“Diabetes is death”: Perceptions and care experiences of people living with type 2 diabetes in urban and rural settings in Central Uganda

“Diabetes is death”: Perceptions and care experiences of people living with type 2 diabetes in urban and rural settings in Central Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article “Diabetes is death”: Perceptions and care experiences of people living with type 2 diabetes in urban and rural settings in Central Uganda Mathias Akugizibwe, Chaka Moreen Namulundu, Paul Kitandwe, Esther Awino, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9178340/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background Type 2 diabetes is among the leading causes of death globally, with the highest burden in low-income countries, where misconceptions about its causes and management remain widespread. This study explored the perceptions and lived experiences of adults with newly diagnosed type 2 diabetes in Central Uganda. Methods Thirty participants diagnosed 2 years prior were purposively enrolled in a longitudinal qualitative study in Kalungu and Masaka districts, Central Uganda. Each participant had two repeat in-depth interviews, and the data were analyzed thematically using the Health Belief Model constructs. Results Participants attributed type 2 diabetes to unhealthy lifestyles (e.g, alcohol use, processed sugars, oily fast food), family history, and (¼ of participants) spiritual causes. Signs and symptoms were classified as either less severe (e.g, sweating, urination, fatigue) or more severe (e.g, thirst, infections, vision issues, stiffness, paralysis, dizziness, low libido). Perceived signs and symptom severity and anticipated benefits influenced care-seeking decisions. Most participants reported using multiple care types, including biomedical, herbal, and spiritual. Care type choice was guided by expected health benefit regardless of sex or location. Conclusions In Central Uganda, newly diagnosed adults categorize diabetes signs and symptoms by severity, which shapes their health-seeking behaviour. The decision to seek a specific care type, biomedical, spiritual, or herbal, was influenced by perceived signs and symptom severity and expected benefit, not by demographic differences. These insights should guide the development of tailored diabetes education interventions. Health sciences/Diseases Health sciences/Endocrinology Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors Diabetes perceptions experiences Uganda Background Type 2 diabetes(T2D) is a major global health burden, currently affecting an estimated 587 million people worldwide, and over 80% of these are in low-and middle-income countries (LMICs)[ 1 ][ 2 ]. In sub-Saharan Africa (SSA), T2D prevalence is rising steadily, with approximately 19 million people currently living with the condition, and this number is projected to be more than double over the next two decades[ 3 ][ 4 ]. In Uganda, as in many SSA countries, the burden of T2D is increasing, although national prevalence estimates vary across studies and regions[ 5 ]. With this in mind, the patient care experiences for the management of T2D remain underexplored in many low-resource settings. Ongoing debates around diet, healthcare access, cultural norms, and social support highlight the complexity of managing T2D in these settings[ 6 ][ 7 ][ 8 ][ 9 ][ 10 ][ 11 ]. Misconceptions about the causes and management of the disease remain widespread[ 12 ][ 13 ][ 14 ], posing a significant barrier to effective care[ 15 ][ 16 ]. These knowledge gaps can delay care-seeking, reduce treatment adherence, and worsen outcomes[ 17 ]. This study aimed to explore how newly diagnosed adults with residence (rural /urban) in Central Uganda perceive T2D, how they navigate health care options, and what shapes their treatment choices. The analysis was guided by the Health Belief Model (HBM), which frames health behaviour around six constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action[ 18 ] [ 19 ][ 20 ][ 21 ]. Methodology Study design, area, and setting This was a qualitative longitudinal follow-up study conducted in two public and not-for-profit mission hospitals in Central Uganda from October 2019 to August 2021. These were: Masaka Regional Referral Hospital and the General Population Cohort (GPC) diabetes clinics in Kalungu. These facilities were purposively selected to reflect urban and rural populations and had a functional outpatient diabetes clinic. Masaka Regional Referral Hospital, representing the urban population, has a 330-bed capacity, an annual admission of 23,456 patients, and a 91% bed occupancy rate[ 22 ]. The General Population Cohort diabetes clinics in Kalungu district represented the rural population. Established in 1989 by the MRC/UVRI, the GPC began with 15 villages and expanded to 25 by 2000. From 2010, its scope extended to include non-communicable diseases. It runs outpatient services and a clinic led by a physician, including specialised non-communicable diseases care[ 23 ]. Participants, sampling, and recruitment. We purposively selected 40 participants based on consent. Eligibility included participants aged 18 years and above who were clinically stable, with controlled blood glucose, pressure, and cholesterol levels. Additional inclusion criteria required that participants had taken part in the wider Uganda diabetic study, had consented to future research participation, and had been diagnosed within the preceding two years. Participants were contacted via phone using details from the facilities. They were informed about the study and invited to participate. Recruitment continued until 40 participants consented, at which point data saturation was reached. No participants withdrew consent. All interviews were conducted at secure and private offices of the Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI and LSHTM) field stations, offices of Masaka and Kyamulibwa-Kalungu. Privacy was ensured by limiting interview attendance to the participant and the interviewer. Data collection Two trained research assistants (one male, one female) conducted in-depth interviews using a semi-structured guide developed from the study objectives. The guide was piloted and refined before use. Each participant was interviewed twice, with a one-month interval between sessions. The first interview focused on rapport building, while the second interview explored perceptions of diabetes, diagnosis, treatment history, and care-seeking behaviour. With participant consent, all interviews were audio recorded. The Interviews lasted 30–90 minutes and were conducted in the Luganda language. Daily debriefings were held to review key findings and plan for subsequent sessions. Data management Audio recordings were transcribed verbatim. Transcripts were proofread by research assistants and reviewed by a senior social scientist to ensure accuracy, anonymization, and completeness. All data were securely stored on a restricted-access server. Field notes and transcripts were repeatedly reviewed to identify themes. A coding frame based on the Health Belief Model (HBM) constructs was drafted by the research team. After refinement and pilot testing with five transcripts from each round of interviews, a coding frame was finalized. Research assistants coded the data manually, and the senior social scientist resolved the disagreements. Data analysis The coded data were analyzed thematically using the HBM framework with room to further identify the emergent themes beyond the HBM constructs[ 20 ][ 21 ]. Key emergent themes included perceived susceptibility, severity, and benefits of care seeking. Additional themes outside the HBM framework were also captured. Representative participant quotes were included to illustrate the findings. Identifiers were limited to age, sex, and location to protect participant confidentiality. Ethical considerations This study was approved by: Uganda Virus Research Institute's Research and Ethics committee, Uganda National Council for Science and Technology (UNCST), and the London School of Hygiene and Tropical Medicine Ethics Committee (LSHTM). Written informed consent was obtained after explaining study details, including purpose, risks, benefits, and interview duration. All COVID-19 standard operating procedures were observed to ensure safety. Results Participants demographic profile The total number of participants in this study was 40. The majority of these participants were women (57%), Christians by faith (63%), and married (73%), with a mean age of 43.6 years and a range of 27–75 years. More than half of the study participants (23/40) had attained primary education and engaged in subsistence farming for a livelihood. See detailed sociodemographic information is available in Table 1 below. Table 1 Socio-demographic characteristics of participants Demographics Variables categories Percentages (%) Total (N) Sex Male 43 17 Female 57 23 Age range 27–34 7 3 35–42 13 5 43–50+ 80 32 Highest Level of education Senior four certificate 20 8 Secondary dropout 17 7 Primary 57 23 Never received formal education 6 2 Religion Christian 63 25 Muslim 34 14 Others 3 1 Marital status Married 73 29 Widowed 7 3 Divorced/separated 20 8 Source of livelihood Formal/office job 4 2 Farming 76 30 Casual laborer 4 2 Business 16 6 Biological children Has children 97 39 Has no children 3 1 Perceived susceptibility to developing type 2 diabetes People who live unhealthy lifestyles Most of the study participants (26/40) reported that they believed their eating and drinking habits made them susceptible to developing type 2 diabetes. The participants narrated that eating fried foods and drinking alcohol and juices with a lot of sugar was unhealthy and resulted in becoming fat/obese, putting them at risk of developing type 2 diabetes. The participants also observed that unhealthy eating habits of too much fried food and sugary juices were more common among rich households. This reporting was similar across participants' age brackets, sex, and rural and urban settings. I used to take it(juice), and I would tell the housemaids or anyone making it that, if it's not concentrated enough, add in more sugar, (Rural_ Female aged 30 yrs ). Honestly, at home, my parents are not diabetic neither are my siblings…I think I developed it because I loved sugary things (Urban Female aged 40 yrs ). However, there were a few participants who reported that type 2 diabetes did not distinguish between the poor and the rich. They explained that even poor people could be diagnosed with diabetes, a disease that was previously associated with being rich. I used to think that diabetes was a disease for the rich who ate fatty foods and those who are fat, but if I can be told that I am diabetic... That was strange because I grew up eating greens and bitter things, maybe I was born with obesity (Rural_ Female aged 77 yrs). Being born in a family with a history of diabetes Slightly more than a third of the study participants (15/40) reported that their genes put them at risk of developing diabetes (type 2 diabetes). They explained that people born in families with a history of diabetes (type 2 diabetes) were believed to be susceptible to developing the disease. This reporting was more common among female participants, mostly educated to the primary level, and aged 40 years and above. There were no rural-urban differences in reporting this. … when I was diagnosed with diabetes, I recalled that my father was diabetic, and I thought that maybe it’s a disease within the family because even most of my siblings were also suffering from diabetes ( Urban _ Female aged 52 yrs ). In both rural and urban settings, there were participants across all ages, male and female who reported losing a family member due to diabetes. They further added that this convinced them that diabetes is hereditary and that they would also die. I realized that my grandparents died of diabetes, my uncle too was suffering from diabetes and… the fact that I had witnessed many relatives suffering from the same sickness……, I always had the fear that I would also die like some of them died. I could have inherited diabetes … ( Urban _ Female aged 46 yrs ). Type 2 diabetes is a disease attributed to spiritual forces Over a quarter of the study participants (11/40) reported that they developed type 2 diabetes because of spiritual forces like witchcraft, being a punishment by God, or misfortune. 