Chronic diseases are the leading causes of disability worldwide although health complications can be prevented with lifestyle change (CDC, 2013). Type 2 diabetes is a growing global epidemic, and its prevalence is predicted to increase from 6.4% (285 million adults) in 2010 to 7.7% (439 million adults) by 2030 (Shaw, Sicree, & Zimmet, 2010). Given the reality of cultural diversity in contemporary society, the aim of this study was to address the need for research that integrates both cultural and psychological factors with behaviors central to diabetes control among culturally diverse populations (Betancourt & López, 1993; Betancourt, Flynn, Riggs, & Garberoglio, 2010). Based on Bandura’s theory of self-efficacy (1977a; 2004), it was expected that self-efficacy would play a significant role in treatment adherence. Second, based on Betancourt’s integrative model of culture, psychology, and behavior, cultural factors identified as relevant to diabetes control were expected to influence treatment adherence directly and/or indirectly through self-efficacy. In support of hypotheses, results based on the analysis of structural equations indicated that cultural beliefs concerning susceptibility to social influence impacted diabetes self-care behaviors and HbA1c, a biological measure of adherence to treatment, through diet self-efficacy. Specifically, diet self-efficacy was a function of the identified cultural factors and influenced adherence to treatment, which in turn impacted HbA1c. Findings underscore the importance of examining the indirect effect of culture on behavior, rather than solely testing one-to-one relationships. Had only the direct effect been examined, findings would incorrectly conclude that culture had no effect on diabetes treatment adherence. As expected, results reflected an indirect effect of cultural beliefs about explicit social influence and susceptibility to social influence on diabetes treatment adherence. Specifically, explicit social influence had an indirect effect on both poor diabetes self-care and HbA1c. Future research should focus on specifying the role of sociodemographic factors that contribute to cultural beliefs about social influence and further clarify underlying mechanisms to explain the variability in diabetes treatment adherence.

LLU Discipline

Clinical Psychology




School of Behavioral Health

First Advisor

Betancourt, Hector M.

Second Advisor

Flynn, Patricia M.

Third Advisor

Gleason, Peter C.

Fourth Advisor

Herbozo, Sylvia M.

Degree Name

Doctor of Philosophy (PhD)

Degree Level


Year Degree Awarded


Date (Title Page)




Library of Congress/MESH Subject Headings

Diabetes Mellitus; Type 2; Health Behavior; Treatment adherence;

Subject - Local

type 2 Diabetes; Self-efficacy; Cultural influences on treatment



Page Count


Digital Format


Digital Publisher

Loma Linda University Libraries

Usage Rights

This title appears here courtesy of the author, who has granted Loma Linda University a limited, non-exclusive right to make this publication available to the public. The author retains all other copyrights.


Loma Linda University Electronic Theses and Dissertations

Collection Website



Loma Linda University. Del E. Webb Memorial Library. University Archives