Adherence to Treatment and Psychological States of Patients with Type 2 Diabetes

Adherence to Treatment and Psychological States of Patients with Type 2 Diabetes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adherence to Treatment and Psychological States of Patients with Type 2 Diabetes Özge Kısaoğlu, Meral Kelleci This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8575733/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Diabetes mellitus exerts a broad impact on individuals, influencing not only physical health but also behavioral patterns and interpersonal relationships. These physiological and behavioral disruptions may lead to psychological consequences, such as increased emotional distress. This descriptive and cross-sectional study aimed to examine the association between psychological state and adherence to treatment using both subjective and objective indicators. The study was conducted with 753 patients attending a diabetes outpatient clinic in XX. Data were collected using Patient Information Form, the Type 2 Diabetes Mellitus Treatment Adherence Scale, the General Health Questionnaire-12, and recent HbA1c values. Group comparisons were performed using the Mann–Whitney U test and Kruskal–Wallis test with Dunn post hoc analysis. Path analysis was conducted to assess the effect of psychological state on treatment adherence and HbA1c levels. Treatment adherence was generally moderate, glycemic control was poor. Although psychological distress had no significant direct effect on treatment adherence, higher GHQ-12 scores were significantly associated with increased HbA1c levels. Women and individuals with comorbidities exhibited higher psychological distress and lower adherence. These findings underscore the necessity of integrating routine psychological screening into diabetes care to support individualized treatment planning and improve glycemic outcomes. Treatment adherence psychological state type 2 diabetes adult Introduction Diabetes mellitus is a chronic condition that places sustained psychological, behavioral, and emotional demands on individuals (Kalra et al., 2018 ). Effective management requires continuous monitoring, medication use, and lifestyle changes to control the condition. In this context, a high level of illness acceptance understood as the cognitive and emotional adaptation to a chronic diagnosis is crucial for sustaining treatment and care (Xu et al., 2024 ). Due to its chronic progression, diabetes requires patients to engage in long-term and multifaceted treatment regimens, encompassing continuous medical and lifestyle management. Individuals with diabetes who understand healthcare recommendations, adjust blood glucose levels or medication, and manage treatments like carbohydrate counting are more likely to engage in these behaviors. Such competencies are linked to higher self-efficacy, which is a psychological construct associated with better treatment adherence. These actions increase the frequency of utilizing healthcare services and strengthen patients' self-confidence. Improved diabetes-related health behaviors also indicate better adherence to disease management (Al Sayah et al., 2013 ; Al-Lawati, 2017 ). In clinical practice, it is crucial for healthcare professionals to determine the treatment adherence and psychological state of individuals with diabetes, as these factors affect both holistic care and the patients' physical and psychological health (Ernawati et al., 2021 ; Chireh et al., 2019 ). Diabetes mellitus (DM) has significant negative effects on all aspects of patients' lives, often creating physical and behavioral limitations, as well as impacting social interaction patterns related to the disease (Chireh et al., 2019 ; Cho et al., 2018 ). These psychosocial stressors may exacerbate emotional burden and hinder effective disease management. Research shows that the risk of individuals in with diabetes is 1.5 to 2 times higher than in the general population (Roy & Lloyd, 2012 ; Zhou et al., 2017 ). Additionally, more than 80% of patients with type 2 diabetes (T2DM) experience depressive and anxiety disorders (Chireh et al., 2019 ; Cho et al., 2018 ; Babenko et al., 2019 ). Previous studies have highlighted that psychological distress, including anxiety and depression, is significantly higher among individuals with type 2 diabetes compared to the general population (Chireh et al., 2019 ; Roy & Lloyd, 2012 ). The burden of diabetes management, coupled with the fear of complications, can contribute to emotional distress, which