Community and Worksite Health Screenings to Determine Hypertension and Diabetes Risk Among Adults Living in Rural Mississippi

Introduction

Hypertension,¹ prediabetes,² and diabetes³ represent major public health challenges, with profound implications for health systems, communities, and individuals. Despite advances in diagnosis and treatment, many remain unaware of their conditions until complications arise.^4,5 Lack of awareness is particularly concerning given the effectiveness of early intervention in reducing disease progression and preventing adverse outcomes.^6–8

Mississippi has some of the highest rates of diabetes nationally, with approximately one in six residents (15.3%) living with the disease.⁹ Additionally, an estimated 38% of adults have prediabetes, meaning over half of adults in Mississippi have some form of diabetes. Furthermore, an estimated 80% of those individuals with prediabetes are unaware of their condition.⁵ These figures underscore the importance of early detection to prevent diabetes and associated complications and comorbidities.

Although Mississippi has one of the highest diabetes rates in the country, adults in the state are significantly less likely to report that they have ever been told they have diabetes or prediabetes. National Behavioral Risk Factor Surveillance System (BRFSS) data from 2023¹⁰ show that about 14.7% of adults reported receiving a diagnosis of prediabetes, while only 11.1% of Mississippi residents reported the same. This statistic is striking because independent estimates suggest that more than one-third of Mississippi adults have blood glucose levels in the prediabetic range.¹⁰ The gap between true prevalence and reported diagnosis indicates that elevated glucose may go undiagnosed, thus suggesting missed opportunities for early intervention, since lifestyle changes and targeted prevention strategies are most effective before diabetes develops.

In Mississippi, diagnosed diabetes imposes a substantial economic burden. A recent report estimates the total cost at roughly $5.1 billion per year, which includes approximately $3.4 billion in direct medical costs and $1.7 billion in indirect costs such as lost productivity.¹⁰ Individuals with diabetes also tend to have significantly higher medical expenses that are, on average, 2.3 to 2.6 times greater than those without diabetes.¹⁰ Given that over one-third of Mississippi adults are estimated to have prediabetes, and a substantial fraction may progress to diabetes without timely detection and intervention, the future economic burden, both in medical costs and lost productivity, is expected to increase.

Prediabetes reflects a prolonged period of insulin resistance and compensatory hyperinsulinemia that typically precedes overt hyperglycemia by years, sometimes decades. During this phase, β-cells increase insulin secretion to maintain near-normal glucose levels, masking the underlying metabolic stress. Over time, this high-demand state accelerates β-cell dysfunction and loss, increasing the likelihood of progression to Type 2 diabetes and its complications. In this sense, prediabetes and high-normal HbA1c values are the metabolic “smoke before the fire” particularly when considering that hyperinsulinemia may be present well before glucose levels rise appreciably.

Importantly, vascular injury can begin before glucose levels meet traditional criteria for diabetes. A growing body of evidence shows that microvascular complications, including early retinopathy,¹¹ nephropathy,¹² and neuropathy,¹³ are present at increased rates in individuals with prediabetes compared with normoglycemic controls.¹¹ Similarly, observational data consistently link higher HbA1c levels, even within the nondiabetic and prediabetic range, with greater cardiovascular disease (CVD) risk and increased all-cause mortality.¹⁴

Hyperinsulinemia itself is an important and sometimes under-emphasized risk factor. Insulin resistance and compensatory hyperinsulinemia are tightly linked with central obesity, dyslipidemia (elevated triglycerides and low HDL cholesterol), hypertension, nonalcoholic fatty liver disease, and the clustering of risk factors described as the metabolic syndrome.^15,16 These conditions, in turn, substantially increase the risk of coronary heart disease, stroke, heart failure, and other chronic illnesses that are highly prevalent in Mississippi.^17,18 By the time patients’ HbA1c first appear in the prediabetes range, many already carry a significant cardiometabolic burden and may have begun to accumulate microvascular damage even before glucose levels rise appreciably.¹⁹

Community and worksite-based health screenings are uniquely positioned to bridge this awareness gap.^20,21 By meeting people where they live and work, screenings help overcome barriers such as time constraints, transportation, and limited access to primary care. They not only identify patients at risk with elevated numbers but also as educational and engagement strategies, empowering individuals to take action toward improved health.

The objective of this study is to determine the prevalence of hypertension and diabetes risk in a diverse population attending worksite screenings. The analysis focuses on disease awareness, racial disparities in recognition, and implications for future interventions.

Methods

In this cross-sectional descriptive study, The Mississippi Diabetes Network (MDN) conducted free onsite health screenings for blood glucose, hemoglobin A1C (HbA1c), and blood pressure. Screenings were conducted between October 2023 and February 2025. The primary objective of these screenings was to identify undiagnosed diabetes and prediabetes among individuals, particularly those residing in rural Mississippi. The study protocol was approved by the William Carey University Institutional Review Board (IRB #2025-026).

