We′ve come this far by faith: Faith and spirituality as a facilitator to self-care management of type 2 diabetes among African-American men

Abstract

Purpose: To explore and understand how the church, faith, and spirituality plays a role in type 2 diabetes management among African-American men (AA men). Materials and Methods: Participants (n = 19) were AA men ages 35-69 years, who were diagnosed with type 2 diabetes. Participants were recruited via community outreach efforts, including barbershops and churches located in predominantly African-American communities in southeast US. Upon the consent, individual interviews were conducted, audio-recorded and subsequently transcribed. Transcripts were analyzed using a phenomenological approach, and focused on identifying common themes among the descriptions of AA men′s experiences specific to type 2 diabetes. Results: Overall the participants from the present study stated that their faith in God as well as attending church does help them in their daily diabetes management. Interestingly, 2 of the 19 participants chose not to answer the faith and spirituality questions and 1 of the 19 stated that his faith was nonexistent. Conclusions: Diabetes self-management may be facilitated by incorporating the spiritual beliefs and virtues of AA men living with the illness. Little is still known, in general, about the process of how spirituality affects self-management of chronic illness. Further research should also focus on faith-based diabetes education among diabetics of all ethnic backgrounds.

African-American men - faith - self-management - spirituality - type 2 diabetes

Introduction

Type 2 diabetes is a major health problem for African-Americans and according the Centers for Disease Control and Prevention, diabetes is currently the seventh deadliest disease.[1] According to American Diabetes Association data, as of 2013, 4.9 million, or 18.7% of all non-Hispanic blacks aged 20 years or older, have diabetes.[2] Specifically, type 2 diabetes has and remains to hammer the African-American community especially hard. African-Americans are 2.7 times as likely to suffer from amputations and 2.5-5.6 times likely to suffer from kidney disease than any other ethnicity as a result of having diabetes.[2] A key factor that may prevent or reduce mortality and morbidity of the illness is following a self-management program of blood glucose, self-monitoring, diet, exercise, and medications.[3]

Self-management, defined as the knowledge and skills necessary to care of oneself, manage crisis, and change one′s lifestyle to manage illness successfully,[4] is an important aspect of controlling blood sugar levels. Over the last few decades, type 2 diabetes self-management has expanded from simply depending upon the medication to a more extensive structure that includes proper nutrition, regular physical activity, stress management and daily blood glucose monitoring. Spirituality is an integral part of African-American culture,[5] and may profoundly affect health care.[6] African-American spirituality is defined as an acknowledgement of a nonmaterial force that permeates all affairs, human and nonhuman.[7]

Spirituality also incorporates religion, which is commonly defined by African American scholars as a system of beliefs, and rituals about a god or gods, shared within a community.[7] [8] According to Mattis and Jagers,[7] religion, for African Americans is one, but not the only practical manifestation of spirituality. For many African-Americans, spirituality is as a source of support in managing diabetes.[9] [10] Some, however, may also turn their self-management practices over to God in lieu of following health provider recommendations.[11] [12] [13] This practice may be related to distrust of health care providers. Abrums reported that the African American studied did not trust physicians regarding their health. Lack of trust may lead to a disregard of physician′s recommendations and a tendency to rely on God to manage illness.[11] [12] [13] Historically, spirituality has served as a personal and communal source of liberation, solace, hope, meaning, and forgiveness, particularly in relationship to social, political, and economic injustices.[14]

Therefore, spirituality can be seen as part of the journey toward becoming whole and being healthy, notwithstanding someone′s personal motivation for seeking it. This study contributes to an expanding body of literature investigating the conjunction between religious faith and self-care management of type 2 diabetes. However, evidence is very limited regarding faith-based personal motivation (fatalism, religiosity, spirituality) as a mechanism for thwarting depressive symptoms among patients with diabetes.[15] The primary aim of this study is to explore and understand how faith and spirituality plays a role in type 2 diabetes management among African-American men (AA men).

