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THE PERCEPTIONS OF MIDDLE-AGED, LOW‘INCOME OBESE
HISPANICS ABOUT THE RELATIONSHIP BETWEEN
OBESITY AND THE PERCEIVED RISK OF
DEVELOPING NON-INSULIN DEPENDENT

DIABETES MELLITUS (TYPE II)

BY

Suzanne Van Wieren

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF NURSING

College of Nursing

1981

ABSTRACT

THE PERCEPTIONS OF MIDDLE-AGED, LOW-INCOME OBESE
HISPANICS ABOUT THE RELATIONSHIP BETWEEN
OBESITY AND THE PERCEIVED RISK OF
DEVELOPING NON-INSULIN DEPENDENT
DIABETES MELLITUS (TYPE II)

BY
Suzanne Van Wieren

This pilot study explored the health beliefs of a
specific ethnic population, the Hispanics. The individual
perceptual variables of susceptibility, severity, benefits,
and barriers, as well as related modifying and motivational
variables were explored in order to further understand
factors which affect an individual's perceptions of the risk
of developing diabetes mellitus (Type II).

Both descriptive and inferential statistics were used
to analyze the data. Significant correlations were found
between increasing age and barriers; increasing age in males
and both susceptibility and barriers; increasing age in
females and benefits; increasing age in females and negative
susceptibility; increasing family develoPmental stage and
barriers; and motivational "cues to action" and negative
susceptibility.

A major implication drawn from the research findings

was the need for training culturally sensitive health care

Suzanne van Wieren

providers who could develop and implement health teaching
tools and methods which were firmly grounded in cross-
cultural nursing theory, and which reflected the individual

perceptions of the client.

To Jerry with all my love

ii

ACKNOWLEDGMENTS

Sincere thanks to my committee members Barbara Given,
Ph.D., chairperson, Louise Brouillette, M.P.H., Nancy Kline,
M.N., and Brigid Warren, M.S.N. for their support, guidance,
and unfailing encouragement during the research project.

To Connie Marin, R.N. of the Cristo Rey Health Clinic
without whose support the project would not have been
possible, a special thanks for her effort as a cross-
cultural resource person and in providing contacts with
subjects. To Thomas Ziegler, M.S., nutritionist and medical
student for his expert advice and support and to Rob Hymes
for his expertise in statistical analysis.

I am grateful to all the Hispanics in the local com-
munity who Opened their thoughts and homes to me in support
of my educational goal. A special thank you to my husband,
Jerry, for his support and encouragement throughout my

graduate education.

iii

 

TABLE OF CONTENTS

LIST OF TABLES O I O O O O O O O O O O 0

LIST OF FIGURES. O O O O O O O O O O O 0

Chapter

I.

II.

THE PROBLEM. . . . . . . . . . . .
Introduction. . . . . . . . . . .
The Hispanics as a Minority Group. . . .
The Prevalence of Poverty Among Hispanics .
Obesity as a Medical and Social Risk

Factor . . . . . . . . . . . .
The Prevalence of Obesity Among Low-Income
and Ethnic Populations. . . . . . .
The Prevalence of Obesity Among Hispanics .
The Prevalence of Diabetes Among Hispanics.
The Study of Health Beliefs Within a Low-
Income Population . . . . . . . .
Purpose of the Study . . . . . . . .
Statement of the Problem. . . . . . .
Research Questions. . . . . . . . .
Definitions of Terms . . . . . . . .
Limitations of the Study. . . . . . .
Assumptions . . . . . . . . . . .
Overview of the Chapters. . . . . . .
CONCEPTUAL FRAMEWORK. . . . . . . . .

mmndav. . . . . . . .
The Health Belief Model . .
Perceived Susceptibility. .
Perceived Severity. . . .
Perceived Benefits. . . .
Perceived Barriers. . . .
Modifying Factors . . .
Motivational “Cues to Action" . .
Nursing Theory . . . . . . .
Summary . . . . . . . . .

iv

Page
vii

ix

\lO‘Ul La) WNH l-‘

Chapter

III.

IV.

V.

THE LITERATURE REVIEW

Overview. . .

The Preventive Health Belief Model
The Health Belief Model and Preventive
Health Behavior.
Motivational and Modifying Variables in
Relation to the Health Belief Model . .
Perceived Susceptibility and Perceived

Severity . .

Perceived Benefits and

Reduction. .

Health Beliefs and

Summary . . .
METHODOLOGY . .

Overview. .
Sample . .

Obese . .
Middle-aged
Low-income
Hispanic .

Setting . . .
Instrument . .

Operational Definitions

Variables .

the

Barriers to Weight
Hispanic . . . .
of the Study

Validity of the Instrument
Reliability of the Instrument .

Pretest of the Study Questionnaire
Date Collection Procedure

Scoring . . .

Procedures for Data

Summary . . .
DATA PRESENTATION

Overview. . .

Research Questions
Descriptive Data .

Age. . . .
sex. I O 0

Analysis

Family Developmental
Family History of Diabetes
Additional Descriptive Data.

Stage

Page

97
101
103

104
105
106
109
110

111

111
111
113

113
114
114
114
115

Chapter

Reliability of the Instrument .
Presentation of Data Related

VI.

SUMMARY,
FINDINGS .

Research

Research
Research
Research
Research
Research
Research
Research

Summary .

Overview .
Summary and Interpretation

Research
Research
Research
Research
Research
Research
Research

Limitations of

Sample .

Questions .

Question
Question
Question
Question
Question
Question
Question

Question
Question
Question
Question
Question
Question
Question

Instrument. . .

Analysis

1.
2.
3.
4O
5.
6.
7.

INTERPRETATION,

1.
2.
3.
4.
5.
6.
7.

Implications for

Recommendations for Future Research
Summary

APPENDICES
Appendix

A.
B.
C.
D.
E.

BIBLIOGRAPHY.

AND

IMPLICATIONS OF

of

the Findings.

t0

the

Findings

Nursing Practice.
Implications for Nursing Education

Height-Weight Table .
Low-Income Classification .
Pilot Test . .
Sociodemographic Data and Ins
Consent Letter and Human Rights Protection

vi

trument

Page
118

120

120
121
122
122
123
123
127

128

130

130
130

131
133
135
137
139
140
146

148

148
150
151

152
157
159
161

164
165
166
167
174

184

Table

1.

2.

lo.

11.

12.

13.

14.

15.

LIST OF TABLES

Subjects by Age Category . . . . . . .
Sex of Subjects . . . . . . . . . .
Family Developmental Stage . . . . . .
Family History of Diabetes . . . . . .
Birthplace of Subjects. . . . . . . .
Religious Preference of Subjects . . . .
Marital Status of Subjects . . . . . .
Number of Children Among the Subjects. . .

Total Score Distributions on the Six-Point
Likert Scale . . . . . . . . . .

Standardized Reliability Coefficient Alphas.

T-test for Independent Samples for Suscepti-
bility, Severity, Benefits, and Barriers .

Pearson Product-Moment Correlation Matrix for
Susceptibility, Severity, Benefits, and
Barriers. . . . . . . . . . . .

Pearson Product-Moment Correlation Matrix of
Age and Sex With Susceptibility, Severity,
Benefits, and Barriers . . . . . . .

Chi-square Values for Age and Sex in Relation
to Susceptibility, Severity, Benefits, and
Barriers. . . . . . . . . . . .

Pearson Product-Moment Correlation of Family

Developmental Stage With Susceptibility,
Severity, Benefits, and Barriers. . . .

vii

Page
113
114
115
115
116
116
117
117

119

119

121

124

125

125

126

Table Page

16. Pearson Product-Moment Correlation of Family
History of Diabetes With Susceptibility,
Severity, Benefits, and Barriers . . . . . 127

17. Pearson Product-Moment Correlation of Motiva-
tional "Cues to Action" With Susceptibility,
Severity, Benefits, and Barriers . . . . . 128

18. T-test for Independent Samples for Motivational
"Cues to Action" and Its Three Components;
Powerful Others, Chance, and Lay or Scientific
Practitioners . . . . . . . . . . . 128

viii

LIST OF FIGURES

Figure Page
1. Health Belief Model . . . . . . . . . . 29

2. Comparison of Health Belief Model and
Transcultural Nursing Model. . . . . . . 49

3. Decision Tree Model . . . . . . . . . . 153

4. Modified Health Belief Model . . . . . . . 163

ix

CHAPTER I

THE PROBLEM

Introduction

 

Individuals whose first language is Spanish, Hispanics,
comprise a sizable minority in the United States today
(Spector, 1979). Both obesity and non-insulin dependent
diabetes mellitus (Type II) have been identified by health
care providers as significant threats to health within the
Hispanic culture. In order for health professionals to com-
municate effectively the potentially negative effects of
marked obesity upon a specific ethnic population, it is
necessary for the provider to possess knowledge of the
cultural norms of the ethnic group and to be cognizant of
potential cultural barriers within the ethnic group which
may hinder the effective application of conventional health
teaching programs.

This research study focused upon the perceived effect
which obesity has upon the development of diabetes within
an Hispanic population. In order to provide a cultural
framework for studying obesity among the Hispanic pOpula-

tion, common health beliefs and attitudes toward health

care were examined. Obese low-income Hispanics were inter-
viewed to determine their perceived susceptibility to
diabetes, the perceived severity of diabetes as a disease
entity, and the perceived benefits and barriers to weight
reduction as a preventive health care action. Both cultural
norms and individual variations in belief were explored in
order to propose the development of culturally relevant
teaching methods to aid in reducing the threats of obesity

and diabetes within the Hispanic pOpulation.

The Hispanics as a Minority Group

 

The United States Department of Commerce Current Popu-
lation Reports state that as of March 1979, there were 12.1
million persons of Hispanic origin in the United States;
including 7.3 million Mexican-Americans; 1.7 million Puerto
Ricans; 800,000 Cubans; 800,00 Central and South Americans,
and 1.4 million designated as "other." Thus, Hispanics
comprise over 5% of the present United States population.
Census projections for 1977 stated that by the mid-19805
Hispanic individuals would surpass the number of Blacks and
would become the largest single minority group in the United
States (Spector, 1979).

The majority of Hispanics reside in the southwestern
United States, but sizable p0pulations also exist in other
states, notably Florida and New York. In Michigan, in 1979,
there were 193,000 HiSpanics, who comprised 2.1% of the
population as compared to 1.7% in 1970 (United States

Department of Commerce, 1979). While the southwestern

Hispanics are mainly of Mexican origin and the eastern
Hispanics are of Cuban or Puerto Rican origin, the Hispanic
pOpulation in Michigan is varied, with Cuban, Puerto Rican,
and central American populations in the major cities, and
many persons of Mexican heritage scattered throughout the

state, especially in the agricultural centers.

The Prevalence of Poverty Among Hispanics

The prevalence of poverty is higher among Hispanics
than among the general United States population. In 1969,
the number of families below the official United States
poverty line was five times greater among Hispanics than
non-Hispanics (Spector, 1979). For a non-farm family of
four in the United States in 1981, the average poverty
threshold was set at $8,449. At this level, 20.4% of all
Hispanics fell below the poverty line (United States Depart-
ment of Commerce, 1979). Thus, the Hispanic population
contains a disproportionately high number of low-income

persons.

Obesity as a Medical and Social Risk Factor

 

Obesity is an ever increasing phenomenon in the United
States, associated with both a decrease in hard physical
labor and exercise, and with an abundance of material
resources (Mayer, 1975). Using standard indicators for
obesity, it has been estimated that between 30 and 40% of
the American population at present is obese (Nuttall, 1979).

Although current research indicates that mild to moderate

obesity may not present any serious health risks (Andres,
1980), marked obesity, greater than 20-30% over average
weight for height, may be a precursor to a host of medical
and/or social maladies.

Medically, obesity has been implicated in the incidence
of diabetes mellitus (Type II), osteoarthritis, varicose
veins, hernias, and gallbladder disease (Albrink, 1975).
Obesity may also lead to increased mortality rates resulting
from the develOpment of diseases such as diabetes (Mitchell,
Rynberger, Anderson, & Dibble, 1976).

Socially, while the incidence of obesity is rising, the
media has portrayed the ideal of "youthful slenderness" as a
goal to be attained and maintained by middle-aged individuals.
While obesity (especially in women) may be valued in a
number of traditional societies, it is discouraged in the
image of the present day American (Powdermaker, 1973)
Overweight is often viewed as "sin" or as a disease by the
mass media (Allon, 1973). Obesity may lead to discrimina-
tion in employment and social relations (Martin, 1977).
Obese individuals have been the objects of social stigma
due to peer opinion that, unlike other physical infirmities,
they are to blame for their condition (Bray, 1976).

It may be argued that the preceding description of the
social stigma of obesity is relevant only among white,
middle and upper-class Anglo Americans, and that obesity
carries no such powerful negative image among the predomi-

nately low-income Hispanic population (Schulman & Smith,

1963). Allon (1973), however, stated that although differ-
ences in the perception of obesity exist among various
ethnic, racial, and religious groups, it appears that con-
cern about the social consequences of overweight is now
cutting across all socioeconomic lines, especially among

the younger age groups. Allon advocated the need for further
research into the effect that racial, ethnic, or religious
status had upon the perceptions of obesity. The present
research study's emphasis upon perceived benefits and per-
ceived barriers to weight reduction was designed to investi-
gate ethnic effects upon perceptions of obesity and thus may
contribute to the body of knowledge regarding obesity and
ethnic identity.

The Prevalence of Obesity Among Low-Income
and Ethnic Populations

 

There is an increased prevalence of obesity among low-
income persons. Goldblatt, Moore, and Stunkard (1965) found
obesity six times as prevalent among low-income women than
among upper-income women and two times as prevalent among
men in a non-random sample in New York City. Silverstone,
Gordon, and Stunkard (1969) and McLean, Baird, Silverstone,
Grimshaw, and Ashwell (1975) reported similar findings of
increased obesity among the lower social classes, especially
among women.

The Ten State Nutrition Survey (1972); Garn, Bailey,
Cole, and Higgins (1977); and Kohrs, Wang, Eklund, Paulsen,

and O'Neal (1979) all found that increased skinfold fatness

in females was inversely related to income, while obesity
increased with income for males. Silverstone et al. (1969)
suggested that low-income men were less prone to obesity

due to the hard manual labor they often perform. Oken,
Hartz, Giefer, and Rimm (1977) postulated that obesity in
women due to weight changes brought on by repeated child-
bearing was primarily related to the low-income groups.
Regardless of the origins of the obesity, the evidence indi-
cates that obesity is prevalent among low-income populations
and is more common among women.

Ethnic identity was also correlated with obesity by
Srole, Langner, Michael, Kirkpatrick, Opler, and Rennie
(1978). Various ethnic groups were examined (including
Puerto Ricans, a subset of Hispanics) with the resulting
evidence showing that obesity was more prevalent among
recent low-income immigrants to the United States, than
among third or fourth generation Americans.

From the above evidence, it may be concluded that the
low-income Hispanic population (especially recent immigrants
and women) is more prone to obesity. The actual evidence

attesting to this hypothesis follows.

The Prevalence of Obesity Amonngispanics
Chase, Kumar, Dodds, Sauberlich, and Hunter (1971);
Yanochik-Owen and White (1977); Larson, Dodds, Massoth, and
Chase (1974); and Ziegler (1980) found obesity to be pre-
valent among Hispanic children, particularly among girls.

Seventeen percent of the 40,000 low-income persons studied

in the Ten State Nutrition Survey (1972) were Hispanic.
Obesity was found to be widespread among the adult women,
children, and adolescents. Kaufman, Lewis, Hardy, and
Droulx (1973); and McGanity (1969) found obesity prevalence
rates of up to 40% among their adult Hispanic samples.
Overall, these studies found a higher prevalence of obesity
among Hispanic women than among men, which is similar to the
findings of the general low-income and ethnic studies. The
Hispanic p0pulations studied ranged from first generation

in the United States to those individuals whose families had
resided in the southwestern United States for centuries, but
data were not available correlating length of residency with

obesity.

The Prevalence of Diabetes Among Hispanics

Since obesity is a precursor of non-insulin dependent
diabetes mellitus (Type II), it can be postulated that any
p0pulation with a high incidence of obesity may be at in-
creased risk for the development of Type II diabetes. The
almost uniformly obese Pima Indians of Arizona have the
world's highest known incidence of Type II diabetes (over
30% of adults) (Knowler, Bennett, Bottazzo, & Doniach,
1979; West, 1972).

A host of studies have confirmed a relationship between
obesity and diabetes, and have described the incidence and
prevalence of Type II diabetes in various populations around

the world including the central Pacific, Haiti, Israel, the

Eskimos, the Cherokees of North Carolina, and Central
America (Zimmet, Taft, Guinea, Guthrie, & Thoma, 1977;
Charles & Medard, 1969; Cohen, 1961; Mouratoff, Carrol, &
Scott, 1967; Stein, West, Robey, Tirador, & McDonald, 1965;
and West & Kalbfleisch, 1970). However, no descriptive
studies have been conducted investigating the incidence or
prevalence of diabetes among Hispanics in the United States.

United States government health statistics revealed
that in 1973 the prevalence rate for diabetes for whites
in the United States was 19.9 per 1,000 population (1.9%),
and for non-whites was 23.9 per 1,000 population (2.3%)
(Rudov & Santangelo, 1979). A review of government and non—
governmental health statistics records revealed that data
regarding diabetes were only recorded according to the white/
non-white criterion, and that no separate data on minority
subgroups were reported (Michigan Department of Public
Health, 1979; Bureau of Census, 1979). As Hispanic is a
linguistic and not a racial categorization, no specific
information on Hispanics was reported. However, it was
reported that the prevalence of diabetes varied widely with
different population and ethnic groups and was markedly
higher among low-income groups. For persons with incomes
less than $3,000, the prevalence rate was 249% higher than
for persons with incomes greater than $15,000 (Rudov &
Santangelo, 1979).

In order to gather relevant statistics on the Hispanic

population, it would be necessary to separate the data

according to white, black, and native American categories

to rule out the influence of possible racial factors in

the rates. Because of the complexity of that task, it is
not surprising that no specific statistics are available for
diabetes among Hispanics.

The Study of Health Beliefs Within a
Low-Income Population

 

The present research explored the health beliefs of a
low-income, ethnic population regarding obesity and its
role as a precursor of chronic disease, specifically diabetes.
Rosenstock (1969) described the preventive Health Belief
Model and how its components of perceived susceptibility,
perceived severity, perceived benefits, and perceived
barriers related to a specific health action designed to
prevent disease. Research studies based upon the preventive
Health Belief Model found that those persons who took pre-
ventive action and participated in programs to improve their
health tended to be young, white, female, well-educated,
and of high socioeconomic status (Rosenstock, 1974). Using
this data, the preventive Health Belief Model might be
assumed to have only limited applicability to low-income
persons of ethnic origin.

Rosenstock (1969) supported this contention when he
assumed that the low-income person existed in a distinct
"culture of poverty." The concept of a subculture of
poverty with its own cultural attributes was first described

by social scientists who sought to explain the behavior they

10

observed in ghetto areas such as laziness, lack of ambition,
and irresponsibility (Warner, 1962; Davis, 1948; Davis,
Gardner, & Gardner, 1941), by using a cultural, rather than
socioeconomic, argument to define the origins of the observed
behavior. Lewis (1959; 1961; 1968) designated the term
"culture of poverty" to the most deprived, poorest, and dis-
organized of the lower class, those he felt had little or

no hope of escaping a cycle of poverty. Harrington (1962),
the theoretical architect of the federal government's so-
called "war on poverty," stated that poverty itself creates
a culture which then becomes self-perpetuating and which
denies access to increased affluence to those caught in the
cycle. The individual within the "culture of poverty" was
described as having a low level of aspiration, feelings of
hopelessness, and feelings that life is controlled by fate
(Bullough, 1972).

Rosenstock (1969) applied the concept of "culture of
poverty" to health beliefs by stating that the poor tended
to not possess the beliefs which would lead to preventive
health actions. The poor were seen as having less knowledge
of the disease process and less ability to plan for the
future. Rosenstock hypothesized that the origins of health
behavior by the poor might have arisen out of economic
deprivation, but that now the "culture of poverty" had its
own self-perpetuating structure. Removal of economic
barriers alone would not lead to increased utilization of

health care services by the poor, because they felt bypassed

11

by the professional health care system and were more com-
fortable with a lay or folk health care system (Rosenstock,
1969).

Since its inception, much criticism has been directed
at the concept of "culture of poverty." The "culture of
poverty" concept asserts that the deprived possess different
attitudes and perceptions about life and health than the
more affluent population. Valentine (1968) defined poverty
as "a condition of being in want of something that is needed,
desired, or generally recognized as having value" (p. 12)
and stated that "the essence of poverty is inequality and
relative deprivation" (p. 13). Valentine argued that refer-
ences to "culture of poverty" and all other attempts to
categorize the poor as a separate cultural group contradicted
the positive meaning of the concept of culture and denied
the basic injustices which result in poverty. He suggested
that the poor have similar cultural values to the middle
class, but that these have been modified due to situational
stress. Thus, the lack of attention to preventive health
care which Rosenstock (1969) pointed to as a symbol of
"culture of poverty" may in fact be more indicative of a
different set of financial priorities due to necessity,
rather than of a different set of cultural beliefs.

Alternative theories to the "culture of poverty," also
developed in the 19605, emphasized the examination of
economic, political and structural features of society

rather than beliefs or values (Harris, 1968). Kupferer

12

(1962) found that behavioral differences in matters of
health.were more closely related to social class than to
acculturation and advocated economic reform to improve
health status rather than attempting to change cultural
beliefs. Valentine (1968) cautioned that the poor should
not be lumped together indiscriminately, but that ethnic
differences should be explored, in order to differentiate
between cultural and socioeconomic causes of behavior.
Nursing research has also emphasized the need for both
socioeconomic and cultural studies concerning health beliefs
and practices (Dorsey & Jackson, 1976; Spector, 1979).
Bullough (1972) studied the impact of social alienation in
three forms; powerlessness, hopelessness, and social isola-
tion, as barriers to preventive health care. This social
alienation was thought to have deve10ped out of poverty.
Boyden-West (1980) studied both ethnic and poverty issues
and differed from Rosenstock in that Boyden-West attributed

a difference in knowledge due to cultural variation, rather

 

than a lack of knowledge, as being the prime factor in the
variance among health beliefs within different populations.
Both Bullouth and Boyden-West subscribed to a modified
theory of the "culture of poverty" which they related to
both economic poverty and to minority status in the United
States.

In conclusion, controversy exists as to whether the
"poor" are different than other members of society in ways

other than socioeconomic. Most early research focused on

13

individual beliefs and values, while more recent researchers
have emphasized the need for a more thorough investigation
into the causes of poverty. The present research was under-
taken with the understanding that the low-income Hispanic
population is beset by both economic and cultural barriers
to preventive health care. However, the concepts that these
individuals are hopelessly caught in a "culture of poverty"
which defeats all attempts at self-care, or that these
individuals are necessarily different because they are poor
are rejected by this researcher. Even Rosenstock (1974)
conceded that individual variance, within low-income and
ethnic groups, existed and that individual health beliefs
could override specific socioeconomic and cultural barriers
to preventive health behavior.

Therefore, the present research focused on the study
of individual Hispanics and their health beliefs, while
acknowledging and studying the impact of both socioeconomic
and cultural identity upon perceptions of health. Based on
the knowledge generated, appropriate nursing interventions
can be proposed which are sensitive to the needs of the

Hispanic population.

Purpose of the Study

 

This research study focused on the health beliefs of a
specific ethnic population and on the effect these beliefs
may have upon possible preventive health care behavior.
Middle-aged, low-income obese HiSpanics, at risk to develOp

diseases such as diabetes, are affected by a number of

14

subjective factors which may inhibit attempts at weight
reduction. These factors include individual perceptions
about the risk of developing a disease as the result of
obesity, about the potential severity of the disease pro-
cess, and about emotional, physical, and socioeconomic
benefits and barriers to weight reduction. Collection of
subjective data about these factors can aid in the develop-
ment of weight reduction teaching programs which are as

individually and culturally barrier free as possible.

Statement of the Problem
What are the perceptions of middle-aged, low-income
obese Hispanics about the relationship between obesity and
the perceived risk of develoPing non—insulin dependent

diabetes mellitus (Type II)?

Research Questions

 

1. Does the middle-aged, low-income obese Hispanic
perceive that he/she is susceptible to develop
non-insulin dependent diabetes mellitus (Type II)?

2. What is the perceived severity of Type II diabetes
mellitus among middle-aged, low-income obese
Hispanics?

3. Are there perceived benefits to weight reduction
among middle-aged, low-income obese Hispanics?

4. Are there perceived barriers to weight reduction

among middle-aged, low-income obese Hispanics?

15

5. What are the relationships between perceived
susceptibility to and perceived severity of disease,
and perceived benefits and perceived barriers to
weight reduction?

6. What are the relationships between the modifying
variables of age, sex, family developmental stage,
and family history of diabetes, and the main per-
ceptual variables of susceptibility, severity,
benefits, and barriers?

7. What are the relationships between the motivational
"cues to action" and the main perceptual variables

of susceptibility, severity, benefits, and barriers?

