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Towards A Conceptual Model of T2DM Self-Management in Chinese Immigrants with Type 2 Diabetes Mellitus. Seven key interrelated components comprise the model and include: socio-demographic characteristics, behavioral and psychological characteristics, social support, linguistic barriers, cultural characteristics, T2DM self-management, and health outcomes.
Outpatient Parenteral antibiotic therapy; an economic, clinical humanistic analysist at a quaternary hospital. Project Title: A study to investigate and evaluate the impact of a clinical pharmacist on the safety and quality of the prescribing on a post take ward round. This paper presents the state of science regarding the factors that may influence diabetes self-management among Chinese immigrants in the US and the potential health outcomes. IntroductionThe World Health Organization projects that worldwide more than 180 million people have diabetes, and estimates this number will double by the year 2030 [1]. This model postulates that socio-demographic characteristics, behavioral and psychological characteristics, social support, linguistic barriers, and cultural characteristics impact T2DM self-management.
Design: Using Walker and Avant’s techniques, a search of the literature was conducted from CINAHL, PubMed, OVID, and Web of Science.
Strickland for their great help in editing the manuscript when she took their class in Spring 2010. Author ContributionsAll authors made important contributions to the manuscript preparation in terms of experimental design, literature search, literature review, conceptual model development, and data interpretation.
Potential outcomes derived from improved diabetes self-management include quality of life, glycosylated hemoglobin, and blood pressure and other cardiovascular risk factors. As the population of CIs with T2DM continue to rise, it is important that health care providers caring for this population develop optimal strategies to guide T2DM self-management.Self-management has been referred to as a set of daily behaviors that patients perform to manage their diabetes [4].
Medical treatment and decision should be made with family members rather than by the discretion of the individual [22]. Effective self-management for T2DM is important for improving diabetes related health outcomes [5]. Thus, the model also assumes that T2DM self-management primarily takes place within a family context, and both individuals and family members are influenced by the Chinese culture. Based on the review of the literature, specific research topics that need to fill the gaps in the literature were provided, including family-focused interventions for Chinese immigrant patients with diabetes and the effectiveness of these interventions to improve family functioning. Although a framework for self-management of chronic conditions has been developed [5], a culturally appropriate theoretical model is needed to guide T2DM self-management for CIs, since many continue to believe in and practice Traditional Chinese Medicine (TCM) after immigrating to the U.S. Walker and Avant suggested that conceptual model development begins with identification of focal concepts [20]. A focal concept is the starting point from which a theorist moves out to other interrelated variables or concepts [20]. The conceptual model presented in this paper will build upon previous studies of T2DM self-management in CIs as well as recommendations to guide future studies. T2DM self-management was identified as the focal concept in the proposed conceptual model because it is key for improved health outcomes in CIs. High prevalence of diabetes and impaired fasting glucose among Chinese immigrants in New York City.
A meta-analysis of self-management interventions for T2DM revealed that self-management interventions can improve glycemic control [24].
T2DM self-management behaviors include dietary modification, foot care, medication adherence, oral hypoglycemic agent administration, physical activity, glucose monitoring, and coping with the side-effects of the drug and illness progression. Since self-management involves complex and comprehensive skills, patients with T2DM must learn to evaluate and integrate a variety of these activities into their daily life to successfully perform self-management.
Most T2DM treatment relies on the ability of patients to perform these self-management behaviors correctly. Studies of T2DM self-management across racial and ethnic groups document the group’s culture and social networks can directly influence self-management behaviors [16].
Culture and social networks affect people’s ways of thinking, which people use to inform their health behaviors.Followed by identifying focal concept of self-management, a careful search and comprehensive literature was conducted to identify related factors [20]. The nature of the relationships, including the direction and the strength of relationships were also identified for T2DM self-management behaviors.
Based on the relationships with self-management, these relationships will be presented in details under the subtitles of socio-demographic characteristics, behavioral and psychological characteristics, social support, linguistic barriers, and cultural characteristics. Finally, as the last step in Walker and Avant’s 3-step model [20], the construction of an integrated representation is presented in Figure 1 above.
Socio-Demographic Characteristics AgeTwo studies found that age was positively associated with T2DM self-management.
A possible explanation for this finding is that young people who are employed could be busy, making it difficult to better manage T2DM [18].
However, the strength of the association between older age and specific T2DM self-management behaviors seems weak. For example, in the most recent study of T2DM self-management, higher educational level has been linked to better self-management in terms of taking exercise and glucose monitoring [18].
It was speculated that people with low educational level might have difficulty in understanding diabetes-related information regarding lifestyle changes and glucose monitoring [18].

