The study was led by Majed M. Aljabri, Alya Alghamdi, and Bandar S. Alharbi, researchers in the Community and Psychiatric Mental Health Nursing Department at the College of Nursing, King Saud University in Riyadh. The team recruited 413 adults with diabetes who were attending primary healthcare centers in the Saudi capital. Roughly one-third of the participants — 31.0 percent — had lived with diabetes for more than a decade, and just over a quarter, 26.9 percent, reported experiencing diabetes-related complications, a reminder that the cohort included many people for whom the stakes of good self-care were already painfully concrete. Ethical approval was obtained from the Research Ethics Committee of King Saud University, and the study was conducted in accordance with the principles of the Declaration of Helsinki, with informed consent from all participants.

To capture the psychological dimensions of the problem, the researchers deployed three well-established instruments. The 18-item Multidimensional Health Locus of Control Scale, or MHLC, breaks health-related beliefs into distinct components: Internal Health Locus of Control, reflecting confidence in one’s own agency; Powerful Others Health Locus of Control, reflecting reliance on healthcare professionals and other authority figures; and Chance or Fate Health Locus of Control, reflecting the sense that health outcomes are determined by luck or destiny. Illness perceptions were measured with the Brief Illness Perception Questionnaire, which probes how patients understand their condition — its consequences, its timeline, its controllability, and the emotional weight it carries. Self-care behavior was assessed with the Summary of Diabetes Self-Care Activities, a validated measure covering domains such as diet, exercise, blood glucose testing, foot care, and medication adherence.

The analytical strategy unfolded in two stages, each answering a different question. First, the team used multivariable linear regression to ask whether each locus-of-control dimension was associated with diabetes self-care after statistically adjusting for sociodemographic and clinical characteristics — a crucial step, because raw correlations between beliefs and behavior can easily be distorted by age, education, disease duration, or the presence of complications. Second, the researchers turned to structural equation modeling, a statistical framework that allows investigators to test hypothesized pathways linking variables simultaneously, including indirect effects that pass through an intermediate variable. Here, the intermediate variable was positive illness perception, and the question was whether locus of control influences self-care directly, or whether it works by first shaping how patients mentally frame their disease.

The regression results were striking in their asymmetry. Internal Health Locus of Control showed a positive association with diabetes self-care, with a standardized coefficient of 0.29 and a 95 percent confidence interval running from 0.11 to 0.47. Powerful Others Health Locus of Control was nearly identical in magnitude, with a coefficient of 0.28 and a confidence interval of 0.09 to 0.47. In plain terms, people who believed they controlled their own health, and people who trusted the power of their healthcare providers, both tended to report better self-care. The Chance and Fate dimension, by contrast, showed no significant direct association with self-care at all — a finding that might seem to suggest fatalism is irrelevant to diabetes management, until the structural equation modeling revealed otherwise.

That second stage of analysis is where the study becomes genuinely illuminating. Internal Health Locus of Control was strongly and positively associated with positive illness perceptions, with a coefficient of 0.620 and a p-value below 0.001. Positive illness perceptions, in turn, were strongly associated with better diabetes self-care, with a coefficient of 0.506, again at p below 0.001. When the researchers traced the indirect pathway — from internal control beliefs, through more constructive perceptions of the illness, to self-care behavior — the indirect effect was 0.314, with a confidence interval of 0.126 to 0.502 that excluded zero. In other words, a substantial share of the relationship between believing in one’s own agency and actually practicing good self-care appears to run through the way patients conceptualize their disease: how controllable they judge it to be, how serious they consider its consequences, and how coherent their understanding of it feels.

Perhaps the most unexpected result concerned the Chance and Fate dimension. Although fatalistic beliefs showed no direct link to self-care in the regression models, the structural equation model detected a significant indirect association: the pathway from Chance Health Locus of Control through positive illness perceptions to self-care carried a coefficient of 0.113, with a confidence interval of 0.025 to 0.201. This suggests that the relationship between fatalism and diabetes behavior is more nuanced than a simple negative correlation. The authors concluded that Internal and Chance dimensions of health locus of control are associated with self-care primarily through their relationships with illness perceptions, whereas the Powerful Others dimension showed a direct association with self-care behavior — implying that trust in clinicians may motivate action more immediately, without needing to first reshape how the patient views the disease.