Definitions of Terms

Obesity--A1though there is much controversy over the
Operational definition of obesity, most definitions linked
skeletal size and body weight. Bray defined obesity in
terms of an energy balance, an excess caloric intake relative
to caloric expenditure, which results in the storage of fat
(Texter, 1977). Obesity may also be defined as a bodily
state in which there is an excessive accumulation of fat in
both the absolute and relative sense or as body weight
greater than is consistent with body build (Kiell, 1973).
Mayer made a distinction between obesity, which is a patho-
logical accumulation of weight much beyond normal, and over-
weight, which is body weight in excess of average (1980).

To determine obesity in the individual, the appearance

of the naked person is often sufficient for a qualitative

l6

diagnosis to be made. When quantitative data are desired,

the easiest and most commonly used guidelines are height-
weight tables such as those of the Metropolitan Life Insurance
Company based on data reported in 1959 or the tables of the
1960-1962 health survey of the United States Department of
Health, Education, and Welfare (Mayer, 1980). The indi-
vidual's weight is compared to a standard weight determined
for height, sex, and age. Overweight is generally defined

as up to 20% over the standard, and obese is greater than

20% over the standard weight.

There are both limitations and benefits to utilization
of the height-weight tables. Although the tables are cate-
gorized into different body builds, no criteria are given
for determination of body build. The tables also cannot
distinguish between muscle weight and true adiposity, there-
fore a muscular athlete and a sedentary overweight indi-
vidual may both be typed as obese without adequate descrip-
tion of the source of the extra poundage (Mayer, 1980).

The major benefit of the height-weight tables is the
ease with which they can be utilized compared to more
scientific measurements of body fat such as the measurement
of skin-fold thickness with calipers of the use of whole
body specific gravity (Albrink, 1975). Exact as the latter
methods may be, they are not crucial to a study of adults
which does not require an exact percentage of obesity. For
the purpose of this study, the ease of utilization combined

with a good "estimate" of body weight in a general adult

17

population resulted in the decision to use the tables of
the United States Department of Health, Education, and
Welfare, 1966 (Appendix A). Obesity was defined as 20%

over the standard weight for height.

Non-insulin dependent diabetes mellitus (Type II)--The
traditional nomenclature for non-insulin dependent diabetes
has been adult-onset or maturity-onset diabetes. In accor—
dance with the National Diabetes Data Group classification
of 1979, the designation was changed to non-insulin dependent
diabetes mellitus or Type II. Within this category, there
are two subsets, obese and non-obese. For the purpose of
the present study, only the obese non-insulin dependent
diabetes was considered.

In Type II diabetes, the pancreas possesses a diminished
islet cell reserve of insulin. The relative insulin defi-
ciency and consequent decreased tolerance to glucose may
only become apparent when an external factor such as obesity
exerts an extra demand on the pancreas for insulin (Albrink,
1975). Type II diabetics are not prone to ketosis and
generally do not require insulin replacement unless diet or
oral agents do not control their fasting blood glucose. The
Type II diabetic may be asymptomatic and non-detected for
years and even decades, yet is subject to the same systemic
disease manifestations (macroangiopathy, microangiopathy,
neuropathy, and cataracts) as the insulin dependent diabetic

(National Diabetes Data Group, 1979).

18

The etiology of Type II diabetes involves several
factors. There is a genetic basis for the disease, which
appears stronger than for insulin dependent diabetes.
Environmental factors interacting with genetic predisposition
account for many occurrences of the disease. Excessive
caloric intake leading to weight gain and obesity are impor-
tant etiologic agents. It has been estimated that between
60 and 90% of all Type II diabetics are obese in Western
society. Although the most common onset is after age 40,
the disease may occur at any age. In obese persons with
Type II diabetes, glucose tolerance and hyperglycemia are
often improved by weight loss (National Diabetes Data Group,
1979).

The National Diabetes Data Group (1979) stated that a
diagnosis of diabetes should be based on one of the follow-
ing:

1. Unequivocal elevation of plasma glucose concentra-

tion together with the classical symptoms of

diabetes.

2. Elevated fasting plasma glucose concentration
(above 140 mg/dl) on more than one occasion.

3. Elevated plasma glucose concentration after an
oral glucose challenge on more than one occasion.

The definitive diagnosis of diabetes has often been
made from the results of the glucose tolerance test. How-
ever, Siperstein (1979) argued that the glucose tolerance
test may be an inaccurate predictor of hyperglycemia and may
have caused many individuals to be falsely labeled as

diabetic. The National Institute of Health, on the basis

19

of Siperstein's work, stated that persistent (at least two)
fasting plasma glucose levels in excess of 140 mg/dl are a
reliable diagnostic indicator of diabetes (1979). Since the
label of diabetic may carry a serious social stigma (in-
creasing insurance rates, and possible job and other dis-
crimination) and often requires drastic changes in habits,

an accurate diagnosis is essential.

Middle-aged--The middle-aged adult was chosen for study

 

in the present research for two reasons; the potential impact
of family developmental stage upon perceptions of obesity
and disease risk and the typical age of onset of Type II
diabetes. Stevenson (1977) defined early middle-age or
middlescence I as age 30 to 50. During this life stage, the
individual is concentrating on childrearing and launching
the children into society, as well as achieving personal and
occupational goals. According to Duvall's (1977) eight
stages of family development, the family progresses smoothly
from the early stages of establishing the marital unit and
childbearing, to childrearing and the launching of children
into society. The Duvall model is based on the presupposi-
tion that childbearing will occur during a fairly short span
of time, thus allowing the children to progress almost
simultaneously through the various stages of development.

In contrast, within the Hispanic culture, it is common
to begin childbearing at a young age, to have a large family,
and to bear the last child at an older age (Clark, 1970).

Therefore, the tasks of raising and launching the family,

20

very important in the Hispanic culture, are prolonged in
comparison to Stevenson's definition of middlescence I.

The Hispanic family may be involved in several stages of
development at one time, such as caring for preschoolers
and launching teenagers. These family demands may preoccupy
the Hispanic individual to the extent that individual goals
are difficult to focus on. Thus, the Hispanic middle-aged
person may not have the time or energy to be concerned with
obesity and its risk factors. Likewise, the ability to
adhere to a diet regimen may be severely compromised when
meals must be prepared for a large family with varied
schedules. Even with these deterrents to the perception of
the potential seriousness of obesity, it is important to
study the middle-aged Hispanic because of the typical age
of onset of Type II diabetes mellitus.

Aging is an important factor in the incidence of both
obesity and Type II diabetes. Silverstone stated that
average weight increases with age as does the incidence of
significant obesity (1973). The Metropolitan Life Insurance
Company tables documented an increase in weight in advancing
years (Mayer, 1980), and the National Center of Health Sta-
tistics for the Public Health Service stated that the maximum
average weight for men is attained between the ages of 35
and 54 and for women between 55 and 64 (Mayer, 1980). The
National Diabetes Data Group (1979) defined Type II diabetics

as generally over 40 years of age.

21

The above data have shown that it is important to study
obesity in middle-aged Hispanics both because the middle-
aged Hispanic may have many family stressors which contri-
bute to obesity and difficulty in weight reduction and
because the incidence of both obesity and Type II diabetes
increase with advancing age. For the present research the
age range of 30 to 60 was chosen to define middle-aged.

The upper limit was extended from Stevenson's age 50 for
middlescence I because of the tendency to bear the last child
at an older age among the Hispanic population, and thus to
prolong the stage of childrearing and launching into society.
Since it is the youngest child who determines how long the
couple will be responsible for childrearing, it was also the
age of the youngest child which was used to determine the

family developmental stage.

Low-income--In March 1981, the federal government's

 

poverty threshold for a non-farm family of four was $8,449.
The federal guidelines are utilized by individual states and
counties to establish charges for health care. Generally,
families with up to double (200%) the federal poverty
threshold income are classified as low-income (Appendix B).
For the purpose of this study, the term low-income was
applied to those individual whose family income fell below

200% of the poverty threshold set by the federal government.

Hispanic--The term Hispanic was used in this study to

refer to any individual whose first language is Spanish.

22

This includes Spanish-speaking persons from diverse locations
such as Cuba, Puerto Rico, Mexico, and Central and South
America, as well as Spanish-speaking individuals born in

the United States (Verway, 1978). Spanish-speaking people
are of varied and often mixed racial background and, for the
1980 census, were able to choose the race with which they

most closely identified.

Modifying Variables or Factors--The modifying variables
studied included age, sex, family developmental stage, and
family history of diabetes. Age and sex provided background
sociodemographic data. The determination of family develop-
mental stage provided insights into possible environmental
factors affecting perceptions of obesity and diabetes.

Because diabetes has a genetic component and because familiar-
ity with the disease within the family structure may affect
the individual's perceptions, it was important to ascertain

whether the individual had a history of familial diabetes.

Motivational "Cues to Action"--The Hispanic culture
traditionally places a strong emphasis upon the power of the
spirit world. In many rural regions of Latin America, the
Native American spiritual beliefs have remained virtually
untouched by the Catholic church. In other areas, the
Catholicism of the Spanish conquistadores blended with the
traditional religions into a belief system which emphasizes
the individual's submission to fate (whether fate is exPressed

as the will of God, the power of the devil or spirits, or

23

merely as chance). The attaining and maintaining of good
health is linked to the interaction between good (as repre-
sented by God and the saints) and evil (the devil and human
witches) (Holland, 1978).

The present investigation explored the extent of local
Hispanics reliance upon powerful others and/or chance for
guidance in relation to health matters. Reliance upon
scientific and/or lay or folk health care practitioners was

also studied.

Limitations of the Study

 

l. The subjects who agreed to participate in the study
may be different from those persons who refused.
The subjects may, therefore, not be representative
of the low-income Hispanic population at large.

2. The sample was a convenience, rather than a random
sample. Every person who qualified in the age,
weight, and language categories and was not a
diagnosed diabetic was asked to participate.

3. The questions in the interview were close-ended and
therefore limited the subjects' answers to those
perceptions which the researcher believed were
important. The questionnaire may not have measured
other valid perceptions of the subjects.

4. The sample was drawn from a limited geographic

area.

24

5. Subjects who had close family or friends with
diabetes may have possessed significantly more

knowledge about the disease than other subjects.

Assumptions
1. The subjects were able to understand the questions
on the instrument (given in interview format) and
answered in as honest a manner as possible.
2. Study participants acknowledged that they were
obese and answered the items accordingly.
3. The subjects had at least heard the term "diabetes"

and held some opinions about the disease.

Overview of the Chapters

In the preceding chapter, an introduction to the study,
statement of the problem, research questions, definition of
concepts, limitations, and assumptions were presented. In
Chapter II, a conceptual framework is presented which inte-
grates the preventive Health Belief Model variables and
modifying and motivational factors with cross-cultural
nursing and self-management theories. In the review of the
literature, Chapter III, the sources of concepts relevant
to the research questions are documented.

The methodology and procedures utilized in this study
are presented in Chapter IV. Descriptions of the sample,
setting, instrument, data collection procedures with human
rights protection, scoring of the data, and procedures for

data analysis are presented. Data describing the study

25

sample and data pertaining to the research questions are
presented in Chapter V. In Chapter VI, the summary and
interpretations of the findings are presented. The research
findings are analyzed in terms of limitations, implications
for nursing practice and education, and recommendations for

future research.

CHAPTER II
CONCEPTUAL FRAMEWORK

Overview

In this chapter, a conceptual framework is presented
which integrates the preventive Health Belief Model variables
and modifying and motivational factors with cross-cultural
nursing and self-management theories. The framework pre-
sentation includes a brief review of the origin of the pre-
ventive Health Belief Model; descriptions of the main study
variables of perceived susceptibility, perceived severity,
perceived benefits, and perceived barriers; a discussion of
modifying and motivational factors which may affect indi—
vidual perceptions (Rosenstock, 1974); and an exploration
of the manner in which cross-cultural nursing theory
(Leininger, 1978) can be utilized to enhance preventive

health care behavior.

The Health Belief Model

 

The Health Belief Model was developed to explain pre-
ventive health behavior which was defined by Kasl and Cobb

(1966) as

26

27

Any activity undertaken by a person who believes
himself to be healthy for the purpose of preventing
disease or detecting disease in an asymptomatic

stage. (p. 246)

The Health Belief Model described by Rosenstock (1974) is
based upon the theories of decision-making and behavior
motivation first proposed by Lewin (1935), who postulated
that behavior is derived from positively, negatively, or
neutrally valued individual perceptions. Each individual
constructs his own world view, giving meaning to events,
objects, or words from the symbolism they represent to the
individual rather than from any universal cultural deter-
minant or stereotype. This theoretical framework emphasizes
the importance of the individual defining one's own behavior
(Wagner, 1970). In developing the Health Belief Model, Rosen-
stock utilized an individually based definition of percep-
tion:

that it is the world of the perceiver that determines

what he will do and not the physical environment,

except as the physical environment comes to be repre-
sented in the mind of the behaving individual.

(1974, p. 2)

The Health Belief Model integrates Lewin's psychologi-
cal theories of decision-making into a framework which per-
mits the analysis of the individual's process of decision-
making regarding health behaviors. This Health Belief Model
allows sociopsychological variables to be used to explain
preventive health behavior. Using Rosenstock's (1974) inter-
pretation of Lewin's theory, disease would be regarded as

negative. An individual would initiate action to change

health behavior to avoid or minimize the disease unless that

28

preventive action was perceived by the individual as more
negative than the actual disease process. In order for
preventive action to occur, the individual would have to
feel personally susceptible to the illness, would have to
acknowledge the potential severity of the diagnosis, would
have to recognize that the preventive action would produce
benefits in the form of reduced susceptibility and/or
severity, and would have to feel that there would not be
insurmountable barriers to its enactment.

For the present research, the preventive Health Belief
Model was utilized to determine the individual perceptions of
obese Hispanics regarding their perceived risk of developing
Type II diabetes mellitus (Figure 1). In the following
sections, the individual variables of perceived susceptibi-
lity, perceived severity, perceived benefits, and perceived
barriers are examined in relation to traditional Hispanic

health beliefs.

Perceived Susceptibility

 

In order to perceive a disease such as diabetes mellitus
as a potential threat to one's own health, the individual
must feel both susceptible to the disease, and that the
disease is severe in present or future ramifications.
Susceptibility is defined by Rosenstock as "the subjective
risk of contracting a condition" (1974, p. 3).

Within the Hispanic culture susceptibility to a disease

can be based upon several factors. The traditional Catholic

29

 

 

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30

and folk religious beliefs permeate the conceptions of life
and health. The traditions of the Catholic church remain
strong within the Hispanic culture. "God . . . is omnipotent"
and man is "subject to His judgment and justice" (Samora,
1978, p. 66). Because man is perceived as basically evil,
there will always be hardships and sufferings in this life.
However, by subjecting one's life to God's will, the indi-
vidual may achieve both eternal salvation for the soul, and
the peaceful knowledge that the sufferings of this life,
whether caused by "castigos" or punishments meted out by

God for wrongdoing, or merely to strengthen the individual

to endure suffering for its own sake, are not without meaning
(Samora, 1978).

Samora viewed this life of "submission and acceptance"
as "fatalistic and even defeatist," stating that an indi-
vidual with this world view can do little, if anything, to
attempt to change life's course.

Such a conception of life is highly resistant to

active, conscious attempts to change the way of

life, because one accepts life as it is and adjusts

to it in general and to specific situations in

particular. (1978, p. 67)

Thus, it might be presumed to be very difficult to introduce
the concept of disease prevention into a culture which
allows for precautionary measures to be taken against
natural occurrences, but does not believe it can "prevent

God's will" from taking place, or illness from occurring if

it has been preordained.

31

In addition to traditional religious beliefs, there
are two other explanations for disease causation among the
Hispanic p0pulation; the personalistic and the naturalistic
medical systems (Foster, 1978). Within the personalistic
system, illness is believed to be caused by the intervention
of an agent who may be supernatural or human. The affected
individual is deemed the victim of aggression carried out
by the intervenor.

In the Hispanic culture, the general category of per-
sonalistic or "unnatural" illness is known as "mal puesto."
"Mal puesto" is perceived of as a "product of undue influ-
ence one individual exercises over another" (Rubel, 1966,

p. 155), and as a social device of coercion and influence.
The condition of "mal puesto" may be brought about through
the use of bewitchment, magic, or Satanic forces, and is
cured by a special healer through the use of countermagic
or by removing the source of harm (Madsen, 1973; Rubel, 1966).
Common causes of "mal puesto" are family or lovers quarrels,
personal jealousy or envy of material possessions. It is
thought possible that an illness of "natural" etiology may
be further prolonged by "mal puesto." Thus, chronicity of
a condition, regardless of its origin, is often associated
with the concept of "mal puesto" (Madsen, 1973).

The second explanation for disease causation within the
Hispanic culture, the naturalistic medical system, developed
from the humoral theory of disease. Humoral pathology,

mentioned in literature as early as the sixteenth century

32

B.C., is based upon the Greek theory of the four "elements"
of earth, water, air, and fire. Hippocrates is credited
with combining the four elements with the four "qualities"
of hot, cold, dry, and moist, to produce the four "humors"
of blood (hot and moist), phlegm (cold and.moist), black
bile or melancholy (cold and dry) and yellow bile or choleric
(hot and dry).

Using the naturalistic medical system, in order to
maintain good health, it is necessary that the individual
possess the correct proportions of each substance according
to body type. Pain occurs when one of the substances is
deficient, in excess, or not well-mixed throughout the body.
Each person is believed to possess a distinct personality
type based on the dominant humor within the body, thus the
origin of the term "melancholic" individual (Foster, 1978).
Medical care based upon humoral pathology consists of
examining the natural temperment of the individual, dis-
covering any momentary imbalances, and prescribing special
diets, medicines, or purges (Foster, 1978).

The concepts of humoral medicine, translated from Greek
to Arabic, were refined and modified by the Persian physician,
Avicenna, in the eleventh century. As the Arabs conquered
North Africa and Spain, humoral medicine was integrated with
European medicine. During the transition to the New WOrld,
the classical humoral system lost the concepts of moist (or
wet) and dry (Foster, 1953), and was integrated with native

Indian health beliefs.

33

Today, Hispanic folk medical practices are based mainly
on a hot-cold dichotomy with health being attributed to a
balance of hot and cold forces within the body and illness
being the result of excess heat or cold. Actual temperature,
as with immersion in hot or cold water, or a more metaphori-
cal explanation such as attributing hot properties to a
certain herb, may be used to explain the imbalance and to
prescribe treatment. Treatment consists of correcting the
imbalance through the use of opposing forces, such as using
a "cold" treatment to cure a "hot" illness. The hot-cold
dichotomy is also used to classify foods, beverages, and
medicines, again according to their effect upon the body,
rather than solely upon their physical properties (Clark,
1970; Foster, 1953).

As stated previously, it may be very difficult to dis-
cuss the concept of susceptibility to disease as something
which the individual may have control over within the con-
text of Hispanic culture. The traditional religious and
health beliefs all point to the conclusion that God, an
evil spirit, or a "natural“ force are dictating the occur-
rence and/or prevalence of disease. The individual may take
precautionary measures (such as prayer, countermagic, or
employing the opposing force in the hot-cold dichotomy) to
decrease the severity of any impending or existing condi-
tion, but there is little evidence to suggest that preventive
medicine has been traditionally employed within the Hispanic

culture. Preventive medicine, is therefore, a concept which

34

has been introduced by the scientific medical community and
which may be met by resistance if there is credibility to
Samora's view that the Hispanic way of life is "fatalistic
and even defeatist" (1978, p. 67).

Because of the traditional emphasis on precautionary,
rather than preventive, health care measures, and the belief
that man does not have control over his own destiny (Samora,
1978), it could be predicted that the Hispanic subjects in
the present study might not perceive themselves as susceptible
to the development of Type II diabetes mellitus. In the
present research, both the perceived susceptibility to
diabetes as a result of obesity, and the perceived suscepti-
bility to illness as a result of the power of external forces
were explored. The concept of susceptibility to diabetes
as a result of obesity was pursued under the individual per-
ceptual variable of susceptibility in the Health Belief Model
(Figure 1). The significance of external forces such as
powerful others and chance in the perceived susceptibility
to disease was explored as a "cue to action" under motiva-

tional factors in the conceptual framework (Figure 1).

Perceived Severity

 

The perceived severity of a condition is dependent upon
the perceptions of the present or potential physical limita-
tions to be incurred, the socioeconomic burdens imposed, the
individual emotional arousal and the cultural connotation
of the diagnosis (Rosenstock, 1974). None of these dimensions

pertaining to the obese Hispanic and his/her perceptions of

35

Type II diabetes mellitus has been discussed in the litera-
ture. The present research was, therefore, concerned with
an initial attempt to tap the variable of perceived severity
within the known cultural context of health and illness.

Baca stated that the Hispanic perceives health status
according to how he feels at the present moment. To be
healthy is to be pain free and to be active in society. The
healthy person is "well-fleshed, the face is full, and the
complexion is rosy" (1978, p. 92). Good health is associated
with the ability to work hard and to thereby maintain
respectability within the community through fulfilling one's
responsibilities (Schulman & Smith, 1963).

Illness is not often acknowledged unless it is incapaci-
tating and then it is viewed as misfortune because it prevents
the individual from completing social and moral obligations
and may result in the loss of respect from family and
friends within the community (Clark, 1970). Because of the
possibility of social stigma, the potential severity of an
illness is often not acknowledged until there is physical
or emotional discomfort. If no symptoms occur, (as in most
Type II diabetics), no illness is admitted, for illness is
viewed by the Hispanic community as expensive, time-consuming,
and threatening to economic and social well-being (Clark,
1970).

In order to perceive either susceptibility to or
severity of a disease entity, it is virtually imperative

that the individual possess some medical knowledge base.

36

However, this knowledge base is not easy for the Hispanic

to attain. Even among Hispanics who are fluent in English,
technical terms may be misleading or confusing. The Spanish-
speaking Hispanic may never have had any verbal health
teaching in Spanish or any simple written instruction made
available to acquire basic knowledge (Martinez, 1978). It
can also be hypothesized that even the well-informed Hispanic
who theoretically understands the severity of diabetes may
deny perceived severity in order to avoid facing the negative
prospect of possibly disabling symptoms, discomfort, or
death.

In conclusion, it can be stated that the Hispanic gen-
erally regards health and the ability to be active as very
high priorities. This may lead to the denial of the impor-
tance of asymptomatic or potential disease both because it
does not seem to adversely affect the robust individual and
because the diagnosis signifies illness, which may carry a
strong social stigma within the culture. As with the con-
cept of perceived susceptibility, it appears unlikely that
the individual Hispanic would acknowledge that obesity might
be a potential threat to health, especially since the obese
person may be culturally defined as being a perfect example
of good health. The ability of the present research study
to assess the perceived severity of diabetes as a disease
within an Hispanic population served to further knowledge
about the cultural perceptions of disease and to aid in the
development of culturally relevant preventive health teach-

ing methods.

37

Perceived Benefits

 

The physical and psychosocial benefits to be incurred
from a preventive health measure such as weight reduction
must be weighed against possible barriers related to the
action itself such as cost, inconvenience, or painful physi-
cal or emotional stimuli. If the perceived benefits out-
weigh the barriers to action, it is highly possible that the
individual will initiate action without any outside inter-
vention such as teaching or counseling. If, however, the
perceived barriers to action outweigh the benefits, or if
both the benefits of action and the barriers to it are costly
in terms of material, physical, or emotional consequences,
outside intervention may be necessary to instigate action
(Rosenstock, 1974).

Both physical and psychosocial benefits to weight
reduction have been described in the literature. Craddock
(1978) found both increased mortality rates and a specific
increase in the incidence of diabetes among the obese,
especially those 20% or more overweight. He concluded that
physical benefits to weight reduction would include a
decrease in mortality to the normal age-correlated rates, a
decrease in the incidence of Type II diabetes mellitus, and
a lessening of the adverse effects of various chronic medi-
cal conditions. Because low-income Hispanics have been
shown to have a high incidence of both obesity and Type II

diabetes mellitus, it can be assumed that weight reduction

38

among the Hispanic population would have the same types of
physical benefits as Craddock described.

Psychosocial advantages to weight reduction include
increased job opportunities, increased ability to obtain
attractive clothing (Craddock, 1978), improved body image
(Wineman, 1980), increased self-esteem, increased social
acceptance and increased desire for social conformity
(Rodin, Bray, Atkinson, Dahms, Greenway, Hamilton, & Molitch,
1977). Whether the low-income Hispanic has assimilated the
dominant negative American attitude towards obesity as Allon
asserted has been occurring among various low-income, ethnic,
and religious groups (1973), or whether the low-income
Hispanic still ascribes to the traditional view that the
"robust" appearance is favored (Schulman & Smith, 1963),
determines the potential benefits that Hispanics would per-
ceive as accruing from weight loss.

If the traditional beliefs are still dominant in the
individual's perception, weight loss which signifies loss
of the "robust" healthy appearance will not be perceived as
desirable. Conversely, Hispanics who have been influenced
by the mass media or by association with the Anglo culture
may agree that weight loss would lead to increased benefits
and opportunities both socially and psychologically such as
increased job mobility, improved appearance, increased self-
esteem, and increased social acceptance by peers within the
wider social environment. The present research explored

which of these perceptions regarding the physical and/or

39

psychosocial desirability of weight reduction are held by

the low-income Hispanic population.

