Determinants and impacts of glycemic control on quality of life among type 2 diabetes mellitus patients in Palestine: a cross-sectional study

INTRODUCTION

Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disorder characterized by persistent hyperglycemia resulting from insulin resistance and relative insulin deficiency, posing a profound global health burden.^(1,2)^ The importance of T2DM lies in its escalating prevalence; it is a leading cause of morbidity and mortality worldwide, with the International Diabetes Federation projecting a continued surge in cases over the coming decades.^(1,3)^ Glycemic control, typically measured by Glycated Hemoglobin (HbA1c), is the primary therapeutic target, as maintaining optimal levels is crucial to delaying devastating microvascular and macrovascular complications.^(4,5)^ However, achieving and maintaining glycemic control is heavily dependent on rigorous diabetes self-management education (DSME) and self-care practices—such as dietary adherence, physical activity, and glucose monitoring—which empower patients but are often difficult to sustain.^(6)^ When glycemic control is suboptimal, individuals suffer from debilitating physical symptoms, psychological distress, and reduced functional capacity, which severely diminishes their Health-Related Quality of Life (HRQoL).^(7)^ Consequently, the societal and economic impacts are staggering, as poor QoL and uncontrolled diabetes lead to increased hospitalizations, loss of workforce productivity, and overwhelming healthcare expenditures.^(1,8)^ This study specifically focuses on adult patients with T2DM, as this population bears the greatest burden of disease complications and requires sustained, complex self-management strategies to navigate the daily regimen of diabetes care, making them highly vulnerable to QoL deterioration.^(9)^

Internationally, the relationship between diabetes management and quality of life is well-established, with evidence consistently demonstrating that uncontrolled glycemia significantly deteriorates patient well-being. Global research confirms that self-care practices—such as regular physical activity and dietary control—are strongly associated with improved glycemic control and enhanced HRQoL.^(1,6,10)^ Furthermore, international studies highlight that diabetes distress and health anxiety frequently accompany T2DM, acting as barriers to self-efficacy and medication adherence, which subsequently worsens both clinical outcomes and QoL.^(11)^ Recent innovations, such as online DSME applications and digital health technologies, have shown promise in improving self-care autonomy and reducing HbA1c globally, particularly when interactive and feedback-driven components are utilized.^(12,13)^ Additionally, valid and reliable measures of self-efficacy, such as the Diabetes Management Self-Efficacy Scale, have been developed to assess and support these interventions.^(14)^ Cross-sectional studies from diverse international settings, such as Thailand, have shown that younger age, higher income, regular exercise, and the absence of complications are significant predictors of a good quality of life.^(15)^

Regionally, the Middle East faces one of the highest prevalences of T2DM globally, yet patients frequently exhibit poor glycemic control despite pharmacological treatment.^(5)^ Research from Middle Eastern countries highlights that socio-cultural barriers, low health literacy, and inadequate self-management education severely limit patients' ability to maintain target HbA1c levels.^(9,16)^ Specific regional determinants, including lifestyle and clinical factors, significantly impact glycemic control in this population.^(17)^ Additionally, low health literacy has been identified as a barrier to glycemic control in Middle Eastern settings.^(18)^ Regional studies affirm that females, patients with multiple complications, and those with poor glycemic control report significantly lower HRQoL.^(16)^ Furthermore, disease duration exceeding 10 years and the presence of diabetic foot or renal complications have been shown to independently reduce the physical functioning and general health domains of QoL in Saudi T2DM populations.^(7,19)^ Interventions like DSME have proven effective in the Middle East, significantly improving clinical outcomes and self-efficacy,^(5)^ while cognitive behavioral therapy has shown promise in reducing diabetes distress and improving QoL in neighboring Pakistan.^(11)^ Importantly, research in Jordan indicates that self-efficacy is the strongest predictor of diabetes self-management, heavily mediating the relationship between patient characteristics and health outcomes.^(20)^

