Abstract
Purpose
This study aimed to examine the level of adherence to self-care behaviors across socio-demographic and clinical characteristics in patients with type 2 diabetes mellitus (T2DM).
Methods
A total of 270 patients with diabetes who were referred to two medical centers in Gorgan, Iran, participated in this cross-sectional study. We assessed adherence using a reliable questionnaire, the Summary of Diabetes Self-Care Activities (SDSCA). The anthropometric measurements and blood pressure were assessed based on a standard protocol. The biochemical variables were gathered based on the medical documents of the centers. To compare adherence scores across clinical and demographic variables, independent t-test and ANOVA were used. A p-value less than 0.05 was considered statistically significant.
Results
The mean age of participants was 57.16 ± 9.20 years, and nearly 66% of patients were female. The mean SDSCA score was 3.50 ± 0.87. Regarding self-care domains, the highest adherence scores were observed for medication use (6.07 ± 1.42) and foot care (6.05 ± 1.50), while blood glucose monitoring (2.16 ± 1.89) yielded the lowest score. A significant difference was observed between adherence scores and better glycemic control (P<0.001) and a more favorable lipid profile (P=0.001). No significant difference was observed between factors such as age, gender, duration of diabetes, BMI, and type of medication used with total score adherence.
Conclusion
Overall adherence to self-care practices among T2DM patients was suboptimal. Moreover, higher adherence to self-care behaviors is associated with a better metabolic situation. Targeted educational and awareness programs are recommended to enhance self-care behaviors and optimize metabolic outcomes in this population.
Keywords: diabetes mellitus, self-care, SDSCA, blood glucose
Introduction
Type 2 diabetes mellitus (T2DM) is a growing concern throughout the world, making up more than 96% of all diabetic cases.1 In 2021, 537 million people were living with diabetes globally. This represents a 90.5% increase in prevalence since 1990. It is predicted that by 2045, the number of people with diabetes will increase to nearly 800 million.2 Likewise, the estimated prevalence of T2DM in Iran is between 10% and 15%, and experienced a 417% increase in total cases between 1990 and 2019.3 Based on data from the International Diabetes Federation, Iran ranks third in the Middle East in terms of its diabetic population.4 Furthermore, diabetes is among the top causes of death in Iran, ranking seventh, with a rate of 14 deaths per 100,000 population.5
The individual and societal burden, complications, and mortality related to diabetes can be reduced by proper disease management.6 The effective treatment and control of diabetes rely heavily on self-management.7 Therefore, patients are advised to adhere to a treatment plan that includes taking anti-hyperglycemic medications, following a healthy diet, and engaging in regular exercise.8 The combination of these activities, along with regular blood sugar testing and foot care, is considered the major domains of diabetes self-care based on the Summary of Diabetes Self-Care Activities (SDSCA).9 SDSCA is a standardized tool designed to assess adherence to recommended diabetes self-care behaviors.9 Self-care behaviors are not only cost-effective for individuals but are also strongly associated with lower HbA1c levels, a reduced risk of chronic complications, and improved quality of life.10,11
Recent research indicates that adherence to treatment and self-care behaviors among patients with T2DM is often at a moderate or suboptimal level.12–17 Lack of sufficient knowledge and awareness in performing self-care activities increases the burden of disease and leads to more admissions and visits to hospitals.14 Although previous studies have assessed adherence to treatment in type 2 diabetes, most have focused primarily on individual components, particularly medication adherence.18–21
Given the increasing prevalence of T2DM in Iran, it is essential to examine patients’ adherence to self-care behaviors and therapeutic interventions. Furthermore, most research has measured the association of self-care behaviors with socio-demographic characteristics,14,22–24 and fewer studies, especially in Iran, have aimed to examine the self-care status in different clinical and metabolic characteristics, including glycemic control, lipid profile, blood pressure, body mass index (BMI), duration of diabetes and type of diabetes medication. It seems that a comprehensive assessment of these domains may provide a more accurate understanding of patients’ adherence patterns. Therefore, this study aimed to investigate the level of adherence to self-care behaviors in different socio-demographic characteristics and clinical situations in T2DM patients.
