Provider perspectives on family support in diabetes self management in rural Adamawa Nigeria

Provider perspectives on family support in diabetes self management in rural Adamawa Nigeria | 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 Research Article Provider perspectives on family support in diabetes self management in rural Adamawa Nigeria Jimmy Reyes, Jennifer Tyndall, Jamiu Olumoh, Roland Stephen, Victory Inyang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8565281/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 Diabetes mellitus is rapidly increasing across low- and middle-income countries, yet rural communities face persistent inequities in chronic disease care. In Northeastern Nigeria, family members often provide essential support for diabetes self-management, but their role is influenced by poverty, cultural beliefs, and fragmented primary healthcare systems. This study examined healthcare providers’ perspectives on how family dynamics, socioeconomic conditions, and community resources shape diabetes care in rural Adamawa State. A descriptive qualitative design was used across five Local Government Areas. Twenty-five healthcare providers were purposively sampled based on their direct involvement in diabetes care. Semi-structured interviews were conducted in English or Hausa, audio-recorded, transcribed, and analyzed through inductive content analysis with triangulation across sites. Six themes emerged. Providers emphasized that poverty constrained access to medications, glucose monitoring, and recommended diets. Food insecurity and limited local substitutions made dietary adherence challenging. Knowledge gaps, spiritual interpretations of disease, and reliance on herbal treatments influenced care-seeking behaviors. Families served as frontline caregivers, assisting with transportation, food preparation, and medication adherence, although their capacity varied. Stigma and neglect were context-dependent, shaped by gender norms and misconceptions. Community support was described as sporadic and dependent on individual or religious leaders rather than structured systems. Diabetes care in rural Nigeria is shaped by intertwined socioeconomic, cultural, and structural determinants. Strengthening primary care platforms with family-centered diabetes education, culturally tailored outreach, community led home support, and affordability measures could reduce inequities and enhance self-management. Policies that institutionalize sustained community partnerships are essential for improving outcomes in low-resource settings. Nigeria diabetes self-management family support qualitative research primary healthcare rural health Introduction Diabetes mellitus type 2 has increasingly become a significant public health problem in Nigeria, with a growing prevalence in both urban and rural areas [ 1 ]. Despite national efforts to strengthen non-communicable disease (NCD) control, health disparities persist, particularly in low-income and rural populations where healthcare access remained limited [ 2 ]. In Yola and other parts of Adamawa State, healthcare providers continue to face systemic and infrastructural challenges, including inadequate supplies, staff shortages, and the high cost of medications and diagnostic services [ 3 ]. Within these contexts, families played a critical role in diabetes self-management, often providing daily care, financial assistance, and emotional support. Yet, the extent and quality of family involvement vary, influenced by poverty, cultural beliefs, and gender roles [ 4 ]. Healthcare providers and community health navigators in rural settings such as Yola have a unique vantage point from which to observe how family structures, traditional practices, and social norms affects diabetes care. This study explored healthcare providers’ perspectives on the role of family support in diabetes self-management and identified potential interventions to enhance diabetes care in low-income and socially disadvantaged rural communities in Northeastern Nigeria. A descriptive qualitative design was used to capture the lived experiences and professional insights of providers working across primary and secondary care levels. Background Nigeria’s diabetes burden has been steadily increasing, with the International Diabetes Federation (IDF) estimating that over 3.6 million Nigerians were living with diabetes by 2021, though the actual number was likely higher due to underdiagnosis in rural areas [ 5 ]. In Northern Nigeria, particularly Adamawa State, socioeconomic deprivation, food insecurity, and limited healthcare infrastructure further compound these challenges. Primary healthcare centers in rural local government areas (LGAs) such as Yola South, Jada, and Shelleng often lack essential medications, diagnostic equipment, and trained personnel [ 3 ]. For most patients in rural Nigeria, diabetes self-management depends heavily on family and community support. Families assist with meal preparation, transportation to clinics, and payment for medications and laboratory tests. However, when poverty and unemployment constrain households, sustaining such support becomes difficult [ 6 ]. Cultural and spiritual beliefs also shape health-seeking behaviors; some families encourage the use of herbal remedies or faith-based healing, occasionally leading to delays in biomedical care [ 7 ]. Healthcare providers in Yola and surrounding areas thus operate within complex sociocultural and economic environments. They often act not only as clinicians but also as counselors and community educators, attempting to reconcile biomedical advice with traditional understandings of disease causation and care. This dynamic makes the providers’ perspective essential in developing interventions that could engage families more effectively in diabetes management. Literature Review Family Support and Diabetes Self-Management in Rural Nigeria Several studies across Nigeria and Sub-Saharan Africa have demonstrated that family support plays a pivotal role in diabetes management [ 8 , 9 ]. Woodward et al. [ 6 ] reported that patients with strong family support exhibited better medication adherence and dietary control than those without such support. Similarly, Hailu et al. [ 10 ] found that families often served as the primary caregivers, particularly for older adults in rural areas. However, this support was frequently informal and unstructured, with family members lacking adequate knowledge about diabetes and its complications. In Adamawa and other northern states, poverty and food insecurity frequently undermine dietary recommendations. Some families cannot afford specialized diets or glucose monitoring supplies, forcing patients to substitute cheaper, carbohydrate-heavy staples [ 11 ]. Moreover, patriarchal structures often influenced decision-making regarding treatment expenditures, with women, who frequently manage household food preparation, lacking control over financial resources [ 12 , 13 ]. These realities mean that the family’s role in diabetes care is both enabling and constraining. Positive engagement promotes adherence, while misinformation, fatalistic beliefs, and financial hardship contributes to treatment discontinuation or delayed clinic attendance [ 14 ]. Healthcare Providers’ Perspectives on Family Involvement Studies in Nigeria and other low-resource settings revealed that healthcare providers recognized the importance of family involvement but encountered persistent barriers in operationalizing it. Iregbu et al. [ 15 ] found that Nigerian clinicians viewed family members as critical allies in reinforcing education on medication adherence and dietary practices. However, they noted that limited consultation time, lack of culturally tailored educational materials, and misconceptions about diabetes within families complicated these efforts. In rural Northern Nigeria, providers often had to engage entire families during visits to correct misunderstandings about diabetes causation and management. Traditional and religious beliefs, such as perceiving diabetes as a curse or spiritual affliction, were commonly cited as barriers to effective self-management [ 15 ]. Providers also expressed frustration with structural challenges: irregular drug supplies, high patient loads, and lack of follow-up systems that would enable family-centered care. These perspectives highlight the need for context-sensitive interventions that equip providers to integrate family engagement into diabetes care. Training programs that enhance communication skills, cultural competence, and family counseling capacity could help bridge the gap between clinical recommendations and household realities. Interventions for Low-Income and Rural Populations Evidence from sub-Saharan Africa suggested that community-based and family-oriented interventions could improve diabetes outcomes in rural settings [ 16 ]. Community health workers (CHWs) and peer educators had proven effective in promoting adherence and providing culturally adapted education in low-resource areas [ 17 ]. Integrating CHWs into primary care allowed for home visits, family counseling, and follow-up support, particularly where literacy and transport barriers were prevalent. In Northern Nigeria, programs that linked primary care providers, faith leaders, and community volunteers demonstrated potential in improving awareness and early detection of non-communicable diseases [ 18 ]. Such models could be adapted for diabetes by incorporating family-based education and small-group sessions focused on diet, exercise, and medication adherence. The findings from this study contributed to this growing evidence base by documenting how healthcare providers in Yola and surrounding rural communities perceived and managed family involvement in diabetes care. Their insights offered valuable guidance for designing interventions that were feasible, culturally relevant, and responsive to the socioeconomic constraints of rural Nigerian populations. Methodology Study Design This study employed a descriptive qualitative design to explore healthcare providers’ perspectives on the role of family support in diabetes self-management and to identify potential interventions to strengthen diabetes care in low-income and socially disadvantaged communities of Adamawa State, Nigeria. The approach allowed for a contextualized understanding of providers lived experiences, beliefs, and practices in resource-limited healthcare settings. Ethical approval for this study was obtained from the American University of Nigeria Institutional Review Board Protocol #PRO-13-11-24, Approval Code AUN-05-02-25. All study procedures were conducted in accordance with the approved IRB protocol and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and the Council for International