Psychological Health and Diabetes Self-Management among Patients with Type 2 Diabetes during COVID-19 in the Southwest of Saudi Arabia

Background and objectives: The prevalence of type 2 diabetes in Saudi Arabia is high and rising steeply. However, the management of type 2 diabetic patients has largely employed a medical approach and ignored the self-care management approach. This observation has even been obscured further by the COVID-19 pandemic, which has affected the psychological health of these patients. This study aimed to understand the effects of psychological health and DSM on type 2 diabetic patients in the Jazan region during COVID-19. Materials and methods: An analytical cross-sectional study was employed in this study. Participants were type 2 diabetic patients from the diabetic center at Jazan, Saudi Arabia. The Arabic-translated version of the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7) were used to collect data. Data were analyzed using SPSS software. Results: Depression and anxiety were higher in females compared to males and were more reported by participants from urban compared to rural settings. Smoking and Khat chewing were inappropriate diabetic self-care management practices while exercising was appropriate. A negative correlation was observed between depression vs. health care utilization, and depression vs. diabetic self-care management. Anxiety results also showed similar findings to that of depression. Additionally, depression and anxiety were easily predicted by urban residence, and diabetic self-care management was predicted by exercise. Conclusions: Adequate self-care behavior in patients with type 2 diabetes is needed. Medical professionals should ensure improved efforts to accurately ascertain how an individual can implement the recommended lifestyle changes and facilitate self-care education.


Introduction
Diabetes mellitus (DM), a multifactorial disease and most common chronic endocrine disorder, affects about 5-10% of adults globally [1]. If not diagnosed or well treated, DM can lead to multiple chronic complications that can result in disability and death [1]. Diabetes mellitus is on the rise in developing countries, Saudi Arabia inclusive. It is estimated that by 2030, the prevalence of diabetes among those aged 20-79 years may increase to 7.7% [2]. According to the World Health Organization, the East Mediterranean region ranks 1.
To determine the prevalence of depression, anxiety, and DSM across the sociodemographic characteristics.

2.
To assess the correlation between psychological health and DSM.

3.
To determine the factors that strongly predict depression, anxiety, and DSM.

Materials and Methods
Design and setting: An analytical cross-sectional study was conducted in the diabetic center at Jazan, Saudi Arabia from 23 August 2021 to 2 February 2022. The diabetic center serves as a referral center for controlled and uncontrolled diabetic patients from all primary healthcare centers in the region. This center serves over 10,000 diabetic patients and it is the only center in Jazan.
Study population and sample size: Patients aged ≥ 18, diagnosed with type 2 diabetes for at least one year were included in this study. Patients with type 1 diabetes and mentally and severely ill were excluded from the study. The selection process was carried out to obtain a representative sample of type 2 diabetic patients. A sample size of 375 patients for this study was determined using the formula n = P (1 − P) × Zα 2 /d 2 , where n is the calculated sample size, P is the expected proportion in population, based on previous studies (the prevalence of mental illness among diabetic patients of 57% based on a study conducted in Jazan [14]), Z is the z-value for the selected level of confidence (95%), and d is absolute error or precision (0.05) [15].
The 5% precision catered for the nonresponse rate. Samples were enrolled using a systematic random sampling technique until the estimated sample size was achieved. This systematic sampling was dependent on the center's medical records file numbers for the diabetic patients.
Data tool and collection: A participant self-administered questionnaire was used for the data collection. The Arabic-translated version of the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7) were used to collect data. These questionnaires used the 4-point Likert scale and were valid and reliable for determining the prevalence of depression and generalized anxiety disorder. The response on each item ranged from 0 "not at all", 1 "several days", 2 "more than half the days" and 3 "nearly every day".
The PHQ-9 instrument consists of 9 items; each one is scored 0 to 3, yielding a severity score of 0 to 27. A score of 5, 10, 15, or 20 on the PHQ-9 scale indicates mild, moderate, moderately severe, or severe depression, respectively. A PHQ-9 score ≥ 10 was considered as depression [16].
The total Likert scores ranged from 0 to 10, with the higher score indicating better self-management. Based on the recommendation of Schmitt et al., the DSMQ scores of the participants were classified as "adequate" (scores that were greater than six) or "inadequate" (scores that were equal to or less than six).
Furthermore, the sociodemographic data of the participants were collected. These data included age, gender, level of education, residential place, marital status, occupation, social status, family monthly income, nationality, smoking status, khat chewing, exercise, and years since diabetes was diagnosed.
Data management and analysis: All the collected data were entered in an Excel sheet, cleaned, coded, and transported to SPSS version 26 for analysis. Descriptive statistics were conducted for all the coded variables and presented in a frequency table. The Chi-square test was used to test the statistical significance of associations between individual study variables and depression, anxiety, and DSM. Pearson's correlation coefficient was used to evaluate the correlation between psychological health and diabetes self-management domains. Logistic regression models were used to assess depression, anxiety, and diabetes self-management predictors among type 2 diabetes mellitus. A p-value < 0.05 was used to indicate the statistically significant findings.
Ethical Consideration: Ethical approval was obtained from the Jazan Hospital Institutional Review Board (reference number: H-10-Z-073) with ethical approval number-2141. Written informed consent was obtained from all the participants before enrolment. For purposes of confidentiality, the questionnaires were preidentified to create anonymity. This study did not pose any risk of harm to any of the participants.