The clinical implications of this pathway analysis are considerable. Diabetes self-care is the foundation of glycemic control and the primary defense against the long-term complications that make diabetes one of the world’s most burdensome chronic diseases — retinopathy, nephropathy, neuropathy, and cardiovascular disease among them. Yet self-care is notoriously difficult to change through education alone. If the Saudi findings generalize, interventions that target illness perceptions — for example, helping patients develop a more coherent and controllable mental model of their diabetes — could unlock self-care improvements that information-only programs fail to achieve. The results also hint that different patients may need different psychological levers: those with strong internal control beliefs might benefit most from perception-focused work, while those who defer heavily to their doctors may respond well to structured clinical support and clear, actionable guidance from trusted providers.

The study’s context matters as well. Saudi Arabia faces a substantial and growing diabetes burden, and primary healthcare centers in Riyadh serve a diverse population in which cultural and religious framings of health and destiny can shape how illness is understood. The cross-sectional design, however, imposes an important limitation: because beliefs, perceptions, and behaviors were all measured at a single point in time, the analysis cannot prove that locus of control causes illness perceptions, or that illness perceptions cause self-care. Reverse pathways — in which successful self-management fosters a stronger sense of control, for instance — remain plausible, and longitudinal or interventional studies will be needed to establish directionality. The authors also relied on self-report instruments, which are vulnerable to social desirability and recall bias, although all three scales are widely validated in diabetes research.

Even with those caveats, the research adds a compelling piece to the psychology of chronic disease management. It suggests that the mind’s model of an illness is not merely a passive reflection of medical facts but an active mechanism that converts belief into behavior. For the 413 adults in Riyadh who participated, and for the hundreds of millions of people worldwide living with diabetes, the message is that how you think about your disease — whether you see it as manageable, coherent, and within your influence — may matter almost as much as the medications in your cabinet. And for the clinicians treating them, the study argues that listening to how patients perceive their illness could be as clinically productive as prescribing the next dose.

Subject of Research: Health locus of control, illness perceptions, and diabetes self-care among adults with diabetes in Saudi Arabia

Article Title: Associations of health locus of control with diabetes self-care: the role of illness perceptions among adults with diabetes in Saudi Arabia

Article References: Aljabri, M. M., Alghamdi, A., & Alharbi, B. S. (2026). Associations of health locus of control with diabetes self-care: the role of illness perceptions among adults with diabetes in Saudi Arabia. BMC Endocrine Disorders. https://doi.org/10.1186/s12902-026-02567-6

Image Credits: AI Generated

DOI: 10.1186/s12902-026-02567-6

Keywords: diabetes, health locus of control, illness perceptions, diabetes self-care, self-management, health psychology, structural equation modeling, Saudi Arabia, primary health care, chronic disease, patient behavior, endocrinology

The research team set out to address a practical gap in diabetes care. Existing questionnaires tend to measure self-care as a broad construct, aggregating many activities into a single score, and subjective judgements about personal glucose levels have been shown to predict distress more strongly than objective continuous glucose monitoring data. Clinicians, meanwhile, face time-pressured consultations packed with glycaemic metrics but often lack a rapid way to pinpoint which concrete behaviours might be driving a patient’s results. To fill that gap, the investigators used the Behavioural Diabetes Care Record, or BDCR, a questionnaire of 18 items that can be completed in under five minutes, with separate versions tailored to multiple daily injections and continuous subcutaneous insulin infusion pump therapy.

Most BDCR items ask respondents to give a number describing how often a specific behaviour occurred in the preceding 14 days. Questions include how many times per day blood glucose was tested, on how many days a main meal was eaten without administering insulin, and on how many days hypoglycaemia treatment food was carried for most of the day. Pump users are asked about cannula and infusion line changes, while injection users are asked about missed doses. The record also asks individuals to rate, on a scale of one to ten, how well they are achieving their personal diabetes self-care goals and how willing they are to make changes. Previous work has shown the measure responds to behavioural intervention, with medium to large effect sizes, and that improvements in individual behaviours correspond with improvements in HbA1c and distress.

The cross-sectional study recruited 105 adults aged 18 to 40 who had lived with type 1 diabetes for at least six months and were independently managing their condition, drawing participants from consecutive outpatient appointments over eight months. The cohort, 53 percent male with an average age of 27 and average diabetes duration of 12.6 years, had a mean HbA1c of 8.7 percent. Two-thirds used multiple daily injections and about a third used insulin pumps, while 29 percent used some form of continuous glucose monitoring. Alongside the BDCR, participants completed the 17-item Diabetes Distress Scale, the Acceptance and Action Questionnaire-II, reverse scored to index psychological flexibility, and a short form of the Behavioural Activation for Depression Scale. Point-of-care HbA1c values were taken from the medical record.

