficacy a nd repo rted poorer self management behaviors. For many participants this finding was recursive: having a decrease in denial and depression also influenced greater acceptance and awareness of disease. The importance of collective efficacy as well as knowledge a nd awar eness, or sabidura is pervasive and may be useful in designing future research studies and programs. Theoretical Implications My findings support the use of a s ocio ecologic model (Figure 2.1) to explore social support and self efficacy in relation to the self management of T2DM by Latinas. This model enabled me to explore and operationalize the socio ecological environments that were most relevant to the study population with regard to performing daily self ma nagement of T2DM. T he relationship s between sources of social su pport as illustra ted in the socio ecologic model and self management were positively influenced efficacy to manage her disease; t he stronger the social su efficacy, and therefore better self management of disease. Literature shows that self management behaviors generally decline when interventions end, but the reasons why this occurs is not clear (Lorig and Holman, 2003; Norris a iples in my Socio Ecologic Sources Of Influence Model (Figure 2.1) to help understand the dynamic between individual behaviors and family, hea lth care, community, and cultural factors of social support influence as they may help maintain self management behaviors over time (Sallis, Owen, and Fisher, 2008). Understanding the relationships between the

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143 patient and her sources of social support may help researchers and health care providers create programs and interventions that have sustainable health outcomes even after the program or intervention ends. My findings suggest that having a sense of familism, an important value within Latino culture, supports collective efficacy that can come from f eeling a part of a family within various social support sources (e.g., family, health care, community, and culture) and is important for increasing and maintaining self manageme nt behaviors in Latinas who have T2DM The stratification of my study populati on supported this idea, which was present regardless of age, acculturation, and level of education. This finding has not been adequately explored in the literature to date for this population and may be generalizable to Latino men. In this dissertatio n, four sources of social support (family, health care, community and culture) were examined to understand their importance and inter relationships as they influence self efficacy and self management of T2DM. The comparative importance of sources of social support was evident through the thematic results with family and cultural social support being most important to the participants. Current literature suggests that individuals with T2DM perceive they have better health when they have positive social supp ort systems in place (Morrow, Haidet, Skinner, and Naik, 2008; Goodall and Halford, 1991). My findings are similar in that when individuals reported positive support at the family and cultural levels they perceived their capabilities to be greater to manag e their disease. Some research also suggests that individuals who perceive their capabilities to be slightly greater than they actually are have a greater likelihood of being successful in their actions or behaviors (Goddard, Hoy, and Woolfolk Hoy, 2004 ). However, I did not find this to be true in my study population; some participants reported how even when

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144 they felt they were capable of performing a self management behavior, frequently their health in the form of depression or a physical limitation (e .g. inability to move very well) got in the way of them performing the actions they felt they were capable of performing. The significan ce of denial and depression for the stu dy participants was an important finding as they negatively influenced self effic acy toward specific self management behaviors (e.g., eating a healthy diet, doing regular physical activity, medication adherence, and blood glucose monitoring) as well as hindered acceptance that they had the ability to take care of their T2DM. The sense of awareness that many participants spoke to upon learning to accept their T2DM and overcoming depression associated with their disease was also a surprising finding as i t influenced participants sense of collective efficacy to help others with similar situations and health as they learned to help themselves manage their disease. Specific forms of social support, including emotional, informational, appraisal, and tangible, were represented throughout the interview s Participants expressed that emotional and tangible social support came primarily from their families and culture. Interestingly, unlike other research findings that suggest nagging as a form of informational or tangible support about behaviors that can be detrimental to self management, my r esearch found the opposite. Participants did not view naggings from family and loved ones to be negative, but rather endearing. This finding suggests that for Latinas, nagging can be viewed as a type of positive social support that encourages on going self management behaviors. Not surprisingly, informational support came primarily from physicians and health care providers, and was viewed positively when participants felt they were being respec ted and listened to. Consistent with recent literature, partic ipants reported satisfaction with having a physician who understood her culture and preferred a provider

