Rural-Urban Differences in Self-Reported Participation in Diabetes Self-Management Education

Context: Rural America faces a dual challenge with a higher prevalence of diabetes mellitus (hereafter, diabetes) and diabetes-related mortality. Diabetes self-management education (DSME) can improve glucose control and reduce adverse effects of diabetes, but certified DSME programs remain disproportionately limited in rural counties than in urban counties.

Objective: The goal of this study is to examine the proportion of urban and rural adults who report having received DSME using a nationwide, 29-state survey while considering the potential consequences of lower service availability.

Design: This cross-sectional study used data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS). Residence was defined as urban (metropolitan county) vs rural (non-metropolitan county). Logistic regression, incorporated survey weights, was used to determine the odds of having received DSME by residence.

Setting: BRFSS is a nationally representative survey, and this study included participants from 29 states that were distributed throughout all regions of the United States.

Participants: The study sample consisted of 28,179 adults who reported having diabetes, lived in one of the states that administered the diabetes module in 2019, and answered all relevant questions.

Main outcome measures: The main outcome measure was whether a participant had ever received DSME. Participants were considered to have received DSME if they self-reported having ever taken a class on how to manage diabetes themselves.

Results: Overall, 54.5% of participants reported having received DSME; proportionately fewer rural residents (50.4%, ±1.1%) than urban residents (55.5%, ±1.0%) reported DSME. Rural disparities persisted after adjusting for demographic, enabling, and need factors (Adjusted Odds Ratio = 0.79; CI, 0.71-0.89). By sociodemographic factors, Hispanic persons vs non-Hispanic White persons and single vs married/coupled individuals were less likely to report DSME receipt (both 0.76 [0.62-0.94]).

Conclusions: Ongoing national efforts addressing rural disparities in diabetes-related complications should target individuals most at risk for missing current diabetes educational programming and design appropriate interventions.