Screenings were held at community, school, and worksite locations (Table 1). Screening participants were informed of the events in advance through communications coordinated by the participating organizations. Participation was voluntary. Each screening required approximately 10 minutes per participant. At each event, participants completed registration and provided informed consent before undergoing screening. The same intake form, Siemens DCA Vantage Analyzer, automated blood pressure procedure, and general screening protocol were used at all sites. During registration, participants reported age in years, race, insurance type, and whether they had a known history of hypertension, prediabetes, or diabetes. Age was recorded in years. Race was categorized as African American, Caucasian, or Other, and insurance was categorized as private, Medicare, Medicaid, military, or none.

Blood pressure was measured using standard automated devices. Participants were seated and given a rest period of about three minutes. They were asked to remove thick or restrictive clothing such as sweatshirts and jackets. They were asked to relax their arm, and the blood pressure cuff was then adjusted to fit each individual appropriately. In the event of a high reading, the person was asked to relax and breathe for a few minutes, and a second reading was taken. The lowest of the two readings was recorded.

Blood pressure was recorded in millimeters of mercury (mm Hg) and categorized as normal (<120/<80 mm Hg), elevated (systolic 120-129 and diastolic <80 mm Hg), Stage 1 hypertension (systolic 130-139 or diastolic 80-89 mm Hg), Stage 2 hypertension (systolic at least 140 or diastolic at least 90 mm Hg), or hypertensive crisis (systolic greater than 180 and/or diastolic greater than 120 mm Hg).⁸

Capillary blood samples were obtained via fingerstick using a sterile lancet. Glucose levels were assessed with a point-of-care glucometer, and the same sample was used for HbA1c analysis using the Siemens DCA Vantage Analyzer, which requires approximately six minutes to process each specimen. HbA1c was recorded as a percentage and categorized as below the prediabetes range (<5.7%), prediabetes (5.7%-6.4%), or diabetes (at least 6.5%).⁷

Participants waited in a designated area while results were processed. A trained team member reviewed results with each participant, providing immediate feedback and brief counseling as well as a healthy living resource guide. Participants with abnormal values received tailored education on risk factors and lifestyle modification and were referred to local healthcare providers for follow-up care.

Descriptive statistics summarize demographics and clinical outcomes. Agreement between self-reported and clinical measures was calculated as percent of concordance. Chi-square tests were used to assess racial differences in lack of awareness. Analyses included complete cases only.

Awareness was defined as self-report of the corresponding condition among participants with an elevated screening result. Hypertension awareness indicated self-reported hypertension among participants with blood pressure above the normal range. Prediabetes or diabetes awareness indicated self-report of the condition corresponding to the HbA1c category. Concordance referred to agreement between self-reported status and the screening classification. Cramer’s V was calculated as the effect size for chi-square analyses. Because the Other race category was small and produced sparse expected cell counts, it was presented descriptively and excluded from inferential testing.

Results

A total of 832 individuals participated in screening for hypertension (n=85), diabetes (n=59), or both (n=688) (Table 2). Among 783 participants who provided data on race, 53.3% identified as African American (n=417), 45.6% identified as Caucasian (n=357), and 1.1% identified as Other (n=9). Among 790 participants that provided their age, the largest groups were 50-59 years (26.2%, n=207), 40-49 years (21.1%, n=167), and 60-69 years (18.5%, n=146). Insurance coverage type was provided by 778 participants. The most frequently reported type was private insurance (88.2%, n=686). Among participants screened for hypertension (n=773), 94.6% had readings above the normal range, with 5.0% categorized as elevated, 25.4% as Stage 1 hypertension, 61.3% as Stage 2 hypertension, and 2.8% as hypertensive crisis (Table 2). The mean systolic blood pressure was 143.2 mm Hg (SD 16.7), and the mean diastolic blood pressure was 87.9 mm Hg (SD 11.1).

Among participants with a blood pressure result above the normal range and self-report data, 341 of 696 (49.0%) reported hypertension awareness (Table 3). Among participants with race data, awareness was 59.2% among African American participants (202/341), 37.2% among Caucasian participants (120/323), and 16.7% among participants in the Other category (1/6). In the African American-versus-Caucasian comparison, awareness differed by race (chi-square=32.00, df=1, p<.001; Cramer’s V=.220). The Other category was not included in the inferential test because of sparse cell counts.

