Abstract
To gain better insight to the preferred methods of managing and treating type 2 diabetes among African American men (AA men). Participants (n = 19) were AA men aged 35 to 69 years, who were diagnosed with type 2 diabetes. Participants were recruited via community outreach efforts, including barbershops and churches located in predominantly African American communities in Southeast United States. On consent, individual interviews were conducted, audio recorded, and subsequently transcribed. Transcripts were analyzed using a phenomenological approach, and focused on identifying common themes among the descriptions of AA men’s experiences specific to type 2 diabetes. Participants’ statements indicated three main commonalities regarding treatment preferences which were medication, dietary changes, and increase in exercise. Some participants from the study stated that they preferred taking oral medication primarily out of convenience, lack of pain, and how well the medicine makes them feel. Others stated educating themselves and having a consistent relationship with the diabetes physician has assisted them the most. Other participants shared preferences of being dedicated to proper diet and exercise without any medication (pill or injection), as well as maintaining the mental motivation needed to sustain management. Some participants preferred to not take an oral pill, while some did not mind taking pills at all. For some of the participants, it appears that it is easier for them to manage their diabetes by prescription medication than by lifestyle changes such as diet and exercise. Future studies are needed to investigate how social support system also assists these men in managing their diabetes.
Introduction
Diabetes is a chronic disease characterized by elevated blood glucose (Asimakopoulou & Hampson, 2005). Approximately 29.1 million people or 9.3% of U.S. population are currently suffering from diabetes mellitus. Out of this figure, 21 million people have been diagnosed, while 8.1 million people (27.8% of people with diabetes) have not been diagnosed (Centers for Disease Control and Prevention [CDC], 2014). Type 2 diabetes is responsible for about 90% to 95% of all cases of diagnosed diabetes in the United States (Healthline, 2014). According to the CDC, diabetes was the seventh leading cause of disease in the United States in 2010 (CDC, 2011). Compared with White men, research has reported that African American men (AA men) are 80% more likely to be diagnosed with diabetes mellitus (U.S. Department of Health and Human Services, 2014). About 18.7% of AA men, aged 20 years and older have been diagnosed with diabetes in the United States (CDC, 2014).
In 2010, AA men were more likely to develop end-stage kidney disease from diabetes compared with White men and also are more likely to die from diabetes complications compared with Hispanic and Asian men (U.S. Department of Health and Human Services, 2014). Type 2 diabetes is managed either by lifestyle modifications such as healthy diet, exercise program, weight loss, or by taking oral medication (CDC, 2014). The goal of the two treatment modalities is to attain good glycemic control. Lifestyle modification plays a central role in the management of type 2 diabetes (American Diabetes Association, 2008). Evidence has identified that African Americans diagnosed with type 2 diabetes are more likely to have poor glycemic control (Harris et al., 1999). There are several factors that need to be taken into consideration before choosing whether to use oral medication or lifestyle changes in the management of type 2 diabetes for a particular patient.
Risk factors for the development of type 2 diabetes are either modifiable or nonmodifiable. Modifiable risk factors include overweight/obesity, physical inactivity, and smoking, while nonmodifiable risk factors include age, ethnicity, race, gender, and family history (American Diabetes Association, 2014). Studies have reported that interventions targeted at improving modifiable factors is very beneficial in controlling symptoms of diagnosed diabetes (Look AHEAD Research Group, 2007). Evidence has suggested that with a mean sustained weight loss of >20 kg, type 2 diabetes can be virtually eliminated (Dixon et al., 2008). There are few adverse consequences of such lifestyle interventions other than difficulty in incorporating them into usual lifestyle and sustaining them. Usually, minor musculoskeletal injuries and potential problems associated with neuropathy, such as foot trauma and ulcers that may occur as a result of increased activity (Davidson et al., (2007)).
If it can be achieved, weight loss is the most cost effective means of controlling type 2 diabetes (Davidson et al., (2007)). The use of oral medication is largely determined by the level of hyperglycemia in type 2 diabetes (Davidson et al., (2007)). When the level of blood glucose is very high, early initiation of oral medication and the use of combination therapy are highly recommended (Peters & Davidson, 1996). Other factors to also consider when selecting the type of oral medication to be used for each patient include side effects of the medication, tolerability, ease of use, long-term adherence, expense, and the nonglycemic effects of the medications (David et al., 2009).
