Structural Effect of Informational-Motivational-Behavioral Skills and Acceptance-Commitment in Self-Management, Adherence, and HbA1c in Diabetes: The Mediating Role of Distress
Abstract
Objective: Psychological and behavioral factors play a critical role in diabetes management. This study investigates the structural relationships among the informational-motivational-behavioral skills (IMB) and acceptance and commitment processes with self-management, treatment adherence, and Glycated hemoglobin (HbA1c) levels in diabetic patients, with distress as a mediator.
Method: A cross-sectional study was conducted with 321 patients with type 2 diabetes patients referred to health centers in Jiroft, Iran. Data were collected using the Diabetes Self-Management Questionnaire-Revised (DSMQ-R), the IMB-based Diabetic Self-Management Scale (IMB-DSMS), the Diabetes Distress Scale (DDS-17), the Diabetes Acceptance and Action Scale-Revised (DAAS-R), and the Diabetes Mellitus Treatment Adherence Scale (DMTAS). Structural equation modeling (SEM) was employed using LISREL-8.8 for analysis.
Results: Acceptance and commitment were positively associated with IMB skills (β = 0.34, P < 0.001), self-management (β = 0.51, P < 0.001), and treatment adherence (t = 8.19, β = 0.55), while negatively associated with distress (β = -0.24, P < 0.001). IMB skills were associated with increased self-management (β = 0.43, P < 0.001) and adherence (β = 0.46, P < 0.001), and also negatively associated with distress (β = -0.40, P < 0.001). Distress was also negatively associated with self-management (β = -0.22, P < 0.001) and adherence (β = -0.29, P < 0.001), and positively associated with HbA1c levels (β = 0.19, P < 0.001). Bootstrap results confirmed distress as a mediator between IMB skills, acceptance, and commitment, and self-management/adherence (P < 0.05). The model showed excellent fit (RMSEA = 0.046, χ²/df = 2.51).
Conclusion: This cross-sectional study tested a structural model integrating acceptance-commitment and IMB frameworks. Findings highlight associations among psychological flexibility, IMB skills, reduced distress, and improved self-management. These relationships inform potential intervention targets. Longitudinal and experimental studies are required to evaluate causal effects and clinical implementation.
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8. Karekla M, Karademas EC, Gloster AT. The Common Sense Model of Self-Regulation and Acceptance and Commitment Therapy: integrating strategies to guide interventions for chronic illness. Health Psychol Rev. 2019;13(4):490–503.
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13. Fisher WA, Fisher JD, Harman J. The information‐motivation‐behavioral skills model: a general social psychological approach to understanding and promoting health behavior. Social psychological foundations of health and illness. 2003:82–106.
14. Ferrari M, Speight J, Beath A, Browne JL, Mosely K. The information-motivation-behavioral skills model explains physical activity levels for adults with type 2 diabetes across all weight classes. Psychol Health Med. 2021;26(3):381–94.
15. Seo S, Kim CJ, Kang HS, Kim DJ, Schlenk EA. Medication-Taking Trajectory and Its Correlates in Patients With Diabetes: Based on the Information-Motivation-Behavioral Skills Model. Sci Diabetes Self Manag Care. 2025;51(1):100–9.
16. Skinner TC, Joensen L, Parkin T. Twenty-five years of diabetes distress research. Diabet Med. 2020;37(3):393–400.
17. Li H, Li Y, Wang J, Zhang Y, Ben S. Enablers and Barriers to Medication Self-Management in Patients With Type 2 Diabetes: A Qualitative Study Using the COM-B Model. Patient Prefer Adherence. 2025;19:485–501.
18. Zu W, Zhang S, Du L, Huang X, Nie W, Wang L. The effectiveness of psychological interventions on diabetes distress and glycemic level in adults with type 2 diabetes: a systematic review and meta-analysis. BMC Psychiatry. 2024;24(1):660.
19. Ajele KW, Idemudia ES. The role of depression and diabetes distress in glycemic control: A meta-analysis. Diabetes Res Clin Pract. 2025;221:112014.
