Zoe Pantis

H&S 490

Step 1
The health issue I will be addressing is diabetes in women over 50 in Sacramento, California
and how to better manage this chronic illness once it has occured. Women expirence many
different symptoms with diabetes including their ability to metabolise enzymes and breakdown
glucose after menopause. I want to focus on the different symptoms women face and the possible
barriers that different ethnicities, cultures, and even finances permit. There are many objectives
given in healthy people 2030, the main objectives that focus on the specific target (management
of older diabeteic women) are very slim and limited to only older adults i.e. Reduce the rate of
hospital admissions for diabetes among older adults (2016), Increase the proportion of people
with diabetes who get formal diabetes education (2017), Increase the proportion of eligible
people completing CDC- recognized type 2 diabetes prevention programs and Increase the
proportion of adults with diabetes who get a yearly urinary albumin test. The objectives given
are directly related to self-care and management of diabetes. They share similar goals such as
regular check ups to maintain health, screenings, support, and education. The objectives listed
are not specific to older women however, share the same goals in maintaining good health and
reducing risk. It is important to discuss, research, promote, and share ideas about the ways to
manage diabetes in women to focus on the care that is given and could be given to promote a
healthier lifestyle and to recognize the changes in women as they age.
Step 2
Figures 1-8 discuss demographic data regarding the quality of life in Sacramento, CA.
Figure 1. Table 1
Race over Age 65
Race 65+ Sacramento county California

Asian 13.58% 15.05%

Black 10.99% 12.64%

White 16.81% 16.40%

Native American/ 14.24% 11.70%

Alaskan

Total 55.62% 55.79%

Figure 2. Table 2
Income Per Capita
Area Population Total Income Per Capita Income ($)

Sacramento 1,524,553 $49,929,922,500 $32,750

California 39,283,497 $1,451,730,311,700 $36,955

Figure 3. Table 3
Eduction
Area No High Some A.S Degree B.S Degree Graduate/
Diploma school only College Professiona
l Degree

Sacrament 12.28% 22.4% 24.8% 9.7% 20.4% 10.4%

o

California 16.96% 20.5% 21.1% 7.8% 21.2% 12.8%

Total 29.24% 42.9% 45.9% 17.5% 41.6% 23.2%

Figure 4. Table 4
Diabetes Management Through A1c Tests
Area Medicare Enrollees Enrollees with Enrollees With
with Diabetes Annual Exams Diabetes and Annual
Exams

Sacramento 8,445 7,134 84.48%

California 269,472 227,502 84.43%

Total 277,917 234,636 168.91%

Figure 5. Table 5
Diabetes Population By Age

Area 65+ Less than 65 Years

Sacramento 27.1% 22.9%

California 27.3% 26.7%

Toal 54.4% 49.6%

Figure 6. Table 6
Adults with Diabetes by Gender, (2019)
Area Male Male (%) Female Female (%)

Sacramento 54,560 9.5% 56,790 8.6%

California 1,390,026 9.2% 1,379,715 8.3%

 Total 1,444,586 18.7% 1,436,505 16.9%

Figure 7. Poverty Below 100% FLP

Report Area Total Population Population in Poverty Poverty (%)

Sacramento, CA 1,504,340 220,713 14.67%

California 38,535,926 5,149,742 13.36%

United States 316,715,051 42,510,843 13.42%

Figure 8. Uninsured Population by Age and Race

Age Group
Report Area Under 18 Age 18-64 Age 65+

Sacramento, CA 2.53% 7.77% 0.66%

California 3.29% 10.66% 1.08%

United States 5.08% 12.42% 0.79%

Race

Report Non- Black Native Asian Native Other Multiple

Area Hispanic American Hawiian Race Race
White or Alaska or Pacific
Native Islander

