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. 2020 Oct 11;26(4):307–317. doi: 10.1177/1744987120943936

Predictors of diabetes distress among older persons with type 2 diabetes mellitus in Indonesia

M Ischaq Nabil Asshiddiqi 1,2,✉, Kantaporn Yodchai 3, Ploenpit Taniwattananon 4
PMCID: PMC8894986  PMID: 35251256

Abstract

Background

Older persons living with diabetes have an obligation to change their daily lifestyle, which may contribute to diabetes distress. Furthermore, predictive factors of diabetes distress in older persons might be different from other age groups due to age-related factors.

Aims

The purpose of the study was to examine the predictive factors of diabetes distress in older persons diagnosed with type 2 diabetes mellitus (T2DM) in Indonesia.

Methods

A cross-sectional design was used in this study. Participants were recruited from an outpatient department of a tertiary hospital in Klaten City, Central Java, Indonesia. Data were analysed using multiple linear regression with a stepwise method.

Results

A total 198 older persons were included in the study. The study demonstrated self-efficacy (β = −0.298, P < 0.01), spirituality (β = −0.139, P < 0.05), blood glucose (β = 0.134, P < 0.05), and non-supportive family behaviour (β = 0.135, P < 0.05) as the variables that could statistically predict diabetes distress in older persons with T2DM.

Conclusions

Self-efficacy is the strongest predictor of diabetes distress. Moreover, the findings can be used as evidence to guide identification and future management of diabetes distress among older persons with T2DM.

Keywords: blood glucose, diabetes distress, family support, older persons, self-efficacy, spirituality, type 2 diabetes mellitus

Introduction

Diabetes in older persons is increasing rapidly, and is predicted to reach more than 200 million by 2040 (Lau, 2016). The prevalence of diabetes in Indonesia was sixth in the world, with 10.3 million people in 2017. This is estimated to increase to 16.7 million people by 2045 (International Diabetes Federation, 2017). Moreover, in Indonesia, diabetes was the third largest cause of death (accounting for 6.7% of deaths), behind stroke (21.1%) and cardiovascular disease (12.9%), in 2014, and nearly 185,000 deaths in Indonesia originated from diabetes in 2015 (McCall, 2016).

Persons living with diabetes have to manage their daily lifestyle, which may have a negative impact on their psychological state and may contribute to diabetes distress (Fisher et al., 2012). Diabetes distress is an emotional state that arises from living with diabetes and the burden of self-management, wherein the person with diabetes experiences extraordinary feelings such as stress, guilt or rejection (Kreider, 2017).

Diabetes distress is common and can be experienced by up to 40% of patients with diabetes worldwide; the incidence is increasing over time (Berry et al., 2015). Moreover, several studies have shown the prevalence of diabetes distress among patients with type 2 diabetes mellitus (T2DM) occurring among 49.2% of T2DM patients in Malaysia (Chew et al., 2016), 48.5% in Bangladesh (Islam et al., 2014), and 35% in Iran (Baradaran et al., 2013). In addition, a cross-national study showed diabetes distress was reported by 44.6% of the participants with diabetes (Nicolucci et al., 2013). Furthermore, in Indonesia, the prevalence of diabetes distress was found to be higher than in other countries. Diabetes distress was reported by more than half (53.5%) of individuals with T2DM in Indonesia (Arifin et al., 2017). Additionally, Indonesian people with diabetes distress were mostly (69%) older persons.

Screening and management of diabetes distress is important to achieve optimal results, including increased blood glucose control (American Diabetes Association (ADA), 2019a). High levels of diabetes distress significantly impact medication-taking behaviours, and negatively affect dietary, and exercise behaviours. Diabetes distress through such behaviours leads to higher haemoglobin A1C (HbA1C) levels, high rates of complications (Fisher et al., 2012) and degraded quality of life (Faridah et al., 2017).

Several studies have revealed the factors related to diabetes distress in patients with T2DM. However, several studies have shown inconsistent findings. These factors include education (AlSayah et al., 2019; Devarajooh and Chinna, 2017), monthly income (AlSayah et al., 2019; Aljuaid et al., 2018), treatment regimen (Zhou et al., 2017), diabetes duration (Islam et al., 2014) and blood glucose level (Nanayakkara et al., 2018). Patients with higher diabetes distress were those who had lower educational level (AlSayah et al., 2019; Devarajooh and Chinna, 2017), and lower income (AlSayah et al., 2019; Aljuaid et al., 2018). Moreover, patients treated with insulin plus oral medication reported the highest diabetes distress score (Zhou et al., 2017). In terms of duration, diabetes distress was higher among those diagnosed with diabetes for more than 10 years (Islam et al., 2014). In addition, higher blood glucose was significantly associated with higher diabetes distress (Nanayakkara et al., 2018).

