Date Published: March 31, 2017
Publisher: Public Library of Science
Author(s): Cassidy Devarajooh, Karuthan Chinna, Mohammad Ebrahim Khamseh.
The prevalence of type 2 diabetes is increasing in Malaysia, and people with diabetes have been reported to suffer from depression and diabetes distress which influences their self-efficacy in performing diabetes self-care practices. This interviewer administered, cross sectional study, conducted in the district of Hulu Selangor, Malaysia, involving 371 randomly selected patients with type 2 diabetes, recruited from 6 health clinics, aimed to examine a conceptual model regarding the association between depression, diabetes distress and self-efficacy with diabetes self-care practices using the partial least square approach of structural equation modeling. In this study, diabetes self-care practices were similar regardless of sex, age group, ethnicity, education level, diabetes complications or type of diabetes medication. This study found that self-efficacy had a direct effect on diabetes self-care practice (path coefficient = 0.438, p<0.001). Self-care was not directly affected by depression and diabetes distress, but indirectly by depression (path coefficient = -0.115, p<0.01) and diabetes distress (path coefficient = -0.122, p<0.001) via self-efficacy. In conclusion, to improve self-care practices, effort must be focused on enhancing self-efficacy levels, while not forgetting to deal with depression and diabetes distress, especially among those with poorer levels of self-efficacy.
Diabetes mellitus is a common chronic disease in Malaysia. According to national studies, the prevalence of diabetes has increased from 11.6% in 2006 to 15.2% in 2011 . People with diabetes suffer from a higher burden of psychosocial problems and psychological disorders . The prevalence of depression is higher among people with diabetes, and is partly attributed by vascular damage which may induce cerebral pathology that constitutes vulnerability for depression . Depression adds to the burden of managing diabetes, as those with depression perform poorer diabetes self-care .
This was a cross sectional study with patients recruited from all 6 primary health clinics in the district of Hulu Selangor. Hulu Selangor is the biggest district in the state of Selangor, measuring about 174,047 hectares. In the district of Hulu Selangor, there were 6,396 patients with type 2 diabetes receiving treatment in 6 government health clinics. The fees for each visit inclusive of consultation, investigation and medication is only 1 Ringgit Malaysia (1 US Dollar = 4.40 Ringgit Malaysia, average exchange rate in December 2016). Eligibility criteria as a participant in this study was being a Malaysian older than 18 years old, having a diagnosis of type 2 diabetes and can at least understand the Malay language. The exclusion criteria were pregnancy and cognitive impairment such as dementia or mental retardation. Eligible patients were approached for written consent for the study.
Four hundred and eighty eligible patients were approached, 391 agreed to participate in this study, giving a response rate of 81.5%. The sex, age, duration of diabetes and HbAc1 values were comparable between responder and non-responder (Refer Table 1)
As has been shown from the pilot study and the factor analysis, the translated Diabetes distress Scale was valid. Factor analysis was performed to ensure that the translated Diabetes distress Scale measures what it was meant to while enabling the items to be reduced into a smaller set to save time and facilitate easier interpretation . The final translated Diabetes Distress scale has 14 items. All the items within the respective domains had item correlation of between 0.3–0.9, which meant that all the items measured the same underlying theory. The KMO (Kaiser-Meyer-Olkin) value for all domains of the translated Diabetes Distress scale were > 0.6, indicating that the sample size was sufficient to perform a factor analysis. Only one factor was extracted from each domain, with the factor loading of all items being >0.5, indicating good relationship between each item with the underlying factor. All pairwise correlations between the constructs were less than 0.85, indicating that there was no sign of multicollinearity .
This study is the first in our knowledge to explore the relationship between depression, diabetes distress and self-efficacy with self-care practices among Malaysians with type 2 diabetes. Having higher levels of self-efficacy was associated with better diabetes self-care practices. Furthermore, managing depression and diabetes distress is important among diabetics as it may lead to poor self-efficacy and subsequently poorer diabetes self-care. Based on the insights gained from this study, future research should focus on the same topic, with more emphasis on increasing patient’s self-efficacy level and to reduce depression and diabetes distress with the ultimate aim of improving diabetes self-care practices.
There are limitations to this study that should be acknowledged. Firstly, the result of this study represents the population under study, which are people with type 2 diabetes who were being cared for in government healthcare centers in the district of Hulu Selangor. Therefore, the results should not be generalized and needs to be replicated in different patient groups. Secondly, the questionnaires utilized in this study were self-reported. Thirdly, this study was of a cross sectional study design, thus no statement of causality can be made.