Barriers to diabetes self-management in the North Shoa Zone, Ethiopia: a qualitative study with patients and healthcare providers

Abstract

Background

Despite advanced behavioral interventions and programmes, many patients face complex barriers leading to poor self-care. Understanding these complex challenges and obstacles is crucial for promoting effective behavior change and empowering patients to manage their conditions independently. This study explored barriers to diabetes self-management among patient and health care provider.

Methods

A qualitative exploratory study was conducted in the North Shoa Zone from July 1 to July 30, 2024. The study included 20 diabetic patients and five health care providers selected with the maximum variation sampling method. Relevant data were collected from participants using interview guides and were recorded, translated and analyzed using ATLAS.ti v25 software. A thematic framework was employed to identify key codes, subthemes, and principal themes concerning the challenges and barriers associated with diabetes self-management behavior.

Results

In this study, the challenges and barriers to diabetes self-management behaviors were categorized into individual, interpersonal and community levels, including eight different subthemes. The key challenges and barriers identified include inadequate self-care knowledge, socioeconomic constraints, inadequate guidance, psychological factors such as low motivation and stress, limited social support, cultural influence and limited access to resources.

Conclusions

The main challenges and barriers to diabetes self-management fall on the individual, interpersonal and community levels. Addressing these issues requires integrated behavioral interventions, mental health support, stress management, and stronger community partnerships and helps individuals establish and achieve personal health goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26621-z.

Introduction

Diabetes mellitus (DM) represents a significant global health concern that currently affects 1.92 million adults in Ethiopia [1, 2]. Lifelong lifestyle changes and continuous behavioral adjustments are needed to achieve effective self-care and overall health in patients with diabetes [3–6]. Despite the implementation of advanced behavioral interventions, individuals with diabetes still face significant challenges in maintaining self-care practices and adhering to prescribed treatment regimens [7]. In Ethiopia, nonadherence to recommended self-care practices remains a critical public health challenge, despite the government’s ongoing efforts to address this issue [8–11]. Successful self-management of diabetes requires fundamental knowledge, skill development, lifestyle changes, and psychological support [12].

Although recommended self-care practices are essential for managing diabetes-related morbidity and mortality, adherence to these practices remains low due to systemic, personal, psychological, and behavioral barriers [6, 13]. Patients with diabetes encounter complex challenges and barriers, specifically individual, cultural, and health system-related issues that collectively impede effective management of their condition [14, 15]. An umbrella review revealed that psychological and behavioral factors are key influences on diabetes self-management [16]. A recent review identified psychosocial barriers to diabetic self-management, including cognitive-emotional factors, faith, and behavioral change constraints [17].

Various published reviews and studies identify barriers to diabetes self-management, such as limited knowledge, low motivation, lack of social support, economic constraints, high care costs, and restricted healthcare access [13, 16, 18]. As a result, diabetes prevention has become a global priority, emphasizing the need for comprehensive evidence on the barriers to effective management [16, 19].

Research in Ethiopia is limited, and existing studies present inconsistent evidence regarding the challenges and barriers faced [20–22]. Published quantitative studies in Ethiopia highlight barriers to effective diabetes self-management, including poor self-care knowledge, limited diabetes education, inadequate care services, insufficient collaboration, lack of provider training, socioeconomic constraints, limited support, psychological factors, cultural challenges, and restricted access to resources [13, 23–26]. A qualitative study in Ethiopia identified fragmented care, inadequate collaboration, and knowledge gaps among patients as significant barriers to effective diabetes self-management [23].

Given the complexity of barriers to diabetes self-management, comprehensive efforts to gather evidence and enhance patient self-care practices are essential [6]. Despite ample quantitative evidence on self-care barriers, qualitative insights into the challenges faced by diabetes patients in Ethiopia remain limited. The dominance of quantitative research limits an in-depth understanding of the challenges and barriers to effective diabetes self-management. In addition, self-management is complex in real life and requires the identification of barriers faced by both patients and healthcare providers, as highlighted by previous studies [27]. This study seeks to address this gap by examining the challenges and barriers through qualitative methods, allowing patients to share their personal experiences. In addition, understanding the challenges and barriers to diabetes self-care is crucial for creating personalized care plans and overcoming obstacles. This study examined barriers to diabetes self-management from the perspectives of patients and healthcare providers in the North Shoa Zone.

Method of study

Study setting and design

The study was conducted in the North Shoa Zone of the Amhara Region from July 1 to July 30, 2024. This zone, which borders Oromia, South Wollo, and Afar, includes 32 districts [28]. A qualitative exploratory approach was employed to investigate the challenges and barriers to diabetes self-management. This approach was employed to gain in-depth insights by enabling patients and healthcare providers to share their experiences and perspectives on diabetes self-management, including the associated barriers and challenges.

