1. S.A. Denham, K.E. Remsberg, & L. Wood Ohio University, Athens, Ohio Diabetes: A Family Matter Conference March 18, 2009

2.  Graduate assistants who contributed to this project by distributing surveys and compiling data were:  Cara Butcher  Tammy Collier  Eimi Lev  Patricia Harris  Stacey Hartman  Tara O’Brien  Funding sources:  CDC’s National Diabetes Education Program,  Ohio Department of Health Diabetes Prevention and Control Program  Ohio University, Diabetes Research Initiative & Appalachian Rural Health Institute, College of Health & Human Services, School of Nursing

3.  Prevalence of diabetes, U.S. 2008 all ages*  Total: about 24 million people (7.8% of the population)  Diagnosed: 17.9 million people  Undiagnosed: 5.7 million people  1.5 million new cases diagnosed in 2005  Mortality  7 th Leading cause of death  Under-reported (only 35-40% with diabetes had it listed on death certificates)  Twice as high as for others without diabetes  (2007) Direct costs $116 Billion Indirect Costs $58 Billion

4. BRFSS [2006], CDC/Div. of Diabetes Translation6.6 to 10.1% said yes to “Did a doctor tell you that you have diabetes?”

5. 2005 Greater Cincinnati Community Health Status Survey: White Appalachian Chart Book

7. 2006 ARHI

8.  US Prevalence  About half of those with diabetes have taken a class on diabetes self- management, (52%)  Those older than 65 years of age are less likely (46%)  Diabetes Education and Insurance (under 65 years)  Uninsured (42%)  Medicare (46%)  Medicaid/Indian Health Service (49%)  Private Insurance (54%)  Veterans Administration (79%)  Other traits and Diabetes Education  More likely  Female  African American  Insulin Use  Less likely  Appalachian (Virginia Dept. Health, 2004)

9. Evaluate provider perceptions about the provision of diabetes education throughout the Appalachian region of the United States.

10.  Distressed County  Poverty 1.5x national average  Unemployment > 1.5x national average  Per capita market income no more than 2/3 national average  OR, poverty 2x national average, plus unemployment or PCMI  At-Risk County  Poverty ≥ 1.25x national average  Unemployment ≥ 1.25x national average  Per capita market income no more than 2/3 national average  OR meeting 2 of 3 distressed criteria

11.  Federally Qualified Health Centers  N = 135 (54 clinics/hospitals and 81 HD)  Health Departments  N = 82  Diabetes Educators  N = 47 (46 situated in hospitals/clinics and 1 in a HD)

12.  A 40-item questionnaire  Information collected from the survey:  Amount, type of diabetes education available  Providers of education  Patient barriers to receiving education  Provider obstacles to delivering education

13.  Descriptive analyses of factors assessed by provider perceptions of Diabetes Education.  Cross-sectional comparison of percentages according to Distressed-At-Risk County status  P-values ≤ 0.05 were statistically significant

14. VariablesDAR%NDAR%P-value Level of Rural-Urban Rural Rural Mixed Mixed Urban Urban48.8%28.0%23.2% 3.0% 3.0%30.0%67.0% < 0.001 Type of Site Clinic/Hospital Clinic/Hospital Health Department Health Department48.8%51.2%60.0%40.0%ns Percent of Population 0-17yo in 2000 23.9%22.9%0.007 Percent of Population in poverty, 2000 20.5%12.9%<0.001 Health, Social and Educational Workers 19.9%21.2%ns Physicians, mean # per 100,000 59.1166.9 < 0.001

15. VariablesDAR%NDAR%P-value Any Diabetes Education Programs Separate Type 1 and 2 classes Family Participation 59.4%12.8%84.8%44.8%27.5%78.3%0.1010.092ns Classes on a Single Day Length of Classes, 1-2 hours 51.2%36.4%31.3%34.8%0.054ns Primary Educator, CDE 10.4%30.9%0.001 Primary Educator, Nurse 46.7%35.1%ns

16. VariablesDAR%NDAR%P-value Travel Time 37.339.0ns Gas Money 70.156.10.078 Literacy38.847.6ns Lack Public Transport 64.251.2ns Fail to Keep Appointments 67.278.0ns No Phone to Schedule 28.430.5ns No One to Drive Them 68.763.4ns Poor Personal Health 40.347.6ns Lack Insurance 40.364.60.003

17. VariablesDAR%NDAR%P-value Lack Staff 39.522.00.014 Lack Insurance 31.661.5 < 0.001 Lack Space 17.1 9.9 9.9 ns ns Lack Time 34.231.9ns Lack Teaching Resources 31.618.70.054 Patient Reading Level 13.212.1ns

18.  Provision of Diabetes Education - Appalachia:  DAR may not be worse than NDAR  Provider needs: Lack of resources, medical specialists, staff and CDEs to provide diabetes education  Patient barriers: Lack of transportation, insurance, literacy  Perception/reality of increasing diabetes, costs  Lead to further discrepancy between diabetes and education/care needed.

19.  Fewer CDEs available in DAR, educators more likely to be busy RNs  CDEs more likely to be employed in hospitals than clinics and health departments  Fewer people in the Appalachian region appear to be getting diabetes education than nationally  Broad inclusion of family in diabetes education  Barriers (e.g., costs, distance, etc.) need to be addressed locally  Low literacy and health literacy