Blood Glucose Management Behaviour Among Haemodialysis Patients with Diabetes: A Qualitative Study Guided by the Theory of Planned Behaviour

Abstract

Objective

To utilise the Theory of Planned Behaviour as a theoretical framework, employing qualitative interviews to gain an in-depth understanding and analysis of the motivations and influencing factors of blood glucose management behaviours among haemodialysis patients with diabetes.

Methods

Employing the phenomenological research method within qualitative research, in-depth semi-structured interviews were conducted with 12 haemodialysis patients with diabetes. Themes were then categorised using Colaizzi’s seven-step content analysis method.

Results

Themes were categorised according to the Theory of Planned Behaviour, yielding four categories: 1. Attitudes towards blood glucose management: perceived benefits and perceived burdens; 2. Subjective norms for blood glucose management: injunctive norms and descriptive norms; 3. Perceived behavioural control for blood glucose management: facilitating factors and impeding factors; 4. Behavioural intention versus actual behaviour: high intention-high execution, high intention-low execution, low intention-low execution, comprising nine themes in total.

Conclusion

Using the Theory of Planned Behaviour, this study identifies key modifiable factors underlying glycaemic self-management among diabetic patients on maintenance haemodialysis, including conflicting attitudes, social-norm influences, and major perceived-behavioural-control barriers that produce intention-behaviour gaps. Interventions should shift from knowledge-only education towards enhancing patients’ practical execution and perceived control. Individualised feasible management plans, together with integrated support from healthcare teams, families and social resources, are needed to address real-world barriers and improve glycaemic self-management outcomes for this patient group.

Introduction

According to the International Diabetes Federation,¹ approximately 537 million people worldwide had Diabetes Mellitus (DM) in 2021, projected to rise to 784 million by 2045. China hosts a substantial DM patient population with persistently rising incidence rates, making it the nation with the highest number of DM patients globally. Epidemiological studies indicate that the prevalence of DM among Chinese adults reached 12.8% in 2017, equating to approximately 129.8 million affected individuals. Diabetes has become the primary cause of chronic kidney disease, with 40% or more of diabetic patients potentially progressing to chronic kidney disease, ultimately requiring haemodialysis treatment due to renal failure.²

Research indicates that haemodialysis patients with diabetes are prone to blood glucose fluctuations, which activate distinct metabolic pathways leading to microvascular and macrovascular complications.³ Recurrent hypoglycaemic episodes compromise cardiovascular stability, increasing the incidence of cardiovascular events.⁴ Severe hypoglycaemia may also cause irreversible pathological changes in brain tissue,⁵ triggering cerebrovascular or cardiovascular accidents. These complications adversely affect dialysis patients’ quality of life and clinical prognosis, underscoring the critical importance of glycaemic control. Research indicates that glycaemic control is intrinsically linked to patient self-management behaviours⁶ haemodialysis patients with diabetes are required to follow haemodialysis-related dietary restrictions while strictly controlling blood glucose, which substantially complicates their self-management behaviours.

Maintaining robust self-management capabilities can prevent and delay diabetic complications. International studies reveal that factors influencing glycaemic management behaviours include social support, patient attitudes and perceived treatment effort, comorbidities, disease duration, and hypoglycaemic risk. These are further modulated by personal characteristics (such as medical history, age, health beliefs and attitudes), diabetes knowledge, health literacy, physical limitations, family support, economic status, and sociocultural factors.⁷ Current research predominantly focuses on quantitative studies, with limited in-depth exploration of glucose management behaviours among haemodialysis patients with diabetes from a qualitative perspective.

The Theory of Planned Behaviour (TPB), proposed by Ajzen,⁸ provides researchers with a theoretical framework for understanding behavioural change factors. This theory posits that behavioural intention is the core predictor of action. Behavioural attitudes, subjective norms, and perceived behavioural control indirectly influence self-care behaviours through behavioural intention. Compared with other behavioural theories, TPB places greater emphasis on the intention–behaviour mechanism and integrates perceived behavioural control, making it more suitable for explaining and predicting complex self-management behaviours in Diabetes.⁹

Grounded in TPB, this study employs qualitative interviews to explore and analyse the motivations and influencing factors of blood glucose management behaviours among haemodialysis patients with diabetes. Findings aim to inform future decision-making and intervention strategies for glycaemic control in this population.

