Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
EXPLORING HEALTH PERCEPTIONS AND
DIABETES SELF CARE IN IU MIEN
OLDER ADULTS
A Thesis Presented to the Facultyof
California State University, Stanislaus
In Partial Fulfillmentof the Requirements for the Degree
of Master of Science in Nursing
ByMey C. SaephanhDecember 2015
CERTIFICATION OF APPROVAL
EXPLORING HEALTH PERCEPTIONS AND
DIABETES SELF CARE IN IU MIEN
OLDER ADULTS
byMey C. Saephanh
Signed Certification of Approval Page is on file with the University Library
Dr. Carolyn Martin, PhD, RNAssociate Professor of Nursing
Dr. Elizabeth Halifax, PhD, RNResearch Specialist, UCSF
April Roberts Aleman, MS, RNSchool Nurse, Watsonville, CA
Date
Date
Date
Signed Certification of Approval Page is on filewith the University Library
© 2015
Mey C. SaephanhALL RIGHTS RESERVED
iv
DEDICATION
To Mackenzie, Thonnie, Peter, Koy, Annie, and Nai—let’s be trailblazers. To
Roscoe and Keiko for keeping me company in the early mornings.
v
ACKNOWLEDGEMENTS
Thank you to all the participants and families in this study. You have
graciously volunteered to share your time, your home, and most importantly, your
experiences with me. To M. Saeyang, thank you for your help with translation.
To the faculty and staff at the School of Nursing, it has been a wonderful,
enriching experience. To Dr. Marla Seacrest and my classmates: Kristi, Jen, Wendy,
Melanie, Roberto, & Mahsa—it has been a blast. Marla, I’ve enjoyed your classes
and thank you for your input in this thesis.
To the Center for Excellence in Graduate Education and Student Engagement
in Research, Scholarship, and Creative Activity, thank you for your support.
To my committee chair and members, Dr. Carolyn Martin, Dr. Elizabeth
Halifax, and April Roberts Aleman, your guidance, support, and understanding have
been monumental to this chapter in my life. Carolyn you are an excellent advisor,
champion, and role model. I have enjoyed the seminars immensely and your wisdom.
Thank you for seeing this through with me. Liz, your thoughtful insights and
contributions have really improved this process for me. I utilize what I’ve learned
from your class in my practice every day. April, thank you for all the opportunities
you’ve given me. It was a pleasure to be your graduate assistant and work with you.
To my family and friends—thank you for putting up with me during this
process and for all your help. This would not be possible without you.
vi
TABLE OF CONTENTSPAGE
Dedication ............................................................................................................... iv
Acknowledgements................................................................................................. v
List of Figures ......................................................................................................... viii
Abstract ................................................................................................................... ix
CHAPTERI. Introduction........................................................................................... 1
The Impact of Diabetes ............................................................. 1Disparities in Diabetes .............................................................. 3Diabetes in the Iu Mien............................................................. 4Statement of the Problem.......................................................... 5
II. Review of the Literature ....................................................................... 7
The Chronic Care Model .......................................................... 8Diabetes and the Chronic Care Model ...................................... 11Population of Interest ................................................................ 12Role of Nursing......................................................................... 22
III. Methodology......................................................................................... 26
Institutional Review Board and Human Participants................ 26Subject Recruitment.................................................................. 26Inclusion Criteria ...................................................................... 27Procedure .................................................................................. 28Data Analysis ............................................................................ 30
IV. Findings................................................................................................. 31
Demographics ........................................................................... 31Cultural Barriers........................................................................ 33Mistrust ..................................................................................... 38Family Support.......................................................................... 39
V. Discussion ............................................................................................. 42
vii
Comparison to the General Population ..................................... 42Cultural Barriers and Mistrust .................................................. 47Family Support.......................................................................... 50Limitations ................................................................................ 51Implications for Practice ........................................................... 53
References............................................................................................................... 57
Appendices
A. Letter for use of the Care Model Image...................................................... 72B. University Institutional Review Board Approval ....................................... 73C. Informed Consent........................................................................................ 74D. Recruitment Flyer ....................................................................................... 76E. Questionnaire Tool...................................................................................... 77
viii
LIST OF FIGURES
FIGURE PAGE
1. The Care Model ................................................................................................ 9
2. Concepts Affecting Productive Western Healthcare Interactions in the OlderIu Mien Adults .................................................................................................. 33
ix
ABSTRACT
Asian Americans are at increased risk for diabetes and poor health outcomes
compared to the general population. Although the Asian American population is
increasing four times faster than the general population, diabetes research remains
limited. Diabetes research in Asian populations address the more populous groups
such as Chinese, Japanese, and South Asians; the less known ethnic groups of
Southeast Asians are often overlooked or clumped together despite differences in
health beliefs, health literacy, and access to healthcare. The aim of this study is to
describe the diabetes self care behaviors and health perception of Iu Mien older
adults. A descriptive research methodology using qualitative content analysis was
used to describe and categorize data from n=5 participants. Findings revealed themes
of cultural barriers in the form of language, knowledge gaps, and attitudes towards
Western medicine influence Iu Mien experiences with diabetes and the healthcare
system. Family support was found to be a critical component of diabetes
management. These findings increase the understanding of effective diabetes
management in this population.
1
CHAPTER I
INTRODUCTION
The Impact of Diabetes
Diabetes mellitus II (DM) is a chronic disease that affects 29.1 million people
in the United States (U.S.) (Centers for Disease Control and Prevention, 2014).
Worldwide, DM affects 387 million people and that number is expected to increase to
592 million by 2035 (International Diabetes Federation, 2013). It is a metabolic
disorder characterized by insulin resistance or a decrease in insulin production that
results in hyperglycemia (American Diabetes Association, 2014). Risk factors for
DM include age, obesity, decreased activity, genetic disposition, and comorbid
conditions such as dyslipidemia, cardiovascular disease, and hypertension.
Diagnostic criteria for DM include the following: (a) a hemoglobin A1C (measures
the concentration of glucose molecules that become irreversibly attached to
hemoglobin in red blood cells at a rate dependent on the blood glucose concentration
over the life span of the blood cell) of 6.5% or greater, (b) fasting plasma glucose ≥
126 mg/dL, (c) two hour plasma glucose ≥ 200 mg/dL/ during an oral glucose
tolerance test, and (d) a random plasma glucose ≥ 200 mg/dL/11.1mmol/L in a patient
with clinical signs and symptoms of hyperglycemia (American Diabetes Association,
2014).
Diabetes often leads to complications such as renal failure, neuropathy,
nontraumatic limb amputations, and blindness. The Centers for Disease Control and
2
Prevention (CDC) estimates that 282,000 emergency room visits are due to
hypoglycemia yearly (2014). Diabetes is the seventh leading cause of death in the
U.S. The direct financial cost of DM is estimated to be $176 billion with 43% of
those costs associated with acute hospital care (American Diabetes Association,
2013). Indirect costs such as loss in work productivity are estimated to be $69
billion. Indirect costs do not account for changes in quality of life. Those with DM
have 2.3 times more healthcare expenses than the general population (American
Diabetes Association, 2013).
The cornerstone of DM treatment is self care management. Diabetes self care
includes lifestyle changes, medication management, problem solving skills, and
education (American Diabetes Association, 2015). Factors such as health literacy,
language, culture, access to healthcare, social support, self-efficacy, and acculturation
affect the management of DM (Choi, Lee, & Rush, 2011; Ngo-Metzger, Sorkin,
Billimek, Greenfield, & Kaplan, 2011; Oza-Frank, Stephenson, & Venkat Narayan,
2011; Sarkar, Fisher, & Schillinger, 2006). The American Diabetes Association
(ADA) recommends that treatment strategies and goals be patient-centered: goals
should consider the social and work environment, cultural beliefs, medical diagnoses,
physical and mental capabilities, and health priorities of individuals (ADA, 2015).
An active well-informed patient working in tandem with the primary care provider is
the key to successful lifelong management of DM.
3
Disparities in Diabetes
Health disparities exist in the prevalence of DM. The risk of DM is higher
and health outcomes are worse in minorities compared to non-Hispanic whites (Peek,
Cargill, & Huang, 2007). Asian Americans are at a 20% higher risk for DM
compared to non-Hispanic whites and it is the fifth leading cause of death in Asian
Americans (Office of Minority Health, 2013). Although the Asian American
population is increasing at a rate four times faster than the general U.S. population
(U.S. Census Bureau, 2012), research specific to DM in Asian populations remain
sparse. The myth that Asian Americans are a model minority with successful and
prosperous lives and few problems hides the unique problems and health risks of each
ethnic subgroup of Asian Americans (Suzuki, 1977). The diversity in immigration
histories, cultural beliefs and practices, and levels of acculturation make
generalizations difficult in ethnic Asian American populations. Research shows that
the prevalence of DM differs widely among Asian subgroups (Choi, Liu,
Paloniappan, Wang, & Wong, 2013; Staimez, Weber, Venkat Narayan, & Oza-Frank,
2013). Compared to non-Hispanic whites, Asian Indians, Chinese, Filipino, Japanese,
Korean, and Vietnamese Americans have a higher prevalence of DM after adjusting
for age and body mass index (Wang et al., 2011). The prevalence of DM also varies
among Asian countries with Asian Indians having the highest rate of DM at an earlier
age compared to other countries (Diabetes Epidemiology Collaborative Analysis of
Diagnostic Criteria in Asia, 2003). To complicate matters, wide variability exists in
the recruitment, definition, and methodology used to estimate the prevalence of
4
disease states in ethnic Asian subgroups, which limits comparisons between different
racial groups and within subgroups (Staimez et al., 2013). Health studies concentrate
on the six largest groups of Asian Americans—Chinese, Filipino, Asian Indians,
Vietnamese, Korean, and Japanese—leaving a knowledge deficit among the many
other Asian subgroups.
Diabetes in the Iu Mien
Diabetes research in Asian populations usually focuses on larger and more
established populations of Asian Americans such as Chinese, Japanese, South Asians,
and Pacific Islanders. There is very little data available on the Iu Mien (Mien), a
Southeast Asian ethnic group that resettled in the U.S. under the Indochinese Refugee
Assistance Program and the Refugee Act of 1980 (U.S. Department of Health and
Human Services, 1982). The Mien share similar experiences with other Southeast
Asian refugees such as the Vietnamese, Cambodians, and Laotians; however, their
small numbers, relative isolation, lack of exposure to Western ideas, concepts, and
technology, and lack of access to education and healthcare creates challenges for
healthcare providers in the communities where they live.
Mien communities are located in California, Oregon, and Washington. In
1997, California was estimated to have 87% of the Mien population in the U.S. or
27,920 (MacDonald, 1997). A recent community population survey identified the
population of Merced County, California as 9.6% Asian and DM as one of the most
prominent healthcare problems of the county (Merced County Department of Public
Health, 2012). This county ranks 50th out of 58 counties (with rank 1 having the
5
lowest mortality and the 58th the highest mortality) in the state for deaths related to
DM in 2008-2010 (Merced County Department of Public Health, 2012). The only
survey of the Mien population in Merced County estimated the population to be 1,220
(Barker & Saechao, 1997).