Organizations of Medical Sciences International Ethical Guidelines for Health-Related Research Involving Humans. Study Setting The study was conducted in five Local Government Areas (LGAs) within Adamawa State, Northeastern Nigeria: Demsa, Jada, Mubi South, Shelleng, and Yola South. These LGAs represented diverse rural and peri-urban settings characterized by limited health infrastructure, low socioeconomic indices, and constrained access to specialized diabetes services. Each site had at least one functioning primary healthcare facility where routine diabetes screening and management were conducted. The facilities served as the main point of care for local populations, with most diabetes cases managed at the primary level before referral to secondary or tertiary centers in Yola or neighboring states. Participants and Sampling A total of 25 healthcare providers participated in the study, with five participants purposively selected from each LGA. Participants included community health extension workers, nurses, midwives, laboratory technicians, and facility managers directly involved in the management or support of diabetes patients. Purposive sampling was used to ensure variation in professional background, years of experience, and facility type. Eligible participants were those with at least one year of experience in diabetes care or screening within their respective LGAs. Participation was voluntary, and all respondents provided verbal informed consent prior to interview commencement. Data Collection Data collection took place between February and March 2025 using a semi-structured interview guide developed collaboratively by researchers from the American University of Nigeria and Proteus Agricultural Clinic in Iowa. The guide contained open-ended questions grouped into five sections: (1) provider background and experience, (2) role of family in diabetes self-management, (3) barriers to family support, (4) potential interventions, and (5) closing reflections. Each interview lasted 30–45 minutes and was conducted face-to-face in English or Hausa, depending on participant preference. Interviews were held in private spaces within healthcare facilities to ensure confidentiality. All sessions were audio-recorded with participant consent, and detailed field notes were taken to capture non-verbal cues and contextual information. Interviewers followed the same introduction and consent procedures across all LGAs, explaining the study purpose, ensuring confidentiality, and reiterating the voluntary nature of participation. Participants were encouraged to share examples, local idioms, and culturally specific practices relevant to diabetes and family support. Across LGAs, providers described extensive variation in family involvement ranging from active participation in medication adherence and dietary support in Demsa and Shelleng, to limited or absent support in low-income households in Yola South and Jada. Common interview prompts explored financial barriers, gender dynamics, cultural beliefs, and community-based solutions such as involvement of religious leaders, peer-support groups, and community health workers. Data Management and Analysis Interviews were transcribed verbatim, and those conducted in Hausa were translated into English by bilingual research assistants to ensure the preservation of meaning and cultural nuance. All transcripts were reviewed by two independent researchers to confirm linguistic accuracy and contextual integrity. The research team conducted an inductive content analysis using a systematic, multi-step process that involved familiarization through repeated reading, open coding to identify significant statements, and categorization to group related codes into coherent clusters. These categories were then synthesized into higher-level analytic themes following established qualitative content analysis procedures. Inter-coder agreement was strengthened through iterative comparison of coded transcripts, and any discrepancies were resolved through consensus among analysts. To enhance the trustworthiness of the analysis, triangulation across the five LGAs was conducted to identify both shared and context-specific patterns. Peer debriefing sessions between team members from AUN and Proteus were used to refine code definitions and ensure analytic rigor and consistency. Representative quotes were systematically extracted to illustrate analytic interpretations in later stages of reporting. All digital data were stored securely in password-protected files accessible only to authorized members of the research team, and participants were informed that their data would be used solely for academic and policy-related purposes without any impact on their employment or facility operations. Results Overview A total of 25 healthcare providers were interviewed across the five Local Government Areas (LGAs) of Demsa, Jada, Mubi, Shelleng, and Yola South. Participants included community health extension workers, nurses, laboratory staff, and facility managers with direct involvement in diabetes care. See Table 1 for demographic information. Table 1 Demographic Information Role Percentage Number of Participants Years of Experience Community health workers 40% 10 1–10 years Nurse/Midwives 32% 8 3–15 years Laboratory technicians 12% 3 2–12 years Facility managers 16% 4 5–20 years Through inductive content analysis, six overarching themes emerged, illustrating how socioeconomic, cultural, and structural conditions shape diabetes self-management and family involvement in rural Adamawa State. These themes included: (1) poverty as a central force influencing both the management and non-management of diabetes, (2) the daily struggle to maintain a healthy diet amid scarcity and competing food demands, (3) persistent knowledge gaps and the influence of traditional and biomedical belief systems, (4) the critical role of family members as frontline caregivers, (5) context-dependent experiences of stigma and neglect, and (6) fragmented healthcare and community resources that result in ad-hoc and inconsistent support for people living with diabetes. Theme 1: Poverty Drives (Non-) Management of Diabetes Healthcare providers consistently described poverty as the dominant factor shaping how patients and their families managed diabetes. Across all LGAs, financial hardship limited access to medications, glucose testing, and recommended diets. Respondents explained that even when families were supportive, their ability to maintain care was curtailed by economic strain. A provider in Shelleng explained: “The main barriers are the cost of drugs and food. Many families can’t afford them. We refer patients, but most can’t afford travel or care at secondary facilities.” In Mubi, a respondent added: “Most diabetic foods are expensive. Patients and their families can’t buy them. Even if they know what to eat, they can’t sustain it.” Providers reported that poverty led to inconsistent adherence and reliance on “whatever food is available.” Some families initially contributed but later withdrew as costs accumulated. One Demsa participant stated: “Families try, but after some time, they get tired. Diabetes doesn’t go away, and supporting a chronic condition is expensive.” Poverty thus emerged as both a clinical and social determinant, limiting choices, reducing follow-up visits, and straining family relationships. Theme 2: Diet as a Daily Battleground Dietary modification was viewed as a constant struggle, shaped by food insecurity, cultural norms, and taste preferences. Providers across LGAs reported that patients frequently “got tired” of eating the same foods, especially when choices were limited by cost or local availability. In Yola South, a participant observed: “A normal diabetic patient shouldn’t take sugary food. But once they are used to eating it, changing becomes a big challenge.” In Shelleng, another provider highlighted monotony and fatigue: “Even when the food is available, they get tired of eating the same thing every day.” Providers described how family members often tried to enforce dietary recommendations but lacked knowledge about local substitutions. As a Mubi participant reflected: “They know the patient should avoid rice and yam, but they don’t know what else to give, so the person ends up skipping meals or eating wrong foods.” Dietary adherence was thus a “daily battleground,” requiring continuous negotiation between cost, culture, and cravings. Providers recommended locally tailored food guides and community nutrition outreach to bridge this gap. Theme 3: Knowledge Gaps and Competing Belief Systems Limited health literacy and cultural interpretations of diabetes were recurrent themes. Many families associated diabetes with spiritual causation, witchcraft, or hereditary “wind illness” (“iska”), affecting their willingness to engage in biomedical care. A Mubi health worker noted: “One patient’s husband told her she could eat anything because he gave her herbs. That belief affected her recovery.” Similarly, in Demsa, a participant observed: “If only they knew what to do, when to do it, the patient’s case would not be severe. But they don’t have the knowledge or think it’s just fate.” Providers reported that traditional healers and religious leaders sometimes advised patients to avoid mixing herbal and hospital treatments, leading to delayed follow-ups or medication discontinuation. Despite these challenges, several respondents emphasized that families were receptive to education when provided in Hausa or local dialects. Community education, especially through faith-based gatherings and radio, was widely suggested as a culturally appropriate strategy. Theme 4: Family as the Frontline Care Team Healthcare providers unanimously viewed the family as the central support system in diabetes care. Families provided transportation, purchased medications, assisted with diet control, and offered moral support. A Shelleng provider recounted: “I have a patient whose son provides the appropriate food for her and even helps with her treatment at times.” Another from Mubi shared: “My aunt was diabetic. We supported her with food and medicine. That made a real difference in her health.” However, family involvement was not uniformly positive. Providers noted cases where relatives’ ignorance, frustration, or negligence worsened outcomes. In Demsa, one participant reported: “The caregiver added sugar to the patient’s meal even when told not to. The man eventually didn’t make it. The family’s attitude mattered.” Gendered expectations also shaped support. Male patients tended to receive priority financial help, while women’s care often depended on extended family goodwill. Despite these inequities, providers viewed families as indispensable partners in sustaining long-term care. Theme 5: Stigma and