Another factor that can affect diabetes distress is family support. Support from family members has been considered vital for people with T2DM because it enhances the patient’s physical and emotional functioning (Karlsen and Bru, 2014). Among Indonesians with diabetes, family support is one of most significant coping strategies used in dealing with diabetes distress (Arifin et al., 2019).

Self-efficacy is defined as an individual’s confidence in their abilities to perform behaviours that achieve desired outcomes. A person who believes that he or she can lead a self-determined life will experience less hopelessness and thus may experience less diabetes distress (Kim et al., 2015). A previous study reported a negative significant association between self-efficacy and diabetes distress in patients with T2DM (Wardian and Sun, 2014).

Spirituality has also been associated with diabetes distress in patients with T2DM (Newlin et al., 2008). Spirituality is a source of emotional support that protects people against negative feelings, ways of life and behaviour by strengthening individuals to deal with daily challenges caused by their illness in a more effective way (Darvyri et al., 2018).

Literature shows a relationship between family support, self-efficacy, spirituality and diabetes distress. Among Indonesian patients with T2DM, qualitative studies have found that family support (Arifin et al., 2019; Badriah and Sahar, 2018), self-efficacy and spirituality (Arifin et al., 2019) are potential approaches in overcoming distress. However, these studies did not propose to explain the predictive value of those factors over diabetes distress. Moreover, it is rare that a study is conducted with the purpose of showing the prevalence of diabetes distress and its factors in Indonesia. In addition, studies conducted on the aforementioned variables are rarely conducted in older persons. Globally, Indonesia has one of the largest populations of older people in the world. The prevalence of older persons in Indonesia was 23 million people in 2017 (United Nations, 2017).

To see the underlying problem, it is crucial to find predictive factors that could affect diabetes distress among older persons. Predictive factors of diabetes distress in older persons could be affected by age-related factors. Therefore, exploring these predictive factors would help nurses provide appropriate nursing care to possibly reduce diabetes distress specific to older persons with T2DM. Hence, the purpose of this research study is to explore the predictive factors of diabetes distress among Indonesian older persons with T2DM.

Methodology

Design, setting and sample

This study was conducted with a cross-sectional predictive design. Data were collected between May and June 2019 from older persons with T2DM from an outpatient geriatric clinic of a tertiary hospital in Klaten City, Central Java, Indonesia. A total of 198 participants were included and no participants declined to take part in this study. Participants were at least 60 years of age, diagnosed with T2DM, able to communicate in the Indonesian language, and did not have cognitive impairment diagnosed by a physician. The purposive sampling technique was used to recruit the participants.

Data collection

In the present study, the primary investigator went to the geriatric clinic of the hospital to provide an overview of the aims and methods of the study. Inclusion criteria were explained to the nurses and a physician. The latter then identified patients who met the eligibility criteria and agreed to participate. The primary investigator then approached potential participants in person and provided information about the objectives, benefits, potential risks, data collection procedures and consent form. After obtaining their approval to participate in the study, medical records were accessed to gather information on clinical characteristics. The primary investigator then read the questionnaire and explained the instructions to the participants. The questionnaire was filled out by the primary investigator based on participant’s responses.

Study measurements

Data, including demographic and clinical characteristics of participants, were completely collected from the Personal Characteristics Questionnaire developed by the researcher. Moreover, the Diabetes Distress Scale Indonesian version was used to measure diabetes distress. This is a 17-item scale that measures diabetes distress in four domains, including emotional burden, physician-related distress, regimen-related distress, and interpersonal distress. All statements were measured on a 6-point Likert scale ranging from 1 = not a problem to 6 = serious problem. The mean score of the 17 items was used, with higher scores indicating greater distress (Fisher et al., 2008).

Family support was measured with the Diabetes Family Behaviour Checklist (DFBC). This scale consists of 16 items with 9 positive (supportive) items including items numbers 1, 3, 5, 8, 9, 10, 12, 13 and 15, and 7 negative (non-supportive) items including items numbers 2, 4, 6, 7, 11, 14 and 16. This scale includes response alternatives according to a 5-point Likert-type scale: never, seldom, sometimes, often and very often (scores from 1 to 5) in the areas of medication compliance, glucose testing, exercise and diet (Choi, 2009). Family support was divided into supportive and non-supportive behaviour categories (Karlsen and Bru, 2014).