Perceived Barriers

 

Regardless of how many benefits the individual may per-
ceive as the potential result of weight loss, the positive
reward symbolized by the benefits must be weighed against
the perceived barriers related to the action of weight
reduction itself. In order for weight loss to actually
occur, the barriers must be reduced to a minimum so that the
benefits clearly outweigh the barriers.

Perceived barriers related to weight reduction include
the perceived cost of special diets, the inconvenience of
special and/or unusual meal preparation, and potentially
painful emotional or physical stimuli. Oscanova and Hejda
(1975) stated that a high protein, low calorie diet is far
more expensive than a high fat and high carbohydrate diet.
Although no research has explored the perceptions of diet
cost among low-income persons, it can be assumed that the
mass media emphasis on special dietetic foods and on special
weight loss programs such as Weight Watchers, which are
commonly thought to be expensive, may lead to a perception
that dieting requires extra expense.

For a family accustomed to a diet high in refined carbo-
hydrates and in fats and low in fresh fruits and vegetables,
as is the typical Hispanic diet (Williams, 1974), having one
member on a special diet may be considered a major incon-

venience to the family's functioning. This may be eSpecially

40

true if the dieting woman is expected to continue cooking

the traditional foods for her husband and children. In
addition, the typical low calorie, high protein diet con-
sisting of bland ingredients is often unappealing and foreign
to the Hispanic would-be dieter. Thus, both the perceived
cost and the inconvenience of food preparation may be signi-
ficant barriers to weight reduction among the Hispanic
population.

Painful emotional or physical stimuli related to weight
reduction efforts may also be barriers to weight loss. A
variety of psychiatric researchers concluded that the obese
individual may maintain a balanced emotional status by the
mechanism of overeating (Freed, 1947; Crisp & McGuinness,
1976; Simon, 1963; Hamburger, 1951; Bruch, 1957; and Stunkard,
1976). These researchers cautioned against weight reduction
attempts in individuals who use their obesity as a protective
mechanism. Other studies emphasized that psychiatrists would
naturally be exposed to a higher incidence of psychological
pathology among obese individuals than the general practi-
tioner (Silverstone & Solomon, 1965; Silverstone & Lascelles,
1966; Silverstone, 1973; Shipman & Plesset, 1963; and McCance,
1961). Craddock (1978) concluded that individuals who
exhibit symptoms of significant emotional disturbances
related to obesity should not be encouraged to undertake
weight reduction without psychiatric consultation. However,
the majority of obese individuals who present themselves to

a primary health care provider for the problem of obesity

41

can reduce safely without fear of precipitating serious
emotional reactions. These individuals, who are not psy-
chologically disturbed, may eat when challenged with the
minor stresses of everyday life, instead of, or in addition
to, using other c0ping behavior such as smoking, drinking
alcohol or caffeine or biting the nails. Craddock (1978)
characterized these persons as often being hypersensitive
individuals whose reaction to life is frequently passive
rather than active.

The "hypersensitivity" Craddock (1978) referred to is
related to the theory that physical or emotional stimuli
affect some individuals more than others. It has been
hypothesized that a greater than normal response to external
stimuli among some individuals is the cause of overeating
and weight gain (Rodin, 1975). Rodin and Slochower (1976)
postulated that external reactivity is a general response
style, acquired either biologically or through early environ-
mental influences, which easily affects weight when salient
cues are present. The hyperresponsive individual is readily
affected by external food cues such as sight, smell, or
taste of food whether or not actual physiological hunger is
present. Why some hyperresponsive individuals become obese,
while others can control their impulses is not known, but
hyperresponsiveness to food cues has been found among normal
weight as well as obese persons (Rodin & Slochower, 1976).
It is not known to what extent emotional or physical response

signals contribute to obesity among the Hispanic population.

42

In conclusion, the perceived cost of special diets, the
inconvenience of special food preparation, and potentially
painful physical or emotional stimuli are barriers to weight
reduction which have not been researched within the Hispanic
population. The present research attempted to ascertain the
extent to which some of these potential barriers to weight
reduction are perceived by middle-aged, low-income obese

Hispanics.

ModifyingyFactors

 

In addition to the individual perceptual variables of
susceptibility, severity, benefits, and barriers defined
above, Becker (1974) postulated that there are a variety of
modifying factors which may alter an individual's perception
of the threat of a disease entity (Figure 1). For the
purpose of this study, demographic, developmental, and
knowledge related modifying variables were selected.

The demographic variables of age and sex were determined
for each subject in order to identify whether there were
age or sex-related differences in relation to the individual
perception variables. The particular stage of family
development (Duvall, 1977) and prior knowledge of and con-
tact with diabetes within the family unit may also affect
the individual's perceptions. Therefore, family develop-
mental stage and family history of diabetes were determined
for each subject. In summary, the modifying factors investi-
gated in this study were age, sex, family developmental

stage, and family history of diabetes.

43

Motivational "Cues to Action"

In addition to factors which modify the individual's
perceptions of the threat of disease, there are motivational
"cues to action" which may trigger the individual to preven-
tive action in a balanced benefit-barrier situation or when
perceived barriers outweigh perceived benefits (Figure 1).
Among the Hispanic population, there are several sources of
"cues to action"; the coercion of extra-human forces through
propitiatory actions, the lay practitioners who utilize folk
or traditional medicine, and the scientific health care
practitioners (Samora, 1978).

Extra-human forces, whether God, saints, or spirits, are
called upon when the individual perceives that a potential
or actual illness may be severe. Ritualistic propitiatory
actions; promise-making, visiting shrines, and offering
medals, candles, and/or prayers are undertaken in the hope
of mitigating the potentially negative influences of the
illness (Samora, 1978). Nall and Speilberg (1978) hypothe-
sized that the extent to which Hispanics adhere to these
traditional religious rituals might inhibit their acceptance
of scientific medical treatment regimens. Thus, the Hispanic
individual who believes in the power of extra-human forces
might be more inclined to call upon them rather than to seek
or believe in scientific health care practices.

Lay practitioners are generally divided into two cate-
gories; family and friends being the first avenues of help

for the suffering individual, and, if their intercession

44

fails, the folk specialist, who is considered to possess a
more detailed knowledge of folk medicine than the ordinary
layman (Samora, 1978). The folk specialist or "curandero"
may possess special healing powers considered a gift from
God in addition to specialized knowledge about folk illnesses
(Baca, 1978; Dorsey & Jackson, 1976).

A number of benefits of using the folk health system are
acknowledged by many Hispanics; services are readily avail-
able and accessible without transportation or translation
difficulties, the "curandero" is usually personally acquainted
with the person, uses familiar medicines and caring behaviors,
is less expensive, and provides a ready local support if the
individual suffers any further discomfort or side effects
(Leininger, 1978). The whole social milieu between "curan-
dero" and client within the Hispanic community fosters an
atmosphere of warmth and caring which is often absent if
the Hispanic individual seeks health care from a scientific
practitioner who is unfamiliar with the culture. By offering
a treatment modality rooted in the power of prayer and
faith, the "curandero" may function as an intermediary
between the extra-human forces and the individual Hispanic
(Dorsey & Jackson, 1976).

In contrast, the scientific health care practitioner
may be perceived by the Hispanic as relying upon a body of
specialized technical knowledge. Physicians and nurse
clinicians may be consulted by the Hispanic if traditional

methods of treatment have failed to alleviate the problem.

45

Several areas of conflict exist between the lay practitioner
and the scientific practitioner. The lay practitioner is
consulted for advice only, and does not give "orders."
Scientific practitioners who provide "cues to action" to
Hispanics must be careful not to give orders or to assume
authoritarian roles, which, especially outside the perceived
domain of medical authority, may be perceived as insults

and will not be honored (Clark, 1970). The positive role
which nursing can assume in providing motivational "cues to
action" is further discussed under nursing theory.

As mentioned under perceived susceptibility, many
Hispanics possess a fatalistic world view, which precludes
belief in any motivational "cues to action." For these
individuals, illness is the result of chance occurrences or
fate and there is nothing which can be done to prevent or
to alleviate suffering (Samora, 1978).

In summary, the motivational "cues to action" which may
prompt the Hispanic individual to institute preventive health
care are belief in the power of extra-human intervention,
and the therapeutic advice of lay or scientific health care
practitioners. The present study explored the perceived
value of these "cues to action" among the Hispanic pOpula-
tion as well as investigating the extent to which the
Hispanic population rejects the power of "cues to action"

and holds a fatalistic world View.

46

Nursing Theory

 

According to the preventive Health Belief Model, if the
perceived benefits outweigh the barriers, the individual
will initiate preventive action without any outside inter-
vention. If, however, there is an equal benefits-barriers
situation, or if the perceived barriers outweigh the bene-
fits, therapeutic intervention is necessary for preventive
action to occur (Figure 1). It is in this situation that
nursing can interface as a motivational "cue to action" to
provide support for preventive health care.

Nursing, because of its emphasis on the caring, nurturing,
and counseling aspects of health care, is in the unique
position of potentially offering the Hispanic individual the
most culturally relevant mode of scientific health care.
The nurse clinician caring for the Hispanic individual may
combine the knowledge gained from advances in scientific
theory with the caring attributes Hispanics admire in the
traditional lay practitioner. Thus, sensitive nurses may
circumvent the authoritarian stereotype of scientific prac-
titioners and may assume a caring role Hispanics feel com-
fortable with (Clark, 1970).

Cultures that have been traditionally dependent upon

kinship groups for caring will expect more humanistic

kinds of nursing care practices and less scientific,

technological care-giving services. (Leininger, 1978,

p. 37)

Although stereotyped or simplified formulas have been

developed for assessing the needs of culturally diverse

clients, theoretically sound constructs based on a

47

consideration of the cultural milieu of the client in con-
junction with his/her physical, psychological, and social
attributes have been lacking (Leininger, 1978, p. viii).
Leininger has been the main proponent of the development of
the subfield of transcultural nursing since the mid-19603.
Trans- or cross-cultural nursing seeks to utilize anthr0pol-
ogical constructs to further enhance the nurturing role of
the nurse working in a different cultural context. Culture
has been defined as

the sum total of the learned ways of doing, feeling,

and thinking, past and present, of a social group

within a given period of time. (Murray & Zenter,

1976, p. 382)

Leininger defined transcultural nursing as

focusing upon a comparative study and analysis of

different cultures and subcultures of the world with

respect to their caring behavior; nursing care; and
health-illness values, beliefs, and patterns of be-
havior with the goal of develOping a scientific and
humanistic body of knowledge in order to provide

culture-specific and culture-universal nursing care

practices. (1978, p. 8)

Culture-universal traits are those facets of behavior
found universally in all cultures, such as the concept of
caring. Culture-specific behaviors refer to the manner in
which a concept such as caring is expressed by a particular
cultural group, for example through the use of touch
(Leininger, 1978). Nurses working with other cultures
naturally tend to utilize their own outside or "etic"
cultural perspectives, rather than the perspectives of the

client, in planning and instituting care. This produces

what Leininger termed "gaps, or cultural discrepancies in

48

health norms" (1978, p. 77). To reduce this ethnocentric
tendency, Leininger advocated the examination of the cultural
life of a people from their own perspective, or "emic."
Implicit to this approach is the presumption that people can
articulate their own perceptions. Thus, similar to the
preventive Health Belief Model, data are gathered from the
subjective views of the subjects rather than the observer
(Leininger, 1978).

Leininger developed a model of transcultural or ethno-
nursing based on the study of the individual's perceptions.
The individual perceptions, modifying and motivating factors
of the preventive Health Belief Model are analagous to
Leininger's discussion of the major sources from which
ethnonursing is derived, which include health—illness caring
system beliefs, values, and caring practices, and social
structure features of the culture (1978, p. 39). The
similarities between the preventive Health Belief Model and
Leininger's model for transcultural nursing can be utilized
to incorporate the study of health beliefs with transcultural
nursing theory within the present research (Figure 2).

Leininger mentioned a number of caring behaviors or
constructs which nursing can utilize if preventive health
care cannot be initiated by the individual. Those relevant
to weight reduction include stress alleviation measures,
health instruction, and health consultation. Because these
nursing interventions are based upon culturally appr0priate

caring concepts, there is a greater likelihood that they

49

 

 

Preventive Health Belief Model Transcultural Nursing Model
I. Individual Perceptions I. Health-illness caring system
a. perceived susceptibility a. beliefs
b. perceived severity b. values
c. perceived benefits c. norms

d. perceived barriers

II. Modifying Factors II. Major Social Structure
Features
III. Motivational "Cues to III. Role caring practices
Action"

Figure 2. Comparison of Health Belief Model and Transcultural Nursing
Model.
may be effective with the Hispanic population (Figure 1).
These interventions do not imply a passive audience, but
rather encourage an active self-management approach to weight
loss and diet control (Ormiston, 1980), in which the nurse
serves in an instructional and supportive, rather than
authoritarian, role.

It can be concluded that nursing intervention for the
obese low-income middle-aged Hispanic should be based upon
culturally acceptable methods of interaction and should
emphasize the importance of individual responsibility and
self-care as much as possible while still considering
cultural determinants of behavior such as belief in powerful

others or in chance or fate.

Summary
In this chapter, the preventive Health Belief Model with

its individual perception variables of susceptibility,

50

severity, benefits, and barriers, and the modifying and
motivational factors which may affect individual percep-
tions, were examined and combined with cross-cultural
nursing theory to develop a conceptual framework (Figure 1).
This framework demonstrates the interrelationships of the
variables and their potential contribution to cross-cultural
nursing research, and provides a rationale for the present

research.

CHAPTER III
THE LITERATURE REVIEW

Overview

In the review of the literature, studies relevant to the
areas of preventive health care beliefs and/or behavior are
presented. The studies which utilized Rosenstock's (1974)
Health Belief Model in its entirety were reviewed, as well as
research which explored one or more of the perceptual vari-
ables of susceptibility, severity, benefits, or barriers.
Since few of these studies focused upon the Hispanic popu-
lation, the interaction between the traditional Hispanic
health belief system and modern Hispanic health care prac-
tices was explored under a separate heading of "Health
Beliefs and the Hispanic." The review of the literature
provides a review of material which enhances the statement
of the problem and the conceptual framework, Chapters I and

II.

The Preventive Health Belief Model

 

Health beliefs manifested by adults reflect the social
and cultural background of the individual. These individual
beliefs or perceptions are influenced1x>varying degrees by

the cultural origins of the person. Spector stated that

51

52

"meanings attached to the notions of health and illness are
related to the basic, culture-bound values by which we define
a given experience and perception" (1979, p. 75).

This study was concerned with possible influences that
Hispanic cultural values bear upon individual perceptions
about obesity and its role as a precursor of diabetes.
Because the Health Belief Model presumes that individual
perceptions are unique, valid, and of importance, these per-
ceptions are the basis for the present research. However,
individual perceptions cannot be explored within a vacuum
without considering the influence which the cultural heri—
tage and socioeconomic pressures may exert upon preventive
health beliefs and/or behaviors.

An ethnic or cultural group "refers to any continuing
group or division of mankind" (Saunders, 1954, p. 107)
which shares social experiences, values, norms,attitudes and
a cultural identity. These shared attributes all influence
health beliefs and behaviors which may be unique to the
ethnic or cultural group-—"ethnic group labels are . . .
indicative of socio-cultural differences" (Suchman, 1964,

p. 321). Suchman stated that as the cultural groups values
and experiences change, the individual within that group
will also modify his/her behavior and response to health
and illness.

In order to understand more fully the individual per-
ceptions of the Hispanic population under study, the litera-

ture pertaining to the Hispanic health beliefs and behaviors

53

was reviewed. In addition, an overview of research con-
ducted using the preventive Health Belief Model was pre-
sented as well as literature related to each of the variables
of the Health Belief Model.

The Health Belief Model and Preventive
Health Behavior

 

 

The Health Belief Model was originally developed to
explain preventive health behavior. Later, the model was
modified to account for illness behavior and sick role behav-
ior (Kasl & Cobb, 1966). As the present study was concerned
with the perceptions of non—symptomatic obese individuals,
only the literature pertinent to the preventive Health
Belief Model was reviewed.

Seven early studies which utilized the Health Belief
Model were identified by Rosenstock (1974). These consisted
of four retrospective and three prospective studies. The
value of the retrOSpective studies is diminished by the
nature of retrospective research. RetrOSpective analysis
a priori suffers from the threat of cognitive dissonance
(Festinger, 1957). It is often impossible to decipher
retrospectively whether a belief actually preceded an action
or whether statements to that effect are made in order to
achieve consonance with later behavior. It is with the
acknowledgment of the threat of cognitive dissonance to
the validity of retrospective study that the following

retrOSpective studies were reviewed.

54

The most thoroughly documented retrospective studies
were conducted by Hochbaum (1958) and Kegeles (1963a).
Hochbaum attempted to identify the underlying factors which
cause individuals to seek a chest x-ray to detect tubercu-
losis. A random sample of 1,200 adults were interviewed in
Boston, Cleveland, and Detroit. Two indices of suscepti-
bility were examined; whether the individual believed that
he might contact tuberculosis, and whether the individual
believed that a person might have tuberculosis in the absence
of all symptoms. The perceived benefits of early detection
were also studied. Open-ended questions and pictures were
used to gather data on the individual's experiences with
chest x-rays over the past 7 years.

In the original study, no mention was made of the type
of statistical analysis used or the significance of the
results. Hochbaum found that four out of five persons who
believed in susceptibility to tuberculosis and the benefits
of x-ray had taken preventive action, while four out of five
without the beliefs had not taken any action. Susceptibility
was found to be a more significant motivator to action than
benefits.

In conclusion, Hochbaum discussed both motivating fac-
tors and possible barriers to action. The three cities
utilized for the study had all participated in varying
degrees of tuberculosis case—finding and educational cam-
paigns. The residents of Cleveland, in particular, were

exposed to an extensive mass-media campaign during the course

55

of the study. Unfortunately, Hochbaum did not categorize

his data geographically to allow for comparison of the effect
of the motivating factor of publicity upon the variables of
susceptibility and benefits.

Although he did not directly measure perceptions of bar-
riers to x-ray, Hochbaum mentioned the existence of possible
barriers which might affect utilization, such as cost, access,
and time to obtain an x-ray. Though the sample size was large
and randomly selected, the study did not measure all four
variables of the Health Belief Model and suffered from meth-
odological and statistical deficiencies.

Kegeles (1963a) measured the perceived susceptibility,
severity, benefits, and barriers to preventive dental check-
ups or prophylaxis in the absence of symptoms for members of
a pre-paid dental plan. Open-ended interviews were conducted
with two samples; all 50 supervisors and a random sample of
380 workers at a factory in New York. Results showed that
persons who felt themselves susceptible to dental disease,
who believed in the seriousness of dental problems, who be-
lieved in the benefits of preventive dental care, and who ex-
hibited few barriers to care (fear of pain, anxiety, negative
perception of the dentist) made the most preventive visits.

Kegeles concluded that programs were needed to increase
the feelings of susceptibility and severity of dental dis-
ease and to decrease barriers to care. However, a major
barrier to preventive health care was inherently absent as

this was a pre-paid plan. The study suffered from a high

56

attrition rate, as only 77 interviews were completed, and
data were not presented separately for the convenience and
random samples.

Rosenstock (1974) concluded that, although the retro-
spective studies were not convincing evidence of the via-
bility of his model, they were indicative of a positive
trend. Rosenstock, however, agreed with Festinger (1957)
that the value of retrospective research may be diminished
by cognitive dissonance.

Two-step prospective studies allow a belief to be
acknowledged at one point and actual behavior to be measured
later. Three such studies were conducted using the Health
Belief Model; Kegeles (1963b); Leventhal, Hochbaum, and
Rosenstock (1960); and Kirscht, Haefner, Kegeles, and
Rosenstock (1966).

Kegeles (1963b) followed up his first dental care study
3 years later by reinterviewing the same factory workers and
a control group of 450 other workers. The restudy question-
naire explored the three most recent dental visits of the
subjects. In contrast to the first study, perceived severity
and perceived benefits were not significantly related to
behavior. Orientation to preventive care was found to have
decreased from the first study, 56% to 45%. Kegeles con-
cluded that the population retained similar health beliefs
and behaviors over time, as 77% of the original respondents

displayed the same orientation in both studies. This second

57

study of Kegeles had a 79% return rate which provided a more
solid basis for analysis than most of the other studies.

Leventhal et a1. (1960), studied the threat of influ-
enza before, during, and after the Asian flu epidemic of
1957 in two cities. The study design called for flexible
interviews and reinterviews of 200 families in each city.
However, the epidemic hit the cities before the first inter-
view, rendering only 86 usable interviews from both cities.
From this very small sample, it was found that those persons
who believed in susceptibility to and severity of the dis-
ease took preventive measures (immunization) to avoid influ-
enza, while those who rejected susceptibility and severity
did not receive immunizations. The results were statisti-
cally significant at the .01 level, but the sample was too
small and too regionalized to allow any generalizations to
be made. It is interesting to note that the vast majority
of the total (non-sample) population in both cities per-
ceived neither susceptibility to or severity of the influ-
enza, and that over 90% of the families made no preparation
for the epidemic.

The most comprehensive study using the preventive Health
Belief Model was a prospective study by Kirscht et a1. (1966)
which analyzed beliefs and behaviors of 1500 persons in 1963
and followed with a repeat survey of 589 persons 15 months
later. Data were collected on cancer, tuberculosis, tooth
decay, and gum disease from a stratified, multi-stage proba-

bility sample of adults in 70 geographic areas of the United

58

States. Personal interviews were conducted and information
gathered on toothbrushing behavior over the past day, dental
visits over 3 years, preventive medical checkups over 5 years,
and tuberculosis and cancer screening over 10 years.

Complete data were gathered on only 297 persons. Those
individuals who took one preventive action were found to be
more likely to engage in other preventive health care behav-
ior. However, there were no significant correlations between
susceptibility, severity, or benefits and the four types of
preventive action.

The subjects were also compared for actions in relation
to sociodemographic factors. It was found that those per-
sons with higher income, education, and job status were
more likely to undertake preventive actions, even relatively
inexpensive ones such as toothbrushing. Kirscht et al.
(1966) noted the similarity of these findings to those of
other studies and concluded that more than knowledge and an
ability to pay are included in preventive health behavior.
They reiterated the common conclusion that persons at vary-
ing socioeconomic levels possess different socially defined
views of what is appropriate behavior, and that these views
determine what actions they will manifest.

Rosenstock advanced the hypothesis that the lack of
correlaton between the Health Belief Model variables and
actions in the Kirscht et a1. (1966) study may have been
related to the absence of direct stimulus to take preventive

action. The other studies cited incentives to seek

59

preventive care such as accessibility (Hochbaum, 1958) or
prepaid health plans (Kegeles, 1963a, 1963b). In contrast,
Kirscht et al.'s (1966) nationwide sample had not been
exposed to intensive health teaching and were not promised
the availability of free or easily accessible resources.
Thus, Rosenstock (1974) concluded that cues to action at
the time of the earlier studies may have been a significant
variable which affected later behavior.

An alternative explanation for the lack of correlation
between beliefs and subsequent action in Kirscht et al.'s
(1966) study might be the variable of barriers. The studies
which provided incentives for preventive health behavior had
artificially removed what are often formidable barriers
(cost, accessibility) to the general population who do not
have prepaid insurance. Researchers such as Kegeles (1963a,
1963b) mentioned personal barriers such as fear and anxiety,
but did not acknowledge that the majority of the population
does not have access to prepaid preventive health care.

In summary, it cannot be concluded definitely that these
early studies bore conclusive evidence of a relationship
between the variables identified in the Health Belief Model
and subsequent health behavior. In general, the data
revealed a relationship between susceptibility and behavior,
and between benefits and behavior, but not between severity
and behavior. As stated above, evidence was found for a

relationship between several personal barriers and behavior,

60

but many of the crucial structural barriers were removed
from the studies.

There were high attrition rates from most of the samples,
with even the nationwide study (Kirscht et al., 1966) pre-
senting data on only 20% of the original sample. Due to
small sample size and regionalization of many of the studies,
it is difficult to make generalizations about preventive
health behavior from these studies. Also, none of these
studies was concerned with ethnic identity or weight
reduction as a preventive health behavior which may limit
their applicability to the present research study. The
studies which were reviewed all date from the late 19505 to
mid 19605 and thus may reflect attitudes or behaviors which
are no longer prevalent in American society. There were no
recent studies found which utilized the preventive Health
Belief Model as Rosenstock (1974) had devised it.

Motivational and Modifying Variables in
Relation to the Health Belief Model

 

 

The lack of a motivational variable was the most impor-
tant criticism of the early Health Belief Model (Antonovsky
& Kats, 1970). Haefner and Kirscht (1970) employed a strong
incentive or motivator to promote changes or modifications
in health behavior. One hundred sixty-six paid volunteers
were tested in an experimental laboratory setting to deter-
mine the relationships between beliefs, experimental treat-
ments, subsequent beliefs, intentions to action, and actual

behavior. Three experimental groups shown films on cancer,

61

heart disease, and tuberculosis, and a control group, were
tested immediately after the sessions and with a follow-
up questionnaire 8 months later.

