University of South Florida Scholar Commons Graduate Teses and Dissertations Graduate School 10-16-2009 Living with Sugar: Socioeconomic Status and Cultural Beliefs About Type 2 Diabetes Among Afro-Caribbean Women Chrystal A.S Smith University of South Florida Follow this and additional works at: htps://scholarcommons.usf.edu/etd Part of the American Studies Commons Scholar Commons Citation Smith, Chrystal A.S, "Living with Sugar: Socioeconomic Status and Cultural Beliefs About Type 2 Diabetes Among Afro-Caribbean Women" (2009). Graduate Teses and Dissertations. htps://scholarcommons.usf.edu/etd/22 Tis Dissertation is brought to you for free and open access by the Graduate School at Scholar Commons. It has been accepted for inclusion in Graduate Teses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact Living with Sugar: Socioeconomic Status and Cultural Beliefs About Type 2 Diabetes Among Afro-Caribbean Women by Chrystal A.S. Smith A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology College of Arts and Sciences University of South Florida Co-Major Professor: Lorena Madrigal, Ph.D. Co-Major Professor: David Himmelgreen, Ph.D. Elizabeth Barnett Pathak, Ph.D. Fatimah Jackson, Ph.D. Nancy Romero-Daza, Ph.D. Date of Approval: October 16, 2009 Keywords: Migrants, Cultural Consensus Analysis, Caribbean, Cross-Cultural, Florida © Copyright 2009, Chrystal A.S. Smith Dedication In loving memory of my mother, Maureen Smith who inspired me to embark on this academic journey. This dissertation also would not be possible without the loving and unwavering support of my godmother, Zita St. John as well as my friends, Collette Brown, Laura DiDio and Teresa Leslie. Acknowledgements My gratitude to my Committee: my advisors Dr. Lorena Madrigal and Dr. David Himmelgreen, Dr. Nancy Romero-Daza, Dr. Elizabeth Barnett and Dr. Fatimah Jackson. Your support and guidance throughout this process was greatly appreciated. Special thanks to the late Trevor Purcell who though not present for the latter stages was instrumental at the beginning and continued to be an inspiration. I also extend thanks to the members of the Caribbean Cultural Association, Dr. Kevin Sneed, Mrs. Shani Davis, Mrs. Estrella Clemens, Mrs. Kate Hagelin, Dr. Patrick Watson, Ms. Susan Forde, Dr. Dinorah Martinez-Tyson, Mr. Reginald Lee, Ms. Tasha- Neisha Wilson, and Dr. Kathryn Borman. Without their assistance with networking, data collection activities and responding to my many requests, I would not have been able to conduct this dissertation research. Finally, I wish to express my gratitude to the women who participated in my research. Their forthrightness and cooperation enriched the data and gave me insight into their lives as they met the challenge of managing this incurable disease. Table of Contents List of Tables ..................................................................................................................... iv List of Figures .................................................................................................................... vi ABSTRACT ...................................................................................................................... vii Chapter I - Introduction ...................................................................................................... 1 Statement of Problem .............................................................................................. 2 Purpose and Significance of this Research ............................................................. 4 Research Questions, Hypotheses, and Objectives .................................................. 6 Chapter II – Conceptual Framework and Literature Review .............................................. 9 Conceptual Framework ........................................................................................... 9 Political Economy of Health ..................................................................... 11 Acculturation............................................................................................. 15 Cultural Consensus Analysis .................................................................... 18 Literature Review.................................................................................................. 21 Etiology of Type 2 Diabetes ..................................................................... 21 Treatment of Type 2 Diabetes ................................................................... 30 Pathogenesis of Type 2 Diabetes .............................................................. 31 Thrifty Genotype Hypothesis ........................................................ 31 Thrifty Phenotype Hypothesis ...................................................... 38 Microevolution and the English-speaking Caribbean ............................... 43 Epidemiological Transition Theory .......................................................... 48 Epidemiological History of the Caribbean ............................................... 52 Health and the English-speaking Caribbean ............................................. 57 Health and English-speaking Caribbean Migrants ................................... 65 Type 2 Diabetes in the English-Speaking Caribbean ............................... 68 English-Speaking Caribbean Attitudes about Type 2 Diabetes ................ 80 Traditional Caribbean Diet and Nutrition ................................................. 86 Health and Migration: Acculturation and Weight Gain ............................ 90 Migration and Identity: Afro-Caribbean Migrants in the U.S. ................. 94 Chapter III – Methodology ............................................................................................... 99 First Phase of Research ....................................................................................... 