BACKGROUND AND OBJECTIVES:Disparities in type 2 diabetes mellitus (diabetes) represent an ongoing public health challenge. Black older adults are at high risk of diabetes and diabetes' complications. Diet, physical activity, and medication can control these risks, yet disease rates remain elevated. Utilizing an intersectionality framework, we seek to extend understanding of the social dimensions of diabetes through an examination of the diabetes self-care process from the perspective of Black older adults.RESEARCH DESIGN AND METHODS:This project involved a thematic analysis of diabetes illness narrative interviews with Black participants (N = 41) in our National Institute on Aging-funded study of diabetes. In a narrative approach, the participant communicates the significance of actions and events.RESULTS:The findings suggest that diabetes self-care involves interconnected struggles across four domains of care: (1) multimorbidity management, (2) financial well-being, (3) family support, and (4) formal health care.DISCUSSION AND IMPLICATIONS:Black older adult self-care reflects an active process of pursuing meaningful social goals and critical health needs. An intersectional framework, however, reveals the ongoing histories of inequity that shape this process. Further intervention to address the racist policies and practices found in Black older adults' communities and clinical care is needed to make true progress on diabetes disparities.

While postsecondary education appears to promote civic mindedness and engagement, relatively little is known about the association between civic outcomes and types of postsecondary education, as well as across different academic programs. Using a convenience sample from two postsecondary education institutions in the Mid-Atlantic U.S., this research examines the differences in civic mindedness and civic engagement between 2-year community college and 4-year university students, as well as students in different majors. Despite no significant difference between 2- and 4-year institutions, social science majors have greater civic outcomes in the specific areas compared to other majors.

Diabetes in older adults is a growing public health concern with nearly 30% of Americans 65 and older having diabetes. This includes 2.6 million older adults with undiagnosed diabetes who are at high risk of microvascular and cardiovascular complications (Centers for Disease Control and Prevention, 2022). The majority of cases are Type-2 diabetes. The past decade has witnessed an expansion in screening recommendations in an effort to reduce rates of undiagnosed older adults. Drawing on the sociology of diagnosis, we suggest further attention to the social factors that shape the diagnosis process is needed. We examine the diabetes diagnosis process from the perspective of older adults with type 2 diabetes. The data derive from diabetes illness narrative interviews with non-Hispanic White and African American older adult men and women (age ≥50) with type 2 diabetes (N=83). Our thematic analysis reveals four pathways to diagnosis: 1. Annual wellness exam, 2. Workplace screening, 3. Community-based opportunities, and 4. Health event or alarm. Diabetes' early symptoms are often normalized within daily life, with health insurance gaps, providers' dismissal of symptoms, and nonprescription medications reinforcing efforts to address initial symptoms within the home. Wellness visits, as well as worksite and community-based screening, critically intercede in the unfolding of symptoms. In contrast, diagnosis in connection with a health event or alarm carries an additional toll on social and emotional well-being. These findings have implications for national screening policies and local diabetes control efforts.

Abstract Over seven million U.S. adults are estimated to have undiagnosed diabetes and are at heightened risk of diabetes complications and poorer long-term glycemic control. Key to addressing undiagnosed diabetes is identifying how persons encounter diabetes testing in everyday life and the contextual factors that lead to consulting a health care provider. As part of the NIA-funded Subjective Experience of Diabetes Study we examined the pathways through which community-living African-American and non-Hispanic White older adults with type 2 diabetes (T2D) (N=75) received their T2D diagnosis. Systematic, thematic analyses using ATLAS.ti reveals three primary routes to diabetes diagnosis: diagnosis through continuity of primary care, diagnosis through happenstance testing, and diagnosis following the exacerbation of symptoms. While diagnosis as part of routine care was the least reported (N=13), participants’ accounts suggest diagnosis in primary care validates the patient-provider relationship and provides an occasion to calmly establish a treatment plan. More frequently, however, diagnosis occurs through fortuitous encounters with glucose tests, e.g., through work or community research projects (N=15) or after symptoms become alarming and disrupt daily life (N=47). Participants’ experiences in these latter two categories reveal the critical role of insurance and social prompts in the decision to consult a clinical provider regarding symptoms. At the same time, the abundance of over-the-counter therapies treating conditions commonly found early in the emergence of diabetes can delay clinical follow up. These findings highlight the importance of social prompts and community-based testing in the fight to reduce undiagnosed diabetes.

Background: Inflammatory bowel disease (IBD), comprising Crohn disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of this study, telemedicine for patients with IBD (TELE-IBD), was to compare disease activity and quality of life (QoL) in a 1-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL, but there were no significant differences between groups. Study adherence to the text-based intervention was less than 80%, the targeted goal. Objective: To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants’ perceptions, including their recommendations for future monitoring. Methods: In this study, patients attending 3 tertiary referral centers with worsening IBD symptoms in the previous 2 years were eligible for randomization to remote monitoring via SMS text messages (short message service, SMS) every other week, weekly, or standard care. Participants (n=348) were evenly enrolled in the treatment groups, and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and nonadherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% (278/348) or more of the weekly or every other week self-assessments. Semistructured interviews conducted by phone surveyed (1) the strengths and benefits of TELE-IBD, (2) challenges associated with using TELE-IBD, and (3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on a priori concepts and emergent themes with the aid of ATLAS.ti, version.7 qualitative data analysis software. Results: Participants' discussions centered on 3 elements of the intervention: (1) self-assessment questions, (2) action plans, and (3) educational messages. Participants also commented on text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and nonadherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive the intervention as effective in facilitating IBD self-management. Conclusions: Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants’ perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD.