Statistically, it was found that perceived suscepti-
bility was raised significantly in the experimental groups
as were perceived benefits. Little change occurred in per-
ceived severity as a resultcfifthe intervention, perhaps due
to the fact that all three diseases were initially perceived
as being quite serious.

The follow-up survey revealed that those persons in the
experimental groups had obtained more preventive checkups.
However, in an analysis of personal living habits, there was
no significant change in preventive behaviors at home among
the experimental groups. Apparently, changing the person's
beliefs about health resulted in the adoption of preventive
health measures requiring occasional effort such as checkups,
but did little to alter well-established routines of diet
and exercise. It is interesting to note for the present
study that Haefner and Kirscht (1970) found that the personal
health behavior most difficult to control was the limiting
of calories.

Several researchers (Suchman, 1964; Langlie, 1977;
Bullough, 1972) explored dimensions not mentioned in the
original Health Belief Model which were valuable to the
present researcher's study of obese low-income Hispanics.
These variables were the ability to control health matters

personally versus a resignation to the power of external

62

forces, and confidence in modern medical practices versus
folk practices. They were included in the present conceptual
framework under the heading, motivational "cues to action."

Suchman (1964) sought to define the underlying causes
of the resistance of lower socioeconomic and ethnic groups
to either accept control over their own health or accept
scientific health care. In 1960-1961, personal interviews
were conducted with a representative cross-section of adults
in New York City who were from six different backgrounds;
Peurto Rican, Black, white Protestant, Jewish, Catholic, and
Irish Catholic. Follow-up in-depth interviews on 1,900
persons were conducted with a completion rate of 90%. Results
were obtained using Guttman scale analysis techniques.

The greatest contrast was found between the Puerto
Ricans and the white Protestants and Jews. The Puerto Ricans
were the most skeptical about medical care, had the least
preventive health behavior, and the least knowledge of dis-
ease. As a result of the study, Suchman proposed a parochial-
cosmopolitan dichotomy in which the parochial individual
(characterized as ethnocentric, having traditional family
structure, and valuing friendship and solidarity within a
small group) is more likely to utilize a nonscientific popu-
lar or folk health system, while the cosmopolitan individual
(characterized as progressive, Open, and individualistic,
with frequent interaction with non-kin) tends to hold a
scientific point of View and accept a modern medical system.

Suchman (1964) concluded that although ethnic and social

63

class differences both contributed independently to the
parochial-cosmopolitan dichotomy, the dichotomy itself was
the most important factor in determining health orientation.

In Suchman's (1964) study, the Puerto Rican population
(a subset of the Hispanic population) exhibited the most
parochial health behavior. Thus, this finding was of impor-
tance in predicting whether the present Hispanic population
under study exhibited traditional or so—called "parochial"
behavior. Adherence of the Hispanic community to traditional
folk medical practices was explored further in the present
literature review under "Health Beliefs and the Hispanic."

Langlie (1977) explored the relationship of preventive
health behavior to several modifying and motivational vari-
ables including socioeconomic status, cosmopolitan versus
parochial orientation, ability to control one's own life
versus a belief in the power of external forces, and belief
in the value of health. Langlie (1977) concurred with
Rosenstock's (1974) hypothesis that the preventive Health
Belief Model would have greater applicability to middle—
class individuals who exhibit goal-oriented, future-
directed behavior, than to low-income individuals who sup-
posedly opt for immediate gratification.

A systematic random sample of the adult population of
Rockford, Illinois were questioned by mail with a 62%
return rate<1f383 subjects. Preventive health behaviors
measured by Langlie included driving habits, smoking, exer-

cise, nutrition, and preventive medical and dental checkups.

64

Perceived susceptibility, benefits, and barriers were mea-
sured. Severity was excluded due to earlier failure to
prove its significance in studies of preventive health
behavior.

Langlie's findings were generally consistent with the
predictions based on previous work with the preventive Health
Belief Model in terms of sociodemographic data. Individuals
who engaged in preventive health behavior tended to be of
high socioeconomic status, to interact frequently with
others, to have positive attitudes towards scientific health
care providers,to believe they could control their own
lives, to be Older and female. Conversely, those persons
who exhibited few signs of engaging in preventive health
behavior tended to originate from the parochial group and
were low—income. Langlie, however, found no substantiation
for the accepted belief that high perceived susceptibility
led to increased preventive health behavior (Rosenstock,
1974).

Researchers such as Rosenstock (1974) and Langlie
(1977) concluded that the person of low-income and/or ethnic
origin is less likely to engage in preventive health behav-
ior than the middle-class white. These findings have sig-
nificance for the present research in that this study popu-
lation was both low-income and of ethnic origin and may
therefore prove to be resistent to preventive health care

measure S .

65

The underlying factors causing the positive relation-
ship between socioeconomic status and the utilization of pre-
ventive health care services have remained unclear. Bullough
(1972) hypothesized that the low-income individual was
beset by social alienation barriers; powerlessness, hopeless—
ness, and/or social isolation which hindered preventive
health care behavior.

Bullough (1972) utilized Seeman's (1959) definition of
alienation to explore the effect that social alienation
has upon preventive health behavior. Seeman's definition of
powerlessness as the "expectancy or probability held by the
individual that his own behavior cannot determine the occur-
rence of the outcomes or reinforcements he seeks" (1959,

p. 783) is similar to Langlie's (1977) definition of the
parochial individual as one who feels helpless to control
the events of his life, and is related to the concept of the
power of external forces over the individual discussed in
the conceptual framework.

Bullough (1972) interviewed 806 low-income black, Anglo,
and Mexican—American post-partum women in Los Angeles in
1971 regarding their preventive health care beliefs and
behaviors in the areas of prenatal and post-partum care,
well-baby checkups, family planning, immunizations, and
dental care for themselves and their children. Bullough
(1972) found that the three facets of alienation were signif—
icant in relation to the obtaining of preventive care for

children and prenatal and post-partum care for the mothers

66

and highly significant in relation to family planning.
Financial barriers appeared to hold more significance in
relation to dental care than the concept of alienation.

Ethnic differences were found as the Mexican-American
(Hispanic) subjects felt less powerlessness and less hope-
lessness than the Black women. Bullough hypothesized that
this finding may have been caused by lower levels of segre-
gation and discrimination for the Mexican-American population
or by the fact that it is the less alienated Mexican who
migrates to the United States. Bullough summarized by
advocating a correlation between the "culture of poverty"
concept and feelings of alienation among minority populations

Both poverty and a minority ethnic identity relate

to these feelings of alienation, and the attitudes

are in turn related to a low level of utilization

of preventive care. (1972, p. 358)
Thus, Bullough (1972) reiterated the assertion that poverty
is negatively related to utilization of preventive health
care and postulated the additional psychological barrier Of
alienation as a further explanation of why low-income and
ethnic populations do not readily seek preventive health
care. Bullough's study provided further emphasis of the
fact that low-income Obese Hispanics may not be prone to
utilizing preventive health care measures such as weight
reduction. Although the present research was not directly
measuring the concept of social alienation, powerlessness

and a sense of hopelessness were included under the concepts

of perceived susceptibility and motivational "cues to action."

67

Additional research related to these concepts was reviewed
under "Health Beliefs and the Hispanic."

The review of the literature on the preventive Health
Belief Model and preventive health behaviors in general
revealed some identifiable relationships between perceived
susceptibility, perceived benefits,anuiperceived barriers
(both financial and psychosocial) and preventive health
behavior. The low utilization of preventive health services
by low-income and/or persons of ethnic origin was documented
with tentative proposals made as to the cause of this phe-
nomenon. The literature review did not reveal specific
research concerned with beliefs about weight reduction as a
preventive health measure against the development of diabetes
mellitus (Type II). Because a correlation has been iden—
tified between health beliefs and health behaviors, the
preventive Health Belief Model was employed in the present
study to investigate the perceptions of low-income obese
Hispanics regarding weight reduction and the perceived
threat of diabetes. The literature review documented low
utilization rates of preventive health services among low-
income and/or ethnic populations. Therefore, it is important
to investigate perceived barriers to preventive health care
behavior among low-income Hispanics.

The following section reviews literature specifically
related to the main perceptual variables of susceptibility,

severity, benefits, and barriers.

68

Perceived Susceptibility and Perceived Severity

 

Within the Hispanic culture, the belief persists that
"God . . . is omnipotent" and man "subject to His judgment
and justice" (Samora, 1978, p. 66). This strong adherence
to the beliefs that God and/or spirits are in control of
man's destiny and may bring illness down upon man for testing
or for punishment may profoundly decrease the Hispanic
individual's ability to feel personally responsible for dis—
ease prevention. Even the "naturalistic" medical system of
balancing "humors" within the body is concerned primarily
with repairing imbalances rather than preventing them. The
traditional Hispanic medical belief system, based upon Greek,
Catholic, and indigenous practices was reviewed in the con-
ceptual framework and was not repeated in the literature
review.

Perceived susceptibility and perceived severity both
contribute to the perceived threat of a disease entity. In
order to perceive something as a threat, its future ramifi-
cations must be acknowledged. Thus, for a person to acknowl-
edge that obesity is a threat to his/her future health, he/
she must admit that obesity may lead to future complications,
such as Type II diabetes mellitus. Acknowledgment of this
threat may be difficult to elicit within the Hispanic popu-
1ation because the Hispanic perceives health status accord-
ing to how he feels at the present moment. To be healthy is
to be pain free and to be active in society, to be well—

fleshed, with a full face (Baca, 1978). Thus, obesity may

69

be accepted as a sign of good health, rather than as a dis-
ease precursor.

Various researchers have documented the concept of self-
image among different Hispanic populations. Schulman and
Smith (1963) studied the Spanish-speaking villagers of north-
ern New Mexico and southern Colorado and inquired into the
meaning of health, both physical and mental, within that
population. The concept of health was found to be correlated
with perceived normality and with an orientation to present
time. The healthy person was perceived as a mature adult
with family, job, and social obligations to fulfill within
the community.

Schulman and Smith found that ability to engage in a
high level of physical activity, absence of pain, and a well—
fleshed robust body with a rosy complexion were thought to
signify health. "Even a fat man, if he stands erect, and
'carries his weight well,‘ is considered healthy" (1963,

p. 229). Weight gain after an illness was considered a

good indication of recovery. The authors noted, however,
that the morbidly obese person was a rarity in that impov—
erished area. "Fatness" was the definition for excess pound-
age which could be removed easily by exercise, not for
obesity as defined for the present research. The villagers
could not readily differentiate between the words "robust"
and "fat," perhaps due to the lack of significant obesity

within that Hispanic subgroup. {Muaassociation of health

70

with a robust, well-fleshed appearance was found among both
men and women.

Schulman and Smith's (1963) portrayal of the healthy,
Spanish-speaking individual as active, robust, and without
pain was based on a specific subset of the Hispanic culture,
persons who were culturally non-assimilated and whose fami—
lies had lived in rural isolation for 3 centuries. It is
not known whether this self-perception of health can be
applied without modification to Hispanics presently living
in integrated communities in the Midwest.

Ziegler (1980) used Schulman and Smith's study to
explain the apparent lack of a social stigma associated with
obesity within a midwestern Hispanic population (migrants in
Mason, Michigan, 1979). It can be hypothesized that the
tendency to associate the robust, physically active person
as being full of health may have become distorted within
present Hispanic culture to include those persons of more
than robust or modestly overweight proportions. Thus,
morbid Obesity might not be perceived as potentially harm-
ful if the person remained relatively active. Likewise,
perceived loss of physical strength, or tiredness, might
carry more negative connotations in regard to health than
mere obesity. The overweight person might be perceived to
have the benefit of carrying a little extra weight to protect
himself/herself in case of illness, rather than being per—
ceived as being at risk for developing chronic illnesses

such as diabetes. In researching nutritional status in

71

migrants in mid-Michigan, Ziegler (1980) found no voluntary
mention of dieting and few references to exercise, other
than physical work, among that Hispanic population.

Poor or negative self—image may also affect Hispanics.
In a study of 280 Hispanics, Dworkin (1965) found a wide-
spread self-characterization among both foreign and native-
born Hispanics as being "short, fat, and dark." Overall,
Dworkin found that the Hispanics who were still migrating
seasonally appeared to have better self-images than the
settled Hispanics.

Gecas (1973) described two components of self-concept
which have been measured; the evaluative—-or the individual's
feelings about himself (such as Dworkin's study), and the
substantive--one's ideas about oneself which constitute an
identity. Gecas stated that most previous research on
Hispanics stressed the evaluative component, studies on
self-attributes such as emotions and laziness, and had
little conclusive data to report. Gecas stressed the impor-
tance of the categorical substantive element of self-concept,
which allows for identity within a social structure. He
studied the self-concepts Of members of 85 rural poor fami-
lies in a farming valley in Washington state. Both migrant
and settled Hispanics were interviewed. Similar to Dworkin's
evaluative study, Gecas found that migrants tended to be more
positive in indices of moral worth, competence, self-

determination, and altruism.

72

Gecas concluded that the migrant Hispanic may still
hold strong emotional and cultural ties to the traditional
culture, and be relatively untouched by the dominant American
values. The settled Hispanic, however, must live simultane-
ously in two worlds, exposed to new expectations and frames
of reference regarding diet and the importance of a slender
figure, while not possessing the resources, financial and
otherwise, which are perceived as necessary to overcome the
barriers to weight reduction inherent within the ethnic
identity.

Thus, the research has shown that the Hispanic individ-
ual may not perceive the potential threat of his/her obesity
as a precursor to a disease such as diabetes mellitus
(Type 11) because the obesity is confused with a "robust,
healthy" appearance. The possibility also exists that the
settled Hispanic in mid-Michigan is beset by a negative
self-image as a result Of conflicting values between the
traditional image Schulman and Smith (1963) described and
the prevalent American emphasis on slenderness.

Perceived Benefits and Barriers
to Weight Reduction

 

 

The studies reviewed under perceived susceptibility and
perceived severity have shown that it may be difficult for
the Hispanic individual to perceive himself/herself as being
at risk due to obestiy. As a consequence, it may also be

difficult for the obese Hispanic to value the benefits of

73

weight reduction as more significant than the barriers to
reducing.

The general literature described both physical and
psychosocial benefits to weight reduction. Craddock (1978)
detailed both the increased mortality overall and the spe-
cific increase in incidence of diabetes among the obese,
eSpecially those 20% or more overweight and concluded that
physical benefits to weight reduction would include a
decrease in mortality to the normal rates, a decrease in
the incidence of Type II diabetes, and a lessening of the
adverse effects of various chronic medical conditions
(Craddock, 1975).

Potential psychosocial advantages to weight 1055
include increased job Opportunities, increased ability to
dress fashionably, decreased shyness (Craddock, 1978),
improved self-esteem, and an increased desire for social
acceptance and social conformity (Rodin et al., 1977).
Rodin et al. (1977) studied 15 males and 129 females in a
weight reduction clinic to determine what factors were
associated with successful weight loss. A personality
inventory for self-esteem and a social acceptance scale
were used to measure the variables. Because Obesity is
stigmatized in western society (Allon, 1975), Rodin postu-
lated that self-esteem would be related to weight loss.

However, successful weight reduction was not found to
be related to the concept of self—esteem. Success was sig-

nificantly correlated to the concepts of desired social

74

conformity and social acceptance. These results showed that
individuals who were strongly aware of western social norms
of slenderness were thus motivated to conform and increase
their social acceptability through weight reduction.

The question remains of whether Hispanics who are
"settled" in mid-Michigan ascribe to the social values which
led the individuals in Rodin et al.'s study to be success-
ful in weight loss, or whether they adhere to the more tra-
ditional concept of the healthy individual as "robust." If
they adhere to the traditional values, it is not likely that
they will perceive positive benefits to weight reduction, and
thus it may be futile to attempt to include them in scien-
tifically based weight reduction programs. However, if they
have acculturated to the prevailing attitudes presented in
the media about the need for weight reduction, then it may
be valid to include these Hispanics in weight loss programs
tailored to accommodate their dietary preferences. The
present research attempted to validate the need for ethni-
cally relevant weight reduction programs by collecting data
on previously unstudied aspects of the perceived benefits
of weight reduction among a segmentcnfthe Hispanic
population.

Regardless Of their individual nature, in order for
perceived benefits to result in actual weight loss, the
benefits must outweigh any perceived barriers to weight
loss. Potential perceived barriers to weight reduction

include the perceived cost of special diets, the

75

inconvenience of special and/or unusual meal preparation,
and potentially painful emotional or physical stimuli. No
research was found which explored the concepts of perceived
cost of diets, or the perceived inconvenience of special
food preparation. Studies related to painful emotional or
physical stimuli can be separated into two broad categories;
studies related to the psychological make-up of the obese
individual and studies of reSponsiveness to external stimuli
among the obese.

Psychiatrists' studies of Obese individuals referred to
them for psychotherapy revealed a tendency among the obese
toward immature psychological behavior. In the review of
the data collected on obesity in the "Midtown" mental health
study, Moore, Stunkard, and Srole (1962) found in 334 obese
men and women and 1,042 controls that the obese had signifi-
cant pathological scores in immaturity, rigidity, and
suSpiciousness.

Individual case studies reported by psychiatrists
revealed similar results. Hamburger (1951) felt that over-
eating served a defensive function and produced both the
primary gain of mitigating undesired feelings of uncertainty,
insecurity, or anxiety, and the secondary gain of using
Obesity as a weapon against others in social interaction.
Both Bruch (1957) and Stunkard (1976) gave detailed accounts
of their psychotherapeutic efforts with obese patients, and
warned against simple weight reduction efforts with such

individuals. Bruch defined obesity as a symptom of emotional

76

instability and claimed that the Obese often held a deroga-
tory attitude towards their own bodies. Stunkard defined
the obese as possessing a severe disturbance of the body
image, and cautioned that they may be used as scapegoats by
other family members, especially when dieting efforts are
perceived as potentially threatening to the fragile balance
of family functioning.

Criticism of the strong pathology in the mental health
of the obese found by psychiatrists was raised by Silver-
stone (1965, 1966, 1973). As most psychoanalytic studies
were done on upper socioeconomic groups, Moore et a1. (1962)
concluded that the findings of immature behavior among the
cross—sectional "Midtown" population was significant,
especially since the obesity in this group was mainly among
the low-income groups. However, Silverstone (1973) countered
with the proposition that actually little major difference
was found in the psychiatric status between the obese and non-
obese subjects, the one area of immaturity being the
exception which Moore et a1. (1962) emphasized.

Silverstone (1973) claimed that there was little, if
any, controlled evidence to support the psychiatrists' asser-
tions that Obesity was the consequence of neurotic eating
patterns, and stated that controlled studies provided evi-
dence to the contrary. Silverstone and Solomon (1965) found
that of 32 obese patients who agreed to participate in a
l-year weight reduction clinic, 11 were considered neurotic

by the Cornell Medical Index, a result higher than the

77

general population, but not significantly so. The study was
carried out on a middle socioeconomic status group.

Shipman and Plesset (1963) studied the emotional effects
of dieting on 151 obese patients and found that 15% of the
patients from both hospital and general practices were
anxious or depressed at the beginning of the treatment and
the same percentage were disturbed at the end, with most of
them being the same persons. Thus, few persons became
depressed through dieting, although the small percentage
cited manifested psychological symptoms before dieting.
Unfortunately, the study lacked continuity because the
individuals were treated with different protocols for vary-
ing lengths of time.

Silverstone and Lascelles (1966) studied 60 volunteer
subjects in a l6-week weight reduction clinic in an urban
practice. No persons became severely depressed during diet-
ing and only slight rises in mild depression and anxiety were
found.

McCance (1961) found no evidence of increased neuro—
ticism among a group of 100 Obese individuals attending the
diet clinic in a London hospital when compared to a group of
non-obese persons. He concluded that psychiatric disturb-
ances have no bearing on Obesity. It was pertinent to the
present research to note that McCance's sample, in contrast
to the private clients seen by Silverstone, were mainly from
the lower socioeconomic groups who utilized the teaching

hospital clinics.

78

In a longer study, Silverstone (1973) assessed 344
adults in two London general practices which covered all
socioeconomic status ranges. Over one-half of the subjects
were at least 15% overweight. No significant difference in
the incidence of neuroticism between the obese and normal
wieght subjects was found. Silverstone (1973) concluded that
the prevalence of psychiatric disturbance was no greater
among Obese persons than among normal weight persons, and
discarded the previously mentioned assertion that obesity is
a defense mechanism against depression, by citing his
research findings (Silverstone & Lascelles, 1966) which
revealed no correlation between dieting and depression.
Though the warnings of the psychiatrist must not be ignored,
and individuals who exhibit psychological problems should be
referred for counseling before any weight reduction program
is instituted, the research evidence on non—psychiatric
clients presented above emphasized that the average obese
person is not in danger of psychiatric disturbance if he/she
undertakes a weight reduction program.

The second category of barriers to weight loss dealt
with the extent to which Obese individuals are influenced by
internal or external signals which facilitate overeating.
This concept bears some similarity to the psychological
variables previously discussed. Bruch (1973) hypothesized
that eating disorders were caused by difficulty in differ-
entiating between physical hunger and emotional reactions.

Obese persons were felt to often mistake an emotional state

79

as hunger and thus overeat without physiologic need. Simi-
larly, an external signal may trigger the impulse to eat
with physiologic symptoms of hunger.

Schachter (1967) proposed both an external and an inter-
nal hypothesis for overeating based on experimental research.
The external hypothesis states

. . . there is growing reason to suspect that the eat—

ing behavior of the Obese is relatively unrelated to

any internal gut state, but is, in large part, under
external control; that is, eating behavior is initiated
and terminated by stimuli external to the organism.

(1967, p. 117)

The external stimuli tested have been related to food itself,
its taste, smell, or texture; and also to other environmental
factors such as distractibility, time perception, and emo-
tionality. The internal hypothesis states

The relationships are quite the reverse for the normal

subject; his eating behavior seems directly linked to

internal state but relatively unaffected by the exter-
nal circumstances surrounding the eating routine and

ritual. (1967, p. 117)

Experimental evidence bore out the validity of the
external hypothesis, but provided little support for the
internal hypothesis, and suggested that many normal weight
subjects may also be very susceptible to external stimuli,
contrary to Schachter's theory. Most of the research on the
impact of external stimuli on the individual was carried
out either on volunteers from psychology classes or as

observer studies of large groups of people in public places

such as restaurants.

80

Various studies demonstrated a correlation between
excessive weight and external responsiveness. The eating
behavior of the obese was found to be more influenced by
the time of day (Schachter & Gross, 1968), by the taste and
sight of food (Nisbett, 1968a, 1968b; Wooley, Wooley, &
Williams, 1976) and by the visual prominance of the food
cues (Ross, 1974).

Other research showed that the increased responsiveness
of the obese occurred with stimuli other than food. Over-
weight individuals were found to be more responsive to exter-
nal cues than normal weight subjects in terms of distract-
ibility (Rodin, 1973; Rodin & Slochower, 1974), emotion-
ality (Pliner, 1974; Rodin, Elman, & Schachter, 1974), and
time perception (Pliner, 1974; Rodin, 1975).

The causal element in the relationship between obesity
and external re5ponsiveness has not been clearly determined.
Three main hypotheses linking the two concepts have been pro-
posed: that obesity is a precursor to external responsive-
ness; that a third, underlying concept such as deprivation,
correlates obesity and external responsiveness; or that
externality is the cause of overeating and weight gain
(Rodin, 1975).

The first two hypotheses were not substantiated in the
research findings. Rodin and Slochower (1976) supported the
third hypothesis, that externality itself is the cause of
overeating and weight gain, as proposed by Schachter and

Rodin (1974).

81

Rodin and Slochower (1976) tested the third hypothesis
on a group of normal weight individuals to rule out obesity
as a cause of external responsiveness. An 8-week summer camp
was studied in which all participants (125 girls, aged 9 to
15) had access to the same food, same activities, and lived
in the same environment. The children who exhibited hyper-
responsiveness tended to have more absolute changes in
weight, either gains or losses, than children with low respon-
siveness. It thus appears that many non—obese as well as
obese individuals may be susceptible to external food cues.
Rodin and Slochower (1976) concluded that

Perhaps externally re5ponsive people who maintain normal

weight are those who are responsive to major shifts in

food cues that produce short-term weight gain, but for
whom long-term regulation is re5ponsive to other fac-
tors. Externals who have become overweight are those
individuals whose long-term regulatory mechanisms do
not inhibit the continued weight gain that results from

heightened re5ponsiveness. (p. 343)

For as yet unknown reasons, some individuals readily
respond by eating when confronted with the external stimuli,
and become obese, while other persons either possess more
self-control or have learned that other concerns are more
important than the desirability of the food, for example
appearance or praise from significant others. It is possible
that environmental, especially family, influences may serve
to mitigate the potentially self-destructive tendencies of
some persons who are susceptible to external stimuli and
thus to prevent Obesity in that segment of the population.

