Behavioural and social determinants of type 2 diabetes self-care adherence in a low-resource setting in South Ethiopia: a cross-sectional study using integrated health belief model and health-related quality-of-life frameworks

Abstract

OBJECTIVES: To investigate the behavioural and social determinants of type 2 diabetes mellitus (T2DM) self-care adherence in South Ethiopia using the integrated health belief model (HBM) and health-related quality-of-life (HRQoL) frameworks. DESIGN: A cross-sectional study. SETTING: Three public hospitals in South Ethiopia: Wolaita Sodo University Comprehensive Hospital, Humbo Primary Hospital and Boditi Primary Hospital. PARTICIPANTS: 404 systematically sampled adults aged 18-60 years with a confirmed diagnosis of T2DM who had been attending follow-up clinics for at least 12 months. Exclusion criteria included newly diagnosed T2DM, pregnancy, severe comorbidities or critical illness and unwillingness to participate. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was adherence to diabetes self-care, assessed using the Summary of Diabetes Self-Care Activities scale across five domains: diet, physical activity, medication intake, blood glucose monitoring and foot care. Good adherence was defined as engagement in recommended behaviours on ≥50% of days per week. Secondary outcomes included socio-demographic factors, clinical variables, HBM constructs (perceived susceptibility, severity, benefits, barriers, cues to action and self-efficacy) and HRQoL domains (physical, psychological, social and environmental). RESULTS: Of 404 participants, 58.4% demonstrated good adherence. In multivariable analysis, insulin-only treatment (AOR=3.0; p<0.001), having comorbidities (AOR=2.02; p=0.007) and poor glycaemic control (AOR=3.6; p=0.003) were positively associated with adherence. Factors associated with poor adherence included low income (AOR=0.18; p=0.002), living alone (AOR=0.19; p=0.012), low self-efficacy (AOR=0.18; p<0.001) and poor psychological health (AOR=0.53; p=0.024). CONCLUSION: The findings challenge the direct application of standard behavioural models in low-resource settings. Structured factors, such as poverty, can overwhelm psychological mechanisms. Effective interventions must integrate economic support with psychological care to improve self-care adherence.