The African-American church

Due to the amplifying evidence of ethnic and racial disparities among African-Americans, churches in the African-American community have reformed to be a major community-based location for health education, interventions, and health programs centered on faith. The church in the African-American community plays a historical role in meeting the educational, spiritual, social, civic and health needs of its members and the larger community.[16] The audience of the African-American church is a diverse group of people from all socioeconomic classes. Nonetheless, religion and spirituality is viewed by many African-Americans as a major cultural tie that bonds African-Americans together.[16] The leaders in the African-American church are pastors, nuns, bishops and priests and these individuals are situated to encourage, influence, and guide faith-based interventions.

The African-American church in recent years has emerged as a primary venue for health fairs, educational seminars covering a variety of health illnesses, and interventions due to the amount of African-Americans who are living and managing chronic health disparities. Some African-American churches have what is known as a “health ministry” whose purpose centers on the needs of children, women, and men, the sick and shut-in, and other auxiliaries that provide outreach services to its members and surrounding communities.[17] [18] [19] [20] [21] Having events and meetings that focus on chronic illnesses and disease declare the church′s commitment to health awareness, education, promotion and prevention. Social networks in the church are the result of familial, sociocultural, biological, denominational, and geographical connection.[16]

Selection and description of participants

The target population was AA men with a physician diagnosis of type 2 diabetes, who reside in the southern state of the U.S. The inclusion criteria were:

1. Participant was self-identified as African-American;

2. Age 18-70 years;

3. Physician-diagnosed with type 2.

Each participant selected their interview location. Most chose to conduct their interview at their place of residence. Two of the participants chose to have their interview at their place of employment due to convenience factors. At each interview location, the interviewer and participant sat face to face in a private location.

The final sample consisted of 19 AA men in Southeast Texas, of which most (68.4%) were over age 55 years. About 66% had lived with diabetes for 10 years or less. [Table 1] fully details relevant sociodemographic characteristics of the final sample. The age limit on the higher end was set as part of an attempt to include men who had been medically diagnosed with type 2 diabetes, but to exclude those who were living with and/or managing any other major chronic illness as it could confound the aims of the study. A community-focused recruitment strategy was used; Establishments with high-proportions of African American clienteles (e.g., barbershops, urban churches) were targeted. This strategy was combined with snowball sampling, which is used when researchers are coping with issues of access and sensitivity of the topic.[14]

Table 1 Participant Demographics

Age Range	N	Percent
34-44	2	10.5
45-54	4	21.1
55-64	6	31.6
65-70	7	36.8
Annual Income
<25,000	2	10.5
25,000-34,999	2	10.5
35-000-49,999	1	5.3
50,000-74,999	4	21.1
75,000-99,999	2	10.5
100,000-149,999	4	21.1
>150,000	4	21.1
Marital Status
Single	2	10.50
Married	14	73.70
Divorced	2	10.50
Widowed	1	5.30
Education Level
<High School	1	5.3
Some college but no degree	7	36.8
Associate’s degree	3	15.8
Bachelor’s degree	5	26.3
Graduate or professional degree	3	15.8
Living with T2DM
1-5 yrs	7	36.8
6-10 yrs	5	26.3
11-15 yrs	2	10.5
16-20 yrs	3	15.8
> 20 years	1	5.3
Don’t know	1	5.3
Ever attended Diabetes Education Class
Yes	9	47.4
No	10	52.6
Diabetes doctor visits per year
1-2 times per year	8	42.10
3-4 times per year	11	57.90

Phenomenological methodology

This study utilized a qualitative research design, specifically, a phenomenological research method. The focus of a phenomenological study according to Patton[21] lies in the “descriptions of what people experience and how it is that they experience.” The goal is to identify the essence of the shared experience that underlies all the variations in this particular learning experience. Essence is viewed as commonalties in the human experiences.[22] This type of research methodology is used to study areas in which there is little knowledge.[23] The original study′s primary focus was to gain a stronger understanding of the essence and lived experiences of AA men living with type 2 diabetes.

