AMERICAN INDIAN DIABETES BELIEFS & PRACTICES: MATERNAL CARE, INFANT MORTALITY....

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Specific Aims This research on American Indian (AI) diabetes beliefs and practices as they relate to maternal care, infant mortality, and adherence seeks to elicit practitioner and patient Explanatory Models of pregestational and gestational diabetes mellitus, and will be conducted in collaboration with the Chickasaw and Choctaw Nations of Oklahoma, under the auspices of the Oklahoma Center for American Indian Diabetes Health Disparities Research (OCAIDHD) at the University of Oklahoma Health Sciences Center (OUHSC) and the General Clinical Research Center (GCRC). The schema for this research is based on Kleinman (1978) concept of health behaviors being located in three sectors: professional (licensed, educated in cosmopolitan institutions), popular (lay), and folk (lay but with social recognition of healing capacity). The research is directed at all three sectors, but telescoped into "professional" and "popular and folk." The professional sector is comprised of health providers that are (AI and non-AI) licensed practitioners whose education is steeped in biomedicine. The popular/folk sector is comprised of pregnant AI women: gestational, pre-gestational, or "never had" diabetes. The popular and folk sector is combined because participants characterized as "folk practitioners" are not sought as direct subjects. However, subjects from the popular sector may make references to "folk" sector participants. If this occurs, that information will be collected as part of the popular sector subjects' experience with diabetes coping. The result is that, if present, the folk sector influence will still be captured but viewed as a part of popular sector subjects' way of managing diabetes. This research will provide practitioners of multiple disciplines new information that delineates patients' ways of help-seeking and adherence/non-adherence with treatment recommendations for pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). Findings will inform practitioners about 1) differing Explanatory Models of diabetes held by their patients, 2) how practitioners' biomedical Explanatory Models of diabetes during pregnancy differ from patient culturallybased models, and 3) areas of concordance and discordance across models. Knowledge gained from this research will facilitate health care delivery in that biomedical diabetes education before and during pregnancy can be more appropriately integrated with pre-existing patient models, thus providing the pregnant woman with access to culturally-relevant diabetes education. Moreover, this research will contribute to a more complete understanding of health beliefs and behavioral dynamics in terms of how disease is culturally constructed, with particular relevance to potential impacts on maternal care and infant mortality in the context of diabetes. Paradoxically, in spite of today's most advanced medical treatment, prevention campaigns, and health promotion strategies, prevalence rates for diabetes mellitus, as well as GDM, are persistent and rising. In the presence of potent drugs and wide-spread health education information, diabetes prevalence should be abating. Since it is not, other factors promoting diabetes must be operating. Preliminary research suggests that one possible source for persistent and increasing diabetes prevalence is that nonobvious sociocultural factors are present that impede the productive application of pharmacologic and health education tools. In addition to poor management of the diabetes, mutual respect between practitioners and patients suffers from communication discordance with the result that both are very dissatisfied with the encounter. The non-obvious sociocultural factors operating to impede effective health care are found in the divergent models of diabetes held by practitioners and patients. Specifically, professional and lay explanations for disease, treatment, and prevention can vary radically. Explanations for the etiology, treatment, course, and preventive measures for sickness are known as "explanatory models." Explanatory Models (EMs) held by providers and patients may be similar. Similar EMs facilitate communication and are associated with increased adherence to treatment recommendations and patient/provider satisfaction. However, EMs that are discordant between practitioners and patients are prone to reduce effective communications, adherence to treatment recommendations, and negatively impact health outcomes. This research will elicit Explanatory Models of diabetes during pregnancy from pregnant diabetics (n=40), 60 pregnant non-diabetics (n=60), and their health care providers (n=60 ) regarding etiology, course, and treatment in order to reduce barriers to adherence and improve diabetes outcomes. All pregnant subjects are AI's. "Health Care Providers" are defined as physicians, licensed nurses, Certified Diabetes Educators (CDE's), and tribal Community Health Representatives (CHR's: paraprofessionals trained for home visits, screenings, health education, community resource identification, and transportation to health care sites). Collaboration with the Choctaw and Chicksaw Nations of Oklahoma will be continuous to strengthen all phases of the research process and assure that appropriate research goals will be met. Specific Aim # 1: Collaboration with Choctaw and Chickasaw Nations on decisions regarding questionnaire refinement, research implementation, and application of the research findings. Specific Aim # 2: Recruit 60 health care providers and 100 pregnant patients to serve as subjects for interviews. Specific Aim #3: Delineate the Explanatory Models held by 100 pregnant women of which 10 will have pre-gestational diabetes, 30 will have gestational diabetes, and 60 will not have diabetes. Hypothesis: Explanatory Models will vary by category of disease experience. Specific Aim # 4: Delineate the Explanatory Models held by patients about maternal and infant outcomes relevant to diabetes during pregnancy. Hypothesis: Patient's Explanatory Models of maternal and infant outcomes may predict help-seeking and adherence behaviors. Specific Aim # 5: Delineate the Explanatory Models of diabetes held by providers regarding their patients' diabetes education, care-seeking behaviors, and adherence/non-adherence to treatment plans. Hypothesis: Provider Explanatory Models of diabetes may be discordant with patient models of diabetes, contributing to communication barriers. Perceptions of patient help-seeking and adherence may either facilitate or be a barrier to optimal care. Specific Aim #6: Delineate provider models of care delivery. Hypothesis: Provider models of care delivery may either facilitate or impede patients' help-seeking and adherence behaviors.. Specific Aim #7: Delineate subjects' degree of identification with traditional AI culture or mainstream culture. Hypothesis: Subjects' cultural identification may predict their Explanatory Model of diabetes. Specific Aim # 8: In collaboration with Choctaw and Chickasaw Nations, disseminate the findings of the research to health care providers in both tribes.