Correlates of psychological outcomes among family members of people with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study

Family involvement and diabetes distress across dyads for adults with type 2 diabetes

OBJECTIVE

Family/friend involvement and diabetes distress are associated with outcomes for persons with type 2 diabetes (PWDs), but little is known about how they relate to each other. We aim to (1) describe associations between PWD and support person (SP) distress; (2) describe associations between involvement and diabetes distress for PWDs, for SPs, and across the dyad; and (3) explore whether associations differ by PWD-SP cohabitation.

METHODS

PWDs and SPs co-enrolled in a study evaluating the effects of a self-care support intervention and completed self-report measures at baseline.

RESULTS

PWDs and SPs (N = 297 dyads) were, on average, in their mid-50s and around one-third identified as racial or ethnic minorities. The association between PWD and SP diabetes distress was small (Spearman's ρ = 0.25, p < 0.01). For PWDs, experienced harmful involvement from family/friends was associated with more diabetes distress (standardized β = 0.23, p < 0.001) independent of helpful involvement in adjusted models. Separately, SPs' self-reported harmful involvement was associated with their own diabetes distress (standardized β = 0.35, p < 0.001) and with PWDs' diabetes distress (standardized β = 0.25, p = 0.002), independent of SPs' self-reported helpful involvement.

CONCLUSION AND PRACTICE IMPLICATIONS

Findings suggest dyadic interventions may need to address both SP harmful involvement and SP diabetes distress, in addition to PWD distress.

The beneficial effect of a comprehensive diabetes care model on high-risk relatives accompanying patients with type 2 diabetes

AIMS

Assess the effect of a diabetes program on lifestyle, metabolic, and mental health parameters in relatives of patients with T2D, and correlate changes between relatives and patients.

METHODS

Relatives were included in a structured program for patients with T2D. They received individualized interventions or were asked to follow lifestyle modifications indicated to their patient with diabetes. Outcomes were change in BMI, fat loss, patients achieving LDL-c and triglycerides goals, exercise, and mental health indicators at three and twelve months.

RESULTS

We included 200 relatives. Obesity was present in 42 %, hypertension in 8.5 %, hypercholesterolemia in 29.5 %, and hypertriglyceridemia in 46 % of relatives. Relatives lost - 3.7 kg and - 3.0 kg of body fat at three months and one-year evaluations. At least 60 % achieved normal triglycerides and LDL-c, and 40 % exercised at least 150 min/week. Anxiety symptoms dropped from 37 % to 22 % (p = 0.001), and depressive symptoms from 22 % to 12.9 % (p = 0.01) at three months. Correlations were found between the changes in relatives and patients in weight at three months (r = 0.22, p = 0.001), one year (r = 0.3, p < 0.001), and the number of goals achieved at one year.

CONCLUSION

Relatives of patients with diabetes attending a multidisciplinary program for T2D benefit in metabolic, lifestyle, and mental health indicators.

Efficacy of DiaLife, an Education Program for Relatives of Adults with Diabetes - A Cluster Randomized Controlled Trial

OBJECTIVE

Diabetes affects the lives of patients and their close relatives. Considering the proven benefit of patient education programs, DiaLife was elaborated as the first German education program addressing the needs of relatives. The objective of this study was to investigate its efficacy.

METHODS

The evaluation was implemented in the form of a cRCT with longitudinal design and waiting list condition.In total, 179 relatives were recruited. Participants' diabetes-related knowledge was defined as the primary outcome. Diabetes-related strains, family interaction and other psychosocial factors were determined as secondary outcomes.

RESULTS

A generalized estimating equation model showed a persistent increase of diabetes-related knowledge in the intervention group compared to the control group regardless of the type of diabetes. Concerning secondary outcomes, mixed linear models showed an improvement for relatives of people with type 2 diabetes who participated in the DiaLife program.

