Impact of behavioral determinants on the control of type 2 diabetes mellitus: Translational nursing systematic review

Impact of behavioral determinants on the control of type 2 diabetes mellitus: Translational nursing systematic review | 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 Systematic Review Impact of behavioral determinants on the control of type 2 diabetes mellitus: Translational nursing systematic review Starlin Javier Martínez García, Fausto Antonio Suriel Rosario, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8895914/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Type 2 Diabetes Mellitus (T2DM) is a priority health challenge due to its prevalence and the clinical impact of poor glycemic control. Behavioral determinants play a central role in modulating metabolic outcomes within nursing practice. Aim: To determine the impact of behavioral determinants on glycemic control in adults with T2DM from a translational nursing perspective. Methods: Systematic review following PRISMA 2020 guidelines. Observational studies and randomized clinical trials evaluating self-care, self-efficacy, health literacy, and glycemic control (HbA1c) were included. Data were integrated using traceability and critical evidence matrices to normalize heterogeneous statistical metrics. Results: Nursing-led interventions and the strengthening of self-efficacy and self-care are associated with clinically significant improvements in HbA1c. Conversely, low health literacy was identified as a critical risk factor for metabolic poor control. Conclusion: Behavioral determinants are the main modulators of glycemic control in T2DM. Translational nursing emerges as a strategic axis for transforming scientific evidence into high-impact clinical interventions. Nursing Health Economics & Outcomes Research Health Policy Diabetes mellitus type 2 Self Care Self Efficacy Health Literacy Translational Nursing Figures Figure 1 Introduction Type 2 diabetes mellitus (DM2) represents a priority public health problem due to its high prevalence, chronic course and high burden of complications associated with inadequate glycemic control. Poor metabolic control, usually assessed by glycosylated hemoglobin (HbA1c), significantly increases morbidity, mortality, and health care costs. In this context, current evidence indicates that the control of T2DM does not depend exclusively on pharmacological treatment but is strongly influenced by behavioral and cognitive determinants related to the patient's self-care. ( 1 , 3 ) Observational studies carried out in different geographical contexts have shown consistent associations between higher levels of self-care, therapeutic adherence, healthy eating, physical activity and glycemic self-monitoring and lower HbA1c values, confirming the cross-sectional role of these behaviors in metabolic control. ( 1 , 2 , 11 , 14 ) Likewise, health literacy and self-efficacy have been identified as key determinants that mediate the adoption of healthy behaviors and clinical outcomes, showing that low levels of therapeutic understanding increase the risk of poor glycemic control. (4.7) In low- and middle-income countries, structural and social factors such as educational attainment, access to health services, comorbidities, and family support limit self-care capacity, contributing to a high prevalence of poor glycemic control. ( 10 , 12 , 15 ) From a nursing perspective, educational interventions, patient empowerment, and nurse-led models of care have demonstrated clinically relevant reductions in HbA1c, aligning with translational nursing principles. ( 8 , 16 , 19 , 21 , 22 ) However, there is still a need to integrate the available evidence comparatively to estimate the relative magnitude of the clinical impact of the different behavioral determinants. Therefore, the objective of this systematic review is to determine the impact of self-care, self-efficacy and health literacy on glycemic control in adults with type 2 diabetes mellitus, from the perspective of translational nursing. Methodology Design and Protocol A systematic review of the scientific literature was carried out following the guidelines of the PRISMA 2020 ( Preferred Reporting Items for Systematic Reviews and Meta-Analyses ) statement. The study is based on the paradigm of translational nursing, whose objective is: To determine the impact of behavioral determinants on glycemic control in adults with type 2 diabetes mellitus from the perspective of translational nursing. Research Question: To what extent do behavioral determinants (self-care, self-efficacy, and health literacy) influence the variation of glycemic control, assessed through HbA1c, in adults with type 2 diabetes mellitus versus individuals with suboptimal health behaviors? The research question was structured using the PICO format (Population, Intervention/Exposure, Comparison, Outcome): Final Structure of the PICO Question P (Population): Adults (≥ 18 years) diagnosed with T2DM I (Exposure): Behavioral determinants, including self-care, self-efficacy, and health literacy. C (Comparison): Deficient levels or absence of optimal health behaviors related to diabetes management. O (Outcome): Variation in metabolic control, assessed by the reduction of glycosylated hemoglobin (HbA1c) and the stability of basal and postprandial glycemic levels. Search Strategy and Information Sources An exhaustive search was carried out in the PubMed, Scopus, Web of Science and SciELO databases, limited to articles published between January 2020 and January 2026. MeSH/DeCS terms and Boolean operators were used: (Type 2 Diabetes Mellitus) AND (Self-care OR Self-efficacy OR Health literacy) AND (Glycemic control OR HbA1c) AND (Nursing) Study Selection and Eligibility Criteria The selection process was executed in four phases: identification, screening, eligibility and inclusion. The criteria were: Inclusion: Primary studies (observational and experimental) with objective measurement of HbA1c, available in full text, in English or Spanish. Exclusion: Reviews, studies in the paediatric population, gestational or type 1 diabetes, and studies with qualitative data without clinical correlation. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71. DOI : 10.1136/BMJ . N71 Assessment of Methodological Quality and Risk of Bias To ensure the integrity of the evidence, we conducted a thorough critical evaluation of each included study. Methodological quality and risk of bias were assessed individually and systematically, using validated instruments to ensure objectivity in the interpretation of the findings. The evaluation was structured on two levels: Quality of Reporting: The STROBE guidelines ( 23 ) for observational studies and CONSORT ( 24 ) for clinical trials were used, ensuring transparency in the description of the findings. Risk of Bias: Specific tools were applied according to the study design: Observational Studies: The Critical Evaluation Checklists of the Joanna Briggs Institute (JBI) were used, analyzing the internal validity, representativeness of the sample and statistical accuracy. ( 36 ) Randomized Clinical Trials (RCTs): The RoB 2.0 (Cochrane Risk of Bias) tool was used, evaluating five critical domains: randomization process, deviations from interventions, missing data, outcome measurement, and report selection. ( 37 ) Data Synthesis and Analysis To determine the clinical impact, a Critical Evidence Matrix was developed based on the translational paradigm. Due to the heterogeneity of the reported metrics, β coefficients, odds ratios (OR), Pearson's correlation coefficients (r), explained variance (R²) and absolute reductions in glycosylated hemoglobin (HbA1c), a Codebook designed for the normalization of the results was used. In this process, values of statistical significance (p) were assigned to each behavioral determinant, considering not only the crude statistical value, but also the methodological rigor and the power of the magnitude of the reported effect. This systematization allowed the determinants to be prioritized according to their relative weight on metabolic control, transforming empirical evidence into comparable and transferable indicators for nursing practice. Instruments and variables evaluated The included studies used standardized and previously validated instruments, which reported adequate levels of internal consistency in their original validations Table 1 Table 1 . Standardized instruments, validation and reliability (n = 22). Variable evaluated Instrument (acronym) Reference Original Reliability (α) Self-care (DSMQ) ( 25 ) 0.84 Health literacy (HLQ) ( 26 ) 0.85 Self-efficacy (DMSES) ( 33 ) 0.89 Family management (FaMM) ( 34 ) 0.80 Adherence / Social Support (SDSCA) ( 29 ) 0.80 Diet/Nutrition PREDIMED ( 27 ) 0.84 Structured assessment of comorbidities (based on CC-Q) (CC-Q) ( 39 ) 0.75 Nursing intervention (TNI-P) ( 31 ) 0.82 Knowledge in diabetes (DKT) ( 23 ) 0.86 Lifestyle (HPLP-II) ( 30 ) 0.92 Empowerment (DES-SF) ( 28 ) 0.84 Physical activity (IPAQ) ( 32 ) 0.80 Social determinants (SDH-Q) ( 38 ) 0.79 Source Authors' elaboration based on the studies included in the systematic review. The reported Cronbach's alpha coefficients correspond to the original validation studies of each instrument and not to analyses performed again in the included studies, being cited by the authors as support for the internal consistency of the tools used, with values generally higher than 0.70, considered acceptable for health research. Ethical considerations As it is a systematic review of published literature, it was not necessary to request informed consent or approval by an ethics committee, complying with international regulations on the handling of publicly accessible secondary data. Results . Systematic analysis of the 22 included studies allowed us to integrate robust evidence on behavioural determinants in T2DM. The findings were organized to initially present the statistical and clinical effects on metabolic control, facilitating a translational interpretation that identifies the variables with the greatest influence on HbA1c levels and general health outcomes in adults. Table 2 . Statistical Metrics of Behavioral Impact on Glycemic Control (HbA1c) Table 2 Statistical Metrics of Behavioral Impact on Glycemic Control (HbA1c) Studies Statistical Finding Value (r, β, OR,R2, RR, %-HbA1c) Significance (p) 1 Correlation r = − 0.62 < 0.001 2 Correlation r = − 0.48 < 0.01 3 Variance R2 = 0.15 < 0.05 4 Risk OR = 2.45 < 0.01 5 Risk OR = 2.10 < 0.05 6 Regression β = 0.42 < 0.01 7 Risk OR = 2.78 < 0.01 8 Correlation r = − 0.55 < 0.001 9 Regression β = 0.45 < 0.01 10 Variance R2 = 0.18 < 0.05 11 Correlation r = − 0.38 < 0.05 12 Correlation r = − 0.58 < 0.001 13 Correlation r = − 0.42 < 0.05 14 Diff. Tights -28 mg/dL < 0.01 15 Correlation R = − 0.44 < 0.01 16 Reduction Δ -0.85% < 0.001 17 Regression β = 0.36 < 0.01 18 Reduction Δ -0.72% < 0.001 19 Reduction Δ -1.10% < 0.001 20 Risk RR = 0.72 < 0.01 21 Reduction Δ -0.65% < 0.01 22 Reduction Δ -0.50% < 0.05 Insert Table 2 here. Source Authors' own elaboration based on the studies included in the systematic review. The greatest effects on glycemic control were observed in experimental studies and randomized clinical trials, where nursing interventions, patient empowerment, and supervised physical activity achieved absolute reductions of (HbA1c) between 0.69% and 0.80%, exceeding the threshold of clinical relevance. ( 18 , 21 , 22 ) Self-efficacy and self-care were identified as the most consistent predictors of metabolic control (p < 0.001) (1,8), while family management and social determinants explained a relevant proportion of the variance in glycemic control (R² = 0.18 and 0.15). ( 3 , 10 ) On the contrary, low health literacy increased the risk of poor glycemic control between 2.10 and 2.70 times, evidencing the need for educational interventions adapted from translational nursing. ( 4 , 5 , 7 ) Overall, the evidence confirms that glycemic control depends on the interaction between self-care, self-efficacy and structural context, consolidating behavioral determinants as the main modulator of DM2 management. Table 3 . Analytical matrix of the impact of behavioral determinants on glycemic control (HbA1c) in adults with DM2. Table 3 Analytical matrix of the impact of behavioral determinants on glycemic control (HbA1c) in adults with DM2. Design Variable Analyzed Metrics Reported Value p Transversal ( 1 ) Self-care vs HbA1c β −0.28 < 0.001 Transverse ( 2 ) Education vs HbA1c OR 4.12 < 0.01 Transverse ( 3 ) Self-care vs HbA1c CI −0.01 < 0.05 Transverse ( 4 ) HL → Self-Care → HbA1c β −0.045 < 0.01 Cross ( 5 ) HL vs Total Self-Care ρ 0.136 < 0.05 Cross ( 6 ) Adjusted HL vs HbA1c β −0.524 < 0.01 Transversal ( 7 ) HL vs HbA1c OR 1.93 < 0.01 ECA ( 8 ) Educational intervention vs HbA1c Δ HbA1c −0.80% < 0.001 Cross ( 9 ) Self-efficacy vs HbA1c β 0.45 < 0.01 Prospective ( 10 ) Family self-regulation vs HbA1c β −0.39 < 0.001 Cross ( 11 ) Self-care vs Quality of life r −0.38 < 0.05 Cross ( 12 ) Self-care vs HbA1c OR 2.15 < 0.001 Prospective ( 13 ) Self-care vs Control OR 2.41 < 0.05 Prospective ( 14 ) Knowledge vs HbA1c AOR 3.20 < 0.01 Transverse ( 15 ) Comorbidity vs Self-Care p — < 0.01 RCT ( 16 ) APS Education vs HbA1c Δ HbA1c −0.85% < 0.001 Transversal ( 17 ) Knowledge vs Self-Efficacy r 0.62 < 0.01 ECA ( 18 ) Nursing Intervention APS vs HbA1c Δ HbA1c −0.72% < 0.001 RCT ( 19 ) Clinical Nursing vs HbA1c Δ HbA1c −1.10% < 0.001 Prospective ( 20 ) Lifestyle vs HbA1c RR 0.65 < 0.01 RCT ( 21 ) Empowerment vs Self-Care r 0.58 < 0.01 Experimental ( 22 ) Physical activity vs metabolism Δ HbA1c −0.50% < 0.05 Insert Table 3 here. Note Table prepared by the authors based on the synthesis, standardization and hierarchy of the studies included in the systematic review, according to a translational nursing approach. The convergence analysis showed that nurse-led interventions had the highest statistical strength, with reductions in glycosylated hemoglobin (ΔHbA1c) of up to 1.10% and high levels of significance (p < 0.001), evidencing a superior clinical impact to conventional treatment. ( 8 , 16 , 18 , 19 ) Self-care and self-efficacy were inversely and significantly associated with metabolic control (β=−0.28; r = 0.58), confirming that greater patient empowerment translates into a consistent reduction in blood glucose levels. ( 1 , 9 , 21 ) On the other hand, low health literacy and insufficient therapeutic knowledge were identified as relevant risk factors, with high odds ratios (OR = 4.12; AOR = 3.20), indicating that these limitations substantially increase the likelihood of poor glycemic control. ( 2 , 14 ) Table 4 Translational Hierarchy of the Clinical Impact of Behavioral Determinants ID Behavioral determinant Type of evidence Clinical Magnitude (Metrics) Impact Level Translational priority 1 Nursing Education Randomized Clinical Trial (RCT) Extreme (Δ HbA1c ≥ 1.1%) Critical Priority 2 Self-efficacy/empowerment RCT / Observational High (r = 0.62 / Δ − 0.8%) High Very high 3 Baseline Self-Care Prospective Consistent (β = −0.28 / OR > 2) High Very high 4 Literacy/Knowledge Observational Critical Risk (AOR = 3.20) Moderate High 5 Lifestyle/Exercise Experimental Moderate (RR = 0.65) Moderate Intermediate 6 Family Support Prospective Moderate (R² = 0.18) Moderate Intermediate Note : Table prepared by the authors based on the translational synthesis of the 22 studies included in the systematic review. Hierarchy is based on the clinical magnitude of the effect, the type of evidence, and the statistical consistency of the results. Discussion The evidence integrated in this review confirms that nurse-led interventions represent the main driver of metabolic improvement in adults with type 2 diabetes mellitus. The included randomized clinical trials ( 18 , 19 , 21 , 22 ) reported absolute HbA1c reductions of up to 1.10%, a clinical effect comparable to that observed with second-line oral drug therapies. This finding coincides with what has been described in previous experimental studies, which indicate that structured and continuous educational interventions manage to overcome the therapeutic inertia associated with conventional management of DM2. However, the impact of such interventions is not presented in isolation but mediated by specific behavioral determinants. The included observational and prospective studies ( 1 , 8 , 12 ) show that baseline self-care is an inverse and consistent predictor of glycemic control, with significant regression coefficients (β ≈ −0.28). This pattern suggests that the efficacy of clinical interventions depends on the patient's prior ability to integrate self-management behaviors, which explains the greater metabolic stability observed in long-term follow-ups. In a complementary way, self-efficacy and empowerment emerge as critical modulators of therapeutic behavior. The included studies ( 9 , 17 , 21 ) reported moderate- to high-magnitude positive correlations between self-efficacy and glycemic control (r ≈ 0.58–0.62), supporting theoretical models of behavioral self-regulation. These findings are consistent with the literature that describes the perception of competence as the cognitive substrate necessary to sustain therapeutic adherence beyond the short term. In contrast, health literacy is positioned as the main limiting factor of the translational process. Studies evaluating this determinant ( 4 , 5 , 7 , 14 ) showed that low levels of therapeutic understanding increase the risk of poor glycemic control by two to three times, with adjusted odds ratios reaching values of up to 3.20. This consistency across studies suggests that health literacy acts as a structural bottleneck: without minimum cognitive competencies, self-care behaviors and self-efficacy fail to consolidate sustainably. In the same vein, the presence of comorbidities and the burden of chronicity intensify the complexity of care. The prospective studies included ( 13 , 15 ) show that the coexistence of chronic pathologies not only aggravates the metabolic profile, but also reduces the patient's functional and behavioral capacity, weakening self-care. This finding reinforces the need to prioritize nursing interventions according to their behavioral impact, prioritizing those aimed at structured education, strengthening self-efficacy, and improving health literacy. Overall, the cross-sectional comparison of the evidence confirms that glycemic control in DM2 does not depend on a single determinant, but on the hierarchical interaction between education, self-efficacy and health literacy. These results consolidate the strategic role of translational nursing as a bridge between scientific evidence and clinical practice, guiding decision-making towards high-impact behavioral interventions and clinical sustainability. Conclusion The synthesized evidence positions behavioral determinants as the core of metabolic control in type 2 diabetes mellitus, and translational nursing as the main vehicle for its effective modification. The use of analytical matrices and prioritization of clinical impact opens the door to predictive intervention models, capable of optimizing resources and anticipating metabolic risk. This paradigm projects a structural change in health systems, where nursing leads the transition from a reactive model to a preventive, intelligent, and