Results
As shown in Table 1, the majority of participants were females (51.7%) and between 50 and 65 years. Most of the participants were Saudi, married, and living in urban areas, at 89.6%, 65.9%, and 63.5%, respectively. Regarding education level and family income, 33.1% of patients were highly educated, and 46.5% had a monthly family income of less than 5000 SAR.
Smoking and Khat chewing habits were prevalent among 18.7% and 20.0% of the study participants, respectively. The majority (38.1%) of the participants reported living with type 2 DM for 1-5 years, while 52.8% of the participants reported exercising. As shown in Table 2, When the groups under each variable were compared with depression status to see whether there was a statistically significant difference between them using Chi-square, females had a statistically higher prevalence of depression compared to their male counterparts (p = 0.000). Participants between the ages of 20 and 34 were found to have a statistically significant higher rate of depression compared to those in other age groups (p = 0.033). Urban residents had a statistically significant higher rate of depression than rural residents (p = 0.007). Unemployed individuals had a statistically significant higher rate of depression than other groups (p = 0.008). Participants who exercised had a statistically significantly higher rate of depression compared to those that did not. There were no statistically significant associations between depression and marital status, level of education, duration of diagnosis of diabetes mellitus, smoking, or khat chewing. Table 3 demonstrates the distribution and Chi-square tests of anxiety in participants with type 2 diabetes mellitus (T2DM) according to their demographic characteristics (n = 375). Females had a higher prevalence of anxiety (65.6%) than males, a highly significant difference (p < 0.001). The rate of anxiety was higher in urban areas (60.6%) than in rural areas (p = 0.022). There were no statistically significant differences in other sociodemographic characteristics.  Bold to indicate that is p < 0.05 (significant). Table 4 demonstrates the distribution of diabetes self-management among participants with type 2 diabetes mellitus (T2DM) according to their demographic characteristics (n = 375). Smokers had a statistically significantly higher rate of inappropriate self-care behavior than nonsmokers (p = 0.018). Those who chewed Khat had a statistically significantly higher inappropriate self-care behavior than those who did not (p = 0.043). The participants who exercised had statistically significantly higher appropriate DSM compared to those that did not exercise (p = 0.008). There were no statistically significant differences in other sociodemographic characteristics. Table 5 demonstrates the correlation coefficient (Pearson's r) between depression, anxiety, and the DSM subscale. The findings indicate that depression had a statistically significant negative correlation with healthcare utilization (r = 0.164, p < 0.01) and overall DSM score (r = 0.166, p < 0.001), yet with a positive statistically significant correlation with anxiety (r = 0.781, p < 0.01). Besides that, anxiety had a significant negative correlation with healthcare utilization (r = 0.180, p < 0.01) and overall DSM score (r = 0.173, p < 0.01). On the other hand, the correlation coefficient between the DSM shows that glucose management had a significant positive correlation with dietary control (r = 0.557, p < 0.01). Furthermore, healthcare utilization had a significant positive correlation with dietary control, glucose management, and physical activity ((r = 0.429, p < 0.01), (r = 0.38, p < 0.014), and (r = 0.354, p < 0.01), respectively). Table 6 shows the simple logistic regression analysis of factors associated with depression, anxiety, and DSM. In terms of depression, the analysis showed that urban residency is a statistically strong predictor of depression risk (OR = 1.78, p = 0.007, 95% C. I: 1.170-2.739). The rest of the sociodemographic characteristics were lesser predictors of depression.
According to anxiety, the analysis established that urban residency was still found to be a statistically strong predictor of anxiety risk (OR = 1.644, p = 0.022, 95% C. I: 1.073-2.519). The rest of the sociodemographics were lesser predictors of the characteristics of anxiety. Regarding the factors contributing to successful DSM, the analysis determined that exercise was a strong predictor of effective self-care (OR = 1.775, p = 0.008, 95% C. I: 1.161-2.712). On the other hand, smoking and Khat chewing were found to be less predictors of effective self-diabetic care, with (OR = 0.498, p = 0.019, 95% C. I: 0.278-0.893) and (OR = 0.567, p = 0.045, 95% C. I: 0.326-0.988), respectively.

