Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 487

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Attitude and Empowerment as Predictors Of Self-Reported Self-Care and A1C Values among African Americans With Diabetes Mellitus

Diabetes mellitus rates in theUnited States have risen to epi-demic proportions (Centers forDisease Control and Preven – tion [CDC], 2012) with a correspon- ding increase in the incidence of patients with diabetes who have end stage renal disease (ESRD) (U.S. Renal Data System [USRDS] (2013). The incidence of ESRD has histori- cally been higher among African Americans than Caucasians. Accord ing to the USRDS (2013), the incidence of ESRD among African Americans has recently been declining. However, among those whose ESRD is caused by diabetes, racial disparities continue, particularly among younger African Americans. There are 4.9 million (18.7%) African Americans 20 years of age or older who have diabetes, and these individuals continue to be at high risk for the development of dia- betes-related blind ness, amputation, and kidney disease. African Ameri – cans are nearly 50% more likely to develop diabetic ret inopathy, 2.6 to 5.6 times more likely to develop kid-

Jo Ann Kleier Patricia Welch Dittman

Continuing Nursing Education

Jo Ann Kleier, PhD, EdD, ARNP, ACNP-BC, is a Professor and Director of Research, College of Nursing, Nova Southeastern University; and a Nurse Practitioner, The Urology Center of South Florida, Ft. Lauderdale, FL. She can be contacted directly via email at jkleier@comcast.net

Patricia W. Dittman, PhD, RN, CDE, MSN and PhD Program Director, College of Nursing, Nova Southeastern University, Ft. Lauderdale, FL.

Authors’ Note: This research was funded by Nova Southeastern University Health Professions Division Research Grant. The Michigan Diabetes Research and Training Center is acknowledged for use of their survey instruments.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in rela- tion to this continuing nursing education activity.

Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 494.

This offering for 1.3 contact hours is provided by the American Nephrology Nurses’ Association (ANNA).

American Nephrology Nurses’ Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu- ing nursing education requirements for certification and recertification.

Kleier, J.A., & Dittman, P.W. (2014). Attitude and empowerment as predictors of self- reported self-care and A1C values among African Americans with diabetes mellitus. Nephrology Nursing Journal, 41(5), 487-493.

Diabetes mellitus is a leading cause of end stage renal disease among African Americans. The complications associated with diabetes can largely be reduced with effec- tive diabetes self-management. Selected variables were tested as predictors of self-report- ed self-care, and self-reported self-care was tested as a predictor of A1C among 100 African-American individuals with diabetes. Participants scored high on their under- standing of diabetes, its treatment, and engagement in self-care activities, but this was not reflected in their body mass index levels or A1C values.

Key Words: Diabetes mellitus, self-care, attitudes, empowerment, theory of planned behavior.

Goal To provide an overview of the impact of self-reported care measures on individuals’ self- care activities in the management of diabetes in the African-American population.

Objectives 1. Discuss disparities in health care among African Americans. 2. Review the impact of self-care techniques in the African-American population on dia-

betic outcome measures. 3. Determine the impact of this study on nephrology nursing practice.

ney disease, and 2.7 times more likely to experience lower-limb amputation (American Diabetes Association [ADA], 2014).

Factors associated with the differ- ences in diabetes prevalence and out- comes among African Americans have been explored. Genetic predis- position is a major contributor to in – creased risk for developing subse- quent ESRD (Freedman, Tuttle, &

Spray, 1995). Health disparities, dis- proportionate healthcare resource allocation and utilization, quality of diabetes care, dietary habits, physical activity, perceived self-efficacy, and socioeconomic factors have been implicated as leading to a disconnect between treatment recommendations and self-care (Bullock, Edwards, Greene, Shah, & Blaszczyk, 2013; Gazmararian, Ziemer, & Barnes, 2009; King et al.,

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Attitude and Empowerment as Predictors of Self-Reported Self-Care and A1C Values among African Americans with Diabetes Mellitus

2010; LaVeist, Thorpe, Galarraga, Bower, & Gary-Webb, 2009; Maskarinec et al., 2009; Signorello et al., 2007). A prominent reason for the increased rate of complications, specifically microvascular complications, is inad- equate blood glucose control (Harris et al., 1999; Kirk et al., 2006). Even when adjusting for socioeconomic status, access to health care, and severity of disease, racial differences in glycemic control and ESRD persist (Freedman et al., 1995; Kirk et al., 2006; Maskarinec et al., 2009; Sarkar, Fisher, & Schillinger, 2006; Saydah, Cowie, Eberhardt, De Rekeneire, & Narayan, 2007).