Neglect are Context-Dependent Experiences of stigma varied significantly across the five LGAs. In some communities, diabetes was seen as a manageable chronic disease; in others, it carried shame or misinterpretation as a contagious or morally linked illness. A Shelleng participant described one case: “One of my patients avoids church due to frequent urination. She sometimes soils herself and finds it hard to socialize.” Conversely, a Yola South respondent asserted that diabetes “is not stigmatized because people know it’s not contagious”. Providers in Mubi and Demsa recounted incidents where family members distanced themselves or even sought divorce due to the patient’s perceived weakness or reduced productivity. One health worker shared: “A man’s wife asked for a divorce because he was no longer sexually active. That’s stigma within the home.” These accounts illustrated that stigma was context-dependent, influenced by local knowledge, gender expectations, and cultural framing of chronic illness. Providers emphasized community sensitization as critical to dispelling misconceptions and fostering empathy. Theme 6: Fragmented Resources and Ad-Hoc Community Support The interviews revealed that community-level support for diabetes was sporadic and unsystematic. While occasional donations or outreach programs occurred, providers noted the absence of structured community resources or sustained interventions. A Shelleng respondent explained: “Sometimes groups donate supplies, but it’s not regular or organized. They help for a time, then stop.” Others highlighted one-off initiatives led by traditional leaders: “The Emir organized free testing and awareness with community heads and health workers. Many discovered their status, that helped.” In most LGAs, religious organizations, local elites, or NGOs occasionally covered drug costs or supported awareness programs. However, respondents agreed these efforts were “ad hoc,” driven by individual goodwill rather than institutionalized policy. As one Demsa provider concluded: “There are no formal community resources. Only individuals, churches or rich people, help once in a while.” Providers called for the creation of sustained multi-sectoral partnerships, including health authorities, local councils, and faith groups, to institutionalize diabetes outreach and medication support at the community level. Discussion and Implications This study provided in-depth insight into how healthcare providers in five Local Government Areas of Adamawa State, Demsa, Jada, Mubi, Shelleng, and Yola South, understood the role of family support in diabetes self-management. Providers portrayed families as the frontline caregivers, yet described how poverty, food insecurity, limited knowledge, stigma, and fragmented community resources profoundly constrained self-management in rural Nigeria. Despite these barriers, providers articulated clear, pragmatic recommendations for strengthening family-inclusive care through education, economic support, and community partnerships. Consistent with prior Nigerian and regional evidence [ 19 ], poverty emerged as the most pervasive barrier to diabetes management. Providers’ observations that high costs of medications, diagnostic tests, and transportation discouraged follow-up were congruent with national analyses showing that over 80% of Nigerians paid out-of-pocket for diabetes care [ 20 – 22 ]. Similar patterns had been reported across sub-Saharan Africa, where Kibirige et al. [ 23 ] found insulin and oral hypoglycemics to be both scarce and unaffordable in primary-care pharmacies. Rising food prices and insecurity further compounded this challenge. These financial pressures explained why families often supported patients intermittently, helping initially but withdrawing as resources depleted. Dietary management represented an equally formidable obstacle. Providers’ accounts of patients’ fatigue with repetitive diets and difficulty affording protein-rich or low-glycemic foods echoed findings from Kumah et al. [ 24 ] and Wilson et al. [ 25 ], who noted that adherence to dietary prescriptions was lowest among rural African patients facing food insecurity. In Nigeria, the cultural centrality of carbohydrate-based staples such as rice and yam complicated efforts to maintain recommended meal patterns [ 26 ]. These parallels highlighted the need for culturally tailored nutrition counseling using locally available foods, a gap that remains largely unaddressed in current diabetes education curricula. Knowledge deficits and competing belief systems also influenced care. Many families, as providers described, interpreted diabetes through spiritual or traditional frameworks and alternated between herbal and hospital treatments. This finding aligned with Ekpor et al. [ 27 ] and Aina et al. [ 28 ] who documented widespread reliance on traditional medicine among Nigerians with chronic illness and a belief that combining herbs and pharmaceuticals was dangerous. Studies by Iregbu et al. [ 15 ] and Ogunlana et al. [ 29 ] likewise emphasized that health professionals must integrate cultural understanding and communication skills into diabetes counseling. Providers in this study mirrored that view, suggesting that bilingual health education and collaboration with traditional and religious leaders could enhance family comprehension and acceptance of biomedical advice. Family members were repeatedly described as indispensable to diabetes self-management. They financed medications, supervised diets, accompanied patients to clinics, and provided emotional support. These insights aligned with Ojewale et al. [ 30 ] and Baig et al. [ 31 ], who demonstrated that family involvement improved adherence, glucose control, and quality of life among adults with type 2 diabetes. Yet, as providers in Adamawa noted, the same family systems could create friction when relatives became frustrated or when gender hierarchies limited caregiving for women. Such duality has been widely reported across African contexts, where both positive and negative family dynamics directly influence treatment adherence [ 32 ]. The variability of stigma and neglect observed across LGAs reflected how sociocultural interpretation determined community response to chronic illness. In some areas, diabetes was viewed as a manageable condition; in others, it carried embarrassment or social isolation, especially when symptoms, such as frequent urination or weight loss, resembled those of HIV. Comparable findings have been reported in Ghana and Kenya, where stigma toward non-communicable diseases emerged from confusion with infectious conditions [ 33 ]. In the Adamawa context, stigma was often internal to families, manifesting as shame, spousal conflict, or withdrawal of support. Providers’ accounts underscored the importance of sensitization programs to reframe diabetes as a chronic but controllable disease. Equally significant was the description of fragmented and ad-hoc community support. Providers explained that interventions from religious or traditional leaders, local elites, or NGOs were sporadic and unsustained, findings that echoed Ajisegiri et al. [ 18 ], who reported similar gaps in Nigeria’s community health-worker networks for non-communicable diseases. While isolated outreach programs, such as free testing days organized by traditional rulers, raised awareness, they lacked the continuity necessary for long-term impact. The absence of a structured community-based diabetes program limited opportunities for sustained family and patient engagement. Taken together, these findings underscored how diabetes care in rural Nigeria was shaped by intersecting social, cultural, and structural determinants. The results reinforced that family-centered care could not succeed without addressing economic barriers and strengthening the primary healthcare (PHC) system. The perspectives of Adamawa providers closely paralleled emerging African evidence supporting culturally tailored, family-inclusive diabetes self-management education (DSMES) [ 15 , 34 ]. DSMES interventions that integrated caregivers and community health workers have demonstrated moderate reductions in HbA1c and improved adherence when adapted to local contexts [ 35 – 37 ]. From a policy standpoint, these findings highlighted the need for multi-level strategies that combined affordability measures, family engagement, and community mobilization. Providers’ recommendations to organize “caregiver days,” implement free drug programs, and embed diabetes education within religious and community platforms were consistent with the World Healthcare Organization and IDF guidance promoting health-literacy and family participation at the primary-care level [ 38 , 39 ]. Strengthening CHW-led household follow-ups could operationalize this model by bridging the gap between clinic-based advice and home-based practices. At the same time, medicine price-control policies and food-voucher programs could alleviate financial strain and enable families to adhere to treatment. In practical terms, this study suggested that brief, structured family-education sessions during PHC visits could improve knowledge and reduce misinformation. Incorporating CHWs into follow-up visits could further enhance adherence and provide opportunities for culturally appropriate counseling at the household level. Collaboration with religious and traditional leaders could amplify health messages and counteract harmful beliefs about diabetes causation and treatment. Finally, the integration of diabetes and nutrition support into existing community programs, such as maternal health or immunization days, could extend reach without additional infrastructure. Overall, the findings reinforced the need to move beyond individual-centered care toward family- and community-anchored strategies. Addressing poverty, enhancing affordability, and building sustainable local support systems are indispensable for improving diabetes outcomes in rural Northern Nigeria. When families are empowered with knowledge and economic stability, and when communities were mobilized to sustain support, diabetes self-management becomes more feasible and effective [ 40 ]. These insights align with a growing body of African research demonstrating that culturally responsive, family-inclusive approaches are both practical and impactful in low-resource contexts [ 41 ]. In conclusion, healthcare providers in this study illuminated the realities of delivering diabetes care in resource-limited settings where family networks, cultural beliefs, and poverty intersect. Their perspectives offered a grounded framework for designing interventions that place families, not individuals, at the center of diabetes management. Future implementation research should evaluate the effectiveness and cost-efficiency of