Illness Perception and Health-Related Quality of Life Among Patients With Type 2 Diabetes: The Mediating Role of Diabetes Distress and the Moderating Role of Perceived Social Support

Zhang Minyi; Nino Tsiklauri; Selin Aydemir

doi:10.61838/7c9vvk80

Authors

Zhang Minyi Department of Cognitive Psychology, Zhejiang University, Hangzhou, China Author https://orcid.org/0009-0005-6543-7443
Nino Tsiklauri Department of Clinical Psychology, Tbilisi State University, Tbilisi, Georgia https://orcid.org/0009-0009-4839-2238
Selin Aydemir Department of Clinical Psychology, Middle East Technical University, Ankara, Turkey Author https://orcid.org/0009-0004-9613-8035

DOI:

https://doi.org/10.61838/7c9vvk80

Keywords:

Type 2 diabetes, illness perception, diabetes distress, health-related quality of life, perceived social support, moderated mediation

Abstract

Objective: This study aimed to examine the relationship between illness perception and health-related quality of life among patients with type 2 diabetes, with diabetes distress as a mediator and perceived social support as a moderator.

Methods and Materials: This cross-sectional descriptive-correlational study was conducted among 384 adult patients with type 2 diabetes receiving outpatient care in Georgia. Participants were selected through convenience sampling from diabetes and endocrinology clinics in Tbilisi, Kutaisi, and Batumi. Data were collected using a demographic and clinical information form, the Brief Illness Perception Questionnaire, the Diabetes Distress Scale, the Multidimensional Scale of Perceived Social Support, and the 12-Item Short Form Health Survey. Data were analyzed using SPSS version 27 and AMOS version 24. Descriptive statistics, Pearson correlation coefficients, mediation analysis, moderation analysis, and moderated mediation modeling with 5,000 bootstrap samples were used. Age, gender, duration of diabetes, and diabetes-related complications were entered as control variables.

Findings: Illness perception was positively associated with diabetes distress and negatively associated with health-related quality of life. Diabetes distress was negatively associated with health-related quality of life, while perceived social support was positively associated with health-related quality of life and negatively associated with diabetes distress. Mediation analysis showed that diabetes distress partially mediated the relationship between illness perception and health-related quality of life. Moderation analysis showed that perceived social support weakened the relationship between illness perception and diabetes distress and also reduced the negative effect of diabetes distress on health-related quality of life. The conditional indirect effect was strongest among patients with low perceived social support and weakest among those with high perceived social support.

Conclusion: The findings indicate that threatening illness perceptions reduce health-related quality of life partly by increasing diabetes distress, while perceived social support buffers this adverse psychological pathway. Integrating distress screening, illness perception modification, and social support enhancement into diabetes care may improve patients’ quality of life.

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References

Akbari, M., Seydavi, M., Rowhani, N. S., & Nouri, N. (2022). Psychological Predictors of Treatment Adherence Among Patients With Diabetes (Types I and II): Modified Information–motivation–behavioural Skills Model. Clinical Psychology & Psychotherapy, 29(6), 1854-1866. https://doi.org/10.1002/cpp.2746

Alyami, M., Serlachius, A., Mokhtar, I., & Broadbent, E. (2021). Longitudinal Associations Between Illness Perceptions and Glycemic Control in Type 2 Diabetes. International Journal of Behavioral Medicine, 29(4), 398-407. https://doi.org/10.1007/s12529-021-10024-y

Bablis, P., Day, R. R., & Pollard, H. (2024). Treatment of Type 2 Diabetes and Stress Using Neuro-Emotional Technique: Case Report. Frontiers in Endocrinology, 15. https://doi.org/10.3389/fendo.2024.1382757

Carlton, J., Powell, P. A., Rowen, D., Broadley, M., Pouwer, F., Speight, J., Heller, S., Gall, M. A., Rosilio, M., Child, C. J., Comins, J. D., McCrimmon, R. J., Galan, B. E. d., & Brazier, J. (2022). Producing a Preference‐based Quality of LIFE Measure to Quantify the Impact of HYPOGLYCAEMIA on People Living With Diabetes: A Mixed‐methods Research Protocol. Diabetic Medicine, 40(3). https://doi.org/10.1111/dme.15007

