University of Southern California Dissertations and Theses

The effects social determinants of health have on the higher prevalence of diabetes in low socioeconomic status Hispanics compared to non-Hispanic Whites

(USC Thesis Other)

The effects social determinants of health have on the higher prevalence of diabetes in low socioeconomic status Hispanics compared to non-Hispanic Whites

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

The Effects Social Determinants of Health Have on the Higher Prevalence of Diabetes in
Low Socioeconomic Status Hispanics Compared to Non-Hispanic Whites
by
Rafael Villaruz

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

December 2022

© Copyright by Rafael Villaruz 2022
All Rights Reserved

The Committee for Rafael Villaruz certifies the approval of this Dissertation

Eric Canny
Maria Ott
Rufus Spann, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
Hispanics from a low socioeconomic background suffer from diabetes at a higher prevalence
than non-Hispanic Whites. Socioeconomic status affects the way an individual engages with
health care providers and impacts the sustainability of healthy behaviors (Nelson et al., 2019).
The Hispanic population is expected to grow to 28% of the U.S. population in the next 40 years,
and more than 15% of Hispanics are affected by poverty. The intersection of socioeconomic
status and health create challenges for the Hispanic population that are rarely addressed by health
care services. The purpose of this phenomenological study was to explore the societal challenges
and barriers that impact low socioeconomic status Hispanics with diabetes when accessing health
care, engaging in daily activities, and dealing with financial challenges. The qualitative research
study guided by Bronfenbrenner’s ecological systems theory (1979), utilized 10 individual
narratives that provided a descriptive account of the challenges living with diabetes. Data was
coded by inductive analysis and combined with themes discovered in the literature review. The
findings from the research study outlined specific challenges that low socioeconomic status
Hispanics with diabetes face, which are rarely addressed by health care providers. The study’s
recommendations were to implement culturally concordant care coordination teams to simplify
the process for this population to improve health, and to utilize support systems to address the
psychosocial challenges that result from having diabetes.
Keywords: culturally concordant care, health disparity, social determinants of health.

v
Dedication
To Kristina, my loving and supportive wife. I could not have gone through this journey without
you right next to me cheering me on. Your encouragement to do my best work, your willingness
to make sure that each Saturday I had my breakfast and coffee, and your patience with how much
time this journey took over the last 3 years made this dream a reality. Thank you for being my
best friend through it all and for always believing in me. This dissertation is as much mine as it is
yours. Thank you for your love and support through it all.

To Michael and Gabriel, my caring and thoughtful children. Thank you for always inspiring me
to be the best version of myself. Your creativity, imagination, and inquisitiveness push me every
day to continually be better. Believe in yourselves as much as you believed in me during this
journey. Thank you for always making me smile and laugh through it all.

vi
Acknowledgements
I would like to thank the best cohort over, Cohort 17. I didn’t know what I was getting
into when we started this program at the beginning of the pandemic, but each of you made the
journey worth it. To the Saturday crew, thank you for pushing me to think differently and for
always providing laughter and joy while we sacrificed our Saturday mornings. Your ideologies,
experiences, and wisdom have forever changed me for the better. I will always be thankful for
letting me enjoy this journey with each of you.
I would like to thank my dissertation committee, Dr. Canny and Dr. Ott. Thank you for
your willingness to guide me through the dissertation journey. I’m honored to have had both of
you as professors, and the way both of you led your classes has forever changed the way I view
education. I’m appreciative to have been blessed with both of your wisdom and guidance. I
would like to thank my dissertation chair, Dr. Spann. Thank you for the guidance and support
throughout this journey. I’m grateful for your commitment to ensure I do my best work.
Lastly, I would like to thank the participants of the research study. I could not have
completed this study without the rich, descriptive narratives you shared with me. Thank you for
your kindness to share candid stories with me and for the time you took away from your families,
friends, and jobs to speak with me. Thank you to my colleagues and professional support system,
who encouraged and supported me throughout this journey.

vii
Table of Contents
Abstract ..................................................................................................................................... iv
Dedication .................................................................................................................................. v
Acknowledgements ................................................................................................................... vi
List of Figures ............................................................................................................................ x
List of Tables ............................................................................................................................. xi
Chapter One: Introduction to the Study ....................................................................................... 1
Background of the Problem ............................................................................................. 1
Organizational Context and Mission ................................................................................ 3
Stakeholder Groups ......................................................................................................... 4
Purpose of the Project and Research Questions ............................................................... 5
Importance of the Study .................................................................................................. 5
Overview of Theoretical Framework ............................................................................... 6
Definitions ...................................................................................................................... 7
Organization of the Dissertation ...................................................................................... 8
Chapter Two: Literature Review ................................................................................................. 9
Studied Population .......................................................................................................... 9
Health Disparities Faced by Hispanics............................................................................. 9
Racial Discrimination .................................................................................................... 12
Socioeconomic Status ................................................................................................... 17
Accessing Health Care Services .................................................................................... 26
Conceptual Framework ................................................................................................. 32
Summary....................................................................................................................... 36
Chapter Three: Methodology .................................................................................................... 37
Research Questions ....................................................................................................... 37

viii
Overview of Design ...................................................................................................... 37
Research Setting............................................................................................................ 38
The Researcher ............................................................................................................. 39
Participating Stakeholders ............................................................................................. 41
Data Sources ................................................................................................................. 41
Validity and Reliability ................................................................................................. 44
Ethics ............................................................................................................................ 44
Chapter Four: Results and Findings .......................................................................................... 46
Research Study Stakeholders ......................................................................................... 46
Interviews ..................................................................................................................... 48
Data Analysis ................................................................................................................ 49
Findings for Research Question 1: Effects on Daily Lifestyle ........................................ 49
Findings for Research Question 2: Challenges ............................................................... 54
Findings for Research Question 3: Confidence .............................................................. 61
Findings for Research Question 4: Health Care Services ............................................... 64
Summary....................................................................................................................... 68
Chapter Five: Recommendations .............................................................................................. 69
Discussion of Findings .................................................................................................. 69
Research Question 1: How Does Receiving a Diagnosis, Such as Diabetes, Affect
the Daily Lifestyle of Low Socioeconomic Status Hispanic Individuals? ....................... 69
Research Question 2: What Challenges Do Individuals From a Low
Socioeconomic Status Background Face to Keep Their Diabetes In Control? ................ 72
Research Question 3: What Is the Confidence Level of Low Socioeconomic
Status Hispanic Individuals to Take Care of Their Own Health?.................................... 74
Research Question 4: What Is the Experience of Low Socioeconomic Status
Hispanics When Accessing Health Care Services to Treat Their Diabetes?.................... 77
Recommendations for Practice ...................................................................................... 80

ix
Recommendation 1: Build Culturally Concordant Care Coordination Teams to
Augment Primary Care Physicians, Promoting a Team-Based Approach. ...................... 81
Recommendation 2: Family-Based Approach to Diabetes Management ........................ 83
Limitations and Delimitations ....................................................................................... 86
Recommendations for Future Research ......................................................................... 87
Conclusion .................................................................................................................... 88
References ................................................................................................................................ 90
Appendix A: Interview Protocol ............................................................................................. 111
Appendix B: Additional Participant Quotes ............................................................................ 113

x
List of Figures
Figure 1: Research Study Conceptual Framework: Modified Bronfenbrenner’s Ecological
Systems Model ..................................................................................................................... 35

xi
List of Tables
Table 1: List of Participants and Demographics .................................................................... 47
Appendix A: Interview Protocol ......................................................................................... 111
Appendix B: Additional Participant Quotes ........................................................................ 113

1

Chapter One: Introduction to the Study
Good health affords an individual to live to their fullest potential and actively participate
in society; however, racial minorities in the United States experience different health outcomes
based on their socioeconomic status. There is a disproportionately higher number of Hispanics
that contract Type 2 diabetes (T2D) compared to non-Hispanic Whites (American Diabetes
Association, 2021). T2D is caused by increased blood sugar in the body, but most interventions
in health care services primarily focus on medication treatment with little consideration for
societal and cultural influences that could contribute to the disease (Grzywacz et al., 2013). The
U.S. Hispanic population has grown over 20% in the past 10 years, totaling more than 60 million
individuals, which is the fastest growing minority population (Noe-Bustamante et al., 2020).
Health risks for Hispanics differ from non-Hispanic Whites, which have resulted in 50% more
chance of contracting diabetes, 62% more chance of having chronic liver disease, and 168%
more chance of contracting human immunodeficiency virus (HIV) disease (Centers for Disease
Control and Prevention [CDC], 2004). There has been some improvement in Hispanic health
with less heart disease and less cancer, but the widening gap of chronic disease prevalence
among Hispanics is a cause of concern and a continued focus of health care systems (CDC,
2015). Uncontrolled diabetes in the Hispanic population cause debilitating effects, which afflicts
the ability to actively participate in society and further creates population and generational poor
health outcomes.
Background of the Problem
The problem of practice addressed in this research study focused on the higher
prevalence of diabetes among low socioeconomic status (SES) Hispanics in comparison to non-
Hispanic Whites. The difference in prevalence rates is a problem because SES shapes the way

2

individuals engage in health care services and how healthy behaviors are sustained (Nelson et al.,
2019). More than 15% of Hispanics are affected by poverty, which reached an all-time low in
2019, but still remains the second highest poverty rate among minority groups, which contributes
to poor health within this population (Creamer, 2020). The combined effect of Hispanic poverty
rates and the debilitating result of living with a chronic illness, is an issue that needs to be solved
to improve population health (Braveman & Egerter, 2008). This problem is important to address
because health care disparities result in poor health outcomes, lower health self-efficacy, and a
financial burden of up to $400 million annually (Buescher et al., 2010; Cuevas & Zuniga, 2021).
More importantly, health disparities are necessary to address because poor health extends from
an individual to the community, resulting in continued perpetuation of inequities in SES and
health outcomes.
Hispanics make up 19% of the U.S. population and are expected to grow to over 28% in
the next 40 years, which highlights the importance of decreasing health disparities in an
exponentially growing population (Krogstad & Noe-Bustamante, 2021; U.S. Census Bureau,
2021). Hispanic children and adolescents have the highest rates of obesity compared to other
ethnic and racial groups, which is a contributor to the prevalence of T2D and is greatly affected
by household SES (Mellus & Cannonier, 2016). Furthermore, 50% of Hispanic youth will
develop T2D in their lifetime because of high rates of obesity, lifestyle, and SES factors, which
could be seen as a death sentence for a large portion of this population if not addressed (Narayan
et al., 2003). Without addressing the health disparities affecting Hispanics, the exponential
growth of the population will increase poor health for individuals and the communities they
reside.

3

The negative impact of low household income on Hispanics due to living in
socioeconomic disadvantaged neighborhoods further worsens health disparities. As income
increases from the federal poverty line, consequently health status improves for Hispanics
(Braveman, Egerter, and Mockenhaupt, 2011). Additionally, Hispanics have lower household
income compared to non-Hispanic Whites, and Hispanic immigrants suffer from an even greater
income gap than those born in the United States (Tienda & Mitchell, 2006). A study conducted
by Braveman and Egerter (2008) suggests that lower annual income results in poor health for
Hispanics, which supports an intersection and relationship between income and health. Income
provides opportunities to live a healthy lifestyle, which further perpetuates equity issues,
resulting in annual income as a predictor of good health.
Health care systems are challenged to find a solution to the growing problem of diabetes
within the Hispanic population. Income disparities cause individuals and families to forego
needed care or have yearly wellness exams due to the cost of care, which affects individual
health by living with worsening diabetes symptoms and not accessing health care services
(Sommers et al., 2017). The ability to maintain good health requires time away from work and
money; since Hispanics earn less than non-Hispanic Whites, rent and food are prioritized higher
than health (Bureau of Labor Statistics, 2020). The growing size of the Hispanic population and
perpetuation of low SES groups could create negative health outcomes that affect individuals and
spread to families, neighborhoods, and society at large.
Organizational Context and Mission
Total Health Care (a pseudonym) is a health care system based in the United States and
has achieved most of its clinical quality performance goals; however, the organization continues
to have challenges in addressing uncontrolled diabetes in the Hispanic population. Total Health

4

Care’s mission is to provide high-quality, affordable health care services to improve individual
and population health. Total Health Care works to reduce health disparities and remove barriers
to improve health, by creating a vertically integrated health care system that provides an
individual less hassle to access multiple medical subspecialties and ancillary health care services.
The organization is built to allow individuals to access all facets of health care, without having to
go outside of the health care system. Total Health Care serves over 12 million individuals and
aims to improve wellness and quality of life, through advancing medical practice and utilizing
innovation to change the way health care is delivered. The goal of Total Health Care is to deliver
high-quality equitable health care available to all.
Stakeholder Groups
The research study has three different stakeholder groups that have interest and could
benefit from the study’s findings. The primary stakeholder of the research study is low SES
Hispanics with diabetes who have challenges in accessing health care and have uncontrolled
diabetes. The primary stakeholder group will be the population of individuals who will directly
benefit from the study’s findings because it could improve their overall health and wellbeing.
The secondary stakeholder group that has interest in the research study are the medical providers
that deliver direct patient care. Medical providers have the ability to incorporate the study’s
findings in care plans to treat low SES Hispanic individuals with diabetes, and monitor their
progress in order to ensure that their health improves or is sustained once their diabetes is
controlled. The tertiary stakeholder group that has interest in the research study is senior
leadership within Total Health Care. Senior leadership within Total Health Care is responsible
for the quality performance of the organization. With the findings of the research study, senior

5

leadership could mobilize resources to implement and improve workflows to treat this
population.
Purpose of the Project and Research Questions
The purpose of this study was to explore the societal challenges and barriers low SES
Hispanics with diabetes face when accessing health care, engaging in daily activities, and dealing
with financial challenges. Additionally, the research study aimed to assess how the lifestyle of
low SES Hispanics change when being diagnosed with diabetes. The importance of reducing
health disparities and providing equitable health outcomes among different ethnic populations
acted as an overarching goal for the study. The research questions guiding the study are as
follows:
1. How does receiving a diagnosis, such as diabetes, affect the daily lifestyle of low SES
Hispanic individuals?
2. What challenges do individuals from a low SES background face to keep their
diabetes in control?
3. What is the confidence level of low SES Hispanic individuals to take care of their
own health?
4. What are the experiences of low SES Hispanics when accessing health care services
to treat their diabetes?
Importance of the Study
The problem of low SES Hispanics experiencing a higher prevalence of diabetes is
important to address. Research shows a positive relationship between SES and health outcomes,
which suggests that a pathway to improve individual health could be to improve annual income
(Elgar et al., 2015). In health care services, care plans are normally created with minimal

6

consideration of specific demographic characteristics, review of societal influences, or
understanding language proficiency (Parker et al., 2017). The need to address this problem is
necessary to achieve positive population health outcomes that contribute to the overall health of
the Hispanic community.
Low SES individuals are associated with lower educational attainment and annual
income, both affecting the ability to comprehend health care plans and the ability to access health
care services. Perpetuating poor health and widening health disparities could be consequences of
not addressing the problem. Additionally, costs over a 3-year period related to medical
expenditures totaling more than $230 billion direct costs, could further create an economic
burden if not addressed (LaVeist et al., 2011). Parker et al. (2017) found that individuals who
were seen by a culturally concordant primary care physician experienced better diabetes control
rates than those individuals who were seen by a culturally discordant primary care physician. A
simple change of matching patient with a culturally concordant provider has shown positive
health outcomes, which provides tangible and intangible benefits to Hispanic individuals and the
communities they are part of. The continued active approach to align individuals considering
their culture, SES, and educational understanding, with medical providers is an opportunity to
reduce health disparities.
Overview of Theoretical Framework
The theory used to address the problem of practice was Bronfenbrenner’s ecological
systems theory (1979). Bronfenbrenner’s ecological systems theory presents a perspective of the
interconnectedness of an individual and its environment, and the effects of environmental
structures that an individual has little to no control over. Bronfenbrenner’s ecological systems
theory (1979) introduces different systems that influence individual behavior, which include: (a)

7

the microsystem, which is the immediate influences that directly impact individual behavior; (b)
the mesosystem, which encompasses the interactions between the individual microsystems; (c)
the exosystem, which include the societal structures that indirectly influence individual behavior;
(d) the macrosystem, which include the cultural elements that affect behavior, such as race,
ethnicity, and socioeconomic status; and (e) the chronosystem, which consists of all the
environmental systems that influence an individual over time (Gardiner & Kosmitzki, 2008). The
research study utilized a qualitative approach to understand the social determinants of health that
contribute to poor health through interviews with the specified sample.
Definitions
The key concepts that are essential to understand the problem of practice are:
Hispanics refer to individuals who trace their ancestry to Mexico, Spain, and Spanish-
speaking countries in the Caribbean, Central America, and South America (U.S. Census Bureau,
2015).
Social determinants of health are the integrated and historical social structures, and
economic systems that contribute to health inequities, such as economic status, educational
attainment, community and neighborhood infrastructure, social environment, and access to
health care (Handmaker, 2017).
Socioeconomic status refers to the complex measured social standing accounting for the
differences in educational attainment, annual income, employment, and geographical residence
(Eke et al., 2021).
Health disparity is a difference in health status and health outcomes among unique
identities and differences between gender, race or ethnicity, education, income, and housing
(Carter-Pokras & Baquet, 2002).

8

Culturally concordant care is a set of congruent behaviors, attitudes, and policies that
work together in a health care system that enable health care providers to work effectively in
cross cultural settings (Cross et al., 1989).
Organization of the Dissertation
The research study utilized the five-chapter dissertation model. Chapter One provides
background and an introduction to the problem of practice of the research study. The chapter also
introduced the purpose of the study and theoretical framework used for the study, and defined
key terms pertinent to the problem of practice. Chapter Two provides a review of the literature
focused on three aspects of the problem of practice; racial discrimination affecting health
outcomes, the relationship between socioeconomic status and individual health, and unique
challenges Hispanics face when trying to instill a healthy lifestyle. Chapter Three details the
research methodology and design of the study, as well as addresses the positionality and ethics of
the researcher. Chapter Four provide the findings and results of the data collection process.
Chapter Five closes with recommendations to address the problem of practice, addressing any
limitations, and providing suggestions for future research.

9

Chapter Two: Literature Review
This chapter reviews literature that highlights the factors affecting the higher prevalence
of diabetes in the Hispanic population. The first section focuses on the prevalence of racial
discrimination in societal structures that affect individual health. The second section focuses on
the role socioeconomic status has on individual health outcomes. The final section reviews the
challenges Hispanics face when accessing health care services. The chapter presents literature
findings and ends with an overview of the conceptual framework used to frame this research
study.
Studied Population
A definition of the studied population is important to specify and understand the
challenges that contribute to a higher prevalence of diabetes. In this review, Hispanics include
individuals who trace their ancestry to Mexico, Spain, and Spanish-speaking countries in the
Caribbean, Central America, and South America (U.S. Census Bureau, 2015). Hispanics make
up approximately 20% of the U.S. population and is expected to grow to 28% by the year 2060
(U.S. Census Bureau, 2021). However, regardless of socioeconomic status, Hispanics are 70%
more likely to be diagnosed from diabetes compared to non-Hispanic White individuals (Centers
for Disease Control and Prevention [CDC], 2021). The importance to address the health of a
growing population is necessary for a positive health to be spread within communities and to
future generations.
Health Disparities Faced by Hispanics
Hispanics suffer from health disparities that are important to address to improve society,
community, and population health. Health disparities are the differences in the prevalence and
burden of diseases, as well as other adverse health conditions that are experienced by socially

10

disadvantaged racial and ethnic groups (CDC, 2017). The Hispanic population suffers from
health disparities at an overwhelming rate compared to non-Hispanic Whites. Hispanics are 50%
more likely to die from diabetes and have 24% more uncontrolled high blood pressure compared
to Whites (CDC, 2015). Additionally, Hispanics are 23% more likely to be obese, which is a
contributing factor to poor health and a comorbidity that affects diabetes control (CDC, 2015).
Findings across all racial and ethnic groups show, six in 10 adults in the United States
suffer from a chronic disease that inhibits daily activity, which affects work, social relationships,
and physical activity (CDC, 2021). Type 2 diabetes mellitus (T2D) is the most common
endocrine disorder and is caused by a consistent level of increased blood sugar levels in the
body. T2D affects more than 37 million Americans, and Hispanics are the second highest
impacted ethnic minority group, with more than 6.5 million Hispanics in the United States with
the disease (American Diabetes Association, 2021; CDC, 2020). Deaths attributed to T2D, which
was the seventh leading cause of death in the United States, totaled more than 270,000 in 2017
(American Diabetes Association, 2021). A study conducted by Schneiderman et al. (2014) shows
that the risk of contracting T2D is associated with low socioeconomic status and strongest in
high-income countries, such as the United States. More importantly, uncontrolled diabetes, if not
appropriately cared for, perpetuate poor health to future generations, communities, and society at
large.
Reducing health disparities is an important problem to address in order to reduce the
financial burden experienced by health care systems and individuals, which amounted to $327
billion in the United States in 2017 (CDC, 2020). In a study of Hispanic internationally-trained
nurses in Baltimore, Maryland, the majority reported a lack of information being conveyed to the
Hispanic community in the United States compared to their country of origin, which perpetuates

11

disparities and creates misinformation, as it acts as an obstacle in promoting positive health
(Carter-Pokras et al., 2008). The majority of factors driving uncontrolled diabetes are mutable
factors, meaning they could be changed with interventions by a health care system or through
individual behavior, proving that the social determinants of health, such as socioeconomic status,
housing, education, are necessary to address to improve population health (Walker et al., 2015).
Hispanics are the top demographic group living with diagnosed or undiagnosed diabetes at 22%,
compared to non-Hispanic Whites at 12% (Cheng et al., 2019). Most clinical interventions focus
on losing weight, adhering to medications, or eating healthy on an individual level; however,
refocusing the priority on a structural level in order to reduce health disparities is important
(Cartwright, 2021). Societal structures and health care services are interwoven in promoting or
inhibiting individual healthy behavior, but the primary responsibility has been held with the
individual, rather than addressing the external environments that impact individual health.
Hispanics in the United States have suffered from poorer health than non-Hispanic
Whites, which has caused Hispanics to have more uncontrolled chronic diseases and a lower life
expectancy rate. Studies have proven that changes in individual behavior could help in keeping
diabetes in control, yet many of the challenges Hispanics face are not directly related to health
care services, such as social support and building individual health confidence (Walker et al.,
2015). The prevalence of diabetes within the Hispanic population has increased, and social
factors play a major role in Hispanic health; however, education, language concordance, and
income are rarely taken into consideration when addressing individual health (CDC, 2015). The
evidence suggests a need for public entities and health care services to shift the focus on treating
T2D from clinical education and self-management skills, to incorporating social support systems
to improve Hispanic health (Walker et al., 2015). Utilizing societal structures as pathways to