In low- and middle-income countries (LMICs) such as Palestine, the management of T2DM is further complicated by severe socio-economic and political determinants. The Palestinian healthcare system operates under chronic resource constraints, military occupation, and frequent violence, which disrupts continuous care, limits access to medications, and restricts physical movement.^(21,22)^ These contextual threats dictate that self-care behaviors—particularly physical activity and dietary adherence—are exceptionally challenging to maintain in Palestine, directly threatening glycemic control.^(1)^ Recent evidence from Palestinian healthcare settings shows that nurses and nursing students face significant violence, checkpoint-related delays, and psychological distress, which mirror the broader systemic instability affecting all healthcare services, including diabetes outpatient clinics.^(23–25)^ Moreover, critical care and emergency departments in Palestine suffer from poor alarm management practices, inadequate cardiopulmonary resuscitation (CPR) training, and limited access to reliable electronic medical record systems, all of which compromise patient safety and the continuity of chronic disease follow-up.^(26–28)^ A recent comparative cross-sectional study in Palestine revealed that QoL is moderately impaired among diabetic patients, with the impact domain (reflecting physical and social burdens) being the most severely affected, and that the presence of complications significantly worsens QoL.^(21,29)^ This study is implicitly guided by Self-Efficacy Theory, which posits that a patient's belief in their capability to execute self-management behaviors directly influences their clinical outcomes (glycemic control) and psychosocial well-being (QoL). Global evidence supports this framework, demonstrating that self-efficacy is a strong predictor of self-management, communication, and disease activation,^(30)^ and that valid, reliable measures of self-efficacy are directly and negatively correlated with HbA1c levels.^(31)^ The theory suggests that cognitive processes shape behavior, and self-efficacy beliefs are powerful determinants of self-management actions.^(32)^

While existing literature provides valuable insights into diabetes management, significant gaps remain. Most studies are descriptive, focus on isolated demographic or clinical factors, and heavily rely on generic QoL instruments that fail to capture the disease-specific burdens of satisfaction, impact, and worry unique to T2DM.^(33)^ Qualitative and mixed-methods research is scarce, especially in conflict-affected settings, limiting the development of context-specific interventions. Furthermore, the explicit pathway linking glycemic control to disease-specific QoL dimensions—while accounting for the compounding socio-political barriers of life in an LMIC—remains underexplored. Critically, no prior study in Palestine has systematically examined the specific impact of glycemic control on the satisfaction, impact, and worry domains of QoL exclusively among T2DM patients, nor has any study integrated the local realities of economic deprivation and restricted mobility to explain why uncontrolled glycemia so profoundly devastates the physical and psychosocial well-being of this population.

Therefore, this study aims to investigate the determinants and impacts of glycemic control on quality of life among Type 2 diabetes patients in Palestine. Specifically, it (a) analyzes the demographic, clinical, and behavioral characteristics of T2DM patients; (b) evaluates the quality of life across satisfaction, impact, and worry domains; (c) identifies the socio-demographic and clinical factors associated with QoL; and (d) determines the impact of glycemic control on QoL, guided by the premise that self-efficacy and contextual barriers dictate clinical and psychosocial outcomes.

METHODS

RESULTS

DISCUSSION

This study investigated the demographic, clinical, and behavioral factors influencing Quality of Life (QoL) among Type 2 Diabetes Mellitus patients in Palestine, with a specific focus on the impact of glycemic control. The findings reveal a population characterized by high obesity, low socio-economic status, and alarmingly poor glycemic control. QoL was moderately impaired, with the physical impact of diabetes—specifically fatigue and pain—being the most severely affected domain. Crucially, uncontrolled glycemia, female gender, physical inactivity, and low income were identified as significant independent predictors of a worse quality of life.