Although a study by Wanko et al. (2004) determined the exercise preference and barriers in urban AA men with diabetes, an online search of literature using different keywords produced no previous studies to determine the treatment preferences between medication and lifestyle modification among AA men with type 2 diabetes. The purpose of this study is to determine the treatment preferences of type 2 diabetes among AA men. As Wanko et al. (2004) concluded in their study, knowing treatment preferences may help develop a health education intervention plan to help AA men with diabetes optimize their glycemic control.
Phenomenological Methodology
This study utilized a qualitative research design, specifically, a phenomenological research method. According to Patton (1990), the focus of a phenomenological study lies in the “descriptions of what people experience and how it is that they experience (p.71).” The goal is to identify essence of the shared experience that underlies all the variations in this particular learning experience. Although none of the participants were related in any way, they all share the same phenomenon which is type 2 diabetes. Essence is viewed as commonalties in the human experiences (Creswell, 2007). This type of research methodology is used to study areas in which there is little knowledge (Donalek, 2004). The original study’s primary focus was to gain a stronger understanding of the essence and lived experiences of AA men living with type 2 diabetes.
Selection and Description of Participants
The study received approval by the Texas A&M University International Review Board committee to begin data collection after making corrections from the committee. The target population was AA men with physician-diagnosed type 2 diabetes who reside in the urban city of Houston, Texas. Recruitment took place at three predominately African American churches and two barbershops located in two different primarily African American communities. At each barbershop, the researcher obtained approval from the owner of the shop to post study flyers with the researcher’s contact information in the waiting area as well as make announcements during high-volume traffic days, which were on Fridays and Saturdays. The researcher received permission from the pastor of each church to make an announcement about the study during the announcement period at each service. Flyers containing information about the study were distributed among the congregation and the researcher was available after each service to answer any questions and collect contact information from interested men.
Within 2 days after the church visit, the researcher contacted those who were interested to schedule a date and time to conduct a one-on-one interview. From the recruitment locations, 28 men gave the researcher their contact information and phone calls were made to each person. However, some chose not to participate or simply did not follow through with the scheduled interview. Only 4 participants came from the barbershop recruitment effort and the remaining 15 came from the church recruitment for a total of 19 participants. Each participant selected their interview location; 17 participants chose to conduct their interview at their residence. The remaining 2 participants chose to have their interview at their place of employment due to convenience factors.
At each interview location, the interviewer and participant sat face-to-face in a private location. The inclusion criteria for the study were (a) participant was self-identified as African American, (b) age 18 to 70, and (c) physician-diagnosed with type 2 diabetes. The final sample consisted of 19 AA men, most (68.4%) of whom were older than 55 years. About 12 participants (66.0%) had lived with diabetes for 10 years or less. Table 1 provides details on relevant sociodemographic characteristics of the final sample. A community-focused recruitment strategy was used; establishments with high proportions of African Americans (e.g., barbershops, urban churches, waiting room at an urban diabetes clinic) were targeted. This strategy was combined with snowball sampling, which is used when researchers are coping with issues of access and sensitivity of the topic (Patton, 1990). Snowball sampling is a nonprobability sampling technique where existing study subjects recruit future subjects from among their acquaintances. Thus, the sample group is said to grow like a rolling snowball. As the sample builds up, enough data are gathered to be useful for research. This sampling technique is often used in hidden populations which are difficult for researchers to access (Goodman, 1961).
Sample Characteristics (n = 19).
Instruments and Data Collection
A semistructured interview guide was used to collect data concentrating on six areas: diabetes management practices, knowledge and beliefs about diabetes, perceived barriers to diabetes management, social support, symptoms, and personal versus interpersonal feelings regarding diabetes management (see Table 2). One of the questions from the guide asked: “What kind of treatment(s) do you prefer to help you manage your diabetes?” The focus of this article is to share the results of this question as told by the participants, in the exact way that they each answered the question.
Semistructured Interview Guide.
Each interview was recorded using a digital voice recorder with the following protocol: (a) read the consent form, discuss participants’ rights, and obtain informed consent; (b) request the participant to complete the demographic profile questionnaire; and (c) perform the face-to-face recorded interview. Each participant was given the option to end the session at any time without penalty. At the conclusion of the session, each participant was given a $25 gift card as a way of thanking them for their time and commitment to allowing the researcher to conduct an interview with them.