Population and sampling method

The study included 20 diabetic patients and five key informants from healthcare facilities. The number of interview participants was finalized when no new insights emerged, in line with established evidence [29, 30]. The inclusion of five key informants offered complementary insights and helped validate the findings from patients. Patients were recruited from four districts in the area, and five participants were interviewed from each district. All diabetic patients were asked by the data collectors and researchers to agree to participate. Participants were required to be older than 18 years and to live in the area. Patients who were unable to communicate during the data collection period were excluded from the study. The recruitment of diabetic patients was performed using a maximum variation sampling method, taking into account age, sex, marital status, occupation, and type of diabetes to capture a wide range of perspectives on the challenges and barriers to self-management.

Interview process and data collection method

Trained data collectors gathered and recorded the data under the supervision of the research team and two faculty members from Debre Berhan University. Research instruments were developed through literature reviews [31, 32] and expert feedback and subsequently validated by field experts. The interview guide was pretested for clarity and relevance in similar environments. The survey included hints to explore challenges and barriers to self-management and to gather suggestions for improvement. Informed consent was obtained, and an interview was conducted for 30 to 40 min at a convenient time and location.

Trustworthiness of the study

Qualitative researchers emphasize trustworthiness through credibility, dependability, transferability, and confirmability [33–37]. Credibility was ensured through triangulation, data saturation, and a comprehensive review of the interview guides, transcriptions, and coding. Dependability was maintained with careful documentation, regular error checks, and clear procedural descriptions. Confirmability was achieved by minimizing biases, validating results with feedback, and using investigator triangulation. The interviews were recorded, and the findings were peer reviewed to ensure transparency. Transferability was supported by diverse sampling methods and detailed descriptions of the study context and methods.

Researcher reflexivity statement

Throughout the study, we continuously reflected on our assumptions, biases, and experiences to maintain objectivity and minimize potential influence on data collection, analysis, and interpretation. The research team critically examined both the data and relevant literature, recognizing that our multidisciplinary backgrounds and prior experiences inevitably shaped our understanding of the context. The team had no direct engagement or formal relationships with participants during data collection. While we strived for neutrality, we acknowledge that personal perspectives may have subtly influenced interpretation. By addressing these factors, we aim to enhance transparency and encourage critical appraisal of our findings.

Data management and analysis method

Data transcription and analysis commenced immediately and were conducted concurrently with the data collection process. The data were translated into Microsoft Word and analyzed using ATLAS.ti v25 software, employing a thematic framework to identify key themes and explore participant perspectives [38, 39]. The analysis followed a thematic framework and was predominantly inductive, allowing themes to emerge directly from participants’ narratives. The analysis aimed to identify codes, subthemes, and overarching themes representing the challenges and barriers to diabetes self-management. A total of 18 codes were generated and systematically organized into five subthemes. Interviews were conducted face-to-face in Amharic, the participants’ local language, to facilitate open and accurate expression of experiences. All sessions were audio-recorded with informed consent, transcribed verbatim in Amharic, and subsequently translated into English for analysis (Fig. 1).

Fig. 1.

The data analysis followed a systematic process involving transcription, coding, and thematic development

Patient experiences with diabetes self-care barriers were organized into three main levels: individual, interpersonal and community. These were further divided into eight subthemes: lack of basic knowledge of self-care, psychological barriers, socioeconomic problems, lack of family and community support, provider-related barriers, cultural barriers and limited access to resources. The initial analysis identified 24 encoded statements that were organized under these subthemes. This structure has helped to improve our understanding of the challenges facing patients with diabetes management.

Finally, the themes were reviewed to ensure that they addressed the research questions. In addition, the narrative information was organized according to emerging themes and concepts directly related to the research questions. The analysis also included direct quotes from participants to reflect their views. The study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guidelines [40].

Results

Demographic and socioeconomic characteristics of the study participants

Sociodemographic profiles of patients with diabetes

The study included 20 in-depth interviews. Of these, 60% were men and 60% were middle-aged. Most respondents (60%) lived in urban areas, and 45% were not sure of a specific type of diabetes (Table 1).

Table 1.