5 participants narrated that Satan is the root cause of all problems, including stress, misfortunes, and death, which leads to the development of type 2 diabetes. The majority of these participants (4/5) who reported this were from the rural setting and aged above 40 years. These participants further reported that diabetes (type 2 diabetes) can only be cured through spiritual intervention, for example, praying to God intensively. I think satanic stuff can also cause diabetes like stress brings diabetes. You know Satan can cause misfortunes, for example, if you lose a loved one and you get overly stresses you can get diabetes. So what Satan does is to bring things that increase your stress levels and you later be diagnosed with diabetes ( Rural _ Female aged 38 yrs ). In my other experience, I thought that being a diabetic was a punishment from God. Scriptures noted that diseases that never healed would dwell amongst people who were sinners. I resorted to repentance and I felt relieved that God forgave my sins (Rural_ Male aged 54 yrs ) Similarly, a few (3/40) participants, all based in rural settings, believed that diabetes could be acquired through witchcraft. I think these diseases are from witches, the way it makes you feel when you get it is strange. Once it attacks you, it comes with a lot of itching, you can’t sleep at night hahaha, that’s why I say maybe its witchcraft ( Rural _ Female aged 57 yrs). However, the majority of the urban female participants reported that they did not believe that diabetes (type 2 diabetes) was caused by witchcraft. I don’t believe that diabetes was spread through black magic because I know very well the causes of diabetes and they are; poor eating habits, worry/depression or hypertension . ( Urban _ Female aged 46 yrs ). Perceived severity of type 2 diabetes Experienced signs and symptoms of type 2 diabetes The majority of participants reported experiencing a range of diabetes signs and symptoms, which they described as more or less severe. The participants explained that their experience with the diabetes signs and symptoms formed the basis for them to suspect that they could develop diabetes. However, the decision to seek medical care depended on the severity of the signs and symptoms experienced. Overall, the majority of the participants reported experiencing, thirst, blurred vision, reduced sexual libido, on top of feeling dizzy, and headaches that presented with fevers as severe diabetes signs and symptoms. They also mentioned other complications that are not typical symptoms of diabetes, such as stiffness, temporal paralysis, limb swelling, piercing pins or tingling sensations. They added that they were compelled to seek health care as a consequence of experiencing these symptoms. I started with symptoms like too much thirst, pain in the legs with a burning sensation, pain that felt like piercing needles in the legs, fingers and everywhere, then thirsting frequently, dry throat. I experienced blurry vision, that is why I decided to go for check-up… (Rural_ Female aged 77 yrs). The reason why I went for check-up was because of frequent paralysis/stiffness of my fingers (Urban_ Female aged 54 yrs ). I experienced the lack of sexual prowess during intimacy with my wife, this prompted me to go find out from the health facility. At the hospital I was given certain medication and I was told the cause of that lack of sexual man power was diabetes ( Urban _ Male aged 42 yrs ). The signs and symptoms of diabetes that the participants reported to be less severe included: general body pain and general weakness, frequent sweating, thirst, and urination. They further added that, given the low severity of these signs and symptoms, they never sought health care when they experienced them. I didn’t know at first that it was diabetes, I used to feel a lot of thirst and I would even wake up at night and drink water. What I didn’t know was that it was diabetes, and I used to drink passion fruits with sugar in it, so I took it like that, but I used to have a fever all the time and generally my body was weak. So, I decided that let me go to the Health Centre and they take tests to find out what was disturbing me ( Urban _ Female aged 52 yrs ). The condition came about as a headache and fever and even feeling pain all over the body for some time. Later, decided to seek health care. The health workers found out that it wasn’t malaria fever, I didn’t have a fever and when they tested me for diabetes, I was found to be out of normal range for sugar levels , ( Urban _ Male aged 43 yrs). Some participants (7/40) reported delays in seeking health care till they were severely ill health. Such delays in seeking health care were common among men than women in rural areas. I used to feel a great deal of thirst, and I usually took like 5 litres of water, and I wondered whether I would end up having very watery blood. Later I went to Kabungo Health centre, where the health workers told me that those looked like signs of diabetes but at that health centre, it was not being tested, then I decided that I will go to MRC-Kyamulibwa, but I was hesitant to go. Later on I got a terrible fever and I went to Kyamulibwa at Musaanya’s Health Centre, on being tested, they told me that the sugar levels are so high that the gadget [glucometer] that measured it wasn’t even able to do it well, that’s when I came to know that I’m diabetic and I spent the whole week there admitted on a drip, and I left the health center knowing that I had diabetes (Rural_ Male aged 55 yrs). Health care-seeking practices of patients living with type 2 diabetes The majority of participants (26/40) reported that they had sought care for diabetes from the biomedical option only. Continued retention in biomedical health care for type 2 diabetes was largely attributed to the desire to check the status of the disease and how they responded to the treatment. Other participants sought biomedical options hoping to learn from health workers how to do self-check-ups on their own as this would help to minimize health facility visitation in future. As a result, some participants, especially females, confirmed that they had developed the capacity to do self-checkups, which made it easy for them to buy medication from the nearby pharmacy. I frequented the hospital especially when my blood sugar levels changed. I also made sure I had my medications and adhered to taking that medication so that I would live. I want to live and that is why I always look after myself and adhere to my medication. I usually buy my medication from the pharmacy after self-check-up (Rural_ Female aged 70 yrs ). Close to a third of the participants (11/40) reported the use of a mix of biomedical, herbal, and or spiritual health care options at the same time, with no clear starting order determined. Some participants revealed that the choice of which care to seek was determined by the severity of the signs and symptoms experienced. Less severe signs and symptoms determined the delay to seek biomedical health care options, and more often started with self-medication with biomedical and herbal or a combination of these. In addition, some participants reported that the use of alternative medicine followed their use of a biomedical option, which they found less comprehensive. They opted to complement the biomedical option with other alternatives because type 2 diabetes was considered a complicated condition. At one time I had an issue whereby the sugar level rose from 7 to 19 points…I started taking the herbal medication. I confess that since I started the mixture of the herbal and drugs [modern medicine] treatment I have never felt any problem apart from a few pains in the body… ( Urban _ Female aged 52 yrs ). Most participants (31/40) reported their use of herbal medication following a referral from fellow diabetic patients and the anticipated immediate health outcome/benefit from herbal medicine. Combining herbal and modern medicine was reported in both rural and urban settings by both men and women in all age brackets. … when we share ideas with fellow diabetics, some have testimonies of the great impact of herbals in their lives and so I intentionally follow what other patients do (use referred herbals). Herbs have helped me with my diabetes, especially when I’m badly off. ( Urban _ Female aged 46 yrs ). On how many times I had used the herbal treatment since I came to know that I had diabetes, it’s not the number of times but I was using it all the time along with the western medicines because I don’t need to buy it but they directed me to pick this or that, then boil it especially those herbs that taste bitter and drink the solutions (Rural_ Male aged 55 yrs). Nearly a quarter of participants (9/40) reported having been encouraged to also seek divine healing for diabetes as they continue taking their medication. These revealed a strong belief in God, while adhering to medication would be key to healing (managing diabetes). One participant narrated about this as follows: …my mother instead encouraged me to be courageous and to swallow my medication and pray earnestly to God for healing. I also believed in God for healing while taking my tablets ( Urban _ Female aged 54yrs ). Discussion of findings This study set out to explore the perceptions and diabetic