Introduction
Initially referred to as adult-onset diabetes or non-insulin-dependent diabetes mellitus, Type 2 Diabetes Mellitus (T2DM) entails a metabolic disorder or disease characterized by increased blood glucose levels due to insulin deficiency and resistance (Ginter & Simko, 2012). T2DM’s typical symptoms include weight loss, fatigue, increased thirst, and frequent urination. Genetic and lifestyle factors cause the disorder. According to Ginter and Simko (2012), environmental toxins are also responsible for the increased T2DM worldwide. Notably, T2DM in families is significantly increased by having sick relatives. Environmental factors (including obesity and diet) and genetic makeup significantly contribute to T2DM’s development. Insulin resistance refers to human tissues’ inability to appropriately regulate glucose levels when insulin is produced and secreted (Ginter & Simko, 2012). Contrary to Type 1 Diabetes Mellitus (T1DM), insulin resistance is associated with cells’ insulin receptors failing to respond to insulin appropriately, and lack of insulin production does not play a role.
Worldwide, T2DM is a common disorder. However, its prevalence changes with ethnicity/race and geographical regions (Golden et al., 2019). Urbanization and economic development have significantly heightened the diabetes burden worldwide (Khan et al., 2019). Diabetes negatively impacts people’s quality of life and functional capacities, causing premature mortalities and morbidities. In the recent findings (Khan et al., 2019), diabetes has been indicated to negatively impact even younger populations, making it a dire concern. Sedentary lifestyles and unhealthy diets have increased fasting blood glucose, and Body Mass Index (BMI) has risen dramatically in diabetes prevalence. Specifically, individuals with high BMI readily develop T2DM (Khan et al., 2019). The increasingly aging world population is also a significant factor contributing to the current increased diabetes cases. Diabetes healthcare’s cost has approximately tripled the mean per capita care expenditure due to the associated complications. Appropriate blood pressure and glucose control remain important factors among diabetic patients. The lack of health promotion and awareness required for better diabetes control has been jeopardized.
Problem Statement
Ethnic and racial minority populations, including African Americans, record a more significant diabetes burden and prevalence than whites, associated with few complications. Regardless of the increased medical care access and advances in the United States of America, disparities in the healthcare and health system prevail (Chow et al., 2012). According to Nelson (2003), the Institute of Medicine indicated that ethnic and racial healthcare access disparities impact unequal treatment. This confirms that whites are treated differently from ethnic and racial minorities in America’s health system, consequently affecting poor Americans disproportionately. Specifically, the Institute of Medicine reported that minority groups like African Americans experience 50 to 100% diabetes mortality and illness more than their white counterparts (Nelson, 2003).
Despite the dire impacts of diabetes, it is more prevalent among African Americans than whites. Among the Centers for Medicaid Services (CMS) beneficiaries, 30% more African Americans are affected by diabetes (CMS, 2021). Young African Americans have been increasingly reported to be disproportionately affected by diabetes than their white counterparts. Although African Americans and white CMS beneficiaries engage in diabetes self-management interventions, many black patients are characterized by limited self-management knowledge regarding diabetes management and blood sugar control. Fewer African American diabetic patients do not fully understand Medicare insurance policies for diabetes treatment and management than whites. Therefore, to improve diabetes treatment and management among minority groups like African Americans, it is essential to explore how the social healthcare and education access disparities impact diabetes treatment and management in the target population.
Gaps in Research
Epidemiological research studies have consistently explored the relationship between T2DM incidents and socioeconomic status (SES) (Heltberg et al., 2017). Generally, diabetes-related mortalities have decreased worldwide because of multifaceted diabetes interventions and effective pharmacotherapy. However, diabetes trends continue to increase among poor people, even in nations that have made significant strides in increasing equity in the healthcare system (Booth et al., 2012). The prevailing research has insufficiently explored the connection between socioeconomic status and mortality rates associated with T2DM (Heltberg et al., 2017). The increased mortalities among poor T2DM patients can be attributed to disparities in treatment goals’ attainment and low pharmacotherapy levels. Indigent patients have limited access to diabetes multidrug regimens, and medication adherence is impacted by their low socioeconomic status (Walker et al., 2014). The lack of sufficient literature regarding the impact of social disparities in healthcare access and diabetes treatment, particularly among the black Americans in south New Jersey, presents a considerable research gap. The prevailing literature has also explored the importance of Diabetes Self-Management Education (DSME) on diabetes management among patients.