behavior-focused one. Limitations of the study The main limitations include the diversity of measurement scales, which made an overall quantitative analysis difficult, and the cross-sectional design of most studies, which prevents definitive causality from being established. The variability in the educational interventions analyzed shows the urgency of standardizing nursing protocols to strengthen the evidence and its clinical application. Declarations Author Contributions Based on the profiles you provided earlier, here is a draft using the CRediT taxonomy: Author Contributions: Starlin Javier Martínez García: Conceptualization, Software, Formal analysis, Writing - Original Draft, and Visualization. Fausto Antonio Suriel Rosario: Methodology, Validation, Resources, Data Curation, and Supervision. Enmanuel Liriano Parra: Investigation, Writing - Review & Editing, and Project administration. Conflict of Interest Following COPE guidelines, if there are no competing interests, use this standard phrasing: Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Data Availability Statement The data used in this systematic review were obtained from previously published studies. The sources are cited within the manuscript. References Popoviciu MS, Marin VN, Vesa CM, Stefan SD, Stoica RA, Serafinceanu C et al (2022) Correlations between Diabetes Mellitus Self-Care Activities and Glycaemic Control in the Adult Population: A Cross-Sectional Study. 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BMC Public Health 24(1):2507. 10.1186/S12889-024-19990-W Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN (2003) The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research. Arthritis Rheum 49(2):156–163. 10.1002/Art.10993 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8895914","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":592366917,"identity":"f97337c5-87e5-4d8f-919b-b120bb9b5659","order_by":0,"name":"Starlin Javier Martínez García","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIie3PsYrCMBjA8e8jkC7irTki+gqRDjr0uAdxiRScWhxcyxEQ4qRzBx9GKPQZbpKi4JxJHIpY25sO2uDmkP+UfORHEgCX6w2jgAWY58pD9TexEiIwBQFAGsKspDoqSK8mzZZZQZ+v8RyU5WiyJvr0mxx/qklmIAlmrQ8bZMSPtRjvM9z4Ub5idJBLAfkiVm2ELXMeq+o/BDWPqGSURUKiyjpISPm0FN8NuT/J0hysBKiY1yTW9S2oLISMt9oPG7KTn5otfJAdfxmlIRa3cviVepsLj67yo5qcjUmCVtKSfO24y+Vyuf71ADVbSmgNbh50AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0006-5951-3531","institution":"Sinclair Community College","correspondingAuthor":true,"prefix":"","firstName":"Starlin","middleName":"Javier Martínez","lastName":"García","suffix":""},{"id":592367384,"identity":"0c5d7b33-3b7d-4990-a29d-51dec602fc8e","order_by":1,"name":"Fausto Antonio Suriel Rosario","email":"","orcid":"https://orcid.org/0009-0008-7746-8994","institution":"Universidad Católica Santo Domingo","correspondingAuthor":false,"prefix":"","firstName":"Fausto","middleName":"Antonio Suriel","lastName":"Rosario","suffix":""},{"id":592367385,"identity":"8d3e2312-3df2-4bbf-966f-574727bc277c","order_by":2,"name":"Enmanuel Liriano Parra","email":"","orcid":"https://orcid.org/0009-0004-6323-6560","institution":"Universidad Autónoma de Santo Domingo","correspondingAuthor":false,"prefix":"","firstName":"Enmanuel","middleName":"Liriano","lastName":"Parra","suffix":""}],"badges":[],"createdAt":"2026-02-16 19:57:43","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8895914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8895914/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102904863,"identity":"04078553-4ac5-4a08-a3f3-b569c6440253","added_by":"auto","created_at":"2026-02-18 09:00:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70724,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the study selection process following the PRISMA 2020 guidelines.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8895914/v1/4dcf63cf706d90b91c30ff56.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eImpact of behavioral determinants on the control of type 2 diabetes mellitus: Translational nursing systematic review\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eType 2 diabetes mellitus (DM2) represents a priority public health problem due to its high prevalence, chronic course and high burden of complications associated with inadequate glycemic control. Poor metabolic control, usually assessed by glycosylated hemoglobin (HbA1c), significantly increases morbidity, mortality, and health care costs. In this context, current evidence indicates that the control of T2DM does not depend exclusively on pharmacological treatment but is strongly influenced by behavioral and cognitive determinants related to the patient's self-care. \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eObservational studies carried out in different geographical contexts have shown consistent associations between higher levels of self-care, therapeutic adherence, healthy eating, physical activity and glycemic self-monitoring and lower HbA1c values, confirming the cross-sectional role of these behaviors in metabolic control. \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e Likewise, health literacy and self-efficacy have been identified as key determinants that mediate the adoption of healthy behaviors and clinical outcomes, showing that low levels of therapeutic understanding increase the risk of poor glycemic control. \u003csup\u003e(4.7)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn low- and middle-income countries, structural and social factors such as educational attainment, access to health services, comorbidities, and family support limit self-care capacity, contributing to a high prevalence of poor glycemic control.\u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e From a nursing perspective, educational interventions, patient empowerment, and nurse-led models of care have demonstrated clinically relevant reductions in HbA1c, aligning with translational nursing principles. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, there is still a need to integrate the available evidence comparatively to estimate the relative magnitude of the clinical impact of the different behavioral determinants. Therefore, the objective of this systematic review is to determine the impact of self-care, self-efficacy and health literacy on glycemic control in adults with type 2 diabetes mellitus, from the perspective of translational nursing.