Challenges In Ensuring Long-Term Care For Individuals Living With Diabetes: A Qualitative Study

Challenges In Ensuring Long-Term Care For Individuals Living With Diabetes: A Qualitative Study | 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 Challenges In Ensuring Long-Term Care For Individuals Living With Diabetes: A Qualitative Study Raziyeh Iloonkashkooli, Giti Setoodeh, Mitra soltanian, Marzieh Momennasab, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6689333/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2025 Read the published version in Journal of Diabetes & Metabolic Disorders → Version 1 posted You are reading this latest preprint version Abstract Aim: Investigating Challenges in Providing Lifelong Care for People with diabetes to Design Comprehensive Long-Term Care Programs at Shahid Dr. Beheshti Clinic, Shiraz, Iran Method : Conduct interviews with a diverse group of 18 individuals, including patients, their families, and the hospital care team, utilizing a purposeful sampling approach, followed by qualitative content analysis. Results: Three overarching themes emerged: (1) Erratic Adherence to Self-Care, (2) Ineffective Family Support Throughout the Diabetic Journey, and (3) Deficiencies in Supportive Organizations. These challenges were further categorized into six distinct areas: Dysfunctional Attitudes, Lack of Awareness and Skills, Mental Health Deviations, Neglect in Family Education, Psychosocial Challenges in Family Caregiving, and Issues in Sustaining Human Resources and Infrastructure. Based on the prevailing conditions, solutions were proposed within the framework of a long-term diabetes care program to effectively address these challenges. Conclusion: The findings of the present study highlight significant challenges faced by people with diabetes, their families, and care-providing organizations in delivering long-term care. Consequently, all three groups require structured support to effectively fulfill their caregiving responsibilities. Diabetes Mellitus Patients Long-Term Care challenges Qualitative research Figures Figure 1 1: Introduction diabetes mellitus is a major health concern worldwide. In 2024, an estimated 589 million adults aged 20–79 years were living with diabetes, accounting for 11.1% of the global population in this age group. The prevalence of diabetes is projected to rise, with the number of affected adults expected to reach 853 million (13%) by 2050. It is estimated that 252 million adults with diabetes remain undiagnosed. Additionally, over USD 1 trillion was spent on diabetes management in 2024, representing 12% of global health expenditure. Alarmingly, more than 3.4 million individuals succumbed to diabetes-related causes in the same year, accounting for 9.3% of global mortality from all causes( 1 ).In Iran, according to the latest official statistics, more than 5 million individuals are afflicted with diabetes, and 8 million are at risk of developing the disease( 1 , 2 ).it is estimated that the annual growth rate of diabetes in Iran until 2030 will rank second in the region, following Pakistan( 3 ). The rising prevalence of diabetes, alongside its associated healthcare costs and mortality rates, underscores an undeniable reality: establishing equitable and implementable healthcare systems and clinical practices across countries with diverse conditions remains a formidable and persistent challenge in global health( 4 ). the complexity and time-intensive nature of diabetes management, effective care and long-term planning are crucial for achieving positive clinical outcomes( 5 , 6 ). When designing chronic disease management programs, it is essential to consider planning for continuous care and support of patients suffering from these conditions, while minimizing care costs for families and caregiving organizations. This is particularly critical in low- and middle-income countries with a disproportionate focus on disease treatment rather than comprehensive care. Chronic diseases require continuous, high-quality care to ensure their long-term management and enhance the affected patients' quality of life( 7 ). the World Health Organization defines long-term care as all health caregiver activities for individuals at risk or with risk factors, aimed at enhancing functional capabilities, independent living, and quality of life. It emphasizes that these caregiving activities should align with universal rights, freedoms, dignity, and human status( 8 , 9 ). Long-term care varies from country to country, and terms such as continuous care, sustainable care, comprehensive long-term care, or home-based follow-up care may represent the fundamental concept of long-term care in different countries( 10 ).Nevertheless, long-term care is an integral component of healthcare and social systems, and the type of long-term care required is influenced by factors such as disease and the resources and conditions of different societies( 11 ). Health system policymakers understand that diabetes management occurs within the framework of long-term support and follow-up care, necessitating the development of local care programs at healthcare service delivery centers( 12 ). The increasing prevalence of diabetes in Iran places a significant responsibility on health policymakers and professionals across various domains, including economists, physicians, and nurses, to address this issue effectively( 13 , 14 ).Although the national diabetes prevention and control program of the Ministry of Health aims to implement early detection, appropriate treatment, care, and management of diabetes-related complications in the country, and the healthcare system transformation plan has proven effective in diabetes control, we still witness individuals unaware of their diabetes condition or suffering from severe and chronic diabetes complications, imposing high costs on the healthcare system( 4 , 15 ). The Social Security Organization bears a significant portion of the expenses incurred by these patients, and insured individuals under this organization, comprising more than half of Iran's population, receive free medical and healthcare services at hospitals and treatment centers affiliated with this organization( 16 ). The challenges of long-term care for People with diabetes vary across different contexts and are influenced by factors such as the cultural, social, and economic backgrounds of care recipients, their lifestyles, organizational factors, available resources, limitations, evolving care conditions, and responses to the emergence of widespread and novel diseases. This qualitative study was conducted to examine the specific challenges in long-term care for People with diabetes attending Shahid Dr. Beheshti Clinic in Shiraz, with the ultimate goal of designing and implementing a tailored long-term diabetes care program. 2: methods 2.1. Study design This study employed a qualitative research methodology, utilizing semi-structured in-depth interviews to examine participants' perceptions of diabetes long-term care existing challenges (DLTCEC) at Shahid Dr. Beheshti Clinic. Participants included professional caregivers, managerial staff at the clinic, individuals with diabetes, and their families. The data collected were analyzed through a qualitative content analysis approach, ensuring a comprehensive and systematic investigation of the topic. 2.2. Recruitment After identifying participants through purposive and criterion-based sampling methods, the study objectives, interview procedures, and timing and location were explained to them. Upon their acceptance to participate in the study, the participants completed informed consent forms. Data collection was carried out through semi-structured individual and group interviews, with ethical considerations considered. The researcher proceeded to select participants with maximum diversity (i.e., various groups with experience in diabetes diagnosis, care, and treatment) who could share their experiences and serve as key informants (individuals with sufficient insight into the study topic) capable of engaging in interaction and providing rich and valuable information to the researcher. 2.3. Informants For face-to-face interviews with internal medicine specialists, general physicians, nutritionists, and clinical psychologists, appointments were made in advance and interviews were conducted in their respective offices upon request. Interviews with experienced nurses in diabetes care, patients, and their families took place in a quiet room within Shahid Dr. Beheshti Clinic. Additionally, two group interviews were conducted: one involving nurses, hospital and clinic managers, and general Physician; and the other including individuals with diabetes and their families. Furthermore, one interview session with a patient's family was conducted via video call. Two interview sessions were held with different participants. Each interview session lasted between 25 to 80 minutes.َ 2.4. Data collection The research setting was Shahid Dr. Beheshti Clinic in Shiraz. IRAN. The research participants include People with diabetes and their families, general physician and internal medicine specialists, nurses, nutritionists, wound care specialists, psychologists, and hospital administrators and policymakers of Shahid Dr. Beheshti Clinic, who participated in the study through purposive sampling method. The inclusion criteria for participants in the study, in addition to their willingness to participate and engage in interviews, are outlined in different groups as presented in Table 1. Table 1: The inclusion criteria for participants from various groups Participants Inclusion criteria People with diabetes and their families · Diagnosis of type 1 or type 2 diabetes mellitus with a minimum of 6 months elapsed since diagnosis. · Family members living with the People with diabetes who can collaborate in the patient's care. physicians Internal medicine or endocrinology specialists and General Physicians with at least 1 year of work experience at Shahid Dr. Beheshti Clinic. nurses · Holding a bachelor's degree or higher · A minimum of one year of professional experience in internal medicine or emergency departments, attributed to their experience in providing care for individuals with diabetes. nutritionists and psychologists A minimum of one year of professional experience working with individuals diagnosed with diabetes. Wound care specialists Minimum of two years of experience in treating diabetic wounds hospital administrators and policymakers At least one year of experience in their current role Exit criteria included unwillingness to continue participation in the research. 2.4.1. Interview guide The questions posed to various individuals differed, with some general inquiries encompassing the following topics: 1. What are the current challenges in providing long-term care for patients with diabetes? How can long-term care for People with diabetes be effectively implemented? Please elaborate. 2. What structures are necessary for long-term care of People with diabetes? 3. What obstacles exist for long-term care of People with diabetes at Shahid Dr. Beheshti Clinic? 4. Describe what your care needs and challenges have been in the past six months. how you met your needs? (People with diabetes) Then, with further questioning, efforts were made to understand their perception of long-term care in diabetes, which was collected and analyzed. Interview enhancement techniques such as probing, providing examples, describing, asking exploratory questions, summarizing interviewee statements, active listening, and reflecting on their speech were used to improve the interview process. 2.5. Data analysis The process of interviewing and analyzing data was conducted simultaneously, utilizing both manifest and latent content analysis methods. Adhering to Graneheim and Lundman approach. the analysis was non-linear, involving iterative back-and-forth movements between the original text and related segments. Initially, the text was read multiple times to deeply engage the researcher and achieve a comprehensive understanding. Following this, the analysis unit was identified by comparing the interview texts. The text was then segmented into semantic units and summarized, with codes assigned accordingly. These codes were compared based on their differences and similarities, resulting in the formation of subcategories and categories. These categories were then discussed and refined by the researchers until a consensus was reached regarding their classification(17).Finally, the fundamental meanings represented by the content of the categories were synthesized into indexes. For data analysis, MAXQDA software version 2020 was used. 2.6. Ethical consideration As part of the initial phase of this doctoral dissertation, a comprehensive exploration of the challenges in long-term care for individuals with diabetes was meticulously conducted through a qualitative study at Shahid Dr. Beheshti Clinic. Ethical considerations were rigorously observed throughout the research process. Informed consent was obtained from all participants to ensure voluntary participation. Confidentiality and anonymity were strictly upheld during data collection, analysis, and reporting. The study adhered to the ethical principles and guidelines outlined by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1401.045), and official authorization to conduct the research was duly granted. 3: results The final interview sample included 18 participants, (10 health provider and policymakers in Shahid Beheshti Hospital, with 16.7±4.9 years of Work Experience in this setting and position, 7 persons living with diabetes and their families 43.86±13.96 years ). The characteristics of the participants are presented in Table 2. Insured patients, due to their insurance coverage, have historically received free healthcare services at Shahid Beheshti clinic and hospital. Their minimum literacy level was the ability to read and write. healthcare caregivers and managers admitted that patients should not incur any costs for treatment and care at this facility. In the content analysis, 1,097 open codes were categorized into three themes, six categories, and 14 subcategories, along with 65 initial codes, which are schematically presented in Fig. 1. Table 2: Demographic Characteristics, Roles, and Professional Backgrounds of Participants in This Study participants / number of them code age (y) and gender work experience (y) in-depth interviews focus groups Clinic And Hospital Managers/ 2 P1 51 / male 18 2 1 (6 participants) P2 44 / male 15 Nurse / 4 P3 43 / female 18 4 P4 32 / female 7 P5 42 / male 17 P6 31 / female 8 General Physician /1 P7 53 / male 21 1 Clinical Psychologist 1 P8 49 / female 20 1 Nutritionist/1 P9 46 / female 18 1 Wound Specialist/1 P10 43 / male 18 2 Internal Medicine Specialist /1 P11 56 / male 24 1 Persons Living With Diabetes /4 P12 67 / female Diabetes duration 5 1 (5 participants) 15 years P13 44 / female 6 years P14 59 / male 10 years P15 47 / male 13 years Family Members Of People With Diabetes /3 P16 32/female job 4 self-employment P17 27 / female kindergarten trainer P18 31 / male shopkeeper 1. Erratic Self-Care Adherence In the analysis of challenges associated with providing long-term care for individuals living with diabetes, one of the prominent themes identified was 'erratic self-care adherence,' emphasizing the necessity of enhancing patient awareness, attitudes, and skills. Another crucial dimension of this theme was 'deviation from mental well-being,' which is further elaborated within each subcategory. 