Health ecology-based nursing impact on stigma, anxiety, and depression in young and middle-aged type 2 diabetes patients

Abstract

BACKGROUND

Most people with type 2 diabetes mellitus (T2DM) are young or middle-aged. These individuals often face pressure from work, society, and family, leading many to experience shame, anxiety, and depression related to T2DM. The nursing model based on health ecology theory provides multi-level nursing interventions at the individual, family, community, and societal levels. However, its effect on stigma, anxiety, and depression among young and middle-aged T2DM patients remains unclear.

AIM

To examine the effect of nursing intervention based on health ecology theory on stigma, anxiety, and depression in young and middle-aged T2DM patients.

METHODS

A total of 60 young and middle-aged T2DM patients hospitalized in the Department of Endocrinology and Traditional Chinese Medicine of the Ninth People’s Hospital of Suzhou from March 2024 to July 2025 were retrospectively selected as the research objects. Based on nursing approach, patients were divided into a control group (n = 30; routine nursing) and an observation group (n = 30; nursing based on health ecology theory). Scores for glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), 2-hour postprandial blood glucose (2hPBG), Diabetes Self-Care Scale (DSCS), Perceived Social Support from Family Scale (PSS-Fa), Social Support Rating Scale (SSRS), Type 2 Diabetes Stigma Assessment Scale (DSAS-2), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) were compared at admission, on the day of discharge, and three months after discharge.

RESULTS

At admission, the two groups showed no significant differences in the scores of HbA1c, FBG, 2hPBG, DSCS, PSS-Fa, SSRS, DSAS-2, SAS, and SDS (P > 0.05). On the day of discharge, no significant differences were observed in HbA1c, FBG, 2hPBG, or SSRS scores (P > 0.05). However, the observation group had higher DSCS (74.49 ± 11.72 points vs 65.76 ± 10.65 points, P = 0.004) and PSS-Fa (9.98 ± 1.25 points vs 7.42 ± 1.06 points, P < 0.001) scores, and lower DSAS-2 (54.45 ± 5.61 points vs 57.46 ± 5.88 points, P = 0.047), SAS (46.34 ± 2.87 points vs 48.83 ± 3.12 points, P = 0.047), and SDS (45.25 ± 2.59 points vs 47.64 ± 3.25 points, P = 0.003) scores than the control group. At 3-month follow-up, the observation group had lower HbA1c (6.15% ± 0.87% vs 6.76% ± 0.93%, P = 0.011), lower FBG (6.36 ± 0.58 mmol/L vs 6.93 ± 0.62 mmol/L, P = 0.001), lower 2hPBG (7.81 ± 0.72 mmol/L vs 8.63 ± 0.95 mmol/L, P = 0.001) indexes, and significantly lower DSCS, PSS-Fa, SSRS, DSAS-2, SAS, and SDS scores than those of the control group (all P < 0.05).

CONCLUSION

Nursing intervention based on health ecology theory can improve self-management behaviors and glycemic indicators in young and middle-aged T2DM patients, improve family and social support, reduce stigma, and alleviate anxiety and depression.

Key Words: Health ecology; Nursing intervention; Young and middle-aged; Type 2 diabetes mellitus; Stigma; Anxiety; Depression

Core Tip: Many young and middle-aged patients with type 2 diabetes experience disruptions in daily life and work due to long-term glucose management, making them vulnerable to anxiety, depression, and stigma stemming from social discrimination. This study shows that nursing intervention based on health ecology theory improves diabetes self-management and glycemic control while reducing stigma and emotional distress, providing a reference for more effective type 2 diabetes management.

