Psychosocial stress in South African patients with type 2 diabetes

Objective: Diabetes mellitus is considered an emotionally and behaviourally demanding condition which adds to the stress of a patient’s daily living. There is a paucity of literature in South Africa regarding stress and diabetes. This study therefore aims to identify the areas and contributory factors of psychosocial stress in South African patients with diabetes. Method: A cross-sectional study was conducted at two public facilities and five private medical practices on the north coast of KwaZulu-Natal, South Africa. The Questionnaire on Stress in Diabetes – Revised was administered to 401 participants. Results: Eighteen percent of the sample reported having extreme psychosocial stress. Depression, physical complaints and self-medication/diet were the main areas which contributed to high psychosocial stress. Factors that also contributed to high levels of psychosocial stress were low educational level, unemployment, female gender, attending the public sector and high HbA1c levels. Conclusion: Psychosocial stress affects metabolic control in patients with diabetes, thereby increasing the risks of long-term complications.


Introduction
The prevalence of diabetes mellitus (DM) has increased globally with an estimate of 415 million adults living with the disease in 2015. 1 Type 2 diabetes is most common and affects millions of people worldwide. 2Diabetes prevalence has also rapidly risen in middle-and low-income countries. 2The International Diabetes Federation estimates that in Africa, 14.2 million adults have diabetes.This figure is expected to increase to 34.2 million in 2040. 1 In South Africa, 2.3 million people are estimated to be living with diabetes, with 1.39 million people who have not yet been diagnosed. 1In 2014, diabetes was among the first three leading causes of death in South Africa. 3abetes is considered an emotionally and behaviourally demanding condition 4 which adds to the stress of a patient's daily living.Stress is associated with both the onset and exacerbation of diabetes because of the demanding nature of the disease.Stress is a physiological or psychological response to external stimuli or stressful events themselves, which can be negative, positive or both. 5Although some individuals respond positively to stress, others cannot cope with the additional demands of the disease. 5örntorp 6 formulated a theory on the stress-diabetes association which states that perceived psychological stress with a helplessness reaction can lead to an activation of the hypothalamicpituitary-adrenal axis resulting in high cortisol levels which antagonise the actions of insulin.Many studies support this theory that psychosocial stress and stressful life events have been associated with the onset of type 2 diabetes. 7,8Further, stress significantly affects compliance to treatment and management of DM. 9 The daily self-management tasks of diabetes (diet, adherence to medication and monitoring glucose) can also be a source of stress. 5,10Patients feel frustrated or 'burned out' by the daily hassles of disease management and the self-care demands. 11ressful experiences have been linked to poor metabolic control 12,13 which can lead to deleterious long-term complications in patients with diabetes, such as blindness, kidney failure and lower limb amputation. 2 Further, these complications have financial implications for the patients with diabetes and their families and impacts on health systems and national economies through direct medical costs, loss of work and income. 2

Participants
Participants 18 years and older diagnosed with type 2 diabetes for at least 6 months and who were fluent in either English or isiZulu were included in the study.The total sample size (N = 401) consisted of 200 participants from the private sector, and 201 were from the public sector.

Procedure
Trained research assistants approached patients waiting for their scheduled appointments, explained the study to them and requested their participation.Those who agreed to participate were requested to sign informed consent forms.A research questionnaire was administered to the patient in the language of their choice.