12

improve Hispanic health could reduce the higher prevalence of chronic diseases and increase life
expectancy in this population.
Racial Discrimination
Racial discrimination in societal structures, such as education and health care services,
act as catalysts that negatively affect mental and physical health. A study by Finch et al. (2000)
found that individuals who went to school in their country of origin and continued schooling in
the United States, were more likely to experience racial discrimination in societal structures, as
their levels of using English and acculturating to U.S. norms increase. The correlation between
racial discrimination in education is a factor that has perpetuated poor individual health: since
higher education provides opportunities to interact with people outside of the minority group,
individuals are exposed to differing ideologies and biases where discrimination could be
experienced (Kessler et al., 1999). Consequently, health disparities cannot be improved if racial
discrimination persists in societal structures, such as health care services, which are built to
improve health and to provide services for the specific challenges Hispanics face (Ford &
Airhihenbuwa, 2008). High blood pressure, diabetes, and stress, are more prevalent in minorities
that report discrimination, which negatively affects the ability to live a healthy lifestyle yet is
rarely addressed by health care systems (Finch et al., 2000). Societal structures, such as
educational entities and health care services, could provide Hispanics with the appropriate
knowledge and skills to live a healthy life; however, when engaging with health care services,
providing treatment plans addresses the symptom of the problem and does not address the
underlying issue of discrimination being a factor that affects individual health.
Health Care Providers

13

Health care services and health care providers play an essential role in promoting
individual health behaviors; however, racial discrimination among health providers create
challenges for Hispanic health. Accessing health care services requires an individual to interact
with a health care provider to improve their health and monitor disease progression; however,
racial discrimination in health care has resulted in individuals with more uncontrolled diabetes,
debilitating diabetes symptoms, and noncompliance with preventative tests (Ryan et al., 2008).
Additionally, discrimination has shown to have adverse effects on individual emotional well-
being, but most societal and health care services fail to question the health effects of
discrimination when creating efforts to aide low-socioeconomic communities (Kessler et al.,
1999).When individuals access health care services to assist in creating healthy behaviors, the
distrust and perceived discrimination by health care providers, contributes to poor quality of care
and a greater chance of uncontrolled diabetes (Lopez & Golden, 2014). Health care providers are
a contributing factor in improving individual health, but discrimination has pushed away
Hispanics from accessing care, resulting in diseases to progress without any intervention.
Evidence has been well-documented identifying negative health outcomes and unmet
health needs resulting from discrimination (Reader & Gillespie, 2013). In a nationally
represented population study, one in five Hispanics reported feeling discrimination when seeing
a health care provider and completely avoided accessing health care services because of
discrimination (Findling et al., 2019). The strong relationship between experiencing
discrimination and unmet health suggests a dire reality of how minority populations view health
care providers (Kitchling et al., 2020). The beliefs and attitudes of health care providers
contribute to below-standard care, which negatively impacts individual health and the perceived
care received by health care providers (Reader & Gillespie, 2013). Hispanics, regardless of

14

whether they are in a higher socioeconomic class, report more discrimination in health care
settings and less engagement with health care systems, which is opposite for non-Hispanic
Whites (Findling et al., 2019). Once an individual experiences racial discrimination with their
health care providers, trust is lost and assumptions form on how future interactions may
transpire, which results in health issues that could be prevented.
Health Issues Because of Discrimination
Racial discrimination not only affects the interaction between a health care provider and
an individual, but it also results in poor quality of care, an increase in health-related issues, and
discourages the individual in creating healthy habits. The association between racial
discrimination and health outcomes has been well-documented to have negative consequences
for daily lifestyle, with individuals engaging in more unhealthy habits, such as alcohol
consumption and poor nutrition, which could perpetuate poor health within families,
communities, and social groups at large (Paradies et al., 2015). In a large population study, more
than 60% of participants self-reported perceived discrimination on a daily basis, which was also
linked to health problems, such as chronic diseases, stress, and mental health disorders (Kessler
et al., 1999). Furthermore, Dias et al. (2020) found that racism and discrimination was positively
associated with depressive symptoms and stress related to diabetes for minorities. As health care
services aim to reduce the exposures of racism, the perception of exposure to racism could be
enough to affect individual health (Krieger, 2003). One study found that individuals that perceive
racial discrimination by health care providers had 50% less probability of adhering to diabetes
self-management practices (Ryan et al., 2008). Health issues ensue well after an individual
interacts with a health care provider, and those health issues perpetuate health for future
generations and the community at large. As Hispanics actively combat racial discrimination, the

15

community and environment they live in continue to create challenges for living a healthier life,
which suggests exploring different pathways to improve health.
Social support could be a pathway that reduces the negative effects of discrimination, but
depending on how social networks are formed, discrimination could continue to permeate and
affect individual health. Discrimination has been found to have a lesser impact on health for
individuals who have higher levels of social support, but could be detrimental for individuals
who lack social support through their community, family, or their workplace (Finch & Vega,
2003). Hispanics have migrated to new destinations in the United States due to affordability,
greater opportunity, and as a response to discrimination (Lichter et al., 2010). However, due to
individuals migrating away from metropolitan areas to relocate to more rural and suburban areas,
leaving their social support systems could continue to pose discrimination issues as local
residents have been challenged with accepting newcomers (Lichter et al., 2010). Lebron et al.
(2014) suggest that discrimination in societal structures, health care services, and health research
inhibit the improvement of Hispanics to keep their diabetes in control, and creates long-term
challenges, as this population tries to improve their health and the health of the community they
live in. Hispanics who experience discrimination, whether immigrants or long-term U.S. citizens,
continue to face chronic diabetes-stress and mental health issues that affect their daily lifestyle
(Lebron et al., 2014). Discrimination is apparent through societal structures that aim to improve
health; however, the constant stress Hispanics face when dealing with discrimination negatively
effects their ability to improve and sustain long-term health.
Underrepresentation in Clinical Research
Biomedical research and clinical trials are pathways that could lead to improvements in
treatment and advances in medical care. However, most research trials lack a representation of

16

minority populations, which has caused variations in the disease process to be uncharacterized
among race and culture (Aviles-Santa et al., 2017). A study by the National Emphysema
Treatment Research Group (2003) proved the lack of representation, where 99% of the 1,218
patients in the trial were White or African American. With a lack of representation, health
research could have inaccuracies, specifically when treating race as a biological variable, and
fails to acknowledge the influence racism has on health (Krieger, 2003). Studies conducted 20
years ago are still in practice today and show that that health care access for Hispanics are
worsening compared to improvements in other minority groups (Stone & Balderrama, 2008).
The homogeneity of clinical research has failed to include an accurate sample of Hispanics,
which has led to antiquated practices and beliefs. Whether discrimination is overt or subtle, the
effects of discrimination impede the progression of Hispanics to live a healthy life.
Hispanics from a low socioeconomic status that lack trust with health care providers and
have access to health care services, could also play a factor in this population lacking
representation in health research. Fisher and Kalbaugh (2011) found that in clinical research,
Hispanics are overrepresented in phase I trials but lack representation in phase III trials, which
could be due to financial incentive for participation in phase I; however, as more time is needed
when research moves to phase III, individuals are less likely to take time away from work that
could harm their financial situation. Clinical research may inadvertently exclude Hispanics from
participation, as state-of-the-art clinical research is limited in rural areas and low socioeconomic
communities, which contribute to creating health disparities (O’Bryant et al., 2021). Hispanic
underrepresentation in clinical research is a significant concern as it raises issues of
generalizability in creating care plans without consideration of ethnicity and race (Rivera-Goba

17

et al., 2011). Health research has implicitly excluded Hispanics, which suggests that racial
discrimination has direct and indirect effects on population health.
Socioeconomic Status
Socioeconomic status markers, such as education, employment, and housing, act as risk
factors that contribute to the higher prevalence of diabetes (Dias et al., 2020). Socioeconomic
status plays an important role in health, as it provides access to nutrition-rich foods, communities
that promote health, educational opportunities to instill health knowledge, and stability with
employment to create a financial foundation for an individual. Individuals across all
socioeconomic groups in the United States who suffer from poverty and have less than a high
school diploma, experience a higher prevalence of worse health compared to individuals who
have higher education or from a higher income group, proving that there are pathways to
improve health outside of conventional health care settings (Braveman, Egerter, and
Mockenhaupt, 2011).
The United States has the lowest ratio of social service spending to health care spending
among industrialized countries, with the average of other industrialized countries social service
spending 1.5 times more than the United States (Bradley et al., 2017). Additionally, the United
States devotes approximately 20% of its gross domestic product to health care, which is four
times more than public education and 20 times more than public housing, showing the lack of
focus on improving societal structures to aide in individual health (Bradley et al., 2017). Low
socioeconomic individuals are more susceptible to living in poor housing, unsafe neighborhoods,
access to innutritious foods, and lack of employment opportunities, which all affect health.
Although the majority of established social services target improving low socioeconomic
neighborhoods, with a lack of public funding, the economic investment is limited and the impact

18

on the community is dismal (Bradley et al., 2017). The following sections focus on the role
income, housing, and education play in socioeconomic status and Hispanic health.
Income
The amount of income an individual makes affords them the opportunity to live a healthy
life or forces them to sacrifice their health over other financial decisions. The relationship
between income and individual health, proves that an individual’s income has detrimental effects
on living a healthy lifestyle (Braveman & Gottlieb, 2014). Sommers et al. (2017) found that
individuals earning $25,000 or less annually reported receiving fair or poor care 29 percentage
points higher than individuals earning over $100,000 annually. For every dollar of non-Hispanic
White wealth, Hispanics earn $0.32 less, which has improved over the last 40 years yet remains a
large gap that increases income disparity (Orzechowski & Sepiellli, 2003; Mora & Davila, 2018).
The disparity between income groups is a challenge Hispanics face, as they sacrifice their health
because of their economic status (Kochhar & Cillufo, 2018). Additionally, Hispanics have the
lowest weekly income among minority groups and have seen a 4% increase in weekly earnings
from 2018 to 2019, compared to other minority groups seeing between a 6% to 7% increase
during the same period (Bureau of Labor Statistics, 2020). The reality faced by Hispanics shows
a stark contrast between ethnicity groups, resulting in income-driven decisions focused on the
immediacy of daily living opposed to making choices that focus on long-term health.
Improving socioeconomic status, specifically annual income, could lead to positive health
outcomes, as income allows for household decisions to be made to support health: purchasing
nutrition-rich foods, accessing health care services, social resources linked with personal
networks (Zhang & Xiang, 2019). The relationship between increasing income and improving
health related quality of life has shown a positive correlation, meaning the higher income an

19

individual makes, the healthier they are (Zhang & Xiang, 2019). More than 64% of Hispanics in
the United States earn less than $40,000 annually compared to 40% of non-Hispanic Whites,
affecting financial decisions related to health (Kochhar & Cillufo, 2018). Furthermore, Hispanics
make up 59% of unskilled, high-risk jobs compared to 38% for non-Hispanic Whites, showing
the disparity of available work for this population (Velasco-Mondragon et al., 2016). Adults in
poverty are more than twice as likely to contract T2D than high-income earners, which shows a
correlation that improving socioeconomic status could lead to better health (Braveman &
Egerter, 2008; Braveman, Egerter, and Mockenhaupt, 2011). Additionally, national income
inequality has a positive relationship to health inequalities, further proving that income could be
a risk factor that could improve individual health (Elgar, et al., 2015). Income and life
expectancy have shown a strong association over the last four decades, with risk factors, such as
increasing geographical segregation by income, reduced economic opportunities, and digital
inequality, further exacerbating the income and health gap (Bor et al., 2017). The importance of
income to live a healthy life suggests that socioeconomic status could be an indicator of
individual health, while employment challenges, arguably the most important factor in
improving income, concurrently results in the inability to live a healthy lifestyle.
Employment
Employment is another factor affecting the ability to earn more, to support the habits
needed to live a healthy lifestyle, and to ultimately improve socioeconomic status. However,
Hispanics are affected by high poverty rates due to low paying jobs, resulting in sacrificing
health maintenance in order to provide basic individual and family needs, further supporting that
low income worsens health (Rycroft, 2013). Health behaviors are strongly shaped by social
factors, including annual income, employment, and educational attainment (Braveman &

20

Gottlieb, 2014). In a study of 1,423 minorities living in a poor community, Horowitz et al.
(2003) found that 40% of residents with diabetes did not keep a diabetic diet due to money
concerns and 20% skipped taking medication due to money concerns, which could be remedied
with greater employment opportunities. Additionally, income disparities cause individuals and
families to forego needed care or having yearly wellness exams due to the cost of services
(Sommers et al., 2017). Employment and income normally work together to improve health, but
as Hispanics face differing employment realities than non-Hispanic Whites, the inequities
stemming from employment negatively affect Hispanic health.
Employment availability, whether due to residential segregation or lack of job
qualification, contributes to the ability Hispanics have to improve their socioeconomic status and
ultimately, their health. Easley (2018) found that as Hispanics live in segregated communities
from non-Hispanic Whites, the residential segregation has also led to varying labor markets,
which include a lack of high-paying jobs and more lower-wage blue-collar work. Additionally,
Hispanics who face chronic illnesses or hospitalization, have reported more difficulty in securing
stable employment compared to non-Hispanic Whites (Arango-Lasprilla et al., 2010). Studies
have shown that financial hardship and health self-efficacy have a negative association, which
perpetuates health disparities that could be improved through employment (Tucker-Seeley,
2015). Furthermore, household income is correlated with longer life expectancy, however,
chronic disease prevalence is greatest at the lowest household income level, which proves that
health inequities continue to exist based on social class (Braveman, Egerter, and Williams,
2011). Employment has been linked with poor health outcomes, and improving the ability to
increase income through employment could also affect the community and housing an individual
resides.

21

Community and Housing
The community an individual resides, and the physical structure of their home could
affect the ability to instill healthy behaviors or could perpetuate poor health. Increased
geographical segregation of high-income and low-income earners result in different access to
neighborhood amenities focused on health and education, which continues to affect health
inequities (Bor et al., 2017). Low socioeconomic Hispanic communities center around areas with
low-paying and low-skilled jobs, highlighting an area of focus to increase income, promote
health, and ultimately improve socioeconomic status (Lichter et al., 2010). Hispanic household
income in 2020 was $55,000 annually affecting the neighborhoods and communities where
Hispanics can afford to reside (Shrider, 2021). The combination of low income and unaffordable
housing, creates housing instability and an emotional toll on individuals, which has proven to be
a major factor in health self-management (Martinez-Cardoso et al., 2020). Studies have shown
that the community an individual lives in plays a vital role in the creation of healthy behaviors,
by acting as a support system in living a healthy lifestyle (Boch et al., 2020). Buttazzoni et al.
(2021) suggest that neighborhood characteristics, specifically those in urban areas, have a major
influence on the health and well-being of young adults, and those habits are carried into
adulthood and spread within families and communities. Communities and low socioeconomic
neighborhoods play an important role in individual health, which could intensify poor health
when accounting for the structural home an individual resides.
The physical structure of an individual’s house has as much impact on individual health,
as does income, education, and the interactions with health care providers. Environmental
conditions, such as safe neighborhoods, clean drinking water, and an undamaged home,
contribute to improving individual health (Stone & Balderrama, 2008). Boch et al. (2020) found

22

that poor housing quality, such as living in an unsafe neighborhood or an overcrowded
household, was associated with a greater risk for becoming hospitalized. Individuals living in the
poorest household income reported living in conditions that did not have acceptable energy-
efficient resources to heat their home, which had direct and indirect impact on individual health
(Marmot & Bell, 2012). Additionally, individuals that reside in lower-income neighborhoods
needed more health care interventions than individuals that live in urban and more affluent areas,
where health care services and options are abundant and primarily located (Brown, 2014). The
physical house in which an individual resides has an important role in health, but the food that is
stored and eaten inside the home is equally important to living a healthy lifestyle.
The availability of nutrition-rich foods and the ability to have community resources that
support physical activity, both play a key role in individual health. Hispanics in the working
class have higher rates of inadequate physical activity, unhealthy nutrition, and are mostly
employed in labor-intensive positions, such as construction workers, housekeeping cleaners, and
food service workers (Bucknor, 2016). In working class populations, the thought of purchasing
healthy food is an afterthought, especially as this population may be juggling multiple jobs or
prioritizing expenses that provide them shelter (Chaufan et al., 2011). The United States
Department of Agriculture (USDA) mandates a national standard for affordable, nutritious,
family food plans across the nation. However, in a minority community with limited access to
personal automobiles and inaccessible public transportation, the USDA national standard for
affordable foods cost up to 36% more than initial estimates, further creating issues for
individuals and families to access nutritious foods (Chaufan et al., 2011). Furthermore, in a study
assessing availability of foods in low-income areas, healthy food items were limited or
completely missing from the grocery selection (Chaufan et al., 2011). This caused individuals to

23

purchase high-priced items or completely forego the healthier option, as finances and time to
find alternatives were taken into consideration (Chaufan et al., 2011). The cheaper alternative to
nutritious foods is normally high caloric, low-nutrient foods, which worsens control rates for
diabetes and increases the onset of diabetes symptoms (van Ommen et al., 2018). The access to
nutritious foods is related to the community in which an individual resides, concurrently also
affecting the ability for an individual to exercise to live a healthy life.
Physical activity and exercise are factors to help reduce the prevalence of diabetes and
could aide in keeping diabetes and other chronic diseases in control. The concentration of
Hispanics that reside in low-income communities with less public assistance, results in excess
traffic, deteriorating streets and sidewalks, and unsafe neighborhoods, which have been
correlated with less physical activity among community residents (Martinez-Cardoso et al.,
2020). Furthermore, in a study of a predominantly Hispanic community, residents mentioned the
reluctance to allow their children to play outside in an unsafe community and the lack of access
to healthy foods in their neighborhood, as barriers to living a healthy lifestyle (Hardy et al.,
2012). Healthy behaviors, including physical activity, are developed within an individual’s
ecologic and social environment, which could be compromised if neighborhoods and
communities lack the characteristics needed to promote a healthy lifestyle (Soltero et al., 2021).
Additionally, physical activity requires time away from work and at times money towards gym
memberships, which act as barriers for improved health in low socioeconomic status individuals
(Martinez-Cardoso et al., 2020). Issues arises when individuals delay lifestyle changes, such as
improving physical activity, until their diabetes impede daily lifestyle, which suggests the need
to focus on health prevention rather than health reaction in this population (Parry et al., 2004).
The relationship between neighborhood characteristics and physical activity are a pathway to

24

promote a proactive approach in increasing physical activity, that sustains healthy behaviors
before diabetes affects daily living.
Education
Education is another social determinant of health that could potentially improve
individual and community health. Individuals in the United States who suffer from poverty and
have less than a high school diploma have a higher prevalence of chronic diseases compared to
individuals who have a higher education or from a higher income group (Braveman, Egerter, and
Mockenhaupt, 2011). Educational attainment, a factor that contributes to socioeconomic status,
further widens health disparities among Hispanics and non-Hispanic Whites. Comparing
demographic groups by ethnicity in the United States, the Hispanic population has the least
formal schooling, which create barriers when trying to improve socioeconomic status, as well as
instill healthy behaviors (Gallo et al., 2019). Education provides opportunity for employment and
creates knowledge needed to improve individual health (Mechanic, 2005). School systems in low
socioeconomic communities suffer from lack of funding, which negatively affects student
opportunities to improve socioeconomic status and reduce health disparities (Aikens & Barbarin,
2008). In a study by Schneiderman et al. (2014), results found that individuals who have
completed high school had a lower prevalence of diabetes, further suggesting the negative
association between diabetes prevalence and educational attainment. Among Hispanics ages 25
to 29, only 15% hold a bachelor’s degree or higher, compared to 41% of non-Hispanic Whites,
which magnifies the importance to promote educational equity as a pathway to improve health
(Krogstad, 2016). Improving Hispanic educational opportunities could have a positive result in
reducing income and health disparities, as well as provide future generations with the skills and
knowledge to improve overall population health.