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145 who spoke Spanish. Unlike some research, my findings did not find access to health care to be a significant concern for my study population, even when the participant did not have health insurance because most of the participants had some access to health care (Beach, Gary, Price, Robinson, Gozu, Palacio et al., 2005; Smedley, Stith, and Nelson, 2003). Although many of my participants had health care ins urance through Kaiser Permanente (n=23), several of my participants were from the Salud Family Health Center (10) barriers to health care for those without health care insurance. My findings suggest that many of my participants were happy with their access to health care and their providers, regardless of whether or not they had insurance, and participants mentioned fewer structural barriers to health care generally reported in the l iterature for Latinas (e.g. inconvenient hours, little or no interpreter services, long wait lines, poor education materials). This finding was a surprise finding and leads me to question whether or not structural barriers to health care for Latinas are c hanging ; an important finding that warrants additional research. Similar to other research findings, community social support was mostly in the form of appraisal support as participants reported assistance with coping strategies and resources to help ma nage their diabetes (Langford, Bowsher, Maloney, and Lillis, 1997). Like other resear ch findings, my study found increase d c ommunity social support was positively influential on increased physical activity through the use of walking partners, utilization o f recreation and community centers for exercise, and other community activities that promote activity (Stahl, Rutten, Nutbeam, Bauman, Kannas, Abel, Luschen, Rodriquez, Vinck, and van der Zee, 2001; Giles Corti and Donovan, 2002). As evidenced by the fin dings, the theme of knowledge is present in all sources of social support as it directly influences both self efficacy and self management. At the

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146 family level, as the primary care giver to their families, participants shared knowledge with family members and see this as a very important aspect of their role in the family. Through increased knowledge about their disease, participants recognized the importance of taking care of themselves, too, in order that that they would then be able to better care for t heir families. At the health care level, participants reported the value in feeling empowered by a physician who listens and works together to identify best care practices. Participants reported the importance of having a physician who took the time to understand them as an individual and culturally. The notion of respeto, or respect, was common throughout the interviews when participants spoke about their physicians, and most participants felt they had very good doctors. However, when participants repo rted they did not have a good physician patient relationship, the primary concern was that they felt that they were not respected or understood by the provider, which undermined the information the physician or provider offered. At the community level, pa rticipants gained knowledge from others who were Latinas or diabetics through shared experiences. Community level information available through recreation and community centers and organizations also helped participants gain knowledge and find support syst ems that empowered them to learn about how to manage their diabetes more effectively. At the cultural level, participants spoke to the importance of increasing health knowledge to share with new generations and changing some of the cultural expectations t o help prevent diabetes in the future. A sense of collective efficacy at the cultural level with others who share similar values and ideas about health also supported the sharing and idea exchange that helped foster improved self management for the partic ipants. Further, participants who reported increased knowledge across the four social support sources had the greatest

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147 increase in the exercise of self efficacy, which lead to an increase in self management skills. High family and cultural social suppor t were also found to be more important than other sources of social support as related to self efficacy. Similarly to other studies, this study supports how stronger self efficacy beliefs in relation to specific self management behaviors can help maintain the management behavior. However my study also found that the influence of family and cultural social support strongly relates to how those behaviors are maintained over time; namely, even when the individual knows she is capable of doing a specific self management behavior such as cooking a healthy meal, exercising daily, and monitoring her blood sugars, she may choose not to do the behavior depending on the influence of others and/or cultural expectations. This influence of family and culture to self ef ficacy was pervasive throughout the interviews. Prior studies support the concept of self efficacy as an important mechanism to behavior change (King, Glasgow, Toobert, Strycker, Estabrooks, Osuna, and Faber, 2010; Krichbaum, Aarestad, and Buethe, 2003 ; Bandura, 1997). show a significant influence on self efficacy is a lack of or limited knowledge of self management that is present when an individual is either in denial about their disease or feels depressed. The concept of awarene ss was also present throughout the interviews as supporting the increase of knowledge and how it helped bring them out of a state of denial. Both depression and denial were themes that participants spoke to as re straining them from learning what they need ed to understand to better manage their diabetes, and served as negative influences to self efficacy. Knowledge that is facilitated through social support increases confidence and beliefs around successfully carrying out self management behaviors. For the participants, increased self efficacy was due to believing they had the information and knowledge necessary to no w know what to do

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148 Once participants accepted their disease, learned how to take care of it, and identified with others who had similar situat ions, their confidence and beliefs in their ability to make the necessary changes toward managing their T2DM significantly increased. However, when the support systems were not in place to foster the new behav ior changes, through continuity and routine, ma ny participants commented that it was harder to maintain their new behaviors and self efficacy diminished. As previously discussed I also found collective efficacy to be an important factor that needs to be considered when working with Latinas as an infl uence on the exercise of self efficacy for self management. While it is known that culture influences self efficacy through norms and beliefs (Concha, Kraviz, Chin, Kelley, Chavez, and Johnson, 2009), research to date has not explored culture as it influe nces perceptions around behavioral capabilities collectively for Latinas. My findings suggest that collective efficacy may impact self management different ly for Latinas based on specific self management behaviors (e.g. diet, physical activity, A1c monit oring and medication adherence). For example, the collective influence on physical activity was greater for my study population when the participants involvement in t he ¡Viva Bien! study as the perceived collective efficacy was supported through the four sources of efficacy development: mastery experience, vicarious experience, social persuasion and affective states (Bandura, 1986, 1997). ings support that individual efficacy may be strongly influenced by collective efficacy at the cultural and community levels, further establishing the significance of fostering self efficacy through knowledge and awareness Although they differ in the uni t of agency, both collective and individual efficacy, are grounded in similar beliefs and functions as evidenced in the ¡ Viva Bien! study; namely, the vicarious