Sacramen 26,937 6,140 744 11,325 1,782 13,954 4,559

to

Californi 576,186 127,687 34,864 270,394 11,069 775,271 93,446

a

United 11,541,94 4,024,678 515,950 1,200,568 62,249 3,230,689 813,166

States 9

The quality of life in Sacramento, California based on the data presented above by SparksMap, I
was very surprised at the amount of people enrolled in medicare with diabetes and got annual
check ups. This reflects very positively on awareness within the community. California and
Sacramento are predominantly white in the population that I have selected; however, the Asian
population is at a high value as well. It is concerning that diabetic men outnumber adult women
in the data presented on diabetes by gender. This could be from a number of factors including
lifestyle, exercise, nutrition, stress, and accepting care. Including other factors such as A1c tests,
education, income and race in Sacramento, California allows a better analysis of the quality of
life in this specific area. Income being one of the most crucial areas due to the expenses of
medical care focused in the management of diabetes was shocking. It is very expensive to live in
California let alone have insurance or money saved to help with medical bills especially if
money is hard to come by. This is an important factor because this and poverty rankings
determine access to health care and engagement in healthy behaviors such as access to healthy
food. With the poverty level as high as 14% in Sacramento, California, health care access is even
more challenging to access especially in minority groups . The number of uninsured adults over
65+ was shockingly low. This reflects positively on the target group I am focusing on and their
access to health services however it is very alarming that ages 18-64 have the highest percent of
uninsured people.

Step 3
Figures 1-6 include important health outcomes and data in Sacramento, California in comparison
to the United States.
Figure 1. Demographics - Population with Diabetes in Sacramento, California

Figure 2. Health Outcomes

Measure Overall AIAN Asian Black Hispanic White

Premature 5,300 9,600 3,100 9,700 4,800 5,600

death

Life 81.7 78.3 87.7 76.2 83.8 80.5

expectancy

Premature 270 440 160 480 240 290

age -
adjusted
mortality

Child 40 50 30 70 40 30
mortality
 Infant 4 5 4 8 4 4
mortality

Low 7% 8% 8% 12% 7% 6%
birthweight

Figure 3. Diabetes Prevalence in Sacramento, California

% of adults Ages 20+ Diagnosed with Diabetes
County County Value Error Margin California Summary

Sacramento (SA) 9% 8-11% Overall: 9%

Figure 4. Health Data in Sacramento, California

Health US CA CA Min CA Max

behaviors

Adult smoking 17% 11% 10% 19%

Adult obesity 30% 24% 16% 39%

Food 7.8 8.8 6.2 9.4

environment
index

Physical 23% 18% 11% 34%

inactivity

Access to 84% 93% 42% 100%

exercise

Excessive 19% 18% 17% 25%

drinking

Alcholo- 27% 29% 0% 60%

impaired deaths

STI 539.9 585.3 155.3 1,073.2

Teen Births 21 17 6 38

Figure 5. Leading Cause of Death with Diabetes ranked at #8

Figure 6. Population with Disability

Any Disability
Report Area Total Population Population with a Population with a
Disability Disability(%)