Data Analysis and Member Checking
Narrative analyses have been used to explore life experiences of individuals with diabetes (Stuckey, 2013). Fidelity to the phenomenon as it is lived means capturing and understanding it as perceived through the person living the situation (Moustakas, 1990). Participants in this study told their unique story of how they prefer to manage and treat their type 2 diabetes. Therefore, excerpts from their transcripts were not edited or corrected, and are presented in their unique voice as originally recorded. Table 3 provides all 19 responses from the participants of this study in their own words regarding treatment preferences for their type 2 diabetes. To establish the validity of the interview data, member checking was done after all 19 interviews were completed. Lincoln and Guba (1985) posit that member checking is the most crucial technique for establishing creditability. Member checking is when data, analytic categories, interpretations, and conclusions are tested with the members of those groups from whom the data were originally obtained (Creswell, 1998).
Illustrative Quotes Regarding the Treatment Preferences of Type 2 Diabetes Described by African American Men.
In this study, member checking occurred as follows. A meeting was scheduled with all of the participants for them to read their completed interview transcripts. The transcripts were typed word for word from the audio recording and were not edited or corrected in terms of grammar. These are the stories that this group of men shared and the transcripts were typed in their unique voices. The main purpose of the researcher doing member checking was to give each participant the opportunity to correct any errors and challenge anything that was wrong or incorrect in the transcript.
Results
Treating Type 2 Diabetes With Medication
As expected, a majority of the study participants stated they preferred to treat their diabetes by way of oral pill form or injections. Responses indicate that participants are more comfortable or feel that taking medication is easier for them in maintaining their blood glucose levels. Participants stated that the pills are convenient in assisting them the most and that they prefer taking pills because they are not always able to get the needed exercise or proper dietary behaviors that one should have for optimal self-management. Below are a few quotes from some of the participants: I prefer the pill because I don’t know no better, it’s convenient. If I knew another way I probably would do that but ummm . . . diet and exercise is hard for me. My doctor has put me on medicine . . . it’s a little bity pill, one pill a day and that’s all I take . . . that’s all I have to take for diabetes. And it seems to be doing pretty good. I’m taking one particular medication to manage that . . . it’s called Glimepiride. That’s the only diabetic medicine I’m taking. After going through this for as long as I have, the pills would probably be the easiest because there’s no injections, no pain
Two participants stated that they were using insulin injections at first, but due to staying away from foods that were high in sugar as well as exercising, their doctors changed their medication from injections to pills. Their responses were as follows: Well you know I started out on the insulin shots in the stomach and I did that for about six months. But because I was paying attention to the doctor and on top of the shots I was doing the exercise and not eating sugar, they took me off the insulin shots and put me on pills. So I’d rather the pills. I’m still currently taking pills. They took me off of a medicine that I was injecting every day because I was responding better in terms of my blood sugar.
Last, one participant stated that he can manage his diabetes with medication due to having a dislike for needles. His response was as follows: I can do it with medication as long as needles aren’t involved . . . I can’t stand needles. If diet and exercise is the true key, I’ll go that way with it.
Treating Type 2 Diabetes Without Medication
Three participants responded to the question stating they would prefer to not have to take any form of medication to manage their diabetes. Their preferred treatment is a combination of diet and exercise. One participant stated that he was leery or apprehensive about taking medication for fear that it will overpower him. Some of the quotes that support the theme of lack of medication are as follows: Well that’s going to be a combination of diet and exercise and I’m not on insulin regimens. So all three of those in combination is what I use to keep it in check. What I would prefer would be diet and exercise without any kind of medication. But what I’m looking forward to is the point where I can put the insulin down, and if it means diet, exercise, with some medication other than insulin, I’m fine with that. I just want to be able to manage it. Well if I can do it without taking any type of medication. If I can do it, then I will but if it begins to overpower me and I do need the medicine then I will. I’m a little leery about taking the pill because of my friend I told you about that was taking insulin first and then they changed it. I think whatever they put you on first, you should stick with that instead of switching up to something else.
