The Science of Diabetes Self-Management and Care2023, Vol. 49(3) 206–216© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106231169693journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of this study was to examine racial and ethnic differences in diabetes self-management education (DSME) participation among adults with diabetes.
Methods: Population-based, cross-sectional data from the 2020 Behavioral Risk Factor Surveillance System diabetes module were analyzed. Study cohort included 9881 adults age 18 years or older with self-reported diabetes living in 11 US states, Washington, DC, and Puerto Rico. The outcome variable was participation in DSME. Weighted descriptive statistics and multivariable logistic regression were computed to investigate the association between race and ethnicity and participation in DSME, adjusting for self-reported social determinants of health factors (eg, sex, education, employment, health insurance).
Results: Overall, 19.3% self-identified as non-Hispanic Black, 16.5% as Hispanic, and 59.9% as non-Hispanic White. Of participants, 44.3% were between 66 and 80 years old, and 50.4% were women. Half (50.1%) reported participating in DSME, and 78.5% had seen clinicians for diabetes-related care 1 to 5 times in the past year. Hispanic participants were less likely to report participation in DSME (28.5%) compared to non-Hispanic Black (60.3%) and non-Hispanic White (53.4%) participants (P < .001). Adults with diabetes who were less likely to participate in DSME tend to be unmarried, have high school or lower-level education, and not exercise regularly.
Conclusions: Racial and ethnic differences exist in DSME participation. Because DSME has been shown to improve diabetes outcomes, there is a need to develop strategies promoting equity in DSME participation, particularly among Hispanic populations, to reduce health disparities in diabetes care.
Diabetes is a serious chronic health condition affecting 11% of the US population.1 In 2019, over 1.4 million adults were diagnosed with diabetes in the US. It is estimated that 1 out of every 3 Americans will develop diabetes in their lifetime.2 Individuals with diabetes are at increased risk for developing several health complications, including cerebrovascular diseases, foot ulcers, and retinopathy, especially if the condition is not well managed.3 It is important for persons with diabetes to engage in self-management behaviors, including glucose monitoring, exercise, healthy eating, and medication taking, to support optimal health and prevent complications.
Research has shown that individuals with diabetes who engage in diabetes self-management education (DSME) have better health outcomes, including improvements in glycaemic stability, quality of life, self-efficacy, lipid profiles, and reductions in diabetes complications and depressive symptoms.4,5 The DSME is an evidence-based and patient-centered structured program that provides education, knowledge, and skills with the goal of empowering individuals with diabetes to effectively manage their condition.5 DSME essentially supports persons with diabetes to navigate the self-management tasks and decisions required to meet their health goals. Previous studies have shown that individuals with diabetes who did not receive DSME are 4 times more likely to have major diabetesrelated complications compared to those who did.6 In addition, DSME is a cost-effective program that has been found to reduce overall health care cost.7 This is notable given that health care utilization associated with the management of diabetes and its related complications is costly, accounting for 25% of US health care cost.7
From Yale School of Nursing, Yale University, Orange, Connecticut (Mr Akyirem, Ms Choa, Dr Poghosyan).
Corresponding Author:
Samuel Akyirem, Yale School of Nursing, Yale University, 400 West Campus Drive, Orange, CT 06520, USA.