Methods and Materials
Study Design and Population
In the present cross-sectional study, 270 patients with T2DM were recruited between December 2024 and March 2025. Patients were entered to the study based on simple random sampling method. Patients aged between 18 and 65, who were referred to Dezyani and Sayyad Shirazi medical centers in Gorgan entered the study. The protocol of this research was approved by the ethical committee of Golestan University of Medical Sciences (IR.GOUMS.REC.1403.292). The diagnosis of T2DM was considered based on (FBG ≥ 126 mg/dl or 2-hour postprandial plasma glucose ≥ 200 mg/dl or HbA1c ≥ 6.5%).25 Participants were excluded from the study if they met any of the following criteria: cancer, end-stage renal failure, cirrhosis, or congestive heart failure. Sample size was calculated via OpenEpi 2.3 software, based on the %10 prevalence of DM,26 95% confidence interval, a 0.05 margin of error, 10% non-response rate the number of participants was estimated 270 patients. At first, the process of the study was illustrated for eligible patients, and a written consent form was gathered by patients willing to participate in the current research.
Data Collection Tools and Methods
Data were collected through face-to-face interviews. A self-developed questionnaire was used to collect demographic data (age, gender, education, employment and marital status) and clinical factors (comorbidities, duration of diabetes, type of medication). The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire is a standard tool for assessing self-care behaviors in patients with T2DM. It was originally developed by Toobert et al.9 The Persian version was used to evaluate adherence to self-care behaviors (diet, physical activity, blood glucose monitoring, foot care, and smoking). Previous studies reported acceptable internal consistency for the Persian SDSCA, with Cronbach’s alpha ranging from 0.68 to 0.95.13,27–30 Each item of the questionnaire asks how many days (0–7) during the past 7 days the individual performed the behavior. The score for each domain is calculated as the mean of the items within that domain, and the overall questionnaire score is calculated as the average of all domain scores. Within the smoking domain, participants reported the number of days during the preceding 7 days on which they had smoked a cigarette, including occasions involving even a single puff. Scoring was based on 0–7 scale, with 0 indicating no days of smoking and 7 indicating smoking on all 7 days. Therefore, vs the other self-care domains, a lower score indicates fewer days of smoking and consequently better health behavior. The smoking score was included in the calculation of the overall questionnaire score using its original scoring and was not reverse coded.9
In addition, biochemical variables including fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), total cholesterol (TC), and triglyceride (TG) were extracted from the patients’ medical records. Researchers used only the biochemical values that were recorded during one month ago. Blood pressure was measured twice after 15 minutes of rest, and the average was reported. Furthermore, weight was measured using a digital scale with an accuracy of 100 grams, and height was assessed with a non-elastic tape with an accuracy of 0.5 cm. BMI was calculated based on the formula: weight (kg) / height (m)2.31
Statistical Analysis
In the present study, statistical analysis was conducted using SPSS version 21. The Kolmogorov–Smirnov test was used to assess the normality of data. The quantitative and qualitative data were reported as mean ± standard deviation and frequency (percentage), respectively. To compare qualitative variables, the chi-square test was used. Independent t-test and ANOVA were used to compare continuous variables between groups. Assumptions of quantitative analysis, including the normal distribution and homogeneity of variances, were checked before performing analyses. A p-value less than 0.05 was considered statistically significant. The analysis included all 270 participants and no subjects were excluded due to missing data.
Results
The demographic variables of participants are illustrated in Table 1. The mean age of subjects was 57.16 ± 9.20 years, and the mean duration of diabetes was 13.52 ± 8.26 years. Nearly %66.6 of the participants were female. The mean and standard deviation of BMI of patients was in the overweight range (28.95 ± 3.67).
Table 1.
