Epidemiology/Health Services/Psychosocial Research B R I E F
R E P O R T
Language and Other Factors Associated With Foot Self-Management Among Puerto Ricans With Diabetes in New York City AKIKO S. HOSLER, PHD1,2 THOMAS A. MELNIK, DRPH1
D
aily self-inspection of feet for sores and irritations is an essential and cost-effective diabetes self-management practice to prevent foot complications (1,2). It is relatively easy to perform and does not require equipment or supplies, yet nearly 40% of people with diabetes in New York state do not practice daily foot inspection, and Hispanics are the least likely to do so (3). Puerto Ricans are the largest Hispanic group in the state and have a markedly high prevalence of diabetes (4,5). Studies have found that Puerto Ricans show poor overall selfmanagement of diabetes (6,7) and suffer from a high prevalence of foot complications (8 –10). Poor English skills are often identified as a major reason for their suboptimal self-care practice (11,12), but some studies concluded that language may not be a barrier (13,14). The present study examines factors associated with Puerto Ricans’ daily foot self-inspection practice using population-based survey data.
RESEARCH DESIGN AND METHODS — The data were collected in 2000 –2001 through a random digit– dialing telephone survey aimed to reach Puerto Rican adults (ⱖ18 years of age) residing in New York City (5). The survey protocol and questions were taken from the Behavioral Risk Factor Surveillance System developed by the Centers for Disease Control and Prevention (15). Those who responded affirmatively to the question “Have you been told by your doctor
that you have diabetes?” were identified as having diabetes (n ⫽ 606). Daily foot selfinspection practice was measured by the question, “About how often do you check your feet for any sores or irritations?” Instructions were given to include times when checked by a family member or friend but not by a health care professional. Those who reported checking their feet once or more a day were identified as practicing daily foot self-inspection. In the analysis, respondents were divided into three groups based on their language usage pattern. Respondents who chose to be interviewed in English and also reported using English at home were considered “English dominant” (n ⫽ 204). Those who chose to be interviewed in English but reported using Spanish at home (n ⫽ 189) or vice versa (n ⫽ 12) were considered “bilingual.” Those who used Spanish both for interview and at home were identified as “Spanish dominant” (n ⫽ 201). The multivariate logistic regression model included language and standard demographic variables (age, sex, and education) and other variables associated with daily foot self-inspection including years since diabetes diagnosis, vision impairment, history of lowerextremity ulcer, current diabetes medication, daily self-monitoring of blood glucose, number of times a professional checked feet in the previous year, diabetes education (ever had), and current smoking. History of lower-extremity ulcer was measured by the question “Have you ever had an ulcer or sore on your leg or foot
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From the 1Bureau of Chronic Disease Epidemiology and Surveillance, New York State Department of Health, Albany, New York; and the 2Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York. Address correspondence and reprint requests to Akiko S. Hosler, PhD, Bureau of Chronic Disease Epidemiology and Surveillance, New York State Department of Health, 565 Corning Tower, ESP, Albany, NY 12237-0679. E-mail:
[email protected]. Received for publication 6 September 2005 and accepted in revised form 20 November 2005. A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion factors for many substances. © 2006 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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that took more than four weeks to heal?” Variables that resulted in statistically significant changes (P ⬍ 0.05) in ⫺2 loglikelihood ratio were retained in the model using the stepwise selection method (16) while holding the demographic variables in the model. RESULTS — Overall, 54% of Puerto Ricans with diabetes checked their feet for sores and irritations every day. In the unadjusted bivariate model, the odds ratio of daily foot self-inspection was 1.36 for the English-dominant group and 1.27 for the bilingual group, and these remained significant (P ⬍ 0.05 to ⬍0.01) as other variables were added. In the final model (Table 1), English-dominant and bilingual groups were twice as likely as the Spanish-dominant group to practice daily foot self-inspection. Those who