INTRODUCTION

The number of people with diabetes in China ranks first globally, with type 2 diabetes mellitus (T2DM) accounting for more than 90% of cases[1]. Among individuals with T2DM in China, young and middle-aged adults, defined by the World Health Organization as young adults aged 18 years to 44 years and middle-aged adults aged 45 years to 59 years, represent two-thirds of the total number of patients with diabetes[2]. Thus, this group constitutes a large proportion of the T2DM population. T2DM can lead to complications such as stroke, cardiovascular disease, kidney disease, retinopathy, and diabetic foot, making it highly harmful. As key contributors to family and society, young and middle-aged adults must manage responsibilities across work, family, and social environments. Consequently, they often experience anxiety and depression due to the impact of T2DM on daily life and work[3], and may also develop a sense of stigma stemming from discrimination by relatives or friends[4]. Stigma involves internalizing personal perceptions and external prejudice, leading to negative beliefs such as shame, guilt, concealment, and avoidance[5]. Relevant studies have shown that stigma has become a major psychological obstacle to effective self-management in T2DM[6]. Consequently, many T2DM patients conceal their condition by delaying or missing insulin injections, avoiding glycemic monitoring outside the home, or refusing to join social activities such as dining parties. These behaviors hinder timely treatment, disrupt social and work functioning, and further exacerbate anxiety and depression.

Health ecology theory posits that human health results from the combined effects of individuals, lifestyles, environment, and health services. It emphasizes the multi-level and complex interrelationship between individuals and their surroundings and advocates providing health information across these dimensions to promote overall health. Multi-level disease management interventions are generally more effective than single-level approaches[7]. Current studies show that timely, targeted interventions across multiple levels and dimensions can support comprehensive management of chronic diseases[8] and positively affect disease incidence and population health[9]. However, very few studies in China have examined nursing interventions based on health ecology theory among young and middle-aged patients with T2DM. Therefore, this study aimed to explore the effects of such interventions on stigma, anxiety, and depression in this population to inform improved T2DM management.

MATERIALS AND METHODS

Research object

Using a retrospective design, sixty young and middle-aged patients with T2DM who were hospitalized in the Department of Endocrinology and Traditional Chinese Medicine of Suzhou Ninth People’s Hospital from March 2024 to July 2025 were selected as the research subjects. Based on the nursing intervention method, they were divided into control and observation groups, with 30 cases in each group.

Inclusion criteria: (1) Meeting the diagnostic criteria for T2DM, namely fasting blood glucose (FBG) ≥ 7.0 mmol/L, or 2-hour postprandial blood glucose (2hPBG) ≥ 11.1 mmol/L, or glycosylated hemoglobin (HbA1c) ≥ 6.5%[10]; (2) Age 18 years to 59 years; and (3) Mentally clear, capable of using a smartphone, able to complete remote intervention and information collection, and able to communicate smoothly with investigators.

Exclusion criteria: (1) Presence of diabetic ketoacidosis and hypoglycemic coma; (2) History of mental illness; (3) Severe infectious diseases, such as acquired immunodeficiency syndrome, condyloma acuminata, or tuberculosis; and (4) Diseases affecting appearance, including urinary incontinence, psoriasis, epilepsy, paraplegia, obesity, amblyopia, or burns.

Intervention methods

The control group received routine nursing interventions. During hospitalization, nurses provided routine drug therapy according to physicians’ orders and delivered routine care following the departmental health-education pathway, including diabetes-related education, dietary guidance, and distribution of health-education brochures to the patients. After discharge, specialized nurses conduced monthly telephone follow-ups for three months to inquire assess patients’ medication adherence and blood glucose monitoring.

The observation group received nursing intervention based on the health ecology theory: (1) An intervention team for diabetic patients was established according to the theoretical model of health ecology. The team included one head nurse, one diabetes specialist nurse, two endocrinologists, four endocrinology nurses, and one psychologist. The diabetes specialist and endocrinology nurses conducted data collection, information registration, dietary guidance, blood glucose monitoring, and health education; the physicians provided medical diagnosis and treatment and remote guidance through the Metabolic Management Center (MMC) for standardized diabetes management; the psychologists offered psychological support; and (2) The nursing intervention plan focused on the individual patient and delivered multi-level interventions through the family, community, and society. After three months of continuous intervention, outcomes were evaluated. The specific intervention contents and methods are shown in Table 1.

Table 1 Content and methods of health ecological theory model-based nursing intervention in the observation group.