Demographic and Clinical Characteristics of Participants
| Variable | Value |
|---|---|
| Age (years) | 57.16 ± 9.20 |
| BMI (kg/m2) | 28.95 ± 3.67 |
| Duration of diabetes (years) | 13.52 ± 8.26 |
| SBP (mmHg) | 129.33 ± 18.87 |
| DBP (mmHg) | 71.78 ± 17.43 |
| FBS (mg/dL) | 173.88 ± 55.67 |
| HbA1c (%) | 8.24 ± 1.47 |
| TG (mg/dL) | 162.47 ± 109.06 |
| Cholesterol (mg/dL) | 151.25 ± 48.16 |
| Gender | |
| Male | 90 (33.3) |
| Female | 180 (66.6) |
| Type of medication | |
| Oral | 175 (64.8) |
| Insulin | 95 (35.2) |
| Employment status | |
| Employed | 69 (25.5) |
| Non-employed | 201 (74.4) |
| Comorbidities* | |
| Yes | 192 (71.1) |
| No | 78 (28.8) |
| Marital Status | |
| Married | 258 (95.5) |
| Single | 12 (4.4) |
Notes: Data are reported as mean ± SD for continuous variables and as frequency and percentage [n (%)] for categorical variables. *Comorbidities include dyslipidemia, coronary artery disease, thyroid disorder, and history of cardiovascular surgery/MI.
Abbreviations: BMI, Body Mass Index; SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure; FBS, Fasting Blood Sugar; HbA1c, Glycated Hemoglobin; TG, Triglycerides.
Totally, the average SDSCA score was 3.50 ± 0.87. Regarding SDSCA domains, the highest adherence scores were observed for medication use (6.07 ± 1.42) and foot care (6.05 ± 1.50), while blood glucose testing yielded the lowest score (2.16 ± 1.89) (Table 2). The score for the smoking subscale was low (0.23 ± 1.26); since a lower smoking score reflects fewer days of smoking (a positive self-care behavior), this indicates that the majority of participants were non-smokers. Regarding the metabolic status, 50.3% of participants had FBG levels ≥151 mg/dL (upper median), and 52.5% had HbA1c levels ≥7.9% (upper-median). Additionally, elevated systolic (SBP) and diastolic blood pressure (DBP) were observed in 32.2% and 47.4% of patients, respectively. Furthermore, about half of the participants showed elevated triglyceride (49.6%) and total cholesterol (48.5%) levels. Statistical analysis demonstrated that patients with FBG <151 mg/dL showed significantly higher scores than those with FBG ≥151 mg/dl (3.70 ± 0.76 vs 3.29 ± 0.92, p < 0.001). Similarly, adherence scores in patients with HbA1c <7.9% were significantly higher compared with those with HbA1c ≥7.9% (3.73 ± 0.82 vs 3.28 ± 0.86, p < 0.001). Also, major differences were found for the lipid profile, where patients with TG (<143.5) and total cholesterol (<145.5) levels below the median demonstrated higher adherence than those in the upper median (p = 0.001 for both). In contrast, there were no significant differences between the upper and lower medians of ages and duration of diabetes, females and males, blood pressure situation, BMI categories, and type of treatment (Table 3).
Table 2.
Total Score and Subscales of Treatment Adherence in Patients with Type 2 Diabetes
| Adherence Domain | Mean ± SD | Range (Min–Max) |
|---|---|---|
| Diet | 3.47 ± 1.66 | 0–7 |
| Physical activity | 3.00 ± 1.99 | 0–7 |
| Blood sugar testing | 2.16 ± 1.89 | 0–7 |
| Foot care | 6.05 ± 1.50 | 0–7 |
| Medication | 6.07 ± 1.42 | 0–7 |
| Smoking | 0.23 ± 1.26 | 0–7 |
| Total SDSCA score | 3.50 ± 0.87 | 0.8–5.8 |
Note: Data are presented as mean ± standard deviation (SD).
Table 3.
