Acculturation and diabetes care utilization among Asian Americans with diabetes Open Access

Abstract

In the United States, diabetes and its complications cause significant morbidity and mortality and are associated with substantial healthcare costs for the healthcare system and society. Although effective treatments for diabetes exist, unmanaged diabetes remains a major challenge for many individuals, healthcare providers, and insurers. Even though unmanaged diabetes is common and can occur in all racial groups, disparities exist in diabetes care, especially in Asian Americans. Acculturation is a multidimensional socialization process in which individuals from one culture adapt components of another culture. Acculturation can be associated with the prevalence of diabetes among Asian Americans in the United States. There is also evidence linking acculturation to better diabetes care. Therefore, this study explored acculturation’s role in diabetes prevalence and diabetes care utilization among Asian Americans in the United States. A conceptual model was developed drawing on the Anderson Behavioral Model for Health Care Utilization. This model had three main components: predisposing, enabling, and need-for-care factors. Another component was personal health behaviors. This study used 2013-2018 California Health Interview Survey (CHIS) data. We restricted our sample to 11,313 adults who self-reported as Asians. Then, we included 1,423 respondents who had diabetes in our analytic sample. This was the first population-based study of the association between acculturation and diabetes prevalence and diabetes care utilization among Asian-American adults in California. No significant association was found between acculturation and diabetes prevalence after adjusting for covariates and personal health behaviors. However, there was a significant association between acculturation and medical plan for diabetes. Higher levels of acculturation were associated with increased use of diabetes care plans among Asian Americans with diabetes, controlling for covariates and personal health behaviors. Acculturation was not significantly associated with foot or eye examinations, hemoglobin A1C checks, and flu shots among Asian-American adults with diabetes. With and without personal health behaviors variables introduced, the results were similar. Acculturation picked up on mechanisms outside of what was measured through personal health behaviors. The study could help develop future health interventions applicable to Asian Americans with diabetes for better diabetes care use.

Table of Contents

Introduction 1

Literature Review 4

Diabetes in Asian Americans 4

Acculturation and prevalence of diabetes among Asian Americans 5

Acculturation and use of diabetes care among Asian Americans with diabetes 6

California 7

Methods 9

Theoretical Framework 9

Figure 1: Conceptual model 10

Focal Relationships 10

Covariates 12

Hypotheses 13

Dataset 14

Analytic sample derivation 15

Figure 2: Sample derivation flowchart 17

Measurement 18

Table 1: Constructs measures to estimate the association between acculturation and diabetes care utilization 20

Analytic strategy 22

Sensitivity Analyses 23

Results 24

Results from Descriptive Analyses 24

Sample Characteristics of all Asian Americans 24

Table 2: Weighted sample characteristics of all Asian Americans 24

Sample Characteristics of Asian Americans with diabetes 25

Table 3: Weighted sample characteristics of Asian Americans with diabetes 26

Results from Regression Analyses 28

Association between acculturation and prevalence of diabetes among Asian Americans 28

Table 4: Unadjusted logistic regression to estimate the association between acculturation and prevalence of diabetes among Asian Americans 28

Table 5: Adjusted logistic regression to estimate the association between acculturation and prevalence of diabetes among Asian Americans 29

Association between acculturation and use of diabetes care among Asian Americans with diabetes 29

Table 6: Unadjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes 31

Table 7: Adjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes, adjusting for all covariates 31

Table 8: Adjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes, adjusting for all covariates and personal health behaviors 33

Results from Sensitivity Analyses 35

Discussion 37

Key findings 37

Implications 39

Limitations and strengths 40

Future research 41

Conclusion 42

Appendix 43

Supplemental Table 1: Adjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes, adjusting for predisposing and enabling characteristics 43

Supplemental Table 2: Weighted sample characteristics of all Asians by three acculturation levels 44

Supplemental Table 3: Weighted sample characteristics of Asians with diabetes by three acculturation levels 45

Supplemental Table 4: Unadjusted logistic regression to estimate the association between acculturation and prevalence of diabetes among Asian Americans 47

Supplemental Table 5: Adjusted logistic regression to estimate the association between acculturation and prevalence of diabetes among Asian Americans 47

Supplemental Table 6: Unadjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes 48

Supplemental Table 7: Adjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes, adjusting for all covariates 48

Supplemental Table 8: Adjusted logistic regression to estimate the association between acculturation and diabetes care utilization among Asian Americans with diabetes, adjusting for all covariates and personal health behaviors 50

References 53

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Health Policy and Management
Degree	M.S.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Diabetes Acculturation Care utilization Asian Americans
Committee Chair / Thesis Advisor	Chehal, Puneet Kaur, Emory University
Committee Members	Wilk, Adam S, Emory University Shah, Megha, Emory University

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