Mediating Effect of Diabetes Acceptance on the Relationship between Social Support and Self-Care Behaviors in Patients Newly Diagnosed with Type 2 Diabetes Mellitus

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J Korean Acad Fundam Nurs. 2025;32(4):520-529

Publication date (electronic) : 2025 November 30

doi : https://doi.org/10.7739/jkafn.2025.32.4.520

Jinsun Park¹⁾, Moonkyoung Park^2),

¹⁾Doctoral Student, College of Nursing, Chungnam National University, Daejeon, Korea

²⁾Associate Professor, College of Nursing, Chungnam National University, Daejeon, Korea

Corresponding author: Park, Moonkyoung College of Nursing, Chungnam National University 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel: +82-42-580-8325, Fax: +82-42-580-8309, E-mail: lunarnr@cnu.ac.kr

*This article is a condensed form of the first author's master's thesis from Chungnam National University.

Received 2025 August 4; Revised 2025 October 1; Accepted 2025 November 16.

Abstract

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by insulin resistance or impaired insulin secretion leading to persistent hyperglycemia. In 2022, over 589 million adults worldwide had diabetes, with projections reaching 643 million by 2030[1]. In South Korea, the adult prevalence rose to 13.2% in 2023, a 19% in-crease over five years, highlighting its growing public health burden [2]. Compared with Western populations, Korean adults tend to have low body mass index (BMI) but show diminished β-cell function and higher suscepti-bility to glucose intolerance, potentially because of high-carbohydrate diets and sedentary lifestyles [3]. T2DM is associated with serious complications, such as cardiovas-cular disease, kidney failure, neuropathy, and premature mortality [1].

Early glycemic control and lifestyle modifications are critical for preventing disease progression and complications. The core components of diabetes self-care include dietary regulations, physical activity, medication adherence, and blood glucose monitoring. However, newly diagnosed patients often struggle with psychological distress, including anxiety, fear, and denial, which can im-pede their engagement in self-care behaviors [4-6]. Social support from family members and healthcare professionals has been consistently associated with improved adherence and clinical outcomes [7].

Patients newly diagnosed with diabetes experience their first year as a psychologically vulnerable period, often characterized by shock, confusion, and heightened support needs [8]. Contemporary guidelines recommend prompt diabetes self-management education and support, lifestyle modification, and routine psychosocial assess-ment after diagnosis [9]. Moreover, higher diabetes self-ef-ficacy is associated with better self-care and glycemic control, underscoring the value of targeting acceptance early [10]. Accordingly, promoting self-care behaviors among individuals within the first year of diagnosis is of critical importance.

Recent studies have highlighted diabetes acceptance as a key psychological factor that mediates the effect of social support on health behaviors [11,12]. Defined as a patient's emotional and cognitive integration of illness into daily life, higher acceptance is associated with improved self-regulation and sustained adherence to treatment [11]. Conversely, low acceptance, which is particularly common in newly diagnosed patients, has been associated with poor behavioral adaptation and delayed engagement in care [12].

Despite the increasing recognition of the importance of diabetes acceptance in chronic illness management, few studies have examined its mediating role in the relationship between social support and self-care behaviors during the early diagnosis phase of T2DM. This stage is marked by high psychological vulnerability and serves as a critical window for habit formation, making early adaptation particularly important for long-term outcomes.

Furthermore, most previous studies have treated social support as a unidimensional construct without distin-guishing between its different sources [13-15]. Social support is a multidimensional construct that encompasses several domains, including emotional support, which refers to expressions of warmth and valuing the patient's behaviors; appraisal support, which facilitates understanding of stressful events; informational support, which in-volves giving advice and providing relevant information; and tangible support, which refers to practical assistance such as financial aid or goods and services [13]. According to previous study, family members primarily provide emotional and tangible support in patients’ self-care, including practical assistance such as meal preparation, medication reminders or administration, support with exercise and household tasks, accompanying patients to medical appointments, and offering emotional encourage-ment [14]. In contrast, healthcare professionals typically provide informational and appraisal support based on their clinical expertise, including counseling, education, provision of medical guidance during consultations, and enhancing patients’ understanding of disease management strategies to facilitate adaptation and self-care [16]. Support from family and healthcare professionals may function through distinct pathways— emotional versus cognitive-affective— that may differentially influence psychological adaptation and self-care [15]. A more nuanced understanding of this differentiation is necessary to develop tailored stage-specific interventions.