family-inclusive DSME models integrated within Nigeria’s PHC system, with particular attention to how such models can be scaled sustainably across rural regions. Declarations Competing Interests The authors declare that there are no financial or non-financial competing interests directly or indirectly related to this work. Ethical Approval Ethical approval for this study was obtained from the American University of Nigeria Institutional Review Board (Protocol PRO-13-11-24; Approval Code AUN-05-02-25). All study procedures were conducted in accordance with the approved IRB protocol and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and the Council for International Organizations of Medical Sciences International Ethical Guidelines for Health-Related Research Involving Humans. Consent to Participate Informed consent was obtained from all participants prior to data collection. Participants were informed of the study purpose, procedures, voluntary nature of participation, and their right to withdraw at any time without penalty. Consent for Publication All participants provided informed consent for the use of anonymized data in publications and presentations resulting from this study. No identifying information is included in the manuscript. Funding No external funding was received for the preparation of this manuscript. Author Contribution JAR (Jimmy A. Reyes) conceptualized the study, led the development of the study design, coordinated international team collaboration, conducted qualitative data analysis, interpreted the findings, and was the lead writer of the manuscript.JT (Jennifer Tyndall) contributed to refining the study methodology, supported data interpretation, drafted sections of the results and discussion, and provided substantial revisions to the manuscript.RS (Roland Stephen), VI (Victory Inyang) contributed to study conceptualization, guided the analytic framework, provided critical review of the analysis, and contributed to editing and strengthening the manuscript's theoretical and policy sections.LD (Lucy Damasane) provided expertise in community-based health systems, supported interpretation of findings within the African public health context, and contributed to manuscript drafting and revisions.SK (Sophia Kalomeris) contributed to the interpretation of global health implications and provided critical revisions to the final manuscript. Data Availability This study is based on qualitative data that include participant interviews transcripts containing potentially identifiable information. In accordance with ethical approval requirements and to protect participant confidentiality, the full qualitative datasets are not publicly available. De-identified excerpts relevant to the study findings are included within the manuscript. Additional de-identified data may be made available from the corresponding author upon reasonable request and with permission from the institutional review board. References Ogbera AO, Ekpebegh C. Diabetes mellitus in Nigeria: The past, present and future. World J Diabetes. 2014;5(6):905–11. https://doi.org/10.4239/wjd.v5.i6.905 . Di Cesare M, Khang YH, Asaria P, Blakely T, Cowan MJ, Farzadfar F, Ezzati M. Inequalities in non-communicable diseases and effective responses. Lancet. 2013;381(9866):585–97. https://doi.org/10.1016/S0140-6736(12)61851-0 . Abubakar SD, Sunday NJ. 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PLOS Global Public Health. 2022;2(6):e0000566. https://doi.org/10.1371/journal.pgph.0000566 . Ozioko N, Kamalakannan S. Barriers and enablers of access to diabetic screening services in Nigeria: A qualitative study. Int J Community Med Public Health. 2024;11(9):3642–50. https://doi.org/10.18203/2394-6040.ijcmph20242571 . Aregbeshola BS. Out-of-pocket payments in Nigeria. Lancet. 2016;387(10037):2506. https://doi.org/10.15171/IJHPM.2018.19 . Okonofua F, Ntoimo LF, Ogu R, Isikhuemen M. Public policy and health system responses to diabetes mellitus in Nigeria: A call for reform. Health Syst Reform. 2025;11(1):2477941. https://doi.org/10.1080/23288604.2025.2477941 . Olatunde OI. Challenges and opportunities for diabetes care policy in Nigeria. Open Health. 2025;6., Article 20230056. https://doi.org/10.1515/ohe-2023-0056 . Kibirige D, Olum R, Kyazze AP, Bongomin F, Sanya RE. Availability and affordability of essential medicines and diagnostic tests for diabetes mellitus in Africa. Tropical Med Int Health. 2022;27(10):942–60. https://doi.org/10.1111/tmi.13819 . Kumah E, Otchere G, Ankomah SE, Fusheini A, Kokuro C, Aduo-Adjei K, Amu H. Diabetes self-management education interventions in the WHO African Region: A scoping review. PLoS ONE. 2021;16(8):e0256123. https://doi.org/10.1371/journal.pone.0256123 . Wilson D, Diji AK, Marfo R, Amoh P, Duodu PA, Akyirem S, Tetteh J. Dietary adherence among persons with type 2 diabetes: A concurrent mixed methods study. PLoS ONE. 2024;19(4):e0302914. https://doi.org/10.1371/journal.pone.0302914 . Petrikova I, Bhattacharjee R, Fraser PD. The Nigerian diet and its evolution: A review of the literature and household survey data. Foods. 2023;12(2):443. https://doi.org/10.3390/foods12030443 . Ekpor E, Osei E, Akyirem S. Prevalence and predictors of traditional medicine use among persons with diabetes in Africa: A systematic review. Int Health. 2024;16(3):252–60. https://doi.org/10.1093/inthealth/ihad080 . Aina O, Gautam L, Simkhada P, Hall S. Prevalence, determinants and knowledge about herbal medicine and non-hospital utilisation in southwest Nigeria: A cross-sectional study. BMJ Open. 2020;10(9):e040769. https://doi.org/10.1136/bmjopen-2020-040769 . Ogunlana MO, Oyewole OO, Aderonmu JA, Onyeso OK, Faloye AY, Govender P. Cultural competence practice among Nigerian hospital-based healthcare professionals. BMC Med Educ. 2023;23., Article 933. 10.1186/s12909-023-04910-0 . https://link.springer.com/article/ . Ojewale LY, Almutairi WM, Alonazi WB, Alshammari EM. A survey on patients’ characteristics, perception of family support, and diabetes self-management. Nurs Open. 2019;6(3):1103–11. https://doi.org/10.1002/nop2.236 . Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve diabetes outcomes for adults. Ann N Y Acad Sci. 2015;1353(1):89–112. https://doi.org/10.1111/nyas.12844 . Suglo JN, Evans C. Factors influencing self-management in relation to type 2 diabetes in Africa: A qualitative systematic review. PLoS ONE. 2020;15(10):e0240938. https://doi.org/10.1371/journal.pone.0240938 . Omosigho PO, John OO, Musa MB, Aboelhassan Y, Olabode ON, Bouaddi O, Abdalla M. Stigma and infectious diseases in Africa: Impact and strategies for reduction. Annals Med Surg. 2023;85:6078–82. https://doi.org/10.1097/MS9.0000000000001470 . Iregbu S, Spiers J, Duggleby W, Salami B, Schick-Makaroff K. Nigerian health care providers’ perspectives and practices related to diabetes self-management support. Qual Health Res. 2023;33(1):92–105. https://doi.org/10.1177/10497323221143889 . Collinsworth AW, Vulimiri M, Schmidt KL, Snead CA. Effectiveness of a community health worker–led diabetes self-management education program. Diabetes Educ. 2013;39(6):792–9. https://doi.org/10.1177/0145721713504470 . Ernawati U, Wihastuti TA, Utami YW. Effectiveness of diabetes self-management education in type 2 diabetes mellitus: A systematic review. J Public Health Res. 2021;10(2):2240. https://doi.org/10.4081/jphr.2021.2240 . Evans J, Ha H, White PT. Effectiveness of community health worker interventions on glycaemic control in type 2 diabetes mellitus: A systematic review and meta-analysis. BMJ Open. 2025;15(3):e096651. https://doi.org/10.1136/bmjopen-2024-096651 . Cavan D, Diogo J, Huang Y, Makaroff L. (2019). Access to medicines and supplies for people with diabetes: A global survey. Int Diabetes Federation. https://idf.org/media/uploads/2023/05/attachments-43.pdf Mphasha M, Skaal L, Mothiba T, Ngoatle C, Hlahla L. Primary health care–family partnership for better diabetes outcomes: A systematic review. J Endocrinol Metabolism Diabetes South Afr. 2023;28(1):1–6. https://doi.org/10.1080/16089677.2022.2140517 . Mayberry LS, Berg CA, Harper KJ, Osborn CY. (2016). The design, usability, and feasibility of a family-focused diabetes self-care support mHealth intervention for diverse, low-income adults with type 2 diabetes. Journal of Diabetes Research, 2016 , 7586385. https://doi.org/10.1155/2016/7586385 Ageru, T. A., Le, C. N., Wattanapisit, A., Woticha, E. W., Truong, N. T., Stanikzai,M. H., … Beran, D. (2024). Diabetes self-care intervention strategies in Sub-Saharan Africa: A systematic review. PLOS ONE, 19(5), e0305860. https://doi.org/10.1371/journal.pone.0305860. Additional Declarations No competing interests reported. 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. 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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-8565281","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589115386,"identity":"406c4797-2c25-43f7-b81a-5db81c6e8aa0","order_by":0,"name":"Jimmy Reyes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYBAC9mYgwfjHBsaXIKyFEaylLQ1IMiNpOYBPSwNYy2GYFgYitLRzp27mbTufZ97ef/Axzx+LPP4G3oOPP+B1GO+227x/bhfLnDnMbMzbJlEscYAv2QCvLWAtH24nzpBIZpPmbZBI3MDAYyZBWMuMcyAt7L95/oC1mP/Ap0UQrKXnANgWZh42iC14vS/NzLvt5ty25GIJnsPGknPbJBJnHOYxljiDRwsf/9ltN9622eVJsDc+/PDmT11if3uP4YcKPFpAgImHgSEBwWXGqRABGH+gaBkFo2AUjIJRgAYARHdNYHAcnbIAAAAASUVORK5CYII=","orcid":"","institution":"Proteus","correspondingAuthor":true,"prefix":"","firstName":"Jimmy","middleName":"","lastName":"Reyes","suffix":""},{"id":589115387,"identity":"511e0318-38ac-444b-847c-7a95b79e6a77","order_by":1,"name":"Jennifer Tyndall","email":"","orcid":"","institution":"American University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Tyndall","suffix":""},{"id":589115388,"identity":"583ecf1f-5f41-4b38-89c0-b1e5c94451d2","order_by":2,"name":"Jamiu Olumoh","email":"","orcid":"","institution":"American University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Jamiu","middleName":"","lastName":"Olumoh","suffix":""},{"id":589115389,"identity":"cfb54c44-2d47-48be-98db-033d42ea18ec","order_by":3,"name":"Roland Stephen","email":"","orcid":"","institution":"Modibbo Adama University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Roland","middleName":"","lastName":"Stephen","suffix":""},{"id":589115390,"identity":"2f7ab84c-3faf-4dc1-8eb3-895760fe4eef","order_by":4,"name":"Victory Inyang","email":"","orcid":"","institution":"American University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Victory","middleName":"","lastName":"Inyang","suffix":""},{"id":589115391,"identity":"457d90d4-226f-49af-9107-8b2c18c82917","order_by":5,"name":"Lucy Damasane","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Lucy","middleName":"","lastName":"Damasane","suffix":""},{"id":589115392,"identity":"0315301a-d3df-469d-b63d-ea9f5abb0604","order_by":6,"name":"Sophia