Health Extension for Diabetes: Development,Implementation,and Effectiveness of a Community-Based Diabetes Self-Management Support Program

Abstract

Objectives:

Health Extension for Diabetes (HED) is a community-based diabetes self-management support program facilitated by trained rural health and nutrition agents who lead 8 biweekly educational sessions supported by a diabetes clinical expert. We evaluated the program using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods:

Since the HED program’s conception in 2017, ongoing longitudinal evaluation has measured participant knowledge, self-efficacy, and other health behaviors via pre- and postsurveys (at program completion, at 1 year, and at 2 years). We used paired-sample t tests to assess significant changes in effectiveness outcomes from pre- to postintervention.

Results:

Of 1526 participants enrolled in the HED program from 2018 to 2024, 1434 (94.0%) graduated. Mean physical health–related quality-of-life scores rose from 42.8 to 45.1, and mental health scores increased from 51.4 to 52.9 (on a 100-point scale). We assessed weekly diabetes self-care activities and found improvements in general diet (from 4.1 to 5.0 days/week), specific diet (from 3.9 to 4.7 days/week), exercise (from 2.6 to 3.7 days/week), blood glucose testing (from 4.2 to 5.2 days/week), and foot care (from 3.4 to 4.6 days/week). Average diabetes knowledge increased from 76.4% to 85.0%, and self-efficacy increased from 7.1 to 8.2 on a 10-point scale. Participants had reductions in weight (−3.4 pounds), body mass index (from 34.3 kg/m² to 33.7 kg/m²), and self-reported hemoglobin A_1c (from 7.5% to 7.0%). All pre- to postsurvey changes were significant at α = .05.

Conclusions:

The HED program offers a scalable and sustainable approach to community-based diabetes self-management support. Program expansion and replication should leverage key implementation strategies identified via this RE-AIM framework evaluation.

Keywords

diabetes self-management support community-based intervention implementation science RE-AIM framework preventive medicine

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References

Sun

Saeedi

Karuranga

, et al. IDF Diabetes Atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. doi:10.1016/j.diabres.2021.109119

GBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2023;402(10397):203-234. doi:10.1016/S0140-6736(23)01301-6

Powers

Bardsley

Cypress

, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41(4):417-430. doi:10.1177/0145721715588904

Adu

Malabu

Malau-Aduli

AEO

Malau-Aduli

BS.

Enablers and barriers to effective diabetes self-management: a multi-national investigation. PLoS One. 2019;14(6):e0217771. doi:10.1371/journal.pone.0217771

Davies

Heller

Skinner

, et al. Effectiveness of the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ. 2008;336(7642):491-495. doi:10.1136/bmj.39474.922025.BE

Davis

Fischl

Beck

, et al. 2022 National standards for diabetes self-management education and support. Diabetes Care. 2022;45(2):484-494. doi:10.2337/dc21-2396

Dale

Williams

Bowyer

What is the effect of peer support on diabetes outcomes in adults? A systematic review. Diabet Med. 2012;29(11):1361-1377. doi:10.1111/j.1464-5491.2012.03749.x

Johnson

O’Brien

Orionzi

Trahan

Rockwood

Pilot of community-based diabetes self-management support for patients at an urban primary care clinic. Diabetes Spectr. 2019;32(2):157-163. doi:10.2337/ds18-0040

Lorig

Ritter

Villa

Armas

Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educ. 2009;35(4):641-651. doi:10.1177/0145721709335006

10.

Tang

Ayala

Cherrington

Rana

A review of volunteer-based peer support interventions in diabetes. Diabetes Spectr. 2011;24(2):85-98. doi:10.2337/diaspect.24.2.85

11.

Knowler

Barrett-Connor

Fowler

, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. doi:10.1056/NEJMoa012512

12.

Association of Diabetes Care and Education Specialists, Kolb

. An effective model of diabetes care and education: the ADCES7 Self-Care Behaviors™. Sci Diabetes Self-Manag Care. 2021;47(1):30-53. doi:10.1177/0145721720978154

13.

South Carolina Revenue and Fiscal Affairs Office. Population estimates by county 2010-2020, 2000-2009. Accessed March 7, 2024. https://rfa.sc.gov/data-research/population-demographics/census-state-data-center/population-data/population-estimates-counties

14.

Dietz

Sherrill

Ankomah

Rennert

Parisi

Stancil

Impact of a community-based diabetes self-management support program on adult self-care behaviors. Health Educ Res. 2023;38(1):1-12. doi:10.1093/her/cyac034

15.