Background: Contemporary treatment of type 2 diabetes mellitus (hereafter diabetes) heavily emphasizes “diabetes control,” largely defined by measurable blood glucose parameters. Little is known about how people living with the condition themselves define diabetes control within the lived experience of their disease. Methods: As part of a qualitative study investigating the subjective construction of diabetes, 83 in-depth interviews were conducted with African American and non-Hispanic white older adults. Using content analysis, 4237 pages of narrative data were analyzed to explore how informants conceptualized diabetes control. Findings: Four themes emerged from the data, describing varied understandings of diabetes control: (a) blood sugar regulation, (b) practicable treatment adherence, (c) bodily experience, and (d) degree of pharmaceutical need. Findings demonstrate that among persons with diabetes, the term diabetes control is multifaceted. Conclusion: While clinical guidelines have established target blood glucose parameters as the standard indicator of diabetes control, persons with diabetes conveyed varied and diverse meanings situated within personal experiences. To foster empathetic and collaborative care, health-care providers tending to this population may consider integrating the emergent themes into communicative and treatment approaches.

An estimated 33% of U.S. adults ≥65 have type 2 diabetes (T2D). Physical activity is a key component of successful T2D self-management. Yet, only 25% of older adults with T2D meet American Diabetes Association physical activity guidelines. Newly available findings from a NIA-funded ethnographic study of T2D among African-American and non-Hispanic Whites (n=83) provide insights into participants’ questions and concerns that impede their physical activity. Systematic, thematic analyses using Atlas.ti, reveal first, considerable confusion regarding the appropriateness of physical activity in the context of changing comorbidities. Second, concerns regarding insulin levels and fears about exercising alone undermine the perceived safety of physical activity. Finally, participants struggle to find specific types of physical activity that match their fitness level, lifestyle preferences, and economic constraints. Faced with these barriers, participants report not being physically active, even as they acknowledge the importance of physical activity for their T2D control. These findings are of immediate relevance to diabetes education. Personalized, ongoing diabetes education that is tailored to address physical activity in the context of T2D and participants’ comorbidities is critically needed. Furthermore, detailed information on the range of community physical activity opportunities, their accessibility, and safety for participants may play a critical role in increasing levels of physical activity among the diverse older adults with T2D.

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

OBJECTIVES:Rowe and Kahn's concept of successful aging remains an important model of well-being; additional research is needed, however, to identify how economically and socially disadvantaged older adults experience well-being, including the role of life events. The findings presented here help address this gap by examining the subjective construction of well-being among urban African American adults (age ≥ 50) with Type 2 diabetes.METHOD:As part of the National Institute on Aging-funded Subjective Experience of Diabetes among Urban Older Adults study, ethnographers interviewed African American older adults with diabetes (n = 41) using an adaptation of the McGill Illness Narrative Interview. Data were coded using an inductively derived codebook. Codes related to aging, disease prognosis, and "worldview" were thematically analyzed to identify constructions of well-being.RESULTS:Participants evaluate their well-being through comparisons to the past and to the illnesses of friends and family. Diabetes self-care motivates social engagement and care of others. At times, distrust of medical institutions means well-being also is established through nonadherence to suggested biomedical treatment.DISCUSSION:Hardship and illness in participants' lives frame their diabetes experience and notions of well-being. Providers need to be aware of the social, economic, and political lenses shaping diabetes self-management and subjective well-being.

Purpose of the study: This article presents data from 2 qualitative studies, confirming what gerontologists observed 30 years ago. Multilevel senior housing residents experience stigma and distress in an environment where people are grouped by levels of functioning.Design and Methods: Qualitative, interview-based (N = 367) studies were conducted in senior housing settings offering multiple levels of care (N = 7). Analyses involved revisiting coded narrative data, ethnographers' field-based knowledge, and identification of pattern saturation.Results: Residents and places reflecting the highest levels of care are stigmatized in a context where people are monitored for health changes and required to relocate. Consequently, residents self-isolate, develop a diminished sense of self, and hide health and cognitive conditions out of fear of relocation.Implications: Developers, operators, staff, and potential residents need to recognize the personal and social challenges typically experienced even in within-site relocation. It is important to rethink the predominant model of senior housing that requires residents with changing needs to move and adapt to the setting.

