Understanding type 2 diabetes self-management in the Marshall Islands: A mixed-methods exploration of sociocultural and structural barriers

Type 2 diabetes mellitus (T2DM) poses a critical public health challenge in the Republic of the Marshall Islands, where prevalence rates are among the highest globally. Despite the central role of self-management in diabetes care, adherence and utilization of health services remain inadequate and are major contributors to diabetes-related morbidity and mortality. We aimed to identify factors influencing self-management and to explore the sociocultural context shaping these behaviors using an explanatory sequential mixed methods approach. From March to May 2023, we surveyed 123 randomly selected T2DM outpatients aged 18 years and older in Majuro Atoll. We assessed self-management practices, illness perception, diabetes knowledge, clinical characteristics, and sociodemographic factors, and used regression analysis to identify key predictors of self-management. Subsequently, semi-structured interviews with ten patients and three healthcare providers were conducted and analyzed thematically. Findings revealed that 76% of participants demonstrated inadequate self-management. Despite 90% recognizing diet as a causative factor, dietary control scored lowest among self-management domains, highlighting a disconnect between awareness and action. A higher perceived threat of illness was associated with poorer self-management, suggesting that fear may discourage rather than encourage coping action. While attending diabetes education classes was positively associated, diabetes knowledge level was not a significant predictor. Three key themes emerged as barriers to self-management that lie beyond individual control: i.Dysfunctional healthcare service delivery, ii. Diabetes fatalism, and iii. Food desert. This study highlights the need for culturally tailored health education, psychological support to counter diabetes fatalism along with strengthening health systems to better respond to patient needs, and policies to improve food security, which are critical to improving diabetes outcomes in this high-risk population.