A recent study by Erdoğ an Yuce and Yı ldı rı m [11] demonstrated that diabetes acceptance mediated the relationship between social support and treatment adherence; however, it did not distinguish the types of support or fo-cus on the newly diagnosed population. This study aimed to fill these gaps by investigating whether diabetes acceptance mediated the relationship between family and healthcare professional support and diabetes self-care behaviors among individuals newly diagnosed with T2DM. These findings are expected to develop culturally appropriate, early phase psychological and behavioral interventions to promote self-care behaviors.

METHODS

RESULTS

1. General Characteristics and Differences in Diabetes Self-Care Behaviors among Patients Newly Diagnosed with T2DM

Of the patients newly diagnosed with T2DM, 65.0% were men, and 47.5% were aged 40∼59 years. The most common BMI category was 23∼25 kg/m² (46.7%), and 75.8% of the patients were in the middle-income level. Most lived with their families (82.5%), and 45.8% had a college degree or higher. Current smoking and alcohol consumption rates have been reported to be 27.5% and 55.8%, respectively. Comorbid conditions, such as hypertension, hyperlipidemia, or cardiocerebrovascular disease, were present in 62.5% of the patients, and 88.3% received pharmacological treatment. A family history of diabetes was noted in 47.5% of the patients, and 49.2% perceived their health as good.

Diabetes self-care behavior scores were significantly higher among patients without comorbidities (4.55±1.02) than among those with comorbidities (4.07±1.00) (t=2.48, p=.015). No other characteristics were significantly different between the two groups (Table 1).

Table 1.

Difference in the Participants’ Diabetes Self-care Behaviors According to General Characteristics (N=120

2. Relationships among Social Support, Diabetes Acceptance, and Diabetes Self-Care Behaviors

Social support was assessed in two domains: support from healthcare professionals and family members. The mean scores for healthcare professional and family support were 4.14±0.77 (range: 1∼5) and 4.22±0.85 (range: 1∼5), respectively. The mean score for diabetes acceptance was 2.22±0.52 (range: 0∼3), whereas the mean score for diabetes self-care behaviors was 4.25±1.03 (range: 0∼7).

Because the diabetes self-care behaviors was non-nor-mally distributed, Spearman's rank correlations (ρ) were used. Significant positive associations were observed between self-care and healthcare professional support (ρ= .36, p<.001), family support (ρ=.38, p<.001), and diabetes acceptance (ρ=.28, p=.002), whereas the association between family support and diabetes acceptance was non-significant (ρ=.15, p=.104) (Table 2).

Table 2.

Correlations Between Health Care Professional Support, Family Support, Diabetes Acceptance, and Diabetes Self-care Behavior in Newly Diagnosed T2DM Patients (N=120)

3. Mediating Effect of Diabetes Acceptance

Prior to the GSEM analysis, regression assumptions were verified. Tolerance values (0.51∼0.88) and VIF values (1.04∼1.97) indicated no evidence of multicollinearity. The Shapiro-Wilk test confirmed that the diabetes self-care behavior deviated from normality; therefore, GSEM with a negative binomial link function was applied to appropriately account for the count distribution of the outcome variable. Comorbidity status was included as a covariate in all models.

1) Mediating effect of diabetes acceptance in the relationship between healthcare professional support and diabetes self-care behaviors

Healthcare professional support had a significant positive effect on diabetes acceptance (B=0.38, SE=0.12, p= .002; IRR=1.46, 95% CI [1.16, 1.83]) and on diabetes self-care behaviors (B=0.01, SE=0.00, p=.001; IRR=1.01, 95% CI [1.00, 1.01]). Diabetes acceptance was significantly associated with diabetes self-care behaviors (B=0.01, p=.029; IRR=1.01, 95% CI [1.00, 1.01]). The indirect effect of healthcare professional support on diabetes self-care behaviors through diabetes acceptance was statistically significant (B=0.002, 95% BCa bootstrap CI [0.00, 0.01]) (Table 3, Figure 1).

Table 3.

Mediating Effect of Diabetes Acceptance between Healthcare Professional Support and Diabetes Self-Care Behavior (N=120)

Figure 1.

