# Different Barriers, Different Needs: A Qualitative Study on How Educational Level Shapes Barriers to Type 2 Diabetes Self-Management in Urban Pakistan

## TL;DR

This study shows how education level affects diabetes self-care challenges in urban Pakistan, highlighting the need for tailored interventions based on cultural and educational contexts.

## Contribution

The study reveals how educational level shapes distinct barriers to diabetes self-management in Pakistan, emphasizing the need for education-sensitive and culturally tailored interventions.

## Key findings

- Higher-educated individuals face barriers like time constraints and inadequate dietary guidance from healthcare providers.
- Lower-educated participants often have misconceptions about exercise and diet, such as believing household chores are sufficient exercise.
- Both groups struggle with adhering to dietary restrictions in social settings due to cultural norms discouraging food refusal.

## Abstract

Objective

This study aimed to explore how individuals with different educational levels in urban Pakistan experience barriers to type 2 diabetes mellitus (T2DM) self-care across key self-care dimensions.

Methods

A qualitative phenomenological study was conducted at the Diabetes Clinic of the Pakistan Institute of Medical Sciences, Islamabad. Forty-three adults diagnosed with T2DM were recruited and stratified by educational level (≥ high school, n = 17; < high school, n = 26). Semi-structured interviews were conducted, and transcripts were thematically analyzed to examine how educational level shapes barriers to T2DM self-care within Pakistan’s sociocultural context. Coding was performed iteratively until thematic saturation was reached, ensuring comprehensive representation of participant perspectives.

Results

Participants with higher education reported barriers such as time constraints due to demanding workloads and restrictive sociocultural expectations that limit engagement in public physical activity (e.g., walking) and structured meal planning. Many also reported receiving insufficient dietary guidance from healthcare providers tailored to their schedules and lifestyles. Predominant misconceptions among participants with lower education included equating household chores with adequate exercise and failing to recognize hypoglycemic symptoms. They also demonstrated limited understanding of dietary principles, such as believing that fruit juice is beneficial for individuals with T2DM. Notably, participants across both educational strata found it difficult to adhere to dietary restrictions in social settings, particularly during weddings and communal meals, where refusing food is culturally discouraged.

Conclusions

Barriers to T2DM self-care in urban Pakistan differ markedly by educational level. Improving T2DM self-care requires education-sensitive, community-based interventions tailored to the local sociocultural context. Higher educational attainment alone does not ensure adequate self-care, as cultural norms exert a strong influence that education alone cannot overcome. For individuals with lower education, self-care programs should prioritize tailored foundational dietary education to address fundamental knowledge gaps. For those with higher education, interventions should emphasize practical implementation strategies, including structured guidance on integrating self-care practices into demanding work routines and community-based initiatives that promote physical activity and challenge restrictive cultural norms. Such context-specific, stratified approaches may enhance T2DM self-care, improve glycemic control, and lead to better health outcomes.