The incidence of complications can be reduced through careful man- agement directed at maintaining gly – cemic control in the adult, non-gesta- tional individual with type 2 diabetes at a target A1C level of less than 7% (ADA, 2013). While diabetes manage- ment requires the cooperative activi- ties of an interprofessional health care team, the individual must ultimately assume responsibility for daily glu- cose control. Self-management of dia- betes includes adherence to pharma- cotherapy, diet, exercise, monitoring of glucose, foot care, dental care, eye care, immunization, and access to resources (ADA, 2008; U.S. Depart – ment of Health & Human Services [DHHS], 2009). Diabetes education is directed at teaching the patient how to engage in self-care.

Problem Statement

Diabetes is a chronic disease that is increasing in society, is affecting the African-American population dispro- portionately, and is the leading cause of ESRD in African Americans. The ill effects of diabetes and the associat- ed costs can be largely reduced if individuals consistently practice self- care techniques. However, such tech- niques appear to be inconsistently practiced and at an alarmingly low rate among the African-American popula- tion. Little is known about the person- al factors that may promote or inhibit the practice of self-care among the African-American population.

Purpose of the Study

The purpose of this study was to examine and describe attitude and perceived behavioral control, select- ed constructs of the theory of planned behavior, and to test these constructs as predictors of the behavior of dia- betes self-care practices among a sam- ple of African-American individuals diagnosed with diabetes.

Research Hypotheses

Two research hypotheses were directly derived from theory and were used test the theoretical propositions.

Research Hypothesis 1 Among African Americans with

diabetes, performing diabetes self-care behaviors is significantly and positively predicted by attitude towards the dis- ease and perceived behavioral con- trol over the disease.

Research Hypothesis 2 Among African Americans with

diabetes, there is a significant inverse relationship between having engaged in diabetes self-care activities and the objective measure of blood glucose control over time, A1C.

Theoretical Framework The theory of planned behavior

(Ajzen, 1985) proposes that actual behavior can be predicted based on an individual’s attitude toward that be – havior, the influence of significant oth- ers, and the perception of having the necessary tools, empowerment to carry out the behavior, and the inten- tion of carrying out the behavior. A depiction of the selected theoretical variables that were measured and the propositions that were tested using this theory are shown in Figure 1.

Literature Review Attitude has been shown to be an

important predictor of intent to carry out diabetes self-care behaviors (Clark & Hampson, 2003; Gatt & Sammut, 2008). Various factors have been shown to affect or support positive self-management attitudes in patients with diabetes, including ongoing access to information on diabetes care, treat- ment options, outcome goals, fre- quent interactions with heath care providers (Clark & Hampson, 2003; Gensichen et al., 2009; Polonsky et al., 2010), perceived difficulty in perform- ing the self-management behaviors (Gatt & Sammut, 2008; Shankar,

Figure 1 Selected Variables of the Theory of Planned Behavior, Theoretical Propositions, Research Hypotheses, and Operational Definitions

Attitude: Diabetes

Attitude Scale

Perceived Behavioral

Control: Diabetes

Empowerment Scale

Behavior: Summary

of Diabetes Self-care Activities

Evidence of

Behavior: A1C

H1 F(2, 95) = 5.02, p = 0.01

H2 rho = -0.16, p (two-tailed) > 0.05

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 489

Conner, & Bodansky, 2007), past health behaviors (Shankar et al., 2007), and health literacy of the indi- vidual (Boren, 2009; Schillinger et al., 2002).