Sacramento, CA 1,510,932 178,919 11.84%

California 38,787,337 4,101,034 10.57%

United States 319,706,872 40,335,099 12.62%

Any Disability by Age Group

Report Area Under 18 Age 18-64 65+

Sacramento, CA 3.51% 9.50% 37.15%

California 3.31% 7.98% 34.47%

United States 4.21% 10.25% 34.48%

Detailed above are just some of the health outcomes and statistics of Sacramento county
compared to those in both California and the United States. The areas that are significantly poor
in comparison are obesity, increased number of negative health outcomes in African Americans,
smoking, food environment index, physical inactivity, access to exercise, excessive drinking, and
the alarming numbers of adults over 65 with a disability. Many factors can contribute to such
poor health rates in Sacramento and in California in comparison to the United States including
poverty, disparities, access to care, overpriced food, high taxed healthier options, addiction, and
even mental health. It's also been proven that diabetics have a higher rate of disability especially
those aged 45-70 years. The United States has the largest number of diabetics of all the
developed countries, infact, “By 2025, an estimated 22 million Americans will have diabetes.
Approximately 90% of these will be type 2 diabetics, including almost 6 million who will be
undiagnosed”(Black, 2002)
According to healthy People 2030, Older adults and people with disabilities are especially
vulnerable to experiences of discrimination. I could not find any related objectives on
specifically women over 50 in Sacramento California that have experienced inequalities and
disparities However, there is lots of information provided in many research and peer reviewed
articles. Low socioeconomic status has been related to higher levels of mortality and morbidity
for adults with type 1 diabetes even amongst those with access to a universal healthcare system.
People from BAME groups(black, asian, minority ethnic) experience more barriers to accessing
diabetes-related health care resources compared to Caucasian groups. According to an article
written concerning these inequalities, “ These barriers include generational, geographical and
gender differences within specific BAME communities. Additionally, language barriers, a lack
of culturally relevant information and poorer knowledge are deemed to be other contributing
factors. The economic burden to society of diabetes-related health disparities is well described
and includes greater health care costs, increased morbidity and premature mortality”
(Seewoodhary, 2021). Not only are there many inequalities faced in the healthcare system among
those receiving care for diabetes, there are many disparities amongst the general care between
men and women that are extremely crucial. For instance many diabetic women have a higher risk
for getting UTIs, yeast infections, and the unpredicted ups and downs of blood sugar levels
caused by menopause according to CDC.

Step 4
Maintaining healthy lifestyle behaviors and health behavior is amongst the most helpful and
successful ways to help maintain and improve the symptoms and difficulties that come with
being diabetic. In a study involving women with type 2 diabetes ranging from ages 21-75 were
being observed by their behavior when placed into interventions of “education/counseling,
exercise, diet, or combined components of varying duration. The included studies used a variety
of objective indicators, including glycaemic control, lipid profile and anthropometric indices, as
well as a number of diabetes-specific and generic subjective scales”(Seib & Parkson, 2018). The
results of the study showed a reduction in BMI, improvement in HBA1c levels, some
improvement in self- efficiency, mental health, and diabetes problem solving. It is proven that
“Anthropometric measures were largely responsive interventions that included dietary and/or
exercise modifications”. The results during this study show the success in intervention styles and
the promotion of self-care in relation to the management of type 2 diabetes in women. The article
suggests that the reason for many people hesitating to approach such interventions is due to
“their failure to address the broader and correlated nature of many unhealthy lifestyle behaviors”.
The health behaviors of many diabetic women can be influenced by education, income, culture,
sleeping patterns, eating habits etc. that can largely be attributed to better lifestyle behaviors.
The concept of self-compassion in learning to become more self care oriented when being
diabetic, “is linked with motivation after setbacks and can decrease negative reactions when
setbacks or health threats (e.g. cardiovascular disease) arise. self-compassion was associated with
engagement in health behaviors through decreasing perceived stress , and overall negative
affect . Moreover, self-compassion fosters an improved desire to treat oneself in a caring way
and has been shown to decrease defensiveness and self-derogation that thwart engagement”
(Morgan, et al., 2020). Based on the correlation between self- comparison and diabetic women in
a study based on 2 cross sectional studies, self-compassion was shown to be positively linked to
“ self-management behaviors, with the strongest associations being with dietary care and
physical activity”. Without the willingness of an individual, there will be little to no progress.
With the study of how self-comparison relates to management strategies of health behaviors, it is
crucial to understand where the patient is at and moving forward, how to help with their mental
strength first before moving to other external factors.
Risk factors in women can range from the development of Gestational diabetes which can later
in their life develop type 2 diabetes, dietary factors including the dietary quality of carbohydrates
and fat intake and red meat, sugary beverages, and physical activity (Zhang & Ning, 2011).
Figures 1-4 Show the behavioral health data of the population in California and amongst solley
diabetic women in the age group of 18-65+.
Figure 1.
Health US CA CA Min CA Max
Behaviors

