MAREN J. COFFMAN, P H D , R N , CYNTHIA K . NORTON, MSN, ANP-BC, LARA BEENE, M F A

Abstract: Purpose: This study examined the extent of undetected and untreated type 2 diabetes in a sample of recent Latino immigrants, and looked at the relationships among diabetes symptoms, blood glucose level, diabetes knowledge, health literacy level, and riealth care use. Methods: Using a descriptive and correlational design, 144 Latino adults were interviewed. Results: Many participants had diabetes and reported symptoms, but they were not aware of the disease and were not receiving adequate health care. Lack of diabetes knowledge, low health literacy, and barriers to health care prevented appropriate symptom responses. Conclusions: Interventions that teach health literacy skills and diabetes symptom interpretation may improve health care use. Key Words: Type 2 Diabetes, Diabetes Symptoms, Health Care Use, Health Literacy

DIABETES SYMPTOMS, HEALTH LITERACY, AND HEALTH CARE U S E IN ADULT LATINOS WITH DIABETES RISK FACTORS

A

ccording to the National Center for Health Statistics (2006), nearly 15% of Latino adults in the U.S. have type 2 diabetes, compared to 9% of non-Hispanic whites. Further, Latinos are more likely to suffer from serious diabetes complications, including amputations and retinopathy (Center for Disease Control and Prevention [CDC], 2011) due, in part, to inadequate diabetes education and lack of access to preventive health care. The Symptom Interpretation Model (SIM) explains individual reactions to the symptom experience, and the reasoning and behavioral responses that result (Teel, Meek, McNamara, & Watson, 1997). According to the model, when diabetes symptoms occur, an individual with adequate symptom experience, diabetes knowledge, and health literacy will be able to recognize, interpret, and respond to the symptoms. Health care services can then be accessed, leading to improved blood glucose control. Inaccurate symptom interpretation, however, may lead individuals to disregard symptoms, self-treat, or delay professional health care. According to the SIM, the symptom experience includes a) sensory awareness of symptoms, b) interpretation of symptoms based on identification, knowledge, and reasoning, and c) the actions and behaviors that follow

Maren J. Coffman, PhD, RN, teaches at the University of North Carolina at Charlotte School of Nursing located at 9201 University City Boulevard, Charlotte, NC 282230001. Dr. Copnan may be reached at: (704)687-7979; [email protected]. Cynthia K. Norton, MSN, ANPBC, works at Central Carolina Medical Associates. Lara Beene, MFA, works at Brigham Young University. Journal of Cultural Diversity • Vol. 19, No. 1

(Teel et al., 1997). Symptoms, defined as the "subjective, multidimensional awareness of an internal system disturbance to which meaning has been assigned" (Teel et al., p. 176), are interpreted and acted upon based on cultural beliefs and personal factors. For Latinos, symptom awareness may be based on culturally defined explanatory models rather than biomédical models. Latinos tend to explain diabetes based on their symptoms, while non Hispanic whites use biophysical explanations (Caban & Walker, 2006). For example, in one study, Mexican American women with type 2 diabetes described the disease as confusing and silent. To them, a lack of discernible symptoms indicated that the disease was either absent or under control (Alcozer, 2000; O'Connell et al., 1984; Phinney & Wallhagen, 2003). Conversely, the presence of diabetes symptoms was viewed as an indication that the disease had advanced or that complications were present'(Alcozer, 2000). Once there is awareness, the symptom experience is interpreted. According to Teel et al. (1997), symptoms are interpreted through a personal, cultural lens that influences associated meanings. Appropriate interpretation of symptoms is based on knowledge structures, which are exemplars or prototypes developed from past experiences. Inadequate diabetes knowledge and understanding in Latinos (Garcia, Villagomez, Brown, Kouzekanani, & Hanis, 2001) may inhibit appropriate development of knowledge structures. Thus, Mexican Americans who have type 2 diabetes may incorrectly interpret serious symptoms as benign (Garcia, 2005). Further, they may make judgments without checking their blood glucose, even when they have blood glucose monitors and supplies (Brown, Upchurch, Garcia, Barton, & Hanis, 1998). In one study of symptoms in Spring 2012