Many of these factors have been identified as healthcare barriers for African Americans. Sorkin, Ngo- Metzger, and De Alba (2010) report- ed that 13% of the African-American patients they surveyed perceived that access and quality of health care were negatively impacted by their race. Tang, Stansfield, Oh, Anderson, and Fitzgerald (2008) demonstrated a dis- parity in attitudes between healthcare providers and African-American patients, which may have important implications for healthcare attitudes in these patients in terms of long-term diabetes self-care management.

Empowerment suggests that patients have learned enough about their disease to be able to judge the benefits and costs of adopting health- care recommendations; they have both the knowledge required to make informed decisions, and enough con- trol and resources to implement these decisions. Empowerment may direct- ly, as well as indirectly, predict per- formance of self-care behaviors, indi- cating this may be an important factor that should be taken into considera- tion by healthcare professionals when assessing the likelihood of persons with diabetes performing recom- mended self-care activities (Anderson et al., 2005; Gatt & Sammut, 2008).

Individuals with higher levels of perceived control, self-efficacy, or empowerment report better self-care practices (Bean, Cundy, & Petrie, 2007; Gatt & Sammut, 2008), which in turn are related to glycemic out- comes measures ( Johnston-Brooks, Lewis, & Garg, 2002; Jones et al., 2003; Sousa & Zauszniewski, 2005). Empowering self-management train- ing has been found to result in lower A1C levels more than didactic educa- tion (Kulzer, Hermanns, Reinecker, & Haak, 2007) and in lower long-term A1C levels (Ko et al., 2007). Partici – pation in empowerment interventions has been associated with improve- ments in metabolic and cardiovascu-

lar outcome measures, including A1C, blood pressure, and lipid levels (Anderson et al., 2005). A positive relationship exists between self-effica- cy and self-care behaviors in African- American populations (Sarkar et al., 2006).

Methods

Research Design This was a non-experimental,

descriptive, correlational study in which survey data were collected to measure participants’ perceptions of the theoretical variables and link these to their reports of engagement in dia- betes health protective behaviors.

Setting and Sampling Strategy A non-probability, convenience

sampling strategy was used to recruit African-American adults diagnosed with diabetes who self-selected as par- ticipants by being available at the time and place of recruitment and by volunteering to participate. Recruit – ment occurred at sites in South Florida where large numbers of African-American individuals were known to gather, including shopping centers, grocery stores, and churches. Sample size was determined by means of a priori power analysis using G*Power 3.1.5 (Faul, Erdfelder, Lang, & Buchner, 2012). Consideration was given to the use of continuous data, the statistical tests to be used and the number of variables considered in each test, two-tailed tests, and the sta- tistical significance criterion of alpha 0.05 and power at 0.80. A sample of 100 participants was needed to detect an anticipated medium effect.

Procedures Consenting individuals meeting

inclusion criteria completed the sur- vey instruments and provided blood for A1C testing. A1C results were reported onsite, and participants with values that exceeded the normal limit of 7% were provided brief counseling by a nationally certified diabetes edu- cator (CDE) and a recommendation to follow up with their health care

provider. All participants received educational materials related to dia- betes management (National Diabetes Education Program, 2009) and a $10.00 gift card to a local grocery store.

Instrumentation Demographic questions were

included to assure each individual met eligibility criteria and to describe the sample as an indicator of general- izability of study results.

The Diabetes Attitude Scale, 3rd version, consists of 33 items with a 7-point Likert scale that provides both a measure of general diabetes related attitudes or can be divided into five subscales. Possible scores range from 1 to 7, with higher scores indicating a more positive attitude. Responses to the items are summed and then divided by 33 if using the entire scale, as in this study. Anderson, Fitzgerald, Funnell, and Gruppen (1998) reported Cronbach’s alpha (α) values for each subscale as ranging from 0.65 to 0.80. Additional information regarding psychometric estimations is available from the University of Michigan Health System (n.d.) on its website.

