The Science of DiabetesSelf-Management and Care2025, Vol. 51(2) 180–193© The Author(s) 2025Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106251319541journals.sagepub.com/home/tde
AbstractPurpose: The purpose of this study was to explore the barriers and facilitators to taking medication in newly diagnosed patients with type 2 diabetes (T2DM) at each stage of change from the perspective of the Transtheoretical model.
Methods: This qualitative descriptive study used purposive sampling to select 32 newly diagnosed patients with T2DM, with 8 representing each of the 4 stages of change (precontemplation, contemplation, preparation, and action). Participants were recruited at a community health service center in Sichuan Province, China. Semistructured interviews were conducted, and data were transcribed and analyzed using qualitative content analysis.
Results: This study identified barriers and facilitators related to the patient, medication, health care service, and sociocultural dimensions. At the precontemplation and contemplation stages, various barriers across different domains predominated (e.g., incomplete comprehension of the disease; gaps in medication knowledge regarding importance, benefits, and indications; limited access to care; preferred traditional and alternative medication approaches). At the preparation and action stages, although patient, medication, health care service, and sociocultural facilitators were more reported (e.g., awareness of medication benefits, health system financial support, peer medication experiences), medication-related barriers persisted (e.g., medication knowledge gaps regarding side effects, adverse reactions, administration procedures, and missed dose management).
Conclusions: The primary barriers to taking medication in newly diagnosed patients with T2DM are medicationrelated factors, with barriers and facilitators dynamically evolving across the stages of change. Future research should focus on developing and evaluating stage-matched interventions to promote medication-taking behavior and patient well-being.
Diabetes has become a significant public health concern globally. It is estimated that 537 million adults worldwide have been diagnosed with diabetes, a number expected to rise to 783 million by 2045.1 Among these, China reports the highest diabetes prevalence, with 140 million cases, comprising 26.2% of the global diabetes population.1 It is important to note that 96.0% of these diagnoses are type 2 diabetes mellitus (T2DM).2 Additionally, the prevalence of T2DM among middle-aged individuals in China is increasing, from 11.5% in 2007-2008 to 15.9% in 2010.3,4 Diabetes can lead to severe complications, such as cardiovascular diseases, chronic kidney disease, and diabetes retinopathy, while also imposing a substantial economic burden.5,6 Effective glycemic management in middle-aged patients with T2DM is of importance given these challenges.
Although glycemic management is always crucial, the first year after diagnosis represents a critical period for patients with T2DM because better glycemic control during this initial year can reduce the risk of future complications.7 In addition to lifestyle modifications, oral antidiabetes medications remain the primary approach to achieving glycemic control.8 The Association of Diabetes Care and Education Specialists (ADCES) recognizes taking medication as 1 of the 7 core self-care behaviors in their ADCES7 model, emphasizing its fundamental role in diabetes management. This model underscores the interconnectedness of self-care behaviors, with medicationtaking positioned in the inner ring alongside healthy eating and being active, forming the basis of many care plans.9
However, taking medication poses a significant challenge, with studies indicating that the first year after initiating chronic medication therapy is associated with the highest risk of inconsistent medication usage.10 Reported rates of inconsistent medication among patients with T2DM vary across countries, ranging from 21.2% in China and 23% to 24% in Germany to as high as 59.8% in Singapore.11-13 Additionally, a study conducted in Chinese community settings revealed that only 23.5% of patients with T2DM exhibited consistent medication-taking behavior.14 Moreover, studies have demonstrated that a 10% increase in consistent use of oral antidiabetes medications is associated with a 0.1% reduction in glycosylated hemoglobin levels, highlighting the importance of taking medication in diabetes management.15
Taking medication for T2DM has garnered significant attention among researchers. The literature review identified 2 main categories of research. The first category explores the influencing factors of taking medication for diabetes. A systematic review by Krass et al16 detailed and categorized several factors associated with taking medication in middle-aged patients. The study identified patient-related factors such as increasing age, gender, race, marital status, mental health status, educational level, the perceived need for medication, overall health status, and low socioeconomic status. Medical and treatment-related factors included the duration of diabetes, number of comorbidities and complications, type of diabetes medication, quantity of medications/daily doses, and perception of medication side effects. Health-care-related factors encompass health care costs, possession of health insurance, and regular or frequent communication with health care