The Relationship of depression, anxiety, and stress with self-care behaviors in women with gestational diabetes

Introduction

The prevalence and incidence of diabetes continue to increase in most countries without stopping, and it is expected that the number of people with diabetes will reach 300 million by 2025 (1). The World Health Organization has predicted that diabetes will affect about 6.8% of the population in Iran by 2025 (2). Gestational diabetes is defined as varying degrees of carbohydrate intolerance which is first started or diagnosed during pregnancy (3), and its prevalence is increasing worldwide (4). According to the estimation of the World Health Organization, the prevalence of this disease in 2035 will be about 1.5 times higher than that in 2000 (5).

In a review study conducted by Khoshniyat et al. (2008), the prevalence of diabetes was estimated at 4.4% among risk-free females in Tehran, Iran (6). Factors contributing to insulin resistance before pregnancy seem to be more damaging during pregnancy and are among the risk factors for gestational diabetes (7). About 70% of gestational diabetes cases are without clinical symptoms (8, 9). Complications of gestational diabetes include increased incidence of polyhydramnios and preeclampsia, need for labor induction and cesarean section (10, 11), shoulder dystocia, hypoglycemia, neonatal jaundice, and hyper bilirubinemia(10). Born children are also susceptible to future obesity and diabetes (12). Approximately, 20% of the patients also maintain glucose tolerance disorder in the postpartum period (13).

These issues confirm the necessity of providing appropriate therapeutic facilities for the more optimal control of diabetes mellitus, which also has psychological benefits for the patient (1). In females with gestational diabetes mellitus (GDM), nutrition therapy and low carbohydrate-controlled diet are the main intervention strategies in order to control blood glucose levels and reduce complications of this disease (14). In this regard, walking is also recommended at least three times a week for 30 min (14). In a systematic review conducted by Tobias et al. (2011) in the United States, it was shown that the risk of gestational diabetes in women with high physical activity was 24% lower than that in women with low physical activity (15). Furthermore, the results of the study performed by Chasan et al. (2008) in the United States indicated that the physical activity even to a lesser extent than that given in the current guidelines may be associated with a reduced risk of gestational diabetes in American women (16).

Females with severe hyperglycemia and those who cannot regulate their blood sugar by diet and physical activity need insulin to control their blood sugar (17, 18). The American Diabetes Association recommends self-monitoring of blood sugar three or more times a day in diabetic pregnant women who use insulin (19, 20).

Finally, success in the treatment of diabetes depends on the individuals' ability to adopt effective self-care behaviors, such as adherence to medication, diet, exercise, and self-monitoring glycemia (21). One of the most comprehensive theories of self-care is Orem's self-care theory (22). In this theory, self-care is considered as a regulative function of human species; moreover, it is required for providing necessary equipment in order to sustain life and maintain its physical and mental performance and development of the individual within the natural and appropriate limits for life and comprehensiveness (23). Support for self-care includes improved health and quality of life, increased patient satisfaction, rational use of services, and reduced health costs (24). A study conducted by Heisler et al. (2002) in the United States indicated that adherence to self-care programs reduced the incidence of diabetes complications by more than 50% (25). The results of the studies carried out by Glasgow et al. (1997) in the United States and Northam et al. (2006) in Australia have shown that self-care promotion is associated with improved metabolic control, self-efficacy, and better control of blood sugar in diabetic patients (26, 27).

On the other hand, psychological factors appear to be involved in controlling the disease (28). In a study conducted by Peyrot et al. (1997) on 578 diabetic outpatients, diabetes was found to be associated with an increased risk of psychological disorders and symptoms (29). Dietary restrictions, drug treatment, blood glucose control, poor clinical outcomes, economic decline caused by illness, and inadequate compatibility styles are the causes of depression in diabetics (30). Depression is the fourth leading cause of disability in the world and is predicted to become the second leading cause of disability by 2020 (31). Lee Rowe et al. (2008) and Kogan et al. (2007) reported that type 2 diabetic patients suffered from high levels of depression (32, 33). The first symptom of depression is a decrease in motivation and interest followed by a decrease in activity, efficiency, life expectancy, and self-care, as well as a tendency to die (34). Depression is undiagnosed and untreated in two-thirds of diabetic patients (30). Prenatal depression is an important and significant issue that affects 12-20% of mothers (31). Depression in pregnancy can lead to inattention, lack of prenatal care, lack of self-care, inadequate nutrition, smoking, medication, low birth weight, and preterm delivery (35).

Birami quotes McKay et al. (2011) that depressed and high-stress pregnant women have lower levels of performance than non-depressed women (36). Furthermore, depressed patients with diabetes are likely to be less adherent to drug and dietary treatments, which in turn will lead to poorer glycemic control (28).