Adult Smoking 17% 11% 10% 19%

Adult Obesity 30% 24% 16% 39%

Food 7.8 8.8 6.2 9.4

Environment

Physical 23% 18% 11% 34%

inactivity

Access to 84% 93% 42% 100%

exercise

Excessive 19% 18% 17% 25%

drinking

Uninsured (>65) 10% 8% 5% 12%

Primary Care 1,320:1 1,250:1 1,100:0 630:1

physicians

Dentists 1,400:1 1,150:1 1,130:0 640:1

Screenings Ages 42% 36% 28% 46%

(64-74)

Mental Health 380:1 270:1 920:1 110:1

providers
Figure 2. Inactive Diabetic Women over 65

Figure 3.
Figure 4. Tobacco Use in Diabetic women

The most important risk factors that are also capable of alteration in women with diabetes are
mainly obesity, tobacco use, exercise, diet, hypertension, and cholesterol.
Smoking can further amplify cardiovascular risks in patients with diagnosed diabetes and
hypertension. Smoking is a risk factor for mortality and coronary heart disease in hypertension
and in diabetes. The risk for stroke is less consistent in hypertension and appears to be smaller
than that of CHD in diabetes (Fagard, 2009). Some well known risk factors also include genetics,
atmosphere, loss of very first phase associated with insulin launch, sedentary way of life, lack of
physical exercise, smoking, alcoholic beverages, dyslipidemia, reduced β-cell sensitivity,
hyperinsulinemia, improved glucagon activity are the primary risk elements for prediabetes and
DM. Diabetes can be managed by most importantly changing diet, regular physical exercise,
maintaining reasonable body weight, monitoring lipid profile, and having appropriate medication
when necessary. “Taking low glycemic food, complex carbohydrate, protein, and
polyunsaturated fatty acid (PUFA) and fiber can help to maintain normal blood sugar. Moderate
exercise which decreases obesity helps lowering blood glucose levels through insulin-
independent glucose transport into the muscle” (Alam et al.,2021). Managing diabetes involves
practicing healthy behaviors and breaking unhealthy habits. Maintenance can be successful
through monitoring diet, exercise, decreasing substance use, quitting smoking, and monitoring
insulin.