Dietz

Sherrill

Stancil

Rennert

Parisi

McFall

Health extension for diabetes: impact of a community-based diabetes self-management support program on older adults’ activation. Diabetes Spectr. 2023;36(1):59-68. doi:10.2337/ds21-0054

16.

American Diabetes Association. Tools and calculators: take the type 2 risk test. May 8, 2024. Accessed May 8, 2024. https://diabetes.org/diabetes-risk-test

17.

Clemson University. Cooperative extension service. 2025. Accessed May 2, 2024. https://www.clemson.edu/extension/index.html

18.

Prisma Health. About Prisma Health. 2025. Accessed May 8, 2024. https://prismahealth.org/about-prisma-health

19.

White

McFall

Parisi

MA.

Reaching at-risk communities through extension—clinical partnerships. 2021. Accessed May 8, 2024. https://lgpress.clemson.edu/publication/reaching-at-risk-communities-through-extension-clinical-partnerships

20.

Funnell

Kloss

Nwankwo

Life With Diabetes: A Series of Teaching Outlines. 6th ed.

American Diabetes Association;

2020. doi:10.2337/9781580407151

21.

American Diabetes Association Professional Practice Committee. Standards of care in diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S5-S10. doi:10.2337/dc24-SREV

22.

Powell

Waltz

Chinman

, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. doi:10.1186/s13012-015-0209-1

23.

Glasgow

Harden

Gaglio

, et al. RE-AIM Planning and Evaluation Framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. doi:10.3389/fpubh.2019.00064

24.

Pinnock

Barwick

Carpenter

, et al. Standards for Reporting Implementation Studies (StaRI) statement. BMJ. 2017;356:i6795. doi:10.1136/bmj.i6795

25.

Harris

Taylor

Minor

, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j.jbi.2019.103208

26.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

JG.

Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010

27.

Rhoden

Hall

Stancil

Sherrill

WW.

EHR smart phrases used as enrollment mechanism in diabetes self-management support programs: preliminary outcomes. J Healthc Qual. 2024;46(4):235-244. doi:10.1097/JHQ.0000000000000438

28.

Economic Innovation Group. Distressed Communities Index (DCI). 2024. Accessed July 29, 2024. https://eig.org/issue-areas/distressed-communities-index-dci

29.

American Diabetes Association. American Diabetes Association launches new diabetes support directory to connect communities to diabetes support programs. Press release. 2019. Accessed May 8, 2021. https://diabetes.org/newsroom/diabetes-support-directory

30.

Healthy Me—Healthy SC. Our programs. 2025. Accessed May 8, 2024. https://healthymesc.org/programs

31.

Glasgow

Vogt

Boles

SM.

Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-1327. doi:10.2105/AJPH.89.9.1322

32.

Kwan

McGinnes

Ory

Estabrooks

Waxmonsky

Glasgow

RE.

RE-AIM in the real world: use of the RE-AIM framework for program planning and evaluation in clinical and community settings. Front Public Health. 2019;7:345. doi:10.3389/fpubh.2019.00345

33.

Ware

Kosinski

Keller

SD.

A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233. doi:10.1097/00005650-199603000-00003

34.

Toobert

Hampson

Glasgow

RE.

The Summary of Diabetes Self-care Activities Measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23(7):943-950. doi:10.2337/diacare.23.7.943

35.

Stewart

Ware

Sherbourne

Wells

. Psychological distress/well-being and cognitive functioning measures. In: Stewart

Ware

, eds. Measuring Functioning and Wellbeing. Duke University Press; 1992:102-142.

36.

Dietz

Doherty

Emerson

Kemper

Rennert

Sherrill

WW.

Understanding primary care provider’s knowledge and perceptions of diabetes self-management education and support. Prim Care Diabetes. 2024;18(6):637-643. doi:10.1016/j.pcd.2024.10.005

37.

Barker

Steventon

Williamson

Deeny

SR.

Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records. BMJ Qual Saf. 2018;27(12):989-999. doi:10.1136/bmjqs-2017-007635

38.

Ahn

Basu

Smith

, et al. The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health. 2013;13(1):1141. doi:10.1186/1471-2458-13-1141

39.

Hodkinson

Bower

Grigoroglou

, et al. Self-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis. BMJ. 2020;370:m2521. doi:10.1136/bmj.m2521

40.

Wensing

Sales

Aarons

Wilson

Evidence for objects of implementation in healthcare: considerations for implementation science and implementation science communications. Implement Sci. 2022;17(1):83. doi:10.1186/s13012-022-01249-w

41.

Tobias

Merino

Ahmad

, et al. Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine. Nat Med. 2023;29(10):2438-2457. doi:10.1038/s41591-023-02502-5