Aile Sağlığı Merkezlerine Başvuran Tip 2 Diyabeti Olan Bireylerde Anksiyete, Depresyon ve İlişkili Psikososyal Faktörler

Öz

Amaç: Bu çalışma, aile sağlığı merkezlerine başvuran Tip 2 diyabetli bireylerde diyabetin çok boyutlu faktörlerini ve anksiyete ile depresyon düzeylerini incelemeyi amaçlamaktadır. Gereç ve Yöntemler: Kesitsel tipteki bu araştırmaya, rastgele seçilen üç aile sağlığı merkezine kayıtlı 180 Tip 2 diyabet hastası dâhil edilmiştir. Veriler, Haziran-Kasım 2023 tarihleri arasında Çok Boyutlu Diyabet Ölçeği (MDQ) ve Hastane Anksiyete ve Depresyon Ölçeği (HADS) kullanılarak toplanmıştır. Elde edilen veriler Mann-Whitney U testi, Kruskal-Wallis testi ve çoklu doğrusal regresyon analizi ile değerlendirilmiştir. Bulgular: Katılımcıların %63,3’ünde hastalık süresi 1-5 yıl arasında olup %75,6’sı kan şekeri düzeylerini kendi kendine izlediğini belirtmiştir. Katılımcıların %11,1’inde anksiyete semptomları, %74,4’ünde ise depresif semptomlar saptanmıştır. Analizler sonucunda, anksiyete semptomları ile ilişkili faktörlerin algılanan engel ve yanlış yönlendirme davranışları olduğu bulunmuştur. Ayrıca, algılanan engel, algılanan hastalık ciddiyeti ve sonuç beklentilerinin depresif semptomların ortaya çıkmasına anlamlı düzeyde katkıda bulunduğu belirlenmiştir (p<0,05). Sonuç: Daha etkili diyabet yönetimi sağlanabilmesi için aile sağlığı merkezlerinin güçlendirilmesi ve bu merkezlerde kapsamlı diyabete özgü hizmetler ile eğitimlerin güvence altına alınması gereklidir. Ayrıca, diyabete yönelik hizmetlerin planlanmasında hastalığın çok boyutlu faktörleri ve psikolojik yönleri dikkate alınmalıdır.

Anahtar Kelimeler

• Diabetes mellitus
• Tip 2
• Anksiyete
• Depresyon
• Erişkin

Anxiety, Depression, and Associated Psychosocial Factors in Individuals with Type 2 Diabetes Attending Family Health Centers

Öz

Aim: The present study aims to explore the multidimensional factors of diabetes, as well as the anxiety and depression levels, in individuals with Type 2 diabetes attending family health center. Material and Methods: This cross-sectional study included 180 patients with Type 2 diabetes registered in three randomly selected family health centers. We collected data using the Multidimensional Diabetes Questionnaire (MDQ) and the Hospital Anxiety and Depression Scale (HADS) between June and November, 2023. The data were then subjected to the Mann-Whitney U test, the Kruskal- Wallis test, and multiple linear regression analysis. Results: The disease duration was 1-5 years for 63.3% of participants, and 75.6% reported self-monitoring their blood glucose levels. While 11.1% of participants exhibited symptoms of anxiety, 74.4% had depressive symptoms. Our analysis showed the factors associated with anxiety symptoms to be perceived interference and misguided support behaviors. Moreover, perceived interference, perceived severity, and outcome expectancies significantly contributed to the manifestation of depressive symptoms (p<0.05). Conclusion: To attain more effective diabetes management, it seems key to reinforcing family health centers and securing comprehensive diabetes-specific services and training in family health centers. Moreover, the multifaceted factors and psychological aspects of diabetes should be considered in the planning of diabetes-oriented services.