Materials and Methods

Design

This study employed a qualitative descriptive approach, which provides the most direct and intuitive portrayal of participants’ experiences and perceptions. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were adhered to in this study [see Appendix 1].

Data and Methods: Study Population

Purposive sampling was employed to select long-term maintenance haemodialysis outpatients from a tertiary-level general hospital between March and May 2025 for semi-structured interviews. Inclusion criteria: (1) Age ≥ 18 years; (2) Diagnosed with diabetic nephropathy and undergoing stable maintenance haemodialysis for over 3 months, 3 sessions/week, 3.5–4 hours/session; (3) Clinically stable with no cognitive or communication impairments; (4) Voluntary participation. Exclusion criteria: (1) Language barriers preventing effective communication; (2) History of psychiatric disorders; (3) Experiencing bereavement, divorce, or other personal events affecting emotional state within the preceding 2 months.

The sample size of this qualitative study was determined based on the data saturation principle. In this study, a total of 12 participants were enrolled and interviewed, which fully met the data saturation requirement. All participants were anonymized and identified using codes N1–N12. This study was approved by the Ethics Committee of the Seventh Affiliated Hospital of Sun Yat-sen University (IRB No. KY-2024-350-01).

Data Collection

Semi-structured interviews were conducted in this study, with each participant numbered sequentially from N1 to N12. A preliminary interview outline was drafted based on a systematic review of domestic and international literature and repeated discussions within the research team. The final interview outline focused on participants’ perceptions of haemodialysis and diabetes, blood glucose management behaviors, lifestyle modifications, behavioral motivation, perceived impacts of changes, and demands for healthcare services.

Prior to each interview, researchers fully explained the study objectives, guaranteed the confidentiality of all interview content, and obtained signed informed consent from all participants. All face-to-face semi-structured interviews were conducted in a quiet, independent teaching demonstration room of the blood purification center in a tertiary hospital, ensuring a private and interference-free interview environment. The interview duration was strictly standardized to 30–45 minutes per session. During the interview process, researchers listened attentively, closely observed participants’ emotional changes, recorded detailed field notes, and performed full audio recording for subsequent data analysis.

Bias control and researcher reflexivity: All interviewers received unified standardized qualitative research training before data collection to ensure consistent interview skills and communication norms. To minimize interviewer bias, researchers strictly followed the finalized interview outline, avoided subjective guidance and suggestive questions, and maintained a neutral and objective attitude throughout the interview. Additionally, regular group reflexive discussions were conducted during the research process. Researchers systematically reflected on personal preconceptions, subjective biases, and potential influences on data collection and interpretation. They recorded reflexive logs continuously to enhance the credibility and trustworthiness of the qualitative findings.

Data Analysis

In this study, NVivo 15 was uniformly adopted for qualitative data sorting and analysis, and Interpretative Phenomenological Analysis (IPA) was used as the analytical framework. Within 24 hours after each interview, all audio recordings were transcribed verbatim into textual data. Colaizzi’s seven-step content analysis method was strictly followed for data processing.

Finally, all valid data were systematically organized and analyzed, repeated core content was screened out, and typical expressions related to the research topic were refined. The core themes reflecting the blood glucose management experiences, intentions, and dilemmas of patients with diabetic nephropathy undergoing maintenance haemodialysis were ultimately synthesized and summarized.

Results

This study included 12 haemodialysis patients with diabetes, among whom there were 8 males and 4 females (Table 1). Themes were categorised according to the Theory of Planned Behaviour, yielding four categories: 1. Attitudes towards blood glucose management: perceived benefits and perceived burdens; 2. Subjective norms for blood glucose management: injunctive norms and descriptive norms; 3. Perceived behavioural control for blood glucose management: facilitating factors and impeding factors; 4. Behavioural intention versus actual behaviour: high intention-high execution, high intention-low execution, low intention-low execution, comprising nine themes in total. Table 2 systematically presents the TPB domains, corresponding subthemes, participant codes, and representative verbal quotations derived from the participants, which fully summarizes the core findings of this study.

