ORIGINAL ARTICLE Nov 2014. Christian Journal for Global Health, 1(2):19-28. Evaluation of Jamaican Knowledge of Diabetes and Health Beliefs Melody L. Hartzler a , Aleda M.H. Chen b , Bethany L. Murphy c , Sarah J. Rodewald d a, PharmD, Asisstant Professor of Pharmacy Practice, Cedarville University School of Pharmacy b PharmD, MS, PhD, Vice Chair and Assistant Professor of Pharmacy Practice, Cedarville University School of Pharmacy c Pharm D, Assistant Professor of Pharmacy Practice, Union University School of Pharmacy d BSN, Registered Nurse, Miami Valley Hospital, Dayton, Ohio Abstract Background & Aims: The International Diabetes Federation (IDF) estimated that over 382 million people worldwide were affected by diabetes in 2013. The Caribbe- an region consistently is above the global average in regard to diabetes prevalence. Specifically, in Jamaica, researchers have found that the management of diabetes is not consistent with international guidelines, and in Caribbean culture, there are ad- ditional health beliefs that may need to be addressed. The purpose of this study is to (1) evaluate patient diabetes-related knowledge and health beliefs and (2) de- termine the association between diabetes-related knowledge and health beliefs in rural Jamaica. Methods: Rural Jamaican patients with diabetes (N=48, mean age = 55.16±15.08) were asked to complete questionnaires for cross-sectional examination of knowledge and health beliefs during a medical mission trip to the parish of St. Eliza- beth in Jamaica. Participants were asked to verbally complete the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD, 10 items) and Health Belief Model-11 (HBM-11, 11 items), as well as a demographic instrument. Analyses were performed in SPSS v. 20.0. Descriptive statistics were performed for all items. Spearman or Pearson correlations, as appropriate, were utilized to assess associa- tions. Differences in HBM subscales by demographic characteristics were assessed using paired t-tests. Results: Participants had poor knowledge of diabetes, particularly regarding signs and symptoms of hyper/hypoglycemia, importance of foot and eye exams, fasting blood glucose levels, and long-term diabetes complications. Knowledge deficits were associated with educational attainment, as many participants had only com- pleted primary school. Most participants indicated they were ready to take action regarding their health, but they perceived there were significant barriers to doing so. Also, older adults were more likely to believe that they could control their dia- betes. There were no other differences in knowledge or health beliefs based on demographic characteristics. 20 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. Conclusions: Among this population of rural Jamaican patients, general knowledge regarding diabetes remains low, but patients want to take action regarding their di- abetes. These results indicate a continued need to develop programs to provide di- abetes-related education to patients living in rural Jamaica, as patients are ready to improve their management of diabetes. Introduction Diabetes is not only highly prevalent in the United States but worldwide. The Inter- national Diabetes Federation (IDF) estimated that over 382 million people worldwide were affected by diabetes in 2013. 1 IDF anticipates that in less than 25 years that number will climb beyond 592 million. Eighty-percent of the total number of patients affected are liv- ing in low and middle income countries and suggest this is a worrying indication for the future impact of diabetes to global develop- ment. 1 In regard to mortality, diabetes ac- counts of 13.5% of all deaths among adults in the North American and Caribbean region; while this includes the United States and Canada, the prevalence of diabetes in the Caribbean islands is consistently above the global average. 1 In 2013, the national preva- lence for diabetes in Jamaica was estimated at 10.59%. 1 In addition, a recent cross- sectional study of Jamaican adolescents found that one-third had more than three risk factors for type 2 diabetes, with adolescent girls having more risk than boys. 2 Research- ers have also found that the management of diabetes in Jamaica is not consistent with in- ternational guidelines. 3 Traditionally, Jamaican patients have relied on the physician for diabetes infor- mation and self-management recommenda- tions. 4 However, research has found pa- tients’ adherence, attitude, beliefs, and knowledge about diabetes may affect diabe- tes self-management. 5 Improved adherence has been linked to patients who have a higher level of confidence in their ability to follow medical recommendations. 6 Also, culture and language may influence patients’ health beliefs, attitudes, and health literacy, which may then affect diabetes management. 5 It is important to identify factors that influence patients’ self-management, particularly pa- tients’ health beliefs, to provide a compre- hensive treatment and education plan for dia- betes. The Barrier Analysis model 7 provides a framework by which to identify and address “behavioral determinants associated with a particular behavior so that more effective be- havior change communication messages and support activities (e.g., changing social norms) can be developed.” In the 7 steps of this method, community health team mem- bers move from defining and developing questions to collecting and analyzing results to using the results to improve care. The Health Belief Model (HBM) is rec- ognized as a key framework within the Barri- er Analysis model 7 for understanding patient psychological readiness to take positive health actions. The model is based on the theory that perception of reality, instead of reality itself, determines whether individuals take action. 8 The overall HBM theory recog- nizes that for an individual to take action to avoid disease, he or she has to believe (1) (s)he is susceptible to it, (2) the presence of disease would have at least a moderate im- pact on a component of his/her life, and (3) that taking a certain action would be benefi- cial to improving disease risk or disease pro- gression and would not include overcoming important psychological barriers such as cost, convenience, etc. 8 Knowledge itself may not be sufficient to promote adherence. Pa- tient beliefs are strong motivators of their be- havior; thus, it is imperative practitioners un- derstand a patient’s beliefs, especially when 21 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. caring for patients whose beliefs may be very different than their own. Specifically, in Caribbean culture, there are additional health beliefs that are different than typical US-based diabetes management practices and may need to be addressed. A widely used practice of treating with non- prescription and folk remedies for diabetes is found in many Caribbean cultures including St. Vincent and Jamaica. 4,9 Wint et al. con- ducted a descriptive study to determine the extent of knowledge, motivation, and barriers to lifestyle changes for control of diabetes in Jamaica. 4 A few of the barriers to making positive lifestyle changes included: lack of self-monitoring of blood glucose, lack of per- ceived risk of complications, overweight or obese status, inadequate knowledge, little motivation, non-compliance, use of bush teas, and belief that diabetes can be cured. Jamaican patients also wanted more diabetes- related education and explanations of diabe- tes-related complications. 4 Many of these bar- riers, such as lack of education about the chronic nature of diabetes and use of natural remedies, need to be addressed during diabe- tes educational efforts in Jamaica. Integrating longitudinal lay educator personnel in com- munities has led to improvements in hemo- globin A1C (A1C); 10 however, longitudinal diabetes education is not always feasible in rural or underserved areas in Jamaica. The Parish of St. Elizabeth is a rural ar- ea of Jamaica that often receives additional health care support from United States medi- cal mission organizations. Without medical mission teams, many of the patients in this area would go without physician medical care. These organizations have recently shift- ed their goals from only providing short-term medical teams to finding partners on the ground in the country to continue to carry on work after they have gone home. Assessing knowledge and barriers to care on the mis- sion field will best allow mission organiza- tions to address educational barriers while in the country and continue to develop local partnerships and train lay personnel to further address educational barriers after leaving. This study was conducted to better under- stand patient health beliefs about diabetes in the Parish of St. Elizabeth in order to develop proper education and programming to meet their short- and long-term needs, as recom- mended by the Barrier Analysis model. 7 Research Objectives 1. To evaluate rural Jamaican patient di- abetes-related knowledge and health beliefs. 2. To determine the association between diabetes-related knowledge and health beliefs in rural Jamaican patients with diabetes. . Materials and Methods Research Design This cross-sectional, exploratory study using a convenience sample was conducted during a medical mission trip to the St. Eliza- beth parish of Jamaica from February 6 to 10 th , 2012. A team researcher had previously been on a short-term medical mission trip to St. Elizabeth and identified that there were barriers to diabetes education and care. Based on her experience, and after perform- ing an extensive literature search, the study objectives and corresponding survey instru- ments were identified (Steps 1-3 in Barrier Analysis). 7 Survey instruments were verbal- ly-administered by an investigator (pharma- cist, nurse, or student pharmacist) after verbal consent was obtained (Steps 4-5 in Barrier Analysis). 7 After completing the instruments, participants were invited to attend a 30- minute diabetes education session led by one of the investigators. All patients were given the opportunity to attend the educational ses- sion regardless of study participation. Sample The sample consisted of patients who were at least 18 years of age with type 1 or type 2 diabetes, lived in St. Elizabeth parish 22 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. in Jamaica, and came to the medical mission clinic for treatment. All participation was voluntary; patients were asked to participate if they had a diagnosis of diabetes. Data Collection Institutional review board approval was obtained by Cedarville University prior to data collection. This project was conducted at the “final step” of the clinic. At that point, patients had been seen by the medical pro- vider and were waiting for their medications. Study investigators identified, approached, and asked individuals who met study criteria to participate. If they declined, they were informed about and invited to the diabetes education class. If they agreed, researchers verbally administered three surveys: a de- mographic survey, Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD), 11 Health Belief Model-11 (HBM-11). 12 Once the surveys were completed, study investigators invited participants to at- tend a diabetes education class. All investi- gators completed a 1-hour training session going over the information presented during the class to ensure consistency in education. Investigators utilized the International Diabe- tes Federation as well as the American Dia- betes Association standards of care to create the patient education and included the fol- lowing concepts: types of diabetes, diabetes complications, prescription and herbal treat- ments for diabetes, exercise, signs and symp- toms of hyper/hypoglycemia, and diabetic foot care. 13 Instruments Demographic Instrument The demographic instrument was com- prised of questions regarding participant age, sex, education level, race, height, weight, blood pressure, prior diabetes education, dia- betes treatment (diet, exercise, insulin, tab- lets, other remedies), duration of diabetes, and source of information about diabetes. Spoken Knowledge in Low Literacy in Diabe- tes Scale (SKILLD) 11 The SKILLD is a 10-item scale de- signed to measure knowledge of diabetes in patients with low literacy. The 10 open- ended items relate to the signs and symptoms of hyper/hypoglycemia, treatment of hypo- glycemia, foot and eye exams, normal fasting blood glucose and hemoglobin A1c, exercise, and long-term complications. Each question is worth one point, with a maximum score of 10. Higher scores indicate greater knowledge of diabetes. Participants were read the full question and given 10-15 seconds to respond. If the participant responded correctly, then a point was awarded. If the answer was in- complete, incorrect, or not known, then no points were awarded. The SKILLD is found to be valid and reliable for use in low health- literate patients (Cronbach’s alpha = 0.72; r=0.22, p=0.007 for literacy level). Health Belief Model-11 (HBM-11) 12 The HBM-11 is an 11-item scale de- signed to measure patient psychological read- iness to take positive action in diabetes. This scale is theoretically-based on the Health Be- lief Model and includes perceived suscepti- bility/seriousness of the health condition (in this case, diabetes) and benefits of and barri- ers to taking action. Within the scale, 4 items relate to perceived seriousness, 3 items to benefits of taking action, and 4 items to bar- riers to taking action. Participants are asked to rate their level of agreement with state- ments using a 5-point Likert-type scale (1=Strongly Disagree, 5=Strongly Agree). Negatively-worded items were reverse scored. Scores range from 11 to 55, with higher scores indicating a readiness to take positive diabetes health actions. The HBM- 11 is both valid and reliable and has been successfully utilized in low health-literate patients. 12,14 Data Analysis All data were analyzed using IBM SPSS v. 20.0 for Windows (Armonk, New York) (Step 6 of Barrier Analysis). 7 An a 23 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. priori level of P=0.05 was used for statistical significance. Descriptive statistics were used to assess participant information, including frequencies for categorical variables, means for continuous variables, and medians for Likert-type data (individual items and total HBM-11 score). Spearman or Pearson corre- lations, as appropriate, were utilized to assess associations. Paired t-tests were used to ex- amine differences in HBM-11 subscale by demographic characteristics. Results A total of 48 patients completed the questionnaires. Participants were mostly fe- male, had a primary school education, and had been diagnosed with diabetes in the last 10 years (see Table 1). Table 1. Demographic Information The average diabetes-related knowledge (SKILLD score) of participants was 3.8 out of 10 possible points, and partic- ipant mean score on the HBM was 38.28 out of a possible maximum score of 55. No question on the signs and symptoms of high/low blood glucose, foot/eye exams, fasting blood glucose levels, and long-term complications was answered correctly by more than 25 participants. Only one partici- pant gave a correct answer regarding normal hemoglobin A1c levels (see Table 2). Table 2. Participant diabetes knowledge, as measured by the Spoken Knowledge in Low Literacy in Diabetes (SKILLD) scale Question Answered Correctly Treatment of low blood sugar 30/48 Exercise length and frequency 28/48 Recommended frequency of foot checks 25/48 Importance of foot checks 23/48 Long-term complications of dia- betes 18/48 Signs/symptoms of high blood sugar 17/48 Frequency of eye exams and im- portance 16/48 Normal fasting blood glucose 14/48 Signs/symptoms of low blood sugar 6/48 Normal hemoglobin A1c 1/48 Participants believed they could control their diabetes (median response = Strongly Agree) but indicated that adhering to diet reg- imens was challenging (median response = Agree) (see Table 3). There was a statistically-significant, positive association between educational at- tainment and diabetes knowledge (r=0.32, p=0.03, see Table 4). Also, there was a significant positive association between age and item 6 on the HBM-11 scale (Benefit to Taking Action: I believe I can control my diabetes; r=0.36, p=0.01). There were no oth- er significant associations between demo- graphic characteristics, even when collapsed into binary variables, and diabetes knowledge total score and individual items, readiness to Demographic N or Mean±SD Female 32/43 Age 55.16±15.08 Education None 4/47 Primary Education 29/47 Secondary Education 12/47 Tertiary Education 2/47 Length of Time with Diabetes <5 Years 15/46 5-10 Years 14/46 10-20 Years 13/46 >20 Years 4/46 Received Prior Diabetes Education 32/46 Diabetes Treatment Tablets only 37/47 Insulin and Tablets 6/47 Insulin Only 2/47 Diet and/or Exercise Only 2/47 Local Remedies for Diabetes 19/47 Bush Tea 10/19 Cinnamon Leaf 3/19 Other, not specified 6/19 Weight (kg) 78.44±17.69 Systolic Blood Pressure 143.37±22.64 Diastolic Blood Pressure 83.86±13.89 SKILLD Score 3.79±2.26 HBM-11 Score 38.28±5.63 24 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. take action, or any of the HBM-11 constructs (seriousness, benefits, barriers) or individual items (p>0.05). Participant diabetes knowledge and readiness to take action were not associated (r=0.10, p=0.52). Table 3. Participant readiness to take action, as measured by the Health Belief Model-11 (HBM-11) scale 4 items relate to perceived seriousness, 3 items to benefits of taking action, and 4 items to barriers to taking action. Question M e d ia n S c o re S tr o n g ly D is a g re e a n d D is - a g re e U n d e c id e d A g re e a n d S tr o n g ly A g re e Perceived Seriousness/Susceptibility Q5. I believe I will always need my diabetes diet and insulin/pills. 4 (Agree) 3 1 43 Q3. My diabetes will have a bad effect on my future health. 4 (Agree) 6 5 35 Q4. My diabetes will cause me to be sick a lot. 4 (Agree) 15 1 31 Q2. My diabetes is no problem to me as long as I feel all right.* 4 (Agree) 12 1 34 Benefits of Taking Action Q6. I believe I can control my diabetes. 5 (Strongly Agree) 3 0 44 Q1. I believe that my diet and insulin/pills will prevent diseases (complications) related to diabetes. 4 (Agree) 2 0 45 Q7. I believe that my diet and insulin will control my diabetes. 4 (Agree) 2 1 44 Barriers to Taking Action Q8. I would have to change too many habits to follow my diet.* 4 (Agree) 17 1 28 Q9. It has been difficult following the diet prescribed for me.* 4 (Agree) 16 1 30 Q11. Taking my insulin/pills interferes with my normal daily activities.* 4 (Agree) 22 0 25 Q10. I cannot understand everything I’ve been told about my diet.* 3 (Undecided) 23 2 22 *Reverse-score result shown, as it was utilized for the final HBM-11 score Table 4. Associations of diabetes knowledge (SKILLD score) and readiness to take action (HBM-11 score) with demographic characteristics Readiness to take action (HBM-11) Diabetes knowledge (SKILLD) N Correlation P N Correlation P Age 45 -0.04 a 0.78 45 -0.08 0.60 Gender 43 -0.08 b 0.60 43 0.09 0.58 Education 47 0.01 b 0.94 47 0.32 0.03 Length of time with diabetes 46 0.07 b 0.63 46 0.14 0.35 a Pearson Correlation b Spearman Correlation Discussion General knowledge of survey partici- pants, based on the SKILLD test, was found to be low. Over half of participants knew how to treat low blood sugar, about exercise recommendations, and how often to check their feet. However, only a few patients knew the symptoms of low blood sugar, and only one patient knew what their normal he- moglobin A1c should be. Overall, knowledge of signs and symptoms and nor- mal values were low. This can lead to chal- lenges for patients in managing blood glu- cose and dealing with hyper- and hypogly- cemic episodes, and educators should assist with their patients in dealing with these chal- 25 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. lenges. Further examination of the HBM-11 scores indicate that while participants tended to agree with statements regarding perceived susceptibility and benefits of taking action, they also agreed that they experienced barri- ers to action. Given the context of the Barri- er Analysis model and that the final steps are to analyze and use the results, 7 it is important to examine these findings in context of the literature. For example, these findings reflect pre- vious surveys of Jamaican individuals that suggest a continued need for diabetes-related education. 4 Indeed, examining the broader context of the literature suggests that many patients with low health literacy, irrespective of cultural group or geographic location, lack diabetes-based knowledge. 14,15 Lower educa- tional attainment has consistently been found to be related to lower health literacy and less disease-based knowledge. 16,17 The partici- pants in this study were similar, as lower ed- ucational attainment was associated with less knowledge. However, in spite of this low overall knowledge regarding diabetes, greater knowledge regarding diabetes was not asso- ciated with an increased readiness to make changes related to the disease. Knowledge simply is not enough to induce change. Oth- er researchers have found that regardless of literacy level or knowledge, patients can per- ceive disease severity, see the positives, and overcome barriers associated with therapy adherence. 14 Likewise, participants in this study perceived that their disease was serious and possessed an overall readiness to take action regarding their diabetes. However, these participants perceived that barriers to action were significant and may have been unsure as to whether these aspects could be overcome. Patients perceiving that barriers to action are too high, typically, have poorer diabetes self-management. 18,19 Education for patients with diabetes, irrespective of geo- graphic location, may need to focus on how to overcome barriers. One of the greatest barriers seemed to be dietary changes, which is consistent with the literature. 18,19 However, participants did see the benefits of a proper diet, combined with use of pills and/or insulin, in leading to better control of diabetes and preventing complications. The International Diabetes Federation (IDF) advocates nutritional thera- py and physical activity to prevent and man- age Type 2 diabetes but recognizes that these measures are only effective in a small per- centage of diabetics due to difficulties with adherence and physiological conditions re- quiring pharmaceutical intervention. 20 In- deed, Duff and colleagues studied self-care and diabetes management adherence in Ja- maicans and found that only 45% were com- pliant with their medications and only 56.4% to the recommended diet. 21 Similar barriers of dietary and medication adherence were reported in our participants as well. Instead, many participants surveyed re- ported using bush teas for diabetes control. Bush teas, such as Cerasee, are frequently utilized among Jamaicans to lower blood glucose levels. 3 There have been limited studies, in animal models alone, demonstrat- ing their efficacy 22 and may, instead of being efficacious, be contaminated with toxins and produce unwanted side effects. 23 Until fur- ther information is available, patient beliefs about bush teas need to be assessed, and pa- tients need to be informed of risks and bene- fits of consumption. Educational programs in rural Jamaica would be beneficial if used to improve dis- ease-related knowledge among individuals with diabetes as well as focusing on how to overcome barriers to positive action. Since increases in disease-related knowledge have been linked to improvement in self- management of diabetes 6 and because it ap- pears that many Jamaicans are ready and willing to take steps to manage their diabetes, programs to equip individuals with the tools to do so must be developed. Particularly, these tools should address overcoming the 26 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. barriers to taking effective action but will need to be expanded to more thoroughly ad- dress all the complexities that undergird pa- tient decision-making. The high prevalence of diabetes in Jamaica 1 and the lack of acces- sibility to healthcare services for many rural patients further increase the challenges of identifying barriers to self-care management and determining solutions. While addressing the components identified in this study dur- ing short-term mission trips may be benefi- cial, longer term solutions also are necessary, yet outside the scope of this study. However, other researchers, such as Less and col- leagues, suggest training individuals in the community to provide education training and reinforcement. 10 This type of programmatic development could be considered by mis- sions organizations. Limitations to this study include a po- tential for self-selection bias, since participa- tion in the survey was voluntary. Additional- ly, the sample size was small and consisted mostly of women. Knowledge scores had a large variability, which makes inferential analyses challenging. Finally, this study serves only to highlight the need for future education of this group of people and does not assess the impact of the educational ses- sion provided. Future studies should assess varying techniques of providing patient edu- cation to Jamaican individuals to determine the most effective method. Conclusions This study of rural Jamaican individuals indicates that while knowledge of disease is important and often less than desired, patients understand the seriousness of diabetes and the benefits of making changes. However, the challenges of making changes proved to be a noteworthy barrier. Results of these surveys can be used to encourage more in- depth assessments of patient barriers to self- management using the Barrier Analysis method and development of future educa- tional initiatives that provide individuals with both the knowledge and tools needed to begin self-management of diabetes, ultimately im- proving diabetes-related outcomes in Jamai- ca. This project was conducted on the mis- sion field, where a team of US-based health care providers served this region by provid- ing primary care services. This team returns to the same location every year, and this in- formation gives the team and future teams a great foundation to continue to evaluate pa- tient needs and challenges as well as for pre- paring diabetes education materials and con- tinuing to empower this population to make changes in their behaviors to improve the di- abetes epidemic in Jamaica. References 1. International diabetes federation (IDF) diabetes atlas-sixth edition [Internet]. Brussels (Belgium): In- ternational Diabetes Federation; [updated 2013 cited 3 March 2014]. Available from: http://www.idf.org/diabetesatlas (p. 9, 11, 62, 120). 2. Barrett SC, Huffman FG, Johnson P, Campa A, Mangus M, Ragoobirsingh D. A cross-sectional study of Jamaican adolescents’ risk for type 2 diabetes and cardiovascular diseases. BMJ Open. 2013;3:e002817. http://dx.doi.org/10.1136/bmjopen- 2013-002817 3. Wilks RJ, Sergeant LA, Gulliford MC, Reid ME, Forrester TE. Management of diabetes mellitus in three settings in Jamaica. Pan Am J Public Health. 2001;9(2):65-72. http://dx.doi.org/10.1590/S1020- 49892001001100001 4. Wint YB, Duff EM, McFarlane-Anderson N, O'Connor A, Bailey EY, Wright-Pascoe RA. Knowledge, motivation and barriers to diabetes con- trol in adults in Jamaica. West Indian Med J. 2006; 55 (5):330-3. 5. Nam S, Chesla C, Stotts NA, Kroon L, Janson SL. Barriers to diabetes management: patient and provider factors. Diabetes Res Clin Pract. 2011;93(1):1-9. http://dx.doi.org/10.1016/j.diabres.2011.02.002 6. Gherman A, Schnur J, Montgomery G, Sassu R, Veresiu I, David D. How are adherent people more likely to think? A meta-analysis of health beliefs and http://www.idf.org/diabetesatlas http://dx.doi.org/10.1136/bmjopen-2013-002817 http://dx.doi.org/10.1136/bmjopen-2013-002817 http://dx.doi.org/10.1590/S1020-49892001001100001  http://dx.doi.org/10.1590/S1020-49892001001100001  http://dx.doi.org/10.1016/j.diabres.2011.02.002 27 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. diabetes self-care. Diabetes Educ. 2011;37(3):392- 408. http://dx.doi.org/10.1177/0145721711403012 7. Barrier Analysis Model. [Internet]. Washington DC (United States): Food for the hungry;[updated 2004 cited August 2014] Available from: http://barrieranalysis.fhi.net/ 8. Rosenstock IM. Historical origins of the health belief model. Health Educ Behav. 1974;2(4):328-35. http://dx.doi.org/10.1177/109019817400200403 9. Moss MC, McDowell JRS. Rural Vincentians' (Caribbean) beliefs about the usage of non- prescribable medicines for treating type 2 diabetes. Diabet Med. 2005;22(11):1492-6. http://dx.doi.org/10.1111/j.1464-5491.2005.01676.x 10. Less LA, Ragoobirsingh D, Morrison EY, Boyne MS, Anderson-Johnson P. The Jamaican lay facilita- tors program: a positive impact on glycemic control. Diabetes Manage. 2011;1(2):167-73. 11. Rothman RL, Malone R, Bryant B, Wolfe C, Padgett P, DeWalt DA, et al. The spoken knowledge in low literacy in diabetes scale. Diabetes Educ. 2005; 31(2):215-24. http://dx.doi.org/10.1177/0145721705275002 12. Hurley AC. The health belief model: evaluation of a diabetes scale. Diabetes Educ. 1990;16 (1):44-8. 13. Standards of medical care in diabetes—2012. Di- abetes Care 2012; 35(Supplement 1):S11- S63. http://dx.doi.org/10.2337/dc12-s011 14. Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ. 2007; 33(1):144-51. http://dx.doi,org/10.1177/0145721706297452 15. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Executive summary: health literacy interventions and outcomes: an updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality;2011. 16. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166-72. 17. Institute of Medicine. Health literacy: A prescrip- tion to end confusion. National Academy of Sciences; 2004. 18. Aljasem LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care behav- iors in type 2 diabetes. Diabetes Educ. 2001;27(3): 393-404. http://dx.doi.org/10.1177/014572170102700309 19. Ayele K, Tesfa B, Abebe L, Tilahun T, Girma E. Self care behavior among patients with diabetes in Harari, Eastern Ethiopia: The health belief model per- spective. PLoS ONE. 2012;7(4): e35515. http://dx.doi.org/10.1371/journal.pone.0035515 20. Global guidelines for type 2 diabetes [Internet]. Brussels (Belgium): International Diabetes Federation; 2012 [cited 24 Jan 2013]. Available from: http://www.idf.org/global-guideline-type-2-diabetes- 2012 21. Duff E, O’Connor A, McFarlane-Anderson N, Wint Y, Bailey E, Wright-Pascoe R. Self-care, compliance and glycaemic control in Jamaican adults with diabetes mellitus. W Indian Med J. 2006; 55(4):232-6. 22. Bailey C, Day C, Turner S, Leatherdale B. Cerasee, a traditional treatment for diabetes. Studies in normal and streptozotocin diabetic mice. Diabetes Res. 1985;2(2): 81-4. 23. Allen D. 'Bush' tea danger: Cerassie, ganja tea, aloe vera among potentially harmful home remedies [Internet]. Kingston (Jamaica): Jamaica Observer; 2012 Mar 29 [updated 2012 Mar 29, cited 29 Jan 13]. Available from: http://www.jamaicaobserver.com/news/-Bush-tea- danger_11141393 Peer Reviewed Competing Interests: None declared. Acknowledgements: Cedarville University School of Pharmacy; Medical Ministry International; William John Van Schepen, PharmD Candidate 2016. http://dx.doi.org/10.1177/0145721711403012 http://barrieranalysis.fhi.net/ http://dx.doi.org/10.1177/109019817400200403 http://dx.doi.org/10.1111/j.1464-5491.2005.01676.x http://dx.doi.org/10.1177/0145721705275002 http://dx.doi.org/10.2337/dc12-s011 http://dx.doi,org/10.1177/0145721706297452 http://dx.doi.org/10.1177/014572170102700309 http://dx.doi.org/10.1371/journal.pone.0035515 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.jamaicaobserver.com/news/-Bush-tea-danger_11141393 http://www.jamaicaobserver.com/news/-Bush-tea-danger_11141393 28 Hartzler, Chen, Murphy & Rodewald Nov 2014. Christian Journal for Global Health, 1(2):19-28. Correspondence: Melody L. Hartzler, Cedarville University School of Pharmacy, 251 N. Main St. Cedarville, OH 45314, USA mhartzler@cedarville.edu Cite this article as: Hartzler, ML, AMH Chen, BL Murphy, SJ Rodewald. Evaluation of Jamaican knowledge of dia- betes and health beliefs. Christian Journal for Global Health (November 2014), 1(2):19-28. http://dx.doi.org/10.15566/cjgh.v1i2.13 © Hartzler, ML, et al. This is an open-access article distributed under the terms of the Creative Commons Attrib- ution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the origi- nal author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:mhartzler@cedarville.edu http://dx.doi.org/10.15566/cjgh.v1i2.13 http://creativecommons.org/licenses/by/3.0/