The Diabetes Empowerment Scale consists of eight items with a 7- point scale that allows for a brief over- all assessment of diabetes-related psy- chosocial self-efficacy. The authors report use of rigorous psychometric testing with factor analysis and Cronbach’s alpha (α = 0.84) (University of Michigan Health System, n.d.). Res ponses are summed and then divided by eight. Higher scores indicate a higher level of per- ception of behavioral control over diabetes.

The Summary of Diabetes Self-Care Activities consists of 11 items that ask the individual to reflect over the previous seven days and self- report how frequently they carried out specific diabetes self-care activi- ties related to diet, exercise, blood glucose testing, foot care, and smok- ing. Reliability over time by means of test-retest was found to be significant. Reliability as internal consistency has

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Attitude and Empowerment as Predictors of Self-Reported Self-Care and A1C Values among African Americans with Diabetes Mellitus

been reported based on average inter- item correlations (M = 0.47) as accept- able, with the exception of the items specific to diet (consistently unreli- able) (Toobert, Hampson, & Glasgow, 2000) with Cronbach’s alphas ranging from 0.71 for diet to 0.84 for exercise (Bean et al., 2007). The range of pos- sible scores is 0 to 43, with higher scores indicating a higher level of engagement in self-care activities. Detailed instructions on scoring are provided in their report, and re – searchers considering use of the in – strument are referred to this resource for guidance.

Hemoglobin A1C was meas- ured by means of the A1CNow+® (Bayer Healthcare, 2014). The instru- ment requires a small (5 uL) blood sample that provides results in five minutes. Meter values may range from less than 4.0% to greater than 13.0%. The manufacturer provides evidence on its website that the clini- cal performance of the product has met the standards of several quality assurance agencies, including the National Glycohemoglobin Standard – ization Program, the Diabetes Con – trol and Complications Trial, and the International Federation of Clinical Chemistry.

Results Statistical analyses were carried

out using SPSS version 20. Des – criptive statistics were used to des – cribe the sample and results for the variable scores. Frequency histo – grams and the Kolmogorov-Smirnov statistic (KS) to evaluate distribution were considered for the dependent variables – scores for self-care activi- ties and A1C values. Each instrument was evaluated for reliability as inter- nal consistency by means of Cronbach’s alpha. Hypothesis testing was carried out by multiple linear regression and non-parametic bivari- ate correlation.

Description of the Sample A total of 100 participants en –

gaged in the study. The majority of these were female (n = 73, 73%), 27

(27%) were male, with ages ranging from 18 to 81 years (M = 57.7, SD = 13.2). The education level of the sam- ple is presented in Table 1. Body weight ranged from 125 to 350 pounds. Using the height and weight for 98 individuals reporting, the body mass index (BMI) was calculated and categorized (CDC, 2011) and report- ed in Table 1. Based on BMI (M = 3.57, SD = 0.64), nearly the entire sample (n = 90, 90%) was either over- weight or obese.

The participants had been diag- nosed with diabetes between less than one year to over 40 years (M = 10.61, SD = 8.38). For those who had ever completed a formal educational pro- gram for diabetes, the length of time since they completed it ranged from one to 21 years (M = 4.70, SD = 4.5).

On a scale of 1 to 7, with higher val- ues indicating better understanding, they rated their understanding of dia- betes and its treatment rather highly (M = 5.26, SD = 1.68). Diabetes rarely prevented them from carrying out their normal daily activities (M = 2.24, SD = 1.87), and they felt able to fit diabetes in their life in a positive manner (M = 5.41, SD = 1.89). Importantly, they felt comfortable asking their healthcare provider ques- tions about diabetes (M = 6.26, SD = 1.56).

