Ethnic differences in outcomes of diabetes care and the role of self-management behavior
Introduction
Diabetes mellitus is a major health problem in Europe and the United States, mainly because of the end-stage complications. In both continents, diabetes and its complications disproportionately affect minority populations [1], [2]. Diabetic patients have to deal with a complex package of tasks in order to treat and regulate their disease. This self-management behavior includes adherence to dietary advice, engaging in regular exercise, adjusting medication, and monitoring blood glucose levels. Supporting diabetes self-management is a crucial task in diabetes care, because good/adequate self-management leads to better glycemic [3], metabolic [4], blood pressure [5], and weight control [6], which are important predictors of complications. Although the relationship between self-management and the outcomes of diabetes care has been demonstrated, the mutual relationships between determinants of self-management in diabetes care, self-management and ethnic differences in diabetic outcomes have not yet been studied. Several models are available for explaining self-management behavior. In particular, Personal Models and Barriers (PMB) has been applied in diabetes studies to explain variance in self-management (Fig. 1). Personal Models are patients’ representations of their illness, including disease-related beliefs, emotions, knowledge, and experiences [7]. Studies concerning Personal Models mainly reported that beliefs about treatment effectiveness appear to have an important influence on diabetes self-management [8]. Patients’ Barriers represent the problems experienced in self-management, for example how often a patient is outdoors at the moment that medication should be taken [8]. Barriers and beliefs about treatment effectiveness do influence self-management [7]. Another useful tool in describing the determinants of self-management is the Attitudes-Social support self-Efficacy (ASE) model (Fig. 1). This model has been successfully applied to explain various aspects of health behavior, such as fruit and vegetable consumption [9], [10], fat intake [11], smoking [12], [13], and participation in fitness programs [14]. In the ASE model, it is assumed that intention and subsequent behavior are primarily determined by the following variables: attitudes, social influences, and self-efficacy expectations [9]. Empirical support exists that at least two constructs of the ASE model, social support and self-efficacy, play an important role in the self-management of diabetes [15], [16].
We conducted a study to describe ethnic differences in the outcomes of outpatient diabetic care, and investigated whether these differences could be explained by self-management and its determinants. Ascertaining the role of self-management in ethnic differences in outcomes of diabetes will help health professionals to take appropriate decisions with regard to the most suitable care for ethnic minority patients with diabetes.
Section snippets
Study population
The study was performed at the outpatient department of a university hospital (Erasmus Medical Center in Rotterdam, The Netherlands). Patients were selected according to two inclusion criteria. Firstly, patients had to be clinically diagnosed with diabetes mellitus (type 1 or type 2) and be under the treatment of a diabetes specialist for at least 1 year. Secondly, patients were either of Dutch origin or immigrants from Turkey or Morocco. The latter groups consisted of immigrant workers who
Study population
The study included 204 patients, of which 50% were of Dutch origin, 25% were immigrants from Turkey and 25% from Morocco (all first-generation immigrants) (Table 1). No differences were observed between the three groups for age and gender, which implied that matching for these variables was successful. Nevertheless, matching for socioeconomic status was not fully successful. Although all groups had an income below the national average, the Dutch patients had a higher mean income than the ethnic
Discussion and conclusion
This study showed ethnic differences among diabetes patients, with ethnic minorities having higher levels of HbA1c and lipids than native Dutch patients. These differences could not be explained by ethnic differences in levels of self-management. However, several determinants of self-management partly contributed to an explanation of these ethnic differences. Self-efficacy explained a fifth of the ethnic differences in HbA1c. ASE for monitoring of blood glucose proved to be a protective
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