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eDesign and Protocol\u003c/p\u003e \u003cp\u003eA systematic review of the scientific literature was carried out following the guidelines of the PRISMA 2020 (\u003cem\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/em\u003e) statement. The study is based on the paradigm of translational nursing, whose objective is: To determine the impact of behavioral determinants on glycemic control in adults with type 2 diabetes mellitus from the perspective of translational nursing.\u003c/p\u003e \u003cp\u003eResearch Question:\u003c/p\u003e \u003cp\u003eTo what extent do behavioral determinants (self-care, self-efficacy, and health literacy) influence the variation of glycemic control, assessed through HbA1c, in adults with type 2 diabetes mellitus versus individuals with suboptimal health behaviors?\u003c/p\u003e \u003cp\u003eThe research question was structured using the PICO format (Population, Intervention/Exposure, Comparison, Outcome):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFinal Structure of the PICO Question\u003c/p\u003e\u003cp\u003e \u003cb\u003eP\u003c/b\u003e (Population): Adults (\u0026ge;\u0026thinsp;18 years) diagnosed with T2DM\u003c/p\u003e\u003cp\u003e \u003cb\u003eI\u003c/b\u003e (Exposure): Behavioral determinants, including self-care, self-efficacy, and health literacy.\u003c/p\u003e\u003cp\u003e \u003cb\u003eC\u003c/b\u003e (Comparison): Deficient levels or absence of optimal health behaviors related to diabetes management.\u003c/p\u003e\u003cp\u003e \u003cb\u003eO\u003c/b\u003e (Outcome): Variation in metabolic control, assessed by the reduction of glycosylated hemoglobin (HbA1c) and the stability of basal and postprandial glycemic levels.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSearch Strategy and Information Sources\u003c/p\u003e \u003cp\u003eAn exhaustive search was carried out in the PubMed, Scopus, Web of Science and SciELO databases, limited to articles published between January 2020 and January 2026. MeSH/DeCS terms and Boolean operators were used:\u003c/p\u003e \u003cp\u003e(Type 2 Diabetes Mellitus) AND (Self-care OR Self-efficacy OR Health literacy) AND (Glycemic control OR HbA1c) AND (Nursing)\u003c/p\u003e \u003cp\u003eStudy Selection and Eligibility Criteria\u003c/p\u003e \u003cp\u003eThe selection process was executed in four phases: identification, screening, eligibility and inclusion. The criteria were:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInclusion: Primary studies (observational and experimental) with objective measurement of HbA1c, available in full text, in English or Spanish.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExclusion: Reviews, studies in the paediatric population, gestational or type 1 diabetes, and studies with qualitative data without clinical correlation.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThe PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71.\u003c/em\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eDOI\u003c/span\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/BMJ\u003c/span\u003e\u003cspan address=\"10.1136/BMJ\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eN71\u003c/span\u003e\u003c/p\u003e \u003cp\u003eAssessment of Methodological Quality and Risk of Bias\u003c/p\u003e \u003cp\u003eTo ensure the integrity of the evidence, we conducted a thorough critical evaluation of each included study. Methodological quality and risk of bias were assessed individually and systematically, using validated instruments to ensure objectivity in the interpretation of the findings. The evaluation was structured on two levels:\u003c/p\u003e \u003cp\u003eQuality of Reporting: The STROBE guidelines (\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e) for observational studies and CONSORT (\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e) for clinical trials were used, ensuring transparency in the description of the findings.\u003c/p\u003e \u003cp\u003eRisk of Bias: Specific tools were applied according to the study design:\u003c/p\u003e \u003cp\u003eObservational Studies: The Critical Evaluation Checklists of the Joanna Briggs Institute (JBI) were used, analyzing the internal validity, representativeness of the sample and statistical accuracy. \u003csup\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRandomized Clinical Trials (RCTs): The RoB 2.0 (Cochrane Risk of Bias) tool was used, evaluating five critical domains: randomization process, deviations from interventions, missing data, outcome measurement, and report selection. \u003csup\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eData Synthesis and Analysis\u003c/p\u003e \u003cp\u003eTo determine the clinical impact, a Critical Evidence Matrix was developed based on the translational paradigm. Due to the heterogeneity of the reported metrics, β coefficients, odds ratios (OR), Pearson's correlation coefficients (r), explained variance (R\u0026sup2;) and absolute reductions in glycosylated hemoglobin (HbA1c), a Codebook designed for the normalization of the results was used.\u003c/p\u003e \u003cp\u003eIn this process, values of statistical significance (p) were assigned to each behavioral determinant, considering not only the crude statistical value, but also the methodological rigor and the power of the magnitude of the reported effect. This systematization allowed the determinants to be prioritized according to their relative weight on metabolic control, transforming empirical evidence into comparable and transferable indicators for nursing practice.\u003c/p\u003e \u003cp\u003eInstruments and variables evaluated\u003c/p\u003e \u003cp\u003eThe included studies used standardized and previously validated instruments, which reported adequate levels of internal consistency in their original validations\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Standardized instruments, validation and reliability (n\u0026thinsp;=\u0026thinsp;22).