Email: Samuel.akyirem@yale.edu
Despite the numerous benefits of participating in DSME, uptake of DSME has been low in the US.5,8 The participation rate has been reported as low as 26% in some counties.9 Like most health behaviors, participation in DSME is influenced by sociodemographic factors and structural dynamics as dictated by the social determinants of health framework (SDH).10 The SDH framework highlights conditions such as access to education, health care, and economic stability as important factors in determining health behaviors and outcomes.11 A number of studies in the US and Asia have shown that social determinants such as education, place of residence, and employment are all factors influencing participation in DSME programs.12-15 For instance, in North Carolina, people living in urban areas were more likely to participate in DSME than rural dwellers.14
Race and ethnicity are a central part of the SDH framework. In the US, racially and ethnically minoritized groups, including Hispanics/Latinos and Black Americans, disproportionately experience reduced access to quality education and health care compared to their White counterparts.16,17 Diabetes prevalence is also higher among American Indians/Alaskan Natives (14.5%), non-Hispanic Blacks (12.1%), and Hispanics (11.8%) compared to non-Hispanic Whites (7.4%).2 Prior studies have shown evidence of racial and ethnic differences in DSME participation.8,17 That is, being Hispanic or Black is associated with less likelihood of DSME participation compared to being White.9,18,19 These studies, however, either relied on state-level data or did not make race and ethnicity a central component of their analyses. In contrast, this study focused on the racial and ethnic differences in DSME participation using a population-based, nationally representative large and diverse sample of adults with diabetes to determine whether DSME participation uptake is different among non-Hispanic Whites individuals compared with racially and ethnically minoritized individuals.
The purpose of this study was to examine racial and ethnic differences DSME participation among adults with diabetes living in 11 US states, Washington, DC, and Puerto Rico, using data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) diabetes module. The current study was guided by the SDH framework because of the utility of the framework in elucidating health disparities and inequities.11 Identifying racial and ethnic differences in DSME participation will enable policymakers, researchers, and practitioners to tailor health care planning and services to population groups that are at higher risk of experiencing disparities in diabetes outcomes.9
This study was a secondary data analysis of the 2020 BRFSS diabetes module.20 The BRFSS is a nationally representative, cross-sectional telephone survey conducted annually by the Centers for Disease Control and Prevention (CDC) with standardized questionnaires across all 50 US states, Washington, DC, and 3 territories.21 The BRFSS includes a core questionnaire administered across all states and territories, optional subject-specific modules that states can choose to administer based on their needs, and additional questions from specific states. The BRFSS collects data on health-related risk behaviors, long-term health conditions, and use of preventive practices.20 Details about the BRFSS design and sampling can be found at the CDC website.22 Because these data were publicly available, institutional review board approval was not needed in accordance with the exempt criteria under 45 Code of Federal Regulations part 46.102.
The study sample included adults 18 years or older from 11 US states (Delaware, Florida, Georgia, Indiana, Maine, Mississippi, Missouri, North Dakota, South Dakota, Virginia, and Wisconsin), District of Columbia, and 1 territory (Puerto Rico). Data from these 13 geographical areas were used because they are the only regions of the US that administered the BRFSS diabetes optional module in 2020. Participants were identified as having self-reported diabetes (either type 1 or 2) if they responded “yes” to the following question: “Has a doctor, nurse, or other health professional ever told you that you had diabetes?” Overall, 14 552 adults with self-reported diabetes were identified. Participants who were told they had diabetes only during pregnancy (N = 775) and those with missing data on the DSME variable (n = 507) and all other variables (N = 3359), were further excluded, leaving a final analytic sample of 9881 adults with self-reported diabetes, as shown in Figure 1.
The outcome variable of interest was participation in DSME. Participants with self-reported diabetes were asked the following question with response options “yes” or “no”: “Have you ever taken a course or class on how to manage your diabetes yourself?” Those who responded yes to this question were coded as 1, and those who responded no were coded as 0.
The main independent variable was self-reported race and ethnicity. Race and ethnicity were recoded as Hispanic, non-Hispanic Black, non-Hispanic White, and others (which included American Indian, Alaskan Native, Asian, and other race).
Covariates. Based on SDH framework and current evidence,12-15 self-reported covariates were included in the analyses. Sociodemographic variables included in the data analyses were age (18-33, 34-49, 50-65, 66-80), sex (male, female), marital status (not married, widowed, divorced/separated, married), employment (employed, unemployed, not in workforce), health insurance coverage (yes, no), level of education (up to high school, attended some college, graduated college), and household income ($0-$25 000; $25 000-$49 999; $50 000+). Clinical characteristics included number of diabetes-related clinic visits in the past 12 months (none, 1-5 times, 6-10 times, 11 or more) and general health status (poor/fair and good/better). Physical activity in the past 30 days was also included (yes, no).
