Glycemic control and association with diabetes-related distress, self-management behavior, financial toxicity, and cost-related non-adherence: a mixed-methods study

Background: The prevalence of diabetes is a growing global health concern. Currently, Nigeria has the highest burden of diabetes in sub-Saharan Africa, and this burden is projected to increase by over 100% by 2050. In a lower-middle-income country, a comprehensive understanding of the emotional burden, behavioral factors, and financial determinants of glycemic control is imperative. Methods: An explanatory sequential study design was conducted among patients with T2DM attending follow-up visits at three secondary-level hospitals. For the cross-sectional strand (n = 355), the Diabetes Distress Scale (DDS), Diabetes Self-Management Questionnaire (DSMQ-R), Financial Toxicity, and Cost-related Non-adherence questionnaires were used. Long-term glycemic control (HbA1c) was estimated using the Clover A1c system (Infopia). Moreover, semi-structured interviews (n = 19) were conducted to further explore the effect of psychosocial, behavioral, and financial factors on glycemic control. Results: The mean HbA1c was 7.04% (SD: 2.2), and 43% (n= 152) of the respondents had HbA1c ≥7%. The percentage of participants with diabetes-related distress, poor self-management, worse financial toxicity, and the practice of cost-related non-adherence was 32%, 56%, 54%, and 48.3%, respectively. Although poor self-management (β: 2.02; CI: 1.18 - 3.45) and diabetes-related distress (β: 2.13; CI: 1.22 - 3.72) were significantly associated with poor glycemic control, financial toxicity and cost-related non-adherence were not significantly associated with glycemic control. Younger age (<55 years), use of multiple antidiabetic medications, insulin use, and lack of access to an endocrinologist were significant covariates associated with poor glycemic control. In the qualitative interview, the themes extracted for diabetes-related distress and financial toxicity in the good and poor glycemic control groups were relatively similar. However, there was a considerable difference in the diabetes self-management behavior; participants with poor glycemic control had (1) 'difficulty adapting to lifestyle changes' and (2) 'medication non-adherence due to fear of after effects from prolonged use or polypharmacy'. Conclusion: Approximately half of the participants across the study sites had poor glycemic control. Poor self-management, diabetes-related distress, the type of treatment regimen, and lack of access to an endocrinologist are independent determinants of poor glycemic control. Diabetes education grounded in behavioral modification strategies and psychological support should be a routine practice. Moreover, the inclusion of trained primary care physicians and endocrinologists in care is imperative.