Statement of the Problem
The prevalence of DM in the Mien population is not known. The absence of
aggregate data and health information for this ethnic group makes it difficult to
identify current health problems and outcomes. In a rural community where DM
related mortality is higher than the state average (Merced County Department of
Public Health, 2012), it is important to understand how DM is managed across all
populations. Prevention of both acute and long term complications of DM is largely
dependent on an individual’s understanding and management of disease and
interactions with the healthcare system. Currently, there is no data available on Mien
self management behaviors and understanding of DM. In order to help this
population have better health outcomes, more knowledge is needed about current
beliefs, behaviors, and healthcare practices. The purpose of this study is to explore
basic healthcare practices and understanding of DM in older Mien adults. This study
will review the disparities in healthcare among Asian Americans, the history and
migration of the Mien to the U.S., and discuss the role of nursing in health promotion
and the management of DM. Qualitative research methods were used to explore
participants’ understanding of their disease with the primary goal of expanding the
6
knowledge for healthcare practitioners and identifying areas for interventions to
improve health outcomes in this group.
7
CHAPTER II
REVIEW OF THE LITERATURE
The World Health Organization (WHO) reports that chronic diseases
are responsible for 68% of the worlds’ deaths in 2012 (2014). The WHO has
identified four major groups of chronic diseases: (a) cardiovascular diseases such as
heart attacks and strokes, (b) respiratory diseases such as asthma, (c) cancer, and (d)
diabetes (DM). Chronic diseases are preventable by modifying risk factors through
interventions aimed to change behaviors such as tobacco use, unhealthy diets, and
physical inactivity. Chronic disease treatments and associated costs can propel
individuals into poverty and decrease productivity, undermining conditions needed
for sustainable development in many countries (World Health Organization, 2014).
Chronic diseases are more prevalent in developed countries such as the United States
(U.S.) where some of the most advanced healthcare technology is available. This
chapter will briefly review the shift of U.S. healthcare systems from acute care to
primary care; describe the Chronic Care Model, an effective framework for
reorganizing healthcare to manage chronic diseases; review the little that is known
about the Iu Mien (Mien), and review the role of nursing in DM.
In the U.S., 117 million people have one or more chronic health conditions
with 86% of U.S. healthcare dollars being spent on chronic medical conditions
(Centers for Disease Control and Prevention, 2015b). With longer lifespans and an
increasing population of older adults, the Institute of Medicine’s (IOM) report,
8
Crossing the quality chasm: A new health system for the 21st century, recognized the
need for a redesign of the healthcare system to meet the challenges of caring for
chronic diseases (2001). The IOM made recommendations for a healthcare delivery
system focused on the delivery of safe, effective, timely, patient-centered, efficient,
and equitable care (2001). The high costs and challenges of managing chronic
diseases have led to a paradigm shift in the provision of healthcare in the U.S.
Previously, healthcare primarily focused on treating acute life threatening medical
conditions. Current shifts in healthcare policy and changes in reimbursements are
now focused on the prevention of complications and exacerbations of chronic
diseases in the community setting (Patient Protection and Affordable Care Act, 2010).
The Chronic Care Model
The Chronic Care Model (CCM) provides a framework for a comprehensive
system to provide high quality care for people with chronic diseases (Wagner, 1998).
The CCM was created out of the realization that patients with chronic diseases
needed regular, planned interactions in the primary care setting with a focus on
prevention of complications and exacerbations (Wagner, 1998). It outlines methods
to provide support for both healthcare providers and patients in the management of
chronic disease through six key elements: (a) Health systems, (b) Delivery system
design, (c) Clinical information systems, (d) Self-management support, (e)
Community resources and policies, and (f) Decision support (Wagner, 1998). The
CCM was later modified into the Care Model by Wagner and colleagues at the
MacColl Center for Healthcare Innovation (2002). The Care Model (Figure 1) added
9
recommendations from the IOM 2001 report, which includes care that is safe, patient
centered, timely and efficient, evidence based, and well coordinated (MacColl Center
for Healthcare Innovation, 2002). The CCM is a blueprint to improve health
outcomes through integration of better patient self management, and healthcare
provider support, meaningful use of evidence based guidelines in clinical informatics,
and effective utilization of community resources.
Figure 1. The Care Model (reprinted with permission from MacColl Center
for Healthcare Innovations, 2002, see Appendix A).
10
Listed below are the bulleted points of the CCM framework.
Health systems should promote a culture of safety and quality patient care
and move towards a proactive approach (prevention). To decrease fragmented
care, organizations should prioritize chronic diseases, facilitate
communication, and initiate care coordination.
Delivery system designs should include planned regular visits and follow up
for patients. All members of the primary care team should have defined roles
and tasks. Case management should be provided for complex patients and
care should be culturally appropriate.
Clinical information systems should be used to organize patient and
population data to facilitate care and make communication between different
care providers easier. Systems should be designed that can monitor the
performance and provide feedback for the care team for quality improvement
processes as well as provide reminders for evidence based care.
Self management support is crucial to empower the patient to act as the
principle in managing his or her disease. This includes strategies for patients
to manage their health through problem solving, action planning, and
acquiring skills to self manage and linking them to community resources. It
differs from the traditional patient education which offers information and
technical skills and moves towards an informed, active participant involved in
his or her own care.
11
Community resources and health policies need to focus on preventative and
quality care, which includes reimbursement modalities.
Decision support includes the integration of evidence based clinical
guidelines in the management of chronic illnesses (Bodenheimer, Lorig,
Holman, & Grumbach, 2002; Bodenheimer, Wagner, & Grumach, 2002a;
Bodenheimer, Wagner, & Grumach, 2002b; Wagner, 1998; Wagner et al.,
2001).
Diabetes and the Chronic Care Model
The American Diabetes Association’s (ADA) recommendations incorporate
all six elements of the CCM into its standards of care (2015). Diabetes self-
management education (DSME) and diabetes self-management support (DSMS) are
recommended to provide individuals with the problem solving skills and knowledge
to be active in caring for oneself. Both DSME and DSMS are patient centered with
individual’s needs, goals, capacity, and experiences driving the process. Both DSME
and DSMS address psychosocial issues and support. Strategies for improving DM
care include: changing the system of healthcare delivery by decreasing fragmentation
in care coordination; aligning reimbursement strategies to reward high quality care
rather than visit based billing; supporting patient behavior changes through lifestyle
modifications; enhancing health team behaviors to address barriers to care; and
integrating evidenced-based guidelines in practice (ADA, 2015).
Diabetic interventions using one or more of the CCM components have been
found to be effective at improving health outcomes. A systematic review of the use
12
of CCM elements in DM found that many elements were incorporated into healthcare
systems with good outcomes such as reductions in hemoglobin A1c (hbA1c) and
improved foot care (Stellefson, Dipnarine, & Stopka, 2013). Interventions ranged
from obtaining support from governing boards of health systems, using automated
telephone calls to remind patients, health registries, training healthcare providers on
evidenced based guidelines, and the implementation of diabetes days for some
primary care offices to improve patient outcomes. Delivery system redesign was
identified as one of the most important strategies for incorporating DSME by
addressing accessibility to DSME classes. However, few studies looked at
community resources and healthcare policies and their effects on improving DM
outcomes highlighting the need for growth in community resource partnerships
(Stellefson et al., 2013).
Population of Interest
The population known as the Iu Mien (Mien) in the U.S. and Yao in Asia
lived in isolation in the hills of Laos. Most were subsistence farmers and had limited
access to education and healthcare (Moore-Howard, 1989). As refugees with poor
education and socioeconomic means, their experience and integration into U.S.
differs vastly from more recognized Asian groups such as the Chinese, Koreans, and
Japanese. The Mien are often grouped together with other Laotian refugees or
mistaken for the Hmong. Both the Hmong and Mien share similar histories and had
limited contact with Western society and medicine until the 1970’s. Thus the Hmong
13
is the most comparable group for examining phenomena in the Mien when no data is
available.
Historical Background
The earliest references to the Mien places them in the Chinese provinces of
Hunan, Hubei, Jiangxi, and Anhui between the 5th and 8th century before Christ (B.C.)
(MacDonald, 1997). Although there is controversy regarding the Mien’s first
appearance in the written history of China, there is a general consensus that the Mien
resisted taxation during the Han Dynasty (221 B.C.-A.D. 220) and had a tumultuous
relationship with the government of China for centuries. Centuries of revolt and
rebellion resulted in the Mien losing their land and migrating to the mountainous
regions of southern China and Southeast Asia. Despite the extensive migration of the
Mien throughout Asia, scholars note that the Mien have been able to maintain a
strong degree of cultural identity (MacDonald, 1997). The Mien throughout Asia are
identified by four common traits:
(1) A common descent from a totemic ancestor known as Bienh Hungh (Pan
Wang in Chinese); (2) a restricted literacy in Chinese characters with which
they write traditional forms of literature and religious texts; (3) a syncretic
religion combining ancient Chinese Taoist rituals, animistic beliefs, and
ancestor worship; and (4) a long legalistic relationship to the majority cultures
of the countries in which they lived (MacDonald, 1997, p. 15).
14
Secret War in Laos
In the 1970’s, the U.S. became actively involved in preventing the spread of
Communism to the area formerly known as Indochina (Vietnam, Cambodia, and
Laos) with military troops deployed to Vietnam. To further the efforts of South
Vietnam against communist forces, the Central Intelligence Agency (CIA) proposed
to use native guerilla fighters in Laos (Leary, 2007). The Mien fought as a part of
Hmong General Vang Pao’s Armée Clandestine trained to disrupt supply lines and
gather intelligence. With the fall of the U.S. backed Royal Lao government to the
Pathet Lao, many Mien that served in the Royal Lao military or aided the CIA were
persecuted by the new regime. Many fled on foot to Thailand where they applied for
asylum and permanent resettlement to other countries (MacDonald, 1997).
Refugee Health
From 1975 to the 1980s, many Southeast Asians were admitted to the U.S.
under refugee status, spurring research about their care and integration into society.
The plight of a refugee differs from that of immigrants moving for socioeconomic or
family reasons. The 1951 Refugee Convention defined a refugee as the following:
…owing to well-founded fear of being persecuted for reasons of race,
religion, nationality, membership of a particular social group or political
opinion, is outside the country of his nationality and is unable or, owing to
such fear, is unwilling to avail himself of the protection of that country; or
who, not having a nationality and being outside the country of his former
15
habitual residence as a result of such events, is unable or, owing to such fear,
is unwilling to return to it. (United Nations, 1951, Article I, section 2).
Many Southeast Asian refugees experienced physical and emotional trauma from
war, relocation from their country of origin, and life in the settlement camps of
Thailand. These experiences include torture, malnutrition, and forced abandonment
of home, belongings, and family members. Many of the Mien faced interrogations,
threats, and abduction of young men into the Communist armies (Moore &
Boehnlein, 1991). Men were forced to flee ahead of their wives and families since
they were in the most imminent danger, leaving behind women, children, and the
elderly to make the dangerous trek to Thailand on their own (MacDonald, 1997).
Crossing the Mekong River held its own dangers with Thai pirates and heavy bribes.
Those who made it into the refugee camps faced limited food, water, and unsanitary
conditions. Additionally, many rumors ran throughout the camps about Americans:
Americans were cannibals (Moore & Boehnlein, 1991) and no Mien would be safe
from scientific experiments (MacDonald, 1997). Many Mien waited in the refugee
camps from one to five years before emigrating to the U.S. Only families that
actively assisted the U.S. were allowed admittance. Other families resettled in France
and Canada (MacDonald, 1997).