25

Improving education could be a pathway to secure employment, leading to economic
security, which shows the need to support education early in childhood for future adult health
(Stone & Balderrama, 2008). A study conducted by Braveman, Egerter, and Mockenhaupt
(2011) found that babies born to mothers with less than a high school education, are twice as
likely to die before their first birthday as babies born to mothers with at least a college degree.
The correlation between socioeconomic status and reading levels, show that family, school, and
the neighborhood an individual lives in are all factors that could create or discourage healthy
behaviors (Aikens & Barbarin, 2008). An individual’s education has been associated with their
ability to comprehend nutrition labels on foods, proving that reading levels and healthy behaviors
work together to improve individual health (Fernandez et al., 2021). The importance of education
in providing fundamental skills and knowledge to create healthy behaviors suggest a pathway to
improve community and population health.
Education could be a primary factor in creating healthy behaviors, however, the
considerable financial burden that education could incur pose challenges. The issues of
availability and affordability for secondary and higher education, are barriers that should be
addressed to improve the ability for Hispanics to have greater lifetime earning potential and
establish healthy behaviors to be passed through generations (Philbin et al., 2018). Residential
and income segregation have been fundamental causes for health and educational inequalities,
and as a result, the limited access to quality elementary and high schools create issues when
preparing individuals for employment and higher education (Williams & Sternthal, 2010).
Education segregation affects the quality of schoolteachers and inequities in school funding,
which have direct and indirect impacts on individual health (Fuller et al., 2019). Education is a

26

primary health risk factor for Hispanics, and increasing education could improve socioeconomic
status, increase household income, and instill long-term healthy behaviors.
Accessing Health Care Services
Health care services play an essential role in improving health disparities. The United
States has the highest medical care expenditure per capita than any other country, however, ranks
among the lowest performing countries in key quality health indicators (Tikkanen & Abrams,
2019; Organisation for Economic Co-Operation and Development, 2021). Although the
Affordable Care Act increased medical coverage for Hispanics, they continued to report having
fewer health screenings and less likely to engage in follow-up care (Shoemaker & White, 2016).
Additionally, Hispanics that do access care reported an overall lower quality of care, which
through individual perception, could shape the relationship with all health care providers and
potentially form stress when interacting with a health care system (Lanting et al., 2005). Before
Hispanics engage with a health care provider, factors such as health insurance and immigration
policy, affect the ability to instill healthy behaviors.
Health Insurance
Health care insurance, the primary payment for health care services in the United States,
is normally provided through employers. Hispanics are largely represented in jobs that do not
provide health benefits, which result in paying for health care from individual and family
earnings (Tienda & Mitchell, 2006). Hispanics consist of 34% of the uninsured population under
the age of 65, which is the greatest among all minority groups (Kaiser Family Foundation, 2009).
The cost of health care becomes a burden, and more precedent expenses, such as housing and
rent, take priority when deciding the allocation of household income (Shelton et al., 2011).
Individual health gets sacrificed and delayed without insurance or a means to pay for services,

27

which results in seeking medical care when diseases impede daily life rather than prioritizing
preventive care (Williams et al., 2010).
In a population study of over 3,000 Hispanics, there was a strong association between
undiagnosed diabetes and having no health insurance. More than 50% of the undiagnosed
participants did not have health insurance for at least a year, which could perpetuate issues of
diabetes with a lack of access to health care services (Casagrande et al., 2018). Issues arise with
the lack of health insurance for Hispanic individuals, because without health insurance,
individuals access health care less and could remain unaware of their medical conditions
(Casagrande et al., 2018). The complexity of health insurance creates confusion and lack of
engagement, which has been proven in a study that found half of the U.S. population did not
understand basic health insurance terminology, causing subsequent challenges when improving
health (Edward, 2021). In a study by Kuo et al. (2003), health insurance status and the
consistency of taking medications showed a negative relationship, which highlights the
challenges Hispanics are faced with to cover medication costs without health insurance.
Health insurance could be a pathway for individuals to improve health, however,
providing health insurance for every person is likened to treating the symptom rather than the
problem. Universal health care coverage has been discussed as a possible solution to improve
health disparities, however, the United Kingdom, a country with universal health care coverage,
and the United States share similar results in health disparities due to income and social class
(Braveman & Gottlieb, 2014). The results in the United Kingdom further suggest that providing
health insurance to every person only secures access to care, but the allocation of household
income to continue medication regimes or purchasing a gym membership to improve physical
activity still continue to be challenges. The increased cost of health care and the costs associated

28

with living a healthy lifestyle have been reported as barriers and a major cause to deter Hispanics
in promoting healthy behaviors (Carter-Pokras et al., 2008). Individuals who did not access care,
due to lack of health insurance or a lack of time to see a health care provider, were six times at
greater risk of being unaware of their diabetes diagnosis (Menke et al., 2017). The quality of
health insurance in the United States varies across social and income classes, which result in
health insurance acting as a barrier for low-income and working-class populations.
Immigration
Immigration status affects the accessibility of health care services, through employment
or medical insurance coverage. Policies created for immigrants are factors that affect Hispanic
individual, household, and generational health. In a 40-year period, the population of individuals
living in the United States born in Mexico or other Latin American countries increased from 9%
to 50%, highlighting an increase in Hispanic immigrants living in the United States (Budiman et
al., 2020). Additionally, Hispanics counted for 310,000 individuals that immigrated to the United
States in 2018, highlighting the importance of addressing health in a large growing population
(Budiman et al., 2020). Immigrants, both documented and undocumented citizens, live their lives
in fear of potential deportation, which worsens health and leads to chronic stress (Cavazos-Rehg,
2007). The stress immigrants experience when reestablishing their homes, social networks,
education, and employment opportunities are competing priorities that overshadow individual
health (Gallo et al., 2009). In a Hispanic community study, residents mentioned the reluctance to
allow their children outside for fear of retaliation or deportation, which affect children
psychologically and physically as they live in fear and are incapable of living a healthy lifestyle
(Hardy et al., 2012).

29

Immigration laws create an exclusionary stigma, which leads to stress and is associated
with increased levels of blood sugar and high blood pressure (Hardy et al., 2012). Immigration
policy could contribute to poor health, as stress and immigration stigma experienced by
Hispanics, create less engaged and fearful individuals (Philbin et al., 2018). Studies have shown
that individuals living in anti-immigration focused communities access less health care, which is
detrimental to immigrants’ mental health and chronic disease onset (Martinez-Cardoso et al.,
2020). Acculturation stress, the stress faced by immigrants to acclimate to country norms, while
also experiencing a tension to maintain behaviors and characteristics from their country of origin,
are factors that affect Hispanic health (Cervantes & Castro, 1985). Immigrants, specifically
Mexican Americans, experience higher levels of acculturation stress affecting their family and
parenting, which has been correlated with an increase in mental health disorders (Cervantes et
al., 2019). The undocumented status of immigrants creates chronic stress that may not be as
pronounced compared to acute stress, but the consistent stressful environment makes taking care
of individual health a lesser priority (Cavazos-Rehg et al., 2007). Further, Pedraza et al. (2017)
found that Hispanic immigrants are reluctant to share information with public and private entities
in fear of retaliation or an adjustment with their citizenship status. The issue of fear becomes
instilled in immigrants and their families, which pushes the population away from engaging in
public life and social support systems, making instilling healthy behaviors more difficult
(Pedraza et al., 2017). Additionally, immigration laws impact health by limiting access to
secondary and higher education, which are essential pathways to promote creating health
knowledge and healthy behaviors (Philbin et al., 2018). Immigrants face acculturation stress and
chronic stress, which disengage this population with public entities, including U.S. health care
systems.

30

The U.S. health care system could be difficult to understand and could create a barrier for
accessing health care services. As a result, many Hispanic immigrants in the United States have
little knowledge of how the U.S. health care system works (Carter-Pokras et al., 2008).
Communication and language barriers have also been found to be reasons Hispanics describe as
inhibiting their diabetes care (Horowtiz et al., 2003). Although becoming a citizen is a goal for
immigrants, the effects of living in the United States longer contribute to poor health for
Hispanic individuals. The loss of culture, the assimilation into U.S. society, the adoption of
unhealthy behaviors, and the prolonged period of acculturation stress all act as risk factors that
contribute to poor health (Finch & Vega, 2003; Lopez & Golden, 2014). Hispanic immigrants
are at risk for poor health outcomes due to policies and public entities, as stress and a lack of
health knowledge prohibit living a healthy life.
Culturally Concordant Care
The experience individuals have when accessing health care services also shape how
healthy behaviors are sustained when individuals are at home, school, work, or in their
community. The relationship between a medical provider and an individual affects healthy
behavior for families, communities, and society at large. A study by Baghikar et al. (2019) found
that participants reported that poor communication from their health care provider was a barrier
in taking medication. Individuals rely on health care providers to provide medication regimes
and ultimately provide a diagnosis for chronic illnesses. However, the lack of trust Hispanics
face with health care providers result in individuals being unaware of their diabetes (Menke et
al., 2017). Language is a way to instill trust in culturally concordant care and could be a pathway
to improve trust among this population. Hispanics with low English proficiency and do not see a
language concordant physician, are four to five times more likely to be confused about

31

medications and their care plan, which highlights the importance of incorporating language in
culturally concordant care (Wilson et al., 2005). Health care providers that speak an individual’s
primary spoken language and understands their culture, suggests an area of focus that could
improve Hispanic health.
Few health care systems have coupled immigrant-friendly practices with culturally
concordant care; however, for health care systems that have prioritized these efforts, results show
diabetes self-management and clinical outcomes sustained, and trust built among health care
providers and patients (Iten et al., 2012). Failure to address language barriers experienced by
Hispanics have resulted in less adherence to medication regimes and less confidence in self-
management skills (Martinez-Cardoso et al., 2020). Additionally, due to the lack of
understanding from health care providers of Hispanic culture, the recommendations and care
plans outlined by health care providers were reported as incongruent with family, cultural, and
social circumstances (Penedo et al., 2015). Culturally concordant care could be a pathway to
improve Hispanic health, but the sustainability and applicability in practice may jeopardize the
benefits of these programs.
Culturally concordant care could help Hispanic individuals instill healthy behaviors and
gain trust to engage in health care services. Although health care organizations aim to provide
culturally concordant care in practice, the lack of bilingual medical providers impedes
sustainability (Brown, 2014). Research has shown that culturally concordant care could improve
population health, but lack of funding and political support, negatively affect the sustainability of
these efforts (Carter-Pokras et al., 2008). Hue et al. (2016) found that using bilingual
interventions and teaching strategies for Mexican Americans doubled their diabetes knowledge,
which proves to be a pathway to improve healthy behaviors. Poor care, specifically care that

32

does not account for cultural practices or familial support, has shown to be positively associated
with physical health and mental health problems, signifying the impact health care providers
have on Hispanics with diabetes (Alderete et al., 1999). Language concordance coupled with
culturally concordant care could be a focus of health care services to reduce health disparities
and improve Hispanic health.
Conceptual Framework
The extensive evidence identified societal factors that have direct and indirect effects on
individual health, highlighting the importance of looking at ecological factors outside an
individual that could be pathways to improve health. Bronfenbrenner’s ecological systems theory
(1979) presents a theoretical framework to view health as a result of the interconnectedness of an
individual and its environment, while acknowledging that the effects of environmental structures
on an individual are significant, yet subtle and indiscernible (Stokols, 1996). Most health
challenges are complex and are only understood from a comprehensive approach that
incorporates health, social, and public policy to improve population health (Stokols, 1996). The
different ecological systems affecting Hispanic health expand beyond an individual’s control,
which suggest that health outcomes are dependent on the collaboration of societal structures to
address population health.
Using Bronfenbrenner’s ecological systems theory (1979) as the foundation of the study
created different pathways to understand individual health and the experiences of daily life that
affect health. Ecological systems theory is grounded in foundational principles that consider the
interrelationships between environmental systems and individual behavior, ultimately affecting
individual health (Stokols, 1996). The term ecology refers to the interrelationships between
organisms and its environment, which is an appropriate lens to understand the high prevalence of

33

diabetes in the Hispanic population and to analyze the multiple levels of influence on individual
health behaviors. Simultaneously, the societal environment has bidirectional impact on health
care services, which consequently affect individual health.
The ecological systems theory was an appropriate use to create a foundation for the
conceptual framework that was utilized to understand the higher prevalence of diabetes in the
Hispanic population, as the theory takes an interdisciplinary approach to solve a complex
problem. Ericksson et al. (2018) found in a meta-analysis of health research, that useful
recommendations for public health interventions were created by considering the relationships
between ecological systems. The use of ecological systems theory views the individual as a
unique system, in which cognitive, social, and motivational processes operate synchronously and
in coordination with one another (Bronfenbrenner, 1979). Utilizing the ecological systems
theory, provided an inclusive and sensitive lens to view an individual within the context of an
interrelated hierarchical social structure, which have direct and indirect effects to individual and
population health (Buser et al., 2020). Ecological systems theory took a holistic approach to
health, acknowledging that most health behaviors are a result of the systems and environments
that an individual has little to no control over.
Health care services and health care providers that view health from multiple perspectives
take the ecological systems theory into practice when creating treatment plans and providing
education to patients. In a study on health behaviors and health knowledge, using ecological
systems theory suggested that health care providers should be aware of the influences of different
ecological systems that affect health decision-making, instilling healthy behaviors, and accessing
health care services (Buser et al., 2020). The importance of using ecological systems theory to
understand the higher prevalence of diabetes supports forming an understanding of how health

34

care providers work to care for patients in a culturally concordant way, while considering the
individual in context-specific situations (Bryans et al., 2009). Additionally, in a study of health
care providers in the United Kingdom, evidence suggests that health care providers serve as a
liaison in creating linkages between the person and the ecological systems to improve individual
and population health (Bryans et al., 2009). The salience of health care providers to view and
treat health as a cause of multiple environmental factors, creates a strong rationale to utilize
ecological systems theory to understand the higher prevalence of diabetes in the Hispanic
population.
The model in Figure 1 presents the conceptual framework utilized in the study, which
suggests pathways that could reduce health disparities and improve population health. Health
care and the societal environment concurrently affect individual health, but most health care
interventions inadequately address the impact societal factors of an individual. Figure 1
illustrates how societal factors, such as schools, housing, availability of nutritious food, impact
individual health. Additionally, health care is impacted by the same societal factors, while also
directly impacting individual health. The conceptual framework aims to look at factors that are
inadequately addressed in health care services and explore pathways where individual health
could be positively impacted.

35

Figure 1
Research Study Conceptual Framework: Modified Bronfenbrenner’s Ecological Systems Model

Note. Adapted from The Ecology of Human Development, Bronfenbrenner, 1979. Copyright
1979 by the President and Fellows of Harvard College.

36

Summary
Chapter Two provided an overview of the literature supporting the factors that contribute
to Hispanic health, which also affects the higher prevalence of diabetes in this population. The
first section explored the effects of racial discrimination on individual health, which occurs from
health providers and the lack of Hispanic representation in medical research. The second section
highlighted the relationship between socioeconomic status and the ability to instill healthy
behaviors, which ultimately affects individual health. The final section reviewed challenges with
health insurance, immigration policy, and the lack of culturally concordant care that perpetuate
poor Hispanic health. The chapter concluded with an introduction of the conceptual framework
that this research study utilized when addressing the problem of the higher prevalence of diabetes
in the Hispanic population.

37

Chapter Three: Methodology
The purpose of the research study was to understand the barriers and challenges low SES
Hispanics face living with diabetes. The findings of the research study aim to provide health care
services with opportunities to augment health care services, in order to address salient challenges
faced by this population, which could help to improve individual and population health. A
narrative inquiry approach was utilized for the research study to gain an understanding of the
reality and lived experiences of this population. This chapter provides an overview of the
research design, the setting the research will take place, the positionality of the researcher, and
the specific data collection methods used in the study.
Research Questions
The research questions that guide the study are as follows:
1. How does receiving a diagnosis, such as diabetes, affect the daily lifestyle of low SES
Hispanic individuals?
2. What challenges do individuals from a low SES background face to keep their
diabetes in control?
3. What is the confidence level of low SES Hispanic individuals to take care of their
own health?
4. What are the experiences of low SES Hispanics when accessing health care services
to treat their diabetes?
Overview of Design
A phenomenological qualitative study research design was used to understand
participants’ lived experiences regarding the phenomenon of living with diabetes. The research
design aligns with the purpose of the study by utilizing participants’ first-hand accounts on the

38

challenges living with diabetes. The strategy of inquiry used in the study was individual
interviews conducted by the researcher focusing on the themes of the research questions, which
are incorporated in fifteen interview questions. The research design considered the credibility of
the study by ensuring that the participants’ narratives were kept unmodified, as well as
conducting member checks to ensure accurate understanding of participant answers (Merriam &
Tisdell, 2016). The interviews allowed the researcher the ability to ask clarifying questions if
more information was needed to gain a comprehensive understanding of the participants’
experience.
Research Setting
The study utilized a purposeful sampling approach. The sampling approach was chosen
to gain an in-depth understanding of low SES Hispanics with diabetes and the daily challenges
they face living with the disease (Merriam & Tisdell, 2016). There were 10 participants in the
sample, who were individually interviewed by the researcher. The sample was comprised of
individuals who are Hispanic, have had diabetes for more than 2 years, and who have seen their
primary care physician at least once in the past 2 years.
The sample criteria for this research study were chosen to align with the purpose of the
study, by selecting participants who could best describe experiences and challenges living with
diabetes. Additionally, the criterion for the sample also aimed to learn from a population who
have interest in their health, but because of their daily lifestyle may have challenges with
accessing health care services and keeping their diabetes in control. Recruitment of participants
was done by identifying individuals that meet the specified criteria within the studied
organization, with the goal of learning from participants who have different health care access
and various health care insurance. Identification of participants was done through a report

39

generated within the studied organization that included the research study criteria to capture a
specific population of individuals, which resulted in the researcher calling individuals from the
report inviting them to participate in the research study. The credibility of the study was
considered and ensured by conducting interviews with multiple individuals to gain adequate
information that represented the studied population, as well as conducted member checks to
ensure accurate representation of participant narratives.
The Researcher
The researcher’s positionality was considered to ensure that assumptions and biases do
not affect the integrity of the study. The researcher has a close relationship to the problem of
practice, as they were born to immigrant parents who faced health issues and were considered
low-to-middle working class. Additionally, the researcher has moved along the classism axis
from a working-class family living in a lower-income neighborhood to an upper-middle class
family living in a highly populated affluent neighborhood (Morgan, 2018). The progression
along the axis could create a belief in improving one’s class as a meritocratic action. As a result
of experiencing family members with health issues, the researcher avoids the notion of
meritocracy by actively trying to understand the obstacles immigrants face in living a healthy
lifestyle.
The researcher has a first-hand account of experiencing immigrant parents who were
college graduates but lacked the knowledge and access to resources to improve their personal
health and financial situation. The researcher had parents who spoke English as their second
language and had challenges to understand the Western culture where they immigrated. The first-
hand experience in seeing immigrants try to navigate the healthcare system and improve their

40

health issues, could provide an understanding of the population related to the problem of
practice.
The researcher works in the studied health care organization and was responsible for
diabetes-related strategy for one of Total Health Care’s medical centers, which provides health
care for over 400,000 individuals. The experience the researcher has working to reduce health
disparities has instilled knowledge and created biases that improving health extends to societal
structures outside of health care systems. Furthermore, the researcher is a student in a doctoral
program, studying how to improve equitable outcomes in education, society, and health care.
Additionally, the researcher identifies as a minority, who has been taught beliefs that
meritocratic actions and behaviors are required to achieve success. However, the researcher
continually questions the “model minority” myth that promotes meritocracy, due to economic
and health issues faced by their family and friends (Yu, 2006). The experiences and education of
the researcher has formed an inclusive point of view that seeks diverse knowledge to further
question meritocratic social structures.
In order to mitigate the researcher’s positionality and bias, the interview questions were
carefully constructed to ensure that leading questions were eliminated and that a neutral stance
was consistent through the interaction (Merriam & Tisdell, 2016). To maintain the integrity of
the participants narrative, the researcher ensured member checks were conducted for accurate
understanding and clarifying questions were asked to resolve any uncertainty. The role of the
researcher in the interview process was only that of an investigator researching a phenomenon to
improve individual and population health. The researcher’s training, education, and experience
contribute to the credibility of the researcher, during conducting the research study. The
researcher’s training within the health care field, business and educational background, and

41

experience working with the studied patient population, strengthens the credibility and
trustworthiness of the researcher. Additionally, the researcher ensured that narratives were kept
unmodified to limit bias and reduce the affect assumptions could have on data collection.
Participating Stakeholders
The primary stakeholder group for this research study were low SES Hispanics with
diabetes. This stakeholder group was selected because this group would be able to give an
accurate depiction of the challenges living with diabetes and the competing priorities that this
population face in their daily life. Low SES Hispanics with diabetes is a specific group within
the organization that are intimately aware of how the organization’s health care delivery model
functions and the barriers that arise to access care. Additionally, the primary stakeholder group
has the most insight on pathways that could help improve their diabetes and reduce the health
disparities faced by this population.
Data Sources
Interviews were the primary and sole data collection method used for the research study,
as the narrative approach was the most appropriate to understand the experiences of the studied
population.
Interviews
Interviews were used for the research study to gain a comprehensive understanding of the
studied population’s challenges living with diabetes, as well as obtain opinions and beliefs
regarding their own health (Creswell & Creswell, 2018). The use of one-on-one interviews was
appropriate because beliefs, opinions, and values are not directly observable and could only be
learned through discourse, and interviews aligned with the study’s research questions (Creswell
& Creswell, 2018). Interviews helped form the narrative of the studied population, which

42

eliminated any potential assumptions or biases that health care systems may have when caring
for this population. The qualitative research study included 10 participants aligned with the
below criteria.
Participants
Criterion 1. Participant must be Hispanic. The researcher chose this criterion because the
study focused specifically on the higher prevalence of diabetes in the Hispanic population. The
ethnic demographic group has faced health disparities in the United States, so it is essential to
include Hispanic individuals who could provide direct and specific responses of their lived
experiences with diabetes.
Criterion 2. Participant must have been diagnosed with diabetes for at least 2 years. The
criterion chosen was specific to participants who are familiar living with the disease. The
researcher chose having a diagnosis for 2 years, as adequate time has passed since initial
diagnosis, which should give the participant enough experiences and challenges that would be
useful to understand the studied population. Individuals who have diabetes for at least 2 years
may have gone through lifestyle changes, which takes ample time, that have helped keep their
disease in control. Conversely, having a diabetes diagnosis for 2 years that remained
uncontrolled, could cause severe diabetes-related problems, which provide rich narrative on the
challenges of living with diabetes.
Criterion 3. Participant must have seen their primary care physician at least once in the
past 2 years. The researcher chose this criterion because seeing a primary care physician shows a
level of engagement with personal health. Even if the visit was due to an illness, the participant
has an established relationship with a physician who is aware of their current disease.
Furthermore, the participant could have seen their primary care physician more than once, which

43

gave the researcher the ability to ask questions regarding the different levels of engagement of
the studied population.
Instrumentation
The interview protocol is outlined in Appendix A, which consisted of semi-structured and
open-ended questions. Open-ended questions were useful in the research study as it allowed the
narrative inquiry process to allow participants to express and voice their opinions, values, and
beliefs related to living with diabetes (Creswell & Creswell, 2018). The questions were chosen to
gain the best and most realistic understanding of the challenges living with diabetes. The study’s
research questions and conceptual framework were aligned with the interview questions, and
probe questions were identified to gain more granular details of the studied population.
Data Collection Procedures
The data collection procedures took place either via video conferencing or via telephone
call. Each interview was recorded, and the audio transcript was transcribed by the video software
or a third-party transcription service. Audio transcripts were reviewed by the researcher to ensure
integrity was maintained, as well as to provide coding themes based on participant answers.
Interviews lasted between 25–45 minutes and took place one at a time with each participant. All
participants were provided informed consent and the researcher obtained permission for audio
recording prior to interview questioning. During the interview, the researcher took notes that
provided context to the situation, such as nonverbal body language, pauses in their speech, and
the environmental setting of the interview.
Data Analysis
The research data was analyzed after the conclusion of each scheduled interviews. The
audio transcripts were transcribed and exported into a word processing document. The data was

44

then coded based on themes among the participants that were aligned with the research questions
guiding the study. The use of coding for the research study was appropriate as it allowed the
researcher to organize the data based on words that represent categories salient to the participants
and their experience living with diabetes. Once the data was coded, the researcher provided
themes related to the conceptual framework of the study.
Validity and Reliability
The research study was designed to ensure that validity and reliability of the data was
collected in an ethical manner (Merriam & Tisdell, 2016). The goal of the researcher was to
provide confidence to readers when discussing data collected from interviews. Validity refers to
the extent the collected data can be generalized to the larger population and relatability refers to
consistency in the data collection process (Merriam & Tisdell, 2016). To improve validity, the
researcher chose a sufficient number of participants that represent the broader population, in
order to gain multiple perspectives for the problem of practice. Additionally, the researcher used
member checks to ensure understanding of participant views and provided participant narratives
unmodified or unaltered. To improve reliability, triangulation was used with the reviewed
literature to compare themes that were captured through the data coding process. Furthermore,
the final part of triangulation included an audit trail on how the data was collected and how the
themes were created, to show how the final results were derived (Merriam & Tisdell, 2016). The
researcher ensured that the data collection process meets the validity and reliability requirements
to generalize the findings to the broader population with the goal of improving population health.
Ethics
The study utilized informed consent, which was provided to participants prior to
interviews and a copy of the informed consent was given to the participant prior to being

45

interviewed (Creswell & Creswell, 2018). Participants were emailed a copy of the informed
consent prior to the interview. Participants were reminded that they could stop the interview at
any time and that their voices were kept unaltered to ensure accurate representation of their
responses. Participant confidentiality was honored using pseudonyms for names, and each
participant was informed that their responses would remain anonymous. Additionally, all
participant recordings were kept secured by utilizing a password-protected, encrypted folder on
an external hard-drive in the researcher’s possession. Participants were not compensated nor
incentivized to participate in the study. Participation was voluntary, and the researcher ensured
that participants understood that the purpose of the study was to improve health care for the
studied population. The researcher explained their positionality in the study and was transparent
of their role within the organization to participants. The study proposal went through two IRB
processes, one through the university and the second through the organization the researcher is
employed by.
The study serves the interest of the Hispanic population, as well as health care
organizations to improve health care services that address social determinants of health affecting
this population. Hispanic individuals suffering from diabetes would benefit from improved care,
as well as the organization would benefit from more individuals with diabetes in control that
improves community and population health. The study did not pose harm to participants or the
organization. The researcher designed the interview questions and framed the scope of the study,
with the purpose to understand experiences faced by this population when living with diabetes.
The results of the study will be disseminated to senior leadership within the organization, and
key stakeholders involved in caring for individuals with diabetes.