Level	Intervention content	Intervention method
Individual level	(1) Daily life support: Provide individualized daily self-management education to patients, enabling them to acquire self-management skills and enhancing their confidence and self-efficacy; (2) Emotional support: Explain the disease and treatment information to patients, improving their understanding of the disease. Encourage patients to communicate with each other. Encourage patients to express their feelings and understand their viewpoints, correcting their incorrect perceptions; and (3) Medical care support: During the patient’s hospitalization, diabetes specialist nurses and psychologists jointly provide mental health education to the patients. Before the patient is discharged, assist the patient in completing the installation of the MMC software APP on their mobile phone. Set up medication reminder through the MMC software APP client to prevent patients from forgetting to take medication after discharge. Automatically synchronize the designated blood glucose instrument to the MMC software APP (that is, the blood glucose values monitored by the patient through the blood glucose meter can be automatically transmitted to the MMC software APP). Doctors can understand the patient’s blood sugar situation through the MMC software and adjust the medication reminder according to the blood sugar fluctuation. Patients complete the medication according to the reminder. Nurses regularly push diabetes-related health content to the patient through the MMC software APP, such as healthy recipes, exercise plan formulation, etc. Patients can directly feedback their questions to the medical staff through the MMC software APP client, and the medical staff will reply through the APP client	(1) On the first day of the patient’s admission, the health ecology theory was utilized to conduct a comprehensive assessment of the patient; and (2) During the second to fourth days of hospitalization, the responsible nurse provided face-to-face guidance on the patient’s daily life, emotional support, and medical care, lasting approximately 30 minutes to 60 minutes
Family aspect	(1) The responsible nurse provides education on diabetes self-management knowledge to the family members, enabling them to supervise the patient’s diet and treatment, informing them of the key points of diabetes treatment and care, and enhancing the self-care ability and compliance behavior of both the patient and the family members; (2) The responsible nurse helps the family members deepen their understanding of their loved one, providing emotional and material support, and building the patient’s confidence in life; and (3) The responsible nurse encourages the family members to organize gatherings with relatives and friends to obtain emotional and information support, in order to alleviate the patient’s sense of shame and negative psychological state	From the 5th to the 8th day of the patient’s hospitalization, the responsible nurse conducted face-to-face communication and guidance for the patient’s family members, which lasted for approximately 30 minutes to 60 minutes
Community aspect	(1) The diabetes specialist nurses are responsible for coordinating and guiding the care with community family doctors and family nurses, and informing them about the need to address patients’ feelings of stigma and negative psychological issues; and (2) The specialist nurses contact community staff to hold regular diabetes knowledge popularization lectures, reducing discrimination against diabetes patients among the community population	After the patient is discharged, the endocrinologist, the head nurse and the diabetes specialist nurse will conduct a diabetes knowledge popularization lecture in the community once a month for three consecutive months. Each lecture lasts approximately 50 minutes to 60 minutes
Social aspect	(1) Endocrinologists and nurses collaborate with social media to disseminate knowledge about diabetes and the reasons for the stigma faced by diabetic patients to the general public, enabling them to understand the physical and psychological challenges that patients with diabetes encounter, and reducing the public’s prejudice and negative stereotypes towards diabetes; and (2) Help the public correctly understand diabetes, generate a positive public opinion, increase society’s acceptance of diabetic patients, and at the source, reduce the stigma faced by patients and the psychological challenges they encounter due to the disease	Through the media, relevant videos, QR codes or websites about diabetes stigma should be shared and disseminated on platforms such as WeChat, Douyin, and hospital official accounts

APP: Application; MMC: Metabolic Management Center; QR: Quick response.