101 Second Phase of Research .................................................................................. 102 i Research Setting.................................................................................................. 103 Sampling and Recruitment .................................................................................. 105 Telephone Interviews .............................................................................. 109 Materials ............................................................................................................. 111 Socio-Demographic Questionnaire ......................................................... 111 Semi-structured Interview Protocol ........................................................ 112 Free List Exercise ................................................................................... 114 Cultural Beliefs about Type 2 Diabetes Questionnaire ........................... 115 Analysis............................................................................................................... 118 Cultural Consensus Analysis .................................................................. 119 Analysis of Individual Cultural Knowledge Scores................................ 121 Analysis of Cultural Belief Themes ........................................................ 122 Analysis of Self-Reported Measurements .............................................. 123 Chapter IV – Results ....................................................................................................... 128 Free List Data ...................................................................................................... 128 Socio-demographic Data ..................................................................................... 134 Medical Data ....................................................................................................... 140 Beliefs and Behavioral Characteristics ............................................................... 143 Characteristics of Study Participants without Type 2 Diabetes .......................... 144 Research Question 1 ........................................................................................... 144 Cultural Consensus Analysis .................................................................. 145 Cultural Belief Model about Type 2 Diabetes ........................................ 153 Research Question 2 ........................................................................................... 158 Efficaciousness of Traditional/Alternative Remedies ............................ 158 Modification of Traditional Caribbean Diet and Lifestyle ..................... 168 Prayer and Faith ...................................................................................... 174 Research Question 3 ........................................................................................... 180 Inadequate Health Insurance Coverage .................................................. 181 Cost of Medicines and Physician Visits.................................................. 183 Cost of Glucometer Testing Strips .......................................................... 185 Transnational Migration.......................................................................... 188 Research Question 4 ........................................................................................... 191 Anthropometric Findings ........................................................................ 191 Chapter V – Discussion .................................................................................................. 207 Cultural Consensus Analysis .............................................................................. 209 Cultural Beliefs and Practices about Type 2 Diabetes ............................ 216 Efficaciousness of Traditional/Alternative Remedies ............................ 217 Modified Caribbean Diet and Lifestyle .................................................. 224 Prayer and Faith ...................................................................................... 230 Structural Barriers to Type 2 Diabetes Care ....................................................... 232 Inadequate Health Insurance Coverage .................................................. 233 ii Transnational Migration.......................................................................... 238 Obesity and Overweight ......................................................................... 242 Limitations .......................................................................................................... 253 Researcher as Native Anthropologist...................................................... 253 Selection Bias.......................................................................................... 257 Information Bias: Misclassification ........................................................ 258 External Validity ..................................................................................... 261 Sample Size ............................................................................................. 262 No Access to Medical Records ............................................................... 264 Lack of Detailed Physical Activity and Environment Data .................... 264 No Data on Severity of Sequelae ............................................................ 265 Chapter VI – Conclusion ................................................................................................ 266 Recommendations ............................................................................................... 270 Contributions to Biocultural Anthropology Framework..................................... 275 Contributions to Applied Anthropology ............................................................. 