Language and Other Factors Associated With Foot Self-Management Among Puerto Ricans With Diabetes in New York City

The data were collected in 2000–2001 through a random digit–dialing telephone survey aimed to reach Puerto Rican adults (≥18 years of age) residing in New York City (5). The survey protocol and questions were taken from the Behavioral Risk Factor Surveillance System developed by the Centers for Disease Control and Prevention (15). Those who responded affirmatively to the question “Have you been told by your doctor that you have diabetes?” were identified as having diabetes (n = 606). Daily foot self-inspection practice was measured by the question, “About how often do you check your feet for any sores or irritations?” Instructions were given to include times when checked by a family member or friend but not by a health care professional. Those who reported checking their feet once or more a day were identified as practicing daily foot self-inspection.

In the analysis, respondents were divided into three groups based on their language usage pattern. Respondents who chose to be interviewed in English and also reported using English at home were considered “English dominant” (n = 204). Those who chose to be interviewed in English but reported using Spanish at home (n = 189) or vice versa (n = 12) were considered “bilingual.” Those who used Spanish both for interview and at home were identified as “Spanish dominant” (n = 201). The multivariate logistic regression model included language and standard demographic variables (age, sex, and education) and other variables associated with daily foot self-inspection including years since diabetes diagnosis, vision impairment, history of lower-extremity ulcer, current diabetes medication, daily self-monitoring of blood glucose, number of times a professional checked feet in the previous year, diabetes education (ever had), and current smoking. History of lower-extremity ulcer was measured by the question “Have you ever had an ulcer or sore on your leg or foot that took more than four weeks to heal?” Variables that resulted in statistically significant changes (P < 0.05) in −2 log-likelihood ratio were retained in the model using the stepwise selection method (16) while holding the demographic variables in the model.

Overall, 54% of Puerto Ricans with diabetes checked their feet for sores and irritations every day. In the unadjusted bivariate model, the odds ratio of daily foot self-inspection was 1.36 for the English-dominant group and 1.27 for the bilingual group, and these remained significant (P < 0.05 to <0.01) as other variables were added. In the final model (Table 1), English-dominant and bilingual groups were twice as likely as the Spanish-dominant group to practice daily foot self-inspection. Those who received professional foot check in the previous year were 1.7–2.3 times more likely to inspect their feet daily than those who did not (P < 0.01). Additionally, female sex, history of lower-extremity ulcer, daily self-monitoring of blood glucose, and diabetes education were positively and significantly (P < 0.05) associated with daily foot self-inspection. Relevant interaction effects were examined but none contributed significantly to the model.

Compared with English-dominant and bilingual Puerto Ricans, Spanish-dominant Puerto Ricans were less likely to practice daily foot self-inspection. The results of this study are consistent with studies where poor English skills were linked to suboptimal diabetes self-management behavior among Hispanic subjects (11,12). The findings also support previous studies that reported Hispanic subjects with limited English skills were less likely to actively seek medical and preventive care than Hispanic subjects with a good command of English (17–19).

Our data indicate that 52% of English-dominant, 90% of bilingual, and 99% of Spanish-dominant respondents were born outside the mainland U.S. Spanish-dominant individuals were less educated, with only 14.6% having completed high school education, compared with 73.4% in English-dominant and 41.7% in bilingual individuals. It is plausible that Spanish-dominant Puerto Ricans not only had a limited command in English but also had lower levels of Spanish literacy and language comprehension. Further study is needed to explain the causal mechanism of language status and self-management behavior, including language concordance between the respondents and their diabetes care providers.

Other individuals less likely to practice recommended foot self-management include those who did not receive professional foot inspection in the previous year, those who never had diabetes education, individuals not checking blood glucose daily, males, and those who have not had a lower-extremity ulcer. Similar findings have been reported by studies that examined foot self-care behavior in non-Hispanic, English-speaking populations (20,21). The present study also indicates that 36.6% of Puerto Ricans did not receive professional foot care in the previous year at all. This rate is notably higher than the rate for the statewide population with diabetes (26%) (3)

Study limitations include self-reporting and possible recall bias. The Centers for Disease Control and Prevention reports, however, that the bias associated with this type of telephone survey is minimal (10,15). The findings of this study support previous recommendations to increase the availability of Spanish-speaking diabetes care providers and/or language translators with training in low-literacy health communication and cultural competency to improve foot self-inspection among Puerto Ricans (6,8). It is also important that diabetes care providers are in compliance with the recommended standards of foot-specific and overall diabetes care, education, and self-management.

This study was supported by funding from the Association of Schools of Public Health (no. S0742-18/19).

The study was reviewed and approved by the New York State Department of Health Institutional Review Board for the Protection of Human Subjects (no. 98-2-07).