1. Identify the clinical experience and describe the events noting the 4 areas of Community Health Nursing: Intake, Chronic Care, Medication Administration, and Episodic Care/Sick Call.2.

Social Work in Public Health, 29:518–527, 2014

ISSN: 1937-1918 print/1937-190X online

DOI: 10.1080/19371918.2014.888533

Current Approaches to Support the Psychosocial Care of African American Adults with Diabetes: A Brief Review

Jamie Ann Mitchell

School of Social Work, Wayne State University, Detroit, Mic higan, USA

Jaclynn Hawkins

School of Social Work, University of Michigan, Ann Arbor, Mi chigan, USA

African Americans are disproportionately affected by Type 2 diabetes and experience signi cantly

higher age-adjusted prevalence of the disease. Psychosoci al support, material resources, and education

can have a signi cant impact on successful diabetes managem ent, particularly among populations

with diabetes-related psychological distress such as Afri can Americans. This brief review of the

literature identi es and synthesizes current evidence on f aith-based, community-based, empowerment-

based, strength-based, and culturally competent strategi es that may be particularly relevant for social

work practitioners supporting African American adults at r isk for or diagnosed with Type 2 diabetes.

Discussion focuses on multiple in uences on the self-deter mination of clients working to manage their

condition.

Keywords : Diabetes, African American, social work

With the increase in numbers of Americans living with diabet es, speci cally among minority

populations, clinicians are seeing an increase of clients w ith diabetes and diabetes-related com-

plications. Often overlooked is the lack of psychosocial ca re available to individuals managing

a Type 2 diabetes diagnosis. Psychosocial care has been desc ribed in the diabetes care literature

as social, psychological, and emotional support, material resources, and education that helps to

reduce stigma, promote social functioning, and improve qua lity of life (Barnard, Peyrot, & Holt,

2012) for individuals with diabetes. Prior relevant litera ture found that frustration with diabetes

self-care routines, feeling overwhelmed by disease-relat ed lifestyle changes, and a perceived loss

of control are common among newly diagnosed adults (Pouwer e t al., 2010; Roy & Lloyd, 2012).

For example, it is common for individuals newly diagnosed wi th diabetes to be expected to monitor

or address their blood sugar, a new or more intense exercise r outine, insulin supplementation and

other medications, and several health care appointments wi th primary physicians and specialists

(Ayalon et al., 2008). There is a growing literature base ind icating that African American adults

are at increased risk for experiencing psychosocial distre ss and depression associated with poor

adjustment to a diabetes diagnosis and the accompanying lif estyle changes (Spencer et al., 2006),

particularly when exacerbated by a lack of family, communit y, or professional support (Chesla

et al., 2004; Kogan, Brody, Crawley, Logan, & Murry, 2007).

Address correspondence to Jamie Ann Mitchell, MSW, PhD, Ass istant Professor, School of Social Work, Wayne State

University, 337 Thompson Home, 4756 Cass Avenue, Detroit, M I 48202, USA. E-mail: [email protected]

518 PSYCHOSOCIAL CARE OF AFRICAN AMERICANS WITH DIABETES519

A community-based qualitative study of African American ad ults with Type 2 diabetes in

Arkansas indicated that helplessness, fatalism, and fear o f failure about adhering to rigid diet,

exercise, and medication recommendations was a reported ba rrier to self-con dence about diabetes

management (Bhattacharya, 2012). Although several studie s exist examining the psychosocial bar-

riers facing adults with Type 2 diabetes generally, few in re cent years address speci c interventions

or approaches employed with African American patients to im prove their psychosocial health in

the context of their diabetes care (Steinhardt, Mamerow, Br own, & Jolly, 2009). Thus, the purpose

of this review is to highlight successful or promising strat egies speci cally tailored to African

Americans with Type 2 diabetes as described in peer-reviewe d literature, as a resource for social

work clinicians supporting this population.

Diabetes Epidemiology

Calling attention to effective clinical strategies for wor king with clients with diabetes is essential

given the increasing number of Americans living with diabet es and diabetes-related complications.