Table 1.

Participant Demographics and Disease-Related Information

Number	Gender	Age (Years)	Educational Level	Marital Status	Profession	Payment Method of Medical Expenses	The Duration of Diabetes Mellitus (Years)	The Duration of Hemodialysis (Years)	Vascular Access for Hemodialysis
N1	Male	59	Illiteracy	Married	Retiree	②	21	3	AVF
N2	Male	53	Senior school education	Married	Private entrepreneur	①	11	0.25	AVF
N3	Female	45	Junior high school education	Married	Jobless	③	12	4	AVF
N4	Male	69	Primary school education	Married	Retiree	②	12	2	TCC
N5	Male	55	Associate degree/Bachelor’s degree	Married	Company employee	①	10	1.25	AVG
N6	Male	48	Junior high school education	Divorced	Company employee	①	15	1.5	AVF
N7	Male	63	Junior high school education	Married	Retiree	②	16	2.5	AVF
N8	Female	50	Associate degree/Bachelor’s degree	Married	Worker	①	8	1.5	AVF
N9	Female	69	Senior school education	Widow	Retiree	②	11	4	AVF
N10	Female	72	Illiteracy	Married	Jobless	②	25	1.25	AVF
N11	Male	62	Senior school education	Married	Retiree	②	30	5	AVF
N12	Male	41	Associate degree/Bachelor’s degree	Single	Company employee	①	8	5	AVF

Notes:①: Employee medical insurance; ②: Residents’ medical insurance; ③: New Rural Cooperative Medical Scheme.

Abbreviations: AVF, Arteriovenous Fistula; TCC, Tunneled Cuffed Catheter; AVG, Arteriovenous Graft.

Table 2.

Overview of TPB Domains, Subthemes, Participant Codes, and Representative Quotations

TPB Domain	Subtheme	Participant Code	Representative Quotation
Attitudes towards blood glucose management	Perceived benefits	N2, N5, N6	Better blood sugar control relieves dialysis discomfort, improves physical status, and motivates active self-management.
	Perceived burdens and negative consequences	N1, N3, N7, N10	Frequent blood collection and finger pricking, persistent physical exhaustion, and tedious dietary calculation bring severe physical and mental burdens, leading to negative management attitudes.
Subjective norms for blood glucose management	Injunctive norms	N2, N6, N9, N10	Family members, doctors, and nurses explicitly require standardized dietary and lifestyle management to prevent diabetic complications.
	Descriptive norms	N1, N4	Observing severe complications (eg, diabetic foot infection and amputation) in fellow patients provides behavioral warning cues.
Perceived behavioural control	Facilitating factors	N3, N6, N11	Family dietary support, online health knowledge resources, and continuous glucose monitoring equipment greatly facilitate daily glycaemic management.
	Impeding factors	N3, N4, N5, N8, N10, N12	Post-dialysis physical fatigue, conflicting dietary requirements between dialysis and diabetes, hypoglycaemia fear, economic pressure, insufficient professional knowledge, and long-term disease emotional burden jointly hinder effective self- management.
Behavioural intention versus actual behaviour	High intention-high execution	N6	Patients with long- term disease experience and positive cognition actively learn management knowledge and adhere to standardized glycaemic control to improve quality of life.
	High intention-low execution	N3, N5	Although patients have clear management awareness and positive willingness, physical limitations and objective living conditions restrict their actual management behaviours.
	Low intention-low execution	N1	Negative disease cognition and lack of family support lead to complete abandonment of blood glucose self-management.

Attitudes Towards Blood Glucose Management

Positive or negative evaluations and beliefs held by haemodialysis patients with diabetes regarding effective blood glucose management behaviours.

