Discordant health beliefs and telehealth use in African Americans with diabetes.

Abstract

Four trends are transforming healthcare in the United States—aging of the population; the rapid growth of the African-American population; rising rates of diabetes; and accelerating use of telehealth. Studies in predominately white populations suggest that telehealth use (i.e., online access to physicians and health records) improves glycemic control.1 African Americans, however, have worse glycemic control and lower telehealth use than whites.2, 3 Racial differences in social determinants of health, diabetes knowledge, and health and computer literacy account for these disparities.4 Discordant health beliefs (i.e., patient health beliefs that diverge from those of physicians) may also contribute.5, 6 This study explored the relationship between discordant health beliefs and telehealth use in African Americans with diabetes. This was a cross-sectional study of baseline data from an randomized controlled trial (RCT) that tested the efficacy of a behavioral intervention to reduce return emergency department visits by African Americans with diabetes who had primary care physicians at Thomas Jefferson University Hospital (N = 94). IRB approval was obtained and participants provided informed consent. At baseline, race-concordant community health workers administered a standardized assessment that included demographic data, point-of-care hemoglobin A1c testing, the Diabetes Self-Care Inventory-Revised (DSCI-R), and the Beliefs About Medicines Questionnaire (BMQ).7, 8 The DSCI-R yields a continuous measure of self-reported adherence to diabetes self-care behaviors (e.g., exercise, diet); a maximal attainable score of 100 indicates the best adherence.7 The BMQ assesses 18 beliefs about medications (e.g., harmful, addictive, overused) that can be considered discordant.8 Discordant health beliefs that were agreed to or strongly agreed to were considered present. Telehealth use was determined from the electronic medical record. Statistical tests included one-way analysis of variance (ANOVA) for continuous data, and cross-tabulations (generating odds ratios) for categorical variables. Participants had the following characteristics: mean age 67.0 (7.5) years; 83% women; mean years of education 12.9 (2.1); and mean HbA1c 8.2% (1.9%). Figure 1 shows that participants with no telehealth use (n = 73; 68.6%) tended to have higher rates of discordant health beliefs than participants with telehealth use (n = 21; 31.4%). Figure also shows the odds ratios for each belief in relation to the likelihood of using telehealth use. For example, participants who stated, “Medications worry me” were 0.32 times [confidence interval 0.86, 1.19] as likely to use telehealth as participants who did not hold that belief. Overall, 79% of all participants held one or more of these six discordant health beliefs. Participants with two or more beliefs (n = 49; 52.3%), compared to participant with fewer beliefs (n = 45; 47.7%), had worse diabetes self-care (i.e., lower DSCI-R scores, 47.0 [SD 14.9] vs 55.5 [16.9], respectively; F = 6.69; df [1,93]; p = 0.011) and tended to have higher HbA1c levels (8.4% [1.9] vs 7.9% [1.9], respectively; F = 1.31; df [1,93]; p = 0.23). This exploratory study suggests that discordant health beliefs are common in African Americans with diabetes and are associated with low telehealth use and worse diabetes self-care and glycemic control. The small sample, underpowered analyses, and uncertain generalizability limit these findings yet the findings align with previous studies reporting low telehealth use in minority populations.4 This study adds to this literature by suggesting that discordant health beliefs may contribute to this racial disparity. Whether concordant (i.e., patient and physician health beliefs align) or discordant (i.e., patient and physician health beliefs diverge), health beliefs are strongly held. For this reason, interventions that respect patient beliefs while nevertheless promoting positive attitudes about diabetes treatment and the potential to improve one's health may mitigate the effects of discordant health beliefs. In the meantime, racial disparities in telehealth use and glycemic control remain. This study, despite its limitations, may advance efforts to ensure that African Americans gain the benefits of high-quality medical care that is otherwise available to everyone. Achieving this goal will reduce the racial disparities that now characterize healthcare in the United States. The authors have no conflicts of interest to disclose. Concept and design: Both authors. Acquisition, analysis, or interpretation of data: Both authors. Drafting of the manuscript: Barry W. Rovner, Robin J. Casten. Statistical analysis: Robin J. Casten. Obtained funding: Barry W. Rovner, R.C. Pennsylvania Department of Health, Grant/Award Number: SAP # 4100077081 This randomized controlled trial (ClinicalTrials.gov NCT03393338) was supported by a grant from the Pennsylvania Department of Health (SAP #4100077081). The sponsors played no role in the design, methods, subject recruitment, data collections, analysis, or preparation of the paper.