Diabetes is the seventh leading cause of death in the United S tates, and currently 8% of the U.S.

population or nearly 26 million people are affected by this c ondition; the Centers for Disease

Control and Prevention (CDC; 2012) estimates that by the yea r 2050 as many as one third of all

Americans will be diabetic or at high risk of developing the d isease. Type 2 diabetes is the most

common form of this condition, which is characterized by an i nability of the body to produce

or appropriately metabolize insulin (Naranjo, Hessler, De ol, & Chesla, 2012). Poor management

of Type 2 diabetes can result in disabling complications tha t include a lower life expectancy,

increased risk of heart disease, lower limb amputation, kid ney failure, and adult-onset blindness

(Katzmarzyk & Staiano, 2012), making it critical to highlig ht and continue to develop clinical

strategies for social workers and other health care provide rs working with this population.

The increased prevalence of diabetes and diabetes-related complications among African Amer-

icans requires more attention be given to calling attention to and developing clinical strategies

in this population. African Americans are disproportionat ely affected by Type 2 diabetes and

experience signi cantly higher age-adjusted prevalence o f the disease (including diagnosed and

undiagnosed cases) compared to non-Hispanic Whites (Katzm arzyk & Staiano, 2012); with nearly

13% of all African Americans older than age 20 diagnosed with diabetes compared to just 7.1%

for non-Hispanic Whites (Castro, Shaibi, & Boehm-Smith, 20 09); and an additional 7% of African

Americans have undiagnosed diabetes (Naranjo et al., 2012) . In addition, African American adults

are between 2 and 4 times more likely to experience blindness , amputations, and renal disease as

a result of their unmanaged diabetes than Whites of the same a ge (CDC, 2012), and 20% more

likely to die of those diabetes-related complications than their White counterparts (Naranjo et al.,

2012). As a result of the disproportionate impact of diabete s on African Americans, the following

focuses on and overview of clinical strategies within this p opulation.

This article is a minireview of effective psychosocial clin ical strategies for working with clients

with Type 2 diabetes. A systematic literature review was con ducted using PubMed, Cochrane

Library, and Scopus from 2000 to January 2012 to assess the cu rrent status of psychosocial

clinical strategies for working with persons with Type 2 dia betes, speci cally African Americans.

Although the literature base on psychosocial strategies sp eci cally targeting African Americans

with diabetes is somewhat limited, we feel that the scope of t ime chosen for this review strikes

the appropriate balance of recency and attention to the chan ging landscape of knowledge and

interventions for diabetes care. Studies were identi ed us ing the following headings and search

terms alone and in combination: diabetes, clinical, program, intervention, adult, Black, African

American, self-management, self-care, utilization, andhealth care use . To the author’s knowledge,

no other literature review exists that focuses on identifyi ng effective clinical strategies for social

work practitioners working with persons with Type 2 diabete s. The authors conducted a critical 520J. A. MITCHELL AND J. HAWKINS

review of the literature .The following offers an overview o f psychosocial strategies in diabetes

care and concludes with directions for future research. As s tated previously, the purpose of this

article is to review effective clinical strategies in diabe tes care speci cally tailored to African

Americans with Type 2 diabetes, as described in peer-review ed literature, in an effort to assist

social work clinicians working with this population.

An Overview of Psychosocial Strategies in Diabetes Care

As previously discussed, receiving emotional, social, psy chological, material, and educational

support (i.e., psychosocial care) can have a signi cant imp act on successful diabetes manage-

ment, particularly among populations with high rates of psy chological distress related to diabetes

diagnoses and management such as African Americans. Althou gh we know that social workers

can play a critical role in providing services and support to individuals with diabetes, the literature

on psychosocial interventions designed or delivered by soc ial workers in this area is scant. The

following discussion covers a range of multidisciplinary s trategies that highlight trends in diabetes-

related psychosocial care of African Americans with diabet es. Although each of these strategies

are not exclusively social work focused, they are particula rly relevant for social work practitioners

supporting individuals at risk for or diagnosed with Type 2 d iabetes.