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149 experience s and social persuasion toward the e xercise of self efficacy collectively had a sign ificant impact on the study participants. Furthermore, t hematic results found a sense of collective efficacy to be an important influence to the exercise of self efficacy and community level social support as it influenced self management. An increase in self management skills worked reciprocally as a positive influence to self and collective efficacy. In addition, t hematic findings of consistency and routine were supported as positive concepts in relation to self management as they further enabled the establishment of mastery and vicarious experiences thereby increasing self efficacy at the individual and collective levels. These relationships are interrelated, and can be figured conceptually in a triangle to show the potential pathways between social support, self efficacy, and self ma nagement as they were moderated by linking themes, which influenced the strength between the concepts. way relationship between social support a nd self efficacy, with knowledge, awareness, and collective efficacy indicating a theoretical pathway. Knowle dge, awareness, and collective efficacy increased participant self efficacy and also influenced how the participants received social support. Depression and a sense of denial about their T2 DM had a two way relationship between efficacy and self management. When depressed and/or in denial about their disease participants had lower perceptions of self efficacy and reduced self management behaviors. There was also a two way relationship between social support and sel f management. C ontinuity of social support and routine in self management behaviors were indicators of the theoretical pathway between social support and self management and were reinforced through an increas ed awareness and sense of collective efficacy Participants expressed the importance of continuity and routine to help manage their T2DM. The routine of self management behaviors and on going

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150 social support further increased social support and helped the w omen maintain their self management behaviors (Figure 6.1 ). FIGURE 6.1 : Recursive Conceptual Pathways In summary, the increase in knowledge awareness, and collective efficacy in the study participants had the greatest positive impact on increased sel f efficacy as it influenced self management of disease and opposed denial and depression This relati onship was supported w hen incre ased self management behaviors reinforced through mastery of repeated activity further incre ased self efficacy, which su pported increased knowledge and awareness Thematic interpretation also suggests that community and culture play an important role in, and are positively associated with, a sense of collective efficacy; creating a pathway from individual self efficacy to c ollective

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151 self efficacy. This relationship appears to work both ways, as it influences individual self efficacy toward self management of disease, and fosters a culture of perceived collective efficacy that may further influence individual self efficacy. I believe that these findings suggest a reciprocal relationship between self and collective efficacy that are important to sustaining good self management behaviors for Latinas. The theoretical pathways may be tested quantitatively in additional research to further examine the influ ence of age, acculturation, level of education and other factors as influence d by collective efficacy. Intervention Implications My findings support the need for interventions and programs that help increase self efficacy at a youn ger age for Latinas. Younger Latina women have delayed diagnosis, treatment, and mismanagement of T2DM leading to poorer health outcomes. Further, t his study suggests that there is a generational difference between younger and older Latinas. Partici pants in my study spoke to the importance of sharing knowledge and increasing awareness to prevent T2DM in younger Latinos, and suggested that younger Latinas are also more aware of how to prevent disease thr ough healthier behaviors ; this is a findin g that is supported by research showing how early screening and prevention of T2DM are important to reducing health disparities, comorbidities and mortalities, health care costs, and poor health outcomes (Black, 2002; Heart Study Outcome Prevention Evaluation St suggest that health views of younger generation Latinas are changing, and that there may be a shift in how younger Latinas view health behaviors. All ages of s tudy participants reported denial and depression as being negative influences to the exercise of self efficacy. Implications for future behavior change interventions are that researchers and health care providers need to reach out to Latinas at a younger age to

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152 help prevent or delay the onset of T2DM thr ough increased awareness. Informing Latinas at a younger age to be more proactive in their health may help prevent denial of health ailments, such as T2DM, and may help Latinas feel more empowered; thereby helping to prevent or reduce depression. As the primary care givers in their families, participants frequently discussed the importance of taking care of their families first. Several of the study participants spoke to the difficulty of taking better care of their health after they had children, with m any participants commenting that they had their children at a young age. With T2DM on the rise in the U.S. at younger ages, it is imperative that interventions and health care providers reach out to younger Latinas (teen to early 20s) to both educate and increase awareness of health behaviors that will decrease T2DM in this growing population. Incorporation of cultural aspects of d iet, exercise, and medication into management regimen through culturally competent care is needed to ensure that information is relevant and understood by the patient. is the importance of continuity within social support settings for Latinas. Participants expressed the importance of socializat ion and collective efficacy as part of their family, community, and culture. Participants reported a reduction in both self efficacy and self management when social opportunities were limited; a finding that was evident in participants who expressed depre ssion and reduced self management when social groups ended. Thematic findings show that the social support group setting within ¡Viva Bien! had the greatest impact on the self management behaviors of the study participants. The sense of collective effica cy that the participants spoke of as care givers to their families and within their culture was exemplified when they participated in ¡Viva Bien! The importance of collective efficacy was expressed by participants when they commented

