Abstract
Context
Diabetes is a serious public health problem that is increasing worldwide.
Objectives
The aim of this study is to evaluate acceptance of the illness, emotional distress, depression and quality of life in individuals with type 2 diabetes mellitus.
Subjects and Methods
This study was conducted in 145 individuals with type 2 diabetes mellitus, 73 males (50.3%) and 72 females (49.7%), ranging in age from 20 to 65 years old. Research data were collected using the face-to-face interview technique by the researchers. The Acceptance of Illness Scale for the determination of individuals’ acceptance of the illness, Problem Areas in Diabetes Scale for emotional distress, Beck Depression Inventory for depression and Short Form-36 scales for quality of life was used.
Results
The mean score of individuals’ Acceptance of Illness Scale was 30.2±5.62. Compared to women, men had lower emotional distress, depression levels (p<0.05), higher physical, mental quality of life (p<0.001). Correlations among acceptance of illness, emotional distress, depression and quality of life were found to be significant (p<0.05). Also, models of multiple linear regression analysis were statistically significant (p=0.000).
Conclusions
The main goal in the treatment of diabetes should be to eliminate complaints in patients, to reduce, prevent or delay the development of complications, to increase the quality of life, to ensure that the individual has a physically, emotionally, spiritually and mentally regular life in addition to metabolic control. For this reason, it is beneficial to carry out the treatment with a multidisciplinary approach in type 2 diabetes mellitus.
Keywords: acceptance of illness, depression, emotional distress, quality of life, type 2 diabetes mellitus
INTRODUCTION
Type 2 diabetes mellitus (T2DM), which is the most common type of DM, accounts for approximately 90-95% of all diabetes cases (1). According to the recent estimations of The International Diabetes Federation, in 2019, 1 (463 million) in every 11 adults (20-79 years old) has diabetes, and this number is predicted to be 700 million in 2045 (2).
Lower levels of patient acceptance of diabetes were significantly associated with less active coping with the disease, reduced self-care, higher glycated hemoglobin (HbA1c) levels, more diabetes distress, and more depressive symptoms. Thus, assessment of diabetes acceptance may facilitate the identification of patients at high risk and may provide a key target for treatments to improve diabetes control (3). Individuals with type 2 diabetes often also experience depression and diabetes distress (4). It is known that high diabetes distress is directly related to decreased self-care and increased HbA1c (5).
Factors affecting quality of life in individuals with DM can be divided into four groups; disease, diet and lifestyle, treatment-related and psychological factors (6). Some complications and accompanying diseases may worsen the quality of life in individuals with T2DM (7). Diabetes distress, many medical factors and sociodemographic factors can also affect quality of life (8, 9). Therefore, the aim of this study is to assess the acceptance of illness, emotional distress, depression and quality of life in individuals with T2DM. The relationship of these factors with each other was also examined.
SUBJECTS AND METHODS
Participants
This study carried out with 145 T2DM volunteer individuals, 73 males and 72 females, aged between 20-65 years, who applied to Family Health Centers between December 2019-June 2020. Individuals that are pregnant, lactating women, have T1DM, newly diagnosed with a disease and using drugs for psychological problems excluded from the study. Written and verbal informed consent was obtained from all individual participants included in the study. In order to carry out this research, ethics committee approval was obtained from the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee with approval number 1005.
Study plan
The questionary form prepared by researchers, consist of questions examining individuals’ demographic characteristics and health informations. Total of 4 scales were applied. The questionnaire that prepared by researchers was completed while using face-to-face interview technique to the individuals with T2DM.
Materials
Acceptance of Illness Scale (AIS) was generated by Felton and Revenson (10). The scale has 5-point Likert type and consists of 8 items. The total collected point changes between 8-40. Low scores indicate the lack of acceptance of the illness and high score indicate presence of acceptance of the illness. The Cronbach’s α value of the scale is 0.83 (10), and it was found 0.70 in this study. The Problem Areas in Diabetes (PAID) Scale is designed to reduce the spread of emotional responses to DM and to provide taking clinical and research screening measures in DM. The PAID Scale consists of 20 items (11). The scores obtained from the scale are added up, multiplied by 1.25 and converted into 0-100 points. High scores in the scale indicate emotional distress (12). The Cronbach’s α value of the scale is 0.95 (11), and it was found 0.87 in this study. Beck Depression Inventory (BDI) was developed by Beck et al. (13) to determine the level of depression. The scale consists of 21 items and has a 4-point Likert type (14). In this study, Cronbach’s α value was found 0.84. Short Form-36 (SF-36) is one of the most widely used general health measures in quality of life studies with proven validity and reliability (15). Designed by Ware and Sherbourne (16) the SF-36 is a 36-item scale that evaluates eight health concepts. The scale gives a separate total score for each subcomponent, and the subcomponents evaluate health between 0-100. It indicates poor health status as 0 and good health status as 100, and it is understood that the quality of life is good as the score increases. Also, SF-36 can be evaluated as physical component summary (PCS) and as mental component summary (MCS) (17).