46

Chapter Four: Results and Findings
This chapter summarized the results and findings from the individual interviews that were
conducted to understand the societal barriers and daily challenges low SES Hispanics face with
diabetes. The research study utilized Bronfenbrenner’s ecological systems theory (1979) to gain
insight on different factors that influence low SES Hispanics’ health behavior. Once the
individual interviews were completed, the data was analyzed to determine themes from
participants that would answer the study’s research questions. The themes that were discovered
provide greater context and actionable interventions that could help Total Health Care reduce
health disparities faced by low SES Hispanics. Four research questions guide this study:
1. How does receiving a diagnosis, such as diabetes, affect the daily lifestyle of low SES
Hispanic individuals?
2. What challenges do individuals from a low SES background face to keep their
diabetes in control?
3. What is the confidence level of low SES Hispanic individuals to take care of their
own health?
4. What are the experiences of low SES Hispanics when accessing health care services
to treat their diabetes?
Research Study Stakeholders
The stakeholder group that participated in individual interviews were low SES Hispanics
that met the sampling criteria outlined in Chapter Three. Participants were invited to participate
in the research study based on being Hispanic and having diabetes for over 2 years. Once
participants agreed to participate and met the sampling criteria, they were asked a set of 15 open-
ended questions, outlined in Appendix A, that allowed for detailed and personal responses.

47

There were 10 participants that are Hispanic, have been diagnosed with diabetes for over
2 years, and have seen or spoken to their primary care physician within the last 2 years. Of the 10
participants, nine females and one male participated in the study. The unequal balance of female
and male participants was notable, as multiple males were contacted and some agreed to
participate in an interview; however, the majority of male invitees did not respond to the
invitation or were absent during the interview. To ensure that participants were considered low
SES, income and education screening questions were asked prior to the research study questions.
Table 1 outlines key demographic information for participants.

Table 1
List of Participants and Demographics
Participant
(pseudonym)
Age
Household
size
Annual household
income above/below
400% federal poverty
level
Highest education
completed
Trish 70 1 Below Trade school
Penelope 46 2 Above Some college
Alexandra 44 3 Below Some college
Anita 51 4 Below Some college
Christina 41 2 Above Trade school
Gwen 38 5 Below Some college
Jacob 53 2 Below Some college
Olivia 42 3 Below Master’s degree
Claudia 71 2 Above Bachelor’s degree
Victoria 53 5 Below High school diploma

48

Socioeconomic Status
Socioeconomic status was assessed based on a combination of education, household
income, and geographic residence (Eke et al., 2021). Each of the participants live in the Los
Angeles area, mostly in urban locations surrounding metropolitan areas, with more than 50% of
participants discussing the gentrification of their neighborhood. The federal poverty limit was
used as a qualification question, as household income level is a primary driver of socioeconomic
status, and household size could provide context on the financial situation of each participant.
Household income above or below 400% of the federal poverty limit was used as a baseline due
to the tax credits and savings that are provided for lower premiums for health insurance
coverage. Additionally, the federal poverty level was used as a basis to understand the societal
and financial challenges participants face that require a decision between prioritizing health or
other lifestyle factors.
Interviews
Ten semi-structured interviews were conducted with low SES Hispanics who met the
sample criteria in Chapter Three and reside in the greater Los Angeles area. Six interviews were
conducted via Zoom and four interviews were conducted telephonically, due to inaccessibility to
the Zoom application. The interview lengths ranged from 25 to 45 minutes. Interview questions
were designed to understand the challenges and lifestyle changes interviewees experience after
being diagnosed with diabetes, as well as to discern individual motivation and self-confidence.
The interview questions allowed for additional inquiry to gain more in-depth responses from
each participant’s perspective. Participation was solicited via telephone outreach calls for
patients that are Hispanic, have been diagnosed with diabetes for over 2 years, and have seen

49

their primary care physician within the last 2 years. Additional inclusion criteria were confirmed
once participants agreed to be interviewed.
Data Analysis
Each interview was audio recorded and transcribed manually or using the Zoom platform.
Audio files and transcriptions were saved in a password-protected folder to ensure confidentiality
and participant protection. The transcriptions were uploaded to ATLAS.ti, a qualitative data
analysis application that allows for aggregating files and thematic coding. Once transcriptions
were uploaded, each interview file was reviewed to ensure accuracy and notes were added based
on interview notes that provided context to the participant’s response. Thematic codes were
discovered based on inductive analysis and were updated throughout the process. Each transcript
was reviewed multiple times to ensure that each interview file went through a comprehensive
coding process.
Findings for Research Question 1: Effects on Daily Lifestyle
The first research question provided an opportunity for exploration into different facets of
the participants’ lives. The research question focused on understanding the daily life and
challenges individuals face once they have been diagnosed with diabetes. Findings from the first
research question resulted in themes of mental health impacts, family considerations, and
financial constraints. The themes are presented to outline the interconnectedness between
receiving a diabetes diagnosis and its impact on the environmental aspects of an individual.
Mental Health
During interviews, 80% of participants mentioned mental health issues, such as anxiety,
depression and chronic stress, as primary effects of receiving a diabetes diagnosis. Regardless of
being diagnosed with a mental health disorder by a health care provider or not, participants

50

reported mental health issues pre-and-post diabetes diagnosis. Participants reported that the stress
of having a chronic illness, such as diabetes, affects their mental state and subsequently leads to
affecting other facets of their lives. One of the participants, Penelope explained that her
depression would create challenges getting out of the house, which would affect her physical
activity and isolate her from their support system. As Penelope was reflecting on her mental
health and diabetes, it appeared that she was surprised once a link was made of how mental
health and physical health work together. She seemed not to realize that both work together and
she noticed that when she would struggle with her mental health, her diabetes would also suffer.
Alexandra, another participant that discussed mental health, mentioned that she was dealing with
family health issues and her own health issues, which created insurmountable stress and
exacerbated her own health condition. Additionally, five other participants reported that after
diagnosis they experienced feelings of devastation and sadness when they experienced changes
within their health. Mental health disorders and stress affects participants’ ability to care for their
own health after diagnosis, which created a bidirectional effect between mental health and
physical health. The mental health effects of diabetes on participants have continued since
diagnosis and created ongoing considerations to keep their diabetes in control, which includes
tangential effects of diabetes on family members.
Family
Familial changes were reported by 90% of the participants as a daily effect resulting from
being diagnosed with diabetes. The primary subtheme that was reported were the changes family
members made in cooking and preparing meals due to their family member having diabetes.
Anita was a participant that lives with her mother and prior to her diagnosis, she explained that
they had unhealthy cooking habits: however, after she was diagnosed, her mother changed her

51

cooking habits and was more conscious of her diet restrictions. Anita’s experience was unique
because her mother has been cooking primarily Hispanic foods for most of her life, so the change
that her mother made was culturally significant and uncommon. Trish, another participant,
shared a similar story, explaining that her sister is responsible for cooking her food because of
her sister’s culinary skills and her willingness to take ownership to ensure that their food was
healthy. Even at Trish’s age of 70, she still relies on her sister to cook meals, which highlights
the impact that diabetes has on an individual’s family members.
Participants also shared negative daily effects because their family members were
unsupportive of their diabetes. Alexandra experienced her mother continuing to cook food with
ingredients that would make her diabetes worse. Alexandra had to result in buying her own food,
which increased her food budget, and she had to learn how to cook to ensure her nutrition was
aligned with a diabetes-recommended diet. She also mentioned that having two people cook in
Hispanic households can be controversial because of the ritual for Hispanic mothers to be the
primary cook, which she had to constantly deal with the balance of respecting her mother and
prioritizing her health. Victoria was another participant that felt pressure from her children
because they wanted more child-friendly snacks that are normally high in sugar, which create
challenges with which foods to purchase that could feed all family members. Nutrition is a
primary effect on participant’s daily lifestyle, which could result in a supportive network or
having to make personal decisions to care for one’s health that may go against family norms.
Additionally, familial obligations were another effect on the daily lifestyle of low SES
Hispanics with diabetes. Obligations of having to take care of an ill family member resulted in
less time to take care of one’s health. Penelope had to travel to another state to care for her ill
family member for 5 months. She was focused on caring for her family member, that she lost

52

sight of her medication regime and it took her 3 months to realize that she had not taken her
diabetes medication. Family obligations superseded taking care of individual health for multiple
participants. Claudia shared that she has to care for her sister since she doesn’t cook, drive, or
have any children that live nearby. Since Claudia has to care for her sister in addition to herself,
it limits the time she has to engage in physical activity and care for her own health. She also
mentioned that because her food budget has increased, she has to make decisions that sacrifice
nutrition and healthy eating to ensure that the budget includes purchasing enough food to include
her sibling. Familial changes and obligations affect the ability for individuals to make healthy
decisions after being diagnosed with diabetes, which could be worsened by financial
considerations that individuals face.
Financial Considerations
Participants reported that their financial situation affects how they treat their diabetes and
live a healthy life. Participants faced decisions whether to prioritize their health or their day-to-
day living, which is a trade-off that could reduce an individual’s ability to keep their diabetes in
control (Tucker-Seeley et al., 2015). Finances were discussed by multiple participants as a
primary concern within their daily life and the affect it has on their health.
Trish described that within the last few years her copayment to see a doctor has
increased, so she had to decide whether to pay the copayment to see a doctor for her diabetes or
pay for her diabetes medication. She shared that because she has to make a financial decision on
whether to pay for care or medication, the two decisions rarely coincide, which makes keeping
her diabetes in control a constant challenge. Similarly, Alexandra described a recent job change
that affected her daily lifestyle and created a challenge with her diabetes diagnosis. With her
recent job change, she faced the decision between waiting three to four weeks to see a physician

53

regarding her diabetes or pay over $300 to see a physician immediately that is outside of her
insurance plan’s network. She said, “I wouldn’t want to pay $300”, so her immediate health
needs were not addressed, and she continued to take her diabetes medication without consulting
a physician if changes were needed. Both participants expressed dissatisfaction with having to
consider finances when trying to care for their own health.
Penelope was another participant that shared the effect of diabetes related to her finances,
specifically, her eating habits and prioritizing convenience over health. In response to challenges
she faces, she said, “I wasn’t making very much money, so I kind of just ate a lot of fast food, or
just you know, whatever was around kind of thing. But I never ever felt good [about it].” She
also explained that because she had a long commute due to her job and family obligations, she
would see a fast-food restaurant, and quickly stop for a meal without thinking about the
nutritional impact it had on her diabetes. Her food choices were consistently made with financial
consideration, rather than health focused.
Victoria shared the impact her diabetes had on her family and their financial situation.
She shared a story about when she was in a wheelchair because of medical complications. She
saw a physician who recommended amputating her leg due to her diabetes; however, her family
and her believed that there had to be an alternative to amputation. Due to her health insurance
restrictions of only seeing physicians within network, her family had to go out of network and
took a $20,00 personal loan to get the care she needed. She expressed feelings of sadness,
frustration, and ambivalence towards the health care system because her family had to go into
debt to get the care she needed. Financial considerations superseded health considerations as
participants make daily decisions to prioritize survival, which may not be the best decision for
their health.

54

Summary
Participants reported different effects to their daily lifestyle after being diagnosed with
diabetes. Mental health and stress, family impact and changes, and financial considerations were
the primary themes that participants reported. The participants shared a collective sense that they
wanted to maintain and improve their health, but different factors affected the ability to focus on
their health. Participants reflected on those decisions and mentioned that at the time of the
decision, they didn’t realize that they were prioritizing other facets of their life over health; most
participants noted that they were decisions mostly out of survival. As participants reported the
effects diabetes has on their daily lifestyle, specific challenges were shared that helps to answer
the second research question.
Findings for Research Question 2: Challenges
The second research question explored deeper the specific challenges that participants
experienced due to being diagnosed with diabetes. Findings from the second research question
resulted in themes related to the COVID-19 pandemic, their work and profession, and eating
habits in keeping their diabetes in control. The thematic findings below are outlined to highlight
that individual health improvement cannot be solely relied on to change individual behavior: the
environmental system that an individual interacts with is just as, if not, more important.
COVID-19 Pandemic
The COVID-19 pandemic that began in 2020 created salient challenges for participants:
70% of participants reported that the pandemic directly impacted their ability to keep their
diabetes in control. A concurrent theme of limited physician appointment availability was also
related to the COVID-19 pandemic. Olivia was a participant that said the limited availability of
appointments to see a doctor was a cause of concern because she was not sure what to do with

55

her medications. She was scared to contract COVID-19 if she went into the health care facility,
which delayed her restarting her medication regime. Victoria was another participant that
discussed the need to see a physician face-to-face. In addition to having diabetes, Victoria had
cancer and is required to follow-up with her physician every three to four months; however, the
pandemic shifted appointments to be more virtual, so due to inaccessibility to a computer or
smartphone, she has been unable to have a visit with her primary care physician for over a year.
An underlying theme from participants was the need to see their physician frequently in order to
maintain progress in keeping their diabetes in control.
Fear related to the transmission of COVID-19 was discussed as a challenge for
participants to keep their diabetes in control. Jacob, the only male participant, has comorbidities
and is susceptible to acquiring COVID-19, and he was fearful to leave his home during the
pandemic. He mentioned that he used to go to a gym prior to the pandemic and because of his
fear of acquiring the virus, his physical activity stopped and his diabetes remained uncontrolled.
He mentioned that his physical activity is limited to his work as a warehouse worker: packing,
sorting items and boxes. Penelope was another participant that discussed that the fear of
transmission, specifically at her local gym, exacerbated her diabetes. Prior to the pandemic she
began working from home in a more sedentary profession and the gym was her primary venue
for physical activity. Once the pandemic hit, she credits the sedentary job and the fear of
acquiring COVID-19 for her lack of physical activity, her declining health, and her uncontrolled
diabetes. Olivia also shared her fear about COVID-19 and mentioned that she has not gone to a
gym in over 2 years because of potential transmission, yet continues to pay the membership dues
without utilizing the services. Olivia’s experience was shared among other participants that were
fearful of acquiring COVID-19 and because of the virus, they stopped going to a gym without

56

finding an alternative for physical activity. Participants fear of acquiring and spreading COVID-
19 created challenges in keeping their diabetes in control. Additionally, the sedentary professions
of the participants coupled with the fear of acquiring COVID-19, specifically at gyms, worsened
diabetes control.
Work/Profession
Participants reported that their work and jobs create challenges in keeping their diabetes
in control. Working long hours for additional income was reported by two participants as a work-
related challenge that affects their health. Trish explained that her work in a medical clinic
caused her to frequently work long hours to ensure that patients are attended to. Trish said:
I don’t have enough time for myself. While I’m working, I have to prioritize the situation,
the doctor, the office, and then myself. It was always the office first. The patients were
first. I would leave my house at 6 o’clock in the morning and come home at around 9 or
10 o’clock, and then realized I haven’t been able to eat all day.
She continued to provide context of work experiences where she sacrificed eating lunch and
attributed her work schedule to missing taking her medication, forgetting to eat lunch, and
resulting to fast-food restaurants for dinner.
Jacob was another participant that discussed their work schedule as a challenge with
keeping his diabetes in control. He explained that the company he works for has been short-
staffed, and for the last 5 to 7 years he has consistently picked up overtime hours. Picking up
overtime hours is necessary for Jacob, he said “I need the work. I need to maintain my economic
level right here right now. Work is work. It takes a lot of hours of the day, and it consumes a lot
of the hours of the day.” He said because he works long hours, he has no time to maintain a

57

physical regime and not enough energy to do much after work, which results in him constantly
struggling to keep his diabetes in control.
An additional theme related to work, was work-related stress and how it inhibits living a
healthy life. Alexandra explained that she works a stressful job and she goes through a pattern of
being anxious or stressed from work, and falling into unhealthy habits. Additionally, she
mentioned that her long commute to work coupled with the work-related stress results in limited
time and energy to keep her diabetes in control. Alexandra said:
[My] stress at work is there’s a lot of work to be done, and then you come home [and]
you’re basically tired, you don’t want to prep your food so it’s easier just to go to a fast-
food [restaurant] in the morning, or for lunch, just go to the cafeteria get anything that’s
there you know.
She continued to explain the challenges she faces with her work and how work-related stress is a
primary challenge with her diabetes. Alexandra explained challenges with work-related stress
and how it affects her eating habits, which is another theme that was found from participants’
responses.
Eating Habits
Eating habits was a topic mentioned multiple times by different participants as a primary
challenge in keeping their diabetes control. Participants had mixed responses of the reason eating
habits were a challenge; varying from self-discipline to challenges with incorporating healthy
foods into their diet. The lack of healthy foods in participants’ diet was a common theme and
was continually credited as a reason for having diabetes. Alexandra shared that during the work
week, she is frequently tired and stressed from her job. Since she is physically and mentally
tired, she doesn’t prepare food at home and results in eating at fast-food restaurants for up to two

58

meals a day. Alexandra mentioned, “I love to eat. I love sweets and to me, it’s a struggle not to
be able to have a dessert that has sugar for the rest of my life.” She continued discussing the
daily challenge she faces of having to eliminate sugar and carbohydrate-heavy meals, and shared
that she has tried to plan her meals for the week but has not been successful due to the
convenience of going to cheap fast-food restaurants.
Christina was another participant that shared her dietary habits and discussed that her
eating habits have continued since childhood. She explained that as a child, she was allowed to
eat most foods because her mom was constantly working. She was left by herself and she would
be responsible for making her own food, which consisted of frozen meals and high-sugar snacks.
Christina mentioned that when her mom was able to leave work early, they would celebrate by
regularly eating at McDonalds or other fast-food restaurants. She said, “It was always fast-food
whenever we ate together as a family, and it’s continued into my adult life.” Christina tries to
limit her sugar and soda intake during the week, but normally eats salty foods from fast-food
restaurants. Since she eats salty foods, she normally wants something to offset the salty taste and
finds herself consistently challenged with wanting to eat sugary foods. Fast-food restaurants that
lack healthy foods are a staple in her daily life, which continues to create challenges in keeping
her diabetes in control.
The proximity of restaurants surrounding an individual’s work was discussed as a
challenge in keeping diabetes in control. Jacob works more than 40 hours a week with routine
overtime. Since he finds himself working long hours, he normally eats foods close to work and
rarely prepares meals from home. He said that he normally eats out for breakfast and lunch, and
tries to prepare his dinner if he doesn’t work overtime; however, if he does work overtime, the
restaurants around his work are his preferred destination. Jacob mentions a diet that consists of

59

pizza, hamburgers, and burritos as frequent foods that are available near his work. Additionally,
proximity to an individual’s home was also discussed. Olivia was discussing her dietary habits
and that she frequents fast-food restaurants. She said that when she looks out of the window in
her house, she could see more than three fast-food restaurants within walking distance. Olivia
said that the distance of available food is a factor in what her family eats and creates a challenge
because her two children see fast-food restaurants regularly. Olivia explained that her children
want snacks and high-sugar foods that could make her diabetes worse. A concurrent theme with
financial challenges, Olivia results in purchasing food for her kids with the limited money they
have and subjects herself to eating foods that go against her diet. The lack of nutritious and
healthy foods is a common challenge that participants face; however, when participants have the
knowledge of what dietary habits would help their diabetes, they are normally faced with making
a decision that is more financially-appropriate or prioritize convenience.
Self-discipline with eating habits was mentioned by participants as a daily challenge that
they face in keeping their diabetes in control. Penelope explained that when she was diagnosed
with diabetes she made changes to her diet, but continued to find herself eating foods that
worsened her diabetes instead. She said, “My biggest challenge really is myself and my own
self-discipline. I have none. I eat entirely way too much sugar, even though I know my [blood
sugar] is up.” Penelope mentioned multiple times during the interview that she knows the foods
she needs to eat to be healthy, but finds herself consistently challenged wanting to eat sugary
foods. She continued to explain that her lack of discipline gets in the way of her eating habits,
which creates issues with her diabetes. The shared sense from participants was that counseling
and nutrition guidance to help with diabetes is untenable due to their daily schedules, the
financial cost of the services, and the sacrifice of time away from their work.