Anxiety is another common mental disorder in people with diabetes. Anxiety rates have been reported to be between 7% and 15% in the Iranian population (37), and it is more common in diabetic patients than the general population (38). Studies have shown that the risk of anxiety doubles in those suffering from diabetes (39). Anxiety is defined as a feeling of stressed, anxious, and frightened with common signs and symptoms of sweating, heartthrob, headaches, and restlessness (40). This disorder is one of the most common symptoms in pregnant mothers (41). Babies of stressful and anxious mothers are at an increased risk of restlessness and low birth weight (42). On the other hand, insulin therapy is an invasive procedure that requires daily repetition and is difficult to follow (43). Anxiety induced by injection is the first psychological barrier to adherence to daily insulin injection in patients with diabetes (44). Evidence suggests that improving psychological conditions can lead to positive therapeutic outcomes (28).

On the other hand, psychological factors are potentially a mediator for the relationship between stress and diabetes control, especially in the youth community (45). Stress is the adverse reaction of individuals to severe pressures or other types of cases that are imposed on them (46). Moreover, it is the most prominent symptom in the clinical behaviors and symptoms of pregnant women. Pregnancy stress can have consequences for the fetus, including low birth weight, preterm labor (41), mental retardation at the age of two (36), delay in walking and speaking, sleep and emotional disturbances, and motor disorders (47). Stress can indirectly affect blood sugar levels by intensifying behavioral changes and patients' non-adherence to health-care regimes (48).

Undoubtedly, the diagnosis of diabetes is a major source of stress for the family and may change the family's normal life course. These changes begin shortly after diagnosis. Therefore, by identifying the level of anxiety, interventions can be made to reduce anxiety and prevent its associated consequences (44). There is a dearth of research investigating gestational diabetes during pregnancy (49); moreover, a limited number of studies have been conducted in this regard in Iran. Therefore, the present study aimed to determine the relationship of depression, anxiety, and stress with self-care among women with gestational diabetes who referred to the midwifery clinics and public hospitals (i.e., Omolbanin, Imam Reza, and Ghaem) affiliated to Mashhad University of Medical Sciences, Mashhad, Iran, in 2015.

Materials and Methods

This descriptive-predictive correlational study was performed on 400 females with gestational diabetes in Mashhad, Iran, from June to November 2015. The study population consisted of all women with gestational diabetes who were admitted to the healthcare centers and midwifery clinics of public hospitals (i.e., Omolbanin, Imam Reza, and Ghaem) affiliated to Mashhad University of Medical Sciences, Mashhad, Iran. A multistage sampling method was utilized to perform the sampling. Initially, all centers in Mashhad were selected through a stratified sampling method and a number of centers under categories (proportional to all centers covered by each center) were randomly selected as cluster. Subsequently, a number of health centers were selected for sampling from each cluster through sortition according to the covered population (proportional to size).

The participants were selected from those who referred to the clinics and health centers. A total of 15 health centers were selected. The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (IR.MUMS.REC.1394.137). It should be noted that all participants were informed of the research objectives and procedures, and written informed consent was obtained from them.

The sample size was obtained at 398 people based on the results of a preliminary study on 30 females with gestational diabetes with a 95% confidence level and 80% test power. Accordingly, 418 people were included in the study considering the sample attrition. The inclusion criteria were: 1) Iranian nationality, 2) residency in Mashhad, 3) minimum level of education (i.e., fifth grade at elementary school), 4) singleton pregnancy, 5) gestational diabetes diagnosed by a physician based on an oral glucose tolerance test, 6) elapsed time of at least a week since diagnosis because self-care questionnaire measures self-care activities for the past seven days, 7) lack of speech and hearing disorders that prevent communication with the researcher, 8) lack of drug addiction, 9) no record or current medical or mental illnesses, 10) no occurrence of stressful accidents during six months prior to the study and during the study, 11) no record of infertility, 12) no history of abnormal newborn or fetus, 13) lack of education in medical sciences, and 14) access to telephone to make or receive telephone calls.

On the other hand, the females who terminated their pregnancy before the completion of follow-up and hospitalization were excluded from the study. The data were collected using demographic characteristics forms, midwifery questionnaires, and a self-care questionnaire obtained from the Summary of Diabetes Self-Care Activities (SDSCA) developed by Toobert and Glasgow (50), as well as Depression, Anxiety, and Stress Scale (DASS-21) (51).

The self-care questionnaire is a 14-item short self-report instrument measuring the dietary self-care activities (n=6), physical activity (n=2), blood glucose level monitoring (n=3), insulin injections (n=1), oral medication (n=1), and smoking (n=1) of the patients during the past 7 days. The participants were asked to report their self-care behaviors related to diabetes, except smoking, on a continuum from 0 (i.e., I did not do it at all in the last week) to 7 (I did it every day in the last week). In addition, the question related to smoking was given a score of either 0 (i.e., smoking) or 1 (i.e., not smoking). Considering the fact that merely diet, physical activity, implementation of blood glucose levels monitoring, insulin injections or metformin consumption, or any of these cases together were recommended to the individuals, they responded to the questionnaire based on the type of treatment.