Sociodemographic profiles of patients with diabetes in the North Shoa zone, Amhara region, Ethiopia, 2024

Variables	Frequency n (%)
Sex of the respondent
Male	12 (60%)
Female	8 (40%)
Age of the respondent
Young age (25–43)	6 (30%)
Middle age (44–60)	12 (60%)
Elderly age (> 61)	2 (10%)
Place of residence
Urban	8 (40%)
Rural	12 (60%)
The employment status of the respondents
Government employee	6 (30%)
Private/merchant	1 (5%)
Farmer	3 (15%)
Housewife	5 (25%)
Daily worker and self-worker	5 (25%)
Type of diabetes
Type one diabetes	4 (20%)
Type two diabetes	7 (35%)
I don’t know the type of diabetes	9 (45%)

Sociodemographic characteristics of the healthcare providers

The study included five health care providers interviewed by key informants, three men aged 25–44 years two of whom were internist doctors. All of them worked in chronic follow-up clinics and had an average of 2.2 years of experience (Table 2).

Table 2.

Sociodemographic characteristics of health care providers in the North Shoa Zone, Amhara Region, Ethiopia, 2024

Variables	Frequency n (%)
Sex of the respondent
Male	3 (60%)
Female	2 (40%)
Age of the respondent
The mean age of the respondent	30.5 ± 6.2
Young age (25–43)	3 (60%)
Middle age (44–60)	2 (40%)
Profession of the respondents
Physician	4 (80%)
Nurse	1 (20%)
Working experience of the respondents
Mean working experience	2.2 ± 1.32
Less than two year	2 (40)
Greater than two year	3 (60)

Diabetic self-management behaviors

Diabetes self-management behaviors were grouped into five subthemes: diet, exercise, adherence to medications, monitoring of blood glucose and foot care (Fig. 2). Self-management of diabetes is still a major challenge for many respondents, and they do not comply with recommended practices. Although most patients take antidiabetic medications, many patients face difficulties in monitoring blood sugar levels, maintaining food, engaging in regular exercise, and providing foot care. The health service providers reported that patients often ignore the recommendations for physical activity and diet adjustment despite continuous guidance.

Fig. 2.

A summary of self-management behaviors in the north Shoa zone, Amhara Region, Ethiopia, 2024

Barriers to diabetic self-management behaviors

The barriers to diabetes self-management are organized into three levels: individual, interpersonal and community. The participants were further divided into eight subthemes: lack of self-care knowledge, psychological barriers, socioeconomic problems, insufficient family support, provider-related challenges, cultural factors, and limited resource access (Table 3; Fig. 3).

Table 3.

Barriers to diabetic self-management behaviors in the North Shoa zone, Amhara Region, Ethiopia, 2024

Main theme	Sub-theme/categories	Selected coded statement
Individual-level barriers	Knowledge related factors/barrier	o Lacked sufficient knowledge and were unsure of what actions to take.
		o Did not know the appropriate exercises and how to perform blood sugar tests.
		o Lacked knowledge of the recommended food content, portions, and types.
		o Insufficient information on recommended foot inspections, washing, drying, and other foot care practices.
	Psychological barrier	o Motivated to follow to recommended self-care practices
		o Lacked personal motivation to follow the recommended self-management behaviors.
		o Negligent and impatient, with little attention to the disease, limits self-care adherence.
		o Stress and hopelessness affect adherence to recommended self-management behaviors.
	Socioeconomic factors/barriers	o Financial constraints and economic instability limit the following recommendations.
		o Limited income makes it difficult to afford self-care resources.
Barriers at the interpersonal level	Family support-related barriers	o Lack of family understanding and support to manage diabetes.
		o Received limited support from family members.
		o Preparing separate meals for a diabetic family member is difficult.
	Barriers related to community support	o Social gatherings and events impact self-care.
		o Community awareness of recommended actions is lacking.
		o There are no community programs or support groups for diabetes management available locally.
	Provider-related barrier	o Healthcare providers did not provide clear instructions or sufficient guidance on self-care.
		o No education on recommended self-care practices
		o Healthcare providers focus primarily on basic treatment and current blood sugar levels, neglecting overall well-being and feelings.
Community-level barriers	Culturally related barriers	o Social gatherings are a challenge for eating unhealthy food
		o Misconceptions about the disease and neglect of recommended care
	Availability and accessibility-related barrier	o Lack of access to a glucometer, with no knowledge of how to use one.
		o Inadequate access to diverse food options and exercise facilities in the locality.
		o Live in a remote area with limited access to diabetes management resources.

Fig. 3.

A summary of challenges and barriers to diabetes self-management behavior in the North Shoa Zone, Amhara Region, Ethiopia, 2024

Theme one. Individual-level barriers

Knowledge-related barriers

The most frequently cited difficulty in adopting the recommended self-management practice is the lack of knowledge about self-care practice. In the study, 45% of participants were unsure of their specific type of diabetes, indicating a substantial and fundamental knowledge gap. Health providers and patients highlighted the inability to understand a healthy diet, exercise, foot care and confusion about blood sugar monitoring as major obstacles. Many participants found that the lack of information on self-management made them uncertain as to what actions they should take, what exercises they should do, how often they should exercise and how to set up a coherent plan of physical activity. Doctors, nurses and diabetic patients agree that the lack of information limits the understanding of recommended foods and diet restrictions for diabetic patients.