professionals. Although depression and health care costs were consistently mentioned across most of the studies, the evidence on the positive or negative association of other factors with medication-taking behavior was not conclusive. A review study on the factors influencing taking medication in Chinese patients with T2DM revealed that low educational level, medication-related factors such as multiple medication types and adverse effects, and unfavorable medication beliefs negatively impacted consistent and appropriate medication use.17 Notably, Cohen et al18 found a positive association between the long duration of diabetes and consistent medication routines, which prompted our interest in taking medication among newly diagnosed patients. Furthermore, previous studies overlooked sociocultural aspects despite the critical role of social support in aiding patients with diabetes in managing the disease and facilitating appropriate medication use.19
Regarding intervention research on taking medication in patients with T2DM, numerous studies have employed different interventional measures to promote taking medication as prescribed. Existing systematic reviews on interventions for taking medication in patients with diabetes have reported limited and inconsistent efficacy results, with no intervention consistently facilitating sustained and appropriate medication use.20,21 Furthermore, a recent systematic review by Teo et al22 revealed that very few behavior change techniques in medication-taking interventions described their context, used theory, or were tailored to address specific barriers to taking medication. To better inform the development of targeted interventions, a deeper understanding of the perceived barriers and facilitators of patients with T2DM at different stages of behavior change is required, which could be achieved through studies based on theoretical models of behavior change.
The stage of change (SOC) in taking medication is essential in understanding medication-taking behavior in patients with T2DM. The Transtheoretical model (TTM) provides a comprehensive framework for understanding behavior change as a process involving different stages and has been widely applied in various health behaviors, including taking medication.23 A study by Arafat et al24 demonstrated that based on the TTM, patients’ SOC significantly and positively predicted taking medication, validating the value of the TTM in identifying patients who may require targeted interventions to optimize their medication-taking behavior. Following a specific medication plan involves various actions beyond taking pills, such as attending scheduled appointments, refilling prescriptions, and aligning with the recommended dosing schedule.25
Therefore, conducting qualitative research to gain insights into the barriers and facilitators influencing medicationtaking among newly diagnosed patients with T2DM would be valuable. Uncovering the factors involved in this behavior change process would address the current limited research investigating taking medication and providing empirical evidence to inform the development of effective TTM-based interventions. The purpose of this study is to explore the barriers and facilitators to taking medication among newly diagnosed patients with T2DM across different SOC from the perspective of the TTM.
This study employed a qualitative descriptive (QD) approach, which is particularly suitable for health care research and for exploring poorly understood phenomena.26,27 The QD method provides a direct description of participants’ experiences, making it ideal for exploring the barriers and facilitators to medication taking among newly diagnosed patients with T2DM across different SOCs. This study conducted a QD interview involving 32 semistructured interviews with newly diagnosed patients with T2DM, 8 representing each of the 4 SOCs: precontemplation, contemplation, preparation, and action. The interviews were audio-recorded, transcribed verbatim, and analyzed using the Braun and Clarke28 thematic analysis framework. This method of thematic analysis is flexible, allowing for a thorough understanding of comprehensive data, which is suitable for this study because it involves participants from various SOCs in their medication experiences.
This study was guided by the TTM, a widely accepted theoretical framework of health behavior change.29 The TTM framework consists of 4 key components: SOCs, processes of change, decisional balance, and self-efficacy. In this framework, SOC represents behavior change progression, self-efficacy functions as a mediating variable, processes of change serve as strategic tools, and decisional balance examines pros (facilitators) and cons (barriers). The integration of SOCs and decisional balance guided our analysis of barriers and facilitators across stages, providing insights into cognitive and motivational changes.23
The TTM posits that the decision-making and enactment of behavior change constitute a continuous, cyclical process comprising 5 SOCs: precontemplation, contemplation, preparation, action, and maintenance. It focuses on the transition from behavioral intention (precontemplation, contemplation, and preparation) to actual behavior (action and maintenance), and the change process at the action stage is similar to maintenance.23 Therefore, this study conducted interviews only with participants at the precontemplation, contemplation, preparation, and action stages.