60

Alternatively, Gwen was a participant that explained her self-discipline was a challenge
because she cooks for a family of five. When she was diagnosed with diabetes, she discussed
with her family that she had to incorporate more healthy foods when she cooks. Gwen still gets
pressured by her children and husband to cook certain foods that she cannot eat, which results in
her having to cook meals that she may not be able to eat or having to take extra time in her
limited schedule to cook something that adheres to her diabetes diet. She also mentioned that
family gatherings are another challenge she frequently encounters. Since her family eats mostly
Hispanic foods, she faces the same challenge of either eating the unhealthy food or waiting to eat
something healthy later. Eating habits were discussed by multiple participants as a challenge in
keeping their diabetes in control. Proximity to the home and work played a large part in what
foods and restaurants participants would eat, as well as the challenge of self-discipline to adhere
to a healthy diet.
Summary
Participants reported various challenges in order to keep their diabetes in control. An
individual’s job, the COVID-19 pandemic, and eating habits were concurrent challenges reported
by participants. The participants provided their personal experience of living with diabetes,
however, the external challenges they faced negatively impacted their ability to live a healthy
life. Participants also explained the daily challenge of having to choose their work, their safety,
and their family, over their individual health. External challenges could hinder living a healthy
life, yet most participants have built their confidence in order to move towards keeping their
diabetes in control.

61

Findings for Research Question 3: Confidence
The third research question explored the confidence level of participants to take care of
their health. Confidence was discussed to explore participants’ intrinsic belief to keep their
diabetes in control and living a healthy life. Confidence is important for being able to manage
one’s diabetes and deal with the daily challenges result from having diabetes (Morley, 2021).
Participants were asked about their confidence level and their ability to maintain a healthy
lifestyle, which highlights the importance of their mentality in controlling their diabetes and
facing other daily life challenges.
Eight of the 10 participants reported having high self-confidence to care for their own
health. Participants explained different reasons for their confidence level including being
engaged in seeing their blood sugar levels. Alexandra discussed that she uses a continuous
glucose monitor that tracks her blood sugar and provides her immediate feedback on what is
happening with her body. She said that her confidence level goes up when she sees her blood
sugar levels go down. In addition to Alexandra, Olivia also uses the immediate feedback of a
continuous glucose monitor to raise her confidence level. She mentioned that she struggles with
making healthy decisions daily, but the continuous glucose monitor helps to see how her body
reacts to certain foods. Alexandra and Olivia are actively engaged in using technology to help
keep their diabetes in control, which suggests that incorporating instant feedback as a lever to
promote living a healthy life and raise individual confidence.
During discussions with participants about confidence, some participants expressed high
confidence, but their habits proved to remain unhealthy. The incongruent answers provided a
lens into the mental state of how participants live with diabetes and the constant internal
challenge they experience to keep the disease in control. Additionally, when participants reported

62

high levels of confidence, they also provided reasons of their current challenges, which showed
self-awareness, but did not reflect action. Jacob answered most questions presumptuously, and
when asked about his confidence level, he did not answer the question directly. He provided
explanations of what he needs to do to keep his diabetes in control, but also mentioned that he
lacks a routine, which is the key to maintain control of his diabetes. His lack of routine was
attributed to the pandemic, which shows the interconnectedness of external factors and its effect
on individual health. Alexandra was another participant that shared she has high confidence in
managing her diabetes, but within the same response also shared that she needs the push from
others to focus on her health. Alexandra said that she normally keeps up with a physical regime
when she has someone to go to the gym or workout with her. Similar to Jacob, since the
pandemic began, Alexandra has had little to no physical activity and attributes not having anyone
to work out with as the main driver in her uncontrolled diabetes. As confident as she responded,
she also mentioned that if she doesn’t have anyone to work out with, she doesn’t push herself.
Gwen is another participant that shared she has high confidence to take care of her health, but
also mentioned in the same sentence that she struggles with willpower. She said that she knows
the food she needs to eat to help her health and is fairly confident, but explained that she
struggles to avoid foods like pasta and pizza. Her answer eluded confidence, and when she
explained that her children are the main reason she has high confidence, it provided an emotional
relationship as her intrinsic motivator. Participants’ confident responses showed incongruence
between their words and actions, which supports that individuals in this population have the
knowledge of what is needed to live a healthy life, but societal and environmental factors affect
their confidence to do so.

63

Victoria was a participant that shared that her support system is the main reason for her
high self-confidence. When responding about her confidence she explained that her family is
actively engaged in her health. Her husband and children consistently ensure that she’s eating the
right foods and getting out to move her body. Victoria said, “My husband learned how to cook
once I was diagnosed with diabetes and now he takes the lead in cooking for the family.” She
also said, “because [my husband] cares for me it gives me motivation and confidence that I can
get through this.” Listening to Victoria explain her confidence and how its connected with her
support system, suggests that confidence could come from external sources to help the daily
challenges of living with diabetes.
Two participants shared having low self-confidence in keeping their diabetes in control.
When both participants were responding they expressed self-awareness of their own limitations
and their mindset, which was important to provide a sense of realism rather than pessimism of
their health. Penelope is a participant who was candid about the challenges she faced with her
own self-discipline to maintain a healthy lifestyle. When asked about her confidence level, she
said “I have 20% confidence to get my diabetes in control. I haven’t put myself mentally in the
right place to tackle [diabetes].” She continued to explain that she knows what to do, but has not
done anything specific to address her diabetes. Similar to Penelope, Christina shared the same
mindset about their self-confidence. When asked about her self-confidence, she responded, “I
know what I have to do, but am I going to do it? I don’t know. I would say yes, but then I know
myself.” Christina was referring to earlier comments about her quickly falling back into
unhealthy habits as she tried to change her lifestyle. Penelope and Christina were the only two
participants who reported low self-confidence and addressed that their own self-limitations were

64

the reasons for their lack of confidence. The lack of self-confidence suggests that in order to
combat the challenges of diabetes, mental health and support systems are important to address.
Participants varied in confidence levels, with the majority of participants reporting high
confidence to keep their diabetes in control. A theme that emerged from participants was the
incongruence between their confidence and the daily choices they made for their health. The
factors that affect individual confidence were not explored; however, environmental factors
should be considered as a pathway to improve health. Additionally, confidence emerges from
strong support systems, which could extend past immediate family to friends or health care
providers, highlighting the importance of understanding the external systems that affect
individual health.
Findings for Research Question 4: Health Care Services
The final research question explored participants’ experience when accessing health care
services. Health care services was discussed with participants to gain an understanding of
environmental and societal factors that encourages or prohibits keeping diabetes in control.
Health care services, where participants were diagnosed with diabetes, provide different
experiences for individuals that could work in unison with their self-confidence to maintain a
healthy life, or could be detrimental for individuals to continue with unhealthy behaviors.
Participants provided a range of responses that highlight the importance of health care services to
balance personalization and cultural-sensitivity when providing medical care.
Health Care Providers
A primary theme from participants was their interactions with health care providers: 70%
of participants reported challenges with health care providers since they have been diagnosed
with diabetes. Multiple participants discussed the lack of time they have when seeing a health

65

care provider. Trish shared an experience about waiting weeks for her appointment, and when
she was finally in the exam room with her doctor she said, “it was rushed and the doctor only
wanted to discuss one issue. They don’t have time.” Trish’s experience was common and the
theme of physicians having limited time with their patients creates a challenge, as participants
require education and attention, to create a basic understanding of how to improve their diabetes.
Olivia was another participant that discussed having to attend a diabetes class at the
request of her primary care physician, which was three 2-hour sessions that review the effects of
diabetes and discuss methods to improve living with diabetes. She shared that during the class
the instructor discussed carbohydrates and its effects on the body. Olivia was frustrated and lost
among the information presented during the class: she said “I don’t know what a carb is. I don’t
know what a protein is. I just know rice, beans, tortillas, and bread.” Participants experienced
challenges with requiring more time from their health care providers and a lack of understanding
of how to relate diabetes interventions to their individual lives.
Trust between health care providers and patients was important to multiple participants.
Anita was one of two participants that reported having a positive and trustful relationship with
her primary care physician. She sees or speaks to her primary care physician every three to four
months, and has built a strong relationship over the past 2 years. She credits her primary care
physician with helping to keep her diabetes in control. In contrast, Alexandra discussed that she
didn’t have a connection nor was trust built with the doctors she saw for diabetes. She said, “I
feel if you don’t have a connection with your doctor and you can’t explain how you’re feeling,
[then] you don’t get an answer.” She continued to discuss that trust and a strong connection with
her doctor is critical to help her diabetes get into control. Fortunately, Alexandra was able to find
a physician that she began to build a strong connection with and she’s been more engaged in her

66

health. Trust and a personal connection are challenges participants reported, as well as the
difficulty to build trust once a bad experience occurred. Claudia was another participant that
shared her challenges of building a trustful relationship with her doctor after having a bad
experience with multiple doctors in a health care system. She said that when she was initially
diagnosed with diabetes, her physician lacked empathy and an understanding of how receiving
the diagnosis would affect her. The one bad experience has led to years of having a distrustful
relationship with health care providers, and has resulted in Claudia underutilizing health care
providers to help with her diabetes.
An additional topic that was discussed by participants was the issue of limited available
appointments to see a doctor. Christina has a job where the company’s business hours coincide
with the availability to see her doctor. She said that in order for her to see her doctor, she has to
“either be late to work or leave early.” The situation that Christina finds herself in results in
having to decide between jeopardizing her job or sacrificing her health. Trish also shared a story
that the past few appointments she scheduled were more than 2 months away because of how
impacted her doctor’s schedule was. By the date of the appointment, she would forget about the
scheduled appointment and have to reschedule to a time and date a few months away. The access
to health care providers was a ubiquitous theme among participants, which has created a salient
challenge in keeping their diabetes in control. Health care provider availability, the relationship
with health care providers, and the interactions individuals have once they see a health care
provider have created challenges for individuals diagnosed with diabetes.
Another theme related to the final research question was the stigma and judgement
participants experienced interacting with health care providers. Specifically, participants
discussed insensitive comments and discrimination from health care providers that have affected

67

their trust with the health care system, which consequently affects their ability to engage with
health care providers to improve their diabetes. Olivia stated that she feels physicians have
preemptively judged her because of her weight and have provided unsolicited weight-loss advice
with little context. She further explained that she is aware of being overweight and understands
how losing weight would benefit their diabetes, however, it creates stress knowing that the
medical team you are seeking care from defaults to weight as a topic to discuss. Additionally,
Alexandra explained that her mental health suffered because when judged by health care
providers it resulted in more confusion; she discussed further that she was never educated on
what questions to ask doctors or raised to advocate for their health, so she felt lost after being
diagnosed. Encounters with health care providers after being diagnosed with diabetes has
resulted in divisive trust that pushes individuals away from health care system, which adds to the
mental health issues and chronic stress experienced by participants.
Summary
Health care providers play an important factor in the health of their patients. A trustful
relationship, caring for patients without judgement, and providing a foundational understanding
of diabetes were reported as vital to a provider-patient relationship. Health care providers that
build a strong relationship with their patient still face challenges that are beyond their control
with limited appointment supply and limited appointment time to meet with each patient. The
relationship with health care providers is an avenue that was reported as helping improve
individual diabetes health, and with the challenges of limited appointment supply and time, the
strength and personalization of the relationship proved more important.

68

Summary
Chapter Four provided an overview of the findings from participant interviews for the
study’s research questions. The findings for the first research question related to the daily effects
to participants mental health, family, and financial considerations after being diagnosed with
diabetes. The second research question found that the challenges participants faced with their
diabetes centered around challenges with their work, the COVID-19 pandemic, and daily eating
habits. The third research question focused on participant confidence, which found that
participants had high confidence, but lacked behavioral change that would improve their
diabetes. The final research question asked participants about experiences with health care
providers, which found the lack of time spent with their physicians, the lack of trust and
relationship between patient and provider, the foundational understanding of what is needed for
positive health, and the judgement experienced from health care providers were all challenges
related to keeping their diabetes in control. The findings will be discussed further in the
following chapter.

69

Chapter Five: Recommendations
This chapter provides recommendations for Total Health Care to improve health
outcomes for low SES Hispanics with diabetes. The recommendations outlined in this chapter
are based on the research study’s literature review, the research findings through individual
interviews, and tailored to focus on the research study’s population. The chapter concludes with
the research study’s limitations and delimitations, and recommendations for further research.
Discussion of Findings
During the research process, participants were aware of the challenges that prohibited
them from prioritizing their health and concurrently expressed a need to address those challenges
to live a healthier life. The shared theme among participants was the importance of identifying
pathways to improve health that augment the medical care received by a health care provider.
The shared theme highlights the importance of assessing the individual influences within their
environment that could lead to positive behavioral change. The findings for each research
question are outlined below to provide insight on how to improve diabetes control for low SES
Hispanics.
Research Question 1: How Does Receiving a Diagnosis, Such as Diabetes, Affect the Daily
Lifestyle of Low Socioeconomic Status Hispanic Individuals?
The themes that emerged from the research study to answer this research question
centered around the effects on mental health, family obligations, and financial considerations.
Mental health issues, such as depressive symptoms and cognitive impairment, have been found
to have a relationship with poor nutritional habits and living with diabetes (Caban et al., 2008;
Handmaker, 2017). Eight of the 10 participants mentioned that living with diabetes affected their
mental health, specifically the constant stress of trying to balance their health and other daily

70

priorities. Stress was discussed by all participants as creating a daily challenge, yet each
participant discussed different sources of stress. Familial and financial obligations were two of
the most mentioned causes of stress. Being diagnosed with diabetes and the stress from other
daily factors created a continued compounding effect from initial diagnosis to present.
Familial lifestyle changes and obligations affected the daily lifestyle of low SES
Hispanics with diabetes, highlighting the importance of family engagement for individuals living
with diabetes. Two participants reported that their family, their primary support system, changed
their cooking and eating habits once they were diagnosed with diabetes. Having an individual
with diabetes in a household quickly becomes a family diagnosis for Hispanics, and behavior
change normally happens to the entire family. Changing eating habits and engaging in physical
activity are two examples of family behavior change that occurred for participants after being
diagnosed with diabetes. Consequently, two other participants reported that their families were
unsupportive after being diagnosed with diabetes, and both individuals tried to change their
health behavior but encountered challenges to sustain the behavior without a support system
positively influencing their behavior.
Familial obligations to care for elderly or ill family members had a compounding effect
on participants’ daily lifestyle, their mental health, and their diabetes. Two participants shared
detailed accounts of experiences that required caring for ill family members, which quickly
changed the focus from individual health to family member health. The focus on family
members came at a cost of neglecting their own health. The two participants shared additional
details on the fluctuation of their health, which may be improved with a strong support system to
keep them on track. Familial obligations also created financial challenges related to diabetes, as

71

caring for family members incurred additional costs that could have been allocated to support
their own health.
Financial considerations and obligations affected the daily lifestyle of low SES Hispanics
with diabetes. The cost of health care services, such as copayments and medications, were
common expenses for participants related to their diabetes. However, high copayments and
costly medications were normally sacrificed by participants as they allocated their finances to
expenses such as food and housing. The overall cost of healthcare was mentioned by multiple
participants as a frequent decision that they face, as most participants were responsible for high
out-of-pocket costs for seeking emergency care or out-of-network care. One notable
consideration was the financial cost of obtaining second opinions for treatment plans or seeking
care immediately, which was a common theme among participants. Participants that paid higher
costs to see a health care provider quicker, did so because their health worsened and they
incurred debt to pay for immediate care. Preventative medicine utilizes clinical care that includes
societal factors on preventing illness and keeping individuals healthy outside of the health care
system, which was uncommon among participants (Ghosh et al., 2022). Incorporating
preventative medicine in conventional clinical care could reduce overall health care costs if
participants would be able to access health care providers timely, which could improve the health
of low SES Hispanics.
Additional financial considerations faced by participants were decisions related to food.
For low SES Hispanics with diabetes, the cost of food was an important factor to consider for
their daily eating habits. The inexpensive cost of fast-food restaurants was a common reason that
participants ate unhealthy foods, which is a habit that has continued since childhood for some
participants. The cost of health care and food are two important factors for low SES Hispanics

72

with diabetes in keeping their diabetes in control. Socioeconomic status of individuals is
conventionally viewed as a factor impacting individual health, yet the daily choices of sacrificing
health over finances is an environmental impact that is rarely addressed. The effects on daily
lifestyle of having diabetes centered around the impact on mental health, family members, and
finances; however, each factor compounds the effects of diabetes and creates chronic challenges
that will be addressed by the following research question.
Research Question 2: What Challenges Do Individuals From a Low Socioeconomic Status
Background Face to Keep Their Diabetes In Control?
The second research question explored the challenges to keep diabetes in control for the
studied population, with themes from participants focusing on the COVID-19 pandemic, work
and professional obligations, and daily eating habits. The main overarching challenge shared by
the majority of participants to keep their diabetes in control was the COVID-19 pandemic. The
COVID-19 pandemic affected health care provider availability, which is a primary avenue for
participants to get advice for their health and to ensure that they are on track with keeping their
diabetes in control. Due to the fear of spreading and acquiring COVID-19, participants adhered
to social distancing by not leaving their home, which affected their physical activity and
engagement with their support system. The COVID-19 pandemic compounded with jobs
becoming more sedentary or the increased physical demand in labor-intensive jobs, exacerbated
the challenges that many low SES Hispanics faced in keeping their diabetes in control. Sedentary
jobs resulted in less movement and physical activity, while labor-intensive jobs led participants
to having less energy after work to engage in healthy behaviors: both resulting in ongoing
challenges faced by low SES Hispanics during the COVID-19 pandemic. The pandemic affected
millions worldwide, however for this specific population, health disparities were amplified as

73

this population was affected by the socioeconomic impact of the pandemic and the limitations of
accessing health care providers in-person.
Another challenge faced by low SES Hispanics were the responsibilities of their work
and work-related stress caused by their job. In alignment with the financial considerations
discussed in the first research question, most participants had to choose prioritizing their job over
their health. Participants discussed working overtime frequently because they need the money to
maintain their lifestyle; however, the constant need to work long hours resulted in tired
individuals with little to no energy to focus on preparing meals, choosing healthy food options,
and engaging in physical activity. Additionally, work-related stress also created challenges for
participants in keeping their diabetes in control. Similar to the consequences of working long
hours, the stress from work caused challenges for participants that affected their health. Work-
related stress caused participants to eat at more fast-food restaurants because they did not have
the energy or time to prepare their meals or because they worked long hours. Stress and working
long hours, were two challenges that participants faced in keeping their diabetes in control.
Challenges related to eating habits was the final theme reported by participants in
keeping their diabetes in control. The lack of self-discipline in choosing healthy foods over
unhealthy foods was common among participants. Participants mentioned being aware of the
foods they need to eat to keep their diabetes in control, but they consistently chose foods that are
high-sugar and unhealthy. The theme related to self-discipline highlights that keeping diabetes in
control encompasses addressing physical, emotional, and mental health. While participants
lacked the discipline to choose healthy foods over unhealthy foods, the challenge reported by
participants is hard to distinguish if other daily factors led to the lack of self-discipline or if self-
discipline was only related to eating habits. One participant mentioned that her lack of self-

74

discipline is a cause of having to care for her family, which resulted in sacrificing her individual
health.
Work-related stress, a concurrent challenge mentioned along with self-discipline, resulted
in participants choosing convenient, inexpensive, unhealthy foods. Eating habits were also
reported to form in childhood and continue to adulthood, which created habits that were more
difficult to change. Participants mentioned that eating at fast-food restaurants was commonplace
and used as a reward during their childhood, which is a habit that has carried into their
adulthood. The continued rituals centered around unhealthy eating habits is an avenue that could
be explored to instill healthy behaviors at a young age. Challenges from the COVID-19
pandemic, from work-related responsibilities and from daily eating habits were reported by
participants as being consistent themes they face.
Research Question 3: What Is the Confidence Level of Low Socioeconomic Status Hispanic
Individuals to Take Care of Their Own Health?
The research study found that the confidence level of low SES Hispanics with diabetes to
care for their own health fluctuates based on their support system. The support system of
participants was reported as the highest influence in keeping their diabetes in control. Victoria
was one participant that reported her family changed their eating habits and became engaged in
her diabetes care, which has helped to keep her diabetes in control. Participants that reported
lower or wavering confidence did not mention that their support system was actively trying to
help them through challenging times. Alexandra was a participant that shared that her confidence
of caring for her health wavers depending on if she has someone to push her. She mentioned that
she loses motivation and focus to take care of her health if she does not feel supported or pushed,
which highlights the importance of an active support system for positive behavior change. The

75

strength of an individual’s support system had a significant effect on the ability for participants
to handle the daily challenges of living with diabetes, which emphasizes the importance to
understand the specific ways low SES Hispanics view their health behaviors and how to utilize
their support system to improve their confidence.
The uniqueness of participant’s support systems was a blend of utilizing human-based
support systems and technology-powered support systems to improve individual confidence.
Support systems were reported as technological systems that ensure individuals have the
information and data about their diabetes daily. Two participants reported using continuous
glucose monitoring systems to monitor their daily blood sugar levels, and based on the daily data
they actively adjust their daily habits. Both participants mentioned that the ability to have readily
available data keeps them accountable for their health, and subsequently increases their
confidence when they see their blood sugar numbers moving in the right direction. Participants
were not asked directly about technological systems that could help with diabetes; however,
having individuals knowledgeable and aware of how foods affect their blood sugar in real-time
could be a pathway to raise individual confidence.
The research study also found an incongruence between reported self-confidence and the
ability to manage diabetes. Eight participants reported high self-confidence for their diabetes and
mentioned having daily challenges to keep their diabetes in control. The daily challenges that
hindered their ability to keep their diabetes in control were related to work and caring for family
members. Jacob was one participant that discussed working long hours to maintain his lifestyle,
which was a primary challenge in managing his diabetes; however, as the interview continued,
he mentioned having high self-confidence in getting his diabetes in control. He mentioned that in
the last 5 to 7 years he has continued to gain weight, which has resulted in being obese and has

