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Healthcare Mistreatment and Cultural Beliefs Impact HbA1c in Patients with

Type 2 Diabetes Mellitus

Article · August 2019

DOI: 10.22201/fpsi.20074719e.2019.2.258

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 ORIGINAL

Healthcare Mistreatment and Cultural Beliefs Impact

HbA1c in Patients with Type 2 Diabetes Mellitus
La Negligencia Médica y las Creencias Culturales impactan
BhA1C en Pacientes con Diabetes Mellitus tipo 2
Hector Betancourt1 a, b and Patricia M. Flynnb
a
Loma Linda University
b
Universidad de la Frontera

Received May 16, 2019; Accepted July 29, 2019

Abstract

The aim of this research was to examine the effects of healthcare mistreatment and cultural beliefs on psycholo-
gical, behavioral, and biological phenomena relevant to treatment adherence and health outcome among patients
with Type 2 Diabetes Mellitus (T2DM). The study was conducted in Chile, where the prevalence of T2DM is one
of the highest in Latin America and is increasing at an accelerated rate. The research was guided by Betancourt’s
Integrative Model and bottom-up mixed-method cultural research approach. Consistent with the hypotheses of
the study, the test of a structural equation model based on the Integrative Model, including exposure to healthca-
re mistreatment, diabetes-related cultural beliefs, psychological distress, and medical avoidance as determinants
of HbA1c, a biological measure of diabetes control, fit the data. The fact that the analysis of structural equations
accounted for significant variance in HbA1c provides supporting evidence for extending the Integrative Model,
to explain biological phenomena based on cultural and psychological factors.

Keywords: Healthcare, Culture, Diabetes, Beliefs, Integrative Model

Resumen

El propósito de este trabajo fue evaluar los efectos de la negligencia médica y las creencias culturales sobre fenó-
menos biológicos, conductuales y psicológicos relevantes para la adherencia al tratamiento y consecuencias de
salud en pacientes con diabetes mellitus tipo 2 (DMT2). El estudio se llevó a cabo en Chile, donde la prevalencia
de DMT2 es una de las más altas de América Latina y sigue en aumento de manera acelerada. La investigación
se basó en el Modelo Integrativo de Betancourt y en el enfoque mixto-abajo-arriba de investigación cultural.
Congruente con las hipótesis del estudio, el modelo de ecuaciones estructurales basado en el modelo integrativo,
que incluyó la exposición a negligencia médica, creencias culturales vinculadas a la diabetes, estrés psicológico,

1 Hector Betancourt, Department of Psychology, Loma Linda University, USA, and Universidad de La Frontera, Chile; Patricia
M. Flynn, Department of Psychology and Department of Preventive Medicine, Loma Linda University, USA. Correspondence
should be addressed to Dr. Hector Betancourt, Department of Psychology, Loma Linda University, Loma Linda, CA 92350. Email:
hbetancourt@llu.edu. This research was funded by CONICYT (Government of Chile), FONDECYT Project 1090660, to Dr. H.
Betancourt, P.I.

DOI: https://doi.org/10.22201/fpsi.20074719e.2019.2.258 ACTA DE INVESTIGACIÓN PSICOLÓGICA. VOL. 9 NÚMERO 2 · AGOSTO 2019 5

 MISTREATMENT, CULTURE, AND DIABETES OUTCOMES
H. Betancourt and P. Flynn

y evitación médica como determinantes del HbA1c, una medición biológica de control diabético, mostró buen
ajuste. El hecho de que el modelo de ecuaciones estructurales explique gran parte de la varianza del HbA1c apor-
ta suficiente evidencia para ampliar el modelo integrativo en la explicación del fenómeno biológico con base en
factores culturales y psicológicos.