Kalomeris","email":"","orcid":"","institution":"Columbia University","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"","lastName":"Kalomeris","suffix":""}],"badges":[],"createdAt":"2026-01-10 03:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8565281/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8565281/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104885798,"identity":"d39e13dd-605b-4789-863a-01ac5eb83453","added_by":"auto","created_at":"2026-03-18 09:59:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":728886,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8565281/v1/5e7d1a99-ff9a-4923-b999-371c2887088e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Provider perspectives on family support in diabetes self management in rural Adamawa Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus type 2 has increasingly become a significant public health problem in Nigeria, with a growing prevalence in both urban and rural areas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite national efforts to strengthen non-communicable disease (NCD) control, health disparities persist, particularly in low-income and rural populations where healthcare access remained limited [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Yola and other parts of Adamawa State, healthcare providers continue to face systemic and infrastructural challenges, including inadequate supplies, staff shortages, and the high cost of medications and diagnostic services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin these contexts, families played a critical role in diabetes self-management, often providing daily care, financial assistance, and emotional support. Yet, the extent and quality of family involvement vary, influenced by poverty, cultural beliefs, and gender roles [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Healthcare providers and community health navigators in rural settings such as Yola have a unique vantage point from which to observe how family structures, traditional practices, and social norms affects diabetes care.\u003c/p\u003e \u003cp\u003eThis study explored healthcare providers\u0026rsquo; perspectives on the role of family support in diabetes self-management and identified potential interventions to enhance diabetes care in low-income and socially disadvantaged rural communities in Northeastern Nigeria. A descriptive qualitative design was used to capture the lived experiences and professional insights of providers working across primary and secondary care levels.\u003c/p\u003e\n\u003ch3\u003eBackground\u003c/h3\u003e\n\u003cp\u003eNigeria\u0026rsquo;s diabetes burden has been steadily increasing, with the International Diabetes Federation (IDF) estimating that over 3.6\u0026nbsp;million Nigerians were living with diabetes by 2021, though the actual number was likely higher due to underdiagnosis in rural areas [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Northern Nigeria, particularly Adamawa State, socioeconomic deprivation, food insecurity, and limited healthcare infrastructure further compound these challenges. Primary healthcare centers in rural local government areas (LGAs) such as Yola South, Jada, and Shelleng often lack essential medications, diagnostic equipment, and trained personnel [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor most patients in rural Nigeria, diabetes self-management depends heavily on family and community support. Families assist with meal preparation, transportation to clinics, and payment for medications and laboratory tests. However, when poverty and unemployment constrain households, sustaining such support becomes difficult [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Cultural and spiritual beliefs also shape health-seeking behaviors; some families encourage the use of herbal remedies or faith-based healing, occasionally leading to delays in biomedical care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealthcare providers in Yola and surrounding areas thus operate within complex sociocultural and economic environments. They often act not only as clinicians but also as counselors and community educators, attempting to reconcile biomedical advice with traditional understandings of disease causation and care. This dynamic makes the providers\u0026rsquo; perspective essential in developing interventions that could engage families more effectively in diabetes management.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLiterature Review\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eFamily Support and Diabetes Self-Management in Rural Nigeria\u003c/h2\u003e \u003cp\u003eSeveral studies across Nigeria and Sub-Saharan Africa have demonstrated that family support plays a pivotal role in diabetes management [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Woodward et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported that patients with strong family support exhibited better medication adherence and dietary control than those without such support. Similarly, Hailu et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] found that families often served as the primary caregivers, particularly for older adults in rural areas. However, this support was frequently informal and unstructured, with family members lacking adequate knowledge about diabetes and its complications.\u003c/p\u003e \u003cp\u003eIn Adamawa and other northern states, poverty and food insecurity frequently undermine dietary recommendations. Some families cannot afford specialized diets or glucose monitoring supplies, forcing patients to substitute cheaper, carbohydrate-heavy staples [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, patriarchal structures often influenced decision-making regarding treatment expenditures, with women, who frequently manage household food preparation, lacking control over financial resources [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese realities mean that the family\u0026rsquo;s role in diabetes care is both enabling and constraining. Positive engagement promotes adherence, while misinformation, fatalistic beliefs, and financial hardship contributes to treatment discontinuation or delayed clinic attendance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eHealthcare Providers’ Perspectives on Family Involvement\u003c/h3\u003e\n\u003cp\u003eStudies in Nigeria and other low-resource settings revealed that healthcare providers recognized the importance of family involvement but encountered persistent barriers in operationalizing it. Iregbu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] found that Nigerian clinicians viewed family members as critical allies in reinforcing education on medication adherence and dietary practices. However, they noted that limited consultation time, lack of culturally tailored educational materials, and misconceptions about diabetes within families complicated these efforts.\u003c/p\u003e \u003cp\u003eIn rural Northern Nigeria, providers often had to engage entire families during visits to correct misunderstandings about diabetes causation and management. Traditional and religious beliefs, such as perceiving diabetes as a curse or spiritual affliction, were commonly cited as barriers to effective self-management [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Providers also expressed frustration with structural challenges: irregular drug supplies, high patient loads, and lack of follow-up systems that would enable family-centered care.\u003c/p\u003e \u003cp\u003eThese perspectives highlight the need for context-sensitive interventions that equip providers to integrate family engagement into diabetes care. Training programs that enhance communication skills, cultural competence, and family counseling capacity could help bridge the gap between clinical recommendations and household realities.\u003c/p\u003e\n\u003ch3\u003eInterventions for Low-Income and Rural Populations\u003c/h3\u003e\n\u003cp\u003eEvidence from sub-Saharan Africa suggested that community-based and family-oriented interventions could improve diabetes outcomes in rural settings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Community health workers (CHWs) and peer educators had proven effective in promoting adherence and providing culturally adapted education in low-resource areas [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Integrating CHWs into primary care allowed for home visits, family counseling, and follow-up support, particularly where literacy and transport barriers were prevalent.\u003c/p\u003e \u003cp\u003eIn Northern Nigeria, programs that linked primary care providers, faith leaders, and community volunteers demonstrated potential in improving awareness and early detection of non-communicable diseases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Such models could be adapted for diabetes by incorporating family-based education and small-group sessions focused on diet, exercise, and medication adherence.\u003c/p\u003e \u003cp\u003eThe findings from this study contributed to this growing evidence base by documenting how healthcare providers in Yola and surrounding rural communities perceived and managed family involvement in diabetes care. Their insights offered valuable guidance for designing interventions that were feasible, culturally relevant, and responsive to the socioeconomic constraints of rural Nigerian populations.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a descriptive qualitative design to explore healthcare providers\u0026rsquo; perspectives on the role of family support in diabetes self-management and to identify potential interventions to strengthen diabetes care in low-income and socially disadvantaged communities of Adamawa State, Nigeria. The approach allowed for a contextualized understanding of providers lived experiences, beliefs, and practices in resource-limited healthcare settings. Ethical approval for this study was obtained from the American University of Nigeria Institutional Review Board Protocol #PRO-13-11-24, Approval Code AUN-05-02-25. All study procedures were conducted in accordance with the approved IRB protocol and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and the Council for International Organizations of Medical Sciences International Ethical Guidelines for Health-Related Research Involving Humans.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in five Local Government Areas (LGAs) within Adamawa State, Northeastern Nigeria: Demsa, Jada, Mubi South, Shelleng, and Yola South. These LGAs represented diverse rural and peri-urban settings characterized by limited health infrastructure, low socioeconomic indices, and constrained access to specialized diabetes services. Each site had at least one functioning primary healthcare facility where routine diabetes screening and management were conducted. The facilities served as the main point of care for local populations, with most diabetes cases managed at the primary level before referral to secondary or tertiary centers in Yola or neighboring states.