Data analysis was conducted with STATA version 17. The recommended sample weights were applied to account for the complex survey design to generate representative results to population estimate of 4 466 267 adults with self-reported diabetes. First, weighted descriptive statistics were computed to summarize characteristics of participants. Then, the sample characteristics were stratified by 4 levels of race and ethnicity (ie, Hispanic, non-Hispanic Black, non-Hispanic White, others). Multivariable logistic regression analysis was conducted to evaluate the association between race and ethnicity and DSME participation while adjusting for all other sociodemographic and clinical covariates. A 2-sided P value of less than 5% was considered statistically significant.
Table 1 shows characteristics of study participants. Overall, 16.5% self-identified as Hispanic, 19.3% non- Hispanic Black, and 59.9% non-Hispanic White. Most (44%) were aged between 66 and 80 years, and half (50.4%) were women. Majority of participants were married (52.5%), not in the workforce (57.8%), and had an income of <$25 000 (41.1%), and about half had up to high school education (49.8%). Among the study sample, 78.5% had seen clinicians for diabetes-related care 1 to 5 times in the past year. The prevalence of DSME participation was 50.1%.
As shown in Table 2, Hispanic participants were less likely to report participation in DSME (28.5%) compared to non-Hispanic Black (60.3%) and non-Hispanic White (53.4%) participants (P < .001). More Hispanic participants (65%) had up to high school education level compared to non-Hispanic White (45.2%), non-Hispanic Black (53.9%), non-Hispanic White (45.2%), and other (37.6%) participants. Similarly, a larger proportion of Hispanic participants were in the lowest annual income group of <$25 000 (77.0%) compared to non-Hispanic Black (42.6%), non-Hispanic White (31.1%), and other (35.2%) participants. Hispanic participants were also less likely to be married, employed, and engaged in physical activity and more likely to report poor or fair health.
Table 3 presents results from the multivariable logistic regression model. It was found that participants who selfreported as non-Hispanic Black were 67% (AOR 1.67, 95% CI, 1.31-2.11, P < .001) more likely to participate in DSME compared to those who self-reported as non-Hispanic White. In contrast, Hispanic participants had 38% (AOR 0.62, 95% CI, 0.41-0.94, P = .025) lower odds of DSME participation compared to their non-Hispanic White counterparts. The odds of participating in DSME were also higher for those who were married (AOR 1.50, 95% CI, 1.14-1.97, P = .004), attended some college (AOR 1.46, 95% CI, 1.22-1.76, P < .001), and graduated college (AOR 1.97, 95% CI, 1.61-2.41, P < .001). Adults who did not exercise regularly in the last 30 days were less likely to participate in DSME (AOR 0.64, 95% CI, 0.54-0.75, P < .001). In addition, the odds of DSME participation were higher among participants with higher frequency of diabetes-related clinic visits compared to those who did not have clinic visit for diabetes care in the past 12 months.
Using a population-based, nationally representative sample of adults with self-reported diabetes, this study investigated racial and ethnic differences in DSME participation. Results showed that only about half of the people with diabetes (50.1%) reported ever participating in DSME. It was found that many individuals—an estimated 2 229 126 adults—with self-reported diabetes did not participate in DSME. Possible reasons for such low participation might be a lack of understanding regarding the necessity of DSME, limited access to culturally or linguistically congruent DSME, and inadequate reimbursement for DSME services.5 According to Healthy People 2030,23 the target rate of DSME participation is 55.1% by 2030. Unfortunately, the population in the current study fell short of this target. While 87.3% of current study participants reported having at least 1 clinic visit in the past 12 months, this has not yet converted to meet the 55.1% target for DSME participation. Such low participation rates put many individuals at high risk for poor health outcomes. Providing structured diabetes education can help persons with diabetes gain the knowledge and skills needed to effectively self-manage their condition.12 Evidence is clear that participation in DSME improves patient-reported health outcomes. For example, individuals who participate in DSME are more likely to engage in daily glucose testing, foot examination, and physical activity.24 In a systematic review of 120 studies reporting 118 unique self-management education interventions, 61.9% of the interventions recorded significant improvements in A1C.25 In addition, DSME has been shown to significantly improve serum cholesterol and body mass index in persons with diabetes.26 These studies underscore the importance of ensuring equitable access to DSME across all racial groups. New strategies are thus needed to raise awareness of the benefits and improve availability of DSME that meet the diverse needs of individuals with diabetes.
