Abstract
Type 2 diabetes (T2D) is changing the burden of disease across Latin America. In this formative, qualitative study, we explored experiences of T2D diagnosis and management among adults in rural Dominican Republic. We conducted 28 in-depth interviews (12 men, 16 women) and used inductive analysis to explore the emotional burden of T2D and identify coping strategies. We found that stress relating to T2D began at diagnosis and persisted throughout management. Stress was produced by concerns about healthy food and medication access, fears about illness-induced injury, and the cyclical process of experiencing stress. Participants identified diabetes care and free medication services as external stress-reducers. Internally, participants’ mitigated stress by not thinking about diabetes (“no dar mente”). Our study highlights the importance of a contextualized understanding of diabetes-related stress and the need for individual, clinic, and community-level interventions to reduce stressors and improve health outcomes among adults with T2D.
Introduction
The epidemiological transition from acute, infectious diseases to noncommunicable, chronic conditions has changed the health profile of Latin America and the Caribbean (LAC; Sepúlveda & Murray, 2014). Simultaneous processes of urbanization and industrialization have contributed to a nutritional transition resulting in diets high in sugar, poor quality fats, processed foods low in fiber, and reduced physical activity (Aschner, 2016). In LAC, the prevalence of diabetes is estimated to be 10%; of these cases, more than 90% are type 2 diabetes (T2D; Bello-Chavolla & Aguilar-Salinas, 2017). In the Dominican Republic (DR), age-standardized diabetes prevalence has steadily increased since 1980 (World Health Organization, 2016). Recent estimates of diabetes prevalence in the DR range from 7.6% to 9.3% (Bello-Chavolla & Aguilar-Salinas, 2017; World Health Organization, 2016). An estimated 594,000 Dominican adults will have T2D by 2030, more than double the current estimate of 245,000 (World Health Organization, 2017). As the burden of T2D continues to rise in the DR, and across the LAC region, there is a need for a contextualized understanding of how people manage life with diabetes across different settings.
The process of managing T2D is influenced by the complex interplay of psychosocial, relational, and structural factors (American Diabetes Association, 2018). While healthy eating and exercise can improve diabetes outcomes and prevent diabetes-related health complications (American Diabetes Association, 2017; Colberg et al., 2010), psychosocial factors such as insufficient knowledge, poor coping and problem-solving skills, depression, and fear can hinder consistent and effective self-management (Ahola & Groop, 2013). At the relational level, those with social support from family and peers are more likely to improve self-management skills than those who lack such support (Fisher et al., 2015; Koetsenruijter et al., 2016). Structural barriers, such as inadequate financial resources or lack of health insurance, can limit care and medication adherence needed to manage diabetes (Nam, Chesla, Stotts, Kroon, & Janson, 2011).
Individuals with T2D may experience challenges related to diabetes diagnosis and management that can affect their emotional well-being (Garrett & Doherty, 2014). As people with chronic illnesses must continuously adjust to disease-related stress throughout their lives (Due-Christensen, Zoffmann, Willaing, Hopkins, & Forbes, 2018), particularly as they age, chronic stressors (i.e., financial strains, family-related pressures, health issues) can negatively affect self-care and other health behaviors (Stanton, Revenson, & Tennen, 2007). This phenomenon, referred to as diabetes distress and diabetes-related stress (Boden & Gala, 2018), has been defined as a “person-environment relationship in which perceived diabetes-related demands tax or exceed perceived coping resources” (Karlsen, Idsoe, Dirdal, Rokne Hanestad, & Bru, 2004). A key aspect of this definition is the “person-environment relationship,” reflecting that the experience of managing T2D is shaped by the context in which people live and is not a purely individual experience.
As a highly contextualized phenomenon, understanding diabetes-related stress (DRS) requires in-depth, qualitative examination of its sources and impact across distinct settings (Snoek & Skinner, 2006). We conducted a formative, qualitative study to explore the experience of diagnosis and life with diabetes among adult men and women in rural communities in the DR. In our analysis, we identified examples of stress as a salient part of these experiences. Through an inductive analysis, we explore how participants describe DRS, including both sources of stress and coping strategies.