Instrument
This article forms part of a larger study on psychological well-being and type 2 diabetes.Participants completed a comprehensive questionnaire which included demographic details and co-morbidities.Participants took 45-60 minutes to complete this questionnaire.Participants were provided with refreshments and time to take a break.None of the participants reported to be tired during the collection of data.Data were collected over a period of 6 months.This article focuses on their responses to the Questionnaire on Stress in Diabetes -Revised (QSD-R).This questionnaire can be administered to patients with type 1 and type 2 diabetes.The questionnaire was designed based on interviews with patients, consultations with psychotherapists and reports from diabetes specialists.After a comprehensive survey with 90 items, the QSD was modified for clinical reasons and reduced to 45 items. 17The QSD-R is a self-assessment questionnaire which measures sources of stress for people with diabetes. 18The items in this questionnaire are grouped into eight subscales: 'leisure time' which covers activities such as travel, hobbies or other interests which cannot be pursued to the desired extent as a consequence of the diabetes; 'depression and fear of future' which refers to a worsening of mood and feelings as a result of the diabetes and includes worrying about the future; 'hypoglycaemia' which describes problems that are associated with low blood sugar such as the fear of further low blood sugars, fear of being alone or fear of unpleasant symptoms during a hypoglycaemic episode; 'self-medication/diet' that deals with problems related to the treatment plan such as monitoring blood sugar levels, injecting themselves to check blood sugar levels and keeping to the diet; 'physical complaints' which lists the most frequent physical complaints of patients with diabetes such as increased thirst, excessive sweating, episodes of weakness, gas or painful feet; 'work' which refers to problems that patients with diabetes may have at work, for example, not being able to find a new job, limited advancement opportunities or days being sick due to diabetes; 'partner' which describes problems that may arise with partners, for example, worrying about the partner or having less sex; and 'doctor-patient relationship' which deals with patients' experiences with their doctor.Participants are presented with a list of situations that they might encounter which might cause stress.They are requested to indicate whether the statement applies or does not apply to them.If the statement applies, participants are requested to indicate on a five-point scale, ranging from 1 = 'only a slight problem' to 5 = 'a very big problem', how much of a problem the situation is for them. 18The above-mentioned subscales were totalled to given an overall QSD-R score (mean global stress score).If any participant had a score greater than one standard deviation above the mean, they were classified as having extreme psychosocial stress. 18The Cronbach's alpha values for the scales vary from 0.96 to 0.81. 19In this study, the values ranged from α = 0.67 to 0.82.

Data analysis
STATA version 13.0 20 was used to process and analyse the data.T-test or Wilcoxon rank-sum test was used to compare means (or ranks) of continuous data across two groups (e.g.public vs. private sector), while Pearson χ 2 test or Fisher's exact were used for the cross tabulations of categorical variables.In addition, bivariate and multivariable logistic regressions were performed to assess factors associated with extreme psychosocial stress.Model fit was assessed.

Ethical considerations
Ethical approval was obtained from the Biomedical Ethical Research Committee of the University of KwaZulu-Natal.The Provincial Department of Health granted permission for the study to be conducted at the public health facilities.Doctors in the private sector consented to the research being conducted at their practices.
The mean HbA1c levels of the group with extreme psychosocial stress (M = 13.25, s.d.= 5.82) were significantly higher than the mean HbA1c levels of the group with low psychosocial stress (M = 11.78,s.d.= 4.80; p = 0.039).
Eighteen percent of the sample reported having extreme psychosocial stress.Table 2 shows the participants' responses to the subscales.Participants had high scores on the depression/fear of the future, self-medication/diet and physical complaints subscales.This implies that these areas were the most stressful.The mean scores for depression/ fear were 10.90 (s.d.= 8.07) and 5.80 (s.d.= 5.44) for hypoglycaemia and 14.55 (s.d.= 9.94) for self-medication.According to the QSD-R, almost 21.00% (n = 84) of the participants had depressive symptomatology, 18.95% (n = 76) had physical complaints, 17.96% (n = 72) found that self-medication/diet was stressful to manage, 17.46% (n = 70) had problems with hypoglycaemia, 17.21% (n = 65) had a stressful relationship with their doctor as a patient, 16.21% (n = 65) experienced poor leisure time quality, 15.96% (n = 64) had work-related stress and 15.46% (n = 62) had stress with their partner.
As shown in Table 3, participants with a lower educational level (n = 58, 19.08%) had higher extreme psychosocial stress

