Two factors differentiate the self-management strategies of those in the GOOD-GC and POOR-GC samples. One relates to the overall approach that was particularly evident in the food and diet and the HGM domains. The other involves the use of formal services.
First, the GOOD-GC sample demonstrated an approach to self-management that was more structured and disciplined than that of the POOR-GC sample. This was particularly evident in the food and diet domain. GOOD-GC individuals talked in terms of specific foods, not general categories. They also advocated specific behaviors such as portion control. These aspects of their discourse indicate that these individuals are conscious of the specific foods they eat and have developed ideas about whether such foods should be included in or excluded from their usual diet. Portion control suggests an attitude of discipline and self-control. These individuals also had a social support network that helped them remain self-disciplined by making sure the foods they needed were available. In contrast, the POOR-GC group talked in generalities, using terms like “starches” and “vegetables” that are common in diet instructions but show no evidence of having been translated into practical applications. In contrast to portion control, they confided that they “cheated” on their diet, including consumption of high-fat and high-sugar foods. This cheating was assisted by their social network that provided foods that tempted them away from their recommended diet.
The same difference in approach was evident in language in the discussion of HGM and reported HGM behavior. Persons in the GOOD-GC group evidenced structure and discipline. They stated precise target glucose levels in the range advocated by health professionals. They also monitored their blood glucose levels on a regular basis, being proactive about keeping blood glucose at proper levels. In contrast, the POOR-GC sample listed general glucose levels rather than specific targets. They did not monitor on a regular basis but appeared to monitor in response to symptoms. Their approach was less structured and more reactive.
Second, the two groups differed in their use of formal services. Eight of 24 in the GOOD-GC group had in-home aides compared with only 1 of 24 in the POOR-GC group. None of the aides were interviewed directly, but the respondents referred to their work across different domains of diabetes self-management. There was particular emphasis on the participation of these aides in diet, medication management, and glucose monitoring. By participating in grocery shopping and food preparation, aides may have been able to provide a better balanced meal of appropriate portion size than would the older person alone. It is likely that with an aide preparing meals, family and friends feel less obligated to provide food (potentially the wrong type of food) in support of these older adults. Medication management should ensure that the person with diabetes takes the prescribed medications at the appropriate times. Respondents also reported that the aides ordered prescription refills as needed, so medication use should have been consistent. With the aide participating in glucose monitoring, as well as medication management and meal preparation, information from the monitoring may have been fed back into alterations of diet or medications to achieve better glycemic control.
These two differences in self-management strategies are likely to account for the much of the difference between the groups in glycemic control. Current dietary advice for persons with diabetes centers on controlling weight, controlling dietary fat and carbohydrate intake, and recognizing foods with a higher glycemic index (ADA, 2009
), as these are ways of controlling blood glucose level. Portion control is one of several dietary behaviors that was established to be a lifestyle change conducive to better glycemic control and reduction of diabetes risk factors in the Diabetes Prevention Program (Knowler et al., 2002
) and is frequently included in diabetes education. Its adoption in the GOOD-GC group appears to be part of their successful self-management strategy.
HGM is currently recommended for persons with diabetes using insulin and can be used by those on noninsulin regimens. When used, HGM is intended to provide information to a person to assess the success of their self-management strategy (ADA, 2009
). The descriptions of usage by the GOOD-GC group, in contrast with the POOR-GC group, indicate that the former are using HGM appropriately to feed information back into their self-management strategy. The POOR-GC group reported monitoring largely in response to symptoms. This may be particularly problematic, as a recent study has shown that older adults are particularly poor at detecting symptoms of abnormal glucose (Bremer, Jauch-Chara, Hallschmid, Schmid, & Schultes, 2009
). Thus, monitoring only in response to symptoms increases the likelihood that an individual will unknowingly experience blood glucose extremes.