Self-efficacy was assessed with the Diabetes Management Self-Efficacy Scale (DMSES), which is a widely used measure of diabetes-specific self-efficacy (Bijl et al., 1999). The questionnaire originally contained 20 items with a 10-point Likert-type scale ranging from 1 = yes, to 10 = definitely not. Total score ranges from 0 to 200, lower scores indicating low self-efficacy for coping with the activities listed (Chew et al., 2018).

Spirituality was measured with the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale expanded version (FACIT-Sp-Ex), which is a widely used measure of spirituality in people with chronic illness. The scale consists of 23 items and three sub-domains of spirituality including meaning/peace, faith and relational. The questionnaires use a 5-point Likert-scale ranging from 0 = not at all; 1 = a little bit; 2 = somewhat; 3 = quite a bit; 4 = very much (Bredle et al., 2011). Total score ranges from 0 to 92, which can be calculated by summing individual item scores and multiplying them by 23 then dividing by the number of items answered. A higher score indicates a higher level of spirituality (Peterman et al., 2014).

Data analysis

Data analysis was performed by using SPSS version 20. The personal characteristics data, diabetes distress, family support, self-efficacy and spirituality were analysed by descriptive statistics consisting of frequency, percentage, mean and standard deviation (SD). Multiple regression with a stepwise method was used to examine the predictive factors of family support, self-efficacy and spirituality on diabetes distress. Assumptions of multiple regression consisting of normality, linearity, homoscedasticity, multicollinearity and autocorrelation were checked prior to analysing the data.

Results

Sample characteristics

The participants in the study were 198 older persons with T2DM between the ages of 60 and 88 years old with a mean age of 69.34 years old. More than half of participants (58.6%) were aged between 60 and 69 years old. The highest percentage (58.6%) of participants was female. More than half of participants’ religion (59.6%) was Islam. The majority (70.7%) of participants had completed high school education. Moreover, most participants (97.5%) reported that their monthly income was more than 1 million IDR.

In addition, in terms of treatment regimen, 124 (62.6%) participants received oral medication, 45 (22.7%) participants received both oral medication and insulin, and only 29 (14.7%) received insulin alone. Regarding diabetes duration, this ranged from 2 months to 30 years, with a mean duration of 12.58 (SD = 7.43); more than half (65.7%) of them were diagnosed with diabetes 10 years previously. More than two-thirds (77.3%) of participants did not have diabetes complications. Regarding blood glucose, the majority (71.2%) had controlled blood glucose (<200 mg/dL) (Table 1).

Table 1.

General characteristics of participants.

Characteristics N = 198 %
Age
 60–69 years 116 58.6
  ≥70 years 82 41.4
Mean = 69.34, SD = 5.57, Min–Max = 60–88
Gender
 Female 116 58.6
 Male 82 41.4
Level of education
 Less than high school 58 29.3
 High school or more 140 70.7
Monthly Income
 <1 million IDR 5 2.5
 ≥1 million IDR 193 97.5
Treatment regimen
 Oral medication 124 62.6
 Insulin 29 14.7
 Both oral medication and Insulin 45 22.7
Duration of diabetes
 ≤10 years 68 34.3
 >10 years 130 65.7
Mean = 12.58, SD = 7.43, Min–Max = 0.2–30
Diabetes complications
 0 153 77.3
 1 35 17.7
 ≥2 10 3.0
Blood Glucose
 Controlled blood glucose (<200 mg/dL) 141 71.2
 Uncontrolled blood glucose (≥200 mg/dL) 57 28.8
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IDR: Indonesian Rupiah; M: mean; SD: standard deviation; min: minimum; max: maximum; N: frequency; %: percentage.

*

1 USD = 14,221 IDR.

Factors predicting diabetes distress

The variables under study, i.e. education, monthly income, treatment regimen, diabetes duration, complication, blood glucose, family support (supportive and non-supportive behaviour), self-efficacy and spirituality were entered into the stepwise regression (Table 2). The stepwise regressions showed 18.1% (R2 = 0.181) of the variance in diabetes distress of older persons with T2DM was due to self-efficacy, spirituality, non-supportive family behaviour and blood glucose. Self-efficacy was the strongest predictor of diabetes distress among older persons with T2DM (β = −0.298), followed by spirituality (β = −0.139), blood glucose level (β = 0.135) and non-supportive family behaviour (β = 0.134).

Table 2.