Data SourcesFollowing the Walker-Avant methodology, an extensive search of the literature was conducted. Literature retrieval was conducted using the following databases: CINAHL, PubMed, OVID, and Web of Science. Behavioral and Psychological Characteristics Diabetes Self-EfficacyCoined by Bandura in 1977, self-efficacy is a key tenet in the Social Cognitive Theory [26]. The following terms were entered for the first round of literature search as key terms for the related journal articles published from 2004 to 2014 and included: diabetes mellitus, type 2, self-care, and Chinese immigrants. Diabetes self-efficacy has been defined as the judgment of one’s own capability to monitor, plan, and perform diabetes activities [27].
Since self-care and self-management, and Chinese Americans and Chinese immigrants have been used interchangeably in the literature, diabetes mellitus, type 2, self-management, and Chinese Americans were also entered during second round of search in order to obtain a full list of relevant research reports. The electronic search was supplemented by a manual search of current issues of periodicals and follow-up of other cited materials. Self-efficacy has been reported to be associated with T2DM self-management in ethnically diverse populations as well.
These findings support that incorporating self-efficacy into a T2DM education program may be a strategy to enhance T2DM self-management and related health outcomes among CIs.The definition of self-efficacy indicates that self-efficacy is behavior-specific, and efficacy beliefs may vary considerably across health behaviors [30].
For instance, if an individual has high self-efficacy with regard to exercise, this may or may not be generalized to persistence in diet management. Glucose monitoring self-efficacy, exercise self-efficacy, dietary self-efficacy, and medication self-efficacy have been separately evaluated and correlated with the frequency of adherence to glucose monitoring, exercise, diet, and taking oral medication, respectively. Therefore, understanding T2DM self-efficacy is complicated because performance in one field does not necessarily predict performance in another. It has been suggested that self-efficacy should be evaluated and presented separately for each aspect of self-management behaviors rather than constructing a general measure of self-efficacy without reference to the specific behavior and situation [31].
However, it is not clear what component of self-efficacy would have the greatest impact for improving self-management of T2DM in CIs.
It provides a comprehensive framework to explore the relationships that influence T2DM self-management among CIs. Social SupportSocial support is defined as an interaction involving two or more people whose purpose is to provide awareness and education, provide emotional instrumental, financial support, and assist with problem-solving skills [38]. A systematic review of randomized controlled trials literature on the effect of the social support focused interventions on self-management and health outcomes in T2DM found that based on limited evidence available, social support is influential on self-management and outcomes of T2DM [40]. General support from one’s family is related to improved subjective health [41], while family separation undermined T2DM management in CIs [42]. In particular, patient-appraised marital satisfaction was independently linked to T2DM management [43], because high relationship satisfaction between spouse and patient would most likely create a positive emotional atmosphere for support and empathy [44].Different sources of social support have been linked to specific T2DM self-management behavior. Support from family and friends had a beneficial effect on glucose monitoring, foot care, and following a diabetes meal plan, whereas support from health care professionals was negatively associated with adherence to a diabetes meal plan among African-American and Latino diabetic patients [45]. Likewise, Shaw and colleagues reported that support from family and friends was positively associated with adherence to diabetes meal plan and foot care, and support from neighborhood was positively related to adherence to diabetes meal plan, foot care, and physical activity [46].
These studies suggest that one source of social support may not necessarily improve all self-management behaviors and related health outcomes.
However, to date, no specific study has examined the relationship between social support and T2DM self-management in CIs.
Further research is especially needed to address the following questions: Which source of social support is linked to which specific self-management behaviors in CIs?
Linguistic BarriersLinguistic barriers have been repeatedly reported to result in communication problems with health care providers among CIs which leads to misinterpretation of information and poor diabetes outcomes [16,42,47]. CIs who preferred to speak English demonstrated higher levels of diabetes knowledge and lower level of HbA1c than those preferred to speak Chinese [47].
CIs who spoke English were also linked to receiving more T2DM self-management advice from health care providers [48].
Focus group discussions with CIs revealed that employing culturally competent health care providers or providing professional interpreter service might increase their ability to identify learning issues and promote better self-management [47,49]. However, it is worth noting that cultural familiarity and competency goes much deeper than language proficiency and simple translation. Although CIs found Chinese-language diabetes educational materials easy to read and comprehend, some CIs still thought that the verbatim translated diabetes educational materials were too simplistic to be useful. Therefore, providing language translation service is only the first step in achieving better diabetes care.
More importantly, cultural knowledge on a specific area of diabetes care can also affect diabetes care.