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153 about the social supp ort component of the study; namely participation in the so cial support group fostered both socialization and expectations around self management of T2DM. This finding has implications for future interven tions. The sense of collective efficacy was eviden t from the participants who felt a sense of responsibility and accountability to their peers and the program, and was strongly supported through the on going social support group setting that helped establish trust among the participants. This finding ref lects how self efficacy at the individual level may be influenced by the collective efficacy of the group. Implications for future interventions include the potential benefits of incorporating components of collective expectations toward goal achievement though support group settings that are maintained over time Based on my study findings, I believe a stronger emphasis on collective, organizational, socialization may be applicable and beneficial to multiple health interventions and throughout primary c are systems, and generalizable to other populations. Specific to Latinas, interventions within medical clinics and community level programs could incorporate culturally competent care initiatives with information targeted to the needs and culture of Latina s Furthermore, these interventions could focus on young Latinas who are genetically predisposed to T2DM, and/or have g estational diabetes The importance of having consistent programs and interventions that are sust ainable cannot be understated, and effe ctiveness studies could be developed to explore how to increase long term results through sustained self management programs available in health care systems and community settings. Implications for the Patient Population of Latinas The foremost import ance of family for Latinas demands that future health services research on this growing population needs to factor family and cultural levels of influence into the research design. This study found that high family and cultural social

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154 support are more impo rtant than other sources of social support as related to self efficacy for Latinas. Study findings suggest that family and cultural social support, and the sense of familism and collective efficacy, is in need o f additional research. T he influence of col lective efficacy for Latinas may be an important next step to explore as it relates to increasing greater awareness of T2DM and individual self efficacy for on going self familism gaine d at the community level sharing with other women who had diabetes, and who struggl ed with similar family issues support; namely, a sense of collective efficacy can help foster and empower Latinas to feel mo re confident in making necessary health behavior changes. In addition, participants expressed the influence of knowledge and awareness, or sabidura which is grounded in culture though applicable in each social support level, was more relevant to the exe rcise of self efficacy. An important finding was how knowledge and awareness, or sabidura impacted increased wisdom which helped several participants get out of a state of denial about their T2DM, and it also helped participants feel empowered to do som ething about their disease, reducing depression by doing so. Wisdom, or sabidura was gained through learning with other Latin as and diabetics, and from care givers and providers, as it instilled true learning around self management of T2DM. Findings a lso suggest the importance of having diabetes specific social support opportunities for Latinas to help reduce fe elings of loneliness especially those who are older, who are struggling with feelings of denial and depression around their disease. Further, this study supports future research in the areas of denial and depression for Latinas as they negatively influence social support, self efficacy, and self management of T2DM behaviors.

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155 Finally, interview data from the study revealed discrepancies in the health care knowledge provided to the participants that may help elucidate why programs for self management of diabetes for Latinas are not fully effective. Although current literature supports the cultural adaptation of programs and interventions that ar e targeted to Latinas, my study p articipants expressed how some current treatment programs are not adequately tailored to the cultural needs and expectations of Latinas. For example, as primary care givers, Latinas frequently put their own health needs aft er the needs of family members, which my findings suggests helps to enable a sense of denial or lack of awareness around health and the importance of self management. Specifically, middle aged Latinas were high l y suspicious about prescription medication, and could benefit from more information and discussion from their healthcare team to help assure medication adherence. This finding supports the need for additional guidelines for f her condition and treatment options and provide a more culturally tailored message to the patient. Conclusion man agement of T2DM for Lati nas. Effective self management of T2DM requires continuity of treatment regimens that are culturally informed. Gaining knowledge and wisdom, or sabidura is a process that takes time. Awareness and acceptance of the disease is a first step to manage T2D M effectively. Social support sources of influence are moderated by knowledge, which facilitates self findings suggest that cultural influences and a sense of collective efficacy informed the regarding self management of T2DM. Denial of disease and depression suppresses awareness and knowledge of self efficacy toward self