Palabras Clave: Salud, Cultura, Diabetes, Creencias, Modelo Integrativo

Patient-physician interactions are critical to managing was guided by a bottom-up mixed-methods research
chronic diseases (Aikens, Bingham, & Piette, 2005; approach (Betancourt et al., 2010), which resulted in
Ratanawongsa et al., 2013) such as type 2 diabetes the identification of several instances of healthcare
mellitus (T2DM). Yet, racial or ethnic minority and mistreatment experienced by culturally diverse pa-
lower socioeconomic status (SES) patients, who in the tients during routine cancer screening. These instan-
U.S. experience higher rates of T2DM, are also more ces of healthcare mistreatment reflected poor interper-
likely to feel disrespected, not listened to, and treated sonal quality-of-care, such that healthcare providers
unfairly in the healthcare system (Barr & Wanat, 2005; “treat me like an object” and “do not listen to me”
Blanchard & Lurie, 2004; Blendon et al., 2008). Des- (Flynn et al., 2015). This line of research also led to
pite physicians’ best intentions to provide equitable the identification of several cultural factors relevant
care, research reveals that providers’ implicit cultural to cancer screening behaviors such as cultural biases
biases about racial or ethnic minority and low SES about healthcare providers (Betancourt et al., 2011)
patients influence their medical interactions, including and cancer screening fatalism (Flynn et al., 2011).
visit length, affect, empathy, and patient-centeredness This collective body of research revealed that both
(Cooper et al., 2012; Penner et al., 2016). Because healthcare mistreatment and cultural beliefs predict
patient perceptions of poor quality-of-care and heal- cancer screening, medical avoidance, and continuity
thcare mistreatment impact their subsequent medical of healthcare among low SES Latino American pa-
interactions (Hagiwara, Dovidio, Eggly, & Penner, tients in the United States.
2016; Hausmann et al., 2011; Hausmann, Kwoh, The present study was designed to examine the
Hannon, & Ibrahim, 2013) and treatment adherence impact of healthcare mistreatment and cultural belie-
behaviors (Kronish et al., 2013; Ortiz, Baeza-Rivera, fs about diabetes on disease outcomes among T2DM
Salinas-Onate, Flynn, & Betancourt, 2016), this is a patients. The study was conducted in Chile, a country
particularly important issue for minority and low SES in which the incidence of T2DM is one of the highest
populations who, in the case of T2DM, are less likely in South America and is increasing at an accelerated
to meet HbA1c goals and are more likely to die from rate. In 2013 the prevalence of T2DM in Chile was
the disease than non-Latino White (Anglo) Americans 10.4% and by the year 2035 it is projected to reach
in the United States (Xu, Murphy, Kochanek, Bastian, 12.7%, surpassing the 11.6% projection for the Uni-
& Arias, 2018). ted States (Guariguata et al., 2014). The increasing
The present study, which examines diabetes out- prevalence of T2DM in Chile and problems related to
comes in a Latin American country experiencing high the management of this complex disease have been at-
rates of this disease, builds on our previous research tributed to globalization, economic growth, and urba-
examining the implications of healthcare mistreat- nization, including changes in diet, physical activity,
ment and cultural beliefs on cancer screening beha- and lifestyle in general (Uauy, Albala, & Kain, 2001).
viors among low SES Latin Americans (Latino) and The treatment of T2DM requires the management
Anglo Americans in the United States (Betancourt, of complex medication regimens and lifestyle changes,
Flynn, & Ormseth, 2011; Betancourt, Flynn, Riggs, which highlight the critical need for quality patient-pro-
& Garberoglio, 2010; Flynn, Betancourt, & Ormseth, vider relations to ensure successful clinical outcomes.
2011). That research in the area of cancer screening Our research with indigenous T2DM patients in Chile,

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 MISTREATMENT, CULTURE, AND DIABETES OUTCOMES
H. Betancourt and P. Flynn

however, reveals high rates of healthcare discrimina- 45% of patients experience diabetes-related distress
tion, attributed by patients to their lower levels of edu- (Nicolucci et al., 2013), which is associated with poor
cation and income (Ortiz et al., 2016). Moreover, these medication adherence and glycemic control (Gonza-
attributions of healthcare discrimination resulted in a lez, Shreck, Psaros, & Safren, 2015). These findings
greater likelihood that patients would discontinue their suggest an important need for research that can syste-
diabetes medical care. These findings suggest that so- matically investigate the impact of socially shared (i.e.
cial inequities and socioeconomic disparities between cultural) beliefs about diabetes and healthcare mis-
patients and providers, within the context of a clas- treatment as determinants of psychological distress,
sist society, can affect healthcare interactions and be- treatment adherence, and T2DM outcomes.
haviors relevant to seeking medical care for T2DM. The present research is guided by Betancourt’s in-
In addition to the noted experiences of mistreat- tegrative theoretical model for the study of culture
ment and discrimination in the healthcare setting, and behavior in psychology (Betancourt, Hardin, &
many individuals with T2DM also report stigma and Manzi, 1992; Betancourt & Lopez, 1993), adapted
social rejection from society in general, across many for health behavior (Betancourt & Flynn, 2009; Be-
life domains including work and relationships (Brow- tancourt et al., 2010; Flynn et al., 2011). The model
ne, Ventura, Mosely, & Speight, 2013; Liu et al., 2017; specifies how culture relates to health behavior and
Schabert, Browne, Mosely, & Speight, 2013). These mediating psychological factors as well as to social
socially shared experiences among individuals with structural factors conceived as sources of cultural
T2DM could have significant implications for psy- variation. According to the Integrative Model (see
chological well-being and clinical outcomes. In fact, Figure 1), aspects of culture (B) such as the socially
an international study indicates that approximately shared beliefs, values, norms and practices relevant to

