Impediments to diabetes management among older women: A qualitative study from rural Meghalaya,India

Abstract

Objectives

This study aims to explore the impediments to diabetes management among older women living in rural areas of Meghalaya, a northeastern state in India.

Methods

The study adopted a narrative inquiry approach. In-depth interviews were conducted with 29 older women (aged 60 and above), selected purposively. Findings were analyzed thematically using the open or inductive coding approach in NVivo 12.0.

Results

Seven key themes emerged from the study. These were: (i) negative impacts of physiological changes on diabetes management for the participants, (ii) weak social support which hindered diabetes care, (iii) experiences of ill-treatment by relatives and a sense of helplessness, (iv) caregiving roles as barriers to care, (v) difficulties in accessing treatment due to geographical barriers, (vi) expensive treatment due to comorbidities, and (vii) feelings of guilt due to financial dependency.

Conclusions

Our study found a confluence of structural and individual-level barriers that hindered diabetes management among older women in rural Meghalaya. These barriers were linked not only to age and disease but also to gendered social roles, systemic health care gaps, and economic insecurity. This study emphasises the need to reinforce current healthcare policies and programmes targeting older women and to advocate for a comprehensive, multisectoral approach to address these issues effectively.

Keywords

diabetes care older women tribal health qualitative Meghalaya India

Introduction

Diabetes is one of the major chronic non-communicable diseases (NCDs) affecting older adults globally.¹ Studies have shown that the prevalence of diabetes is increasing among indigenous or tribal people, especially among women.^2,3 Older women suffer from a high burden of chronic illness, comorbidities, and disability, particularly when they also belong to the most marginalized and socio-economically disadvantaged groups.⁴ Besides gender, sociocultural and economic factors including living conditions, affect the development and management of chronic diseases such as diabetes.^5,6 People with diabetes require additional health care including, at times, hospitalization.⁷ The discrimination women face worldwide, particularly indigenous women, in accessing economic resources and contributing to decision-making, exacerbates the challenge of managing chronic illnesses such as diabetes.⁸ In India, groups referred to internationally as indigenous peoples are officially classified as Scheduled Tribes by the Government of India under Article 342 of the Constitution of India.⁹ A range of terms such as Adivasi, tribal, and indigenous peoples are found in the literature, with “tribal” still the administratively recognized category, despite its colonial origins.⁹ Adivasi (“original inhabitants”) is not widely accepted in northeast India, where communities prefer “tribal” or “indigenous peoples.”⁹⁽⁴³⁾

In this study, ‘tribal women’ refers only to women from constitutionally recognized Scheduled Tribe communities in India, and not to other indigenous or marginalized groups elsewhere. Tribal women face numerous challenges in accessing health care related to their poverty, geographical isolation, poor public transportation, and discriminatory attitudes of healthcare providers towards them.¹⁰ This is reflected in the poor health status of tribal women, which worsens when they experience chronic illnesses such as diabetes.

Although India has introduced multiple policies to promote the welfare of older women, these interventions have not sufficiently reduced their economic and health deprivation.¹¹ The National Policy on Older Persons, implemented in 1999 by the Government of India, defines “elderly” or “senior citizen” as a person anyone aged 60 years or older.¹² It has been documented that the number of individuals aged 60 years and above is increasing in northeastern India. This has profound implications for the living arrangements of older women, as northeast India is considered a less developed region, where the only source of care and support is the family.¹¹ Government-run nursing homes for older women are almost absent in northeast India, and even where available, such care is unaffordable for most older women. Thus, older women living alone in poverty face additional challenges compared to those living with family members.¹¹ These challenges encompass feelings of loneliness, absence of support, and frailty.¹³ Frailty is associated with aging, multimorbidity including chronic diseases, absence of social support, and limited physical activity.¹³ Further, the risk of comorbidities and multimorbidities is also higher among older women.¹⁴ Frailty is of particular concern for older women with diabetes residing in impoverished environmental conditions. Given these more general concerns, this qualitative study investigated the specific impediments to effective diabetes management among older women living in rural areas.