Comparison of Mean Total Treatment Adherence Score by Demographic and Clinical Variables
| Variable | N (%) | Mean ± SD | p-value | Effect Estimate (95% CI) |
|---|---|---|---|---|
| *Age (years) | 0.283 | −0.11 (−0.32 - 0.09) | ||
| <60 | 141 (52.2) | 3.44 ± 0.92 | ||
| ≥60 | 129 (47.7) | 3.56 ± 0.90 | ||
| *FBS (mg/dL) | <0.001 | 0.41 (0.21–0.61) | ||
| <151 | 134 (49.6) | 3.70 ± 0.76 | ||
| ≥151 | 136 (50.3) | 3.29 ± 0.92 | ||
| *HbA1c (%) | <0.001 | 0.44 (0.24–0.64) | ||
| <7.9 | 128 (47.4) | 3.73 ± 0.82 | ||
| ≥7.9 | 142 (52.5) | 3.28 ± 0.86 | ||
| *Medication type | 0.576 | −0.06 (−0.28 – 0.15) | ||
| Oral | 175 (64.8) | 3.47 ± 0.87 | ||
| Insulin | 95 (35.1) | 3.53 ± 0.87 | ||
| *DBP (mmHg) | 0.589 | 0.05 (−0.15 – 0.26) | ||
| Normal (<90) | 142 (52.5) | 3.52 ± 0.92 | ||
| High (≥90) | 128 (47.4) | 3.46 ± 0.80 | ||
| *SBP (mmHg) | 0.213 | 0.14 (−0.08 to 0.36) | ||
| Normal (<130) | 183 (67.7) | 3.54 ± 0.86 | ||
| High (≥130) | 87 (32.2) | 3.40 ± 0.88 | ||
| *TG (mg/dL) | 0.001 | 0.35 (0.15–0.56) | ||
| Normal (<143.5) | 136 (50.3) | 3.67 ± 0.82 | ||
| High (≥143.5) | 134 (49.6) | 3.31 ± 0.87 | ||
| *Total cholesterol (mg/dL) | 0.001 | 0.35 (0.15–0.55) | ||
| Normal (<145.5) | 139 (51.4) | 3.66 ± 0.81 | ||
| High (≥145.5) | 131 (48.5) | 3.31 ± 0.88 | ||
| *Gender | 0.908 | −0.01 (−0.23 – 0.20) | ||
| Male | 90 (33.3) | 3.49 ± 0.91 | ||
| Female | 180 (66.6) | 3.50 ± 0.85 | ||
| *Duration of diabetes (years) | 0.420 | 0.09 (−0.13 – 0.31) | ||
| <14 | 178 (65.9) | 3.52 ± 0.91 | ||
| ≥14 | 92 (34.0) | 3.43 ± 0.77 | ||
| **BMI (kg/m2) | 0.864 | - | ||
| Normal (<24.9) | 48 (17.7) | 3.55 ± 0.87 | ||
| Overweight (25–29.9) | 110 (40.7) | 3.50 ± 0.92 | ||
| Obese (≥30) | 112 (41.8) | 3.47 ± 0.81 | ||
| **Education level | 0.068 | - | ||
| Group 1 (Illiterate) | 66 (24.4) | 3.30 ± 0.80 | ||
| Group 2 (Lower Diploma) | 109 (40.3) | 3.50 ± 0.86 | ||
| Group 3 (Diploma) | 74 (27.4) | 3.54 ± 0.90 | ||
| Group 4 (University) | 21 (7.7) | 3.90 ± 0.88 |
Notes: *Comparisons were performed using the independent-samples t-test.95% CI, 95% confidence interval for the mean difference between the two groups. **Comparisons were performed using one-way ANOVA. BMI cut-off points were defined based on WHO criteria (17). For all other variables, cut-off points were determined based on the median values.
Abbreviations: BMI, Body Mass Index; SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure; FBS, Fasting Blood Sugar; HbA1c, Glycated Hemoglobin; TG, Triglycerides.
Further analysis of the SDSCA subscales revealed differences across clinical characteristics. For instance, patients with FBG <151 mg/dL had higher adherence scores in diet (p < 0.001), foot care (p = 0.028), and medication (p = 0.003) subscales. Also, patients with lower-median of blood glucose (HbA1c <7.9) had a higher adherence to diet (p < 0.001), physical activity (p < 0.001), and blood glucose monitoring (p = 0.04). Moreover, patients who were in the lower median of TG and TC levels had a higher adherence to the diet (p < 0.001) and physical activity (p = 0.001) subscales. Exercise scores were significantly different across BMI categories (p = 0.038) and levels of education (p = 0.001). A major difference was found between gender and adherence to exercise (p = 0.006), foot care (p = 0.042), and smoking (p = 0.032). Men had higher exercise scores, whereas women demonstrated higher scores for foot care and lower scores for smoking (as a positive self-care behavior). An impressive difference was also observed between various age categorizes and the smoking subscale (p = 0.016) (Table 4).
Table 4.
