Glycemic Control and Health-Related Quality of Life in Palestinian Adults with Type 2 Diabetes: a cross-sectional analysis of satisfaction, impact, and worry

INTRODUCTION

Type 2 Diabetes Mellitus (T2DM) is a long-term metabolic condition marked by chronic hyperglycemia arising from a combination of insulin resistance and inadequate insulin secretion, and it now ranks among the most pressing global health concerns.(1,2) Its significance stems largely from a trajectory of rising case numbers; the International Diabetes Federation forecasts that the disease will continue to expand its footprint of morbidity and mortality in the decades ahead.(1,3) Glycated hemoglobin (HbA1c) serves as the principal marker used to gauge glycemic control, and keeping this value within target range is essential for postponing the microvascular and macrovascular damage diabetes can inflict.(4,5) Reaching and sustaining this control, however, hinges on consistent diabetes self-management education (DSME) and day-to-day self-care behaviors — dietary discipline, physical activity, and glucose monitoring — all of which are empowering in principle but frequently hard to sustain in practice.(6) When glycemic levels drift out of range, patients contend with disabling physical symptoms, psychological strain, and diminished functional capacity, all of which erode Health-Related Quality of Life (HRQoL).(7) The downstream societal and economic costs are considerable, as poor QoL and unmanaged diabetes translate into more frequent hospitalizations, lost productivity, and mounting healthcare expenditure.(1,8) This study centers on adult patients with T2DM specifically, given that this group shoulders the heaviest burden of disease-related complications and must sustain complex self-management routines over time, leaving them particularly susceptible to declining QoL.(9)

At the global level, the link between diabetes management and quality of life is well documented, and the evidence consistently shows that unmanaged glycemia takes a measurable toll on patient well-being. Studies from around the world confirm that self-care behaviors — notably routine physical activity and dietary control — go hand in hand with better glycemic outcomes and richer HRQoL.(1,6,10) International research further shows that diabetes distress and health-related anxiety commonly travel alongside T2DM, undermining self-efficacy and adherence to medication, which in turn drags down both clinical results and quality of life.(11) More recently, digital tools such as online DSME platforms have shown potential for boosting self-care autonomy and lowering HbA1c, especially when they incorporate interactivity and real-time feedback.(12,13) Instruments to measure self-efficacy, including the Diabetes Management Self-Efficacy Scale, have likewise been developed and validated to support these interventions.(14) Cross-sectional evidence from Thailand, for instance, identifies younger age, greater income, regular exercise, and freedom from complications as strong predictors of favorable quality of life.(15)

Within the Middle East, T2DM prevalence is among the highest anywhere in the world, and yet glycemic control frequently remains poor despite the availability of pharmacological treatment.(5) Research conducted across the region points to socio-cultural obstacles, limited health literacy, and insufficient self-management education as major reasons patients struggle to reach target HbA1c levels.(9,16) Lifestyle and clinical variables specific to the region further shape glycemic outcomes.(17) Low health literacy in particular has been flagged as an obstacle to glycemic control in Middle Eastern populations.(18) Regional studies also converge on the finding that women, those with multiple complications, and patients with poor glycemic control report markedly lower HRQoL.(16) In Saudi cohorts, disease duration beyond 10 years and the presence of diabetic foot or renal complications have each been shown to independently erode physical functioning and general health domains of QoL.(7,19) DSME programs have proven their worth in this region by measurably improving clinical outcomes and self-efficacy,(5) while in neighboring Pakistan, cognitive behavioral therapy has been effective at easing diabetes distress and lifting QoL.(11) Notably, Jordanian research identifies self-efficacy as the single strongest predictor of diabetes self-management, functioning as a key mediator between patient characteristics and health outcomes.(20)