Methods

This qualitative study was conducted among older women of the Pnar tribal community residing in the West Jaintia Hills District of Meghalaya. The study adopted a narrative inquiry approach.¹⁵ The study follows the consolidated criteria for reporting qualitative studies (COREQ) (see Supplementary Information File S1).¹⁶

Selection of participants

Older women living with diabetes were identified and contacted by researchers with assistance from frontline healthcare providers, including Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), Anganwadi Workers (AWWs), Surveillance Workers (SWs), and Mid-Level Healthcare Providers (MLHPs). A total of 29 women aged 60 years and above were recruited using purposive sampling based on the following criteria: residence in villages within the study district, self-identification as belonging to a Scheduled Tribe, and a diagnosis of diabetes for at least 1 year. This approach enabled the selection of participants with direct and sustained experience of living with diabetes in a rural tribal context. The definition of the age group for older women is as per the National Program for Health Care of the Elderly (NPHCE) launched by the Government of India (GoI) in 2010.¹⁷

The sample size for in-depth interviews in qualitative studies ranges from one to more than 100, depending on the study design, the objectives of the study, and data saturation.¹⁸ In the present study, we stopped recruiting participants as no new themes emerged after in-depth interviews were conducted with 29 older women. For older women with hearing difficulties, their caregivers assisted them in answering the interview questions. 10 caregivers participated in interviews in total, their characteristics can be found in the Supplementary Information File (S2).

Data collection and analysis

Fieldwork for the study was conducted between April and July 2022. In-depth interviews were conducted at the participants’ homes using a semi-structured interview guide, with follow-up interviews conducted by telephone. A semi-structured interview guide was developed in English and translated into Pnar during the interviews by the Pnar-speaking interviewer (Supplementary Information File S3). The interview guide examined health-seeking behaviour and service use (treatment choices, follow-up, access, and costs), alongside daily work and caregiving roles, adherence to diet, exercise, and medication, and barriers related to poverty, transport, health systems, and family support.

Verbal consent for the in-depth interviews and audio-recording was obtained from participants. The purpose of the study was explained to each participant before the interview, using a written consent form or verbally explained by the interviewer for those participants unable to read the written information. The confidentiality of older women was assured, and pseudonyms were used wherever necessary to protect their identities. All 29 participants completed one initial face-to-face interview. Follow-up telephone interviews were conducted with a subset of participants (n = 12). Of these, two participants completed three follow-up interviews, and 10 completed two follow-up interviews. In total, 55 interviews were conducted. The purpose of follow-up interviews was to clarify responses and explore emerging themes from the initial interviews.¹⁹ These interviews did not repeat the full interview guide but instead focused on specific issues that required further explanation. Observational data from home visits were used to triangulate the interview findings as were documents including medical reports, prescriptions, diagnostic test advice, registration slips, and hospital bills.

In this study, face-to-face interviews allowed the researcher to observe the participants' living environments, to triangulate the data gathered during the interviews and add to the study’s trustworthiness.²⁰ Follow-up telephone conversations allowed insights into the ongoing experiences of participants of their chronic condition. All in-depth interviews were conducted by the first author, AM, a member of the Pnar tribe and indigenous to the West Jaintia Hills District, and who was able to establish rapport with the participants, facilitating open and meaningful conversations.

The audio-recorded interviews were transcribed verbatim and later translated into English. Both authors checked the interview transcripts. The transcripts were imported into computer-assisted qualitative data analysis software (CAQDAS),²¹ specifically NVivo 12.0 for open, or inductive, coding.²² Each transcript was read, and the researchers conducted open coding, as a first step of qualitative analysis.²² After all the transcripts had been coded, a codebook was generated from the NVivo 12 software.²³ The codebook was then exported to Microsoft Word, where the authors manually grouped similar codes from the transcripts manually into themes. The socio-cultural context and background of participants were compiled (see Table 1).

Table 1.

Socio-demographic profile of Older Women.