A1C values ranged from 5.8% to greater than 13.0% (M = 8.23, SD = 2.05). These values were re-coded into ordinal level data, with 1 representing values from less than 4.0% to 6.0% considered non-diabetes (n = 5, 5%), 2 representing values from 6.0% to 8.0%

Table 1 Characteristics of Participants (N = 180)

Descriptive n %

Type of Diabetes

Type 1 8 8.0

Type 2 92 92.0

Management Type

Oral medications alone 72 72.0

No medications 28 28.0

Insulin alone or in combination with oral medications 32 32.0

Experience with Diabetes Education

Never participated 38 38.0

Had participated at some time 62 62.0

Body Mass Index (BMI) (n = 98)

Normal (18.5 to 24.9) 8 8.0

Overweight (25.0 to29.9) 26 26.0

Obese (30.0+) 64 64.0

Education Level (n = 100)

8th grade or less 14 14.0

Some high school 21 21.0

High school graduate 23 23.0

Technical school 7 7.0

Some college 19 19.0

College graduate 16 16.0

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 491

considered controlled diabetes (n = 55, 55%), and 3 representing values greater than 8.0% considered non- controlled diabetes (n = 37, 37%).

Responses to the Research Instruments

The scales to measure attitude towards diabetes and diabetes em – powerment were both measured by means of a 7-point Likert scale, where higher values indicated better atti- tudes and higher perceptions of empowerment. Possible mean scores for these scales ranged from 1 to 7. Possible scores for the instrument used to measure diabetes self-care activities ranged from 1 to 43. The results are shown in Table 2.

Reliability as Internal Consistency

Cronbach’s alpha was calculated for each of the scales: diabetes attitude (n = 97, α = 0.70), diabetes empower- ment (n = 99, α = 0.84), and diabetes self-care activities (n = 99, α = 0.83). All alphas met or exceeded the benchmark of 0.70, which was accepted as indica- tion of reliability. However, examina- tion of the corrected item-total correla- tions for Diabetes Attitude Scale found that 15 (45%) of the items correlated below 0.30, the benchmark considered to be acceptable.

Hypothesis Testing Hypothesis 1 sought to determine

if the measure of attitude towards dia- betes and diabetes empowerment would have a predictive relationship with diabetes self-care activities. Regression analysis found that 13.1% (R2 = 0.131, adj R2 = 0.112) of the vari- ance in the dependent variable was explained by the model and that the relationship was significant, F (2, 93) = 6.99, p = 0.001. Examination of the beta weights revealed that only dia- betes empowerment contributed to the model. Summaries of the analyses are provided in Tables 3 and 4.

Hypothesis 2 considered the cor- relational relationship between the variables of diabetes self-care activi- ties and A1C values. The values for A1C were non-normally distributed

(KS = 0.37, p = 0.00), with values tending to pile up on the upper end of the distribution. Spearman’s bivariate correlation analysis indicated that these variables were negatively corre- lated, indicating that as scores for self- care activities decreased, the values for A1C increased. However, the relationship was not significant (rho = -0.16, p [two-tailed] > 0.05).

Limitations Concerns identified during data

collection and analyses impose threats and limit both confidence in the results and ability to generalize the findings. First, South Florida is home to a large number of African Americans who have emigrated from the Caribbean islands. Their cultural and educational experiences may be quite

different from those of the broader and more culturally diverse African- American population.

All data, except assessment of A1C, relied on self-report. This is par- ticularly problematic for the report of body weight; it is suspected some par- ticipants may have reported a weight that was less than an actual measure. The instrument used to measure atti- tude was lengthy, and many items were negatively worded. These posed particular difficulty for those partici- pants with lower literacy skills. Future research would benefit from either recruiting participants from a more culturally diverse geographic area or specifying that the population of interest was more focused by using a scale to objectively measure body weight and using a shorter, easier-to- read instrument to measure attitude.