Method
Study Setting
We conducted this formative, qualitative study from June to July 2015 at two nongovernmental organization (NGO) rural health clinics in the Cibao Valley of the DR. This agricultural region produces staples such as cacao, rice, and plantains, though residents purchase most foods at colmados (neighborhood shops), open-air produce markets, and, to a lesser extent, supermarkets in larger towns and cities. We collaborated with the Institute for Latin American Concern (ILAC) and Chronic Care International (CCI). ILAC is a Dominican NGO with health and education programs in rural communities across the DR (Misión ILAC, 2018). CCI is a U.S.-based nonprofit that collaborated with ILAC in 2010 to launch T2D and hypertension management programs in two ILAC-supported clinics (CCI, 2017). The T2D component of the program provides enrolled participants with the following services: (a) health talks (charlas) provided by community health workers, known locally as cooperadores, on topics such as healthy eating, physical activity, and glucose management; (b) medical screenings of glucose, glycosolated hemoglobin A1C, cholesterol, and hypertension; and (c) diabetes (glucose-lowering) medications (i.e., metformin); all at no cost. The two clinics had approximately 900 enrolled patients in 2015. ILAC and CCI collaborated on the development of interview guides and facilitated our access to clinics.
Fieldwork Team and Reflexivity
Our primary interviewers 1 were then graduate students in public health at the University of North Carolina at Chapel Hill (UNC). The fieldwork team resided in one of the clinic communities during fieldwork. The interviewers and two Dominican women transcribed interviews verbatim. One transcriptionist was a university-educated Dominican psychologist with extensive transcription experience. The second transcriptionist was a university-educated Dominican woman from one of the participating communities trained by the fieldwork team.
As researchers from a U.S. university, we were cognizant of the social and class power dynamics that existed between the participants and ourselves. We did our best to facilitate a relaxed and open environment where participants felt comfortable sharing their experiences. Although we conducted interviews in Spanish, the diversity of our team led to regional and stylistic differences in accents, and the use and interpretation of words, phrases, and ideas. Conscious of this, and when appropriate, we probed participants to define unfamiliar words and phrases to ensure we understood and interpreted their descriptions as accurately as possible. We also tried to define and explain unfamiliar words or expressions we used so participants understood us clearly.
Participants and Recruitment
Individuals 18 years and older with a confirmed T2D diagnosis enrolled in the diabetes program were eligible. We purposively sampled 28 participants (12 men, 16 women) across the program’s geographical catchment area. Participant ages ranged from 26 to 79 years, and years diagnosed with T2D ranged from 1 to 50 years. Most participants had a primary-level education. Table 1 displays participant characteristics.
Participant Characteristics, CCI T2D Program, June-July 2015.
Note. CCI = Chronic Care International; T2D = Type 2 Diabetes.
Clinic staff referred the first three participants. Thereafter, we independently recruited participants from clinic waiting rooms. After conducting several interviews, we gender-matched interviewers and participants whenever possible to reduce potential discomfort around sensitive topics, such as the impact of T2D on sexual performance. We interviewed participants in private rooms within each clinic, outdoor spaces, or nearby community spaces, such as schools and churches. Eight participants opted to interview at their home. We obtained oral consent from participants, who received a gift bag with toiletries valued at 200 Dominican Pesos (US$5). This study received approval by the Institutional Review Board at UNC.
Data Collection
We conducted and audio-recorded interviews in Spanish. Interview times ranged from 30 to 120 minutes. Our broad interview guide included questions on perceptions of the current health situation and transitions in health problems in participants’ communities, experiences living with T2D, and use of health services to manage T2D. We wrote field notes for each interview to capture our immediate impressions and interesting themes.
Data Analysis
We analyzed data in Spanish using an inductive approach (Thomas, 2006) that began during fieldwork. During fieldwork, our team debriefed daily and reviewed field notes together to identify themes of interest. Through this iterative process, we identified that the emotional burden of diabetes was a more central part of the overall diabetes experience than we had expected at the beginning of the study. Rather than providing direct commentary on the impact of diabetes on mental health, participants embedded references to their emotional well-being, and specifically examples of the stress they felt related to diabetes, in their general narratives of their experiences with diagnosis and then living with and managing their illness. As a result, we revised our guide to probe on participants’ feelings and reactions to the events and experiences they described in their stories. We also included the question, “What worries do you have about living with diabetes?” to generate more discussion on topics that concerned participants.