76

exacerbated his diabetes. The incongruence of reporting high self-confidence and the reality of
continued challenges in managing his diabetes was notable as multiple participants reported
similar experiences. The responses from participants regarding having high self-confidence and
daily unhealthy habits, provided an opportunity to reflect on the reasons that led to an inability to
maintain healthy habits. Similar to having a support system to help with living a healthy life, the
lack of a support system led to engaging in unhealthy habits. Alexandra mentioned that she has
high self-confidence, but relies on others to keep her focused on her health. While participants
mentioned having high self-confidence, their actions and daily habits showed otherwise.
Two of the 10 participants mentioned having low self-confidence due to their mindset
and the lack of discipline to maintain healthy habits. One participant, Penelope, mentioned
having “20% confidence” in keeping her diabetes in control, which was notable because
throughout the interview she mentioned multiple challenges that she faced related to her health.
She mentioned having to care for a family member and mental health as priorities that she
focuses on, while also being honest that she lets the focus of her diabetes fall because she is
aware of her own limitations. Similar to Penelope, Christina also shared the same sentiment of
being aware of her lack of self-discipline and willpower to manage her diabetes. Both
participants mentioned eating unhealthy foods and not engaging in physical activity as two
actions that are quickly overlooked once they have to make a choice. The candidness of the two
individuals that reported low self-confidence was reassuring as they provided congruent accounts
of their challenges with diabetes and the way they cope with dealing with those challenges.
Confidence levels of participants varied from high self-confidence because of their
support systems to low self-confidence because of their mindset to address limitations and
challenges. The confidence level was difficult to ascertain as the majority of participants reported

77

high self-confidence, but their daily actions remained unhealthy and their diabetes remained
uncontrolled. An important factor that was consistent among participants that reported high self-
confidence and maintained their diabetes well was the support system that was used to motivate,
encourage, and keep individuals on track to live a healthy lifestyle. The use of technological
support systems to monitor blood sugar levels was a finding that highlighted a different lens of
how support systems function with this population. While human support systems provided
motivation and encouragement, the lack of a support system created greater challenges for
individuals and their diabetes. Confidence levels fluctuate, but confidence could improve when
reinforced by a strong support system. Support systems have been found to be an accountable,
trustful, and helpful asset in living with diabetes and should be considered when caring for low
SES Hispanics.
Research Question 4: What Is the Experience of Low Socioeconomic Status Hispanics
When Accessing Health Care Services to Treat Their Diabetes?
The experiences of low SES Hispanics with diabetes was explored to understand the
challenges health care systems create for Hispanic individuals to maintain their diabetes. The
experience with health care providers was the primary theme that emerged from the research
study, as this population relies on health care providers to guide the management of their
diabetes care. A primary finding was the limited amount of time physicians have to see each
patient. Participants reported feeling rushed during an appointment with a physician, which
created a poor experience with health care providers. Additionally, multiple participants
mentioned lacking a foundational understanding of what is needed to improve their diabetes and
with the limited amount of time, participants were unable to build their health knowledge. The
experience of having an appointment with a health care provider is important for participants and

78

the lack of dedicated, personalized time creates a feeling of being more of a number rather than a
human. Furthermore, a common theme among participants was feelings of nervousness and
anxiety going to the doctor’s office, which stemmed from the Hispanic cultural meaning of
seeing a doctor and generational information about medicine. The emotions of going to see a
health care provider is a reason that most participants mentioned needing a personal connection
with their health care provider to positively influence health behavior.
In addition to the experience of not having enough time with a health care provider once
an appointment is scheduled, the difficulty in initially scheduling an appointment was a finding
that frustrated and disengaged participants from health care services. The impacted schedules of
physicians were notable as participants required frequent discussions with their physicians to
ensure they were on the right track to manage their diabetes. The high demand to see a physician
affects this population as scheduling an appointment requires taking time off work or having to
find a babysitter to take care of their kids. Additionally, low SES Hispanics experience stress
when seeing a health care provider due to concerns of understanding medical terminology and
the potential language barrier they may encounter, which layers on additional stress before
having an appointment with a health care provider. Having a health care provider appointment
was viewed as an event to plan for and look forward to, but the difficulty in scheduling
appointments resulted in participants having to wait up to 2 months to see their provider.
Participants reported scheduling an appointment when they felt symptomatic or needed a
checkup, but the delay in being seen resulted in either not taking their medication or continuing
their unhealthy habits until their appointment. The difficulty in scheduling an appointment was a
notable finding for participants, which created disengagement and frustration. Conversely, the
increased availability of telehealth appointments aimed to provide more convenient health care

79

and is useful for populations that have access to technology: however, for low SES Hispanics,
telehealth appointments lacked the ability to form a trustful relationship with their health care
provider and created an unknowing disparity for individuals that did not have adequate access for
telehealth appointments.
The lack of trust was a byproduct of experiences with health care providers for multiple
participants. Participants felt that building a trustful relationship with their physician was
necessary to keep their diabetes in control. However, the lack of trust between patient and
provider resulted from the difficulty of scheduling an appointment, the experience once they had
the visit, and the unconscious barrier that telehealth appointments created for low SES Hispanics.
A notable finding was the stigma and judgement participants experienced by their health care
provider. Participants mentioned their health care providers making insensitive comments during
their visit, which resulted in participants feeling discriminated and judged. The importance of
weight loss is significant for an individual with diabetes; however, participants mentioned the
over emphasis of weight became the primary intervention and providers would not discuss other
ways to improve health. Low SES Hispanics have different experiences with health care
providers that slowly disengage the population and create mistrust with the overall health care
system. Health care systems should address the individual experience in order to improve their
health and provide care that could lead to positive behavior change.
Participants mentioned different experiences when having a culturally concordant health
care provider, which was highlighted as an important factor in keeping their diabetes in control.
Culturally concordant health care includes behaviors, attitudes, and policies that work in unison
by health care providers and systems to work effectively in cross-cultural situations (Cross,
1989). The ability for health care providers to empathize and understand the Hispanic culture is a

80

foundation of a trustful relationship, which has helped some of the participants keep their
diabetes in control and live a healthy lifestyle. Additionally, culturally concordant health care
providers could identify the cultural meaning diabetes has on the Hispanic culture and recognize
the culture-specific behaviors that could lead to improving their diabetes (Farmer et al., 2018).
Hispanic culture, similarly to other minority cultures, creates cultural meanings and familial
behaviors that only health care providers that are culturally concordant would understand and be
aware of in their treatment plans. The ability for health care systems to improve the experience
of low SES Hispanics is necessary to improve population health and requires a system-wide
commitment to treat this population with culturally concordant care, rather than providing a
universal treatment plan without considering cultural nuances.
Recommendations for Practice
The recommendations for practice to address the health needs of low SES Hispanics with
diabetes will be outlined below. The recommendations are supported by literature and aim to
address the gaps that health care systems unknowingly create, which continue to make living
with diabetes a challenge for this population. Recommendations will be presented as pathways to
augment the provider-patient relationship, which would address the daily environmental and
societal challenges this population faces. Each recommendation outlines organizational
considerations prior to implementation; however, both recommendations require senior
leadership support and financial funding for implementation costs. Senior leadership support is
required to ensure that health care providers and staff are held accountable for improving the
health of low SES Hispanics with diabetes. Financial funding is required for any implementation
costs, and subsequently allocating funding could show support for the organizational initiative.

81

Recommendation 1: Build Culturally Concordant Care Coordination Teams to Augment
Primary Care Physicians, Promoting a Team-Based Approach.
This recommendation addresses the gap of medical culturally concordant care that low
SES Hispanics with diabetes require. Participants discussed challenges that are unlikely to be
addressed when meeting with their primary care physician, such as familial issues, financial
constraints, and work-related stress, which all impact health. By providing culturally concordant
care with a team approach, individuals with diabetes have been found to improve their attitude,
their health knowledge, and their diabetes self-management (Ali & Johnson, 2017). Care
coordination represents the process of organizing a patient’s care and providing services that
would help with disease management, which include social workers, nurses, medical specialists,
and primary care physicians (Weeks et al., 2013). By utilizing care coordination teams, health
care organizations benefit by using the appropriate scope of practice for clinical staff to care for
individuals and provide a centralized point-of-contact for patients. Individuals benefit from care
coordination by having a team of health care professionals who can sequence care among health
care providers and improve comprehension of medical advice and communication, which keeps
a patient-centered approach. Research study participants mentioned a lack of understanding of
what actions are needed to improve their health, but with the limited time for primary care
physicians to explain and educate patients, care coordination would be able to augment the
limited visit and provide individuals with actionable information to manage their diabetes. An
additional benefit of implementing culturally concordant care teams, would be the ability to
address health care staffing shortages and shifting the burden of care away from physicians to a
team-based approach.

82

The recommendation encompasses building a team including a social worker, a registered
nurse, an administrative representative, and a primary care physician. A social worker would be
able to provide social support and connect individuals with resources that could help address the
societal challenges that negatively impact their health. The registered nurse would be able to
provide medical interventions with medication dosage adjustments, conducting preventative
care, and work directly with the physician to keep them informed of their patient’s health. The
administrative representative would work to help schedule the patient for diagnostic tests,
specialty department appointments, and primary care follow-up visits. If a patient sees
specialists, those physicians would also be included in the care team to ensure the medical team
is apprised of their patient’s health. The team-based approach allows each individual on the team
to provide service within their role that could help improve individual health, rather than
primarily relying on a physician for intervention.
Additionally, the importance of having care coordination is the connectedness of care for
the patient; however, culturally concordant trained individuals would provide the most benefit
for this population. Culturally concordant teams have been found to improve patient acceptance
for nutrition counseling, improve glycemic control for individuals with diabetes, and connect
better with patients (Parker et al., 2017). Care coordination itself could improve health care
services for this population, however, ensuring that one or more members of the care
coordination team are culturally concordant could make the most impact with this population.
Culturally concordant care could help build trust among health care providers and the patient, as
well as assess the health literacy and knowledge of patients without fear of judgement. The
importance of having culturally concordant care was reported by many participants as a pathway
to improve their diabetes and engage more with health care services. Participants mentioned

83

having a strong relationship with their health care provider that is based on trust, acts as a
motivator to improve their health. The ability to build trust by understanding the culture of the
patient is an opportunity for health care services to serve low SES Hispanics with diabetes better
and improve overall population health.
In order to implement culturally concordant care coordination, the following five things
must be considered prior to implementation: agreement from each clinical department, training
for health care providers, labor negotiations with unions, facilitated collaboration between the
care team, and program evaluation metrics. Each contingency works together to ensure that the
recommendation can be sustained and evaluated properly. Clinical departments would need to
agree to support the program to ensure that each patient receives equitable care, which could
impact staffing models and departmental budgets. All health care providers would need to
participate in culturally concordant training, in order to ensure proper understanding of how
different cultures view, understand, and improve health. Labor negotiations would also be
required to ensure that unionized staff are working within their agreed upon job duties.
Structured collaboration time between the care team would also be required to ensure that
teambuilding occurs among health care providers, as well as to outline the steps and pathways of
care available for different patients. The organization would also have to outline the evaluation
metrics for the program in order to address the problem of practice and to adapt if changes are
needed to the program.
Recommendation 2: Family-Based Approach to Diabetes Management
This recommendation addresses the need for a support system to augment the care and
support from health care providers. The research study’s findings provided insight on how a
support system could positively impact an individual’s health, and ultimately how they live with

84

diabetes. Including family or trusted friends into the diabetes management care plans could
provide this specific population the support they need to deal with the daily challenges, the
societal effects, and the emotional labor that diabetes brings to their lives. With the ability to
have a team of close individuals in the care plan, it provides health care providers opportunities
to understand challenges in the patient’s history that may not always be discussed and could be
worsening their diabetes.
Similar to cancer treatment including a family-based treatment approach for chronic
diseases, such as diabetes, would provide health care providers additional individuals that could
influence a patient’s behavior and provide needed intervention if the patient’s health is at risk.
Improving one’s diabetes requires behavior change from the individual and the family, as it has
been found that family behavior influences individual health behavior (Kent et al., 2016). A
benefit for including a support system in diabetes care gives health care providers reprieve by
allowing support for patient behavioral health change outside of the health care system. Findings
show that utilizing a family-based approach and leveraging the existing familial relationships for
positive health behavior change is an effective method that creates accountability and
sustainability (Soltero et al., 2021). Due to the impacted availability of health care providers,
augmenting health care within the close environment of an individual, is a way for individuals to
improve their confidence and concurrently, improve their diabetes. An advantage with utilizing
family and friends in disease management is that patients become less reliant on health care
providers for direction and could engage their support system for help with their health.
The practice of moving to a family-based treatment approach could be difficult for some
low SES Hispanics that have no family or friends who could be included in their treatment. The
proposed recommendation would make family-based treatment for chronic diseases a standard of

85

practice for a health care system; however, for individuals who lack familial support, a social
worker will be included in the treatment to conduct a psychosocial assessment and if needed,
connect the individual to additional resources, such as counseling and support groups, to
augment the support system required to improve their diabetes control. Health care providers
would also be required to assess whether an individual is improving their diabetes control on
their own or if an intervention is needed, which would be the time the social worker could
provide needed resources to improve the individual’s health. The unique advantage of
implementing a family-based treatment for low SES Hispanics with diabetes is for health care
services to understand the cultural aspect of receiving a diagnosis and the burden it produces to
the individual and their family. Utilizing a family-based approach couples culturally concordant
care with the support system that is needed to improve diabetes and sustain positive behavior
change.
An ancillary benefit of this recommendation for health care systems is the experience in
utilizing family-based approaches to cancer treatment, which has provided health care providers
additional individuals that could capture the information that may not be retained by the
individual living with the disease. Family-based treatment plans have been used to address
tobacco use, drug use, psychosocial effects of cancer, and eating disorders, proving that the
approach could be used across different demographic populations and disease groups (Ruebush
et al., 2020; Lock et al., 2019; Milton et al., 2022). Findings show that including family members
in care plans has helped to handle the psychological weight of cancer and cease tobacco use,
which highlights the importance of looking at the immediate system that affects an individual to
improve their health (Ruebush et al., 2020). With the rising rates of individuals with diabetes,
health care systems are required to move more into the individual’s home, their work, and their

86

close relationships to accelerate behavior change. The family-based approach would work well
for the study’s population, as the findings have shown that a support system could promote
healthy behavior change and provide accountability partners to keep the individual focused on
their health.
In order to implement a family-based approach to treating chronic diseases, training,
evaluation metrics, and staffing models should be considered. Training would be a perquisite
before implementing family-based approach, as health care providers and staff would be required
to understand how to facilitate discussions that would best help the patient improve their health.
Additionally, training should provide standards of care and service, as well as outline the metrics
that will evaluate the program. Staffing models should be considered as patient-provider
discussions using the family-based approach could require more time, which may create
challenges for other individuals that receive care without a family-based approach. The
organization would also need to assess if more health care providers are needed to meet patient
demand.
Limitations and Delimitations
Limitations and delimitations are discussed to identify external weaknesses or issues the
researcher experienced during the research study. Limitations are important to recognize to be
transparent of the challenges that affected the current research study, which could potentially
affect future research (Creswell & Creswell, 2018). The research study had limitations in the
research design, sample population, and sample size. The research design of the study utilized
interviews as the method of data collection, and participants could have provided biased
information and may not have articulated the information truthful or with the desired intent. The
sample population of participants was also a notable limitation. The youngest participant was 40

87

years old, which resulted in the findings representing a specific age demographic and their
challenges with diabetes. The research study’s sample size was an additional limitation, as the
data collection method included 10 interviews, which may not have represented the entire target
population. Additionally, participants may not have responded to questions truthfully and
candidly due to the sensitive nature of the subject.
Delimitations are the boundaries set for the research study by the researcher (Merriam &
Tisdell, 2016). Individuals who have diabetes and have seen their primary care physician within
the last 2 years were inclusion criteria for the research study, which provided a unique point-of-
view of living with diabetes. The sample population represented individuals who have been
actively engaged with their health care provider. The delimitation of the inclusion criteria
narrowed the range of participants’ experiences living with diabetes regardless of the level of
engagement with their health care provider. The scope and duration of the study provided
limitations to expanding the inclusion criteria. Additionally, the researcher followed a scripted
interview protocol, which could have limited the depth and breadth of information that was
collected.
Recommendations for Future Research
Recommendations for future research should include expanding the inclusion criteria to
obtain a larger data set. The limited inclusion criteria were created due to the scope and timeline
of the research study; however, future research should expand into discussing childhood health
habits, interviewing household or family members, and exploring the methods participants have
tried to maintain their diabetes. The ability for future research to obtain more granular data could
provide opportunities and ideas on how to improve the health of the study’s population. An
additional recommendation for future research is to include health care providers and low SES

88

Hispanics who are not actively involved with the health care system as stakeholder groups for
the research study. The research study focused on the experiences of the sample population,
which provided a singular lens on ways to improve the diabetes care for low SES Hispanics.
Including health care providers could provide insight on the challenges faced when the sample
population accesses health care services and ways that the health care system has tried to care for
these individuals. The ability to gather data from health care providers and individuals with
diabetes could provide future research with a larger population and different insight on the
studied population. Additionally, including low SES Hispanics who have not engaged with their
health care provider within the last 2 years could provide a different viewpoint on the challenges
they face to improve their diabetes. The ability to collate and aggregate data across multiple
stakeholder groups could provide information that could better augment health care services and
engage individuals that have been disengaged with their health.
Conclusion
The purpose of the research study was to explore the societal challenges and barriers low
SES Hispanics with diabetes face when accessing health care services, engaging in daily
activities, and dealing with financial challenges. Additionally, the research study aimed to
understand the lifestyle of low SES Hispanics with diabetes. The research study included 10
interviews with low SES Hispanics with diabetes, which provided findings that identified
opportunities for health care services to improve the care for individuals with diabetes. The
results of the research study found that low SES Hispanics with diabetes require support and a
trustful relationship with their health care providers to elicit positive behavior change. The
perceptions of low SES Hispanics from health care providers, was mostly negative as reported
by participants. The stigma and judgement that low SES Hispanics faced stemmed from a lack of

89

a trustful relationship with their health care provider due to the challenges faced obtaining an
appointment and the interactions once seen by the provider. The findings provided actionable
data that health care services could implement to increase the trust in provider-patient
relationships and to augment the care given by health care providers.
Hispanics continue to face health disparities due to societal and environmental challenges
they face daily. Having diabetes was reported by participants as similar to receiving a death
sentence, which affected the mental health and daily routine of individuals with diabetes. Health
care systems unknowingly create barriers for this population that disengage them from utilizing
health care services, which decrease individual confidence to instill positive healthy behaviors
and leads to poor health. Couple the health care system-wide barriers with the episodic societal
health challenge of the COVID-19 pandemic, and the result of worsening health disparities
experienced by low SES Hispanics has led to poor diabetes control rates and poor overall
population health. It is essential for health care systems to take the necessary steps to reduce the
barriers faced by low SES Hispanics in order to improve their health and reduce health
disparities faced by minorities.
Navigating care within health care systems could be difficult, yet the simplification of
coordinating care or understanding how to treat a diverse population could make the difficulty of
navigating care easier. The ability to navigate a health care system should not impact how
healthy an individual is, yet the difficulty of coordinating care is rarely attributed as a factor
impacting health. This study was conducted to help Hispanics and other minority populations
live healthier lives and to provide health care organizations recommendations to have their
patients and communities live to their fullest potential. Living a healthy life is important and
health care organizations need to redefine how care is delivered to treat diverse populations.

