How pain shapes type 2 diabetes self-management in rural communities: a qualitative study

Rural adults in the Southern U.S. experience disproportionate burdens of type 2 diabetes (T2D) and pain, including chronic pain (CP; ≥ 3 months). These burdens are compounded by structural and economic inequities that may limit access to effective management strategies. This study explored how pain, including chronic pain, shapes diabetes self‑management among rural adults with T2D. Participants were recruited from the Risk Underlying Rural Areas Longitudinal (RURAL) Cohort. Eligible participants had T2D, and pain was assessed using a measure that included past‑week pain severity, presence of pain lasting ≥ 3 months (CP), pain location, pain severity, and pain interference. Focus groups were conducted at a community location in Selma, Alabama. Audio recordings were transcribed verbatim and analyzed using deductive and inductive thematic analysis. Inter-coder consistency checks and consensus procedures ensured analytic rigor. Two semi‑structured focus groups ( N = 18) were conducted with rural adults with T2D. Twelve participants reported chronic pain, five reported pain, and one reported no current pain. Across discussions, pain emerged as a prominent influence on diabetes self-management, disrupting physical activity, sleep, household tasks, and overall self-care capacity. Additional barriers included psychosocial stress, financial strain, medication burden, and limited access to healthy foods. Participants also described several facilitators of self-management, including adaptive coping strategies, social support from family, coworkers, churches, and community networks, movement as a means of maintaining function, use of alternative remedies, and reliance on faith and spirituality to manage pain and stress. Pain was a salient factor shaping diabetes self-management among rural adults with T2D, although experiences varied in nature and severity. Findings highlight the interconnected social, psychological, and structural factors influencing self-care in rural settings. Future interventions may benefit from addressing shared self-management targets across diabetes and pain, while leveraging existing rural strengths such as social networks, faith communities, and community connectedness. Culturally responsive approaches that address treatment burden, food access, and pain management may improve self-management support for rural populations.