Participant no.	Age	Marital status	Educational Qualification	Occupation	Religion	Above poverty Line (APL)/Below poverty Line (BPL)
p1	73	Married	No schooling	Farmer	Christianity	BPL
P2	67	Widow	Matric passed	Retired government employee	Christianity	APL
P3	63	Widow	No schooling	Homemaker	Christianity	APL
P4	66	Widow	No schooling	Farmer	Indigenous with a blend of Hinduism	BPL
P5	61	Widow	Primary	Homemaker	Indigenous with a blend of Hinduism	APL
P6	66	Widow	Upper primary	Retired government employee	Indigenous with a blend of Hinduism	APL
P7	66	Married	No schooling	Dependent	Indigenous with a blend of Hinduism	BPL
P8	68	Widow	No schooling	Farmer	Christianity	BPL
P9	63	Separated	No schooling	Dependent	Christianity	BPL
P10	82	Widow	No schooling	Dependent	Christianity	BPL
P11	69	Married	No schooling	Shopkeeper	Christianity	BPL
P12	82	Widow	Upper primary	Retired teacher	Christianity	BPL
P13	61	Married	No schooling	Trader	Christianity	BPL
P14	69	Widow	No schooling	Dependent	Christianity	BPL
P15	62	Married	No schooling	Farmer	Christianity	APL
P16	63	Widow	Class III	Small trader	Christianity	APL
P17	81	Widow	Class III	Dependent	Christianity	BPL
P18	63	Married	Matric passed	Retired government employee	Christianity	APL
P19	62	Married	Class III	Dependent	Christianity	APL
P20	77	Widow	Class IV	Dependent	Christianity	APL
P21	64	Married	No schooling	Dependent	Christianity	BPL
P22	72	Widow	Class IX	Dependent	Christianity	APL
P23	69	Widow	Class I	Dependent	Christianity	BPL
P24	66	Widow	No schooling	Dependent	Christianity	BPL
P25	68	Widow	Class III	Dependent	Christianity	BPL
P26	68	Widow	No schooling	Farmer	Christianity	BPL
P27	78	Widow	No schooling	Dependent	Christianity	BPL
P28	61	Married	No schooling	Dependent	Christianity	BPL
P29	66	Widow	No schooling	Dependent	Christianity	BPL

Ethical approval

Ethical approval for the study was granted by the Institute Human Ethics Committee (IHEC), Indian Institute of Technology Guwahati (Reference No.: IHEC/2022/DP/4).

Results

Table 1 describes the socio-demographic characteristics and economic conditions of the 29 participants interviewed for the study. Of the 29, most (n = 22) were between 61 and 70 years old, four were between 70 and 80 years of age and three were in their 80s. Nineteen participants were widows, nine were married and one separated. Seventeen participants had no formal education and 20 depended financially on family members and children. Most (n = 19) belonged to Below Poverty Line (BPL) households. BPL is the poverty estimation methodology calculated by the Government of India based on indicators such as land holdings, type of house, availability of clothing, food security, and income earned to purchase food to obtain necessary calories.²⁴ BPL households were identified based on the availability of the Antyodaya or ration card provided to the poorest households. The majority (n = 25) of the participants practiced Christianity.

Qualitative analysis identified seven interrelated descriptive themes of how older women in rural and tribal areas of Meghalaya experienced and navigated challenges in diabetes management. These themes represent participants’ interpretations of their everyday experiences of living with diabetes, particularly in relation to difficulties in self-management, limited familial support, and financial constraints. Themes are: (i) the negative impact of physiological changes on diabetes management, (ii) weak social support which hindered diabetes care, (iii) ill-treatment by relatives and a sense of helplessness, (iv) caregiving roles as barriers to care, (v) difficulties in accessing treatment due to geographical barriers, (vi) expensive treatment due to comorbidities, and (vii) feeling of guilt due to financial dependency.

Impact of physiological changes on diabetes management

The older women who participated in the study reported various physiological and hormonal changes, related to the challenges that they found came with ageing. Common health problems reported included diminishing eyesight, difficulty in hearing, frailty and susceptibility to fractures. Older women shared their fears of seeking health care due to the likelihood of falls, especially when they were physically weak, as the following narrative of a 66-year-old widow illustrates:

The last time I went out, I felt dizzy, so I fell and happened to hit a car. That is why I never go out, not even for a check-up. Then, the people who saw me carried me towards the side, poured water over me. When I became conscious, the people made me eat the soil so there would be no evil effect. But only a little for the namesake (P4: Dependent, 66 years).