In conclusion, environmental stimuli, as well as the

more classic psychological issues of depression and

82

alterations in self—concept, have been shown to be possible
psychosocial barriers to weight reduction. While researchers
such as Craddock (1975) assumed that the average primary

care population would be relatively free of serious
depression or alterations in body image which would require
psychiatric care, the research studies on environmental stim-
uli were conducted mainly on samples drawn from the general
population and showed a widespread incidence of external
responsiveness among that population. Thus, the primary
health care provider can reasonably expect to be confronted
with the problem of the obese individual who is very respon—
sive to external stimuli, whether to food and/or to other
cues. Again, although there was no research which dealt
specifically with the issue of ethnic identity and external
re5ponsiveness, it is reasonable to assume that the low-
income obese Hispanic population may contain many individuals
who are very responsive to external stimuli and who may thus
be faced with this barrier to effective weight reduction.

The present research explored the general psychosocial bar—
riers to weight reduction among middle-aged, low-income

obese Hispanics.

Health Beliefs and the Hispanic

 

The traditional reliance of the Hispanic individual
upon the power of fate (whether expressed as the will of
God, the power of the devil or spirits, or merely as chance)

has been discussed in Chapters I and II. This traditional

83

belief system may strongly influence the choices made by
individual Hispanics regarding the utilization of traditional
or scientific health care providers.

A number of researchers concluded that age and socio—
economic status differences strongly affect the perception
and utilization of traditional or scientific health care
services, (Holland, 1978; Madsen, 1973; Kay, 1977; Nall &
Speilberg, 1978), while other researchers contended that
sociocultural attributes cut across age and class barriers
and are the most important determinants of an individual's
preference for one type of health care over another (Snow
& Johnson, 1977; Martinez & Martin, 1978; Lee, 1976; and
Johnston, 1977).

Holland (1978) sought to demonstrate that individuals
choose one type of health care over another according to
their level of integration into the Anglo culture. He
studied 250 Hispanic families in Tucson, Arizona, the major-
ity of whom were first or second generation immigrants from
Mexico and of low socioeconomic status. Data were gathered
on a variety of socioeconomic and cultural variables includ-
ing strength of belief in traditional disease concepts.

Holland (1978) identified the three phases of assimi-
lative integration into the Anglo culture as conservative
(not assimilated), transitional, and highly assimilated.

The 25% of the respondents categorized as conservative
expressed strong belief in the folk health belief system, a

preference for herbal remedies, and preferred the services

84

of the folk healer or "curandero." They were found to be
skeptical of Anglo physicians and likely to use their ser-
vices only if traditional cures had proven unsuccessful. The
conservative individuals were found to be low-income and
poorly educated.

The 50% of the respondents who were rated as in the
transitional phase utilized both the traditional and scien-
tific health care systems and held beliefs common to both
systems. Members of this group were also low-income and
recent immigrants, but tended to possess employment as
skilled laborers.

The 25% of the sample who were considered to be highly
assimilated possessed education and income levels similar to
Anglos, were English speakers, and deemed nuclear family
ties as more important thantflmaextended kinship system.
These individuals might still utilize herbal remedies or the
services of a "curandero" if dissatisfied with the results
of scientific treatment, but generally preferred to utilize
the modern health care system.

Holland (1978) concluded that, although any Hispanic
may still employ traditional health care practices, there is
a general trend toward assimilation into the modern health
care system and a gradual decline in the importance of
traditional folk health beliefs as the assimilative process
occurs.

Nall and Speilberg (1978) also investigated the effects

of assimilation into the dominant culture upon the

85

acceptance of scientific health care practices. They
studied 53 Hispanic adults from McAllen, Texas in the Rio
Grande River Valley, in relation to their acceptance or
rejection of the recommended treatment regime for tuber-
culosis. Social integration or assimilation was measured by
integration into the family group, the ethnic locality group,
and by language used outside the home. Those persons who
were found to be highly socially integrated into their
traditional culture were considered non-assimilated into the
dominant Anglo culture and were less likely to accept treat-
ment for tuberculosis. These persons were generally older,
married, had close kinship ties, and spoke only Spanish.
Conversely, those persons who were not found to be socially
integrated into traditional culture and who accepted the
treatment regimen were younger, not married, had no close
kinship ties, and were predominately English-speaking. These
persons were not, however, necessarily assimilated into the
Anglo culture.

Similarities can thus be found between Nall and Speil-
berg's (1978) socially integrated traditional Hispanics who
rejected scientific treatment and Holland's (1978) conserva-
tive group, but not necessarily between Nall and Speilberg's
non-socially integrated group which accepted treatment and
Holland's assimilated group. It can be concluded from both
studies that those persons who were more closely tied to
their traditional culture (socially integrated) tended to

reject scientific health care practices. However, Nall and

86

Speilberg (1978) did not find that commitment to folk medi-
cal beliefs, propitiatory religious acts, or "curanderos"
was related to rejection of scientific health care. They
thus refuted the traditional opinion that belief in the folk
health belief system is a barrier to health care services
(Madsen, 1973; Rubel, 1960; Saunders, 1954).

Madsen (1973) found that the degree of reliance on
traditional or scientific health care systems is correlated
with socioeconomic status or class and education. He stated
that there was a gradual transition from the lower class
which relied most heavily on folk healers to those individ-
uals in the highest social classes who depended almost
entirely on physicians and prayer. Madsen (1973), however,
did not specify what criteria were employed to determine
social class.

Kay (1977) studied 60 adult women from ages 22 to 78
who were members of four families in a Hispanic neighbor-
hood in a large southwestern city. The older women were most
knowledgeable about folk health beliefs, especially those
related to women's health care.

In summary, Holland (1978), Nall and Speilberg (1978),
Madsen (1973), and Kay (1977) all concluded that Hispanics
can adhere to both traditional and scientific health belief
systems simultaneously, and that the traditional folk health
belief system is undergoing a gradual process of assimilation
with scientific health care practices. These researchers

claimed that there is an age and/or socioeconomic status

87

related difference in the belief and practice Of folk medi—
cine. There is also some indication that belief in the
magico-religious disease concept is no longer as strong as
belief in other traditional health concepts. Sixty percent
of Holland's (1978) respondents denied belief in disease
caused by magic or extra—human forces and stated that it was
a "superstition contrary to Catholic doctrine to which only
the older generations adhered" (p. 115). Kay's (1977)
informants denied that God sends illness as a punishment,
and claimed that "Help yourself, and God will help you"

(p. 123). These studies indicate that there may not be as
strong a tendency toward fatalistic thinking as the process
of assimilation occurs and scientific causes for illness
are provided.

Other researchers did not find age-related differences
in folk health beliefs and practices. Snow and Johnson
(1977) interviewed 40 low-income, poorly educated Hispanic
women enrolled in a public health clinic in Michigan to
determine their understanding of menstruation and its effects
on health and illness. The women responded according to the
traditional hot-cold dichotomy; thus the issue of blood,
which is hot and dry, could be stopped by any food, medi-
cation, or environmental agent which is perceived as cold
and wet. Although traditional health beliefs and practices
were widely acknowledged by this group of women, no age-

related difference was found among the respondents.

88

Johnston (1977), a nurse researcher, studied expecta-
tions held by Anglo, English-speaking Hispanic, Spanish-
speaking Hispanic, and Black mothers regarding the perceived
efficacy of vitamins. Her sample of 200 women with a mean
age of 28 years revealed no age-related differences among
the folk health beliefs of the women.

Martinez and Martin (1978) studied the Hispanic folk
health belief system, particularly beliefs concerning eti-
ology, symptomatology, and modes of disease treatment. A
structured interview was used on 75 Hispanic women in a
southwestern city. Martinez and Martin (1978) found that
belief in folk illness was almost universal, with almost
97% of the women claiming knowledge of folk diseases, and
95% personal contact with folk illnesses within their own
families. There was no relationship between belief in and
reported occurrences of folk diseases and age, education,
or birthplace of the informants.

Martinez and Martin's (1978) findings conflicted with
Holland's (1978) findings in that Martinez and Martin found
no relationship between age and/or socioeconomic status and
belief in the folk health belief system. Martinez and
Martin (1978) concluded instead that the preservation of
folk beliefs is a result of sociocultural isolation, "accul-
turation and assimilation of persons of Mexican origin . . .
has been slowed by social mechanisms of the larger society

which tend to keep these people separate" (p. 276).

89

Lee (1976) also found that sociocultural factors influ-
enced belief in scientific health care practices more than
socioeconomic status. He gathered data on 416 Hispanic fami-
lies in a California neighborhood health center and found
that there was no relationship between socioeconomic status
of the family and the utilization of health care services.

The role of the folk healer or "curandero" within the
Hispanic culture today has been disputed in the literature.
Clark (1970), Holland (1978), Madsen (1973), Rubel (1960,
1966), and Saunders (1954) documented the importance of
the "curandero" in northern California, Arizona, New Mexico,
and south Texas. Martinez and Martin (1978) also reported
that their subjects consulted the "curandero" for treatment
Of folk illnesses.

Edgerton, Karno, and Fernandez (1978), however, inter—
viewed 500 Hispanics in East Los Angeles and found that less
than 1% of the sample identified the "curandero" as a
potential health care provider. Kay (1977) found that the
role and the perceived efficacy of the "curandero" was widely
disputed among her respondents, with the younger women
acknowledging scant acquaintance with folk treatments or
"curanderos."

Edgerton et al.'s (1978) and Kay's (1977) studies sug-
gest that there may be age or geographically related dif-
ferences in the perceptions of the "curandero" as a valid
health care provider. It is also possible that the HiSpanic

population who are more acculturated (younger or living in

90

urban areas) may be reluctant to acknowledge the use of

folk medicine, especially if the interviewer is not Hispanic.
There was no research found which documented this last
contention.

In summary, the literature on motivational "cues to
action" showed that there may be a decreasing tendency among
Hispanics to believe in the power of extra-human forces or
chance to determine their health status and an increasing
tendency to believe that one can help oneself through pre-
ventive health care behavior (Holland, 1978; Kay, 1977).
Whether health beliefs and practices are affected more by
age and socioeconomic status or by sociocultural factors was
not conclusively determined. It was, however, shown by a
number of researchers (Holland, 1978; Nall & Speilberg,
1978) that a gradual assimilation of traditional health
beliefs and practices and scientific beliefs and practices
has been occurring. Both health care systems can be utilized
simultaneously, without the traditional system serving as a
barrier to seeking preventive or curative scientific health
care (Nall & Speilberg, 1978; Martinez & Martin, 1978).

The nursing literature documented both the survival of
the folk health belief system and the necessity of providing
culturally relevant scientific health care for the Hispanic
individual. Dorsey and Jackson (1976), Baca (1978),
Gonzales (1976), Hautman (1979), Johnson (1978), Spector
(1979), and White (1977) discussed folk health beliefs and

practices within the Hispanic culture and their interaction

91

with the professional health care system. Proposed nursing
interventions based on their writings and on the present

research are presented in Chapter VI.

Summary

The review of the literature documented studies per—
taining to the preventive Health Belief Model in general and
to its components of perceived susceptibility, perceived
severity, perceived benefits, and perceived barriers. Health
beliefs specifically related to the Hispanic p0pulation were
also documented. The literature review failed to discover
many research studies pertaining to the Hispanic population
and/or to the issue or weight reduction as a preventive
health measure.

However, it was documented that perceived susceptibility
to and perceived severity of diabetes as a result of obesity
may be a concept foreign to the Hispanic mind and thus the
threat of diabetes may not be perceived as very relevant to
the average Hispanic (Schulman & Smith, 1963). Although per-
ceived benefits to weight reduction were documented and
would theoretically apply to the Hispanic population, no
research has proven their applicability to this cultural
group. In contrast, the perceived barriers to weight
reduction, especially external responsiveness, were shown to
have more universal characteristics and thus may be valid in
relation to the Hispanic population. In light of the above

findings, it is questionable whether the Hispanic individual

92

will find himself/herself seeking out preventive health care
in the form of weight reduction without a direct motivational
"cue to action."

Nursing practice may provide a culturally relevant "cue
to action" by acknowledging the contribution of both folk
and scientific health belief systems to the action of pre-
ventive health care. The present research study added to
the knowledge base of nursing in the planning and implement-
ation of these "cues to action."

In Chapter IV, the methodology and procedures utilized
in this study are presented. The sample, setting, instrument,
procedures for data collection with human rights protection,
scoring procedures, and techniques of data analysis are

discussed.

CHAPTER IV

METHODOLOGY

Overview

This research study investigated the individual per-
ceptions and health beliefs of middle-aged, low-income obese
Hispanics. The subjects were 30 Hispanics residing in a
midwestern urban area of 200,000 peOple. Perceived sus-
ceptibility to the development of non-insulin dependent
diabetes mellitus (Type II) as a result Of obesity, the
perceived severity of the diagnosis of Type II diabetes
mellitus, and the perceived benefits and perceived barriers
to weight reduction were the study variables derived from
the preventive Health Belief Model (Rosenstock, 1974).
Modifying variables such as age, sex, family developmental
stage, and family history of diabetes were determined
through the gathering of sociodemographic data. The motiva-
tional variable or "cues to action" was measured through the
gathering of data concerning the influence of "powerful
others" and "chance" upon the individual. The instrument
was translated into Spanish and presented in an interview
format to the participants. The techniques used for analy-

sis of the data included descriptive and inferential statistics.

93

94

The purpose of this chapter is to present the methodology
and procedures utilized in this research study. The sample,
setting, instrument, pretest procedure, data collection
procedure with human rights protection, scoring techniques,

and procedures for data analysis are discussed.

Sample

The subjects were 30 middle-aged, low-income obese
Hispanic individuals. The convenience sample was drawn from
persons who were permanent residents of a midwestern urban
area with a population of approximately 200,000 peOple.

The subjects were either regular clients of the health clinic
at a low-income community center or were individuals known
personally by the clinic coordinator. Results of this study,
therefore, can be generalized only to those individuals who
possess the same characteristics as individuals defined in
the sample, and are not indicative Of a random sample of the

Hispanic population.

9932
The obese Hispanic was defined as the individual who

was at least 20% over the average weight for height according

to the tables of the Department of Health, Education, and

Welfare, 1966 (Appendix A).

Middle-aged
The middle-aged Hispanic was defined as an individual
(male or female) between the ages Of 30 and 60. The lower

age limit was set by the lower limit in Stevenson's (1977)

95

definition of middlescence and in order to include virtually
all persons at risk to develOp Type II diabetes. The upper
limit of 60 was extended from the end of Stevenson's middle-
scence I, 50 years, because one of the prime tasks of the
middle-aged couple, the raising and launching into society
of children, may not be completed in the Hispanic family by
the age of 50. The task Of childrearing was chosen as an
indicator for this study because the demands of children's
and teenagers' eating schedules may serve as a significant
barrier to weight reduction among their parents. Single,
middle-aged Hispanics without children were not included in
the study design because they would not be affected by this
potential barrier. However, divorced parents, in close con-

tact with at least one of their children, were included.

Low-income

 

All of the subjects were clients of a low-income com-
munity clinic. They met the designated criteria of the

federal government for low-income classification (Appendix B).

Hispanic

 

The term Hispanic referred to any individual raised in
a Spanish-speaking environment whose first language was

Spanish.

Setting

The low-income community center utilized in this study
serves a multi-racial and linguistic population in a low-

income area. The majority of clients, however, are of

96

Hispanic origin. The community center provides English
language classes, employment assistance, substance abuse

and mental health counseling, and emergency financial
assistance, as well as physical health care. The health
clinic offers weekly adult health and pediatric clinics
staffed by physicians and also employs a full-time nurse who
serves as the clinic coordinator. The community center is
Operated by the local Catholic diocese and is funded by both
the Catholic church and the federal government.

Both the community center and the private homes of the
subjects were utilized as settings to gather the data. At
the community center, a quiet, private location, free from
interruptions, was used for the interviews. In the sub-
jects' homes, the kitchen or dining room table was generally
the only surface area available for writing. Again, attempts
were made to ensure a quiet, private atmosphere. Most of
the private dwellings, which included single family homes,
apartments, and public housing projects, were within two

miles of the community center.

Instrument

 

The instrument was based upon the preventive Health
Belief Model (Rosenstock, 1974) and combined items drawn
from three sources; published instruments, the literature
review, and the results of a pilot test designed by the
researcher which addressed pertinent concepts not included
in the literature review. Selected items were drawn from

three published instruments; the Diabetes Mellitus Patient

 

97

Interview (Bowen, Rich, & Schlotfeldt, 1979), the Health

 

Perceptions Questionnaire (Ware, Wright, & Snyder, 1974),
and the Locus of Control Scales (Wallston, Wallston, &

De Vellis, 1978). A pilot test was develOped by the
researcher to tap concepts not included in the literature
review, but which were deemed important to Hispanics. Open-
ended questions (Appendix C) concerning Obesity and diabetes
were asked of 10 Hispanics, both obese and non-Obese,
diabetic and non-diabetic, in order to develOp additional
instrument items.

The total instrument contained 56 items which measured
each of the major perceptual variables; perceived suscepti-
bility to diabetes (10 items), perceived severity of diabetes
(15 items), perceived benefits of weight reduction (10 items),
perceived barriers to weight reduction (11 items), and the
motivational variable "cues to action" (10 items) (Appendix
D). Modifying factors were assessed through the collection
of sociodemographic data (Appendix D). The instrument con-
tained both positively and negatively worded close-ended
items which were arranged randomly. The instrument was
translated into Spanish by a Spanish language graduate
student (Appendix D).

Operational Definitions of the
Study Variables

Festinger (1957) stated that beliefs about beliefs can

be assumed to be equivalent to the beliefs themselves.

Fishbein and Ajzen hypothesized that beliefs about an Object

98

are the basis for the formation of attitudes about the
object (1975). The individual person may hold a large
number of beliefs about a particular object. Only those
beliefs which are active in forming an attitude at a given
time are termed salient (Fishbein & Ajzen, 1975). The indi-
vidual beliefs or perceptions which were tested in this
study may or may not prove relevant in the individual's
ability to form an attitude about his/her susceptibility to
Type II diabetes or about the severity of diabetes as a
disease since the total instrument has not been previously

tested.

Perceived Susceptibility

The concept of susceptibility to Type II diabetes as an
internal factor of which the individual could have some
prior knowledge and control over was tested through items
drawn from the Diabetes Mellitus Patient Interview (Bowen
et al., 1979) (Appendix D, items 1 and 11), and from the
literature review and the pilot test (Appendix D, items 6,

16, 21, 26, 31, 37, 43, and 49).

Perceived Severity

The perceived severity of diabetes mellitus (Type II)
as a disease was measured by questions which elicited both
beliefs and cognitive knowledge. The items reflected the
present or potential limitations of diabetes mellitus
(Type II) as a disease, the potential complications of

Type II diabetes, the perceived socioeconomic burden of the

99

disease, and the emotional significance of the diagnosis.
The severity items were developed from Bowen at al. (1979)
(Appendix D, items 17, 39, 44, and 51), Ware et a1. (1974)
(Appendix D, item 12), and from the literature review and
the pilot test (Appendix D, items 2, 7, 22, 27, 32, 33, 38,

45, 50, and 55).

Perceived Benefits

The items which measured the perceived benefits of
weight reduction were derived solely from the literature
and from the pilot test. The concept of perceived benefits
of weight reduction was operationalized through the use of
items which measured the perceived decreased risk of
developing Type II diabetes as a result of weight reduction
(Appendix D, items 3 and 8), and from items which measured
feelings Of self-esteem (Appendix D, items 13 and 18),
physical well-being (Appendix D, items 23, 28, 40, 46, and
52), and social support from significant others (Appendix D,

item 34).

Perceived Barriers

The items which measured the perceived barriers to
weight reduction were also derived solely from the litera-
ture and from the pilot test, since there was no previously
tested instrument available. Barriers to weight reduction
were measured by items concerned with economic factors
(Appendix D, items 14 and 19), perceived inconvenience

(Appendix D, items 24 and 29), and painful physical and/or

100

emotional external stimuli (Appendix D, items 4, 9, 35, 41,

47, 53, and 56).

Motivational "Cues to Action"

As documented in Chapter I and II, there exists a strong
tendency among the Hispanic population to attribute illness
to either the action Of powerful others such as God, spirits,
or powerful persons (lay or scientific practitioners), or to
chance or fate. Items which measured the concept of chance
or fate were derived solely from the Locus of Control Scales
(Wallston et al., 1978) (Appendix D, items 36, 42, and 48).
The concept of powerful others such as God or spirits was
measured through the development of items from the literature
review (Appendix D, items 5 and 10). Items which measured
the perceived efficacy of lay and scientific health care
practitioners were drawn from the Locus of Control Scales
(Wallston et al., 1978) (Appendix D, items 20 and 25) and
from the literature (Appendix D, items 15, 30, and 54).
Modifying Variables--

Sociodemographic Data

Sociodemographic data were gathered in order to deter-

mine age, sex, family developmental stage, and family

history of diabetes among the subjects (Appendix D).

Age. The convenience of middle-aged, low-income obese
Hispanics was divided into three age groups:
1. ages 30-39

II. ages 40-49
III. ages 50-60

101

Sex. The numbers of males and females who participated
in the study were calculated in order to measure possible

variations in individual perceptions according to sex.

Family Developmental Stage. Duvall's (1977) stages of

 

family development were used to determine the present stage
of each individual's family. Because the population avail-
able for study was limited, Duvall's eight stages were con-
densed into four broader stages in order to include more
individuals in each category. Family develOpmental stage
was determined by the age of the youngest child in the
family. The age of the youngest child determines the length
of time the family will be involved in childrearing. The
four develOpmental stages used in this study were birth to
school age (I), ages five through twelve (II), teenagers--
ages 13 through 17 (III), and those families with only adult

children (over age 18) (IV).

Family History of Diabetes. Data on family history of

 

Type II diabetes mellitus were gathered to determine whether
a relationship existed between the presence of a family
history of diabetes and perceptions of the risk of develop-
ing diabetes. Specific data were gathered regarding grand-

parents, parents, and siblings of the subjects.

Validity of the Instrument
Content validity refers to the extent to which the

items accurately reflect the subject matter under question

102

(Crano & Brewer, 1973). The researcher necessarily makes
judgments concerning which items reflect the desired con-
tent; therefore, content validity is subjective (Polit &
Hungler, 1978). In this study, content validity was deter-
mined by the subjective appraisal of each item by the
researcher and by conferring with five experts in the fields
Of obesity, diabetes, and cross-cultural nursing.

There were a number of threats to validity which were
pertinent to this study. Several of these threats could not
be avoided. Because the instrument was previously untested,
response bias was a possibility; that is, the particular
wording of the items, rather than their actual content,
might have influenced the answers. The translation of the
instrument into another language furthered the possibility
that choice of words, rather than actual content, might have
influenced the responses. The subjects also may have tended
to give socially desirable answers, rather than to risk
exposing negative feelings or behaviors. This was parti-
cularly important for the present research as the interview
format significantly decreased the amount of privacy the
subjects had when answering the questionnaire.

Several other potential threats to validity were at
least partially minimized in the construction of the instru-
ment. The threat of acquiescence, in which the subject
would tend to agree with positively worded statements, was
partially eliminated through the use of both positively and

negatively worded items. An attempt was made to decrease

103

the possibility of extreme response set, in which the sub-
jects respond to one of the extremes of the scale rather
than using fine discrimination, through the use of a six-
point Likert scale which provided a wide range of possible
answers. The tendency to answer at the middle Of the scale
or under the heading "undecided" was minimized through the
use of a scale which had no designated midpoint. Potential
cultural biases were screened for by an expert in cross-

cultural nursing who is a native Spanish-speaker.

Reliability of the Instrument

 

Coefficient Alpha was used to examine the internal con-
sistency of the items in each of the main study variable
scales; perceived susceptibility, perceived severity, per-
ceived benefits, and perceived barriers, and on the scale
of motivational "cues to action." The standard for internal
consistency is a correlation of at least .80 (Crano & Brewer,
1973). A coefficient Alpha of such a high level is usually
attained after several pretests of the items on the instru-
ment and with the utilization of both a large sample size
and an instrument with many items. The present research,
as an exploratory descriptive study, was a first testing of
the instrument upon a relatively small sample and thus could
not be expected to yield as high a coefficient Alpha as a

previously tested and refined instrument.

104

Pretest of the Study Questionnaire

The total instrument, containing the page of socio-
demographic data and the 56 item questionnaire (Appendix D),
was pretested for readability, clarity of directions, and
time required for completion by four Hispanic individuals
who were attending a senior citizens lunch at the low-income
community center. The pretest sample was similar to the
actual study sample in relation to low-income status, Spanish
language preference, sex (both male and female), family
history of diabetes, and present physical status (none was
a diagnosed diabetic). They differed in that the ages of
the pretest group ranged from 61 to 65, which excluded them
from the 30 to 60 age range for the actual study sample.

The decision was made to utilize this slightly Older pretest
sample because of the very limited number of eligible sub-
jects in the area. Employing a pretest sample within the
age range would have seriously compromised the size of the
actual sample.

The pretest subjects were asked to provide feedback to
the researcher in relation to readability, clarity of
directions, and time needed to complete the interview.
Subjects often found the negative items to be confusing.
These items were rechecked for content and readability by
the translator and by the cross-cultural nursing expert.

The decision was made by the researcher to retain the
negatively worded items in order to decrease the threat of

acquiescence.