Furthermore, to delineate participants in different SOCs, this study integrated the TTM’s definitions of each SOC with the findings from Wang et al,30 which demonstrated that up to 4 instances of not taking medication as prescribed per month are clinically tolerable for patients with T2DM. This study defined the criteria for participant inclusion in the precontemplation, contemplation, preparation, and action stages (Figure 1).
This study was conducted at a Community Health Service Center (CHSC) in Sichuan Province, China. The inclusion criteria were (1) ages 40-59 years, inclusive; (2) diagnosed with T2DM and within the first 12 months of their disease course; (3) prescribed to take oral antidiabetes medication; and (4) in the precontemplation, contemplation, preparation, or action stage. The exclusion criteria were (1) in the maintenance stage, (2) other types of diabetes, and (3) treated with insulin.
A purposive sampling strategy was used. Participants were first screened based on the inclusion criteria through the chronic disease management system of the CHSC by staff with authorized access. Next, the researcher contacted eligible participants by phone, explained the study details, and obtained verbal informed consent. Then, participants’ SOC was determined through a brief assessment of their medication-taking behavior according to the criteria outlined in Figure 1, with those in the maintenance stage being excluded. Concurrently, data collection and preliminary analysis were conducted. After every 4 to 5 interviews, the emergence of new themes was evaluated. Finally, data saturation was considered reached when new interviews no longer produced substantial new information and all major themes were adequately defined. The final sample size was determined based on ensuring representation across all stages and achieving data saturation.
For data collection, BZ exclusively conducted semistructured interviews to minimize potential biases from having multiple interviewers. These interviews were audio-recorded, transcribed verbatim, and then cross-checked against the recordings to ensure accuracy. During the interviews, participants were invited to provide information about (1) daily medication routines, (2) barriers and facilitators to taking medication, (3) underlying reasons for these barriers and facilitators, and (4) suggestions for promoting consistent medication use. The questions in the interview guide were as follows:
Could you describe how you typically take your diabetes medications?
What challenges or factors influence your ability to follow the recommended oral medication plan?
What helps or motivates you to take your prescribed oral medications as suggested?
How do these barriers/facilitators influence your taking medication?
What kind of support or resources could assist you in better aligning with the recommended oral diabetes medication plan?
We employed a combined deductive and inductive approach in our content analysis, integrating the flexibility of Braun and Clarke’s28 thematic analysis with the structure provided by the TTM. This methodology facilitated the identification of themes grounded in the data while also considering the TTM framework, enabling the exploration of both anticipated and emergent concepts in medication-taking behavior. The interviews were meticulously transcribed verbatim by BZ, GL, and SL, and interviews ceased when data saturation was achieved, at which point no new themes or information emerged.31
For deductive analysis, we used TTM framework to categorize participants into different SOCs and established 4 core domains (patient, medication, health care service, and sociocultural) as the analytical framework. Two researchers, BZ and GL, independently coded the transcripts into these predefined stages and domains. In instances of divergent views, a third researcher, SK, provided verification, and the researchers discussed until consensus was reached. In the subsequent inductive analysis, BZ and GL identified how barriers and facilitators manifested and evolved across stages and domains, showing their progression from barrier dominance to facilitator emergence. Two additional researchers, AP and JS, reviewed and validated our coding framework and interpretations of the patterns identified, and consensus among researchers confirmed the credibility of the findings
The CHSC granted permission to conduct the study. At the outset, all potential participants were contacted by phone and provided with comprehensive information about the research objectives, methodologies, confidentiality measures, and their unconditional right to withdraw participation. This study received approval from the Ethical Review Committee for Human Research (MUPH 2022-154), and verbal informed consent was duly obtained from every participant before their involvement in the study.
Thirty-two newly diagnosed patients with T2DM participated in this study, representing 4 SOCs: precontemplation, contemplation, preparation, and action. Data saturation was reached for each stage, resulting in 8 patients in each stage. The average age of the participants was 54.31 years (SD = 4.85). Among them, 71.9% were female, and 59.4% had blood glucose levels not within the recommended target ranges. The average duration of the interviews was 35.41 minutes (SD = 15.99).