\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eA total of 25 healthcare providers participated in the study, with five participants purposively selected from each LGA. Participants included community health extension workers, nurses, midwives, laboratory technicians, and facility managers directly involved in the management or support of diabetes patients. Purposive sampling was used to ensure variation in professional background, years of experience, and facility type. Eligible participants were those with at least one year of experience in diabetes care or screening within their respective LGAs. Participation was voluntary, and all respondents provided verbal informed consent prior to interview commencement.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData collection took place between February and March 2025 using a semi-structured interview guide developed collaboratively by researchers from the American University of Nigeria and Proteus Agricultural Clinic in Iowa. The guide contained open-ended questions grouped into five sections: (1) provider background and experience, (2) role of family in diabetes self-management, (3) barriers to family support, (4) potential interventions, and (5) closing reflections.\u003c/p\u003e \u003cp\u003e Each interview lasted 30\u0026ndash;45 minutes and was conducted face-to-face in English or Hausa, depending on participant preference. Interviews were held in private spaces within healthcare facilities to ensure confidentiality. All sessions were audio-recorded with participant consent, and detailed field notes were taken to capture non-verbal cues and contextual information.\u003c/p\u003e \u003cp\u003e Interviewers followed the same introduction and consent procedures across all LGAs, explaining the study purpose, ensuring confidentiality, and reiterating the voluntary nature of participation. Participants were encouraged to share examples, local idioms, and culturally specific practices relevant to diabetes and family support.\u003c/p\u003e \u003cp\u003eAcross LGAs, providers described extensive variation in family involvement ranging from active participation in medication adherence and dietary support in Demsa and Shelleng, to limited or absent support in low-income households in Yola South and Jada. Common interview prompts explored financial barriers, gender dynamics, cultural beliefs, and community-based solutions such as involvement of religious leaders, peer-support groups, and community health workers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Management and Analysis\u003c/h2\u003e \u003cp\u003eInterviews were transcribed verbatim, and those conducted in Hausa were translated into English by bilingual research assistants to ensure the preservation of meaning and cultural nuance. All transcripts were reviewed by two independent researchers to confirm linguistic accuracy and contextual integrity. The research team conducted an inductive content analysis using a systematic, multi-step process that involved familiarization through repeated reading, open coding to identify significant statements, and categorization to group related codes into coherent clusters. These categories were then synthesized into higher-level analytic themes following established qualitative content analysis procedures. Inter-coder agreement was strengthened through iterative comparison of coded transcripts, and any discrepancies were resolved through consensus among analysts.\u003c/p\u003e \u003cp\u003eTo enhance the trustworthiness of the analysis, triangulation across the five LGAs was conducted to identify both shared and context-specific patterns. Peer debriefing sessions between team members from AUN and Proteus were used to refine code definitions and ensure analytic rigor and consistency. Representative quotes were systematically extracted to illustrate analytic interpretations in later stages of reporting. All digital data were stored securely in password-protected files accessible only to authorized members of the research team, and participants were informed that their data would be used solely for academic and policy-related purposes without any impact on their employment or facility operations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOverview\u003c/h2\u003e \u003cp\u003eA total of 25 healthcare providers were interviewed across the five Local Government Areas (LGAs) of Demsa, Jada, Mubi, Shelleng, and Yola South. Participants included community health extension workers, nurses, laboratory staff, and facility managers with direct involvement in diabetes care. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for demographic information.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\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\u003eDemographic Information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth colname=\"c1\" style=\"text-align: left;\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e\u003cth colname=\"c2\" style=\"text-align: left;\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e\u003cth colname=\"c3\" style=\"text-align: left;\"\u003e \u003cp\u003eNumber of Participants\u003c/p\u003e \u003c/th\u003e\u003cth colname=\"c4\" style=\"text-align: left;\"\u003e \u003cp\u003eYears of Experience\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd colname=\"c1\" style=\"text-align: left;\"\u003e \u003cp\u003eCommunity health workers\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c2\" style=\"text-align: left;\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e\u003ctd char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c4\" style=\"text-align: left;\"\u003e \u003cp\u003e1–10 years\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colname=\"c1\" style=\"text-align: left;\"\u003e \u003cp\u003eNurse/Midwives\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c2\" style=\"text-align: left;\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e\u003ctd char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c4\" style=\"text-align: left;\"\u003e \u003cp\u003e3–15 years\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colname=\"c1\" style=\"text-align: left;\"\u003e \u003cp\u003eLaboratory technicians\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c2\" style=\"text-align: left;\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e\u003ctd char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c4\" style=\"text-align: left;\"\u003e \u003cp\u003e2–12 years\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colname=\"c1\" style=\"text-align: left;\"\u003e \u003cp\u003eFacility managers\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c2\" style=\"text-align: left;\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e\u003ctd char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd colname=\"c4\" style=\"text-align: left;\"\u003e \u003cp\u003e5–20 years\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eThrough inductive content analysis, six overarching themes emerged, illustrating how socioeconomic, cultural, and structural conditions shape diabetes self-management and family involvement in rural Adamawa State. These themes included: (1) poverty as a central force influencing both the management and non-management of diabetes, (2) the daily struggle to maintain a healthy diet amid scarcity and competing food demands, (3) persistent knowledge gaps and the influence of traditional and biomedical belief systems, (4) the critical role of family members as frontline caregivers, (5) context-dependent experiences of stigma and neglect, and (6) fragmented healthcare and community resources that result in ad-hoc and inconsistent support for people living with diabetes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Poverty Drives (Non-) Management of Diabetes\u003c/h2\u003e \u003cp\u003eHealthcare providers consistently described poverty as the dominant factor shaping how patients and their families managed diabetes. Across all LGAs, financial hardship limited access to medications, glucose testing, and recommended diets. Respondents explained that even when families were supportive, their ability to maintain care was curtailed by economic strain.\u003c/p\u003e \u003cp\u003eA provider in Shelleng explained: “The main barriers are the cost of drugs and food. Many families can’t afford them. We refer patients, but most can’t afford travel or care at secondary facilities.” In Mubi, a respondent added: “Most diabetic foods are expensive. Patients and their families can’t buy them. Even if they know what to eat, they can’t sustain it.” Providers reported that poverty led to inconsistent adherence and reliance on “whatever food is available.”\u003c/p\u003e \u003cp\u003eSome families initially contributed but later withdrew as costs accumulated. One Demsa participant stated: “Families try, but after some time, they get tired. Diabetes doesn’t go away, and supporting a chronic condition is expensive.” Poverty thus emerged as both a clinical and social determinant, limiting choices, reducing follow-up visits, and straining family relationships.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Diet as a Daily Battleground\u003c/h2\u003e \u003cp\u003eDietary modification was viewed as a constant struggle, shaped by food insecurity, cultural norms, and taste preferences. Providers across LGAs reported that patients frequently “got tired” of eating the same foods, especially when choices were limited by cost or local availability. In Yola South, a participant observed: “A normal diabetic patient shouldn’t take sugary food. But once they are used to eating it, changing becomes a big challenge.” In Shelleng, another provider highlighted monotony and fatigue: “Even when the food is available, they get tired of eating the same thing every day.”\u003c/p\u003e \u003cp\u003eProviders described how family members often tried to enforce dietary recommendations but lacked knowledge about local substitutions. As a Mubi participant reflected: “They know the patient should avoid rice and yam, but they don’t know what else to give, so the person ends up skipping meals or eating wrong foods.” Dietary adherence was thus a “daily battleground,” requiring continuous negotiation between cost, culture, and cravings. Providers recommended locally tailored food guides and community nutrition outreach to bridge this gap.