Self care practices, health beliefs, and attitudes of older diabetic Chinese Americans.
Article Type: Report
Subject: Health attitudes (Demographic aspects)
Self-care, Health (Methods)
Self-care, Health (Usage)
Type 2 diabetes (Diagnosis)
Type 2 diabetes (Care and treatment)
Type 2 diabetes (Demographic aspects)
Authors: Washington, Gail
Letzkus, Ming Fang Wang
Pub Date: 12/22/2009
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2009 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Winter, 2009 Source Volume: 32 Source Issue: 3
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250034408

Type 2 diabetes is one of the most chronic debilitating diseases in the United States and because of the chronicity and debilitating effects of the disease there is an increased incidence of morbidity and mortality. Consequently, a major portion of diabetes health care dollars is spent on health care and research for adults with this disease. However, research is sparse involving adults 65 years' old or older and ethnic minorities with diabetes (Chen, 2001). These underrepresented populations are vulnerable populations because they are disproportionately affected by diabetes and bear and undue burden of the deleterious effects of the disease. These populations are usually ethnic minorities who are poorer, less educated and face chronic health problems with limited access to health care. Health disparities among vulnerable populations exist and are an ongoing concern in the equitable distribution of resources (Flaskerud &Winslow 1998; Jang, Lee & Woo 1998). Consequently, chronic modifiable diseases such as type II diabetes should be a focus of research and should include underrepresented vulnerable populations. Chinese Americans, in particular, are a vulnerable population in need of evidence-based research to improve diabetes management and health outcomes.

Chinese Americans, one of the most rapidly growing vulnerable populations in the United States, have a higher incidence of diabetes than the general population (Daniels, 2006). For example, Asians are 1.5 times more likely to be diagnosed with diabetes than Caucasians (National Diabetes Fact Sheet, 2006). Although there is little data on the specific number of Chinese Americans with diabetes, it is estimated that approximately 13-21% Chinese in California (the highest in the nation) has this disease (Reyes, 2001). The prevalence of diabetes among Chinese Americans is rising and cultural and socioeconomic factors such as education, income, insurance, language and lack of acculturation prevent obtaining optimal diabetes management outcomes (Chun & Chesla, 2004; Rankin, Galbraith, & Huang, 1997; McNeely & Boyko, 2004; Peyrot, Rubin, Lauritzen, Snokes, Matthews & Skovlund, 2005; Wang & Chan, 2005).

The specific aims of this exploratory descriptive study were three fold. First, to explore the self-care practices of Chinese American immigrants with type 2 diabetes; secondly, to identify risk factors related to lifestyle, attitudes and health beliefs; and lastly, to disseminate findings in a public diabetes forum. Community Based Participatory Research (CBPR) and the Vulnerable Populations Conceptual Model for Research and Practice (VPCM) that assesses resource accessibility and relative threat to health status (Flaskerud & Winslow, 1998) provided the philosophical and theoretical approaches to guide this study. As in the Community Based Participant Research (CBPR) approach, community participation was used in every phase of the study.


According to Wang and Abbott (2001), it is necessary to provide education with an integration of cultural values into a culturally tailored diabetes management program. This intervention has been effective in improving patient outcomes. Jang, Bergman, Schonfeld & Molinarei (2007) and Lee & Shiu (2004) also determined that ethnic specific interventions facilitate self-care. Moreover, according to Marrocco, Dwyer, Bermudez & Ouyang (2001), self-care during chronic disease is better facilitated when cultural competence and congruency is incorporated in the management approach. Persons who actively engage in self-care are also affected by age and socio-economic conditions. These persons may require more assistance and may be more challenged in managing their self-care. Regardless, self-care management of chronic disease should be an ultimate goal of nursing care.

Because culture, age, and low socio-economic status affect self-care management, diet, exercise and/ or medication, they should be addressed within a multifaceted context. In particular, this context may pose concern for adults 65 years old and older. According to Aldridge (2005) self-care management in general is more challenging and problematic in this age group because of the multiplicity and chronicity of other debilitating diseases. In addition, facilitating diabetic self-care practices among different ethnic groups in general and Chinese American older adults in particular, is challenging because of cultural differences, beliefs and practices. Since knowledge is a necessary component of any chronic disease management, culturally relevant and appropriate information for diabetes care should be provided (Kemp & Chang, 2002).