This experience, and others related to this theme, reflects how age-related bodily changes complicate diabetes management by affecting mobility, confidence, and everyday routines. Episodes such as dizziness or falls create fear and hesitation around seeking care, often leading women to limit their movements outside the home. As a result, diabetes management becomes shaped not only by physical decline but also by lived experience and culturally grounded responses to perceived risk. In the quote above, participants reported a belief that ingesting a small amount of soil after a fall can ward off harmful or “evil” effects.

Weak social support hinders diabetes care

Social support was reported to be limited by participants, further adding to their difficulties. Most older women partcipants were either widowed or abandoned at the child-rearing age and, thus, the sole providers of child care and child support. The leading causes of their husbands’ deaths were excessive alcohol consumption, communicable diseases, such as malaria, and non-communicable diseases, such as asthma. Consequently, older women were left alone to care for large families with six or more children.

Even when older women received support from their husbands, it was purely financial. In most cases, their husband were away from the home for work, so most household responsibilities fell on the women, as illustrated in the following interview:

In times like these, I cannot say I have a husband. He cannot come here; we also sit like this, struggling to get food. They did not allow him to come home or me to go to his workplace [referring to the traveling restrictions imposed during the COVID-19 pandemic] (P13: Small Trader, 61 years).

This participtant’s husband worked at a brick construction site in another district. He would usually visit his wife once a month. Travel restrictions during the COVID-19 pandemic stopped even the monthly visits. This further increased the financial pressure on the participant, affecting her ability to manage her diabetes. This experience illustrates how social support can be fragile, with pandemic restrictions disrupting spousal support, leaving the participant to cope alone with food shortages and daily hardship. Physical separation from spouses can weaken the emotional and material support that is essential for managing diabetes, and undermine diabetes care during times of crisis.

Ill-treatment of older women living with diabetes by relatives

The Pnars follow a culture of matriliny where the clan’s name and the inheritance rights are passed on from mother to daughters. The youngest daughter, who has the right to ancestral property, is expected to live with her parents and take care of them. Older women without daughters often depend on the charity of relatives. If the female older adult is poor, her relatives do not treat her well, and she often faces abuse within the household. A 63-year-old widow who used to work in coal mines narrated how she was mistreated after returning to her village due to ill health, including being diagnosed with diabetes and hypertension. She also suffered from a hip fracture and had numerous difficulties accessing goods for her basic needs, social welfare schemes, and visiting banks. She shared:

I do not want to talk about those nieces and nephews. When I was lying sick in their mother’s house, they took my belongings from my house; they took my utensils, plates, cups, clothes, and pots, and took them to their houses. They even took the wooden box where I kept my clothes. They removed the clothes and took the box. They even took my knor [wooden stool] mura [stool made from bamboo] …I have lots of difficulties (P9: Dependent, 63 years).

This narrative highlights how older women can be denigrated. Left alone in the village due to their children migrating for work, they face vulnerability and abuse. Being ill exposed them to mistreatment from relatives, such as having their belongings taken, adding to their distress and making their efforts to manage their health, including their diabetes, even more difficult.

Expensive treatment for diabetes and other comorbidities

Most older women in the study reported that the average cost of ambulatory diabetes care at private allopathic clinics was approximately INR 1,000-5,000 (USD 21.21-61.04) per month, including travel expenses. Costs increased for hospitalizations, and more so for private hospitals. The comorbidity of hypertension with diabetes and the presence of other illnesses increases the likelihood of frequent hospitalization; most older women (n = 18) suffered from the comorbidity of diabetes and hypertension. For instance, a 67-year-old retired government employee participant who had lived with diabetes for 30-35 years was diagnosed with hypertension and suffered from migraines. She was hospitalized frequently in a private hospital. She shared:

Earlier [in the 1990s-2000s], it was cheaper; they used to charge her (INR) 5000-6000 [USD 60.21-72.25] for one week of hospitalization, but now [since the 2010s], they are charging (INR) 1 lakh [USD 1,204.14] per week (P2: Retired government employee, 67 years).