Observation indicators: (1) Baseline data: Age, gender, marital status, educational level, complications (such as hypertension and hyperlipidemia), family income, T2DM duration and treatment method, medical-expense payment methods were compared between the two groups; and (2) Blood glucose indices HbA1c, FBG, 2hPBG, were recorded at admission, on the day of discharge, and three months after discharge. Diabetes self-management, family support, social support, and T2DM stigma, anxiety, and depression were also evaluated. Among them: (1) Diabetes self-management: The Diabetes Self-Care Scale (DSCS)[11] consisting of 26 items covering medication adherence, blood glucose monitoring, diet control, exercise, foot care, and management of high/Low blood sugar, was used. It employs a Likert scale (1-5), with a total score of 26-130; higher scores indicate better self-management behavior; (2) Family support: The Perceived Social Support from Family Scale (PSS-Fa)[12] includes 15 questions, with options being “Yes” (counting 1 point) and “No” (counting 0 points). The total score was 1-15, with higher scores indicating stronger family support; (3) Social support: The Social Support Rating Scale (SSRS)[13] contains 10 items assessing objective support, subjective support, and support utilization, using a 4-point Likert method. For item 5, responses are scored 1-4 (“none” to “full support”). For items 6 and 7, a response of “none” is scored 0. The total score was 12-66; higher scores indicate social support; (4) T2DM stigma: The Type 2 Diabetes Stigma Assessment Scale (DSAS-2)[14] consists of 19 items addressing differential treatment, blaming/judging, and self-humiliation, scored on a 5-point Likert scale (1-5). Total scores range from 19 to 95, with higher scores indicating stronger perceived or experienced stigma; and (5) Anxiety and depression: Anxiety was assessed using the Self-Rating Anxiety Scale (SAS)[15], which uses a 4-point rating system. The total raw score is multiplied by 1.25 and rounded to obtain the standard score: < 50 indicates no anxiety, 50-59 indicates mild anxiety, 60-69 indicates moderate anxiety, and ≥ 70 indicates severe anxiety. Depression was assessed with the Self-Rating Depression Scale (SDS)[16] using the same scoring and conversion method mentioned above: < 53 indicates no depression, 53-62 indicates mild depression, 63-72 indicates moderate depression, and ≥ 73 indicates severe depression.

Statistical analysis

Data were analyzed using SPSS 25.0 software. Measurement data were tested for normal distribution using the S-W method and expressed as mean ± SD. Intergroup comparisons were performed using the t-test. Count data were expressed as n (%) and compared using the χ² test. The significance level was set at α = 0.05, and P < 0.05 indicated a statistically significant difference.

RESULTS

Comparison of baseline data between the two groups

The were no significant differences in age, gender, marital status, educational level, hypertension, hyperlipidemia, family monthly income, T2DM duration and treatment method, or payment methods for medical expenses between the two groups (P > 0.05; Table 2).

Table 2 Comparison of baseline data between the two groups, n (%).

Baseline data	Control group (n = 30)	Observation group (n = 30)	t/χ2 value	P value
Age			0.341	0.559
18-44 years old	7 (23.33)	9 (30.00)
45-59 years old	23 (76.67)	21 (70.00)
Gender			0.271	0.602
Male	16 (53.34)	18 (60.00)
Female	14 (46.66)	12 (40.00)
Marital status			0.098	0.754
Married	23 (76.67)	24 (80.00)
Unmarried/divorced	7 (23.33)	6 (20.00)
Educational level			0.317	0.573
High school and below	8 (26.67)	10 (33.33)
College degree or above	22 (73.33)	20 (66.67)
Combined hypertension			0.131	0.718
Yes	4 (13.33)	5 (16.67)
No	26 (86.67)	25 (83.33)
Combined hyperlipidemia			0.373	0.542
Yes	6 (20.00)	8 (26.67)
No	24 (80.00)	22 (73.33)
Monthly household income (yuan)			0.673	0.724
< 5000	8 (26.67)	7 (23.33)
5000-8000	15 (50.00)	18 (60.00)
> 8000	7 (23.33)	5 (16.67)
Course of T2DM			0.326	0.850
< 1 year	8 (26.67)	7 (23.33)
1-3 years	14 (46.66)	13 (43.34)
> 3 years	8 (26.67)	10 (33.33)
Treatment method			0.743	0.863
No-pharmacological treatment	7 (23.33)	8 (26.67)
Oral hypoglycemic drugs	15 (50.00)	13 (43.34)
Injecting insulin	5 (16.67)	7 (23.33)
Oral hypoglycemic drugs combined with insulin injection	3 (10.00)	2 (6.66)
Medical expense payment method			0.162	0.688
Self-funded	3 (10.00)	4 (13.33)
Medical insurance	27 (90.00)	26 (86.67)

T2DM: Type 2 diabetes mellitus.