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Knowledge Gaps and Competing Belief Systems\u003c/h2\u003e \u003cp\u003eLimited health literacy and cultural interpretations of diabetes were recurrent themes. Many families associated diabetes with spiritual causation, witchcraft, or hereditary “wind illness” (“iska”), affecting their willingness to engage in biomedical care. A Mubi health worker noted: “One patient’s husband told her she could eat anything because he gave her herbs. That belief affected her recovery.” Similarly, in Demsa, a participant observed: “If only they knew what to do, when to do it, the patient’s case would not be severe. But they don’t have the knowledge or think it’s just fate.”\u003c/p\u003e \u003cp\u003eProviders reported that traditional healers and religious leaders sometimes advised patients to avoid mixing herbal and hospital treatments, leading to delayed follow-ups or medication discontinuation. Despite these challenges, several respondents emphasized that families were receptive to education when provided in Hausa or local dialects. Community education, especially through faith-based gatherings and radio, was widely suggested as a culturally appropriate strategy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Family as the Frontline Care Team\u003c/h2\u003e \u003cp\u003eHealthcare providers unanimously viewed the family as the central support system in diabetes care. Families provided transportation, purchased medications, assisted with diet control, and offered moral support. A Shelleng provider recounted: “I have a patient whose son provides the appropriate food for her and even helps with her treatment at times.” Another from Mubi shared: “My aunt was diabetic. We supported her with food and medicine. That made a real difference in her health.” However, family involvement was not uniformly positive. Providers noted cases where relatives’ ignorance, frustration, or negligence worsened outcomes. In Demsa, one participant reported: “The caregiver added sugar to the patient’s meal even when told not to. The man eventually didn’t make it. The family’s attitude mattered.” Gendered expectations also shaped support. Male patients tended to receive priority financial help, while women’s care often depended on extended family goodwill. Despite these inequities, providers viewed families as indispensable partners in sustaining long-term care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Stigma and Neglect are Context-Dependent\u003c/h2\u003e \u003cp\u003eExperiences of stigma varied significantly across the five LGAs. In some communities, diabetes was seen as a manageable chronic disease; in others, it carried shame or misinterpretation as a contagious or morally linked illness. A Shelleng participant described one case: “One of my patients avoids church due to frequent urination. She sometimes soils herself and finds it hard to socialize.” Conversely, a Yola South respondent asserted that diabetes “is not stigmatized because people know it’s not contagious”.\u003c/p\u003e \u003cp\u003eProviders in Mubi and Demsa recounted incidents where family members distanced themselves or even sought divorce due to the patient’s perceived weakness or reduced productivity. One health worker shared: “A man’s wife asked for a divorce because he was no longer sexually active. That’s stigma within the home.” These accounts illustrated that stigma was context-dependent, influenced by local knowledge, gender expectations, and cultural framing of chronic illness. Providers emphasized community sensitization as critical to dispelling misconceptions and fostering empathy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6: Fragmented Resources and Ad-Hoc Community Support\u003c/h2\u003e \u003cp\u003eThe interviews revealed that community-level support for diabetes was sporadic and unsystematic. While occasional donations or outreach programs occurred, providers noted the absence of structured community resources or sustained interventions. A Shelleng respondent explained: “Sometimes groups donate supplies, but it’s not regular or organized. They help for a time, then stop.” Others highlighted one-off initiatives led by traditional leaders: “The Emir organized free testing and awareness with community heads and health workers. Many discovered their status, that helped.”\u003c/p\u003e \u003cp\u003eIn most LGAs, religious organizations, local elites, or NGOs occasionally covered drug costs or supported awareness programs. However, respondents agreed these efforts were “ad hoc,” driven by individual goodwill rather than institutionalized policy. As one Demsa provider concluded: “There are no formal community resources. Only individuals, churches or rich people, help once in a while.” Providers called for the creation of sustained multi-sectoral partnerships, including health authorities, local councils, and faith groups, to institutionalize diabetes outreach and medication support at the community level.\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion and Implications","content":"\u003cp\u003eThis study provided in-depth insight into how healthcare providers in five Local Government Areas of Adamawa State, Demsa, Jada, Mubi, Shelleng, and Yola South, understood the role of family support in diabetes self-management. Providers portrayed families as the frontline caregivers, yet described how poverty, food insecurity, limited knowledge, stigma, and fragmented community resources profoundly constrained self-management in rural Nigeria. Despite these barriers, providers articulated clear, pragmatic recommendations for strengthening family-inclusive care through education, economic support, and community partnerships.\u003c/p\u003e\u003cp\u003eConsistent with prior Nigerian and regional evidence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], poverty emerged as the most pervasive barrier to diabetes management. Providers’ observations that high costs of medications, diagnostic tests, and transportation discouraged follow-up were congruent with national analyses showing that over 80% of Nigerians paid out-of-pocket for diabetes care [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similar patterns had been reported across sub-Saharan Africa, where Kibirige et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] found insulin and oral hypoglycemics to be both scarce and unaffordable in primary-care pharmacies. Rising food prices and insecurity further compounded this challenge. These financial pressures explained why families often supported patients intermittently, helping initially but withdrawing as resources depleted.\u003c/p\u003e\u003cp\u003eDietary management represented an equally formidable obstacle. Providers’ accounts of patients’ fatigue with repetitive diets and difficulty affording protein-rich or low-glycemic foods echoed findings from Kumah et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and Wilson et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], who noted that adherence to dietary prescriptions was lowest among rural African patients facing food insecurity. In Nigeria, the cultural centrality of carbohydrate-based staples such as rice and yam complicated efforts to maintain recommended meal patterns [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These parallels highlighted the need for culturally tailored nutrition counseling using locally available foods, a gap that remains largely unaddressed in current diabetes education curricula.\u003c/p\u003e\u003cp\u003eKnowledge deficits and competing belief systems also influenced care. Many families, as providers described, interpreted diabetes through spiritual or traditional frameworks and alternated between herbal and hospital treatments. This finding aligned with Ekpor et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and Aina et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] who documented widespread reliance on traditional medicine among Nigerians with chronic illness and a belief that combining herbs and pharmaceuticals was dangerous. Studies by Iregbu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Ogunlana et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] likewise emphasized that health professionals must integrate cultural understanding and communication skills into diabetes counseling. Providers in this study mirrored that view, suggesting that bilingual health education and collaboration with traditional and religious leaders could enhance family comprehension and acceptance of biomedical advice.\u003c/p\u003e\u003cp\u003eFamily members were repeatedly described as indispensable to diabetes self-management. They financed medications, supervised diets, accompanied patients to clinics, and provided emotional support. These insights aligned with Ojewale et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and Baig et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], who demonstrated that family involvement improved adherence, glucose control, and quality of life among adults with type 2 diabetes. Yet, as providers in Adamawa noted, the same family systems could create friction when relatives became frustrated or when gender hierarchies limited caregiving for women. Such duality has been widely reported across African contexts, where both positive and negative family dynamics directly influence treatment adherence [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe variability of stigma and neglect observed across LGAs reflected how sociocultural interpretation determined community response to chronic illness. In some areas, diabetes was viewed as a manageable condition; in others, it carried embarrassment or social isolation, especially when symptoms, such as frequent urination or weight loss, resembled those of HIV. Comparable findings have been reported in Ghana and Kenya, where stigma toward non-communicable diseases emerged from confusion with infectious conditions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In the Adamawa context, stigma was often internal to families, manifesting as shame, spousal conflict, or withdrawal of support. Providers’ accounts underscored the importance of sensitization programs to reframe diabetes as a chronic but controllable disease.\u003c/p\u003e\u003cp\u003eEqually significant was the description of fragmented and ad-hoc community support. Providers explained that interventions from religious or traditional leaders, local elites, or NGOs were sporadic and unsustained, findings that echoed Ajisegiri et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], who reported similar gaps in Nigeria’s community health-worker networks for non-communicable diseases. While isolated outreach programs, such as free testing days organized by traditional rulers, raised awareness, they lacked the continuity necessary for long-term impact. The absence of a structured community-based diabetes program limited opportunities for sustained family and patient engagement.