Self-Care Subscales Scores in Different Demographic/Clinical Characteristics
| Variable | Diet | Exercise | Blood Sugar Testing | Foot Care | Medication | Smoking |
|---|---|---|---|---|---|---|
| Age (years) | ||||||
| <60 | 3.40 ± 1.70 | 2.92 ± 1.81 | 2.21 ± 1.88 | 6.10 ± 1.41 | 5.98 ± 1.47 | 0.05 ± 0.59 |
| ≥60 | 3.55 ± 1.63 | 3.08 ± 2.18 | 2.11 ± 1.91 | 6.00 ± 1.61 | 6.17 ± 1.38 | 0.43 ± 1.70 |
| p-value | 0.460 | 0.525 | 0.670 | 0.587 | 0.270 | 0.016 |
| Gender | ||||||
| Male | 3.28 ± 1.59 | 3.47 ± 2.04 | 1.98 ± 1.81 | 5.79 ± 1.71 | 5.96 ± 1.56 | 0.47 ± 1.76 |
| Female | 3.57 ± 1.69 | 2.76 ± 1.93 | 2.25 ± 1.93 | 6.18 ± 1.38 | 6.13 ± 1.35 | 0.12 ± 0.90 |
| p-value | 0.175 | 0.006 | 0.264 | 0.042 | 0.348 | 0.032 |
| FBS (mg/dL) | ||||||
| <151 | 3.98 ± 1.70 | 3.19 ± 2.04 | 2.27 ± 1.91 | 6.25 ± 1.32 | 6.33 ± 1.26 | 0.21 ± 1.20 |
| ≥151 | 2.97 ± 1.47 | 2.80 ± 1.93 | 2.05 ± 1.87 | 5.85 ± 1.65 | 5.81 ± 1.54 | 0.26 ± 1.33 |
| p-value | <0.001 | 0.105 | 0.348 | 0.028 | 0.003 | 0.744 |
| HbA1c (%) | ||||||
| <7.9 | 3.91 ± 1.63 | 3.47 ± 2.13 | 2.41 ± 1.99 | 6.21 ± 1.34 | 6.23 ± 1.29 | 0.17 ± 1.07 |
| ≥7.9 | 3.08 ± 1.59 | 2.57 ± 1.76 | 1.94 ± 1.78 | 5.91 ± 1.63 | 5.93 ± 1.52 | 0.30 ± 1.41 |
| p-value | <0.001 | <0.001 | 0.040 | 0.098 | 0.086 | 0.398 |
| Medication Type | ||||||
| Oral | 3.53 ± 1.66 | 2.97 ± 1.96 | 2.09 ± 1.94 | 6.01 ± 1.54 | 6.05 ± 1.50 | 0.20 ± 1.17 |
| Insulin | 3.35 ± 1.67 | 3.05 ± 2.07 | 2.28 ± 1.81 | 6.12 ± 1.45 | 6.11 ± 1.28 | 0.30 ± 1.43 |
| p-value | 0.424 | 0.732 | 0.440 | 0.582 | 0.736 | 0.534 |
| SBP (mmHg) | ||||||
| <130 | 3.46 ± 1.64 | 3.03 ± 2.09 | 2.19 ± 1.98 | 6.10 ± 1.40 | 6.21 ± 1.21 | 0.27 ± 1.35 |
| ≥130 | 3.49 ± 1.71 | 2.93 ± 1.79 | 2.10 ± 1.69 | 5.95 ± 1.71 | 5.77 ± 1.77 | 0.16 ± 1.06 |
| p-value | 0.913 | 0.710 | 0.743 | 0.463 | 0.016 | 0.525 |
| DBP (mmHg) | ||||||
| <90 | 3.56 ± 1.71 | 3.10 ± 2.05 | 2.17 ± 1.95 | 6.03 ± 1.58 | 6.09 ± 1.44 | 0.20 ± 1.16 |
| ≥90 | 3.37 ± 1.61 | 2.88 ± 1.92 | 2.15 ± 1.83 | 6.08 ± 1.43 | 6.05 ± 1.41 | 0.28 ± 1.37 |
| p-value | 0.342 | 0.374 | 0.933 | 0.784 | 0.799 | 0.612 |
| Triglyceride (mg/dL) | ||||||
| <143.5 | 4.01 ± 1.68 | 3.38 ± 2.04 | 2.25 ± 1.85 | 6.04 ± 1.56 | 6.13 ± 1.33 | 0.26 ± 1.32 |
| ≥143.5 | 2.92 ± 1.46 | 2.61 ± 1.87 | 2.07 ± 1.94 | 6.07 ± 1.46 | 6.02 ± 1.52 | 0.21 ± 1.20 |