Perceived Benefits: Some Patients in the Interviews Recognised the Advantages of Achieving Good Glycaemic Control

N2: “With better blood sugar control, dialysis isn’t as uncomfortable. The dizziness and fatigue are milder, and these symptoms rarely occur now”. N5: “Since starting dialysis, I go for a walk after every meal. My blood sugar is well managed. The ward nurse also monitors my blood sugar management closely, which feels really reassuring”. N6: “Now I’m keen to share my blood sugar management efforts with others. I didn’t understand before, but since starting dialysis, I’ve gradually learned a lot through various channels. I’m very careful about what I eat, especially as I’ll be on long-term dialysis. I know poor blood sugar control affects the heart and eyes”.

Perceived Burden and Negative Consequences

N1: “Can’t eat anything – what’s the point of living? I’ve given up on everything now. Just taking each day as it comes”. N3: “Every check-up involves drawing loads of blood tubes. Testing blood sugar means pricking my finger multiple times daily. My blood’s nearly gone(sighs)”. N7: “After each dialysis session, I’m already exhausted, yet I still have to calculate my food intake. It’s mentally draining”. N10: “Having to test my blood sugar daily, and so many times at that, I can’t bring myself to do it. I dread the pain. Now that I’m on dialysis, I haven’t monitored my blood sugar at all”.

Subjective Norms for Glycaemic Control: Social Pressure Perceived by Patients from Significant Others (or Groups) Regarding Whether They Should Manage Their Blood Glucose

Directive Norms Refer to Explicit Expectations and Demands from Significant Others (eg, Family Members, Doctors, Nurses)

N2: “Since my diabetes progressed to kidney disease requiring dialysis, my family stopped buying overly sweet foods. My wife only gives me low-glycaemic items like whole grains”. N6: “The doctors and nurses here often emphasise that diabetic dialysis patients require far greater vigilance than non-diabetic dialysis patients. Diabetic patients frequently develop numerous complications”. N9: “My carer manages my diet. She prepares low-glycaemic meals and restricts my fruit intake”. N10: “After meals, my husband always reminds me to go downstairs for a walk, not letting me snack at home”.

Descriptive Norms Refer to Behaviours Observed in Fellow Patients

N1: “That fellow patient who often comes in a wheelchair—I heard his foot got infected because his blood sugar was poorly controlled, and they had to amputate”. N4: “Uncle Zhou’s foot—diabetic foot—keeps getting infected and necrotic. They can’t manage it properly. It’s truly miserable”.

Perceived Behavioural Control in Glycaemic Management

Patients’ perceived ease or difficulty in managing blood glucose, reflecting their assessment of personal capability and external barriers.

Facilitating Factors Content

Perceived factors that ease management. N3: “My wife prepares all the meals, so I don’t need to worry much. I eat on time”. N6: “There’s loads of info on controlling blood sugar on WeChat and Douyin now. I often follow the advice there – it’s very convenient”. N11: “I now use this 24-hour continuous glucose monitor, which is very convenient. I can view my blood glucose levels on my phone”.

Barriers

Factors perceived as making management exceptionally difficult: Physiological limitations: N3: “After each dialysis session, I feel utterly drained and simply can’t manage to go for a walk or exercise”. Dietary conflicts: N4: “The doctor tells us to limit potassium and phosphorus, yet also to control sugar intake. Many foods suitable for people with diabetes are off-limits for us—it’s unclear what we can actually eat”. Fear of hypoglycaemia: N5: “Dialysis often triggers low blood sugar, causing dizziness and blurred vision. So I dare not skip meals, preferring to keep my levels slightly elevated otherwise”. Financial and knowledge burdens: N8: “Test strips are too expensive to use regularly”.N10: “No one teaches us; we can’t understand it ourselves and can’t remember”. Emotional and disease burden: N12: “Having this illness puts me in a bad mood; I don’t want to deal with anything. There are so many different types of medication to take, plus insulin injections – it’s a huge burden”.