“I am not familiar with different types of physical exercise beyond what my doctor says, which is walking. I do not have detailed instructions about other exercises and how they are performed. (A 45 and 54 years old T2DM patients)

“I have no experience with diabetes-friendly diet guidelines, but I understand the foods recommended and the foods that should be avoided.” (Woman, DM patients).

“I do not have enough details about the type and content of food suitable for diabetic patients, so I simply eat what I can find.” (Housewife, DM patient).

Most of the respondents were not informed that regular foot inspections and care for diabetic patients were recommended. Most participants neglected practices such as washing their feet with warm water, properly drying them, or providing appropriate foot care. They do not have information about how to inspect, wash and care for their feet effectively. Most patients do not know whether they can monitor blood sugar at home; they can only check blood sugar levels during follow-up visits.

“I do not regularly check my feet or know how to care for diabetic feet. I also did not know I had to monitor my blood sugar at home”. (28 and 57 farmer DM patients)

Psychologically related factors

The most common psychological barriers to diabetes self-care are lack of motivation, sadness, stress and anger. Many respondents struggled with personal motivation, but some still motivated themselves to follow the recommended self-management practices. Healthcare providers reported that limited understanding of the importance of self-management strategies contributes to low patient motivation. Health care providers reported that diabetic patients often felt frustrated with self-management advice and found it difficult to maintain effective self-care. In addition, most participants said that their motivation and acceptance of self-care practices were influenced by their level of pain and their severity of health.

“I have not focused much on my disease, and I have struggled to consistently follow the tasks of self-care. My unstable life also made it difficult to maintain regular exercise, food practices and other recommendations.” (47-year-DM patient).

“I neglect the recommended practices because of carelessness, impatience and frustration, which leads to frequent diseases and high blood sugar levels. (23-year old T1DM)

Many participants noted that stress is the main obstacle to self-care. They reported that fear and stress often prevented them from performing these practices. Some participants mentioned that despite diet and exercise management, increased blood sugar may cause confusion and increase stress and hopelessness.

“…when I feel hopeless and stressed, it is difficult to maintain effective self-care and often eat all available food.” (Housewives DM patients).

“I stopped taking the drug after my brother’s death, resulting in a consistently high blood sugar level of 250 mg/dL.” (55-year-old DM patients).

Socioeconomic-related factors

Financial restrictions are often cited by participants as major obstacles to diet changes, physical activity, glucose monitoring and other self-care activities. Participants noted that financial difficulties and limited access to key resources for diabetes treatment hampered patients’ access to quality health care. Due to limited income, healthy food costs made it difficult to follow the recommended diet. Participants frequently cited financial constraints arising from low incomes and socioeconomic status as major obstacles to adequate self-care.

“… My limited income and low socioeconomic status make it challenging to afford healthy diets and glucose meters. How can I manage my care effectively under these constraints? How do I access the variety of foods?” (57and 60 years-old DM patients).

Theme two. Interpersonal-level barriers

Family support-related factors

The participants strongly emphasized that family support was essential for compliance with recommended self-care practices. The authors stressed the importance of family assistance in maintaining a healthy diet, food preparation, reminders of medications, and other self-care tasks. Some participants noted that their families understood and supported their diabetes management needs, but most identified the lack of family support as a major obstacle to following the recommendations of self-care practices.

“… My family is concerned about my health and encourages me to eat a healthy diet.” (25 and 50 years old DM patients).

“I did not receive any family support and had to take care of all aspects of diabetes myself.” (Male DM patients).

Health care providers and diabetic patients often report that it is difficult to maintain a healthy diet because it is difficult to prepare separate meals for themselves and their families.

“I know that healthy diets are important, but I eat everything prepared at home. It is difficult to cook separate meals for me and my family.” (54-year-old DM patients).

Community support-related barrier

Health professionals and diabetic patients note that peer pressure and social events often lead to poor self-management behavior, especially unhealthy eating and irregular exercise. They reported being influenced by friends, colleagues, and relatives, particularly during social events like weddings, festivals, and religious celebrations where unhealthy foods were commonly consumed.

“I know the recommended food, but I eat forbidden food when I have fun with friends because my appetite takes over”. (22-years-old T1DM patient)

“Some patients with diabetes end up eating forbidden foods at festivals and social events because there are no healthy alternatives.” (Medical doctor).