Anahtar Kelimeler

• Diabetes Mellitus
• Type 2
• Anxiety
• Depression
• Adult

Kaynakça

1. 1. World Health Organization. Diabetes [Internet]. 2023 [cited 2023 Nov 2]. Available from: https://www.who.int/newsroom/ fact-sheets/detail/diabetes
2. 2. Satman I, Omer B, Tutuncu Y, Kalaca S, Gedik S, Dinccag N, Karsidag K, Genc S, Telci A, Canbaz B, Turker F, Yilmaz T, Cakir B, Tuomilehto J; TURDEP-II Study Group. Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. Eur J Epidemiol. 2013;28(2):169-180.
3. 3. International Diabetes Federation. IDF Diabetes Atlas 2019 [Internet]. International Diabetes Federation. 2019 [cited 2023 Nov 10]. Available from: http://www.idf.org/about-diabetes/ facts-figures
4. 4. Ahlqvist E, Storm P, Käräjämäki A, Martinell M, Dorkhan M, Carlsson A, Vikman P, Prasad RB, Aly DM, Almgren P, Wessman Y, Shaat N, Spégel P, Mulder H, Lindholm E, Melander O, Hansson O, Malmqvist U, Lernmark Å, Lahti K, Forsén T, Tuomi T, Rosengren AH, Groop L. Novel subgroups of adult-onset diabetes and their association with outcomes: a data-driven cluster analysis of six variables. Lancet Diabetes Endocrinol. 2018;6(5):361-369.
5. 5. Pigeyre M, Hess S, Gomez MF, Asplund O, Groop L, Paré G, Gerstein H. Validation of the classification for type 2 diabetes into five subgroups: a report from the ORIGIN trial. Diabetologia. 2022;65(1):206-215.
6. 6. Marrero D, Pan Q, Barrett-Connor E, de Groot M, Zhang P, Percy C, Florez H, Ackermann R, Montez M, Rubin RR; DPPOS Research Group. Impact of diagnosis of diabetes on health-related quality of life among high risk individuals: The Diabetes Prevention Program outcomes study. Qual Life Res. 2014;23(1):75-88.
7. 7. Florez H, Pan Q, Ackermann RT, Marrero DG, Barrett-Connor E, Delahanty L, Kriska A, Saudek CD, Goldberg RB, Rubin RR; Diabetes Prevention Program Research Group. Impact of lifestyle intervention and metformin on health-related quality of life: the diabetes prevention program randomized trial. J Gen Intern Med. 2012;27(12):1594-1601.
8. 8. Lee HJ, Chapa D, Kao CW, Jones D, Kapustin J, Smith J, Krichten C, Donner T, Thomas SA, Friedmann E. Depression, quality of life, and glycemic control in individuals with type 2 diabetes. J Am Acad Nurse Pract. 2009;21(4):214-24.