Step 5
Of the four environmental factors, (physical environment, Social environment, political
environment, economic environment) I believe each influences the likelihood of the participation
in a healthy behavior such as the management of diabetes. The most important factors affecting
health services and self-care in diabetic women are the social and economic factors. There are
several social factors influencing patients' self-care practices and habits of diabetic women
especially in low income areas. The main issue among physicians and health care is the lack of
empathy towards diabetic patients and their tendency to assign blame without understanding
their situation fully. Women are more likely to compromise “their dietary needs for the sake of
their familial dietary preferences. The inability of patients to comply with recommended exercise
regimen may be derived from environmental factors; primarily unsafe neighborhoods, lack of
availability of nearby recreational facilities such as public parks, and cultural resistance in
patriarchal social environments”(Basue et al., 2017). Amongst many social factors affecting the
management of diabetic women, there are many possible physical exposures in the environment
that are possibly linked to diabetes risk. These being more prevalent in African Americans,
latinos, and low-income individuals include, “exposures to several toxicants have been
prospectively linked to diabetes risk, including PCBs, organochlorine (OC) pesticides, various
chemical constituents of air pollution, bisphenol A (BPA), and phthalates”(Ruiz et al., 2018).
Lower income individuals especially in California where housing costs amongst many other
comforts and necessities are extremely expensive, are more affected by the economic factors
contributing to diabetes management and receiving quality care. According to the American
Diabetes Association, “Those lower on the SES ladder are more likely to develop T2DM,
experience more complications, and die sooner than those higher up on the SES ladder
found increasing diabetes prevalence at lower levels of income as reflected in the levels of ratio
of income to poverty level. Compared with those with high income, the relative percentage
difference in prevalence of diabetes for those classified as middle income, near poor, and poor,
was 40.0%, 74.1%, and 100.4%” (Adler et al., 2021). The role of policies and their influence on
diabetes is a very important factor to dissect. Since I am targeting the research of women over 50
with diabetes, it is important to observe the policies and habits that were popular during their
adolescence and adulthood that possibly had an influence on their health. For instance, smoking
tobacco was a very social thing that was not seen as harmful or the serving sizes of sugary
beverages and the belief that diet or low sugar is healthy. Since then, “numerous authoritative
governmental and quasi governmental bodies have recognized the role that policy and
environmental change strategies can play in effectuating population-wide behavior changes that
could lead to improvements in diet quality and physical activity, and ultimately reduce and
prevent obesity among children, youth, and adults” (Just et al., 2017).
The primary data needed to learn more about diabetic women over 50 years and the
environmental factors that correspond to the management and risk of diabetes are the attitudes,
experience, and prior health habits/lifestyle of women with diabetes. Knowing more about their
past eating habits, physical activity, possible employment history, and experience with healthcare
providers including insurance benefits can help identify more about the community in
Sacramento, California and the correlation between health behavior. I would like to see how this
differs in different areas of Sacramento within different ethnicities.The methods that could be
used to obtain this data could be done through a survey mailed to each individual with a possible
incentive, a questionnaire given out at a medical office, or possibly conducting interviews with
diabetic women in Sacramento county.
Step 6
Predisposing Factors:
After rigorously searching for the primary knowledge, attitudes, beliefs, and self efficacy of
older women diagnosed with diabetes, I found two Articles stating the beliefs, knowledge, and
attitudes about their health. The first article was to my surprise very negative. The article
discussed a study that was conducted on two groups of patients with a serious illness and their
health ranging from ages 65-70 and 71-85. Based on the results, health beliefs of patients aged
between 65–70 were higher than for patients aged between 71–85 and women had lower scores
than men. Out of the participants in the study, the diabetic patients were less likely to consider
recommendations. In all, the article showed that diabetic patients did not tend to view diabetes as
a serious disease and did not practice healthy management behaviors. The patients that were
female 70 or older who were “less educated and of a lower economic status; who showed poor
adherence to treatment and medical nutrition therapy; and who needed diabetes-related training
had negative health beliefs”(Agrali MsN & Akyar, 2014). In the second article I found, the
discussion of the relationship between health literacy and self efficacy amongst elderly women
with diabetes was observed in a study. The article states that those who had qualities similar to
high education, annual income, a partner, internet access, and employment correlated to having a
higher health literacy rather than those who were older and had been diagnosed with diabetes or
exhibited depressive symptoms. According to the seven factors used to assess health literacy and
self efficacy in diabetic patients, listed as age, years of living with diabetes, employment status,
social support, diabetes education, clarity of physician's explanation, and absence of diabetic
complications, These were directly associated with self efficacy. while independently, depressive
symptoms were negatively correlated to self efficacy (Yi Xu et al., 2018). Simply the quality of
life, economic status, social interaction, and mental health have an effect on self efficacy in older
diabetic women.
I would like to see more information regarding the predisposing factors of women in Sacramento
county. The primary data needed to better understand women's attitudes, knowledge, beliefs,
perception and self efficacy in the management of diabetes. I would like to measure the
knowledge and self efficacy of women in Sacramento to observe their prior education and
support.
