The effectiveness of a value-based EMOtion-cognition-Focused educatIonal programme to reduce diabetes-related distress in Malay adults with Type 2 diabetes (VEMOFIT): study protocol for a cluster randomised controlled trial

Boon-How Chew, Rimke C Vos, Sazlina Shariff Ghazali, Nurainul Hana Shamsuddin, Aaron Fernandez, Firdaus Mukhtar, Mastura Ismail, Azainorsuzila Mohd Ahad, Narayanan N Sundram, Siti Zubaidah Mohd Ali, Guy E H M Rutten, Boon-How Chew, Rimke C Vos, Sazlina Shariff Ghazali, Nurainul Hana Shamsuddin, Aaron Fernandez, Firdaus Mukhtar, Mastura Ismail, Azainorsuzila Mohd Ahad, Narayanan N Sundram, Siti Zubaidah Mohd Ali, Guy E H M Rutten

Abstract

Background: Type 2 diabetes mellitus (T2DM) patients experience many psychosocial problems related to their diabetes. These often lead to emotional disorders such as distress, stress, anxiety and depression, resulting in decreased self-care, quality of life and disease control. The purpose of the current study is to evaluate the effectiveness of a brief value-based emotion-focused educational programme in adults with T2DM on diabetes-related distress (DRD), depressive symptoms, illness perceptions, quality of life, diabetes self-efficacy, self-care and clinical outcomes.

Methods: A cluster randomised controlled trial will be conducted in 10 public health clinics in Malaysia, all providing diabetes care according to national clinical practice guidelines. Patients' inclusion criteria: Malay, ≥ 18 years with T2DM for at least 2 years, on regular follow-up with one of three biomarkers HbA1c, systolic blood pressure and LDL-cholesterol sub-optimally controlled, and with a mean 17-item Diabetes Distress Scale (DDS-17) score ≥ 3. The intervention consists of four sessions and one booster over a period of 4 months that provide information and skills to assist patients in having proper perceptions of their T2DM including an understanding of the treatment targets, understanding and managing their emotions and goal-setting. The comparator is an attention-control group with three meetings over a similar period. With an estimated intra-cluster correlation coefficient ρ of 0.015, a cluster size of 20 and 20% non-completion, the trial will need to enroll 198 patients.

Primary outcome: the between groups difference in proportion of patients achieving a mean DDS-17 score < 3 (non-significant distress) at 6 months post-intervention. Secondary outcomes will be the differences in the above mentioned variables between groups.

Discussion: We hypothesize that primary and secondary outcomes will improve significantly after the intervention compared to the comparator group. The results of this study can contribute to better care for T2DM patients with DRD.

Trial registration: ClinicalTrials.gov NCT02730078 . Registered on 29 March 2016, last updated on 4 January 2017.

Keywords: Blood pressure; Depression; Diabetes education; Diabetes-related distress; HbA1c; LDL-cholesterol; Quality of life; Self-care; Type 2 diabetes mellitus.

Figures

Fig. 1
Fig. 1
Conceptual framework
Fig. 2
Fig. 2
Flow of health clinics and participants through trial. VG: VEMOFIT group; AG: attention-control group
Fig. 3
Fig. 3
Timeline of the interventions. DDS: 17-item Diabetes Distress Scale; PHQ: 9-item Patient Health Questionnaire; MBIPQ: Malay version Brief Illness Perception Questionnaire; WHOQOL-B: World Health Organization Quality of Life- Brief; DMSES: Diabetes Management Self Efficacy Scale; SDSCA: Diabetes Self-Care Activities; PA-CESD: Positive Affects subscale of the Center for Epidemiologic Studies Depression Scale