During the transcription and data quality control processes, which partially overlapped with data collection, we continued noting key themes for further exploration. Following the completion of data collection and transcription, we wrote analytic summaries to capture each participant’s “diabetes story” (Sandelowski, 1995). Through these early analysis processes, we broadly explored the emotional burden of diabetes as a key part of the diabetes experience, which informed the focus of the analysis for this article. We developed a codebook to examine the emotional and mental health aspects of living with diabetes using inductive codes such as “worry,” “sadness,” and “stress,” and the in vivo code, “no le doy mente” (I don’t think about it). We used ATLAS.ti software (version 1.0.43 [176] for Mac) to systematically code transcripts (Gibbs, 2007). Finally, we conducted a second in-depth analysis examining narratives to identify sources of stress and associated coping behaviors. We then reviewed the scientific literature and used the diabetes-related stress construct to aid the interpretation of our results.
Results
We present our findings in two sections. First, we present the main sources of stress as described by participants, both acute and chronic. Next, we describe how participants used both internal and external coping strategies to manage their stress.
Sources of Stress
Stress at diagnosis
Diabetes diagnosis was an acutely stressful experience for most participants, especially for those surprised by their diagnosis. Participants described feeling sadness, uncertainty, and fear at diagnosis. Juana, 55, felt simultaneously scared and sad learning she had diabetes, an illness she viewed negatively, saying, “I was sad, sad, I was, because I heard that it was big—being a diabetic, that it was bad.” Pedro, 37, also felt sad at his diagnosis, “I felt a little sad because [diabetes] is a disease that, according the professionals, is incurable.” In addition to sadness, participants also experienced fear of morbidity and mortality, as expressed by Pedro, “Damn it! I am going to die soon; I am going to die young.”
While some family and friends offered participants support when learning of their diagnosis, others reacted negatively, which induced stress. Pedro reflected on telling others he had diabetes, . . . people think that once you are diabetic, you are sentenced [to death] and that is not how it is . . . there are people who interpret [diabetes] as bad and when you tell them you are a diabetic they say, “Ah! You are going to die!”
As reflected by Pedro, fear-inducing reactions from family and friends upon learning of participants’ diagnosis reinforced negative feelings about diabetes and compounded existing stress.
Participants’ stress about their diabetes diagnosis caused disruptions to their sleep, appetite, and their desire to be social. A motorcycle taxi driver, Marcos, 53, animatedly explained the physical toll of his stress, “I didn’t sleep, I didn’t eat . . .” He worried his illness could affect his diminishing vision, a condition he associated with diabetes. Sophia, 60, felt lethargic and little desire to leave her house when diagnosed. “Yes, when it started, the diabetes, I lasted a month where I did nothing . . . [chuckles briefly] Sluggish, sluggish I was.” Sophia attributed her emotional disruption to her diabetes diagnosis. The acute stress caused by both internal and external reactions to the diagnosis caused a combination of physical, emotional, and social disruptions to participant’s lives.
Chronic stress
Food access and availability
The limited availability and accessibility to healthy food options in rural communities where participants lived was a salient source of chronic stress. Many participants felt they had few options to control their diet in environments with poor access to nutritious foods. Foods such as whole-grain rice were only available in supermarkets and could be twice the cost of white rice, a common staple in the local diet. Lucia, 52, described her stress accessing healthy food, There are people who can follow their diet, but many cannot. We often must eat things that we should not eat because [living with] hunger is hard. . . . [Diabetes] is harder for the poor . . . I would say it is much harder. I feel bad for those of us that suffer from this illness. Sometimes I go to sleep hungry, and more so when one lives in the countryside. Things in the countryside are very difficult.