Predominant psychosocial strategies for diabetes care inc lude the empowerment, faith-based,

cultural competence, and community-based approaches. The empowerment approach has been

used to assist persons with diabetes to engage in diabetes se lf-management (Two Feathers et al.,

2007). Anderson, Funnel, and Arnold (2002) stated that the e mpowerment approach involves

three principals that integrate “the psychology of behavio r change” to promote successful diabetes

management. The principles include (a) an acknowledgment t hat a majority of diabetes care relies

on action by the patient making the patient the locus of contr ol and primary decision maker in

regular diabetes self-care activities; (b) identifying he alth care teams primary tasks as providing

psychosocial support, be a resource for diabetes education to ensure clients can make informed

decisions regarding diabetes self-care; and lastly (c) req uiring health care professionals keep in

mind that behavior change is more likely to occur when client s engage in change behavior that

is salient on a personal level. Diabetes lifestyle interven tions that have utilized the empowerment

approach as described by Anderson, Funnel, and Arnold (2002 ) by providing psychosocial support

and diabetes education in a way that empowers clients and eng ages them in the decision process,

have resulted in increased diabetes self-management in at- risk populations (Two Feathers et al.,

2007). Social work practitioners working with individuals with a diabetes diagnosis can utilize

the empowerment approach to help clients achieve successfu l diabetes self-management.

Faith-based psychosocial approaches to diabetes care have also been utilized with success-

ful results, particularly in the African American communit y (Boltri et al., 2006). Faith-based

psychosocial approaches involve engaging community membe rs in church-based settings and

integrating aspects of faith into diabetes self-care, such as beginning diabetes education classes

with prayer and administering intervention components bef ore or after church services (Boltri

et al., 2006; Hoyo et al., 2004). Faith-based settings can pr ovide the ideal setting for helping

communities engage in diabetes education, prevention, and self-care particularly because of the

existing social networks and support, the potential histor y of other health-related programs, and

because the African American community is already at greate r risk for the disease (Campbell

et al., 1999; Oexmann, Ascanio, & Egan, 2001). It is importan t for social workers to emphasize the

integration of faith-based strategies for certain populat ions to ensure successful diabetes prevention

and management. Culturally competent psychosocial strategies can also enh ance the promotion of diabetes self-

care within diverse populations (Brown, Garcia, Kouzekana ni, & Hanis, 2002; Whittemore, 2007).

Culturally competent diabetes care integrates the cultura l characteristics of the targeted population PSYCHOSOCIAL CARE OF AFRICAN AMERICANS WITH DIABETES521

with standard diabetes self-care practices (Brown et al., 2 002), such as delivering care accessible

community-based locations, using the client’s native lang uage, engaging in self-care activities that

are culturally relevant (i.e., integration of culturally t ailored diet regimens), and utilizing commu-

nity members and/or leaders to deliver diabetes education ( Brown et al., 2002; Whittemore, 2007).

Community-based (or population-based) approaches to deli vering diabetes-related care can

lead to increased knowledge and preventive behaviors (such as adherence to physical activity and

dietary guidelines; Satter eld et al., 2003; Two Feathers e t al., 2007). A goal of community-based

care is to assess community strengths and integrate cultura l characteristics into diabetes care

and to deliver care in the community setting. One such techni que, participatory action research

(PAR), involves researchers working with and supporting th e community to develop strategies

to best engage in diabetes-related care in a culturally rele vant way (Green, Daniel, & Novick,

2001; Harris & Zinman, 2000; Minkler, 2000). Social workers should engage in community-based

approaches to more effectively deliver care to at-risk popu lations.

Below offers a more in-depth discussion of these psychosoci al strategies, speci cally, empow-

erment and cultural competence perspectives, and faith-ba sed, and community-based approaches.