References

    1. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311–321. doi: 10.1016/j.diabres.2011.10.029.
    1. Chew BH, Lee PY, Cheong AT, Ismail M, Shariff-Ghazali S, Goh PP. Messages from the Malaysian Diabetes Registries on Diabetes Care in Malaysian public healthcare facilities. Prim Care Diabetes. 2016;10(5):383–386. doi: 10.1016/j.pcd.2016.07.003.
    1. Nicolucci A, Kovacs Burns K, Holt RI, Comaschi M, Hermanns N, Ishii H, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med. 2013;30(7):767–777. doi: 10.1111/dme.12245.
    1. Low LL, Tong SF, Low WY. Selection of Treatment Strategies among Patients with Type 2 Diabetes Mellitus in Malaysia: A Grounded Theory Approach. PLoS ONE. 2016;11(1) doi: 10.1371/journal.pone.0147127.
    1. Aikens JE. Prospective Associations between Emotional Distress and Poor Outcomes in Type 2 Diabetes. Diabetes Care. 2012;35(12):2472–2478. doi: 10.2337/dc12-0181.
    1. Gask L, Macdonald W, Bower P. What is the relationship between diabetes and depression? a qualitative meta-synthesis of patient experience of co-morbidity. Chronic illness. 2011;7(3):239–252. doi: 10.1177/1742395311403636.
    1. Anderson RJ, Grigsby AB, Freedland KE, De Groot M, McGill JB, Clouse RE, et al. Anxiety and poor glycemic control: a meta-analytic review of the literature. Int J Psychiatry Med. 2002;32(3):235–247. doi: 10.2190/KLGD-4H8D-4RYL-TWQ8.
    1. Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R, Masharani U. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes. Diabet Med. 2008;25(9):1096–1101. doi: 10.1111/j.1464-5491.2008.02533.x.
    1. Hermanns N, Kulzer B, Krichbaum M, Kubiak T, Haak T. Affective and anxiety disorders in a German sample of diabetic patients: prevalence, comorbidity and risk factors. Diabet Med. 2005;22(3):293–300. doi: 10.1111/j.1464-5491.2005.01414.x.
    1. Chew BH, Vos R, Mohd-Sidik S, Rutten GEHM. Diabetes-Related Distress, Depression and Distress-Depression among Adults with Type 2 Diabetes Mellitus in Malaysia. PLoS ONE. 2016;11(3) doi: 10.1371/journal.pone.0152095.
    1. Kaur G, Tee GH, Ariaratnam S, Krishnapillai AS, China K. Depression, anxiety and stress symptoms among diabetics in Malaysia: a cross sectional study in an urban primary care setting. BMC Fam Pract. 2013;14:69. doi: 10.1186/1471-2296-14-69.
    1. Li C, Ford ES, Zhao G, Strine TW, Dhingra S, Barker L, et al. Association between diagnosed diabetes and serious psychological distress among U.S. adults: the Behavioral Risk Factor Surveillance System, 2007. Int J Public Health. 2009;54(1):43–51. doi: 10.1007/s00038-009-0006-1.
    1. Walker RJ, Smalls BL, Hernandez-Tejada MA, Campbell JA, Davis KS, Egede LE. Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes. Gen Hosp Psychiatry. 2012;34(6):598–603. doi: 10.1016/j.genhosppsych.2012.07.005.
    1. Delahanty LM, Grant RW, Wittenberg E, Bosch JL, Wexler DJ, Cagliero E, et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med. 2007;24(1):48–54. doi: 10.1111/j.1464-5491.2007.02028.x.
    1. Kasteleyn MJ, De Vries L, Van Puffelen AL, Schellevis FG, Rijken M, Vos RC, et al. Diabetes-related distress over the course of illness: results from the Diacourse study. Diabet Med. 2015;32(12):1617–1624. doi: 10.1111/dme.12743.
    1. Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes Care. 2005;28(3):626–631. doi: 10.2337/diacare.28.3.626.
    1. Lloyd C, Smith J, Weinger K. Stress and Diabetes: A Review of the Links. Diabetes Spectrum. 2005;18(2):121–127. doi: 10.2337/diaspect.18.2.121.
    1. Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D, Masharani U. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 2010;33(1):23–28. doi: 10.2337/dc09-1238.
    1. Das-Munshi J, Stewart R, Ismail K, Bebbington PE, Jenkins R, Prince MJ. Diabetes, common mental disorders, and disability: findings from the UK National Psychiatric Morbidity Survey. Psychosom Med. 2007;69(6):543–550. doi: 10.1097/PSY.0b013e3180cc3062.