105

Data Collection Procedure

Permission to use the community center and clinic site
for contacting and interviewing subjects was granted by the
director of the center and by the clinic coordinator. The
clinic coordinator (a native Spanish-speaker who was also
the cross-cultural nursing expert) contacted prospective
subjects by telephone or in person at the center. Following
an explanation of the identity of the researcher, the nature
of the study, and the interview format, the prospective
subject decided whether or not to be contacted directly by
the researcher.

Those persons who agreed to participate in the study
were met by the researcher at their convenience either at
the clinic or in their own home. The guidelines of the
Michigan State University Committee on Research Involving
Human Subjects (UCRIHS) were utilized to protect the sub-
jects' rights. An explanation of the study was included in

written form in the Consent Letter (Appendix E) and was read

 

to each subject. This statement delineated the voluntary
nature of the research, the risks and benefits involved,
confidentiality, privacy afforded, and how long it would
take to complete the questionnaire. Questions were answered
by the researcher and the consent form was signed by the
subject with the acknowledgment that the subject was free

to stop the interview at any point without penalty if ter-

mination of the agreement was desired.

106

During the interview, the researcher read each item
once while the subject responded in writing on the question-
naire. The researcher repeated questions upon request for
the purpose of clarity, but answered only procedural ques-
tions about the study itself. At the completion of the
interview, the questionnaire and the consent form were
collected by the researcher. The subject was given a COpy
of the consent form with the researcher's name and phone
number and was also instructed to contact the clinic coordina-
tor if he/she could not get in contact with the researcher
and still had further questions or wished to withdraw con-
sent at a later time.

The questionnaires and consent forms were coded with
the same number so that if an individual chose to withdraw
from the study after the interview, the questionnaire could
be destroyed. The questionnaires were stored in the re-
searcher's home in a file cabinet. Data were recorded from
the questionnaires in aggregate form. The complete pro-
cedures involved in Human Rights Protection are detailed in

Appendix E.

m

In the following paragraphs, the scoring procedures
for the sociodemographic data and for the questionnaire are
presented. In addition to sociodemographic data designed
to investigate age, sex, family developmental stage, and
family history of diabetes, data were also gathered on the

birthplace and the religion of the subjects, on their

107

marital status, and on their total number of children
(Appendix D). This information was used solely for descrip-
tive purposes. There were five categories available regard-

ing birthplace:

Texas Michigan Mexico Florida Other
1 2 3 4 5

and four categories for religious preference:

Catholic Baptist Pentecostal Other Protestant
Demonination
l 2 3 4

These birthplace and religious preference categories were
selected because they were believed by the researcher and

by the expert in cross-cultural nursing to be representative
of the majority of the local Hispanic population. The

marital status was indicated as follows:

Married Separated Divorced Widowed
1 2 3 4

Information on age, sex, total number of children, and
age of the youngest child was also recorded. The age of the
youngest child was used to compute the stage of family
development. The family history of diabetes was recorded
for the following individuals; paternal grandfather, paternal
grandmother, maternal grandfather, maternal grandmother,

father, mother, brothers, or sisters.

108

The 56 items on the preventive Health Belief Model
questionnaire (including the categories of perceived sus-
ceptibility, perceived severity, perceived benefits, per-
ceived barriers, and motivational "cues to action") were
scored using a six-point Likert scale. Crano and Brewer
stated that Likert's method of summated ratings was the most
"popular approach to the generation of reliable attitude
measurement devices" (1973, p. 239). Although a five-point
discrimination scale is the most Widely used, a six-point
scale was chosen for this study in order to eliminate the
"undecided" category and to thereby decrease the possibility
of having many "undecided" answers.

Positively worded items were scored as follows:

Strongly Moderately weakly weakly Moderately Strongly
Agree Agree Agree Disagree Disagree Disagree
6 5 4 3 2 l

Negatively worded items were scored:

Strongly Moderately weakly weakly Moderately Strongly
Agree Agree Agree Disagree Disagree Disagree
1 2 3 4 5 6

Therefore, items which were positively worded received the
highest point value for Strongly Agree and those items which
were negatively worded received the lowest point value for
Strongly Agree. The scores in each of the five categories
(perceived susceptibility, perceived severity, perceived
benefits, perceived barriers, and motivational "cues to

action") were totaled and used to determine the t-test

109

between independent samples and Pearson Product-Moment

correlations.

Procedures for Data Analysis

Both descriptive and inferential statistics were
utilized in this study. The descriptive statistics included
frequencies, percentages, means, modes, ranges, standard
deviations and correlations.

In order to test the relationship between the variables
in this study, the Pearson Product-Moment correlation (E)
was computed. The interrelationships between the main per-
ceptual variables of susceptibility, severity, benefits, and
barriers were determined. The individual perceptual variables
were also correlated with the modifying factors of age, sex,
family develOpmental stage, and family history of diabetes,
and with the motivational "cues to action." "The size of
the correlation coefficient is indicative of the degree of
relationship between the variables, and a low correlation
indicates a low relationship" (Borg & Gall, 1971, p. 358).
The correlation coefficient (5) has a range of value from
-1 to +1. The interpretation of (E) computed between the

variables in this study was:

 

 

Absolute Value of (r) Strength of Relationship
0.00 to 0.20 negligible
0.20 to 0.40 slight or low
0.40 to 0.60 moderate or fair
0.60 to 0.80 marked, somewhat high
0.80 to 1.00 high to very high

(Van Ormer & Williams, 1941, p. 65)

110

The inferential statistics used in this study were the
t-test for independent samples and chi-square. The t-test
compared the actual scores on the five categories (perceived
susceptibility, perceived severity, perceived benefits, per-
ceived barriers, and motivational "cues to action") with the
assumed mean (the score which would have been achieved by
chance). The t-test was utilized in order to determine
whether the differences between the actual mean scores on
the variables and the values of the assumed scores were
statistically significant. The chi-square technique,
utilized to compute differences between categories of data
(Polit & Hungler, 1978), was used in this study to ascertain
whether there were differences between the three age groups
(30-39; 40-49; and 50-60) in their scores on the main per-

ceptual variables.

Summary

Chapter IV provided an overview of the methodology and
procedures utilized in this study. The sample, the setting
for data collection, the development of the instrument and
its pretesting, the actual data collection procedure with
human rights protection, the scoring and the data analysis
techniques were presented. In Chapter V, the data pertain-
ing to the description of the subjects and the analysis of

the research questions are presented.

CHAPTER V

DATA PRESENTATION

Overview

 

The purpose of this study was to determine the per-
ceptions of middle-aged, low-income Obese Hispanics about
the relationship between obesity and the perceived risk of
developing non-insulin dependent (Type II) diabetes mellitus.

The research questions develOped for this study were:

Research_Questions

1. Does the middle-aged, low-income obese Hispanic
perceive that he/she is susceptible to develop non-
insulin dependent diabetes mellitus (Type II)?

2. What is the perceived severity of Type II diabetes
mellitus among middle-aged, low-income obese
Hispanics?

3. Are there perceived benefits to weight reduction
among middle-aged, low-income obese Hispanics?

4. Are there perceived barriers to weight reduction

among middle-aged, low-income obese Hispanics?

111

112

5. What are the relationships between perceived sus-
ceptibility to and perceived severity of disease,
and perceived benefits and perceived barriers to
weight reduction?

6. What are the relationships between the modifying
variables of age, sex, family develOpmental stage,
and family history of diabetes, and the main per-
ceptual variables of susceptibility, severity,
benefits, and barriers?

7. What are the relationships between the motivational
"cues to action" and the main perceptual variables
of susceptibility, severity, benefits, and barriers?

In this chapter, data describing the study sample and

data addressing the research questions are presented. The
study sample is described by age, sex, family developmental
stage, and family history of diabetes. Additional descrip-
tive data on birthplace, religion, marital status, and
number of children, although not directly related to the
study variables, are presented to broaden the description

of the sample. Data pertaining to the research questions
are based on the scores generated from the individual scales
of perceived susceptibility, perceived severity, perceived
benefits, and perceived barriers.

Several statistical analysis techniques were used to

analyze the data. Descriptive statistics included fre-
quencies, percentages, means, modes, ranges, standard

deviations, and the Pearson Product-Moment correlation.

113

Inferential techniques used were chi-square and the t-test
for independent samples. The data are presented as follows;
descriptive data pertaining to the sample, reliability data,
and descriptive and inferential data pertaining to the

research questions.

Descriptive Data

 

The sample consisted of 30 middle-aged, low-income
obese Hispanic men and women who agreed to participate in
the study. The sample had a median age Of 44.7 years, and
there were twice as many women subjects (20) as men (10).
The subjects ranged from 20% over the average weight for
height to over 200%. Two—thirds (21) were over the 30%
overweight which Andres (1980) stated was the lower limit of
Obesity which implied potential disability for the indi-

vidual.

Age
The subjects ranged in age from 31 to 60 with a fairly

even distribution across the age ranges. The mean age of

the subjects was 44.7 years (Table 1).

Table l.-- Subjects by Age Category (N=30).

 

 

Age Number of Subjects Percentage
30-39 9 30.0
40-49 12 40.0
50-60 _2 30.0

TOTAL 30 100.0

 

114

Sex
Two-thirds (66.7%) of the subjects were women, and one-

third (33.3%) were men, as seen in Table 2.

Table 2.--Sex of Subjects (N=30).

 

 

 

Sex Number of Subjects Percentage
Male 10 33.3
Female 29 66.7

TOTAL 30 100.0

 

Family Developmental Stage

Family developmental stage was determined through
ascertaining the age of the youngest child in the family,
as the youngest child determines the number of childrearing
years remaining for the parents. The eight family develop-
mental stages outlined by Duvall (1977) were condensed into
four stages due to the small sample size of the present
study. The stages were numbered I, II, III, and IV, and were
determined as follows; the preschool years (birth to age 5)
as stage I; the school age years (5 through 12) as stage II;
the teenage years (13 through 17) as stage III; and adult

children (18 and above) as stage IV (Table 3).

Family History of Diabetes

 

Of the 30 subjects, 10 acknowledged a known family
history of Type II diabetes mellitus (Table 4). The 10

subjects identified a total of 12 relatives with Type II

115

Table 3.--Family Developmental Stage (N=30).

 

 

Stage Frequency Percentage
I 7 23.3
II 12 40.0
III 6 20.0
IV _5 16.7
TOTAL 30 100.0

 

Table 4.--Family History of Diabetes (N=30).

 

 

 

Number of Relatives Frequency Percentage
0 20 66.7
1 8 26.7
2 _2 6.7
TOTAL 30 100.0

 

diabetes mellitus including one maternal grandmother, 3

fathers, 6 mothers, and 2 sisters.

Additional Descriptive Data

 

Data were also collected on birthplace, religion,
marital status, and total number of children. This infor-
mation is presented to further describe the study popula-

tion.

Birthplace
There were five categories for birthplace; Texas,
Michigan, Mexico, Florida, and other. All of the subjects

were born in Texas, Michigan, or Mexico, with the majority

116

(73.3%) being born in Texas. All of the subjects were of

Mexican descent (Table 5).

Table 5.--Birthp1ace of Subjects (N=30).

 

 

 

Location Number of Subjects Percentage
Texas 22 73.3
Michigan 3 10.0
Mexico _§’ 16.7

TOTAL 30 100.0
Religion

There were four categories for religion; Catholic,
Baptist, Pentecostal, and other Protestant denomination.
The majority of the subjects were Catholic (60.0%), while
the various Protestant demoninations comprised the remaining
40.0%. All of the subjects professed a religious preference

(Table 6).

Table 6.--Religious Preference of Subjects (N=30).

 

 

Religion Number of Subjects Percentage
Catholic 18 60.0
Baptist 4 13.3
Pentecostal ‘ 2 6.7
Other Protestant
Denomination 20.0

 

“’l
cm
H
O
O

O

0

TOTAL

 

117

Marital Status

Only individuals who were or had been married were
included in the study sample. The four categories for
marital status were; married, separated, divorced, or
widowed. The majority of subjects were married (70.0%) and

living with their spouses (Table 7).

Table 7.--Marital Status of Subjects (N=30).

 

 

Status Number of Subjects Percentage
Married 21 70.0
Separated l 3.3
Divorced 4 13.3
Widowed '_4 13.3

TOTAL 30 100.0

 

Total Number of Children
The number of children among the subjects ranged from

one to 12 with a mean Of 6.3 children (Table 8).

Table 8.--Number of Children Among the Subjects (N=30).

 

 

Number of Children Number of Subjects Percentage
l l 3.3
3 5 16.7
4 4 13.3
5 5 16.7
6 3 10.0
7 1 3.3
8 2 6.7
9 4 13.3

11 3 10.0
12 _3_ 6.7

 

0'3
O
E
O.»
O
I-’
O
O
O

 

118

In summary, the descriptive data have included the age,
sex, family developmental stage, and family history of
diabetes of the subjects as well as the extraneous cate-
gories of birthplace, religion, marital status, and number

of children.

Reliability of the Instrument

The reliability of the instrument was measured by com-
puting coefficient Alpha. Five areas of the instrument were
evaluated individually for internal consistency; perceived
susceptibility, perceived severity, perceived benefits, per-
ceived barriers, and motivational "cues to action."

The initial analysis revealed a trend toward homogeneity
among the item responses. That is, the responses tended to
cluster under two of the six possible categories, Strongly
Agree and Strongly Disagree, rather than being more uniformly
spread over the whole spectrum of possibilities. Data
regarding the total number of responses in each category
(30 subjects responding to 56 items each) are presented in
Table 9.

Since the scores were not more evenly distributed
within the six categories, reliable scales could not be
constructed. Thus, the items in each of the five areas
which showed coefficient Alphas greater than .59 were chosen
for analysis. The items utilized were susceptibility (16,
37, and 43); severity (12, 44, 50, and 51); benefits (8, 34,

and 52); barriers (29, 35, and 53); and motivational "cues

119

Table 9.--Total Score Distributions on the Six-Point Likert

 

 

 

 

Scale.

Category Number of Responses Percentage
Strongly Agree ' 697 41.5
Moderately Agree 84 5.0
Weakly Agree 167 10.0
Weakly Disagree 139 8.2
Moderately Disagree 131 7.8
Strongly Disagree 462 27.5

TOTAL 1,680 100.0

 

to action" (42, 48, and 54) (Appendix D). The standardized

coefficient Alphas for each scale are presented in Table 10.

Table 10.--Standardized Reliability Coefficient Alphas.

 

 

Scale Alpha Number of Items
Susceptibility .596 3
Severity .719 4
Benefits .649 3
Barriers .623 3
"Cues to Action" .714 3

 

In conclusion, the coefficient Alphas were computed
from a subset of the original items on each scale; that is,
from the three or four items on each scale which correlated

most closely with each other.

120
Presentation of Data Related to the
Research‘Questions
In this section, descriptive and inferential statistics

are presented as related to the individual research questions.

Research_Question 1

Does the middle-aged, low-income obese Hispanic per-

Iceive that he/she is susceptible to develop non-insulin

dependent diabetes mellitus?

Three items (Appendix D, items 16, 37, and 43) were
utilized in the analysis of perceived susceptibility. Each
item could be scored from 1 to 6 rendering possible total
scores from 3 to 18. The actual mean susceptibility score
was 14.5, the mode was 18.0, the range was 15.0, and the
standard deviation was 3.8. The t-test for independent
samples tested the difference between the actual mean score
and the assumed mean (the range divided by two and added to
the lowest score). The t-value for perceived susceptibility
was 1.54 which, at 29 degree of freedom (N—l), was not
statistically significant (Table 11). Thus, the actual mean
did not differ significantly from the chance mean.

The descriptive data, however, showed a tendency for
the subjects to score towards the high end of the suscepti-
bility scale. Of the 30 subjects, 17 scored between 16 and
18 of the total 18 points. The 13 remaining scores were
distributed across the middle section of the scale, from 8
to 15 points. Only one subject scored below an 8. In con-

clusion, although the descriptive data showed a tendency

121

Table ll.--T-test for Independent Samples for Susceptibility,
Severity, Benefits, and Barriers.

 

 

Actual i Assumed i t-Value
Susceptibility 14.5 10.5 1.54
Severity 16.6 14.0 .46
Benefits 14.2 11.0 1.19
Barriers 11.8 10.5 .39

 

towards high perceived susceptibility, no definitive state-
ments can be made about whether or not the middle-aged, low-
income obese Hispanics perceive themselves as susceptible

to the development of diabetes mellitus (Type II) because
the actual mean did not differ significantly from the chance

mean .

Research Qgestion 2

 

What is the perceived severity of Type II diabetes

mellitus among middle-aged, low-income obese Hispanics?

Four items (Appendix D, items 12, 44, 50, and 51) were
used in the analysis of the concept of perceived severity.
Possible scores ranged from 4 to 24. The actual mean
severity score was 16.6, the mode was 20.0, the range was
20.0, and the standard deviation was 5.6. The t-value for
perceived severity was .46 which, at 29 degrees of freedom,
was non-significant (Table 11). Therefore, the actual mean
did not differ significantly from the assumed mean. The
descriptive data revealed an even distribution of scores

along the whole range from 4 to 24. Thus, it cannot be

122

concluded from the data whether or not the middle-aged,
low-income obese Hispanics perceive the severity of diabetes

mellitus (Type II) as a disease entity.

Research Question 3

 

Are there perceived benefits to weight reduction among

middle-aged, low-income Obese Hispanics?

Three items (Appendix D, items 8, 34, and 52) were used
to analyze perceived benefits, with possible scores ranging
from 3 to 18. The actual mean benefits score was 14.2, the
mode was 18.0, the range was 14.0, and the standard deviation
was 3.9. The t-value for perceived benefits was 1.19 which,
at 29 degrees of freedom, was non-significant (Table 11).

The actual mean did not differ significantly from the assumed
or chance mean.

The descriptive data, however, showed a bimodal distri-
bution of scores with 8 of the subjects scoring near the mean
(13 points) and 10 subjects scoring the highest possible
benefits score, 18 points. Only one subject scored below an
8 on the range from 3 to 18. From the data analyzed, no
definitive conclusions can be drawn about whether the
middle-aged, low-income obese Hispanics perceive benefits

to weight reduction.

Researcthestion 4
Are there perceived barriers to weight reduction among

middle-aged, low-income obese Hispanics?

123

Three items (Appendix D, items 29, 35, and 53) were
used in the analysis of perceived barriers, with possible
scores ranging from 3 to 18. The actual mean barriers score
was 11.8, the mode was 8.0, the range was 15.0, and the
standard deviation was 4.3. The t-value for perceived
barriers was .39 which, at 29 degrees of freedom, was non-
significant (Table 11). Therefore, the actual mean did not
differ significantly from the assumed mean. The descriptive
data revealed an even distribution of scores along the whole
range from 3 to 18. Thus, it cannot be concluded from the
data whether or not the middle-aged, low-income Obese

Hispanics perceive barriers to weight reduction.

Researcthuestion 5

 

What are the relationships between perceived suscepti-
bility to and perceived severity of disease, and per-
ceived benefits and perceived barriers to weight
reduction?

The relationships between the four perceptual variables
were analyzed using the Pearson Product-Moment correlation.
The correlations between all four of the variables were
negligible or low, and none of the results were significant

at the .05 level (Table 12).

Research Question 6
What are the relationships between the modifying vari-
ables of age, sex, family developmental stage, and

family history of diabetes, and the main perceptual

124

Table 12.--Pearson Product-Moment Correlation Matrix for
Susceptibility, Severity, Benefits, and Barriers.

 

 

Suscept. Severity Benefits Barriers
Suscept. x -.0635 -.0479 -.l732
Severity -.0635 x -.1867 -.2601
Benefits -.0479 -.1867 x .1923
Barriers -.l732 -.2601 .1923 x

 

variables of susceptibility, severity, benefits, and

barriers?

Age and Sex

When increasing age was correlated with the main per-
ceptual variables without differentiating between males and
females, a moderate correlation, .3981, was found between
increasing age and perceived barriers, which was signifi-
cant at the .01 level. Within the subset of males only,
increasing age correlated moderately with perceived sus-
ceptibility, .5309, which was significant at the .05 level.
Increasing age correlated highly with perceived barriers,
.7995, which was significant at the .005 level. Among
females, increasing age correlated negatively to a moderate
degree with perceived susceptibility, -.5075, which was
significant at the .01 level, and increasing age also corre-
lated moderately with perceived benefits, .4669, with a
significance of .01 (Table 13).

Chi—square statistics were utilized to analyze the

three age categories (30-39; 40-49; and 50-60) in relation

125

Table 13.--Pearson Product-Moment Correlation Matrix of Age
and Sex With Susceptibility, Severity, Benefits,
and Barriers.

 

 

 

Combined Sex Male Female
Suscept. -.l983 .5309* -.5075**
Severity -.0625 .2749 -.1989
Benefits .2038 -.1280 .4669**
Barriers .3981** .7995*** .2638
* = significant at the .05 level of confidence.
** = significant at the .01 level of confidence.
*** =

significant at the .005 level of confidence.

to the total scores on the main perceptual variables. These
data were also analyzed according to combined sex, male
only, and female only. No significant differences were
found between the age categories on the scores for the per-

ceptual variables (Table 14).

Table l4.--Chi-square Values for Age and Sex in Relation to
Susceptibility, Severity, Benefits, and Barriers.

 

 

 

 

 

Combined Sex Male Female

(x2) (df) (x2) (df) (x2) (df)
Suscept. 14.98 (20) 11.16 (10) 15.87 (18)
Severity 40.13 (30) 20.00 (18) 28.99 (22)
Benefits 21.17 (16) 10.94 (10) 10.27 (10)
Barriers 17.96 (22) 18.00 (14) 18.61 (22)

 

126

Family DevelOpmental Stage

When family developmental stage was correlated with the
main perceptual variables, a fair correlation was found
between increasing family develOpmental stages (increasing
age of the youngest child) and perceived barriers to weight
reduction. This correlation was .3357, which was signifi-
cant at the .05 level. None of the other correlations was
significant (Table 15).
Table 15.--Pearson Product-Moment Correlation of Family

Developmental Stage With Susceptibility, Severity,
Benefits, and Barriers.

 

Susceptibility -.0868
Severity -.1152
Benefits .0951
Barriers .3357*

 

* = significant at the .05 level.

Family History of Diabetes

When family history of diabetes mellitus (Type II) was
correlated with the main perceptual variables, a fair corre-
lation was found between perceived susceptibility and family
history. This correlation, .2684, was significant at the
.07 level, which is reportable, but not of significance for
the present study. The other perceptual variables did not
correlate significantly with family history of diabetes
(Table 16).

In conclusion, the correlations which were found to be

significant between the main perceptual variables and the

127

Table 16.--Pearson Product-Moment Correlation Of Family
History of Diabetes With Susceptibility, Severity,
Benefits, and Barriers.

 

Susceptibility .2684
Severity -.1903
Benefits .1177
Barriers .1789

 

modifying variables were those of increasing age and
barriers; increasing age in males and both susceptibility
and barriers; increasing age in females and benefits;
increasing age in females and negative susceptibility; and
increasing family develOpmental stage and barriers. NO
significant correlations were found between the main per-

ceptual variables and family history of diabetes.

ResearchQuestion 7

 

What are the relationships between the motivational
"cues to action" and the main perceptual variables of
susceptibility, severity, benefits, and barriers?

When motivational "cues to action" were correlated with
the main perceptual variables, a moderate negative correla-
tion was found between motivational "cues to action" and
perceived susceptibility. This correlation, -.4076, was
significant at the .01 level. None of the other correlations
was significant (Table 17).

Because motivational "cues to action" was one of the
scales on the instrument, t-tests for independent samples

were computed for the items used on the final scale

128

Table l7.--Pearson Product-Moment Correlation of Motivational
"Cues to Action" With Susceptibility, Severity,
Benefits, and Barriers.

 

Susceptibility -.4076**
Severity .2618
Benefits -.0482
Barriers -.2208

 

** = significant at the .01 level of confidence.

(Appendix D, items 42, 48, and 54) and for the individual

components of the original scale; powerful others (Appendix

D, items 5 and 10), chance (Appendix D, items 36, 42, and 48),

and scientific and lay practitioners (Appendix D, items 15,

20, 25, 30, and 54). None of the t-values were significant

(Table 18).

Table 18.--T-test for Independent Samples for Motivational
"Cues to Action" and Its Three Components;

Powerful Others, Chance, and Lay or Scientific
Practitioners.

 

 

 

Actual i Assumed i t-Value
"Cues to Action" 9.6 10.5 .20
Powerful Others 5.8 7.0 .78
Chance 10.3 10.5 .07
Lay or Scientific
Practitioners 12.1 10.5 .59
Summary

In Chapter V, data were presented that described the
sample in terms of age, sex, family developmental stage,

family history of diabetes, and several extraneous variables.

129

Data were presented concerning each Of the seven research
questions and were analyzed with descriptive and inferential
statistics. Results were presented regarding the relation-
ships between the four main perceptual variables of sus-
ceptibility, severity, benefits, and barriers; and between
these variables and modifying variables and motivational
"cues to action." The reliability of the instrument was
evaluated using coefficient Alpha. The necessity of utilizing
only a portion of each original scale was explained, and data
were presented using selected items from each scale which
produced moderately high coefficient Alphas. Significant
results were found using the Pearson Product-Moment corre-
lation. An overall summary of the research study and

findings is presented in Chapter VI.