Instruments and data collection

The semi-structured interview guide was used to collect data concentrating on six areas: Diabetes management practices, knowledge and beliefs about diabetes, perceived barriers to diabetes management, social support, symptoms, and personal versus interpersonal feelings regarding diabetes management. However, one of the questions from the guide asked: “How does your church or faith in God help or support you with managing type 2 diabetes?” The focus of the present manuscript is to share the results of this question only as told by the participants, in the exact way that they each answered the question. Each interview was conducted using the following protocol:

• a. Read the consent form, discussed participants′ rights, and obtained informed consent,

• b. Requested the participant to complete the demographic profile questionnaire, and

• c. Performed the face-to-face recorded interview. Interviews lasted approximately 40-90 min.

Each participant was given the option to end the session at any time without penalty. At the conclusion of the session, each participant was given an incentive as a way of thanking them for their time and commitment to allowing the primary author to come and do an interview with them.

Data analysis

Fidelity to the phenomenon as it is lived means capturing and understanding it as perceived through the person living the situation.[24] Participants in this study told their own story and in their own terms. Therefore, excerpts from their transcripts were not edited or corrected, and are presented in their unique voice as originally recorded. [Table 2] shows all nineteen responses from the participants of this study in their own words.

Table 2 Illustrative quotes regarding the supportive role that the chruch or faith in god has in self-care management of type 2 diabetes among African-Amercian Men

Participant #	Response
1	”The church I go to have a lot of programs, but I don’t think… well I don’t know of any programs they have towards helping with diabetes. Because diabetes is the type of illness or disease that… people don’t talk about it a lot. You don’t go out and broadcast it… so umm… a lot of people might have it but I haven’t seen where the church has played a big role in diabetes awareness.”
2	”Awe man… that’s tremendously. My faith has increased by… I don’t know how much since finding out about diabetes and I’ve gotten closer to the Lord. There’s couple members at church that umm… we try and get on each other and make sure that we try and do the right thing when it comes to diabetes.”
3	”My church doesn’t know that I have type 2 diabetes. I’m not as religious as I use to be, but I’ve taken the attitude at this point in my life that what’s going to happen is going to happen, and I don’t worry about it. I just… that’s the way I feel right now. Now tomorrow I might be down crying, but so far, today, I just accept it.”
4	”Well… once again, they are very supportive.”
5	”Well… my faith umm…. There again, kinda tough… my faith is strong in allowing me to make the right decisions, I can say that. My faith was strong prior to me having diabetes.”
6	”Very much so. I’m catholic and I’m constantly in prayer in that I’ve asked him (higher power) for so many things in my lifetime and received them. I think that I have received the assistance that I’ve asked for in terms of diabetes. So it’s (faith in God) very much important to me.”
7	”It’s not really been talked about, but I’m sure that if I brought it up that the church would definitely be behind you with prayers and things like that.”
8	”That’s the whole central part of me being able to wake up every morning.”
9	”Awe man… you can probably see it all over me. Like I said, he (God) has ways of getting our attention. At first, I was going to church, but my mind wasn’t like mentally on the church. When I was there, my mind was always somewhere else. I feel like I wasn’t giving good the time that I really needed to. So I feel like he (God) said, “Hey, I got a way to get your attention. Since you don’t want to listen, you gonna come back to me.”, right… you know what I mean? I found about this here, I made a commitment to God in that hospital, and ever since then, it’s been fine.”
10	”Oh man… look man, don’t talk about that (laughing) I love church!! I love church! I love church man… I left my wife here one day. Talking bout’ she gone be late, I said alright… I left her right here! Yeah she was mad… got to the church and she told everybody that I left her. But imma tell you I love church… I don’t miss no church!”
11	”Well, God is always first and we know that things are going to happen in life, but in knowing and believing that you can overcome this, it’s not a death sentence so you pray and you ask for strength to actually, you know get on a better eating habit and exercise and do things so that’s religion plays a part in that.”
12	Chose to not anwser this question.
13	”I get brochures, I’ve not spoke about it church. They mention, but it’s me coming to them and not the other way.”
14	”Well that’s pretty much your first and last resort isn’t it. Without God, you can pretty much give it up.”
15	”I’d rather not answer that one.”
16	”Well that’s nonexistent for me.”
17	”They are really supportive. They are 100% supportive!”
18	“My personal walk with God I guess is at the top of the list. It helps me to keep myself humble. If I am humble, then I when hear when someone speaks to me and I’ll listen. At my church, they do have a wellness committee, in which they meet and they disseminate information on different things and they have had diabetes.”
19	”Yes indeed… so very important because I put my trust in him and of course there’s scriptures that come to mind about trusting him in all things, and that means also with my diabetes. And scriptures about no weapon formed against me… and diabetes can be a weapon. And those for me, faith and my walk with God and what I get from this verse and that verse… that strengthens me, that encourages me. So it extremely important and it’s critical, really!!It is critical because there are different parts to managing diabetes and think that is a part of it as well.”