Shaw et al. (2011) and Rutledge et al. (2017) confirm that DSME is diabetes care’s foundation and essentially improves skills and knowledge needed to enhance self-management. Notably, preventing costly and devastating complications and proper glycemic control demands comprehensive approaches integrating appropriate self-management and clinical care practices (Shaw et al., 2011). Despite DSME’s importance in diabetes management, little literature has explored how social disparities in DSME impact diabetes management among the poor African Americans in south New Jersey. Therefore, this proposed study is needed to fill the research gaps and address how social disparities in healthcare and DSME access impact diabetes treatment and management among socioeconomically burdened minority populations like the African Americans in south New Jersey. This research is essential since the findings will address the literature research gaps. Besides, the proposed study will inform policymakers and the healthcare system players about the appropriate ways of reducing social disparities in healthcare and DSME access to improve diabetes treatment and management among the disproportionately affected minority populations, like the African Americans in south New Jersey.
Purpose Statement
The proposed study explores the impacts of social disparities in healthcare and diabetes self-management education on diabetes treatment and management among African Americans in south New Jersey. The research will only consider the black American population in south New Jersey. The study sample will entail African American diabetic patients with consistent clinical attendance between 2019 and 2021. This research has a significant social change potential in the targeted population. Besides many factors implicated in the increased T2DM, including African Americans’ genetic makeup (Marshall, 2005), social disparities in healthcare and diabetes education access play a critical role in diabetes treatment and management (Heltberg et al., 2017; Rutledge et al., 2017).
Consequently, inappropriate diabetes treatment and management have contributed to significantly high mortality and morbidity among African Americans. Hence, using a mixed methods research, particularly the sequential exploratory design, this study will explore how the social disparities in healthcare access and diabetes self-management education affect diabetes treatment and management among African Americans in south New Jersey. The findings will inform better approaches to diabetes treatment and management by reducing healthcare disparities and increasing diabetes self-management education in the targeted population. This will ensure that the disproportionately affected African Americans access the necessary diabetes treatment and education, reducing associated high mortalities and morbidities. Besides, the study findings will help the affected African Americans in south New Jersey improve health outcomes and quality of life.
Nature of the Study
The study will be a sequential exploratory mixed methods research. The research will collect and analyze the qualitative data first. The quantitative data strand will be collected and analyzed in the second phase. According to Nicolau et al. (2017), a sequential exploratory uses the qualitative and quantitative methods sequentially. A sequential exploratory research design’s defining characteristic entails the collection and analysis of the qualitative data strand informs the subsequent quantitative data strand collection and analysis. For instance, analyzing the qualitative data strand can tell a theory that can be assessed using a considerable sample size to generalize the results (Nicolau et al., 2017). In this research proposal, the qualitative data analysis findings will help develop a hypothesis that will be tested via collecting and analyzing the quantitative data for amicable generalizations regarding the impact of social disparities in healthcare and diabetes self-management education on diabetes treatment and management among the African Americans in south New Jersey. The independent research variables will include healthcare access, social disparities, and diabetes self-management education access social disparities. The dependent variables entail diabetes treatment and diabetes self-management. The covariate variables include participant age and gender.
Research Questions and Hypotheses
The following research questions and hypotheses will help the study meet its purpose.
Research question 1: What is the connection between social disparities in healthcare access and diabetes treatment among African American diabetic patients in south New Jersey?