In low- and middle-income countries (LMICs) such as Palestine, managing T2DM is complicated further by severe socio-economic and political pressures. Palestine's healthcare system contends with persistent resource shortages, military occupation, and recurring violence — conditions that interrupt continuity of care, restrict access to medication, and curtail patients' freedom of movement.(21,22) These structural threats make it exceptionally difficult to sustain self-care behaviors, particularly physical activity and dietary adherence, which in turn directly jeopardizes glycemic control.(1) Recent Palestinian evidence documents that nurses and nursing students themselves face substantial violence, checkpoint delays, and psychological strain — a reflection of the broader systemic instability touching every corner of the healthcare system, diabetes clinics included.(23,25) Compounding this, critical care and emergency units across Palestine report weak alarm-management practices, inadequate CPR training, and unreliable electronic medical records, all of which threaten patient safety and continuity of chronic disease follow-up.(26,27) A comparative cross-sectional study conducted in Palestine similarly found moderately impaired QoL among diabetic patients, with the impact domain — capturing physical and social burden — the most severely affected, and complications significantly worsening QoL.(21,28) This study draws implicitly on Self-Efficacy Theory, which holds that a patient's confidence in their own capacity to carry out self-management behaviors directly shapes both clinical outcomes (glycemic control) and psychosocial well-being (QoL). Evidence from elsewhere reinforces this framework, showing self-efficacy to be a robust predictor of self-management, communication, and disease activation,(29) and that validated self-efficacy measures correlate negatively with HbA1c.(30) The theory holds more broadly that cognitive processes shape behavior, with self-efficacy beliefs acting as powerful drivers of self-management action.(31)

Despite the breadth of existing literature, meaningful gaps persist. Much of the available research is descriptive, zeroes in on isolated demographic or clinical variables, and leans on generic QoL instruments that miss the disease-specific burdens of satisfaction, impact, and worry that are unique to T2DM.(32) Qualitative and mixed-methods work remains scarce, particularly in conflict-affected settings, which limits the field's ability to design context-appropriate interventions. The pathway connecting glycemic control to disease-specific QoL dimensions — while accounting for the compounding socio-political pressures of LMIC life — remains largely unexplored. Critically, no prior Palestinian study has systematically examined how glycemic control specifically affects the satisfaction, impact, and worry domains of QoL among T2DM patients, nor has any integrated local realities of economic hardship and restricted mobility to explain why poor glycemic control so profoundly undermines this population's physical and psychosocial well-being.

Accordingly, this study set out to investigate the determinants and consequences of glycemic control for quality of life among Palestinian adults with T2DM. Specifically, it aims to (a) characterize the demographic, clinical, and behavioral profile of T2DM patients; (b) assess quality of life across the satisfaction, impact, and worry domains; (c) identify the socio-demographic and clinical factors linked to QoL; and (d) establish the impact of glycemic control on QoL, guided by the premise that self-efficacy and contextual barriers together shape clinical and psychosocial outcomes.

METHODS

RESULTS

Quality of Life

Quality of life was measured across three subscales — Satisfaction, Impact, and Worry — on a 1–5 scale where higher values reflect worse QoL. The overall mean score of 3.31 (SD = 1.03) points to a moderately negative effect of diabetes on participants' quality of life (Figure 1).

Within the Satisfaction subscale, scores ran comparatively low, signaling relatively better satisfaction overall. The greatest dissatisfaction centered on time spent managing diabetes (M = 2.02), whereas participants were most content with their life in general and their diabetes-related knowledge (both M = 1.87).

The Impact subscale produced the highest — and therefore most concerning — scores of the three domains. Physical well-being bore the brunt of this burden: "feeling unwell or tired" registered the single highest item mean in the entire instrument (M = 2.94), closely trailed by "pain due to diabetes treatment" (M = 2.74). Social effects were comparatively muted, with "diabetes limiting social relationships" the lowest-scoring item in this subscale (M = 1.95).

In the Worry subscale, apprehension about future health decline stood out as the dominant concern. "Worried about complications" posted the highest score among worry items (M = 2.45), a finding consistent with the high rate of uncontrolled glycemia (54.2%) observed in this sample. Concerns about fainting (M = 2.05) and physical appearance (M = 1.99) were present but less pronounced.