CONCLUSION

This study provides evidence of DiaLife's efficacy regarding a persistent increase of diabetes-related knowledge and a positive effect on psychosocial outcomes in relatives of people with type 2 but not in type 1 diabetes. Adding (an)other psychosocial module(s) might improve their well-being and psychosocial outcomes.

PRACTICE IMPLICATIONS

Diabetes centers should consider implementing an education program for relatives, such as DiaLife, in their curriculum.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register (DRKS00015157; date of registration: 24.08.2018).

The impact of hypoglycaemia on the quality of life of family members of adults with type 1 or type 2 diabetes: A qualitative systematic review

AIM

To summarize and critically appraise the recent qualitative evidence regarding the impact of hypoglycaemia on the quality of life of family members of adults with type 1 or type 2 diabetes.

METHODS

Four databases were searched systematically (MEDLINE, PsycINFO, CINAHL and Cochrane Library), and results were screened for eligibility. Article quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted, coded and analysed using thematic analysis. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Enhancing transparency in reporting of qualitative research (ENTREQ) guidelines.

RESULTS

Eight qualitative studies were included in the final review. The majority of participants were partners or spouses of adults with type 1 diabetes. Thematic synthesis resulted in six analytical themes: 'Hypoglycaemia alters everyday life, reducing freedoms and increasing disruptions', 'Hypoglycaemia has an adverse impact on sleep', 'Hypoglycaemia negatively changes the relationship with the person with diabetes', 'Hypoglycaemia negatively impacts emotional well-being', 'The detection, prevention, and treatment of hypoglycaemia consumes time and energy' and 'Family members have unmet needs for informational and emotional support regarding hypoglycaemia'. Across the six analytical themes, family members described how hypoglycaemia has a severe negative impact on different aspects of their lives, including daily living, personal relationships and emotional well-being.

CONCLUSIONS

Family members experience the impact of hypoglycaemia as a major recurrent challenge in their lives. The unmet needs of family members need further attention in research and clinical practice.

Spouse's Diabetes Status and Incidence of Depression and Anxiety: An 18-Year Prospective Study

OBJECTIVE

We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse's diabetes.

RESEARCH DESIGN AND METHODS

We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999-2017 (n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse's diabetes status overall and by severity of diabetes.

RESULTS

Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes.

CONCLUSIONS

People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse's diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.

The internal realities of individuals with type 2 diabetes-Psychological disposition in self-management behaviour via grounded theory approach

BACKGROUND

A paradigm shift in the disease management of type 2 diabetes is urgently needed to stem the escalating trends seen worldwide. A "glucocentric" approach to diabetes management is no longer considered a viable option. Qualitative strategies have the potential to unearth the internal psychological attributes seen in people living with diabetes that are crucial to the sustenance of self-management behaviour. This study aims to identify and categorize the innate psychological dispositions seen in people with type 2 diabetes in relation to self-management behaviour.

METHODS

We adopted a grounded theory approach to guide in-depth interviews of individuals with type 2 diabetes and healthcare professionals (HCP) at a regional primary care clinic in Malaysia. Twenty-four people with type 2 diabetes and 10 HCPs were recruited into the study to examine the inner narratives about disease management. Two focus group discussions (FGD) were also conducted for data triangulation.

RESULTS

Participants' internal dialogue about the management of their disease is characterized by 2 major processes- 1) positive disposition and 2) negative disposition. Optimism, insight, and awareness are important positive values that influence T2D self-care practices. On the other hand, constructs such as stigma, worries, reservations, and pessimism connote negative dispositions that undermine the motivation to follow through disease management in individuals with type 2 diabetes.

CONCLUSIONS

We identified a contrasting spectrum of both constructive and undesirable behavioural factors that influence the 'internal environment' of people with type 2 diabetes. These results coincide with the constructs presented in other well-established health belief theories that could lead to novel behavioural change interventions. Furthermore, these findings allow the implementation of psychosocial changes that are in line with cultural sensitivities and societal norms seen in a specific community.