received professional foot check in the previous year were 1.7–2.3 times more likely to inspect their feet daily than those who did not (P ⬍ 0.01). Additionally, female sex, history of lower-extremity ulcer, daily self-monitoring of blood glucose, and diabetes education were positively and significantly (P ⬍ 0.05) associated with daily foot self-inspection. Relevant interaction effects were examined but none contributed significantly to the model. CONCLUSIONS — Compared with English-dominant and bilingual Puerto Ricans, Spanish-dominant Puerto Ricans were less likely to practice daily foot selfinspection. The results of this study are consistent with studies where poor English skills were linked to suboptimal diabetes self-management behavior among Hispanic subjects (11,12). The findings also support previous studies that reported Hispanic subjects with limited English skills were less likely to actively seek medical and preventive care than Hispanic subjects with a good command of English (17–19). Our data indicate that 52% of English-dominant, 90% of bilingual, and 99% of Spanish-dominant respondents were born outside the mainland U.S. DIABETES CARE, VOLUME 29, NUMBER 3, MARCH 2006
Hosler and Melnik Table 1—Multivariate logistic regression model for daily foot self-inspection among Puerto Ricans with diabetes in New York City Daily foot self-inspection* Variables Language English dominant Bilingual Spanish dominant† Age (years)‡ Sex Male Female† Education Less than 9th grade 9–12 grade Some college or more† History of lower-extremity ulcer Yes No† SMBG daily Yes No† Professional foot check last year 4 times or more 1–3 times None† Diabetes education (ever had) Yes No†
Odds ratio (95% CI)
P value
204 (33.7) 201 (33.2) 201 (33.2) 56.3 ⫾ 14.5
2.00 (1.18–3.40) 1.98 (1.22-3.22) 1.00 1.01 (0.99–1.02)
0.009 0.006
196 (32.3) 410 (67.7)
0.65 (0.44–0.95) 1.00
0.026
226 (39.5) 224 (39.2) 122 (21.3)
1.03 (0.57–1.86) 1.17 (0.71–1.92) 1.00
0.932 0.532
90 (14.9) 516 (85.1)
1.79 (1.04–3.09) 1.00
0.035
307 (50.7) 299 (49.3)
1.52 (1.05–2.22) 1.00
0.028
228 (37.6) 156 (25.7) 222 (36.6)
2.29 (1.43–3.67) 1.68 (1.09–2.60) 1.00
0.001 0.020
393 (66.4) 199 (33.6)
1.68 (1.27–2.09) 1.00
0.013
0.314
Data are n (%) or means ⫾ SD. *Other variables tested and removed when nonsignificant at P ⬍ 0.05 include years since diabetes diagnosis, vision impairment, current diabetes medication, and current smoking; †reference category; ‡interval measure. SMBG, self-monitoring of blood glucose.
Spanish-dominant individuals were less educated, with only 14.6% having completed high school education, compared with 73.4% in English-dominant and 41.7% in bilingual individuals. It is plausible that Spanish-dominant Puerto Ricans not only had a limited command in English but also had lower levels of Spanish literacy and language comprehension. Further study is needed to explain the causal mechanism of language status and self-management behavior, including language concordance between the respondents and their diabetes care providers. Other individuals less likely to practice recommended foot self-management include those who did not receive professional foot inspection in the previous year, those who never had diabetes education, individuals not checking blood glucose daily, males, and those who have not had a lower-extremity ulcer. Similar findings have been reported by studies that examined foot self-care behavior in non-Hispanic, English-speaking populaDIABETES CARE, VOLUME 29, NUMBER 3, MARCH 2006
tions (20,21). The present study also indicates that 36.6% of Puerto Ricans did not receive professional foot care in the previous year at all. This rate is notably higher than the rate for the statewide population with diabetes (26%) (3) Study limitations include self-reporting and possible recall bias. The Centers for Disease Control and Prevention reports, however, that the bias associated with this type of telephone survey is minimal (10,15). The findings of this study support previous recommendations to increase the availability of Spanishspeaking diabetes care providers and/or language translators with training in lowliteracy health communication and cultural competency to improve foot selfinspection among Puerto Ricans (6,8). It is also important that diabetes care providers are in compliance with the recommended standards of foot-specific and overall diabetes care, education, and selfmanagement.
Acknowledgments — This study was supported by funding from the Association of Schools of Public Health (no. S0742-18/19). The study was reviewed and approved by the New York State Department of Health Institutional Review Board for the Protection of Human Subjects (no. 98-2-07).
