title: Barriers to diabetes self-management education programs in underserved rural Arkansas: implications for program evaluation.
abstract: BACKGROUND
  Diabetes prevalence has reached epidemic proportions. Diabetes self-management education (DSME) has been shown to improve preventive care practices and clinical outcomes. In this study, we discuss the barriers faced during the implementation of DSME programs in medically underserved rural areas of Arkansas.
  
  
  BACKGROUND
  Arkansas is a rural state, with most southeastern counties experiencing a shortage of health care professionals. The Arkansas Diabetes Prevention and Control Program and its partners established 12 DSME programs in underserved counties with a high prevalence of diabetes.
  
  
  METHODS
  DSME programs were delivered by a registered nurse and a dietitian who provided 10 to 13 hours of education to each program participant. Baseline, 6-month, and year-end data were collected on preventive care practices, such as daily blood glucose monitoring, foot examination, systolic and diastolic blood pressure, and glycosylated hemoglobin level, among the participants in newly established DSME programs.
  
  
  CONCLUSIONS
  Of the 12 DSME programs established, 11 received American Diabetes Association recognition. The number of participants in the DSME programs increased 138% in 1 year, from 308 in February 2003 to 734 in March 2004. Preventive care practices improved: daily blood glucose monitoring increased from 56% to 67% of participants, and daily foot examinations increased from 63% to 84% of participants. Glycosylated hemoglobin decreased by an average of 0.5 units per participant who completed the program. However, many anticipated and a few unanticipated barriers during the implementation of the program could not be overcome because of the lack of an evaluation plan.
  
  
  CONCLUSIONS
  Although results point to potential benefits of preventive care practices among DSME participants, interpretation of findings was limited by sample size. Sample size limitations are traced to barriers to assessing program outcome. Program evaluation should be integrated into the planning phase to ensure adequate measures of program effectiveness.
authors.affiliation: Arkansas Department of Health and Human Services, 4815 W Markham, Slot 32, Little Rock, AR 72205, USA. abalamurugan@healthyarkansas.com
authors.forename: Appathurai
authors.initials: A
authors.lastname: Balamurugan
authors.forename: Mark
authors.initials: M
authors.lastname: Rivera
authors.forename: Leonard
authors.initials: L
authors.lastname: Jack
authors.forename: Kristen
authors.initials: K
authors.lastname: Allen
authors.forename: Sharon
authors.initials: S
authors.lastname: Morris
mesh_terms: D000328:Adult; D001131:Arkansas / Q000453:epidemiology; D003922:Diabetes Mellitus, Type 1 / Q000453:epidemiology* / Q000628:therapy; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology* / Q000628:therapy; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008507:Medically Underserved Area; D008875:Middle Aged; D010353:Patient Education as Topic; D015995:Prevalence; D015397:Program Evaluation; D019035:Rural Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D012648:Self Care