Health Care Decision Making Among African Americans Diagnosed with Diabetes and Depression

Background and Purpose: Staggering health care inequities exist in medical services for African Americans (Institute of Medicine, 2002). Discrimination in diagnosis, facility accessibility, treatment type, length of care, and follow-up care remain daily occurrences (Williams & Mohammed, 2013). Empowering low-income African Americans to manage comorbid Type II diabetes and depression that makes sense culturally remains an important, effective approach to improve health outcomes for clinics serving urban communities (Gavin & Wright, 2007). Yet, real-world health settings remain challenged by meaningful service targets for persons learning how to re-engage in managing personal health conditions, especially among African American clients. Changes must be made in service provision to improve health equity. Questions remain about how clinics and social workers will support clients to participate in a patient- centered approach to care when persons do not have experience in having his or her voices heard. The aims of the present study were to understand how formally homeless African Americans make health care decisions when diagnosed with diabetes and depression.
Methods: Participants were recruited from an urban county clinic in California that specializes in providing treatment to homeless and vulnerable populations. The clinic offers integrated medical and psychiatric services. Semi-structured face-to-face interviews were conducted with 42 African American men and women who were older than 18 years of age, reported previous homelessness for at least three years, received a diagnosis of diabetes from the clinic, and had recently enrolled in Medicaid. The semi-structured interview questions were standardized. Participants were asked open-ended questions such as: “What are reasons you seek health care?” Questions elicited a narrative-style response and the interviewer was instructed to clarify responses when appropriate. All interviews lasted between 1 – 1.5 hours, audio-taped, and transcribed verbatim. The interview data were coded into meaningful categories or themes and analyzed using ATLAS.ti (version 7.0).

Results: Participant ages ranged between 28 and 71 years (mean age = 53.5 years). Women represented the majority of the sample (n = 23; 55%). On average, reported annual incomes were less than $9,400 and more than half were high school graduates (55%). Analyses revealed three major themes influenced decision making regarding attending to health care needs: 1) whether health condition information was provided electronically by the clinic, therapist, or physician; 2) provided additional support on dietary choices when oral health was poor; and 3) availability of faith community and knowledge of bible passages to offer support when decisions about health care are made. Most participants expressed a need for treatment professionals to agree on a treatment single message in order to make informed decisions about personal health.

Conclusions: Most participants engaged in the decision making process to manage personal health. Findings suggest that incorporating a form of Telehealth electronics, oral health, and a unified message from treating professionals represent a promising strategy to support health decision-making. Future studies are needed to investigate additional strategies that social workers in community clinics might use to improve involvement in the treatment process that, in turn, improves engagement of dual chronic conditions.