Cross-national comparison of psychosocial well-being and diabetes outcomes in adults with type 1 diabetes during the COVID-19 pandemic in US, Brazil, and Iran

BACKGROUND

The COVID-19 pandemic is a global public health emergency, which presents wide-ranging negative impacts on individuals with diabetes. To examine psychosocial well-being and diabetes outcomes in individuals with type 1 diabetes during the COVID-19 pandemic, and investigate how these factors vary in different countries.

METHODS

Between April and June 2020 we employed a cross national comparative research study in the United States (US), Brazil, and Iran to collect data from 1788 adults with type 1 diabetes using web-based survey. Study participants answered questions relevant to diabetes distress, diabetes burnout, depressive symptoms, COVID-19 related changes, and socio-demographic characteristics. They also reported their last Hemoglobin A1c (HbA1c) and daily Time-in-Range (TiR) blood glucose. We analyzed data using comparative tests (Chi-square, Kruskal-Wallis and McNemar test), logistic and linear regression adjusted for fixed effects.

RESULTS

There were significant changes prior and during the pandemic regarding access to diabetes care, diabetes supplies and medications, healthy food and safe places to exercise in all countries (p < 0.05). Participants in Iran experienced higher levels of diabetes distress (57.1%), diabetes burnout (50%), and depressive symptoms (60.9%), followed by Brazil and US (p < 0.0001). US participants reported better glycemic control (HbA1c = 6.97%, T1R = 69.64%) compared to Brazil (HbA1c = 7.94%, T1R = 51.95%) and Iran (HbA1c = 7.47%, T1R = 51.53%) (p < 0.0001). There were also significant relationships between psychosocial well-being, diabetes outcomes, socio-demographic data, and COVID-19 related challenges in overall sample (p < 0.05).

CONCLUSIONS

Regardless of differences among US, Brazil, and Iran, our findings revealed that different countries may experience similar challenges related to the COVID-19 pandemic which can impact negatively diabetes outcomes and psychosocial well-being in individuals with type 1 diabetes. Countries need to consider modifiable variables associated with poor diabetes outcomes and sub optimal psychosocial well-being and target vulnerable population using significant socio-demographic variables.

Development and validation of a scale to measure diabetes burnout

Introduction

The aim of this study is to establish reliability and validity of the Diabetes Burnout Scale (DBS) among adults with type 1 diabetes (T1D).

Methods

We used a multi-stage, mixed methods approach to developing the DBS. First, the research team identified twenty-eight candidate items through a review of the literature and 117 qualitative narratives from adults living with T1D. Next, items were revised based on the expert (n = 20) and individual with T1D (n = 10) feedback. The resulting 18-item DBS measure along with validated measures of diabetes distress, depressive symptoms, and questions related to diabetes outcomes (i.e., last reported hemoglobin A1c [HbA1c] and Time-in-Range [TiR]) were completed by 1099 adults with T1D across the U.S. The sample was randomly divided into two subsets (n1 = 561, n2 = 538) for exploratory and confirmatory factor analyses (EFA/CFA) to determine the underlying structure of the DBS. Regression analyses examined the relationships of the DBS with self-reported glycemic control and socio-demographic characteristics.

Results

Based on the EFA three factors are identified and the DBS demonstrated strong internal consistency with Cronbach alphas (≥0.80). The validation and confirmatory analysis for the structure of the DBS provided consistent results with EFA. Higher burnout (overall DBS) was positively associated with diabetes distress (b = 0.74; p < 0.01) and depressive symptoms (b = 0.61; p < 0.01). Overall DBS, however was the strongest predictor for poorer HbA1c (r2 = 0.19; p < 0.01) and lower TiR (r2 = 0.17; p < 0.01) compared to diabetes distress and depressive symptoms.

Conclusion

The 12-item DBS is a reliable and valid scale to measure diabetes burnout in adults with diabetes. The results provide a weak to strong degree of association between the validated DBS scale, T1-DDS and PHQ-8. The DBS can contribute to advancement of diabetes science by measuring diabetes burnout and informing clinical interventions to improve psychosocial care in individuals with diabetes.

New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study

AIMS

This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D).

METHODS

A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation.

RESULTS

Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms.

CONCLUSIONS

Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.

Burnout, distress, and depressive symptoms in adults with type 1 diabetes

INTRODUCTION

We identified established scales and subscales related to the hypostatized dimensions of diabetes burnout (exhaustion, detachment, powerlessness) emerging from our preliminary qualitative studies, and examined the relationship of diabetes burnout with diabetes distress, depressive symptoms, and diabetes outcomes.

METHODS

In this cross-sectional study, adults with type 1 diabetes (n = 111) completed an online survey including measures of diabetes distress, depressive symptoms, and proposed measures of diabetes burnout. Participants also answered questions related to diabetes outcomes (i.e., last reported HbA1c, missed appointments) as well as other clinical and sociodemographic characteristics. Items related to diabetes burnout were identified and analyzed in an exploratory factor analysis (EFA). The items retained through the EFA were then used in a series of regression analyses to estimate the relationships of the diabetes burnout measure with participants' background characteristics, diabetes distress, depressive symptoms, and diabetes outcomes.

RESULTS

The EFA provided mixed results. The proposed measures of powerlessness were consistent with the original hypothesis. However, the identified measures of exhaustion and detachment did not load onto the anticipated factors. After revising the subscales based on the results of the factor analysis, the measures of diabetes burnout demonstrated strong internal consistency with Cronbach alphas (all subscales and total scale ≥0.85). Diabetes burnout was significantly associated with both depression (es = 0.70; p < .01) and diabetes distress (es = 0.80; p < .01). While measures of diabetes burnout, distress, and depressive symptoms were significant predictors of multiple diabetes outcomes, overall diabetes burnout was no longer significantly related to these outcomes after controlling for diabetes distress and depressive symptoms.

CONCLUSION

The results of the study provide a first step toward identifying a reliable, valid measure of diabetes burnout. Further research is needed to identify additional items to supplement/replace existing measures and to further differentiate diabetes burnout from diabetes distress and depressive symptoms.