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H. Betancourt and P. Flynn

T2DM can directly impact health behaviors (D), such Table 1

Descriptive Statistics for Study Variables (N=143)
as those involved in the management of T2D (e.g. at-
  n (%)
tending diabetes care visits, adherence to prescribed
treatment). These aspects of culture can also indirect- Age M = 55.64, SD = 14.41
ly influence health behavior through psychological Education
processes (C), such as the experience of distress as- Less than 8 years 53 (37.6%)
sociated with diabetes and medical treatment. Such 9-12 years 65 (45.5%)
aspects of culture (B) may be shared among members More than 12 years 23 (16.2%)
of groups, such as racial, ethnic, SES, or other com-
Income
munities (A).
$0 - $150,000 54 (37.8%)
In a manner consistent with the Integrative Mo-
del that has guided our previous work on the role of $151,000 - $250,000 43 (30.1%)

culture and healthcare mistreatment in the context of $251,000 - $500,000 34 (23.8%)

cancer screening, the aim of this study was to test the $501,000 - $1,000,000 11 (7.7%)
effects of healthcare mistreatment and cultural beliefs More than $1,500,000 1 (0.7%)
on psychological and behavioral phenomena relevant
to treatment adherence and health outcome among
T2DM patients in Chile. Specifically, it was hypothesi- Participants
zed that patients’ level of exposure to healthcare mis- A total of 400 T2DM patients from La Araucania
treatment and their cultural beliefs about diabetes-re- region of Chile participated in the larger research
lated social rejection will be associated with higher project. Inclusion criteria for that larger study inclu-
scores on treatment-related psychological distress. It ded a minimum age of 18, diagnosis of T2DM for
was also expected that diabetes-related psychologi- at least one year, and not dependent on insulin. For
cal distress would predict greater medical avoidan- the purpose of the present study, additional inclusion
ce, which will in turn negatively impact HbA1c (i.e. criteria involved at least one reported experience of
elevated levels), a biological measure of diabetes con- past healthcare mistreatment, as measured by the
trol. By including HbA1c along with social structu- Healthcare Mistreatment Scale (Flynn et al., 2015).
ral, cultural, psychological, and behavioral variables, As discussed earlier, our previous work examined the
this study represents a preliminary effort to extend impact of healthcare discrimination on indigenous
the scope of the Integrative Model to also account for Chilean (Mapuche) T2DM patient outcomes (Oritz et
biological outcomes. al., 2015). Hence, the focus of the present study is
on mainstream Chilean T2DM patients. Of the 254
Methods non-indigenous T2DM patients included in the larger
study, 143 reported at least one experience of prior
This study was part of a larger research project de- mistreatment. Demographics for the study sample are
signed to examine the role of culture, patient-provi- described in Table 1.
der healthcare interactions, and psychological factors
relevant to treatment adherence and outcome among Measures
T2DM patients in Chile. Previous research (Ortiz et Cumulative Exposure to Healthcare Mistreatment.
al., 2016) examined the impact of healthcare discrimi- The present study employed an adapted version of the
nation among T2DM patients of indigenous (Mapu- Interpersonal Health Care Mistreatment scale (Flynn,
che) background. The present study therefore focuses et al., 2015), which was originally developed with
on the experience of healthcare mistreatment among low-income Latino and Anglo American women from
non-indigenous Chilean T2DM patients. Southern California, U.S.A., through a mixed-methods

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 MISTREATMENT, CULTURE, AND DIABETES OUTCOMES
H. Betancourt and P. Flynn