20. Captieux M, Pearce G, Parke HL, Epiphaniou E, Wild S, Taylor SJC, et al. Supported self-management for people with type 2 diabetes: a meta-review of quantitative systematic reviews. BMJ Open. 2018;8(12):e024262.
21. Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas. 2013;76(6):913–34.
22. RVSPK R, Priyanath H, Megama R. Methods and rules-of-thumb in the determination of minimum sample size when applying structural equation modelling: A review. J Soc Sci Res. 2020;15(2):102–9.
23. Schmitt A, Kulzer B, Ehrmann D, Haak T, Hermanns N. A Self-Report Measure of Diabetes Self-Management for Type 1 and Type 2 Diabetes: The Diabetes Self-Management Questionnaire-Revised (DSMQ-R) - Clinimetric Evidence From Five Studies. Front Clin Diabetes Healthc. 2021;2:823046.
24. Hosseinzadegan F, Azimzadeh R, Parizad N, Esmaeili R, Alinejad V, Hemmati Maslakpak M. Psychometric evaluation of the diabetes self-management questionnaire-revised form) Dsmq-R) in patients with diabetes. Nursing and Midwifery Journal. 2021;19(2):109–18.
25. Dai Z, Jing S, Liu X, Zhang H, Wu Y, Wang H, et al. Development and validation of the diabetic self-management scale based on information-motivation-behavioral skills theory. Front Public Health. 2023;11:1109158.
26. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6(3):246–52.
27. Niroomand M, Babaniamansour S, Aliniagerdroudbari E, Golshaian A, Meibodi AM, Absalan A. Distress and depression among patients with diabetes mellitus: prevalence and associated factors: a cross-sectional study. J Diabetes Metab Disord. 2021;20(1):141–51.
28. Gillanders DT, Barker E. Development and initial validation of a short form of the diabetes acceptance and Action Scale: The DAAS-Revised (DAAS-R). Journal of Contextual Behavioral Science. 2019;14:20–8.
29. Keenan ME, Berlin KS, Cook JL, Choquette AE, Ankney RL, Klages KL, et al. Brief assessment of diabetes-specific psychological flexibility in racially and income diverse youth with type 1 diabetes. Pediatr Diabetes. 2022;23(3):370–9.
30. Rajaeiramsheh F, Rezaie Z, Davoudi M, Ahmadi SM, Qorbani-Vanajemi M. Psychometric properties of the Persian versions of acceptance and action diabetes questionnaire (AADQ) and the diabetes acceptance and action scale (DAAS), in Iranian youth with type 1 diabetes. J Diabetes Metab Disord. 2021;20(1):655–63.
31. Hou G, Fang Z, Cao W, Shi Y, Xu X, Han M, et al. Development and validation of a diabetes mellitus treatment adherence scale. Diabetes Res Clin Pract. 2021;172:108629.
32. Heidari Archandani, Z., Rahimian-Boogar, I., Eisazadeh, F. The role of attachment trauma, mentalization deficits, and defense mechanisms in diabetes self-management and glycosylated hemoglobin. Clin Psychol Res Pract Innov. 2025;17(3): 95-109.
33. Tabachnick BG, Fidell LS, Ullman JB. Using multivariate statistics: pearson Boston, MA; 2007.
34. Ngan HY, Chong YY, Loo KM, Chien WT. Preliminary efficacy of acceptance-based diabetes education (ACT-DE) program for people with type 2 diabetes on diabetes distress and self-care behaviors: a pilot randomized controlled trial. J Contextual Behav Sci. 2023; 30:50-60.
35. Hajati E, Gharraee B, Fathali Lavasani F, Farahani H, Rajab A. Comparing the effectiveness of acceptance-based emotion regulation therapy and acceptance and commitment therapy on hemoglobin glycosylated and self-care in patients with type II diabetes: A randomized controlled trial. J Behav Med. 2024;47(5):874–85.