    1. Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabet Med. 2014;31(7):764–772. doi: 10.1111/dme.12428.
    1. Ogbera A, Adeyemi-Doro A. Emotional distress is associated with poor self care in type 2 diabetes mellitus. J Diabetes. 2011;3(4):348–352. doi: 10.1111/j.1753-0407.2011.00156.x.
    1. Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004;363(9421):1589–1597. doi: 10.1016/S0140-6736(04)16202-8.
    1. Fisher L, Hessler D, Glasgow RE, Arean PA, Masharani U, Naranjo D, et al. REDEEM: a pragmatic trial to reduce diabetes distress. Diabetes Care. 2013;36(9):2551–2558. doi: 10.2337/dc12-2493.
    1. Pouwer F. Should we screen for emotional distress in type 2 diabetes mellitus? Nat Rev Endocrinol. 2009;5(12):665–671. doi: 10.1038/nrendo.2009.214.
    1. Sturt J, Dennick K, Hessler D, Hunter BM, Oliver J, Fisher L. Effective interventions for reducing diabetes distress: systematic review and meta-analysis. International Diabetes Nursing. 2015;12(2):40–55. doi: 10.1179/2057332415Y.0000000004.
    1. Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, et al. Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews. BMJ Open. 2015;5(12) doi: 10.1136/bmjopen-2015-009993.
    1. Chew BH, Shariff-Ghazali S, Fernandez A. Psychological aspects of diabetes care: Effecting behavioral change in patients. World J Diabetes. 2014;5(6):796–808. doi: 10.4239/wjd.v5.i6.796.
    1. Maeseneer JD, Moosa S, Pongsupap Y, Kaufman A. Primary health care in a changing world. Br J Gen Pract. 2008;58(556):806–809. doi: 10.3399/bjgp08X342697.
    1. Glasgow RE, Fisher L, Strycker LA, Hessler D, Toobert DJ, King DK, et al. Minimal intervention needed for change: definition, use, and value for improving health and health research. Transl Behav Med. 2014;4(1):26–33. doi: 10.1007/s13142-013-0232-1.
    1. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005;2:Cd003417.
    1. Ontario HQ. Community-based care for the management of type 2 diabetes: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(23):1–40.
    1. Naik AD, White CD, Robertson SM, Armento ME, Lawrence B, Stelljes LA, et al. Behavioral health coaching for rural-living older adults with diabetes and depression: an open pilot of the HOPE Study. BMC Geriatr. 2012;12:37. doi: 10.1186/1471-2318-12-37.
    1. Harkness E, Macdonald W, Valderas J, Coventry P, Gask L, Bower P. Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33(4):926–930. doi: 10.2337/dc09-1519.
    1. Murata GH, Shah JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA, et al. Factors affecting diabetes knowledge in Type 2 diabetic veterans. Diabetologia. 2003;46(8):1170–1178. doi: 10.1007/s00125-003-1161-1.
    1. Duangdao KM, Roesch SC. Coping with diabetes in adulthood: a meta-analysis. J Behav Med. 2008;31(4):291–300. doi: 10.1007/s10865-008-9155-6.
    1. Sturt J, Taylor H, Docherty A, Dale J, Louise T. A psychological approach to providing self-management education for people with type 2 diabetes: the Diabetes Manual. BMC Fam Pract. 2006;7(1):70. doi: 10.1186/1471-2296-7-70.
    1. Lynch CP, Hernandez-Tejada MA, Strom JL, Egede LE. Association between spirituality and depression in adults with type 2 diabetes. Diabetes Educ. 2012;38(3):427–435. doi: 10.1177/0145721712440335.
    1. Myers DG. The funds, friends, and faith of happy people. Am Psychol. 2000;55(1):56–67. doi: 10.1037/0003-066X.55.1.56.
    1. Bradshaw BG, Richardson GE, Kumpfer K, Carlson J, Stanchfield J, Overall J, et al. Determining the efficacy of a resiliency training approach in adults with type 2 diabetes. Diabetes Educ. 2007;33(4):650–659. doi: 10.1177/0145721707303809.
    1. Yi-Frazier JP, Smith RE, Vitaliano PP, Yi JC, Mai S, Hillman M, et al. A Person-Focused Analysis of Resilience Resources and Coping in Diabetes Patients. Stress Health. 2010;26(1):51–60. doi: 10.1002/smi.1258.
    1. Rasmussen NH, Smith SA, Maxson JA, Bernard ME, Cha SS, Agerter DC, et al. Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus. Prim Care Diabetes. 2013;7(3):213–221. doi: 10.1016/j.pcd.2013.04.006.