Psychosocial adjustment of young offspring in the context of parental type 1 and type 2 diabetes: a systematic review

AIMS

To identify all available research on psychosocial outcomes in young people who have a parent with type 1 or type 2 diabetes.

METHODS

Embase, PsychInfo, Scopus, Web of Science, PubMed and ProQuest Social Sciences databases were searched according to a registered study protocol (PROSPERO CRD42019125301). Quality assessment, data extraction and data synthesis were carried out.

RESULTS

The initial search yielded 11 599 articles, 10 of which met the criteria for this review: six for type 1 diabetes and four for type 2 diabetes. Through thematic analysis, five categories emerged related to offspring psychosocial adjustment: offspring mental health, offspring physical health, offspring personal resources, parental illness characteristics and offspring caregiving. Overall, there were few studies focusing solely on the effects of parental type 1 and type 2 diabetes on young people. From the limited available research, there is weak evidence suggesting both parental types of diabetes can adversely impact young offspring. Illness-related variables were only explored in parental type 1 diabetes studies, while offspring caregiving was only examined in parental type 2 diabetes studies.

CONCLUSIONS

Research on the effects of parental diabetes on young people is scarce; however, there was weak evidence to suggest some young people are at risk of adverse psychosocial impacts. Given the rise in the incidence of diabetes globally, there is a pressing public health need to conduct more rigorously designed studies to ascertain the extent to which young people are at risk of mental and physical health problems and to identify risk and protective factors associated with youth adjustment in the context of parental diabetes.

Life With Migraine: Effects on Relationships, Career, and Finances From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

Objective

To assess the effects of migraine on important life domains and compare differences between respondents with episodic and chronic migraine and between sexes.

Background

Migraine is associated with a substantial personal and societal burden and can also affect the interpersonal dynamics, psychological health and well‐being, and financial stability of the entire family of the person with migraine.

Methods

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study is a prospective, longitudinal, Web‐based survey study undertaken between September 2012 and November 2013 in a systematic U.S. sample of people meeting modified International Classification of Headache Disorders, 3rd edition migraine criteria: 19,891 respondents were invited to complete the Family Burden Module, which assessed the perceived impact of migraine on family relationships and life, career and finances, and overall health. Respondents were stratified by episodic migraine (<15 headache days/month) and chronic migraine (≥15 headache days/month) and sex for comparisons.

Results

A total of 13,064 respondents (episodic migraine: 11,944 [91.4%]; chronic migraine: 1120 [8.6%]) provided valid data. Approximately 16.8% of respondents not currently in a romantic relationship (n = 536 of 3189) and 17.8% of those in a relationship but not living together (n = 236 of 1323) indicated that headaches had contributed to relationship problems. Of those in a relationship and living together (n = 8154), 3.2% reported that they chose not to have children, delayed having children or had fewer children because of migraine (n = 260; episodic migraine: n = 193 of 7446 [2.6%]; chronic migraine: n = 67 of 708 [9.5%]; P < .001). Of individuals responding to career/finance items (n = 13,061/13,036), 32.7% indicated that headaches negatively affected ≥1 career area (n = 4271; episodic migraine: n = 3617 of 11,942 [30.3%]; chronic migraine: n = 654 of 1119 [58.4%]), and 32.1% endorsed worry about long‐term financial security due to migraine (n = 4180; episodic migraine: n = 3539 of 11,920 [29.7%]; chronic migraine: n = 641 of 1116 [57.4%]).

Conclusions

Migraine can negatively affect many important aspects of life including marital, parenting, romantic and family relationships, career/financial achievement and stability, and overall health. Reported burden was consistently greater among those with chronic migraine than among people with episodic migraine; however, few differences were seen between the sexes.

Depression is associated with diabetes status of family members: NHANES (1999-2016)

BACKGROUND

The majority of the studies in this area focus on the psychological impact of having diabetic children or adolescents on parents, while a limited number of studies have investigated the effect of diabetes on the mental health status of family members in the general population. Thus, the aim of the current study is to explore the possible association between mental health disorders (depression, anxiety and panic) and diabetes status of family members among a national sample of adults in the United States.