in turn may affect adherence to treatment (Fisher et al., 2010 ). Importantly, the relationship between psychological state and adherence may be bidirectional and mediated by multiple behavioral and clinical factors (Golden et al., 2008; Rotella & Manucci, 2022). Furthermore, while self-reported adherence measures provide valuable insights, their reliability can sometimes be questioned due to response bias (Koekkoek et al., 2015 ). This study aims to address this limitation by incorporating objective clinical measures such as HbA1c levels to cross-validate self-reported adherence data. This study contributes to the existing literature by exploring the impact of psychological states on treatment adherence and investigating whether self-reported adherence aligns with clinical indicators such as HbA1c levels. The findings of this research can help guide healthcare professionals in identifying high-risk patients and implementing targeted psychological interventions to improve adherence and overall diabetes management (Zu et al., 2024 ). Patients who understand healthcare recommendations and know how to use healthcare services are better at maintaining diabetes-related health behaviors. Therefore, patients' psychological states can have a significant impact on treatment adherence. Given the chronic and burdensome nature of type 2 diabetes, investigating these psychological dimensions is critical for advancing person-centered care. This study was conducted to evaluate how the psychological state of individuals with diabetes affects their adherence to treatment. Study Design and Participants This descriptive and cross-sectional study was conducted with individuals diagnosed with type 2 diabetes at a research hospital's diabetes outpatient clinic in XXX between January 15 and April 15, 2021. The inclusion criteria were: a) voluntary participation, b) age 18 or older, and c) at least one year of documented follow-up with a confirmed diagnosis of type 2 diabetes. An a priori power analysis was conducted using G*Power version 3.1 for multiple linear regression. Assuming a small effect size (f² = 0.02), an alpha level of 0.05, a power of 0.90, and two predictors in the model, the minimum required sample size was approximately 500 participants. The study sample consisted of 753 participants. The data were collected through face-to-face structured interviews conducted by trained researchers in a private setting to ensure confidentiality and data integrity. Data Collection Tools The Patient Information Form The Patient Information Form was developed based on a review of the relevant literature and consisted of 11 questions assessing the sociodemographic and disease-related characteristics of individuals with Type 2 diabetes (Alzahrani et al., 2023 ; Babenko et al., 2019 ; Kalra et al., 2018 ). Information on the HbA1C value was obtained from the latest laboratory result sheet upon the consent of the patient. Adherence was evaluated using both self-reported scores from the scale and HbA1c levels for objective validation. Type 2 Diabetes Mellitus Treatment Adherence Scale : This scale, developed by Demirtaş and Akbayrak ( 2017 ), consists of seven sub-dimensions and 30 items scored on a five-point Likert scale. It includes 13 positive and 17 negative statements. Total scores range from 30 to 150, with lower scores indicating better adherence (30–54: good adherence, 55–125: moderate adherence, 126–150: poor adherence). The original study reported a Cronbach’s alpha of 0.77, and the internal consistency in this study was also high (α = 0.76). In addition to self-reported adherence, objective glycemic control was assessed via participants’ most recent HbA1c values (within the last 3 months). General Health Questionnaire-12 (GHQ-12) Developed by David Goldberg, this scale identifies common psychological disorders through 12 items rated on a four-point Likert scale. Kılıç ( 1996 ) validated the Turkish version. Scores below 2 indicate low psychological distress, scores between 2 and 3 indicate moderate, and scores of 4 or more indicate high distress. The Cronbach’s alpha coefficient for the in this study was 0.92, indicating excellent internal reliability. The scale assesses symptoms such as anxiety, insomnia, social dysfunction, and somatic complaints, making it suitable for detecting general psychological distress beyond depression alone. Data Evaluation The data were analyzed using IBM SPSS V23, and IBM AMOS V24. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to assess normality. Due to non-parametric data distribution, the Mann-Whitney U test, Kruskal-Wallis test, Post hoc Dunn test. The effect of the general health score on treatment adherence and HbA1C values was examined using a path analysis. Quantitative data are presented as mean ± standard deviation and median (minimum–maximum), while categorical variables are shown as frequency and percentage. All analyses were conducted with a 95% confidence interval, and statistical significance was set at p < 0.05. Ethical Considerations The study was approved by the university ethics committee (Date: 09.12.2020; Decision No: 218) and conducted in accordance with the principles of the Declaration of Helsinki. Participants were informed both verbally and in writing about the study’s objectives, procedures, and confidentiality safeguards, and written informed consent was obtained before data collection. Results The study included 753 individuals diagnosed with type 2 diabetes. Among the participants, 51.1% were male, 93.4% were married, 63.2% had completed secondary education, 59.6% received oral and insulin treatment, and 94.7% reported having a moderate economic status. Additionally, 42.9% had comorbid conditions, and 40.8% had diabetes-related complications, and 39.8% had poor treatment compliance. The mean age was 57.79 years (range: 30–85), and the average duration of diabetes was 7.01 years. The mean HbA1c value was 8.94%, indicating poor glycemic control overall. The mean adherence score, based on the Type 2 Diabetes Mellitus Treatment Adherence Scale, was 90.6 (SD = ± 13.2), which falls within the moderate adherence range (55–125). The mean GHQ-12 score was 6.29 (SD = ± 3.4), suggesting a high level of psychological distress across the sample. (Table 1 ) A statistically significant difference in adherence scores was found between women (median = 88.00) and men (median = 92.00), with men demonstrating higher adherence (p < 0.001). Individuals with comorbid conditions also showed lower adherence scores compared to those without (p < 0.001). No statistically significant differences were observed in adherence scores based on age, marital status, education, or economic status. (Table 1 ) Table 1 Comparison of patient adherence scale scores by demographic characteristics n(%) X ± SS Median (Min–Max) Test Statistic p-value Gender Female 368 (48.9) 88.92 ± 7.96 88.00(70.00–117.00) 50695.000 1 < 0.001 Male 385(51.1) 92.20 ± 6.73 92.00(64.00–112.00) Marital Status Married 703(93.4) 90.65 ± 7.53 91.00(64.00–117.00) 19061.000 1 0.317 Single 50 (6.6) 89.78 ± 7.60 90.00(71.00–111.00) Education Level Primary 270(35.9) 91.01 ± 7.78 91.00(71.00–117.00) 4.740 2 0.094 Secondry education 476(63.2) 90.30 ± 7.41 90.00(64.00–112.00) Higher 7 (0.9) 95.00 ± 2.77 95.00(91.00–98.00) Economic Status Good 11 (1.5) 92.18 ± 10.34 93.00(71.00–112.00) 0.417 2 0.812 Moderate 713(94.7) 90.58 ± 7.50 90.00(64.00–117.00) Poor 29 (3.9) 90.31 ± 7.28 91.00(76.00–102.00) Comorbid condition Present 323 (42.9) 91.65 ± 8.71 92.00(64.00–117.00) 79185.000 1 0.001 Absent 430(57.1) 89.80 ± 6.41 90.00(70.00–105.00) Diabetes-related complication status Present 307 (40.8) 90.68 ± 8.16 90.00(64.00–117.00) 67802.500 1 0.822 Absent 446 (59.2) 90.54 ± 7.07 91.00(71.00–106.00) Diabetes-related complications Neuropathy 215 (70) 90.67 ± 8.08 90.00(64.00–117.00) 1.435 2 0.488 Retinopathy 80 (26.1) 90.39 ± 8.13 90.00(70.00–110.00) Nephropathy 12 (3.9) 92.83 ± 10.11 95.50(74.00–109.00) 1 Mann Whitney U testi. 2 Kruskall Wallis H testi. a-b: There is no difference between groups with the same letter Regarding psychological distress, women had significantly higher GHQ-12 scores than men (p < 0.001). Individuals with comorbid conditions and complications had significantly higher GHQ-12 scores. (Table 2 ) Table 2 Comparison of general health questionnaire scores by demographic characteristics Mean ± SD Median (Min–Max) Test Statistic p-value Gender Female 7.73 ± 2.26 7.00(0.00–12.00) 98274.000 1 < 0.001 Male 4.92 ± 4.14 3.00(0.00–12.00) Marital Status Married 6.26 ± 3.66 7.00(0.00–12.00) 16238.000 1 0.366 Single 6.72 ± 3.34 7.00(1.00–12.00) Education Level Primary 6.01 ± 3.78 7.00(0.00–12.00) 2.445 2 0.294 Secondry education 6.44 ± 3.55 7.00(0.00–12.00) Higher 7.00 ± 3.56 9.00(2.00–10.00) Economic Status Good 8.00 ± 4.07 10.00(1.00–12.00) 4.356 2 0.113 Moderate 6.30 ± 3.61 7.00(0.00–12.00) Poor 5.52 ± 3.94 7.00(0.00–12.00) Comorbid condition Present 8.81 ± 2.07 9.00(0.00–12.00) 117278.500 1 < 0.001 Absent 4.40 ± 3.41 4.00(0.00–12.00) Diabetes-related complication status Present 8.15 ± 4.15 10.00(0.00–12.00) 106167.000 1 < 0.001 Absent 5.01 ± 2.55 6.00(0.00–10.00) Diabetes-related complications Neuropathy 8.26 ± 4.03 10.00(0.00–12.00) 0.751 2 0.687 Retinopathy 7.78 ± 4.62 10.00(0.00–12.00) Nephropathy 8.67 ± 2.74 9.50(1.00–11.00) 1 Mann Whitney U testi. 