Predictive factors of diabetes distress.

Predictors B SE β t p
Self-efficacy −0.042 0.010 −0.298 −4.337 0.000
Spirituality −0.050 0.024 −0.139 −2.076 0.039
Non-supportive behaviour 0.153 0.077 0.134 1.994 0.048
Blood glucose 1.000 0.482 0.135 2.073 0.039
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R2 = 0.181, adjusted R2 = 0.164.

Self-efficacy negatively affected diabetes distress, with B = −0.042 (P < 0.01). This finding indicates that older persons who had low self-efficacy are 0.042 times more likely to suffer diabetes distress. Spirituality negatively affected diabetes distress, with a significant value of B = −0.050 (P < 0.05). This finding indicates that older persons who had low spirituality are 0.050 times more likely to experience diabetes distress. Moreover, blood glucose level positively affected diabetes distress, with a statistically significant value of B = 0.153 (P < 0.05). This finding indicates that, when the score of blood glucose increases by 1, the score of diabetes distress will increase by 0.153. In addition, non-supportive family behaviour also positively affected diabetes distress, with a statistically significant value of B = 1.0 (P < 0.05). This finding indicates that, when the score of non-supportive family behaviour increases by 1, the score of diabetes distress among Indonesian older persons with T2DM will increase by 1.0.

Discussion

In the present study, stepwise regression analysis revealed self-efficacy, spirituality, non-supportive family behaviour and blood glucose as statistically significant contributing factors for diabetes distress among Indonesian older persons with T2DM. These factors explained the variant of diabetes distress with 18.1% (R2 = 0.181). By contrast, education, monthly income, treatment regimen, diabetes duration and supportive family behaviour did not significantly predict diabetes distress among Indonesian older persons with T2DM.

It showed that self-efficacy was the strongest predictor of diabetes distress. Older persons who had lower self-efficacy tended to experience diabetes distress. Several factors might contribute to this finding. Self-efficacy among individuals with diabetes includes the ability to manage diabetes. For older persons with T2DM, this can be a burdensome activity. Moreover, the actual symptoms and development of diabetes itself are directly related to the incidence of diabetes distress (ADA, 2019a). Among older persons, besides good visual, motor, cognitive abilities or skills, those behavioural demands and diabetes self-management require self-efficacy (ADA, 2019b). In addition, more than half of participants in this study had a high level of self-efficacy.

Individuals with a higher level of self-efficacy perform better diabetes self-management (Chang et al., 2014; Jiang et al., 2019). Improving patients’ self-efficacy by referring to diabetes management is important for achieving clinical control of diabetes (Huang, 2016; Lin et al., 2017). It also mediates the association between diabetes self-management behaviours with diabetes distress (Jiang et al., 2019). Moreover, the results of this study were also supported by the study conducted by Lin et al. (2017), which also showed that self-efficacy negatively affected diabetes distress.

The present study confirmed spirituality as one contributing factor of diabetes distress. Older persons who had lower spirituality tended to suffer from diabetes distress. A prior qualitative study conducted in Indonesian older persons revealed that spirituality was a strategy to cope with diabetes distress. Moreover, older persons used spirituality as the strategy to seek comfort in having a positive attitude, including believing that regularly taking their medicine and having monthly blood sugar checks would result in better outcomes (Arifin et al., 2019). Another study also explained that spirituality is an important method to act as a support to minimize irritability and manage stress among older persons with diabetes mellitus (Badriah and Sahar, 2018). A qualitative study undertaken by Namageyo-Funa et al. (2015) among African Americans explained that spirituality among people with diabetes led to coping strategies such as having hope, religious support, prayer, faith in God, turning things over to God and changing unhealthy behaviours.

Moreover, the present study showed non-supportive behaviours from family as a contributing factor of diabetes distress among older persons with T2DM. Older persons who received non-supportive behaviours from their family were more likely to experience diabetes distress. A previous study revealed that, due to possible frailty, cognitive decline, comorbidity and functional impairment, a support system is more important for older persons with diabetes than for younger persons (Chen et al., 2018).

However, the results of this study indicate that supportive family behaviour does not have a significant effect on diabetes distress. The finding might show that diabetes distress in this study tends to be relatively stable. A previous study conducted by Karlsen et al., (2014) also showed an non-significant relationship between supportive family behaviour and diabetes distress. This finding indicates that family supportive behaviour does not have a significant effect on decreasing diabetes distress. However, the family acts with the aim of supporting the patient to pay attention to the management of their illness, but such actions can be perceived as undesirable and cause distress.