In the aftermath of resettlement, refugees continue to experience post
migration challenges such as cultural and language barriers, loss of cultural identity,
acculturative stress, and discrimination. Their experiences are associated with high
levels of posttraumatic stress disorder (PTSD), anxiety, and depression (Nicholson,
16
1997). Southeast Asian refugees with PTSD were found to be less engaged in
maintaining cultural tradition and ties, tended to express more anger, and were
usually dependent on public assistance (Abe, Zane, & Chun, 1994). Higher trauma
scores have been associated with increase age, higher prevalence of chronic diseases
such as hypertension and DM, and decreased access to healthcare (Kinzie et al., 2008;
Wagner et al., 2013). Common health problems and conditions among refugees are
mental health (adjustment disorder, depression/anxiety, PTSD, social isolation), pain,
and undiagnosed chronic conditions (anemia, asthma, DM, hypertension, chronic
obstructive pulmonary disease, Vitamin D deficiency, dyslipidemia) rather than
infectious diseases such as tuberculosis (Eckstein, 2011). Evidence also suggest that
the longer refugees stay in the U.S., the more at risk they are for DM due to changes
in diet, exercise, lifestyles, and lack of social support associated with acculturation
(Garcia Rios, & Rodriguez, 2008; Huh, Prause, & Dooley, 2008; Oza-Frank,
Stephenson, & Venkat Narayan, 2011).
Healthcare Use
Among Southeast Asian refugees, the use of Western healthcare varied.
Among Cambodians, Vietnamese, Laotians, Chinese Vietnamese, and Hmong, the
Hmong were the least likely to utilize Western healthcare (Chung & Lin, 1994). The
most significant predictors of utilizing Western healthcare among all five groups were
educational level, English proficiency, and age. Women compared to men across all
five Asian subgroups tend to use traditional healthcare methods (Chung & Lin, 1994).
Fifty-eight percent of Southeast Asian patients (Cambodian, Lao, Mien, and ethnic
17
Chinese) at an Oregon refugee clinic were found to use traditional healthcare
practices, although the prevalence and type of traditional method varied among the
four ethnic groups surveyed (Buchwald, Hooton, & Panwala, 1992).
Mien refugees reported used cupping and moxibustion—two Eastern
traditional practices that leave marks on the skin—more than any other groups
(Buchwald et al., 1992). Religion was found to heavily influence the healthcare
behaviors and medical beliefs of a small Mien community in California (Gilman,
Justice, Saepharn, & Charles, 1992). Many of the Mien sought treatment from
physicians for their symptoms and reported taking Western and Eastern medications
for 72% of their illness. The Mien purchased over the counter treatment including
several medications imported from Thailand, Hong Kong, and Canada. Medications
that should be available only by prescription such as penicillin were easily accessible
to the Mien in local Asian markets (Gilman et al., 1992).
Health Literacy
Health literacy is one of the largest barriers to healthcare. Health literacy is
defined as an individual’s ability to process and understand health information to
make informed decisions about his or her healthcare needs (IOM, 2004). Language,
culture, and education are key factors in determining an individual’s health literacy.
United States (U.S.) Census data shows that 38.4% of Laotians (comprised of the
many ethnic groups of Laos such as Laotian, Iu Mien, Khmu, Tai Dam, and Tai Leu)
have poor English-speaking skills compared to the overall aggregate Asian population
of 31.9% and the general U.S. population of 8.7% (Southeast Asia Resource Action
18
Center, 2011). Thirty-seven percent of Hmong respondents report speaking English
less than “very well.”
The Hmong share similar emigration experiences and exposure to Western
culture as the Mien; however, due to their large numbers the U.S. Census treats the
Hmong as a separate category. Educational levels also differ with 67.5% of Laotians
and 64.6% of Hmong completing a high school level education compared to the
overall Asian and U.S. population of 85.9% and 85.6% respectively (Southeast Asia
Resource Action Center, 2011).
Poor health literacy results in poor health outcomes. Asians with limited
English proficiency reported fewer glucose and feet checks compared to non-
Hispanic whites (Choi, Lee, & Rush, 2011). The lack of translators and healthcare
information in languages specific to the many different Asian ethnic groups
contribute to poor outcomes among Asian Americans (Choi et al., 2011). Perez and
Cha (2007) found that lack of equivalent terminology regarding physiology, anatomy,
medical terms, and health beliefs were barriers for Hmong patients. Johnson’s study
of Hmong focus groups highlighted the complexity of the language barrier:
“Explaining about a malfunctioning kidney would require that the interpreter use a
lengthy paragraph to say what could be said with one word in the English language”
(2003, p 127). As a group, Southeast Asians have been described in literature as the
passive obedient patient (Uba, 1992). Southeast Asians view health professionals as
the medical authority and either through cultural restraints, fear of embarrassment,
fear or misunderstanding of the legal system, will often not divulge information or
19
further question the authority person (Uba, 1992). In their work treating psychiatric
disorders in the Mien, Moore and Boehnlein (1991) found that the Mien patient will
avoid addressing issues such as ineffective medications to show respect and protect
the physician’s honor. These cultural behaviors and perception of medical authority
make it difficult for meaningful patient and primary care provider interactions.
Traditional Healthcare Beliefs and Practices
Traditional healthcare practices among Southeast Asians include the following
practices: coining, cupping, pinching, moxibustion, and healing ceremonies
(Buchwald, Hooton, & Panwala, 1992). Coining is done by stroking the skin firmly
with the edge of the coin resulting in red streaks on the skin. It is done to “scrape”
away the illness or disease. Pinching uses pressure applied between the fingers to the
skin. Cupping uses a cup with burning paper placed on the skin. As the paper burns
off and the cup cools, it causes circular, red marks to appear on the skin.
Moxibustion is the creation of small, superficial burns on the surface of the skins with
incense, candles, or herbs. Traditional pinching, cupping, and moxibustion are to
improve qi (life energy in Chinese) circulation in the body. A traditional healer or a
shaman performs healing ceremonies. These rituals target the source of the illness in
accordance with each ethnic group’s beliefs.
Mien patients were found to use moxibustion, cupping, and healing
ceremonies (Buchwald et al., 1992). Moxibustion, cupping, home remedies, and
herbal medications were used for illnesses attributed to physical causes whereas
healing ceremonies were used for ailments with a spiritual cause (Gilman et al.,
20
1992). These ceremonies collectively called sipv mienv are performed for a variety of
reasons including warding off evil spirits and ensuring good health. The ceremonies
also include spiritual money and meal offerings to the spirits or ancestors by
slaughtering and preparing feasts with a chicken, pig, or cow.
The Mien believe that some physical symptoms and conditions are caused by
angry spirits or soul fright and utilize a combination of Western medicine to cure the
physical symptoms and sipv mienv to address the spiritual cause. In addition to
physical ailments, offending the spirits and ancestors can also cause bad luck. Many
Mien believed that the inability to properly bury loved ones that died fleeing to the
refugee camps has created angry spirits (MacDonald, 1997). These spirits can be
contacted through healing rituals with priests. However, the time and cost involved
in finding both herbal remedies and arranging sipv mienv were found to be barriers to
traditional healthcare practices in the U.S. (Gilman et al., 1992; MacDonald, 1997).
These barriers prompted many Mien to convert to Christianity (MacDonald, 1997).
Family and Social Structure
Traditional Mien culture places the extended family as the nucleus of the
social unit, often with three generations of family members in one household
(MacDonald, 1997). Large households ensured that there were enough sons or
daughters to care for the house owner in old age and to care for his or her spirit in the
afterlife. Larger households could also accumulate wealth easier and quicker as
income was shared. Filial duty and mutual dependence between parents and children
are traditional values. During resettlement, many Mien families would move into a
21
single apartment complex with multiple vacancies to recreate a village like
environment since housing occupancy restrictions did not permit large numbers
(MacDonald, 1997). Current adaptations include family members purchasing and
living in homes near each other to provide continued support.
Mien society is patrilineal with women placed lower in the hierarchy than men
of the same generation with the exception of the elderly who are respected without
differentiating between genders. Traditional gender roles placed child rearing,
cooking, gardening, and sewing as women’s work whereas men hunted, fished, and
farmed. Children are adored and well cared for by their grandparents while the
parents worked. Adoption practices for couples that could not have children are
widely accepted in Mien villages (MacDonald, 1977).
In the process of integrating into the U.S., many of these traditional roles have
weakened. In order for families to be economically viable, many women began
working outside of the home and gained power and independence. Childcare
continued to be the responsibility of the grandparents. With both parents out of the
home and the children in school, parents were not able to spend time passing their
own heritage and language to their children. The different levels of acculturation
have resulted in intergenerational conflict as roles have changed (Ying & Chao,
1996). The elderly became dependent and lost social status while children who were
able to learn English easier take on adult roles and responsibilities to help the family
navigate the American system. Western values of independence taught to children at
22
school conflicted with traditional cultural values of family, group identity, and
ancestral relationships (MacDonald, 1997; Ying & Chao, 1996).
Education
For centuries, the Mien relied on oral traditions to communicate and pass
down stories. The Mien have three distinct languages with different functions: the
daily spoken vernacular, literary language, and the ritual language. The literary and
ritual languages are forms of Chinese (MacDonald, 1997). Traditionally, only men
were afforded the opportunity to learn to read and write basic Chinese characters as a
way to record family data. Priests as part of their duty in maintaining religious and
historical scripts had more extensive training in the ritual and literary languages. The
economics of subsistence farming did not allow for many Mien to send their children
to school in the lowland communities of Laos. During the Indochinese war, the CIA
selected men for specialized training at a CIA-run academy in Thailand. These men
learned English and acted as air controllers for American pilots (MacDonald, 1997).
Most Mien became exposed to English script as part of the educational
programs in the refugee camps in Thailand. Literacy programs were instituted to help
the process of acculturation. Upon arriving to the U.S., many stressors such as the
need for financial stability, lack of childcare and transportation made it difficult for
many Mien to get further education.
Role of Nursing
The IOM’s The Future of Nursing: Leading Change, Advancing Health
(2011) called for nurses to perform to the fullest extent of their training and potential.
23
Nurses, as the largest group of healthcare professionals, are uniquely positioned to
effect changes in many settings. In an evolving healthcare system responsive to
individual needs and patient-centered care, nurses need to be full partners, “taking
responsibility for identifying problems and areas of waste, devising and implementing
a plan for improvement, tracking improvement over time, and making necessary
adjustment to realize established goals” (IOM, 2011, p. 32). Nurses need to take an
active leadership role in shaping and directing the revised healthcare system,
initiating policy, advancing research, using technology, and promoting evidenced
based care (IOM, 2011). Nurses’ holistic discipline lends itself to improving patient
interactions; care can truly be designed to meet the needs and lifestyle of the patient.
Bodenheimer, MacGregor, and Stothart (2005) argues that nurses are instrumental to
managing chronic diseases and posits better communication between the nurse and
patient as the rationale for positive interactions and outcomes. Traditional strengths
in nursing such as disease education, health promotion, and therapeutic
communication align with the transformation in healthcare to focus on chronic illness
management and patient centered care. Nursing professionals must expand their roles
in health promotion and prevention across all settings and to all populations.
There is conflicting information about the effectiveness of nurses in the
management of DM. A Cochrane Review found nurses to play a significant role in
leading patient centered interventions (Renders et al., 2000). Nurse led interventions
were found to improve measurable DM markers in the short term (Lew, Nowlin,
Chuun, & Melkus, 2014). Another review found that the involvement of DM nurse
24
specialists had little effect on improving hypoglycemic incidences, hospital
admissions, or quality of life (Loveman, Royle, & Waugh, 2003). Telephone nurse
case management of DM was found to be ineffective at improving hbA1C (Edelman
et al., 2015). These finding suggest that more research is needed to examine the role
of nurses in the management of DM.
