# Self-Management, Adherence, and the Role of Pharmaceutical Care in Patients with T2DM in Primary Practice: A Cross-Sectional Survey in Bulgaria

## TL;DR

The study explores diabetes management in Bulgaria, finding high medication adherence but gaps in lifestyle behaviors and education, suggesting pharmacists could play a bigger role.

## Contribution

Highlights underutilized pharmacist roles in diabetes care and identifies specific educational needs among Bulgarian T2DM patients.

## Key findings

- High adherence to medication (93.0%) but lower adherence to diet, exercise, and glucose monitoring.
- Over 40% of patients expressed a need for additional diabetes education, especially on hypoglycemia and digital tools.
- Pharmacists are a source of information for half of patients, but only 38% are willing to engage in pharmacist-led education.

## Abstract

Background: Type 2 diabetes mellitus (T2DM) is a prevalent chronic disease requiring effective pharmacological treatment, sustained self-management, and patient education. Pharmacists are increasingly recognized as key contributors to diabetes care; however, their role remains underutilized in Bulgaria. This study aimed to assess self-management behaviors, medication adherence, patient awareness, and the perceived role of pharmacists among patients with T2DM in Bulgarian primary care. Methods: A cross-sectional observational study was conducted among 105 patients with T2DM using an anonymous questionnaire based on the Diabetes Self-Management Questionnaire and supplementary items adapted to the local healthcare context. Data were analyzed using descriptive statistics and non-parametric tests to explore associations between demographic characteristics, treatment patterns, self-management behaviors, and educational needs. Results: Most patients were treated with oral antidiabetic therapy (90.0%), predominantly metformin-based regimens (64.0%). Adherence to prescribed pharmacological treatment was high (93.0%), while adherence to dietary recommendations (70.0%), regular physical activity (60.0%), and blood glucose self-monitoring (63.0%) was less consistent. Although 92.0% of participants reported good or excellent disease awareness, 41.0% expressed a need for additional education, particularly regarding confidence in managing hypoglycemia and the use of digital monitoring tools. More than half of respondents (54.0%) had received diabetes-related information from a pharmacist; however, only 38.0% expressed willingness to participate in pharmacist-led education, while 34.0% were undecided. Female sex was associated with a higher prevalence of comorbidities (p = 0.010), while increasing age was associated with reduced metformin use (p = 0.004). Conclusions: Despite good pharmacological adherence and self-reported awareness, gaps remain in lifestyle-related self-management and patient education. The findings support an expanded role for pharmacists in diabetes care, particularly through structured educational and counseling interventions to enhance self-management and complement physician-led treatment.