Study design

This study employed a qualitative systematic review design to synthesize existing research evidence on the barriers and enablers to diabetes self-care among individuals living with diabetes in Ethiopia. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [26] and the PRISMA Extension for Qualitative Evidence Synthesis (PRISMA-QS) [27], ensuring methodological transparency, rigor, and reproducibility throughout all stages of the review process.

Aim of the study

This qualitative systematic review aimed to generate a contextualized and comprehensive understanding of the barriers and facilitators influencing diabetes self-care practices in Ethiopia by synthesizing evidence from primary qualitative studies and the qualitative components of mixed-methods studies.

Review protocol

To ensure accountability and reduce potential bias, a detailed review protocol was developed before commencing the review. The protocol outlined the review objectives, eligibility criteria, search strategy, data extraction procedures, critical appraisal framework, and synthesis method. It was designed by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [3], which provides methodological guidance for qualitative reviews. The protocol was registered with PROSPERO under registration number CRD420251033692 on April 01, 2025, serving as a formal commitment to methodological integrity.

Search strategy

A comprehensive and systematic literature search was conducted across PubMed/MEDLINE, Scopus, CINAHL, Web of Science, and Google Scholar. The search included studies published up to March 15, 2025, and was updated before manuscript submission. Both free-text keywords and Medical Subject Headings (MeSH) terms were used to enhance sensitivity and specificity. Search terms were combined using Boolean operators and included: (“Diabetes” OR “Diabetes Mellitus” OR “Type 2 Diabetes”) AND (“Self-care” OR “Self-management”) AND (“Barriers” OR “Facilitators” OR “Challenges” OR “Enablers”) AND (“Qualitative” OR “Mixed Methods”) AND (“Ethiopia”). In addition, backward citation tracking of reference lists was performed to identify any additional eligible studies missed during the initial database searches.

Inclusion and exclusion criteria

Eligibility criteria were defined using the SPIDER framework, which is well-suited for qualitative evidence synthesis. The Sample (S) included adults diagnosed with diabetes mellitus, as well as healthcare professionals, caregivers, or family members involved in diabetes care within Ethiopia. The Phenomenon of Interest (PI) focused on diabetes self-care practices, specifically barriers and facilitators. The Design (D) included qualitative methodologies such as interviews, focus group discussions, ethnography, and narrative inquiry. Evaluation (E) captured lived experiences, perceptions, beliefs, and contextual influences related to self-care. The Research type (R) included primary qualitative studies and mixed-methods studies with extractable qualitative findings. Studies conducted outside Ethiopia, purely quantitative studies, reviews, editorials, and commentaries were excluded.

Search and screening process

Search results were imported into Zotero reference management software, and duplicates were removed. Two reviewers (SA and FK) independently screened 100% of all titles and abstracts for eligibility. Full-text articles were retrieved and independently assessed in full by both reviewers. Any discrepancies at either screening stage were resolved through discussion and consensus. The study selection process was documented using the PRISMA 2020 flow diagram, capturing the number of studies identified, screened, excluded, and included, along with reasons for exclusion at each stage (Fig 1). The final database search included studies published up to March 15, 2025. Study selection, data extraction, and synthesis were conducted according to the predefined review protocol and PRISMA 2020 guidelines.

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Fig 1. PRISMA 2020 flow diagram describing the selection of studies for the systematic review and meta-analysis on barriers and enablers on diabetic self-care practice in Ethiopia, 2025.

https://doi.org/10.1371/journal.pone.0346867.g001

Data extraction

Data extraction was conducted independently by two reviewers using a standardized, piloted data extraction form. Extracted data included study characteristics, participant details, methodological features, and reported barriers and facilitators to diabetes self-care. Following independent extraction, the reviewers compared extracted data, and any discrepancies or inconsistencies were resolved through discussion and consensus to ensure accuracy and completeness. When study information was missing or unclear, interpretation was restricted to the data explicitly reported in the published articles, and no assumptions were made beyond the available information. Authors were not contacted for additional clarification, as all included studies provided sufficient qualitative data to support thematic synthesis.

Researcher reflexivity

To enhance the credibility and trustworthiness of this qualitative synthesis, reflexivity was actively maintained throughout the review process. The reviewers brought diverse professional backgrounds in nursing, public health, and qualitative research, which offered valuable perspectives but also necessitated careful attention to potential biases. Reflexive practices, including journaling, memo writing, and regular team discussions, were employed to critically examine how personal assumptions, prior experiences with diabetes care, and contextual knowledge of the Ethiopian healthcare system might shape data interpretation. By consciously acknowledging and interrogating our positionalities, we sought to remain transparent and minimize subjective influence during data extraction, coding, and thematic synthesis. This reflexive stance strengthened the integrity and rigor of the review process.