Since the individuals were subjected to different treatments, there were variations in the number of answered questions and their scores. For homogenization of the total score of the questionnaire, the total score of each individual from the questionnaire was divided by the number of questions answered, and the final score of self-care was determined on the basis of 0-6.57.

The DASS-21 has been introduced by Lovibond and Lovibond (1995) in the form of a 21-item scale measuring depression (questions 21, 17, 16, 13, 10, 5, and 3), anxiety (questions 20, 19, 15, 9, 7, 4, and 2), and stress (questions 18, 14, 12, 11, 8, 6, and 1). The scoring is based on a 4-point Likert scale from 0 (none) to 3 (very high). Moreover, depression, anxiety, and stress scores range from 0 to 21. Therefore, the scores of 5-6, 4-5, 8-9 indicate mild depression, anxiety, and stress. The scores of 7-10, 6-7, and 10-12 signify moderate depression, anxiety, and stress. In addition, severe depression, anxiety, and stress are denoted by the scores of 11-13, 8-9, and 13-16, respectively. Moreover, the scores equal to 14 or greater, 10 or greater, and 17 or greater present extremely severe depression, anxiety, and stress, respectively.

The self-care questionnaire and DASS-21 obtained good content validity. Furthermore, Mollahadi (2010) and Mahmoudi (2010) confirmed the validity of DASS-21 in Iran (52, 53). Additionally, the reliability of the DASS-21 and self-care questionnaire were obtained through Cronbach's alpha coefficient at α=0.70 and α=0.83, respectively. Furthermore, the reliability coefficients of the depression, anxiety, and stress were estimated at α=0.66, α=0.62, and α=0.61, respectively.

At the beginning of the study, people who were eligible based on the inclusion and exclusion criteria were requested to complete the demographic form, self-care questionnaire, and DASS-21 in 30 min. The self-care questionnaire was completed three times. After the completion of the first version, two versions of the self-care questionnaires were given to the participants to complete at the end of each week during the next 2 weeks. At the end of 2 weeks, they were asked to refer to the health center or clinic to deliver them. One or two days before the visit, a phone call was made as a reminder. The final score obtained from the self-care questionnaire was the mean of these three measurements. After a 2-week follow-up, fasting blood glucose and 2 h postprandial glucose level were also recorded. The data were analyzed using SPSS software (version 22) through the Spearman correlation coefficient and multiple linear regression. A P-value less than 0.05 was considered statistically significant.

Results

In total, 18 participants were excluded from the study due to not delivering the questionnaires after follow-up (n=12), pregnancy termination before the end of the follow-up (n=1), hospitalization (n=3), and unwillingness to continue the study (n=2). Accordingly, the final analysis was performed on 400 individuals.

The mean age of the participants was 31.34±5.6 years, and the mean body mass index was 27.59±4.8 kg/m². In addition, 159 (39.8%) cases had high school degrees, and 363 (90.8%) females with GDM were housewives. Regarding the socioeconomic status, 224 (56%) participants were included in the average socioeconomic status group. Moreover, 331 participants (82.8%) had wanted pregnancies, and 85 ones (21.2%) had a history of gestational diabetes. All 400 participants (100%) were under recommended diet, physical activity, and blood glucose levels monitoring; in addition, 124 (31%) and 11 (2.75%) individuals were asked to use insulin and metformin, respectively. Furthermore, 11 (2.75%) females were recommended to use metformin and insulin. Totally, 371(92.8%) participants were interested in learning self-care activities (Table 1).

The mean±SD values of depression, anxiety, stress, and self-care were obtained at 4.62±3.8, 5.19±3.7, 6.56±4.2, and 3.99±0.8, respectively. Table 2 tabulates the frequency distribution of females with gestational diabetes in terms of severity of depression, anxiety, and stress (Table 2).

 Moreover, the mean±SD values of fasting blood glucose and 2 h postprandial glucose at the beginning of the study and after 2 weeks are shown in Table 3 (Table 3).

Spearman test results showed no significant linear relationship of depression, anxiety, and stress with self-care (Table4).

   Finally, depression, anxiety, and stress as independent variables and self-care as a dependent variable were entered into the multiple linear regression model. The results showed that none of the variables (i.e., depression, anxiety, and stress) obtained a significant level less than 0.05; therefore, they were not considered as predictors of self-care (Table 5).

    Meanwhile, there was no significant linear relationship between self-care and fasting blood glucose level after a 2-week follow-up (P=0.373, r=0.04); however, after a 2-week follow-up, a significant linear relationship was observed between self-care and 2 h postprandial glucose level (P=0.016, r=0.12).

   It should be noted that the simultaneous effects of intervening variables were investigated on the relationship of depression, anxiety, and stress with self-care using a multiple regression model in this study. According to the results, there were significant multiple correlations between the studied variables and self-care, except for occupation (i.e., employed) that was removed from the regression model (R=0.212, P=0.040, F=1.520, df=12). However, out of variables in the regression model, age (P=0.024, β=0.019) and a history of gestational diabetes (P=0.042, β=0.223) correlated separately and significantly with self-care (Table 6).