36. Kılınç İşleyen E, Kartal A. The effect of information, motivation and behavioural skills model-based Diabetes Education and Motivational Interview Program on health outcomes in middle-aged adults with type 2 diabetes: a randomised controlled study. Psychogeriatrics. 2025;25(1):e13219.
37. Chen Q, Wang H, Wang Y, Wang Z, Zhao D, Cai Y. Exploring effects of self-management on glycemic control using a modified information-motivation-behavioral skills model in type 2 diabetes mellitus patients in Shanghai, China: A cross-sectional study. J Diabetes. 2018;10(9):734–43.
38. Subramaniam S, Dhillon JS, Wan Ahmad WF. Behavioral Theory-Based Framework for Prediabetes Self-Care System-Design Perspectives and Validation Results. Int J Environ Res Public Health. 2021;18(17):9160.
39. Scarton L, Nelson T, Yao Y, DeVaughan-Circles A, Legaspi AB, Donahoo WT, et al. Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services. Diabetes Care. 2023;46(6):1245–51.
40. Elayyan B, Abuhalima D, Al-Jabi SW, Zyoud SH. Association of medication adherence and glycemic control with pain severity among patients with diabetes mellitus: a cross-sectional study from Palestine. BMC Endocr Disord. 2025;25(1):180.
41. Campbell L, Pepper T, Shipman K. HbA1c: a review of non-glycaemic variables. J Clin Pathol. 2019;72(1):12–9.
42. Riangkam C, Sriyuktasuth A, Pongthavornkamol K, Kusakunniran W, Sriwijitkamol A. Effects of a mobile health diabetes self-management program on HbA1C, self-management and patient satisfaction in adults with uncontrolled type 2 diabetes: a randomized controlled trial. Journal of Health Research. 2022;36(5):878–88.
43. Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV. Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care. 2005;28(10):2543–5.
2. Atlas D. International diabetes federation. IDF Diabetes Atlas, 7th edn Brussels, Belgium: International Diabetes Federation. 2015;33(2):3–6.
3. Mohan D, Raj D, Shukla N, Bansal R, Avasthi A, Grover S. Urbanization, unhealthy lifestyles, and diabetes management: A narrative review. Int J Soc Psychiatry. 2022;68(8):1852-1860.
4. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Malanda B, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022; 183:109119.
5. Surawit A, Pongkunakorn T, Manosan T, Mongkolsucharitkul P, Chamnan P, Suvarnabhumi K, et al. Factors influencing optimal diabetes care and clinical outcomes in Thai patients with type 2 diabetes mellitus: a multilevel modelling analysis. BMJ Open. 2024;14(5):e079415.
6. Kurtanty D, Bachtiar A, Candi C, Pramesti A, Fanny Rahmasari A. Information-Motivation-Behavioral Skill in Diabetes Self-ma-nagement Using Structural Equation Modeling Analysis. 2023.
7. Chen HM, Su BY. Factors Related to the Continuity of Care and Self-Management of Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study in Taiwan. Healthcare (Basel). 2022;10(10):2088.
8. Karekla M, Karademas EC, Gloster AT. The Common Sense Model of Self-Regulation and Acceptance and Commitment Therapy: integrating strategies to guide interventions for chronic illness. Health Psychol Rev. 2019;13(4):490–503.
9. Bistara DN, Wardani EM, Septianingrum Y, Ainiyah N, Fitriasari A, Noventi I, et al. Acceptance and commitment therapy (Act) on increasing the compliance of management diabetes mellitus type 2. International Journal of Psychosocial Rehabilitation. 2020;24(9):942–6.
10. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44(1):1–25.
11. Bendig E, Bauereiss N, Schmitt A, Albus P, Baumeister H. ACTonDiabetes-a guided psychological internet intervention based on Acceptance and Commitment Therapy (ACT) for adults living with type 1 or 2 diabetes: results of a randomised controlled feasibility trial. BMJ Open. 2021;11(7):e049238.
12. Sakamoto R, Ohtake Y, Kataoka Y, Matsuda Y, Hata T, Otonari J, et al. Efficacy of acceptance and commitment therapy for people with type 2 diabetes: Systematic review and meta-analysis. J Diabetes Investig. 2022;13(2):262–70.