277 Further Research ................................................................................................. 278 References ....................................................................................................................... 281 Appendices ...................................................................................................................... 326 Appendix A: IRB Approval ................................................................................ 299 Appendix B: Research Flyer ............................................................................... 300 Appendix C: Recruitment Script ......................................................................... 301 Appendix D: Informed Consent Form ................................................................ 302 Appendix E: Socio-Demographic Questionnaire................................................ 306 Appendix F: Semi-Structural Interview Protocol ............................................... 310 Appendix G: Revised Semi-Structural Interview Protocol ................................. 311 Appendix H: Free List Questionnaire ................................................................. 312 Appendix I: Cultural Beliefs About Type 2 Diabetes Questionnaire ................. 314 About the Author …………………………………………………………….. End of Page iii List of Tables Table 1. Criteria for the Diagnosis of Diabetes Mellitus .................................................. 28 Table 2. Overview of 38 Semi-structured Interviews ..................................................... 110 Table 3. Free list Analysis: Prevention of Type 2 Diabetes ........................................... 129 Table 4. Free list Analysis: Causes of Type 2 Diabetes ................................................. 130 Table 5. Free list Analysis: Symptoms of Type 2 Diabetes ............................................ 131 Table 6. Free list Analysis: Complications of Type 2 Diabetes ..................................... 133 Table 7. Free list Analysis: Treatments of Type 2 Diabetes ........................................... 134 Table 8. Characteristics of Study Particpants ................................................................ 135 Table 9. Socio-Demographic Characteristics of Study Participants ............................... 137 Table 10. Medical Conditions of 40 Study Participants Diagnosed ............................... 143 Table 11. Results of Cultural Consensus Analysis ......................................................... 147 Table 12. Spearman Correlation Analysis Results ......................................................... 148 Table 13. Shared Cultural Beliefs of 30 Afro-Caribbean Women .................................. 157 Table 14. Fisher Exact Test Results: Traditional/Alternative Remedies ........................ 160 Table 15. Study Participants who used Traditional/Alternative Remedies .................... 162 Table 16. Frequently Used Traditional/Alternative Caribbean Remedies ...................... 163 Table 17. Fisher Exact Test Results: Traditional Caribbean Diets ................................. 169 Table 18. Study Participants Recommendations to Modify Caribbean Diet .................. 170 iv Table 19. Fisher Exact Test Results of Afro-Caribbean Women Beliefs ....................... 175 Table 20. Beliefs about 40 Study Participants‘ Prayer and Faith ................................... 178 Table 21. Overview of 40 Study Participants‘ Structural Barriers ................................. 180 Table 22. Self-Reported Weight/Height of 33 Study Participants .................................. 191 2 Table 23. BMI (kg/m ) of 33 Study Participants ............................................................ 192 Table 24. Hypertension and BMI in 33 Study Participants ............................................ 193 Table 25. Spearman Correlation Results of 33 Study Participants‘ BMI ....................... 194 Table 26. BMI of 33 Study Participants by Mean Age................................................... 202 Table 27. Mann-Whitney U Test Results of 33 Study Participants by BMI .................. 204 Table 28. Fisher Exact Test Results: BMI and Belief Variables .................................... 206 v List of Figures Figure 1. English-speaking Caribbean Food Groups ........................................................ 87 Figure 2. Overview of the Research Design ................................................................... 100 Figure 3. Overview of the Research Sample and Instruments ........................................ 103 Figure 4. Age at Type 2 Diabetes Diagnosis and Cultural Knowledge Scores .............. 149 Figure 5. Age and Individual Cultural Knowledge Scores ............................................. 150 Figure 6. Years of Type 2 Diabetes Duration and Cultural Knowledge Scores ............. 151 Figure 7. Years Living in the U.S. and Cultural Knowledge Scores .............................. 152 Figure 8. Years of Education and Individual Cultural Knowledge Scores ..................... 153 Figure 9. Study Participant‘s Age of Type 2 Diabetes Diagnosis and BMI ................... 195 Figure 10. Study Participants‘ Age and BMI.................................................................. 196 Figure 11. BMI and Individual Cutural Knowledge Scores ........................................... 197 Figure 12. BMI and Years of Type 2 Diabetes Duration ................................................ 198 Figure 13. BMI and Years Living in the U.S. ................................................................. 199 Figure 14. BMI and Years of Education ......................................................................... 200 Figure 15. Modified Caribbean Diet Described by Afro-Caribbean Women…………..175 vi