Discussion
In this study, we found that 18.2% of the participants had extreme psychosocial stress scores.Depression, physical complaints, self-medication/diet and hypoglycaemia were identified as the predominant areas contributing to psychosocial stress.We also found that other factors contributing to high stress levels were lower educational level, unemployment, female gender, attending public sector facilities and high HbA1c levels.
Similar to our findings, Herpertz et al. 18 found that 17% of patients with diabetes had extreme psychosocial stress and also found that depression, self-medication/diet and physical complaints were predominant in the psychosocial stress profile for patients with type 2 diabetes.Herschbach et al. 19 also found that patients with type 2 diabetes had high levels of stress associated with self-medication, diet and physical complaints.Almost 21% of the participants in this study reported having depressive symptoms.Anderson et al. 21and Ali et al. 22 have documented that the presence of diabetes doubles the odds of having depression.DM is a chronic disease which demands lifestyle changes such as diet, constant monitoring of glucose levels and strict adherence to medication; however, depression has been associated with a decline in self-care behaviour such as poor adherence to medication and diet. 23epression is associated with poor metabolic control and an increased risk of diabetic complications. 21,24Patients with diabetes can become frustrated and overwhelmed by the disease when they are unable to achieve acceptable metabolic targets which further makes them feel hopeless and despondent about possible long-term complications. 25anagement of depressive symptoms will assist in achieving good metabolic control, 26 thereby decreasing the risk of longterm complications.
Adherence to treatment regimen and diet was stressful for participants.Diet is a major barrier to diabetes selfmanagement which is mostly as a result of a lack of knowledge about the disease, financial constraints and/or food portion control. 27,28,29As part of a diabetes treatment programme, public health dietary advice is for patients to adhere to a balanced diet of fruit and vegetables, protein, a limited fat intake and a total energy intake of 45% -60% carbohydrates. 30Although this may be the prescribed requirement for effective management, for many South African families, carbohydrates such as maize, sorghum and brown bread are a staple diet which forms a large portion of meals, thereby constituting an unbalanced diet. 29In a local study done by Muchiri et al., 28 it was also found that family members were reluctant to change diets because the patient with diabetes was the only one in the family.Therefore, the patient with diabetes experienced a lack of support in adherence to diet as part of the treatment of the disease.Furthermore, Muchiri et al. 28 also found that family members do not have enough information about the disease, especially regarding diet, metabolic control and the resultant long-term complications.Studies have shown that family support decreases stress in the patient with diabetes. 31,32It is therefore important to involve the family in the education of diabetes so that they can understand the nature of the disease and the lifestyle changes such as diet and treatment adherence which are essential elements in treating the disease.
Women in this study had higher stress levels compared with men, a finding similar to other studies. 8,33Given that women are often the breadwinners who have many responsibilities such as caring and providing for the family, a chronic condition like diabetes adds to the already stressful demands.
It is therefore important that health care services in South Africa cater for the needs of women and provide more resources in terms of treatment and access to services. 34e average HbA1c level of 12.02% (s.d.= 5.00) in our sample is much higher than the acceptable target figure of ≤ 7.00%. 1 In keeping with other studies, 18,19,31 we found that the group with extreme psychosocial stress had higher HbA1c levels.
Poor glucose control cannot be helped by advice to consume 45% -60% of the diet in the form of carbohydrates, a substance that patients with diabetes are unable to handle.Another factor to consider is the possibility that stress can lead to a vicious cycle of emotional eating (which typically consists of carbohydrates) which leads to worsened diabetes outcomes which in turn creates more stress and more emotional eating of carbohydrates. 35Elevated glucose levels because of stress cannot be metabolised properly in a patient with diabetes, resulting in hyperglycaemia. 13As a result, psychological stress affects metabolic control and poor metabolic control leads to complications. 36The management of stress is therefore of paramount importance in achieving good metabolic control.