METHODS

Our analysis included 1,787 and 25,574 participants in the National Health and Nutrition Examination Survey (NHANES) 1999-2004 and 2005-2016, respectively. Diabetes status of family members was self-reported by the participants, and depression was assessed using the Composite International Diagnostic Interview (CIDI) and the Patient Health Questionnaire-9 (PHQ-9) in NHANES (1999-2004) and NHANES (2005-2016), respectively.

RESULTS

With NHANES (1999-2004) participants, logistic regression indicated a marginally significant association between depression and diabetes status of family members after multivariable adjustment (P = 0.07), and trend analysis suggested that participants who had more diabetic family members were at a higher risk of depression (P_trend < 0.01). We further validated these results using data from NHANES (2005-2016), which indicated diabetes status of family members was associated with both clinically relevant depression (PHQ-9 ≥ 10) and clinically significant depression (PHQ-9 ≥ 15) (P < 0.01).

LIMITATIONS

The information about the mental health status of family members and the exact role of participants in caring for diabetic patients was inadequate.

CONCLUSIONS

A positive association between depression and diabetes status of family members was observed in the general population, suggesting that psychological interventions targeting the family members of diabetic patients are worthy of attention.

US Ethnic Group Differences in Family Member Support for People With Diabetes in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Purpose

The purpose of the study was to describe the perceptions of family members (FM) and people with diabetes (PWD) regarding the frequency and helpfulness of FM support for PWD, including differences among US ethnic groups.

Methods

The US 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) substudy was a survey of independent samples of 238 adult FM and 540 adult PWD. Outcome measures included ratings by FM and PWD of the frequency and perceived helpfulness of 7 FM support behaviors and composite scores for frequency and helpfulness.

Results

Ratings of individual FM support behaviors were strongly correlated between FM and PWD but significantly different among behaviors. FM and PWD reported most frequent support for listening, assisting, and doing activities with PWD and reporting PWD was doing poorly least frequently. Both groups reported listening, assisting, and reporting PWD was doing well as most helpful; reporting PWD was doing poorly was least helpful. PWD rated support and helpfulness of most behaviors lower than FM. Composite measures of support frequency and helpfulness were strongly correlated for both FM and PWD. Ethnic minority PWD and FM reported most support behaviors as more frequent and more helpful than non-Hispanic white Americans.

Conclusions

FM more frequently engage in the support behaviors they view as most helpful, but PWD perceive support to be less frequent and less helpful than FM. FM support differs across ethnic groups, with ethnic minorities reporting higher support frequency and helpfulness. Diabetes care providers should consider ethnic group differences in FM support for PWD.

Strain and Satisfaction in Caregivers of Veterans With Type 2 Diabetes

Purpose

The purpose of this study was to identify predictors of informal caregiver strain and satisfaction associated with caring for veterans with type 2 diabetes (T2DM).

Methods

This study is a secondary analysis of data from 2 prior studies of caregiving in the Veterans Health Administration. The original studies used a telephone survey to examine veteran and caregiver (CG) characteristics associated with caregivers’ responses to caregiving. The data reported here include 202 veterans with T2DM and 202 caregivers. Linear regression models were generated alternatively using forward and backward selection of veteran and caregiver characteristics.

Results

Higher caregiver strain was associated with the CG providing activities of daily living assistance, CG receiving less help from friends and relatives and use of unpaid help, CG use of coping strategies, and CG depression scores. Predictors of CG satisfaction included better relationship quality with the veteran and receipt of social support.

Conclusions

The important role of family and friends in supporting patients with T2DM is widely accepted. Clinicians may engage the caregiver when there is inadequate self-care by the patient. However, less attention has been focused on the effect of caregiving on the caregiver. Greater attention needs to be focused on in-depth exploration of family needs to design and test effective interventions to meet these needs.