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156 management. Further, n egative influences to the exercise of self efficacy, depression and denial, were found to suppress or limit knowl edge and decreased the relationshi p between social support sources of influence and self management. Participants who reported either denial of their disease or depression did not have good self management behaviors. Participants felt that kno wledge awareness and collective efficacy were the largest influence s on their self efficacy and self management. Participants expressed how the decrease in depression and the increase in acceptance of their condition enabled them to accept social suppo rt at higher levels, and encouraged an increase in the exercise of self efficacy as they felt more positive about the behavior change needed. For the purpose of this study, increased knowledge as eviden ced in the came in the form of p articipation in the ¡Viva Bien! program. Several participants suggested that they initially felt inhibited to participate in the ¡Viva Bien! program due to family and life demands and expectations; however, they also felt that their disease was getting ou t of their control and something needed to be done to more effectively manage their disease. Further, many participants spoke to how they had seen suffer the same fate. This factor seemed to be highly associated with participation in the ¡Viva Bien! program and once participants started the program th ey gained a sense of collective efficacy and responsibility to the other participants. This factor encouraged consistency in attendance and fostered self efficacy through mastery experiences, vicarious experiences and social persuasion. Opportunities for building co llective efficacy through similar health care and community programs self efficacy belief s toward improved self management of T2DM.

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157 Limitations represent a small convenience sample of people selected from two healthcare settings who self identified as Latinas with T2DM were at risk for coronary heart disease, and had pa rticipated in the ¡Viva Bien! program All of the study participants had access to some form of health care. However, the availability of health care was inconsistent for some of the women due to inability to schedule appointments that worked with their f amily or work schedules, difficulty getting to appointments due to transportation issues, and financial concerns In addition, r e call bias is an issue that may need to be acknowledged given the study participants were being asked to recall health behavio rs that occurred over their life span. However, the qualitative method of data collection is assumed to be valid, and true, Ano ther proble matic area include s interviewer o btrusiveness, which includes personal bias and subjectivity due to emotions and politic s (Patton, 2002). Interviews were also at risk for self serving probing and unconscious reactivity by the interviewer (Patton, 2002). A nother potential limitation was social desirability bias, which is the interviewees response aimed at being favorably viewed by the interviewer, in an effort to please (Fisher, 1993). This type of behavior may be attributed somewhat to an emphasis on respect in Latin culture (Bassford, 1995). Limitations regarding reliabilit y of f indings were reduced by use of clarify ing probes to ensure understanding of the meanings and dynamics implied by the study participants. Participation in the ¡Viva Bien! study can be considered both a limitation and benefit to the current study. The participants had all just participated in a lifestyle behavior change program aimed at increasing skills around self management of diabetes. Having participated in the ¡Viva Bien! study is a limitation in that the

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158 participants had increased knowledge abou t self management of T2DM, and increased awareness of support systems available in the community; both of which likely influenced their comments during the interviews. Participants were prompted about the ¡Viva Bien! program to elicit com ments reflecting t hemes around the three concepts of self management, self efficacy, and social support ; reactions to the questions were not used to inform analysis of the ¡Viva Bien! program, but rather to enable data collection about themes and concepts. Subsequently, th helped enrich awareness to healt h resources and support systems and informed the An additional limitation of p articipati ng in the ¡Viva Bien! program which was free of cost, was that participants may have higher support levels and self efficacy based on the f act that they participate d in the interventi on. Having participated in the ¡Viva Bien! program may have biased themes and concepts, due to the intervent ion components. For example, it is worth noting that the theme of collective efficacy was in relation to participation in the ¡Viva Bien and had there not been the opportunity for the group to participate in the program collective efficacy may not have bee n as pervasive as a theme. It is worth noting that the current study consisted of a convenience sample of Latinas who want ed to do some thing good for their health, made time to participate, were trying to manag e their chronic illness, were supported at som e capacity to do something about their health, and, again, had just participated in the ¡Viva Bien! program. The information gained can shed light into a small, biased sample of Latinas who have the support and interests to help themselves become healthier The information may not be generalizable to other Latinas with T2DM; however, the findings provide insights into the knowledge, beliefs, and behaviors that Latinas have regardi ng self management of T2DM, adds to the literature on important relationships and

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159 pathways between psychosocial factors that influence health behaviors for a large contingency of women and contributes to intervention recommendations that emerged from this sample. Future Research Even when access related factors are accounted for, the quality of healthcare is considerably lower for racial and ethnic minorities than for non minorities (IOM, 2002). The gap of this health disparity is further widened as culturally sensitive interventions and programs aimed at helping minorities are wa nting. Given the dearth of culturally c ompetent interventions in Latina populations, one strategy previously mentioned is to adapt successful, evidence based treatment or research from one cultural group to another. Although research suggest cultural char acteristics of the target group need to be incorporated into new interventions and programs, often this is not the case. Universally a pplying interventions grounded in data, theory, and methods from one cultural group to another saves time and money but must factor in cultural influences and expectations when adapted. In order to decrease disparities and improve health outcomes research translation needs to consider relevant cultural variables as part of the dissemination and implementation process. Tran slating research into practice toward improved health outcomes and decreased disparities is evidenced by effective dissemination and implementation. This research suggests that a reasonable next step is to apply increased psychosocial measures that evaluat e the underlying cultural factors that influence self management behaviors prior to creating interventions and programs. The recent emphasis on patient centered outcomes research is a current step in this direction, with the attention where it needs to be on the patient. By understanding the larger psychosocial environments for the individual patient and/or the collective population being studied is critical to creating successful interventions and programs