Mexican Americans with type 2 diabetes, though participants had markedly elevated glucose levels, only 50% reported symptoms and half did not think the symptoms were serious (Brown et al, 1998). In another study of a similar group, 97% of participants self-treated headaches with over-the-counter medication without recognizing the headaches as a possible diabetes symptom (Garcia, 2005). Since interpretation of symptoms is often inaccurate (Diamond, Massey, & Covey, 1989; O'Connell, Hamera, Schorheide, & Guthrie, 1990), ongoing blood glucose monitoring and professional assessment are essential. The tendency to interpret symptoms without obtaining biophysical data may be related to limited health literacy. Low health literacy is defined as inability to read, comprehend, and interpret health related information and written materials (Nielson-Bohlman, Panzer, & Kindig, 2005). Low health literacy in individuals with diabetes has been associated with inadequate diabetes knowledge (Gazmararian, Williams, Peel, & Baker, 2003), poor glycémie control (Schillinger et al., 2002), and increased diabetes related complications (Schillinger et al., 2003). As many as 62% of Latinos tested in Spanish have been found to have low or marginal health literacy (Paasche-Orlow, Parker, Gazmararian, NielsonBohlman, & Rudd, 2005). According to the SIM, symptom appraisal is followed by a decision on action (Teel et al., 1997). Responses to symptoms may include no action, self-treatment, care from an alternative provider, or care from a professional medical provider. Self-treatment of diabetes symptoms is common in Latinos (Williams, Baker, Parker, & Nurss, 1998). In fact, in Garcia's study (2005), the most common response to symptoms in Latinos with diabetes was doing nothing or making lifestyle changes such as resting or dietary adjustment. Alternative care options may include home remedies (Garcia, 2005), or consultations with herbalists, curanderos, or folk healer s (Caban & Walker, 2006). Alternative care services are often used in conjunction with professional medical care (Caban & Walker, 2006). Latinos are less likely than others to get consistent professional medical care (Nelson, Chapko, Reiber, & Boyko, 2005). However, if symptoms are interpreted as severe or they interfere with daily activities, professional medical care is usually sought (Dodd et al., 2001; Larkey, Hecht, Miller, & Altorre, 2001). Latino adults, especially unauthorized migrants working in low-income jobs, often do not have health insurance (Doty & Holmgren, 2006). Further, they are less likely than other U.S. residents to have a primary care provider (Agency for Healthcare Research and Quality, 2005). As a result of low access to health care services. Latinos with diabetes may be undiagnosed or under treated; however, the extent of the problem is unknown. The study reported here therefore examined the extent of undetected and untreated diabetes in a sample of recent Latino immigrants with diabetes risk factors, and looked at the relationships among diabetes symptoms, blood glucose level, diabetes knowledge, health literacy levels, and health care use using the SIM as a framework. METHODS Setting and Sample A convenience sample of 150 adult, Spanish speaking Latinos with either self-reported type 2 diabetes or one of two diabetes risk factors were interviewed for this descriptive correlational study. Participants were recruited in one Latino service agency, one faith-based community education center, and several Latino health fairs in a large Southeastern U.S. city. Self-reported type 2 diabetes was defined as a diagnosis by a physician after age 18. Diabetes risk factors included age 45 or greater, or a body mass index of 25 or greater. Exclusion criteria included apparent pregnancy. Approval Journal of Cultural Diversity • Vol. 19, No. 1