The U.S. Mien population is facing chronic diseases that have not been
recognized previously in Laos. Literature regarding the health conditions of this
ethnic group is sparse. The majority of the literature documenting and providing
information about Mien society, culture, and identity has been conducted by other
disciplines such as anthropology (MacDonald, 1977). There is a lack of knowledge
of how best to serve this population in the management of DM. Research that
includes ethnic minorities point to improved outcomes with patient-centered and
culturally appropriate interventions (Hawthorne, Robles, Cannings-John, & Edwards,
2008).
Rising costs in healthcare and poor outcomes have led to systems changes in
healthcare to focus on health promotion, prevention, and management of chronic
diseases. The CCM posits that meaningful interactions are possible in the
management of chronic diseases when both patient and healthcare provider have the
knowledge, support, and resources on both local and systemic levels. Nursing
professionals, with their holistic view of the patient experience, should lead the way
in exploring solutions for improving the patient experience, researching and
disseminating information for all the healthcare team to utilize, and affecting policy
25
to increase better health outcomes for all. An initial step within the Mien population
is to explore recent practices of the Mien and their management of DM. In addition,
it is crucial to understand how acculturation has affected health beliefs, practices, and
behaviors surrounding the care of DM in the home.
26
CHAPTER III
METHODOLOGY
This exploratory study used a qualitative design method to explore the
healthcare beliefs and diabetes (DM) self-care management behaviors of older Iu
Mien (Mien) adults. Qualitative content analysis is an appropriate methodology when
little is known about the subject matter or when knowledge is fragmented (Elo &
Kyngäs, 2007). It allows inferences to be made from the data to their context
(Krippendorf, 1989). The goal of content analysis is to condense data into themes
that describe the phenomena (Elo & Kyngäs, 2007).
Institutional Review Board and Human Participants
University institutional review board (UIRB) approval and informed consent
was obtained from all participants in the study. A copy of the UIRB approval letter is
available in appendix B. The UIRB approved participant consent form is available in
appendix C. Consents were read to participants in the language of their choosing
(English or Mien). The author is fluent in Mien.
Subject Recruitment
A convenience sampling size of n=5 participants were recruited by snowball
sampling. Key informants within the Mien community in a rural community in the
United States (U.S.) were asked to communicate the information regarding the
research by word-of-mouth. Recruitment flyers (see Appendix D) were posted in
various community locations such as Asian food markets, health clinics, churches,
27
and community gathering areas and the author spoke with various community
members.
An initial meeting prior to the interview was arranged with each participant.
During the meeting, study parameters were discussed and informed consent obtained.
To build trust, the initial visit was done with the referring community member
present. Mien social etiquette and customs were observed including but not limited to
accepting offerings of food and drink, polite conversation, and inquiries about the
health of various family members. Participants were given a $10 gift card for their
participation at the end of the interview.
Inclusion Criteria
Participants were selected based on a self-reported diagnosis of DM.
Participants had to be of Mien ethnicity, age fifty or older, and born outside of the
U.S. The cut off age of 50 was selected because the vast majority of Southeast Asian
refugees that settled in the U.S. under the Indochinese Refugee Assistance Program
and the Refugee Act of 1980 were under the age of 34 (U.S. Department of Health
and Human Services, 1982). In addition, the greatest number of people with DM
worldwide is between the age of 40 and 59 (International Diabetes Federation, 2013).
Participants had to speak either Mien or English and be willing to participate in a
face-to-face interview. Participants were excluded if diagnosed with gestational
diabetes, have hearing or speaking impairments despite the use of assistive
communication devices, or unable to participate in a face-to-face interview.
28
Procedure
The participants were given a copy of informed consent and it was read in the
language of their choice. Once informed consent was obtained, a meeting time was
arranged to interview the participant in his or her home. The home setting was
integral to the goal of observing self-care behaviors. Any family member that took
part in the participant’s care was allowed to participate in the interview. A semi-
structured questionnaire tool (see Appendix E) created with input from experienced
researchers was used. Interviews were digitally recorded with consent.
Measurements
Weight was obtained by the following procedure:
The scale is placed on a flat, even, non-carpeted surface.
The scale is cleaned with disinfectant wipes and zeroed according to
manufacturer’s instructions.
Participant removes shoes and socks and any bulky outerwear clothing such as
jackets and scarves.
Participant stands on the scale until weight is displayed in kilograms and
recorded.
Height was obtained by the following procedure:
Participant removes shoes and hat.
Participant stands on even, non-carpeted surface with back to the wall and
heels touching the wall.
29
A straight edge level is placed on the top of the participant’s head; adjust until
level is perpendicular to the ground.
The bottom edge of the level is marked with a piece of tape.
The distance from the floor to the bottom edge of the tape is measured with a
measuring tape.
Data were recorded in centimeters.
Body mass index (BMI) was calculated using the online tool from the Centers
for Disease Control and Prevention (2015a). Participants were asked to demonstrate
a DM self care behavior in the home such as foot care, glucometer use, meal
planning, or medication administration.
Debriefing
After the interview was completed, observational notes were reviewed to
confirm the accuracy of the information obtained. Participants were asked what they
felt was the most important thing they shared and to review key points identified as
salient. The debriefings were used to refine questions for subsequent interviews.
Translation
Audio recordings were transcribed verbatim to English. For idiomatic
expressions or vocabulary without a direct English translation, the author consulted
with a Mien community member to derive the meaning of the sentence within the
context of the paragraph. A consensus was reached regarding the English translation
of the expression while preserving the Mien meaning.
30
Data Analysis
Inductive qualitative content analysis was used to encode the data and
organize codes into categories as they emerged (Elo & Kyngäs, 2007). Data were
read multiple times to achieve emersion. Open coding was used to analyze each
sentence. Key words were the unit of analysis. Key words were identified and
compared, context interpretations were made and grouped into categories (Elo &
Kyngäs, 2007). Subcategories were grouped into main categories until no further
abstraction could be made.
The author worked with a researcher with expertise in qualitative and
quantitative data. Both author and researcher worked independently to identify key
words. Key words were categorized into groups with similar themes. Themes were
compared and a consensus was reached. Participant feedback related to the themes
was obtained.
31
CHAPTER IV
FINDINGS
Demographics
All participants (n=5) were first generation Iu Mien (Mien) refugees with self
reported diabetes mellitus II (DM). Participant A produced medical records from
2012 with DM listed in the history and physical and a hemoglobin A1C (hbA1C) of
10.9. Participants B, C, and E all had family members that confirmed the diagnosis
of DM. The mean age of the participants was 60.8 years with a range of 55-68. The
average years of residence in the United States (U.S.) was 33.8 years. Three
participants were male, two female. Four out of the five participants received some
sort of education in the U.S. with two of the males receiving 4-5 years of education—
mostly English as a second language and vocational training courses as part of
California’s public assistance program. Four of the participants reported the ability to
read and write English and two of the participants, D and E, were able to read and
write “some” in the Unified Mien Script. Two participants preferred the interview in
Mien and three English. All were married. Participant A’s spouse was present and
participated in the interview. Participant B and C’s spouses were present, but did not
contribute to the interview discussions. All of the participants practiced the
traditional religion. Two of the participants converted back to the traditional religion
from Christianity.
32
All five participants had co-existing health conditions in addition to DM as
shown in Table 1. The mean Body Mass Index (BMI) was 38 with four participants
Table 1 Health Data
Age Body Mass Index Medical History Medication RegimenMales Kg/m2
A 56 21.8 StrokeHypertensionRetinopathyNeuropathyHyperthyroidism
MetoprololCilostazolHydroclorothiazideGlipizideProbenecidLisinoprilClopidogrelLevothyroxineVitamin B12LovastatinAllopurinolInsulin glargine
C 63 46.4 Heart failureObstructive sleep apneaMetastatic cancerHypertensionArthritisPancytopeniaChronic obstructivepulmonary diseasePneumonia
MetforminCarvedilolValsartanHydrochlorothiazidePotassiumAspirinFenofibrateSimvastatinHydrodone/acetaminophenFluoxetineGlimepirideAtroventFurosemideAzithromycin
E 55 42.7 Cardiovascular diseaseMyocardial infarctionHypertensionHigh cholesterolChest painPercutaneous coronaryintervention with stent
MetforminGlyburideAspirinSimvastatinMetoprololNitroglycerinClopidgrelLisinoprilAmlodipineIsosorbide mononitrateFamotidine
FemaleB 68 40.4 Hypertension
HyperlipidemiaHigh cholesterolGastroesophageal refluxdiseaseDepression
MetforminProtonixAspirinFluoxetineMetoprololDiltiazemHydrochlorothiazideTriamtereneAlbuterolSimvastatinGlyburide
D 62 39 Hypertension MetforminSpironolactoneHydrocodone/acetaminophen
33
meeting the Centers for Disease Control and Prevention’s definition for obesity
(2015a). Participants had a mean of 10.2 medications prescribed. Only one
participant (age 62) in this study had three prescription medications. All the other
participants (age 56-68) reported taking 11 to 14 medications.
The participants in this study expressed views about their DM and experiences
with healthcare that centered on the following themes: cultural barriers, mistrust, and
family support. Cultural barriers led to feelings of mistrust when interacting and
utilizing the Western healthcare system. Strong family support helped to mitigate
both cultural barriers and mistrust (See Figure 2).
Figure 2. Concepts Affecting Productive Western Healthcare Interactions in
Older Iu Mien Adults.
Cultural Barriers
Cultural barriers stemmed from language barriers, attitudes toward illness, and
knowledge gaps. They emerged in the use of the term sweet blood to describe DM,
FamilySupport
MistrustCulturalBarriers
34
the perception that it was not important, knowledge gaps regarding disease process,
and the inconsistency in how it was managed.
“Sweet Blood”
The term sweet blood encapsulates the concept of a language barrier that was
prevalent in the data. Participants’ understanding of DM was hindered by language
barriers as a result of the lack of terminology to describe pathophysiology and
anatomy in DM. Diabetes was translated by the participants as sweet blood as there
was no terminology for DM in the Mien language:
Participant A: Diabetes…what—what—what can I say? I know exactly. Its
uh—uh—uh, from your—uh—sweet blood is not good. That’s all I can tell.
That’s it.
Researcher: That’s it? Are there Mien words to describe it?
Participant A: No, whatever, diabetes, we have no words to call it. We Mien
say our blood sweet is high. I mean blood is sweet. Sweet blood is not good.
That’ it. That’s what we call diabetes.
Participant E reported that sugar in the blood made it difficult for the blood to travel,
equating it to his understanding of cardiovascular disease. This participant did not
know the terminology for blood vessels. Participants also did not have language to
describe the different types of medical practitioners and used English terms for doctor
and physicians assistant (P.A.).
Due to the lack of terminology, participants often interpreted healthcare
providers’ counseling literally. Participant B and D related the causation of DM to
35
intake of candy; their understanding of DM stemming from the association of
elevated blood glucose with dietary lifestyle modifications recommended by
healthcare providers:
Participant B: I don’t know. I just hear the doctor say my blood is sweet and
told me not to eat candy.
Researcher: Candy? What kind?
Participant B: Candy. The sweet stuff. But I don’t eat that much candy.
Sometimes I eat a little or eat small amounts from grandchildren—they bring
it over. The doctor says to not eat candy, rice, and to exercise.
Researcher: What causes your blood to be sweet? How does it happen?
Participant B: Well—the doctor says not to eat sweet things. L.Y. [daughter-
in-law] says the same thing—it must be the food here.
The concept of carbohydrates was not familiar to any of the participants; rather, it
was the association of sweet tasting things and rice that caused the blood to be sweet.
During one interview for example, a participant was eating spicy beef jerky and was
unaware of the high sugar content in the product.
