{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T18:48:03Z","timestamp":1774291683773,"version":"3.50.1"},"reference-count":35,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2025,9,19]],"date-time":"2025-09-19T00:00:00Z","timestamp":1758240000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2025,9,19]],"date-time":"2025-09-19T00:00:00Z","timestamp":1758240000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Clinical Nursing"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>\n                      To examine the associations among diabetes\u2010related stress, treatment adherence, perceived social support, and health\u2010related quality of life (\n                      <jats:styled-content style=\"fixed-case\">HRQoL<\/jats:styled-content>\n                      ) in adults with type 1 diabetes mellitus (\n                      <jats:styled-content style=\"fixed-case\">DM1<\/jats:styled-content>\n                      ), and to explore the mediating roles of support and adherence in this relationship.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A cross\u2010sectional observational study using self\u2010report standardised measures and mediation analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A total of 772 Spanish adults with\n                      <jats:styled-content style=\"fixed-case\">DM1<\/jats:styled-content>\n                      completed validated instruments measuring diabetes\u2010related distress, perceived social support, treatment adherence, and\n                      <jats:styled-content style=\"fixed-case\">HRQoL<\/jats:styled-content>\n                      . Hierarchical multiple regression and serial mediation analysis (\n                      <jats:styled-content style=\"fixed-case\">PROCESS<\/jats:styled-content>\n                      Model 6, 10,000 bootstraps) were conducted, controlling for age, sex, and time since diagnosis.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources<\/jats:title>\n                    <jats:p>Not applicable (primary data collection, not a review).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Diabetes\u2010related stress was the strongest predictor of lower\n                      <jats:styled-content style=\"fixed-case\">HRQoL<\/jats:styled-content>\n                      . Perceived social support and treatment adherence also contributed significantly. Mediation analyses indicated that the impact of stress on\n                      <jats:styled-content style=\"fixed-case\">HRQoL<\/jats:styled-content>\n                      was partially mediated by perceived social support and, in sequence, by treatment adherence. The indirect path through social support alone and the sequential path involving both mediators were significant.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      Stress and social support are critical in understanding and improving\n                      <jats:styled-content style=\"fixed-case\">HRQoL<\/jats:styled-content>\n                      in adults with\n                      <jats:styled-content style=\"fixed-case\">DM1<\/jats:styled-content>\n                      . Treatment adherence appears to be influenced by perceived support, highlighting an indirect mechanism linking stress to quality of life.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implications for the Profession and\/or Patient Care<\/jats:title>\n                    <jats:p>Healthcare professionals should integrate psychosocial assessments and interventions into routine diabetes care. Targeting stress reduction and enhancing social support may improve adherence and overall well\u2010being in adults with DM1.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Impact<\/jats:title>\n                    <jats:p>What problem did the study address? The study addressed the need to understand how psychosocial factors\u2014specifically stress, perceived social support, and treatment adherence\u2014contribute to HRQoL in adults with DM1. While prior research often focused on paediatric or clinical populations and rarely explored mediation models, this study sought to fill those gaps with data from a large community sample of adults.<\/jats:p>\n                    <jats:p>What were the main findings? The main findings indicate that diabetes\u2010related stress is the most significant predictor of reduced HRQoL. This relationship is partially mediated by perceived social support and, sequentially, by treatment adherence. While stress directly affects HRQoL, its negative impact is also channelled through diminished social support and decreased adherence. The indirect effect through treatment adherence alone was not significant.<\/jats:p>\n                    <jats:p>Where and on whom will the research have an impact? The research has implications for adults living with DM1, particularly those in community settings outside of clinical supervision. It informs healthcare providers, diabetes educators, and policymakers on the importance of addressing emotional distress and strengthening support networks to improve both treatment adherence and overall quality of life.