ORIGINAL RESEARCH
Diabetes & Chronic Disease

Health Beliefs Predict Self-Care Practices and Glycaemic Control in Malaysian Patients With Insulin-Treated Diabetes: A Longitudinal Study

Background and Context

Malaysia faces one of the highest diabetes prevalence rates in the Western Pacific Region, with the National Health and Morbidity Survey consistently reporting rising rates of type 2 diabetes across all ethnic groups. According to national surveillance data, approximately 3.9 million Malaysian adults were living with diabetes by the mid-2010s, with a significant proportion requiring insulin therapy for glycaemic management. Despite the availability of clinical guidelines and widespread access to primary care, achieving optimal glycaemic control remains a persistent challenge in the Malaysian healthcare system.

Self-care practices — including dietary management, regular insulin administration, physical activity, and self-monitoring of blood glucose — are foundational to diabetes management. Yet adherence to these behaviours varies widely among patients, and poor self-care is strongly associated with suboptimal glycaemic control, increased risk of microvascular and macrovascular complications, and higher healthcare costs. Understanding the psychological and cognitive factors that drive or hinder self-care behaviour is therefore essential for designing effective diabetes education programmes.

The Health Belief Model (HBM), originally developed in the 1950s to explain preventive health behaviours, provides a well-established theoretical framework for this investigation. The HBM posits that health-related behaviour is influenced by an individual’s perceptions of their susceptibility to a disease, the severity of the disease, the benefits of taking action, the barriers to action, and external cues that prompt behaviour. While the HBM has been applied extensively in Western diabetes research, its application among insulin-treated patients in Malaysian populations had been notably limited prior to this study.

Study Design and Methods

This study employed a longitudinal design with self-reported questionnaire measures administered at two time points: baseline (Time 1, or T1) and six months later (Time 2, or T2). Participants were recruited from three endocrinology clinics in Malaysia. The study focused specifically on young to middle-aged adults (aged 18–40 years) with insulin-treated diabetes, a demographic chosen because of the dynamic lifestyle changes prevalent at this life stage that may influence self-care behaviour.

The questionnaire battery included validated instruments measuring HBM constructs (perceived susceptibility, severity, benefits, barriers, and cues to action), diabetes self-care activities (dietary habits, insulin adherence, physical activity, and self-monitoring of blood glucose), and glycaemic control assessed through HbA1c levels obtained from clinical records. Data from 27 diabetes educators practising in the study settings were also collected to contextualise the educational environment in which patients were receiving care.

Key Results

The results demonstrated that perceived benefits of self-care were the most consistent predictor of positive diabetes management behaviours. Patients who held stronger beliefs in the benefits of dietary management and insulin adherence were significantly more likely to engage in these self-care activities, and these beliefs predicted actual glycaemic outcomes over the six-month follow-up period. Conversely, perceived barriers — including difficulties integrating self-care into daily routines, financial constraints, and competing life priorities — were associated with poorer glycaemic control at the six-month mark.

Notably, perceived severity of diabetes was the only HBM construct that did not significantly predict any self-care or glycaemic outcome. This finding suggests that simply understanding the seriousness of diabetes may be insufficient to motivate behavioural change without concurrent beliefs about the efficacy and benefits of self-care actions.

Qualitative Insights from Diabetes Educators

The qualitative component of the study, which captured data from 27 diabetes educators practising across the study settings, revealed important contextual findings. Some participants reported that they had not received formal diabetes education since diagnosis, while others described receiving information that was inconsistent or inaccurate — for instance, conflicting dietary advice from different healthcare providers within the same clinic. These findings highlight potential systemic weaknesses in the diabetes education infrastructure within Malaysian clinical settings.

Implications for Malaysian Diabetes Care

The findings carry significant implications for the design of diabetes education programmes in Malaysia. Rather than relying solely on knowledge-based education — which assumes that understanding the disease will automatically translate into better self-care — the results suggest that interventions should actively target patients’ health beliefs, particularly by strengthening perceptions of the benefits of self-care activities and addressing perceived barriers through practical problem-solving strategies.

For diabetes educators, this means moving beyond standardised information delivery toward more personalised, belief-oriented counselling that identifies and addresses individual patients’ cognitive frameworks regarding their disease management. Motivational interviewing techniques, tailored health messaging, and culturally sensitive approaches that account for Malaysia’s multi-ethnic dietary and lifestyle diversity could enhance the effectiveness of such interventions.

The study also underscores the importance of ensuring consistency and accuracy in diabetes education across clinical settings. Training programmes for diabetes educators should emphasise evidence-based guidelines and provide regular updates to align clinical practice with current best evidence.

Limitations

The study focused on young to middle-aged adults (18–40 years), limiting generalisability to older diabetic populations who represent a substantial proportion of insulin-treated patients in Malaysia. The six-month follow-up period, while adequate for capturing short-term behavioural patterns, may not reflect long-term self-care trajectories. Self-reported measures of dietary habits and insulin adherence are subject to social desirability and recall biases. Additionally, the study was conducted at tertiary endocrinology clinics, which may not represent the primary care settings where the majority of Malaysian diabetes patients receive care.

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