Navigating Pain: A Qualitative Study of Opportunities and Barriers to Type 2 Diabetes Self-Management in Rural Communities

Background Rural adults in the southern U.S. experience disproportionate burdens of type 2 diabetes (T2D) and chronic pain (CP; ≥3 months), with structural and economic inequities limiting access to effective management of both conditions. This study explores factors shaping diabetes self‑management among rural adults with diagnosed T2D and CP. Methods Participants were recruited from the Risk Underlying Rural Areas Longitudinal (RURAL) Cohort in Appalachian and Mississippi Delta regions. Eligible participants had T2D, and pain was assessed using a pain measure that included past‑week pain severity, chronic pain duration (≥ 3 months), pain locations, and pain interference ratings. Focus groups were held at the Selma Public Library, a central and accessible location for participants from both counties. Audio recordings were transcribed verbatim and analyzed using deductive thematic analysis. Coding drew on Social Cognitive Theory (SCT) constructs. Inter-coder consistency checks and consensus procedures ensured rigor. Results Two semi‑structured focus groups (N = 18) were conducted with rural adults. Most participants (12/18) had chronic pain, five reported having pain, and one reported no current pain. Pain emerged as a central disruptor, impeding exercise, sleep, household tasks, and overall capacity to manage T2D. Psychosocial stress, financial strain, medication burden, and limited access to healthy foods in rural environments further undermined self‑care. Facilitators highlighted resilience and resourcefulness: reframing pain and creative distraction (pain resilience/adaptive coping), mobilizing social support from family, coworkers, churches, and community networks, movement as therapy to relieve pain and sustain functioning, use of alternative remedies amid constrained access to multimodal pain care, and reliance on faith and spiritual beliefs to manage pain and stress. Conclusions Findings underscore the complex interplay between pain, including CP, and diabetes self- management in rural settings. For rural adults with both conditions, self-care is shaped by intersecting structural, social, and psychological factors. Experiences of pain varied, with some participants reporting worsened pain during physical activity and others experiencing relief, suggesting differences in nociceptive versus neuropathic pain commonly associated with T2D. Interventions should leverage local social networks, reduce food and medication burdens, and strengthen self-efficacy using culturally responsive strategies tailored to rural Southern communities.