TRENDS IN DIABETES-RELATED PSYCHOSOCIAL CARE OF AFRICAN AMERICANS

Empowerment and Strengths Perspective in Psychosocial Car e

Two prominent strategies employed in psychosocial interve ntions with various client populations

in social work practice are the empowerment and strengths pe rspectives.Empowerment practice

in social work can be de ned as “a social action process by whi ch individuals, communities, and

organizations gain mastery over their lives in the context o f changing their social and political

environment to improve equity and quality of life” (Wallers tein, 2002, p. 73). Empowerment

practice speaks to the value orientation that individuals a nd families bring unique experiences and

resources to the table and has at their disposal, personal va lues, beliefs, identities, and strengths

to draw upon for improving their situation or outcome (Dabel ko & DeCoster, 2007; DeCoster &

Dabelko, 2008). Likewise, a strengths-based perspective s peaks to how social work practitioners

view clients and their innate abilities to accomplish desir ed change. Strengths-based perspectives

require that the social worker foster hope within the client by focusing on what clients have

done successfully in the past (even if very little) and uses t hose previous successes as building

blocks for future change and growth (Labonte, 1994). Streng ths perspective also promotes seeing

clients as the expert on their problems and avoids stigmatiz ing labels of the client that promote

the clinician as expert (Labonte, 1994). Empowerment practice has speci cally been used in working w ith clients with diabetes to pro-

mote self-management and mastery of the, often burdensome, medical regimens that accompanies

a diagnosis of diabetes. For example, DeCoster and Dabelko ( 2008) suggested more than 40 social

work practices that promote the empowerment of older patien ts with diabetes, some being:

encouraging older adults to express their feelings about di abetes; recognizing the older adult as the

expert [in their care]; accept older adults and avoid trying to change them; recognize the elder in

the environment; redistribute power; identify existing st rengths, competencies and resources; endorse

attainable goals; solicit and support intuitive solutions ; focus on the here and now; and foster self-

awareness and insight. (pp. 77–79)

Additionally, Miley and DuBois (2007) encouraged social wo rkers to conceptualize empower-

ment practice as a “social justice contract” between the cli nician and society at large; ensuring

that social workers practice in a way that ensures “the socia l participation of individuals and their 522J. A. MITCHELL AND J. HAWKINS

capacity to contribute to the resource pool of society” (p. 3 1). Empowerment-oriented social work

practice most often incorporates the strengths perspectiv e. When applied to clinical interventions

in diabetes prevention or management, social workers offer a unique care perspective, which seeks

to partner with the clients, value their expertise, highlig ht the resources and skill set clients can

utilize to solve the presenting problem, and build upon past successes to encourage future growth

(DeCoster & Dabelko, 2008; Labonte, 1994; Wallerstein, 200 2).

Faith-Based Psychosocial Care

Social workers and other health care providers may be reluct ant to integrate aspects of a client’s

spirituality or religiosity in efforts to promote diabetes education and self-management (Austin &

Claiborne, 2011). However, a growing body of knowledge deli neates the usefulness of faith-based

diabetes interventions, particularly for African America ns who view and value spirituality and reli-

gious institutions as signi cant sources of psychological and social support (Austin & Claiborne,

2011; Kilbourne, Cummings, & Levine, 2009). For example, Au stin and Claiborne (2011), in

collaboration with the health ministries (i.e., committee s or boards) of four predominately African

American churches in the Northeast, developed a 7-week educ ational intervention at each of the

four churches focused on heart health, healthy eating, phys ical activity, and routine health care

among congregants of each church who were diagnosed with Typ e 2 diabetes (Austin & Claiborne,