research approach to instrument development (Betan- “strongly agree”. Reliability for this factor was good
court et al., 2010). A similar mixed-methods approach (α = .72).
was implemented with T2DM patients in Chile to re- Medical Treatment Distress. The previously des-
fine existing items, eliminate non-relevant items, and cribed mixed-methods research approach was also
identify additional instances of healthcare mistreat- used to identify the psychological consequences of
ment experienced in the Chilean healthcare system. healthcare mistreatment, which resulted in the deve-
The adapted scale included seven items reflecting spe- lopment of two items. Participants were asked, “As
cific instances of negative interpersonal healthcare en- a result of what happened to you, were you more
counters such as a lack of respect and communication stressed or nervous about having to go to your next
issues. Participants were presented with the seven appointment?” and “As a result of what happened to
items and asked to check a box if they ever experien- you, were you more concerned about the future of
ced the mistreatment incident during a diabetes care your illness?” Participants responded to these items
visit. A sample item includes, “The physician showed based on a Likert scale ranging from 1 “strongly di-
no interest in me or my health.” A cumulative expo- sagree” to 7 “strongly agree”. Higher scores reflect
sure to healthcare mistreatment score was derived by higher levels of distress. Reliability for the measure
summing the total instances of mistreatment endorsed was .69.
by participants (α = .81). Medical Avoidance. Participants indicated the ex-
Cultural Beliefs about Diabetes-Related Social Re- tent to which they “postponed or delayed going to
jection. Guided by the bottom-up cultural research their next diabetes care appointment,” as a result of
approach to instrument development (Betancourt the mistreatment incident. This item was based on
et al., 2010), qualitative interviews with 50 T2DM a 7-point Likert scale, with higher scores reflecting
patients in Chile were conducted to identify cultu- greater medical avoidance.
ral beliefs, values, expectations, and norms relevant Glycosylated Blood Glucose Level (HbA1c). Par-
to T2DM and treatment adherence. The bottom-up ticipants’ HbA1c levels were measured at the time
cultural research approach begins with specific obser- of data collection. HbA1c levels are indicative of
vations relevant to an area of research (e.g. treatment the long-term level of glucose in one’s blood. Higher
adherence), which are derived through interviews HbA1c levels reflect poorer diabetes control.
from the population of interest (e.g. Chilean diabetes Social Structural Sources of Cultural Variation. De-
patients), and evolves from these observations to the mographic information including age, gender, income,
development of quantitative instruments. An advan- and highest educational level, were self-reported on
tage of this approach is that it allows for the identifi- the demographic section of the research instrument.
cation of aspects of culture directly from individuals,
rather than based on stereotypical views. Procedures
One of the cultural factors that emerged from the Approval for the study was obtained from the public
bottom-up cultural research approach reflected cultu- university ethics committee for research and the regio-
ral beliefs about the social rejection of diabetes pa- nal office of the Chilean Ministry of Health (SEREMI
tients. Two close-ended items were developed to as- de Salud, Region de La Araucanía). Participants were
sess this cultural construct. Participants were asked to recruited through healthcare personnel and flyers pos-
think about diabetes patients and indicate the extent ted and distributed at public and private healthcare
to which they agreed with the following statements, centers. Individuals interested in participating con-
“diabetes patients feel left out by others at parties tacted the study research office. Potential participants
where there is eating and drinking,” and “diabetes were provided with information on the study and were
patients feel discriminated because of their disease”. screened to ensure they met the study inclusion crite-
Responses were recorded on a 7-point Likert scale an- ria. Eligible individuals were informed that their par-
chored at the extremes from “strongly disagree” to ticipation would involve answering a questionnaire

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 MISTREATMENT, CULTURE, AND DIABETES OUTCOMES
H. Betancourt and P. Flynn

that took 30-45 minutes to complete. They were also hypothesis via EQS 6.3 (Bentler, 1985-2017). The
told that they would receive free test-results of their data were screened revealing no outliers. Table 2
HbA1c level and would be compensated 5,000 Chi- includes the means, standard deviations, and corre-
lean pesos (approximately $10 USD) for their time. lations among the study variables. There was a vio-
Those interested in participating scheduled a time for lation of multivariate normality and hence robust
data collection and were provided with directions to model fit indices are reported. Adequacy of model fit
one of the data collection locations. was assessed using the non-significant χ2 goodness-of-
Two research assistants were present during data fit statistic, a χ2/df ratio less than 2.0 (Tabachnick &
collection, which included 4-6 participants per ses- Fidell, 2001), a Comparative Fit Index (CFI) of .95 or
sion. The research assistants reiterated the purpose of greater (Kline, 2015), and a Root Mean Square Error
the study, reviewed the informed consent form, and of Approximation (RMSEA) of less than .05, with the
obtained written consent from all participants. The upper limit of the 90% confidence interval less than
research assistants distributed the questionnaire and .10 (Kline, 2015). In conjunction with theoretical and
encouraged the participants to ask any questions for conceptual reasoning, the Wald and LaGrange test
clarification. If the participant was unable to read, statistics were reviewed to determine if eliminating or
one of the research assistants administered the ques- adding paths would improve model fit and if so they
tionnaire in a private setting. Once the questionnaire were implemented in a step-wise manner.
was completed, a trained research assistant obtained
the participant’s height and weight and administe- Results
red the HbA1c test. Lastly, participants were given
their HbA1c results and were provided with mone- A structural equation model including the hypothe-
tary compensation for their participation, which took sized theory-based relations among cumulative heal-
approximately one hour including processing time for thcare mistreatment, cultural beliefs about diabe-
the HbA1c. tes-related social rejection, medical treatment distress,
medical care avoidance, and HbA1c was tested. Age,
Statistical Analyses gender, income, and education were also included in
Structural equation modeling with Maximum Li- the tested model as sources of variation in the cultural
kelihood (ML) estimation was used to test the study factor. A review of the Wald test statistic suggested