The ability to communicate with the healthcare provider was important. One
participant chose his healthcare provider based on his ability to understand her:
This doctor, she tries to help, but if we don’t understand, she says it again in
easy words, but she’s India, so sometimes it’s hard to understand her. That is
the one we kept.
36
Participant E described a hospital encounter where she struggled to communicate
with staff:
I pressed the button, there was a voice coming into the room but I didn’t know
what it said—no one came for a very long time. When someone did come, I
pointed to the bathroom. It was cold too. I had to wait til L. Y. or F. H.
[family] or someone to come so I could tell them to tell the people that I was
cold.
Diabetes is Not Important
Diabetes was not viewed as a serious condition by any of the participants
because of the lack of symptoms. Most participants described healthy as being able
to undertake physical activities such as walking, baby sitting, sewing, and harvesting
crops—not the absence of disease. One participant included mental capacity in his
description of good health and another participant described healthy as freedom from
pain, dietary restrictions, medications, and independence from other people. Two
participants described themselves as healthy. Participant A stated:
I can talk. I can walk. Do everything…only when you can’t do things—just
getting old that’s it. Other than that—I’m okay. That in Mien words—I’m in
good health.
Most participants did not think their DM made them sick due to the lack of
identifiable symptoms. One participant described that seeking the treatment of
doctors was something only to be done in extreme cases of illness in Laos, especially
since it required a one to two day journey by foot through the jungle. Similar views
37
were expressed by other participants regarding when to seek medical care. Only one
individual saw his healthcare provider on a regularly scheduled basis. Two
participants had recent hospitalizations involving other comorbid conditions that they
considered more serious than DM. All five participants were asked whether they had
a healing ritual performed in regards to their DM. Four participants did not think DM
warranted a healing ritual, citing that DM did not affect their health greatly. One
participant thought it was an organic condition of the body rather than a spiritual
condition.
Knowledge Gaps
Participants reported symptoms indicative of progressive DM disease such as
neuropathy, but did not attribute the cause to DM. Participant A describes a deer
hunting episode as the reason why his feet became numb. All five participants could
not physically distinguish when their blood sugars were elevated by symptoms alone,
nor did they report experiencing any symptoms outside what they considered their
norm. Participants C, D, and E reported illness associated with other comorbid
conditions. None of them recognized the role that DM play in exacerbating their
comorbid conditions and illnesses such as congestive heart failure, pneumonia,
cellulitis, and chest pain respectively. Knowledge gaps existed between the purpose
of self care behaviors and the prevention of complications as indicated by participant
E’s comment, “All I do is poke it, write down the number. What am I suppose to do
with that number? It’s high—that’s why they gave me medicine.”
38
Managing Diabetes My Way
Diabetes self care behaviors were performed inconsistently for most
participants. Each participant/family unit performed it according to what was
convenient for them. All the participants mentioned self monitoring of blood glucose
(SMBG) as part of their prescribed regimen and oral hypoglycemic agents.
Additionally, Participant A used insulin. Participants A, B, C, and E were on two
medications for DM. Most participants were not consistent in performing SMBG:
participants C and E disliked being “poked” by needles. Participants A, B, C, and E
reported taking their medications whereas participant D did not take the oral
hypoglycemic agent due to side effects that interfered with her ability to work.
The participants did not share their regimen adjustment or concerns with their
healthcare providers. Participant A recognized signs of hypoglycemia and the
subsequent need for assessing blood glucose. His insulin was recently increased from
16 units to 20 units. Participant A also stated that a blood glucose of 70 was too low
for him. However, his concerns regarding lowering his blood sugar was never
discussed with the healthcare provider and he planned on waiting to discuss his
hypoglycemic episodes until his next follow up appointment.
Mistrust
Cultural barriers and ineffective communication lead to the feelings of
mistrust for the participants. Mistrust took many forms. Participant E reported that
his student doctors spoke to each other, but not to him. He felt excluded from
39
discussions. He viewed his healthcare providers as students—“young doctors” and
therefore not real doctors. This led to perceptions of inequality of treatment.
Participant A and his family described incidences of mistrust with interpreters.
They expressed concerns that healthcare providers were not aware when interpreters
were giving out wrong information: “The doctor says one thing and they [interpreter]
say something else” and “… he [interpreter] doesn’t know how to speak any Laos or
Mien, but he pretends he does.” In this instance, the healthcare providers are also
perceived as being deceived by the interpreter. One participant recounted an incident
involving the hospitalization of a family member requiring surgery and viewed the
hospital provided interpreter as working for the hospital and the physician rather than
being there to help them. Participant C described a time when he was at an
appointment with his family support person:
I asked what was cancer and the doctor talked for a while. The person—she
just said, “You have cancer, it’s bad and you can die.” That was all she said.
That’s when C. [daughter] got mad and talked over her to the doctor.
Participant B chose not to go to appointments if a family member was not with her.
Family Support
The concept of family support emerged as a theme for participants. All the
participants had varied levels of assistance with their healthcare from a family
member. Many of the participants relied on family members to help with
appointments, medical interpretation, and meal preparation. Those who were more
independent acquired their skills and understanding from family members.
40
Participant B and C were dependent on family members to provide routine SMBG
care, assistance with medications, and appointments. Participant A shared
responsibility with his family member, but was capable of performing SMBG on his
own. The interaction between participant A and his family demonstrate a supportive
relationship:
Participant: Hmmmm. I don’t know. I just take them [medications]. But
these—these—I know—I don’t feel dizzy with them. Or it could be this one
too. This one is new, they gave it for—ah—for—my neck surgery for—for…
Family: Not this one, you’ve been on this one for a while.
Participant: Is it this one?
Family: You said it’s the one for the neck surgery. The one you’ll have to
take always. It’s the newest one of your medicines.
Participant A self-administered his insulin nightly, but required assistance from his
spouse when he needed to rotate injections to the left abdomen. Participant D had a
family member check her blood pressure. Participant E was the most independent,
but relied on his family member to understand DM. He had a daughter also
diagnosed with DM. Participant B was the most dependent on family members for
her care—a family member assisted with medication, accompanied her to
appointments, and performed her SMBG.
Family also dictated care practices: participant E did not use traditional
practice of consulting the spirits in his home in deference to his wife’s religion:
Researcher: Do you do healing rituals?
41
Participant E: No. I’ll go to them, to the eating part, but I don’t do my own.
My wife doesn’t like it. I used to be Christian too, but then I got a heart attack
and I switched back.
Researcher: You switched back because of the heart attack.
Participant E: My ex wife was Christian and she wanted me to be Christian so
that’s why I did it. After we divorced, I went back…I left the church, but my
wife [current spouse] is Christian. The sipv mienv—sometimes they help. If
I need to do it—I do it at my brother’s house.
The majority of participants reported positive family interactions. There was usually
one identifiable key family member that took on the bulk of the caregiving role. Only
one participant lived in the same physical home as his family support person.
42
CHAPTER V
DISCUSSION
Comparison to the General Population
The complexity of care was evident throughout the participant’s responses.
From polypharmacy to lifestyle changes—there appeared to be large gaps in
understanding and performing of self care behaviors. This highlights the difficulty in
managing diabetes (DM) when cultural barriers in the form of language, knowledge
gaps, attitudes towards Western healthcare, and mistrust color the Iu Mien (Mien)
health experience.
The management of DM is often compounded by the complexity of managing
multiple chronic disease conditions at the same time. Diabetic disease progression
and complications such as end stage renal disease (ESRD), myocardial infarction
(MI), stroke, and heart failure (HF) varied in the participants. Although this study
specifically recruited Mien participants with DM, all of the participants had at least
one other chronic disease. The most common triad of chronic diseases among United
States (U.S.) adults is hypertension, arthritis, and DM (Ward & Schiller, 2013).
Although only one Mien participant reported arthritis, all participants reported having
hypertension. Similarly, 57% of Hmong diabetics reported having hypertension
(Johnson, 1995). A study looking at a large patient population in northern California
compared the risk of complications (MI, ESRD, stroke, HF, and nontraumatic lower
extremities amputations) in Chinese, Japanese, South Asian, Filipino, and Pacific
43
Islander with African American, Latino, and White participants and found large
variations within the Asian groups’ risk for disease complications compared to White
participants (Kanaya et al., 2011) highlighting the need for studies in disaggregate
Asian subgroups.
Cultural beliefs about medicine and health influenced how closely individuals
followed treatment regimens. Self monitoring of blood glucose (SMBG) was
inconsistent and infrequent by all participants. This is similar to findings from the
2009 California Health Interview Survey that reported that Asians compared to non-
Hispanic whites, African Americans, Hispanics, and American Indian/Alaskan
Natives were the least likely to perform SMBG (Kim, Ford, Chiriboga, & Sorkin,
2012). Previous studies found that the Mien have cultural beliefs that influence
attitudes to blood and invasive procedures (Moore & Behnlein, 1991). Although
most Mien have become comfortable with lab draws when necessary, frequent draws
similar to the lab work in the hospital setting and large amounts of blood drawn are
causes for concern.
Obesity
Obesity is a risk factor for many chronic diseases. Of interest was the fact that
four of the five participants were obese or morbidly obese. This surpasses the
prevalence of obesity found in in the general U.S. adult population of 34.9% (Ogden,
Carroll, Kit, & Flegal, 2014). In the Asian American population, the risk of having
DM is higher even after adjusting for body mass index (BMI) prompting the
American Diabetes Association to recommend lowering the BMI screening threshold
44
of 25 kg/m2 to 23 kg/m2 for Asian Americans (2015). Data from the Nurses’ Health
Study showed that for every 5 kilogram of weight gained in Asian women, the risk of
DM increases by 84% compared to 37% for Caucasian women (Shai et al., 2006).
Asians also have a higher body fat percentage per BMI compared to Caucasian
populations internationally (Deurenberg, Deurenberg-Yap, & Guricci, 2002).
Obesity trends may be related to multifactorial causes such as food
deprivation, lifestyle changes, acculturation, and cultural views of body image. Prior
to their arrival to the U.S., the participants in this study were active subsistence
farmers with minimal access to processed foods. They were physically active and
had a diet consisting of regional vegetation, crops, and livestock. Researchers have
hypothesized that food deprivation can lead to overconsumption of foods once
restrictions are lifted (VanEenwyck & Sasbel, 2003). The Mien faced malnutrition
and limited food supplies in the refugee camps. It was not uncommon for parents to
feed insects to their children when food rations were short (M. Saeyang, personal
communication, October 18, 2015). Cultural ideas of beauty and wealth may
contribute to obesity as well. The Mien equate obesity with wealth and health (M.
Saeyang, personal communication, October 18, 2015). Those that could produce
food in excess of their immediate needs were able to stockpile and barter for other
goods. Food that could not be stored or bartered immediately was consumed thus
showcasing wealth and health by the person’s ability to produce larger quantities of
food (M. Saeyang, personal communication, October 18, 2015).
45
Acculturation Effects
It is difficult to tell in the Mien participants whether DM was a pre-existing
condition or developed through the process of acculturation. Acculturation is the
process of adopting the culture, beliefs, and traits of another group (acculturation,
n.d.). Studies of immigrant populations show that immigrants are generally healthier
than the native born population, but over time, this healthy effect disappears as the
immigrants acculturate and lifestyle habits change (Antecol & Bedard, 2006; Cho &
Hummer, 2001; Devlin, Roberts, Okaya, & Moua Xiong, 2006; Frisbie, Cho, &
Hummer, 2001; Jasso, Massey, Rosenzweig, & Smith, 2004; Marmot, Adelstein, &
Bulusu, 1984). Although the Mien arrived to the U.S. as refugees, it can be argued
that selectivity was for the healthiest Mien, able to make the journey from Laos to the
refugee camps of Thailand. This does not preclude the Mien participants from having
chronic diseases such as DM prior to their arrival in the U.S. The International
Diabetes Federation (2013) estimates that South-East Asia region (consisting of India,
Sri Lanka, Bangladesh, Nepal, Mauritius, and Maldives) and Western Pacific Region
(consisting of multiple countries including Australia, New Zealand, China, Thailand,
Cambodia, Fiji, Samoa, Vietnam, and North Korea) account for 60% of all people
with undiagnosed DM. Poor access to healthcare in Laos and the practice of utilizing
doctors for symptomatic illnesses could account for the DM being undiagnosed.