\u003c/p\u003e\u003cp\u003eTaken together, these findings underscored how diabetes care in rural Nigeria was shaped by intersecting social, cultural, and structural determinants. The results reinforced that family-centered care could not succeed without addressing economic barriers and strengthening the primary healthcare (PHC) system. The perspectives of Adamawa providers closely paralleled emerging African evidence supporting culturally tailored, family-inclusive diabetes self-management education (DSMES) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. DSMES interventions that integrated caregivers and community health workers have demonstrated moderate reductions in HbA1c and improved adherence when adapted to local contexts [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e–\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFrom a policy standpoint, these findings highlighted the need for multi-level strategies that combined affordability measures, family engagement, and community mobilization. Providers’ recommendations to organize “caregiver days,” implement free drug programs, and embed diabetes education within religious and community platforms were consistent with the World Healthcare Organization and IDF guidance promoting health-literacy and family participation at the primary-care level [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Strengthening CHW-led household follow-ups could operationalize this model by bridging the gap between clinic-based advice and home-based practices. At the same time, medicine price-control policies and food-voucher programs could alleviate financial strain and enable families to adhere to treatment.\u003c/p\u003e\u003cp\u003eIn practical terms, this study suggested that brief, structured family-education sessions during PHC visits could improve knowledge and reduce misinformation. Incorporating CHWs into follow-up visits could further enhance adherence and provide opportunities for culturally appropriate counseling at the household level. Collaboration with religious and traditional leaders could amplify health messages and counteract harmful beliefs about diabetes causation and treatment. Finally, the integration of diabetes and nutrition support into existing community programs, such as maternal health or immunization days, could extend reach without additional infrastructure.\u003c/p\u003e\u003cp\u003eOverall, the findings reinforced the need to move beyond individual-centered care toward family- and community-anchored strategies. Addressing poverty, enhancing affordability, and building sustainable local support systems are indispensable for improving diabetes outcomes in rural Northern Nigeria. When families are empowered with knowledge and economic stability, and when communities were mobilized to sustain support, diabetes self-management becomes more feasible and effective [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. These insights align with a growing body of African research demonstrating that culturally responsive, family-inclusive approaches are both practical and impactful in low-resource contexts [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn conclusion, healthcare providers in this study illuminated the realities of delivering diabetes care in resource-limited settings where family networks, cultural beliefs, and poverty intersect. Their perspectives offered a grounded framework for designing interventions that place families, not individuals, at the center of diabetes management. Future implementation research should evaluate the effectiveness and cost-efficiency of family-inclusive DSME models integrated within Nigeria’s PHC system, with particular attention to how such models can be scaled sustainably across rural regions.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eCompeting Interests\u003c/strong\u003e \u003cp\u003eThe authors declare that there are no financial or non-financial competing interests directly or indirectly related to this work.\u003c/p\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003e Ethical approval for this study was obtained from the American University of Nigeria Institutional Review Board (Protocol PRO-13-11-24; Approval Code AUN-05-02-25). All study procedures were conducted in accordance with the approved IRB protocol and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and the Council for International Organizations of Medical Sciences International Ethical Guidelines for Health-Related Research Involving Humans.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Participate\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all participants prior to data collection. Participants were informed of the study purpose, procedures, voluntary nature of participation, and their right to withdraw at any time without penalty.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication\u003c/strong\u003e \u003cp\u003eAll participants provided informed consent for the use of anonymized data in publications and presentations resulting from this study. No identifying information is included in the manuscript.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo external funding was received for the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJAR (Jimmy A. Reyes) conceptualized the study, led the development of the study design, coordinated international team collaboration, conducted qualitative data analysis, interpreted the findings, and was the lead writer of the manuscript.JT (Jennifer Tyndall) contributed to refining the study methodology, supported data interpretation, drafted sections of the results and discussion, and provided substantial revisions to the manuscript.RS (Roland Stephen), VI (Victory Inyang) contributed to study conceptualization, guided the analytic framework, provided critical review of the analysis, and contributed to editing and strengthening the manuscript's theoretical and policy sections.LD (Lucy Damasane) provided expertise in community-based health systems, supported interpretation of findings within the African public health context, and contributed to manuscript drafting and revisions.SK (Sophia Kalomeris) contributed to the interpretation of global health implications and provided critical revisions to the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThis study is based on qualitative data that include participant interviews transcripts containing potentially identifiable information. In accordance with ethical approval requirements and to protect participant confidentiality, the full qualitative datasets are not publicly available. De-identified excerpts relevant to the study findings are included within the manuscript. Additional de-identified data may be made available from the corresponding author upon reasonable request and with permission from the institutional review board.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOgbera AO, Ekpebegh C. Diabetes mellitus in Nigeria: The past, present and future. 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The design, usability, and feasibility of a family-focused diabetes self-care support mHealth intervention for diverse, low-income adults with type 2 diabetes. \u003cem\u003eJournal of Diabetes Research, 2016\u003c/em\u003e, 7586385. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2016/7586385\u003c/span\u003e\u003cspan address=\"10.1155/2016/7586385\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgeru, T. A., Le, C. N., Wattanapisit, A., Woticha, E. W., Truong, N. T., Stanikzai,M. H., \u0026hellip; Beran, D. (2024). Diabetes self-care intervention strategies in Sub-Saharan Africa: A systematic review. PLOS ONE, 19(5), e0305860. https://doi.org/10.1371/journal.pone.0305860.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Nigeria, diabetes self-management, family support, qualitative research, primary healthcare, rural health","lastPublishedDoi":"10.21203/rs.3.rs-8565281/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8565281/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDiabetes mellitus is rapidly increasing across low- and middle-income countries, yet rural communities face persistent inequities in chronic disease care. In Northeastern Nigeria, family members often provide essential support for diabetes self-management, but their role is influenced by poverty, cultural beliefs, and fragmented primary healthcare systems. This study examined healthcare providers\u0026rsquo; perspectives on how family dynamics, socioeconomic conditions, and community resources shape diabetes care in rural Adamawa State. A descriptive qualitative design was used across five Local Government Areas. Twenty-five healthcare providers were purposively sampled based on their direct involvement in diabetes care. Semi-structured interviews were conducted in English or Hausa, audio-recorded, transcribed, and analyzed through inductive content analysis with triangulation across sites. Six themes emerged. Providers emphasized that poverty constrained access to medications, glucose monitoring, and recommended diets. Food insecurity and limited local substitutions made dietary adherence challenging. Knowledge gaps, spiritual interpretations of disease, and reliance on herbal treatments influenced care-seeking behaviors. Families served as frontline caregivers, assisting with transportation, food preparation, and medication adherence, although their capacity varied. Stigma and neglect were context-dependent, shaped by gender norms and misconceptions. Community support was described as sporadic and dependent on individual or religious leaders rather than structured systems. Diabetes care in rural Nigeria is shaped by intertwined socioeconomic, cultural, and structural determinants. Strengthening primary care platforms with family-centered diabetes education, culturally tailored outreach, community led home support, and affordability measures could reduce inequities and enhance self-management. Policies that institutionalize sustained community partnerships are essential for improving outcomes in low-resource settings.\u003c/p\u003e","manuscriptTitle":"Provider perspectives on family support in diabetes self management in rural Adamawa Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 14:41:27","doi":"10.21203/rs.3.rs-8565281/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":"407c942f-9fb4-4b05-820a-bb8bcadff973","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:58:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 14:41:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8565281","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8565281","identity":"rs-8565281","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}