The role of hypoglycemia in the burden of living with diabetes among adults with diabetes and family members: results from the DAWN2 study in The Netherlands

Background

To examine the relation between self-reported hypoglycemic events, worries about these episodes, and the burden of diabetes in adults with diabetes and family members from The Netherlands.

Methods

As part of the second multinational Diabetes Attitudes, Wishes and Needs (DAWN2) study, 412 Dutch adults with type 1 or type 2 diabetes and 86 family members completed questions about the burden of living with diabetes, the frequency of hypoglycemia, worries about these events, and several demographic and clinical factors. Analyses included hierarchical logistic regression.

Results

In total, 41% of people with diabetes and 56% of family members considered diabetes at least somewhat of a burden. In people with diabetes, diabetes burden was independently associated with self-reported current insulin use (fully adjusted OR = 2.75, 95% CI 1.49–5.10), self-reported frequent non-severe hypoglycemia in the past year (OR = 2.45, 1.25–4.83), self-reported severe hypoglycemia in the past year (OR = 1.91, 1.02–3.58), and being very worried about hypoglycemia at least occasionally (OR = 3.64, 2.18–6.10). For family members, the odds of experiencing living with diabetes as a burden was increased only for participants who were at least occasionally very worried about hypoglycemia (adjusted OR = 5.07, 1.12–23.00).

Conclusions

Approximately half of adults with diabetes and adult family members experienced at least some diabetes burden. In both groups, diabetes burden appeared to be associated with being very worried about hypoglycemia at least occasionally. If these results are replicated, new intervention studies could test new ways of decreasing the traumatic consequences of previous or anticipated hypoglycemic events for people with diabetes and family members.

Evaluation of glycated albumin (GA) and GA/HbA1c ratio for diagnosis of diabetes and glycemic control: A comprehensive review

Diabetes Mellitus (DM) is a group of metabolic diseases characterized by chronic high blood glucose concentrations (hyperglycemia). When it is left untreated or improperly managed, it can lead to acute complications including diabetic ketoacidosis and non-ketotic hyperosmolar coma. In addition, possible long-term complications include impotence, nerve damage, stroke, chronic kidney failure, cardiovascular disease, foot ulcers, and retinopathy. Historically, universal methods to measure glycemic control for the diagnosis of diabetes included fasting plasma glucose level (FPG), 2-h plasma glucose (2HP), and random plasma glucose. However, these measurements did not provide information about glycemic control over a long period of time. To address this problem, there has been a switch in the past decade to diagnosing diabetes and its severity through measurement of blood glycated proteins such as Hemoglobin A1c (HbA1c) and glycated albumin (GA). Diagnosis and evaluation of diabetes using glycated proteins has many advantages including high accuracy of glycemic control over a period of time. Currently, common laboratory methods used to measure glycated proteins are high-performance liquid chromatography (HPLC), immunoassay, and electrophoresis. HbA1c is one of the most important diagnostic factors for diabetes. However, some reports indicate that HbA1c is not a suitable marker to determine glycemic control in all diabetic patients. GA, which is not influenced by changes in the lifespan of erythrocytes, is thought to be a good alternative indicator of glycemic control in diabetic patients. Here, we review the literature that has investigated the suitability of HbA1c, GA and GA:HbA1c as indicators of long-term glycemic control and demonstrate the importance of selecting the appropriate glycated protein based on the patient's health status in order to provide useful and modern point-of-care monitoring and treatment.

Correlates and outcomes of worries about hypoglycemia in family members of adults with diabetes: The second Diabetes Attitudes, Wishes and Needs (DAWN2) study

OBJECTIVE

We examined (a) the demographic and clinical correlates of worries about hypoglycemia in adult family members of adults with diabetes, and (b) the association of these worries with measures of diabetes support.

METHODS

The second multinational Diabetes Attitudes, Wishes and Needs (DAWN2) study cross-sectionally surveyed 2057 family members from 17 countries. Participants completed questions about demographics, diabetes, and psychosocial functioning, including worry about overall and nocturnal hypoglycemia. Analyses included hierarchical ordinal and linear regression.

