Specific AimsThis research on American Indian (AI) diabetes beliefs and practices as they relate to maternalcare, infant mortality, and adherence seeks to elicit practitioner and patient Explanatory Models of pregestationaland gestational diabetes mellitus, and will be conducted in collaboration with the Chickasawand Choctaw Nations of Oklahoma, under the auspices of the Oklahoma Center for American IndianDiabetes Health Disparities Research (OCAIDHD) at the University of Oklahoma Health Sciences Center(OUHSC) and the General Clinical Research Center (GCRC).The schema for this research is based on Kleinman (1978) concept of health behaviors beinglocated in three sectors: professional (licensed, educated in cosmopolitan institutions), popular (lay), andfolk (lay but with social recognition of healing capacity). The research is directed at all three sectors, buttelescoped into 'professional' and 'popular and folk.' The professional sector is comprised of healthproviders that are (AI and non-AI) licensed practitioners whose education is steeped in biomedicine. Thepopular/folk sector is comprised of pregnant AI women: gestational, pre-gestational, or 'never had'diabetes. The popular and folk sector is combined because participants characterized as 'folkpractitioners' are not sought as direct subjects. However, subjects from the popular sector may makereferences to 'folk' sector participants. If this occurs, that information will be collected as part of thepopular sector subjects' experience with diabetes coping. The result is that, if present, the folk sectorinfluence will still be captured but viewed as a part of popular sector subjects' way of managing diabetes.This research will provide practitioners of multiple disciplines new information that delineatespatients' ways of help-seeking and adherence/non-adherence with treatment recommendations for pregestationaldiabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). Findings will informpractitioners about 1) differing Explanatory Models of diabetes held by their patients, 2) howpractitioners' biomedical Explanatory Models of diabetes during pregnancy differ from patient culturallybasedmodels, and 3) areas of concordance and discordance across models. Knowledge gained from thisresearch will facilitate health care delivery in that biomedical diabetes education before and duringpregnancy can be more appropriately integrated with pre-existing patient models, thus providing thepregnant woman with access to culturally-relevant diabetes education. Moreover, this research willcontribute to a more complete understanding of health beliefs and behavioral dynamics in terms of howdisease is culturally constructed, with particular relevance to potential impacts on maternal care and infantmortality in the context of diabetes.Paradoxically, in spite of today's most advanced medical treatment, prevention campaigns, andhealth promotion strategies, prevalence rates for diabetes mellitus, as well as GDM, are persistent andrising. In the presence of potent drugs and wide-spread health education information, diabetes prevalenceshould be abating. Since it is not, other factors promoting diabetes must be operating. Preliminaryresearch suggests that one possible source for persistent and increasing diabetes prevalence is that nonobvioussociocultural factors are present that impede the productive application of pharmacologic andhealth education tools. In addition to poor management of the diabetes, mutual respect betweenpractitioners and patients suffers from communication discordance with the result that both are verydissatisfied with the encounter.The non-obvious sociocultural factors operating to impede effective health care are found in thedivergent models of diabetes held by practitioners and patients. Specifically, professional and layexplanations for disease, treatment, and prevention can vary radically. Explanations for the etiology,treatment, course, and preventive measures for sickness are known as 'explanatory models.' ExplanatoryModels (EMs) held by providers and patients may be similar. Similar EMs facilitate communication andare associated with increased adherence to treatment recommendations and patient/provider satisfaction.However, EMs that are discordant between practitioners and patients are prone to reduce effectivecommunications, adherence to treatment recommendations, and negatively impact health outcomes.This research will elicit Explanatory Models of diabetes during pregnancy from pregnantdiabetics (n=40), 60 pregnant non-diabetics (n=60), and their health care providers (n=60 ) regardingetiology, course, and treatment in order to reduce barriers to adherence and improve diabetes outcomes.All pregnant subjects are AI's. 'Health Care Providers' are defined as physicians, licensed nurses,Certified Diabetes Educators (CDE's), and tribal Community Health Representatives (CHR's:paraprofessionals trained for home visits, screenings, health education, community resourceidentification, and transportation to health care sites). Collaboration with the Choctaw and ChicksawNations of Oklahoma will be continuous to strengthen all phases of the research process and assure thatappropriate research goals will be met.
Specific Aim # 1: Collaboration with Choctaw and Chickasaw Nations on decisions regardingquestionnaire refinement, research implementation, and application of the research findings.
Specific Aim # 2: Recruit 60 health care providers and 100 pregnant patients to serve as subjects forinterviews.
Specific Aim #3 : Delineate the Explanatory Models held by 100 pregnant women of which 10 will havepre-gestational diabetes, 30 will have gestational diabetes, and 60 will not have diabetes.Hypothesis: Explanatory Models will vary by category of disease experience.
Specific Aim # 4: Delineate the Explanatory Models held by patients about maternal and infant outcomesrelevant to diabetes during pregnancy.Hypothesis: Patient's Explanatory Models of maternal and infant outcomes may predict help-seeking andadherence behaviors.
Specific Aim # 5: Delineate the Explanatory Models of diabetes held by providers regarding theirpatients' diabetes education, care-seeking behaviors, and adherence/non-adherence to treatment plans.Hypothesis: Provider Explanatory Models of diabetes may be discordant with patient models of diabetes,contributing to communication barriers. Perceptions of patient help-seeking and adherence may eitherfacilitate or be a barrier to optimal care.
Specific Aim #6 : Delineate provider models of care delivery.Hypothesis: Provider models of care delivery may either facilitate or impede patients' help-seeking andadherence behaviors..
Specific Aim #7 : Delineate subjects' degree of identification with traditional AI culture or mainstreamculture.Hypothesis: Subjects' cultural identification may predict their Explanatory Model of diabetes.
Specific Aim # 8: In collaboration with Choctaw and Chickasaw Nations, disseminate the findings of theresearch to health care providers in both tribes.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Exploratory Grants (P20)
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Special Emphasis Panel (ZRG1-DIG-B (52))
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University of Oklahoma Health Sciences Center
Oklahoma City
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