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable evaluated\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstrument (acronym)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOriginal Reliability (α)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(DSMQ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(HLQ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e 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colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructured assessment of comorbidities (based on CC-Q)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(CC-Q)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TNI-P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge in diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(DKT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(HPLP-II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(DES-SF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(IPAQ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial determinants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(SDH-Q)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSource\u003c/strong\u003e \u003cp\u003e \u003cem\u003eAuthors' elaboration based on the studies included in the systematic review.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe reported Cronbach's alpha coefficients correspond to the original validation studies of each instrument and not to analyses performed again in the included studies, being cited by the authors as support for the internal consistency of the tools used, with values generally higher than 0.70, considered acceptable for health research.\u003c/p\u003e \u003cp\u003eEthical considerations\u003c/p\u003e \u003cp\u003eAs it is a systematic review of published literature, it was not necessary to request informed consent or approval by an ethics committee, complying with international regulations on the handling of publicly accessible secondary data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e. Systematic analysis of the 22 included studies allowed us to integrate robust evidence on behavioural determinants in T2DM. The findings were organized to initially present the statistical and clinical effects on metabolic control, facilitating a translational interpretation that identifies the variables with the greatest influence on HbA1c levels and general health outcomes in adults.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Statistical Metrics of Behavioral Impact on Glycemic Control (HbA1c)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical Metrics of Behavioral Impact on Glycemic Control (HbA1c)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatistical Finding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue (r, β, OR,R2, RR, %-HbA1c)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificance (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR2\u0026thinsp;=\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR2\u0026thinsp;=\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiff. Tights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-28 mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ -0.85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ -0.72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ -1.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRR\u0026thinsp;=\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ -0.65%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ -0.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSource\u003c/strong\u003e \u003cp\u003e \u003cem\u003eAuthors' own elaboration based on the studies included in the systematic review.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe greatest effects on glycemic control were observed in experimental studies and randomized clinical trials, where nursing interventions, patient empowerment, and supervised physical activity achieved absolute reductions of (HbA1c) between 0.69% and 0.80%, exceeding the threshold of clinical relevance. \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSelf-efficacy and self-care were identified as the most consistent predictors of metabolic control (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (1,8), while family management and social determinants explained a relevant proportion of the variance in glycemic control (R\u0026sup2; = 0.18 and 0.15). \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOn the contrary, low health literacy increased the risk of poor glycemic control between 2.10 and 2.70 times, evidencing the need for educational interventions adapted from translational nursing. \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOverall, the evidence confirms that glycemic control depends on the interaction between self-care, self-efficacy and structural context, consolidating behavioral determinants as the main modulator of DM2 management.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Analytical matrix of the impact of behavioral determinants on glycemic control (HbA1c) in adults with DM2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalytical matrix of the impact of behavioral determinants on glycemic control (HbA1c) in adults with DM2.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable Analyzed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMetrics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReported Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransversal \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse \u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHL \u0026rarr; Self-Care \u0026rarr; HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHL vs Total Self-Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eρ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted HL vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransversal \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHL vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECA \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducational intervention vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-efficacy vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProspective \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily self-regulation vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care vs Quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProspective \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care vs Control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProspective \u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComorbidity vs Self-Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRCT \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAPS Education vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransversal \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge vs Self-Efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECA \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing Intervention APS vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRCT \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Nursing vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;1.