90

References
Aikens, N., & Barbarin, O. (2008). Socioeconomic differences in reading trajectories: the
contribution of family, neighborhood, and school contexts. Journal of Educational
Psychology, 100(2), 235–251. https://doi.org/10.1037/0022-0663.100.2.235
Alderete, E., Vega, W. A., Kolody, B., & Aguilar-Gaxiola, S. (1999). Depressive
symptomatology: prevalence and psychosocial risk factors among Mexican migrant
farmworkers in California. Journal of Community Psychology, 27(4), 451–471.
https://doi.org/10.1037/a0019722
Ali, P. A., & Johnson, S. (2017). Speaking my patient’s language: bilingual nurses’ perspective
about provision of language concordant care to patients with limited English proficiency.
Journal of Advanced Nursing, 73(2), 421–432. https://doi.org/10.1111/jan.13143
American Diabetes Association. (2021). Statistics about diabetes.
https://www.diabetes.org/resources/statistics/statistics-about-diabetes
Arango-Lasprilla, J. C., Ketchum, J. M., Francis, K., Lewis, A., Premuda, P., Wehman, P., &
Kreutzer, J. (2010). Race, ethnicity, and employment outcomes 1, 5, and 10 years after
spinal cord injury: a longitudinal analysis. PM&R, 2(10), 901–910.
https://doi.org/10.1016/j.pmrj.2010.05.009
Aviles-Santa, M. L., Heintzman, J., Lindberg N., Guerrero-Preston, R., Ramos, K., Abraido-
Lanza, A. L., Bull, J., Falcon, A., McBurnie, M. A., Moy, E., Papanicolaou, G., Pina, I.
L., Popovic, J., Suglia, S., & Vazquez, M. A. (2017). Personalized medicine and Hispanic
health: improving health outcomes and reducing health disparities – a National Heart,
Lung, and Blood Institute workshop report. BMC Proceedings, 11(11).
https://doi.org/10.1186/s12919-017-0079-4

91

Aviles-Santa. M. L., Schneiderman, N., Savage, P. J., Kaplan, R. C., Teng, Y., Perez, C. M.,
Suarez, E. L., Cai, J., Giachello, A. L., Talavera, G. A., & Cowie C. C. (2016).
Identifying probable diabetes mellitus among Hispanics/Latinos from four U.S. cities:
findings from the Hispanic community healthy study/study of Latinos. Endocrine
Practice, 22(10), 1151–1160. https://doi.org/10.4158/EP151144.OR
Baghikar, S., Benitez, A., Pineros, P. F., Gao, Y., & Baig, A. A. (2019). Factors impacting
adherence to diabetes medication among urban, low income Mexican-Americans with
diabetes. Journal of Immigrant and Minority Health, 21, 1334–1341.
https://doi.org/10.1007/s10903-019-00867-9
Boch, S., J., Taylor, D. M., Danielson, M. L., Chisolm, D. J., & Kelleher, K. J. (2020). ‘Home is
where the health is’: housing quality and adult health outcomes in the Survey of Income
and Program Participation. Preventive Medicine, 132.
https://doi.org/10.1016/j.ypmed.2020.105990Get
Bor, J., Cohen, G., & Galea, S. (2017). Population health in an era of rising income inequality:
USA, 1980-2015. Lancet, 389, 1475–1490. https://doi.org/10.1016/S0140-
6736(17)30571-8
Bradley, E. H., Sipsma, H., & Taylor, L. A. (2017). American health care paradox-high spending
on health care and poor health. QJM: An International Journal of Medicine, 61–65.
https://doi.org/10.1093/qjmed/hcw187
Braveman, P., & Egerter, S. (2008). Overcoming obstacles to health: report from the Robert
Wood Johnson foundation to the Commission to Build a Healthier America. Robert
Wood Foundation. http://www.commissiononhealth.org/PDF/ObstaclesToHealth-
Report.pdf

92

Braveman, P., Egerter, S., & Williams, D. (2011). The social determinants of health: coming of
age. Annual Review of Public Health, 32(1), 381–398. https://doi.org/10.1146/annurev-
publhealth-031210-101218
Braveman, P. A., Egerter, S. A., & Mockenhaupt R. E. (2011). Broadening the focus: the need to
address the social determinants of health. American Journal of Preventive Medicine,
40(1), S14–S18. https://doi.org/10.1016/j.amepre.2010.10.002
Braveman, P., Gottlieb, L. (2014). The social determinants of health: It’s time to consider the
causes of the causes. Public Health Reports, 129(2), 19–31.
https://doi.org/10.1177/00333549141291S206
Bronfenbrenner, U. (1979). The Ecology of Human Development. Harvard University Press.
Chapter 1: Purpose and Perspective.
Brown, S. A., & Hanis, C. L. (2014). Lessons learned from 20 years of diabetes self-
management research with Mexican Americans in Starr County, Texas. The Diabetes
Educator, 40(4), 476–486. https://doi.org/10.1177/0145721714531336
Bryans, A., Cornish, F., & McIntosh, J. (2009). The potential of ecological theory for building an
integrated framework to develop the public health contribution of health visiting. Health
and Social Care in the Community, 17(6), 564–562. https://doi.org/10.1111/j.1365-
2524.2009.00856.x
Bucknor, C. (2016). Hispanic workers in the United States. Center for Economic and Policy
Research. https://cepr.net/images/stories/reports/hispanic-workers-2016-11.pdf
Budiman, A., Tamir, C., Mora, L. & Noe-Bustamante, L. (2020). Facts on U.S. immigrants,
2018. Pew Research Center. https://www.pewresearch.org/hispanic/2020/08/20/facts-on-
u-s-immigrants/

93

Buescher, P. A., Whitmire, J.T., & Pullen-Smith, B. (2010). Medical care costs for diabetes
associated with health disparities among adult Medicaid enrollees in North Carolina.
North Carolina Medical Journal, 71(4), 319–324.
Bureau of Labor Statistics. (2020). Usual weekly earnings for wage and salary workers fourth
quarter 2019. https://search.proquest.com/docview/2231391121
Buser, J., Boyd, C., J., Moyer, C. A., Ngoma-Hazemba, A., Zulu, D., Mtenje, J. T., Jones, A. D.,
& Lori, J. R. (2020). Operationalization of the ecological systems theory to guide the
study of cultural practices and beliefs of newborn care in rural Zambia. Journal of
Transcultural Nursing, 31(6), 582–590. https://doi.org/10.1177/1043659620921224
Buttazzoni, A., Doherty, S., & Minaker, L. (2021). How do urban environments affect young
people’s mental health? A novel conceptual framework to bridge public health, planning,
and neurourbanism. Public Health Reports, 1–14.
https://doi.org/10.1177/0033354920982088
Caban A., Walker, E. A., Sanchez, S., & Mera, M. S. (2008). “It feels like home when you eat
rice and beans”: perspectives of urban Latinos living with diabetes. Diabetes Spectrum,
21(2), 120–127. https://doi.org/10.2337/diaspect.21.2.120
Carter-Pokras, O. C., & Baquet, C. (2002). What is a “health disparity”? Public Health Reports,
117, 426–434. https://doi.org/10.1093/phr/117.5.426
Carter-Pokras, O. C., Brown, P., Martinez, I., Solano, H., Rivera, M., & Pierpoint, Y. (2008).
Latin American – trained nurse perspective on Latino health disparities. Journal of
Transcultural Nursing, 19(2), 161–166. https://doi.org/10.1177/1043659607312972

94

Cartwright, K. (2021). Social determinants of the Latinx diabetes health disparity: a Oaxaca-
Blinder decomposition analysis. SSM – Population Health, 15.
https://doi.org/10.1016/j.ssmph.2021.100869
Casagrande, S. S., Menke, A., Aviles-Santa, L., Gallo, L. C., Daviglus, M. L., Talavera, G. A.,
Castaneda, S. F., Perreira, K., Loop, M. S., Tarraf, W., Gonzalez, H. M., & Cowie, C. C.
(2018). Factors associated with undiagnosed diabetes among adults with diabetes: results
from the Hispanic community health study study/study of Latinos (HCHS/SOL).
Diabetes research and clinic practice, 146, 258–266.
https://doi.org/10.1016/j.diabres.2018.11.004
Cavazos-Rehg, P., Zayas, L., & Spitznagel, E. (2007). Legal status, emotional well-being and
subjective health status of Latino immigrants. Journal of National Medical Association,
99(10), 1126–1131. https://pubmed.ncbi.nlm.nih.gov/17987916/
Centers for Disease Control and Prevention. (2004). Health disparities experienced by Hispanics
– United States. Morbidity and Mortality Weekly Report, 53(40).
https://doi.org/10.1001/jama.292.19.2330
Centers for Disease Control and Prevention. (2015). Hispanic health.
https://www.cdc.gov/vitalsigns/hispanic-health/index.html
Centers for Disease Control and Prevention. (2017). Health disparities.
https://www.cdc.gov/aging/disparities/index.htm
Centers for Disease Control and Prevention. (2020). Prevalence of diagnosed diabetes.
https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-diabetes.html
Centers for Disease Control and Prevention. (2021). Chronic diseases in America.
https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm

95

Centers for Disease Control and Prevention. (2021). Tables of Health Statistics.
https://www.cdc.gov/nchs/nhis/shs/tables.htm
Cervantes, R., & Castro, F. (1985). Stress, coping, and Mexican American mental health: a
systematic review. Hispanic Journal of Behavioral Sciences, 7(1), 1–73.
https://doi.org/10.1177/07399863850071001
Cervantes, R., Gattamorta, K., & Berger-Cardoso, J. (2019). Examining differences in
immigration stress, acculturation stress, and mental health outcomes in six
Hispanic/Latino nativity and regional groups. Journal of Immigrant and Minority Health,
21, 14–20. https://doi.org/10.1007/s10903-018-0714-9
Chaufan, C., Davis, M., & Constantino, S. (2011). The twin epidemics of poverty and diabetes:
understanding diabetes disparities in a low-income Latino and immigrant neighborhood.
Journal of Community Health, 36(6), 1032–1043. https://doi.org/10.1007/s10900-011-
9406-2
Cheng, Y. J., Kanaya, A. M., Araneta, M. R. G., Saydah, S. H., Kahn, H. S., Gregg, E. W.,
Fujimoto, W. Y., & Imperatore, G. (2019). Prevalence of diabetes by race and ethnicity
in the United States, 2011-2016. JAMA, 322(24), 2389–2398.
https://doi.org/10.1001/jama.2019.19365
Creamer, J. (2020, September 15). Inequalities persist despite decline in poverty for all major
race and Hispanic origin groups. Washington D.C.: U.S. Census Bureau. Retrieved from
https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-
reached-historic-lows-in-2019.html
Creswell, J. W. & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed
methods approaches. Sage Publications.

96

Cross, T., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Towards a culturally competent
system of care: a monograph on effective services for minority children who are severely
emotionally disturbed. Washington, DC: CASSP Technical Assistance Center,
Georgetown University Child Development Center.
Cuevas, H., & Zuniga, J. (2021). Latinx with type 2 diabetes: perceptions of cognitive health.
Journal of Immigrant and Minority Health, 23, 337–343. https://doi.org/10.1007/s10903-
020-00995-7
Dias, J., Echeverria, S., Mayer, V. & Janevic, T. (2020). Diabetes risk and control in multi-ethnic
US immigrant populations. Current Diabetes Report, 20(73).
https://doi.org/10.1007/s11892-020-01358-0
Easley, J. (2018). Spatial mismatch beyond black and white: levels and determinants of job
access among Asian and Hispanic subpopulations. Urban Studies, 55(8), 1800–1820.
https://doi.org/10.1177/0042098017696254
Edward, J., Thompson, R., & Jaramillo, A. (2021). Availability of health insurance literacy
resources fails to meet consumer needs in rural, Appalachian communities: implications
for state Medicaid workers. The Journal of Rural Health, 37(3), 526–536.
https://doi.org/10.1111/jrh.12485
Eke, P. I., Borgnakke, W. S., & Albandar, J. M. (2021). Measurements and distribution of
periodontal diseases. In A. K. Mascarenhas, C. Okunseri, & B. Dye (Eds.), Burt and
Eklund’s Dentistry, Dental Practice, and the Community (7
th
ed., pp 171–188). Saunders.
https://doi.org/10.1016/B978-0-323-55484-8.00015-0
Elgar, F. J., Pfortner, T-K., Moor, I., De Clercq, B., Stevens, G. W. J. M., & Currie, C. (2015).
Socioeconomic inequalities in adolescent health 2002-2010: a time-series analysis of 34

97

countries participating in the Health Behaviour in School-aged Children study. The
Lancet, 385, 2088–2095. http://dx.doi.org/10.1016/S0140-6736(14)61460-4
Eriksson, M., Ghazinour, M., & Hammarström. (2018). Different uses of Bronfenbrenner’s
ecological theory in public mental health research: what is their value for guiding public
mental health policy and practice. Social Theory and Health, 16(4), 414–433.
https://doi.org/10.1057/s41285-018-0065-6
Farmer, A., Edgar, T., Gage, J., & Kirk, R. (2018). “I want to walk with my moko.” The
application of social cognitive theory in the creation of a diabetes prevention
documentary with New Zealand Maori. Journal of Health Communication, 23(3), 306–
312. https://doi.org/10.1080/10810730.2018.1442531
Fernandez, A., Lozano, A., Lee, T. K., Messiah, S. E., & Prado, G. (2021). A healthy lifestyle
intervention for Hispanic families: moderating effects of education, income, nativity.
Journal of Nutrition Education and Behavior. https://doi.org/10.1016/j.jneb.2021.05.001
Finch, B. K., Kolody, B., & Vega, W. A. (2000). Perceived discrimination and depression among
Mexican-origin adults in California, 41(3), 295–313. https://doi.org/10.2307/2676322
Finch, B. K., & Vega, W. A. (2003). Acculturation stress, social support, and self-rated health
among Latinos in California. Journal of Immigrant Health, 5(3), 109–117.
https://doi.org/10.1023/a:1023987717921
Findling, M. G., Bleich, S. N., Casey, L. S., Blendon, R. J., Benson, J. M., Sayde, J. S., & Miller,
C. (2019). Discrimination in the United States: experiences of Latinos. Health Services
Research, 54(S2), 1409–1418. https://doi.org/10.1111/1475-6773.13216

98

Fisher, J. A., & Kalbaugh, C. A. (2011). Challenging assumptions about minority participation in
US clinical research. American Journal of Public Health, 101(12), 2217–2222.
https://doi.org/10.2105/AJPH.2011.300279
Fisher, L., Polonsky, W., Asuni, A., Jolly, Y., & Hessler, D. (2020). The early impact of the
COVID-19 pandemic on adults with type 1 or type 2 diabetes: a national cohort study.
Journal of Diabetes and Its Complications, 34(12).
https://doi.org/10.1016/j.jdiacomp.2020.107748
Ford, C., & Airhihenbuwa, C. (2010). Critical race theory, race equity, and public health: toward
antiracism praxis. American Journal of Public Health, 100(1), S30–S35.
https://doi.org/10.2105/ajph.2009.171058
Fuller, B., Kim, Y., Galindo, C., Bathia, S., Bridges, M., Duncan, G. J., & Valdivia, I. G. (2019).
Worsening school segregation for Latino children? Educational Researcher, 48(7), 407–
420. https://doi.org/10.3102/0013189X19860814
Handmaker, K. (2017). Incorporating social determinants into population health management.
Healthcare Financial Management, 71(3), 60–64.
https://www.hfma.org/topics/article/52923.html
Gallo, L. C., Penedo, F. J., Espinosa de los Monteros, K., & Arguelles, W. (2009). Resiliency in
the face of disadvantage: do Hispanic cultural characteristics protect health outcomes?
Journal of Personality, 77(6), 1707–1746. https://doi.org/10.1111/j.1467-
6494.2009.00598.x
Gardiner, H., & Kosmitzki, C. (2008). Lives Across Cultures. Allyn & Bacon.

99

Ghosh, T., de la Vega, P. B., Brenji, M., & Smith, H. J. (2022). The role of preventative
medicine in improving societal health. American Journal of Preventative Medicine,
62(4), 653–655. https://doi.org/10.1016/j.amepre.2021.12.005
Grzywacz, J. G., Arcury, T. A., Ip, E. H., Nguyen, H. T., Saldana, S., Reynolds, T., Bell, R. A.,
Kirk, J. K., & Quandt, S. A. (2013). “Culture” in diabetes-related beliefs among low- and
high-education African American, American Indian, and White older adults. Ethnicity
and Disease, 22(4), 466–472. https://pubmed.ncbi.nlm.nih.gov/23140078/
Hardy, L., Getrich, C., Quezada, J., Guay, A., Michalowski, R., & Henley, E. (2012). A call for
further research on the impact of state-level immigration policies on public health.
American Journal of Public Health, 102(7), 1250–1254.
https://doi.org/10.2105/ajph.2011.300541
Horowitz, C., Williams, L., & Bickell, N. (2003). A community-centered approach to diabetes in
east Harlem. Journal of General Internal Medicine, 18, 542–548.
https://doi.org/10.1046/j.1525-1497.2003.21028.x
Hue, J., Amirehsani, K. A., Wallace, D. C., McCoy, T. P., & Silva, Z. (2016). A family-based
culturally tailored diabetes interventions for Hispanics and their family members. The
Diabetes Educator, 42(3), 299–314. https://doi.org/10.1177/0145721716636961
International Diabetes Federation. (2019). IDF diabetes atlas [9th edition].
https://www.diabetesatlas.org/en/resources/
Iten, A. E., Jacobs, E. A., Lahiff, M., & Fernandez, A. (2014). Undocumented immigration status
and diabetes care among Mexican immigrants in two immigration “sanctuary” areas.
Journal of Immigrant and Minority Health, 16(2), 229–238.
https://doi.org/10.1007/s10903-012-9741-0

100

Kaiser Family Foundation. (2009). Key health and health care indicators by race/ethnicity and
state [Data set]. https://www.kff.org/racial-equity-and-health-policy/fact-sheet/key-
health-and-health-care-indicators-by/
Kent, E. E., Rowland, J. H., Northouse, L., Litzelman, K., Chou, W. S., Shelburne, N., Timura,
C., O’Mara, A., & Huss, K. (2016). Caring for caregivers and patients: research and
clinical priorities for informal cancer caregiving. Cancer, 122(13), 1987–1995.
https://doi.org/10.1002/cncr.29939
Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The prevalence, distribution, and
mental health correlates of perceived discrimination in the United States. American
Sociological Association, 40(3), 208–230. https://doi.org/10.2307/2676349
Kitchling, G. T., Firestone, M., Schei, B., Wolfe, S., Bourgeois, C., O’Campo, P., Rotondi, M.,
Nisenbaum, R., Maddox, R., & Smylie, J. (2020). Unmet health needs and discrimination
by healthcare providers among an Indigenous population in Toronto, Canada. Canadian
Journal of Public Health, 111(1), 40–49. https://doi.org/10.17269/s41997-019-00242-z
Kochhar, R., & Cilluffo, A. (2018). Incomes of whites, blacks, Hispanics and Asians in the U.S.,
1970 and 2016. Pew Research Center.
https://www.pewsocialtrends.org/2018/07/12/incomes-of-whites-blacks-hispanics-and-
asians-in-the-u-s-1970-and-2016/
Krieger, N. (2003). Does racism harm health? Did child abuse exist before 1962? On explicit
questions, critical science, and current controversies: an ecosocial perspective. Racism
and Health, 98(1), S20–S25. https://doi.org/10.2105/AJPH.98.Supplement_1.S20
Krogstad, J. M. (2016, July 28). 5 facts about Latinos and education. Pew Research Center
https://www.pewresearch.org/fact-tank/2016/07/28/5-facts-about-latinos-and-education/

101

Krogstad, J. M., & Noe-Bustamante, L. (2021, September 9). Key facts about U.S. Latinos for
National Hispanic Heritage Month. Pew Research Center.
https://www.pewresearch.org/fact-tank/2021/09/09/key-facts-about-u-s-latinos-for-
national-hispanic-heritage-month/
Kuo, Y.F., Raji, M. A., Markides, K. S., Ray, L. A., Espino, D., & Goodwin, J. S. (2003).
Inconsistent use of diabetes medications, diabetes complications, and mortality in older
Mexican Americans over a 7-year period. Diabetes Care, 26(11), 3054–3060.
https://doi.org/10.2337/diacare.26.11.3054
Lanting, L. C., Joung, I. M. A., Mackenbach, J. P., Lamberts, S. W. J., & Bootsma, A. H. (2005).
Ethnic differences in mortality, end-stage complications, and quality of care among
diabetic patients. Diabetes Care, 28(9), 2280–2288.
https://doi.org/10.2337/diacare.28.9.2280
LaVeist, T., Pollack, K., Thorpe, R. Jr., Fesahazion, R., & Gaskin, D. (2011). Place, not race:
disparities dissipate in southwest Baltimore when blacks and whites live under similar
conditions. Health Affairs, 30(10), 1880–1887. https://doi.org/10.1377/hlthaff.2011.0640
Lebron, A. M. W., Valerio, M. A., Kieffer, E., Sinco, B., Rosland, A., Hawkins, J., Espitia, N.,
Palmisano, G., & Spencer, M. (2014). Everyday discrimination, diabetes-related distress,
and depressive symptoms among African Americans and Latinos with diabetes. Journal
of Immigrant Health, 16(6), 1208–1216. https://doi.org/10.1007/s10903-013-9843-3
Lichter, D., Parisi, D., Taquino, M., & Grice, S. M. (2010). Residential segregation in new
Hispanic destinations: cities, suburbs, and rural communities compared. Social Science
Research, 39(2), 215–230. https://doi.org/10.1016/j.ssresearch.2009.08.006

102

Lock, J., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L., Kirz, N., Derenne, J., &
Utzinger, L. (2019). Apply family-based treatment (FBT) to three clinical presentations
of avoidant/restrictive food intake disorder: similarities and differences from FBT for
anorexia nervosa. Internal Journal of Eating Disorders, 52, 439–446.
https://doi.org/10.1002/eat.22994
Lopez, L., & Golden, S. H. (2014). A new era of understanding diabetes disparities among U.S.
Latinos – all are not equal. Diabetes Care, 37(8), 2081–2083.
https://doi.org/10.2337/dc14-0923
Marmot, M. & Bell, R. (2012). Fair society, healthy lives. Public Health, 126, S4-S10.
https://doi.org/10.1016/j.puhe.2012.05.014
Martinez-Cardoso, A., Jang, W., & Baig, A. A. (2020). Moving diabetes upstream: the social
determinants of diabetes management and control among immigrants in the US. Current
Diabetes Reports, 20(48). https://doi.org/10.1007/s11892-020-01332-w
Mechanic, D. (2005). Policy challenges in addressing racial disparities and improving population
health. Health Affairs, 24(2), 335–338. https://doi.org/10.1377/hlthaff.24.2.335
Menke, A., Casagrande, S., Geiss, L., & Cowie, C. C. (2015). Prevalence of and trends in
diabetes among adults in the United States, 1988-2012. JAMA, 314(10), 1021–1029.
https://doi.org/10.1001/jama.2015.10029
Menke, A., Casagrande, S., Aviles-Santa, M. L., & Cowie, C. C. (2017). Factors associated with
being unaware of having diabetes. Diabetes Care, 40, e55–e56.
https://doi.org/10.2337/dc16-2626

103

Mellus, J., & Cannonier, C. (2016). Exploring U.S. Hispanic parents’ length of time in the
United States: influences on obesity outcomes among U.S. Hispanic children. Social
Work in Health Care, 55(10), 826–842. https://doi.org/10.1080/00981389.2016.1223259
Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation. (4th ed.). Jossey-Bass.
Milton, K., Poole, K., Cross, A., Gasson, S., Gokal, K., Lyons, K., Pulsford, R., & Jones, A.
(2022). ‘People don’t get cancer, families do’: co-development of a social physical
activity intervention for people recently affected by a cancer diagnosis. European Journal
of Cancer Care, 31(3). https://doi.org/10.1111/ecc.13573
Mora, M. T., & Davila, A. (2018). The Hispanic-white wage gap has remained wide and
relatively steady: examining Hispanic-white gaps in wages, unemployment, labor force
participation, and education by gender, immigrant status, and other subpopulations.
Economic Policy Institute. https://www.epi.org/publication/the-hispanic-white-wage-gap-
has-remained-wide-and-relatively-steady-examining-hispanic-white-gaps-in-wages-
unemployment-labor-force-participation-and-education-by-gender-immigrant/
Morgan, K. P. (2018). Describing the emperor's new clothes: Three myths of educational (in-)
equity. In The Gender Question In Education (pp. 105–122). Routledge.
Morley, C. M. (2021). Health literacy, health confidence, and simulation: a novel approach to
patient education to reduce readmissions. Professional Case Management, 26(3), 138–
149. https://doi.org/10.1097/NCM.0000000000000456
Narayan, K. M. V., Boyle, J. P., Thompson, T. J., Sorensen, S. W., & Williamson, D. F. (2003).
Lifetime risk for diabetes mellitus in the United States. JAMA, 290(14), 1184–1890.
https://doi.org/10.1001/jama.290.14.1884