Guided by the TTM framework, this study deductively applied the decisional balance component to reveal barriers and facilitators to taking medication among newly diagnosed patients with T2DM across 4 SOCs, focusing on 4 domains: patient, medication, health care service, and sociocultural (Tables 1 and 2). Inductive analysis found that these barriers and facilitators exhibited dynamic changes across the stages. In the precontemplation and contemplation stages, barriers outweighed facilitators. However, as patients progressed to the preparation and action stages, facilitators became increasingly prominent and barriers diminished (Figure 2).
In the precontemplation stage, deductive analysis revealed barriers across 4 domains (patient, medication, health care service, and sociocultural), particularly in the medication domain. Inductively, this stage featured exclusive barriers with no facilitators.
In the patient domain, participants in the precontemplation stage included incomplete disease comprehension and emotional burden. Those with limited education faced difficulties in accepting and understanding their prescribed medication plans. Moreover, being newly diagnosed with T2DM at a relatively young age could initially lead to struggles in accepting reality, causing psychological distress, uncertainty, and even doubts about the diagnosis:
My education level is not high, I don’t understand the information about those medications nowadays. (P7)
I heard others say that the disease can be managed without medication. (P8)
I never thought I would get T2DM at such a young age. . . . I was under a lot of psychological pressure and felt a little overwhelmed. I still wonder if the diagnosis was wrong. (P1)
In the medication domain, participants in the precontemplation stage encountered various barriers to taking medication. These barriers included a medication knowledge gap regarding the importance and benefits of medications, considerable concerns over potential adverse effects, and worry about becoming overly dependent on medications to manage their condition:
Taking medicine is not the most important thing, I can control it through diet. (P4)
Medicine is poisonous, it will hurt the liver and kidneys. (P1)
I’m afraid that once I start taking medication, I’ll have to take it for life and become dependent. (P5)
In the health care service domain, participants at the precontemplation stage predominantly identified negative interactions and experiences with health care professionals and limited care access due to geographical constraints and logistical issues in obtaining medications:
I don’t trust family doctors. They never really took the time to explain my medications to me . . . every visit felt rushed and superficial. (P4)
I moved to the west side of the city, and it’s not convenient to come to the CHSC to get medications. (P3)
In the sociocultural domain, precontemplation stage participants faced 2 primary barriers: a preference for traditional Chinese medicine and other alternatives over prescribed treatments and limited family support. They believed in the effectiveness of Chinese medicine for their condition. Moreover, family members’ preoccupation with different responsibilities and crises contributed to insufficient support for the patients’ medication-taking:
Western medicine harms the liver and kidneys . . . I believe in Chinese medicine more. (P2)
I bought foot patches on the internet. I can cure diabetes without medication. (P3)
My husband does not care about me. He has not advised me on whether to follow the doctor’s recommendations for taking medication. Everything in my daily life remains as it was before the diagnosis. (P7)
In the contemplation stage, deductive analysis revealed barriers still existed across domains, but facilitators emerged specifically in the medication domain. Inductively, compared to the precontemplation stage, participants demonstrated less resistance to medication-taking, although barriers still outweighed facilitators.