The demographic profile of the sample reflects a vulnerable, aging population with a mean age of 61.17 years and a high prevalence of obesity (BMI = 30.65 kg/m²). The predominance of female participants (60.6%) aligns with regional epidemiological data indicating higher T2DM prevalence and poorer QoL among women in the Middle East.^(16)^ Socioeconomically, the sample is highly disadvantaged, with 59% having only elementary education and 58.2% earning less than 2,000 NIS monthly. This intersection of low income and low health literacy is a recognized barrier to diabetes self-care in LMICs, as patients struggle to afford nutritious food, monitor glucose, and access consistent care.^(1,9,34)^ Clinically, the high rate of uncontrolled glycemia (54.2%) despite over half the patients having the disease for more than 10 years underscores a critical failure in achieving therapeutic targets. In the Palestinian context, this is heavily exacerbated by structural barriers: restricted freedom of movement limits access to clinics, while pervasive stress and infrastructural instability disrupt routine self-management and medication adherence.^(21)^ Recent studies on Palestinian healthcare workers demonstrate that military checkpoints, violence exposure, and chronic stress severely degrade quality of life and professional performance, which inevitably extends to diabetes care delivery.^(23,35)^ Furthermore, the alarmingly low levels of physical activity (35.8% rarely or never exercising) are not merely a lifestyle choice but a reality of living in environments where outdoor movement is restricted and unsafe. This is consistent with findings from Sub-Saharan Africa, where structural barriers impede self-management.^(36)^ From the perspective of Self-Efficacy Theory, these environmental barriers severely diminish a patient's belief in their capacity to manage their disease, spiraling into worse clinical outcomes.^(20,31,37)^

The QoL assessment revealed that the "Impact" subscale yielded the highest (worst) scores, with "feeling unwell or tired" (M = 2.94) and "pain due to diabetes treatment" (M = 2.74) being the most prominent burdens. This aligns closely with Alshahrani et al.,^(7)^ who found that physical functioning and general health are the most compromised domains in diabetic patients, particularly as disease duration extends. The fatigue and pain experienced by this Palestinian cohort likely reflect the cumulative physiological toll of prolonged uncontrolled hyperglycemia and obesity. Prolonged disease duration often leads to progressive beta-cell dysfunction and resistance to treatment, complicating management.^(38)^ Conversely, the "Satisfaction" domain scored lowest (indicating better satisfaction), particularly regarding diabetes knowledge (M = 1.87) and overall life (M = 1.87). This relative satisfaction might indicate a degree of resignation or adaptation to the chronic illness, or a reflection of low expectations given the broader socio-political hardships of life in Palestine.^(29)^ Within the "Worry" domain, fear of complications scored highest (M = 2.45), which is a rational psychological response given that more than half the sample has uncontrolled HbA1c and over 73% already suffer from diabetes complications. This pervasive worry mirrors global findings where diabetes distress and health anxiety are dominant psychological burdens that impair treatment adherence.^(11)^ Addressing this worry requires psychological support structures, similar to the cognitive behavioral therapies proven effective in neighboring Pakistan,^(11)^ or digital interventions that provide reassurance and self-management skills.^(12,13)^ However, in Palestine, the high levels of academic and occupational stress documented among nursing students and nurses suggest that even available mental health resources may be overstretched, indirectly affecting diabetes education and patient support.^(24,25,35)^

The non-parametric analysis identified several crucial determinants of QoL. Consistent with regional literature from Saudi Arabia, female patients reported significantly worse QoL than males (Mean Rank = 135.04 vs. 109.54, p = 0.006), a disparity often attributed to biological differences in complication risks, higher rates of depression, and socio-cultural gender roles that limit women's self-care priorities in the Middle East.^(16,39)^ Monthly income was also a significant factor (p = 0.032); patients earning >4,000 NIS had significantly better QoL (Mean Rank = 79.46). This reinforces the premise that in LMICs, economic deprivation directly obstructs self-management—limiting access to healthy diets, glucose strips, and transportation to clinics.^(1,9,40)^