Huang, Gorawara-Bhat & Chin, 2005; Meetoo &, Meetoo, 2005; and Von Korff, 1997, determined that Chinese American's self-care practices are influenced by relevant information that should include: cultural congruency, language comprehension, socio-economic status, education level and level of acculturation. The exploration of these variables using a Community-based Participatory Research (CBPR) approach with a holistic culturally relevant focus will facilitate diabetic self-care management. CBPR allows for more accurate assessment and meaningful substantive validated inferences about health care beliefs and practices. This insightful understanding is a necessary first step for culturally competent care (Chun, Organista & Martin, 2003; Schoenberg, Stroller, Kart, Perzynski & Chapleski, 2004). Using such an approach with a variety of cultures will assist health care practitioners in determining appropriate diabetic management while incorporating attitudes, health beliefs and self-care practices (Lee, 2004).


Qualitative and Community Based Participatory Research methods (CBPR) were used for this pilot study. Two Chinese senior care facilities in southern California were asked to be community partners for a research study. Management and clients from both facilities were eager to participate. When asked to identify a health care need on which to focus, diabetes management was a priority concern. Knowledge and effective interventions were needed to facilitate appropriate self-care practices. Each community wrote letters of support and the California State University, Los Angeles Institutional Review Board (IRB) approved the study. All written materials such as consent forms and recruitment flyers were written in Chinese for the participants and back transcribed in English for the researchers and the IRB. This was done to verify accuracy and appropriateness of content. Two bilingual Chinese American nursing students, trained as research assistants, assisted both researchers, one of whom was Chinese, with translation and data collection.

The pilot study was conducted in two phases. The first phase addressed aims 1 and 2, which were to explore the self-care, practices of Chinese American immigrants with type 2 diabetes and to identify risk factors related to lifestyle, attitudes and health beliefs. The second phase addressed aim 3, which was to disseminate findings in a forum. Consistent with the Community Based Participatory Research (CBPR) methodological approach of involving participants in all aspects of a study was used.

Community Advisory Board

Each facility identified three Community Advisory Board (CAB) members to assist with all aspects of the study. The CAB members provided researchers with guidance in the development and appropriateness of an interview questionnaire and participant recruitment flyer. They assisted with recruiting participants and attended focus groups for the validation of data. Each facility had a CAB that consisted of three members. Two members were clients at the facility with a history of diabetes and one was a staff member.

The researcher met with CAB members at each facility on two different occasions to discuss the need, identify the purpose and collaborate on the procedures for the pilot study. CAB members also assisted with recruiting participants for the study by providing the researchers with suggestions for participant recruitment, development and cultural appropriate of the recruitment flyer and the semi-structured interview questions. For example, the CABs suggested a $30 Chinese supermarket gift certificate instead of the planned $30 cash incentive for participants.

CAB members also suggested specific wording for the semi-structured questionnaire to increase clarity. The CAB as well, was instrumental during dissemination by generating interest in the project at each center.


Two multi-purpose senior care facilities for Chinese American immigrants in Southern California participated in the study. Each facility had a weekly attendance of more than 100 persons age 65 years and older. Flyers written in Chinese were posted in strategic places at each facility and left in place for two weeks. The flyers contained the purpose of the study, participant rights, inclusion criteria, telephone number of the bilingual coinvestigator, and stated an incentive for participation. Each facility was sufficiently large enough to provide privacy for individuals or groups.


Participants freely volunteered for the study. Inclusion criteria were: male or female; 65 years of age or older (M = 78); had a diagnosis of type 2 diabetes for at least one year; Years with diabetes ranged from 1 to 31 years (M = 9.2); were involved in some aspect of self-management; had attended the facility for at least one year or more; and cognitively able and willing to participate in individual or group discussions. Six participants from one facility, 5 males and 1 female (N=6); and seven participants from the other facility, 2 males and 5 females (N=7) totaling 13 participants (N=13) volunteered to participate in the pilot study and signed an informed consent that was written and explained in Chinese.