To the Editor: In recent news, a nurse filed suit against her employer, an assisted living organization, alleging that the organization “failed to protect her from abusive racism from residents.”1 Claims of racism in long-term care (LTC) settings have been reported by minority workers for more than two decades.2 Regrettably, the literature in this area is limited, particularly research addressing the health outcomes of minority staff resulting from negative racial interactions in the workplace. Attesting to the importance of the racial context in LTC, racial and ethnic minorities and immigrants account for more than 50% of the direct care workforce,3 while the older adults who receive care from these workers are on average 80% white.4 Notably, immigrant workers may be at increased risk for negative health outcomes, as they report feeling significantly less respected by both residents and residents' families than workers born in the United States.5 As such, the perspectives of minority workers regarding issues of respect are especially valuable, both because they are the staff who are most often victimized in this manner, and because improved interactions may increase job retention, satisfaction,6 and possibly worker health outcomes. The negative physical and mental health implications of racism have been well documented in the literature.7 Thus, there is good reason to expect that negative racial interactions in LTC settings are additionally problematic in terms of workers' physical and mental health, and that greater attention is needed to address this critical workforce issue as the health of those who provide care may have implications on the quality of caregiving. Racial microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color Research indicates that RMAs are pervasive and can lead to negative health and well-being.8, 9 To our knowledge, RMAs in the workplace have not been examined in the gerontological literature—particularly within the LTC setting—and little has been written about the effects racially based prejudice has upon minority LTC staff physical and mental well-being. Moreover, few studies have viewed social dynamics in senior housing through the lens of staff members, thereby failing to address their emotional well-being as related to their exchanges with residents. One notable exception is an ethnographic, National Institute on Aging-funded study examining stigma in multilevel senior housing, which reveals several cases of racially insensitive communications toward minority staff that subsequently impacted workers' relationships with residents, retention, job quality, and psychological well-being. For example, an African American direct care worker, Gilda (pseudonym), noted how upset she had been by one resident: “… she would yell at you and she would call you the n word and all of that, you know … I left there crying a couple of times … it just hurt …” Gilda lasted only 1 week as a caregiver for this resident: “I thought I could do it but it got too much for me.” Research suggests that verbal, as well as physical, assaults are problematic issues for caregivers in LTC settings.10 Notably, microassault (one dimension of RMA) is a conscious and “explicit racial derogation characterized by a violent verbal or non-verbal attack meant to hurt the intended victim through name calling, avoidant behavior or purposeful discriminatory acts”8 and is harmful to the psychological well-being of the victim by inducing stress, anger, and further marginalization.8, 9 Given the historical context of race in the United States and increased tension related to current racial dynamics in the population, this is an extremely important area and framework for future study. The authors wish to acknowledge Mary Nemec, Ann-Christine Frankowski, Lynn Miescier, and Amanda Peeples, four ethnographers on the study who interviewed LTC staff, and Susan Goldman for assistance in coordinating the study. We would also like to thank Robert Rubinstein, co-PI. Conflict of Interest: The authors declare no conflicts of interest. This work was supported by a grant from the National Institute on Aging (grant number 5R01AG28469, J.K. Eckert, PI). Contents are the authors' sole responsibility and do not necessarily represent official NIH views. Author Contributions: Harris-Wallace: paper conceptualization, data analysis and interpretation, preparation of manuscript. Roth: acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Zimmerman: data analysis and interpretation, preparation of manuscript. Eckert: study concept and design, data analysis and interpretation, preparation of manuscript. All authors provided comments on the draft manuscript and approved the final version. Sponsor's Role: None.

OBJECTIVE:African Americans experience high rates of type 2 diabetes mellitus (T2D). Self-management strategies, such as medication adherence, are key to mitigating negative T2D outcomes. This article addresses a gap in the literature by examining the intersections of drug abuse histories and medication adherence among urban, older African Americans with T2D.METHOD:In-depth interview data were collected as part of a larger ethnographic study examining the subjective experience of T2D among urban older adults. Two representative focal cases were selected and thematic analysis performed to illustrate how former illicit drug addicts perceive prescription medication usage.RESULTS:Narratives reveal that participants are displeased about having to take prescription drugs and are making lifestyle changes to reduce medication usage and maintain sobriety.DISCUSSION:Previous drug abuse not only complicates medication adherence but is also a significant part of how older African Americans who are former drug users frame their understanding of T2D more broadly.

Objectives. The study sought to identify the varied types of change arising from internal and external influences in assisted living (AL) settings, expanding upon the literature's limited focus on resident decline and staff turnover and clarifying the importance of changes to life and work there.Method. This analysis employed qualitative interviews and observations from 4 studies involving 17 ALs to identify elements of change largely absent from the literature. Case material identified by the research team members relating to persons, groups, and settings exemplifying typical changes, as well as variations across settings, are presented.Results. Multiple domains of AL change were identified, to include those in: (a) the external economic or competitive environments; (b) ownership, management, or key personnel; and (c) physical health or cognition of the aggregate resident population. In many cases, the changes influenced residents' satisfaction and perceived fit with the AL environment.Discussion. Change of many types is a regular feature of AL; many changes alter routines or daily life; raise concerns of staff, residents, or families; or modify perceptions of residential normalcy. Environmental gerontology should more often extend the environment to include the social and interpersonal characteristics of collective living sites for elders.