1.1. Dysfunctional Attitudes, lack of awareness and skills Three underlying issues contribute to this categories: Insufficient patient understanding of diabetes and its complications, ineffective patient attitudes towards the disease, and Deficiency in self-care proficiency. 1.1.1. Insufficient Patient Understanding Of Diabetes And Its Complications All participants, including healthcare providers, hospital managers, health policymakers, patients, and their families, highlighted the patients' lack of awareness about diabetes and its complications. In this subcategory, initial codes included patients' unawareness of diabetes concepts, ignorance of the causes and risk factors of diabetes, inadequate recognition of hypoglycemia and hyperglycemia symptoms, patients' lack of knowledge about diabetes management, incomplete awareness of diabetes complications, and ignorance about comorbidities associated with diabetes. In this regard, we refer to some participant's statements: " Diabetes is ultimately a hereditary condition; I inherited it from my father, so there's nothing I can do about it ... ” (P13) " I'm well aware I shouldn't consume sugar, sweets, rice, and potatoes, but my sugar levels spike due to stress even when I eat nothing, it still shoots up... They say it affects my feet, my kidneys..." (P14)(Focus Group 1) “Our patients really don't know what diabetes is? What trouble they bring upon themselves when they don't control it? You ask them, 'Are you managing your diabetes?' They say, 'Yes, we're taking pills.' Then you ask about their sugar levels. They say, 'We don't know, we haven't checked...” (P3) 1.1.2. Ineffective patient attitude towards the diabetes In this study, ineffective patient attitudes have been identified as one of the underlying factors contributing to long-term Careless behaviors and self-care deficiencies . initial codes within this subcategory include patient resistance to insulin initiation, non-adherence to dietary and therapeutic regimens, misperceptions regarding the impact of exercise and diet on diabetes control, skepticism towards smoking cessation, disbelief in the need for regular blood pressure and glucose monitoring, and irrational beliefs regarding the use of herbal remedies instead of prescribed medications. Health caregivers believed that it is necessary for patients to share common beliefs with the treatment team, and having shared mental beliefs contributes to the sustainability of care. Some statements from the participants are provided below: " What's the point of taking all these pills? When I see no benefit, I just say, 'Well, forget it. " (P4) "The patient has yet to believe in the helpfulness of quitting smoking, and we know that it's no longer just about managing diabetes; rather, with diabetes patients, we're contending with a set of misconceptions." (P11) "I'm very active both at home and outside, don't have time for exercise, and my back hurts, but despite all this, my blood sugar doesn't decrease." (P12) (Focus Group 1) 1.1.3. Deficiency in self-care proficiency In this study, the insufficient behavioral skills of People with diabetes include inadequate skills in blood sugar and blood pressure monitoring, difficulties in adjusting the dosage and administration of insulin, poor performance in physical exercise, lack of skill in recording blood sugar and blood pressure levels with date and time, and the absence of foot examination skills. Some of the participants' comments are as follows: "I go to the clinic to check my blood sugar. I have a device, but there's no one to check it for me, and I can't do it myself..."(P15) " When they come to us, we have no idea how they've been taking care of themselves during this time. We can only check their HbA1c and blood pressure. It would be great if we could teach them how to record their blood sugar and blood pressure with the date and even the time, and bring that information to us ." (P7) "I see it myself among the patients; none of them know how to perform a proper foot examination."(P10) 1.2 . Mental health deviation Healthcare providers, policymakers, and care managers in the research environment and patients' families considered deviations from mental health to be inevitable in patients living with diabetes. They identified varying degrees of mental health deviations in all patients, as evidenced by ineffective psychological reactions. They also believed that weak social support exacerbates mental health deviations and that a strong social support network is a cornerstone of long-term care. Mental health deviations lead to disruptions in self-care. The components of this category include: 1.2.1. Inefficient psycho-emotional reactions The initial codes derived from analyzing the participants' comments included fear and anxiety, aggressive behavior in People with diabetes, fatigue from treatment, abandoning medication and diet regimens, noncompliance with medical advice, psychological dependence on family for care, and patients' feelings of helplessness in coping with the disease. These were categorized under ineffective psychological reactions. Let's address some of the participant's comments: "When someone is told they have diabetes, they are initially scared and usually listen to the nurse and doctor, wanting to follow the advice. However, sometimes they get tired and frustrated, which can lead to aggressive behavior towards themselves or those around them."(P5) "My dad knows he needs to take his pill at a certain time, and I remind him beforehand. But then I see that a couple of hours have passed, and he hasn’t taken it. I ask him, 'Dad, why didn’t you take your pill?' and he says, 'You didn't give it to me..."(P17) "There have been times when I got tired and stopped taking my medications for a few days."(P 15) "How long do we have to keep taking these medications? Will it ever be cured? It gets exhausting..."(P13) 1.2.2. Poor Social Support Social support was a concept that all participants pointed to as a challenge in long-term care. Inadequate family support for People with diabetes, deficiencies in the care provider organization's support system, lack of peer support networks, and absence of friend support networks were the initial codes in this subcategory. Below are some examples of participants' remarks during the interviews. "My children have their own challenges; they can't always focus on me. Sometimes, they just give me a call."(P12) "When I see he's not listening to me, I say, 'Well, forget it, why bother repeating myself if he won't listen anyway?"(P16) "If there could be some gatherings where patients share their experiences, sometimes good solutions might emerge from them. They may not listen to us, but they listen better to each other” (P18) "I believe it's unjust to expect a patient to bear the burden of illness alone over an extended period. We all need to, in some way, stand by them."(P8) 2. Ineffective Family Support Across the Diabetic Journey The underlying theme in analyzing the statements of healthcare providers, health policymakers, and family members is evident. Through the discussions of family members of People with diabetes, we realized that long-term support from diabetic families towards the components of care is a challenge in long-term diabetes care. Family support for patients with diabetes encompasses broader dimensions, primarily focusing on educational and psychological support, which become clearer under each dimension. 2.1. Neglect in Educating Families One of the challenges in providing long-term care for individuals living with diabetes is the effective education of families to ensure their acceptance and support of these individuals. It is essential for the families of people living with diabetes to deepen their knowledge and understanding of their diabetic family members' condition. Even the family members themselves have acknowledged the importance of comprehending diabetes care.The subcategories of educational support include the following: 2.1.1. Family inadequate knowledge in diabetes prevention and care The challenge for family educational support stemmed from their lack of awareness about diabetes, as noted by participants, encompassing: inadequate family comprehension of diabetes, limited knowledge among family members regarding symptoms of high and low blood sugar, insufficient understanding within families about emergency condition management in patients, and incomplete awareness among family members about the complications of diabetes. Here, some participant statements are provided as examples of the extracted initial codes. Participants, including healthcare providers and health policymakers, believed that the families of People with diabetes are at risk of diabetes themselves and require preventive education for long-term care. This includes training on identifying risk factors within families, recognizing unhealthy eating habits in diabetic families, and the need for lifestyle changes. Some statements from the participants: "We need to understand the eating habits of the entire family. To ensure that a diabetic individual adheres to their diet in the long term, we must educate their family to improve their eating habits and even their lifestyle." (P9) "Individuals living with someone with diabetes should have sufficient understanding of the condition…….Family members should be educated on the signs of high and low blood sugar and the conditions under which blood sugar levels can fluctuate."(P8) " The doctor had told my sister that if she had arrived at the hospital ten minutes later, her death would have been inevitable. My mother had slipped into a coma, her condition was critical, but we didn't realize it. She was just sleeping all the time, and we thought she was tired from catching a cold, whereas later we found out that even a simple cold should be taken seriously in diabetic " (P17) “My father was experiencing nausea and vomiting, and he had lost his appetite. Even though I reduced his pills, I don't know why his blood sugar spiked." (P18 ) 2.1.2. Family's unawareness of their supportive role Data analysis revealed that families of People with diabetes are not sufficiently aware of their supportive role. This finding is extracted from the following codes. Lack of family awareness about the psychological and emotional needs of patients, misperception of patients' care needs by families, and inadequate understanding of their role in diabetes management among family members. “ Families are unaware that diabetes can lead to depression, stress, and long-term complications, and they don't know how to support their diabetic family members to prevent their condition from worsening day by day. Without the knowledge and ability to assist the individual in controlling their illness, they are unaware of how to provide care, ultimately resulting in complications that affect the entire family." (P8) "If they want to provide long-term support to their loved ones, they need to learn how to interact with them effectively. Families often underestimate their potential to be strong advocates for their patients."(P3) "I really don't know how to be there for him... Sometimes I wonder what I should do for him? How can I help him be more mindful of himself? His relationship with us isn't the same as before. (P18) 2.2. Family Psychosocial challenges in Caregiving Families of People with diabetes take on the burden of caregiving and Psychological support for families of them is crucial in long-term care to ensure effective diabetes management and to mitigate the emotional stress associated with the chronic nature of the disease. The issue of caregivers caring in chronic illnesses is another aspect of long-term care(18, 19). 2.2.1. Family Care Burden In this study, based on the analysis of participants' statements, when long-term care is provided by the family, an imbalance is observed between caregiving demands and the support available for family caregivers. These individuals bear the burden of care, which encompasses the following dimensions: An imbalance between the family members' social roles and the patient's care needs, Presence of stress and fear in family members regarding patient care, Low resilience of family members in caregiving, Fatigue and burnout of family caregivers, Poor family skills in adapting to the illness and Patient's dependence on family for care and treatment. “ It's important to assist families in learning how to care for their patients long-term, even when they are not living together. However, if we expect them to engage more than they are capable of, they might become exhausted and it could lead to difficulties”. (p8) “I tell my dad to get up and go to the clinic himself. I even made an appointment for him, but he refuses to go alone. So, I have to take time off work. Sometimes I wonder what my parents would do if, for any reason, I had to leave this house. Interestingly, both of them say that I am their only concern”. (p17) 2.2.2. Decline of Family Psychological Well-being The term "psychological well-being" is defined as feeling good, living in a rich environment, being valuable to the world, mastering life, and enjoying life. It refers to the quality of one's experienced life(20).The following codes, derived from participants' statements, indicate a decline in the psychological well-being of the family. Conflicts among family members regarding care and treatment, ineffective interpersonal relationships between the patient and the family, and weak social support for family members. Examples of participants' statements: “I'm just one person; I have my own work and life. How long can I take care of them? I get tired too. Sometimes I wish there was someone else beside me."(P16) "I think the respect for our patient in the family is much more important than the treatment. Imagine at a gathering, even at a party, the patient's child yells from across the table, 'Mom, don't drink that soda!' What reaction do you expect from the patient? They'll feel upset, get angry, and if they didn't want to drink it before, now they will."(P8) “ I tell my sister, 'You know Mom has kidney issues and high blood pressure, so why do you make your food so salty?' She doesn't get it. Can you believe she even brings sweets home and offers them to Mom? It makes me so frustrated.” (P18) (Focus Group 1) 3.Deficiencies in Supportive Organizations The analysis of participant interviews revealed another challenge in the long-term care of individuals living with diabetes: deficiencies in supportive organizations. To ensure optimal care for patients over the years, the organization must have adequate human resources and provide sufficient support for them. Additionally, it should possess appropriate physical resources, which will be further elaborated in the following sections. 3.1. Ensuring ongoing human resources The participants referred to human resources as health specialists, program managers, and the service delivery team, including coordinators who connect these individuals with patients. The hiring and retention of these professionals, and aligning them with the values of a long-term diabetes care organization, fall under the category of human resources provision . 