Results

Lacking/chose not respond

Four of the nineteen participants chose not to say very much about their church and faith or chose not to answer the question at all. For example, participant 4 only responded with: “Well…once again, they are supportive”; while participants 12 and 15 chose not to answer the question pertaining how their church or faith help in diabetes support and management. Some people in our society may not participate in church or attend often so, therefore, their faith or church attendance may not have an impact on how they live or manage type diabetes. Interestingly, participant 16 responded with: “Well that′s nonexistent for me”. This participant did not offer any follow-up to his comment, but after listening to his interview further and from his demeanor when sitting in front of him asking this particular question, participant 16 appeared to have a disposition of not attending church regularly or have any interest in it whatsoever.

From [Table 2] above, there were diverse and interesting statements from the majority of the participants indicating that their church, their faith in God, or their spirituality in general, to some degree had a positive and influential role in helping them manage their type 2 diabetes. The other 15 participants had responses that were completely the opposite of participants 4, 12, 15, and 16. These responses were more centered on support, wellness committees, health ministries, prayer, and faith being important as well as tested. For an instance participant, 11 responded with: “Well, God is always first, and we know that things are going to happen in life, but in knowing and believing that you can overcome this, it′s not a death sentence, so you pray, and you ask for strength to actually, you know get on better eating habit and exercise and do things, so religion plays a part in that”.

Participant 18 responded with

“My personal walk with God I guess is at the top of the list. It helps me to keep myself humble. If I am humble, then I when hear when someone speaks to me, and I′ll listen. At my church, they do have a wellness committee, in which they meet, and they disseminate information on different things and they have had diabetes”. From these two responses, one can take away that to him, having type 2 diabetes doesn′t mean that life is over and that praying to God for direction and dedication toward making behavior changes for positive self-management is what helps these men.

Strength and encouragement

Other participants had responses in which their spirituality or faith in God helps to give them strength and self-encouragement with managing their diabetes. This is reflected in the following excerpts, participant 19 said: “Yes indeed… so very important because I put my trust in him (God) and of course there′s scriptures that come to mind about trusting him in all things, and that means also with my diabetes. And scriptures about no weapon formed against me… and diabetes can be a weapon. And those for me, faith and my walk with God and what I get from this verse and that verse… that strengthens me, that encourages me. Hence, it extremely important and it′s critical, really!!It is critical because there are different parts to managing diabetes and think that is a part of it as well”. Participant 6 shared with: “Very much so. I′m catholic, and I′m constantly in prayer in that I′ve asked him (higher power) for so many things in my lifetime and received them. I think that I have received the assistance that I′ve asked for in terms of diabetes. So it′s (faith in God) very much important to me”. Finally participant 2 stated: “Awe man… that′s tremendously. My faith has increased by… I don′t know how much since finding out about diabetes and I′ve gotten closer to the Lord. There′s a couple member at church that umm… we try and get on each other and make sure that we try and do the right thing when it comes to diabetes”.