for the research was granted by the University Institutional Review Board. Recruitment consisted of verbal invitation and advertisements in a local Spanish language newspaper. Before data collection took place, the study was explained and consent forms were signed. Data Collection Data were collected by two research assistants trained in confidentiality, recruitment, and data collection procedures. Because of the potential for low reading literacy, structured interviews were used. The data collected included height, weight, and glycosylated hemoglobin (HbAlc) obtained via finger stick. In addition, participants completed a questionnaire on background and diabetes data, and instruments to measure diabetes symptoms, diabetes knowledge, health literacy, and health care use. Except for the health literacy measure, which was completed without assistance, questionnaires were read to each participant. Participants who had HbAlc levels above 7.0 were informed of their risk for diabetes and encouraged to see a health care provider. Participants were given a list of free and low cost health care providers and $10 compensation for their time. Demographic data included age, gender, nationality, years living in the United States, years of education, household income, health insurance, diabetes self-report, years since diagnosis, and other diabetes information. Diabetes symptoms The Diabetes Symptom Self-care Inventory (DSSCI) was used to measure diabetes symptoms (Garcia, 2005). The survey is based on the SIM and includes ten symptoms specific to diabetes are listed on the DSSCI. Since several symptoms on the checklist are related to advanced diabetes complications, five additional symptoms indicative of early diabetes were added. Participants were asked to indicate how often they had experienced the symptom over the previous 2 weeks from 1, rarely to 4, all the time. The perceived severity of each symptom experienced was measured on a scale from 1, not serious to 4, very serious. The tool has demonstrated reliability and validity and is available in Spanish. Cronbach's alpha for this study was .85. Diabetes knowledge Knowledge of diabetes was measured using the Diabetes Knowledge Questionnaire (DKQ-24), a 24-item test that yields one summary score (Garcia et al., 2001). Each question poses a statement regarding diabetes etiology, care, or treatment. Participants are asked to give a single response - "true," "false," or "I don't know." One point is given for each correct response and respondents are instructed to not guess. The instrument is available in Spanish and has been used with Mexican Americans; Cronbach's alpha was .84 in prior research and was .88 in this study. Health literacy The Short Test of Functional Health Literacy in Adults (S-TOFHLA) Spanish version was used to assess health literacy. This instrument uses a modified cloze method in which one word is removed from a sentence. The blank is followed by four word options with one correct response. The test is scored by summing the items answered correctly. Each participant is given 7 minutes to complete the test independently; those unable to read are given a score of 0. Established cut-off points are 0 to 16, inadequate; 17 to 22, marginal; and 23 to 36, adequate (Baker, Williams, Parker, Gazmaraian, & Nurss, 1999). The test is available in Spanish, has been used extensively with Latinos, and has been validated as a reliable measure of health literacy. Cronbach's alpha was reported as 0.98 in prior research (Nurss, Parker, Williams, & Baker, 1995). Health care use A revised version of the Immigrant Use of Health Care Scale assessed personal use of health care services (Coffman, Shobe, Dmochowski, & Fox, 2007). This 10-item Likert-type instrument was designed to assess the number of health care contacts over the previous year. In the current study, items were based on American Spring 2012

Diabetes Association (2009) treatment standards and included frequency of use of medical exams, hospital services, screenings, mental health services, laboratory, and medical procedures. Scores can range from 0 to 20, with a low score indicating no health care use and 20 indicating significant use. Cronbach's alpha for this study was .80. Diabetes Glucose level was assessed by glycosylated hemoglobin (HbAlc), which provides an average sum of blood glucose levels over the previous 3 months. A portable in-time meter was used to obtain the HbAlc value. Though not used as a diagnostic tool for diabetes, HbAlc has been shown to be a reliable screening tool (Rohlfling et al., 2000) and it does not require fasting. Probable diabetes was defined as HbAlc above 7.0.