3.1.1. Perpetual Presence The Comprehensive Care Team All participants, especially the therapists, agreed on the importance of having skilled and experienced specialists and experts in the care-providing organization. They considered the most crucial person in care coordination to be an "experienced and trained nurse." Patients and their families complained about the difficulty of getting appointments and referrals outside the clinic. In the analysis, the following codes have been extracted and categorized under this subcategory. Requirement for Multidisciplinary Medical Teams in Diabetes Control, unavailability of Counselors or Psychologists, Absence of Wound Care Specialists, Requirement for a Nutrition Specialist, Shortage of Follow-up Nurses, Need for Patient Referral to External Specialists, Absence of a Convenient Appointment Scheduling System for Medical Visits, and Challenges in Accessing Exercise Specialists. Some of the participants' statements in this domain: “Everyone needs to work together. A patient who comes here cannot be treated by just a nurse or a general practitioner. They need, for example, their retina checked every few months, their kidney condition monitored, mental health evaluated, and all other aspects that you are aware of..."(P7) "I think a physiotherapist or a sports specialist should practically teach them how to exercise. Some people might have skeletal or mobility issues, and merely recommending exercise might not be enough.”(P10) "We have an ophthalmologist here, but they don't conduct eye examinations for patients with diabetes. They advise them to go to another center. They can't continue to refer them like this indefinitely." (P11) "We can even make contracts with several good doctors outside, who actually also treat patients with diabetes..."( P1) 3.1.2. Support for the Care and Treatment Team For human resources to remain engaged in a diabetes clinic or care center in the long term and provide continuous and sustained care for individuals living with diabetes, it is necessary for the organization to support and back its staff. In this way, the center itself will continue its work indefinitely. This subcategory has been extracted from the following codes. Financial Support Challenges for the Care and Treatment Team, Educational Needs of Each Specialized Team Member in Their Individual Duties, Achieving Satisfaction Among Team Members, and Team's Need for Receiving Feedback from Clinic Authorities. Examples of participants' statements: "I’m a nurse, and I have to work both in the hospital ward and here. If someone wants to dedicate time to patients with diabetes, they need proper support, not just one day a week. In my opinion, this approach won’t foster a sense of belonging and responsibility in the diabetes room." ( P6 ) "Team satisfaction is crucial. We need to ensure the satisfaction of doctors, nutritionists, and all team members so they remain part of the team and continue collaborating willingly” (P7) "Here, no one tells you 'thank you,' whether you did a good job or a bad one. We all need to feel acknowledged eventually." (P10) 3.2. Infrastructure Challenges In addition to human resources, participants emphasized the lack of adequate physical facilities that could serve as a dedicated space for patient visits. This includes laboratory and diagnostic facilities owned by the center to provide long-term care for individuals living with diabetes, allowing patients to easily schedule tests and examinations, and obtain their medications without hassle. It is important for patients to feel a sense of belonging to a long-term care center, knowing there is a place they can visit for ongoing treatment, support, and conversation. 3.2.1. Providing Physical Facilities Allocating an appropriate space with easy access where patients and their families know they should go for continued care and to be part of the care program. This ensures that when asked to return for further treatment, they know exactly where to go. The following codes pertain to this subcategory: The Absence of a Diabetes Clinic, the requirement for a group education room, lack of space for patient referrals and coordination, a necessity for examination, and individual counseling rooms. The following are some of the sentences that were analyzed: “If there is a diabetes clinic, I know I should come here. Whatever problem I have, I can come here for help” .(P14) Focus Group 2) “The first need is to have a place that patients recognize as a clinic, a specific space…..”(P7) “A space where we can provide group education and personal consultations, a calm room where the patient can confide in us and talk without any interruptions or worries”.(P3) 3.2.2. Access to Comprehensive Laboratory Facilities Some participants believed that the difficulty in accessing laboratory tests was a significant factor in discontinuing care. They emphasized that a laboratory equipped with a well-structured scheduling system is essential for the long-term management of individuals living with diabetes. Incomplete Patient Testing at the Clinic Laboratory, Unstructured Test Appointment Scheduling and Challenges in Booking, Need for Patient Check-ups and Tests to Follow Care Standards Here are the relevant codes for this subcategory: “ Getting an appointment for my test is really tough. I'm a diabetic patient, so I have to fast before the tests. I have to come early hoping to get an appointment, and even if I get one, I have to stay for quite a while until they can take a blood sample from me.” ( P6 ) “When a patient sees how difficult it is to schedule an appointment and undergo tests here, they often give up and leave. Costs outside are high as well, so they end up neglecting their care altogether” . (P11) “After all, these patients need periodic tests according to standard medical care. We should conduct these tests in our own clinic to ensure their proper care”.(P7) 3.2.3. Necessity of Pharmaceutical Support For the provision of long-term care, participants deemed access to diabetes medications essential. They believed that if diabetes medications become scarce or if insurance fails to cover them comprehensively, it could disrupt patients' medication regimens. This disruption might lead to non-adherence to prescribed medications, with patients resorting to self-medication using herbal and traditional remedies instead of the necessary blood sugar-lowering drugs.The relevant codes for this subcategory: lack of Access to All Diabetes Medications, Absence of Insurance Coverage for All Diabetes Medications, Patients' Financial Concerns about Obtaining Medication, Need to Ensure Provision of All Prescribed Medications. Some of the participants' statements: "When we come here to get our medication, they tell us that insurance won't cover more than a few types of drugs. Well, they should provide us with the new combination medications so that we don't have to take so many pills” (P12) "For a while, insulin wasn't available; we were even willing to buy it at a high price, but it simply wasn't in stock." (P16) "A patient living with diabetes shouldn't really have to worry about obtaining medication; it gradually deteriorates their quality of life because managing the disease is a lifelong commitment. Ultimately, with numerous doctor visits that can be costly, let's at least minimize the cost of medication." (P2) 4: Discussion This study addresses the long-term diabetes program challenges by examining the current conditions at Shahid Beheshti Clinic in Shiraz. Managers, health policymakers, and healthcare providers consider long-term care an investment in health and acknowledge that the cost of long-term care is much lower than the cost of treating disease complications. They believed that long-term care for these patients contributes to the overall health of society and the country, increasing motivation for care within the team and inspiring confidence in the decisions of health policymakers regarding treatment and care. They also believed that the burden of care falls on the patient and their family, and care planning is essentially supporting the patient and their family members. They also believed that under current circumstances, the caregiving burden falls more heavily on both the patient and their family, and effective care planning essentially entails comprehensive support for the patient, their family members, and the entire community. Overall, in this study, all participant groups regarded Long-term care for individuals living with diabetes as a patient's right and believed that with financial support from the social security organization, long-term care programs can be advanced. They also emphasized the importance of collaboration among professional teams and patients, encouraging patients and their families to participate in care, and implementing an appropriate follow-up system to minimize care costs. The issues raised in this study by the participants reflect the current conditions in the Shahid Beheshti Hospital clinic and the needs of patients and caregivers for long-term care, as expressed by themselves and health policymakers. as confirmed by other studies, Self-care is a set of health-promoting actions undertaken by individuals themselves, encompassing activities aimed at improving health, preventing illness, managing disease, and maintaining overall well-being. In diabetes self-care, this includes monitoring blood glucose levels, consuming healthy foods, engaging in physical activity, adhering to medication schedules, and minimizing diabetes risk factors( 21 – 23 ). Combining knowledge, positive attitude, and self-care skills are among the key components in diabetes management and improving the quality of life for individuals affected by this condition( 24 , 25 ). Lack of diabetes self-care knowledge has been identified as a barrier to self-care behavior in some studies( 26 , 27 ). Furthermore, the present study's data indicate that deviation from mental well-being contributes to the abandonment of self-care practices. This deviation, in addition to exacerbating the complications of diabetes, is intensified by poor social support and leads to detrimental and ineffective psychological reactions. These findings have been corroborated in several studies, underscoring the importance of addressing depression and its various symptoms in diabetes management, with due consideration for long-term social support( 28 , 29 ). In analyzing the ineffective participation of families in the long-term care of diabetes, issues such as families' unawareness of their supportive role, lack of knowledge regarding diabetes prevention and treatment, and absence of psychological support resources have been raised. Providing psychological support to families of People with diabetes leads to better coping with the burdens of care and enhances the psychological well-being of the family. Some studies have demonstrated that within the family system, the supportive role of diabetic members is one of the fundamental factors in managing this condition. However, regrettably, many families are unaware of the importance of their role in supporting their diabetic members. This unawareness can lead to a decline in the psychological well-being of the family and an increase in the caregiving burden of diabetes. For example, in a family where its members are unaware of the caregiving needs of a diabetic individual, those with diabetes may experience feelings of loneliness, lack of support, and increased psychological pressure( 30 – 33 ). Service-providing organizations can assist families of People with diabetes by offering appropriate training. These trainings may include specialized instructions on diabetes management, dietary regimen, physical activities, and self-care skills( 34 ) Moreover, providing informational resources and support centers, such as health coaches offering counseling sessions and support groups, can assist individuals and their families during episodes of diabetes distress.( 35 ).Organizing educational sessions and experience-sharing workshops is also an effective strategy to enhance families' knowledge and confidence in diabetes management. Additionally, establishing collaborations with local healthcare facilities and ensuring access to medical services and counseling are measures that healthcare organizations can undertake to support families of People with diabetes( 30 , 36 ). The current study has shown that strengthening healthcare organizations is essential alongside the importance of support at the individual and familial levels. The presence of a specialized team within the framework of long-term organizational programs, dedicated to caring for patients and their families, and supported by the organization itself, brings about this chain of effective care for People with diabetes. Infrastructure challenges for therapy and care groups, the shortage of essential facilities for patients, and the lack of easy access to laboratory equipment are among the critical challenges in healthcare delivery. In this regard, conducted studies confirm that given the complexity of diabetes and the need for continuous care, ongoing support through a specialized team can contribute to improving quality of life and better disease management, leading to a reduction in associated complications and problems( 6 , 37 ) Providing guidance, specialized education, and regular assessments, the healthcare team's support in diabetes care boosts the confidence and motivation of those affected by diabetes to adhere to their treatment plan. This, in turn, amplifies the efficacy of disease management( 37 – 39 ). Consisting of diverse specialists such as doctors, nurses, nutritionists, and psychological counselors, this team collaborates and coordinates efforts to provide complete care and tailor diabetes management for each individual( 37 ).A suitable Physical Facilities known as a diabetes clinic, equipped with necessary facilities and equipment for diagnosis, management, and follow-up of diabetes, is essential. This space should be easily accessible to individuals with diabetes, and the services provided therein should be prompt and effective( 40 ). By implementing health standards and utilizing innovative technologies, the Physical Facilities of a diabetes clinic can significantly enhance healthcare services for People with diabetes, leading to increased engagement in self-care( 41 ). Moreover, creating a suitable physical environment in the clinic can foster a welcoming and friendly atmosphere, promoting patients' comfort and confidence during their visits. This, in turn, fosters greater cooperation and collaboration with healthcare staff( 42 ). This review demonstrates that the multidisciplinary team model enhances diabetes treatment outcomes and aids in preventing or reducing complications. However, it can also be a double-edged sword, as poor interactions between healthcare providers may impede the quality of patient care. Additionally, this approach is dependent on the available resources of the health system. Greater effort is required to adapt the multidisciplinary team model to address the evolving needs of patients( 37 , 43 ). Another important aspect of long-term diabetes care is the financial burden and treatment costs on families, insurers, and society, which are increasing daily( 44 ). Although care programs are designed and implemented to reduce the direct and indirect costs of diabetes, these programs need financial support from health policymakers in various countries to remain sustainable and effective in the long term( 45 ). This financial support faces challenges in developing countries due to factors such as the high cost and scarcity of medications and laboratory technologies. This challenge disrupts the program and erodes patients' adherence to medication, treatment, and care( 45 , 46 ). 