13. Fisher WA, Fisher JD, Harman J. The information‐motivation‐behavioral skills model: a general social psychological approach to understanding and promoting health behavior. Social psychological foundations of health and illness. 2003:82–106.
14. Ferrari M, Speight J, Beath A, Browne JL, Mosely K. The information-motivation-behavioral skills model explains physical activity levels for adults with type 2 diabetes across all weight classes. Psychol Health Med. 2021;26(3):381–94.
15. Seo S, Kim CJ, Kang HS, Kim DJ, Schlenk EA. Medication-Taking Trajectory and Its Correlates in Patients With Diabetes: Based on the Information-Motivation-Behavioral Skills Model. Sci Diabetes Self Manag Care. 2025;51(1):100–9.
16. Skinner TC, Joensen L, Parkin T. Twenty-five years of diabetes distress research. Diabet Med. 2020;37(3):393–400.
17. Li H, Li Y, Wang J, Zhang Y, Ben S. Enablers and Barriers to Medication Self-Management in Patients With Type 2 Diabetes: A Qualitative Study Using the COM-B Model. Patient Prefer Adherence. 2025;19:485–501.
18. Zu W, Zhang S, Du L, Huang X, Nie W, Wang L. The effectiveness of psychological interventions on diabetes distress and glycemic level in adults with type 2 diabetes: a systematic review and meta-analysis. BMC Psychiatry. 2024;24(1):660.
19. Ajele KW, Idemudia ES. The role of depression and diabetes distress in glycemic control: A meta-analysis. Diabetes Res Clin Pract. 2025;221:112014.
20. Captieux M, Pearce G, Parke HL, Epiphaniou E, Wild S, Taylor SJC, et al. Supported self-management for people with type 2 diabetes: a meta-review of quantitative systematic reviews. BMJ Open. 2018;8(12):e024262.
21. Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas. 2013;76(6):913–34.
22. RVSPK R, Priyanath H, Megama R. Methods and rules-of-thumb in the determination of minimum sample size when applying structural equation modelling: A review. J Soc Sci Res. 2020;15(2):102–9.
23. Schmitt A, Kulzer B, Ehrmann D, Haak T, Hermanns N. A Self-Report Measure of Diabetes Self-Management for Type 1 and Type 2 Diabetes: The Diabetes Self-Management Questionnaire-Revised (DSMQ-R) - Clinimetric Evidence From Five Studies. Front Clin Diabetes Healthc. 2021;2:823046.
24. Hosseinzadegan F, Azimzadeh R, Parizad N, Esmaeili R, Alinejad V, Hemmati Maslakpak M. Psychometric evaluation of the diabetes self-management questionnaire-revised form) Dsmq-R) in patients with diabetes. Nursing and Midwifery Journal. 2021;19(2):109–18.
25. Dai Z, Jing S, Liu X, Zhang H, Wu Y, Wang H, et al. Development and validation of the diabetic self-management scale based on information-motivation-behavioral skills theory. Front Public Health. 2023;11:1109158.
26. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6(3):246–52.
27. Niroomand M, Babaniamansour S, Aliniagerdroudbari E, Golshaian A, Meibodi AM, Absalan A. Distress and depression among patients with diabetes mellitus: prevalence and associated factors: a cross-sectional study. J Diabetes Metab Disord. 2021;20(1):141–51.
28. Gillanders DT, Barker E. Development and initial validation of a short form of the diabetes acceptance and Action Scale: The DAAS-Revised (DAAS-R). Journal of Contextual Behavioral Science. 2019;14:20–8.
29. Keenan ME, Berlin KS, Cook JL, Choquette AE, Ankney RL, Klages KL, et al. Brief assessment of diabetes-specific psychological flexibility in racially and income diverse youth with type 1 diabetes. Pediatr Diabetes. 2022;23(3):370–9.
