Without culturally and literacy appropriate education and support, rural diabetes patients often feel overwhelmed, misunderstood, or disengaged, leading to poor disease management and worse health outcomes. The absence of accessible, community-based peer and professional support further isolates patients, increasing the risk of preventable complications and long-term costs.
Rural patients with diabetes, including low-income/uninsured children and adults
Underserved racial and ethnic groups (e.g., African American, Hispanic, migrant agricultural workers) who may face language barriers, cultural mismatches in care, and low health literacy
Overburdened providers lack the bandwidth to deliver gradual, personalized education. Generic information is often delivered all at once at a diagnostic visit, which is not equipped to support slow, sustainable habit changes. Emotional overwhelm, cultural food traditions, and mental health challenges often derail efforts to adopt healthier habits. Patients may feel ashamed, avoid asking questions, or believe their diagnosis is inevitable due to family history. Despite the impact of psychological distress on disease management, mental health screening is not routinely integrated into diabetes care, and if it is, limited professional psychological resources exist.
Current attempts to address this include connecting patients with community health workers who are limited in number and reach. Some clinics have a single interpreter to help translate physician-delivered education during visits, but this does not extend beyond discrete in-person visits. Educational materials are often printed and bundled to give to patients to review at home, but there is no consistent process to follow up on information comprehension and retention. Peer-support groups exist, such as Northeast Georgia Health System’s free Diabetes Support Group. Physicians can also refer patients to groups like MedLink’s Diabetes Self-Management Education and Support (DSMES) programs or Whole Health Action Management (WHAM).
NEEDS STATEMENT:
1.Provide personalized, ongoing stepwise learning for patients adjusting to a new diabetes diagnosis that addresses and monitors mental health effects and aligns with each patient’s readiness.
2.Design accessible, low-bandwidth platforms for patient peer support and community engagement.
REQUIREMENTS:
Respect cultural beliefs and provide materials that are available in languages that reflect the lingual/cultural diversity of the area.
Leverage existing community infrastructure and spaces where patients already have high levels of trust/comfort.
ADDITIONAL CONSIDERATIONS:
What are patients most motivated by?
Where do patients naturally gather and are most likely to be receptive to community-based change?
Consider leveraging trusted community health workers or other non-provider individuals as purveyors of behavioral education and management.