Most of the participants were unaware of the symptoms of DM. The few participants
that were currently aware of symptoms may not have had this knowledge 10-20 years
ago nor accessed the healthcare system until symptoms started. A longitudinal
46
analysis of various Asian populations from the California Men’s Health Study lend
support to the high risk of DM in immigrant Asians compared to U.S. born Asians
(Erber, 2014). Immigrants are exposed to acculturative stress and other risk factors
increasing their risk for DM (Erber, 2014).
Polypharmacy
Polypharmacy is the use of more medications than medically necessary
including medications that are not indicated, therapeutic duplications, or they are
ineffective (Maher, Hanlon, & Hajjar, 2014). Polypharmacy can result in an increase
in adverse drug reaction, medication non adherence, and decreased functional
capacity in older adults (Maher et al., 2014). Without a clinical exam and laboratory
data, it would be difficult to surmise whether the medications were clinically
indicated or not. Polypharmacy is complicated by the ability to understand the
instructions on the medication labels.
Complicated medication regimens are often associated with non-adherence to
medication (Maher et al., 2014). Multiple medications are often prescribed for a
single chronic disease such as cardiovascular disease. As adults develop multiple
chronic diseases, it is very easy for the number of prescribed medications to increase.
Other studies have shown that 29% of adults, age 75 to 85 years, use five or more
prescription drugs regularly and that half of those participants regularly use over-the-
counter medications or supplements additionally (Qato et al., 2008). The use of five
or more medications increases with age (Qato, et al., 2008).
47
The number of drugs prescribed compared to the general population is
concerning due to the relatively young age of the participants and the higher than
average number of prescription medications reported. One possible explanation for
this is the increase in intensity of chronic disease treatment and the number of
comorbid conditions of the participants. Studies in treating psychiatric disorders in
the Mien have shown that certain classes of medications are poorly tolerated or have
ineffective therapeutic effects (Moore & Boehnlein, 1991). This may be the case for
some participants with resulting non-adherence and healthcare providers prescribing
more medications to manage an uncontrolled chronic disease process.
Cultural Barriers and Mistrust
Cultural barriers continue to be significant obstacle to better outcomes in older
Mien adults. Despite their years of residency in the U.S., the participants continue to
struggle with English. Many of these participants arrived to the U.S. as young adults
with young children to care for and did not have time for formal education.
Language is a critical component to health literacy; however, interpreter
services for many Asian languages are not always available. This is compounded by
languages such as the Mien that do not have equivalent terminology for medical
terms including anatomy, physiology, and exposure to concepts of cell and germ
theory prior to settlement in the U.S. Terminology is often borrowed from different
languages: one example is the use of the Thai word mbau waanx for DM in a Mien
dictionary (Purnell, 2012). None of these participants were familiar with this term
since they were not from Thailand and did not have access to healthcare there.
48
There are no standardized national or state interpreter certifications available
for the Mien language (Bureau of Labor Statistics, 2015; National Board of
Certification for Medical Interpreters, 2012). Interpreter services used in locales such
as hospitals under California Health & Safety Code §1259 describe a competent
interpreter as someone with the ability to translate body parts, injuries, and symptoms
fluently in the language in question. However, these are decided by the agency
employing or contracting such persons and the dilemma arises when the language
itself does not have the vocabulary for such body parts. The use of telephone
interpreter services is a common widespread practice, however, it can diminish the
relationship between the patient and the healthcare provider (National Diabetes
Education Program, 2006). One narrative from this study demonstrated that the Mien
are uncomfortable with phone interpreters. There is a lack of face-to-face contact
which is important for creating trust, especially in a culture that had limited access to
communication technology.
Participants continue to have difficulty understanding terminology—even
those that were confident in their English speaking abilities. This parallel findings
from the Cambodian Community Health Behavioral Risk Factor Surveillance which
showed that 76% of participants relied on hospital or health center interpreter and
among those that reported that they spoke English well enough to converse, 35%
continued to want an interpreter in the healthcare setting (National Diabetes
Education Program, 2006). Health literacy is not endemic to just limited English
speakers, even native English speakers have difficulty understanding medical
49
terminology and understanding medical forms and directions (Institute of Medicine,
2004).
The inability to communicate differences in cultural beliefs and the lack of
knowledge regarding diseases processes and treatments has caused the Mien to
mistrust the Western healthcare system. Similar findings of cultural barriers and
mistrust are found in other refugee Asian populations such as the Hmong and
Cambodians (Johnson, 2002; National Diabetes Education Program, 2006).
Additional findings in the Hmong population include high rates (52%) of multiple
disease conditions in Hmong refugees, knowledge gaps of acute versus chronic
disease, and knowledge gaps regarding DM pathophysiology and symptoms, and
complications (Johnson, 1995).
The Hmong, which have equally limited access to Western ideas and
concepts, also have very similar diets where large amounts of rice is consumed daily
with every meal and similar beliefs about taking blood from the body (Johnson,
2002). The Hmong were found to self adjust Western medication regimens (Johnson,
1995). Similar findings of regimen adjustment were also found in other Asian groups
such as Cambodian and Korean Americans where health beliefs drove the use of
Western and traditional treatment modalities (Cha et al., 2012; National Diabetes
Education Program, 2006). Communication barriers have led to incidences of
mistrust in the Western healthcare system for other refugees. Refugees have already
experienced psychological and often physiological trauma and abuse and often have
50
difficulty with trust (Eckstein, 2011). Similar incidences of cultural barriers and
mistrust are well documented in the Hmong (Fadiman, 1998; Johnson, 2002).
Family Support
The role of social support has been studied in DM. Support varied from the
acquisition of knowledge, management of disease, material support, to coping
strategies (Kadirvelu, Sadasivan, & Ng, 2012). The younger generation of family
members had a strong role in managing and guiding care of DM. This behavior is
consistent with traditional values of caring and respecting Mien elders. However,
many of the participants did not live in the same household as their support person
making it difficult for the caregiver to perform interventions such as meal preparation
and self monitoring of blood glucose (SMBG).
Family behaviors can enhance self-management behaviors of DM in the home
(Mayberry & Osborn, 2012). Direct support such as assistance with diet, exercise,
and medication was reported as the most common type of support (Mayberry &
Osborn, 2012). Other immigrant populations such as the Chinese immigrants were
found to rely on family and friends as resources for DM care instead of health
professionals (Leung, Bo, Hsiao, Wang, & Chi, 2014). The types of support reported
by participants centered on medication and direct interactions with healthcare
providers.
Knowledge, motivation, and social support are independent predictors of DM
self care behaviors which in turn predicts glycemic control (Osborn & Egede, 2010).
The participants in this study have minimal knowledge of DM and low impetus for
51
change since DM is asymptomatic and the complications are not well understood by
the participants. Participants relied on family members to tell them how to manage
their medications and disease and needed confirmation from family members before
trusting others.
Recruitment
The author had difficulty recruiting participants. Similar to other Southeast
Asian refugee communities, the Mien have mutual assistance associations (MAA)
where elected Mien leaders act as a contact point between the Mien community and
society at large. The author spoke with Mien leaders in an attempt to recruit
participants, but was unsuccessful. This could be due to decrease self awareness of
DM in Mien individuals or a low prevalence in this population. It wasn’t until the
author approached individual community members—mostly caregivers working in
the healthcare system—that awareness peaked regarding the study. This highlights
the importance of family/caregiver roles in this population. A potential avenue for
healthcare providers to disseminate information to this population is to partner with
this community by working with willing Mien leaders. Similar local partnership with
the Hmong community have involved cross training of physicians and Hmong
Shamans to promote a better understanding of both traditional Hmong healthcare
practices and Western medicine (Agency for Healthcare Research and Quality, 2010).
Limitations
The descriptive findings in this study are specific and cannot be generalized to
a large population; however, it allows for the phenomena to be examined in detail.
52
Additional limitations include the number of participants; further research efforts
need to recruit more participants. A cross sectional study of the population would
also be useful to obtain data about the prevalence of DM. Limitations in research
methodology included the skill, experience, and bias of the author in designing and
conducting interview questions and inductive analysis of content. Participants were
recruited via snowball sampling and are not representative of the Mien population.
The validation of identified themes is a limitation of the study. Two
participants with the most formal education were contacted to discuss the final
themes. The two participants had difficulty understanding the concept of themes.
The author explained the process of how themes were derived from the meaning of
the participants’ interviews. One participant expressed disagreement with the themes
identified compared to his literal responses in the interview. The other participant
agreed that the themes reflected his experience managing his DM and accessing the
healthcare system. The discrepancy in responses appeared to be associated with each
participant’s ability to understand the concept of themes. Although both these
participants felt comfortable in conversational English, many literary concepts remain
foreign and difficult for them to comprehend. This suggests that different approaches
for theme validation should be considered in populations with low literacy levels.
Data collected regarding height and weight did follow a standard protocol
using the same scale, however beyond routine disinfection and care, and zeroing of
the scale prior to each use, no method was used to calibrate the scale to assess the
53
validity of the weights obtain. Future research design can include a calibration
protocol for the measurement of weight.
Blood glucose readings obtained by the participants were either self-reported
or from glucometer readings. The use of a glucometer with quality controls and a
written protocol would help to obtain accurate blood glucose data. Since all the
participants declined to demonstrate a self care behavior, it is difficult to verify that
glucometers were used appropriately. Participants reported that they felt
uncomfortable being on camera and cited embarrassment and not wanting to look
“foolish” in front of the author as the main reasons for declining. Also, the
participants may not have trusted the author with the recorded material.
Although various family members were present during the interviews, only
one caregiver was present. The caregiver’s presence and participation in the
interview was beneficial in that she confirmed and validated the experience of the
participant. It also provided insight to how the caregiver-patient relationship
functioned. However, because this participant had expressive aphasia, the family
caregiver talked over the participant occasionally and her presence may have
prompted the participant to behave differently or answer questions differently.
Implications for Practice
Cultural barriers, mistrust, and family support were themes underlying Mien
health beliefs and practices in DM revealed in this study. Family support helps to
mediate participants self care behaviors and interactions with the healthcare system.
Older adults rely on family members to provide medical care, help with medications,
54
organize and keep track of appointments, and interpret in the healthcare setting.
Cultural barriers were prevalent in participants’ understanding of DM and self care
behaviors. Generally, the Mien lack terminology to discuss medical conditions,
anatomy, and pathophysiology and perceive healthcare recommendations literally.
This was found to contribute to participant’s perceptions that DM was not important
since most participants did not have any symptoms. Cultural barriers played a role in
participants’ mistrust of the healthcare system, difficulty understanding their disease,
and ability to navigate a complex and often fragmented healthcare system.
These findings highlight issues in the ability of the older Mien adults to
perform DM self care behaviors and successful management of their disease. Many
research studies have demonstrated the need to disaggregate data regarding Asian
ethnic minorities. However, multiple Asian ethnic minorities and lack of funding
make it difficult to implement these studies. Commonalities were identified between
groups with similar shared experiences and histories suggesting that carefully
designed inclusion criteria for recruiting subjects may elicit more meaningful data.