Behavioural Intentions vs Actual Behaviour

The gap between patients’ behavioural intentions and their actual actions under the influence of the aforementioned factors.

High Intention - High Execution

Patients exhibiting positive attitudes, strong support networks, and high perceived control demonstrate effective adherence to management plans. N6: “Having lived with diabetes for over a decade, I’ve gradually learned much. Still, one must keep studying and observe others’ successful approaches—after all, one seeks quality of life”.

High Intention-Low Implementation

Despite good intentions, patients are unable to act due to perceived behavioural control barriers. N3: “I know I should exercise regularly after dialysis, work up a sweat, and manage my fluid intake—it’s good for blood sugar control. But I always feel so tired, I just can’t be bothered”. N5: “I know I need to control my blood sugar and diet, but it’s impossible. I work all day, eat at the canteen, and rarely have time to cook for myself”.

Low Intention-Low Execution

Patients exhibiting negative attitudes, lacking support, or having given up, resulting in absent management behaviours. N1: “What’s the point in managing when it’s all like this? Just take each dialysis day as it comes. My family doesn’t really look after me anyway. I reckon just being alive is enough. Who knows what tomorrow brings, eh?”

Discussion

This study identified motivational factors and influences on blood glucose management behaviours among haemodialysis patients with diabetes from a Theory of Planned Behaviour perspective.

• (1)Attitudes towards behaviour: Patients’ attitudes are complex and contradictory, encompassing both a desire for health benefits and lamentations over diminished quality of life. One study found¹⁰ that type 2 diabetic patients undergoing haemodialysis exhibited lower cognitive levels and more negative attitudes, primarily due to amplified “perceived burden” from the added dialysis treatment. Future efforts may focus on short-term benefits: Education should emphasise immediate improvements achievable through effective blood glucose control, such as “a smoother dialysis session” or “reduced fatigue”.
• (2)Subjective Norms: Healthcare professionals (particularly dialysis nurses) have significantly more contact with patients than other members of society, enabling them to establish effective directive norms. Consistent with research findings,¹¹ for patients with chronic kidney disease (a long-term condition involving impaired kidney function) and diabetes (a lifelong condition causing elevated blood glucose), healthcare-led educational programmes may enhance diabetes awareness, improve disease management capabilities, and foster changes in self-management behaviours. Moreover, peer groups exert significant descriptive normative influence, with both positive and negative role models exerting potent effects. Research indicates¹² that providing peer support in diabetes management can improve cardiovascular disease outcomes. Simultaneously, offering social and emotional support helps individuals cope with negative emotions and obstacles, thereby promoting disease management.¹³ Future strategies to optimise subjective norms include: ① Establishing dedicated multidisciplinary healthcare teams for glycaemic management (comprising haemodialysis physicians, haemodialysis nurses, diabetes specialist nurses, dietitians, etc.) to deliver targeted health education on blood glucose control.^14,15 Concurrently, ② strengthening family support systems: implementing family education programmes to instruct relatives on providing scientifically grounded, empathetic support rather than simplistic blame or supervision. Furthermore, ③ patient support groups may be leveraged: fostering a culture of positive role models to encourage peers to share effective blood glucose management experiences and techniques.
• (3)Perceptual-behavioural control: The perceptual-behavioural control barriers faced by this group are multifaceted, intertwined, and highly distinctive. This study identified the following perceptual-behavioural control impediments: ① Consistent with other research findings,¹⁶ physiological constraints: symptoms such as post-dialysis fatigue¹⁷ and hypotension¹⁸ may arise, thereby preventing effective blood glucose management behaviours like walking or exercise. ② Dietary confusion: The dual requirement to adhere to dialysis-specific dietary guidelines while also managing carbohydrate intake often leads to dietary inconsistencies, significantly complicating nutritional management. This unique challenge, absent in other diabetic populations, substantially diminishes patients’ sense of self-efficacy. ③ Hypoglycaemia phobia: Research indicates⁴ that dialysis patients are prone to hypoglycaemic episodes during treatment, with such occurrences during dialysis linked to heightened mortality risks.¹⁹ This primarily stems from glucose loss during the dialysis process.²⁰ Patients frequently develop anxiety and fear regarding recurrent hypoglycaemic events.^21,22 Studies reveal this negatively impacts disease management, metabolic control, and patients’ capacity to maintain normal activities (including work and social engagements), thereby compromising their overall quality of life.²³ ④ Financial and Knowledge Burden: Research indicates²⁴ that although medical insurance reimbursement policies cover haemodialysis costs in China, implementation effectiveness remains suboptimal. ⑤ Emotional and Disease Burden: This study reveals a dual disease burden where diabetes and end-stage renal disease create unique behavioural control obstacles. The intertwining of physiological, psychological, and social factors—including symptoms such as fatigue, dialysis-related complications, hypoglycaemic risk, dietary conflicts, financial strain, knowledge gaps, and emotional issues like depression and despair—collectively form a significant black hole of perceived control. Future interventions targeting these perceived behavioural control barriers should focus on: firstly, developing personalised, actionable plans: Healthcare professionals should assist patients in creating dietary and exercise schedules tailored to dialysis timetables and physical capacity, rather than offering generic advice. Secondly, address specific barriers: Provide food exchange tables clearly labelling potassium, phosphorus, and sugar content; discuss strategies for managing hypoglycaemia; connect patients with social resources to alleviate financial burdens. Finally, enhance self-efficacy: Strengthen patients’ confidence in their ability to manage tehrough sharing success stories from fellow patients and skill workshops on topics like blood glucose monitoring and food selection.