5: conclusion Currently, there is a need to design and implement a long-term care program for People with diabetes in developing countries. For designing the program, it is essential to assess the needs and review the existing conditions of the care-providing organization, the overarching policies, as well as the social and cultural context, and the knowledge of both care recipients and providers. These factors play a crucial role in advancing the goals of the care program. Additionally, it is important to consider that in planning to address existing challenges, the major challenges of the care program should not be hindered. Declarations All authors confirm that they have no affiliations or involvement with any organization or entity that holds financial or non-financial interests in the subject matter or materials discussed in this manuscript. They declare no conflicts of interest regarding this study. Ethical approval for this research was obtained from Shiraz University of Medical Sciences, and all ethical principles related to participant involvement were strictly observed. The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request, and all authors have provided their consent for the publication of this manuscript, confirming that no identifiable personal data is included. Funding Declaration: This study was financially supported by Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1401.045). All costs associated with the design, implementation, and data analysis of this research were fully covered by this institution. Acknowledgments: This article is based on a Dissertation authored by Raziyeh Iloonkashkooli at the School of Nursing, Shiraz University of Medical Science in Shiraz, Iran. The authors would like to express their gratitude to the clinic staff and officials of Shahid Beheshti Hospital in Shiraz, as well as to Mr. Dr Abbas Mohseni, and Ms Fatemeh Ouji for their assistance to cooperation in acquiring truthful information and facilitating interview opportunities. Author Contribution authors contributions: Z. Hadian Shirazi and R. Iloonkashkooli and G. Setoodeh conceived of the presented idea. M. Momennasab developed the theory and performed the computations.M.Soltanian and M. Momennasab verified the analytical methods. Z. Hadian Shirazi encouraged M. Ansari and G. Setoodeh to investigate analysis and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript References Mohammed K, Ali KA, Gillian Booth BB, Duncan AJH, William H, Herman EH, Graham D, Ogle DR, Owens MEP, Sattar N, Selvin E. DS, Alan Sinclair, Matilde, Monteiro-Soares RLT, Sarah Wild. IDF Diabetes Atlas. In: Dianna J. Magliano EJB, Irini Genitsaridi, Lorenzo Piemonte PR, Paraskevi Salpea., editors. Idf diabetes atlas: IDF Diabetes Atlas 11th Edition – 2025 | diabetesatlas.org; 2025. pp. 40–71. Veisani Y, Khazaei S, Jenabi E, Delpisheh A. Diabetes mortality and morbidity trends and related risk factors in Iranian adults: an appraisal via current data. J Tehran Univ Heart Cent. 2018;13(4):195. Karami M, Hosseini SM. Prevalence of chronic complications and related risk factors of diabetes in patients referred to the diabetes center of Hamedan Province. 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A critical review of national diabetes prevention and control programs in 12 countries in Middle East. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2021;15(1):439 – 45. Esteghamati A, Ismail-Beigi F, Khaloo P, Moosaie F, Alemi H, Mansournia MA, et al. Determinants of glycemic control: Phase 2 analysis from nationwide diabetes report of National Program for Prevention and Control of Diabetes (NPPCD-2018). Prim Care Diabetes. 2020;14(3):222–31. Esmaili F, Mehrolhassani M, Barouni M, Goudarzi R. Measurement of efficiency of direct medical services affiliated with Iranian Social Security Organization using data envelopment analysis in 2014. 2017. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12. Stawnychy MA, Teitelman AM, Riegel B. Caregiver autonomy support: A systematic review of interventions for adults with chronic illness and their caregivers with narrative synthesis. J Adv Nurs. 2021;77(4):1667–82. Gaugler JE, Teaster P. The family caregiving career: Implications for community-based long-term care practice and policy. J Aging Soc Policy. 2006;18(3–4):141–54. Trudel-Fitzgerald C, Kubzansky LD, VanderWeele TJ. A review of psychological well-being and mortality risk: are all dimensions of psychological well-being equal? 2021. Ahmad F, Joshi SH. Self-care practices and their role in the control of diabetes: a narrative review. Cureus. 2023;15(7). Phillips A. Improving self-management of type 1 and type 2 diabetes. Nurs Standard (2014+). 2016;30(19):52. Association AD. Standards of care in diabetes—2023 abridged for primary care providers. Clin Diabetes. 2023;41(1):4–31. Huang X, Xi B, Xuan C, Bao Y, Wang L, Peng F. Knowledge, attitude, and practice toward postoperative self-management among kidney transplant recipients. BMC Med Educ. 2024;24(1):652. Muhammad FY, Iliyasu G, Uloko AE, Gezawa ID, Christiana EA. Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria. Ann Afr Med. 2021;20(3):222–7. Sadeghi S, Mahani F, Amiri P, Alamdari S, Khalili D, Saadat N, et al. Barriers toward the national program for prevention and control of diabetes in Iran: a qualitative exploration. Int J Health Policy Manage. 2022;12:6908. Bukhsh A, Goh B-H, Zimbudzi E, Lo C, Zoungas S, Chan K-G, et al. Type 2 diabetes patients' perspectives, experiences, and barriers toward diabetes-related self-care: a qualitative study from Pakistan. Front Endocrinol. 2020;11:534873. Beverly EA, Ritholz MD, Dhanyamraju K. The buffering effect of social support on diabetes distress and depressive symptoms in adults with type 1 and type 2 diabetes. Diabet Med. 2021;38(4):e14472. Peimani M, Garmaroudi G, Stewart AL, Yekaninejad M, Shakibazadeh E, Nasli-Esfahani E. Type 2 diabetes burden and diabetes distress: The buffering effect of patient-centred communication. Can J diabetes. 2022;46(4):353–60. Polonsky W, Fisher L, Hessler D, Edelman S. Identifying the worries and concerns about hypoglycemia in adults with type 2 diabetes. J Diabetes Complicat. 2015;29(8):1171–6. Chamberlain JJ, Rhinehart AS, Shaefer CF Jr, Neuman A. Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. 2016;164(8):542–52. Kovacs Burns K, Nicolucci A, Holt RI, Willaing I, Hermanns N, Kalra S, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national benchmarking indicators for family members living with people with diabetes. Diabet Med. 2013;30(7):778–88. Veronika EN. The Influence of Family Support on Therapy Adherence in Diabetes Patients: A Mixed-Methods Study. Int J Health Med Sci. 2024;2(3):114–23. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Clin Diabetes. 2016;34(2):70–80. Chima CC, Swanson B, Anikpezie N, Salemi JL. Alleviating diabetes distress and improving diabetes self-management through health coaching in a primary care setting. BMJ Case Rep CP. 2021;14(4):e241759. Liu Y, Liu C. Effect of the AADE7 Self-Care Behaviors Framework on Diabetes Education Management in a Shared Care Model. Int J Endocrinol. 2024;2024(1):7278207. Tan HQM, Chin YH, Ng CH, Liow Y, Devi MK, Khoo CM, et al. Multidisciplinary team approach to diabetes. An outlook on providers’ and patients’ perspectives. Prim Care Diabetes. 2020;14(5):545–51. McGill M, Blonde L, Chan JC, Khunti K, Lavalle FJ, Bailey CJ. The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios. J Clin translational Endocrinol. 2017;7:21–7. Dankoly US, Vissers D, El Farkouch Z, Kolasa E, Ziyyat A, Rompaey BV, et al. Perceived barriers, benefits, facilitators, and attitudes of health professionals towards multidisciplinary team care in type 2 diabetes management: a systematic review. Curr Diabetes Rev. 2021;17(6):50–70. Association AD. Standards of medical care in diabetes—2021 abridged for primary care providers. Clin diabetes. 2021;39(1):14–43. Rossi MC, Nicolucci A, Arcangeli A, Cimino A, De Bigontina G, Giorda C, et al. Baseline quality-of-care data from a quality-improvement program implemented by a network of diabetes outpatient clinics. Diabetes Care. 2008;31(11):2166–8. Bergin SM, Gurr JM, Allard BP, Holland EL, Horsley MW, Kamp MC et al. Australian Diabetes Foot Network: management of diabetes-related foot ulceration–a clinical update. Med J Aust. 2012;197(4). Jacobs J, Dougherty A, McCarn B, Saiyed NS, Ignoffo S, Wagener C, et al. Impact of a multi-disciplinary team-based care model for patients living with diabetes on health outcomes: a mixed-methods study. BMC Health Serv Res. 2024;24(1):746. Association AD. Economic costs of diabetes in the US in 2017. Diabetes Care. 2018;41(5):917–28. Bansode B, Jungari S. Economic burden of diabetic patients in India: A review. Diabetes Metabolic Syndrome: Clin Res Reviews. 2019;13(4):2469–72. Kvarnström K, Westerholm A, Airaksinen M, Liira H. Factors contributing to medication adherence in patients with a chronic condition: a scoping review of qualitative research. Pharmaceutics. 2021;13(7):1100. Additional Declarations No competing interests reported. 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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-6689333","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477924203,"identity":"6a321bd4-d472-4891-b8d6-5bf363fce28b","order_by":0,"name":"Raziyeh Iloonkashkooli","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Raziyeh","middleName":"","lastName":"Iloonkashkooli","suffix":""},{"id":477924204,"identity":"c1faac77-43f7-424a-90fa-1601582eff5c","order_by":1,"name":"Giti Setoodeh","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Giti","middleName":"","lastName":"Setoodeh","suffix":""},{"id":477924205,"identity":"fb0725d7-77a7-4a82-b949-7f3bd1f443b2","order_by":2,"name":"Mitra soltanian","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mitra","middleName":"","lastName":"soltanian","suffix":""},{"id":477924206,"identity":"3d637c46-4575-4c0a-a8ad-307c320e05b2","order_by":3,"name":"Marzieh Momennasab","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Marzieh","middleName":"","lastName":"Momennasab","suffix":""},{"id":477924207,"identity":"fb5ab07a-3c80-4bc4-841b-e2cdb8d64d07","order_by":4,"name":"Zahra Hadian Shirazi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYBAC+xkMDBIJDAxycBE2QloYoVqMSdQCpBMbiHYYs3TzwxsPau6kz5+RnfyBocaOgU/6AH4tbDLHjC0Sjj3L3XAjd5sEw7FkBja+BPxaeCQSzCQS2A7nbpDI3QY04QADGw8Bh0lIpH+TSPh3OF1+Ru7mDwz/iNBiIJFjJpHYdjiB4QbQIsY24rQUWyT2HTbccObtNonEvmQeglrsZ6RvvPnj22F5+Xagwz58s5OT7yGgBRUkAMODJA2jYBSMglEwCrADACFsPf7bgm1KAAAAAElFTkSuQmCC","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Zahra","middleName":"Hadian","lastName":"Shirazi","suffix":""},{"id":477924208,"identity":"97defee9-948e-4125-ad19-811371b9ae46","order_by":5,"name":"Mansour Ansari","email":"","orcid":"","institution":"Fars Province Health Administration, Social Security Organization","correspondingAuthor":false,"prefix":"","firstName":"Mansour","middleName":"","lastName":"Ansari","suffix":""}],"badges":[],"createdAt":"2025-05-18 01:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6689333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6689333/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s40200-025-01724-3","type":"published","date":"2025-10-09T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85817759,"identity":"23af4b91-e79b-49f6-bc7a-fe1faa11e8b8","added_by":"auto","created_at":"2025-07-02 06:04:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1135745,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"figure1..jpg","url":"https://assets-eu.researchsquare.com/files/rs-6689333/v1/60d5f483d22d41679b3aa8d2.jpg"},{"id":93420192,"identity":"b8721029-c223-4f1b-8564-24876416cbc8","added_by":"auto","created_at":"2025-10-13 16:09:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1699794,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6689333/v1/27bd615b-279f-4292-89ad-c26d824ab386.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges In Ensuring Long-Term Care For Individuals Living With Diabetes: A Qualitative Study","fulltext":[{"header":"1: Introduction","content":"\u003cp\u003ediabetes mellitus is a major health concern worldwide. In 2024, an estimated 589\u0026nbsp;million adults aged 20\u0026ndash;79 years were living with diabetes, accounting for 11.1% of the global population in this age group. The prevalence of diabetes is projected to rise, with the number of affected adults expected to reach 853\u0026nbsp;million (13%) by 2050. It is estimated that 252\u0026nbsp;million adults with diabetes remain undiagnosed. Additionally, over USD 1 trillion was spent on diabetes management in 2024, representing 12% of global health expenditure. Alarmingly, more than 3.4\u0026nbsp;million individuals succumbed to diabetes-related causes in the same year, accounting for 9.3% of global mortality from all causes(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).In Iran, according to the latest official statistics, more than 5\u0026nbsp;million individuals are afflicted with diabetes, and 8\u0026nbsp;million are at risk of developing the disease(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).it is estimated that the annual growth rate of diabetes in Iran until 2030 will rank second in the region, following Pakistan(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The rising prevalence of diabetes, alongside its associated healthcare costs and mortality rates, underscores an undeniable reality: establishing equitable and implementable healthcare systems and clinical practices across countries with diverse conditions remains a formidable and persistent challenge in global health(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ethe complexity and time-intensive nature of diabetes management, effective care and long-term planning are crucial for achieving positive clinical outcomes(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). When designing chronic disease management programs, it is essential to consider planning for continuous care and support of patients suffering from these conditions, while minimizing care costs for families and caregiving organizations. This is particularly critical in low- and middle-income countries with a disproportionate focus on disease treatment rather than comprehensive care. Chronic diseases require continuous, high-quality care to ensure their long-term management and enhance the affected patients' quality of life(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). the World Health Organization defines long-term care as all health caregiver activities for individuals at risk or with risk factors, aimed at enhancing functional capabilities, independent living, and quality of life. It emphasizes that these caregiving activities should align with universal rights, freedoms, dignity, and human status(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Long-term care varies from country to country, and terms such as continuous care, sustainable care, comprehensive long-term care, or home-based follow-up care may represent the fundamental concept of long-term care in different countries(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).Nevertheless, long-term care is an integral component of healthcare and social systems, and the type of long-term care required is influenced by factors such as disease and the resources and conditions of different societies(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Health system policymakers understand that diabetes management occurs within the framework of long-term support and follow-up care, necessitating the development of local care programs at healthcare service delivery centers(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The increasing prevalence of diabetes in Iran places a significant responsibility on health policymakers and professionals across various domains, including economists, physicians, and nurses, to address this issue effectively(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).Although the national diabetes prevention and control program of the Ministry of Health aims to implement early detection, appropriate treatment, care, and management of diabetes-related complications in the country, and the healthcare system transformation plan has proven effective in diabetes control, we still witness individuals unaware of their diabetes condition or suffering from severe and chronic diabetes complications, imposing high costs on the healthcare system(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Social Security Organization bears a significant portion of the expenses incurred by these patients, and insured individuals under this organization, comprising more than half of Iran's population, receive free medical and healthcare services at hospitals and treatment centers affiliated with this organization(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The challenges of long-term care for People with diabetes vary across different contexts and are influenced by factors such as the cultural, social, and economic backgrounds of care recipients, their lifestyles, organizational factors, available resources, limitations, evolving care conditions, and responses to the emergence of widespread and novel diseases. This qualitative study was conducted to examine the specific challenges in long-term care for People with diabetes attending Shahid Dr. Beheshti Clinic in Shiraz, with the ultimate goal of designing and implementing a tailored long-term diabetes care program.