Comparison of blood sugar indicators between the two groups

The were no significant differences in the HbA1c, FBG, or 2hPBG indicators between the two groups at admission or on the day of discharge (P > 0.05). At the 3-month follow-up, the HbA1c, FBG, and 2hPBG indicators in the observation group were significantly lower than those in the control group (P < 0.05; Table 3).

Table 3 Comparison of blood glucose indicators between the two groups, mean ± SD.

Project	Phase	Control group (n = 30)	Observation group (n = 30)	t value	P value
HbA1c	On admission	9.35 ± 1.54	9.41 ± 1.62	0.147	0.884
	On the day of discharge	6.17 ± 0.82	6.01 ± 0.75	0.789	0.434
	Three months after discharge	6.76 ± 0.93	6.15 ± 0.87	2.624	0.011
FBG (mmol/L)	On admission	7.82 ± 1.15	7.89 ± 1.22	0.229	0.820
	On the day of discharge	6.31 ± 0.53	6.25 ± 0.51	0.447	0.656
	Three months after discharge	6.93 ± 0.62	6.36 ± 0.58	3.667	0.001
2hPBG (mmol/L)	On admission	13.87 ± 1.56	13.92 ± 1.63	0.122	0.904
	On the day of discharge	7.54 ± 0.67	7.34 ± 0.58	1.236	0.221
	Three months after discharge	8.63 ± 0.95	7.81 ± 0.72	3.768	0.001

HbA1c: Hemoglobin; FBG: Fasting blood glucose; 2hPBG: 2-hour postprandial blood glucose.

Comparison of diabetes self-management, family support, and social support scores between the two groups

The were no significant differences in the DSCS, PSS-Fa, and SSRS scores between the two groups at admission (P > 0.05). On the day of discharge, the DSCS and PSS-Fa scores in the observation group were significantly higher than those in the control group (P < 0.05), while the SSRS scores differed insignificantly (P > 0.05). Three months after discharge, the DSCS, PSS-Fa, and SSRS scores in the observation group were significantly higher than those in the control group (P < 0.05; Table 4).

Table 4 Comparison of diabetes self-management, family support, and social support scores between the two groups of patients, mean ± SD.

Project	Phase	Control group (n = 30)	Observation group (n = 30)	t value	P value
DSCS (divide)	On admission	48.43 ± 8.69	47.22 ± 8.93	0.532	0.597
	On the day of discharge	65.76 ± 10.65	74.49 ± 11.72	3.019	0.004
	Three months after discharge	62.54 ± 9.83	71.58 ± 10.93	3.368	0.001
PSS-Fa (divide)	On admission	5.63 ± 0.75	5.56 ± 0.72	0.369	0.714
	On the day of discharge	7.42 ± 1.06	9.98 ± 1.25	8.555	< 0.001
	Three months after discharge	6.95 ± 1.02	9.09 ± 1.17	7.551	< 0.001
SSRS (divide)	On admission	20.46 ± 2.67	20.37 ± 2.55	0.134	0.894
	On the day of discharge	23.75 ± 3.73	24.98 ± 2.91	1.424	0.159
	Three months after discharge	23.49 ± 3.65	30.64 ± 5.78	5.729	< 0.001

DSCS: Diabetes Self-Care Scale; PSS-Fa: Perceived Social Support from Family Scale; SSRS: Social Support Rating Scale.

Comparison of stigma scores between the two groups

There were no significant differences in the DSAS-2 scores between the two groups at admission (P > 0.05). On the day of discharge and at three months, the DSAS-2 scores in the observation group were significantly lower than those in the control group (P < 0.05; Table 5).

Table 5 Comparison of stigma scores between the two groups of patients, mean ± SD.