Factors Associated with Quality of Life

Non-parametric tests — Mann–Whitney U for dichotomous variables and Kruskal–Wallis H for those with three or more categories — were used to identify factors linked to QoL, with higher mean ranks throughout denoting worse QoL (Table 3, Figure 3).

Gender proved to be a significant determinant, with women reporting markedly worse QoL (Mean Rank = 135.04) than men (Mean Rank = 109.54; U = 5883.5, p = 0.006). Physical activity emerged as the single strongest associated factor (H = 17.046, p = 0.001), following a clear dose–response gradient: patients who never exercised fared worst (Mean Rank = 158.59), while regular exercisers fared best (Mean Rank = 104.43). Monthly income was also significantly associated with QoL (H = 6.896, p = 0.032), with the highest earners (> 4,000 NIS) reporting the best outcomes (Mean Rank = 79.46). Glycemic control likewise proved to be a significant predictor (U = 6187.5, p = 0.008): uncontrolled patients fared worse (Mean Rank = 136.17) than controlled patients (Mean Rank = 111.78).

Educational level approached but did not reach statistical significance (H = 7.734, p = 0.052), with higher education trending toward better QoL. Marital status (H = 2.789, p = 0.248), smoking status (H = 2.080, p = 0.353), and diabetes duration (H = 3.740, p = 0.291) showed no significant association with QoL.

Table 2. Association Between Demographic and Clinical Factors and Quality of Life (N = 249)

Variable	Category	N	Test Statistic	p-value
Gender	Male	98	U = 5883.500	0.006**
[empty cell]	Female	151	[empty cell]	[empty cell]
Marital Status	Single	21	H = 2.789	0.248
[empty cell]	Married	218	[empty cell]	[empty cell]
[empty cell]	Other	10	[empty cell]	[empty cell]
Educational Level	Elementary	147	H = 7.734	0.052
[empty cell]	Secondary	68	[empty cell]	[empty cell]
[empty cell]	Bachelor's degree	25	[empty cell]	[empty cell]
[empty cell]	Above Bachelor's	9	[empty cell]	[empty cell]
Monthly Income (NIS)	< 2,000	145	H = 6.896	0.032*
[empty cell]	2,000–4,000	90	[empty cell]	[empty cell]
[empty cell]	> 4,000	14	[empty cell]	[empty cell]
Smoking Status	Non-smoker	184	H = 2.080	0.353
[empty cell]	Current smoker	50	[empty cell]	[empty cell]
[empty cell]	Former smoker	15	[empty cell]	[empty cell]
Physical Activity	Regularly	80	H = 17.046	0.001**
[empty cell]	Sometimes	80	[empty cell]	[empty cell]
[empty cell]	Rarely	42	[empty cell]	[empty cell]
[empty cell]	Never	47	[empty cell]	[empty cell]
Duration of Diabetes	< 1 year	11	H = 3.740	0.291
[empty cell]	1–5 years	58	[empty cell]	[empty cell]
[empty cell]	6–10 years	39	[empty cell]	[empty cell]
[empty cell]	> 10 years	141	[empty cell]	[empty cell]
Glycemic Control	Controlled	114	U = 6187.500	0.008**
[empty cell]	Uncontrolled	135	[empty cell]	[empty cell]

Note. QoL = Quality of Life, scored such that higher mean ranks indicate worse quality of life. Mann–Whitney U test applied for dichotomous variables; Kruskal–Wallis H test applied for variables with ≥ 3 categories. * p < 0.05. ** p < 0.01.

Spearman correlations examined relationships between continuous variables and QoL (Figure 2). Neither age (rho = 0.061, p > 0.05) nor BMI (rho = 0.013, p > 0.05) correlated significantly with QoL. HbA1c, by contrast, showed a significant positive correlation with QoL score (rho = 0.209, p = 0.001), confirming that higher — less controlled — blood glucose tracks with worse quality of life.

