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 (