Data synthesis

Thematic synthesis, as described by Thomas and Harden [28], was employed to integrate and interpret findings across studies. Initial line-by-line coding was performed independently by both reviewers. Codes were then compared and collaboratively refined into descriptive and analytical themes. This method involved: (1) line-by-line coding of extracted findings, including both participant quotes and author interpretations; (2) organizing codes into descriptive themes; and (3) developing analytical themes that extended beyond individual study findings to offer new insights into diabetes self-care in Ethiopia. The synthesis process was iterative and collaborative, with continuous engagement among reviewers to refine themes and ensure alignment with the review question and Ethiopian context.

Quality appraisal

To assess the methodological quality of the included studies, the Critical Appraisal Skills Programme (CASP) Qualitative Checklist was applied [29]. This tool examines aspects such as clarity of the research aim, appropriateness of design, sampling strategies, data collection, ethical considerations, reflexivity, and analytical rigor. Two reviewers independently appraised all included studies using the CASP Qualitative Checklist. Disagreements were resolved through discussion, with consensus reached in all cases. Although no study was excluded based on quality, the appraisal helped inform the interpretation and trustworthiness of the review findings.

Assessment of confidence in the evidence

The GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) [30] approach was used to assess the confidence in each synthesized theme. This framework evaluates the methodological limitations of the contributing studies, coherence of the data, adequacy (richness and quantity), and relevance to the review question. Each key finding was assigned a confidence level (high, moderate, low, or very low), and justifications were documented to ensure transparency.

Ethical considerations

This review did not involve the collection of primary data and was based exclusively on previously published studies. Therefore, formal ethical approval was not required. Nonetheless, ethical rigor was ensured by including only studies that had received ethical clearance from their respective institutional review boards and had obtained informed consent from all participants. By synthesizing ethically conducted research, this review upholds the principles of research integrity and respect for participants.

Study selection

A total of 62 records were retrieved from the database search and 02 additional results through other sources, of which 64 unique records were obtained. After screening titles and abstracts, 26 articles remained for full-text screening. Eleven of these studies met the eligibility criteria (Fig 1). Studies excluded after full-text review (n = 15) and their reasons for exclusion are provided in Supplementary file (S1 File). The included studies, published between 2013 and 2023, comprised a diverse range of qualitative and mixed-methods research conducted across Ethiopia to explore the multifaceted barriers and facilitators influencing diabetes self-care [21–23,25,31–37]. These studies were situated in various geographic and institutional contexts, encompassing both urban and semi-urban health facilities, such as Tikur Anbessa Hospital in Addis Ababa [21,33], Dessie Referral Hospital in Northern Ethiopia [36,37], and Kemisse General Hospital in the northeast [22].

Methodologically, most studies adopted robust qualitative approaches, including descriptive [25], phenomenological [22,31], and exploratory designs [21], while others integrated mixed methods to capture both quantitative and qualitative dimensions [34,36]. This methodological pluralism allowed researchers to explore both lived experiences and broader patterns of self-care adherence, guided by theoretical frameworks such as the Health Belief Model and Theory of Planned Behavior [34].

The sample populations were also diverse, ranging from people living with type 1 diabetes as young as 13 years old [22] to older adults living with type 2 diabetes with long disease durations [31]. Several studies also incorporated key informants, including healthcare professionals and caregivers, reflecting a multidimensional understanding of diabetes care ecosystems [23,25]. Data collection techniques primarily relied on in-depth and semi-structured interviews, often supported by thematic analysis using software such as Atlas. Ti or NVivo [25,33], while some studies also employed structured questionnaires and direct observation to enrich data validity [22,36] (Table 1).

Methodological quality of included studies

The overall methodological quality of the included studies was robust, demonstrating rigorous design and thoughtful execution across diverse qualitative paradigms. All eleven studies clearly articulated their research aims and employed appropriate qualitative methodologies aligned with their objectives, including phenomenological, descriptive, exploratory, and mixed-methods approaches [21–23,25,31–37]. Most studies adopted sound recruitment strategies and collected data through in-depth or semi-structured interviews, often complemented by observational methods or supplementary surveys [22,25,34].

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Table 1. Charectrstic of included study on exploring barriers and enablers to diabetes self-care in Ethiopia, 2025.

https://doi.org/10.1371/journal.pone.0346867.t001

Data analysis procedures were consistently rigorous, utilizing thematic analysis supported by qualitative software such as Atlas. Ti, NVivo, and Open Code [21–23,25,31–37]. Findings were presented and well-supported with illustrative quotes, enhancing transparency and trustworthiness. However, a common methodological limitation was the limited reporting on the relationship between researchers and participants. While some studies partially acknowledged reflexivity, most did not fully address how researcher positionality might have influenced data collection or interpretation. Furthermore, ethical considerations were not consistently detailed, with many studies omitting information about consent procedures or ethics approvals. Despite these gaps, the studies were judged to have high to moderate confidence in their contributions, with nearly all rated as “highly valuable” due to their contextual relevance, analytic depth, and practical implications for diabetes self-care in Ethiopia [21,23,33]. These findings affirm the methodological soundness of the current evidence base, while also highlighting areas for improvement in future qualitative health research within similar contexts (Table 2).