HbA1c screening results were available for 747 participants. Among those screened, 54.4% (n=406) had an HbA1c <5.7%, indicating they were below the prediabetes range, 32.4% (n=242) had prediabetes (HbA1c 5.7% to 6.4%), and 13.3% (n=99) had diabetes (HbA1c at least 6.5%). Among 742 participants with a numeric HbA1c value, the mean was 5.8% (SD 1.1) (Table 2). Among 336 participants with a prediabetes- or diabetes-range HbA1c result and self-report data, 31.3% (n=105) reported the corresponding condition (Table 4). When examined separately, awareness was 16.4% (39/238) among participants with prediabetes and 67.3% (66/98) among participants with diabetes.

Among participants with race data, corresponding prediabetes or diabetes awareness was 34.7% among African American participants (74/213), 23.5% among Caucasian participants (23/98), and 0.0% among participants in the Other category (0/3). The African American-versus-Caucasian difference was statistically significant but small (chi-square=3.97, df=1, p=.046; Cramer’s V=.113). The Other category was not included in the inferential test because of sparse cell counts. Further, among the 688 participants who were screened for both hypertension and diabetes, 647 provided self-reported status for both conditions. There were 109 individuals (16.8%) who screened positive for both conditions and were unaware of their status for either condition.

Discussion

These findings underscore the importance of community and worksite health screenings for detecting chronic conditions and identifying awareness gaps. In the current study, participants with an HbA1c in the prediabetes or diabetes range, and those with blood pressure levels above normal who had not previously been diagnosed with those conditions, were advised to follow up with a healthcare provider. Some participants reported that they didn’t receive regular health check-ups, even when they had insurance coverage. This highlights the value of such screenings for discovering disease states participants might not otherwise have known about.

The proportion of participants with Stage 2 hypertension (over 60%) reflects a population highly burdened with HTN. The substantial number with prediabetes (32.4%) also highlights opportunities for prevention through early intervention. Interestingly, patterns of disease awareness differed by condition. African American participants demonstrated greater awareness than Caucasian participants for both hypertension and the corresponding prediabetes or diabetes category, but the difference was larger for hypertension. National studies have also documented racial and ethnic differences in hypertension awareness and prediabetes awareness.^22,23 These condition-specific patterns may reflect differences in health communication, screening access, and culturally tailored education, but these explanations require further study.

Half of participants with elevated blood pressure and self-report data reported hypertension awareness, while awareness differed substantially between participants with prediabetes and those with diabetes. This differing suggests persistent gaps in awareness and/or communication that may delay timely diagnosis and management. Notably, most participants who reported regularly monitoring blood pressure did so at home in the mornings or evenings, a context in which stress and physiologic arousal may be lower than during the workday. The high proportion of elevated blood pressure readings observed at the worksite may therefore reflect higher ambulatory pressures at work that would not be detected through home-only monitoring.

Accordingly, participants were counseled to obtain blood pressure readings during the workday when feasible by measuring blood pressure at various times each day for 3-to-5 consecutive workdays and noting the values. If values remain elevated, participants were instructed to share the data with their clinicians to make informed decisions and improve blood pressure while at work. This approach may better characterize typical daytime blood pressure and inform appropriate medication initiation or titration and/or targeted lifestyle modifications, particularly given that many adults spend 40 or more hours per week at work. Importantly, these findings suggest that even individuals previously diagnosed with hypertension and treated pharmacologically may have unrecognized, persistently elevated workplace blood pressure, underscoring an opportunity to improve detection and support risk-reducing clinical and behavioral interventions.

Worksite screenings that detect elevated blood pressures provide an important and unique opportunity to prevent serious complications such as heart attack, stroke, and kidney disease. Highlighting the severity of these outcomes, paired with encouragement of physical activity and other lifestyle interventions, may encourage individuals to take proactive steps towards improving their cardiovascular health.

Results herein show that community-based and worksite screenings should be integrated with education, navigation, and referral systems. Partnerships with employers, churches, and community organizations can expand their reach. Tailored interventions are needed to address condition-specific awareness of disparities across racial and ethnic groups.

Given this pathophysiology, approaches that frame prediabetes as something to “watch” without a structured plan, or that use vague descriptors such as “borderline,” may unintentionally minimize risk and delay preventive action, Robust evidence from the Diabetes Prevention Program (DPP) and its long term follow-up shows that lifestyle intervention reduced incident Type 2 diabetes by 58% versus placebo, with benefit over more than two decades of follow-up.^24,25 Participants in DPP-based programs who achieve 5% to 7% weight loss not only delay or prevent diabetes, but also improve blood pressure, lipids, and other cardiometabolic markers.²⁶ These findings underscore the importance of patient awareness coupled with early, structured interventions focused on nutrition, movement, sleep, and stress management, particularly at the stage when patients may otherwise be reassured that their HbA1c is only “borderline high,” and that no action is needed beyond monitoring.