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProspective \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLifestyle vs HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRCT \u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpowerment vs Self-Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental \u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical activity vs metabolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ HbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ehere.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e \u003cem\u003eTable prepared by the authors based on the synthesis, standardization and hierarchy of the studies included in the systematic review, according to a translational nursing approach.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe convergence analysis showed that nurse-led interventions had the highest statistical strength, with reductions in glycosylated hemoglobin (ΔHbA1c) of up to 1.10% and high levels of significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), evidencing a superior clinical impact to conventional treatment. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSelf-care and self-efficacy were inversely and significantly associated with metabolic control (β=\u0026minus;0.28; r\u0026thinsp;=\u0026thinsp;0.58), confirming that greater patient empowerment translates into a consistent reduction in blood glucose levels. \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, low health literacy and insufficient therapeutic knowledge were identified as relevant risk factors, with high odds ratios (OR\u0026thinsp;=\u0026thinsp;4.12; AOR\u0026thinsp;=\u0026thinsp;3.20), indicating that these limitations substantially increase the likelihood of poor glycemic control. \u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTranslational Hierarchy of the Clinical Impact of Behavioral Determinants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehavioral determinant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType of evidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Magnitude (Metrics)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImpact Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTranslational priority\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRandomized Clinical Trial (RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExtreme (Δ HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCritical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePriority\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-efficacy/empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRCT / Observational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh (r\u0026thinsp;=\u0026thinsp;0.62 / Δ\u0026thinsp;\u0026minus;\u0026thinsp;0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVery high\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline Self-Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistent (β = \u0026minus;0.28 / OR\u0026thinsp;\u0026gt;\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVery high\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiteracy/Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObservational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCritical Risk (AOR\u0026thinsp;=\u0026thinsp;3.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLifestyle/Exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate (RR\u0026thinsp;=\u0026thinsp;0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate (R\u0026sup2; = 0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote\u003c/b\u003e: \u003cem\u003eTable prepared by the authors based on the translational synthesis of the 22 studies included in the systematic review.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eHierarchy is based on the clinical magnitude of the effect, the type of evidence, and the statistical consistency of the results.\u003c/em\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe evidence integrated in this review confirms that nurse-led interventions represent the main driver of metabolic improvement in adults with type 2 diabetes mellitus. The included randomized clinical trials \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e reported absolute HbA1c reductions of up to 1.10%, a clinical effect comparable to that observed with second-line oral drug therapies. This finding coincides with what has been described in previous experimental studies, which indicate that structured and continuous educational interventions manage to overcome the therapeutic inertia associated with conventional management of DM2.\u003c/p\u003e \u003cp\u003eHowever, the impact of such interventions is not presented in isolation but mediated by specific behavioral determinants. The included observational and prospective studies \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e show that baseline self-care is an inverse and consistent predictor of glycemic control, with significant regression coefficients (β \u0026asymp; \u0026minus;0.28). This pattern suggests that the efficacy of clinical interventions depends on the patient's prior ability to integrate self-management behaviors, which explains the greater metabolic stability observed in long-term follow-ups.\u003c/p\u003e \u003cp\u003eIn a complementary way, self-efficacy and empowerment emerge as critical modulators of therapeutic behavior. The included studies \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e reported moderate- to high-magnitude positive correlations between self-efficacy and glycemic control (r\u0026thinsp;\u0026asymp;\u0026thinsp;0.58\u0026ndash;0.62), supporting theoretical models of behavioral self-regulation. These findings are consistent with the literature that describes the perception of competence as the cognitive substrate necessary to sustain therapeutic adherence beyond the short term.\u003c/p\u003e \u003cp\u003eIn contrast, health literacy is positioned as the main limiting factor of the translational process. Studies evaluating this determinant \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e showed that low levels of therapeutic understanding increase the risk of poor glycemic control by two to three times, with adjusted odds ratios reaching values of up to 3.20. This consistency across studies suggests that health literacy acts as a structural bottleneck: without minimum cognitive competencies, self-care behaviors and self-efficacy fail to consolidate sustainably.