Other demographic information included marital status. Nine participants were married with children and grandchildren. Four participants were widows or widowers.

Five of the nine married participants lived with their children while four lived alone. The four widow/widowers lived with their children.

Although all participants had lived in the United States for 3 to 28 years, with a mean of 15 years, they were not acculturated. For example, participants predominately spoke their native language, associated only with Chinese friends and relatives and ate only Chinese foods every day. Eleven of the 13 participants still celebrate most Chinese holidays and festivals. Spiritually, 5 participants identified themselves as Christians; 2 Buddhists; and six did not specify a religious affiliation.

Data Collection and Analysis

Phase I. The first phase addressed aims 1 and 2 that explored self-care practices of Chinese American immigrants with type 2 diabetes and identify risk factors related to lifestyle, attitudes and health beliefs (Chan & Molassiotis, 1999). During the individual in depth tape recorded interviews, participants responded to open-ended questions related to self-care practices, lifestyle, attitudes, beliefs and risks associated with the chronicity of type 2 diabetes (Dunn & Hoskins, 1984). Examples of semistructured interview questions were as follows: 1) Please tell us about some of the ways that Chinese Americans in your neighborhood take care of themselves when they have diabetes; 2) What are some of the things that make it easy (or hard) for Chinese Americans to take care of themselves when they have diabetes? 3) What kinds of things do Chinese Americans think they should do to stay healthy? 4) How do Chinese Americans describe health?

The bilingual Chinese researcher and both bilingual Chinese student assistants used the interview guide to explore self-care practices, identify risk factors, attitudes and health beliefs of older adults with diabetes. Each individual interview took place in a private area at each facility. All interviews were audio taped and contained no identifying information. Both individual and group interviews lasted approximately 1 to 1% hours and were conducted over a 3-4 week period. Saturation of data was reached when theme consistently reemerged. In addition, each researcher and student assistant maintained a journal of field notes and observations for reflection.

The two bilingual research assistants transcribed and translated the recorded data. The Principal Investigator and Co-Investigator independently analyzed the data and then met to discuss the identified themes and effectively determined that interrater reliability was established. The Vulnerable Populations Conceptual Model VPCM (Flaskerud & Winslow, 1998) guided the study by identifying important variables such as cultural influence, attitudes, beliefs, resources, strengths, risks and protective mechanisms that contributed to each theme

After two themes were identified, the bilingual researcher conducted a one hour taped focus group interview at each facility to validate and clarify findings. The Principal Investigator, Co-Investigator and project consultant attended each focus group interview. The Principal Investigator and consultant were observers and made field notes that contributed to data interpretation and analysis.

Phase II. Aim 3, dissemination of findings, is addressed in the second phase. The VPCM (Flaskerud & Winslow, 1998) was used as a guide to identify the importance of culture, attitudes, beliefs, resources and personal strengths on self-care management among Chinese American older adults.

The principal investigator, co-investigator and one research assistant conducted a one-hour community forum at each facility. A PowerPoint presentation written in Chinese was used to identify and explain themes, discuss the findings, clarify misconceptions about diabetes, and to increase their understanding and knowledge about the disease. An interactive question/answer/discussion strategy was used to encourage the audience to participate in the presentation and to validate comprehension and understanding of the information presented. During the entire dissemination of findings process confidentiality and anonymity of all participants were maintained.


Saturation of data was obtained after 13 individual interviews. Interrater reliability was established when data was independently by each researcher and congruency determined. Two reoccurring 'etic' and 'emic' themes reflecting self-care management emerged from the data were: 1) self-care practices which include diet, exercise and medications; and, 2) health beliefs which include attitudes, lifestyles and health practices.

Self-care Practices

In general, all thirteen participants performed self care for overall health, and not specifically for diabetes care.