“… At weddings, festivals and religious ceremonies, it is often difficult to find suitable foods for diabetics, so I eat what is available.” (Housewife DM patient).

Some participants noted that members of the community often refuse to take prescribed medicines. Individuals fear that the early use of medications means that there is no cure and that diabetes will be a lifelong condition. Some patients are concerned that medication combined with daily exercise could lead to low blood sugar levels. Health care providers have observed that patients and their families misunderstand that diabetes is caused by excessive consumption of carbohydrate-rich foods.

“… I feared that taking the medication would mean accepting diabetes as a permanent disease. I stopped taking the medicine, which caused complications and leg ulcers.” (28-year-old DM patient).

‘… Some members of the community believe that drugs combined with daily exercise can reduce blood sugar and reduce motivation for staying active (57-year-old patient).

Most participants agreed that there were no community programs or support groups available to treat diabetes in their area. They believe that such groups are necessary to support diabetes patients with education on a healthy diet, exercise and general advice.

“… Education and support are crucial because patients do not have a basic understanding of the recommended self-management behavior.” (Nurse professional).

Provider-related barriers

Despite the crucial role played by health care providers, the majority of participants indicated inadequacy and inconsistent self-care guidance, leading to unclear health care plans for their situation.

“I have been advised since the 2005 EC to avoid sweets and walks, but I have not received enough guidance or information on self-care practices.” (70-year-old T2DM).

“Even if I go to the hospital for serious health problems, I do not receive sufficient support or advice to manage my condition at home.” (55-year-old T2DM).

Some participants and service providers found that a high patient load results in limited and inconsistent advice. Due to time constraints, providers focus mainly on treatment, and patients lack guidance on self-care practices. Many participants lacked sufficient self-care guidance and required guidance on diet and exercise. However, nurses noted that some diabetic patients ignored doctors’ advice on diet, exercise and other forms of self-care.

“…when we come for treatment, we receive only basic care. Physicians should devote more time to educating us and raising awareness of the recommended practices. “(55-year-old T2DM).

“Even if health care providers are busy, they should provide education on nutrition, exercise and self-care practices at least once a month.” (50-year-old DM patient).

Some participants noted that doctors often focus on blood sugar levels, neglect patient emotional well-being, and lack sufficient support when patients feel stressed and lose interest in drugs.

“The doctor does not listen to my concerns even when the injection site is injured. I doubt the effectiveness of the medicine because my blood sugar has been remaining at 250 mg/dL for a long time. (41-year-old DM patient)

Theme three. Community-level barriers

Culturally related barriers

Some diabetes patients and service providers have noted that social gatherings such as weddings, holidays, and religious events contribute to unhealthy eating habits. They noted that healthy foods are often unavailable and that there is pressure from peers to eat unhealthy options.

“… Some diabetes patients eat forbidden foods at festivals and social events because there are no healthy food alternatives.” (Medical doctor).

“… At weddings, festivals and religious ceremonies, there is a lack of suitable food for diabetics, so I eat whatever is available.” (60-year-old DM patient).

Although not reported often, some people believe that diabetes is a disease of the rich. People who consider themselves poor can neglect self-care, such as eating, exercising and monitoring glucose, because they cannot afford or follow them.

Availability and accessibility-related barriers

Insufficient access to healthy food, medication, glucose monitoring and exercise facilities impedes diabetes self-management. Patients and health care providers have noted that these shortages are important obstacles. In addition, healthcare providers and patients highlighted the main barriers, including the lack of healthy foods, exercise facilities and affordability. They also reported that public hospitals often did not have prescription medications, forcing patients to buy them at high prices from private pharmacies. Furthermore, their living environment has further weakened access to essential care resources.

“I live in a remote area where access to basic resources such as healthy food, educational materials and exercise facilities is limited.” (57-year-old T2DM).

“Some diabetes patients do not have access to healthy food at home or eat what is available.” (Medical doctor).

“It is often difficult to eat a high-fiber and sugar-free food at home, and it is difficult to maintain a healthy diet due to the distance from the market and the high cost of the food.” (59-year-old T2DM patient).

Discussion

Barriers to diabetic self-management behavior

This study examined the challenges and key barriers to diabetic self-management in the North Shoa Zone. The study revealed that patients faced significant challenges in essential aspects of diabetic self-management, especially in monitoring blood sugar, following food guidelines, engaging in regular exercise, and implementing effective foot care. The study identified major barriers at the individual, interpersonal and community levels, including insufficient knowledge, economic constraints, insufficient guidance, low motivation and stress, limited social support, cultural influence and poor access to resources.