care experiences of newly diagnosed people living with type 2 diabetes in urban and rural settings in central Uganda. Whereas our data reveals that most participants (31/40), in both rural and urban settings, perceived susceptibility to type 2 diabetes was highly dependent on lifestyle, belief in spiritual causes remains commonly reported in rural areas, and a high proportion of patients combined biomedical and other approaches to management. The other care-seeking options were herbal and spiritual remedies, which were often sought simultaneously without a defined order to which came first. Participants expressed diverse views on what made individuals susceptible to type 2 diabetes. Most participants pointed to lifestyle factors, especially diet and physical inactivity. Being affluent was often associated with increased risk, as wealth enabled access to sugary and fatty foods as well as sedentary living. Other perceived causes included genetic inheritance and spiritual causes such as witchcraft. Similar beliefs have been observed in Ghana[ 24 ], Brazil ([ 25 ], and Tanzania[ 26 ], suggesting that perceptions of diabetes risk often blend biomedical and cultural explanations. Our findings align with prior studies[ 16 ][ 27 ][ 28 ], which emphasize type 2 diabetes as a disease shaped by both biological and social factors. Spiritual beliefs were a prominent theme, reflecting the cultural context in which illness is often linked to supernatural causes[ 29 ]. This highlights the need for diabetes interventions to be sensitive to sociocultural beliefs, particularly in how people interpret signs and symptoms and decide when and how to seek healthcare. Participants described a wide range of signs and symptoms affecting their daily life, from physical, for example, pain, blurred vision, and leg swelling, among others, to psychological, for example, reduced sexual desire. These reports echo findings from other studies underlining the complex, multifaceted experience of living with type 2 on quality of life [ 30 ][ 28 ]. Importantly, the severity of these signs was closely related to treatment-seeking behaviour as the patients often tolerated classical symptoms of diabetes such as thirst and polyuria, and only sought care when more severe symptoms, such as dizziness and persistent pain, developed. This aligns with other findings and illustrates the need for community education to increase population awareness of early warning signs of diabetes[ 31 ]. Our findings also show widespread medical pluralism. Participants combined biomedical, herbal, and spiritual approaches to manage type 2 diabetes signs and symptoms. Herbal remedies were often used not for a cure but a symptom relief, sometimes seen as more effective or more readily available than modern medicine. Cost and accessibility were key reasons for preferring herbal remedies, unlike in studies among African-Caribbeans in the UK, where distrust in medical professionals was a major factor[ 32 ]. Study limitations and recommendations Although this study was community-based, we only included patients with a diabetes diagnosis. Including caregivers and health care providers would have added valuable perspectives. The findings of this qualitative study are limited to only two districts of Uganda’s central region and therefore, are short of Uganda’s representativeness as a country. Also, using the Health Belief Model only during analysis, rather than from the outset, meant that some dimensions were underexplored. A full integration of the HBM during design and data collection could have led to richer data. Despite these limitations, the study highlights the need for a multidisciplinary approach to diabetes care, integrating lifestyle change, psychosocial support, education on signs and symptoms, self-management training, and medication. Community-based interventions tailored to local realities can help close the information gap and support both prevention and long-term care. Conclusion This study highlights the complex and interrelated beliefs, attitudes, and experiences surrounding type 2 diabetes among adult Ugandans. Participants’ understanding of the disease was shaped by a combination of cultural, social, economic, psychological, and biological factors. Using the Health Belief Model as a framework helped to reveal how perceptions of susceptibility, severity, and benefits influenced health behaviours. Our findings show that type 2 diabetes has wide-ranging effects on physical, emotional, social, and relational aspects. They also underscore the value of person-centred care that acknowledges the full context of a patient’s life. Interventions should be sensitive to the cultural meanings attached to the illness, the practical realities of care access, and the specific experiences of the individuals. Constructs like perceived severity, cues to action, and expected benefits should guide the design of community awareness and education programs. Likewise, understanding how people perceive their risk (susceptibility) can inform prevention strategies. Ultimately, tailored, culturally grounded, and community-driven approaches will be key in improving type 2 diabetes prevention, management, and care in Uganda. Abbreviations T2D Type 2 Diabetes SSA Sub-Saharan Africa HBM Health Belief Model GPC General Population Cohort MRC/UVRI Medical Research Council/Uganda Virus Research Institute LSHTM London School of Hygiene and Tropical Medicine UNCST Uganda National Council for Science and Technology NIHR National Institute for Health and Care Research. Declarations Ethics approval and consent to participate This study was reviewed and approved by the Uganda Virus Research Institute's Research and Ethics committee GC127/871, and ethical clearance was obtained from the Uganda National Council for Science and Technology (UNCST) SS1200ES and the London School of Hygiene and Tropical Medicine ethics committee (LSHTM). In addition, we obtained administrative clearance from Kalungu and Masaka district administrators to conduct our study in their communities. After sharing detailed study information, we obtained written informed consent prior to data collection from each participant. Shared information included: the purpose of the study, risks, benefits, and duration of interviews. All this was done in light of the need to observe and adhere to ethical principles of; respect for humans as study subjects, do no harm, autonomy, and beneficence according to the Declaration of Helsinki. Clinical trial number Not applicable Consent for publication Not applicable Availability of data and materials Our participants did not consent to have their personal data available for public consumption other than the anonymized information that we promised to publish inform of voice narratives and the successive interpretations. However, in case of a formal request through the Uganda National Council for Science and Technology, some material like the study data collection tools used, can be accessed on the Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Social Science server. Competing interest All authors declared no identifiable competing interests. Funding Statement The study was funded by the UK National Institute for Health and Care Research (NIHR) global health group award 17/63/131. MS is supported by the National Institute for Health and Care Research Exeter Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Authors’ contributions In addition to participating in the analysis, MA, CMN, and PK wrote and reviewed the study. PK and AJN gave the manuscript a critique. DM and AJN were involved in the study's conception and design. In addition to designing and reviewing the manuscript, AM conceived the study and collaborated with DM, DK, MNC, and AJN on its conception. The final manuscript was read and approved by all the authors. All the writers affirm that they have never before submitted this work for publication. Acknowledgement We express our gratitude to the London School of Hygiene and Tropical Medicine (LSHTM-Uganda Research Unit) and the Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) for making this work possible. We also thank every one of our participants for giving up their time to take part in this research. MS was supported by the NIHR Exeter Biomedical Research Centre (BRC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. References Goedecke, J. H. Pathophysiology of type 2 diabetes in sub-Saharan Africans. ;:1967–80. (2022). Atun, R., Davies, J. I. & Gal, E. A. M. Diabetes in sub-Saharan Africa: from clinical care to health policy. ;5:622–67. (2017). Kengne, A. P., Limen, S. N., Sobngwi, E., Djouogo, C. F. T. & Nouedoui, C. Metabolic syndrome in type 2 diabetes: Comparative prevalence according to two sets of diagnostic criteria in sub-Saharan Africans. Diabetol. Metab. Syndr. 4 , 1–8 (2012). Bahendeka, S. Healthcare delivery for paediatric and adolescent diabetes in low resource settings: Type 1 diabetes clinics in Uganda. Glob Public. Health . 14 , 1869–1883 (2019). Kusolo, R. et al. Changes in the prevalence of the common risk factors for non-communicable diseases in Uganda between 2014 and 2023: Informed by nationally representative cross-sectional surveys. PLOS Glob Public. Heal . 5 (4 April), 1–13 (2025). Strzalka-Mrozik, B. et al. Factors associated with changes in endothelin-1 gene expression in patients with diabetic retinopathy in type 2 diabetes mellitus. Mol. Vis. 16 July , 1272–1279 (2010). Dunstan, F. & Luzio, S. D. Incidence of diabetic retinopathy in people with type 2 diabetes mellitus attending the Diabetic Retinopathy Screening Service for Wales: retrospective analysis OPEN ACCESS. ; 874 February:1–11. (2012). Kibirige, D., Atuhe, D., Sebunya, R. & Mwebaze, R. Suboptimal glycaemic and blood pressure control and screening for diabetic complications in adult ambulatory diabetic patients in Uganda: a retrospective study from a developing country. ;:1–7. (2014). Misganaw, A. et al. National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–2015: Findings from the Global Burden of Disease Study 2015. Popul. Health Metr. 15 , 1–17 (2017). Kayombo Clarice. Quality of Diabetic Care Among Patients With Diabetes (October, 2022). Bukenya, D. et al. Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study. PLOS Glob Public. Heal . 2 , 1–23 (2022). Brod, M., Lessard, S. & Meneghini, L. Barriers to Initiating Insulin in Type 2 Diabetes Patients: Development of a New Patient Education Tool to Address Myths, Misconceptions and Clinical Realities. ;:437–450. (2014). Chau, T. K. et al. Misconceptions about smoking in patients with type 2 diabetes mellitus: a qualitative analysis. ;:2545–2553. (2015). Di, A. et al. Renal structure in type 2 diabetes: facts and misconceptions. J. Nephrol. 