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Table 2. Critical appraisal skills programme checklist for qualitative research quality appraisal on exploring barriers and enablers to diabetes self-care in Ethiopia, 2025.

https://doi.org/10.1371/journal.pone.0346867.t002

Synthesis of barriers to diabetes self-care practice in Ethiopia

A synthesis of qualitative findings revealed six interrelated themes that constitute significant barriers to effective diabetes self-care in Ethiopia: health system limitations, individual-level challenges, socioeconomic constraints, behavioral and lifestyle factors, cultural and social norms, and lack of social support (Table 3).

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Table 3. Selected quotes from studies on barriers to diabetes self-care in Ethiopia: Themes, subthemes, and illustrative quotes.

https://doi.org/10.1371/journal.pone.0346867.t003

Health system factors

Health system factors were among the most frequently cited barriers across the studies [21,23,25,33]. Patients reported challenges such as medication shortages, lack of glucometers and test strips, and insufficient staffing, which led to delays in diagnosis, poor follow-up, and missed appointments, “We wait long and can’t get medication” [23,25], while another emphasized the frustration of inconsistent care, stating, “We don’t get all medicines we need from the hospital… even the test results take long… it is discouraging” [21]. In some instances, poor provider interaction caused patients to abandon conventional treatment; as the participant explained, “I abandoned it for 8 months [in favor of holy water]... I became so ugly looking” [33].

Individual-level factors

At the individual level, psychological distress, limited self-efficacy, and poor disease knowledge significantly impede self-care. Patients reported feeling overwhelmed, confused, or incapable of sustaining the required lifestyle changes. Misconceptions such as viewing diabetes as curable through prayer or attributing the condition to supernatural causes further delayed timely medical care [31,32]. At the individual level, several studies highlighted the burden of psychological distress, low confidence in self-management, and limited understanding of the disease [22,25,31,32,34]. Patients frequently described emotional fatigue and demotivation, with one stating, “I feel hopeless and tired… it’s too much” [22,25]. Limited self-efficacy was also a concern, as expressed by a participant who said, “I know what to do, but when I’m tired or broke, I just skip the routine” [34]. Misconceptions and spiritual beliefs about the disease further undermined effective care-seeking. One participant noted, “Some say it goes away with prayer” [32], while another remarked, “I believe being cursed or being a victim of evil eyes led to this illness” [31].

Socioeconomic barriers

Socioeconomic constraints were another common theme, particularly in rural or low-income areas [22,37]. Patients frequently cited financial hardship as a reason for irregular monitoring and dietary non-adherence. For example, one participant explained, “I can’t afford strips. I guess based on how I feel” [22], while another shared, “There are no fruits and vegetables in our village” [37].

Behavioral and lifestyle factors

The theme of behavioral and lifestyle factors emerged through participants’ struggles with adapting to new habits [25,32,35]. Long-standing behaviors and time constraints were major challenges. One patient reflected, “It’s hard to change what I’ve done for years” [25], and another explained, “I just don’t have time to walk” [32]. The inability to monitor blood sugar regularly was also cited: “I don’t check my blood sugar, no machine” [32,35].

Cultural and social norms

Cultural and social norms also shape adherence behaviors. For instance, fasting practices and social stigma around insulin injections posed unique challenges [33,35]. One participant described how faith practices influenced adherence: “The medicine would never be discontinued… even if there is fasting” [33]. Another patient revealed, “It’s not comfortable to go around with injection equipment” [35], pointing to stigma and embarrassment in public settings.

Lack of social support

Finally, a lack of social support was closely linked to poor adherence and emotional fatigue [25,37]. Patients living alone or without caregiver assistance often forgot medications or felt unmotivated. “I live alone… there’s no one to remind me,” said one participant [25], while another noted, “No one reminds me to take my medication” [37], underscoring the importance of interpersonal support in chronic disease management.

Synthesis of facilitators to diabetes self-care practice in Ethiopia

The synthesis of qualitative evidence also identified five overarching themes that facilitate effective diabetes self-care among patients in Ethiopia: social and family support, health system enablers, individual capacities, religious and cultural strengths, and systemic readiness (Table 4).