Treating Type 2 Diabetes With Lifestyle Behavior Changes
Six participants stated that they monitor their diet as best as possible and incorporate exercise as their ideal way to manage their blood sugar. At times, some participants had a difficult time staying committed to eating healthier, in particular, cutting back on desserts and foods that are relatively high in sugar. However, surrounding social support from family and friends appeared to help keep them on track with their diet. Participants indicated that their spouse or children have truly assisted them by abstaining from fried foods and eating smaller portions in general. Here are some quotes indicating support for lifestyle behavior changes: My weight has fluctuated up and down. When I first found out, I went on a strict diet, lost a lot of weight. However, during that time, I have regained some weight. Currently, I’m seeking to do that again (diet) to lose some weight again. But most importantly is to be around my family. Right now it’s a lot more vegetables, a lot more fish, a lot more chicken. I eat very little red meat, ummm it’s a lot more juice, I’ve cut considerably back on any type of alcohol, ummm I drink a lot more water and more grilled foods. Every once in a while, I’ll allow myself once a month to maybe have some fried fish. My wife just won’t let me have it so I just haven’t been getting it. I try to minimize eating sweets and having as proper of a diet as possible. I need to incorporate some more exercises in my life which is something that I’ve been thinking about. The hardest about that is trying to be motivated. Once you get pass the motivation and just do it, you can curve that. I do diesel mechanic repair on heavy equipment . . . I’m climbing and jumping in and out of trucks all day long. So I get exercise but I ain’t able to exercise when I get home [laughing]. That’s enough exercise for this old body. I take the pill every day, but it’s not my first choice so far. I try to get exercise. I watch more of what I eat. I try to eat a little bit more healthier instead of a lot of stuff with grease in it. So I try to eat a little bit healthier. I try to eat some fruit but see I have a problem with eating fruit. I’m allergic to the acid in it . . . I have acid reflex so I have to watch what I eat. All of the above . . . diet and exercise, medication, I figure the more I do the better.
Treating Type 2 Diabetes by a Combination of Changes
After conducting, reading, and listening to the interviews, one take-away message that came across from the participants is that managing type 2 diabetes is very tedious and demanding. Therefore, the participants grappled with various behaviors to manage their diabetes as best as they possibly can. Some acknowledged they have to take medication and participate in regular exercise to control their blood glucose. However, four participants mentioned that educating themselves through diabetes education courses as well as meeting with certified diabetes educator helps them control their blood glucose. Five participants stated that they are not able to exercise as much as they would like to or should due to demanding work schedules, but try and eat as healthy as they can. By increasing their knowledge about type 2 diabetes and how to properly manage it, some have a different perspective that managing diabetes does not have to be complicated, but they have noticed some positive changes simply by making an effort to manage it better. Below are some supporting quotes: It’s a combination of a lot of things. Cutting back on the sweets, cutting back on what you eat, cutting back on what types of foods you eat. So being educated about that and also taking your medication at the right time. But one thing by being in the professional field is that you have to take care of your health. And by eating correctly and taking your medicine correctly, that helped me a whole lot. I’m not saying that I’m perfect with it, but I understand it. Other than exercise, I have gone to one or two diabetic classes to learn more about a balanced diet for diabetics and I have lost weight in the past. My biggest change is cutting sweets out. I love sweets, but I have cut back . . . very seldom do I have them. I very seldom eat sweets now. A biggest change too when I started drinking more water. I think for a person to manage their diabetes successfully, it must begin with an endocrinologist or diabetic specialist that puts you on the right track. And then it requires dedication to that regime. In my case, it has not, I’m not exercising now, but because of the nature of my work, I do a lot of walking and I stay active in playing golf, fishing. But as far as going back there in the fitness center and getting on that equipment, I don’t do that. I haven’t found it necessary for me to do that. I think it’s just a matter of accepting that you have it and right now there’s no cure for it. But they do have some guidelines that you can follow to maintain it . . . to keep it in check. So what I try to do is to stay as close to it as I possibly can. Like I said, sometimes I fall off the wagon, but when you fall off, you realize, hey, I kinda strayed away and you try to come back on course . . . get back on track.
Discussion
The purpose of this study was to determine the treatment preferences of type 2 diabetes among AA men. Participants in this study mentioned all the options available for the treatment of type 2 diabetes medication use, exercise, diet, and weight loss. Twelve participants preferred treating their diabetes with medication only, while seven preferred treatment without medication. Some participants preferred treatment by way of lifestyle behavior changes, and some preferred a combination of all of the treatment preferences. For the participants who preferred medication as their treatment option, many of them stated that they prefer medication because of it being convenient to them. They stated that they are not able to engage in exercise or lifestyle behavior changes that are optimal for diabetes management. Their inability to exercise might be due to one or more barriers. Wanko et al. (2004) reported that pain, lack of willpower, poor health, lack of knowledge about the type of exercise to do, and no one to exercise with are the top five reasons why African Americans with diabetes fail to engage in exercise.