Of the 29 older women in the present study, 10 from the Above Poverty Line (APL) category paid all hospital expenses out of pocket due to the cumbersome process of accessing the government-funded health insurance scheme. However, older women from Below Poverty Line households had no other choice but to forego treatment and live with the illness.

Financial dependency as a barrier to seeking treatment

Older women in this study reported limited participation in economic activity, and therefore had to depend on their children for financial support. However, being dependent comes with an emotional cost, as older women spoke about feeling guilty about asking for money from their children, even for their illnesses. A 72-year-old widow, whose son was a Member of the District Council (MDC) in the Jaintia Hills District Hills Autonomous District Council (JHADC) [Under the Sixth Schedule of the Indian Constitution, Meghalaya is authorized to have its Autonomous District Councils for each district with administrative and governance matters], told us she was afraid of asking her son for money. She narrated:

Lately, I am very scared to even ask my children for money, and I do not get a salary or have any savings. What will I do? I am supposed to visit Banshan [Orthopedic doctor in Shillong], but I am scared to go as I have to spend (INR) 4,000-5,000 (USD 48.17-60.19) at one visit. Previously, when I used to take medicine from Mark [the allopathic doctor], I used to spend (INR) 700 (USD 8.43). Now, I have to pay (INR) 2,000 (USD 24.08) per month. However, it has increased to INR 2,200- 2,300 (USD 26.48-27.68). Though my son is an MDC, it is difficult to ask him for money, as people come every morning and night to ask for money (P22: Dependent, 72 years).

Although her son was financially secure, she decided not to ask for his help. The long-term care needs of older women, especially when they suffer from chronic illnesses like diabetes, add to their feelings of guilt that they need others to take care of them. The sense of guilt wass more common among older women who suffered from complications, when they had to sell their property to afford treatment. This is illustrated in the following narrative of a 69-year-old widow who suffered from chronic kidney disease in 2019 after she was diagnosed with diabetes in 2018:

Because of the ancestral property, I could afford to get my treatment. For now, we can still sell our land. I only wasted everything on myself. My children and grandchildren will not get any more. Poor them. They are unlucky because of getting an illness like this. They did not explain to me from the beginning that once we start doing dialysis, we have to do it always like this. Had they explained to me that it would last longer and I would have to do dialysis till the day I die, I would not have done it. I could have told them to let me die (P14: Dependent, 69 years).

The quote reflects how the high cost and long-term nature of treatment led the participant to exhaust ancestral resources, generate guilt toward her family, and question the value of continuing with care, illustrating how financial dependency becomes a major barrier to seeking and sustaining treatment.

The caregiving role hinders care for diabetes

The sixth theme of the study, caregiving responsibilities and constraints on diabetes management, represents the way that older women in this matrilineal society, with recognized social status, continued to bear caregiving duties similar to those in patrilineal contexts. These social and moral expectations as primary caregivers often restrict their ability to access health services, attend follow-up appointments, complete diagnostic tests, and maintain other aspects of diabetes care. For instance, a 68-year-old widow diagnosed with diabetes in 2022, experiencing various symptoms of diabetes, reported that she could not go for a follow-up because she had to take care of her grandchildren. One of her grandchildren was born with disabilities as his mother had Acquired Immune Deficiency Syndrome (AIDS). She narrated the following:

My youngest daughter had a mysterious disease when she was pregnant. She got AIDS- Have you ever heard of it? Look at her six-year-old son. He cannot eat properly or speak; I do not know if it is because of the medicine or if God made him this way. We took him to Ialong [District Hospital] whenever he became serious. Their father is from the coal mine. Even now, when I speak to you, my legs, feet, and waist are cold. It is also biting, and I have a fierce burning sensation. I told my youngest daughter I must go to Ialong rather than simply taking the treatment from the PHC [primary health clinic]. What if it does not work? However, if she has to take me to Ialong, no one will take care of my grandchildren. Nobody can take care of them. I think I have to go alone, and she will stay home, but I do not know whether she will be free from work, as she is working in the field (P26: Farmer, 68 years).

The quote highlights how caregiving responsibilities, often assumed by older women, constrain their ability to manage chronic conditions like diabetes. The participant’s role in caring for grandchildren forced her to prioritize family needs over her own health, limiting access to appropriate follow-up care and disrupting consistent diabetes management.