Church/faith is not being a factor

Finally, five participants indicated through their responses that to them, the church has not had an active role in assisting them with managing type 2 diabetes. Some stated that this is because they have not shared or mentioned to anyone at their church that they have type diabetes or that it wouldn′t make a difference if they had shared about it. Others stated that their church or health ministry has education material and awareness programs, but that those programs and sessions have not focused on diabetes. One participant stated that his faith and spirituality were strong prior to his diabetes diagnosis, so, therefore, his faith did not increase solely because of becoming diabetic. These are expressed in the following excerpts:

Participant 1: “The church I go to have a lot of programs, but I don′t think… well I don′t know of any programs they have toward helping with diabetes. Because diabetes is the type of illness or disease that… people don′t talk about it a lot. You don′t go out and broadcast it… so umm… a lot of people might have it, but I haven′t seen where the church has played a big role in diabetes awareness”.

Participant 3: “My church doesn′t know that I have type 2 diabetes. I′m not as religious as I use to be, but I′ve taken the attitude at this point in my life that what′s going to happen is going to happen, and I don′t worry about it. I just… that′s the way I feel right now. Now tomorrow I might be down crying, but so far, today, I just accept it”.

Participant 5: “Well… my faith umm…. There again, kinda tough… my faith is strong in allowing me to make the right decisions, I can say that. My faith was strong prior to me having diabetes”.

Participant 7: “It′s not really been talked about, but I′m sure that if I brought it up that the church would definitely be behind you with prayers and things like that”.

Participant 13: “I get brochures, I′ve not spoke about it church. They mention it, but it′s me coming to them and not the other way”.

Discussion

Some of the participants of this study cited their personal faith, their church and/or their belief in a higher power as a meaningful resource for managing their diabetes, as well as substantial influence on their perceptions of the illness. More specifically, because of their strong faith, some participants didn′t see diabetes management as an overwhelming challenge. In 2000, a study of African-American women with diabetes identified the spirituality as an important positive influence in their day-to-day self-management and coping.[25] There is growing public and professional interest in integrating medical and spiritual approaches to healing,[26] and some recent research has begun to address relationships between spirituality and self-care.[27] Because of its chronic nature, diabetes may be especially amenable to approaches that acknowledge and incorporate spiritual beliefs. Patients with diabetes implement much of their own care and must find ways to integrate self-care behaviors into their daily lives.[28]

While several of the participants reported their faith and spirituality having a positive impact on their diabetes management, it is important to note that some participants chose not to respond to the question or responded, but stated that faith and spirituality had no impact on how they choose to manage their diabetes. For the record, just because someone does not attend church regular or choose to talk about their faith or belief in the higher power does not mean that they can′t manage and live with diabetes any more than a person, who does attend church regularly, have faith or have a strong level of spirituality. These individuals faith may lie within them to follow the proper self-management behaviors so that they can live as long as possible.

Based on their spirituality, many African-Americans view God as a major actor in their overall belief system related to health.[6] [29] Some perceive this relationship with God as a source of support in self-management practices that promote health and in managing their health care.[25] [30] In comparison are those who, although they use their relationship with God to help them manage their illness, might also partially or wholly relinquish control of their health care to God. Some of these persons might not choose to follow recommendations as set forth by their primary health care providers. Researchers have also found that spirituality is important in coping with diabetes. Samuel-Hodge et al.[25] noted that African American women mentioned asking God for help in controlling diabetes, and when faced with difficult problems, they would “turn it over to the Lord” (p. 930). Chin et al.[9] found that God played a central role in governing the lives of older AA men and women with diabetes. Anderson et al.[31] concluded that sources of support for AA men and women with diabetes were a strong belief in God, along with prayer, meditation, and support from church members.