9. 9. Marathe PH, Gao HX, Close KL. American Diabetes Association standards of medical care in diabetes 2017. J Diabetes. 2017;9(4):320-324.
10. 10. Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak T. The Diabetes Self-Management Questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes. 2013;11(1).
11. 11. Sukartini T, Theresia Dee TM, Probowati R, Arifin H. Behaviour model for diabetic ulcer prevention. J Diabetes Metab Disord. 2020;19(1):135-143.
12. 12. Beyazit E, Mollaoğlu M. Investigation of effect on glycosylated hemoglobin, blood pressure, and body mass index of diabetes intensive education program in patients with type 2 diabetes mellitus. Am J Mens Health. 2011;5(4):351-357.
13. 13. Çoban L, Beyca C, Mutlu HH. Diyabetik hastalarda bütünlük duygusu ile glisemik kontrol ilişkisi. Turkish J Diabetes Obes. 2021;5(2):124-130.
14. 14. Talbot F, Nouwen A, Gingras J, Gosselin M, Audet J. The assessment of diabetes-related cognitive and social factors: The multidimensional diabetes questionnaire. J Behav Med. 1997;20(3):291-312.
15. 15. Cosansu G, Erdogan S. Influence of psychosocial factors on self-care behaviors and glycemic control in Turkish patients with type 2 diabetes mellitus. J Transcult Nurs. 2014;25:51-59.
16. 16. Pan American Health Organization. Plan of action for the prevention and control of noncommunicable diseases in the Americas 2013-2019 [Internet]. 2014 [cited 2025 Apr 13]. Available from: https://www3.paho.org/hq/dmdocuments/2015/action- plan-prevention-control-ncds-americas.pdf
17. 17. Nouwen A, Breton MC, Urquhart Law G, Descôteaux J. Stability of an empirical psychosocial taxonomy across type of diabetes and treatment. Diabet Med. 2007;24(1):41-47.
18. 18. Tan MY, Magarey J. Self-care practices of Malaysian adults with diabetes and sub-optimal glycaemic control. Patient Educ Couns. 2008;72(2):252-267.
19. 19. American Diabetes Association. 1. Promoting health and reducing disparities in populations. Diabetes Care. 2017;40(Suppl 1):S6-S10.
20. 20. Moitra M, Santomauro D, Collins PY, Vos T, Whiteford H, Saxena S, Ferrari AJ. The global gap in treatment coverage for major depressive disorder in 84 countries from 2000-2019: A systematic review and Bayesian meta-regression analysis. PLoS Med. 2022;19(2):e1003901.
21. 21. World Health Organization. Mental disorders [Internet]. 2022 [cited 2025 Apr 14]. Available from: https://www.who.int/ news-room/fact-sheets/detail/mental-disorders
22. 22. Korkut Bayindir S, Ünsal A. Nursing diagnosis and interventions in the common mental diseases. J Duzce Univ Heal Sci Inst. 2016;6(2):115-119.
23. 23. Firat M, Okanlı A, Kanbay Y, Utkan M, Demir Gökmen B. The prevalence of pandemic anxiety, anxiety and depression during the COVID-19 pandemic in Turkey. Psychiatry Clin Psychopharmacol. 2021;31(2):198-205.
24. 24. Albai O, Timar B, Braha A, Timar R. Predictive factors of anxiety and depression in patients with type 2 diabetes mellitus. J Clin Med. 2024;13(10):3006.
25. 25. Horsbøl TA, Hoffmann SH, Thorsted AB, Rosenkilde S, Lehn SF, Kofoed-Enevoldsen A, Santos M, Iversen PB, Thygesen LC. Diabetic complications and risk of depression and anxiety among adults with type 2 diabetes. Diabet Med. 2024;41(4):e15272.
26. 26. Tuna S, Özden F, Yeniçeri N, Şahin C. Comparison of cognitive reserve, depression and anxiety in patients with diabetes mellitus. Turkish J Diabetes Obes. 2024;8(1):1-5.
27. 27. Çağlar M, Yeşiltepe Oskay Ü. Assesment of prenatal distress and depressive symptoms in women with gestational diabetes. Turkish J Diabetes Obes. 2019;3(2):73-78.
28. 28. Farooqi A, Gillies C, Sathanapally H, Abner S, Seidu S, Davies MJ, Polonsky WH, Khunti K. A systematic review and meta- analysis to compare the prevalence of depression between people with and without Type 1 and Type 2 diabetes. Prim Care Diabetes. 2022 Feb;16(1):1-10.
29. 29. Rajput R, Gehlawat P, Gehlan D, Gupta R, Rajput M. Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center. Indian J Endocrinol Metab. 2016;20(6):746-751.