Other participants echoed Lucia’s stress related to food access. Specifically, they expressed having little control over available food options, and some lamented on their struggles to put enough food on the table. Insufficient food access produced DRS because participants worried about how available foods affected their diabetes outcomes. Notably, Lucia sometimes worried about attending her diabetes clinic appointments fearing she may have elevated glucose levels. Asked how providers would react to her elevated glucose readings, Lucia responded, “Well, they would tell me, ‘What did you do that your sugar increased? What happened?’” Lucia, who liked her providers and the care she received, felt “bad” about herself when she had uncontrolled diabetes despite her best efforts to eat recommended foods. Although well intentioned, provider feedback amplified existing food-related stress and sometimes induced feelings of guilt among participants for their inability to comply with dietary guidance to manage diabetes.
Medication stress
Although participants accessed free medication through the diabetes program, many stressed about their reliance on medication to stay healthy. Antonio, 57, and living with diabetes for more than 20 years, firmly considered diabetes one of the “worst diseases of the century,” If you have AIDS, HIV, you have treatment. [handclap] Done. If you are in treatment, you can live 100 years and die of something else—you will not die of that [HIV]. But with diabetes, a person without treatment can be sure that one day, he will lose his vision. Through diabetes comes the famous diabetic foot or kidney problems. It is a tragedy for them and their family because now you have lost everything.
Antonio’s comparison to HIV, also referenced by other participants, reflects two important points. The first relates to Antonio’s statement that with HIV “you have treatment,” which reflects perceptions that there is greater access to antiretroviral treatment for HIV in the DR than diabetes medication. Participants’ reliance on donated medication made them feel vulnerable and stressed because medications had a central role in diabetes management. The second point relates to the perception that medication alone is enough to control HIV while controlling diabetes requires medication and additional lifestyle changes in diet and exercise.
Injury susceptibility
Participants’ worried that diabetes-related complications could someday result in injury or impairment that could compromise their ability to work and earn a living. Beto, a 78-year-old retired agriculture worker living with diabetes for 50 years, still worried about his diabetes, It worries me a lot and I sometimes do not sleep; if I have something [a health complication] I cannot work. I sometimes worry, you see.
Although retired, Beto worried about his ability to contribute to his household, reflecting the intersection of diabetes and economic-related stress. Other participants’ worried diabetes-related symptoms already affected their economic productivity, as expressed by Laura, 44, who operated a colmado from her home.
It is hard. I have days where I work and I have days where I do nothing. When I have that [prickly feeling] in my feet, I do nothing. I do what I can and what I cannot do, I do not.
Foot pain was the hardest aspect of living with diabetes for Laura because it limited her mobility and productivity. Worries about sustaining a diabetes-related injury translated into participants’ worries about maintaining their physical ability to work and support themselves and their families.
Stress-induced stress
While participants described general feelings of stress associated with diabetes self-management and control, they also worried about experiencing stress and other negative emotions. Participants believed stress, and the negative emotions associated with stress, could increase their blood pressure and affect their “sugar” levels, thereby increasing their risk of other health problems. Many participants believed people with diabetes experiencing stress were more susceptible to pique, or irritability, which they viewed as a driver of stress. Martin, 52, described his beliefs on the relationship between stress, pique, and negative health outcomes: Well, that’s where the [high blood] pressure comes from, from not being tranquil. Having high stress causes the [high blood] pressure, and then a lot of illness results.
Many participants believed experiencing stressful or negative emotions conflicted with the normative belief that people with diabetes should be “tranquilo” or “remain calm.” Rosa, 43, expands on normative beliefs about stress and diabetes: Well, I’d say, you know that the diabetic has a nature that is . . . I don’t know, anything can upset him . . . because a diabetic cannot suffer from a lot of emotions and much less anger and things like that because it is nature. You hear me?
Rosa’s description highlights a tension between the expectation and reality of living with diabetes: Participants believed people with diabetes were susceptible to pique or other negative emotional states and they should actively avoid or control intense, negative emotions. Moreover, participants believed stress, particularly excessive worry, could adversely affect their physical and mental health, as expressed by Marcos, [Living with diabetes] is worse . . . when you think about it. It is worse because you can even die of depression if you think about that, and [it can affect] your heart and all that.
Marcos further explained how excessive worry could result in nervios (nerves), a term we interpret as a general negative emotion in a person’s body that could result in poor health. Perceptions of accelerated susceptibility to early mortality illustrated how participants viewed diabetes-related mortality stemming from diabetes directly and indirectly through excessive worrying about diabetes. For some participants, the constant vigilance of regulating stressful emotions to avoid future health problems was itself a stressor that exacerbated existing stress.