In the patient domain, participants in the contemplation stage exhibited fewer barriers compared to those in the precontemplation stage, primarily due to the lack of perceived symptoms. They believed that the absence of symptoms meant there was no need for taking medication:
I currently have no complications, feel well, and my blood glucose is normal, so medication is unnecessary for now. (P9)
In the medication domain, participants in the contemplation stage demonstrated ambivalence toward changing their medication-taking behaviors. Unlike those in the precontemplation stage, they did not reject medication outright and showed an awareness of its health benefits. However, participants in the contemplation stage still faced significant barriers to consistent medication use, including misunderstandings regarding medication use indications, discontinuation due to medication side effects, and complex dosage schedules:
I plan to manage my condition through dietary control for the present rather than taking medication. (P11)
I had a hard time with my stomach on metformin, so I stopped taking it. (P13)
I take 2 medications, and I’m often confused as to which one to take before bed, or in the morning on an empty stomach, or after a meal, or before a meal. (P14)
I know that medications can cure diseases. Otherwise, why would so many drugs be invented? (P12)
In the health care service domain, participants in the contemplation stage identified no facilitators, time limit for consultation, limited support from health professionals, and diminished trust in health professionals as the primary barriers:
Each visit was limited and crowded, so I didn’t have the opportunity to ask doctors for more medication information. (P16)
The doctor did not particularly strongly suggest that I had to take medication. (P12)
Doctors in community hospitals do not have high professionalism, and many diseases cannot be cured. (P10)
In the sociocultural domain, participants in the contemplation stage noted no facilitators, with stigma avoidance emerging as the key barrier:
Once people see me taking medications, they will ask me if I’m sick, and I don’t want people to know that I have diabetes at such a young age. (P11)
In the preparation stage, participants started taking initial steps toward medication-taking behavior change. Deductive analysis revealed barriers persisted in patient and medication domains, and facilitators emerged in medication, health care service, and sociocultural domains except the patient domain. Inductively, participants demonstrated a balance between barriers and facilitators in their medication-taking behavior.
In the patient domain, participants in the preparation stage encountered a significant challenge with no identified facilitators. The primary barrier was frequently forgetting to take medication due to busy schedules:
I have to take care of my grandchildren. I am too busy, so I occasionally forget to take my medication. (P18)
I am a plumber and I usually have to go out very early in the morning and work until late at night . . . so I often forget to take my medication. (P19)
In the medication domain, participants in the preparation stage primarily faced the challenge of a medication knowledge gap, particularly regarding side effects and adverse reactions. However, their awareness of the benefits of medication in delaying the onset of complications served as a facilitating factor:
I initially took the medication [ie, metformin] before meals, but after taking it, I felt bloating and vomiting. . . . I didn’t know it was an adverse reaction to the medication. (P23)
Diabetes isn’t scary, but the complications are scary if you take your medication on time you won’t get complications so fast, like blurry eyes, rotting feet. (P23)
In the health care service domain, preparation stage participants identified no barriers, in contrast to those in the precontemplation and contemplation stages. Instead, they highlighted trust in health professionals and health system financial support as facilitators that improved medication accessibility and encouraged patients to take their medication as prescribed:
The doctor’s prescription implies this medication aligns with my health needs, regardless of perceived usefulness. . . . Now that health insurance can cover a large part of my expenses, I only spend more than CNY 10 for a month’s worth of medicine in the community. (P19)
In the sociocultural domain, spiritual beliefs emerged as the sole barrier to participants in the preparation stage taking medication on time. Conversely, learning from peers’ experiences with medications served as a critical facilitator for them in following the recommended medication plans:
We don’t take medicine for New Year’s, holidays and birthdays, and it’s taboo for us. (P22)
I have a relative who also has T2DM. She didn’t take medication at the beginning, but later when it got serious, she couldn’t control her blood glucose with the medicine. (P21)
In the action stage, participants consistently progressed in medication-taking behavior. Deductive analysis showed that facilitators dominated in patient and health care service domains and that barriers coexisted with facilitators in medication and sociocultural domains. Inductively, participants demonstrated a clear predominance of facilitators over barriers across domains.