\u003c/p\u003e \u003cp\u003eIn the same vein, the presence of comorbidities and the burden of chronicity intensify the complexity of care. The prospective studies included \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e show that the coexistence of chronic pathologies not only aggravates the metabolic profile, but also reduces the patient's functional and behavioral capacity, weakening self-care. This finding reinforces the need to prioritize nursing interventions according to their behavioral impact, prioritizing those aimed at structured education, strengthening self-efficacy, and improving health literacy.\u003c/p\u003e \u003cp\u003eOverall, the cross-sectional comparison of the evidence confirms that glycemic control in DM2 does not depend on a single determinant, but on the hierarchical interaction between education, self-efficacy and health literacy. These results consolidate the strategic role of translational nursing as a bridge between scientific evidence and clinical practice, guiding decision-making towards high-impact behavioral interventions and clinical sustainability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe synthesized evidence positions behavioral determinants as the core of metabolic control in type 2 diabetes mellitus, and translational nursing as the main vehicle for its effective modification. The use of analytical matrices and prioritization of clinical impact opens the door to predictive intervention models, capable of optimizing resources and anticipating metabolic risk. This paradigm projects a structural change in health systems, where nursing leads the transition from a reactive model to a preventive, intelligent, and behavior-focused one.\u003c/p\u003e"},{"header":"Limitations of the study","content":"\u003cp\u003eThe main limitations include the diversity of measurement scales, which made an overall quantitative analysis difficult, and the cross-sectional design of most studies, which prevents definitive causality from being established. The variability in the educational interventions analyzed shows the urgency of standardizing nursing protocols to strengthen the evidence and its clinical application.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the profiles you provided earlier, here is a draft using the CRediT taxonomy:\u003c/p\u003e\n\u003cp\u003eAuthor Contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStarlin Javier Martínez García:\u003c/strong\u003e Conceptualization, Software, Formal analysis, Writing - Original Draft, and Visualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFausto Antonio Suriel Rosario:\u0026nbsp;\u003c/strong\u003eMethodology, Validation, Resources, Data Curation, and Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnmanuel Liriano Parra:\u003c/strong\u003e Investigation, Writing - Review \u0026amp; Editing, and Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing \u003cstrong\u003eCOPE\u003c/strong\u003e guidelines, if there are no competing interests, use this standard phrasing:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this systematic review were obtained from previously published studies. The sources are cited within the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePopoviciu MS, Marin VN, Vesa CM, Stefan SD, Stoica RA, Serafinceanu C et al (2022) Correlations between Diabetes Mellitus Self-Care Activities and Glycaemic Control in the Adult Population: A Cross-Sectional Study. Healthc (Basel) 10(1):174. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/healthcare10010174\u003c/span\u003e\u003cspan address=\"10.3390/healthcare10010174\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkoye OC, Ohenhen OA (2021) Assessment of diabetes self-management amongst Nigerians using the diabetes self-management questionnaire: a cross-sectional study. 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Arthritis Rheum 49(2):156\u0026ndash;163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/Art.10993\u003c/span\u003e\u003cspan address=\"10.1002/Art.10993\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diabetes mellitus, type 2, Self Care, Self Efficacy, Health Literacy, Translational Nursing","lastPublishedDoi":"10.21203/rs.3.rs-8895914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8895914/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 Mellitus (T2DM) is a priority health challenge due to its prevalence and the clinical impact of poor glycemic control. Behavioral determinants play a central role in modulating metabolic outcomes within nursing practice. Aim: To determine the impact of behavioral determinants on glycemic control in adults with T2DM from a translational nursing perspective. Methods: Systematic review following PRISMA 2020 guidelines. Observational studies and randomized clinical trials evaluating self-care, self-efficacy, health literacy, and glycemic control (HbA1c) were included. Data were integrated using traceability and critical evidence matrices to normalize heterogeneous statistical metrics. Results: Nursing-led interventions and the strengthening of self-efficacy and self-care are associated with clinically significant improvements in HbA1c. Conversely, low health literacy was identified as a critical risk factor for metabolic poor control. Conclusion: Behavioral determinants are the main modulators of glycemic control in T2DM. Translational nursing emerges as a strategic axis for transforming scientific evidence into high-impact clinical interventions.\u003c/p\u003e","manuscriptTitle":"Impact of behavioral determinants on the control of type 2 diabetes mellitus: Translational nursing systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 09:00:25","doi":"10.21203/rs.3.rs-8895914/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a9c6a02-873d-44bf-8575-cb3c8c178899","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63031574,"name":"Nursing"},{"id":63031575,"name":"Health Economics \u0026 Outcomes Research"},{"id":63031576,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-02-18T09:00:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 09:00:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8895914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8895914","identity":"rs-8895914","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}