104

National Emphysema Treatment Trial Research Group. (2003). A randomized trial comparing
lung-volume-reduction surgery with medical therapy for severe emphysema. New
England Journal of Medicine, 348(21), 2059–2073.
https://doi.org/10.1056/NEJMoa030287
Nelson, L. A., Ackerman, M. T., Greevy, R. A., Wallston, K. A., & Mayberry, L. S. (2019).
Beyond race disparities: accounting for socioeconomic status in diabetes self-care.
American Journal of Preventative Medicine, 57(1), 111–116.
https://doi.org/10.1016/j.amepre.2019.02.013
Noe-Bustamante, L., Lopez, M. H., & Krogstad, J. M. (2020, July 7). U.S. Hispanic population
surpassed 60 million in 2019, but growth has slowed. Pew Research Center.
https://www.pewresearch.org/fact-tank/2020/07/07/u-s-hispanic-population-surpassed-
60-million-in-2019-but-growth-has-slowed/
O’Bryant, S. E., Zhang, F., Petersen, M., Hall, J. R., Johnson, L. A., Yaffe, K., Mason, D.,
Braskie, M., Barber, R. A., Rissman, R. A., Mapstone, M., Mielke, M. M., & Toga, A.
W. (2021). A blood screening tool for detecting mild cognitive impairment and
Alzheimer’s disease among community-dwelling Mexican Americans and non-Hispanic
Whites: a method for increasing representation of diverse populations in clinical research.
Alzheimer’s and Dementia, 1–11. https://doi.org/10.1002/alz.12382
Organisiation for Economic Co-Operation and Development. (2021). OECD Health Statistics
[Data set]. https://oe.cd/ds/health-statistics
Orzechowski, S., & Sepielli, P. (2003). Net worth and asset ownership of households: 1998 and
2000 (Report No. P70-88). U.S. Census Bureau.
https://www.census.gov/library/publications/2003/demo/p70-88.html

105

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., &
Gee, G. (2015). Racism as a determinant of health: a system review and meta-analysis.
PLOS ONE, 10(9). https://doi.org/10.1371/journal.pone.0138511
Parker, M. M., Fernandez, A., Moffet, H. H., Grant, R. W., Torreblanca, A., & Karter, A. J.
(2017). Association of patient-physician language concordance and glycemic control for
limited-English proficiency Latinos with type 2 diabetes. JAMA Internal Medicine,
177(3), 380–387. https://doi.org/10.1001/jamainternmed.2016.8648
Parry, O., Peel, E., Douglas, M. & Lawton, J. (2004). Patients in waiting: a qualitative study of
type 2 diabetes patients’ perception of diagnosis. Family Practice, 21(2), 131–136.
https://doi.org/10.1093/fampra/cmh203
Pedraza, F., Nichols, V., & LeBrón, A. (2017). Cautious citizenship: the deterring effect of
immigration issue salience on health care use and bureaucratic interactions among Latino
US citizens. Journal of Health Politics, 42(5), 925–960.
https://doi.org/10.1215/03616878-3940486
Penedo, F. J., Brintz, C. E., LLabre, M. M., Arguellas, W., Isasi, C. R., Arredondo, E. M.,
Navas-Nacher, E. L., Perreira, K. M., Gonzalez, H. M., Rodriguez, C. J., Daviglus, M.,
Schneiderman, N., & Gallo, L. C. (2015). Family environment and the metabolic
syndrome: results from the Hispanic community health study/study of Latinos
(HCHS/SOL) sociocultural ancillary study (SCAS). Annals of Behavioral Medicine,
49(9), 793–801. https://doi.org/10.1007/s12160-015-9713-4
Philbin, M., Flake, M., Hatzenbuehler, M., & Hirsch, J. (2018). State-level immigration and
immigrant-focused policies as drivers of Latino health disparities in the United States.
Social Science & Medicine, 199, 29–38. https://doi.org/10.1016/j.socscimed.2017.04.007

106

Pyatak, E. A., Florindez, D., Peters, A. L., & Weigensberg, M. J. (2014). “We are all going to get
diabetic these days”: the impact of a living legacy of type 2 diabetes on Hispanic young
adults’ diabetes care. The Diabetes Educator, 40(5), 648–658.
https://doi.org/10.1177/0145721714535994
Reader, T. W., & Gillespie, A. (2013). Patient neglect in healthcare institutions: a systematic
review and conceptual model. BMC Health Services Research, 13(156).
https://doi.org/10.1186/1472-6963-13-156
Rivera-Goba, M. V., Dominguez, D. C., Stoll, P., Grady, C., Ramos, C., & Mican J. M. (2011).
Exploring decision-making of HIV-infected Hispanics and African Americans
participating in clinical trials. Journal of the Association of Nurses in AIDS Care, 22(4),
295–306. https://doi.org/10.1016/j.jana.2010.10.007
Ruebush, E., Mitra, S., Meyer, C., Sisler, L., & Oldstein, A. O. (2020). Using a family systems
approach to treat tobacco use among cancer patients. International Journal of
Environmental Research and Public Health, 17(6).
https://doi.org/10.3390/ijerph17062050
Ryan, A. M., Gee, G. C., & Griffith, D. (2008). The effects of perceived discrimination on
diabetes. The John Hopkins University Press, 19(1), 149–163.
https://doi.org/10.1353/hpu.2008.0005
Rycroft, R. (2013). The economics of inequality, poverty, and discrimination in the 21st century.
ABC-CLIO, LLC.
https://books.google.com/books?id=4E8kZkcrGxAC&dq=hispanic+income+inequality&l
r=&source=gbs_navlinks_s

107

Schneiderman, N., Llabre, M., Cowie, C., Barnhart, J., Carnethon, M., Callo, L., Giachello, A.,
Heiss, G., Kaplan, R., LaVange, L., Teng, Y., Villa-Caballero, L., & Aviles-Santa, M.
(2014). Prevalence of diabetes among Hispanics/Latinos from diverse backgrounds: the
Hispanic community health study/study of Latinos (HCHS/SOL). Diabetes Care, 37(8),
2233–2239. https://doi.org/10.2337/dc13-2939
Shelton, R., Goldman, R., Emmons, K., Sorensen, G., & Allen, J. (2011). An investigation into
the social context of low-income, urban Black and Latina women: implications for
adherence to recommended health behaviors. Health Education and Behavior, 38(5),
471–481. https://www.jstor.org/stable/45056746
Shoemaker, M. L., & White, M. C. (2016). Breast and cervical cancer screening among Asian
subgroups in the USA: estimates from the National Health Interview Survey, 2008, 2010,
and 2013. Cancer Causes Control, 27, 825–829. https://doi.org/10.1007/s10552-016-
0750-5
Shrider, E. A., Kollar, M., Chen, F., & Semega, J. (2021). Income and poverty in the United
States: 2020. United States Census Bureau.
https://www.census.gov/content/dam/Census/library/publications/2021/demo/p60-
273.pdf
Soltero, E. G., Navabi, N., Castro F. G., Ayers, S. L., Mendez, J., Thompson, D. I., & Shaibi, G.
Q. (2021). Perceptions of family-level social factors that influence health behaviors in
Latinx adolescents and young adults at high risk for type 2 diabetes. Children, 8(406).
https://doi.org/10.3390/children8050406

108

Sommers, B., McMurtry, C., Blendon, R., Benson, J. & Sayde, J. (2017). Beyond health
insurance: remaining disparities in US health care in the post-ACA era. The Milkbank
Quarterly, 95(1), 43–69. https://doi.org/10.1111/1468-0009.12245
Stokols, D. (1996). Translating social ecological theory into guidelines for community health
promotion. American Journal of Health Promotion, 10(4), 282–298.
https://doi.org/10.4278/0890-1171-10.4.282
Stone, L. C., & Balderrama, C. H. (2008). Health inequalities among Latinos: what do we know
and what can we do? Health and Social Work, 33(1). https://doi.org/10.1093/hsw/33.1.3
Tienda, M., & Mitchell, F., (2006). Hispanic and the future of America. The National Academies
Press. https://www.nap.edu/read/11539/chapter/1
Tikkanen, R. & Abrams, M. K. (2019). U.S. health care from a global perspective, 2019: higher
spending, worse outcomes? [Data set]. The Commonwealth Fund.
https://doi.org/10.26099/7avy-fc29
Tucker-Seeley, R., Mitchell, J., Shires, D., & Modlin Jr., C. (2015). Financial hardship, unmet
medical need, and health self-efficacy among African American men. Health Education
& Behavior, 42(3), 285–292. https://doi.org/10.1177/1090198114557125
United States Census Bureau. (2015). Hispanic heritage month 2015.
https://www.census.gov/newsroom/facts-for-features/2015/cb15-ff18.html
United States Census Bureau. (2018). Hispanic population to reach 111 million by 2060.
https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html
United States Census Bureau. (2021). QuickFacts Dashboard – United States.
https://www.census.gov/quickfacts/fact/dashboard/US/PST045221

109

United States Census Bureau. (2018). Real median household income by race and Hispanic
origin: 1967 to 2017 [Chart].
https://www.census.gov/content/dam/Census/library/visualizations/2018/demo/p60-
263/figure1.pdf
van Ommen, B., Wopereis, S., van Empelen, P., van Keulen, H. M., Otten, W., Kasteleyn, M.,
Molema, J. J. W., de Hoogh, I. M., Chavannes, N. H., Numans, M. E., Evers, A. W. M.,
& Pijl, H. (2018). From diabetes care to diabetes cure – the integration of systems
biology, ehealth, and behavioral change. Frontiers in Endocrinology, 8, 381.
https://doi.org/10.3389/fendo.2017.00381
Velasco-Mondragon, E., Jimenez, A., Palladino-Davis, A. G., Davis, D., & Escamilla-Cejudo, J.
A. (2016). Hispanic health in the USA: a scoping review of the literature. Public Health
Reviews, 37(31). https://doi.org/10.1186/s40985-016-0043-2
Walker, R. J., Smalls, B. L., & Egede L. E. (2015). Social determinants of health in adults with
type 2 diabetes – contribution of mutable and immutable factors. Diabetes Research and
Clinical Practice, 110(2), 193–201. https://doi.org/10.1016/j.diabres.2015.09.007
Weeks, D. L., Polello, J. M., Hansen, D. T., Keeney, B. J., & Conrad, D. A. (2013). Measuring
primary care organizational capacity for diabetes care coordination: the diabetes care
coordination readiness assessment. Journal of General Internal Medicine, 29(1), 98–103.
https://doi.org/10.1007/s11606-013-2566-2
Williams, D. R., & Sternthal, M. (2010). Understanding racial-ethnic disparities in health:
sociological contributions. Journal of Health and Social Behavior, 51(S), 15–27.
https://doi.org/10.1177/0022146510383838

110

Williams, D., McClellan, & Rivlin, A. (2010). Beyond the affordable care act: achieving real
improvements in Americans’ health. Health Affairs, 29(8), 1481–1488.
https://doi.org/10.1377/hlthaff.2010.0071
Wilson, E., Chen, A. H., Grumbach, K., Wang, F., & Fernandez, A. (2005). Effects of limited
English proficiency and physician language on health care comprehension. Journal of
General Internal Medicine, 20(9), 800–806. https://doi.org/10.1111/j.1525-
1497.2005.0174.x
Yu, T. (2006). Challenging the politics of the “model minority” stereotype: a case of educational
equality. Equity & Excellence in Education, 39(4), 325–333.
https://doi.org/10.1080/10665680600932333
Zhang, S. & Xiang, W. (2019). Income gradient in health-related quality of life – the role of
social networking time. International Journal for Equity in Health, 18(44).
https://doi.org/10.1186/s12939-019-0942-1

111

Appendix A: Interview Protocol
Interview question Potential probes
Let’s think back to when you were a child
living with your family (wherever the
person said they lived), tell me about how
health was discussed to you when you were
growing up?
Tell me about your parents, did they have any
health issues that you were aware of
growing up?
Tell me about the experience you had when
you were first diagnosed with diabetes.
How long ago was the diagnosis and how did
you feel the weeks after you knew you had
diabetes?
From when you were diagnosed until today,
what types of challenges have you faced in
keeping your diabetes in control?
How has your day-to-day lifestyle changed
since you knew you had diabetes?
Let’s talk about your work at (insert wherever
the person said they work). How has your
work affected your ability to keep your
diabetes in control?

Now let’s talk about your home life. You
mentioned you (insert what the person said
about their household), what types of
challenges do you face at home in keeping
your diabetes in control?
What about food, how does that affect your
diabetes?

Do you cook or does someone else in the
household cook?
Let’s talk about the neighborhood you live in,
are there any characteristics about your
neighborhood that you think create
challenges to keep your diabetes in control?
How safe do you feel if you were to walk
outside and exercise?
Physical activity is an important factor in
keeping diabetes in control, tell me about
your physical activity level.
Do you exercise alone or do you have
someone that makes sure you exercise?
Now let’s talk about the doctor (or nurse) you
see for your health care. How often do you
see your doctor (or nurse) to help with any
health issues you have?
What do you think hinders you from seeing
the doctor (or nurse)?
Tell me about what your doctor has told you
about how to keep your diabetes in control.
Are you on any medication regimes?
Tell me about your experience with your
doctor on how they understand you as an
individual and the culture you grew up in,
and currently live in.
Do you feel your doctor has a good
understanding of your individual culture?
What do you think your doctor (or nurse)
does well in helping you keep your diabetes
in control?

What do you think your doctor (or nurse)
needs to do better when helping you keep
your diabetes in control?

112

Interview question Potential probes
What keeps you motivated in trying to keep
your diabetes in control?

How confident do you feel in keeping your
diabetes in control related to your other
priorities in your life?

Tell me about your confidence level in
keeping your diabetes under control for the
long-term.

113

Appendix B: Additional Participant Quotes
Participant Quote Themes RQ addressed
CE Is [diabetes] a death sentence or something like
that? No, I just think that, people, sadly in the
Hispanic community it’s too common. It’s just
like there goes another person with diabetes.
Mental
health
RQ1
AL My mom is the one that does the cooking for the
household now that I started buying my own
stuff that’s a little bit healthier like I’ll come
home, and I have to cook or I’ll do the
cooking for at least three days out of the week.
Family RQ1
GL I have three kids. I have one child who is
autistic, so it’s kind of hard for me to even go
back to the work field, because he requires
someone to be with him. With all his therapies
for outside school and in-home therapy, it’s
kind of hard to even think about going back to
a job.
Family;
finances
RQ1
TC And sometimes, when I don’t have the money to
go see the doctor because they charge me $20
per visit, I kind of juggle with it, will I go see
the doctor or buy my medication. That’s
basically what keeps me behind but you know,
I do what I can. I know I have been diabetic
for many, many years. I do take care of
myself, but I have to be honest to you, I like to
eat. Regardless of what the outcome is going
to be, if it’s going to be my coffee [at] night,
my candy during the day, and I like to eat. I
love to eat, you know?
Finances RQ1
AL I think stress is a big factor with me. I tend to
stress out about the littlest things. I think work
is very stressful. And I just, I think in general,
I feel sometimes, when my anxiety hits that
causes even more stress to myself, I get a lot
of anxiety to drive and it’s something I have to
do, every day, so I kind of sometimes have to
talk myself down and be like everything’s fine
and pull over and then continue driving so
that’s just huge for me, every day, every
challenge that I have to face every day of my
life.
Mental
health
RQ1

114

Participant Quote Themes RQ addressed
GL It’s hard you know, being Hispanic and watching
everything that you eat. You go to a family
gathering and that’s harder because there’s not
a lot of healthy choices when it comes to
family gatherings or anywhere else you go.
Family;
eating
habits
RQ1, RQ2
OZ You know it’s funny because [doctors] tell me
‘hey you know you have like four different
kinds of carbs on the plate.’ I don’t know what
a carb is, I don’t know what a protein is. I can
understand that I like to eat rice, beans,
tortillas, and bread.
Eating
habits;
Health care
providers
RQ2, RQ4
VA [I have] challenges with my kids because they
want me to make some like spaghetti, or
something like that. And we’d have to teach
them to do exercise and they don’t like that.
Family;
Eating
habits
RQ1, RQ2
PM The other issue is that I’m just not active at all. I
used to try to go to the gym. I used to run
around a lot more and just be out a lot more. I
had a change in lifestyle, where I started
working from home, which started before the
pandemic. And so that drastically reduced any
activity really outside of the house or going to
the gym or anything like that. And so now I
think my exercise, is probably at about zero.
COVID-19
pandemic
RQ2
JS I was overweight. So yeah, I was surprised
[being diagnosed with diabetes]. I wasn’t
shocked by it because I was, I’m like 30, 40
pounds overweight right now. And that’s
basically more or less the same weight that I
was back. I worked a lot at the post office. So
specifically, the last 5, 7 years, since I’ve been
doing all this overtime, all this other work.
Very, very little time to go out and take a
walk, do some weightlifting, anything of that
nature. I just haven’t had no drive. I’m tired.
Work/
profession;
eating
habits
RQ2
VA I think [I’m confident] because I have people
who support me, my son. First, my husband. I
have an amazing husband. He cares about me.
He learns how to cook. He’s the one who
made the menus every single day. This is good
for you. This is good for you. And that’s why I
say I have an amazing husband. Because he
cares about me and my kids. They always say
you don’t have to eat this, bad for you.
Family; self-
confidence
RQ1, RQ3

115

Participant Quote Themes RQ addressed
JS Getting my diabetes in control is a big priority. I
mean it’s kind of hard when you’re at work,
the area that I’m at. …like I have to
incorporate more fruits, wholesome snack, [go
to] the store Smart and Final. That’s cleaner
than just chips. I’m careful but again, but this
is the bad part, I’m pretty sure that my sugar
levels are normal. But I do need to get a
routine to control it and hopefully eliminate it.
Self
confidence
RQ3
PM I don’t have the self-discipline for it, even
though I know in my head, [diabetes] could
kill me if I don’t eat right.
Eating
habits;
Self
confidence
RQ2, RQ3
PM If I need the insulin on a daily basis and it gets
really painful I’m probably not going to
continue doing it because I know myself like I
would rather, just sounds really stupid and
again it could be. Something tied to my mental
state but I’d rather die than have to do that
forever and to have to like deal with that or
feel that forever and I told [my physician] if it
I just know myself if it becomes a real, I know
that I will not continue doing it.
Mental
health;
self
confidence
RQ1, RQ3
AL If I have somebody [to exercise with] I feel like
I’ll be more like, let’s do this, and I feel like if
I’m by myself, I don’t push myself to go and
do it.
Self-
confidence
; support
system
RQ3
TC No [doctors don’t understand my culture],
because you know, they sometimes just say,
eat what is healthy and not what is unhealthy.
Well, they don’t have to tell me that. I eat that
because that’s what my mother and father can
afford. But now that I’m an adult, that I make
my own money I can eat the way I want to,
not the way that my table was set when I was a
little girl, you know, because at that time, I
didn’t know any better. But now I know much
more than when I was a little girl. But, you
know, they just feel like the Mexican culture
[focuses] on how we eat.
Health care
providers
RQ4

116

Participant Quote Themes RQ addressed
OZ I have to be honest with you. I think, and like I
said, I don’t blame them, but I think [doctors]
see me walk into the room and they
automatically assume that everything that is
wrong with me is due, because I’m
overweight. So, it’s funny when I walk in [the
room] and it’s like, wait you haven’t even
talked to me and you’re telling me I need to
lose weight. I think [I’m] stereotyped to be
honest with you.”
Health care
providers
RQ4
VA “The doctor I had before, one day I went to the
doctor because my legs started hurting me.
And I told the doctor and she said, I don’t care
about your leg. I care about your sugar. I
know. Thanks for that. But I went for my leg
when I start to get pain in my leg. And she
said that to me. I don’t care about your leg. I
care about your sugar. And I say wow, I came
here for my leg and she told me that when I
start to get the problems with my leg, and I
still have my legs. But I lost the [sensitivity]
on my foot, my leg and they do nothing. They
want me to cut my leg … I feel like sad and I
say wow, this is the kind of doctor they have
here because I went to the emergency room
and the doctors say, I can do nothing for your
leg, only cut your leg. They want me to cut my
leg and I say what? And I find another clinic
and another hospital but my husband has to
pay $20,000.”
Health care
providers
RQ4

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Perspectives of diabetes prevention program coordinators in socioeconomically disadvantaged communities: implementation optimization

PDF

Barriers in care access for the marginalized individual: a provider’s role

PDF

The role of healthcare volunteers in addressing social determinants of health

PDF

Hidden perspectives: narratives of female family caregiver experiences

PDF

Increasing the effectiveness of African-American male mentorship

PDF

Health care disparities and the influence of nurse leader cultural competency: an evaluation study

PDF

Reducing employee turnover through organizational identity

PDF

Ambient anxiety within leadership teams and its impact on organizational efficiency in mental health organizations

PDF

The relationship between Latinx undergraduate students’ mental health and college graduation rates

PDF

An examination of ethnic minority physician representation in clinical medicine to reduce health disparities among minoritized groups

PDF

U.S. Army Reserve: the journey to psychological health resources

PDF

Higher education faculty and reflective practice

PDF

A path to K-12 educational equity: the practice of adaptive leadership, culture, and mindset

PDF

Transgender experience in the U.S. military: opportunities for effective inclusion

PDF

Lesbian, gay, bisexual, transgender, and queer health curriculum in medical education: a gap analysis

PDF

Access to ambulatory healthcare services for LGBTQ populations

PDF

The experience of Eritrean refugee women in addressing their mental health needs

PDF

Preparing Asian American leaders in higher education: an exploration study using Bronfenbrenner's ecological model

PDF

Is healthcare for all? A qualitative questionnaire study of systemic racism in healthcare and the perception among stakeholders of U.S. healthcare corporations: an exploration of moral disengagement..

PDF

An evaluation of teacher retention in K-12 public schools

Asset Metadata

Creator Villaruz, Rafael (author)

Core Title The effects social determinants of health have on the higher prevalence of diabetes in low socioeconomic status Hispanics compared to non-Hispanic Whites

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-12

Publication Date 10/19/2022

Defense Date 09/21/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag culturally concordant care,health disparity,OAI-PMH Harvest,social determinants of health

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Spann, Rufus (committee chair), Canny, Eric (committee member), Ott, Maria (committee member)

Creator Email rvillaru@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112124633

Unique identifier UC112124633

Identifier etd-VillaruzRa-11276.pdf (filename)

Legacy Identifier etd-VillaruzRa-11276

Document Type Dissertation

Format theses (aat)

Rights Villaruz, Rafael

Internet Media Type application/pdf

Type texts

Source 20221019-usctheses-batch-987 (), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu