Common Sense Illness Beliefs of Diabetes among At-Risk Latino College Students

Abstract

This study examined the validity of the Implicit Model of Illness Questionnaire (IMIQ - Schiaffino & Cea, 1995) when used with Latino college students (n = 156; 34% male, 66% female) who are at-risk for developing diabetes due to family history of this disease. An exploratory principal-axis factor analysis yielded four significant factors – curability, personal responsibility, symptom variability/seriousness, and personal attributions – which accounted for 35% of variance and reflected a psychosocial-biomedical common sense perspective of diabetes. Factor-based analyses revealed differences in diabetes illness beliefs based on students’ age, generational status, acculturation orientation, and disease experience of the afflicted relative.

Diabetes is the fifth leading cause of death among Latino Americans with an estimated 2.5 million Latinos/as (9.5%) currently afflicted with this chronic disease (Centers for Disease Control and Prevention [CDC], 2005; Heron, 2013). The risk of being diagnosed with diabetes is 70% more probable among Latino ethnicities when compared to non-Hispanic whites of similar ages (US Department of Health and Human Services [HHS] Office Minority Health, 2014). More disturbing is the dramatic increase in recent years of reported cases of type 2 diabetes among Latino youth and young adults of college-age, making this medical disorder an even more serious health threat for this population (CDC, 2014; Lawrence et al., 2009). Genetic predisposition and psychosocial factors associated with the obesity epidemic (lack of physical activity coupled with poor dietary patterns) and acculturative forces (adopting a ‘Westernized’ lifestyle) are the primary reasons noted for the higher incidence and increased risk for type 2 diabetes among younger-aged Latinos (CDC, 2014; Flegal, Carroll, Kit, & Ogden, 2012; Hu, Taylor, Blow, & Cooper, 2011; Hurtado-Ortiz, Santos, & Reynosa, 2011; Kposowa, 2013; Ogden, Carroll, Kit, & Flegal, 2012). Unfortunately, Latino college students are not exempt from this health crisis with recent research indicating that they too evidence a higher incidence of obesity — a primary risk factor for diabetes in the young —when compared to their non-Latino white peers (Knight, Killion, & Knight, 2014; McMahan, Cathorall, & Romero, 2007; Nelson, Gortmaker, Subramanian, Cheung, & Wechsler, 2007).

The present study is part of a National Institutes of Health (NIH) pilot investigation which seeks to examine common sense illness beliefs of Latino college students who are at heightened risk for developing type 2 diabetes in the future because of family history of this disease. In light of the Latino diabetes youth health crisis, understanding diabetes illness beliefs among those who are at-risk but not yet diagnosed with this chronic condition is vital to current national health initiatives aimed at addressing this preventable disease threat in the young (HHS, Healthy People 2020, 2011).

Folk versus Common Sense Models of Illness Representation

Two general explanatory models for representing illness beliefs have dominated the social sciences literature (Baumann, 2003; Diefenbach & Leventhal, 1996; Haller, Sanci, Sawyer, & Patton, 2008; Palmquist, Wilkinson, Sandoval, & Koehly, 2012). One model articulates a socio-cultural representation of folk beliefs unique to an ethnic group and the second points to a set of common sense illness beliefs that reflects a more biomedical-oriented perspective of disease. Both explanatory systems of illness beliefs can overlap and are believed to influence how Latinos interpret diseases such as diabetes (Hatcher & Whittemore, 2007; Palmquist et al., 2012).

Traditional Latino folk illness beliefs of diabetes have been extensively researched and represent “important lay theories of disease causation” shared by many Latino ethnic groups (Palmquist et al., 2012, p. 598). This body of work has primarily utilized qualitative-ethnographic methodologies and has centered on diabetic Latino patients and/or middle-aged Latino community samples (e.g., Arcury, Skelly, Gesler, & Dougherty, 2004; review article see Hatcher & Whittemore, 2007; Weller, Baer, Garcia de Alba Garcia, & Salcedo Rocha, 2012); with a limited number of quantitative studies of Latino folk beliefs with younger age groups being reported in the literature (e.g., Palmquist et al., 2012; Santos, Hurtado-Ortiz & Sneed, 2009). One such study by Santos and colleagues (2009) of Latino college students identified four factor analytic-based beliefs of diabetes illness causation in this age group: emotionality – experiencing strong negative emotions (stress, anger, and anxiety); punitive – a punishment for sinning, behavioral excesses or indulgences; cultural/folk beliefs - God’s will, accidental forces, bad blood, or exposure to hot/cold drafts; and finally, genes or heredity – a family history of diabetes. In general, the validity of the folk illness beliefs derived in this factor analytic study with Latino college students is corroborated by qualitative and quantitative research utilizing Latino community samples (e.g., Baer, Weller, Garcia de Alba Garcia, & Salcedo Rocha, 2012; Hatcher & Whittemore, 2007; Palmquist et al., 2012; Weller et al., 2012).

The Common Sense Model (CSM) of illness, as postulated by Leventhal and colleagues (Leventhal, Meyer & Nerenz, 1980; Leventhal, Nerenz, & Steele, 1984; Leventhal et al., 1997), provides a more mainstream theoretical perspective of the process used by persons to make sense of a disease threat and how such schemas bear on decisions to engage in illness coping and health regulatory behaviors. Illness representations reflect persons’ implicit ‘common sense’ beliefs of an ailment derived from both lay and expert sources as well as personal and vicarious experiences with a disease (Henderson, Orbell, & Hagger, 2009). More specifically, an illness representation for a disease is viewed as a multidimensional construct said to comprise the subsequent main themes or components: identity or the label and symptoms attached to a disease; time-line or disease duration which can be chronic, acute, or cyclical; consequence or the impact of a disease on the individual; causes of a disease and/or its origins; level of personal control in managing a disease or an illness threat; and finally, possibility of disease cure or illness recovery based on medical intervention and health regulatory behaviors. The CSM has received ample support in the literature as a viable framework that illustrates the structure of illness representation in afflicted persons across various serious disease diagnoses including diabetes (Grzywacz et al., 2014; Hagger & Orbell, 2003;Jopson & Moss-Morris, 2003; Moss-Morris et al., 2002; Skinner et al., 2003). Furthermore, a few studies that have utilized healthy college-based samples also indicate that the CSM meaningfully captures students’ illness beliefs of major diseases such as rheumatoid arthritis, multiple sclerosis, human immunodeficiency virus, tuberculosis, and skin cancer (Schiaffino & Cea 1995; Figueiras & Alves, 2007) as well as minor ailments like the common cold, the flu, and allergies (Lau, Bernard, & Hartman, 1989; Lau & Hartman, 1983).

In our review of the literature, however, we found no studies that have examined common sense illness beliefs pertaining specifically to diabetes among college-age Latino students who are at high risk for the disease due to family history. Excluding an early study conducted by Turk, Rudy and Salovey (1986) which employed healthy college students as study participants (yet no information is provided regarding the ethnic composition of the sample), previous research on diabetes common sense illness beliefs with similar age groups has focused primarily on community samples of adolescents and young adults afflicted with type 1 or 2 diabetes who are undergoing medical treatment for their disease (see Hagger & Orbell, 2003; Haller et al., 2008; Skinner et al., 2003). Hence, our ability to generalize such research findings to young persons of Latino ethnicity who are at risk for future diabetes acquisition but not yet diagnosed with this medical condition is limited (Santos et al., 2009). This study will attempt to address this gap in the literature by increasing our understanding of Latino students’ common sense illness representation of diabetes as a disease. Knowledge of how this vulnerable population conceptualizes diabetes is essential given that the nature and content of common sense beliefs about a disease have been shown to influence health-related behaviors and coping strategies which are linked to long-term health outcomes in persons (e.g., Broadbent, Donkin, & Stroh, 2011; Hagger & Orbell, 2003; Hart & Grindel, 2010; Harvey & Lawson, 2009; Searle, Norman, Thompson & Vedhara, 2007; Skinner et al., 2011; Vedhara et al., 2014).

Purpose of Study

The present study sought to provide a systematic examination of common sense illness beliefs of young Latinos who are at high risk for future diabetes onset. More specifically, this study was intended to complement previous research on Latino college students’ cultural folk beliefs regarding the causes of diabetes (Santos et al., 2009) by exploring the more frequently used biomedical-psychosocial oriented CSM of illness representation found in the mainstream literature. It was expected that Latino college students’ schemas of diabetes include not only culturally specific folk beliefs of the disease but also a more Westernized viewpoint of diabetes as presented by the CSM. The extent to which the later theoretical perspective aligned itself with young Latinos interpretation of diabetes was explored.

Accordingly, the purpose of this study was to generate a health-related instrument that describes common sense illness beliefs among non-diabetic Latino college students with a family history of this disease. The Implicit Models of Illness Questionnaire (IMIQ: Schiaffino & Cea, 1995; Turk et al., 1986) was used as a baseline item pool to produce via factor analysis theoretically driven factor scales intended to capture components of the CSM in this sample. The IMIQ is a generic illness representation questionnaire which broadly defines common diseases such as diabetes and has been utilized previously with college students. Because prior factor analytic studies point to discrepancies in the number of illness beliefs extracted based on disease type and a person’s health status (afflicted versus not afflicted with the disease), four and five factor structure solutions were examined in an effort to provide a partial replication of the components proposed in the CSM and a comparison of our findings with prior research reported in the literature (Figueiras & Alves, 2007; Heijmans & Ridder, 1998; Schiaffino & Cea, 1995; Turk et al., 1986). In addition, since Latinos illness beliefs have been found by previous researchers to be moderated by socio-cultural variations that exist within this ethnic group (Palmquist et al., 2012; Perez-Escamilla & Putnik, 2007; Perez-Escamilla, 2011; Santos et al., 2009), this study also sought to explore differences in diabetes illness beliefs based on Latino students’ age, gender, generational status in the country and their psychological acculturation to the United States (i.e., assimilation-, integration-, separate- or marginal- orientation). Lastly, because illness schemas are colored by personal or vicarious exposure to an ailment, differences in students’ common sense illness beliefs based on the disease experience of the afflicted family relative were examined (Hatcher & Whittemore, 2007; Leventhal et al., 1997).

Methods

Participants

One-hundred and fifty-six Latino undergraduate college students (34% male, 66% female; mean age = 23.3 years, SD = 6.78) were recruited from a Hispanic-serving state university located in southern California. Our sample mirrored the Latino students at this university in both age and gender composition. Participants were deemed to be at-risk for developing type 2 diabetes because they had an immediate blood relative that was currently afflicted with the disease. A non-probability purposive sampling technique was used to target at-risk Latino college students from the university site for inclusion in this pilot study. Specifically, 42.3% reported having a parent with diabetes, 31.4% had a grandparent, 14.1% had a sibling, and 12.2% had an aunt/uncle. Body Mass Indices (BMI) and Diabetes Risk Test scores were calculated as objective indicators of participants’ health status. The average BMI weight status for the total sample was 26.7 which is considered overweight (healthy range = 18 – 25) with 25.3% of participants identified to be at a high risk for future diabetes and 44% at a low to moderate risk as indicated by American Diabetes Association Risk Test (www.diabetes.org).

The majority of participants (50.4%) identified themselves as being of Mexican descent, with the remainder identifying as follows: 22.3% Latino, 21.1% Hispanic, and 6.2% Central American. In addition, 21% stated that they were first generation Latinos in the United States and 65% indicated that they were second generation. The median family income reported by participants ranged from US$25,001 to $35,000, with 68% of sample participants working part or full-time and 57% living with parents.

Measures

Implicit Model of Illness Beliefs (IMIQ)

This questionnaire (Schiaffino & Cea, 1995) consists of 45 items that assess cognitions and common sense beliefs of illness. The IMIQ is a 5-point Likert scale, ranging from strongly disagree (1) to strongly agree (5). Sample items include the disease “is controllable,” “chronic or acute,” “caused by stress/nerves,” or “controllable by the individual.” The authors added three additional items – “With treatment gets better over time;” “Symptoms are variable (some good days/bad days)” – based on preliminary qualitative data collected with college students. Previous factor analytic studies indicate that the IMIQ taps into illness dimensions associated with disease “curability”, “personal responsibility”, “symptom variability”, and “serious consequences” (Schiaffino & Cea, 1995) as well as the knowledge of disease invariance or “changeability” over time (Turk et al., 1986).

Severity of Relative’s Illness

Three statements answered on a 5-point Likert scale, ranging from definitely false (1) to definitely true (5), assess participants’ perception of the impact diabetes had on the afflicted family member. Items are “My relative is disabled or partly disabled as a result of diabetes;” “My relative’s quality of life has been affected by diabetes” and “My relative disease is under control.”

Co-morbid Complications

This measure is a compilation of co-morbid health complications that the afflicted relative may have experienced as a result of having diabetes. Participants were asked to check all illnesses that applied to their family member: heart disease and stroke, high blood pressure, blindness, amputations, dental disease, complications of pregnancy, diabetic coma, and other.

Psychological Acculturation

The AHIMSA Scale (Unger, Gallaher, Shakib, Ritt-Olson, Palmer, & Johnson, 2002) consists of 8 items that tap into a person’s socio-cultural orientation: assimilation/US orientation, separation/Latino orientation, marginalization and integration/bicultural orientation. Sample items include “The way I do things and the way I think are from…” and “I am most comfortable with people from…”

Procedure

IRB approval was obtained from the university site prior to data collection and the researchers followed the American Psychological Association (2010) ethical guidelines in the treatment of human participants. Recruitment procedures of study participants included announcements made at ethnic clubs/organizations and classrooms and by posting flyers in noticeable areas throughout the university campus such as the student union, library, and health center. Potential participants were prescreened by phone to confirm that they had a family history of diabetes (a first and/or second degree family member afflicted with the disease) and only those who satisfied this criterion were included in the study. Eligible participants were then scheduled for a 45-minute appointment to complete a paper and pencil health-belief survey which included the self-report questionnaires described in the Measures section. They signed an informed consent, were paid US$15 for their participation, and were fully debriefed at the end of the study. Lastly, participants viewed a brief NIH diabetes video and were provided with educational brochures regarding the causes and prevention of diabetes.

Results

Factor Analysis

An exploratory factor analysis was conducted on the IMIQ using a principle axis factoring method of extraction with a varimax (orthogonal) rotation in an attempt to discern whether a four or five factor solution best captured Latinos’ diabetes illness beliefs. These analyses pointed to a four-factor solution which yielded theoretically interpretable and significant factors as indicated by Kaiser’s eigenvalues > 2 indices and verified by the Scree-Plot test. Furthermore, the Kaiser-Mayer-Olkin (KMO) = .65 (acceptable is ≥.60) provided a “measure of sampling adequacy” and that the “distribution of values is adequate for conducting factor analysis” (Darren & Mallery, 203, p. 256). The four factor solution accounted for 35% of the explained variance in diabetes illness beliefs in Latino students which reflected a psycho-biomedical view of the disease. The criteria used for constructing factor-based scales and for item retention was that each individual item must have a loading ≥ .30 on a given factor and no significant cross loadings on other factors. One omission for cross-loadings was made for the item “has serious consequences for the individual” which theoretically corresponded best with factor 3 and demonstrated adequate discriminant validity (i.e., achieved a factor loading difference ≥.15 between factor 3 and the next highest factor as recommended by Turk et al., 1986). Furthermore, the second criterion used for finalizing the factor scales was to remove an item from a scale if the overall alpha coefficient was improved (Turk et al., 1986). This resulted in three additional items being dropped corresponding to one item from factor 1, 2, and 4 respectively. We note, that albeit alpha reliability increased only slightly from .706 to .712 for factor 4 with removal of the item “has symptom in nervous system”, the decision was based on the item being conceptually unrelated to this factor and empirically demonstrating a low item-total scale correlation of < .30 in the reliability analysis. The final alpha reliability coefficients for the four factors were within acceptable levels and ranged between .67 and .81. The results of the finalized factor-based scale construction are summarized in Table 1.

Table 1.

A Biomedical-Psychosocial Factor Analysis Interpretation of Diabetes Illness Beliefs.

Implicit Illness Beliefs	Curability	Personal Responsibility	Symptom Variability/ Seriousness	Psychological Attributions
Is cured by physical activity	.750
Is cured by eating habits	.746
Is curable	.734
Is cured by rest	.660
Is cured by reduced stress	.644
Is cured by medication	.636
With treatment gets Better over time	.319
Relates to something you did	.302
Often comes back	.301
Is caused by poor diet		.587
Can be avoided		.543
Is related to poor diet		.539
Without treatment gets Worst over time		.487
Is controllable		.444
Is controlled by the Individual		.374
Is disabling			.719
Has symptoms on surface of skin			.637
Requires hospitalization			.582
Is painful			.537
Have serious consequences for the individual			.483
Is terminal			.397
A symptom is fever			.381
Symptoms are variable (Some good days/bad days)			.359
Affects many parts of the body			.339
Has symptoms in stomach/intestines			.323
Is serious			.303
Is caused by stress/nerves				.672
Is affected by stress/nerves				.533
Is influenced by germs/viruses				.434
Is related to ones behavior				.418
Is caused by one’s behavior				.371
Is affected by lack of rest				.336
Factor Eigen Value	6.581	4.091	3.651	2.338
Percent Variance	13.710	8.523	7.605	4.872
Alpha Reliability	.807	.674	.745	.712

The four scales corresponded respectively to curability, personal responsibility, symptom variability/seriousness, and psychological attributions. Factor one – curability – consisted of nine items or illness beliefs associated with restoring health. The second factor contains six items pertaining to health control therefore labeled personal responsibility. The third factor – symptom variability/seriousness – contains eleven items that related to factual knowledge of the disease and its consequence for the person. Finally, factor 4 – psychological attributions – is comprised of six items pointing to causes or reasons for diabetes acquisition. Inter-correlation analyses between the four scales pointed to significant associations between the curability factor with personal responsibility (r = .151, p < .07) and psychological attributions (r = .295, p < .001). Likewise, psychological attributions correlated positively with personal responsibility (r = .180, p <.03) and symptom variability/seriousness (r = .297, p < .001). The above inter-correlation coefficients were less than .80 suggesting these are related but distinct theoretical factors reflecting common sense illness beliefs about diabetes. With the exception of the psychological attribution factor, the conceptual factors that emerged best replicated those outlined by Schiaffino & Cea (1995) and point to the validity of the CSM when applied to diabetes illness beliefs among at-risk Latino college students.

Within Group Variations in Common Sense Illness Beliefs

Correlational analyses of the four illness belief factors with the health status of the diabetic relative (illness severity and co-morbid complications) revealed a positive association between the symptom variability/seriousness factor and relative’s illness severity (r = .161, p. < .05). Furthermore, correlation analyses of students’ acculturation orientation with the illness belief factors revealed a positive trend between making psychological attributions for illness causation and adopting a separate/Latino acculturation orientation (r = .140; p < .09). Comparison of mean tests were conducted to examine differences in illness beliefs based on participants’ age, gender, and generational status in the United States. The analyses of variance tests revealed significant differences by age groups on the psychological attribution illness factor [F(2, 149) = 3.28, p < .05], with younger-aged participants scoring higher (18–24 years M = 17.98) on this illness dimension than older-aged participants (25–35 years M = 16.26; 36 years plus M = 15.27). Furthermore, a significant difference by generational status on the curability factor was also found [F (2, 145) = 3.15, p < .05], with 1^st generation Latinos (M = 22.61) scoring lower on this illness belief factor when compared to 2^nd (M = 25.19) and 3^rd generation plus participants (M = 26.65). Finally, t-Test analyses revealed no significant difference by gender, indicating that Latino men and women hold similar common sense illness beliefs regarding diabetes.