33 , 901–907 (2020). Babak, A., Rouzbahani, S., Safaeian, A. & Poonaki, F. Diabetes Mellitus Type 2 and Popular Misconceptions: A Cross - Sectional Study. ;:1–10. (2025). Seyoum, T. et al. Knowledge of behavioral risk factors for type 2 diabetes mellitus and its associated factors among women of reproductive age. PLoS One . 20 (2 February), 1–15 (2025). Nielsen, J., Bahendeka, S. K., Bygbjerg, I. C., Meyrowitsch, D. W. & Whyte, S. R. Diabetes Treatment as Homework : Consequences for Household Knowledge and Health Practices in Rural Uganda. (2016). https://doi.org/10.1177/1090198115610569 Agofure, O. & Oghenerume, H. Knowledge of Diabetes Mellitus among Students of a Public Secondary School in. ;:1–11. (2017). Ullah, F., Ragazzoni, L., Hubloue, I., Barone-Adesi, F. & Valente, M. The Use of the Health Belief Model in the Context of Heatwaves Research: A Rapid Review. Disaster Med. Public. Health Prep ; 18 . (2024). Tarkang, E. E. & Zotor, F. B. Application of the Health Belief Model (HBM) in HIV Prevention: A Literature Review. Sci. Publ Gr . 1 , 1–8 (2015). Melkamu, L., Berhe, R. & Handebo, S. Does Patients ’ Perception Affect Self-Care Practices ? The Perspective of Health Belief Model Does Patients ’ Perception Affect Self-Care Practices ? Perspective Health Belief Model. ; 7007 . (2021). Nyanz, E. B. W. 2Robert Wangoda, 3Alfred Yayi, 3Samuel Kasibante 1Bernard Kikaire., 1Uganda Virus Research Institute U 2Masaka RR, Hospital, Uganda; 3Jinja Regional Referral Hospital U 10. 1136/bmjg.-2023-E 14. No Title:BUILDING CAPACITY OF THE REGIONAL REFERRAL HOSPITALS IN UGANDA TO CONDUCT ETHICAL REVIEWS IN RESEARCH. A CASE OF MASAKA AND JINJA REGIONAL REFERRAL HOSPITALS. ; 609 (2023). Suppl 10:2023. Asiki, G. et al. The general population cohort in rural south- western Uganda: a platform for communicable and non-communicable disease studies. ; January:129–141. (2013). Korsah, K. A., Mensah, G. P. & Achempim-Ansong, G. The influence of social meanings on treatment seeking behaviours of patients with Type 2 Diabetes Mellitus: A qualitative enquiry in a Ghanaian Hospital. J. Med. Public. Heal . 3 , 1052 (2022). Adailton da Silva, J., Fagundes de Souza, E. C., Echazú Böschemeier, A. G., Maia da Costa, C. C. & Souza Bezerra, H. Lopes Cavalcante Feitosa EE. Diagnosis of diabetes mellitus and living with a chronic condition: participatory study. BMC Public. Health . 18 , 1–8 (2018). Metta, E. A disease that god has given me patients and caregivers’ perspectives on diabetes in southeastern Tanzania. BMC Public. Health . 23 , 1–10 (2023). Hedman, E. & Ljo, B. Internet-based cognitive behaviour therapy for obsessive – compulsive disorder: a randomized controlled trial. ;:2193–2203. (2012). Christian, M. A. & Nagar, K. Understanding Patients Experiences Living with Diabetes Mellitus: A Qualitative Study, Gujarat, India. Objectives : ;:4–12. (2021). Ramachandran, A. & Snehalatha, C. Editorial Prevention of diabetes: How far have we gone ? ; 18 :252–253. (2014). Praveen, R. C., Sarathi, V. & Selvamadheshvaran, R. M SN Hybrid. Cnn-Xgboost Model. Efficient Diabet. Retinopathy Classif. ; 13 :665–673. (2025). Atwine, F. & Hjelm, K. Health professionals’ knowledge and attitudes to healthcare-seeking practices and complementary alternative medicine usage in ugandans with diabetes: A cross-sectional survey. Pan Afr. Med. J. 28 , 1–15 (2017). Brown, K., Avis, M. & Hubbard, M. Health beliefs of African-Caribbean people with type 2 diabetes: A qualitative study. Br. J. Gen. Pract. 57 , 461–469 (2007). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 18 May, 2026 Reviews received at journal 14 May, 2026 Reviews received at journal 08 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers invited by journal 04 May, 2026 Editor invited by journal 23 Mar, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 20 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Akugizibwe","email":"data:image/png;base64,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","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Mathias","middleName":"","lastName":"Akugizibwe","suffix":""},{"id":636939123,"identity":"c8cc8a42-c866-436f-a50c-807207daffbc","order_by":1,"name":"Chaka Moreen Namulundu","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Chaka","middleName":"Moreen","lastName":"Namulundu","suffix":""},{"id":636939124,"identity":"8826812e-8af1-4496-a805-29c66d9604cc","order_by":2,"name":"Paul Kitandwe","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Kitandwe","suffix":""},{"id":636939125,"identity":"8719bbbc-d698-4818-bd67-2ab3eeda3b0d","order_by":3,"name":"Esther Awino","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"","lastName":"Awino","suffix":""},{"id":636939126,"identity":"5c9a4d1a-d8a8-4643-8de7-d8c817341e4b","order_by":4,"name":"Hubert Nkabura","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Hubert","middleName":"","lastName":"Nkabura","suffix":""},{"id":636939127,"identity":"34d95847-10e5-4ae8-b62e-50c29a6158d1","order_by":5,"name":"Davis Kibirige","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Davis","middleName":"","lastName":"Kibirige","suffix":""},{"id":636939128,"identity":"b9a36c06-9044-4dce-baf0-e146c2f6f5ad","order_by":6,"name":"Janate Seeley","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Janate","middleName":"","lastName":"Seeley","suffix":""},{"id":636939129,"identity":"3177f1d1-6a83-4d3d-a8eb-cb375d71c9b4","order_by":7,"name":"Nambusi Kyegombe","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Nambusi","middleName":"","lastName":"Kyegombe","suffix":""},{"id":636939130,"identity":"7c215be5-a79c-49b9-bef1-055f1654ab08","order_by":8,"name":"Anxious Jackson Niwaha","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Anxious","middleName":"Jackson","lastName":"Niwaha","suffix":""},{"id":636939131,"identity":"69312a33-4260-4aa9-a23e-525b7725d283","order_by":9,"name":"Angus Jones","email":"","orcid":"","institution":"University of Exeter Medical School","correspondingAuthor":false,"prefix":"","firstName":"Angus","middleName":"","lastName":"Jones","suffix":""},{"id":636939132,"identity":"4a4f65c2-fbc4-40ce-9199-283052344c38","order_by":10,"name":"Maggie Shepherd","email":"","orcid":"","institution":"University of Exeter Medical School","correspondingAuthor":false,"prefix":"","firstName":"Maggie","middleName":"","lastName":"Shepherd","suffix":""},{"id":636939133,"identity":"1a3cdec9-1290-49be-a61c-5fb3936b16e2","order_by":11,"name":"Dominic Bukenya","email":"","orcid":"","institution":"Medical Research Council and London School of Hygiene and Tropical Medicine, Uganda research Unit","correspondingAuthor":false,"prefix":"","firstName":"Dominic","middleName":"","lastName":"Bukenya","suffix":""}],"badges":[],"createdAt":"2026-03-20 11:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9178340/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9178340/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109118862,"identity":"455ef8f5-995f-4396-ab24-6b7abaa3e278","added_by":"auto","created_at":"2026-05-12 16:55:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":318084,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9178340/v1/f18e75d8-1601-4827-a42b-bc6a53afa841.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Diabetes is death”: Perceptions and care experiences of people living with type 2 diabetes in urban and rural settings in Central Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eType 2 diabetes(T2D) is a major global health burden, currently affecting an estimated 587\u0026nbsp;million people worldwide, and over 80% of these are in low-and middle-income countries (LMICs)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In sub-Saharan Africa (SSA), T2D prevalence is rising steadily, with approximately 19\u0026nbsp;million people currently living with the condition, and this number is projected to be more than double over the next two decades[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Uganda, as in many SSA countries, the burden of T2D is increasing, although national prevalence estimates vary across studies and regions[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith this in mind, the patient care experiences for the management of T2D remain underexplored in many low-resource settings. Ongoing debates around diet, healthcare access, cultural norms, and social support highlight the complexity of managing T2D in these settings[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Misconceptions about the causes and management of the disease remain widespread[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], posing a significant barrier to effective care[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e][\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These knowledge gaps can delay care-seeking, reduce treatment adherence, and worsen outcomes[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to explore how newly diagnosed adults with residence (rural /urban) in Central Uganda perceive T2D, how they navigate health care options, and what shapes their treatment choices. The analysis was guided by the Health Belief Model (HBM), which frames health behaviour around six constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, area, and setting\u003c/h2\u003e \u003cp\u003eThis was a qualitative longitudinal follow-up study conducted in two public and not-for-profit mission hospitals in Central Uganda from October 2019 to August 2021. These were: Masaka Regional Referral Hospital and the General Population Cohort (GPC) diabetes clinics in Kalungu. These facilities were purposively selected to reflect urban and rural populations and had a functional outpatient diabetes clinic. Masaka Regional Referral Hospital, representing the urban population, has a 330-bed capacity, an annual admission of 23,456 patients, and a 91% bed occupancy rate[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The General Population Cohort diabetes clinics in Kalungu district represented the rural population. Established in 1989 by the MRC/UVRI, the GPC began with 15 villages and expanded to 25 by 2000. From 2010, its scope extended to include non-communicable diseases. It runs outpatient services and a clinic led by a physician, including specialised non-communicable diseases care[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants, sampling, and recruitment.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e We purposively selected 40 participants based on consent. Eligibility included participants aged 18 years and above who were clinically stable, with controlled blood glucose, pressure, and cholesterol levels. Additional inclusion criteria required that participants had taken part in the wider Uganda diabetic study, had consented to future research participation, and had been diagnosed within the preceding two years. Participants were contacted via phone using details from the facilities. They were informed about the study and invited to participate. Recruitment continued until 40 participants consented, at which point data saturation was reached. No participants withdrew consent. All interviews were conducted at secure and private offices of the Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI and LSHTM) field stations, offices of Masaka and Kyamulibwa-Kalungu. Privacy was ensured by limiting interview attendance to the participant and the interviewer.