Statistical analysis
Statistical Package for Social Sciences (SPSS) version 18 was used to evaluate the data obtained from the study. Continuous variables (quantitative variables) obtained by measurement are presented with mean, standard deviation, minimum and maximum values, and categorical variables (qualitative variables) with frequency and percentage values. Categorical variables were evaluated using the Chi-Square (X2) test. The compliance of the quantitative variables dealt with in the study to normal distribution was examined using the Kolmogorov-Smirnov test. Independent samples t-test were used for the comparison of two independent groups for the variables for which parametric test conditions were met, and the Mann-Whitney U-test was used for the comparison of two independent groups in cases where parametric test conditions were not met. Correlations between variables were analyzed using Spearman correlation coefficient. Multiple linear regression analysis was used for testing multivariate association between variables. In all statistical analyses, p<0.05 value was accepted as the statistical significance level.
RESULTS
This study was conducted on a total of 145 individuals with T2DM between the ages of 20-65, 73 males and 72 females. 93.8% of the individuals were between 46 and 65 years old (Table 1).
Table 1.
Socio-demographic characteristics of individuals
| Male (n=73) | Female (n=72) | Total (n=145) | |||||
|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | ||
| Age (years) | |||||||
| 20-45 | 4 | 5.5 | 5 | 7.0 | 9 | 6.2 | |
| 46-65 | 69 | 94.5 | 67 | 93.0 | 136 | 93.8 | |
| Educational status | |||||||
| Illiterate | - | - | 6 | 8.3 | 6 | 4.1 | |
| Primary and secondary education graduate | 29 | 39.7 | 48 | 66.7 | 77 | 53.1 | |
| High-school graduate | 24 | 32.9 | 12 | 16.7 | 36 | 24.8 | |
| University graduate | 20 | 27.4 | 6 | 8.3 | 26 | 18.0 | |
| Employement status | |||||||
| Working | 21 | 28.8 | 4 | 5.5 | 25 | 17.2 | |
| Not working | 52 | 71.2 | 68 | 94.5 | 120 | 82.8 | |
| Marital status | |||||||
| Single | 1 | 1.4 | 12 | 16.6 | 13 | 9.0 | |
| Married | 72 | 98.6 | 60 | 83.4 | 132 | 91.0 | |
| Individual/s that is/are lived together | |||||||
| Alone | - | - | 3 | 4.2 | 3 | 2.1 | |
| Family | 73 | 100.0 | 69 | 95.8 | 142 | 97.9 | |
The average score of the individuals in AIS was 30.2±5.62. Emotional distress of men (24.2±14.80) was found lower compared to women (32.4±16.83) (p<0.05). The BDI mean score of individuals was 10.1±6.94, 8.7±7.14 for men and 11.6±6.44 for women. The depression level of men was found lower than women (p<0.001). Male individuals’ physical and mental quality of life was found higher than female individual’s (p<0.001) (Table 2).
Table 2.
Acceptance of Illness Scale, Problem Areas in Diabetes Scale, Beck Depression Inventory and Short Form-36 mean score, standard deviation and min-max values of individuals according to gender
| Gender | MWU/t p |
|||
|---|---|---|---|---|
| Male (n=73) | Female (n=72) | Total (n=145) | ||
| ±S (Min-Max) |
±S (Min-Max) |
±S (Min-Max) |
||
| AIS | 30.8±5.98 (16.0-40.0) |
30.8±5.98 (17.0-38.0) |
30.2±5.62 (16.0-40.0) |
2185.00 0.079MWU |
| PAID Scale | 24.2±14.80 (0.0-66.2) |
32.4±16.83 (3.7-80.0) |
28.3±16.31 (0.0-80.0) |
1869.50 0.003MWUb |
| BDI | 8.7±7.14 (0.0-41.0) |
11.6±6.44 (0.0-32.0) |
10.1±6.94 (0.0-41.0) |
1759.50 0.001MWUa |
| SF-36 MCS | 70.8±19.06 (17.8-100.0) |
60.7±18.53 (24.5-95.5) |
65.8±19.41 (17.8-100.0) |
3.244 0.001ta |
| SF-36 PCS | 77.9±19.17 (18.1-100.0) |
55.4±19.5 (20.6-92.5) |
66.7±22.33 (18.1-100.0) |
972.50 0.000MWUa |
t Independent samples t-test, MWU Mann Whitney U test, a p<0.001, b p<0.05.