30. 30. Basiri R, Seidu B, Rudich M. Exploring the interrelationships between diabetes, nutrition, anxiety, and depression: Implications for treatment and prevention strategies. Nutrients. 2023;15(19):4226.
31. 31. Khambaty T, Callahan CM, Perkins AJ, Stewart JC. Depression and anxiety screens as simultaneous predictors of 10-year incidence of diabetes mellitus in older adults in primary care. J Am Geriatr Soc. 2017;65(2):294-300.
32. 32. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, Colagiuri S, Guariguata L, Motala AA, Ogurtsova K, Shaw JE, Bright D, Williams R; IDF Diabetes Atlas Committee. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2019;157:107843.
33. 33. Ahıskalıoğlu K, Kenger EB. Determining the relationship between diet ınflammatory ındex score, depression and chronotype in individuals with metabolic syndrome: An example of a training and research hospital. Turkish J Diabetes Obes. 2024;8(2):171-179.
34. 34. Owens-Gary MD, Zhang X, Jawanda S, Bullard KMK, Allweiss P, Smith BD. The importance of addressing depression and diabetes distress in adults with type 2 diabetes. J Gen Intern Med. 2019;34(2):320-324.
35. 35. Ranjan R, Nath S, Sarkar S. Association between depression, anxiety and quality of life among patients with diabetes mellitus and/or hypertension in a tertiary care railway hospital in India: A cross-sectional study. Indian J Psychiatry. 2020;62(5):555-558.
36. 36. Hurst CP, Rakkapao N, Hay K. Impact of diabetes self-management, diabetes management self-efficacy and diabetes knowledge on glycemic control in people with Type 2 Diabetes (T2D): A multi-center study in Thailand. PLoS One. 2020;15(12):e0244692.
37. 37. Al-Dwaikat TN, Rababah JA, Al-Hammouri MM, Chlebowy DO. Social support, self-efficacy, and psychological wellbeing of adults with type 2 diabetes. West J Nurs Res. 2021;43(4):288- 297.
38. 38. Cherrington A, Wallston KA, Rothman RL. Exploring the relationship between diabetes self-efficacy, depressive symptoms, and glycemic control among men and women with type 2 diabetes. J Behav Med. 2010;33(1):81-89.
39. 39. Saraco M, Hill MI, Petersen MP, Robinson S, Mandelson J, Gabbay RA. Professional practice committee: Standards of medical care in diabetes-2021. Diabetes Care. 2021;44(Supplement- 1):S3.
40. 40. Alali SM, Alghamdi RL, Al Bosrour ZA, Al Dokhi AA, Alabdulrahim ZA, Almazyad AZ, Alturaifi MH, Henaidi KA, Aldhafeeri NB, Almajhad AA. Role of physicians in diagnosis and management of diabetes mellitus in primary health care. Arch Pharma Pr. 2019;10(2):12-15.
41. 41. Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2018;42(Suppl 1):S1-S325.
42. 42. T.C. Sağlık Bakanlığı. Birinci basamak sağlık kurumlarında Tip 1 diyabet tanı tedavi izlem rehberi [Internet]. 2018 [cited 2025 Apr 11]. Available from: https://hsgm.saglik.gov.tr/ depo/birimler/saglikli-beslenme-ve-hareketli-hayat db/ Doku manlar/Rehberler/Birinci_ Basamak_SK_Tip_1_Diyabet_Rehberi_ duzenlenen.pdf
43. 43. Mahase E. Progress in diabetes care has not improved outcomes in US, study finds. BMJ. 2019;366:l5166.
44. 44. Bongaerts BW, Müssig K, Wens J, Lang C, Schwarz P, Roden M, Rathmann W. Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: a systematic review and meta-analysis. BMJ Open. 2017;7(3):e013076.
45. 45. Kahn R, Anderson JE. Improving diabetes care: The model for health care reform. Diabetes Care. 2009;32(6):1115-1118.
46. 46. Riordan F, McHugh SM, O’Donovan C, Mtshede MN, Kearney PM. The role of physician and practice characteristics in the quality of diabetes management in primary care: Systematic review and meta-analysis. J Gen Intern Med. 2020;35(6):1836- 1848.
47. 47. American Diabetes Association. Standards of care in diabetes- 2023 abridged for primary care providers. Clin Diabetes. 2022;41(1):4-31.
48. 48. Barnacle M, Strand MA, Werremeyer A, Maack B, Petry N. Depression screening in diabetes care to improve outcomes: are we meeting the challenge? Diabetes Educ. 2016;42(5):646- 651.