2 Kruskall Wallis H testi. a-c: There is no difference between groups with the same letter. The general health questionnaire had no effect on patient adherence (p = 0.596). The general health questionnaire score had a positive effect on HbA1c, with a one-unit increase in the general health questionnaire score increasing the HbA1c value by 0.029 units (p = 0.002). (Table 3 ) Table 3 Examination of the effect of general health questionnaire scores on treatment adherence and hba1c levels using path analysis β (Standardized) β (Unstandardized) SE Test Statistic p-value R² Treatment Adherence <--- GHQ -0.019 -0.040 0.076 -0.530 0.596 0.000 HbA1c (%) <--- GHQ 0.113 0.029 0.009 3.129 0.002 0.013 β 1 : Standardized beta coefficient. β 2 : Unstandardized beta coefficient Discussion The findings confirmed that women and individuals with comorbid conditions exhibited significantly higher psychological distress and lower adherence to treatment. This pattern is in line with prior findings suggesting that women may report poorer adherence, although results vary depending on measurement instruments and population characteristics. To our knowledge, few studies have used the Type 2 Diabetes Mellitus Treatment Adherence Scale specifically to examine gender differences. Future studies comparing across adherence scales are warranted to validate these differences. This study also showed that comorbid conditions and diabetes-related complications may increase the risk of psychological distress. Although the average adherence scores indicated moderate adherence, the psychological well-being of patients appeared compromised, as reflected in scores. While means reflect the general patient profile, it is important to recognize individual variability in psychological and behavioral responses. Basiri et al. ( 2023 ) noted that psychological issues such as depression and anxiety are common in individuals with diabetes and that these conditions can negatively affect treatment adherence. For instance, Zhou et al. ( 2017 ) demonstrated that elevated HbA1c levels are associated with increased depressive symptoms in individuals with diabetes, reinforcing the importance of glycemic control in mental health outcomes. This interplay may exacerbate difficulties in diabetes management and subsequently impair treatment adherence. Moreover, studies suggest that individuals with poor psychological well-being are more likely to experience difficulties in adhering to their treatment regimens. Koekkoek et al. ( 2015 ) found that undiagnosed psychological distress can contribute to decreased adherence, making it imperative for healthcare providers to incorporate mental health screenings as part of routine diabetes care. The high average HbA1c levels in this study reflect suboptimal diabetes control. Elevated HbA1c levels can increase the long-term risk of complications and reduce quality of life. Assessments using tools such as the General Health Questionnaire-12 (GHQ-12), validated by Kılıç ( 1996 ), can provide important insights into patients’ psychological status. These data can assist clinicians in tailoring individualized treatment plans. The observed positive correlation between GHQ-12 scores and HbA1c values may suggest that psychological distress contributes to poor glycemic outcomes. Further research is needed to explore the underlying mechanisms and determine how general health perceptions influence diabetes outcomes. When comparing scores by demographic characteristics, significant differences were found based on gender, comorbid conditions, and diabetes-related complications. No significant differences were found for marital status, education level, or type of diabetes treatment. These findings are consistent with the literature and suggest that psychosocial vulnerabilities differ by demographic and clinical variables (Alzahrani et al., 2023 ). Erol et al. ( 2018 ) noted that women are more prone to psychological issues, possibly explaining their higher GHQ-12 scores. Both biological and sociocultural factors may underlie these gender-based differences. Some studies also suggest that longer duration of diabetes may adversely affect perceived health and psychological outcomes. Additionally, discrepancies between self-reported adherence and