The data collection tool I plan to use is the generation of a survey. There are lots of different
platforms that can be customized by region, question, length, style, etc. I feel using a survey to
construct raw data can be very useful when thinking of a specific target area.
Enabling Factors:
The enabling factors such as availability, resources, affordability, policies, services, and facilities
directly impact diabetic women in their efforts to manage their health. Making the availability
easier for women of all ethnicities would drastically change the management of diabetes. So
many individuals are deterred by the cost of medical services, the physicians, and the facilities
that they are receiving care in. Making their healthcare experiences more accessible, affordable,
and friendly to all types of barriers would make the population of women with diabetes more
motivated to practice self-care. Providing resources such as brochures, pamphlets, and even
internet help would create a more informative and friendly environment. Providing services that
help women over 50 make appointments, use devices, and are cost friendly would increase the
number of women receiving care annually. Policies that make healthcare affordable need to be
maintained and barriers of non supplemental insurance and a physician's lack of responsiveness
need to be altered.
Reinforcing Factors:
I think the main reinforcers of my health topic would remain as health care workers, family,
media, and the community. I feel a way to reinforce and influence healthy behavior that would
be very helpful and supportive would be the organization of a support/advice group of women
with diabetes. This could be generated or advertised during healthcare visits, through posters,tv
ads, media, radio ads, churches and spoken through the community. Having a group of women
together that share the same health issue among other battles, can cause a great impact in how
these women receive information, support, possible racial and language barriers, and above all
can work together and share what works and does not work.
Step 7
The most feasible issue to address in my topic is the focus on how diabetic women over 50 are
managing their health behaviors and illness and to promote and assess the types of care, support,
lifestyle changes, disparities, education, and overall health when dealing with diabetes. The most
important target in this issue is older diabetic women in preferably Sacramento, California.
Women with diabetes have very drastic differences than men especially as they age. Women
who are pregnant have a risk of developing diabetes during pregnancy and if so, type 2 diabetes
later on. Not only does pregnauncy affect diabetes but our bodies mentaral cycle and pre/post
menopause phases can drastically change isulin levels. Understanding these differences and
barriers women face when trying to manage their diabetes is important to assess before looking
at what they can change and how.
The predisposing factors affecting women in their self-care practices that are most important to
address are self efficiency, beliefs, and knowledge. Many women are predisposed to believe that
they should try home remedies and cost friendly practices due to their social status or due to their
uncomfortable experiences in a healthcare setting. Increasing the knowledge that diabeteic
women, no matter their disparities, will be provided with optimal resources and services to treat
their health concerns is crucial. Many older individuals are put off by recommendations,
experiences with physicians, and SES. If these were made easier and more friendly, women
would possibly shift their perceptions to a more positive view on healthcare and management of
diabetes.
Enabling factors such as affordability, availability, services, and resources that are provided are
the most crucial focus for my health issue. Each of these play an important role in influencing
care. Those in minority groups and low income areas are most affected by all of these factors.
Most people are deterred by cost which can rule out availability, services, and resources all
together. Because some women are subjected to poverty, does not mean they should have a
harder time accessing care and resources. Especially since most elderly women are very hesitant
to use technology due to the unfamiliarity of the system, this causes a helpless feeling in the
community. Providing services, affordable care, resources, and availability to diabetic women
will increase their healthy behavior and confidence to change. Reinforcement of these factors
through the community, health care workers, women's support groups, and the media can
influence a change in promoting and supporting management of diabetic women. This can be
done through posters, churches, flyers, tv and radio ads, and through community leaders. Above
all, having a women's group would allow the most support and knowledge to be shared amongst
similar experiences and strengthen women dealing with diabetes.
Step 8
The most affected people in my health issue are women over 50 with diabetes. These women can
be involved in the promotion of diabetes management by giving helpful responses to survey
questions, participating in women with diabetes groups, sharing ideas and knowledge, joining an
organization, starting an organization or association, and practicing/promoting healthy behavior.
The barriers that need to be considered are income, inequalities, disparities, poverty, language
barriers, education, age, access to health care, inadequate knowledge, behavioral beliefs, lack of
support, and negative emotions. The barriers to diabetes management can be overcome with
proper knowledge, affordability, equality in healthcare, support by peers or family, reassurance,
resources, and availability.
The types of influencers needed in the promotion of diabetes management for my health topic
are mainly health care physicians, family, women’s groups, church groups, and community
support. Involving influential people in the management and awareness of a chronic illness like
diabetes influences more self care practices and a positive outlook. Using primarily health care
workers I believe is most important because this is where the primary and credible knowledge is
coming from. Often if people model positive behavior and offer a great experience, this will have
a positive effect on the self esteem and mindset of the patient. If a health care worker can provide
a great experience and even develop a relationship with their clients, this can create not only a
more confident visit, but a more informative, constructive environment.

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