participants were predominantly female (78.5%), and their mean age was 43.6 years (SD = 12.6). Most had immigrated to the U.S. in the previous 10 years from Mexico (57.6%), or Central (13.9%) or South America (23.6%). A high percentage had no health insurance (81.3%). Their mean number of years of education was 11.0 (SD = 4.8); nearly half (47%) had not completed high school. Financial resources were limited, with 78.7% of participants reporting household incomes less than $30,000 (see Table 1). Undetected and untreated type 2 diabetes was a significant problem in this sample. Eighteen participants (12.5%) self-reported diabetes, and an additional 17 (13.5%) had unknown but probable type 2 diabetes (HbAlc > 7.0). The mean HbAlc level in those who self-reported type 2 diabetes was 9.3% (SD = 2.1) with a range from 6.1% to 13.0%. The group with unknown but probable type 2 diabetes had a mean HbAlc of 8.2% (SD =1.1) with a range from 7.0% to 10.2%. Another 19 (15%) had HbAlc levels between 6.5% and 6.9%. The mean body mass index (BMI) for participants was 30.7 (SD ^ 5.3). Most of the participants who self-reported type 2 diabetes had had the disease for less than 5 years (66%). Of those with diagnosed diabetes, 12 took oral agents to control the disease, 2 reported controlling the disease with diet, and 4 reported no treatment. Nearly 70% (68.8%),of the sample and 61 % of those with self-reported diabetes did not have a primary care provider. Of the 18 participants who self-reported diabetes, half (n = 9) reported that they never checked their blood glucose, and only 3 reported home glucose monitoring at least daily. Finally, only 6 of the 18 participants who self-

Data Analysis The data were entered into SPSS and cleaned by double checking and visual examinations of box plots and scatter plots. Categorical data were summarized using frequency tables, and continuous data were assessed using means and standard deviations. Associations were assessed using Pearson's correlations. Multiple regression was used to investigate the extent to which the other variables predicted diabetes knowledge and health care use. Residual diagnostics (scatterplots and qqplots) were performed to examine possible violations of multiple regression model assumptions. Results Six participants who were interviewed did not fully meet the inclusion criteria, leaving a final sample of 144. The

Table 1. Demographic Characteristics of Sample (N=144) > Characteristic

n

P

M

••

' . - , ; • ; "[SD •

Age

'

' - , •

' • '

,

•

-

.

43.6

12.6

Years in the U.S.

9.8

8.8

Years of education

11.0

4.8

30.7

5.3

Gender Male Female

31 113

21.5% 78.5%

Nationality Mexico Central America South America Other

83 20 34 7

57.6% 13.9% 23.6% 4.9%

Household income Less than $20,000 $20,000 to $30,000 Over $30,000

81 30 30

57.4% 21.3% 21.3%

Medical insurance None Private Medicare / Medicaid

117 27 0

81.3% 18.8% 0

Diabetes status Self-report Probable diabetes (HbA1c> 7.0)

18 17

12.5% 13.5%

Body Mass Index (BMI)

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'

-

•

-

•

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Table 2. Means and Standard Deviations for the Diabetes Symptom Self-Care Inventory (DSCCI) Frequency M