CHAPTER VI

SUMMARY, INTERPRETATION, AND IMPLICATIONS

OF FINDINGS

Overview
In Chapter VI, a summary and interpretation of the
research findings are discussed. Implications for nursing
education and practice and recommendations for future

research are offered.

Summary and Interpretation of Findings

The sample consisted of 30 middle-aged, low-income
obese Hispanics whose median age was 44.7 years. The sample
was skewed in terms of sex, with two-thirds of the subjects
being women, and age, as 70% of the subjects were over age
40. All of the subjects could be classified as obese and
two-thirds of them were at significant risk to develop
diabetes or other diseases associated with significant
obesity (Albrink, 1975).

The original study criterion defined Hispanic as any
person whose first language was Spanish. The assumption was
that individuals from various parts of the Spanish-speaking

world would be interviewed. However, all of the subjects

130

131

were of Mexican heritage. All of the subjects were enrolled
in the low-income health clinic and had been screened by a
county worker as meeting the federal criteria for the
designation low-income (Appendix B). Thus, although not
evenly distributed in terms of age or sex, the sample met
the established criteria of being middle-aged, low-income

obese Hispanic men and women.

Research_Question l

 

Does the middle-aged, low—income obese Hispanic per-
ceive that he/she is susceptible to develop non-
insulin dependent diabetes mellitus (Type II)?

The items used in the final analysis of perceived
susceptibility (Appendix D, items 16, 37, and 43) measured
susceptibility in terms of age, sex, and heredity. All of
the items were general, rather than referring specifically
to the individual.

16. Only very old people get diabetes.

37. Men and women have equal chances of become diabetic.

43. People whose parents are/were diabetics are more

likely to become diabetic.
Because the actual mean did not differ significantly from
the assumed or chance mean on the susceptibility scale, no
conclusions could be drawn as to overall perceived suscepti-
bility to Type II diabetes mellitus.

There are several possible explanations for the lack
of differentiation between the actual and the assumed mean

with the t-test. It is possible that the scores were widely

132

distributed across the whole range and thus revealed that

the subjects had widely varying answers. It is also possible
that a bimodal distribution existed in which a clustering

of scores on one end of the scale might be Offset by another
mode clustered around the mean. A third possibility for the
lack of differentiation between the actual and the assumed
mean would be scores which clustered around the assumed mean
and thus revealed that the subjects did not feel strongly

one way or another about the question.

In the instance of perceived susceptibility, although
it appeared from the descriptive data that the majority of
the subjects (17) had scored towards the high end of the
susceptibility scale, the scores were still too widely dis-
tributed to reveal any statistically significant results.
Thus, the subjects had widely varying scores on whether or
not they perceived themselves to be susceptible to the
development of diabetes mellitus (Type II), and no definitive
conclusions could be drawn from the data.

As stated in the conceptual framework, there are three
main theories of disease causation within the Hispanic
culture. These are divine intervention by God or spirits to
punish or to challenge the individual; the personalistic
"unnatural" illness caused by bewitchment or magic; and the
naturalistic hot-cold dichotomy (Samora, 1978; Foster, 1953,
1978; Rubel, 1966). Measures which may be taken by an
individual to decrease the potential severity of the disease

entity (such as prayer) are traditionally viewed as

133

precautionary, rather than preventive, measures. There is
no reference to the concept of primary disease prevention
in the literature on traditional Hispanic beliefs.

Because of the traditional emphasis on precautionary,
rather than preventive, health care measures, and the belief
that man does not have control over his own destiny (Samora,
1978), it was predicted that the Hispanic subjects might
not perceive themselves as susceptible to the develOpment of
Type II diabetes mellitus. The lack of significant findings
may have been due to the fact that the particular items
utilized in the final analysis did not accurately reflect

the concept of susceptibility as an individual perception.

ResearchQuestion 2

 

What is the perceived severity of Type II diabetes

mellitus among middle-aged, low-income obese Hispanics?

The items used in the final analysis of perceived
severity (Appendix D, items 12, 44, 50, and 51) measured
severity in terms of potential physical, economic, and
emotional stress. Two of the items measured individual per-
ceptions and the other two measured more general perceptions.

12. If I become a diabetic, my health will be worse

in the future than it is now.

44. It is hard to get a job if you are a diabetic.

50. Becoming a diabetic is a great fear of mine.

51. A diabetic should not exercise.

The actual mean did not differ significantly from the

assumed mean. Therefore, no conclusions could be drawn as

134

to whether or not the subjects perceived Type II diabetes
mellitus as a serious disease entity. The descriptive data
revealed that the scores were widely distributed across the
whole range and thus the subjects held differing Opinions
about the perceived severity Of Type II diabetes mellitus
according to the items used in the analysis.

The studies reviewed in the literature provided evidence
that the traditional Hispanic perception of health involved
a strong "robust" appearance. The healthy person was per-
ceived as well-fleshed, hard-working, and able to fulfill
one's responsibilities in life (Schulman & Smith, 1963).
Within the traditional culture, incapacitating illness was
viewed as a misfortune which might result in loss of respect
for the individual. Because illness was perceived as both
contrary to a healthy appearance and as a potential social
stigma, it is understandable that symptom-free illness
generally was not acknowledged within the Hispanic culture
(Clark, 1970).

Thus, it had been predicted that it still might be
difficult for the Hispanic individual to perceive the
potential severity of an asymptomatic disease such as
diabetes mellitus (Type II) which would threaten the
"robust" and active image of the healthy Hispanic adult.
The data revealed a wide variation in responses, from those
subjects who perceived a low potential severity of the
disease to those individuals who perceived a high level of

severity. The wide variation in response may have been

135

caused by factors such as differences in basic knowledge
about the disease and differences in familial history of,

or personal exposure to, persons with diabetes. It is also
possible that the items used in the final analysis did not
accurately measure perceived severity (especially items 50
and 51) as it was originally conceptualized and thus resulted

in a wide variation of responses.

Research_Question 3

Are there perceived benefits to weight reduction among

middle-aged, low-income obese Hispanics?

The items used in the final analysis of perceived
benefits (Appendix D, items 8, 34, and 52) measured benefits
in terms of decreased risk of developing diabetes, improved
health status, and increased social acceptance. One of the
three items measured individual perception, while the other
two were more general.

8. Fat people are no more likely to develop diabetes
than thin people.

34. My family would be happy if I could lose weight.

52. A thin person tends to be healthier in general.

The actual mean did not differ significantly from the
assumed mean. Therefore, no conclusions could be drawn as
to whether the middle-aged, low-income obese Hispanic sub-
jects perceived benefits to weight reduction. The descriptive
data revealed a bimodal distribution. Thus, while 10
(33.3%) of the subjects scored the highest possible number

of points (18) on the benefits scale, this was offset by the

136

eight subjects who scored 13 points, which was close to the
assumed mean. The descriptive data did reveal that there
were a number of subjects (10) who definitely perceived
benefits to weight reduction.

The psychosocial benefits of weight reduction described
in the literature included a wide variety of concepts such
as increased job and social opportunities and improved body
image and self-esteem which were not reflected in the items
utilized in the final analysis of the data. It is also
possible that item 8 (above) could have been conceptualized
as a measure of perceived susceptibility rather than per-
ceived benefits. Thus, the items used in the final analysis
may not have accurately measured the perception as originally
defined in the conceptual framework.

On the basis of the literature review, it had been pre-
dicted that if traditional beliefs still predominated, weight
reduction would not have been perceived as socially desirable
or physically beneficial because the "robust" appearance
would be compromised. If, however, the local Hispanic had
become somewhat acculturated to the dominant American per-
ception that obesity carries a social and/or medical stigma,
then weight reduction might be perceived as potentially
beneficial.

The research results suggested that some of the Hispanic
individuals studied still accepted the traditional concept
of the "robust" individual as healthy, while other individuals

perceived that there were benefits to weight reduction in

137

terms of the concepts measured. Unfortunately, it appears
that the Hispanic individual today does not make a distinction
between the traditionally "robust" moderately overweight
person (less than 30%) who probably will not benefit physi-
cally from weight reduction (Andres, 1980) and the morbidly
obese person who is at a disadvantage both socially and
medically. In this context, it is interesting to note again
that over two-thirds of the subjects in this study could
have been categorized as morbidly obese. Because these
subjects did not answer the items measuring perceived bene—
fits differently than the moderately obese persons, the
question remains of whether the morbidly obese perceived of

themselves as being merely "robust."

Research_Question 4

 

Are there perceived barriers to weight reduction among

middle-aged, low-income obese Hispanics?

The items used in the final analysis of perceived
barriers (Appendix D, items 29, 35, and 53) measured barriers
in terms of perceived inconvenience of dieting (through eating
different foods) and potentially painful physical (dizziness)
or emotional (friendship) stimuli. Items measuring the per-
ceived economic cost of dieting were not included in the
final analysis. Two of the three items measured individual
perceptions.

29. The types of foods on a diet are the same things

I eat now.

138

35. Dieting won't make you feel weak or dizzy.

53. My friends don't think I should lose weight.

The actual mean did not differ significantly from the
assumed mean on the t-test. Therefore, no conclusions could
be drawn as to whether or not the subjects perceived barriers
to weight reduction. The descriptive data revealed that the
scores were widely distributed across the whole range and
thus, some persons perceived barriers to weight reduction
according to the items analyzed, while others did not per-
ceive barriers.

The review of the literature did not include studies
which had measured either the perceived economic cost of
dieting or the perceived inconvenience associated with
dieting. Therefore, items which measured those concepts
were developed by the researcher based on literature dealing
with Hispanic dietary habits. In contrast, there was a
wealth of literature concerned with potentially painful
physical or emotional stimuli related to weight reduction
in a variety of populations. Thus, it had been predicted
that the barrier of environmental stimuli would have appli-
cability to this Hispanic population.

The lack of significant findings related to perceived
barriers to weight reduction may have been due to several
factors. The items developed by the researcher may not have
adequately measured the theoretical content in terms of
environmental stimuli. The perceived inconvenience item

may not have measured a diet concept relevant to Hispanics,

139

and the perceived economic cost items, which may have been
relevant to a low-income population, were not included in
the final analysis.

In all four of the perceptual variable categories (per-
ceived susceptibility, perceived severity, perceived benefits,
and perceived barriers), not all of the items used in the
final analysis measured actual individual perceptions. Some
of the items were worded more generally to decrease potential
threat to the subjects. This may have caused those items to

have decreased validity as measures of individual perceptions.

Research Question 5

What are the relationships between perceived suscepti-

bility to and perceived severity of disease, and per-

ceived benefits and perceived barriers to weight
reduction?

There were no significant relationships between any of
the main perceptual variables of susceptibility, severity,
benefits, or barriers. This finding indicated that each of
the variable scales was independent of the other scales in
terms of content, and were mutually exclusive.

Based on the literature (Schulman & Smith, 1963), it
could have been predicted that perceived susceptibility to
and perceived severity of diabetes mellitus (Type II) would
have correlated at least to a moderate degree within the
Hispanic population. That is, those persons who felt that

they were susceptible to diabetes and/or had some ability

140

to prevent the onset of the disease, would also perceive
diabetes as a serious condition to be avoided if possible.

Becker et al.'s (1974) original Health Belief Model
also predicted that perceived benefits and perceived barriers
could be analyzed along a continuum. Thus, Becker et a1.
(1974) postulated that perceived benefits minus perceived
barriers would allow a prediction as to the likelihood of
preventive health action occurring (Figure 1).

The present research findings that the four perceptual
variables were completely independent of one another does
not allow any conclusions to be made as to the combined
effects which susceptibility and severity, and/or benefits
and barriers might have upon preventive health behavior.
Thus, the variables must be analyzed separately in order to
describe implications for nursing practice and future

research.

ResearchQBestion 6

 

What are the relationships between the modifying vari-

ables Of age, sex, family developmental stage, and

family history of diabetes, and the main perceptual

variables of susceptibility, severity, benefits, and

barriers?

There were significant and non-significant findings
when the main perceptual variables were correlated with the

modifying variables.

141

Age and Sex

Barriers. In the total sample of 30 individuals,

 

increasing age was found to correlate moderately with per-
ceived barriers, .3981. This correlation was significant

at the .01 level. The older the subjects, the more likely
they were to perceive that certain barriers (types of food,
symptoms of weakness or dizziness, and/or the influence of
friends) existed to successful weight reduction. Within the
subset of male subjects, the correlation of increased age
with the perception of barriers was high, .7995, and signi-
ficant at the .005 level. A significant correlation was not
found for women. Therefore, the significance of the total
sample correlation appeared to be derived from the smaller
(10 subjects) male sample.

The literature review provided no indication as to the
possible causes of the perception of increased barriers with
age, particularly among males. It is possible that as
average weight increases with age (Silverstone, 1973), there
is the general perception that weight gain is inevitable.
The older male may perceive habit and lifestyle changes as
too difficult to accomplish. In relation to the specific
barriers measured, the older male may feel unable or un-
willing to radically change his diet (types of food, item 29),
may perceive that there are physical dangers to dieting at
his age (weakness or dizziness, item 35), or may not wish to

draw attention or possible ridicule from friends if his

142

dieting efforts become known (the influence of friends,

item 53).

Benefits. Increasing age in women correlated moderately

 

with perceived benefits to weight reduction, .4669, which
was significant at the .01 level. The older the woman, the
more benefits were perceived from weight reduction.

The types of benefits described in the literature review
(improved body image and self-esteem, increased job mobility)
might seem to be more meaningful to younger women who are
more socially and occupationally active. However, two of
the three items utilized in the final analysis measured
physical benefits to weight reduction (item 8--decreased
incidence of diabetes, and item 52--increased healthiness in
general) which might be of more immediate importance to
older women who are usually more intimately acquainted with
physical disability than younger women. The older women
also seemed to feel that their families would be supportive
of weight reduction attempts (item 34).

Based on the particular items used in the final analy-
sis, it is not surprising to find that increased benefits
to weight reduction were perceived with increasing age among
the women. There are, however, no indications from the
literature to explain the findings that perceived benefits
and perceived barriers were inversely related among the
sexes: the older men perceived barriers, but not benefits,

to weight reduction; while the older women perceived

143

increased benefits, but not increased barriers to weight
reduction.

It is possible that these findings were related to
extraneous concepts inherent in the particular items used
in the final analysis. It is also possible that the older
men are more conscious of the disruption which dieting would
bring into their lives and are more set in their habits,
while the older women may be more willing to accept the
disruption in lifestyle in order to achieve improved health
status. The older women also seemed to evaluate the potential
reaction of significant others more positively than did the
Older men. From this data, it appears that the older
Hispanic woman may have a better self-image than the older
male Hispanic in that she perceives physical benefits to
weight reduction and positive reaction from significant

others.

Susceptibility. Within the male subset, increasing age

 

also correlated moderately with perceived susceptibility to
diabetes, .5309, which was significant at the .05 level.
However, among females, the correlation between increasing
age and perceived susceptibility was negative to almost the
same degree, -.5075, significant at the .01 level.

Again, there is no literature which has dealt specifi-
cally with the effect of aging upon perceived susceptibility,
but it would seem that an overall concern with health would
increase as a person ages and begins to feel the effects of

physical limitations. Thus, it would be reasonable to

144

assume that perceived susceptibility to disease in general
increases with age. The finding on the male subjects is
consistent with this assumption. Among the female subjects,
however, increasing age correlated negatively with perceived
susceptibility. The older the subject, the less likelihood
that she would perceive herself susceptible to the develop-
ment of diabetes mellitus (Type II). This finding is parti-
cularly interesting as two of the items used in the final
analysis (items 16 and 37) dealt with age and sex in relation
to perceived susceptibility. The possibilities exist that
the older female Hispanic may have passed a certain age and
feels a need to deny perceived susceptibility to diabetes
mellitus (Type II), or that she does not perceive the
potential threat of diabetes due to some external factor

which affects females, but not males, in the study sample.

Family Developmental Stage

It had been predicted that the lower family develop-
mental stages (I and II) would correlate with perceived
barriers to weight reduction due to the distractions and
responsibilities of raising young children. However,
although a majority of the sample were in developmental
stages I or II (their youngest child was less than 13 years
old), there were no significant relationships between any
of the perceptual variables and family developmental stages
I or II.

There was a fair correlation, .3357, between perceived

barriers and increasing family developmental stage (stages

145

III and IV). This correlation was significant at the .05
level. The family in developmental stage III or IV has
teenagers in the home who are less amenable to parental
control than younger children. Thus, the teenager may bring
"junk" food into the home and indulge in front of the over-
weight parent. Teenagers also have large appetites and may
legitimately need to eat frequently, which may produce pain-
ful emotional and/or physical stimuli for the overweight
adult. In addition to the influences the teenager(s) may
bring into the home, the parent may be relaxing his control
over his own eating habits, as the parent no longer needs

to be an example to the teenager who has already formed his
lifelong eating habits.

It is also possible that the individual developmental
stage of the adult subject, rather than the overall family
developmental stage, was responsible for the finding that
barriers were correlated with increased family developmental
stage. The subjects with the families in the higher develop-
mental stages were generally older themselves and may have
been reflecting the overall finding that perceived barriers
correlated with increasing age (especially strong among the
older men). Thus, there were several possible explanations
for the finding that perceived barriers correlated with
increasing family developmental stage. The other perceptual
variables did not correlate significantly with increasing

family developmental stage.

146

Family History of Diabetes

There was no significant correlation between any of the
main perceptual variables and family history of diabetes.
It had been predicted that a strong family history of diabetes
would increase the perception of susceptibility to diabetes
mellitus (Type II). The correlation between perceived
susceptibility and family history of diabetes was the
strongest of the correlations, .2684, but was not significant
at the .05 level. Thus, it could not be concluded from this
study that family history of diabetes contributed to in-
creased perceived susceptibility to the disease. However,
it must be noted that only eight of the subjects claimed a
family history of diabetes and only two persons (6.7%) had
more than one known relative with diabetes. It is possible
that the low incidence of family history of diabetes was a

major cause of the non-significant correlations.

Research_Question 7

 

What are the relationships between the motivational

"cues to action" and the main perceptual variables of

susceptibility, severity, benefits, and barriers?

There was a moderate negative correlation, -.4076,
between perceived susceptibility and motivational "cues to
action," which was significant at the .01 level. Those
individuals who perceived themselves susceptible to diabetes
mellitus (Type II) were less prone to believe in the necessity

of motivational "cues to action" such as powerful others,

147

chance, or the intervention of lay or scientific health care
practitioners. In contrast, those persons who strongly
believed in the power of motivational "cues to action" did
not feel personally susceptible to diabetes.

In terms of the individual motivational "cues to action,"
there were several interesting findings. The subjects
strongly rejected both the concepts that spirits cause ill-
ness and that the "curandero" is an effective health care
provider. They were, however, quite ambiguous about the
perceived efficacy of the scientific health care provider.
As with the literature review of reported Hispanic health
beliefs and practices, the question must be raised of
whether the Hispanic subject is revealing his/her true health
care beliefs or practices, especially when it may be per-
ceived that the researcher is looking for the "modern"
answer. Because there are well-known "curanderos" in the
immediate vicinity of the low-income health clinic, it was
concluded that either the subjects did not wish to reveal
their true familiarity with the folk health belief system
or that they actually did disdain the folk system and were
at least somewhat comfortable with the procedures of the
scientific health clinic.

The findings of this study did not support the re-
searcher's contention, based on the literature review, that
both the folk and scientific health care systems can be
acknowledged and effectively utilized by the Hispanic

population simultaneously. It appears from the present

148

findings that it is more common for adherence to one system
to result in the individual's public denial of the efficacy

of the other system.

Limitations of the Findings

Sample

There were limitations to the findings in terms of
several of the characteristics of the sample. There were
twice as many women as men who participated in the study.
The majority of clients of the low-income community clinic
are female, thus the pOpulation pool from which the con-
venience sample was drawn may have been skewed in favor of
female subjects. Female subjects were also more available
for interviewing during the day as few of them were employed.
Thus, some potential male participants may have been omitted
due to the infrequency of their clinic visits or to con-
flicts during daytime interviewing hours. Evening inter-
views were not scheduled because the clinic was not open
and because of the potential distractions of home visiting
during the evenings (competition with television and
children) and the personal safety of the researcher.

In addition to the sex distribution, the age range of
the subjects may have played a significant role in the study
findings. Although there were subjects in each of the three
age categories (30-39; 40-49; and 50-60), 70% of the sample
were over the age of 40. Because several of the significant

findings were related to increasing age (barriers,

149

susceptibility, benefits), it is difficult to differentiate
whether the findings were related to individual perceptions,
individual developmental stage, or a combination of both
factors. As previously discussed, increasing age of the
individual, rather than overall increasing family develOp-
mental stage, may have produced the significant correlation
between increasing family developmental stage and perceived
barriers to weight reduction.

The third factor which may have affected the findings
related to this particular sample is family history of
diabetes. Only eight of the 30 subjects acknowledged any
family history of diabetes mellitus (Type II). This finding
contradicted the prediction based on the literature that
diabetes mellitus (Type II) was a significant health problem
among the Hispanic pOpulation. Because the sample was con-
centrated in the older age categories, those potential sub-
jects with a strong family history of diabetes may have
already become diabetics and thus were excluded from the
sample. Older non-diabetics without significant family
history may be accurate in feeling that they have low per-
sonal susceptibility to diabetes mellitus. Based on the
findings related to age and family history of diabetes, it
would be necessary to include a younger sample (perhaps to
age 20) in order to determine whether or not the age factor
was the primary cause of the significant results.

Finally, the sample may have differed in some way from

the general Hispanic population in the area because the

150

subjects were persons who were already utilizing, and were
presumably comfortable with, the scientific health care
system. A sample drawn from a broader community base might
have held different perceptions about both individual vari-

ables and the importance of motivational "cues to action."

Instrument

It was initially assumed that all of the subjects would
prefer to have the instrument read to them in Spanish and
that the instrument itself had been adequately tested for
readability at a basic level by the pretest sample. Twelve
of the subjects, however, requested that the instrument be
read to them in English. As with the sample as a whole, some
of these subjects could read Spanish and others could not.
The reason given for requesting the interview in English
was not because the subject could not understand Spanish
and/or the interviewer, but because the instrument contained
too many "fancy" words such as irritable.

Although the items had been tested for simplicity by
the clinic coordinator, and in the pretest, they were too
difficult for some of the subjects to understand in Spanish.
Those individuals who requested the interview in English
spanned the age range and were not different in birthplace
from the overall sample. Berkanovic (1980) recently pointed
out the importance of retranslating an instrument back into
English and checking for discrepancies before the study
begins. This should be accomplished by the method of blind

back-translation, in which the second language version is

151

translated back into English by a translator unfamiliar with
the study. Using this technique, awkward wordings and
meanings can be avoided.

The six-point Likert scale was utilized in order to
avoid an "undecided" middle category and to provide for the
maximum range of choices. However, few of the subjects
used either the Moderately Agree or Moderately Disagree
categories. Considering the poor reading ability and lack
of familiarity with written tests of many of the subjects,
it might have been preferable to have utilized a four-point
scale with only Strongly Agree, Agree, Disagree, and Strongly

Disagree as categories.

Analysis

 

The lack of an even distribution of scores in all six
categories of the Likert scale strongly affected the pre-
sentation and analysis of the data. The final analysis was
completed with only 16 of the original 56 items. The
deletion of so many of the items left the unanswered question
of whether the remaining items really tapped the dimensions
under investigation. Of the 16 items used in the final
analysis, eight appeared to actually measure individual per-
ceptions, while the remainder were more general in nature.
Thus, it is questionable whether the final analysis actually
measured individual perceptions as precisely as had been
anticipated in the study design.

Strengths of this pilot study were that it was possible

to follow the original procedure without major changes,

152

subjects were eager to participate, the language barrier

was relieved through the use of the native language of the
subjects (excluding those who requested the English inter—
view), and the interview format provided a much.more per-
sonal controlled environment for data collection than a
mailed questionnaire. All of the questionnaires were com-
pleted and the necessary sociodemographic data were collected

on each subject.

Implications for Nursing Practice

The implications for nursing practice which can be
drawn from this study are based upon the conceptual frame-
work and upon the findings related to the individual per-
ception variables of susceptibility, severity, benefits, and
barriers. Implications can also be drawn from the relation-
ships between the perceptual variables and the modifying
factors and the motivational "cues to action."

Although there were no significant findings in the
individual perceptual variable categories, instrument items
which most closely tapped the theoretical concepts could be
incorporated into a decision tree which could be utilized
as an assessment tool by nurses working with middle-aged,
low-income obese Hispanics (Figure 3). For example, to test
the concept of perceived susceptibility, an item which
accurately tapped the dimension of perceived susceptibility
would have to be developed since the items used in the final

analysis of the present research were quite general in

153

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154

focus. A question such as "Am I more likely to become
diabetic because I am overweight?" might be asked.