Coping With Stress
Participants identified two main ways of coping with stress. The first was external and related to their enrollment in the diabetes program and the second was internal, which consisted of not thinking about diabetes to avoid stress.
Diabetes program
Participants identified the diabetes program as a significant external resource that reduced the stress of living with diabetes. Diabetes education and self-management techniques provided by cooperadores and providers at the clinic alleviated participants’ stress by reducing their uncertainty about diabetes. For example, Tomás, 59, felt more in control after enrolling in the program because he had access to health professionals responsive to his concerns. Tomás believed services provided by clinic staff helped many patients reduce the stress of living with diabetes, Through them, many people have been able to, as they say, [have] a little joy in their life because they have totally controlled [their] diabetes . . . it is like a blessing from God having them here.
Although participants praised support from cooperadores, most referred to distributed diabetes medications, such as metformin, as a major resource that reduced stress. Participants believed U.S.-imported diabetes medications obtained through the program were superior in quality and effectiveness compared with locally available medications. Diabetes medications afforded participants substantial stress relief by stabilizing their illness and alleviating the stress-inducing symptoms of diabetes. Receiving free diabetes medications also reduced the economic burden of diabetes for participants, though some expressed concern about the sustainability of the diabetes program and its services. Better-managed diabetes enabled participants to reprioritize prior concerns. Reflecting this, Pedro described how his worries shifted after starting program prescribed medications: [I still have concerns] because I am always cautious of getting any injury, but for other things no, because I am very satisfied, apart from everything, with the program because the medication. I would say [medications] had been the major worry, but I [now] have access to it. That is, I have the solution in my hands . . . to be able to fight [diabetes] and know that it is always stable.
Although Pedro still worried about diabetes-related complications, he worried less after enrolling in the program. Others echoed this claim. Medications alleviated the physical symptoms that caused stress among participants, resulting in a better sense of control and stability that consequently reduced the burden of living with a chronic illness.
“No le doy mente.”
No le doy mente (I do not think about it) was a popular phrase used by participants to reflect an internal strategy to cope with diabetes. For example, Marcos said, “You cannot think about it because you can go crazy, honestly . . . you go mad thinking about that.” Like Marcos, others sought to actively ignore or avoid negative thoughts or feelings associated with diabetes to cope with their stress. Some participants diverted their attention and energy to other parts of their lives. Javier, 52, avoided negative stress-inducing thoughts by spending time with his grandchildren. “I have a grandson and I go [see him] and he plays with me.” Spending time with his grandson kept Javier occupied and not thinking negatively. Other participants tried to sideline negative thoughts about diabetes by focusing on managing their illness the best they could, as described by Rosa, I do not pay attention to [diabetes] because imagine life—I am not dedicating myself to worry about that because . . . one has to take care of themselves, . . . as much as they can. If I start worrying, it will be worse. If I focus on only [diabetes], it will be uncontrolled because that is how the sugar also rises, because of [worrying].
Rosa reiterated normative beliefs about the need to avoid stress to prevent more health problems. When asked what she does to worry less about diabetes, Rosa concisely responded, “I take my pill and do not worry about the rest.” Most participants responded similarly: they consistently took their medication and did their best to eat healthier and be more physically active, though most admitted eating healthier and exercising to a lesser extent because these behaviors were more difficult. Most participants primarily managed diabetes by taking medications and relied on medications to help them “not think” about diabetes.
Discussion
Our qualitative study explored the experiences of living with diabetes in rural Dominican communities and found that many participants struggled with the psychosocial burden of diabetes. Stress, as it related to diabetes, began at diagnosis and persisted thereafter. Participants worried about experiencing diabetes-related complications or premature death shortly after diagnosis, a concern that has been shown in the literature among Dominican adults in the United States (Aponte, 2013) and other adult populations with diabetes (Low, Tong, & Low, 2014; Péres, Franco, & dos Santos, 2008; Stuckey et al., 2014). Notably, participants worried about experiencing stress and other negative emotions because they understood these feelings as harmful to their health. As such, the normative belief to avoid stress was itself a source of stress, reflecting the cyclical nature of the DRS process. Other sources of stress included persistent uncertainty living with diabetes, access to recommended foods, and sustained access to diabetes medications.