Chindankutty, N. V., & Devineni, D. (2024). Illness Perception, Coping, and Self-Care Adherence Among Adults With Type 2 Diabetes. Journal of Population and Social Studies, 32, 687-705. https://doi.org/10.25133/jpssv322024.040

Cortés-Hernández, M. E., Cano-Estrada, A., Castañeda-Márquez, A. C., Hurtado-Salgado, E. M., Roa, K. J. A., & Hernández-Mariano, J. Á. (2025). Self-Care and Health-Related Quality of Life in Mexican Older Adults With Type 2 Diabetes. Journal of education and health promotion, 14(1). https://doi.org/10.4103/jehp.jehp_602_24

Ekpor, E., Adawudu, E. A., Agyen, S. A., Romadlon, D. S., & Akyirem, S. (2025). The Moderating Effect of Social Support on the Association Between Healthcare Discrimination and Quality of Life in Persons With Type 2 Diabetes. Healthcare, 14(1), 31. https://doi.org/10.3390/healthcare14010031

Gelhorn, H. L., Balantac, Z., Shinde, S., Thieu, V. T., & Boye, K. S. (2021). The Burden of Type 2 Diabetes and the Value of Achieving Near Normoglycemia From the Patient Perspective. Diabetes Therapy, 12(7), 1821-1837. https://doi.org/10.1007/s13300-021-01054-6

Hermanns, N., Kittel, P., Cerletti, P., Kulzer, B., & Ehrmann, D. (2026). Independent Associations of Mental Health and Diabetes Complications With Health‐related Quality of Life: Evidence From a Cross‐sectional Study. Diabetes Obesity and Metabolism, 28(3), 2383-2392. https://doi.org/10.1111/dom.70434

Hu, J., Mion, L. C., Tan, A., Bartle‐Haring, S., Miller, C. K., & Joseph, J. J. (2025). Family Dyad-Focused Diabetes Self-Management Intervention (FDSMI) for African American Adults With Type 2 Diabetes: Study Protocol. Contemporary Clinical Trials, 156, 108029. https://doi.org/10.1016/j.cct.2025.108029

Hussein, S., Jespersen, L. N., Ingersgaard, M. V., Skovby, P., & Grabowski, D. (2023). Trying to Be Like Everybody Else: A Qualitative Study Revealing the Importance of Social Contexts and Illness Representations Among Adolescents With Type 1 Diabetes and Their Parents. Chronic Illness, 20(1), 37-48. https://doi.org/10.1177/17423953231155287

Jennings, C., Astin, F., Prescott, E., & Bacquer, D. D. (2022). Illness Perceptions and Health Literacy Are Strongly Associated With Health-Related Quality of Life, Anxiety, and Depression in Patients With Coronary Heart Disease: Results From the EUROASPIRE v Cross-Sectional Survey. European Journal of Cardiovascular Nursing, 22(7), 719-729. https://doi.org/10.1093/eurjcn/zvac105

Jensen, N. J., Wodschow, H. Z., Skytte, M. J., Samkani, A., Astrup, A., Frystyk, J., Hartmann, B., Holst, J. J., Larsen, T. M., Madsbad, S., Magkos, F., Miskowiak, K. W., Haugaard, S. B., Krarup, T., Rungby, J., & Thomsen, M. N. (2022). Weight-Loss Induced by Carbohydrate Restriction Does Not Negatively Affect Health-Related Quality of Life and Cognition in People With Type 2 Diabetes: A Randomised Controlled Trial. Clinical Nutrition, 41(7), 1605-1612. https://doi.org/10.1016/j.clnu.2022.05.005

Kheniser, K., Aminian, A., & Kashyap, S. R. (2022). Effects of Metabolic Medicine and Metabolic Surgery on Patient-Reported Outcomes Among Patients With Type 2 Diabetes. Metabolic Syndrome and Related Disorders, 20(9), 497-508. https://doi.org/10.1089/met.2022.0039

Kim, H. J., & Oh, D. W. (2024). The Relationship Between Obstructive Sleep Apnea, Dyspnea, and Health-Related Quality of Life in Lung Cancer Survivors: A Cross-Sectional Study in the Republic of Korea. Osong Public Health and Research Perspectives, 15(6), 533-541. https://doi.org/10.24171/j.phrp.2024.0146