Table 2
Correlations, Means, and Standard Deviations for Study Variables
1 2 3 4 5 6 7 8 9
1. Income —
2. Education .53** —
3. Age -.21** -.31** —
4. Gender .24** .21** .15 —
5. Healthcare Mistreatment .03 .03 .11 .11 —
6. Cultural Beliefs -.33** -.31** .08 .06 -.01 —
7. Treatment Distress -.30** -.27** -.05 -.04 .28** .17* —
8. Medical Avoidance -.13 -.10 -.09 -.04 .18* .03 .49** —
9. HbA1c .00 -.07 .00 .16 .12 .17* .14 .21* __
M 2.04 10.16 55.64 1.45 3.62 2.93 3.65 3.43 7.19
SD 2.12 3.94 14.41 0.50 2.34 2.08 2.25 2.52 1.94
*p < .05, **p < .01, ***p < .001.

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H. Betancourt and P. Flynn

eliminating the path from age to cultural beliefs. In Also consistent with the integrative model guiding this
addition, the LaGrange Multiplier Test indicated that research, lower income and education were predicti-
adding a path from gender and cultural beliefs to ve of higher scores on cultural beliefs about diabe-
HbA1c would improve model fit. Because these su- tes-related social rejection (β = -.30, p < .05; β = -.27,
ggestions were consistent with prior research emplo- p < .05), respectively. Males also reported higher scores
ying the Integrative Model, they were implemented in on cultural beliefs about diabetes-related social rejection
a step-wise manner. The resulting structural equation (β = .14, p > .05).
model including the hypothesized theory-based re-
lations fit the data well [CFI = .97; χ2 (34) = 42.91, Discussion
p = .14; χ2/df = 1.26; RMSEA = .04, 90% CI (.00,
.08); see Figure 2]. The study variables accounted for The test of the structural equation model including the
approximately 15% of the variance in HbA1c. theory-based structure of relations among healthcare
Consistent with the study hypothesis, greater expo- mistreatment, cultural beliefs, distress, and medical
sure to healthcare mistreatment and higher scores on avoidance as determinants of HbA1c, as a biological
cultural beliefs about diabetes-related social rejection outcome of T2DM, fit the data well. These results,
were associated with higher levels of treatment dis- along with the finding that cultural beliefs associated
tress (β = .32, p < .05; β = .24, p < .05), respectively. with the social rejection of T2DM patients influenced
Higher levels of treatment distress predicted greater HbA1, both directly and through its effect on the level
medical avoidance (β = .53, p < .05), which in turn of distress, are particularly significant. The fact that
predicted higher HbA1c (β = .22, p < .05). In addi- the way patients are treated by their healthcare pro-
tion, there was a direct effect of cultural beliefs about viders increases the level of treatment-related distress,
diabetes-related social rejection on HbA1c (β = .22, which in turn leads patients to avoid future medical
p < .05). Gender was also predictive of HbA1c such interactions thereby impacting health outcomes, has
that males had higher HbA1c levels (β = .19, p < .05). major implications for healthcare.

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Despite healthcare providers’ best intentions to Despite the significance of the study findings, there
deliver high quality care to minority and low SES pa- are limitations that must be considered. Specifically,
tients, it is possible that their biases and a lack of cul- even though the structure of hypothesized relations
tural awareness could unintentionally get in the way, included in the structural equation model are solidly
ultimately resulting in poorer quality medical inte- grounded in theory, the cross-sectional nature of the
ractions and worse outcomes for patients from those research must be noted. Hence, future research could
populations. This suggests that, in order to improve further advance knowledge in this area by using struc-
health outcomes for T2DM and other chronic disea- tural equation modeling to test similar hypotheses
ses, policies and interventions should include training with data from longitudinal research.
on cultural competence, interpersonal communication
skills, and the reduction of implicit biases in the heal- References
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MLR.0b013e318215d93c

DOI: https://doi.org/10.22201/fpsi.20074719e.2019.2.258 ACTA DE INVESTIGACIÓN PSICOLÓGICA. VOL. 9 NÚMERO 2 · AGOSTO 2019 13

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