The challenge of travel for diabetes care

Access to public transportation is essential for daily economic activities and for seeking access to treatment services. Most older women live in villages that lack access to primary health care services. Thus, they have to travel to the nearest town by local vehicle. Due to the distance and the expense of travel from remote villages, participants found it challenging to visit clinics in the town for follow-up treatment and monitoring of blood sugar levels. Because of their age, they also found it difficult to travel without a caregiver. For instance, a 72-year-old dependent woman living 10 km from the hospital bought herself a glucometer for INR 1500 (USD 18.06) to monitor her blood sugar at home. However, it had stopped working. She shared her experience:

It is not working anymore because I no longer have the money to buy the pins [referring to the lancet and the glucostrips]. As I am not well, I cannot go to work and earn money to buy even the pins. That is why I go to the doctor only once a month, as it is difficult to travel (P22: Dependent 72 years).

Similarly, other older women seeking treatment from private hospitals in Shillong shared that they found traveling challenging, given their age, the distance, and the fear of traveling alone.

The above quote illustrates how financial constraints and declining health intersect to limit older women’s ability to maintain regular diabetes care. The cost of essential supplies, combined with reduced capacity to work and earn income, restricts their ability to travel for follow-up visits. As a result, care becomes irregular; economic and physical vulnerabilities compound barriers to consistent diabetes management.

Discussion

This study highlights the complex and interrelated barriers to effective diabetes management among older women in rural and tribal areas of Meghalaya, India. Our findings underscore how aging-related physiological challenges, compounded by social, financial, and systemic factors, significantly impede diabetes self-care and access to treatment in this population. These findings align with broader evidence on rural diabetes care challenges in India and other contexts^14,25–27 while also highlighting context-specific psychosocial dynamics. The most notable finding from this study is that, despite being one of the few matrilineal societies in India, older women continued to face gender barriers to management of diabetes similar to the rest of India, which is a predominantly patrilineal society.^5,10

Physiological decline associated with aging, such as joint pain, frailty, impaired vision, and memory loss, directly limits the ability of older women to manage diabetes independently.^14,25 Consequently, older women require sustained support with daily activities and health-related decision-making.²⁷ However, such support is not always available. In India, while a majority of older women live with family, a considerable segment of these women, reside alone or without spousal support, increasing their vulnerability.⁷ Notably, in Northeast India, a higher proportion of older women (3.36%) live alone compared to men (1.23%), primarily due to widowhood and low remarriage rates.¹¹

Social support is a well-established determinant of successful chronic disease management.²⁶ Studies have shown that strong social networks contribute to better glycemic control and self-care, whereas limited social ties, particularly among those from lower-income households, are associated with elevated stress and poorer diabetes outcomes.²⁶ In our study, most participants reported limited emotional, financial, and logistical support, especially those who were widowed or living in poverty. These intersecting disadvantages exacerbated their vulnerability and impeded timely access to care.

Financial barriers were consistently identified as a major impediment to diabetes management. Similar to findings from other contexts, our participants struggled to afford medications, diagnostics, and travel to health facilities.²⁶ This is especially critical for older women with multimorbidity, whose care needs are more complex and costly. The absence of pensions and limited access to health insurance among older women further constrain their ability to seek care.⁷ Financial stress that is intensified by efforts to meet basic daily needs can directly worsen glycemic control by triggering chronic stress responses.²⁶

Gendered norms and caregiving responsibilities further complicate diabetes management for older women. As documented in previous research, women often prioritize the well-being of family members over their own health.⁵ This phenomenon is particularly pronounced in Meghalaya’s matrilineal society, where women assume central caregiving and economic roles.²⁸ Older women continue to shoulder disproportionate unpaid labour, including care work for grandchildren, especially in households affected by abandonment or economic distress. This dual burden of caregiving and economic contribution leaves little room for self-care and regular engagement with healthcare providers in health facilities.⁵ Our findings confirm that caregiving roles persist into old age and significantly restrict health-seeking behaviors.