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160 aimed at disease self management that effective ly reaches the root of the problem at hand. My findings suggest that there are four essential steps necessary for researchers and health care providers to improve health behavior change toward chronic disease self management in Latinas. First, the patien explored to comprehend the comparative importance of sources of social support to the individual, including how these levels are influenced and informed by knowledge, self efficacy, and culture. This includes an evaluat ion of how the patient makes and acts on informed health care decisions. Second, upon having an understanding of psychosocial factors as they influence the individual, information must be presented in the form of understandable knowledge, interventions, an d programs that are balanced culturally appropriate, and accessible for the patient and her family. Having an initial understanding of the psychosocial factors at the individual level will help present information in an effective manner. With the increase of awareness and sabidura or wisdom, that comes from learning from others regarding information pertaining to health care regimens, programs, interventions, and treatment, patients will have increased empowerment and self efficacy to make necessary beha vior changes to manage and support systems within that environment must be conducive to patients acting on the increased knowledge and informati on. If support is not available and negativ e influences exist including depression and denial cultural environments, then change will be difficult to successfully implement. Environments that enable and encourage self efficacy, collective effi cacy, and self management of disease can be refined through increasing and sustaining the necessary

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161 support systems, including mental health care across domains of influence through continued education and information sharing An example of a successful c ommunity environment, which was conducive to creating the support levels needed to foster behavior change, was the ¡Viva Bien! empower participants to make necessary behavi or change toward self management of T2DM. The sense of collective efficacy in the ¡Viva Bien! program helped substantiate the importance of on going social support groups and networks for the study population. This finding may be generalizable to other po pulations and is worth exploring in chronic disease management research. Finally, the last step for successful health behavior change is at the policy level in the community at large. When health polic ies are spread throughout the community, the impac t ca n have a greater effect on decreasing health disparities and reducing budgetary spending on medical care. Recommendations for policy changes need to be made to support culturally competent programs that account for psychosocial factors that influence healt h outcomes of diverse populations. Per the above recommendations, implementation of a larger number of programs and interventions supported through policy change could help increase knowledge, awareness, acceptance, wisdom, self efficacy and behavior chang e to impact the collective good and promote health and prevention at an earlier age.

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177 APPENDIX A INTERVIEW CODE BOOK CATEGORIES Interview Code Book Category Code Probing Questions FAMILY /Family Dynamics FD "Tell me about your family" Relationship Influencers FD RI What relationships do you have in your life that influences your health and health behaviors? Family feelings towards own health FD HSF How do you feel your spouse, partner, and/or children feel about their ow n health? Family feelings towards participant health FD HPF How do you feel your spouse, partner, and/or children feel about your health? How do they support your health? HEALTH CARE / systems HC health care Access to health care and resources HC Acc How did you learn about Kaiser/Salud? Access to health care knowledge HC AK How do you learn about health? Health care Barriers HC B Are there types of HC that you would like to use but are not available/realistic for some reasons o r another? Cost/Value of Health care HC C What was the value of the above HC or resources/what was the cost involved? Good Dr. attributes HC DrAt What makes a good doctor /provider ? Forms/types of health care HC F What forms of health care (mental, ph ysical, complementary) do you have access to? HC source HC KP How did you get Kaiser Permanente? How did you learn about the Salud Health Clinic? I llness other treatment (other care) HC OC How do you get treated by others when you are ill or have health related concerns? Past access to Health care HC PFAcc What kinds of HC did you and your family have access to when you were growing up? Quality of Health care HC Q What was the quality of the above HC or resources? Illness self management (self care) H C SC How do you treat yourself when you are ill or have health related concerns? COMMUNITY/ social support networks SN Healthy Eating Support SN HES Is there anything else in your life that makes it easier to eat healthy? Lack of support areas SN LS Can you think of any sources/types of support that you would like to see your life? Negative health influence SN NHI How do the people in your life influence your health or health behaviors negatively? Physical Activity Support SN PAS Is there anything else in your life that makes it easier to do PA? Positive health influence SN PHI How do the people in your life influence your health or health behaviors positivel y? Providing support to others SN PSO Do you provide support for others in the community ? Stress management support SN SMS Is there anything else in your life /community that makes it easier to do SM?