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eTwo trained research assistants (one male, one female) conducted in-depth interviews using a semi-structured guide developed from the study objectives. The guide was piloted and refined before use. Each participant was interviewed twice, with a one-month interval between sessions. The first interview focused on rapport building, while the second interview explored perceptions of diabetes, diagnosis, treatment history, and care-seeking behaviour. With participant consent, all interviews were audio recorded.\u003c/p\u003e \u003cp\u003eThe Interviews lasted 30\u0026ndash;90 minutes and were conducted in the Luganda language. Daily debriefings were held to review key findings and plan for subsequent sessions.\u003c/p\u003e\n\u003ch3\u003eData management\u003c/h3\u003e\n\u003cp\u003eAudio recordings were transcribed verbatim. Transcripts were proofread by research assistants and reviewed by a senior social scientist to ensure accuracy, anonymization, and completeness. All data were securely stored on a restricted-access server. Field notes and transcripts were repeatedly reviewed to identify themes. A coding frame based on the Health Belief Model (HBM) constructs was drafted by the research team. After refinement and pilot testing with five transcripts from each round of interviews, a coding frame was finalized. Research assistants coded the data manually, and the senior social scientist resolved the disagreements.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe coded data were analyzed thematically using the HBM framework with room to further identify the emergent themes beyond the HBM constructs[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Key emergent themes included perceived susceptibility, severity, and benefits of care seeking. Additional themes outside the HBM framework were also captured. Representative participant quotes were included to illustrate the findings. Identifiers were limited to age, sex, and location to protect participant confidentiality.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e This study was approved by: Uganda Virus Research Institute's Research and Ethics committee, Uganda National Council for Science and Technology (UNCST), and the London School of Hygiene and Tropical Medicine Ethics Committee (LSHTM). Written informed consent was obtained after explaining study details, including purpose, risks, benefits, and interview duration. All COVID-19 standard operating procedures were observed to ensure safety.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipants demographic profile\u003c/h2\u003e \u003cp\u003eThe total number of participants in this study was 40. The majority of these participants were women (57%), Christians by faith (63%), and married (73%), with a mean age of 43.6 years and a range of 27\u0026ndash;75 years. More than half of the study participants (23/40) had attained primary education and engaged in subsistence farming for a livelihood. See detailed sociodemographic information is available in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables categories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentages (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (N)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge range\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e43\u0026ndash;50+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest Level of education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior four certificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary dropout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever received formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSource of livelihood\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal/office job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCasual laborer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBiological children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas no children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived susceptibility to developing type 2 diabetes\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePeople who live unhealthy lifestyles\u003c/h2\u003e \u003cp\u003eMost of the study participants (26/40) reported that they believed their eating and drinking habits made them susceptible to developing type 2 diabetes. The participants narrated that eating fried foods and drinking alcohol and juices with a lot of sugar was unhealthy and resulted in becoming fat/obese, putting them at risk of developing type 2 diabetes. The participants also observed that unhealthy eating habits of too much fried food and sugary juices were more common among rich households. This reporting was similar across participants' age brackets, sex, and rural and urban settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI used to take it(juice), and I would tell the housemaids or anyone making it that, if it's not concentrated enough, add in more sugar, (Rural_\u003c/em\u003e \u003cb\u003eFemale aged 30 yrs\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003eHonestly, at home, my parents are not diabetic neither are my siblings\u0026hellip;I think I developed it because I loved sugary things (Urban\u003c/em\u003e \u003cb\u003eFemale aged 40 yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, there were a few participants who reported that type 2 diabetes did not distinguish between the poor and the rich. They explained that even poor people could be diagnosed with diabetes, a disease that was previously associated with being rich.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI used to think that diabetes was a disease for the rich who ate fatty foods and those who are fat, but if I can be told that I am diabetic... That was strange because I grew up eating greens and bitter things, maybe I was born with obesity (Rural_\u003c/em\u003e \u003cb\u003eFemale aged 77 yrs).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBeing born in a family with a history of diabetes\u003c/h2\u003e \u003cp\u003eSlightly more than a third of the study participants (15/40) reported that their genes put them at risk of developing diabetes (type 2 diabetes). They explained that people born in families with a history of diabetes (type 2 diabetes) were believed to be susceptible to developing the disease. This reporting was more common among female participants, mostly educated to the primary level, and aged 40 years and above. There were no rural-urban differences in reporting this.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026hellip; when I was diagnosed with diabetes, I recalled that my father was diabetic, and I thought that maybe it\u0026rsquo;s a disease within the family because even most of my siblings were also suffering from diabetes\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 52 yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn both rural and urban settings, there were participants across all ages, male and female who reported losing a family member due to diabetes. They further added that this convinced them that diabetes is hereditary and that they would also die.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI realized that my grandparents died of diabetes, my uncle too was suffering from diabetes and\u0026hellip; the fact that I had witnessed many relatives suffering from the same sickness\u0026hellip;\u0026hellip;, I always had the fear that I would also die like some of them died. I could have inherited diabetes \u0026hellip;\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 46 yrs\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eType 2 diabetes is a disease attributed to spiritual forces\u003c/h2\u003e \u003cp\u003eOver a quarter of the study participants (11/40) reported that they developed type 2 diabetes because of spiritual forces like witchcraft, being a punishment by God, or misfortune. 5 participants narrated that Satan is the root cause of all problems, including stress, misfortunes, and death, which leads to the development of type 2 diabetes. The majority of these participants (4/5) who reported this were from the rural setting and aged above 40 years. These participants further reported that diabetes (type 2 diabetes) can only be cured through spiritual intervention, for example, praying to God intensively.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think satanic stuff can also cause diabetes like stress brings diabetes. You know Satan can cause misfortunes, for example, if you lose a loved one and you get overly stresses you can get diabetes. So what Satan does is to bring things that increase your stress levels and you later be diagnosed with diabetes\u003c/em\u003e (\u003cem\u003eRural\u003c/em\u003e_\u003cb\u003eFemale aged 38 yrs\u003c/b\u003e).\u003c/p\u003e\u003cp\u003e \u003cem\u003eIn my other experience, I thought that being a diabetic was a punishment from God. Scriptures noted that diseases that never healed would dwell amongst people who were sinners. I resorted to repentance and I felt relieved that God forgave my sins (Rural_\u003c/em\u003e \u003cb\u003eMale aged 54 yrs\u003c/b\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, a few (3/40) participants, all based in rural settings, believed that diabetes could be acquired through witchcraft.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think these diseases are from witches, the way it makes you feel when you get it is strange. Once it attacks you, it comes with a lot of itching, you can\u0026rsquo;t sleep at night hahaha, that\u0026rsquo;s why I say maybe its witchcraft\u003c/em\u003e \u003cb\u003e(\u003c/b\u003e\u003cem\u003eRural\u003c/em\u003e\u003cb\u003e_\u003c/b\u003e\u003cb\u003eFemale aged 57 yrs).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, the majority of the urban female participants reported that they did not believe that diabetes (type 2 diabetes) was caused by witchcraft.