2011). Using a large focus group .ND23/ comprising congregants and the input of church health

ministers, investigators of this study emphasized that the key to successful implementation of this

study was the integration of spiritual elements in each aspe ct of the intervention. For example,

congregants insisted that each educational session in the i ntervention began and concluded with

a prayer, and that educational sessions included time for ex tended discussions on how caring for

one’s body is addressed in their faith and spiritual text (Au stin & Claiborne, 2011). These authors

concluded that the integration of spiritual practices in co llaboration with and physically situated

within such a culturally-relevant institution (i.e., chur ch) promoted increased understanding of

diabetes-related education and improved speci c diabetes self-management behaviors among

participants who completed the majority of intervention se ssions. Boltri et al. (2006) translated

the National Institutes of Health (NIH)-Diabetes Preventi on Program (DPP) into a church-based

setting focusing on the diabetes lifestyle aspect of the DDP . The DDP is an intensive diabetes

lifestyle modi cation program (Knowler et al., 2002). The s tudy showed that engaging with

participants in a church-based setting utilizing conducti ng blood glucose screening and diabetes

education classes, resulted in better diabetes self-manag ement and positive health outcomes (Boltri

et al., 2006). Beyond affecting diabetes-speci c outcomes in interventi on studies, varied aspects of religiosity

have been examined for their protective effects against dep ression in individuals with Type 2

diabetes. For instance, a community-based cross-sectiona l study of lower-income adults with Type

2 diabetes who lived in low-resource communities, two third s of whom were African American,

found that speci c religious practices such as religious re ading, attending services, and especially

prayer, was inversely associated with depression and other indicators of psychological distress in

African American participants (Kilbourne et al., 2009). Th ese authors suggested that clinicians

screen for depression among diabetic patients and also incl ude discussions of religiosity in initial

assessments, particularly among African Americans, so tha t clients who wish to interpret health

challenges through the lens of spirituality can be appropri ately matched to resources and support.

Culturally Competent Psychosocial Care

Capable social work practice is built upon an understanding of and responsiveness to how

social and cultural patterns in uence mental and physical h ealth status. Moreover, individual PSYCHOSOCIAL CARE OF AFRICAN AMERICANS WITH DIABETES523

and collective attitudes and motivations to engage in certa in health behaviors are shaped by these

cultural in uences. Research indicates that diabetes inte rventions that are closely aligned with

African American cultural values and beliefs have been succ essful in improving self-management

of the disease in this population (Betancourt, Duong, & Bond aryk, 2012; DeCoster & Cummings,

2005; Utz et al., 2008; Williams et al., 2006). For example, i n a health education intervention

study of rural African Americans with Type 2 diabetes, Alexa nder, Uz, Hinton, Williams, and

Jones (2008) utilized an anthropological strategy called “ cultural brokerage.” This intervention

was delivered by a nurse liaison who worked alongside partic ipants to bridge divides between the

health system, requirements for successful diabetes self- management, and cultural norms which

in uenced health behavior using what authors characterize d as an “insider perspective.”

This perspective and the subsequent diabetes education int ervention sessions were informed by

focus groups of African Americans with diabetes that reveal ed that participants preferred to make

use of personal narratives and storytelling in the interven tion curriculum, the acknowledgment

and inclusion of family or signi cant others was decisive to effective diabetes management, there

were barriers to self-care that were unique to the rural envi ronment such as a lack of educational

programs and medical specialists, there was a social stigma associated with being diagnosed

with diabetes; and spirituality and faith was often utilize d as a reference point and source of

encouragement during challenges to managing illness (Alex ander et al., 2008). This culturally-

relevant knowledge became the guiding framework for how inv estigators tailored their recruitment

methods, the content of intervention materials, the method s of delivering educational content, and

the tone of interaction between study participants and thei r “nurse-broker” (Alexander et al., 2008).

Other pilot studies utilizing trained community members as “cultural health brokers” have also

been effective in improving diabetes knowledge and self-ma nagement among African American

adults with Type 2 diabetes who reside in low-resource envir onments (Cadzow, Craig, Rowe, &

Kahn, 2012).