Table 2 Summary of the Scores for the Measurement Scales

Scale Range M SD n

Diabetes attitude scale 3 to 7 5.44 0.59 97

Diabetes empowerment scale 1 to 7 5.78 1.15 99

Diabetes self-care activities 1 to 40.5 25.18 9.10 99

Table 3 Means, Standard Deviations, and Intercorrelations for Diabetes

Self-care Activities and Predictor Variables (N = 96)

Variable M SD 1 2

Diabetes self-care activities 25.31 9.14 -0.07 0.31**

Predictor variable

1. Attitude towards diabetes 5.43 .59 – 0.32

2. Diabetes empowerment 5.79 1.16 – –

** p < 0.01.

Variable B SE B β t p

Attitude towards diabetes -2.99 1.57 -0.19 -1.90 -0.07

Diabetes empowerment 2.94 0.81 0.37 3.66 0.00***

*** p < 0.001.

Table 4 Regression Analysis Summary for Variables Predicting

Diabetes Empowerment

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Attitude and Empowerment as Predictors of Self-Reported Self-Care and A1C Values among African Americans with Diabetes Mellitus

Discussion and Conclusions Based on the findings from this

sample, the theory of planned behav- ior was only partially supported. Scores for diabetes attitude were not predictive of scores for diabetes self- care activities, but scores for diabetes empowerment were. Further, scores for reported diabetes self-care activi- ties were not correlated with actual A1C values. The participants rated their understanding of diabetes and its treatment rather high and reported they were quite able to fit diabetes into their lives. Scores for diabetes self-care indicated that the partici- pants perceived themselves to be well-engaged in such activities, but tended to overstate regarding their behaviors because this was not sup- ported by their BMI values or A1C results. From these results and be – cause a large number of participants had not attended formal diabetes edu- cation (and for those who had, there had been long periods of time with no refresher courses), concerns arise that there is a misconception among this population as to what constitutes dia- betes self-care activities.

Implications for Nursing All patients with diabetes should

receive formal education related to management of the disease. It is sus- pected, however, that benefits of dia- betes education tend to wane over time. Individual understanding of appropriate and correct self-care activ- ities should be periodically evaluated and frequently reinforced by the healthcare team. This is important when determining how and when to use the 10 Medicare allowable visits for diabetes self-management educa- tion and training for the first year, and two hours for subsequent years. This determined number of visits is a cost- effective approach to improve health outcomes and maintain improved con- trol of patients A1C levels (American Association of Diabetes Educators, 2010).

It is further evident that diabetes education should not overly rely on the use of written materials. Indivi –

duals from lower socio-economic or immigrant populations are more likely to have literacy limitations, so diabetes education should be offered using mul- tiple instructional methods, which may include video and audio information.

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Maskarinec G., Grandinetti, A., Matsuura, G., Sharma, S., Mau, M., Henderson, B., & Kolonel, L. (2009). Diabetes prevalence and body mass index differ by ethnicity: The multiethnic cohort. Ethnicity & Disease, 19, 49-55. Retrieved from http://www.ncbi. nlm.nih.gov/pmc/articles/PMC27024 77/?tool=pubmed

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Polonsky, W., Fischer, L., Guzman, S., Sieber, W., Philis-Tsimikas, A., & Edelman, S. (2010). Are patients’ initial experiences at the diagnosis of type 2 diabetes associated with attitudes and self-management over time? The Diabetes Educator, 36(5), 827-834.

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Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5494

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Attitude and Empowerment as Predictors of Self-Reported Self-Care And A1C Values among African Americans with Diabetes Mellitus

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1. I verify I have completed this activity. ■■ Yes ■■ No ______________________________________ 2. What do you plan to change in your practice as a result of completing this educational activity?

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5. I was able to meet the objectives of this educational activity: (Circle one) a. Discuss disparities in health care among African Americans. 1 2 3 4 5 b. Review the impact of self-care techniques in the African-

American population on diabetic outcome measures. 1 2 3 4 5 c. Determine the impact of this study on nephrology nursing

practice. 1 2 3 4 5 6. The content was current and relevant. 1 2 3 4 5 7. The objectives could be achieved using the content provided. 1 2 3 4 5 8. This was an effective method to learn this content. 1 2 3 4 5 9. I am more confident in my abilities since completing this material. 1 2 3 4 5 10. The material was (check one): ■■ New ■■ Review 11. This activity was free of commercial bias. (check one – if no please comment) ■■ Yes ■■ No

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