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178 Social support SN SS Is there anything else in your l ife /community that makes it easier to seek out support? Source of support SN T What kinds of support do you have in the community ? C ULTURE/ Cultural Traditions CT Current Traditions/celebrations CT CC Do you still practice any of those traditions? Traditions/celebration changes since diabetes CT CDC Have any of them changed since you became diabetic? Traditions/celebration changes since VB CT CVBC Have any of them changed since you started part icipating in Viva Bien? Perception of Control over diabetes CT DC Do you think you could have prevented your diabetes? Definition of healthy person CT DHP What does a healthy person look like? Definition of prevention CT DP What does prevention mean to you? Example of healthy person CT EHP Can you think of a person that you know that you think is healthy if so, what are they like? Growing up in household with family CT GUF What was it like to grow up in your household, with your family? Growing up as Latina CT GUL What was it like growing up as a Latina, or in a Latino household? Definition of being healthy CT HD What does being healthy mean to you? Latino background CT LB What kind of Latino background do you have? Latina s experience with diabe tes CT LDE Do you think a Latina s experience with diabetes is different? Past Traditions/celebrations CT PC What kinds of traditions or celebrations did you have? Perception of Diabetes beginning CT PDB How did you become a diabetic or where did your di abetes come from? Perception of contribution to diabetes CT PDC Apart from genetics, was there anything else that may have contributed to your condition? Perception of self health CT PSH Do you consider yourself to be a healthy person? Why or why not? Perceptions of confidence CT PC Do you believe you have the skills necessary to manage your diabetes? Why or why not? Perceptions of self efficacy CT PSE Do you think you can perform certain behaviors to improve your health? Self prevention practice CT S PP Do you practice prevention in your daily life? VIVA BIEN/ experience VBE Changes in life since VB VBE C Has anything changed in your life since Viva Bien? (probe: cultural traditions, celebrations, a ctivities, holidays) Confidence seeking out health resources VBE CH Do you feel that you have more confidence to seek out health resources since your involvement in Viva Bien? Dealing with time commitment VBE CH If time was an issue, how did you deal wit h this time demand? VB helped health VBE H How has Viva Bien helped your health? (probe: ,mental, physical spiritual) Experience with language component VBE L Would you have preferred Spanish only or English only meetings? How do you feel about having th e meetings in both Spanish and English at the same time? Was enough of Viva Bien translated into Spanish? Meaning of VB experience VBE M Tell me what your experience with Viva Bien mean to you? Viva Bien materials VBE MA Would you have preferred more, th e same, or fewer handouts? How could the handouts have been done differently to be more useful?

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179 Structure of Viva Bien VBE S Do you thi n k there is a way to simplify the Viva Bien study? If you could, how would you restructure Viva Bien? Would you have pre ferred receiving information in a different format (e.g. video, more oral) Time commitment VBE T Was the time commitment of Viva Bien a problem for you? BEHAVIOR CHANGE BC Barriers to healthy li festyle BC B What are the barriers to continuing to lead a health y lifestyle? Feel health benefits BC HB Do you feel healthier than you did when you started Viva Bien? If so, what has been beneficial to your health? Why? Barriers to healthy eating BC HEB Is there anything that makes it more difficult to eat healthy? Health in other areas of life BC HOA Did success in the study help you focus on being healthy in other areas of your life? Maintenance behaviors BC MB After participating in the Viva Bien s tudy, what do you think you can do to continue leading a healthy lifestyle (e.g. participating in physical activity on a regular basis, stress management, eating healthy foods, not smoking, having a support network)? Viva Bien not demanding enough BC ND D id you feel that Viva Bien was not demanding enough? Barriers to physical activity (PA) BC PAB Is there anything that makes it more difficult to do PA? Barriers to stress management (SM) BC SMB Is there anything that makes it more difficult to do SM? Ba rriers to social support (SS) BC SSB Is there anything that makes it more difficult to find social support? Viva Bien too demanding BC TD Did you lose interest in Viva Bien because it was too demanding? Perception of success in VB BC VBS Do you feel you were successful in VB? If so, why? VALUE OF VIVA BIEN VBV Weekly meeting attendance reasons VBV AR Why did you go to the Viva Bien meetings every week? Change about Viva Bien VBV C If you could change one thing about Viva Bien what would it be, and why? Like least about Viva Bien VBV LL What did you like the least about Viva Bien, and why? Like most about Viva Bien VBV LM What did you like most about Viva Bien, and why? VIVA BIEN SUPPORT LEVEL VBSL Difficulty of adopting Viva Bien for others VBSL ADO How difficult was it to adopt the lifestyle changes for your family? Difficulty for adopting Viva Bien for self VBSL ADS How difficult was it to adopt the lifestyle changes for you? Would you have preferred to make the changes one at a time or all at once? Viva Bien benefits to family VBSL BO Do you feel Viva Bien benefited your family? If so, could you describe the benefits? Viva Bien benefits to self VB SL BS Do you feel Viva Bien benefited you? If so, could you describe the benefits? Met needs as Latina cultural correctness VBSL CC Do you feel the program met your needs as a Latina? If so, in what ways? Decrease in social support because of Viva Bien VBSL D By participating in Viva Bien did you feel a decrease in support from family and friends? Increase in social support because of Viva Bien VBSL I By participating in Viva Bien did you feel an increase in support from family and friends?

