Factors that Facilitate Patient Activation in Self-Management of Diabetes: A Qualitative Comparison across White and American Indian Cultures

The United States (US) is plagued by a high-cost health care system producing lower than desired patient quality outcomes. In 2012, the Patient Protection and Affordable Care Act was enacted to financially incentivize cost-effective models of care that improve the health of US citizens. One emerging solution is engaging patients with chronic conditions in self-management practices. Guided by Krieger's Eco-Social Theory, this study used semi-structured interviews, scales and a questionnaire to detect factors that facilitate patient activation of self-management in patients with type 2 diabetes. Managed and unmanaged participants were equally represented in the study sample. White participants and participants from two American Indian tribes located in Northeast Wisconsin were included in this study. Findings indicated the establishment of routine behavior and the ability to identify healthy alternatives when routines were disrupted support patient activation of self-management. Experiencing success such as weight loss was also identified as a factor in facilitating patient activation. Social roles and responsibilities challenged unmanaged patients. The study concluded that community, culture and environment have both a negative and positive influence on patient activation of self-management of type 2 diabetes. The current epidemics of obesity and diabetes create an apathetic response to the type 2-diabetes diagnosis that affects subsequent treatment and self-management in the communities studied. Aspects of local cultures such as unhealthy regional and tribal foods, lack of options for menu items low in carbohydrates and sugar in restaurants, high consumption of soda and alcohol and holidays/tribal events provide significant challenges for unmanaged patients. Workplace policies surrounding health insurance premiums had an impact on attendance at educational events but not on sustaining self-management behaviors. Positive aspects of the workplace include the imposition of structure and routine and the emotional support of colleagues. Warm seasons were also found to activate self-management by providing an opportunity for outdoor exercise and healthier modes of food preparation. Consistent with a previous study, high rates of childhood trauma were found among the study groups. However, findings did not support the hypothesis that levels of childhood trauma were linked to self-management. While some evidence of historical grief and loss along with associated symptoms was found among the American Indian populations, there was no correlation between managed condition and level of grief and loss. Further examination of the connection between childhood and historical trauma to the current obesity and diabetic epidemics in these communities is recommended. Recommendations for changes to public health and health care policy are included