Illness uncertainty can be high among people with chronic conditions, especially in low-resource settings similar to communities in our study, where the course of disease and treatment can be unpredictable (Dudas et al., 2013). The anticipation of potentially life-changing diabetes complications shortly after diagnosis can provoke stress (Cox & Gonder-Frederick, 1992; Morris, Moore, & Morris, 2011). Mishel’s Theory of Uncertainty in Illness asserts that negative psychological consequences (i.e., distress) occur among people with chronic conditions when uncertainty is not managed effectively (Mishel, 1990). In our study, participants consistently worried about uncertain, adverse diabetes-related health outcomes and the sustainability of medication access, stressors that clinic staff may not have always assuaged.
Participants’ limited ability to access recommended foods was another source of chronic stress as some participants struggled to find sufficient food for themselves and their families, suggesting that living in an agricultural region did not guarantee access to affordable fresh foods (Valdez, Ramírez, Estrada, Grassi, & Nathan, 2016). Participants’ food concerns highlight the role of food insecurity in chronic stress. Food-insecure adults tend to consume poorer quality foods (high-fat dairy products, salty foods) as a result of poor access to healthier foods (Laraia, 2013; Leung, Epel, Ritchie, Crawford, & Laraia, 2014). Poor glycemic control is more likely among food insecure adults with T2D (Seligman, Jacobs, López, Tschann, & Fernandez, 2012). In our study, uncontrolled glucose readings at clinic appointments exacerbated food-related participant stress. Provider-related stress was not a focus of this study; further research will need to examine how provider communication affects DRS among participants.
Opportunities to improve access to healthier foods for people living with T2D in rural communities in the DR exist. Home or community gardens could supplement access to fruits and vegetables (Barnidge et al., 2013; Govender, Pillay, Siwela, Modi, & Mabhaudhi, 2017) while also increasing physical activity (Soga, Gaston, & Yamaura, 2017). Collaborating with local colmados where rural residents buy most foods is another potential strategy to improve the availability of affordable fresh food options. Initiatives to increase healthy food options in small neighborhood stores have yielded encouraging results in increased sales of healthy food products (Adam & Jensen, 2016). In rural Appalachia (United States), the transformation of 10 country stores that stocked and marketed more produce options increased fresh produce availability by 40%, produce selection by 20%, and increased produce consumption among surveyed respondents (Rushakoff et al., 2017). Increasing access and consumption of healthier, affordable foods will require testing and implementing creative, feasible strategies appropriate to local priorities and environmental settings (Budd et al., 2017; Mayer et al., 2016; Sharif et al., 2017). Future research will need to assess assets, barriers, and opportunities to increase healthier food access in distinct, rural Dominican communities.
Participants’ access to diabetes care and medication served as an external stress coping resource. Access to diabetes medications reduced stress by alleviating diabetes symptoms and the economic burden of diabetes. Populations in poor-resource settings often struggle to access medications for chronic and noncommunicable diseases due to scarce economic resources (El-Sayed, Palma, Freedman, & Kruk, 2015; Famuyiwa, Edozien, & Ukoli, 1985; Mosha & Rashidi, 2009). While participants in our study routinely received quality diabetes care at no cost, medication access remained a source of stress, as participants relied on donated medication and perceived poor access to effective T2D medications beyond the program. Participants’ medication-related stress is rooted in the reality of diabetes care in the DR; although the country has a national diabetes plan, many strategies remain partially implemented (International Diabetes Federation, 2014). Our finding emphasizes the importance of secure access to medication to manage illness-related stress among people with T2D.
