Barriers and Diabetes Care Quality in Public Schools in the United States

Objective: In this study, we examined the influence of multi-level barriers on school diabetes care quality. Methods: We administered an online survey to nurses in Missouri K-12 schools (N = 245). We assessed 57 potential barriers in 5 domains (at individual, school, community, social/ cultural, and political/economic levels). We developed 38 criteria for care quality based on the National Institute of Diabetes and Digestive and Kidney Diseases' school diabetes care guidelines. We carried out structural equation modeling to examine the effect of barriers on school diabetes care quality. Results: School nurses' heavy workloads, teachers'/parents' lack of training/knowledge on evidence-based practices, and lack of funding from government, districts, and schools serving disadvantaged or rural populations were among the key barriers to school diabetes care. Deficiencies in care quality were identified in areas including knowledge/training, communication, school policies, resources and environment, physical activity engagement among students with diabetes, school nurses' diabetes management practices, and trained diabetes practitioners' responsibilities. School diabetes care barriers, overall, were inversely associated with care quality; one standard deviation increase in the barriers was associated with a 0.163 (95% confidence interval = 0.002-0.324) standard-deviation decrease in care quality. Conclusions: Multi-level policy interventions are called upon to address these barriers to improve care quality and ensure the healthy growth of students with diabetes.