Diet. All participants realized that dietary management was necessary for managing health, but participants did not consider measuring the amount or count calories of food eaten, and merely stated they "eat less sugar" or "I don't eat a lot". Also, participants were not aware of food groups or how to make food substitutions. Only one participant said, "Diet is the primary focus for diabetics. If you eat properly, you will have better control of blood glucose levels"; every participants stated that they "reduced sugar intake and fat from [my] meals"; that "having a balanced diet, with more fruits and vegetables" was important; and that their diet consisted of "Less sugar and rice, and more acidic and raw fruits". However, all thirteen participants stated that they ate cultural foods every day. Therefore, main dishes for each meal included different kinds of rice or flour products, such as dumplings, "mein" (noodles), and "man tour" (steamed bund). Moreover, portion sizes were not explicitly stated. Only two participants used "half of banana", "size like a fist", "one third of bowl" to describe the amount of food they consume. Ten of the 13 participants emphasized having a bowl of "hot soup" or a cup of "vegetable juice" as an important part of their daily diet. None of them mentioned eating a Western diet.

Exercise. Instead of cardiovascular exercises, all 13 participants considered light stretching movements, range of motion, walking, and household chores or yard work as a form of exercise. Two participants stated that they practice "Tai Chi", "Zhangong", and Chi Kung" stretching exercises on a regular basis. One attended a structured exercise program, and two practiced Chinese exercises such as "Tai Chi", "Zhangong", "Chi Kung" and "Qigong walking". Quigong exercise in particular is considered very good exercise (Iwago, Kajiyama, Mori, & Oogaki, 1999). Both adult care centers provided 30 minutes of stretching exercise twice a day. Moreover, every participant stated that they had joined at least one exercise program at the center. Interestingly, all participants admitted that they are more sedentary since living in the United States.

Medications. All participants took at least one or more diabetic medicines prescribed by his or her physician. Seven of the 13 participants did not know the name of the medication that they were taking. Only 2 participants followed the instructions for taking the medications. Eleven participants had questions and concerns about the side effects of the medication. And, glucose monitoring was not routinely done during self-care.

In addition to the prescribed medications, they used herbal tea and medications to reduce blood sugar levels or to maintain general health. "According to Chinese traditional medicine, chrysanthemum reduces blood sugar". Another participant stated, "I also drink Jiao Gulan tea and Tuo tea. They are good for blood sugar." Consistent with Koo (1984) there were approximately 21 different herbs mentioned.

Health belief

Participants perceived health as: "no suffering of physical or emotional pain", "stable or controlled medical condition", and the "ability to perform activities independently". "Being able to eat, drink, and sleep well, and live happily everyday is the definition of health to me". "Maintaining a stable disease condition is good enough for me since I know there is no way to cure diabetes". "Health is experiencing no pain or discomfort when you perform daily living activities". Being "happy", "optimistic", "grateful", and "worry free". Participants focused on these attributes to ensure good health.

Lifestyles. Whether they live by themselves or with their children, study participants maintained a traditional, simple and routine lifestyle. The adult center is the primary place for activity and social interactions for these Chinese Americans. However, some participated in programs more actively than others.

All participants stated that diabetes did not cause lifestyle changes such as traveling, family or social gathering, etc. And, most did not perceive diabetes to be a serious disease because they had no pain, no lifestyle changes and not apparent limitations. Instead, they were concerned about other co-morbidities, such as high blood pressure, arthritis, and high cholesterol. Participants admitted that they were inconsistent, and experienced forgetfulness with medication adherence. Additional self-care was influenced by other chronic conditions such as arthritis, friends and relatives. Eleven of the 13 participants expressed a need for accurate information, clear communication and appropriate practices about self-care and the disease process. This information, according to the participants, is more respected from professional care providers.

Attitudes. Participants did not perceive diabetes as a serious disease since it did not cause pain or affect their general sense of "harmony" and ability to "function". Participants valued self-reliance "I am pretty confident about myself"; "I have to find a way to take good bear myself and not bother them [children]"; "older (seniors) should not become a burden on their children"; "We have to be independent"; "I will do it if I can do it"; "I make my own decisions on what I want to eat and what I want to buy." Consequently, all participants perceived self-reliance as an important cultural attribute. The participants valued family support and considered it important for personal well-being. Participants chose to have a holistic approach to health management rather than a disease specific focus. To maintain physiological and psychosocial health "harmony and well-being", multiple herbs were suggested and used by the participants for purposes of maintaining general health. Traditional diet, exercises and Chinese herbs and/or medicines was used as the primary care for diabetic management.