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI don\u0026rsquo;t believe that diabetes was spread through black magic because I know very well the causes of diabetes and they are; poor eating habits, worry/depression or hypertension\u003c/em\u003e. (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 46 yrs\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePerceived severity of type 2 diabetes\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eExperienced signs and symptoms of type 2 diabetes\u003c/h2\u003e \u003cp\u003eThe majority of participants reported experiencing a range of diabetes signs and symptoms, which they described as more or less severe. The participants explained that their experience with the diabetes signs and symptoms formed the basis for them to suspect that they could develop diabetes. However, the decision to seek medical care depended on the severity of the signs and symptoms experienced. Overall, the majority of the participants reported experiencing, thirst, blurred vision, reduced sexual libido, on top of feeling dizzy, and headaches that presented with fevers as severe diabetes signs and symptoms. They also mentioned other complications that are not typical symptoms of diabetes, such as stiffness, temporal paralysis, limb swelling, piercing pins or tingling sensations. They added that they were compelled to seek health care as a consequence of experiencing these symptoms.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI started with symptoms like too much thirst, pain in the legs with a burning sensation, pain that felt like piercing needles in the legs, fingers and everywhere, then thirsting frequently, dry throat. I experienced blurry vision, that is why I decided to go for check-up\u0026hellip; (Rural_\u003c/em\u003e \u003cb\u003eFemale aged 77 yrs).\u003c/b\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eThe reason why I went for check-up was because of frequent paralysis/stiffness of my fingers (Urban_\u003c/em\u003e \u003cb\u003eFemale aged 54 yrs\u003c/b\u003e \u003cem\u003e).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eI experienced the lack of sexual prowess during intimacy with my wife, this prompted me to go find out from the health facility. At the hospital I was given certain medication and I was told the cause of that lack of sexual man power was diabetes\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eMale aged 42 yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe signs and symptoms of diabetes that the participants reported to be less severe included: general body pain and general weakness, frequent sweating, thirst, and urination. They further added that, given the low severity of these signs and symptoms, they never sought health care when they experienced them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI didn\u0026rsquo;t know at first that it was diabetes, I used to feel a lot of thirst and I would even wake up at night and drink water. What I didn\u0026rsquo;t know was that it was diabetes, and I used to drink passion fruits with sugar in it, so I took it like that, but I used to have a fever all the time and generally my body was weak. So, I decided that let me go to the Health Centre and they take tests to find out what was disturbing me\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 52 yrs\u003c/b\u003e).\u003c/p\u003e\u003cp\u003e \u003cem\u003eThe condition came about as a headache and fever and even feeling pain all over the body for some time. Later, decided to seek health care. The health workers found out that it wasn\u0026rsquo;t malaria fever, I didn\u0026rsquo;t have a fever and when they tested me for diabetes, I was found to be out of normal range for sugar levels\u003c/em\u003e, (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eMale aged 43 yrs).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants (7/40) reported delays in seeking health care till they were severely ill health. Such delays in seeking health care were common among men than women in rural areas.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI used to feel a great deal of thirst, and I usually took like 5 litres of water, and I wondered whether I would end up having very watery blood. Later I went to Kabungo Health centre, where the health workers told me that those looked like signs of diabetes but at that health centre, it was not being tested, then I decided that I will go to MRC-Kyamulibwa, but I was hesitant to go. Later on I got a terrible fever and I went to Kyamulibwa at Musaanya\u0026rsquo;s Health Centre, on being tested, they told me that the sugar levels are so high that the gadget [glucometer] that measured it wasn\u0026rsquo;t even able to do it well, that\u0026rsquo;s when I came to know that I\u0026rsquo;m diabetic and I spent the whole week there admitted on a drip, and I left the health center knowing that I had diabetes (Rural_\u003c/em\u003e \u003cb\u003eMale aged 55 yrs).\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHealth care-seeking practices of patients living with type 2 diabetes\u003c/h2\u003e \u003cp\u003eThe majority of participants (26/40) reported that they had sought care for diabetes from the biomedical option only. Continued retention in biomedical health care for type 2 diabetes was largely attributed to the desire to check the status of the disease and how they responded to the treatment. Other participants sought biomedical options hoping to learn from health workers how to do self-check-ups on their own as this would help to minimize health facility visitation in future. As a result, some participants, especially females, confirmed that they had developed the capacity to do self-checkups, which made it easy for them to buy medication from the nearby pharmacy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI frequented the hospital especially when my blood sugar levels changed. I also made sure I had my medications and adhered to taking that medication so that I would live. I want to live and that is why I always look after myself and adhere to my medication. I usually buy my medication from the pharmacy after self-check-up (Rural_\u003c/em\u003e \u003cb\u003eFemale aged 70 yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClose to a third of the participants (11/40) reported the use of a mix of biomedical, herbal, and or spiritual health care options at the same time, with no clear starting order determined. Some participants revealed that the choice of which care to seek was determined by the severity of the signs and symptoms experienced. Less severe signs and symptoms determined the delay to seek biomedical health care options, and more often started with self-medication with biomedical and herbal or a combination of these. In addition, some participants reported that the use of alternative medicine followed their use of a biomedical option, which they found less comprehensive. They opted to complement the biomedical option with other alternatives because type 2 diabetes was considered a complicated condition.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAt one time I had an issue whereby the sugar level rose from 7 to 19 points\u0026hellip;I started taking the herbal medication. I confess that since I started the mixture of the herbal and drugs [modern medicine] treatment I have never felt any problem apart from a few pains in the body\u0026hellip;\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 52 yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants (31/40) reported their use of herbal medication following a referral from fellow diabetic patients and the anticipated immediate health outcome/benefit from herbal medicine. Combining herbal and modern medicine was reported in both rural and urban settings by both men and women in all age brackets.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026hellip; when we share ideas with fellow diabetics, some have testimonies of the great impact of herbals in their lives and so I intentionally follow what other patients do (use referred herbals). Herbs have helped me with my diabetes, especially when I\u0026rsquo;m badly off.\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 46 yrs\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003eOn how many times I had used the herbal treatment since I came to know that I had diabetes, it\u0026rsquo;s not the number of times but I was using it all the time along with the western medicines because I don\u0026rsquo;t need to buy it but they directed me to pick this or that, then boil it especially those herbs that taste bitter and drink the solutions (Rural_\u003c/em\u003e \u003cb\u003eMale aged 55 yrs).\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNearly a quarter of participants (9/40) reported having been encouraged to also seek divine healing for diabetes as they continue taking their medication. These revealed a strong belief in God, while adhering to medication would be key to healing (managing diabetes). One participant narrated about this as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026hellip;my mother instead encouraged me to be courageous and to swallow my medication and pray earnestly to God for healing. I also believed in God for healing while taking my tablets\u003c/em\u003e (\u003cem\u003eUrban\u003c/em\u003e_\u003cb\u003eFemale aged 54yrs\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion of findings","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003cp\u003eThis study set out to explore the perceptions and diabetic care experiences of newly diagnosed people living with type 2 diabetes in urban and rural settings in central Uganda. Whereas our data reveals that most participants (31/40), in both rural and urban settings, perceived susceptibility to type 2 diabetes was highly dependent on lifestyle, belief in spiritual causes remains commonly reported in rural areas, and a high proportion of patients combined biomedical and other approaches to management. The other care-seeking options were herbal and spiritual remedies, which were often sought simultaneously without a defined order to which came first.\u003c/p\u003e \u003cp\u003eParticipants expressed diverse views on what made individuals susceptible to type 2 diabetes. Most participants pointed to lifestyle factors, especially diet and physical inactivity. Being affluent was often associated with increased risk, as wealth enabled access to sugary and fatty foods as well as sedentary living. Other perceived causes included genetic inheritance and spiritual causes such as witchcraft. Similar beliefs have been observed in Ghana[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Brazil ([\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and Tanzania[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], suggesting that perceptions of diabetes risk often blend biomedical and cultural explanations. Our findings align with prior studies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e][\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e][\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which emphasize type 2 diabetes as a disease shaped by both biological and social factors.