    1. Bandura A. Social cognitive theory of self-regulation. Organ Behav Hum Decis Process. 1991;50(2):248–287. doi: 10.1016/0749-5978(91)90022-L.
    1. Cameron LD, Leventhal H. The Self-Regulation of Health and Illness Behaviour: Routledge; 2003.
    1. Harvey JN, Lawson VL. The importance of health belief models in determining self-care behaviour in diabetes. Diabet Med. 2009;26(1):5–13. doi: 10.1111/j.1464-5491.2008.02628.x.
    1. Paschalides C, Wearden AJ, Dunkerley R, Bundy C, Davies R, Dickens CM. The associations of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in patients with type 2 diabetes mellitus. J Psychosom Res. 2004;57(6):557–564. doi: 10.1016/j.jpsychores.2004.03.006.
    1. Barnes L, Moss-Morris R, Kaufusi M. Illness beliefs and adherence in diabetes mellitus: a comparison between Tongan and European patients. N Z Med J. 2004;117(1188):U743.
    1. Skinner TC, Khunti K, Carey ME, Dallosso H, Heller S, Davies MJ. Stability and predictive utility, over 3 years, of the illness beliefs of individuals recently diagnosed with Type 2 diabetes mellitus. Diabet Med. 2014;31(10):1260–1263. doi: 10.1111/dme.12484.
    1. Searle A, Norman P, Thompson R, Vedhara K. Illness representations among patients with type 2 diabetes and their partners: relationships with self-management behaviors. J Psychosom Res. 2007;63(2):175–184. doi: 10.1016/j.jpsychores.2007.02.006.
    1. Dimitraki G, Karademas EC. The association of type 2 diabetes patient and spouse illness representations with their well-being: a dyadic approach. Int J Behav Med. 2014;21(2):230–239. doi: 10.1007/s12529-013-9296-z.
    1. Rutten GE. What effect does diabetes have on the family--do you know? Lancet Diabetes Endocrinol. 2014;2(3):191–192. doi: 10.1016/S2213-8587(13)70122-0.
    1. Fisher L, Chesla CA, Skaff MM, Mullan JT, Kanter RA. Depression and anxiety among partners of European-American and Latino patients with type 2 diabetes. Diabetes Care. 2002;25(9):1564–1570. doi: 10.2337/diacare.25.9.1564.
    1. August KJ, Sorkin DH. Marital status and gender differences in managing a chronic illness: the function of health-related social control. Soc Sci Med. 2010;71(10):1831–1838. doi: 10.1016/j.socscimed.2010.08.022.
    1. Rosland AM, Heisler M, Piette JD. The impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review. J Behav Med. 2012;35(2):221–239. doi: 10.1007/s10865-011-9354-4.
    1. Franks MM, Sahin ZS, Seidel AJ, Shields CG, Oates SK, Boushey CJ. Table for two: diabetes distress and diet-related interactions of married patients with diabetes and their spouses. Fam Syst Health. 2012;30(2):154–165. doi: 10.1037/a0028614.
    1. DiMatteo MR. Social Support and Patient Adherence to Medical Treatment: A Meta-Analysis. Health Psychol. 2004;23(2):207–218. doi: 10.1037/0278-6133.23.2.207.
    1. Willaing I, Rogvi SA, Bogelund M, Almdal T, Schiotz M. Recall of HbA1c and self-management behaviours, patient activation, perception of care and diabetes distress in Type 2 diabetes. Diabet Med. 2013;30(4):e139–e142. doi: 10.1111/dme.12121.
    1. Zeh P, Sandhu HK, Cannaby AM, Sturt JA. The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review. Diabet Med. 2012;29(10):1237–1252. doi: 10.1111/j.1464-5491.2012.03701.x.
    1. Chan AW, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, et al. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ. 2013;346 doi: 10.1136/bmj.e7586.
    1. Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P. Methods and processes of the CONSORT Group: example of an extension for trials assessing nonpharmacologic treatments. Ann Intern Med. 2008;148(4):W60–W66.
    1. Ministry of Health Malaysia . Clinical Practice Guidelines. Management of Type 2 Diabetes Mellitus. 5. Putrajaya: Technology, Health Section, Assessment Division, Medical Development; 2015.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ. 2007;334(7591):455–459. doi: 10.1136/.