The cultural competence perspective also calls for clinici ans to be aware of the in uence of cul-

ture on how health and mental health conditions are interpre ted in different communities (Naranjo

et al., 2012). A recent study reviewed current evidence on ps ychosocial outcomes among minority

adults with Type 2 diabetes and found that satisfaction with the patient–provider relationship was

enhanced and medical mistrust was lessened when clinicians expressed a genuine interest in the

distinctive diabetes-related experiences of African Amer ican and Latino clients (Naranjo et al.,

2012). The authors also reported that an important componen t of psychosocial diabetes care is

addressing the potential for depression, emotional distre ss, and reduced perceived quality of life in

a way that is respectful and relevant to clients’ cultural pe rspective. They recommend clinicians

acknowledge how mental illness may be perceived differentl y some racial/ethnic communities

while emphasizing the potential for depression to be effect ively treated (Naranjo et al., 2012).

Community-Based Psychosocial Care

Community-based participatory strategies are among the mo st well studied methods of addressing

psychological, social, and educational barriers to diabet es self-management in African American

communities. For example, the Racial and Ethnic Approaches to Community Health (REACH)

program was an innovative intervention study in Detroit, Mi chigan, that targeted 150 African

Americans and Latinos with diabetes for a peer-led, cultura lly tailored lifestyle intervention (Two

Feathers et al., 2005). This intervention was structured wi th signi cant input from local community

members in the form of focus groups and a community advisory b oard. Not only did the culturally

relevant knowledge gleaned from community members result i n 10 hours of educational sessions,

but other local residents were trained as “family health adv ocates” to deliver the a curriculum

focused on stress reduction, depression, health eating, ph ysical activity, and the use of social

support to maintain lifestyle changes. Family health advoc ates were speci cally trained to deliver 524J. A. MITCHELL AND J. HAWKINS

content using an empowerment perspective (Two Feathers et a l., 2005). The authors reported

that participants experienced statistically signi cant i mprovements in blood sugar control (as

measured by A1C levels at baseline and postintervention) as well as improved knowledge about

proper diet and self-care (Two Feathers et al., 2005). Hendr icks and Hendricks (2000) conducted

a diabetes self-management education program with 30 Afric an American men with Type 2

diabetes with the goal of testing the intervention and testi ng whether monthly and 3-month follow-

up in uenced patient performance, diabetes-related quali ty of life, and diabetes-related health

outcomes. Participants were recruited from diabetes organ izations located in Washington, DC,

churches, and via community advertisement. The educationa l component involved a diabetes self-

management portion administered at a community-based diab etes self-management center. The

primary goal of the trainings was to increase diabetes knowl edge based on 15 diabetes self-care

guidelines provided by the American Diabetes Association ( ADA). The trainings included lectures,

group discussion, and audio and visual aids. Clinicians rel ied on establishing trust, appealing to

men on a personal level, and expressing sincere interests in their health to motivate men to adhere

to treatment regimens. The authors found that the intervent ion was effective on a variety of diabetes

outcome measures and that men who received monthly follow-u p versus 3-month follow-up had

no signi cant differences in outcomes. Anderson and colleagues (2003) evaluated the effectivenes s of personalized follow-up for

African Americans diagnosed with diabetes receiving routi ne eye examinations in free community-

based urban clinics; 106 patients received a diabetes eye ev aluation and were requested to complete

the examination yearly. Participants were randomized to st andard follow-up (receiving a letter

a month before the appointment) and to the intervention grou p, which received an “intensive

personalized” intervention that involved a personal phone call after reminder letters were sent.

During the phone call patients were reminded of the importan ce of getting the eye exam and

addressed any barriers or concerns related to eye health. Th e study found that individuals who

received personalized phone call reminders were more likel y to return for diabetes eye evaluations

than those who did not. A separate qualitative study of African American REACH part icipants sought to explicate

the speci c components of the intervention, which were effe ctive in participants’ estimation.

