This study aimed to determine the relationship between SS with MA, and QOL in people with type 2 diabetes. Besides, SS in chronic diseases like diabetes type 2 may lead to social avoidance, fear of disclosure of illness, reduced help-seeking, self-harm, feelings of guilt and shame, low self-worth, feelings of unhealthiness, and anxiety about the future. Patients may perceive their illness as a barrier to achieving their valued life goals.
The mean of SSS in Taiwan was reported lower than the present study (17). In the studies in North Korea (18), in China (19), and in Japan (20), the mean SSS were higher than the present study. Kato et al. (2021) reported a score of 75% (21) based on the number of years living with diabetes, which is also higher than the present study. The differences in the results may be related to the cultural differences and the inclusion criteria.
MA mean score in the Czech Republic (22), is to some extent consistent with the present study. In contrast, in China (23), in Nepal (24), in Pakistan, were reported higher and in a study in Iran, (26), was lower than the current study. The reasons for these differences may be related to the differences in the MAS, cultural, educational and socioeconomic differences, number of years with diabetes, and other factors.
In this study, 169 of the participants (73.8%) had poor MA, 59 (25.8%) had moderate, and 1 person (0.4%) had good MA. In contrast, Khanjani et al. (2021) in Iran reported that 47.89% of patients had poor MA, 28.52% had moderate, and 23.59% had good MA (27). The difference may be due to differences in the MAS and differences in the samples and research settings, while they were conducted in a diabetes clinic. Patient’s visits to these centers for diabetes control were voluntary and usually regular, while in the present study, patients who visited primary healthcare centers for various reasons were the research sample. In the study in India, 12.9% of the participants had poor MA and 57.8% had MA (28). The difference may be due to the differences in the MAS, and the differences in the samples and research settings.Because the study was conducted in a hospital setting, where nurses are responsible for MA, which may lead to higher adherence rates compared to patients who visit primary healthcare centers for various reasons. Despite patients' access to new medications and increased efforts in education and targeted interventions to improve MA (29), poor MA is one of the biggest challenges to successful treatment of chronic diseases, including diabetes.
In order to determine the QOL in people, the results of the present study are somewhat consistent with the results of some studies in Korea (18) and in Iran (5).In the study in China, the total QOL was reported lower than the current study. This difference may be due to cultural differences of the research communities and inclusion criteria. A study in India reported the highest score in the social relations domain (30).In contrast, the present study reported the lowest score in this domain and the highest score in the environmental domain.The reasons for this difference may be the difference in the QOLQ and (6-month period since the onset of the disease was one of the inclusion criteria.This may have affected the development of diabetes complications, social decline, and ultimately the QOL of the samples. Even though the difference in the research setting cannot be ignored, in the study patients visiting a diabetes clinic.
In the context of determining the relationship between SS and MA, the results are consistent with the findings of some studies (9, 22, 31). Researchers have shown that SS is one of the potentially important factors that plays a role in non-MA (9).
In the context of determining the relationship between SS and QOL, these findings are consistent with some studies (17-19). It seems that patients who experience a greater sense of social rejection due to their SS have a lower QOL than other patients. This is because in some patients, SS leads to seeking less medical help, social isolation and avoidance, which ultimately has significant impact on their QOL (19).
To determine the relationship between QOL and MA in samples, the findings are consistent with some researchers (23, 25, 32). In contrast, Azmi et al. (2021) in Malaysia, no significant correlation was observed between QOL and MA (33). The researchers themselves endorsed this difference in the patients' inadequate knowledge and the existence of this belief in the patients that, regardless of blood sugar fluctuations, they were safe from the harms of the disease and the disease did not harm them. Even though the research samples and tools used in this study are also different from the present study.
The mean score of SS in this study is not much. It may be for these two reasons: 1- more attention and wider awareness by health planners to people about this disease, the establishment of diabetes clinics and treatment of these patients in comprehensive health centers in recent years in Iran, which will cause a greater number of these patients to be diagnosed as a result of the normalization of this disease among people. 2- Sampling method: In the initial planning, it was supposed to be a simple random sampling according to patients' electronic records, and invite the samples to attend the health centers and participate in the research. Unfortunately, due to the CID-19 pandemic and the non-acceptance of our invitation from patients to attend health centers, we had to change the sampling method and for patients who refer to the health centers themselves, these results cannot be far from expected.
However, this amount should also be reduced, and health planners should pay more attention to education, screening and treatment of type 2 diabetes.