Kintzoglanakis, K., Diamantis, C., Mariolis, A., & Paschou, S. Α. (2024). Patient-Important Outcomes in Type 2 Diabetes: The Paradigm of the Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists. Diabetes and Vascular Disease Research, 21(4). https://doi.org/10.1177/14791641241269743

Kintzoglanakis, K., Pavlou-Skantzis, L., Themeli, T., Kyprianou, M., & Paschou, S. Α. (2023). Determinants of Health-Related Quality of Life of Patients With Type 2 Diabetes and Multimorbidity: A Cross-Sectional Study. https://doi.org/10.21203/rs.3.rs-3256680/v1

Kuklinski, D., Sapin, M., Zeukeng, M.-J., Vogel, J., Barthassat, V., Favre, B. M., DaCosta, H., Tugay, K., Coendoz-Carron, S., Bumann, D., Coclet, J., Schaller, P., & Geißler, A. (2025). Enhancing Type 2 Diabetes Care by an Individualized and Group-Based Therapeutic Patient Education Program: Study Protocol for a Cluster Randomized Trial. https://doi.org/10.21203/rs.3.rs-5678340/v1

Lamedica, A. M., Protic, O., Antognoli, L., Tortato, E., Turchi, F., Luconi, M. P., Menditto, A., Olivieri, F., Spazzafumo, L., & Bonfigli, A. R. (2025). Determinants of Impaired Health-Related Quality of Life in Older Italian Outpatients With Type 2 Diabetes. Journal of clinical medicine, 14(17), 6118. https://doi.org/10.3390/jcm14176118

Langendoen‐Gort, M., Groeneveld, L., Prinsen, C. A. C., Beulens, J. W. J., Elders, P. J. M., Halperin, I., Mukerji, G., Terwee, C. B., & Rutters, F. (2022). Patient-Reported Outcome Measures for Assessing Health-Related Quality of Life in People With Type 2 Diabetes: A Systematic Review. Reviews in Endocrine and Metabolic Disorders, 23(5), 931-977. https://doi.org/10.1007/s11154-022-09734-9

Laverty, B., Jayanandan, S. P., & Smyth, S. (2023). Understanding the Relationship Between Sleep and Quality of Life in Type 2 Diabetes: A Systematic Review of the Literature. Journal of Health Psychology, 28(8), 693-710. https://doi.org/10.1177/13591053221140805

Li, H. T., Moungkum, S., & Jullamate, P. (2025). Factors Influencing Health-Related Quality of Life Among People With Uncontrolled Type II Diabetes Mellitus in Wenzhou, China: A Cross-Sectional Study. Belitung Nursing Journal, 11(3), 321-329. https://doi.org/10.33546/bnj.3785

Mai, Q., Xu, S., Hu, J., Sun, X., Chen, G., Ma, Z., Song, Y., & Wang, C. (2023). The Association Between Socioeconomic Status and Health-Related Quality of Life Among Young and Middle-Aged Maintenance Hemodialysis Patients: Multiple Mediation Modeling. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1234553

Marfu’ah, Sandy, G., & Arifin, M. (2022). The Effect of Illness Representations on Health-Related Quality of Life (HRQoL) in Obesity: The Role of Coping Strategies as Mediator. https://doi.org/10.2991/assehr.k.220203.033

Onu, D. U., & Igwe, E. J. (2024). Distress and Health-Related Quality of Life Among People Living With Type 2 Diabetes: An Analysis of Moderated Mediation Roles of Mindfulness and Social Support. Journal of Health Psychology, 30(10), 2615-2633. https://doi.org/10.1177/13591053241306559

Potočnik, T. V., Gorenjec, N. R., Mihevc, M., Zavrnik, Č., Lukančič, M. M., Susič, A. P., & Klemenc–Ketiš, Z. (2024). Person-Centred Diabetes Care: Examining Patient Empowerment and Diabetes-Specific Quality of Life in Slovenian Adults With Type 2 Diabetes. Healthcare, 12(9), 899. https://doi.org/10.3390/healthcare12090899