    1. Wallace AS, Seligman HK, Davis TC, Schillinger D, Arnold CL, Bryant-Shilliday B, Freburger JK, DeWalt DA. Literacy-appropriate educational materials and brief counseling improve diabetes self-management. Patient Educ Couns. 2009;75:328–333. doi: 10.1016/j.pec.2008.12.017.
    1. Reuben E, Sapienza P, Zingales L. Can We Teach Emotional Intelligence? Columbia Business School Research Paper. 2009. . Accessed 28 Mar 2017
    1. Lewis FM, Zahlis EH. The nurse as coach: a conceptual framework for clinical practice. Oncol Nurs Forum. 1997;24(10):1695–1702.
    1. Hayes E, McCahon C, Panahi MR, Hamre T, Pohlman K. Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes. J Am Acad Nurse Pract. 2008;20(3):155–162. doi: 10.1111/j.1745-7599.2007.00297.x.
    1. Russell SS. An overview of adult-learning processes. Urol Nurs. 2006;26(5):349–352.
    1. Collins J. Education techniques for lifelong learning: principles of adult learning. Radiographics. 2004;24(5):1483–1489. doi: 10.1148/rg.245045020.
    1. World Health Organization Consultation . Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus. Geneva: World Health Organization; 1999.
    1. American Diabetes Association Standards of Medical Care in Diabetes—2017. Diabetes Care. 2017;40(1):S1–S135.
    1. Ramli AS, Selvarajah S, Daud MH, Haniff J, Abdul-Razak S, Tg-Abu-Bakar-Sidik TM, et al. Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial. BMC Fam Pract. 2016;17(1):157. doi: 10.1186/s12875-016-0557-1.
    1. Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ. Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol. 2004;57(8):785–794. doi: 10.1016/j.jclinepi.2003.12.013.
    1. Borrelli B, Sepinwall D, Ernst D, Bellg AJ, Czajkowski S, Breger R, et al. A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J Consult Clin Psychol. 2005;73(5):852–860. doi: 10.1037/0022-006X.73.5.852.
    1. Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443–451. doi: 10.1037/0278-6133.23.5.443.
    1. Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful?: establishing cut points for the Diabetes Distress Scale. Diabetes Care. 2012;35(2):259–264. doi: 10.2337/dc11-1572.
    1. Broadbent E, Petrie KJ, Main J, Weinman J. The brief illness perception questionnaire. J Psychosom Res. 2006;60(6):631–637. doi: 10.1016/j.jpsychores.2005.10.020.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi: 10.1046/j.1525-1497.2001.016009606.x.
    1. Sherina MS, Arroll B, Goodyear-Smith F. Criterion validity of the PHQ-9 (Malay version) in a primary care clinic in Malaysia. Med J Malaysia. 2012;67(3):309–315.
    1. Skevington SM, Lotfy M, O’Connell KA. The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004;13(2):299–310. doi: 10.1023/B:QURE.0000018486.91360.00.
    1. The WHOQOL Group Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28(3):551–558. doi: 10.1017/S0033291798006667.
    1. Bijl JV, Poelgeest-Eeltink AV, Shortridge-Baggett L. The psychometric properties of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus. J Adv Nurs. 1999;30(2):352–359. doi: 10.1046/j.1365-2648.1999.01077.x.
    1. Sharoni SK, Wu SF. Self-efficacy and self-care behavior of Malaysian patients with type 2 diabetes: a cross sectional survey. Nurs Health Sci. 2012;14(1):38–45. doi: 10.1111/j.1442-2018.2011.00658.x.
    1. Vivienne Wu SF, Courtney M, Edwards H, McDowell J, Shortridge-Baggett LM, Chang PJ. Development and validation of the Chinese version of the Diabetes Management Self-efficacy Scale. Int J Nurs Stud. 2008;45(4):534–542. doi: 10.1016/j.ijnurstu.2006.08.020.
    1. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23(7):943–950. doi: 10.2337/diacare.23.7.943.
    1. Yin X, Savage C, Toobert D, Wei P, Whitmer K. Adaptation and testing of instruments to measure diabetes self-management in people with type 2 diabetes in mainland China. J Transcult Nurs. 2008;19(3):234–242. doi: 10.1177/1043659608319239.
    1. Radloff LS. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977;1(3):385–401. doi: 10.1177/014662167700100306.

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