Mindfulness and self-regulation intervention for improved self-neglect and self-regulation in diabetic older adults

Aging populations, including in Iran, face a high burden of chronic diseases such as type 2 diabetes, which complicates self-care due to cognitive and physical decline. Self-neglect—failure or refusal to perform essential self-care—poses serious risks and is associated with factors like executive dysfunction, social isolation, and low socioeconomic status. Self-regulation, a cyclical process involving self-awareness, goal setting, action planning, self-monitoring, and feedback, is crucial for diabetes self-management but may be undermined by depleted self-regulatory resources. Mindfulness practices can improve emotion regulation, executive function, and metacognitive control, thereby enhancing self-regulation. Prior studies in older adults have examined mindfulness or self-regulation interventions separately, showing benefits for psychological well-being, self-management behaviors, and glycemic control. The present study hypothesizes that integrating mindfulness with self-regulation will more effectively reduce self-neglect and improve self-regulation than self-regulation alone, by simultaneously targeting cognitive, emotional, and behavioral processes. The study’s purpose is to evaluate combined mindfulness and self-regulation interventions versus self-regulation-only and routine care among Iranian older adults with type 2 diabetes, addressing a gap in holistic, synergistic approaches within this population.

The paper reviews evidence linking self-neglect in older adults to cognitive decline and executive dysfunction, and highlights self-regulation as a key determinant of diabetes self-management through constructs such as self-efficacy, knowledge, social support, and outcome expectations. Mindfulness is discussed as a modality that enhances emotion regulation, executive function, self-awareness, and metacognitive monitoring, thereby supporting self-regulatory capacity. Prior experimental and clinical studies in older adults with diabetes have demonstrated: (a) mindfulness-based programs improve psychological outcomes and self-regulation; (b) self-regulation interventions increase knowledge, attitudes, and self-management behaviors; (c) tailored self-management training improves glycemic control; and (d) combined, multi-component interventions in older adults yield superior psychological and physical outcomes. These findings support the rationale for a combined mindfulness and self-regulation program to reduce self-neglect and enhance self-regulation in older diabetic adults.

Design: 24-week, double-blinded, three-arm cluster randomized controlled trial conducted in three urban health centers in Shiraz, Iran (December 2020–June 2021). Clusters (health centers) were randomized to: SRIP (self-regulation program), CMSRIP (combined mindfulness + self-regulation), or control (routine care + COVID-19 prevention training). Participants and the main analyst were blinded; analysts labeled groups as 1–3. Interventions and assessments were delivered via WhatsApp and telephone due to COVID-19. Sampling and participants: From 8 diabetes-care urban centers, 3 were randomly selected. Each center contributed 45 participants (total randomized n=135). Eligibility: age 60–80 years; type 2 diabetes ≥6 months; at least elementary literacy; normal cognitive status (MMSE 24–30 via WhatsApp video); ability to perform basic ADLs; smartphone + internet access; ability to use WhatsApp for text/video. Exclusions: serious psychological issues, non-response after three contact attempts, unwillingness to participate. PASS software estimated 45 per group (effect size 0.32, α=0.05, accounting for 10% attrition). Final analyzed n=132 (SRIP 45; CMSRIP 44; control 43) after exclusions (mobile breakdown n=1 in CMSRIP; medical reasons n=2 in control). Interventions: All groups received WhatsApp-based education. Frequency: daily messages for first 8 weeks, then weekly (Mondays) for 16 weeks. Feedback forms and weekly participant/instructor feedback guided tailoring. Message counts over 6 months: control 293; CMSRIP 287; SRIP 240. - SRIP: 8-week self-regulation training (texts, audio, video, links) aligned with constructs: self-awareness, goal setting, action planning, self-monitoring, feedback; plus diabetes self-care content (diet, medication management, stress reduction/smoking cessation, physical activity, foot care, supplements/traditional medicines, glucometer use and insulin technique). - CMSRIP: 16 modules over 8 weeks combining mindfulness (based on Segal et al.’s MBCT framework: breathing exercises, body scan, mindful walking/sitting, lake/mountain meditations, STOP skill, self-compassion practices, audio/silent meditations) with the same self-regulation training as SRIP. First 4 weeks emphasized mindful self-care to improve decision-making and cognitive processing. - Control: routine care + COVID-19 prevention training. Outcome measures and timing: Assessed at baseline (T0), 4 weeks (T1), and 16 weeks (T2) post-intervention onset via telephone interviews. - Elder Self-Neglect Scale (ESNS): 26 items, 6 dimensions (physical environment, physical health, mental health, financial status, social network, self-determinant). 5-point Likert; total 26–130; lower scores reflect more severe self-neglect. Validated in Iranian older adults (RMSEA=0.04, GFI=0.90, CFI=0.95, CMIN/DF=1.48; Cronbach’s α=0.85; test–retest r=0.73). - Short-Form Self-Regulation Questionnaire (SSRQ) Persian version: 20 items, 4 dimensions (self-awareness 6, goal-setting 2, action planning 6, self-monitoring 6); 5-point Likert; total 20–100; higher scores indicate better self-regulation. Psychometrics: RMSEA=0.059, GFI=0.89, CFI=0.92, CMIN/DF=1.87; Cronbach’s α=0.78; test–retest r=0.68. Statistical analysis: SPSS v20. Descriptive statistics; ANOVA for continuous demographics (duration of diabetes, MMSE), chi-square for categorical variables. Normality checked via Kolmogorov–Smirnov. General Linear Model (GLM) repeated measures compared mean changes over time adjusted to baseline; η² effect sizes reported. Bonferroni post hoc pairwise comparisons for timepoint differences. Significance P<0.05. Ethical approval: IR.SUMS.REC.1398.1365; trial registration ISRCTN77260130; informed consent obtained.