30. Rajaeiramsheh F, Rezaie Z, Davoudi M, Ahmadi SM, Qorbani-Vanajemi M. Psychometric properties of the Persian versions of acceptance and action diabetes questionnaire (AADQ) and the diabetes acceptance and action scale (DAAS), in Iranian youth with type 1 diabetes. J Diabetes Metab Disord. 2021;20(1):655–63.
31. Hou G, Fang Z, Cao W, Shi Y, Xu X, Han M, et al. Development and validation of a diabetes mellitus treatment adherence scale. Diabetes Res Clin Pract. 2021;172:108629.
32. Heidari Archandani, Z., Rahimian-Boogar, I., Eisazadeh, F. The role of attachment trauma, mentalization deficits, and defense mechanisms in diabetes self-management and glycosylated hemoglobin. Clin Psychol Res Pract Innov. 2025;17(3): 95-109.
33. Tabachnick BG, Fidell LS, Ullman JB. Using multivariate statistics: pearson Boston, MA; 2007.
34. Ngan HY, Chong YY, Loo KM, Chien WT. Preliminary efficacy of acceptance-based diabetes education (ACT-DE) program for people with type 2 diabetes on diabetes distress and self-care behaviors: a pilot randomized controlled trial. J Contextual Behav Sci. 2023; 30:50-60.
35. Hajati E, Gharraee B, Fathali Lavasani F, Farahani H, Rajab A. Comparing the effectiveness of acceptance-based emotion regulation therapy and acceptance and commitment therapy on hemoglobin glycosylated and self-care in patients with type II diabetes: A randomized controlled trial. J Behav Med. 2024;47(5):874–85.
36. Kılınç İşleyen E, Kartal A. The effect of information, motivation and behavioural skills model-based Diabetes Education and Motivational Interview Program on health outcomes in middle-aged adults with type 2 diabetes: a randomised controlled study. Psychogeriatrics. 2025;25(1):e13219.
37. Chen Q, Wang H, Wang Y, Wang Z, Zhao D, Cai Y. Exploring effects of self-management on glycemic control using a modified information-motivation-behavioral skills model in type 2 diabetes mellitus patients in Shanghai, China: A cross-sectional study. J Diabetes. 2018;10(9):734–43.
38. Subramaniam S, Dhillon JS, Wan Ahmad WF. Behavioral Theory-Based Framework for Prediabetes Self-Care System-Design Perspectives and Validation Results. Int J Environ Res Public Health. 2021;18(17):9160.
39. Scarton L, Nelson T, Yao Y, DeVaughan-Circles A, Legaspi AB, Donahoo WT, et al. Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services. Diabetes Care. 2023;46(6):1245–51.
40. Elayyan B, Abuhalima D, Al-Jabi SW, Zyoud SH. Association of medication adherence and glycemic control with pain severity among patients with diabetes mellitus: a cross-sectional study from Palestine. BMC Endocr Disord. 2025;25(1):180.
41. Campbell L, Pepper T, Shipman K. HbA1c: a review of non-glycaemic variables. J Clin Pathol. 2019;72(1):12–9.
42. Riangkam C, Sriyuktasuth A, Pongthavornkamol K, Kusakunniran W, Sriwijitkamol A. Effects of a mobile health diabetes self-management program on HbA1C, self-management and patient satisfaction in adults with uncontrolled type 2 diabetes: a randomized controlled trial. Journal of Health Research. 2022;36(5):878–88.
43. Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV. Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care. 2005;28(10):2543–5.
| Files | ||
| Issue | Vol 21 No 2 (2026) | |
| Section | Original Article(s) | |
| Keywords | ||
| Acceptance Diabetes Glycated Hemoglobin Information Motivation Behavioral Skills Model Self-Management | ||
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1.
Heidari Archandani Z, Rahimian-Boogar I. Structural Effect of Informational-Motivational-Behavioral Skills and Acceptance-Commitment in Self-Management, Adherence, and HbA1c in Diabetes: The Mediating Role of Distress. Iran J Psychiatry. 2026;21(2):192-201.