Mediating effect of diabetes acceptance on the relationship between health care professional support, family support, and diabetes self-care behavior.

2) Mediating effect of diabetes acceptance in the relationship between family support and diabetes self-care behaviors

Family support did not have a statistically significant effect on diabetes acceptance (B=0.11, SE=0.08, p=.176; IRR=1.12, 95% CI [0.95, 1.31]). Family support had a significant direct effect on diabetes self-care behaviors (B=0.01, SE=0.00, p<.001; IRR=1.01, 95% CI [1.01, 1.02]). Diabetes acceptance was positively associated with diabetes self-care behaviors (B=0.01, SE=0.00, p=.007; IRR=1.01, 95% CI [1.00, 1.02]). The indirect effect of family support on diabetes self-care through diabetes acceptance was not statistically significant (B=0.001, 95% BCa bootstrap CI [-0.00, 0.002]) (Table 4, Figure 1).

Table 4.

Mediating Effect of Diabetes Acceptance between Family Support and Diabetes Self-Care Behavior (N=120)

DISCUSSION

This study examined the mediating role of diabetes acceptance in the relationship between social support and self-care behaviors in patients newly diagnosed with T2DM. Results indicated that healthcare professional support enhanced self-care behavior engagement through in-creased diabetes acceptance. This finding underscores the importance of promoting diabetes acceptance as a psychological pathway for behavioral change at the time of diagnosis. Although family support remained an essential source of emotional and logistical help, it did not significantly influence diabetes acceptance or self-care behaviors in this study. These findings suggest that healthcare professionals play a pivotal role in helping patients cognitively and emotionally integrate their diagnoses, thereby increasing the likelihood of sustained self-care and glycemic control.

Despite high levels of perceived support, participants demonstrated only moderate engagement in diabetes self-care behaviors. This pattern raises important questions re-garding the challenges faced by individuals newly diagnosed with T2DM. Effective self-care from the point of diagnosis is critical because early glycemic control is associated with a lower risk of complications and better long-term outcomes [26]. However, during this initial period, patients may experience psychological burden, including fear, denial, and information overload, all of which hinder their ability to implement recommended self-care behav-iors [27].

Interestingly, although most participants were in the first year of diagnosis, nearly half reported perceiving their health as "good." This may reflect a lack of overt symptoms in the early stages of T2DM, leading to an un-derestimation of disease severity or delayed psychological confrontation with the diagnosis. Such optimistic bias may hinder the urgency of adopting lifestyle changes or adhering to treatment protocols, serve as a barrier to accurate complication risk perception among patients with T2DM, and highlight the need for targeted education to bridges the gap between subjective health perception and objective disease risk [28].

The moderate self-care observed in this study suggests that even when emotional and informational support is present, it may not be sufficient on its own to translate into behavioral change. This underscores the importance of comprehensive, structured diabetes education that ad-dresses not only medication adherence but also other key domains, such as blood glucose monitoring, diet, physical activity, and foot care [29]. An integrated approach should incorporate technical instructions and psychological support to facilitate behavioral adoption.

Moreover, the emotional and cognitive loads associated with receiving a diagnosis of a chronic illness can act as a barrier to self-care. Feelings of being overwhelmed or un-prepared are common among newly diagnosed individuals and may contribute to inconsistent adherence or avoidance [30]. In this context, healthcare professionals play a critical role, not only as educators but also as emotional buffers, by reducing perceived burden, pacing the delivery of information, and fostering patient confidence. Empathetic and patient-centered provider communication improves psychological outcomes and promotes engagement in self-care [31]. Therefore, these findings highlight the need for early phase interventions that are holistic and psychologically attuned. Interdisciplinary strategies that address emotional, educational, and behavioral needs may be essential to support sustainable self-care from the out-set of diagnosis.

Diabetes acceptance emerged as a key factor that asso-ciates healthcare professional support with diabetes self-care behaviors. Defined as the process of integrating illness into one's life, diabetes acceptance facilitates cognitive and emotional adaptation to the chronic condition [11,24]. Support from providers grounded in clinical expertise and authority may exert a stronger influence on shaping patients’ attitudes toward disease responsibility, particularly in the early stages following a diagnosis. This suggests that meaningful interactions between providers and patients serve not only as a source of information but also as psychological anchors that foster behavioral activation [31]. Early support may be critical in helping individuals establish sustainable self-care habits during the formative phase of chronic illness management [32].