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Table 4. Selected quotes from studies on facilitators to diabetes self-care in Ethiopia: Themes, subthemes, and illustrative quotes.

https://doi.org/10.1371/journal.pone.0346867.t004

Social and family support

One of the most consistently reported facilitators was social and family support [22,23,25,34].“ Patients emphasized the vital role played by close family members and caregivers in helping them manage medication schedules, diet, and emotional well-being. For example, one patient noted, “My daughter helps me remember to take meds” [25], while another said, “My mom gives me injections when I feel scared” [22]. Healthcare professionals also highlighted that When we educate both the patient and their caregiver, we see better outcomes” [23]. Moreover, community support structures such as diabetes associations offered encouragement and shared learning opportunities. As one participant shared, “Diabetes association membership…” helped them stay motivated and informed [34].

Health system enablers

Several studies pointed to health system enablers, particularly in the form of targeted education and counseling. Participants who received individualized instruction and consistent follow-up were more likely to adhere to self-care routines [21,25,37]. One remarked, “They show me how to eat and walk” [25], while another reported, “I got advice from my nurse on how to take care of myself” [37]. The availability of trained personnel, including diabetes-focused nurses and educators, also proved valuable. “Having a proper system that gives us education and regular follow-ups would help…” [21].

Individual capacities

Individual capacities such as health knowledge, confidence, and practical skills were crucial for enabling self-care [22,32,34]. Patients who had a strong educational background or had received adequate training were more likely to understand and implement recommended practices. “Because I went to school, I know what not to eat,” said one participant [32]. Others emphasized their confidence and capability in daily management tasks: “Having my machine helps me stay on track with checking sugar” [34], and “I learned how to rotate injection sites” [22]. Positive beliefs and motivation were also pivotal, as expressed by a participant who stated, “I take my meds because I believe it helps” [32].

Religious and cultural practices

Interestingly, some studies found that religious and cultural practices, often perceived as barriers, could also serve as facilitators when aligned with self-care behaviors [31,36]. For instance, a patient shared, “I wash my feet morning and night... up to five times a day” [36], reflecting how religious hygiene routines complemented foot care recommendations. Another participant reflected on the psychological value of managing stress, stating, “Maybe if I manage stress, it can help” [31], linking traditional narratives with modern coping strategies.

Signs of systemic readiness

Signs of systemic readiness also emerged, especially in tertiary settings where specialized care and policy attention were evident [21,23]. One participant shared hope for institutional improvements: “Stakeholders showed interest in developing tailored, patient-centered care models” [21]. Enhanced access to medical tools and better coordination of services were also mentioned as critical supports: “Improved access to tools and trained staff” made a notable difference [23].

Confidence in review findings (GRADE-CERQual assessment) of themes

The study explored barriers and enablers to diabetes self-care in Ethiopia using the GRADE-CERQual approach to assess confidence in synthesized themes. High-confidence evidence highlighted systemic challenges such as medication shortages, poor infrastructure, and workforce gaps as key barriers. Psychosocial distress, limited disease knowledge, and low self-efficacy also hindered self-care, supported by moderate to high confidence. Socioeconomic constraints and cultural beliefs presented additional challenges, while family and social support emerged as strong enablers. Education, motivation, and practical skills significantly promoted self-care, with high confidence. Lastly, the need for integrated, patient-centered care models was strongly endorsed, marking a vital step for future diabetes care reform in Ethiopia (Table 5).

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Table 5. GRADE-CERQual summary of qualitative findings exploring barriers and enablers to diabetes self-care in Ethiopia, 2025.

https://doi.org/10.1371/journal.pone.0346867.t005

Strengths and limitations

This systematic review has several notable strengths. It is the first of its kind to comprehensively synthesize qualitative evidence on barriers and enablers to diabetes self-care in Ethiopia, offering rich, context-specific insights drawn from diverse regions and populations. The use of rigorous methodologies, including adherence to PRISMA 2020 and PRISMA-QS guidelines, application of the Joanna Briggs Institute (JBI) methodology for qualitative systematic reviews, and the GRADE-CERQual approach for assessing confidence in review findings, enhances the credibility and trustworthiness of the synthesis. Furthermore, the inclusion of both patient and healthcare provider perspectives provides a multidimensional understanding of the challenges and opportunities in diabetes self-management. The review has limitations, including geographical underrepresentation of rural communities and a lack of detailed reporting of ethical procedures. Despite these, the findings offer valuable implications for improving diabetes care in Ethiopia and similar low-resource settings, affecting practice, policy, and future research. At the review level, limitations include the inclusion of only English-language publications and potential publication bias, which may have excluded relevant unpublished or non-English studies. At the evidence level, many included studies underrepresented rural populations and provided limited detail on ethical procedures and researcher reflexivity, which may affect transferability.