Participants reported that the REACH program provided a non judgmental environment in which

they could address issues with fear and motivation related t o managing Type 2 diabetes (Heisler

et al., 2009). In addition, participants felt that the indiv idual attention of family health advisors,

emotional support of fellow participants in the group sessi ons, and opportunities to practice and

reinforce new diabetes management strategies increased th eir level of comfort interacting with

health providers—speci cally in terms of asking questions and requesting medical tests and results

(Heisler et al., 2009). A third study of postintervention re sults from the REACH study af rmed

that using community health workers who are speci cally tra ined in empowerment strategies do

facilitate improved self-management behaviors among low- income underserved African Ameri-

cans with diabetes (Spencer et al., 2011). These ndings are signi cant because they represent

promising alternatives to an often impersonal medical mode l of care, which may not be culturally

relevant or accessible to populations with high disease bur dens and few resources.

CONCLUSIONS

Although this brief review of studies addressing the psycho logical and social needs of African

American adults with diabetes is not exhaustive, it is illus trative of recent strategies that acknowl-

edge multiple in uences on the self-determination of clien ts working to manage their condition.

Social work clinicians can ascertain from this review that e fforts to address the psychosocial needs

of African Americans and clients, in general, should consid er the reciprocal relationship between PSYCHOSOCIAL CARE OF AFRICAN AMERICANS WITH DIABETES525

psychological, social, and environmental factors and the d iagnosis and management of diabetes as

a condition. For example, we now better understand how the ne ed to actively monitor and comply

with a rigorous diabetes management plan can be psychologic ally disruptive for African American

adults. As social work clinicians, it is also imperative to i dentify how preexisting mental illness

could impede efforts to consistently manage a complex condi tion like diabetes. Interestingly,

no studies were identi ed for review that addressed the co-o ccurrence of diabetes with one or

more mental health problems; future research should explor e this speci c and relevant aspect of

psychosocial care. This review was able to clarify the context in which a number o f psychosocial interventions

have been applied with success. Studies were reviewed that p oint to the value of assessing

participation in religious communities at the outset of the rapeutic work, giving clients time and

space to express how their beliefs shape and support their he alth efforts. Drawing on culturally

competent psychosocial care, we have identi ed how clinici ans may have opportunities to assess

whether recommended diabetes interventions are responsiv e to the cultural context of their clients.

Indeed many social workers are translating the concept of cu ltural brokerage to practice settings,

tailoring teaching and learning styles, bringing cultural relevance to educational content, and

uncovering unique barriers to care by using narrative techn iques that open communication channels

between clients and their health providers. Further, resea rch related to improving psychological

and social care in the context of diabetes management for Afr ican Americans suggests that

utilizing community-based approaches, educating clients on the potential for depressive symptoms

in culturally sensitive way, and acknowledging clients as e qual and engaged partners in their own

care fosters improved psychosocial and health-related out comes. Lastly, empowerment practice

and strengths perspectives, already prominent strategies in social work practice, were interwoven

throughout several interventions across thematic categor ies—owing to the perspective that clients

or patients should be provided with the information, skills , and support to in uence their own

diabetes care. Embedded within empowerment and strengths p erspectives is the principle of self-

determination, a core social work ethic re ected across nea rly all of the interventions reviewed.

Although the REACH intervention (Heisler et al., 2009) spec i cally addressed efforts to

strengthen the patient-provider relationship and include familial support, we noted a dearth of

additional studies in these two areas; future research shou ld give attention to these and other

important relational aspects of psychosocial diabetes car e. As stated at the outset, we attempted

to ll a gap in knowledge on how clinical strategies speci ca lly tailored to African American

adult diabetes patients addressed their psychosocial need s. From our review, it is clear that social

workers play an important role in helping underserved clien ts with diabetes to navigate the health

care system, implement and maintain the lifestyle changes n ecessary to live with diabetes, and

work through psychosocial barriers to health; the strategi es pinpointed in this review support and

af rm our efforts.

FUNDING

Funding for this work was provided in part by the Southeast Mi chigan Partners Against Cancer

and the Centers for Medicare and Medicaid Services (CMS; Awa rd 1 AO CMS 3000068) and the

Michigan Center for Urban African American Aging Research ( Award 5P30 AG015281).

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