A Cross-Sectional Study of Depressive Symptoms and Diabetes Self-Care in African American and Hispanics/Latinos with Diabetes: The Role of Self-Efficacy

Background: Racial/ethnic minority groups experience a greater diabetes burden with a documented prevalence rate two times that of their non-Hispanic white counterpart of similar age. These underrepresented groups also disproportionately experience compromised profiles of glycemic control, higher rates of diabetes-related microvascular complications, and elevated rates of disease-related mortality. While it is known that bio-psychosocial factors play a role in behavioral management of diabetes there is urgent need to identify the psychological factors and potential mechanistic intermediaries given low engagement levels across multiple diabetes self-care behaviors among low socioeconomic populations and ethnic/racial minorities. Similarly, it is not known if the same psychological factors are significantly associated with diabetes self-management across ethnic minority groups (Hispanic, African American). The aims of this study are: (1) to examine the association of depressive symptoms and diabetes self-care behaviors in low-income African American and Hispanic/Latino patients with type 2 diabetes, and (2) to test whether diabetes-related self-efficacy mediates the relationship between depression and diabetes self-care in these minority patients.

Methods: We analyzed self-report data collected from Africa American and Hispanic/Latino patients with type 2 diabetes aged ≥18 years who were enrolled in a diabetes self-management intervention at Federally Qualified Health Center primary care clinics. The Summary of Diabetes Self-Care Activities was used to assess domains of healthy eating, physical activity, blood sugar testing, foot care and smoking. Depressive symptoms were captured using the 9-item Patient Health Questionnaire. The Diabetes Empowerment Scale-Short Form was used to assess diabetes-related psychosocial self-efficacy. We used the Baron and Kenny regression technique and Sobel testing across mediational testing procedures.

Results: Baseline characteristics of this sample were: mean age of 53 years (SD=12.3); 68% female; 54% African American; 74% with income <$20,000. Participants reported the highest diabetes self-care engagement rates for oral medication use (6.2 days/week) and lowest for physical activity (2.5 days/week). In the African-American subgroup, depressive symptoms were found to be negatively associated with the self-care domains of general (β = -0.032; p = 0.01) and specific diet (β = -0.020; p = 0.02), physical activity (β = -0.046; p < 0.01), and glucose monitoring (β = -0.020; p = 0.01); a trend toward significance was evident for the self-care domain of foot care (β = -0.013; p = 0.09). Only specific diet was significantly associated with depressive symptoms in the Hispanic/Latino subgroup (β = -0.030; p < 0.01). In African Americans, self-efficacy (p=0.02) served a mediational role in the relationship between depression (p=0.22) and foot care.

Implications: The psychological construct of self-efficacy, as measured by the Diabetes Empowerment Scale, was salient as a mediator of the relationship between depression and one self-care activity within the African American group, but was not found to be a mediator within the Hispanic group. Additional exploration with a larger sample is warranted to better understand self-efficacy and other potential mechanistic intermediaries linking depressive symptoms to self-care practices. In clinical practice, diabetes education may consider inclusion of components to build self-efficacy related to diabetes self-care, especially among African American patients.