\u003c/p\u003e \u003cp\u003eSpiritual beliefs were a prominent theme, reflecting the cultural context in which illness is often linked to supernatural causes[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This highlights the need for diabetes interventions to be sensitive to sociocultural beliefs, particularly in how people interpret signs and symptoms and decide when and how to seek healthcare. Participants described a wide range of signs and symptoms affecting their daily life, from physical, for example, pain, blurred vision, and leg swelling, among others, to psychological, for example, reduced sexual desire. These reports echo findings from other studies underlining the complex, multifaceted experience of living with type 2 on quality of life [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e][\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, the severity of these signs was closely related to treatment-seeking behaviour as the patients often tolerated classical symptoms of diabetes such as thirst and polyuria, and only sought care when more severe symptoms, such as dizziness and persistent pain, developed. This aligns with other findings and illustrates the need for community education to increase population awareness of early warning signs of diabetes[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings also show widespread medical pluralism. Participants combined biomedical, herbal, and spiritual approaches to manage type 2 diabetes signs and symptoms. Herbal remedies were often used not for a cure but a symptom relief, sometimes seen as more effective or more readily available than modern medicine. Cost and accessibility were key reasons for preferring herbal remedies, unlike in studies among African-Caribbeans in the UK, where distrust in medical professionals was a major factor[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations and recommendations\u003c/h2\u003e \u003cp\u003eAlthough this study was community-based, we only included patients with a diabetes diagnosis. Including caregivers and health care providers would have added valuable perspectives. The findings of this qualitative study are limited to only two districts of Uganda\u0026rsquo;s central region and therefore, are short of Uganda\u0026rsquo;s representativeness as a country. Also, using the Health Belief Model only during analysis, rather than from the outset, meant that some dimensions were underexplored. A full integration of the HBM during design and data collection could have led to richer data. Despite these limitations, the study highlights the need for a multidisciplinary approach to diabetes care, integrating lifestyle change, psychosocial support, education on signs and symptoms, self-management training, and medication. Community-based interventions tailored to local realities can help close the information gap and support both prevention and long-term care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complex and interrelated beliefs, attitudes, and experiences surrounding type 2 diabetes among adult Ugandans. Participants\u0026rsquo; understanding of the disease was shaped by a combination of cultural, social, economic, psychological, and biological factors. Using the Health Belief Model as a framework helped to reveal how perceptions of susceptibility, severity, and benefits influenced health behaviours. Our findings show that type 2 diabetes has wide-ranging effects on physical, emotional, social, and relational aspects. They also underscore the value of person-centred care that acknowledges the full context of a patient\u0026rsquo;s life. Interventions should be sensitive to the cultural meanings attached to the illness, the practical realities of care access, and the specific experiences of the individuals.\u003c/p\u003e \u003cp\u003eConstructs like perceived severity, cues to action, and expected benefits should guide the design of community awareness and education programs. Likewise, understanding how people perceive their risk (susceptibility) can inform prevention strategies. Ultimately, tailored, culturally grounded, and community-driven approaches will be key in improving type 2 diabetes prevention, management, and care in Uganda.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT2D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eType 2 Diabetes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Belief Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Population Cohort\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRC/UVRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council/Uganda Virus Research Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSHTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLondon School of Hygiene and Tropical Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNCST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUganda National Council for Science and Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Research.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Uganda Virus Research Institute\u0026apos;s Research and Ethics committee GC127/871, and ethical clearance was obtained from the Uganda National Council for Science and Technology (UNCST) SS1200ES and the London School of Hygiene and Tropical Medicine ethics committee (LSHTM). In addition, we obtained administrative clearance from Kalungu and Masaka district administrators to conduct our study in their communities. After sharing detailed study information, we obtained written informed consent prior to data collection from each participant. Shared information included: the purpose of the study, risks, benefits, and duration of interviews. All this was done in light of the need to observe and adhere to ethical principles of; respect for humans as study subjects, do no harm, autonomy, and beneficence according to the\u0026nbsp;Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical trial number\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur participants did not consent to have their personal data available for public consumption other than the anonymized information that we promised to publish inform of voice narratives and the successive interpretations. However, in case of a formal request through the Uganda National Council for Science and Technology, some material like the study data collection tools used, can be accessed on the Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Social Science server.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interest\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declared no identifiable competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding Statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the UK National Institute for Health and Care Research (NIHR) global health group award 17/63/131. MS is supported by the National Institute for Health and Care Research Exeter Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to participating in the analysis, MA, CMN, and PK wrote and reviewed the study. PK and AJN gave the manuscript a critique. DM and AJN were involved in the study\u0026apos;s conception and design. In addition to designing and reviewing the manuscript, AM conceived the study and collaborated with DM, DK, MNC, and AJN on its conception. The final manuscript was read and approved by all the authors. All the writers affirm that they have never before submitted this work for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to the London School of Hygiene and Tropical Medicine (LSHTM-Uganda Research Unit) and the Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) for making this work possible. We also thank every one of our participants for giving up their time to take part in this research. MS was supported by the NIHR Exeter Biomedical Research Centre (BRC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGoedecke, J. H. Pathophysiology of type 2 diabetes in sub-Saharan Africans. ;:1967\u0026ndash;80. (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtun, R., Davies, J. I. \u0026amp; Gal, E. A. M. Diabetes in sub-Saharan Africa: from clinical care to health policy. ;5:622\u0026ndash;67. (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKengne, A. P., Limen, S. N., Sobngwi, E., Djouogo, C. F. T. \u0026amp; Nouedoui, C. Metabolic syndrome in type 2 diabetes: Comparative prevalence according to two sets of diagnostic criteria in sub-Saharan Africans. \u003cem\u003eDiabetol. Metab. Syndr.\u003c/em\u003e \u003cb\u003e4\u003c/b\u003e, 1\u0026ndash;8 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahendeka, S. Healthcare delivery for paediatric and adolescent diabetes in low resource settings: Type 1 diabetes clinics in Uganda. \u003cem\u003eGlob Public. Health\u003c/em\u003e. \u003cb\u003e14\u003c/b\u003e, 1869\u0026ndash;1883 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKusolo, R. et al. Changes in the prevalence of the common risk factors for non-communicable diseases in Uganda between 2014 and 2023: Informed by nationally representative cross-sectional surveys. \u003cem\u003ePLOS Glob Public. Heal\u003c/em\u003e. \u003cb\u003e5\u003c/b\u003e (4 April), 1\u0026ndash;13 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrzalka-Mrozik, B. et al. Factors associated with changes in endothelin-1 gene expression in patients with diabetic retinopathy in type 2 diabetes mellitus. \u003cem\u003eMol. Vis.\u003c/em\u003e \u003cb\u003e16 July\u003c/b\u003e, 1272\u0026ndash;1279 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunstan, F. \u0026amp; Luzio, S. D. Incidence of diabetic retinopathy in people with type 2 diabetes mellitus attending the Diabetic Retinopathy Screening Service for Wales: retrospective analysis OPEN ACCESS. ;\u003cb\u003e874\u003c/b\u003e February:1\u0026ndash;11. (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKibirige, D., Atuhe, D., Sebunya, R. \u0026amp; Mwebaze, R. Suboptimal glycaemic and blood pressure control and screening for diabetic complications in adult ambulatory diabetic patients in Uganda: a retrospective study from a developing country. ;:1\u0026ndash;7. (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisganaw, A. et al. National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990\u0026ndash;2015: Findings from the Global Burden of Disease Study 2015. \u003cem\u003ePopul. Health Metr.\u003c/em\u003e \u003cb\u003e15\u003c/b\u003e, 1\u0026ndash;17 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayombo Clarice. \u003cem\u003eQuality of Diabetic Care Among Patients With Diabetes\u003c/em\u003e (October, 2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBukenya, D. et al. Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study. \u003cem\u003ePLOS Glob Public. Heal\u003c/em\u003e. \u003cb\u003e2\u003c/b\u003e, 1\u0026ndash;23 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrod, M., Lessard, S. \u0026amp; Meneghini, L. Barriers to Initiating Insulin in Type 2 Diabetes Patients: Development of a New Patient Education Tool to Address Myths, Misconceptions and Clinical Realities. ;:437\u0026ndash;450. (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChau, T. K. et al. Misconceptions about smoking in patients with type 2 diabetes mellitus: a qualitative analysis. ;:2545\u0026ndash;2553. (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi, A. et al. Renal structure in type 2 diabetes: facts and misconceptions. \u003cem\u003eJ. Nephrol.