Also, a negative correlation was found between AIS-PAID Scale and between AIS-BDI, a positive correlation was found between SF-36 MCS-AIS and between SF-36 PCS-AIS (p<0.001). While there was a positive correlation between PAID Scale-BDI, a negative correlation was found between SF-36 MCS-PAID Scale and between SF-36 PCS-PAID Scale (p<0.001). A negative correlation was found between SF-36 MCS-BDI, and between SF-36 PCS-BDI (p<0.001) (Table 3).
Table 3.
Correlation analysis between Acceptance of Illness Scale, Problem Areas in Diabetes Scale, Beck Depression Inventory and Short Form-36 scores of individuals
| Scales | AIS | PAID | BDI | |
|---|---|---|---|---|
| PAID | r | -0.544 | ||
| pa | 0.000b | |||
| BDI | r | -0.452 | 0.580 | |
| pa | 0.000b | 0.000b | ||
| SF-36 MCS | r | 0.503 | -0.471 | -0.653 |
| pa | 0.000b | 0.000b | 0.000b | |
| SF-36 PCS | r | 0.412 | -0.497 | -0.577 |
| pa | 0.000b | 0.000b | 0.000b |
a Spearman Correlation, b p<0.001.
The model that emotional distress and SF-36 MCS with acceptance of illness was found to be statistically significant as a result of multiple linear regression analysis (F(2, 142)=58.404, p=0.001). It has been observed that the effect of PAID Scale on the AIS is greater than the effect of PAID Scale on SF-36 MCS. In individuals with T2DM, it was found that acceptance of the disease increased with increasing SF-36 MCS score and decreased with increasing emotional distress. The model that connects the independent variables of AIS, BDI and age (years) with emotional distress was found to be statistically significant (F(3, 141)=53.174, p=0.001). It was found that emotional distress was decreased with the increasing acceptance of illness and age, and it increased with increasing depression in T2DM individuals. The model that connects emotional distress and SF-36 MCS with the depression state was found to be statistically significant (F(2, 142)=82.029, p=0.000). SF-36 MCS effect on BDI was greater. It was found that with the increasing of SF-36 MCS score the depression status decreased, and with the increasing of emotional distress the depression status increased. The model that connects the acceptance of illness and depression state with SF-36 MCS was found to be statistically significant (F(2, 142)=70.937, p=0.001). It has been determined that SF-36 MCS had a greater effect on the BDI. SF-36 MCS score increased as the acceptance of illness status increased, and SF-36 MCS score decreased as depression status increased. The model that connects emotional distress and depression state with the SF-36 PCS was found to be statistically significant (F(2, 142)=42.926, p=0.000). It was found that BDI had a greater effect on the SF-36 PCS, and as the emotional distress and depression level increased, the SF-36 PCS score decreased in T2DM individuals (Table 4).
Table 4.
Multiple linear regression analysis of Acceptance of Illness Scale, Problem Areas in Diabetes Scale, Beck Depression Inventory and Short Form-36 and various independent variables
| Scales | Regression Coefficient | Standardized Regression Coefficient | t | p | R2 |
|---|---|---|---|---|---|
| AIS | |||||
| Constant | 28.179 | 15.094 | 0.000a | 0.444 | |
| PAID | -0.152 | -0.441 | -6.124 | 0.000a | |
| SF-36 MCS | 0.096 | 0.330 | 4.581 | 0.000a | |
| PAID | |||||
| Constant | 86.843 | 7.869 | 0.000a | 0.521 | |
| AIS | -1.186 | -0.409 | -6.058 | 0.000a | |
| BDI | 0.769 | 0.328 | 4.701 | 0.000a | |
| Age | -0.534 | -0.228 | -3.793 | 0.000a | |
| BDI | |||||
| Constant | 17.141 | 8.090 | 0.000a | 0.530 | |
| PAID | 0.153 | 0.359 | 5.421 | 0.000a | |
| SF-36 MCS | -0.172 | -0.481 | -7.265 | 0.000a | |
| SF-36 MCS | |||||
| Constant | 50.608 | 5.953 | 0.000a | 0.493 | |
| AIS | 0.987 | 0.286 | 4.119 | 0.000a | |
| BDI | -1.439 | -0.515 | -7.409 | 0.000a | |
| SF-36 PCS | |||||
| Constant | 90.734 | 29.665 | 0.000a | 0.368 | |
| PAID | -0.382 | -0.279 | -3.359 | 0.001a | |
| BDI | -1.299 | -0.404 | -4.863 | 0.000a | |
R2 Corrected Detarmination Coefficient, t t test, a p<0.001.