\u003c/p\u003e"},{"header":"2: methods","content":"\u003cp\u003e2.1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Study design\u003c/p\u003e\n\u003cp\u003eThis study employed a qualitative research methodology, utilizing semi-structured in-depth interviews to examine participants' perceptions of diabetes long-term care existing challenges (DLTCEC) at Shahid Dr. Beheshti Clinic. Participants included professional caregivers, managerial staff at the clinic, individuals with diabetes, and their families. The data collected were analyzed through a qualitative content analysis approach, ensuring a comprehensive and systematic investigation of the topic.\u003c/p\u003e\n\u003cp\u003e2.2.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Recruitment\u003c/p\u003e\n\u003cp\u003eAfter identifying participants through purposive and criterion-based sampling methods, the study objectives, interview procedures, and timing and location were explained to them. Upon their acceptance to participate in the study, the participants completed informed consent forms. Data collection was carried out through semi-structured individual and group interviews, with ethical considerations considered. The researcher proceeded to select participants with maximum diversity (i.e., various groups with experience in diabetes diagnosis, care, and treatment) who could share their experiences and serve as key informants (individuals with sufficient insight into the study topic) capable of engaging in interaction and providing rich and valuable information to the researcher.\u003c/p\u003e\n\u003cp\u003e2.3.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Informants\u003c/p\u003e\n\u003cp\u003eFor face-to-face interviews with internal medicine specialists, general physicians, nutritionists, and clinical psychologists, appointments were made in advance and interviews were conducted in their respective offices upon request. Interviews with experienced nurses in diabetes care, patients, and their families took place in a quiet room within Shahid Dr. Beheshti Clinic. Additionally, two group interviews were conducted: one involving nurses, hospital and clinic managers, and general Physician; and the other including individuals with diabetes and their families. Furthermore, one interview session with a patient's family was conducted via video call. Two interview sessions were held with different participants. Each interview session lasted between 25 to 80 minutes.َ\u003c/p\u003e\n\u003cp\u003e2.4.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Data collection\u003c/p\u003e\n\u003cp\u003eThe research setting was Shahid Dr. Beheshti Clinic in Shiraz. IRAN.\u003c/p\u003e\n\u003cp\u003eThe research participants include People with diabetes and their families, general physician and internal medicine specialists, nurses, nutritionists, wound care specialists, psychologists, and hospital administrators and policymakers of Shahid Dr. Beheshti Clinic, who participated in the study through purposive sampling method.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for participants in the study, in addition to their willingness to participate and engage in interviews, are outlined in different groups as presented in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1: The inclusion criteria for participants from various groups\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eParticipants\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInclusion criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePeople with diabetes and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e· Diagnosis of type 1 or type 2 diabetes mellitus with a minimum of 6 months elapsed since diagnosis.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e· Family members living with the People with diabetes who can collaborate in the patient's care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ephysicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternal medicine or endocrinology specialists and General Physicians with at least 1 year of work experience at Shahid Dr. Beheshti Clinic.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e· Holding a bachelor's degree or higher\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e· A minimum of one year of professional experience in internal medicine or emergency departments, attributed to their experience in providing care for individuals with diabetes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enutritionists and psychologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA minimum of one year of professional experience working with individuals diagnosed with diabetes.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWound care specialists\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMinimum of two years of experience in treating diabetic wounds\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ehospital administrators and policymakers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt least one year of experience in their current role\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExit criteria included unwillingness to continue participation in the research.\u003c/p\u003e\n\u003cp\u003e2.4.1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Interview guide\u003c/p\u003e\n\u003cp\u003eThe questions posed to various individuals differed, with some general inquiries encompassing the following topics:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp;\u0026nbsp;What are the current challenges in providing long-term care for patients with diabetes? How can long-term care for People with diabetes be effectively implemented? Please elaborate.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp;\u0026nbsp;What structures are necessary for long-term care of People with diabetes?\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;\u0026nbsp;What obstacles exist for long-term care of People with diabetes at Shahid Dr. Beheshti Clinic?\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp;\u0026nbsp;Describe what your care needs and challenges have been in the past six months. how you met your needs? (People with diabetes)\u003c/p\u003e\n\u003cp\u003eThen, with further questioning, efforts were made to understand their perception of long-term care in diabetes, which was collected and analyzed. Interview enhancement techniques such as probing, providing examples, describing, asking exploratory questions, summarizing interviewee statements, active listening, and reflecting on their speech were used to improve the interview process.\u003c/p\u003e\n\u003cp\u003e2.5.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Data analysis\u003c/p\u003e\n\u003cp\u003eThe process of interviewing and analyzing data was conducted simultaneously, utilizing both manifest and latent content analysis methods. Adhering to Graneheim and Lundman approach. the analysis was non-linear, involving iterative back-and-forth movements between the original text and related segments. Initially, the text was read multiple times to deeply engage the researcher and achieve a comprehensive understanding. Following this, the analysis unit was identified by comparing the interview texts. The text was then segmented into semantic units and summarized, with codes assigned accordingly. These codes were compared based on their differences and similarities, resulting in the formation of subcategories and categories. These categories were then discussed and refined by the researchers until a consensus was reached regarding their classification(17).Finally, the fundamental meanings represented by the content of the categories were synthesized into indexes. For data analysis, MAXQDA software version 2020 was used.\u003c/p\u003e\n\u003cp\u003e2.6.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ethical consideration\u003c/p\u003e\n\u003cp\u003eAs part of the initial phase of this doctoral dissertation, a comprehensive exploration of the challenges in long-term care for individuals with diabetes was meticulously conducted through a qualitative study at Shahid Dr. Beheshti Clinic. Ethical considerations were rigorously observed throughout the research process. Informed consent was obtained from all participants to ensure voluntary participation. Confidentiality and anonymity were strictly upheld during data collection, analysis, and reporting. The study adhered to the ethical principles and guidelines outlined by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1401.045), and official authorization to conduct the research was duly granted.\u003c/p\u003e"},{"header":"3: results","content":"\u003cp\u003eThe final interview sample included 18 participants, (10 health provider and policymakers in Shahid Beheshti Hospital, with 16.7\u0026plusmn;4.9 years of Work Experience in this setting and position, 7 persons living with diabetes and their families 43.86\u0026plusmn;13.96 years ). The characteristics of the participants are presented in Table 2.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Insured patients, due to their insurance coverage, have historically received free healthcare services at Shahid Beheshti clinic and hospital. Their minimum literacy level was the ability to read and write. healthcare caregivers and managers admitted that patients should not incur any costs for treatment and care at this facility.\u003c/p\u003e\n\u003cp\u003eIn the content analysis, 1,097 open codes were categorized into three themes, six categories, and 14 subcategories, along with 65 initial codes, which are schematically presented in Fig. 1.\u003c/p\u003e\n\u003cp\u003eTable 2: Demographic Characteristics, Roles, and Professional Backgrounds of Participants in This Study\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"659\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eparticipants / number of them\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003ecode\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eage (y) and gender\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003ework experience (y)\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003ein-depth interviews\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003efocus groups\u003c/strong\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003eClinic And Hospital Managers/ 2\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e51 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e18\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003e2\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\u003cem\u003e1 (6 participants)\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP2\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e44 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e15\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\u003cem\u003eNurse\u003c/em\u003e\u003cem\u003e\u0026nbsp;/ 4\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP3\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e43 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e18\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\u003cem\u003e4\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP4\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e32 / female\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e7\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP5\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e42 / male\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e17\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP6\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e31 / female\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e8\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eGeneral Physician /1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP7\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e53 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e21\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e1\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eClinical Psychologist 1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP8\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e49 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e20\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eNutritionist/1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP9\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e46 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e18\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eWound Specialist/1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP10\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e43 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e18\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e2\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eInternal Medicine Specialist /1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP11\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e56 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e24\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e1\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\u003cem\u003ePersons Living With Diabetes\u0026nbsp;\u003c/em\u003e\u003cem\u003e/4\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003eP12\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003e67 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eDiabetes duration\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\u003cem\u003e5\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"9\" valign=\"top\"\u003e\u003cem\u003e1 (5 participants)\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\u003cem\u003e15 years\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP13\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e44 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e6 years\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP14\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e59 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e10 years\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP15\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e47 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e13 years\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\u003cem\u003eFamily Members Of People With Diabetes\u003c/em\u003e\u003cem\u003e\u0026nbsp;/3\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003eP16\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\u003cem\u003e32/female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003ejob\u003c/em\u003e\u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\u003cem\u003e4\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\u003cem\u003eself-employment\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP17\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e27 / female\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003ekindergarten trainer\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eP18\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003e31 / male\u003c/em\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cem\u003eshopkeeper\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1. \u0026nbsp;Erratic Self-Care Adherence\u003c/p\u003e\n\u003cp\u003eIn the analysis of challenges associated with providing long-term care for individuals living with diabetes, one of the prominent themes identified was \u0026apos;erratic self-care adherence,\u0026apos; emphasizing the necessity of enhancing patient awareness, attitudes, and skills. Another crucial dimension of this theme was \u0026apos;deviation from mental well-being,\u0026apos; which is further elaborated within each subcategory.