n

Seriousness

SD

M

SD

Frequent headaches

83

2.0

1.0

1.7

.7

Intense thirst

48

1.5

.9

1.6

.6

Excessive urination

34

1.5

1.0

1.7

.8

Extreme fatigue

66

1.8

1.1

1.6

.7

Numbness or tingling of extremity

22

1.1

.4

1.4

.6

Dizziness

42

1.4

.8

1.8

.7

Shaky or nervous

52

1.6

.9

1.8

.7

Delayed wound healing

27

1.3

.7

1.7

.7

Blurry vision

47

1.5

.7

1.7

.7

Excessive hunger

46

1.5

.9

1.6

.6

Weakness

49

1.6

.9

1.7

.7

Sweating

30

1.3

.8

1.6

.7

Faint or lightheaded

53

1.7

1.0

1.8

.7

Nausea

43

1.5

.9

1.8

.7

Weight loss ( = .03) were significantly associated with greater health care use. There was no significant relationship between diabetes symptoms and health care use, though the relationship between diabetes knowledge and health care use was near significance (ß = .15,/> = .06; see Table 3). DISCUSSION According to the Symptom Interpretation Model (Teel et al., 1997), effective diabetes self-management begins with the ability to recognize and understand symptoms. Also, some knowledge of the disease may be needed to accurately interpret and categorize symptoms. In fact, diabetes knowledge is associated with education level (Rothman, Malone, Bryant, Bryant, & Wolfe, 2006: Williams et al., 1998), participation in diabetes education classes, and improved diabetes control (Bautista-Martinez et al., 1999; Rothman et al., 2006). Knowledge of how to interpret and act on diabetes symptoms may influence long-term diabetes outcomes. In this study, 24% of participants either self-reported diabetes or had unknown but probable diabetes. Most of these participants did not have a primary care provider, and many of those with known diabetes did not have a medical home, suggesting that their disease was not being adequately monitored by a medical professional. None of the participants with diabetes were on insulin, and consistency in obtaining and taking oral medications was a concern. Few participants performed home glucose monitoring or had taken formal diabetes education classes. As a result, these participants may not have enough information to accurately interpret diabetes symptoms. Prior research suggests that individuals are more likely to seek timely health care if symptoms are perceived as severe and threaten functional status (Larkey et al., 2001). In this study, however, symptom experience and severity did Journal of Cultural Diversity • Vol. 19, No. 1

not result in health care use. The symptoms reported most frequently and perceived as most serious were somewhat vague and may have been the result of other chronic illnesses, depression, or stress. Latinos who knew they had been diagnosed with diabetes were more likely to seek health care than those who experienced symptoms but had not been diagnosed. This suggests that the decision to ignore symptoms may be due to insufficient understanding of diabetes symptoms. Adequate health literacy may help Latinos understand, interpret, and act on diabetes symptoms. Some authors have suggested that adequate health literacy leads to diabetes control, as evidenced by lower HbAlc levels (Gazmararian et al., 2003; Rothman et al., 2006). Though there was no correlation between health literacy and diabetes knowledge in this study, years of education were associated with diabetes knowledge. Further, having adequate health literacy predicted health care use, which presumably leads to better diabetes management and improved diabetes control. The relationship between health literacy and health care use is complex. Though in this study, participants with higher health literacy levels used more health care services, this should be interpreted with caution. Because participants in the study were largely uninsured and had disease related risk factors, they could be over using emergency care and other hospital services, and under using ambulatory and preventive services. In this study, many participants experienced significant health care barriers including lack of health insurance, recent immigration status, and low household income. In a prior study (Chan, Krishel, Bramwell, & Clark, 1996), 80% of Latinos who sought emergency care did so due to perceptions of lower cost than primary care. That study also suggested that Latinos who fear deportation view the emergency department as a safe health care option. When there are barriers to health care access. Latinos with diabetes may not understand the need for primary care and see the emergency department as their only health care option. Unfortunately, this may result in increased diabetes related complications and need for more costly long term health care services. In fact, lack of health insurance has been found to significantly reduce the use of preventive care, contribute to delays in seeking care, and increase complications from chronic diseases (Doty & Holmgren, 2006). This study included a relatively small convenience sample of Latino immigrants. Further, since Latinos with both diabetes and diabetes risk factors participated, results cannot be directly compared to samples made up only of participants with diagnosed diabetes. Nevertheless, the study points to the need for culturally sensitive diagnostic, health promotion, disease management, and educational services for Latinos. Conclusions Little is known regarding how diabetes symptoms are interpreted in this population (Garcia, 2005). If Latinos are using past diabetes symptom experiences to make decisions, they may continue to interpret symptoms incorrectly. This could lead to diabetes related complications, increased health care costs, and poor outcomes. Further research is needed to understand how symptom interpretation influences behaviors and long term outcomes. Health care practitioners need to educate Latinos about their diabetes symptoms. Further, since their low health literacy may contribute to poor symptom interpretation. Latinos with diabetes should be screened for health literacy. Those with inadequate health literacy may need support getting preventive care, testing blood glucose, finding primary care providers, and information on use of the emergency department.