• (4)Behavioural Intentions vs Behavioural Gaps: This study explains the phenomenon of “high intention-low execution”. The primary cause lies in complex perceptual-behavioural control barriers, where good intentions are overwhelmed by practical difficulties. Consistent with other research findings,²⁵ decision-making biases exist in diabetes patients’ self-management behaviours. These biases stem from imbalances between health objectives and practical life considerations. Traditional educational approaches focused solely on knowledge enhancement and attitude modification prove insufficient for this population. Future health education should be tailored to address perceptual behavioural control barriers.

Research Limitations and Future Directions

Limitations

This research, like all qualitative investigations, may be subject to recall bias and social desirability bias. Findings may not be generalisable to populations in countries with differing cultural values and customs, though they offer novel insights.

Future Directions

① Future studies should include a broader range of haemodialysis patients with diabetes from diverse backgrounds to understand the motivations better and influencing factors of their blood glucose management behaviours. ② Based on the findings of this study, develop quantitative questionnaires to validate the influence of these barrier factors in larger samples and determine their priority. ③ Design and evaluate the effectiveness of interventions focused on enhancing perceived behavioural control.

Conclusion

Using the Theory of Planned Behaviour, this study identifies key modifiable factors underlying glycaemic self-management among diabetic patients on maintenance haemodialysis, including conflicting attitudes, social-norm influences, and major perceived-behavioural-control barriers that produce intention-behaviour gaps. Interventions should shift from knowledge-only education towards enhancing patients’ practical execution and perceived control. Individualised feasible management plans, together with integrated support from healthcare teams, families and social resources, are needed to address real-world barriers and improve glycaemic self-management outcomes for this patient group.

Funding Statement

This study was supported by the Guangdong Nurses Association Scientific Research Foundation (No. gdshsxh2024ms22).

Abbreviations

DM, Diabetes Mellitus; TPB, Theory of Planned Behaviour; COREQ, Consolidated Criteria for Reporting Qualitative Research; IPA, Interpretative Phenomenological Analysis.

Data Sharing Statement

All data related to the results are included in the manuscript. The interview transcripts are not publicly available because of individual privacy concerns.

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of the Seventh Affiliated Hospital of Sun Yat-sen University (IRB No. KY-2024-350-01). Informed consent was obtained from all participants before study inclusion. This study adhered to the Declaration of Helsinki. Participants provided written informed consent, which included permission to publish anonymized responses and direct quotations.

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 author(s) report no conflicts of interest in this work.