Powell, P. A., Frances, S. M., Galan, B. E. d., Heller, S., Speight, J., Rosilio, M., Pouwer, F., Gall, M.-A., Child, C. J., McCrimmon, R. J., Tait, K., & Carlton, J. (2026). ‘There Is More to Life Than HbA _1c ’: A Comprehensive Qualitative Framework From the Hypo‐ RESOLVE Project Evidencing the Impacts of Hypoglycaemia on the Quality of Life of Adults Living With Type 1 or Type 2 Diabetes. Diabetic Medicine. https://doi.org/10.1111/dme.70240

Robinson, S., Newson, R. S., Liao, B., Kennedy‐Martin, T., & Battelino, T. (2021). Missed and Mistimed Insulin Doses in People With Diabetes: A Systematic Literature Review. Diabetes Technology & Therapeutics, 23(12), 844-856. https://doi.org/10.1089/dia.2021.0164

Rosenfeld, R. M., Grega, M. L., Karlsen, M., Dabrh, A. M. A., Aurora, R. N., Bonnet, J. P., Donnell, L., Fitzpatrick, S. L., Frates, E. P., Joy, E. A., Kapustin, J., Noe, D., Gunadhar, P., Ram, A., Reisner, L. S. L., Valencia, W. M., Weatherspoon, L., Weber, J. M., Livingston, K. A., & Gulati, M. (2025). Executive Summary of Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults: A Clinical Practice Guideline From the American College of Lifestyle Medicine. American Journal of Lifestyle Medicine, 19(2_suppl). https://doi.org/10.1177/15598276251325485

Shah, S., Abbas, G., Aslam, A., Randhawa, F. A., Khan, F. U., Khurram, H., Chand, U. R., Butt, M. H., Mallhi, T. H., & Khan, Y. H. (2023). Assessment of Health-Related Quality of Life Among Patients With Obesity, Hypertension and Type 2 Diabetes Mellitus and Its Relationship With Multimorbidity. PLoS One, 18(8), e0289502. https://doi.org/10.1371/journal.pone.0289502

Terwee, C. B., Elders, P. J. M., Blom, M. T., Beulens, J. W. J., Rolandsson, O., Rogge, A. A., Rose, M., Harman, N., Williamson, P., Pouwer, F., Mokkink, L. B., & Rutters, F. (2023). Patient-Reported Outcomes for People With Diabetes: What and How to Measure? A Narrative Review. Diabetologia, 66(8), 1357-1377. https://doi.org/10.1007/s00125-023-05926-3

Volčanšek, Š., Lunder, M., & Janež, A. (2023). Health-Related Quality of Life Assessment in Older Patients With Type 1 and Type 2 Diabetes. Healthcare, 11(15), 2154. https://doi.org/10.3390/healthcare11152154

Wit, M. d., Gajewska, K. A., Goethals, E. R., McDarby, V., Zhao, X., Hapunda, G., Delamater, A. M., & DiMeglio, L. A. (2022). ISPAD Clinical Practice Consensus Guidelines 2022: Psychological Care of Children, Adolescents and Young Adults With Diabetes. Pediatric Diabetes, 23(8), 1373-1389. https://doi.org/10.1111/pedi.13428

Yeung, Y.-L., Lee, K. Y., Lau, E. S. H., Yung, T.-F., Yang, A., Wu, H., Wong, K. T., Kong, A. P., Chow, E., C.W, R., Yeung, T., Loo, K.-m., Ozaki, R., Luk, A. O. Y., Lui, J. N., & Chan, J. C. (2024). Associations of Comorbid Depression With Cardiovascular-Renal Events and All-Cause Mortality Accounting for Patient Reported Outcomes in Individuals With Type 2 Diabetes: A 6-Year Prospective Analysis of the Hong Kong Diabetes Register. Frontiers in Endocrinology, 15. https://doi.org/10.3389/fendo.2024.1284799

Zelikovsky, N., & Nelson, E. (2021). Illness Perceptions and Beliefs About Medication: Impact on Health‐related Quality of Life in Adolescent Kidney Transplant Recipients. Pediatric Transplantation, 25(3). https://doi.org/10.1111/petr.13988