In clinical practice, an HbA1c in the prediabetes range can serve as a practical trigger for brief, standardized counseling and streamlined referral. A feasible minimum approach is to (1) name the diagnosis using clear language. For example, patients can be told, “you have prediabetes” rather than relying solely on nonspecific terms such as “borderline,” (2) explain that insulin resistance is associated with vascular risk and can accelerate other cardiometabolic conditions, and (3) offer or referral to diabetes coaching or CDC-recognized lifestyle and nutrition programs (such as Diabetes Solutions or other local DPP programs) that have demonstrated risk reduction and improved health outcomes. Clear, consistent messaging helps patients understand that their numbers are not “normal;” they represent an early warning and a window of opportunity for intervention.

Community screening programs in Nashville and among rural African American women have similarly identified hypertension, diabetes, and other cardiometabolic risks outside traditional clinical settings.^27,28 Direct comparison of rates is limited by differences in populations, recruitment, measurement protocols, and definitions.

Limitations

This study has several limitations. First, participants were recruited from community and worksite settings on a voluntary basis, which may introduce selection bias and limit generalizability to all adults living in Mississippi. Second, clinical measures were obtained in screening environments rather than controlled clinical settings. Blood pressure was assessed at a single point in time for most participants, and elevated readings may reflect transient factors (e.g., recent activity, caffeine intake, acute stress, pain, or “white coat” effects). Accordingly, screening blood pressure values were interpreted as identifying elevated risk and the need for follow-up rather than confirming a clinical diagnosis of hypertension. MDN staff were clear in their post-screening counseling to offer the sentiment that their findings do not represent a diagnosis, that “this reading shows elevated risk, and we encourage you to follow up with your healthcare provider for treatment decisions and confirmation of the diagnosis.” The predominance of worksite participants and participants with private insurance further limits generalizability and does not support estimating statewide healthcare access.

Third, HbA1c was measured using point-of-care testing. While HbA1c provides a useful estimate of longer-term glycemia and is less sensitive to fasting status than capillary glucose, point-of-care testing and fingerstick sampling may differ from laboratory-based venous measurements, and results may be influenced by conditions that affect red blood cell turnover (e.g., anemia or hemoglobinopathies), which were not assessed. And similar to hypertension, staff were careful to say, we are not diagnosing you, we are saying your results here today indicate your blood glucose is or has been running higher than in normal or ideal and we encourage you to seek follow-up health care for treatment and a confirmation of the diagnosis (i.e., prediabetes or diabetes).

Fourth, “awareness” was based on self-report and may be affected by recall error, misunderstanding of terminology (e.g., prediabetes versus “borderline”), or limited health literacy. Finally, although screening staff provided counseling and referrals, follow-up outcomes (e.g., subsequent clinical visits, medication changes, enrollment in lifestyle programs, or longitudinal changes in blood pressure and HbA1c) were not systematically captured, limiting inference about downstream clinical impact. Future work should incorporate standardized follow-up and linkage-to-care measures to quantify care engagement and biomarker change over time.

Future Directions

Future research should assess whether screening setting, insurance type, prior healthcare contact, and result communication explain the condition-specific awareness patterns observed in this study. Larger samples are needed to provide stable estimates for racial and ethnic groups that were underrepresented. Prospective studies should also evaluate referral acceptance, completed follow-up visits, confirmatory testing, enrollment in evidence-based lifestyle programs, and longitudinal changes in blood pressure and HbA1c after community and worksite screening.

Conclusion

Community and worksite-based screenings in rural Mississippi identified a substantial burden of elevated blood pressure and previously unrecognized prediabetes and diabetes. The low concordance between self-reported status and measured values underscores that many adults remain unaware of clinically meaningful cardiometabolic risk, even when they are insured and engaged in employment settings. These knowledge gaps represent missed opportunities for early intervention, particularly in a state where diabetes and CVD contribute disproportionately to premature morbidity, mortality, and healthcare spending.

Delivering screening services in community and workplace settings is an effective “meet people where they are” approach that reduces common barriers to prevention and early detection such as time, transportation, limited clinic access, and competing priorities. In addition to identifying abnormal values, onsite, point-of-care screening provides an immediate, actionable moment for education: participants learn their numbers, understand what those numbers mean, and receive brief counseling and clear next steps for follow-up. This clear direction is especially important for prediabetes and hypertension, where early recognition and timely lifestyle and/or medication management can slow progression, reduce vascular complications, and improve long-term outcomes.

Worksite findings also suggest that traditional home-only blood pressure monitoring may underestimate daytime or work-associated elevations for some individuals. Encouraging employees to obtain serial workplace readings when feasible and share these data with clinicians may improve hypertension recognition and support more appropriate treatment decisions. Because many adults spend 40 or more hours per week at work, improving detection and management of workplace-elevated blood pressure may have downstream benefits not only for cardiovascular risk reduction, but also for energy, well-being, absenteeism, and overall work productivity.

Taken together, these results support accessible screening models that are paired with culturally responsive education, referral pathways, and follow-up support.