DISCUSSION
T2DM is a disease that requires individuals to adhere to a healthy diet, physical activity, and daily medication use and can bring an emotional burden (18). The fact that DM is a chronic disease and brings with it complications weakens the motivation of patients to cope with the disease and their acceptance of the illness (19). Especially, patients with T2DM who are diagnosed later, experience difficulties both mentally and physically while trying to establish a new order for their lives. Anxiety, depression, stress and diabetes distress weaken the motivation of individuals with T2DM to cope with the disease (20). Studies have shown that individuals with T2DM have a low degree of acceptance of the illness (21, 22). However, AIS score may not differ between men and women (21). Similarly, in this study, there was no statistically significant difference between the genders in the acceptance of the illness (p>0.05). However, it is very important for individuals to accept their illnesses in order to show appropriate healthy behaviors.
Emotional distress is observed in most people with T2DM. In a study, the prevalence of diabetes distress in individuals with T2DM was found to be 49.2% (23). In another study, in individuals with early onset (20-45 years old) T2DM, the mean PAID Scale score was found to be higher in women (31.5±21.4) compared to men (21.5±17.4) (24). Similarly in this study, the PAID Scale mean scores of women were higher than men (p<0.05). It is thought that this case is resulted from that women are more sensitive about their own and their families’ health issues, and they have more emotional distress. Depressive symptoms are observed with a higher rate in individuals with T2DM compared to individuals without DM (25-27). In conducted studies, depressive symptoms in patients with DM were observed more frequently in women compared to men (25, 27). Similarly in this study, the BDI mean scores were found to be significantly higher in women compared to men (p<0.05). It is known that there is a two-way causal relationship between depression and DM. The development of anxiety/depression negatively affects the patient’s compliance, response to treatment and the prognosis of the disease. It causes deterioration in self-care and quality of life, an increase in the risk of developing complications, morbidity, mortality and health expenditures, as well. It is thought that traditional gender roles and expectations reveal the psychological consequences like causing despair, so women are more prone to depressive reactions than men. It has been shown that the presence of depression negatively affects the compliance of these patients to treatment (9, 28). Also, it was stated in a study that being a woman and having poor sleep quality increase the possiblity of occurrence of hypoglycemic/hyperglycemic acute events, and anxiety/depression symptoms (29). Also, the presence of T2DM and depression negatively affect the quality of life for individuals (21). It is noteworthy that female individuals’ quality of life is lower compared to male individuals (9, 21, 30). In this study, SF-36 MCS and PCS scores of women were found to be lower than scores of men, as well (p<0.001).
Emotional distress may be experienced during the course of DM, which in return negatively affects the quality of life (31, 32). The quality of life is decreased in individuals with T2DM compared to individuals without diabetes (30). It has been reported that the decrease in the quality of life in individuals with T2DM may result from non-compliance with lifestyle changes (33). The studies have shown that there is a strong negative relationship between depression and quality of life in patients with T2DM (34, 35). In this study, correlations between AIS, PAID Scale, BDI and SF-36 were found to be significant (p<0.05). As a result of the decrease in adherence to medical treatment that occurred according to the decrease in acceptance of illness, problems such as prolongation and delay in the healing process can be seen. For this reason the recommendation of the American Diabetes Association (ADA) is to provide psychosocial care to all individuals with DM in order to improve the health outcomes and quality of life of the individual. It is recommended that all individuals with DM should be evaluated in terms of emotional/diabetes distress, depression and anxiety symptoms (36). Lifestyle behavior change positively affects the general health perception and mental health of individuals (37).
In conclusion, in this study, it was observed that the acceptance of the illness, emotional distress, depression and quality of life of individuals with T2DM could be affected and these may be related to each other. In addition, it has been determined that both mental and physical aspects of the quality of life of individuals with type 2 diabetes can be affected by psychological factors. The main goal in the treatment of diabetes should be to eliminate complaints in patients, to reduce, prevent or delay the development of complications, to increase the quality of life, to ensure that the individual has a physically, emotionally, spiritually and mentally regular life in addition to metabolic control. The strength of this study is that evaluates and compares both male and female individuals with type 2 diabetes in many ways they may have difficulties, thus helping the literature and future studies. The limitations are that more research is needed to generalize the findings.
Conflict of interest
The authors declare that they have no conflict of interest.
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