As expected, we found that an increase in medical comorbidities was associated with extreme psychosocial stress.In this sample, hypothyroidism, HIV and/or TB and other co-morbidities (arthritis and asthma) were associated with an increased chance of having extreme psychosocial stress.Hypothyroidism has been linked to type 2 diabetes 37,38 by being associated with insulin resistance which results in impaired glucose metabolism in type 2 diabetes. 38,39South Africa, particularly KwaZulu-Natal, has high levels of HIV and a concomitant TB burden. 3In the light of this, HIV and TB have been identified as priority areas to reduce infection and increase awareness of the diseases. 40Health practitioners need to adequately screen patients with type 2 diabetes for HIV and TB and also take these co-morbidities into account when treating diabetes.Although highly active antiretroviral therapy (HAART) has improved CD4 counts and the suppression of the viral load in patients with HIV, it has led to an increase in metabolic dysfunction which includes insulin resistance. 41Patients with HIV frequently present with diabetes and metabolic complaints. 41Patients with the double burden of diabetes and HIV and/or TB require psychosocial support and coping skills to help them deal with adherence to medication in addition to the stigma associated with HIV.
In this study, hypertension was not significantly associated with extreme psychosocial stress, which is in contrast to other studies that link hypertension to stress. 42This is unusual, especially since exposure to chronic stress is a risk factor for hypertension 43 and that South Africa is known to have the highest prevalence of hypertension in the world. 44Given the high rates of hypertension in South Africa, participants in this sample may not be aware that they are hypertensive.People are often unaware that they have hypertension unless their blood pressure is specifically measured and monitored at a health care facility. 14Hypertension frequently occurs with diabetes and is part of the metabolic syndrome which, if left untreated, can lead to target-organ damage and premature death. 14Therefore, patients need to be educated about hypertension and should be closely monitored by health care workers.
In our sample, the percentage of participants who were unemployed (28.43%) was higher than the national unemployment rate (25.4%). 45The economic climate adds to the stresses of daily living and also affects the patient's ability to access health care services and to take adequate care of his or her health.A patient with diabetes has to regularly attend health care facilities because of the chronic nature of the disease.However, financial constraints and a lack of transport impact on patients accessing health care facilities. 46other finding in this study was that participants who attended the public health care sector endorsed twice the amount of stress as compared with those who attended the private health care sector.There are long waiting times when attending the public health care facilities which are a deterrent to those who are employed.In many instances, attending a hospital or a clinic for the whole day is a loss of income. 47herefore, health-seeking behaviour is not a priority. 48tients have long waiting times and have limited interaction with the health care provider.The public health sector has limited resources and large demands and therefore cannot cater for the individualised needs of a patient with a chronic condition. 46Given this situation, patients choose to go to work to provide for their families rather than spending a whole day at the hospital or clinic with the threat of loss of income for not being at work.
While South Africa has limited resources, the health services have to cope with the burden of disease. 14South Africa has embarked upon instituting a National Health Insurance strategy which 'aims to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socio-economic status'. 49his initiative will assist patients with diabetes as well as other health conditions to access health care services irrespective of their socio-economic status.
Further, treatment for patients with diabetes should be individually tailored in lieu of their unique stresses and their contexts 50 and their treatment should be holistic.Stress management and support groups should be an integral part of the management of diabetes as well as incorporating a psychologist into the diabetes team and increasing the psychological care of patients with DM.In this way, the patient's mental health will also be addressed which will lead to a reduction in stress in the patient.

Conclusion
Psychosocial stress affects metabolic control in patients with diabetes, thereby increasing the risks of long-term complications.It is therefore imperative that interventions to deal with stress, family support and diabetes education should be considered an integral part of the treatment regimen for patients with diabetes.Accordingly, a mental health clinician should be a part of the multidisciplinary team to help the patient deal with psychosocial stress.

Limitations
The cross-sectional design limits causal inferences.Some ethnic groups had small sample sizes; therefore, results cannot be generalised for these groups.The QSD-R has not been standardised although good reliability and validity have been demonstrated in research.

TABLE 1 :
Demographic characteristics of the total study sample.

TABLE 3 :
A comparison of the QSD-R by gender, sector, marital status, educational level, ethnic group and employment.

TABLE 4 :
Bivariate and multivariable regression for factors associated with extreme psychosocial stress.

TABLE 5 :
Co-morbidities associated with extreme psychosocial stress.