An internal mechanism, no le doy mente (I do not think about it), was a second method of coping with DRS. No le doy mente, a common phrase in the DR, refers to projecting indifference or disassociation to difficult or unpleasant situations. In the context of living with diabetes, participants used this strategy to distance themselves from negative emotions. Descriptions of this coping strategy are consistent with the Common Sense Model, in which perceptions of illness result in behavioral coping responses (Leventhal, Phillips, & Burns, 2016). Importantly, we believe participants engaged in “no le doy mente” to cope with the stress of lifestyle changes imposed by diabetes. A similar strategy has been observed among people living with HIV in the DR who used a discourse of living “una vida normal” (a normal life), to downplay the impact of HIV, especially stigma, on their lives (Barrington, Kerrigan, Ureña, & Brudney, 2018). In the United States, older Korean immigrant adults with T2D presented the public appearance of maintaining good health and control over their T2D to save face in stressful social situations, despite struggling privately with their illness (Pistulka, Winch, Park, Han, & Kim, 2012). While we believe “no le doy mente” is neutral in value, as its purpose was to maintain a sense of normalcy relative to participants’ interpretation of “normal,” the possibility exists that by not thinking enough about diabetes, participants could experience health complications. For example, a qualitative study in rural south Australia found that among people with T2D, apathetic views toward T2D, attributed to the high regional incidence of T2D and T2D-related complications, was a potential risk factor for poor self-management and future health complications (Jones, Crabb, Turnbull, & Oxlad, 2014). Additional research will need to examine coping strategies such as “no le doy mente” to identify how to cultivate the stress-reducing aspects of this phenomenon while limiting extreme avoidance to the point of denial, which can negatively affect health.
Managing a chronic illness requires a holistic approach to long-term care (Barnard et al., 2014). Acknowledging DRS and its various sources needs to be part of routine diabetes care. Participants in our study struggled managing the emotional burden of diabetes despite having access to diabetes care. While improving structural stressors in low-resource settings will remain an enduring challenge, we believe opportunities to reduce the burden of DRS exist within the structure of clinical care. Participants could benefit from stress regulation techniques, such as relaxation exercises or small support/discussion groups for people living with T2D (Majeed-Ariss, Jackson, Knapp, & Cheater, 2015; Seligman, Mendenhall, Valdovinos, Fernandez, & Jacobs, 2015) and context-based problem-solving (Hill-Briggs, 2003; Tanenbaum et al., 2015) and help navigating issues with problem-solving (Due-Christensen et al., 2018; Zoffmann & Kirkevold, 2005). Motivational interviewing or goal setting may help improve and sustain self-management behaviors in diet (Anderson, Christison-Lagay, & Procter-Gray, 2010; Ekong & Kavookjian, 2016) and physical activity (O’Halloran et al., 2014). Where appropriate, the use of humor could be an effective tool to enhance communication between patients and providers (Schöpf, Martin, & Keating, 2017). Creating flexible management plans that acknowledge illness-related stress can improve quality of life and long-term medical outcomes (Frost, Garside, Cooper, & Britten, 2014). Diabetes care strategies must acknowledge that information and resources for diabetes management will likely vary in usefulness and relevance as an individual’s illness-related circumstances change (Nugent, Carson, Zammitt, Smith, & Wallston, 2015; St. Jean, 2012). Individual and dynamic care plans can potentially reduce DRS by helping participants address challenges they feel are important to them over time.
Results of this qualitative study are limited to participants in our sample and may not be generalizable to other populations; however, our contextualized understanding of DRS may provide transferable findings for other settings (Avilés-Santa et al., 2017).
Conclusion
Diabetes diagnosis and management are stressful processes among adults in rural communities of the DR. Our study highlights the importance of understanding DRS across distinct settings to improve health outcomes among adults. People with diabetes in low-resource, rural areas could benefit from individual and community-level interventions to improve access to healthy foods. Within diabetes care clinics, holistic services that provide support for stress reduction and facilitate assets-based, problem-solving strategies could improve clinical outcomes and overall well-being among people living with T2D.
Footnotes
Acknowledgements
We thank participants for sharing their experiences, time, and energy with us. We also thank cooperadores for helping our team facilitate fieldwork in the communities of Comedero Abajo and Sabana Rey. Lastly, we thank our colleagues and partners at Chronic Care International and the Institute for Latin American Concern for providing us the opportunity to work collaboratively in the Dominican Republic.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: the Carolina Global Initiative Award and the Carolina Summer Research Grant awarded by the Institute of African American Research at the University of North Carolina at Chapel Hill supported this work.