One of the primary reasons for the higher incidences of diabetes and prediabetes in rural counties in Texas is that the people who live in them tend not to have easy access to what are known as "Diabetes Self-Management Education and Support," or DSMES programs. (A rural county in Texas has a population that numbers less than 20,000 people.) More specifically, in 153 out of 254 counties (60.3%), they have little or no access to these programs because they either do not exist in those locations as physically available initiatives, or, if they are available but are only accessible online, they require levels of broadband internet connectivity and types of computational resources that many people living in these areas do not have. Additionally, in many cases, the structure and delivery of the content that constitutes the (mostly) web-facilitated programs that rural Texans living with diabetes do have access to has not been designed or written in ways that account for the lower quality and lower levels of education prevalent among this population (compared to those who have been educated in the state's more urbanized areas). Web-facilitated, diabetes-related content that is written and presented in a manner that makes it difficult to understand for this group of users can contribute to a phenomenon known as "diabetes distress," which occurs when someone feels frustrated, defeated, or overwhelmed by having to live with diabetes, or having to care for someone who is. This problem is further exacerbated by the fact that the organizational structure, user interface design, and linguistic style and tone of many of the extant web-facilitated DSMES programs available to people living with diabetes in rural Texas do not appear to have not been informed by one or more types of user research. Specifically, regarding its potential to affect the development and design of these programs, no methodic study of some number of these people appeared to have been operated to determine their needs and wants, or what was causing them one or more types of difficulty, as they attempted to manage their treatment of diabetes. Additionally, these programs do not appear to have undergone much of the kinds of iteratively guided, heuristically informed cycles of prototypical development that allows for various versions of their system components, features, and functionalities to be operated and critically assessed by either their potential users or their stakeholders. In this context, potential users are not only those living with diabetes in rural Texas, but those who are involved in caring for them, or who are affected in some way by their need for day-to-day treatment, or some combination of these. Stakeholders are comprised of the endocrinologists and other physicians who help those living with diabetes in ruralTexas plan andmanage their care, along with thosewho administrate the healthcare systems of which many of these healthcare providers are a part. Other stakeholders include those who facilitate the operation of the insurance companies and (in some cases) government-run programs that help pay for diabetes treatments and care regimens, and those who fulfill roles in some rural areas of Texas as "diabetic educators" to help especially those newly diagnosed learn to effectively understand and manage the day-to-day responsibilities that living with diabetes entails. The combined effects of rural Texans living with diabetes not having easy access to physically available or well-designed, web-facilitated, DSMES programs was a key factor that triggered the initiation of the applied design research endeavor that is described in this paper. Another was the lack of hospital-based or other dedicated, high-operational-level healthcare facilities necessary to support the ministration and treatment needs of many of these people, especially if they live in one of the 77 Texas counties that does not have a hospital, or if they are among the almost one in three rural Texans who does not have health insurance. In January of 2023, this set of circumstances began to fuel a series of conversations between a noted endocrinologist with over 20 years of experience treating people with diabetes, or who were or are prediabetic, in rural and urban areas of Texas, and the author of this paper. The endocrinologist was and is Dr. Wasim Haque, M.D., F.A.C.E. who was and is a is Board Certified in Endocrinology and is a fellow of the American College of Endocrinology, a member of the American Diabetes Association, and the Denton County (Texas, U.S.A.) Medical Society. His primary areas of interest are insulin resistance, hyperlipidemia, thyroid disorders, osteoporosis, and diabetes mellitus. The author of this paper is a Full Professor of Visual Communication Design embedded in the Department of Design at The University of North Texas, a tier one research university located in the Dallas/Fort Worth, Texas metropolitan area of the U.S. Speculation by Dr. Haque and two of his colleagues about how a DSMES that would be specifically tailored tomeet the needs of rural Texans livingwith diabetes had led them to develop a crude-but-operational, online-facilitated DSMES to address these in October andNovember of 2022. Thiswas used as a "starting point" from which a much more comprehensive digitally facilitated system of care could evolve. What follows describes the research that informed the design decision-making processes that affected the initial-to-mid-level development and design of the uniquely tailored DSMES system that came to be known as "EndoMD: an Initative to Empower Rural Texans Living with Diabetes," or, more simply, "EndoMD."