Individualized, patient-centered and culture specific DM self management
education must go beyond providing classes and materials in an individual’s
language. Culturally appropriate assessments and modifications need to be made to
improve health outcomes. Healthcare providers need to be aware of the impact of
language, cultural obstacles, and healthcare experiences when designing diabetic
regimens.
55
Healthcare providers should discuss with the patient whether there is person
that takes on the main caregiver role and communicate with both the family support
person and the patient, with the patient’s permission. Clinical information systems
design can be modified to include involving caregivers through the use of reminder
technologies such as texts and phone calls and clinic hours that can accommodate
working caregiver schedules. It is important for healthcare providers to recognize the
extent of the role of the caregiver/family support person and to include them in
clinical activities.
Nurses are uniquely positioned to affect change for many vulnerable
populations such as the Mien. Nurses can use their strength in communicating to
identify areas of miscommunication and lack of trust. Nurses can improve education
and offer recommendations for patient-centered care and culturally appropriate
interventions in both outpatient and acute care settings. Nurse researchers must
continue to work with vulnerable populations to better understand cultural nuances in
order to improve health outcomes.
REFERENCES
57
REFERENCES
Abe, J., Zane, N., & Chun, K. (1994). Differential responses to trauma: Migration-
related discriminants of post-traumatic stress disorder among Southeast Asian
refugees. Journal of Community Psychology, 22(2), 121-135.
doi:10.1002/1520-6629
acculturation. (n.d). In Merriam-Webster’s online dictionary. Retrieved from
http://www.merriam-webster.com/dictionary/acculturation
Agency for Healthcare Research and Quality. (2010). Use of spiritual healers
reduces cultural misunderstandings and conflicts and increases satisfaction
among hospitalized Hmong patients. Retrieved from
http://www.medscape.com/viewarticle/728470_4
American Diabetes Association. (2013). Economic costs of diabetes in the U.S. in
2012. Diabetes Care, 36(4), 1033-1046. doi:10.2337/dc122625
American Diabetes Association. (2014). Position statement: Diagnoses and
classification of diabetes mellitus. Diabetes Care, 37(S1), S81-S90.
doi:10.2337dc14-2081.
American Diabetes Association. (2015). Standards of medical care in diabetes—
2015. Diabetes Care, 38(S1), S1-S93. doi:10.2337dc15-S001
Antecol, H. & Bedard, K. (2006). Unhealthy assimilation: Why do immigrants
converge to American health status levels? Demography, 43(2), 337-360.
58
Barker, J. C. & Saechao, K. (1997). A household survey of older Iu-Mien refugees
in rural California. Journal of Cross-Cultural Gerontology, 12(2), 121-143.
doi:10.1023/A:1006534300043
Bodenheimer, T., Lorig, K., Holman, H., & Grumach, K. (2002). Patient self-
management of chronic disease in primary care. Journal of American Medical
Association, 288(19), 2469-2475. doi:10.1001/jama.288.19.2469
Bodenheimer, T., MacGregor, K. & Stothart, N. (2005). Nurses as leaders in
chronic care [Editorial]. British Medical Journal, 330(7492), 612-613.
doi:10.1136/bmj.330.7492.612
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002a). Improving primary care
for patients with chronic illness. Journal of American Medical Association,
288(14), 1775-1909. doi:10.1001/jama.288.14.1775
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002b) Improving primary care
for patients with chronic illness. The Chronic Care Model, part 2. Journal of
American Medical Association, 288(15), 1909-1914.
doi:10.1001/jama.288.15.1909
Buchwald, D., Hooton, T. M., & Panwala, S. (1992). Use of traditional health
practices by Southeast Asian refugees in primary care clinic. The Western
Journal of Medicine, 156(2), 507-511.
Bureau of Labor Statistics. (2015). Occupational Outlook Handbook, 2014-15
Edition, Interpreters and Translators. Retrieved from
59
http://www.bls.gov/ooh/media-and-communication/interpreters-and-
translators.htm
California Health & Safety Code § 1259
Centers for Disease Control and Prevention. (2014). National diabetics statistic
report, 2014. Atlanta, GA: U.S. Department of Health and Human Services.
Retrieved from http://www.cdc.gov/diabetes/pubs/statsreport14/national-
diabetes-report-web.pdf
Centers for Disease Control and Prevention. (2015a). About adult BMI. Retrieved
from
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Inter
pretedAdults
Centers for Disease Control and Prevention. (2015b). Chronic diseases: The leading
causes of death and disability in the United States. Retrieved from
www.cdc.gov/chronic disease/overview/index.htm
Cha, E., Yang, K., Lee, J., Min, J., Kim, K. H., Dunbar, S. B., & Jennings, B.M.
(2012). Understanding cultural issues in the diabetes self-management
behaviors of Korean immigrants. The Diabetes Educator, 28 (6), 835-844.
doi:10.117/0145721712460283
Cho, Y. & Hummer, R. A. (2001). Disability status differentials across fifteen Asian
and Pacific Islander groups and the effect of nativity and duration of residence
in the U.S. Social Biology, 48(3), 171-195.
60
Choi, S., Lee, J., & Rush, E. (2011). Ethnic and language disparities in diabetes care
among California residents. Ethnicity & Disease, 21(2), 183-189.
Choi, S. E., Liu, M., Paloniappan, L. P., Wang, E. J., & Wong, N. D. (2013). Gender
and ethnic differences in the prevalence of type 2 diabetes among Asian
subgroups in California. Journal of Diabetes and its Complications, 27(5),
429-435. doi:10.1016/j.jdiacomp.2013.01.002
Chung, R. C., & Lin, K. (1994). Help-seeking behavior among Southeast Asian
refugees. Journal of Community Psychology, 22(2), 109-120.
doi:10.1002/1520-6629
Devlin, H., Roberts, M., Okaya, A. & Moua Xiong, Y. (2006). Our lives were
healthier before: Focus groups with African American, American Indian,
Hispanic/Latino, and Hmong people with diabetes. Health Promotion
Practices, 7(1), 47-55. doi:10.1177/1524839905275395
Deurenberg, P., Deurenberg-Yap, M., & Guricci, S. (2002). Asians are different
from Caucasians in from each other in their body mass index/body fat per cent
relationship. Obesity Review, 3(3), 141-146.
Diabetes Epidemiology Collaborative Analysis of Diagnostic Criteria in Asia.
(2003). Age- and sex-specific prevalence of diabetes and impaired glucose
regulation in 11 Asian cohorts. Diabetes Care, 26(6), 1770-1780.
doi:10.2337/diacare.26.6.1770
Eckstein, B. (2011). Primary care for refugees. American Family Physician, 83(4),
429-436.
61
Edelman, D., Dolor, R. J., Coffman, C. J., Pereira, K. C., Granger, B. B., …Bosworth,
H. B. (2015). Nurse-led behavioral management of diabetes and
hypertension in community practices: A randomized trial. Journal of
General Internal Medicine, 30(5), 626-633. doi:10.1007/s11606-015-3207-8.
Elo, S. & Kyngäs, H. (2007). The qualitative content analysis process. Journal of
Advanced Nursing, 62(1), 107-115. doi:10.1111/j.1365-2648.2007.04569.x
Erber, E. (2014). Acculturation, body mass index and type 2 diabetes risk in Asian
Americans (Doctoral dissertation). Retrieved from Proquest. (3633970)
Fadiman, A. (1998). The spirit catches you and you fall down: A Hmong child, her
American doctors, and the collision of two cultures. New York, NY: Farrar,
Straus and Giroux.
Frisbie, W. P., Cho, Y., & Hummer, R. A. (2001). Immigration and the health of
Asian and Pacific Islander adults in the U.S. American Journal of
Epidemiology, 153(4), 372-380. doi:10.1093/aje/153.4.372
Garcia Rios, P., & Rodriguez, M. T. (Producers). (2008). Becoming American
[Documentary episode]. In L. Adelman & L. Smith (Executive producers),
Unnatural causes…Is inequality making us sick? San Francisco, CA:
Newsreel & Vital Pictures, Inc.
Gilman, S. C., Justice, J., Saepharn, K., & Charles, G. (1992). Use of traditional and
modern health services by Laotian refugees. In Cross Cultural medicine—A
decade later [Special Issue], Western Journal of Medicine, 157(3), 310-315.
62
Hawthorne, K., Robles, Y., Cannings-John, R., & Edwards, A. G. K. (2008).
Culturally appropriate health education for type 2 diabetes mellitus in ethnic
minority groups. Cochrane Database of Systematic Reviews, 2008(3), 1-259.
doi:10.1002/14651858.cd006424.pub2
Huh, J., Prause, J., & Dooley, C. D. (2008). The impact of nativity on chronic
disease, self rated health, and comorbidity status of Asian and Hispanic
immigrants. Journal of Immigrant Minority Health, 10(2), 103-118.
doi:10.1007/s10903-007-9065-7
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for
the 21st century. Washington, DC: National Academies Press.
Institute of Medicine. (2004). Health literacy: A prescription to end confusion.
Washington, DC: The National Academies Press.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing
health. Washington, DC: The National Academies Press.
International Diabetes Federation. (2013). IDF Diabetes Atlas, 6th ed. Retrieved
from http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf
Jasso, G., Massey, D. S., Rosenzweig, M. R., & Smith, J. P. (2004) Immigrant
health: Selectivity and acculturation. In N. B. Anderson & B. Cohen (Eds.),
Critical perspectives on racial and ethnic differences in health in late life
(pp.227-266). Washington, DC: National Academies Press
Johnson, S. K. (1995). Diabetes in the Hmong refugee population (Doctoral
dissertation). Retrieved from Proquest. (9606587)
63
Johnson, S. K. (2002). Hmong health beliefs and experiences in the Western health
care system. Journal of Transcultural Nursing, 13(2), 126-132.
doi:10.1177/104365960201300205
Kadirvelu, A., Sadasivan, S., & Ng, S. H. (2012). Social support in type II diabetes
care: A case of too little, too late. Diabetes Metabolic Syndrome and
Obesity: Targets and Therapy, 5(3), 407-417.
doi:org/10.2147/DMSO.S37183
Kanaya, A. M., Schillinger, D., Adler, N., Adams, A., Moffet, H. H., Ahmed, A. T.,
…Karter, A. J. (2011). Heterogeneity of diabetes outcomes among Asians
and Pacific Islanders in the U.S. Diabetes Care, 34(4), 930-937.
doi:10.2337/dc10-1964.
Kim, G., Ford, K. L., Chiriboga, D. A., & Sorkin, D. H. (2012). Racial and ethnic
disparities in healthcare use, delayed care, and management of diabetes
mellitus in older adults in California. Journal of American Geriatric Society,
60(12), 2319-2325. doi:10.1111/jgs.12003
Kinzie, J. D., Riley, C., McFarland, B., Hayes, M., Boehnlein, J., Leun, P., & Adams,
G. (2008). High prevalence rates of diabetes and hypertension among
refugee psychiatric patients. Journal of Nervous and Mental Disease, 196(2),
108-112. doi:10.1097/NMD.0b013e381b2aa51
Krippendork, L. (1989). Content analysis. In E. Barnouw, G. Gerbner, W. Schram,
T. L. Worth, & L. Gross (Eds), International encyclopedia of communication
64
(Vol. 1, pp. 403-407). New York, NY: Oxford University Press. Retrieved
from hrrp://respository.upenn.eduasc_papers/226
Leary, W. M. (2007). CIA operations in Laos, 1955-1974: Supporting the “Secret
War.” Retrieved from https://www.cia.gov/library/center-for-the-study-of-
intelligence/csi-publications/csi-studies/studies/winter99-00/art7.html
Leung, A., Bo, A., Hsiao, H., Wang, S. S., & Chi, I. (2014). Health literacy issues in
the care of Chinese American immigrants with diabetes: A qualitative study.