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180 Others mad e behavior changes because of Viva Bien VBSL OBC Do you think that there were people in your life (family, friends, coworkers) who made lifestyle changes in their own (e.g. changes in diet or exercise) because of your participation in Viva Bien? If so, cou ld you please describe the changes they made?

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181 APPENDIX B MODIFIED ARSMA II ACCULTURATION MEASURE BRIEF ACCULTURATION RATING SCALE For Mexican Americans: ARSMA II (5 ) Almost Always/Extremely Often (4) Much/Very Often (3) M oderately (2) Very Little/Not V ery Much (1) Not At All 1. Speak Spanish. (1) (2) (3) (4) (5) 2 I spe ak English. (1) (2) (3) (4) (5) 3 I enjoy speaking Spanish. (1) (2) (3) (4) (5) 4 I associate with Anglos. (1) (2) (3) (4) (5) 5 I enjoy listening to English language music. (1) (2) (3) (4) (5) 6 I enjoy Spanish language television. (1) (2) (3) (4) (5) 7 I enjoy Spanish language movies. (1) (2) (3) (4) (5) 8 I enjoy reading books in Spanish. (1) (2) (3) (4) (5) 9 I write letters in English. (1) (2) (3) (4) (5) 10 My thinking is done in the English language. 1) (2) (3) (4) (5) 11 My thinking is done in the Spanish language. (1) (2) (3) (4) (5) 12 My friends are of A ngl o origin. (1) (2) (3) (4) (5)

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182 APPENDIX C Descriptive Characterization of Units of Analysis Coded interviews 33 Single spaced transcribed pages analyzed 1,261 Thematic text units identified 3,184 Thematic text units coded as negative in relation to self management ( ) 104 Thematic text units coded as medication ( ) 13 Thematic text units coded as stress ( ) 14 Thematic text units coded as healthy eating habits ( ) 19 Thematic text units coded as money ( ) 10 Thematic text unit s coded as ( /+) in relation to self management 177 Thematic text units coded as physical activity ( /+ ) 15 Thematic text units coded as social support ( /+ ) 12 Thematic text units coded as positive self management (+) 131 Thematic text units coded as knowledge awarenes s, and education (+) 31 Thematic text units coded as collective efficacy (+) 22 Thematic text units coded as continuity and routines (+) 27 Thematic text units coded as self efficacy 60 Thematic text units coded as definition of healthy individual ( /+ ) 42 Thematic text units coded as healthy is carrying out self management behaviors (+) 23 Thematic text units coded as healthy is being happy and positive (+) 9 Thematic text units coded as neg ative in relation to having self efficacy ( ) 86 Thematic text units coded as denial ( ) 19 Thematic text units coded as depression ( ) 24 Thematic text units coded as po sitive in relation to having self efficacy (+) 83 Thematic text units coded as increased knowledge/ self management behavior (+) 20 Thematic text units coded as collective effic acy (+) 29 Thematic text units coded as family social support 142 Thematic text units coded as care giver 1 9

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183 Thematic text units coded as knowledge and awareness 17 Thematic text units coded as nagging 3 Thematic t ext units coded as unhealthy behaviors 10 Thematic text units coded as health care social support 125 Thematic text units coded as physicians who listen 13 Thematic text units coded as alternative care 11 Thematic text units coded as insurance and acce ss to care 5 Thematic text units coded as knowledge and awareness 8 Thematic text units coded as community social support 111 Thematic text units coded as identify with other diabetics 12 Thematic text units coded as organizations 18 Thematic text un its coded as discrimination 5 Thematic text units coded as knowledge and awareness 15 Thematic text units coded as cultural social support 133 Thematic text units coded as collective efficacy 12 Thematic text units coded as U.S. lifestyle 3 Thematic t ext units coded as generational differences 8 Thematic text units coded as faith 10 Thematic text units coded as familism 13 Thematic text units coded as knowledge and awareness 8