\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e1.1.\u0026nbsp;\u003c/span\u003eDysfunctional Attitudes, lack of awareness and skills\u003c/p\u003e\n\u003cp\u003eThree underlying issues contribute to this categories: Insufficient patient understanding of diabetes and its complications, ineffective patient attitudes towards the disease, and Deficiency in self-care proficiency.\u003c/p\u003e\n\u003cp\u003e1.1.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Insufficient Patient Understanding Of Diabetes And Its Complications\u003c/p\u003e\n\u003cp\u003eAll participants, including healthcare providers, hospital managers, health policymakers, patients, and their families, highlighted the patients\u0026apos; lack of awareness about diabetes and its complications. In this subcategory, initial codes included patients\u0026apos; unawareness of diabetes concepts, ignorance of the causes and risk factors of diabetes, inadequate recognition of hypoglycemia and hyperglycemia symptoms, patients\u0026apos; lack of knowledge about diabetes management, incomplete awareness of diabetes complications, and ignorance about comorbidities associated with diabetes. In this regard, we refer to some participant\u0026apos;s statements:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/em\u003e\u003cem\u003eDiabetes is ultimately a hereditary condition; I inherited it from my father, so there\u0026apos;s nothing I can do about it\u003c/em\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;...\u003c/span\u003e\u003cem\u003e\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003cem\u003eI\u0026apos;m well aware I shouldn\u0026apos;t consume sugar, sweets, rice, and potatoes, but my sugar levels spike due to stress\u003c/em\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cem\u003e\u0026nbsp;even when I eat nothing, it still shoots up... They say it affects my feet, my kidneys...\u0026quot; (P14)(Focus Group 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Our patients really don\u0026apos;t know what diabetes is? What trouble they bring upon themselves when they don\u0026apos;t control it? You ask them, \u0026apos;Are you managing your diabetes?\u0026apos; They say, \u0026apos;Yes, we\u0026apos;re taking pills.\u0026apos; Then you ask about their sugar levels. They say, \u0026apos;We don\u0026apos;t know, we haven\u0026apos;t checked...\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.1.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ineffective patient attitude towards the diabetes\u003c/p\u003e\n\u003cp\u003eIn this study, ineffective patient attitudes have been identified as one of the underlying factors contributing to long-term Careless behaviors\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eand self-care deficiencies\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e initial codes within this subcategory include patient resistance to insulin initiation, non-adherence to dietary and therapeutic regimens, misperceptions regarding the impact of exercise and diet on diabetes control, skepticism towards smoking cessation, disbelief in the need for regular blood pressure and glucose monitoring, and irrational beliefs regarding the use of herbal remedies instead of prescribed medications.\u003c/p\u003e\n\u003cp\u003eHealth caregivers believed that it is necessary for patients to share common beliefs with the treatment team, and having shared mental beliefs contributes to the sustainability of care. Some statements from the participants are provided below:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eWhat\u0026apos;s the point of taking all these pills? When I see no benefit, I just say, \u0026apos;Well, forget it. \u0026quot; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The patient has yet to believe in the helpfulness of quitting smoking, and we know that it\u0026apos;s no longer just about managing diabetes; rather, with diabetes patients, we\u0026apos;re contending with a set of misconceptions.\u0026quot; (P11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;m very active both at home and outside, don\u0026apos;t have time for exercise, and my back hurts, but despite all this, my blood sugar doesn\u0026apos;t decrease.\u0026quot; (P12) (Focus Group 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.1.3. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Deficiency in self-care proficiency\u003c/p\u003e\n\u003cp\u003eIn this study, the insufficient behavioral skills of People with diabetes include inadequate skills in blood sugar and blood pressure monitoring, difficulties in adjusting the dosage and administration of insulin, poor performance in physical exercise, lack of skill in recording blood sugar and blood pressure levels with date and time, and the absence of foot examination skills. Some of the participants\u0026apos; comments are as follows:\u003cspan dir=\"RTL\"\u003e\u003cbr\u003e\u0026nbsp;\u003c/span\u003e\u003cem\u003e\u0026quot;I go to the clinic to check my blood sugar. I have a device, but there\u0026apos;s no one to check it for me, and I can\u0026apos;t do it myself...\u0026quot;(P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003cem\u003eWhen they come to us, we have no idea how they\u0026apos;ve been taking care of themselves during this time. We can only check their HbA1c and blood pressure. It would be great if we could teach them how to record their blood sugar and blood pressure with the date and even the time, and bring that information to us\u003c/em\u003e\u003cspan dir=\"RTL\"\u003e.\u0026quot;\u003c/span\u003e\u003cem\u003e(P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I see it myself among the patients; none of them know how to perform a proper foot examination.\u0026quot;(P10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.2 . Mental health deviation\u003c/p\u003e\n\u003cp\u003eHealthcare providers, policymakers, and care managers in the research environment and patients\u0026apos; families considered deviations from mental health to be inevitable in patients living with diabetes. They identified varying degrees of mental health deviations in all patients, as evidenced by ineffective psychological reactions. They also believed that weak social support exacerbates mental health deviations and that a strong social support network is a cornerstone of long-term care. Mental health deviations lead to disruptions in self-care.\u003c/p\u003e\n\u003cp\u003eThe components of this category include:\u003c/p\u003e\n\u003cp\u003e1.2.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Inefficient psycho-emotional reactions\u003c/p\u003e\n\u003cp\u003eThe initial codes derived from analyzing the participants\u0026apos; comments included fear and anxiety, aggressive behavior in People with diabetes, fatigue from treatment, abandoning medication and diet regimens, noncompliance with medical advice, psychological dependence on family for care, and patients\u0026apos; feelings of helplessness in coping with the disease. These were categorized under ineffective psychological reactions.\u003c/p\u003e\n\u003cp\u003eLet\u0026apos;s address some of the participant\u0026apos;s comments:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When someone is told they have diabetes, they are initially scared and usually listen to the nurse and doctor, wanting to follow the advice. However, sometimes they get tired and frustrated, which can lead to aggressive behavior towards themselves or those around them.\u0026quot;(P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;My dad knows he needs to take his pill at a certain time, and I remind him beforehand. But then I see that a couple of hours have passed, and he hasn\u0026rsquo;t taken it. I ask him, \u0026apos;Dad, why didn\u0026rsquo;t you take your pill?\u0026apos; and he says, \u0026apos;You didn\u0026apos;t give it to me...\u0026quot;(P17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There have been times when I got tired and stopped taking my medications for a few days.\u0026quot;(P 15)\u003cbr\u003e\u0026nbsp;\u0026quot;How long do we have to keep taking these medications? Will it ever be cured? It gets exhausting...\u0026quot;(P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.2.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Poor Social Support\u003c/p\u003e\n\u003cp\u003eSocial support was a concept that all participants pointed to as a challenge in long-term care. Inadequate family support for People with diabetes, deficiencies in the care provider organization\u0026apos;s support system, lack of peer support networks, and absence of friend support networks were the initial codes in this subcategory.\u003c/p\u003e\n\u003cp\u003eBelow are some examples of participants\u0026apos; remarks during the interviews.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;My children have their own challenges; they can\u0026apos;t always focus on me. Sometimes, they just give me a call.\u0026quot;(P12)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When I see he\u0026apos;s not listening to me, I say, \u0026apos;Well, forget it, why bother repeating myself if he won\u0026apos;t listen anyway?\u0026quot;(P16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If there could be some gatherings where patients share their experiences, sometimes good solutions might emerge from them. They may not listen to us, but they listen better to each other\u0026rdquo; (P18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u0026quot;I believe it\u0026apos;s unjust to expect a patient to bear the burden of illness alone over an extended period. We all need to, in some way, stand by them.\u0026quot;(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2. Ineffective Family Support Across the Diabetic Journey\u003cbr\u003e\u0026nbsp;The underlying theme in analyzing the statements of healthcare providers, health policymakers, and family members is evident. Through the discussions of family members of People with diabetes, we realized that long-term support from diabetic families towards the components of care is a challenge in long-term diabetes care. Family support for patients with diabetes encompasses broader dimensions, primarily focusing on educational and psychological support, which become clearer under each dimension.\u003c/p\u003e\n\u003cp\u003e2.1.\u0026nbsp;Neglect in Educating Families\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the challenges in providing long-term care for individuals living with diabetes is the effective education of families to ensure their acceptance and support of these individuals. It is essential for the families of people living with diabetes to deepen their knowledge and understanding of their diabetic family members\u0026apos; condition. Even the family members themselves have acknowledged the importance of comprehending diabetes care.The subcategories of educational support include the following:\u003c/p\u003e\n\u003cp\u003e2.1.1. Family inadequate knowledge in diabetes prevention and care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe challenge for family educational support stemmed from their lack of awareness about diabetes, as noted by participants, encompassing: inadequate family comprehension of diabetes, limited knowledge among family members regarding symptoms of high and low blood sugar, insufficient understanding within families about emergency condition management in patients, and incomplete awareness among family members about the complications of diabetes. Here, some participant statements are provided as examples of the extracted initial codes.\u003c/p\u003e\n\u003cp\u003eParticipants, including healthcare providers and health policymakers, believed that the families of People with diabetes are at risk of diabetes themselves and require preventive education for long-term care. This includes training on identifying risk factors within families, recognizing unhealthy eating habits in diabetic families, and the need for lifestyle changes.\u003c/p\u003e\n\u003cp\u003eSome statements from the participants:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We need to understand the eating habits of the entire family. To ensure that a diabetic individual adheres to their diet in the long term, we must educate their family to improve their eating habits and even their lifestyle.\u0026quot; (P9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Individuals living with someone with diabetes should have sufficient understanding of the condition\u0026hellip;\u0026hellip;.Family members should be educated on the signs of high and low blood sugar and the conditions under which blood sugar levels can fluctuate.\u0026quot;(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003cem\u003eThe doctor had told my sister that if she had arrived at the hospital ten minutes later, her death would have been inevitable. My mother had slipped into a coma, her condition was critical, but we didn\u0026apos;t realize it. She was just sleeping all the time, and we thought she was tired from catching a cold, whereas later we found out that even a simple cold should be taken seriously in diabetic\u003c/em\u003e\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e(P17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My father was experiencing nausea and vomiting, and he had lost his appetite. Even though I reduced his pills, I don\u0026apos;t know why his blood sugar spiked.\u0026quot; (P18\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003e2.1.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Family\u0026apos;s unawareness of their supportive role\u003c/p\u003e\n\u003cp\u003eData analysis revealed that families of People with diabetes are not sufficiently aware of their supportive role. This finding is extracted from the following codes. Lack of family awareness about the psychological and emotional needs of patients, misperception of patients\u0026apos; care needs by families, and inadequate understanding of their role in diabetes management among family members.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eFamilies are unaware that diabetes can lead to depression, stress, and long-term complications, and they don\u0026apos;t know how to support their diabetic family members to prevent their condition from worsening day by day. Without the knowledge and ability to assist the individual in controlling their illness, they are unaware of how to provide care, ultimately resulting in complications that affect the entire family.