It has been adapted for use in older African-American women that have been diagnosed with type 2 diabetes in rural areas of the Southeastern United States. These findings were derived from a series of pilot studies that indicated key symptoms and their affects on the lives of women with diabetes (Skelly, A., Leeman, J., & Carlson, J.(2008). The study by Skelly and associates included three primary strategies of self-care for diabetes. These included physiologic (Medical), behavioral (Self-care practices), and sociopsychological (coping, stress reduction, etc.). Outcomes were measured by monitoring metabolic control, symptom distress, and the patient's self-reported quality of life as related to diabetes. It was found that symptom management correlated with medical monitoring of glucose levels.

The pilot studies found several significant findings related to identified several symptoms in women with type 2 diabetes. However, many women did not associate these symptoms as being related to diabetes (Skelly et al., 2005; Stover et al., 2001). According to these researchers, symptoms of hyperglycemia, hypoglycemia, numbness, tingling and pain in the feet were found to be associated with improper management of diabetes in the study group. The aim of the intervention in the study was to raise awareness of the importance of these symptoms in relation to diabetes management. They also concentrated on educating women about which of their symptoms were of greatest concern, in terms of monitoring their diabetes and in making reports to their doctors.

It was also recognized that there is a significant need to develop culturally relevant teaching materials regarding the importance to recognizing and reporting symptoms to their doctors. As part of the intervention strategy, nurses interviewed patients to assess their attitudes towards symptoms and various aspects of the intervention. For example, family support can be an important part of the treatment strategy. However, patients may feel uncomfortable relying on their family for support because they may not wish to burden them (Skelly et al., 2005). The personality of the patient had an impact on the effectiveness of the treatment strategy. For instance, some are outgoing socialites with a large support system. While others are more solitary. The treatment strategy and its success depend on matching it to the particular needs of the patient and their social environment.

The model upon which this study is based highlights the need to make education and intervention strategies relevant to the patients individual preferences. One of the caveats that an exploration of this conceptual model highlighted, although it was not addressed by the authors, is that the material and intervention not only have to be relevant to the individual, but that they must address cultural influences as well. Cultural explanations can be found for many individual differences, but these concepts only apply when one is generalizing about a group. The approach must be relevant to the individual's culture and to their personality as well. It is important to understand the influence of culture on individual personality in the design and implementation of a treatment strategy. This will be an important consideration in the adaptation of this conceptual model to the parameters of this research study.

Patient Compliance and Diabetes Care

The goal of this research study is to increase patient compliance with self-care and management of diabetes. We have established a connection between symptom management and disease management, as well as explored the conceptual model upon which this study is based, However, compliance with self-care regimes is a psychological and motivational issue. The key problem lies in motivating the patient to take the necessary steps to manage their own care. They can be informed of what they need to do and the reasons for these strategies. However, education alone is no guarantee that the patient will adhere to the needed treatment schedules and activities. The following will examine literature regarding motivation and how it affects the patient's willingness to comply with prescribed treatment plans.

Diabetes care differs from other types of healthcare treatments in that it must be carried out by the patient when the healthcare provider is not present. Effective support systems have a positive outcome in helping patients to manage their diabetes and to stick to the required routines ( Glazier, Bajcar, & Kennie (2006); Heisler, (2009); Heisler & Piette (2005)). The importance of support systems outside the clinical setting is highlighted in these studies. Access to health care can be problematic for those in lower income brackets (Wyn, Ojeda, & Ranji, 2004).

Socioeconomic status was found to have a negative...

Literacy was found to improve the likelihood that a patient would be successful in their diabetes management (Rosal, Carbone, & Goins, 2003). Patient morale and family beliefs were also found to be a key influence in patient attitudes towards self-care among diabetes patients (Chesla, Fisher, & Mullan, 2004). These factors represent external influences that have an impact on the ability of the patient to adhere to necessary self-care routines. However, they are beyond the control of the physician, and many times, beyond the control of the patient. The physician needs to consider these factors when designing an intervention for their patients.
Diabetes management among African-American women represents a separate sector of research. Much attention has been focused on this group, largely because they comprise a high likelihood of developing complications from diabetes and they are considered a high-risk group for non-compliance with self-care routines. Kirk, Bell, & Bertoni et al., (2005) found that ethnic disparities exist regarding the management of not only diabetes, but for other health issues such as blood pressure and LDL cholesterol. Ethnic minorities were found to have poorer outcomes than non-Hispanic whites and was most notable regarding control of diabetes. The degree of self-efficacy was found to be an important factor in the ability of the patient to manage their diabetes (Samuel-Hodge, DeVellis, & Ammerman et al., (2002).

A number of interventions for the control of diabetes were found to have been researched with varying degrees of success among African-American women. Transportation, cost, and commitment were found to be key barriers in the compliance of women with the necessary routines (Rimme, Silberman, & Brunschweig et al., 2002). Programs that required extreme, sudden modifications to the daily routine were found to be less effective than those that used a moderate, slow approach to lifestyle change (Keysering, Samuel-Hodge, & Ammerman et al., 2002).

Cultural Aspects

Developing a culturally appropriate diabetes management program is essential when addressing the needs of African-Americans, or any other ethnic group. If the program is not culturally appropriate, it will not be as effective as one that is geared towards the target audience. A culturally appropriate program cannot be developed unless one is aware of the aspects of that culture that make it unique when compared to other cultures. This research targets a specific ethnic group, requiring the need to establish those cultural differences that may enhance or impede the ability to increase positive diabetes management behavior.

Adherence to dietary control standards is a key component in the ability to manage diabetes. However, American medical practice typically does not recognize the food choices and preferences of other cultures. The diet prescribed is often based on a standard American diet. This may seem unpalatable to those of different cultures (Liburd, 2003). For African-Americans, particularly those located in the South, eating is considered a ritual. They may not be aware that they are engaging in a ritual in the foods that they choose, the manner in which it is prepared, and the method and environment associated with it. However, a ritual is defined as a stylized, repetitive, and stereotyped behavior (Liburd, 2003). By these criteria, food is a highly ritualized characteristic of African-American culture.

Ritual associations with food may make it difficult for African-American women to make the necessary changes to manage their diabetes. This may be particularly true for older women where these cultural norms and values are more entrenched (Liburd, 2003). Traditions within African-Americans stems from their African roots and heritage. In African tradition, women play an important role in the preparation of food. Preparation of food takes on a new social realm within these cultures. Food is seen as a performance and women take great pride in their foods (Liburd, 2003). Food sharing and community collectivity is also connected with African-American traditions (Liburd, 2003).

Food is associated with social functions and reflects on the people that prepare it (Liburd, 2003). When a woman cooks food, particularly that for a special occasion or to share with others, they embody the food, and give it "soul" (Liburd, 2003). Soul food is not so much about the food or recipes as in the feeling that goes into its preparation. This is an issue that must be addressed in the development of programs to help African-American women with diabetes adjust to their new diet. They must find a way to give…