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Reporting Method<\/jats:title>\n                    <jats:p>This study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross\u2010sectional studies. All methods and results are reported in alignment with EQUATOR Network recommendations for transparent and rigorous research reporting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient or Public Contribution<\/jats:title>\n                    <jats:p>The study was conducted in collaboration with the Spanish Diabetes Federation (FEDE), which supported participant recruitment and dissemination through its affiliated associations. Patient input was incorporated throughout the study. A person with lived experience of type 1 diabetes contributed to the conceptual development of the research questions and the interpretation of findings. Their perspective helped ensure that the study design, choice of measures, and implications were relevant and meaningful to people living with the condition. This involvement supported a patient\u2010centred approach to both the research and the manuscript preparation. Patients' participation as voluntary contributors was essential to the data collection process.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jocn.70114","type":"journal-article","created":{"date-parts":[[2025,9,19]],"date-time":"2025-09-19T11:47:13Z","timestamp":1758282433000},"page":"1373-1381","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Stress and Health\u2010Related Quality of Life in Adults With Type 1 Diabetes: The Mediating Role of Perceived Support and Treatment Adherence"],"prefix":"10.1111","volume":"35","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5764-6406","authenticated-orcid":false,"given":"Rafael","family":"Salas\u2010Muriel","sequence":"first","affiliation":[{"name":"Department of Personality, Psychological Assessment and Treatment, School of Psychology University of Salamanca  Salamanca Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3366-2855","authenticated-orcid":false,"given":"Francisco Javier","family":"De Santiago\u2010Herrero","sequence":"additional","affiliation":[{"name":"Department of Personality, Psychological Assessment and Treatment, School of Psychology University of Salamanca  Salamanca Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6519-6329","authenticated-orcid":false,"given":"Mar\u00eda Montfrag\u00fce","family":"Garc\u00eda\u2010Mateos","sequence":"additional","affiliation":[{"name":"Department of Personality, Psychological Assessment and Treatment, School of Psychology University of Salamanca  Salamanca Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0969-9183","authenticated-orcid":false,"given":"Mar\u00eda","family":"del Sol Fortea Sevilla","sequence":"additional","affiliation":[{"name":"Department of Psychology, Sociology and Social Work, School of Education Sciences University of Las Palmas de Gran Canaria  Las Palmas de Gran Canaria Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2060-1658","authenticated-orcid":false,"given":"Cristina","family":"Jenaro","sequence":"additional","affiliation":[{"name":"Department of Personality, Psychological Assessment and Treatment, School of Psychology\/INICO University of Salamanca  Salamanca Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9865-2714","authenticated-orcid":false,"given":"Juan\u2010Jos\u00e9","family":"Igartua","sequence":"additional","affiliation":[{"name":"Department of Sociology and Communication, Faculty of Social Sciences University of Salamanca  Salamanca Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,9,19]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0217771"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1155\/2020\/3548520"},{"key":"e_1_2_9_4_1","doi-asserted-by":"publisher","DOI":"10.1002\/cpp.2746"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.anpedi.2020.03.016"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pec.2019.10.010"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12160\u2010013\u20109585\u20104"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2014.09.012"},{"key":"e_1_2_9_9_1","volume-title":"The Diabetes World: The Development of Sense of Self and Identity in Adults With Early\u2010Onset, Type 1 Diabetes","author":"Bernstein J.","year":"2004"},{"key":"e_1_2_9_10_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen\u20102018\u2010026809"},{"key":"e_1_2_9_11_1","doi-asserted-by":"publisher","DOI":"10.12996\/gmj.2021.126"},{"key":"e_1_2_9_12_1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm10245829"},{"key":"e_1_2_9_13_1","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph14121522"},{"key":"e_1_2_9_14_1","doi-asserted-by":"publisher","DOI":"10.1080\/09638288.2019.1705924"},{"key":"e_1_2_9_15_1","doi-asserted-by":"publisher","DOI":"10.1111\/pedi.13147"},{"key":"e_1_2_9_16_1","volume-title":"Introduction to Mediation, Moderation, and Conditional Process Analysis. 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