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The number of participants in this study who had an opportunity to participate in diabetes education courses suggests that culturally relevant classes need to be more readily available to this population. Adequate diabetes education that focuses on symptom awareness would help Latinos with diabetes make better decisions regarding diabetes self-management and symptom interpretation. Diabetes education could be made available through existing social service programs, primary care providers, or publically-funded health care clinics. These providers could then offer ongoing diabetes education and support. One element of diabetes education for Latinos should focus on symptom management. Nurses and educators need to give Latinos with diabetes the opportunity to describe symptoms and symptom responses. The educator could then reinforce correct responses and redirect inappropriate behaviors. Further, educational materials need to be written at reading levels for individuals with low literacy, consider cultural variations, and be available in Spanish. Education alone is insufficient to control diabetes. To build knowledge structures related to diabetes, low income Latinos with diabetes need access to primary care home. Affordable community-based health care addresses the comprehensive needs of vulnerable Latinos with diabetes are needed. Since the strongest predictors of health care use is insurance coverage (DeNavas-Walt, Proctor, & Mills, 2003), affordable health insurance programs need to be more widely available. REFERENCES Agency for Health Care Research and Quality. (2005). National health care disparities report. (AHRQ Publication No. 06-0017). Rockville, MD: Author. Alcozer, R (2000). Secondary analysis of perceptions and meanings of type 2 diabetes among Mexican American women. The Diabetes Educator, 26(5), 785-793. Baker, D. W., Williams, M. V., Parker, R. M., Gazmararian, J. A., & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education and Counseling, 38(1), 33-42. Bautista-Martinez, S., Aguilar-Salinas, C. A., Lerman, I., Velasco, R., Castellanos, E., Zenteno, E., et al. (1999). Diabetes knowledge and its determinants in a Mexican population. The Diabetes Educator, 25(3), 374-381. Brown, S. A., Upchurch, S., Carcia, A. A., Barton, S. A., & Harüs, C. L. (1998). Symptom-related self-care of Mexican Americans with NIDDM: Preliminary findings of the Starr County Diabetes Education Study. The Diabetes Educator, 24(3), 331-339. Caban, A., & Walker, E. A. (2006). A systematic review of research on culturally relevant issues for Hispanics with diabetes. The Diabetes Educator, 32(4), 584-595. Centers for Disease Control and Prevention. (2011). National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Pre-Diabetes in the United States. Accessed October 31, 2011. Retrieved from http://www.cdc.gov/diabetes/pubs Chan, T. C, Krishel, S. J., Bramwell, K. J., & Clark, R. R (1996). Survey of illegal immigrants seen in an emergency department. Western Journal of Medicine, 164, 212-216. Coffman, M. J., Shobe, M. A., Dmochowski, J., & Fox, S D. (2007). Health care access and utilization among Latino immigrants. Hispanic Health Care International, 5(2), 73-80. DeNavas-Walt, C, Proctor, B. D., & Lee, C. H. (2005). Income, poverty, and health insurance coverage in the U.S.: 2004 (P60-229J. Washington, DC: U.S. Census Bureau. Diamond, E. L., Massey, K. L. & Covey, D. (1989). Symptoms awareness and blood glucose estimation in diabetic adults. Health Psychology, 8(1), 15-26 Dodd, M., Janson, S., Facione, N., Fawcett, J., Froelicher. E. S.. Humphreys. T.. et al. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33(5), 668-676. Doty, M. M., & Holmgren, A. L. (2006). Health care disconnect: Gaps in coverage and care for minority adults. The Commonwealth Fund. Retrieved on August 15, 2006 from http:/ / www.cmwf.org/usr_ doc/941_Doty_hIt_care_disconnect_disparities_issue_bri.pdf. Journal of Cultural Diversity • Vol. 19, No. 1