The behavioural frequencies told a clear story. Participants with HbA1c below 8 percent checked their glucose a median of four times per day, compared with three times among those at or above 8 percent, a statistically significant difference. Days on which prandial insulin was missed were also associated with glycaemic outcome, with a median of zero missed main-meal doses in the better-controlled group versus two in the higher HbA1c group. Among injection users, more frequent insulin administration, around four times per day, was associated with lower HbA1c. Those with better control also detected or tested for hypoglycaemia more often, a median of four times versus two, and were more likely to carry fast-acting treatment food throughout the day.

Distress painted its own distinct picture. Clinically significant diabetes distress, defined as a mean Diabetes Distress Scale score of three or above, was associated with more days on which insulin was skipped for main meals and for snacks, and with less frequent glucose checking before meals. Notably, distress and HbA1c did not move entirely in lockstep: some behaviours separated the groups on one measure but not the other, reinforcing the idea that emotional burden and glycaemic control are related but separable entities. Perceived achievement of personal self-care goals and psychological flexibility were both significantly associated with lower HbA1c and lower distress, while behavioural activation alone was not.

To see whether these signals clustered into recognisable profiles, the researchers applied latent class cluster analysis, guided by statistical fit criteria and input from consumers with lived experience of type 1 diabetes and clinicians from medical, nursing and nutrition disciplines. Three subgroups emerged. Half of participants fell into the first cluster, characterised by near-daily glucose checking, checking before insulin doses, few missed mealtime boluses, ready availability of hypoglycaemia treatment, higher psychological flexibility and strong perceived goal achievement. Only 30 percent of this group had HbA1c at or above 8 percent, and just 4 percent reported clinically significant distress.

The second cluster, about a third of the sample, showed moderate engagement: three-quarters checked glucose daily, but 72 percent had HbA1c at or above 8 percent and roughly 29 percent reported significant distress. The third cluster, nearly 18 percent of participants, stood out as clearly at risk. Ninety-nine percent had HbA1c at or above 8 percent and 72 percent reported clinically significant distress. They checked glucose on only about a third of days, missed main-meal insulin on a mean of nearly six days out of 14, checked before meals only about a quarter of the time, carried hypoglycaemia treatment least often, and recorded the lowest psychological flexibility and goal achievement scores. The authors note that this kind of stratification could allow clinicians to direct attention and resources to those most in need, particularly when glucose levels are suboptimal or distress is evident.

The findings carry implications for how routine consultations are structured. Because the BDCR items are observable and measurable, they can be repeated over time to track behavioural change and response to intervention, and triangulating them with HbA1c and continuous glucose monitoring data may offset some limitations of self-report, such as recall inaccuracy and social desirability bias. The authors suggest the instrument could guide personalised conversations, tailored goals, decisions about diabetes technology, or timely referral to dietitians and clinical psychologists. They also caution that the cross-sectional design limits causal inference and that findings from a tertiary-centre cohort may not generalise to wider populations, including people seen by telehealth or those not attending scheduled appointments.

Even in an era of continuous glucose monitoring and hybrid closed-loop systems, the behaviours highlighted here remain pillars of standard care: checking glucose or a trend arrow before dosing, announcing and administering mealtime insulin, and keeping hypoglycaemia treatment within reach. By showing that a five-minute set of plain questions can flag both metabolic risk and emotional strain, and by linking those patterns to psychological flexibility, the study offers a low-cost foundation for more person-centred, goal-oriented diabetes consultations. The team calls for prospective research to test whether routinely collecting these behavioural data genuinely improves outcomes for adults living with type 1 diabetes.

Subject of Research: Associations between type 1 diabetes self-care behaviours, glycaemic control, diabetes distress and psychological flexibility in adults

Article Title: Frequency of Key Type 1 Diabetes Self‐Care Behaviours Are Associated With Psychological Flexibility, Distress and Glycaemic Outcome

Article References: Nicholas, J. A., Yeap, B. B., Cross, D., Bear, N., & Burkhardt, M. S. (2026). Frequency of Key Type 1 Diabetes Self‐Care Behaviours Are Associated With Psychological Flexibility, Distress and Glycaemic Outcome. Endocrinology, Diabetes & Metabolism, 9(5), Article e70336. https://doi.org/10.1002/edm2.70336

Image Credits: AI Generated

DOI: 10.1002/edm2.70336

Keywords: type 1 diabetes, diabetes self-care, HbA1c, diabetes distress, psychological flexibility, Behavioural Diabetes Care Record, insulin regimen, glucose monitoring, cluster analysis, hypoglycaemia, behavioural intervention, Frequency