- Sample and balance: 132/135 completed (97% response). Groups were comparable at baseline; mean age 66.42±5.35; 55.9% female. No significant baseline differences for SSRQ (P=0.612) or ESNS (P=0.763). - Primary outcomes (Table 3): Self-regulation (SSRQ means [SD]): • CMSRIP: baseline 55.36 (9.76), 1 month 73.89 (4.18), 4 months 68.84 (3.39); within-group P<.001; η²=0.808. • SRIP: baseline 57.76 (13.61), 1 month 70.40 (6.75), 4 months 66.18 (4.52); within-group P<.001; η²=0.537. • Control: baseline 57.04 (6.35), 1 month 65.93 (4.40), 4 months 63.73 (7.28); within-group P<.001; η²=0.627. Between-group: 1 month P<.001; 4 months P<.001. Self-neglect (ESNS means [SD], lower=worse self-neglect): • CMSRIP: baseline 102.67 (6.72), 1 month 75.73 (13.96), 4 months 80.13 (10.70); within-group P<.001; η²=0.836. • SRIP: baseline 100.00 (11.24), 1 month 81.42 (6.28), 4 months 83.07 (10.40); within-group P<.001; η²=0.630. • Control: baseline 101.11 (8.69), 1 month 89.13 (7.25), 4 months 95.13 (10.98); within-group P<.001; η²=0.579. Between-group: 1 month P=0.002; 4 months P<.001. - Abstract-reported omnibus tests: CMSRIP yielded greater improvement in self-regulation (χ^2=73.23, P<.001) and greater reduction in self-neglect (χ^2=62.97, P<.001) at 4 and 16 weeks compared to SRIP. - Pairwise changes (Bonferroni, Table 4; mean change ± SE): ESNS (decreases reflect improvement): SRIP −18.57 at week-4 (P<.001), −16.93 at week-16 (P<.001), week-4→16 change −1.64 (P=1); CMSRIP −26.93 (P<.001), −22.53 (P<.001), week-4→16 +4.40 (P=0.236); Control −11.97 (P<.001), −5.97 (P=0.019), week-4→16 +6.00 (P=0.003). SSRQ (increases reflect improvement; table shows negative values for reduction from baseline, so improvements are absolute increases of 12.64, 18.53, 8.88 etc.): SRIP +12.64 at week-4 (P<.001), +8.42 at week-16 (P=0.001), week-4→16 −4.22 (P<.001); CMSRIP +18.53 (P<.001), +13.48 (P<.001), week-4→16 −5.04 (P<.001); Control +8.88 (P<.001), +6.68 (P<.001), week-4→16 −2.20 (P=0.228). - Temporal pattern: Improvements were largest at 4 weeks and attenuated by 16 weeks across groups; intervention groups maintained significantly better outcomes than control. - Dimension-level trends: SSRQ dimensions increased post-intervention with a slight decline by week 16; goal-setting showed an initial dip at week 4 in all groups before improving by week 16. ESNS dimensions decreased (improved) at weeks 4 and 16 with slight rebound by week 16. - Attrition: minimal (3/135).

The combined mindfulness plus self-regulation program produced greater improvements in self-regulation and reductions in self-neglect than self-regulation alone, supporting a synergistic effect of cognitive (mindfulness) and behavioral (self-regulation) components for diabetes self-management in older adults. Mindfulness likely enhanced executive control, emotion regulation, and present-moment awareness, facilitating adoption of self-regulatory strategies (self-awareness, action planning, self-monitoring) and resulting in better adherence to self-care. The initial decrease in the goal-setting dimension at 4 weeks may reflect short-term anxiety, information overload, and limited early self-management skills; subsequent improvements by 16 weeks suggest adaptation and skill acquisition. The control group’s modest improvements likely reflect routine care, researcher presence, and testing (Hawthorne) effects. The strongest changes occurred in the first month, with partial attenuation by 16 weeks, indicating high short-term responsiveness and the importance of sustained, structured education (weekly boosters) to maintain gains. Overall, the findings underscore the value of integrating mindfulness into self-regulatory frameworks to address cognitive, emotional, and behavioral barriers to self-care and to reduce self-neglect in older adults with type 2 diabetes.

Combining mindfulness and self-regulation interventions effectively enhances self-regulation and reduces self-neglect among older adults with type 2 diabetes, outperforming self-regulation alone and routine care. These results support integrating holistic, cognitive-behavioral approaches and mobile-based delivery (e.g., WhatsApp) into diabetes programs for older populations. Policymakers and clinicians can use these findings to design scalable continuing education and support systems to sustain long-term behavior change. Future research should include longitudinal follow-up to assess durability of effects, evaluate cultural factors influencing uptake, explore technology integration and accessibility, and tailor intervention components to individual needs and cognitive profiles.

- Self-report questionnaires may introduce social desirability bias. - Telephone-based administration may yield different responses than in-person interviews. - Online-only interventions due to COVID-19 may differ in effectiveness from in-person or hybrid delivery. - Double-blinding applied to participants and analysts, but researchers were not blinded, which may introduce bias. - Cluster randomization with three centers could limit generalizability and may be susceptible to cluster-level confounders despite random allocation.