In-home aides used for diabetes management have not been extensively evaluated. However, interventions using community health workers, who might generally be assumed to have similar levels of skill and training, have been found to result in substantial reductions in emergency room visits, hospital admissions, and Medicaid costs (Fedder, Chang, Curry, & Nichols, 2003
) and to be associated with declines in A1C and other health indicators (Gary et al., 2003
Although moderate-intensity aerobic physical activity and resistance training are recommended as part of diabetes self-management (ADA, 2009
), few in either GOOD-GC or POOR-GC samples reported significant physical activity. This is consistent with the quantitative data from the larger sample from which these participants were drawn (Arcury et al., 2006
). We found previously that the idea of rest being important for health in older adults in the general population is particularly salient among minority elders, who caution that rest and avoidance of strenuous work are important for staying healthy (Arcury, Quandt, & Bell, 2001
). Wilcox, Oberrecht, Bopp, Kammermann, and McElmurray (2005)
found similar resistance to “overdoing it” among White and African American southern women and also highlight the environmental barriers (e.g., safety, lack of sidewalks, stray dogs) unique to rural areas.
Paradoxically, the sample in good glycemic control has a number of demographic characteristics that would suggest poorer health status. It has twice as many individuals on Medicaid as the other group (14 vs. 7) and has half the number of high school graduates (5 vs. 10). Low income has been shown by others to restrict self-care options of persons with diabetes. For example, Schoenberg and colleagues (2008)
studied largely low-income older adults from around the United States and found their poverty restricted their ability to engage in some self-management behaviors. Savoca, Miller, and Quandt (2004)
, in a study of middle-aged persons with diabetes, also found poverty associated with poor self-management. Our study differs from these and others by being population based, so that the full range of incomes are represented. It also suggests that there may be opportunities for assistance open to those of low socioeconomic class. In North Carolina, the CAP/DA (Community Alternatives Program for Disabled Adults) provides funding for personal care services in the home to low-income individuals who might otherwise be placed in nursing facilities. Although the present study did not collect information on the funding source for the aides assisting study participants, it is likely that they received assistance from CAP/DA or a similar funding source. Our study suggests that when income is low enough, and local communities have services available that low-income elders can access, self-care resources can be augmented by formal services that appear to benefit health outcomes, as measured by A1C.
Older adults experience numerous challenges for diabetes self-management. Self-management is a complex set of behaviors that require cognitive and physical skills that may be deteriorating in the older adult. Available self-management training may not be geared for elders. Those who took diabetes training when first diagnosed years prior may need additional training that reflects up-to-date recommendations. The out-dated “diet sheets” that some of these older adults still had posted in their kitchens bore testimony to the need for more contemporary instruction. Studies of older diabetes patients suggest that they need diabetes self-management instruction that stresses problem-solving skills rather than “rules” to follow (Lippa & Klein, 2008
This study selected samples with equal representation by ethnicity and gender. This was done to produce samples that might capture the range of approaches to self-management across the population. In analyses, the investigators were alert to any ethnic or gender differences in self-management that might emerge. However, few ethnic differences were particularly salient. The approach of structure and self-management was found across ethnic groups, as was the use of informal support and formal services. Differences by gender were not unexpected. Women and men differed in their resources (e.g., men but not women tended to have a spouse to help), but both genders demonstrated the range of approaches to self-management.
This study has limitations that should be considered. Data came from one area of North Carolina and may not represent other areas of the country. Although the sample of 48 was substantial for a qualitative sample, it may not have represented the complete range of behaviors and attitudes in the larger survey sample. Although home aides are an important part of some self-management strategies, complete data on the type of aides were not gathered. It would have been helpful to know the aides’ training and how those who had aides qualified to receive such services. The A1C cut points may not have been optimum but reflected the pattern of glycemic control found in the sample. Nevertheless, the study has substantial strengths. The sampling procedure to obtain the in-depth interview participants was scientifically sound and had a high response rate. These participants were themselves drawn from a population-based survey that had an excellent response rate. The study includes three ethnic groups and is one of the only studies of diabetes self-management in older American Indians.