Barriers related to self-care knowledge

The study showed that the most common barrier to effective diabetes self-management was a lack of knowledge about essential practices that affected patients’ adherence to recommended self-care. Similar findings have been reported, with previous studies also identifying inadequate self-management knowledge as a key barrier to effective diabetes management [18, 32, 41–44]. A systematic review of high-income Western countries revealed that lack of knowledge is the most common reason for poor self-management of diabetes [45]. In Ethiopia, many people with diabetes lack a basic understanding of the recommended self-care practices, which hinders their ability to follow them effectively [23, 46]. Individualized education, counseling, goal-setting, and regular follow-up with culturally appropriate materials can improve diabetes knowledge and self-care adherence.

Specifically, in this study, most participants had insufficient basic self-care knowledge related to blood sugar monitoring, dietary guidelines, types of exercise, and foot care. Similarly, in previous studies in Ethiopia, there was a lack of basic understanding of specific recommended self-care practices [24, 46–50]. A study in Chennai showed that a lack of understanding of dietary habits made it difficult for individuals to adjust their eating habits [51]. A study in Western China showed that poor understanding of glucose monitoring led to noncompliance [52]. Implement individual-level interventions focusing on blood sugar monitoring, diet, exercise, and foot care, reinforced with counseling and regular follow-up to improve knowledge and self-care adherence.

Psychologically related barriers

This study found that low motivation, stress, sadness, and anger were key psychological barriers to diabetes self-management, aligning with previous research showing challenges in maintaining diet, exercise, foot care, and other self-care behaviors [18, 41, 43, 53]. An umbrella review identifies psychological factors as the primary barrier to adherence to diabetes self-management behaviors [16]. A study in Malawi found that concerns about their lifelong condition and psychosocial factors negatively affect patients’ diabetes self-management behaviors [54]. Ethiopian studies show many diabetic patients lack motivation for self-management, including diet, exercise, glucose monitoring, and medication adherence [13, 23–25]. This highlights the need to boost motivation and correct misconceptions, with mental health support, motivational strategies, and support groups essential for effective diabetes self-care.

In this study, stress was frequently cited as a barrier to self-management; a participant stopped medication after a brother’s death, leading to persistently high blood glucose (250 mg/dL). This aligns with previous findings that stress undermines diabetes management and reduces adherence to self-care behaviors [55]. Similarly, a phenomenological study in Qatar found that psychological distress significantly affects diabetes self-management [56]. A systematic review in high-income countries found that diabetes-related stress greatly hinders self-care adherence [45]. Stress management, counseling, and behavioral interventions should be integrated into routine care to enhance self-care adherence.

In this study, participants highlighted that hopelessness, pain, and frustration with self-care advice hindered self-management. This finding aligns with a study in Ghana, which reported that patients’ hopes and fears about diabetes adversely influenced their self-management practices [57]. Another study in Pakistan found that diabetic patients frequently experience frustration with self-management guidance and care plans [58]. Personalized guidance, supportive counseling, and fostering patients’ sense of responsibility are essential to reduce frustration and improve adherence to self-management. A study in Nepal found that patients with a strong sense of responsibility were more likely to take appropriate actions to manage their diabetes [41].

Socioeconomic-related barriers

Socioeconomic status greatly affects healthcare access. Participants reported financial constraints as major barriers to diet, exercise, glucose monitoring, and overall self-management, aligning with previous research [32, 59–61]. A recent study supports this finding, showing that low-income earners are more likely to adopt unhealthy dietary habits [62]. This study urges expanding affordable services, enhancing community programs, promoting supportive policies, and providing financial counseling to reduce economic barriers to diabetes self-management.

In the Ethiopian context, previous studies have identified financial constraints as a major barrier to diabetes self-management, particularly restricting dietary changes, glucose monitoring, and regular exercise [23, 63, 64]. Additionally, a study in Bahir Dar, Ethiopia, found that financial hardship significantly restricts diabetic patients’ access to timely and quality healthcare [65]. Targeted interventions are needed to alleviate financial burdens for diabetic patients at high risk of complications and hospitalization [62].

Barriers related to family support

Family support plays a crucial role in diabetic self-management, either facilitating or hindering it. This study found that lack of family support is a major barrier to adhering to recommended self-management practices. This finding is consistent with previous studies conducted in Nepal [41], Mumbai [53], Qatar [56] and Ethiopia [24, 25]. The study highlights the need for family-focused education and open communication to enhance family support in diabetes management. Previous evidence supports the positive impact of family behavior on dietary changes, blood glucose control, and overall diabetes self-management [66].