Null hypothesis 1: There is no statistically significant connection between social disparities in healthcare access and diabetes treatment among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Alternative hypothesis 1: There is a statistically significant connection between social disparities in healthcare access and diabetes treatment among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Research question 2: What is the relationship between social disparities in diabetes education access and diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey?
Null hypothesis 2: There is no statistically significant relationship between social disparities in diabetes education access and diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Alternative hypothesis 2: There is a statistically significant relationship between social disparities in diabetes education access and diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Research question 3: What is the impact of a structured intensive diabetes education program on diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey?
Null hypothesis 3: There is no statistically significant impact of a structured intensive diabetes education program on diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Alternative hypothesis 3: There is a statistically significant impact of a structured intensive diabetes education program on diabetes self-management among African American diabetic patients with consistent clinical attendance between 2019 and 2021 in south New Jersey.
Theoretical Framework
This research will be based on the self-management theory. According to Grady and Gough (2014), the self-management theory is a critical approach to addressing chronic conditions, including type 2 diabetes. The self-management theory moves beyond mere education to teach people how to underpin hurdles and actively provide amicable solutions to their illnesses. Self-management is potentially effective across primary, secondary, and tertiary prevention by developing patterns ensuring healthy lives and availing sound strategies for reducing and managing diseases (Grady & Gough, 2014). Similarly, Chester et al. (2018) assert that the self-management theory demands the application of several self-management interventions and choices via interactive educational approaches. Enabling patients to understand clinical and self-management requirements regarding T2DM is a potential approach to controlling diabetes and improving health outcomes and quality of life among the disproportionately impacted populations like black Americans. Besides, the theory encourages self-management and efficacy abilities in addressing chronic conditions. Through the application of the self-management theory, it is possible to identify the enablers and barriers to better diabetes management among the targeted individuals.
Assumptions
The research will assume that the sampled diabetic patients had a consistent clinical attendance between 2019 and 2021 and belong to the African American minority group. Before data collection, it will also be assumed that the research participants are adequately aware of their socioeconomic and demographic status. The study will assume that the sampled patients are willing to participate in the research and will give honest information regarding the study variables. Similarly, it will be considered that the study participants understand the standard English language, can respond to the interview questions audibly, and have the relevant writing and reading knowledge and skills to answer the questionnaire questions as required.
Limitations
The research study will only consider diabetic patients from the African American minority group. The study will consider diabetic patients sampled from hospitals offering diabetes-related treatment and services in south New Jersey. All the participating patients will be residents of south New Jersey only. The sample size for collecting the qualitative data will be 100 and 200 for the quantitative data collection.
Scope/Delimitations
The study participants will be diabetic African American patients with consistent clinical attendance between 2019 and 2021. Patients with inconsistent clinical attendance between the deliberated timeline will not be included. Notably, the study will sample diabetic patients from public government-owned hospitals offering diabetes services in south New Jersey. Private hospitals will not be considered. The social disparities in healthcare and diabetes self-management education access will only include employment status, income, and education level.
Design
This mixed methods research will utilize the sequential exploratory approach. The qualitative data strand will be collected and analyzed first. In the second phase, the quantitative data will be collected and analyzed. Since this is sequential exploratory research, the qualitative data will be used to confirm the qualitative data analysis findings. To integrate the two data strands as needed in mixed methods studies, the qualitative data strand’s analysis results will help the researcher develop a hypothesis that will be tested using the quantitative data. This data integration approach is ideal since it will allow the study to make generalizations regarding the study problem. Correlational analyses will determine the relationship between the study variables to address the research questions and hypotheses.
Participants and Context
The study participants will entail both male and female diabetic patients, distributed equally. All the participants will belong to the African American population and must be residents of south New Jersey. Considering the participation criteria, the patients must be between 20 and 70. Besides, the study participants must have had consistent clinical attendance between 2019 and 2021 to be eligible to participate in the study. Notably, the participants will be sampled purposively. Robinson (2014) indicates that purposive sampling iteratively selects research participants without using any sampling frame. Relating to the chosen theory, purposive sampling involves identifying indicators, concepts, and themes via reflection and observation. Purposive sampling is frequently used to determine informants based on specific inquiry focus, knowledge, and experience (Robinson, 2014). A total sample size of 300 participants will be critical since exploring the relationships between variables will entail correlational analyses. Haitham (2018) affirms that in studies involving correlational analyses, for instance, linear regression, a minimum of 50 participants is needed to obtain sound correlation coefficients.