Discussion

The dimensions that emerged from this factor analytic study represent a cohesive picture of the structure of diabetes as conceptualized by young at-risk Latino college students. More specifically, the resultant factors afforded a partial replication of the general themes presented in the earlier study by Schiaffino and Cea (1995). The four illness dimensions derived evidenced both theoretical and empirical validity, and can provide researchers with a brief commonsense illness scale that encompasses a psychosocial person-centered (personal responsibility and psychological attributions) and biomedical (curability and symptom variability/seriousness) conceptualization of diabetes that is consistent with the general constructs delineated by CSM of disease (Leventhal et al., 1997) that is applicable to young Latinos.

Accordingly, the curability factor emerged as the strongest illness disease dimension of diabetes. This factor reflects the belief that diabetes is not necessarily a permanent disease and can potentially be cured by physical activity, a healthy diet, proper medical illness management, resting, and reducing psychological stress. In line with the CSM the content of this factor identifies specific health regulatory behaviors required of a person in order to restore health or achieve a cure (Leventhal et al., 1980; 1984). Interestingly, we found differences in the endorsement of this illness belief based on the generational status of Latinos in the country, with later generations (2^nd and 3^rd generation plus) more likely than immigrant Latinos to believe that diabetes is a disease that can be cured by adopting healthy life-style patterns and through the use of medication. Given that illness beliefs regarding whether a disease can be cured or managed relate to a persons’ decision to take preventative health measures (Harvey & Lawson, 2009; Vedhara et al., 2014), this finding implies that immigrant Latinos may be more resistant to making changes in life-style habits that could reduce their vulnerability for diabetes.

Also reflected in this factor was a cyclical dimension to diabetes as an illness – a diabetic person can revert back to a healthy or pre-diabetes status and is cured for now – but the disease often “comes back” at a later point. Although this may seem like a misconception, previous studies with Latino community samples also note discrepancies in diabetes illness beliefs between laypersons (even among those diagnosed with diabetes) and medical health practitioners (Weller et al., 2012). Here too, we see how a layperson’s interpretation of what may constitute a cure (e.g., the individual no longer needs insulin and sugar levels are normal) does not necessarily correspond with the technical biomedical definition of disease cure but reflects more accurately effective illness management on the part of afflicted person. For instance, it may appear that the diabetes ‘went away’ or is no longer there; however, once the person stops eating-well, exercising, and regains the weight lost, the diabetes (e.g., variable sugar levels) once again becomes evident, hence its perceived cyclical dimension.

The personal responsibility factor is associated with the belief that diabetes is a disease that can be “avoided” and “controlled by the individual” by assuming responsibility in managing the disease (“can be controlled” and “gets worse without treatment”) and avoiding unhealthy behaviors (“a poor diet”). Consistent with previous research findings (Broadbent, Petrie, Main, & Weinman, 2006; Moss-Morris et al., 2002), this factor points to personal control as an important dimension of illness representation and identifies the person as being primarily in charge of his/her health outcomes and/or its deterioration. Most relevant is that this factor suggests Latino students embrace an internal locus of health control or personal responsibility when interpreting diabetes; beliefs found in past research to be associated with greater readiness to implement adaptive illness preventive strategies (Harvey & Lawson, 2009; Vedhara et al., 2014). This factor was endorsed more strongly by the older-aged student.