Study participants identified a number of other factors that contributed to well-being. These included: self-reliance, content with life, family support, compassion, and being in harmony with others. One participant stated that "at this age I do not have anything to worry about; I enjoy my days and I don't compete with others for anything. Every additional day is like a bonus for me, so, I enjoy every day; I cook for myself; I participate in many activities and have my social life; I also participate in a chorus and my son and grandsons visit me during the weekends and my wife takes care of my daily meals; we need to be forgiving and show kindness; treating others with compassion and harmony brings you wealth." DISCUSSION

Community Based Participatory Research methods (CBPR) and the Vulnerable Populations Conceptual Model (VPCM), (Flaskerud & Winslow, 1998) proved useful in guiding this pilot study and aided in understanding the findings. The health of older adult diabetic Chinese American is directly dependent on culturally appropriate information to provide a clear understanding of the multifaceted approach needed for diabetic self-care management. Since participants did not speak English, there was a scarcity of knowledge among these communities. Accurate, suitable, culturally sensitive knowledge can favorably influence self-care practices and attitudes can affect the relative risk of morbidity and mortality within the Chinese community (Meeto & Meeto, 2005). However, access to knowledge and other resources is particularly challenging for populations who speak little or no English. This was poignant when one participant said "I have to make reservations for travel and appointments in English which I can't do".

Consistent with prior research, participants are very concerned with 'sugar control' because diabetes mellitus translated in Chinese means "sugar in the urine". Consequently, participants believed diabetes is only caused by the over consumption of refined sugar. This belief affected participants' ability to understand or modify other risk factors that could affect diabetic control (Lai, Lew-Ting, & Chie, 2004). Participants believed that if sugar was controlled, glucose monitoring, diet and exercise need not be regularly performed. In addition, diabetes was not perceived as a serious disease since there is no pain and complications are insidious.


This pilot study suggests that although older adult Chinese Americans have been in the United States for several decades, acculturation still has not occurred (Chun, Organista & Marin, 2003). Traditional Chinese culture remains deeply embedded in every aspect of their daily lives. Health beliefs, attitudes and the self-care management of diabetes are influenced by the ability of health care practitioners to provide culturally sensitive and appropriate resource. Although the ability to speak English may be a challenge to gaining knowledge about diabetes management (Dwyer, 2006; Huang, Gorawara-Bhat & Chin, 2005) Chinese Americans continue to have "happy" attitudes and optimism within their community. This cultural belief of optimism and hopefulness suggests that physical health is mediated by subjective perceptions of well-being (Jang, Bergman, Schonfeld & Molinari, 2007). Appropriate self-care management of diabetes can provide an objective validation of physical well-being.

This pilot study supports enhancing Chinese Americans' positive beliefs and attitudes for health management. Healthy behaviors should be integrated using a holistic approach for self-care management. Positive perceptions and optimistic attitudes will optimize diabetic self-care outcomes (Jang, Bergman, Schonfeld & Molinari, 2007; Lai, Lew-Ting & Chie+, 2004).

Interventions planned with this or a similar Chinese community using a Community Based Participatory Research (CBPR) approach should capitalize on cultural strengths such as self-reliance, hopefulness and optimism. Providing information to participants should go beyond trying to change the misconceptions or negative behaviors but should focus on the strengths of the community. Collaboratively crafting an intervention for diabetic self-care management would help Chinese Americans blend the health promoting aspects of their culture with those of Western medicine (Jang, Bergman, Schonfeld & Molinari, 2007; Lai, Lew-Ting & Chie+, 2004).

Having expressed their diabetic self-care needs, Chinese Americans were grateful, and enthusiastically welcomed the opportunity to increase their knowledge and understanding of the disease. Although this pilot study provides some insight into the health beliefs, attitudes, and self-care practices of diabetic older adult Chinese Americans, the results are based upon a limited sample size and geographical location. Future research should focus on developing an intervention that capitalizes on the positive attributes inherent within the culture.

Acknowledgment: The authors would like to thank Drs.

Nancy Anderson and Evelyn Calvillo for their mentorship and assistance in completing this project. And a special thanks to undergraduate research assistants Sirong Li and Jan Cheung.

Funded by: CVPR Pilot Project Research Program P30NR005041-08


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