In this study, diabetic patients struggled to maintain a healthy meal plan due to the difficulty of preparing separate meals. Family meal planning should be adapted to diabetic needs, with families guided on the importance of balanced, diabetes-friendly diets. Studies in Ethiopia [24] and Ghana [57] highlight that preparing separate meals is difficult, as family members often insist on their usual meals rather than accommodating the patient’s dietary needs. A study in India found that families frequently do not support diabetic patients by preparing separate meals [61].

Barriers related to community support

In this study, peer pressure and social events contributed to poor self-management behavior, particularly unhealthy eating and irregular exercise. Published evidence also links inadequate social support to poor self-management [67]. Several studies in Ethiopia have confirmed that limited social support contributes to poor self-management practices [25, 46].

The study urges strengthening community support to help individuals set and achieve personal health goals, thereby enhancing self-management practices. Published evidence indicates that strong social support improves diabetes self-management and psychological well-being [68, 69]. In the Ethiopian context, community members play a key role in helping patients follow recommended dietary practices [64].

In this study, community members held misconceptions about early medication initiation, with some participants resisting treatment, believing it implies a lifelong dependency. Available evidence shows that misconceptions about early medication initiation affect both patients and community members [70]. A systematic review found that lack of support from significant others contributes to poor medication adherence [71].

In this study, some participants reported that community members believe that taking medication and participating in daily physical exercise together could lower blood glucose levels, which reduces the motivation to stay active. This finding is consistent with a study done in Nepal [72]. To address these misconceptions, the study recommends community education on the importance of combining consistent exercise with medication to maintain healthy blood glucose levels.

Barriers related to healthcare providers

In this study, guidance and counseling on self-management were inadequate and inconsistent, leaving patients without a clear plan. This aligns with a study done in Nepal, where patients received insufficient information and support due to limited counseling at each visit [41]. Despite inadequate and inconsistent healthcare support, participants emphasized that physician guidance, support, and communication are vital for effective diabetes self-management. Evidence shows that strong patient-provider relationships and clear communication are essential for promoting healthy behaviors [73, 74]. Additionally, healthcare providers should identify patients’ self-management challenges and actively engage them in consultations to enhance adherence [18].

In this study, limited time and high patient loads were identified as major barriers to effective counseling. A similar issue was observed in an Indian study, where physicians lacked sufficient time for proper patient counseling [61]. In rural Pakistan, physicians believe they provide quality care but struggle to understand why patients often ignore their advice, citing limited time as a key factor [58]. These findings show that limited time and high patient loads impede effective counseling, reducing patients’ adherence to diabetes management. Clinicians should prioritize patient-centered communication and adopt structured consultation strategies to improve self-management.

In this study, physicians focused more on blood sugar levels than on patients’ emotional well-being during stressful periods, reflecting on numerical targets. This aligns with a West Virginia study where providers prioritized numbers over patient concerns [75], highlighting a gap in patient-centered care and the need to integrate emotional and psychological support into diabetes management.

In the study, self-blood glucose monitoring and foot care were poorly understood and practiced due to insufficient information, guidance, and training. Similarly, a study in southwest Ethiopia found that inadequate information, guidance, and training contributed to poor self-management practices among patients [76].

Culturally related barriers

In the study, social gatherings and events such as weddings, holidays, and religious ceremonies negatively affected self-management, particularly dietary practices, due to limited healthy options and peer pressure. This finding aligns with studies in Qatar [56], Pakistan [60] and Ethiopia [24], where social gatherings and cultural food norms often lead to unhealthy dietary choices for people with diabetes. To improve self-management during social gatherings, provide healthier food options, raise awareness of diabetes-friendly meals, and foster peer support to encourage better choices.

A study in Indonesia found that Javanese culture strongly influences dietary management among diabetic patients, creating challenges during cultural events where sweet foods are commonly consumed [77]. Moreover, cultural barriers often hinder the effective implementation of diabetes self-management practices [78]. Evidence shows that cultural values and beliefs strongly influence self-management practices and health-seeking behaviors among individuals with diabetes [79].

Some participants perceived diabetes as a disease of the rich, leading to poor self-management among those with low income. Addressing this misconception requires awareness campaigns, culturally sensitive education, and accessible support for all socioeconomic groups.

Availability of essential resource-related barriers

In the study, limited access to essential resources such as healthy food, medications, glucometers, educational materials, and exercise facilities was found to greatly hinder effective diabetes self-management. Both patients and healthcare providers identified these shortages as major barriers, emphasizing that environmental constraints limit access to essential resources. Similarly, previous studies have shown that lack of access to nutritious food and exercise facilities in local settings hinders effective self-management [80]. In resource-limited countries, the lack of essential self-management resources within communities often hinders effective diabetes management [32].