To test the perceived severity of diabetes mellitus
(Type II) as a disease entity, items which measured the
potential physical, economic, and/or social implications of
the diagnosis could be asked. Examples of items from the
instrument which tapped individual perceptions of perceived
severity were "If I become a diabetic, my health will be
worse in the future than it is now," and "Becoming a diabetic
is a great fear of mine."

Perceived benefits of weight reduction could be assessed
through items from the instrument such as "My family would
be happy if I could lose weight," while perceived barriers
could be assessed through the items "The types of food on a
diet are the same things I eat now" and "My friends don't
think I should lose weight."

After completing the series of questions on individual
perceptions, the nurse could focus attention and plan inter-
ventions based on the perceptual variables which aroused
strong responses from the individual Hispanics. If sus-
ceptibility to or severity of diabetes mellitus (Type II)
were perceived strongly, the nurse could introduce the con-
cept of decreasing the threat of the disease through weight
reduction. If there were little or no perceived susceptibi-
lity to and/or perceived severity Of diabetes mellitus
(Type II), the nurse could instigate a culturally sensitive
discussion to probe the causes of the lack of perception of

those variables.

155

If there were perceived benefits to weight reduction,
the nurse could introduce a diet plan based on the indi-
vidual's diet history, preferences, and family lifestyle
patterns. The diet could be developed jointly by the nurse
and the individual and could utilize self-management strate-
gies (Ormiston, 1980) which might include rewards for weight
loss based on the particular perceived benefits.

If there were specific barriers to weight loss identified
through the questioning, the nurse could problem solve with
the individual regarding possible means to decrease the per-
ceived barriers, for example how to reduce the perceived
importance of economic or inconvenience factors. As the
barriers to weight reduction were resolved, the nurse could
assess the readiness of the individual to begin a weight
reduction plan through further questioning regarding per-
ceived benefits and barriers to weight reduction.

Thus, the decision tree assessment tool (Figure 3)
could be utilized to develop an individualized, culturally
relevant weight reduction plan for the middle-aged, low-
income obese Hispanic. The concept of weight reduction could
be introduced only if the individual Hispanic perceived some
sense of susceptibility to diabetes mellitus (Type II), of
its severity as a disease entity, and of the potential
benefits to weight reduction.

Several significant findings found when the individual
perceptual variables were correlated with the modifying

factors also have implications for nursing practice.

156

Increasing age in male subjects was correlated with per-
ceived susceptibility to diabetes mellitus (Type II), while
the older males also perceived strong barriers to weight
reduction. The nurse could utilize these results to emphasize
the importance of perceived susceptibility and to work on
decreasing perceived barriers among the older male Hispanics.
Similarly, because the older female Hispanics were found to
perceive benefits to weight reduction, this general finding
could be utilized to prompt nurses to place particular
emphasis upon culturally sensitive weight reduction plans
with older females.

Increasing family developmental stage was found to
correlate significantly with perceived barriers. It is
therefore important for the nurse to develop a family-centered
approach to care which allows for the examination of barriers
to weight reduction that may be related to individual and/or
family develOpmental factors within the home. Any weight
reduction program advocated by the nurse must be evaluated
in regards to the feasibility of its effectiveness within
the particular home environment.

In terms of the credibility of the nurse working with
the Hispanic individual, the findings related to motivational
"cues to action" are important. Motivational "cues to action"
were found to be inversely related to perceived susceptibility.
The individual who strongly believed in the power of motiva-
tional "cues to action" did not perceive himself/herself

personally susceptible to diabetes. This person, however,

157

did acknowledge the importance of motivating forces within
his/her life, and thus might be amenable to the influence
of the nurse as a motivating "cues to action." Because the
individual did acknowledge the importance of outside influ-
ences, the nurse, if culturally astute, could integrate
health teaching and counseling into the framework of the
Hispanic individual's belief system. The nurse, acting as
a motivator, might be able to increase the perceived sus-
ceptibility to diabetes mellitus (Type II).

In contrast, the individual who perceived himself/
herself to be personally susceptible to the develOpment of
diabetes mellitus (Type II) did not perceive the importance
of motivational "cues to action." Although this type of
individual does not feel the need for nursing or other out-
side intervention in his/her own life, he/she might be able
to assist the nurse in working with Hispanics who do not
perceive their own susceptibility to diabetes.

Implications for direct nursing practice have been
developed from the conceptual framework, the research instru-
ment, and the results of the research study. The implica-
tions were based upon the individual perceptual variables
of susceptibility, severity, benefits, and barriers, and

upon the modifying and motivational factors.

Implications for Nursing Education
Implications for nursing education can be drawn from

the conceptual framework and from the literature review.

158

Leininger (1978) postulated that nursing, with its strong
emphasis upon nurturing and caring behaviors, may be per-
ceived more favorably by an ethnic population than the
medical profession with its authoritarian stereotype. Thus,
nursing educators should have a strong incentive for edu-
cating culturally sensitive providers. This education, at
the undergraduate or graduate level, must not be accomplished
through a formula or cookbook method of learning, but should
be based upon the theoretical literature of anthropology

and related cross-cultural fields. Leininger (1978) advocated
that the nurse committed to cross-cultural nursing care
pursue advanced education and be well-acquainted with a
variety of cultural groups and their responses to health and
illness. With a strong academic background, the nurse
working with Hispanics could examine the health beliefs of
the individual in light of the knowledge he/she had already
obtained about the perceptions of health and illness in a
variety of cultures.

The nurse educated at the graduate level in cross-
cultural nursing and anthropology could also contribute to
the development of a body of knowledge regarding ethnic
health beliefs and behaviors. The review of the literature
on Hispanic health beliefs revealed few recent studies. All
of the information presently available was drawn from several
classic, but perhaps no longer relevant, studies (Schulman &
Smith, 1963; Foster, 1953; Rubel, 1960, 1966). It is

imperative that further research be conducted on the health

159

beliefs of Hispanic individuals who are not as culturally
isolated as were Schulman and Smith's informants. Theoreti-
cal and/or clinical research generated by the nurse re-
searcher could greatly improve the present literature avail-
able on cross-cultural health beliefs and practices, and
could lead to the proposal of specific nursing interventions
based on more recent research data.

The decision tree model (Figure 3) is an example of
specific interventions which could be proposed on the basis
of nursing research. Models such as this one could be used
in continuing education courses to further the assessment
skills of nurses already working in cross-cultural settings,
as well as in undergraduate nursing education to provide a
framework for the development of culturally relevant nursing
practice. Thus, concepts drawn from both the theoretical
aspects of the present research study and from the actual
study findings could be applied to the broad field of

nursing education.

Recommendations for Future Research
1. This study should be replicated with the following
modifications:
a. A larger sample size with an equal number of
male and female subjects.
b. Decreasing the lower age limit to 25 or even
20 to allow the inclusion of more persons with
significant family history of diabetes who have

not yet developed the disease.

160

c. A more even distribution of the sample across
the age ranges.

d. Writing items which measure individual per-
ceptions rather than more general perceptions.

e. Preparation of more items in those areas which
revealed significant results in this study.

f. More thorough pretesting to increase the inter-
nal consistency or reliability of the perception
scales.

g. The preparation of the instrument in Spanish
using a blind back-translation method to ensure
equal translations.

Those persons who perceived themselves susceptible

to diabetes mellitus (Type II) could be compared

to those persons who did not perceive themselves

susceptible in relation to their perceptions of the

importance of motivational "cues to action."

The relationships between age, sex, and perceived

susceptibility to diabetes mellitus (Type II) could

be examined in more detail.

Individual perceived benefits of and perceived

barriers to weight reduction could be tested to

ascertain which concepts were perceived most
strongly by the Hispanic pOpulation.

The relationship between income level and individual

perceptions could be tested through comparing a

higher income group of Hispanics with the low-income

subjects.

161

6. The effect of age upon the individual perceptions
could be examined in more detail.

7. Differences in individual perceptions could be
tested between subjects who were first generation
Americans and those Hispanics whose families had
lived in the United States for longer periods of
time.

8. The correlations between the perceptions of sus-
ceptibility, severity, benefits, and barriers and
actual reported health behaviors could be studied.

9. The correlation between belief in motivational
"cues to action" and actual reported health be-
haviors (including precautionary measures) could

be studied.

Summary

This study contributed to the knowledge base of nursing
practice by exploring health beliefs within a specific ethnic
population. The individual perceptual variables of sus-
ceptibility, severity, benefits, and barriers, were studied
from the subjective viewPoint of the individual. Demographic,
developmental, and knowledge related modifying factors and
motivational "cues to action" such as extra-human forces,
and lay or scientific health care practitioners, were
explored in order to further understand factors which affect
an individual's perceptions of the risk of developing

diabetes mellitus (Type II).

162

There were no significant findings generated in terms
of the individual perceptual variables and the overall sample.
The exploration of the modifying and motivational factors,
however, did reveal significant results which provided a
basis for future research. Because each individual per-
ceptual variable was found to be independent of the other
variables, no predictions could be made as to how the vari-
ables affected one another. Thus, the type of predictions
for likelihood of action which Becker et a1. (1974) made
(Figure 1), based on a continuum model for the individual
perceptual variables, could not be made in the present study.
In addition, it was not possible to predict whether a strong
perception of any particular variable would or would not
lead to the initiation of preventive health care behavior
by the individual.

Based on the research findings of this study, it could
be predicted that the nurse might be effectively employed
as a motivational "cues to action," particularly with those
individuals who believe strongly in the power of motivating
forces. The nurse would assess the individual through
questioning beliefs in the individual perceptual variables
(Figure 3), and would plan interventions in terms of health
counseling and instruction based on the assessment of indi-
vidual perceptions (Figure 4). In this manner, individual
perceptions could be utilized to promote the adoption of
preventive health care behavior by the middle-aged, low-

income obese Hispanic.

163

 

 

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APPENDICES

APPENDIX A

HEIGHT-WEIGHT TABLE

APPENDIX A

HEIGHT-WEIGHT TABLE

Average Weight for Men and Women 1960-1962*

 

 

 

 

 

Height Men Women
(in) (cm) (lb) (kg) (lb) (kg)
57 145 117 53.2
58 147 121 55.0
59 150 121 55.0
60 152 122 55.5
61 155 124 56.4
62 158 140 63.6 128 58.2
63 160 150 68.2 126 57.3
64 163 139 63.2 126 57.3
65 165 149 67.7 135 61.4
66 168 160 72.7 142 64.6
67 170 153 69.6 140 63.6
68 173 157 71.4 131 59.6
69 175 166 75.5
70 178 165 75.0
71 180 166 75.5
72 183 169 76.8
73 185 183 83.2
74 188 185 84.1

 

Height without shoes; weight partially clothed-clothing

weight estimated as averaging two pounds.

*From Weight by Height and Age of Adults.
Statistics Data.

Pub. No.

1000, Series 11, No.

Vital Health

Washington, National Health Service,

164

14, May 1966.

APPENDIX B

LOW-INCOME CLASSIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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03.2 «3.3 o 3%: «8.: o 3...: 3p...“ - 8%....” 88.2 .. 08$ 39$ . o a
68.2 392 - 31...: 1.8:: - 38$ 45.2 $3: 392 n on: 93.» - o 4
21.: m2...“ .. 2T2 «5.3 u “8.2 48.3 03;. 1.86 - 2b; moo.» . o m
8%: «5.: - m3; 5: - «$6 496 o 23. «2;. - ca} m8.“ .. o m
936 o3.o .. 9“... man.» u “36 43.0 com.“ Smfi - 3m... 8m... - o a
“8“ ace 4 33 3.: now 1 «on: Swim

 

 

 

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.3330“ 1.32: I 3.30m

"m xqazmmmfi

165

APPENDIX C

PILOT TEST

APPENDIX C

PILOT TEST

The following open-ended questions were asked of 10
Hispanics; both obese and non-obese, diabetic and non-
diabetic. The responses were used to generate items for

the instrument.

1. How does a person get fat?

2. Is it bad to be fat?

3. Can you get sick if you are fat for a long time?

4. Who gets diabetes?

5. How serious is diabetes?

6. Is it important for a fat person to lose weight?

7. Why is it important for a fat person to lose weight?

8. Why is it hard to lose weight?

166

APPENDIX D

SOCIODEMOGRAPHIC DATA AND INSTRUMENT

(APPTEHDIX I)
SOCIODEMOGRAPHIC DATA AND INSTRUMENT

Sociodemographic Data

 

Patient number Age Sex
1-2 3-4 5-6
Birthplace
7 Texas 1 Mich. 2 Mexico 3 Flor. 4 other 5

Marital Status
8 Married 1 Separated 2 Divorced 3 Widowed 4

 

Number of Children

 

 

 

 

9—10
Age of Oldest Child Age of Youngest Child
11-12 13-14
Religion
15 Catholic 1 Baptist 2 Pentecost 3 Other 4
Employed
16-17
Income
18 0-3,000 3-6,000 6-9,000 9-12,000 12-15,000 15,000-
(1) (2) (3) (4) (5) (6)

Family History of Diabetes

 

paternal grandfather

19
paternal grandmother

20
maternal grandfather

21
maternal grandmother

22
father

23
mother

24
brothers

25
sisters __

26
children

27

167

168

 

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.mUOOu o>wmcwmxo

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.ouoHn oH ovuoHa oo«mWaoHv on one you ovonm

APPENDIX E

CONSENT LETTER AND HUMAN RIGHTS PROTECTION

Michigan State University
School of Nursing
A Study of the Perceptions about the Risks of
Developing Maturity-Onset Diabetes
Suzanne Van Wieren, Family Nurse Clinician Student 355-7764

Each person has beliefs or ideas about health and ill-
ness which affect his/her behavior. Understanding what
peOple believe about their health can help a nurse clinician
to plan more effective health care for them.

In this study I would like to ask you questions about
what you believe about obesity, about diabetes, about losing
weight, and about your feelings about health care. The
whole interview will take about 30 minutes of your time.

Sometimes answering such questions can make you or your
family or friends thinks of questions you would like to have
answered. If you have any questions during the interview,
please ask them. If you or anyone close to you thinks of
any questions later, please contact me through the Cristo
Rey Community Center Clinic and Connie Marin, R.N. at 372-
4700.

Your answers are completely confidential and your name
will not be attached to your questionnaire. No one else
will know how you answered the questions. Your participation
in the study may not benefit you personally, but the infor-
mation we receive may be used to help nurses better prepare
to serve Spanish-speaking persons with similar beliefs.

You are free to stop the interview at any time if you do not
wish to continue.

 

Suzanne Van Wieren, R.N. date

I voluntarily consent to participate in this study. I have
had an Opportunity to ask questions.

 

signature of subject date

174

175

MICHIGAN STATE UNIVERSITY

School of Nursing

Una investigacidh de las percepciohes sobre los riesgos de sdquirir la diabetis.

Suzanne Van Wieren, Family Nurse Clinician Student 355-7764

Cada persona tiene creencias 0 ideas acerca de la salud y la enfermedad
que afectan sus actitudes. Cuando una enfermera clinics entiende lo que
cree la gente acerca de su salud, ella puede planesr cuidado de salud mas
eficaz para ellos.

En este estudio quisiera hacerlo unas preguntas acerca de lo que cree
Vd. sobre la obesidad, la diabetis, la pérdida del peso, y sus sentimientos
acerca del cuidado de la salud. Toda la entrevista tomara’unos 30 minutos.

A veces contestar tal preguntas puede sugerir a Vd. o a su familia o a
sus amigos preguntas que a Vd. 1e gusts tener respondida. Si Vd. tiene
preguntas durante la entrevista, pregdhtemelas, por favor. Si Vd. 0 nos
persona cercana piensa de otras preguntas mag tarde, haga Vd. e1 favor de
ponerse en contacto conmigo por medio de la clinica de Cristo Rey y la Sra.
Connie Marin, R.N. Teléf. 372-4700.

Sus repuestas son completamente confidenciales y su nombre no estara'
puesto en el cuestionario. Ninguh otro sabra'sus respuestas. Quizas su
participacidh en el estudio no le beneficiara'a Vd. personalmente, pero la
informacioh que recibimos se utilizara'para ayudar a 1as enfermeras en
prepararse mejor para servir a la gente de habla hispana que tiene creencias
2 ideas semejantes a las de Vd. Puede Vd. parar 1a entrevista en cualquier

momento si no quiera continuarla.

 

Suzanne Van Wieren, R.N. fecha

Doy mi consentimiento voluntario para participar en este estudio. Yo he

tenido 1a oportunidad de hacer preguntas.

 

firms del sujeto fecha

176

HHJHSNN!HITEIIHVEEMUW
SCHOOL OF NURSING

“WAN SUBJECTS R_ErVIEH COMITTEE APPLICATION"

Date form comleted: June 1, 1980

1. Principal Investigator

Name: Suzanne M. Van Wieren

 

 

Phone: home 355-7764 office none

Position/Title: graduate student Family Nurse Clinician program

 

Qualifications: Wm Snvinlngy
B.S.N. University of California- Nursing

 

 

 

 

Names and Qualifications of Associates: Barbara Gngg 3 15 p H 12
Louise Brouillette, R.N., M.S.N.

 

Nancy Kline, R.N., I‘toSoNo

 

Brigid Warren, R.N., M.S.N.

 

II. Names and qualifications of other persons responsible for performing or
supervising procedures:

Connie Marin, R.N. - Health clinic coordinator- Cristo Rey

Community Center Clinic- Lansing, Mi.

 

 

111. Title of proposal or activity: m,“ are the poroaptioas of: Jon
income middle-aged obese Latinos about the relationship between

 

obesity and the perceived risk of developing maturity-onset (Type II)
Diabetes—mettitus?

*For further information and clarification, please refer to the Human Subjects
Review Committee ”Policies and Procedures Guidelines.“

 

177

 

 

 

 

 

 

 

IV. Beginning date of proposed activitiy: June 1980
V. Anticipated comletion date: Sept. 1980
VI. Is this activity related to a grant or contract? Yes No x . If
yes, complete A-I.
A. Is it related to a training grant? Yes No
B. Is it related to a fellowship? Yes No
C. Has proposal been submitted? Yes No
0. Has award been made? Yes No
E. Name of Principal Investigator shown (or to be
shown) on proposal:
F. Name of agency to which’proposal was (or will be)
smmfltted:
G. If continuation (or already awarBEd), what is the agency's grant or
contract number?
N. Inclusive dates of grant or contract?
From , through
I. Hill activity so performed if funding is not
received? Yes No

VII. Checklist to be completed by investigator:

A. Hill another organization or agency be involved
(hospitals, Department of Public Health, others)? Yes x. No
Name of other organization(s) or agency:

Cristo Rey Community Center

Name and titles of person(s) in agency from whom
permission to do study must be obtained:

Connie Marin, R.N.-Health clinic coordinator

3. Hill an investigational new drug (IND) be used? Yes No x
If yes, name, proposed dosage, status with Food
and Drug Adninistration and IND nunber. Enclose
one copy of available toxicity data.

1378

Hill other drugs be used? If yes, names and
dosages.

Hill a written consent form(s) be used?
(Required in most cases).

1. If no, explain why a written consent form
will not be used.

2. If no, is a statement attached describing
what participants will be told? Parti-
cipants must be informed of all elements
of VII-E below.

A written script of the verbal explanation
must be attached to this request.

Does (00) the consent form(s) include:
“Michigan State University" heading?

Name, position, department and telephone
number of investigator?

Project Title?

Date?

Copy for subject?

Signature and date lines to be completed by
subject (and legal guardian, if subject is a
udnor or is legally incompetent), and
investigator?

The following elements of consent expressed in
lay terms:

Purpose--benefits to be expected or knowledge
hoped to be gained?

Procedures to be followed only for the
purpose of this activity, and time involved?

Identification of the procedures that are
experimental?

 

 

Yes No 3
Yes xx No
Yes No
Yes x No
Yes 5 No
Yes x No
Yes x No
Yes x No
Yes I No
Yes I No
Yes x No
Yes No x

 

no experimental
procedires

1379

Nature and amunt of risk, or substantial Yes I No
stress or discomfort involved?

Appropriate alternate procedures that might Yes No
be advantageous or available to subject? n/a

(Show N/A, not applicable, when there are

none.)

Costs the subject may immediately or ulti- Yes I No

nately be forced to bear and what reimburse-
ment of costs or other compensation the
subject will receive as the result of
participation in this activity?

 

 

Voluntary nature of participation and free- Yes x: No
dam to withdraw at any point without penalty?

Opportunity to ask questions at any time? Yes x No
Assurance that subject's identity will remain Yes x No
confidential?

Please follow the consent form guideline attached to this application
onm

Describe how, by whom, and where consent will be obtained.

Subjects will initially be contacted in person or by telephone
by the clinic nurse and asked if they will consent to being
contacted by a graduate student nurse interested in talking

to Latinos. If the answer is affirmative, the principal
investigator will contact them, explain the study, distribute
the consent form, have it read to the subjects and‘have them
sign it when the interview actually occurs.

VIII. Subjects

A.

Criteria for selection (include sample size and age group).

40 adults (male and female) who are between the ages of 30
and 60, who are or have been married, are low-income (as
defined by the Michigan poverty level), are obese (20% over
ideal weight for height as measured with scale and tapee

at the site of the interview), are Latino (identify Spanish
as their first language) will be selected using a convenience
sample (the first 40 males or lemales who meet the criteria
will be selected.

Source of subjects (including patients), and how they will be approached.

The subjects will be Latinos in the Lansing area who are
known to the Cristo Rey Community Center and its personnel.
They will be approached in person or by telephone by Connie
Marin, R.N. of the Crista Rey Health Clinic and asked if

they would consent to an interview about their health beliefs.

liiO

C. Hill subjects be paid or otherwise compensated? If so, what
amount? If not, how might the subject bene¥it§

The subjects will be able to ask any questions regarding
obesity and/or diabetes which they might have, and would
be compensated through health teaching. They would also
receive information on services available at Cristo Rey.

Location where procedures will be carried out, e.g., patient's bedside,
conference room, etc.

The interviews will be conducted either in a quiet room at
the Cristo Rey Community Center or in the subject's home,

preferably in a quiet room.

IX. Confidentiality and Anonymity
A. Steps to ensure that participation by subject will be kept confidential.
The consent form and interview answer sheet will be separated
and only the consent form will have the subject's name on it.
The answer sheet will be coded, but no code number will be

placed on the consent forms.

Provisions to ensure anonymity of docunents and data (include provisions
for control over access to documents and data).

The answer sheets and consent forms will be stored in two
separate cabinets in a locked apartment to limit access.e:€

Hhat publications might be helpful to the comittee in consideration of

X.
this application? (Answer only if these might expedite review.)

1131

XI. Outline of Activity.
vaide aware in spaces following A-D below (add sheets, when needed).

A.

Discuss other methods of data collection and reason for rejection.
(i.e., Is there another method for collecting data which would put
the subject at less risk? If so, why was it rejected?)

Handing out the questionnaire or mailing it and allowing the
subjects to complete it alone were other methods, but were
rejected because many of the subjects cannot read either
Spanish or English. It would not have been possible to
control for whether they understood the items sufficiently
to answer them. The alternative methods would have
provided more anonymity.

If any deception (withholding complete information) is required for
the validity of this activity, explain why this is necessary.
Describe the procedure for debriefing.

There is no deception required.

Potential significance of the results (i.e., to patients, society,
nursing). -

The results of the obese, low-income, middle-aged Latinos
perceptions about the perceived risk of developing diabetes
can be utilized to develop culture-specific weight-reduction
programs, to aid in individual counseling and to provide
nursing with a beginning framework for implementing care among
a high-risk minority population.

Nature and degree of risk (stress, discomfort, side effects). Risk
refers to all risks--physical, psychological, social, legal, etc.

There is no physical or legal risk. Psychological risk might
arise from anxiety over doing a new procedure such as answering
a questionnaire since this may be the first exposure as
research subjects for many of these people.

Social risk would be either approval or disapproval of
family or friends about participation in the study which could
occur either in the home or clinic setting.

182

1. Possible adverse effects. Include an assessment of the likelihood
and seriousness of such effects or risks.

There is a possibility of anxiety or confusion about
having the interview which might produce suspicion of future
work. Also, if there was censure from the community, there
might be a reluctance to participate in the future.

Both of these risks are potentially serious for any
health worker in another culture, but the likelihood of such
adverse effects actually occurring appear to be remote in
this instance, as the clients at Cristo Rey have been very
cooperative in the past.

2. Hhat safety precautions or counter-measures are planned to mini-
mize risks in order to protect the rights and welfare of the
individuals?

The interview will be conducted in Spanish so that the subjects
have a chance to ask any questions in the language with which
they are most comfortable. The benefits of reducing the
incidence of diabetes in the population group as a whole will
be explained to any interested community members to offsett
censure or misinformation about the study.

3. Follow-up planned for procedures. Include debriefing statement.

All subjects will be invited to utilize the Cristo Rey clinic
if they are not already familiar with itk. The subjects will
be able to contact the principal investigator through the
clinic.

4. Arrangements for financial responsibility for adverse effects.

There is no expectation that any adverse psychological or
social implication would require financial reimbursement.

183

XII. If you are a graduate student, have you informed your thesis committee
that you are filing this application? Yes 1! No

Suzanne M. Van Wieren
Signature of Principal Investigator

 

Signature of Thesis Committee Member
Approving This Application Form

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