Instruments and Procedures
The qualitative data will be collected using semi-structured interviews (SSI) with 10 items. According to Stuckey (2013), SSIs are readily applied in qualitative studies, especially those related to diabetes treatment and management. Using SSIs will allow the study to precisely create instructions and guidelines for the participants. To adequately design the interview questions, the researcher will engage various certified diabetes educators in south New Jersey. The researcher will undertake a pilot study to determine if the questions are sufficiently clear and understandable. The Walden University Institutional Board will be engaged before the actual data collection. With the help of one assistant, the researcher will administer the interview questions. The audio responses will be recorded and stored in a password-protected flash disk.
The quantitative data strand will be collected using structured questionnaires with ten items. The instrument will consider various social disparities, including the participants’ employment, income, and education level. Similar to the interview questions, the questionnaire items will be tested for clarity before data collection. The main validity threat during data collection includes the participants’ biases and inaccuracies. To address this concern will ensure that participants respond to the same questions, and the maximum number of items will be ten to encourage accurate responses. The main issue of trustworthiness will be the collected data’s credibility. During data collection, the researcher will address this concern by giving enough time to the participants to answer the questions and give their views regarding the research variables.
Data Analysis Plan
In analyzing the qualitative data, the audio files will be converted to transcript texts using appropriate transcription software. The text transcripts will be uploaded into a Computer Assisted Qualitative Data Analysis software for analysis. According to Seale (2011), the software is applicable in qualitative data analysis because it allows data categorization into main characteristics and items. Next, the codes will be derived from the qualitative data using content analysis. Data sorting will classify the data into smaller categories based on common characteristics. Data transformation will tabulate the data for descriptive and non-parametric statistical analyses. The chi-square independence test will determine the connection between the research variables. From the qualitative data analysis results, the researcher will formulate a hypothesis that will be tested using the quantitative data strand. This will be essential in integrating the qualitative and quantitative data strands. The quantitative data will be analyzed using the JASP software. This application is preferable since it is freely available and easy to use. Descriptive statistics will conduct the univariate data analysis to determine the frequencies of the variables. Bivariate data analysis will preferably use Pearson’s product-moment correlation (Rowley, 2014) to determine the relationship between the variables. The hypotheses developed from the analysis of the qualitative data strand will be tested using the quantitative data analysis results to generalize the study’s findings.
Summary and Conclusion
Diabetes continues to be a vital public health concern in the United States of America. Although it affects all populations, it has disproportionately impacted African Americans, demanding considerable research to address the problem. This mixed methods research will use a sequential exploratory approach to explore the effects of social disparities in healthcare and diabetes self-management education access on diabetes treatment and management among African Americans in south New Jersey. Three hundred diabetic African American patients will be sampled purposively from public hospitals offering diabetes services in south New Jersey. The qualitative data strand will be collected first and analyzed using Computer Assisted Qualitative Data Analysis software. The relationship between study variables will be determined using the chi-square independence test.
The qualitative data strand analysis findings will formulate hypotheses to be tested by the quantitative data strand. The quantitative data will be analyzed using the JASP software. Descriptive statistics will conduct the univariate data analysis. Bivariate data analysis using Pearson’s correlation will determine the relationships between the study variables. The quantitative data analysis results will test the developed hypotheses from the qualitative data analysis. The central aspect noted as far as doctoral research is concerned, the process is demanding and lengthy, necessitating proper planning for timely completion. In the following steps, the researcher will extensively read to understand various tests, including the chi-square independence test, to be fully equipped during the primary research.
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