In the patient domain, participants at the action stage no longer faced barriers. Instead, maintaining a daily routine and psychological reassurance emerged as facilitators of taking medication:
I wake up, eat and go to bed on time every day. I have a routine and know exactly when to take my medication. (P32)
I feel secure after taking the medicine, but I feel disconcerted without it. (P27)
In the medication domain, participants at the action stage encountered a barrier stemming from a medication knowledge gap, specifically regarding administration and missed dose management, which could influence their ongoing medication-taking behavior. However, their awareness of medication benefits, such as clinical symptom improvement, emerged as a significant facilitator, encouraging them to continue taking medication as prescribed:
If I miss taking my glucose-lowering medication, I will make up for it by doubling the next dose. (P27)
I take my pills with my milk for breakfast. (P25)
After taking the medication, I feel that my state is better than before . . . and my spirit is much better. (P31)
In the health care service domain, participants at the action stage faced no barriers that affected their medicationtaking behavior. They received satisfactory service delivery and had trust in health professionals, similar to those in the preparation stage. They accepted the knowledge about the disease conveyed by the doctors and believed that taking medication could save on future medical expenses:
My family doctor is supportive, and I think the medicine he gave me has the intended effect. I have confidence in his advice. (P30)
I take my medication on time so that I don’t have to spend a lot of money on treating complications that arise. The money I spend on medication is nothing compared to the money I spend on treating complications. (P27)
In the sociocultural domain, participants at the action stage faced challenges with medication use in social and business settings. However, family support had become a facilitator for their taking medication:
I have many business or social engagements that often involve drinking, so I frequently can’t take my medication. (P30)
My son bought me a pill box and configured it to put on the dining table, so I don’t forget to take my medication every time I eat. (P25)
Taking medication as prescribed is crucial for controlling the condition of patients with T2DM because not taking medication as prescribed can potentially exacerbate the disease and worsen complications.32 This study represents the first application of the TTM to explore the barriers to and facilitators of taking medication in newly diagnosed patients with T2DM through a qualitative method. The following discussion addresses 3 main aspects. Initially, it examines the main barriers and facilitators patients face at SOC, presenting the dynamic process of how these factors change as behavior changes. This aligns with the TTM’s decisional balance concept, where barriers represent cons and facilitators represent pros. Subsequently, it analyzes the barriers and facilitators at specific stages from the perspectives of the core domain of medication and other domains, including patients, health care system, and sociocultural factors. Finally, this study provides valuable insights into medication-taking behavior that inform both health care provider practices and patient self-management.
Through inductive content analysis, this study reveals a pattern in the progression of behavior change stages from precontemplation to action characterized by patients perceiving fewer barriers and more facilitators. This emergent pattern aligns with the concept of decisional balance in the TTM.23 Decisional balance, a component in the TTM, reflects individuals’ evolving assessment of pros and cons during behavior change, transitioning from perceiving obstacles as outweighing benefits to recognizing benefits as surpassing obstacles.23 Furthermore, this study finds that participants in the precontemplation and contemplation stages face more barriers, often due to limited medication knowledge or misconceptions about hypoglycemic medications, echoing findings by Polonsky and Henry.32 Based on these findings, health care providers should prioritize enhancing medication awareness and emphasizing its benefits for the preaction stage to support patients taking medication. Notably, patients across stages encounter various barriers, with those in the preparation and action stages facing fewer obstacles but still encountering challenges, such as medication forgetfulness and misunderstanding of adverse reactions and proper usage. These findings underscore the importance of health care providers providing targeted medication education, especially on adverse reactions and usage, for patients in the preparation and action stages and implementing effective reminder systems to facilitate consistent medication-taking.
Furthermore, through deductive content analysis, this study identified specific barriers and facilitators at different stages from 4 domains: medication, patients, health care system, and sociocultural factors. Our findings align with and expand on the barriers identified in the ADCES7 model.9 Whereas the ADCES7 model highlights general barriers, such as plan complexity, physical limitations, financial constraints, and health beliefs, this study provides a more nuanced understanding of how these barriers manifest across different stages of change. For instance, the ADCES7 model’s emphasis on health beliefs aligns with our findings of misconceptions about medication in the precontemplation and contemplation stages. Similarly, the cognitive and psychological barriers mentioned in ADCES7 correspond to our observations of forgetfulness and emotional burden across various stages. This study extends the ADCES7 model by demonstrating how barriers evolve across the SOCs. For example, whereas the ADCES7 model identifies plan complexity as a general barrier, this study shows how this manifests differently from complex dosage schedules in the contemplation stage to missed dose management in the action stage. This stage-specific understanding can inform more targeted interventions.