Discussion

This study set out to examine the demographic, clinical, and behavioral factors shaping Quality of Life (QoL) among Palestinian adults with Type 2 Diabetes Mellitus, with particular attention to the role of glycemic control. What emerges is a population marked by high rates of obesity, socioeconomic disadvantage, and troublingly poor glycemic control. QoL overall was moderately impaired, and the physical toll of diabetes — fatigue and pain in particular — stood out as the most severely affected dimension. Poor glycemic control, female sex, physical inactivity, and low income all surfaced as independent predictors of diminished quality of life.

The sample's demographic profile points to a vulnerable, aging group: a mean age of 61.17 years alongside a high prevalence of obesity (BMI = 30.65 kg/m²). The predominance of women in the sample (60.6%) mirrors regional patterns of higher T2DM prevalence and poorer QoL among women across the Middle East.(16) Socioeconomically, the group faces considerable disadvantage — 59% had only elementary schooling, and 58.2% earned under 2,000 NIS monthly. This combination of limited income and limited health literacy is a well-recognized obstacle to diabetes self-care throughout LMICs, where patients struggle simply to afford nutritious food, monitor their glucose, and access consistent care.(1,9,33) Clinically, the fact that 54.2% remain uncontrolled despite more than half the sample living with diabetes for over a decade points to a fundamental shortfall in reaching therapeutic targets. In Palestine specifically, structural obstacles compound this problem: restricted freedom of movement limits clinic access, while chronic stress and infrastructural instability disrupt routine self-management and medication adherence.(21) Research on Palestinian healthcare workers similarly shows that checkpoints, exposure to violence, and chronic stress erode quality of life and professional functioning — pressures that inevitably ripple outward into diabetes care delivery.(23) The strikingly low rates of physical activity in this sample (35.8% rarely or never exercising) are less a matter of lifestyle choice than a reflection of living in an environment where outdoor movement is often restricted and unsafe, a pattern that echoes findings from Sub-Saharan Africa, where structural barriers similarly constrain self-management.(34) Viewed through Self-Efficacy Theory, these environmental constraints erode patients' confidence in their own ability to manage their condition, feeding a downward spiral toward poorer clinical outcomes.(20,30,35)

The QoL results show the "Impact" subscale carrying the heaviest burden, with "feeling unwell or tired" (M = 2.94) and "pain due to diabetes treatment" (M = 2.74) as the most prominent complaints. This closely tracks findings from Alshahrani et al.,(7) who similarly identified physical functioning and general health as the most compromised domains among diabetic patients, especially as disease duration lengthens. The fatigue and pain reported by this Palestinian cohort likely reflect the accumulated physiological cost of long-standing, poorly controlled hyperglycemia combined with obesity, as prolonged disease duration tends to accelerate beta-cell decline and treatment resistance, further complicating management.(36) By contrast, the "Satisfaction" domain scored lowest — indicating comparatively better satisfaction — particularly regarding diabetes knowledge (M = 1.87) and overall life satisfaction (M = 1.87). This apparent contentment may reflect a degree of resignation or adaptation to chronic illness, or perhaps diminished expectations shaped by the broader socio-political hardships of daily life in Palestine.(28) Within the "Worry" domain, fear of future complications ranked highest (M = 2.45) — an understandable response given that more than half the sample has uncontrolled HbA1c and over 73% already live with diabetes-related complications. This pervasive worry parallels global evidence identifying diabetes distress and health anxiety as major psychological burdens that undermine treatment adherence.(11) Easing this worry likely calls for structured psychological support, similar to the cognitive behavioral approaches shown to work in neighboring Pakistan,(11) or digital tools offering reassurance and self-management guidance.(12,13) Yet in Palestine, the considerable academic and occupational stress already documented among nursing students and nurses suggests that even existing mental health resources may be stretched thin, with knock-on effects for diabetes education and patient support.(25)

The non-parametric analyses point to several key determinants of QoL. Mirroring regional evidence from Saudi Arabia, women in this sample reported significantly worse QoL than men (Mean Rank = 135.04 vs. 109.54, p = 0.006) — a gap often linked to biological differences in complication risk, higher rates of depression, and socio-cultural gender norms that constrain women's capacity to prioritize self-care in the Middle East.(16,37) Monthly income also proved significant (p = 0.032), with participants earning above 4,000 NIS reporting notably better QoL (Mean Rank = 79.46), reinforcing the broader pattern in LMICs where economic hardship directly obstructs self-management by limiting access to healthy food, glucose-testing supplies, and transportation to clinics.(1,9,38)