Project	Phase	Control group (n = 30)	Observation group (n = 30)	t value	P value
DSAS-2 (divide)	On admission	72.85 ± 8.47	73.76 ± 8.43	0.417	0.678
	On the day of discharge	57.46 ± 5.88	54.45 ± 5.61	2.029	0.047
	Three months after discharge	53.35 ± 4.87	46.92 ± 3.04	6.135	< 0.001

DSAS-2: Type 2 Diabetes Stigma Assessment Scale.

Comparison of anxiety and depression scores between the two groups

There were no significant differences in the SAS and SDS scores between the two groups at (P > 0.05). On the day of discharge and at three months, the SAS and SDS scores in the observation group were significantly lower than those in the control group (P < 0.05; Table 6).

Table 6 Comparison of anxiety and depression scores between the two groups of patients, mean ± SD.

Project	Phase	Control group (n = 30)	Observation group (n = 30)	t value	P value
SAS (divide)	On admission	59.91 ± 5.34	59.46 ± 5.29	0.328	0.744
	On the day of discharge	48.83 ± 3.12	46.34 ± 2.87	3.217	0.002
	Three months after discharge	48.65 ± 5.09	43.97 ± 3.86	4.013	< 0.001
SDS (divide)	On admission	57.21 ± 5.13	58.18 ± 5.05	0.738	0.463
	On the day of discharge	47.64 ± 3.25	45.25 ± 2.59	3.150	0.003
	Three months after discharge	46.48 ± 4.27	42.85 ± 3.24	3.709	< 0.001

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

DISCUSSION

T2DM is a lifelong condition requiring long-term management, and many patients experience fear, anxiety, depression, and stigma during this process. Middle-aged and young adults often carry multiple social, occupational, and family responsibilities, making their stigma and anxiety-depression more susceptible to multiple external factors[17,18]. Addressing these concerns requires multi-level intervention measures. Multi-dimensional nursing interventions that strengthen diabetes self-management are an effective approach to improving the prognosis of young and middle-aged patients with T2DM.

The routine nursing intervention mainly involves providing medication according to the doctor’s instructions and offering diabetes-related education pathway. Patients also received diabetes health-education brochures. After discharge, specialized nurses conducted regular telephone follow-ups to assess medication use and glycemic monitoring. However, many diabetic patients receive limited family or social support after discharge, which can reduce self-worth and sense of happiness increase anxiety and depression susceptibility. According to the theory of health ecology, multi-dimensional and multi-level behavioral interventions can provide long-term, continuous health support and ensure that health promotion measures meet patients’ needs[19]. Therefore, this study adopted a multi-level nursing intervention based on the health ecology theory for the observation group, while the control group received routine nursing intervention. The results showed no significant differences between groups in HbA1c, FBG, and 2hPBG indicators, as well as SSRS scores on the day of discharge. However, the observation group had higher DSCS and PSS-Fa scores and lower DSAS-2, SAS, and SDS scores than those the control group. The reasons for this may include: (1) Blood glucose indicators in middle-aged and young T2DM patients must be effectively controlled before discharge, explaining the lack of significant group differences in HbA1c, FBG, and 2hPBG at that time. The SSRS measures the patients’ perception of social support, including objective support, subjective support, and utilization of support; during hospitalization, limited social interaction restricts these perceptions, leading to similar SSRS scores between groups; and (2) Traditional hospital education is often one-way and disease-centered, with patients passively receiving information. However, the health ecology-based intervention improves diabetes-related cognition in young and middle-aged T2DM patients from multiple levels and encourages daily self-management education. For example, on days 2-4 of hospitalization, the responsible nurse provides individualized face-to-face guidance addressing daily life, spiritual comfort, and medical care, strengthening patients’ self-efficacy and reducing anxiety and depression to a certain extent. At the family level, relatives are thought diabetes self-management skills, encouraged to supervise diet and treatment, and informed about care requirements. Family understanding and emotional and informational support helps patient feel more confident. Harper et al[20] found that adults with T2DM often monitored and judged by family members, which can create guilt or shame in the patients and prompt concealment of their diabetic condition, negatively affecting their mental state. Therefore, face-to-face communication and guidance with families is essential. Bukhsh et al[21] reported that family support is a key factor influencing diabetic self-care behavior. In this study, the health ecology-based intervention included structured family-level guidance; for example, on days 5-8 of hospitalization, nurses provided targeted education to enhance family members’ understanding and encourage emotional support. By helping patients and families re-understand T2DM from a multi-dimensional, life-oriented perspective, patients shift from passive “worry-avoidance” to active “recognition-response”, which helps alleviate stigma, anxiety, depression, and other adverse psychological states.