The medication domain is a crucial component of all SOCs. This study revealed that medication knowledge gaps are prevalent across the precontemplation, contemplation, preparation, and action stages. Despite this commonality, the specific knowledge gaps differ at each stage. Williams et al33 emphasized the importance of providing personalized medication information and advocated for interventions tailored to patients’ evolving needs. This study indicated that specifically, in the precontemplation stage, patients may hesitate to initiate medications due to underestimating their significance and benefits; in the contemplation and preparation stages, gaps in understanding indications and potential side effects pose barriers to continuing medication use; in the action stage, patients may misuse or miss doses due to uncertainty about proper administration. Moreover, Williams et al33 noted that perceptions of treatment ineffectiveness impact taking medication in patients with T2DM. This study confirms this finding, demonstrating that consistent medication-taking is facilitated when patients recognize and experience the benefits of their treatment and have a deeper understanding of their disease and its management. Therefore, this study underscores the necessity of delivering targeted, stage-specific health education to enhance taking medication in patients with T2DM by addressing evolving barriers and facilitating awareness of medication efficacy.
Although the medication domain is crucial, the patient, health care service, and sociocultural domains are indispensable dimensions that shape medication-taking.34 For newly diagnosed patients, psychological barriers, such as anxiety and fear, especially in the preparation stage, could contribute to difficulties in consistently taking medications, as this study revealed. Accordingly, this study proposes offering psychological support alongside health education to address patients’ initial hesitancy or concerns, foster positive perspectives regarding their condition, promote acceptance, and ultimately, facilitate consistent medication-taking behaviors. Prior research indicated health beliefs played a role in the interplay between depressive symptoms and consistent medication routines among patients with diabetes, which aligns with the importance of shaping appropriate health beliefs for this study.35 Moreover, this study revealed that maintaining a daily routine facilitated consistent medication-taking among newly diagnosed patients with T2DM, echoing Hashimoto et al,36 who found that an orderly lifestyle facilitated consistent medication routines in patients with diabetes for over a year. This study further supported Jaam et al’s34 findings on the impact of patient-provider communication given that this study found that negative medical experiences hindered consistent medication-taking and that trust in and positive attitudes toward doctors promoted consistent medication usage. Interestingly, the beliefs that traditional Chinese medicine treats root causes influenced medication behavior in patients in the preparation stage. Although traditional Chinese medicine can reduce blood glucose and delay prediabetes progression, its long-term efficacy in treating diabetes and its complications remains unclear.37 It necessitates that health care professionals provide information on both treatment modalities and elucidate their differences, strengths, and complementary uses to cultivate accurate health beliefs.
The strength of this study lies in its combined analytical approach, which not only structured findings through TTM stages but also extended the framework by revealing dynamic patterns of barriers and facilitators across domains. Based on this structured analysis through TTM stages, the results of this study suggest several practical implications. First, health care providers need to recognize the dynamic nature of medication-taking behavior, where barriers dominate in early stages and facilitators gradually emerge and expand across domains. Second, our findings reveal important paradoxes requiring attention. Although medication knowledge gaps persist across all stages, their nature evolves from fundamental understanding in precontemplation to specific administration issues in action stage. Furthermore, although health care service barriers are prominent in early stages, trust in health care professionals becomes a key facilitator in later stages, highlighting the importance of sustained provider-patient relationships. Finally, the complex interplay between domains suggests that interventions should be tailored to both stage-specific characteristics and domain-specific challenges, particularly considering the role of cultural beliefs and family support in medication-taking behavior.
Our findings also suggest stage-specific strategies to enhance patient self-management. In the precontemplation stage, when patients face comprehensive barriers, self-management focuses on active information seeking about disease progression and medication benefits while building family support systems and improving health care communication. Moving into contemplation stage, as facilitators emerge in medication domain, patients benefit from systematic symptom tracking and medication effect monitoring, with enhanced provider communication to address concerns. During preparation stage, when facilitators expand across health care and sociocultural domains, selfmanagement emphasizes developing personalized medication routines, engaging with peer support networks, and using health care resources effectively. By action stage, although specific medication challenges persist, patients can strengthen their established routines by integrating medication-taking into daily life, maintaining family support, and reinforcing the psychological reassurance from consistent medication use.