| p-value | <0.001 | 0.001 | 0.430 | 0.867 | 0.528 | 0.761 |
| Cholesterol (mg/dL) | ||||||
| <145.5 | 3.87 ± 1.73 | 3.38 ± 2.06 | 2.32 ± 1.93 | 6.10 ± 1.50 | 6.14 ± 1.32 | 0.20 ± 1.17 |
| ≥145.5 | 3.05 ± 1.48 | 2.58 ± 1.84 | 1.99 ± 1.84 | 6.00 ± 1.52 | 5.99 ± 1.53 | 0.27 ± 1.35 |
| p-value | <0.001 | 0.001 | 0.160 | 0.584 | 0.384 | 0.660 |
| Duration of Diabetes | ||||||
| <14 years | 3.43 ± 1.64 | 3.03 ± 1.99 | 2.29 ± 1.98 | 6.10 ± 1.53 | 6.12 ± 1.45 | 0.20 ± 1.16 |
| ≥14 years | 3.55 ± 1.71 | 2.93 ± 2.00 | 1.90 ± 1.67 | 5.96 ± 1.45 | 5.98 ± 1.38 | 0.31 ± 1.44 |
| p-value | 0.586 | 0.715 | 0.109 | 0.456 | 0.447 | 0.495 |
| BMI (kg/m2) | ||||||
| Normal (<24.9) | 3.55 ± 1.59 | 4.53 ± 2.10 | 2.12 ± 1.64 | 5.96 ± 1.56 | 6.00 ± 1.56 | 0.14 ± 0.99 |
| Overweight (25–29.9) | 3.62 ± 1.83 | 2.86± 2.07 | 2.15 ± 2.97 | 6.08 ± 1.46 | 5.95 ± 1.55 | 0.38 ± 1.59 |
| Obese (≥30) | 3.31 ± 1.53 | 2.92 ± 1.86 | 2.18 ± 1.92 | 6.06 ± 1.52 | 6.23 ± 1.20 | 0.13 ± 0.94 |
| p-value | 0.372 | 0.038 | 0.533 | 0.889 | 0.318 | 0.280 |
| Education Level | ||||||
| Group 1 (Illiterate) | 3.20 ± 1.55 | 2.24 ± 1.52 | 1.89 ± 1.70 | 6.18 ± 1.29 | 5.89 ± 1.42 | 0.42 ± 1.68 |
| Group 2 (Lower Diploma) | 3.56 ± 1.62 | 3.02 ± 2.13 | 2.06 ± 1.89 | 6.12 ± 1.46 | 6.13 ± 1.42 | 0.13 ± 0.94 |
| Group 3 (Diploma) | 3.42 ± 1.74 | 3.38 ± 1.98 | 2.45 ± 2.02 | 5.69 ± 1.79 | 6.07 ± 1.55 | 0.28 ± 1.39 |
| Group 4 (University) | 4.06 ± 1.98 | 4.00 ± 1.80 | 2.59 ± 2.00 | 6.53 ± 1.07 | 6.24 ± 1.03 | 0.00 ± 0.00 |
| p-value | 0.234 | 0.001 | 0.248 | 0.083 | 0.708 | 0.404 |
Notes: Data are presented as Mean ± Standard Deviation (SD). Comparisons were performed using independent-samples t-test for two-group variables and one-way ANOVA for variables with more than two groups (BMI and Education Level).
Abbreviations: BMI, Body Mass Index; SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure; FBS, Fasting Blood Sugar; HbA1c, Glycated Hemoglobin; TG, Triglycerides.
Discussion
In the present study, the overall level of adherence to treatment recommendations based on the SDSCA questionnaire was moderate (3.50 ± 0.87 out of 7), and patients with a lower median of FBG and HbA1c had a higher score of self-care. No significant difference was shown between factors such as age, gender, duration of diabetes, BMI, and type of medication used with overall score adherence.