The symptom variability/seriousness scale relates to beliefs associated with disease identity and consequences for the individual. Diabetes was perceived as a very “serious,” potentially “disabling” and “terminal” disease which “affects many parts of the body” requiring (at times) “hospitalization” with the afflicted person experiencing day-to-day fluctuations in overall health (“some good days/bad days”). Hence, diabetes is accurately seen as a dangerous disease with potentially severe and life-threatening consequences for the individual that can negatively impact overall quality of life. We note that in other research studies, disease identity and consequence emerge as separate factors (e.g., Broadbent et al., 2006; Moss-Morris et al., 2002) but for young Latinos, consequence was a dimension of the disease identity definition as reflected in the seriousness of symptoms experienced and its associated negative health outcomes for the person (i.e., terminal, requires hospitalization). The content of this factor reflects a dimension of diabetes that is supported by the CSM and congruent with the biomedical perspective of this disease (Harvey & Lawson, 2009; Leventhal et al., 1984; Leventhal et al., 1997).

As expected, we found that Latino college students’ perception of diabetes - symptom variability/seriousness - varied as a function of their prior familial experiences with this disease. Indeed, Latinos with a relative for whom diabetes had severely compromised quality of life and overall health functioning scored higher on this dimension and viewed the disease to be quite serious, dangerous and life-threatening. In line with the CSM of illness beliefs, vicarious experiences with a specific disease emerged as a significant factor that shaped participants’ definition of disease threat as it pertains to diabetes (Leventhal et al., 1997).

The psychological attributions factor addresses possible causes or influences associated with diabetes acquisition. More specifically, the content of this factor includes internal (the person) and external (the environmental) forces interacting as causal agents or triggers for diabetes that impact the disease process. A person’s behavioral health history (“caused by/related to one’s behavior;” “influenced by lack of rest”) and exposure to life stress (“caused by/affected by stress/nerves”) as well as “viruses/germs” were seen as precipitating factors for diabetes acquisition and disease vulnerability. All of these ‘reasons’ interact to heighten an individual’s susceptibility for the disease. As in other studies, we note the difficulty of clearly identifying the locus dimension of some items for this factor given stress(ors) and germs/viruses originate outside of the person (external) but “stress/nerves” and “germs/viruses” are also experienced internally within the person (Lau & Hartman, 1983; Lau et al., 1989). Nonetheless, this factor is consistent with the CSM which states that the identification of possible causes or origins of a disease is one of the main components characterizing an illness representation (Leventhal et al., 1997).

As noted, this factor speaks to attributions regarding the reasons why a person develops diabetes. This illness belief identifies the person to be at fault or to be blamed for acquiring the disease which is a result of his/her behavior. Furthermore, there is decidedly emotional aspect to this factor which underscores the importance Latinos place on negative “stress(ful)” experiences and “stress/nerves” as a causal explanation for illnesses (Hatcher & Whittemore, 2007; Santos et al., 2009; Weller et al., 2012), making the person more susceptible to environmental influences such as viruses/germs as a trigger for disease. In accordance with the Latino cultural script for disease acquisition which emphasizes the emotional dimension of illness causation and person attributions for illness-blame, we found that students with a separation/Latino orientation scored higher on this illness belief factor (Baer et al., 2012; Santos et al., 2009). This suggest that students who embraced a traditional Latino cultural orientation were more likely to assume that diabetes is caused or influenced by a person’s behavioral history and experiences of stress/nerves. Likewise, this illness belief was endorsed more strongly by younger-aged Latinos than their older counterparts meaning that younger persons were more inclined to endorse both internal and external forces as reasons for diabetes acquisition.

Albeit few variations in common sense illness beliefs were found as a function of socio-cultural variables, the above discussion does point to several important within-group differences among Latino students. More specifically, the level of endorsement of the identified common sense illness factors differed by age of the Latino student, their acculturation orientation and generational status in the country, and the disease experience within the family. Hence, a consideration of such within group differences in illness beliefs is pertinent given it serves to elucidate discrepancies frequently observed in the literature in regards to health-related behaviors and attitudes in this ethnic group (Hurtado-Ortiz et al., 2011; Santos et al., 2009).