\u0026quot;\u003c/em\u003e (P8)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If they want to provide long-term support to their loved ones, they need to learn how to interact with them effectively. Families often underestimate their potential to be strong advocates for their patients.\u0026quot;(P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I really don\u0026apos;t know how to be there for him... Sometimes I wonder what I should do for him? How can I help him be more mindful of himself? His relationship with us isn\u0026apos;t the same as before. (P18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Family Psychosocial challenges \u0026nbsp;in Caregiving\u003c/p\u003e\n\u003cp\u003eFamilies of People with diabetes take on the burden of caregiving and Psychological support for families of them is crucial in long-term care to ensure effective diabetes management and to mitigate the emotional stress associated with the chronic nature of the disease. The issue of caregivers caring in chronic illnesses is another aspect of long-term care(18, 19).\u003c/p\u003e\n\u003cp\u003e2.2.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Family Care Burden\u003c/p\u003e\n\u003cp\u003eIn this study, based on the analysis of participants\u0026apos; statements, when long-term care is provided by the family, an imbalance is observed between caregiving demands and the support available for family caregivers. These individuals bear the burden of care, which encompasses the following dimensions:\u003c/p\u003e\n\u003cp\u003eAn imbalance between the family members\u0026apos; social roles and the patient\u0026apos;s care needs, Presence of stress and fear in family members regarding patient care, Low resilience of family members in caregiving, Fatigue and burnout of family caregivers, Poor family skills in adapting to the illness and Patient\u0026apos;s dependence on family for care and treatment.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIt\u0026apos;s important to assist families in learning how to care for their patients long-term, even when they are not living together. However, if we expect them to engage more than they are capable of, they might become exhausted and it could lead to difficulties\u0026rdquo;. (p8)\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u0026ldquo;I tell my dad to get up and go to the clinic himself. I even made an appointment for him, but he refuses to go alone. So, I have to take time off work. Sometimes I wonder what my parents would do if, for any reason, I had to leave this house. Interestingly, both of them say that I am their only concern\u0026rdquo;. (p17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2.2.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Decline of Family Psychological Well-being\u003c/p\u003e\n\u003cp\u003eThe term \u0026quot;psychological well-being\u0026quot; is defined as feeling good, living in a rich environment, being valuable to the world, mastering life, and enjoying life. It refers to the quality of one\u0026apos;s experienced life(20).The following codes, derived from participants\u0026apos; statements, indicate a decline in the psychological well-being of the family.\u003c/p\u003e\n\u003cp\u003eConflicts among family members regarding care and treatment, ineffective interpersonal relationships between the patient and the family, and weak social support for family members.\u003c/p\u003e\n\u003cp\u003eExamples of participants\u0026apos; statements:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026apos;m just one person; I have my own work and life. How long can I take care of them? I get tired too. Sometimes I wish there was someone else beside me.\u0026quot;(P16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think the respect for our patient in the family is much more important than the treatment. Imagine at a gathering, even at a party, the patient\u0026apos;s child yells from across the table, \u0026apos;Mom, don\u0026apos;t drink that soda!\u0026apos; What reaction do you expect from the patient? They\u0026apos;ll feel upset, get angry, and if they didn\u0026apos;t want to drink it before, now they will.\u0026quot;(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo; I tell my sister, \u0026apos;You know Mom has kidney issues and high blood pressure, so why do you make your food so salty?\u0026apos; She doesn\u0026apos;t get it. Can you believe she even brings sweets home and offers them to Mom? It makes me so frustrated.\u0026rdquo; (P18) (Focus Group 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.Deficiencies in Supportive Organizations\u003c/p\u003e\n\u003cp\u003eThe analysis of participant interviews revealed another challenge in the long-term care of individuals living with diabetes: deficiencies in supportive organizations. To ensure optimal care for patients over the years, the organization must have adequate human resources and provide sufficient support for them. Additionally, it should possess appropriate physical resources, which will be further elaborated in the following sections.\u003c/p\u003e\n\u003cp\u003e3.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ensuring ongoing human resources\u003c/p\u003e\n\u003cp\u003eThe participants referred to human resources as health specialists, program managers, and the service delivery team, including coordinators who connect these individuals with patients. The hiring and retention of these professionals, and aligning them with the values of a long-term diabetes care organization, fall under the category of human resources provision\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e3.1.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Perpetual Presence The Comprehensive Care Team\u003c/p\u003e\n\u003cp\u003eAll participants, especially the therapists, agreed on the importance of having skilled and experienced specialists and experts in the care-providing organization. They considered the most crucial person in care coordination to be an \u0026quot;experienced and trained nurse.\u0026quot; Patients and their families complained about the difficulty of getting appointments and referrals outside the clinic. In the analysis, the following codes have been extracted and categorized under this subcategory.\u003c/p\u003e\n\u003cp\u003eRequirement for Multidisciplinary Medical Teams in Diabetes Control, unavailability of Counselors or Psychologists, Absence of Wound Care Specialists, Requirement for a Nutrition Specialist, Shortage of Follow-up Nurses, Need for Patient Referral to External Specialists, Absence of a Convenient Appointment Scheduling System for Medical Visits, and Challenges in Accessing Exercise Specialists.\u003c/p\u003e\n\u003cp\u003eSome of the participants\u0026apos; statements in this domain:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Everyone needs to work together. A patient who comes here cannot be treated by just a nurse or a general practitioner. They need, for example, their retina checked every few months, their kidney condition monitored, mental health evaluated, and all other aspects that you are aware of...\u0026quot;(P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think a physiotherapist or a sports specialist should practically teach them how to exercise. Some people might have skeletal or mobility issues, and merely recommending exercise might not be enough.\u0026rdquo;(P10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We have an ophthalmologist here, but they don\u0026apos;t conduct eye examinations for patients with diabetes. They advise them to go to another center. They can\u0026apos;t continue to refer them like this indefinitely.\u0026quot; (P11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We can even make contracts with several good doctors outside, who actually also treat patients with diabetes...\u0026quot;( P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.1.2.\u0026nbsp;Support for the Care and Treatment Team\u003c/p\u003e\n\u003cp\u003eFor human resources to remain engaged in a diabetes clinic or care center in the long term and provide continuous and sustained care for individuals living with diabetes, it is necessary for the organization to support and back its staff. In this way, the center itself will continue its work indefinitely. This subcategory has been extracted from the following codes.\u003c/p\u003e\n\u003cp\u003eFinancial Support Challenges for the Care and Treatment Team, Educational Needs of Each Specialized Team Member in Their Individual Duties, Achieving Satisfaction Among Team Members, and Team\u0026apos;s Need for Receiving Feedback from Clinic Authorities.\u003c/p\u003e\n\u003cp\u003eExamples of participants\u0026apos; statements:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I\u0026rsquo;m a nurse, and I have to work both in the hospital ward and here. If someone wants to dedicate time to patients with diabetes, they need proper support, not just one day a week. In my opinion, this approach won\u0026rsquo;t foster a sense of belonging and responsibility in the diabetes room.\u0026quot; (\u003c/em\u003e\u003cem\u003eP6\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Team satisfaction is crucial. We need to ensure the satisfaction of doctors, nutritionists, and all team members so they remain part of the team and continue collaborating willingly\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Here, no one tells you \u0026apos;thank you,\u0026apos; whether you did a good job or a bad one. We all need to feel acknowledged eventually.\u0026quot; (P10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.2.\u0026nbsp;Infrastructure Challenges\u003c/p\u003e\n\u003cp\u003eIn addition to human resources, participants emphasized the lack of adequate physical facilities that could serve as a dedicated space for patient visits. This includes laboratory and diagnostic facilities owned by the center to provide long-term care for individuals living with diabetes, allowing patients to easily schedule tests and examinations, and obtain their medications without hassle. It is important for patients to feel a sense of belonging to a long-term care center, knowing there is a place they can visit for ongoing treatment, support, and conversation.\u003c/p\u003e\n\u003cp\u003e3.2.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Providing \u0026nbsp;Physical Facilities\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAllocating an appropriate space with easy access where patients and their families know they should go for continued care and to be part of the care program. This ensures that when asked to return for further treatment, they know exactly where to go. The following codes pertain to this subcategory:\u003c/p\u003e\n\u003cp\u003eThe Absence of a Diabetes Clinic, the requirement for a group education room, lack of space for patient referrals and coordination, a necessity for examination, and individual counseling rooms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following are some of the sentences that were analyzed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If there is a diabetes clinic, I know I should come here. Whatever problem I have, I can come here for help\u0026rdquo; .(P14) Focus Group 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The first need is to have a place that patients recognize as a clinic, a specific space\u0026hellip;..\u0026rdquo;(P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A space where we can provide group education and personal consultations, a calm room where the patient can confide in us and talk without any interruptions or worries\u0026rdquo;.(P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.2.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Access to Comprehensive Laboratory Facilities \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome participants believed that the difficulty in accessing laboratory tests was a significant factor in discontinuing care. They emphasized that a laboratory equipped with a well-structured scheduling system is essential for the long-term management of individuals living with diabetes.\u003c/p\u003e\n\u003cp\u003eIncomplete Patient Testing at the Clinic Laboratory, Unstructured Test Appointment Scheduling and Challenges in Booking, Need for Patient Check-ups and Tests to Follow Care Standards\u003c/p\u003e\n\u003cp\u003eHere are the relevant codes for this subcategory:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eGetting an appointment for my test is really tough. I\u0026apos;m a diabetic patient, so I have to fast before the tests. I have to come early hoping to get an appointment, and even if I get one, I have to stay for quite a while until they can take a blood sample from me.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eP6\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When a patient sees how difficult it is to schedule an appointment and undergo tests here, they often give up and leave. Costs outside are high as well, so they end up neglecting their care altogether\u0026rdquo;\u003c/em\u003e\u003cspan dir=\"RTL\"\u003e.\u0026nbsp;\u003c/span\u003e\u003cem\u003e(P11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;After all, these patients need periodic tests according to standard medical care. We should conduct these tests in our own clinic to ensure their proper care\u0026rdquo;.(P7)\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e3.2.3. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Necessity of Pharmaceutical Support\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eFor the provision of long-term care, participants deemed access to diabetes medications essential. They believed that if diabetes medications become scarce or if insurance fails to cover them comprehensively, it could disrupt patients\u0026apos; medication regimens. This disruption might lead to non-adherence to prescribed medications, with patients resorting to self-medication using herbal and traditional remedies instead of the necessary blood sugar-lowering drugs.The \u0026nbsp;relevant codes for this subcategory:\u003c/p\u003e\n\u003cp\u003elack of Access to All Diabetes Medications, Absence of Insurance Coverage for All Diabetes Medications, Patients\u0026apos; Financial Concerns\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eabout Obtaining Medication, Need to Ensure Provision of All Prescribed Medications.\u003c/p\u003e\n\u003cp\u003eSome of the participants\u0026apos; statements:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When we come here to get our medication, they tell us that insurance won\u0026apos;t cover more than a few types of drugs. Well, they should provide us with the new combination medications so that we don\u0026apos;t have to take so many pills\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;For a while, insulin wasn\u0026apos;t available; we were even willing to buy it at a high price, but it simply wasn\u0026apos;t in stock.\u0026quot; (P16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;A patient living with diabetes shouldn\u0026apos;t really have to worry about obtaining medication; it gradually deteriorates their quality of life because managing the disease is a lifelong commitment. Ultimately, with numerous doctor visits that can be costly, let\u0026apos;s at least minimize the cost of medication.