Geographic remoteness and poor healthcare infrastructure in rural Meghalaya further exacerbate these challenges. Consistent with previous research, our participants reported long travel times, poor transport connectivity, and inadequate availability of specialized diabetes care in public health facilities.²⁹ While private healthcare facilities offer better services, they remain inaccessible to low-income older women due to prohibitive costs. Public sector facilities often lack essential diagnostics, medications, and adequately trained personnel, pushing patients to delay or forego treatment altogether.³⁰

Overall, our study reveals a confluence of structural and individual-level barriers that hinder diabetes management among older women in rural Meghalaya. These barriers are rooted not only in age and disease but also in gendered social roles, systemic healthcare gaps, and economic insecurity. Despite experiencing complications from diabetes, many older women in our study were unable to seek timely care due to financial and geographical constraints. Addressing these disparities requires a comprehensive and gender-sensitive policy approach. Improving access to affordable diabetes care, strengthening public health infrastructure in rural areas, and expanding social protection schemes for older women are critical steps. Community-based interventions that recognize and alleviate the caregiving burden of older women could further enhance their capacity to manage chronic illnesses. Placing the health of women, especially older women, at the centre of public health planning is essential to achieving Sustainable Development Goal 3, which seeks to ensure health and well-being for all at all ages. As older women have contributed significantly to the welfare of families and communities throughout their lives, a reciprocal societal investment is warranted to ensure they receive the care, dignity, and support they deserve in old age.¹⁰

Strengths and limitations of the study

This is the first qualitative study, to our knowledge, to explore impediments to diabetes management among older women in a matrilineal society, showing experiences of Pnar’s older women of diabetes management in their social context. This study reveals the challenges faced by this vulnerable group of tribal older women living in poverty in rural and remote areas of Meghalaya. This study indicates the need to strengthen existing policies and programs for older women through a multisectoral approach, such as the National Policy for Older Persons (NPOP) and the NPHCE in India.^12,17

Although this study is situated in a matrilineal tribal context, the themes identified, including age-related physiological challenges, limited social support, ill-treatment by relatives, competing caregiving responsibilities, geographical barriers to care, high treatment costs related to comorbidities, and feelings of guilt associated with financial dependence, reflect difficulties that extend beyond the Pnar community. Comparable constraints are experienced by older women in rural and remote areas of India and in other low- and middle-income countries, where poverty, limited health infrastructure, and aging-related physiological changes shape chronic disease management.^26,27 These shared conditions suggest that the findings may be relevant to other marginalised rural populations. The study underscores the importance of culturally sensitive, community-based diabetes care, strengthened outreach and follow-up services, and closer linkages between formal health systems and local support structures.

While not statistically generalizable, the findings offer transferable insights for developing interventions for older women with chronic illnesses in comparable socio-economic and geographic settings. Moreover, the present study helps fill gaps in the existing literature on general health and diabetes in under-researched areas of northeast India.

Supplemental material

Supplemental Material - Impediments to diabetes management among older women: A qualitative study from rural Meghalaya, India

Supplemental Material for Impediments to diabetes management among older women: A qualitative study from rural Meghalaya, India by Alacrity Muksor and Daksha Parmar in Journal of Health Services Research & Policy

Footnotes

Acknowledgments

We express our sincere thanks to Shri. Ramkumar S., Indian Administrative Service (IAS), former Secretary of the Health and Family Welfare Department, Government of Meghalaya. We also thank Dr Helen Uriah and Dr R. Pohsnem, Health Officials of the Government of Meghalaya.

ORCID iD

Alacrity Muksor

Ethical considerations

Ethical clearance for the study was granted by the Institute Human Ethics Committee (IHEC), Indian Institute of Technology Guwahati (Reference No.: IHEC/2022/DP/4).

Author contributions

Conceptualization – Alacrity Muksor and Daksha Parmar.

Methodology – Alacrity Muksor and Daksha Parmar.

Data Collection – Alacrity Muksor.

Data Curation – Alacrity Muksor.

Formal Analysis – Alacrity Muksor.

Writing – Original Draft – Alacrity Muksor.

Writing – Review & Editing – Alacrity Muksor and Daksha Parmar.

Supervision – Daksha Parmar.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The qualitative datasets (interview transcripts) generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

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