Limitations of the study

This study highlights the need for healthcare professionals to address diabetes self-management barriers at the individual, interpersonal, and community levels through integrated, patient-centered interventions. However, the study has some limitations. The absence of family caregivers and social workers limited the breadth of perspectives, and including them in future research would strengthen data triangulation and contextual understanding. As the study was conducted in one geographic zone, the findings are not statistically generalizable but provide valuable, transferable insights. Additionally, social desirability bias may have influenced participant responses during interviews.

Conclusion

The study identified major challenges to diabetes self-management at individual, interpersonal, and community levels, categorized into eight subthemes: insufficient knowledge and self-care practices, social and economic constraints, inadequate guidance and support, psychological factors such as low motivation and stress, limited social support, cultural influences, and restricted access to resources. Notably, 45% of participants were unsure of their specific type of diabetes, highlighting a substantial knowledge gap. These findings suggest that the interplay of limited knowledge with psychosocial and systemic barriers is the key obstacle to effective self-management, emphasizing the need for patient-centered, multi-level interventions that address knowledge deficits, reduce psychological distress, alleviate financial burdens, and strengthen cultural, community and health system support.

Implications for practice

The study revealed that insufficient diabetes self-management stems from barriers at the individual, interpersonal, and community levels. To address these challenges, practical and coordinated interventions are essential. Developing visual, low-literacy educational materials on foot care, glucose monitoring, and healthy eating using locally available foods can improve understanding and daily practice. Integrating mental health and stress management, establishing peer support groups, and introducing motivational strategies will enhance adherence and self-efficacy. Training healthcare providers in patient-centered communication and empathy, along with raising community awareness that diabetes affects all socioeconomic groups, can create supportive environments for behavior change. Ensuring accessible and continuous support services through collaboration with community organizations will further promote sustainable self-care.

The study also calls for increased access to affordable healthcare services, stronger community partnerships, and policy support to address financial and structural barriers to diabetes management. Community-based programs and advocacy efforts should aim to ensure equitable access to essential resources such as nutritious food, medications, glucose monitors, educational materials, and exercise facilities.

Furthermore, implementing family-focused counseling can help integrate diabetic-friendly diets into shared family meals and strengthen family support for diabetes management. Educating families about balanced, culturally appropriate meal options and encouraging open communication can enhance adherence to dietary recommendations. Establishing support networks, promoting healthy social events, increasing awareness of diabetes-friendly foods, and encouraging peer support can positively influence social decisions related to food and lifestyle. Finally, helping individuals set and achieve personal health goals can empower them to manage social influences and maintain long-term self-care behaviors.

Abbreviations

EC

Ethiopian calendar

T2DM

Type 2 diabetes mellitus

T1DM

Type 1 diabetes mellitus

Authors’ contributions

Conceptualization: Akine Eshete, Prof David D. Mphuthi, Data curation: Akine Eshete.Formal analysis: Akine Eshete.Funding acquisition: Akine Eshete.Investigation: Akine Eshete, Prof David D. Mphuthi.Project administration: Akine Eshete, Prof David D. Mphuthi, Software: Akine Eshete, Prof David D. Mphuthi, Dr.Abera Lembebo, Dr. Lemma Getacher, Dr. Tewodros Kifleyohans, Dr.Yibeltal Assefa.Supervision: Akine Eshete, Prof David D. Mphuthi, Validation: Akine Eshete, Prof David D. Mphuthi, Visualization: Akine Eshete, Prof David D. Mphuthi, Writing – original draft: Akine Eshete, Prof David D. Mphuthi, Dr.Abera Lembebo, Dr. Lemma Getacher, Dr. Tewodros Kifleyohans, Dr.Yibeltal Assefa.Writing – review & editing: Akine Eshete, Prof David D. Mphuthi, Dr.Abera Lembebo, Dr. Lemma Getacher, Dr. Tewodros Kifleyohans, Dr.Yibeltal Assefa.

Funding

This research was supported by Debre Berhan University and the University of South Africa. The funder has not participated in the study design, collection of data, analysis, publication decision or manuscript preparation.

Data availability

All data generated in this study are fully included in the manuscript. For any additional data requests, anyone contact the corresponding author with [akine.eshete@yahoo.com](mailto: akine.eshete@yahoo.com).

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Review Committee of the Asrat Woldeyes Health Science Campus at Debre Berhan University and the Ethics Review Committee of the University of South Africa’s School of Human Sciences (Approval No:19833555_CREC_CHS_2024). Permission was also obtained from the appropriate administrators. The study did not any risk or inconvenience to participants. All research procedures strictly adhered to the 2008 Declaration of Helsinki [81]. Written informed consent was obtained from all participants. Participant confidentiality was ensured by removing all identifiers from the questionnaires, and all data were handled with strict confidentiality throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.