Additionally, the findings of the correlation analyses revealed theoretical associations among the derived illness belief factors which illustrate the process delineated by the CSM for illness construction. First of all, psychological attributions regarding the causes of diabetes related positively with the curability factor. This signaled a correspondence between what Latino students identified as potential causes of diabetes acquisition and the health regulatory behaviors required to restore or manage health (Lau et al., 1989; Lau & Hartman, 1983; Leventhal et al., 1997). For example, stress is seen as a cause or trigger for diabetes (in the psychological attribution factor) and reducing stress is noted as an illness coping strategy in the curability factor. Likewise, diabetes can be caused or influenced by a person’s behavior (psychological attribution), and changes in dietary habits and physical activity were identified as health-related behaviors which can lead to a diabetes cure (in the curability factor). Secondly, personal responsibility also correlated positively with the curability factor. This suggests that the perception of health control for diabetes is believed to reside within the person. Thereby, the individual is primarily responsible for his/her recovery and the curability factor points to the specific illness management measures required of the person for regaining health. This argument is further supported by the positive association observed between psychological attributions of diabetes causation (i.e., the person) and assuming personal responsibility for preventing or controlling the disease. These results are relevant considering that the study participants are at a heighten risk for future diabetes onset and suggest that this group may be especially receptive to college-based intervention initiatives. Persons must believe that they can avoid, prevent, or potentially cure an illness if they are to engage in health regulatory life-style changes aimed at minimizing a perceived health threat (Broadbent et al., 2011; Hart & Grindel, 2010; Harvey & Lawson, 2009; Vedhara et al., 2014). In accordance with the goals stipulated by Healthy People 2020, the university setting affords an ideal context for implementing interventions geared at reducing diabetes-risk among young Latinos by promoting the establishment of healthy life-long dietary and exercise patterns (HHS, Healthy People 2020, 2011) in this vulnerable population. As the last “formal structure for education” Hispanic serving universities are in a unique position to respond to this national call to action that aims to address current ethnic health disparities that exist between Latinos and non-Latino whites (Frost, 1992, p. 317).

Limitations & Conclusions

A potential weakness of this study is that a non-probability purposive sampling strategy was used to target diabetes at-risk Latino students for inclusion in the pilot sample. Although study participants mirrored in age and gender the characteristics of other Latino students at the university site, the pilot sample was not formed using probability-based sampling techniques and therefore may not be representative of Latinos students attending universities in other parts of the country. For instance, our participants evidenced a higher incidence of obesity (57.7% were overweight/obese) when compared to a sample of Latinos (41% overweight/obese) in a US study of obesity among college students (Nelson et al., 2007). Furthermore, albeit the sample size of 156 participants met the 100 to 150 cases minimum required for conducting a factor analysis (Gorsuch, 1983; MacCallum, Widaman, Zhang & Hong, 1999), a larger sample would add further empirical validity. Thus, future research should focus on corroborating the construct validity of the reported findings via execution of confirmatory factor analysis studies that utilize, for increased representativeness, a larger sample of Latino participants recruited from multiple universities.

To conclude, the findings from this investigation add to previous research of Latino college students’ folk beliefs regarding diabetes (Santos et al., 2009). More specifically, they highlight the importance of also including a more Western biomedical-psychosocial common sense view of diabetes alongside a Latino cultural folk interpretation if we are to accurately capture illness cognitions among college-age Latinos. The common sense illness factors identified in this study describe a more person-centered and biomedical representation of diabetes that encompasses an individual’s “emotional as well as objective, rational response to illness” that when combined with a Latino folk perspective will allow researchers to make more informed predictions regarding the links between diabetes illness beliefs, health-related behaviors, and health outcomes in young Latino ethnicities (Harvey & Lawson, 2009, p. 5).