The study yielded some interesting findings. We observed low DSME prevalence (28.5%) among Hispanic adults with diabetes. This finding is consistent with previous studies.9,18,19 It is striking to note the extent that racial and ethnic disparities in DSME participation have persisted over the last decade. Cultural and linguistic barriers have been identified as potential reasons for the low participation rate. For instance, in a study among low-income Hispanic adults with diabetes, participants reported that in their culture, diabetes was associated with shame and weakness.15 Participants also reported that shame precluded them from participating in group DSME.15 Given that the prevalence of diabetes among Hispanic populations is higher than the national prevalence rate, it is important to identify strategies to increase participation in DSME among this disproportionately affected community.
In recent years, several efforts have been made to develop and test culturally appropriate DSME tailored specifically for Hispanic populations.27-30 Findings from these studies suggest that providing interventions and materials that are linguistically appropriate (ie, Spanish) can improve DSME participation. Additionally, addressing structural barriers to access, such as transportation challenges and financial needs, can also support participation in this target group.28,30 Although these findings provide convincing evidence in favor of developing culturally appropriate DSME for Hispanic populations, efforts thus far have been limited to communities in specific regions or counties. There is, therefore, an urgent need to scale up these interventions for a wider reach of Hispanic communities across the US.
The findings from this study also showed that participation in DSME was positively associated with having a higher income, being married, being employed, having higher formal education, and being physically active. These findings are consistent with previous studies examining the impact of income and education on DSME.31-33 It is worth noting that Hispanic participants in the present study sample had lower education status and income compared with other racial groups. These underlying socioeconomic disparities might also account for the lower DSME participation rate observed among Hispanic participants by producing circumstances that either limit access or reduce opportunity to participate in DSME that is tailored to meet their needs.
This study has some limitations. First, the cross-sectional design does not allow us to infer causal relationships. Second, the level of detail for race and ethnicity was limited to what was provided in the BRFSS data set. Also, it was not possible to make separate comparisons between certain racial and ethnic groups, such as Asians, Native Americans, and Alaskan Natives, due to the small number of participants in these categories. Third, the DSME participation in the BRFSS data set was measured with only 1 item, which may be another limitation. For instance, there were no data on the frequency of participation and how long it had been since participants’ last DSME class. The American Diabetes Association recommends DSME at 4 critical timepoints: at time of diagnosis, annually, onset of complications, and during care transitions.5 Future studies are needed to assess DSME by race and ethnicity using a multiitem measure. Moreover, the use of self-report measures for diabetes diagnosis and DSME participation, among others, could have introduced bias in the BRFSS data. Lastly, the type of diabetes was not specified in the BRFSS data set. Individuals with type 1 and type 2 diabetes have different health care needs and may differ in their engagement with DSME programs. Future studies should distinguish differences in DSME participation among persons with type 1 and type 2 diabetes.
The findings from this cross-sectional study revealed the presence of racial and ethnic differences in DSME participation among adults with self-reported diabetes. Because DSME has been shown to improve diabetes outcomes, there is a need to develop strategies promoting equity in DSME participation, particularly among Hispanic populations, to reduce health disparities in diabetes care. Such strategies may include delivering DSME in appropriate languages (eg, Spanish for Hispanic population) and addressing social determinants of health-related barriers such as transportation and financial challenges.
The authors declare that there is no conflict of interest.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Samuel Akyirem https://orcid.org/0000-0002-1654-2774