This study highlights its strength in using the TTM framework to explore medication-taking behaviors among newly diagnosed patients with T2DM, identifying key barriers and facilitators at various SOCs. The findings validate and expand on existing research, uncovering common and unique challenges in taking medication.24,38 Notably, all stages shared the hurdle of insufficient medication information, with psychological issues, patientprovider communication, and family support needs receiving particular attention in the precontemplation and contemplation stages. Furthermore, the analysis across the medication, patient, health care system, and sociocultural domains sets a foundation for crafting more encompassing strategies to promote medication-taking behavior. This study enriches the literature on T2DM medication-taking based on the TTM, offering an in-depth perspective on the dynamics of change.24,38
Although the study offers a beneficial understanding of medication-taking issues experienced by newly diagnosed patients with T2DM, not considering perspectives from health care providers, caregivers, or family members that might have provided more valuable insights into taking medication could be considered as the study limitation.
This study recommends that future interventions specifically target newly diagnosed patients with T2DM, identify their SOC in medication-taking behavior, and develop stage-specific intervention strategies based on the common and unique barriers and facilitators encountered at each SOC, as revealed by this study. Additionally, this TTM-based qualitative methodology could be applied to broader populations, including older adults with T2DM, individuals with prediabetes, and those with other diabetes types, to dissect the nuances of behavior change stages and pinpoint precise barriers and facilitators.
The findings underscore the critical importance of enhancing doctor-patient communication in the health care system, a key factor influencing medication-taking behavior among newly diagnosed patients with T2DM, particularly highlighting the roles of trust in doctors and their attitudes. Although financial support from the public health system facilitates treatment, this study advocates prioritizing health policies that enhance service attitudes and communication skills of community doctors. Cultivating patient trust is vital to promoting consistent medicationtaking behaviors. Practically, health care providers should undergo professional training to improve their communication techniques and attitudes toward patient care. Moreover, based on the TTM, health care providers should tailor patient education to cover medication details, psychological support, and family involvement to match patients’ SOC, fostering an environment that promotes consistent medication use.
This study provides original qualitative insights into the multifaceted nature of barriers to and facilitators of taking medication among newly diagnosed patients with T2DM. Predominantly, medication domain barriers are mentioned more frequently by patients across all SOCs than barriers related to the patient, health care system, and sociocultural factors. These barriers and facilitators dynamically evolve as patients progress through different SOCs. Specifically, in the precontemplation and contemplation stages, barriers across all dimensions dominate, such as incomplete comprehension of the disease; gaps in medication knowledge regarding importance, benefits, and indications; and limited access to care. Conversely, in the preparation and action stages, facilitators from all domains become more prominent, including awareness of medication benefits and health care subsidies, although challenges related to medication and forgetting to take it still necessitate careful consideration. These findings are crucial for public health practitioners and organizations to craft stage-specific interventions, fostering behavioral change in patients and thus improving medication-taking and disease management.
The authors appreciate the support from the Community Health Service Center diabetes team; the facilitation and student assistance from the School of Nursing, Southwest Medical University; and all participating patients for sharing their experiences.
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors and are in agreement with the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
This work was supported by the Southwest Medical University Social Science Association Research Project (No. SMUSS202227), the Sichuan Modern Design and Culture Research Center Scientific Research Project (No. MD22E006), and the Sichuan Province University Student Innovation and Entrepreneurship Training Plan Project (No. S202310632139).
Baolu Zhang https://orcid.org/0009-0001-1905-0767
Surintorn Kalampakorn https://orcid.org/0000-0003-1193-8937
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From School of Nursing, Southwest Medical University, Luzhou, China (Dr Zhang, Miss Li); Department of Nursing, The Affiliated Hospital, Southwest Medical University, Luzhou, China (Ms Zhang); Department of Public Health Nursing, Faculty of Public Health, Mahidol University, Bangkok, Thailand (Dr Zhang, Dr Powwattana, Dr Kalampakorn); Department of Biostatistics, Faculty of Public Health, Mahidol University, Bangkok, Thailand (Dr Sillabutra); and Department of Orthopedics and Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China (Dr Liu).
Corresponding Author:Surintorn Kalampakorn, Department of Public Health Nursing, Faculty of Public Health, Mahidol University, 420/1 Rajvithi Rd, Bangkok, 10400, Thailand.Email: surintorn.kal@mahidol.ac.th