References 1. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 28 (Suppl. 1):S4 –S36, 2005 2. Waxman R, Woodburn H, Powell M, Woodburn J, Blackburn S, Helliwell P: FOOTSTEP: a randomized controlled trial investigating the clinical and cost effectiveness of a patient self-management program for basic foot care in the elderly. J Clin Epidemiol 56:1092–1099, 2003 3. Centers for Disease Control and Prevention: New York 2004 Module Variable Report: Behavioral Risk Factor Surveillance System. Atlanta, Georgia, Centers for Disease Control and Prevention, 2005 4. Flegal KM, Ezzati TM, Harris MI, Haynes SG, Juarez RZ, Knowler WC, Perez-Stable EJ, Stern MP: Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic Health and Nutrition Survey, 1982–1984. Diabetes Care 14:628 – 638, 1991 5. Melnik TA, Hosler AS, Sekhobo JP, Duffy TP, Tierney EF, Engelgau MM, Geiss LS: Diabetes prevalence among adult New York City Puerto Ricans, 2000. Am J Public Health 94:434 – 437, 2004 6. Brunt MJ, Milbauer MJ, Ebner SA, Levenson SM, Millen BE, Quatromoni P, Chipkin SR: Health status and practices of urban Caribbean Latinos with diabetes mellitus. Ethn Dis 8:158 –166, 1998 7. Von Goeler DS, Rosal MC, Ockene JK, Scavron J, De Torrijos F: Self-management of type 2 diabetes: a survey of lowincome urban Puerto Ricans. Diabetes Educ 29:663– 672, 2003 8. Tucker KL, Bermudez OI, Castaneda C: Type 2 diabetes is prevalent and poorly controlled among Hispanic elders of Caribbean origin. Am J Public Health 90:1288 – 1293, 2000 9. Young BA, Maynard C, Reiber G, Boyko EJ: Effects of ethnicity and nephropathy on lower-extremity amputation risk among diabetic veterans. Diabetes Care 26:495– 501, 2003 10. Centers for Disease Control and Prevention: History of foot ulcer among persons with diabetes-United States 2000 –2002. MMWR Morb Mortal Wkly Rep 52:1098 – 1101, 2003 11. Bernal H, Woolley S, Schensul JJ, Dickinson JK: Correlates of self-efficacy in diabetes self-care among Hispanic adults with diabetes. Diabetes Educ 26:673– 680, 2000 705
Foot self-management in Puerto Ricans 12. Karter AJ, ferrara A, Darbinian J, Ackerson LM, Selby JV: Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes. Diabetes Care 23:477– 483, 2000 13. Lasater LM, Davidson AJ, Steiner JF, Mehler PS: Glycemic control in Englishvs Spanish-speaking Hispanic patients with type 2 diabetes mellitus. Arch Intern Med 161:77– 82, 2001 14. Brown AF, Gerzoff RB, Karter AJ, Gregg E, Safford M, Waitzfelder B, Beckles GLA, Brusuelas R, Mangione CM, the TRIAD Study Group: Health behavior and quality of care among Latinos with diabetes in managed care. Am J Public Health 93:
706
1694 –1698, 2003 15. Centers for Disease Control and Prevention: Behavioral Risk Factor Surveillance System Operational and User’s Guide. Atlanta, Georgia, Centers for Disease Control and Prevention, 2005. Available from //www.cdc.gov/brfss/pdf/userguide.pdf. Accessed on 5 August 2005 16. Kleinbaum DG, Kupper LL: Applied Regression Analysis and Other Multivariable Methods. North Scituate, MA, Duxbury Press, 1978 17. Schur C, Albers LA: Language, socioeconomics, and health care use of Hispanic adults. J Health Care Poor Underserved 7:140 –158, 1996 18. Derose KP, Baker DW: Limited English
proficiency and Latinos’ use of physician services. Med Care Res Rev 57:76 –91, 2000 19. Fiscella K, Franks P, Doescher MP, Saver BG: Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care 40:52–59, 2002 20. Pollock RD, Unwin NC, Connolly V: Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract 64:117–122, 2004 21. Bell RA, Arcury TA, Snively BM, Smith SL, Stafford JM, Dohanish R, Quandt SA: Diabetes foot self-care practices in a rural triethnic population. Diabetes Educ 31:75– 83, 2005
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