Cultural Characteristics Cultural Health BeliefsCulture influences an individual’s health beliefs and attitudes, thereby impinging on T2DM self-management behavior [50].
According to Andrews and Boyle, there are three views of health beliefs: magico-religious, holistic, and scientific [51]. The holistic health paradigm, which is very common in Chinese culture, attributes illness to natural imbalance. The goal of treatment is therefore to re-achieve yin-yang balance through a holistic approach [52].

The holistic health paradigm is contradictory to the western biomedical model, which takes a disease-specific focus [53]. Because the theories of TCM are based on thousands of years of experience, TCM is still commonly practiced in China and among CIs is the U.S. On the one hand, the strong adherence to traditional Chinese health beliefs among CIs with T2DM is evidenced by their reluctance to using Western medicine and desire to incorporate TCM into their diabetes treatment regimen [6]. The central idea embedded in the food balance is that certain foods have a “hot” property while others have a “cold” quality based on TCM [53].
On the other hand, extent to which CIs with T2DM seek cultural health treatments is contingent upon the level of acculturation of the patient and the family [19].
During acculturation, CIs are confronted with multiple demands in terms of accessing health care and evaluating different treatment options. They may respond by sticking to their cultural health beliefs, or adopting new disease management strategies, or integrating different forms of treatment plan together [19]. The practice of Western medicine, Chinese holistic treatment, or treatment combination of both approaches suggests a strong effect that health beliefs and practices have on T2DM self-management among CIs. Those who are less acculturated may choose to treat T2DM with TCM to restore yin-yang balance. However, the differences on how Western medicine or TCM treatment plan influences T2DM self-management remains unclear and warrants further study. Further research is also needed to address how acculturation affects T2DM self-management and health seeking patterns in CIs.
In general, foods have been conferred an important and special cultural meaning in traditional Chinese culture: they are not only considered as a survival need, but also the freedom to enjoy foods plays an integral part of people’s quality of life [19]. The T2DM dietary restrictions conflict with this cultural norm in that CIs may view these restrictions as a way of preventing them from living a full life [19].
Foods in Chinese culture also serve the purpose of building and solidifying relationships with others in a social setting, and keeping portion sizes in check may diminish the enjoyment and raise concern on how to cater to the desires of others [19]. Additionally, the carbohydrate limit, such as restriction on rice, is particularly challenging [53,55]. In Chinese families, rice is served in almost every meal and is believed to maintain holistic well-being [53].
Reduced rice consumption in a diabetic diet is thus distressing and a source of suffering for CIs with T2DM [53]. The cultural values about food restrictions underscore the importance of tailoring treatment protocols that should be culturally acceptable and followed by CIs without sacrificing their desire for a full and healthy life.
Therefore, providing language translation service and cultural knowledge on food preparation is more helpful than providing language assistance alone.
Numerous studies have found that good glycemic control is associated with effective T2DM self-management [65,66,67,68].
Two recent studies reported that CIs improved glycemic control after culturally tailored T2DM self-management program [61,69]. However, both studies employed a sing-group pre-post-test design with a relatively short follow-up period of time. In another quasi-experimental study by Chesla and coworkers [62], there was no significant change in HbA1c after the culturally adapted coping skills training. Randomized controlled trials with longer follow-up evaluation period are needed to test the long-term effect of a culturally tailored T2DM self-management program on glycemic control among CIs.
Typically, the incidence of hypertension and cardiovascular disease increases in patients with diabetes. Therefore, blood pressure is used as one of the biological outcomes to assess the risk of CIs to develop secondary cardiovascular disease in this conceptual model. It was one of the key outcomes in the Wang and Chan’s [61] pilot study who developed a culturally-tailored diabetes education program focused on T2DM self-management behaviors.
In this study, the participants’ blood pressure decreased and remained within optimal range 3 months after the program indicating that blood pressure may be a highly relevant outcome to explore as part of T2DM self-management.
However, it is not clear what changes in other cardiovascular risk factors, such as dyslipidemia, can be made in response to better T2DM self-management behaviors in this population.
T2DM self-management is therefore important for CIs to achieve better diabetes related health outcomes. T2DM self-management behaviors are influenced by multiple factors, including socio-demographic characteristics, behavioral and psychological characteristics, social support, linguistic barriers, and cultural characteristics. The relationships reported in this conceptual model should be tested and verified by future clinical trials. In addition, more research is also needed to identify the interactions between these factors. The presented conceptual model can serve as a starting point for developing a culturally tailored T2DM self-management randomized controlled trial in CIs.

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