Discussion
To the best of our knowledge, this is the first study to examine the prevalence of depression, anxiety, and diabetes self-management among patients with type 2 diabetes in Jazan, Saudi Arabia, during the COVID-19 pandemic. Regarding psychological health, we discovered a high prevalence of depression and anxiety among people with type 2 diabetes during the COVID-19 pandemic. Depressive and anxiety symptoms were reported at 54.4% and 47.1%, respectively, of all participants in this study. This rate is nearly identical to what was observed in Saudi Arabia and the Gulf countries during the COVID-19 outbreak among diabetic and nondiabetic patients [19].
Moreover, our findings corroborate what was discovered during the COVID-19 pandemic among diabetic patients in Brazil [20]; 43.3% of participants had anxiety while 45.1% of participants had depression. Our study discovered that depression rates were likewise similar to those observed in Bangladeshi patients with chronic diseases [21]; 59% of participants had anxiety while 71.6% of participants had depression.
The rate of depression and anxiety in Germany after the initial COVID-19 outbreak was 21.3% and 22.9%, respectively [22]. A subsequent Germany study reported the rates to be 19.3% for depression and 22.6% for anxiety [23]. These reported rates are lower than the rate observed in our study. The disparity between our population and other populations in other studies could be due to the inability to access healthcare during a lockdown. Social isolation and fear of infection have a negative effect on mental health or may result from other factors such as genetics, culture, or education. So, to avoid such unfavorable consequences, existing initiatives, including telephone consultations and online support services for mentally ill people who are experiencing the effects of the ongoing pandemic, could be used [24].
We discovered that women were more likely to suffer from diabetes-related depression and anxiety. Our results agree with those of past studies [25][26][27][28]. This observation is largely attributed to hormonal factors contributing to an increased risk of developing depression and anxiety. Pregnancy, fertility, menopause, and menstrual cycle issues increase women's risk of developing depression and anxiety [29].
Subsequently, our study showed that residents of urban areas were more likely to suffer from depression and anxiety. This observation is similar to studies elsewhere [30][31][32]. Urbanization has several negative effects on mental health, including increased stressors and factors such as a crowded and polluted environment, a high level of violence, and decreased social support [33]. These factors can either increase or lead to depression and anxiety among the population.
Additionally, it was discovered that unemployed individuals suffer from depression, which is coherent with the findings of other studies [34,35]. Evidence shows that the majority of unemployed people are not able to attain the recommended diabetic self-care. Indeed, the high unemployment (at 48%) and poverty in the population studied have played an important role in the study findings.
Mental health decline has been partly attributed to the social consequences of pandemic restrictions and economic uncertainty, job loss, and unemployment. With the economic costs yet to be fully realized, those bearing the brunt will likely experience further deterioration in mental health [36]. Regular exercise is associated with a decreased risk of developing psychological problems such as depression.
Our findings indicate that individuals with type 2 diabetes who do not engage in regular physical activity are more likely to suffer from depression. This finding is consistent with previous studies [37,38].