Internet information technology now plays an important role in diabetes management[22]. In this study, young patients with T2DM were followed-up for three months. At the 3-month review, the observation group had a lower HbA1c, FBG, and 2hPBG levels and a significantly higher DSCS score than the control group. This may reflect differences in post-discharge support. Patients in the control group received telephone follow-up from specialist nurses, which focused mainly on medication use and blood glucose monitoring and lacked continuous community and social support. However, patients in the observation group installed the MMC software APP on their mobile phones before discharge and set medication reminders in real time, helping prevent missed doses and improving glycemic control. Nurses also used the MMC software APP to send relevant health recipes, exercise plans, and other health information to patients. When problems arose in daily life, patients could communicate directly with medical staff through the MMC software application client. These functions strengthened diabetes self-management (improving DSCS scores) and reduced anxiety associated with unresolved problems. Studies have shown that people with T2DM frequently experience anxiety, depression, and diabetes-related distress[23,24], often influenced by environmental factors such as discriminatory community attitudes or low public acceptance of diabetes. These factors may increase shame, anxiety, and depressive symptoms. Routine verbal reassurance is often insufficient for young and middle-aged patients with T2DM, making it difficult to build an effective psychological support network and potentially compromising care outcomes. Therefore, post-discharge interventions for middle-aged and young patients with T2DM should also target community and societal levels. The results of this study show that at the 3-month follow-up, the observation group had significantly higher PSS-Fa and SSRS scores and significantly lower DSAS-2, SAS, and SDS scores than the control group. Possible explanations include the health ecology-based interventions that incorporate community-level components and help create a “de-stigmatizing” social microenvironment. Community health lectures, patient groups, and similar activities make diabetes-related topics more open and normalized. Within this environment, patients observe that “others are like me”, which helps challenge and reduce internalized sense of shame. For example, after discharge, the diabetes specialist nurses coordinate care with community doctors and nurses, informing them of the patient’s feelings of stigma and negative psychological issues. Ramadan[25] also noted that community nurses have a deep understanding of patients’ daily lives and can provide essential support, education, and advocacy for those who may have difficulty managing their own conditions. In addition, collaboration with community staff to deliver regular public diabetes-related lectures helps reduce discriminatory behaviors toward diabetic patients in the community. Wu et al[26] found that enhancing social support for patients with T2DM can alleviate their anxiety and depression. The social component of the health ecology intervention also involves disseminating diabetes-related knowledge through social media to promote accurate public understanding. This approach fosters positive public opinion, increases social acceptance, and reduces prejudice and negative stereotypes toward diabetes. Consequently, diabetic patients experience less shame and fewer psychological challenges[27]. Overall, the findings suggest that the effectiveness of health ecology-based nursing interventions arises from a sustained virtuous cycle in which external support (family, society, and community) strengthens internal psychological processes (cognitive restructuring, identity repair, and efficacy enhancement).

This study has several limitations. First, it is a single-center retrospective analysis with a small, single-source sample, which may introduce selection bias and limit generalizability. Second, because of funding constraints, patients were only followed-up for three months after discharge, an interval too short to assess long-term effects intervention effects, such as changes in blood glucose and psychological status after six months or one year). Third, social support outcomes were assessed mainly with the SSRS, whose content lacks targeted indicators (e.g., experiences of social discrimination and participation in social activities), potentially affecting the precision of the evaluation. Therefore, future studies should include larger and more diverse samples, extend follow-up duration, and use multiple scales to enhance the validity of social support assessments.

CONCLUSION

Multi-level nursing interventions based on health ecology theory can effectively improve the diabetes self-management behaviors and glycemic outcomes in young and middle-aged patients with T2DM, strengthen family and social support, reduce stigma, and alleviate anxiety and depression.