Garcia, A. A. (2005). S)imptom prevalence and treatments among Mexican Americans with type 2 diabetes. The Diabetes Educator, 31(4), 543-554. Garcia, A. A., Villagomez, E., Brown, S. A., Kouzekanani, K. & Hanis, C. (2001). Development of the Spanish-language diabetes knowledge questionnaire. Diabetes Care, 24(1), 16-21. Gazmararian, J. A., Williams, M. V, Peel, J. & Baker, D. (2003). Health Uteracy and knowledge of chronic disease. Patient Education and Counseling, 51, 267-275. Larkey, L. K., Hecht, M. L., Miller, K., & Alatorre, C. (2001). Hispanic cultural norms for health-seeking behaviors in the face of symptoms. Health Education & Behavior, 28(1), 65-80 National Center for Health Statistics. (2006). Health, United States, 2006, with chartbook on trends in the health of Americans (DHHS Publication No. ADM 76-641496). Washington, DC: U.S. Government Printing Office. Nelson, K. M., Chapko, M. K., Reiber, G., & Boyko, E. J. (2005). The association between health insurance coverage and diabetes care: Data from the 2000 Behavioral Risk Factor Surveillance Survey. Health Services Research, 40(2), 361-372. Nielson-Bohlman, L., Panzer, A., & Kindig, D (2005). Health literacy: A prescription to end confusion. Washington DC: National Academies Press. Nurss, J. R., Parker, R. M., Williams, M. V., & Baker, D. W. (1995). TOFLHA, Test of Functional Health Literacy in Adults. (2"'' Ed.). Snow Camp, NC: Peppercorn Books. O'Connell, K. A., Hamera, E. K., Knapp, T. M., Cassmeyer, V. L., Eaks, G. A., & Fox, M. A. (1984). Symptom use and self-regulation in type n diabetes. Advances in Nursing Science, 6(3), 19-28. O'Connell, K.A., Hamera, E.K., Schorfheide, A., & Guthrie, D. (1990). Symptom beliefs and actual blood glucose in Type II diabetes. Research in Nursing and Health, 13(3), 145-151. Paasche-Orlow, M. K., Parker, R. M., Gazmararian, J. A., Nielson-Bohlman, L. T., & Rudd, R. R. (2005). The prevalence of limited health literacy. Journals of General Internal Medicine, 20, 175-184. Phinney, A., & Wallhagen, M. (2003). Recognizing and understanding the symptoms of type 2 diabetes. Clinical Journal of Nursing Research, 35(4), 108-124. Rohlfling, C. L., Littie, R. R., Wiedmeyer, H., England, J. D., Madsen, R., Harris, M. I., et al. (2000). Use of Ghb (HbAlc) in screening for undiagnosed diabetes in the U.S. population. Diabetes Care, 23(2), 187-191. Rothman, R. L., Malone, R., Bryant, B., Wolfe, C, Padgett, P, DeWalt. D.A. et al. (2006). The Spoken Knowledge in Low Literacy in Diabetes Scale: A diabetes knowledge scale for vulnerable patients. The Diabetes Educator, 31(2), 215-224. Schillinger, D., Grumbach, K., Piette, J., Wang, R, Osmond, D., Daher, C, et al. (2002). Association of health Uteracy with diabetes outcomes. JAMA, 288(4), 475-482. Schillinger, D., Piette, J., Grumbach, K., Wang, R, Wilson, C, Daher, C, et al. (2003). Closing the loop: Physician communication with diabetic patients who have low health Uteracy. Archives of Internal Medicine, 163(1), 83-90. Teel, C. S., Meek, P., McNamara, A. M. & Watson, L. (1997). Perspectives unifying symptom interpretation. Image: Journal of Nursing Scholarship, 29(2), 175-181. WilUams, M. V, Baker, D. W., Parker, R. M., & Nurss, J. R. (1998). Relationship of functional health Uteracy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Archives of Internal Medicine, 158(2), 166-172. This work was supported by funds provided by the University of North Carolina at Charlotte, Elinor Brooks Caddell Faculty Scholar Award, and Sigma Theta Tan Gamma Iota chapter.

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