British Medical Journal Open, 4(e005294), 1-12. doi:10.1136/bmjopen-2014-
005294
Lew, K. N., Nowlin, S., Chuun, D., & Melkus, G. D. (2014). State of the science:
Diabetes self-management interventions led by nurse researchers. Western
Journal of Nursing Research, 36(9), 1111-1157.
doi:10.1177/019394914532033.
Loveman, E., Royle, P., & Waugh, N. (2003). Specialist nurses in diabetes mellitus.
Cochrane Database of Systematic Reviews, 2, 1-27.
doi:10.1002/14651858.CD003286
MacColl Center for Healthcare Innovations. (2002). The Care Model. Retrieved
from http://www.improvingchroniccare.org/
MacDonald, J. L. (1997). Transnational aspects in Iu-Mien refugee identity. New
York, NY: Garland Publishing, Inc.
65
Maher, R. L., Hanlon, J. T., & Hajjar, E. R. (2014). Clinical consequences of
polypharmacy in elderly. Expert Opinion on Drug Safety, 13(1), 57-65.
doi:10.1517/14740338.2013.827660
Marmot, M. G., Adelstein, A. M., & Bulusu, L. (1984). Lessons from the study of
immigrant mortality. Lancet, 323(8392), 1455-1457. doi:10.1016/S0140-
6736(84)91943-3
Mayberry, L. S., & Osborn, C. Y. (2012). Family support, medication adherence,
and glycemic control among adults with type 2 diabetes. Diabetes Care,
35(6), 1239-1245. doi:10.2337/dc11-2103
Merced County Department of Public Health. (2012). Merced County health status
profile, 2012. Merced, CA: Merced County Department of Public Health.
Retrieved from http://www.co.merced.ca.us/documents/
Moore, L. J. & Boehnlein, J. K. (1991). Treating psychiatric disorders among Mien
refugees from highland Laos. Social Science & Medicine, 32(9), 1029-1036.
doi:org/10.1016/0277-9536(91)90160-E
Moore-Howard, P. (1989). The Iu Mien: Tradition and change. Sacramento, CA:
Sacramento City Unified School District.
National Board of Certification for Medical Interpreters. (2012). Multiple languages
available. Retrieved from
http://www.certifiedmedicalinterpreters.org/multiple-languages-a
National Diabetes Education Program. (2006). Silent trauma: Diabetes, health
status, and the refugee Southeast Asians in the United States. Retrieved from
66
www.aapcho.org/resources-db/silent-trauma-diabetes-health-status-and-the-
refugee/
Nicholson, B. L. (1997). The influence of pre-emigration and post-emigration
stressors on mental health: A study of Southeast Asian refugees. Social Work
Research, 21(1), 19-31.
Ngo-Metzerg, Q., Sorkin, D. H., Billimek, J., Greenfield, S., & Kaplan, S. H. (2011).
The effects of financial pressures on adherence and glucose control among
racial/ ethnically diverse patients with diabetes. Journal of General Internal
Medicine, 27(4), 432-437. doi:10.1007/s11606-011-1910-7
Office of Minority Health. (2013). Diabetes and Asian and Pacific Islander.
Retrieved from
http://minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=5&ID=305
7
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of
childhood and adult obesity in the United States, 2011-2012. Journal of the
American Medical Association, 311(8), 806-814. doi:10.1001/jama.2014.732
Osborn, C. Y. & Egede, L. E. (2010). Validation of an Information–Motivation–
Behavioral Skills model of diabetes self-care (IMB-DSC). Patient Education
and Counseling, 79(1), 49-54. doi:10.1016/j.pec.2009.07.016
Oza-Frank, R., Stephenson, R., & Venkat Narayan, K. M. (2011). Diabetes
prevalence by length of residence among U.S. immigrants. Journal of
Immigrant Minority Health, 13(1), 1-8. doi:10.1007/s1093-009-9283-2.
67
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).
Peek, M. E., Cargill, A., & Huang, E. S. (2007). Diabetes health disparities: A
systematic review of health care interventions. Medical Care Research and
Review, 64(S5), S101-S156. doi.org/10.1177/1077558707305409
Perez, M. A. & Cha, K. (2007). Diabetes knowledge, beliefs, and treatments in the
Hmong population: An exploratory study. Hmong Studies Journal, 8, 1-21.
Purnell, H. (2012). An Iu-Mienh—English Dictionary with Cultural Notes. San
Francisco, CA: Center for Lao Studies.
Qato, D. M., Alexander, G. C., Conti, R. M., Johnson, M., Schumm, P., & Tessler
Lindau, S. (2008). Use of prescription and over-the-counter medications and
dietary supplements among older adults in the United States. Journal of the
American Medical Association, 300(24), 2867-2878.
doi:10.1001/jama.2008.892
Renders, C. M., Valk, G. D., Griffin, S. Wagner, E. H., Eijk, J.T., & Assendelft, W. J.
(2000). Interventions to improve the management of diabetes mellitus in
primary care, outpatient and community settings. Cochrane Database
Systematic Reviews, 4. doi:10.1002/14651858.CD001481
Sarkar, U., Fisher, L., & Schillinger, D. (2006). Is self-efficacy associated with
diabetes self-management across race/ethnicity and health literacy? Diabetes
Care, 29(4), 823-829. doi:10.2337/diacare.2.9.04.06dcp5-1615
68
Shai, I., Jiang, R., Manson, J. E., Stamper, M. J., Willett, W. C….& Hu, F. B. (2006).
Ethnicity, obesity, and risk of type 2 diabetes in women: A 20-year follow-up
study. Diabetes Care, 29(7), 1585-1590. doi:10.2337/dc06-0057
Southeast Asia Resource Action Center. (2011). Southeast Asian Americans at a
glance. Washington, DC: Southeast Asia Resource Action Center.
Staimez, L. R., Weber, M., Venkat Narayan, K. M., & Oza-Frank, R. (2013). A
systematic review of overweight, obesity, and type 2 diabetes among Asian
American subgroups. Current Diabetes Reviews, 9(4), 312-331.
doi:org/10.2174/15733998113099990061
Stellefson, M., Dipnarine, K., & Stopka, C. (2013). The Chronic Care Model and
diabetes management in U.S. primary care settings: A systematic review.
Preventing Chronic Disease, 10. Retrieved from
http://www.cdc.gov/pcd/issues/2013/12_0180.htm
Suzuki, B. (1977). Education and the socialization of Asian Americans: A
revisionist analysis of the “Model Minority” thesis. Amerasia Journal, 4(2),
23-51. doi:10.17953/amer.4.2.x203l74863857108
Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public
Health Reports, 107(5), 544-548.
United Nations. (1951). Convention and protocol relating to the status of refugees.
Retrieved from www.unhcr.org
U. S. Census Bureau. (2012). The Asian population: 2010. Retrieved from
http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf
69
U. S. Department of Health and Human Services. (1982). Report to Congress:
Refugee Resettlement Program. Retrieved from
http://www.acf.hhs.gov/sites/default/files/orr/annual_orr_report_to_congress_
1982.pdf
VanEenwyck, J. & Sasbel, J. (2003). Self-reported concern about food security
associated with obesity—Washington, 1995-1999. Retrieved from
htt:///www.cdc.gov/mmwr/pdf/wk/mm5235.pdf
Wang, E. J., Wong, E. C., Dixit, A. A., Fortmann, S. P., Linde, R. B., & Palaniappan,
L. P. (2011). Type 2 diabetes: Identifying high risk Asian American
subgroups in a clinical population. Diabetes Research and Clinical Practice,
93(2), 248-254. doi:10.1016.diabres.2011.05.025
Wagner, E. H. (1998). Chronic disease management: What will it take to improve
care for chronic illness [Editorial]. Effective Clinical Practice, 1(1), 2-4.
Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A.
(2001). Improving chronic illness care: Translating evidence into action.
Health Affairs, 20(6), 64-78. doi:10.1377/hlthaff.20.6.64
Wagner, J., Burke, G., Kuoch, T. Scully, M., Armeli, S., & Rajan, T. V. (2013).
Trauma, healthcare access, and health outcomes among Southeast Aisan
Refugees in Connecticut. Journal of Immigrant Minority Health, 15(6), 1065-
1072. doi:10.1007/s10903-012-9715-2.
70
Ward, B. W. & Schiller, J. S. (2013). Prevalence of multiple chronic conditions
among US adults: Estimates from the National Health Interview Survey,
2010. Preventing Chronic Disease, 10, 1-15. doi:org/10.5888/pcd10.120203
World Health Organization. (2014). Global status report on noncommunicalbe
diseases 2014. Geneva: World Health Organization Press. Retrieved from
www.who.int/publications
Ying, Y. & Chao, C. (1996). Intergenerational relationship in Iu Mien American
families. Amerasia Journal, 22(3), 47-64.
APPENDICES
72
APPENDIX A
LETTER FOR USE OF THE CARE MODEL IMAGE
73
APPENDIX B
UNIVERSITY INSTITUTIONAL REVIEW BOARD APPROVAL
74
APPENDIX C
PARTICIPANT CONSENT FORM
Informed ConsentDear Participant:
You are being asked to participate in a research project that is being doneto fulfill requirements for a Master’s degree in Nursing at CSUStanislaus. We hope to learn how you take care of your diabetes at homeand what you know about diabetes and your health. If you decide tovolunteer, you will be asked to meet with a researcher and a Miencommunity member in a place of your choosing. You may choose to dothe interview in Mien or English. You may have family members presentas well. The researcher will ask you questions about your diabetes, yourdoctor’s visits, the foods that you eat, take your height and weight, andask to watch you perform any care that you normally do for yourdiabetes. The interview will take about two hours. If you agree, theentire interview will be audio recorded and the care that you perform willbe videotaped using the camera on a phone. You will also be asked toweigh yourself on a scale without shoes on. The researcher will alsomeasure how tall you are without shoes.
There are no known risks to you for your participation in this study.
It is possible that you will not benefit directly by participating in thisstudy. The information collected will be protected from all inappropriatedisclosure under the law. All data will be kept in a secure location. Onlythe primary researcher, Mien community member, and committee chairwill have access to the audio recordings and videotape. Audio recordsand video record will be coded. Video recording will avoid capturingfacial features if possible.
There is no cost to you beyond the time and effort required to completethe procedures described above. Your participation is voluntary. Refusalto participate in this study will involve no penalty or loss of benefits.
75
You may withdraw at any time without penalty or loss of benefits. Youwill receive at $10 gift card to Target as a thank you for your time andparticipation.
If you agree to participate, please indicate this decision by signing below.If you have any questions about this research project please contact me,Mey Saephanh, at 209-667-6591 or my faculty sponsor, Dr. CarolynMartin at 209-667-6591. If you have any questions regarding your rightsand participation as a research subject, please contact the UIRBAdministrator by phone (209)667-3784 or [email protected].
Sincerely,Mey Saephanh
I give consent to be digitally recorded during this study: Please initial _____Yes_____No
I give consent to be visually recorded during this study: Please initial _____Yes_____No
_________________________________________________________________________Signature Date
76
APPENDIX D
RECRUITMENT FLYER
77
APPENDIX E
QUESTIONNAIRE TOOL
78
79
80
81
82