More authors have found that some African Americans might turn their self-management regimens over to God. In Mathews et al.[12] study of African American women with advanced breast cancer, some of the participants believed that only God had the power to heal. Many of these women, therefore, chose to not follow the care and recommendations of a physician. In Chin et al.′s[9] study, one participant remarked that those who have a strong faith do not need to see a doctor, as God does the healing. Thus, spiritual faith might lead some African Americans with chronic illness to rely on God for healing and reduce or eliminate their responsibility for self-management. Therefore, spirituality is a critical consideration that should be considered in the arrangement of health care for AA men living with type 1 and type 2 diabetes.

A few participants in the present study stated at the time of their interview that even though they attend church on a regular basis, they have not disclosed with anyone that they have an illness so, therefore, no one at their church is aware that they are living with type 2 diabetes. The author argues that if perhaps members of the church, whether male or female, would share with the leadership of the church that they are living with a chronic illness, changes could be made in within the church to incorporate diabetes educational sessions. The church leadership could develop a health ministry group, whose focus would be to contact various health professionals (certified diabetes educators, general practitioners, diabetes specialist nurses, diabetes dieticians, and patient navigators) within their city, these individuals could come and speak at designated times to increase the awareness and education of diabetes and help educate those who are already living with the illness.

Conclusion

The focus of this manuscript was to explore and understand how the faith and spirituality plays a role in type 2 diabetes management among AA men. Little is still known, in general, about the process of how spirituality affects self-management of chronic illness. Further research should also focus on participants who are members of a variety of cultural backgrounds. In addition, most research has examined African-Americans with a Christian faith. There is a need to extend this research to African-Americans who are members of a variety of religious faith, as well as to those who are not members of organized religious groups.

More definitive work needs to be conducted to establish such studies. For example, this question from a large study that focused on self-care management experiences of type 2 diabetes, has shown that for some AA men, faith and spirituality are important resources in diabetes self-management. Nonetheless, the quantity or recurrence of such practices is not known. How much faith or spirituality and how often? Which biblical passages give support in self-management? Pilot research applying interviews and focus groups could produce the answers to such questions. For many AA men and African-Americans in general, spirituality is an important factor that impacts the self-care management of their diabetes. Another implication is that for some African-Americans, spiritual practices such as prayer, meditation, church attendance, reading the Bible, and church fellowship might be important resources in self-management.

The church is concrete location for health care professionals to promote and encourage diabetes awareness, education, and management programs due to how many African-Americans in general, are living with and managing diabetes. More and more African-Americans are joining the ranks of the underinsured or uninsured. Accordingly, it is imperative that health advocacy that develop knowledge and assist those living with diabetes to make healthy lifestyle choices be convenient, attainable, and sufficient within the African-American community. The church in the African-American community has historically and conventionally been the leader during dispiriting times and continues to be needed today.

With lacking government funding due to the national financial crisis of recent years, the church continues to be the primary structure providing essential services to the economically impoverished. Church support represents spiritual support, which translates into hope.[32] Diabetes educators, professionals and programs that recurrently collaborate with African-American patients, should be inspired to work with churches in order to design educational programs that incorporate faith and spirituality into prevention education.

How to cite this article: Sherman LD. We’ve come this far by faith: Faith and spirituality as a facilitator to self-care management of type 2 diabetes among African-American men. J Soc Health Diabetes 2015;3:26-32.

Source of Support: This study was funded, in part, by the Transdisciplinary Center for Health Equity Research (TCHER). TCHER is housed in the Department of Health and Kinesiology, College of Education and Human Development, at Texas A&M University. I gratefully acknowledge the study participants who gave of their time and showed me patience throughout the process.

Conflict of Interest

None declared.

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