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e, 901\u0026ndash;907 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBabak, A., Rouzbahani, S., Safaeian, A. \u0026amp; Poonaki, F. Diabetes Mellitus Type 2 and Popular Misconceptions: A Cross - Sectional Study. ;:1\u0026ndash;10. (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeyoum, T. et al. Knowledge of behavioral risk factors for type 2 diabetes mellitus and its associated factors among women of reproductive age. \u003cem\u003ePLoS One\u003c/em\u003e. \u003cb\u003e20\u003c/b\u003e (2 February), 1\u0026ndash;15 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNielsen, J., Bahendeka, S. K., Bygbjerg, I. C., Meyrowitsch, D. W. \u0026amp; Whyte, S. R. Diabetes Treatment as Homework : Consequences for Household Knowledge and Health Practices in Rural Uganda. (2016). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1090198115610569\u003c/span\u003e\u003cspan address=\"10.1177/1090198115610569\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgofure, O. \u0026amp; Oghenerume, H. Knowledge of Diabetes Mellitus among Students of a Public Secondary School in. ;:1\u0026ndash;11. (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUllah, F., Ragazzoni, L., Hubloue, I., Barone-Adesi, F. \u0026amp; Valente, M. The Use of the Health Belief Model in the Context of Heatwaves Research: A Rapid Review. \u003cem\u003eDisaster Med. Public. Health Prep\u003c/em\u003e ;\u003cb\u003e18\u003c/b\u003e. (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarkang, E. E. \u0026amp; Zotor, F. B. Application of the Health Belief Model (HBM) in HIV Prevention: A Literature Review. \u003cem\u003eSci. Publ Gr\u003c/em\u003e. \u003cb\u003e1\u003c/b\u003e, 1\u0026ndash;8 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelkamu, L., Berhe, R. \u0026amp; Handebo, S. Does Patients \u0026rsquo; Perception Affect Self-Care Practices ? The Perspective of Health Belief Model Does Patients \u0026rsquo; Perception Affect Self-Care Practices ? \u003cem\u003ePerspective Health Belief Model.\u003c/em\u003e ;\u003cb\u003e7007\u003c/b\u003e. (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyanz, E. B. W. 2Robert Wangoda, 3Alfred Yayi, 3Samuel Kasibante 1Bernard Kikaire., 1Uganda Virus Research Institute U 2Masaka RR, Hospital, Uganda; 3Jinja Regional Referral Hospital U 10. 1136/bmjg.-2023-E 14. No Title:BUILDING CAPACITY OF THE REGIONAL REFERRAL HOSPITALS IN UGANDA TO CONDUCT ETHICAL REVIEWS IN RESEARCH. A CASE OF MASAKA AND JINJA REGIONAL REFERRAL HOSPITALS. ;\u003cb\u003e609\u003c/b\u003e (2023). Suppl 10:2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsiki, G. et al. The general population cohort in rural south- western Uganda: a platform for communicable and non-communicable disease studies. ; January:129\u0026ndash;141. (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorsah, K. A., Mensah, G. P. \u0026amp; Achempim-Ansong, G. The influence of social meanings on treatment seeking behaviours of patients with Type 2 Diabetes Mellitus: A qualitative enquiry in a Ghanaian Hospital. \u003cem\u003eJ. Med. Public. Heal\u003c/em\u003e. \u003cb\u003e3\u003c/b\u003e, 1052 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdailton da Silva, J., Fagundes de Souza, E. C., Echaz\u0026uacute; B\u0026ouml;schemeier, A. G., Maia da Costa, C. C. \u0026amp; Souza Bezerra, H. Lopes Cavalcante Feitosa EE. Diagnosis of diabetes mellitus and living with a chronic condition: participatory study. \u003cem\u003eBMC Public. Health\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e, 1\u0026ndash;8 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetta, E. A disease that god has given me patients and caregivers\u0026rsquo; perspectives on diabetes in southeastern Tanzania. \u003cem\u003eBMC Public. Health\u003c/em\u003e. \u003cb\u003e23\u003c/b\u003e, 1\u0026ndash;10 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHedman, E. \u0026amp; Ljo, B. Internet-based cognitive behaviour therapy for obsessive \u0026ndash; compulsive disorder: a randomized controlled trial. ;:2193\u0026ndash;2203. (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristian, M. A. \u0026amp; Nagar, K. Understanding Patients Experiences Living with Diabetes Mellitus: A Qualitative Study, Gujarat, India. \u003cem\u003eObjectives\u003c/em\u003e : ;:4\u0026ndash;12. (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamachandran, A. \u0026amp; Snehalatha, C. Editorial Prevention of diabetes: How far have we gone ? ;\u003cb\u003e18\u003c/b\u003e:252\u0026ndash;253. (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePraveen, R. C., Sarathi, V. \u0026amp; Selvamadheshvaran, R. \u003cem\u003eM SN Hybrid. Cnn-Xgboost Model. Efficient Diabet. Retinopathy Classif.\u003c/em\u003e ;\u003cb\u003e13\u003c/b\u003e:665\u0026ndash;673. (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtwine, F. \u0026amp; Hjelm, K. Health professionals\u0026rsquo; knowledge and attitudes to healthcare-seeking practices and complementary alternative medicine usage in ugandans with diabetes: A cross-sectional survey. \u003cem\u003ePan Afr. Med. J.\u003c/em\u003e \u003cb\u003e28\u003c/b\u003e, 1\u0026ndash;15 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown, K., Avis, M. \u0026amp; Hubbard, M. Health beliefs of African-Caribbean people with type 2 diabetes: A qualitative study. \u003cem\u003eBr. J. Gen. Pract.\u003c/em\u003e \u003cb\u003e57\u003c/b\u003e, 461\u0026ndash;469 (2007).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetes, perceptions, experiences, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-9178340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9178340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eType 2 diabetes is among the leading causes of death globally, with the highest burden in low-income countries, where misconceptions about its causes and management remain widespread. This study explored the perceptions and lived experiences of adults with newly diagnosed type 2 diabetes in Central Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThirty participants diagnosed 2 years prior were purposively enrolled in a longitudinal qualitative study in Kalungu and Masaka districts, Central Uganda. Each participant had two repeat in-depth interviews, and the data were analyzed thematically using the Health Belief Model constructs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants attributed type 2 diabetes to unhealthy lifestyles (e.g, alcohol use, processed sugars, oily fast food), family history, and (\u0026frac14; of participants) spiritual causes. Signs and symptoms were classified as either less severe (e.g, sweating, urination, fatigue) or more severe (e.g, thirst, infections, vision issues, stiffness, paralysis, dizziness, low libido). Perceived signs and symptom severity and anticipated benefits influenced care-seeking decisions. Most participants reported using multiple care types, including biomedical, herbal, and spiritual. Care type choice was guided by expected health benefit regardless of sex or location.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn Central Uganda, newly diagnosed adults categorize diabetes signs and symptoms by severity, which shapes their health-seeking behaviour. The decision to seek a specific care type, biomedical, spiritual, or herbal, was influenced by perceived signs and symptom severity and expected benefit, not by demographic differences. These insights should guide the development of tailored diabetes education interventions.\u003c/p\u003e","manuscriptTitle":"“Diabetes is death”: Perceptions and care experiences of people living with type 2 diabetes in urban and rural settings in Central Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 16:53:21","doi":"10.21203/rs.3.rs-9178340/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-18T18:25:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-14T15:00:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T13:58:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116644248820983101703847205048226537908","date":"2026-05-07T09:13:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88326371519329047988440221553340188411","date":"2026-05-06T05:39:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91950103330746470237311952575738075717","date":"2026-05-05T12:49:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246843880600858688075295768125161199369","date":"2026-05-05T10:05:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91813712996584611716920199443197181866","date":"2026-05-05T06:04:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-04T18:10:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T11:22:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-21T06:01:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T06:00:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-03-20T11:05:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13ef4bc3-b74c-40d8-a0ed-83a7efd287f4","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-18T18:25:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-14T15:00:03+00:00","index":99,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T13:58:11+00:00","index":98,"fulltext":""},{"type":"reviewerAgreed","content":"116644248820983101703847205048226537908","date":"2026-05-07T09:13:12+00:00","index":97,"fulltext":""},{"type":"reviewerAgreed","content":"88326371519329047988440221553340188411","date":"2026-05-06T05:39:16+00:00","index":96,"fulltext":""},{"type":"reviewerAgreed","content":"91950103330746470237311952575738075717","date":"2026-05-05T12:49:12+00:00","index":93,"fulltext":""},{"type":"reviewerAgreed","content":"246843880600858688075295768125161199369","date":"2026-05-05T10:05:02+00:00","index":91,"fulltext":""},{"type":"reviewerAgreed","content":"91813712996584611716920199443197181866","date":"2026-05-05T06:04:57+00:00","index":90,"fulltext":""},{"type":"reviewersInvited","content":"16","date":"2026-05-04T18:10:53+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[{"id":67796881,"name":"Health sciences/Diseases"},{"id":67796882,"name":"Health sciences/Endocrinology"},{"id":67796883,"name":"Health sciences/Health care"},{"id":67796884,"name":"Health sciences/Medical research"},{"id":67796885,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-18T18:39:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 16:53:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9178340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9178340","identity":"rs-9178340","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}