49. 49. Karpenko OA, Melikhov OG, Tyazhelnikov AA, Kostyuk GP. Diagnosing and treating depression and anxiety in patients with cardiovascular disorders and diabetes mellitus in primary healthcare: Is training of physicians enough for improvement? Consort Psychiatr. 2021;2(4):2-12.
50. 50. Bickett A, Tapp H. Anxiety and diabetes: Innovative approaches to management in primary care. Exp Biol Med (Maywood). 2016;241(15):1724-1731.
51. 51. T.C. Sağlık Bakanlığı. Hastalık yönetim platformu uygulaması [Internet]. 2023 [cited 2025 Apr 8]. Available from: https:// hsgm.saglik.gov.tr/tr/hastalik-yonetim-platformu.html
52. 52. Konstantinou P, Kassianos AP, Georgiou G, Panayides A, Papageorgiou A, Almas I, Wozniak G, Karekla M. Barriers, facilitators, and interventions for medication adherence across chronic conditions with the highest non-adherence rates: a scoping review with recommendations for intervention development. Transl Behav Med. 2020;10(6):1390-1398.
53. 53. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health [Internet]. Version 3.01. Atlanta (GA): Emory University; 2013 [cited 2024 Nov 27]. Available from: https://www.openepi.com
54. 54. Coşansu G, Erdoğan S. Çok boyutlu diyabet anketi Türkçe formunun geçerlik ve güvenirlik çalışması. Ataunihem. 2010;13(4):10-18.
55. 55. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361-370.
56. 56. Aydemir Ö. Hastane anksiyete ve depresyon ölçeği Türkçe formunun geçerlilik ve güvenilirlik çalışması. Turk Psikiyatri Derg. 1997;8(4):280-287.
57. 57. Maldonado G, Greenland S. Simulation study of confounder- selection strategies. Am J Epidemiol. 1993;138(11):923-936.
58. 58. Raffield LM, Brenes GA, Cox AJ, Freedman BI, Hugenschmidt CE, Hsu FC, Xu J, Wagner BC, Williamson JD, Maldjian JA, Bowden DW. Associations between anxiety and depression symptoms and cognitive testing and neuroimaging in type 2 diabetes. J Diabetes Complications. 2016;30(1):143-149.
59. 59. Kosiborod M, Gomes MB, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, Watada H, Shimomura I, Chen H, Cid-Ruzafa J, Fenici P, Hammar N, Surmont F, Tang F, Khunti K; DISCOVER investigators. Vascular complications in patients with type 2 diabetes: Prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovasc Diabetol. 2018;17(1):150-162.
60. 60. Rosenstock IM. Health Belief Model. In: Kazdin AE, editor. Encyclopedia of psychology. Vol. 4. New York: Oxford University Press; 2000. p. 78-80.
61. 61. Ponzo MG, Gucciardi E, Weiland M, Masi R, Lee R, Grace SL. Gender, ethnocultural, and psychosocial barriers to diabetes self-management in Italian women and men with type 2 diabetes. Behav Med. 2006;31(4):153-160.
62. 62. Figaro MK, Elasy T, Belue R, Speroff T, Dittus R. Exploring socioeconomic variations in diabetes control strategies: Impact of outcome expectations. J Natl Med Assoc. 2009;101(1):18-23.
63. 63. T.C.Sağlık Bakanlığı. Erişkin diyabetli bireyler için eğitimci rehberi [Internet]. 2015 [cited 2024 Sep 23]. Available from: www.beslenme.gov.tr
64. 64. Kristianingrum ND, Wiarsih W, Nursasi AY. Perceived family support among older persons in diabetes mellitus self-management. BMC Geriatr. 2018;18(1):1-5.
65. 65. Yıldız Aslan G, Tekir Ö, Yıldız H. Diyabetli bireylerde aile desteği ile yaşam kalitesi arasındaki ilişki. Cukurova Med J. 2021;46(1):299-309.
66. 66. Zafirah DN, Pristianty L, Rahem A, Priyandani Y. Relationship between family support and compliance in diabetes mellitus patients. Pharm Educ. 2022;22(2):267-269.
67. 67. Özdemir I, Hocaoglu Ç. Tip 2 diabetes mellitus ve yaşam kalitesi: Bir gözden geçirme. Goztepe Tip Derg. 2009;24(2):73-78.
68. 68. Al-Ghamdi SH, Ahmad GAU, Ali AH, Bahakim NO, Alomran SI, Alhowikan WK, Almutairi SM, Basalem TA, Aljuaid FF. How do Saudi diabetic patients perceive their illness? A multicenter survey using revised-illness perception questionnaire. J Fam Community Med. 2018;25(2):75-81.
69. 69. Amuta AO, Barry AE, McKyer ELJ. Risk perceptions for developing type 2 diabetes among overweight and obese adolescents with and without a family history of type 2 diabetes. Vol. 39, American Journal of Health Behavior. PNG Publications and Scientific Research Limited; 2015. p. 786-793.