\u0026quot; (P2)\u003c/em\u003e\u003c/p\u003e"},{"header":"4: Discussion","content":"\u003cp\u003eThis study addresses the long-term diabetes program challenges by examining the current conditions at Shahid Beheshti Clinic in Shiraz. Managers, health policymakers, and healthcare providers consider long-term care an investment in health and acknowledge that the cost of long-term care is much lower than the cost of treating disease complications. They believed that long-term care for these patients contributes to the overall health of society and the country, increasing motivation for care within the team and inspiring confidence in the decisions of health policymakers regarding treatment and care. They also believed that the burden of care falls on the patient and their family, and care planning is essentially supporting the patient and their family members. They also believed that under current circumstances, the caregiving burden falls more heavily on both the patient and their family, and effective care planning essentially entails comprehensive support for the patient, their family members, and the entire community. Overall, in this study, all participant groups regarded Long-term care for individuals living with diabetes as a patient's right and believed that with financial support from the social security organization, long-term care programs can be advanced. They also emphasized the importance of collaboration among professional teams and patients, encouraging patients and their families to participate in care, and implementing an appropriate follow-up system to minimize care costs.\u003c/p\u003e \u003cp\u003eThe issues raised in this study by the participants reflect the current conditions in the Shahid Beheshti Hospital clinic and the needs of patients and caregivers for long-term care, as expressed by themselves and health policymakers.\u003c/p\u003e \u003cp\u003eas confirmed by other studies, Self-care is a set of health-promoting actions undertaken by individuals themselves, encompassing activities aimed at improving health, preventing illness, managing disease, and maintaining overall well-being. In diabetes self-care, this includes monitoring blood glucose levels, consuming healthy foods, engaging in physical activity, adhering to medication schedules, and minimizing diabetes risk factors(\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCombining knowledge, positive attitude, and self-care skills are among the key components in diabetes management and improving the quality of life for individuals affected by this condition(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Lack of diabetes self-care knowledge has been identified as a barrier to self-care behavior in some studies(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Furthermore, the present study's data indicate that deviation from mental well-being contributes to the abandonment of self-care practices. This deviation, in addition to exacerbating the complications of diabetes, is intensified by poor social support and leads to detrimental and ineffective psychological reactions. These findings have been corroborated in several studies, underscoring the importance of addressing depression and its various symptoms in diabetes management, with due consideration for long-term social support(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn analyzing the ineffective participation of families in the long-term care of diabetes, issues such as families' unawareness of their supportive role, lack of knowledge regarding diabetes prevention and treatment, and absence of psychological support resources have been raised. Providing psychological support to families of People with diabetes leads to better coping with the burdens of care and enhances the psychological well-being of the family.\u003c/p\u003e \u003cp\u003eSome studies have demonstrated that within the family system, the supportive role of diabetic members is one of the fundamental factors in managing this condition. However, regrettably, many families are unaware of the importance of their role in supporting their diabetic members. This unawareness can lead to a decline in the psychological well-being of the family and an increase in the caregiving burden of diabetes. For example, in a family where its members are unaware of the caregiving needs of a diabetic individual, those with diabetes may experience feelings of loneliness, lack of support, and increased psychological pressure(\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eService-providing organizations can assist families of People with diabetes by offering appropriate training. These trainings may include specialized instructions on diabetes management, dietary regimen, physical activities, and self-care skills(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Moreover, providing informational resources and support centers, such as health coaches offering counseling sessions and support groups, can assist individuals and their families during episodes of diabetes distress.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).Organizing educational sessions and experience-sharing workshops is also an effective strategy to enhance families' knowledge and confidence in diabetes management. Additionally, establishing collaborations with local healthcare facilities and ensuring access to medical services and counseling are measures that healthcare organizations can undertake to support families of People with diabetes(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study has shown that strengthening healthcare organizations is essential alongside the importance of support at the individual and familial levels. The presence of a specialized team within the framework of long-term organizational programs, dedicated to caring for patients and their families, and supported by the organization itself, brings about this chain of effective care for People with diabetes. Infrastructure challenges for therapy and care groups, the shortage of essential facilities for patients, and the lack of easy access to laboratory equipment are among the critical challenges in healthcare delivery.\u003c/p\u003e \u003cp\u003eIn this regard, conducted studies confirm that given the complexity of diabetes and the need for continuous care, ongoing support through a specialized team can contribute to improving quality of life and better disease management, leading to a reduction in associated complications and problems(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Providing guidance, specialized education, and regular assessments, the healthcare team's support in diabetes care boosts the confidence and motivation of those affected by diabetes to adhere to their treatment plan. This, in turn, amplifies the efficacy of disease management(\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsisting of diverse specialists such as doctors, nurses, nutritionists, and psychological counselors, this team collaborates and coordinates efforts to provide complete care and tailor diabetes management for each individual(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).A suitable Physical Facilities known as a diabetes clinic, equipped with necessary facilities and equipment for diagnosis, management, and follow-up of diabetes, is essential. This space should be easily accessible to individuals with diabetes, and the services provided therein should be prompt and effective(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBy implementing health standards and utilizing innovative technologies, the Physical Facilities of a diabetes clinic can significantly enhance healthcare services for People with diabetes, leading to increased engagement in self-care(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Moreover, creating a suitable physical environment in the clinic can foster a welcoming and friendly atmosphere, promoting patients' comfort and confidence during their visits. This, in turn, fosters greater cooperation and collaboration with healthcare staff(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e This review demonstrates that the multidisciplinary team model enhances diabetes treatment outcomes and aids in preventing or reducing complications. However, it can also be a double-edged sword, as poor interactions between healthcare providers may impede the quality of patient care. Additionally, this approach is dependent on the available resources of the health system. Greater effort is required to adapt the multidisciplinary team model to address the evolving needs of patients(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother important aspect of long-term diabetes care is the financial burden and treatment costs on families, insurers, and society, which are increasing daily(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Although care programs are designed and implemented to reduce the direct and indirect costs of diabetes, these programs need financial support from health policymakers in various countries to remain sustainable and effective in the long term(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). This financial support faces challenges in developing countries due to factors such as the high cost and scarcity of medications and laboratory technologies. This challenge disrupts the program and erodes patients' adherence to medication, treatment, and care(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e"},{"header":"5: conclusion","content":"\u003cp\u003eCurrently, there is a need to design and implement a long-term care program for People with diabetes in developing countries. For designing the program, it is essential to assess the needs and review the existing conditions of the care-providing organization, the overarching policies, as well as the social and cultural context, and the knowledge of both care recipients and providers. These factors play a crucial role in advancing the goals of the care program. Additionally, it is important to consider that in planning to address existing challenges, the major challenges of the care program should not be hindered.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll authors confirm that they have no affiliations or involvement with any organization or entity that holds financial or non-financial interests in the subject matter or materials discussed in this manuscript. They declare no conflicts of interest regarding this study. Ethical approval for this research was obtained from Shiraz University of Medical Sciences, and all ethical principles related to participant involvement were strictly observed. The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request, and all authors have provided their consent for the publication of this manuscript, confirming that no identifiable personal data is included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e This study was financially supported by Shiraz University of Medical Sciences (IR.SUMS.NUMIMG.REC.1401.045). All costs associated with the design, implementation, and data analysis of this research were fully covered by this institution.\u003c/p\u003e\n\u003cp\u003eAcknowledgments:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis article is based on a Dissertation authored by Raziyeh Iloonkashkooli at the School of Nursing, Shiraz University of Medical Science in Shiraz, Iran. The authors would like to express their gratitude to the clinic staff and officials of Shahid Beheshti Hospital in Shiraz, as well as to Mr. Dr Abbas Mohseni, and Ms Fatemeh Ouji for their assistance to cooperation in acquiring truthful information and facilitating interview opportunities.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eauthors contributions: Z. Hadian Shirazi and R. Iloonkashkooli and G. Setoodeh conceived of the presented idea. M. Momennasab developed the theory and performed the computations.M.Soltanian and M. Momennasab verified the analytical methods. Z. Hadian Shirazi encouraged M. Ansari and G. Setoodeh to investigate analysis and supervised the findings of this work. 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BMC Med Educ. 2024;24(1):652.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammad FY, Iliyasu G, Uloko AE, Gezawa ID, Christiana EA. Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria. Ann Afr Med. 2021;20(3):222\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi S, Mahani F, Amiri P, Alamdari S, Khalili D, Saadat N, et al. Barriers toward the national program for prevention and control of diabetes in Iran: a qualitative exploration. Int J Health Policy Manage. 2022;12:6908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBukhsh A, Goh B-H, Zimbudzi E, Lo C, Zoungas S, Chan K-G, et al. Type 2 diabetes patients' perspectives, experiences, and barriers toward diabetes-related self-care: a qualitative study from Pakistan. Front Endocrinol. 2020;11:534873.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeverly EA, Ritholz MD, Dhanyamraju K. 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Pharmaceutics. 2021;13(7):1100.\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diabetes Mellitus, Patients, Long-Term Care challenges, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-6689333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6689333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInvestigating Challenges in Providing Lifelong Care for People with diabetes to Design Comprehensive Long-Term Care Programs at Shahid Dr. Beheshti Clinic, Shiraz, Iran\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: Conduct interviews with a diverse group of 18 individuals, including patients, their families, and the hospital care team, utilizing a purposeful sampling approach, followed by qualitative content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree overarching themes emerged: (1) Erratic Adherence to Self-Care, (2) Ineffective Family Support Throughout the Diabetic Journey, and (3) Deficiencies in Supportive Organizations. These challenges were further categorized into six distinct areas: Dysfunctional Attitudes, Lack of Awareness and Skills, Mental Health Deviations, Neglect in Family Education, Psychosocial Challenges in Family Caregiving, and Issues in Sustaining Human Resources and Infrastructure. Based on the prevailing conditions, solutions were proposed within the framework of a long-term diabetes care program to effectively address these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of the present study highlight significant challenges faced by people with diabetes, their families, and care-providing organizations in delivering long-term care. Consequently, all three groups require structured support to effectively fulfill their caregiving responsibilities.\u003c/p\u003e","manuscriptTitle":"Challenges In Ensuring Long-Term Care For Individuals Living With Diabetes: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 06:04:49","doi":"10.21203/rs.3.rs-6689333/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":"dee6128a-e362-4000-8abd-24bf4bc1702c","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:08:13+00:00","versionOfRecord":{"articleIdentity":"rs-6689333","link":"https://doi.org/10.1007/s40200-025-01724-3","journal":{"identity":"journal-of-diabetes-and-metabolic-disorders","isVorOnly":false,"title":"Journal of Diabetes \u0026 Metabolic Disorders"},"publishedOn":"2025-10-09 15:57:40","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-07-02 06:04:49","video":"","vorDoi":"10.1007/s40200-025-01724-3","vorDoiUrl":"https://doi.org/10.1007/s40200-025-01724-3","workflowStages":[]},"version":"v1","identity":"rs-6689333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6689333","identity":"rs-6689333","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}