RESULTS

Eighty-five percent of family members (n=1661) were at least occasionally very worried about the risk of hypoglycemic events overall. Correlates of worries about hypoglycemia included female gender, higher age and lower education in the family member, younger age of the person with diabetes and this person being a parent or another adult (versus spouse or partner), insulin or non-insulin injectable treatment, severe or non-severe hypoglycemia in the past 12months, and family member recognition of hypoglycemia. Elevated worries about hypoglycemia had a significant independent association with increased odds of diabetes-related family arguments and family member frustration in providing helpful support (OR range 1.60-3.72). High levels of worries about hypoglycemia were associated with increased odds of attending diabetes-related health-care visits. Worries about hypoglycemia were not associated with family member involvement in diabetes care. Similar results were found for worries about nocturnal events.

CONCLUSION

Worries about hypoglycemia were common in family members and were associated with suboptimal diabetes support. This issue therefore deserves increased clinician attention.

Correlates of psychological outcomes in people with diabetes: results from the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study

AIMS

To assess country- and individual-level correlates of psychological outcomes, and differences among countries in the associations of individual characteristics with psychological outcomes among adults with diabetes.

METHODS

The second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study assessed self-reported characteristics of people with diabetes in 17 countries, including 1368 adults with Type 1 diabetes and 7228 with Type 2 diabetes. In each country, a sample of 500 adults, stratified by diabetes type and treatment, completed a questionnaire incorporating the validated WHO-5 wellbeing index, the WHOQOL-BREF, and the five-item Problem Areas in Diabetes Scale, as well as the newly developed Diabetes Impact on Life Dimensions that assessed impact ranging from very positive to very negative, with no impact as the midpoint. Multilevel regression analyses identified significant (P < 0.05) independent correlates of psychological outcomes.

RESULTS

There were significant variations in all outcomes across countries before adjustment for individual-level factors; adjustment reduced between-country disparities. Worse psychological outcomes were associated with more complications, incidence of hypoglycaemia, hypoglycaemic medication, perceived burden of diabetes, family conflict and experience of discrimination. Better psychological outcomes were associated with higher self-rated health, greater access to diabetes education and healthcare, and more psychosocial support from others. The associations of many factors with the outcomes were mediated by modifiable factors. The association of all factors with the outcomes varied across (interacted with) countries, highlighting the need for country-specific analyses.

CONCLUSIONS

Improvements in modifiable risk factors (reductions in burden and increases in support) may lead to better psychological outcomes in adults with diabetes.

Correlates of psychological care strategies for people with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study

AIMS

To assess the ways in which healthcare professionals address psychological problems of adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study.

METHODS

Approximately 120 primary care physicians, 80 diabetes specialists and 80 nurses and dietitians providing diabetes care participated in each of 17 countries (N=4785). Multiple regression analyses were used to evaluate independent statistically significant associations of respondent attributes concerning psychological care strategies, including assessment of diabetes impact on the patient's life, assessment of depression, provision of psychological assessment and support, and coordination with mental health professionals.

RESULTS

Psychological care strategies were positively associated with each other but differed by healthcare practice site and discipline; nurses and dietitians were less likely to assess depression than other healthcare professionals, while primary care physicians were less likely to coordinate with mental health specialists or ask patients how diabetes affects their lives. Psychological care was positively associated with healthcare professionals' beliefs that patients need help dealing with emotional issues and that clinical success depends on doing so, and also with level of psychological care training, multidisciplinary team membership and availability of resources for psychological care. There were significant between-country variations in psychological care strategies, before and after adjustment for individual-level factors, and significant country-by-covariate interactions for almost all individual-level factors investigated.

CONCLUSIONS

Improvements in training and resources, recognition and assessment of psychological problems, and increased belief in the efficacy of psychological support may enhance healthcare professionals' efforts to address psychological problems in adults with diabetes.