In 2021, the International Diabetes Federation (IDF) reported that the prevalence of diabetes increases with age and is highest among those aged 75-79 years (24.0%).1 Among the reported incidences, type 2 diabetes mellitus (T2DM) accounts for 90% of the cases.2 As a complex chronic disease, T2DM not only causes serious physical and psychological distress to patients and their families.3 but also imposes a heavy economic burden on the society.4 Therefore, the treatment of T2DM and the prevention of its complications are particularly important.5

Self-management is considered to be the cornerstone of diabetes management.6 Numerous studies have shown that patients with greater self-management ability typically have better health outcomes and associated quality of life.7, 8, 9, 10 Also, self-management improves metabolic control and delays the development and progression of complications.11 However, effective self-management is achieved through a complex set of activities, including medications, diet and exercise management, foot care, blood glucose monitoring and prevention of complications.12,13 This may be relatively challenging for older patients with T2DM.14 Therefore, healthcare professionals should identify factors that increase the risks associated with diabetes and promote self-management in order to develop interventions to improve self-management in people with diabetes.

Patient activation (PA), a psychosocial construct,15 An activated patient has the motivation, confidence, and skills necessary to enact behavioral changes and make health-related decisions.16 Patient activation means that patients recognise that they have an important role to play in self-management, health maintenance, and communication in collaboration with healthcare providers.17 That is, patients with high levels of patient activation have higher physical and mental functional status scores. They are also more likely to perform self-management behaviors and use self-management services.18,19 Studies have shown that patient activation is an important predictor of patient health outcomes, health behaviors, and quality of health care.20, 21, 22 Previous studies on patients with chronic diseases have shown that patient activation has a positive effect on self-management.23 However, little is known about how patient activation stimulates diabetes self-management, especially in older patients with T2DM in the community. Therefore, understanding how the activation of elderly patients with type 2 diabetes in the community is related to self-management behavior can help identify which patients need more self-management support and provide tailor-made care and counseling for patients, at the same time, provide information for intervention in such groups.24

Self-efficacy is the degree of confidence that people have in their ability to use their skills to accomplish a specific goal,25 is a crucial factor that may explain adherence to health behaviors in general.26 It is an important component of self-management in people with diabetes27,28 and also plays an important role in improving the health status of people with diabetes.29 Studies have shown that self-efficacy directly improves adherence to medication, metabolic outcomes, self-management, and quality of life in people with diabetes.13,30,31 And the relationship between self-efficacy and patient activation has been well established, particularly in patients with chronic diseases and for certain health behaviors, such as medication, diet and exercise.32, 33, 34 Also, previous studies have demonstrated the relationship between self-efficacy and patient activation with self-management ability, respectively.35,36 However, as far as we knowledge, the relationships among self-efficacy, patient activation and self-management ability have not been explored. In addition, researchers have not explored the potential mediation role of self-efficacy between patient activation and self-management ability.

The purpose of this study is to address these gaps by assessing the relationships among patient activation, self-efficacy, and self-management ability and exploring whether self-efficacy plays a mediation role between patient activation and self-management ability. Knowledge about their inter-relationships will inform the development of interventions for healthcare providers to reduce adverse health outcomes due to low self-management of diabetes.