70. 70. Abubakari AR, Cousins R, Thomas C, Sharma D, Naderali EK. Sociodemographic and clinical predictors of self-management among people with poorly controlled type 1 and type 2 diabetes: The role of illness perceptions and self-efficacy. J Diabetes Res. 2016;2016:6708164.
71. 71. Tang J, Gao L. Illness perceptions among patients with type 2 diabetes mellitus: A cross-sectional study. Int J Nurs Pract. 2020;26(5):e12801.
72. 72. Helgeson VS, Honcharuk E, Becker D, Escobar O, Siminerio L. A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency. Pediatr Diabetes. 2011;12(1):25-30.
73. 73. Farmer A, Wade A, French DP, Goyder E, Kinmonth AL, Neil A. The DiGEM trial protocol--a randomised controlled trial to determine the effect on glycaemic control of different strategies of blood glucose self-monitoring in people with type 2 diabetes [ISRCTN47464659]. BMC Fam Pract. 2005;6:25.
74. 74. O’Kane MJ, Bunting B, Copeland M, Coates VE. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): Randomised controlled trial. BMJ. 2008;336(7654):1174-1177.
75. 75. Clar C, Barnard K, Cummins E, Royle P, Waugh N; Aberdeen Health Technology Assessment Group. Self-monitoring of blood glucose in type 2 diabetes: Systematic review. Health Technol Assess. 2010;14(12):1-140. 76. Song M, Lipman TH. Concept analysis: self-monitoring in type 2 diabetes mellitus. Int J Nurs Stud. 2008;45(11):1700- 1710.
76. 77. Chicco D, Warrens MJ, Jurman G. The coefficient of determination R-squared is more informative than SMAPE, MAE, MAPE, MSE and RMSE in regression analysis evaluation. PeerJ Comput Sci. 2021;7:e623.
77. 78. Gupta A, Stead TS, Ganti L. Determining a Meaningful R-squared Value in Clinical Medicine. Acad Med Surg. 2024;1- 6.
78. 79. Abraham AM, Sudhir PM, Philip M, Bantwal G. Illness perceptions and perceived barriers to self-care in patients with type 2 diabetes mellitus: an exploratory study from India. Int J Diabetes Dev Ctries. 2015;35(2):137-144.
79. 80. Indelicato L, Dauriz M, Santi L, Bonora F, Negri C, Cacciatori V, Targher G, Trento M, Bonora E. Psychological distress, self-efficacy and glycemic control in type 2 diabetes. Nutr Metab Cardiovasc Dis. 2017;27(4):300-306.
80. 81. Vermeire E, Hearnshaw H, Rätsep A, Levasseur G, Petek D, van Dam H, van der Horst F, Vinter-Repalust N, Wens J, Dale J, Van Royen P. Obstacles to adherence in living with type-2 diabetes: an international qualitative study using meta-ethnography (EUROBSTACLE). Prim Care Diabetes. 2007;1(1):25- 33.
81. 82. Abraham AM, Sudhir PM, Philip M, Bantwal G. Illness perceptions and perceived barriers to self-care in patients with type 2 diabetes mellitus: an exploratory study from India. Int J Diabetes Dev Ctries. 2015;35 (Suppl 2):137-144.
82. 83. Berenguera A, Molló-Inesta À, Mata-Cases M, Franch-Nadal J, Bolíbar B, Rubinat E, Mauricio D. Understanding the physical, social, and emotional experiences of people with uncontrolled Type 2 diabetes: a qualitative study. Patient Prefer Adherence. 2016;10:2323-2332.
83. 84. Alzubaidi H, Mc Mamara K, Chapman C, Stevenson V, Marriott J. Medicine-taking experiences and associated factors: Comparison between Arabic-speaking and Caucasian English- speaking patients with Type 2 diabetes. Diabet Med. 2015;32(12):1625-1633.
84. 85. Nyarko K, Kugbey N, Atindanbila S. Illness Perception, Religiosity and Mental Health of Diabetic Patients in Ghana. Am J Appl Psychol. 2014;3(1):12-20.
85. 86. Hansen S, Huttunen-Lenz M, Sluik D, Brand-Miller J, Drummen M, Fogelholm M, Handjieva-Darlenska T, Macdonald I, Martinez AJ, Larsen TM, Poppitt S, Raben A, Schlicht W. Demographic and social-cognitive factors associated with weight loss in overweight, pre-diabetic participants of the PREVIEW study. Int J Behav Med. 2018;25(6):682-692.
86. 87. Chen F, Wei G, Wang Y, Liu T, Huang T, Wei Q, Ma G, Wang D. Risk factors for depression in elderly diabetic patients and the effect of metformin on the condition. BMC Public Health. 2019;19(1):1063.