The possibility of developing type 2 diabetes and its complications can be abated through lifestyle modifications (Knowler et al., 2002; U.K. Prospective Diabetes Study Group, 1998). However, contributing factors to health disparities are multifactorial in nature and include patient behavior and characteristics (e.g., adherence, health literacy), physician behavior (e.g., treatment threshold and target), and health care system factors (e.g., access to care, continuity of care; Brown et al., 2004; Brown et al., 2005). Worthwhile approaches to preventing and managing diabetes in this population are urgently needed to improve clinical care and self-management behaviors and thereby reduce complications and improve quality of life.
The design of patient-level interventions and educational programs should take into account multiple levels of intervention, for instance, combining traditional parameters of diabetes care, socioeconomic issues, and family concerns simultaneously (Batts et al., 2001) as well as targeting multiple behaviors. In addition, the conceptual or theoretical framework for intervention is key to developing and incorporating appropriate educational and behavior change components of an intervention. Furthermore, these interventions must have tailoring sections that fit the determined needs of the specific African American population or subgroup of interest. “Cultural tailoring,” for example, likely needs to recognize the demographic subgroups of gender (lack of data for men specifically), age (younger and older groups), lower education, low literacy, and lower socioeconomic status. This will likely maximize reach and effectiveness.
Moreover, because African Americans suffer a disproportionate burden of diabetes-related complications and disability, there is a need for tailoring of patient educational materials and protocols to meet accessibility guidelines and recommendations (American Association of Diabetes Educators Position Statement, 2002; Williams, 1999) to accommodate prevalent visual and cognitive impairment in poorly controlled patients, which can adversely affect learning and retention. Finally, linking clinical care with community support for self-managementwill create intensive interventions that will produce meaningful clinical results and evaluating the public health impact (Glasgow, Lichtenstein, & Marcus, 2003; Glasgow, McKay, Piette, & Reynolds, 2001) will expand the potential for translation to clinic and community settings (Glasgow et al., 2001; Glasgow et al., 2003).
A previous study reported that African American patients with type 2 diabetes are more concerned than White or Hispanic patients about the side effects of diabetes medication (Huang et al., 2009). This may explain the reason why these participants are afraid of taking diabetes medication. Several participants stated they prefer lifestyle behavior changes such as dietary modification and weight loss as a treatment option for their type 2 diabetes. They stated they were able to remain dedicated to this option because of the support they receive from their family members, friends, and colleagues who are also living with diabetes. This is in conformity with previous studies (Hawkins et al., 2015; Rosland et al., 2008) which have identified the significant role of social support in the self-management of type 2 diabetes. Education on making sensible dietary choices as well as physical activity journals may perhaps motivate and aid these men to make better decisions regarding type 2 diabetes management.
Implications for Future Research
An argument can be made that those in the African American male social support system such as close friends and family can assist in encouraging successful self-management of type 2 diabetes. Most of the participants struggled with managing their diabetes and some counted on their own potential or performance, as well as the encouragement of their family and extended family. These findings are consistent with the results of other studies (Cohen, 1988; Miller & Davis, 2005) in which family and friend support was eminent to assist in the management of diseases. Additional studies are needed to center on interventions adapted to AA men and more ways to engage friends and family in helping with type 2 diabetes management.
The objective of successful diabetes management is to help those living with the condition improve their self-management experience and to increase chances for a healthy lifestyle that will be sustained throughout their existence toward a more favorable level of health. As noted by one participant in talking about type 2 diabetes, Actually, it’s been a Godsend because it’s something that you need to do anyway . . . dieting and exercise. So it just makes you a little bit more aware of some of things you need to do anyways in a given light so I don’t look at it as being that negative.
Footnotes
Authors’ Note
This article is based on work coming from the doctoral dissertation by the author at Texas A&M University. I affirm that the article has not been published and is not under consideration for publication elsewhere.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded, in part, by the Transdisciplinary Center for Health Equity Research (TCHER). TCHER is housed in the Department of Health and Kinesiology, College of Education and Human Development, at Texas A&M University.