Furthermore, T2DM affects family members differently, either by improving family cohesion or causing distress. In some families, the obligation to support the patient is experienced as a burden. They are affected by changes in the patient’s health and need to know how to provide the best support. Pressure and forceful behaviours lead to negative emotional responses and have a negative effect on health behaviours. They are also shown to lead to distress (Bennich et al., 2017).

The findings also revealed that blood glucose level is a predictor of diabetes distress. Older persons with T2DM who had higher levels of blood glucose tended to have a higher level of diabetes distress. This finding was contradicted by the study conducted by Janoo et al. (2019), which showed diabetes distress as the predictor of blood glucose level. Diabetes distress positively affected blood glucose level. Hence this particular finding confirmed that diabetes distress and blood glucose level have a two-way positive influence on each variable.

Therefore, the findings of this study indicated that the predicting factors of diabetes distress among older persons with T2DM were self-efficacy, spirituality, non-supportive family behaviour, and blood glucose level. Non-supportive family behaviour and uncontrolled blood glucose level caused a negative emotional response in older persons with T2DM and led to diabetes distress, whereas self-efficacy enhanced better diabetes self-management performance through better self-autonomy, confidence, initiative and persistence in dealing with the sustained demands of diabetes which can affect diabetes distress. Similarly, spirituality was used as a coping mechanism to deal with the burden of diabetes in relieving diabetes distress.

This study also has limitations. The theoretical model of variables proposed in the present study was based on the literature review of factors associated with diabetes distress among individuals with T2DM. While this was sufficient for this study, there might be other factors that may not have been included as predicting factors in this study. Moreover, the researcher read the questions during data collection, which was also one of the limitations of this study. However, the data collection process did not involve research assistants. Therefore, researcher bias in this study was minimised.

Conclusion

The study highlighted, self-efficacy, spirituality, non-supportive behaviour and blood glucose level as variables that could predict diabetes distress among older persons with T2DM. It also showed that self-efficacy is the strongest predictor of diabetes distress among older persons with T2DM.

The findings of this study indicate the need to develop nursing interventions and programmes that can improve self-efficacy of older persons with T2DM. Nursing interventions must focus on increasing self-efficacy, which includes participants ability to perform diabetes self-management. Moreover, designing methods or supporting tools for older persons to carry out diabetes self-management activities easily and effortlessly will be beneficial to minimise their burden. Further study is needed to examine the impact of self-efficacy, spirituality, non-supportive behaviour and blood glucose level on diabetes distress among older persons with T2DM.

Key points for policy, practice and/or research

  • Knowledge from this study can contribute to evolving nursing practice by enhancing patients’ self-efficacy and spirituality, and reducing non-supportive behaviour of the family to minimise diabetes distress among older persons with T2DM.

  • Self-efficacy, spirituality, non-supportive family behaviour and blood glucose level of older persons with type 2 diabetes should be regularly assessed for identifying diabetes distress.

  • Nurses need to be aware of the possible effect of non-supportive family behaviour and uncontrolled blood glucose level on increasing diabetes distress among older persons with T2DM.

  • Further research in different settings such as long-term care facilities and a large number of health-care facilities is suggested to be conducted to further explore more predictive factors of diabetes distress among older persons with T2DM.

Biography

M Ischaq Nabil Asshiddiqi is a Master of Nursing Science Candidate at Prince of Songkla University, Thailand, and a Faculty Member at Alma Ata University, Indonesia. His current research interests are in chronic illnesses and gerontological nursing.

Kantaporn Yodchai is an Assistant Professor in the Faculty of Nursing, Prince of Songkla University. Her main research interests lie in clinical nursing for acute and chronic illnesses.

Ploenpit Thaniwattananon is an Associate Professor in Nursing at the Department of Adult and Gerontological Nursing, Prince of Songkla University. Her research interests lie in medical and gerontological nursing.

Footnotes

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical permission: Data collection was conducted after the ethics of this research was approved by the Institutional Review Board, Behavioural and Social Science, Prince of Songkla University, Thailand number PSU IRB 2019-NSt 004. Permission was also obtained from the tertiary hospital (RSUP Soeradji Tirtonegoro) Indonesia number DP.02.01/II.2.2//2019/7666.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Higher Education Research Promotion and ThailandĨœs Education Hub for Southern Region of ASEAN Countries Project Office of the Higher Education Commission.

ORCID iD: M Ischaq Nabil Asshiddiqi https://orcid.org/0000-0002-7208-5918

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