According to diabetes self-management, such activities include glucose monitoring, adherence to prescribed medications and diets, regular healthcare follow-up, and participation in other physical activities [10]. This study's findings indicate that two-thirds of Jazan's population has poor self-care behaviors for diabetes management, with a rate of 69.9%. Thus, only 38.1% of the participants demonstrated adequate self-care behaviors. This observation is consistent with the findings of previous studies [30][31][32][33][34][35][36][37][38][39][40][41][42]. However, the percentage was higher in our findings than in these previous studies. This disparity could be due to many Saudis consuming honey and dates promoted by the holy Koran (considered sacred foods). They may believe that honey and dates can cure a variety of diseases that modern medicine is incapable of treating, yet this could be why they are unable to engage in physical activities during the lockdown. In addition, insufficient education about the disease and their lack of experience plays an active role in its management, leading to a lack of family support or inability to obtain a blood glucose monitoring device [43].
This disconnect between patient-perceived and self-reported self-care behaviors and unfilled glycemic outcomes should alert physicians to be more cautious in their advice to patients regarding self-care behavior. The current study discovered that diabetic patients who chewed Khat and smoked were more likely to have poor self-care for their diabetes. Our findings were consistent with previous studies [44][45][46]. There is a relationship between the habit of Khat chewing and the development of noninsulin-dependent diabetes mellitus, which may be explained by the adverse health effects of pesticide residues on Khat chewers. Khat chewers usually have significantly lower insulin than nonchewers because chewing Khat elevates cortisol levels and lowers insulin secretion and sensitivity [47].
Diabetes self-care requires a high level of problem-solving ability, and both depression and anxiety have a negative impact on this ability. This can lead to poorer self-care practices and ultimately poorer glycemic control. The current study demonstrates a negative correlation between depression and healthcare utilization, as well as between depression and DSM. As healthcare utilization and diabetes self-care management decreased, depression increased.
Similarly, anxiety increased with decreasing healthcare utilization and DSM. These findings were consistent with previous studies [48][49][50] that found healthcare utilization and DSM to be important considerations in addressing depression and anxiety among diabetic patients. Healthcare utilization, dietary control, glucose management, and physical activity positively correlated with DSM. These aspects are components of the diabetes self-care management package [10], and in this study, a satisfactory demonstration of their usability was observed.
Urban residence strongly predicted both anxiety and depression. Participants who lived in urban settings were more likely to develop anxiety and/or depression. This observation is explained by the social setup of the urban settings, because it is characterized by violence, congestion/crowding, and much stressful daily needs, compared to their counterparts in the rural settings.

Limitation
This study has several limitations. First, the current study was conducted in a single city, which cannot be considered representative of the entire Saudi population. Second, DSMQ, PHQ-9, and GAD-7 were evaluated purely based on participant self-reporting. As a result, the data may contain bias due to either over-or under-reporting. Additionally, this study did not cater for data about diabetes control, body weight, and dietary habits. As such, we do not know if patients were in proper glycemic control or not, normal weight, overweight or obese, or followed proper food intake or not. Lastly, HbA1c was not measured, yet it correlates with the risk of long-term diabetes complications.

Conclusions
Depression and anxiety are prevalent among the studied type 2 diabetic patients. The female gender and urban residents are associated with depression and anxiety in patients with type 2 diabetes. Diabetic patients should be screened for signs and symptoms of depression and should be referred to a social worker or psychologist regularly. Additionally, poor self-care behavior is widely prevalent among patients with type 2 DM in Jazan, Saudi Arabia. Smokers and Khat chewers are significantly associated with inadequate self-care behavior.
It is, therefore, critical to ensure adequate diabetes self-care behavior in patients with type 2 DM. Medical professionals should ensure ongoing efforts to accurately ascertain how individuals can implement the recommended lifestyle changes and raise self-care education.