The findings of the present study were consistent with the results of Bekele et al14 and Yekta et al,24 who reported moderate or suboptimal adherence. Our findings indicated that adherence to self-care behaviors can be have beneficial effects on blood glucose control and a more favorable lipid profile, emphasizing the important role that adherence plays in effective diabetes management. Similarly, in the study by Wondom et al,32 higher levels of self-care activities, including diet, foot care, exercise, blood glucose testing, and total SDSCA score, were significantly linked to lower-median of glycemic indices. Likewise, studies conducted in Jordan, Pakistan, and Canada showed that blood glucose monitoring, diet, and physical activity were strongly correlated with better glycemic control and reduced HbA1c levels.33–35
According to this study, the highest levels of adherence were related to medication and foot care, respectively. The lowest level of adherence was observed for blood sugar monitoring, similar to the findings of Wondom et al.32 However, in a study conducted in China, in addition to blood sugar monitoring, foot care received a low score.36 Shojaei et al,13 illustrated that adherence to self-care behaviors in southwestern regions of Iran, also reported the lowest level of adherence related to physical activity and foot care, whereas in our study, foot care was among the items with high adherence.
The findings regarding the types of medications and diabetes self-care practices are inconsistent. In our study, no difference was observed between the type of medication used (insulin and oral hypoglycemic drugs) and self-care adherence. Another study revealed that patients who inject insulin had a higher level of self-care adherence.24 In a study conducted in Ethiopia, patients who used a combination of oral agents and insulin injections showed greater adherence.37
On the other hand, although we did not observe a significant difference between education level and overall adherence, but studies in Iran24 and Lebanon23 showed that patients with higher education had better self-care adherence. These discrepancies may be due to differences in study design, differences in health systems, and instruments used to measure adherence. In addition, differences in cultural and socioeconomic conditions play an important role in shaping the results.
The moderate level of self-care adherence observed in this study reflects the inherent difficulty of self-management for a long-term control of T2DM. A study investigated that self-efficacy, social support, and disease awareness as key determinants of self-care adherence, whereas significant barriers of self-care are medication side effects and treatment complexity.38 It appears that self-care is associated more with the patient’s behaviors and awareness than with demographic characteristics. Previous studies have shown that patients who are unaware of their blood glucose levels tend to have poorer adherence to treatment.14,39 Educational interventions may therefore serve as a practical strategy for supporting self-care behaviors, especially when they are delivered consistently and tailored to individual needs. These approaches may help patients follow treatment recommendations more effectively and reduce HbA1c levels.40 In addition, digital health tools such as mobile applications may support self-care adherence. Therefore, integrating these educational methods into routine diabetes care is recommended.41
This study has some limitations. First, Due to the cross-sectional design, it was not possible to examine causal interferences. Second, utilizing a self-report questionnaire might have led to less accurate responses, as patients might have been concerned about the clinical implications of reporting low adherence. To this end, we assured participants of the anonymity and confidentiality of all data. Third, administering questionnaires within a clinical setting may have influenced patient responses due to time constraints or environmental factors. To minimize this effect, questionnaires were completed in a calm, relaxed environment at appropriate times. A final limitation is that we did not assess variables including psychological factors (depression, diabetes distress), and prior diabetes education, which may affect both self-care adherence and metabolic control.
Conclusion
In conclusion, adherence to self-care behaviors among patients with T2DM was suboptimal. Furthermore, patients demonstrated low adherence to blood glucose monitoring. Higher adherence to self-care behaviors was associated with lower median of glycemic indices and a more favorable lipid profile. Educational and awareness programs may be implemented to support self-care behaviors among patients with T2DM. Future interventional studies are recommended to investigate the effects of these educational programs on glycemic control and metabolic status.
Funding Statement
No funding was received for conducting this study.
Data Sharing Statement
The data presented in this study will be available on request from the corresponding author by this journal representative at any time during submission or after publication.
Ethics Approval
The protocol of the study was approved by the ethics committee of Golestan University of Medical Sciences, Gorgan, Iran (IR.GOUMS.REC.1403.292). This study complies with the Declaration of Helsinki.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors declare no conflicts of interest in this work.
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Data Availability Statement
The data presented in this study will be available on request from the corresponding author by this journal representative at any time during submission or after publication.