Physical activity stood out as the strongest predictor of QoL overall (p = 0.001), following a clear dose-response gradient: patients who never exercised reported the worst QoL (Mean Rank = 158.59), while regular exercisers reported the best (Mean Rank = 104.43). This finding aligns closely with Tamornpark et al.,(15) who similarly identified regular exercise as a key correlate of good QoL. In the Palestinian context, where the occupation and associated security constraints heavily restrict physical movement, involuntary inactivity becomes a structural determinant of disease burden rather than simply a personal choice. Through the lens of Self-Efficacy Theory, an inability to exercise chips away at patients' belief in their own capacity to manage their condition, feeding a decline in both clinical and psychological outcomes.(20,29) Interestingly, and in contrast to Alshahrani et al.,(7) diabetes duration showed no significant relationship with QoL in this sample (p = 0.291) — suggesting that in Palestine, acute socio-economic and behavioral pressures such as income and inactivity may outweigh the sheer chronological length of illness in shaping day-to-day well-being.

The central finding of this study — that poor glycemic control independently and significantly predicts reduced QoL — rests on converging evidence. Patients with uncontrolled glycemia reported markedly worse QoL (Mean Rank = 136.17) than their controlled counterparts (Mean Rank = 111.78; U = 6187.5, p = 0.008), a pattern reinforced by the significant positive correlation between continuous HbA1c values and worse QoL scores (rho = 0.209, p = 0.001). This aligns with Mikhael et al.,(5) who identified reaching target HbA1c as the single most critical factor for improving both clinical and patient-reported outcomes across the Middle East. Uncontrolled hyperglycemia appears to directly drive the physical symptoms captured in the Impact subscale — fatigue, pain, and general malaise — which then feed into the psychological worry surrounding future complications. This self-reinforcing cycle, in which poor metabolic control fuels physical decline and psychological distress, aligns with the core premise of Self-Efficacy Theory, whereby unfavorable clinical feedback erodes a patient's confidence in managing their own condition.(30) These findings confirm that, in Palestine as elsewhere, suboptimal HbA1c is not merely a laboratory value but a pervasive disruptor of functional, social, and emotional life.(11,21,39) Consequently, interventions need to extend beyond pharmacological prescribing to include structured DSME programs (6) and to confront the contextual barriers — economic hardship, restricted mobility, and diminished self-efficacy — that stand between patients and the glycemic control needed for a tolerable quality of life. The considerable stress and trauma documented among Palestinian healthcare workers further suggest that the healthcare system as a whole is under strain, which may compromise the quality of diabetes education and support patients receive.(23) Bolstering the resilience of the healthcare workforce through targeted mental health support and improved working conditions could yield secondary benefits for chronic disease management more broadly.(24)

CONCLUSION

This study demonstrates that quality of life among Palestinian adults with Type 2 Diabetes Mellitus is significantly compromised, with patients facing substantial physical burdens — chiefly fatigue and pain — alongside considerable worry about future complications. Poor glycemic control stands out as a central, independent predictor of diminished QoL, compounding both physical and psychological distress. The overlapping pressures of female gender, physical inactivity, and economic hardship further concentrate disease burden among an already vulnerable subgroup. Taken together, these findings point to the need for diabetes care in Palestine to move beyond a narrowly biomedical model toward a multi-dimensional, person-centered approach — one that pursues strict glycemic control while simultaneously strengthening self-efficacy, expanding safe and accessible physical activity, and dismantling the socio-economic and structural barriers that stand in the way of self-management. Future work should adopt longitudinal and interventional designs to clarify causal pathways and to test the effectiveness of culturally tailored DSME programs in improving both clinical outcomes and overall quality of life in this population.

Conflicting Interest

The author declares no potential conflicts of interest with respect to the research, authorship, or publication of this article.

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