Physical activity emerged as the strongest predictor of QoL (p = 0.001), demonstrating a clear dose-response relationship: patients who never exercised had the worst QoL (Mean Rank = 158.59), while regular exercisers had the best (Mean Rank = 104.43). This robust finding mirrors the work of Tamornpark et al.,^(15)^ who identified regular exercise as a primary correlate of good QoL. In Palestine, where physical movement is heavily restricted by the occupation and security constraints, enforced physical inactivity becomes a structural determinant of disease burden. From the perspective of Self-Efficacy Theory, the inability to exercise diminishes patients' belief in their capacity to manage their disease, spiraling into worse clinical and psychological outcomes.^(20,30)^ Interestingly, unlike Alshahrani et al.,^(7)^ duration of diabetes was not significantly associated with QoL in this sample (p = 0.291). This suggests that in the Palestinian context, the acute socio-economic and behavioral barriers (like income and inactivity) may overshadow the chronological duration of the disease in determining a patient's day-to-day well-being.

The central finding of this study conclusively demonstrates that poor glycemic control is a significant and independent predictor of reduced QoL. Patients with uncontrolled glycemia reported significantly worse QoL (Mean Rank = 136.17) compared to controlled patients (Mean Rank = 111.78; U = 6187.5, p = 0.008). This categorical finding is strongly corroborated by the Spearman correlation, which showed a significant positive association between continuous HbA1c values and worse QoL scores (rho = 0.209, p = 0.001). This aligns with Mikhael et al.,^(5)^ who noted that achieving target HbA1c is the most critical factor in improving both clinical and patient-reported outcomes in the Middle East. Uncontrolled hyperglycemia directly drives the severe physical symptoms—fatigue, pain, and malaise—identified in the Impact subscale, which in turn fuels the psychological worry about future complications. This cycle of poor metabolic control leading to physical decline and psychological distress severely degrades QoL, reflecting the core tenets of Self-Efficacy Theory where poor clinical feedback diminishes a patient's confidence in managing their condition.^(31)^ The findings validate that in Palestine, much like in global contexts, suboptimal HbA1c is not just a biochemical failure, but a pervasive disruptor of a patient's functional, social, and emotional life.^(11,21,41)^ Therefore, interventions must go beyond pharmacological prescriptions to include structured DSME programs^(6)^ and address the contextual barriers—economic hardship, restricted movement, and low self-efficacy—that prevent patients from achieving the glycemic control necessary for a tolerable quality of life. The high levels of stress and trauma documented among Palestinian healthcare workers further suggest that the entire healthcare system is under duress, which may compromise the quality of diabetes education and support provided to patients.^(23,35)^ Strengthening the resilience of the healthcare workforce through targeted mental health support and improved working conditions could have secondary benefits for chronic disease management.^(24,26)^

CONCLUSION

This study highlights that Quality of Life among Palestinian adults with Type 2 Diabetes Mellitus is significantly compromised, with patients experiencing substantial physical impacts—primarily fatigue and pain—and profound worry about future complications. Poor glycemic control emerges as a central, independent predictor of diminished QoL, exacerbating both physical and psychological distress. Furthermore, the intersection of female gender, physical inactivity, and economic deprivation creates a vulnerable population that struggles disproportionately with the burdens of diabetes management. These findings underscore the necessity of moving beyond a purely biomedical approach to diabetes care. Effective interventions in Palestine must adopt a multi-dimensional, person-centered framework that prioritizes strict glycemic control while simultaneously enhancing self-efficacy, promoting safe and accessible physical activity, and dismantling the socio-economic and structural barriers that hinder self-management. Future research should employ longitudinal and interventional designs to further clarify causal pathways and evaluate the effectiveness of targeted, culturally sensitive DSME programs in improving both clinical outcomes and the overall quality of life for this population.

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42. 42 CONFLICTING INTEREST
43. 43 The author declares no potential conflicts of interest with respect to the research, authorship, or publication of this article.