Interestingly, a mediating role of diabetes acceptance in the relationship between family support and diabetes self-care behavior was not observed. Although family involvement demonstrated a direct positive effect on self-care, it did not significantly influence diabetes acceptance. In the Korean cultural context, family support may not always facilitate illness acceptance. While families are generally expected to provide care and assistance, such involvement may manifest as excessive control or criticism rather than empathetic support. Previous research indicates that when support is perceived as intrusive or misaligned with patients’ needs, it may contribute to psychological burden, self-stigma, or even resistance to illness. Recent studies of Korean patients with T2DM have shown that self-stigma and diabetes distress are closely linked to psychological maladaptation and reduced quality of life, suggesting that family support, if not delivered appropriately, may in-advertently reinforce these negative experiences [33,34]. These cultural dynamics may explain why family support in this study did not show a significant association with diabetes acceptance. Rather than solely providing encour-agement or logistical assistance, families should be guided to participate in structured educational sessions that enhance their understanding of the illness and equip them to support patients in ways that align with their psychological adaptation goals [7]. Empowering family members to reinforce the treatment rationale, normalize self-care routines, and model coping behaviors may help bridge the gap between emotional support and acceptance [32]. Thus, involving families not only as caregivers but also as active facilitators of adaptation may enhance the overall impact of social support on long-term diabetes self-care.

This study offers important insights by focusing on individuals newly diagnosed with T2DM, a period marked by heightened psychological vulnerability and behavioral plasticity. Unlike previous studies, which typically inves-tigated long-term self-care among patients with establish-ed diabetes, this study emphasized the psychosocial dynamics that occur during the critical initial phase. By iden-tifying diabetes acceptance as a key mediator between healthcare professional support and self-care behaviors, this study provides a novel understanding of the psychological mechanisms underlying early behavioral formation. This underscores the importance of not only clinical instruction but also psychological support in interventions aimed at early adaptation to chronic illness.

These findings highlight the need for early interventions that are psychologically attuned and patient-specific, suggesting that provider-led efforts should go beyond information delivery to include active facilitation of cognitive and emotional adjustment. This study provides foun-dational evidence for the development of tailored interventions that address the emotional and behavioral di-mensions of diabetes care in the immediate post-diagnosis period.

However, this study has several limitations. Because of its cross-sectional design, causal inferences cannot be made. Convenience sampling at two institutions in a single re-gion may also limit the generalizability of the findings. In addition, psychological variables known to influence self-care, including diabetes knowledge, emotional distress, and self-efficacy, were not assessed. Although the diabetes acceptance scale showed high reliability in this study, its psychometric properties have not been formally validated in a Korean population, which limits the interpretability of diabetes acceptance scores in culturally specific Korean contexts. The social support instrument employed was developed decades ago, not specifically for diabetes, and may not fully capture disease-specific support or reflect the contemporary healthcare and cultural context. Furthermore, although the GSEM approach appropriately ad-dressed overdispersed count data and mediation effects, it has methodological limitations. The piecewise model com-bining linear and negative binomial regressions did not account for measurement error or latent variables, and conventional fit indices (e.g., CFI, RMSEA) were unavail-able. The modest sample size may also have reduced the precision of bootstrap estimates.

Future studies should adopt longitudinal designs to ex-plore how diabetes acceptance and self-care behaviors evolve over time and how they interact with other psychological mediators. Furthermore, research should aim to re-cruit more diverse and representative samples and develop or adapt culturally appropriate measurement tools for Korean patients with early stage of T2DM.

CONCLUSION

This study demonstrates that healthcare professional support contributes to improved diabetes self-care behav-iors by enhancing diabetes acceptance among individuals newly diagnosed with T2DM. Despite reporting high levels of perceived support, participants exhibited only moderate engagement in self-care behaviors, indicating that support alone may not be sufficient to initiate sustained behavioral changes. The lack of a mediating role of diabetes acceptance in the relationship between family support and self-care behaviors further highlights that different forms of support may operate through distinct psychosocial pathways. These findings underscore the importance of early psychological engagement in chronic disease management and the formative role of healthcare professional-patient interactions in shaping long-term self-care behavior trajectories.

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