objective indicators such as HbA1c should be addressed. Fisher et al. ( 2010 ) emphasized the need to integrate both types of measures to achieve more accurate assessments of adherence. Given these findings, it is essential to address psychological components in diabetes management. Interventions such as cognitive-behavioral therapy (CBT) and diabetes self-management education (DSME) have been shown to improve both mental health and treatment adherence (Ernawati et al., 2021 ; Al-Lawati, 2017 ). By incorporating psychosocial support into diabetes care plans, healthcare providers can enhance patient outcomes and quality of life (Chireh et al., 2024 ; Lee EH et al., 2017 ). Meneghini et al. ( 2007 ) stated that longer duration of diabetes may increase the risk of complications, which can negatively influence individuals’ perceived health. This reinforces the potential impact of disease duration on general health perception and calls for a multidimensional evaluation approach. Future studies should consider integrating various psychological, behavioral, and clinical factors to offer more robust insights. Overall, these results highlight the importance of providing psychosocial support particularly for high-risk groups—to improve diabetes outcomes. Conclusions The study found that individuals with comorbid conditions and women are at higher risk for psychological issues and generally have lower treatment adherence. No significant differences in treatment adherence or psychological state were found based on age, marital status, education level, or economic status. A weak but statistically significant correlation was observed between HbA1c levels and psychological distress, suggesting that glycemic control may be influenced by mental health factors, though the exact mechanisms require further exploration. In addition, the presence of diabetes-related complications and comorbidities emerged as important risk factors for poor psychological outcomes. These findings highlight the necessity of incorporating psychological assessment into routine diabetes care. By identifying high-risk groups particularly women and individuals with comorbid conditions interventions can be tailored more effectively. Furthermore, the combined use of subjective and objective (e.g., HbA1c) indicators is recommended for a more accurate assessment of patients’ adherence and mental well-being. This multidimensional approach may also help clinicians personalize treatment strategies and prioritize psychosocial support. By addressing psychological factors in diabetes management strategies, healthcare professionals can improve both mental well-being and treatment adherence, ultimately leading to better health outcomes. Gender-specific coping differences, as discussed by Matud ( 2004 ), further underscore the need for personalized psychosocial strategies. Routine incorporation of mental health evaluations and targeted psychological strategies into diabetes care may enhance patient adherence and promote more favorable health trajectories. Declarations Ethical statement The study was approved by the university ethics committee (Approval date: 09 Dec 2020; Approval number: 218). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Funding statement The authors have declared no funding specifically requested for this project. Author Contribution M.K. and Ö.K. conceptualized and designed the study. M.K. conducted data collection and performed the statistical analyses. M.K. and Ö.K. wrote the main manuscript text. Ö.K. critically revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript. References Al-Lawati, J. A. (2017). Diabetes mellitus: A local and global public health emergency. Oman Medical Journal , 32 (3), 177–179. https://doi.org/10.5001/omj.2017.34 Al Sayah, F., Majumdar, S. R., Williams, B., Robertson, S., & Johnson, J. A. (2013). Health literacy and health outcomes in diabetes: A systematic review. Journal of General Internal Medicine , 28 , 444–452. https://doi.org/10.1007/s11606-012-2241-z Alzahrani, O., Fletcher, J. P., & Hitos, K. (2023). Quality of life and mental health measurements among patients with type 2 diabetes mellitus: A systematic review. Health and Quality of Life Outcomes , 21 (1). Article 27. https://doi.org/10.1186/s12955-023-02063-5 Babenko, A. Y., Mosikian, A. A., Lebedev, D. L., Khripko, O. P., & Skorodumova, E. A. (2019). Mental state, psychoemotional status, quality of life and treatment compliance in patients with type 2 diabetes mellitus. Journal of Comparative Effectiveness Research , 8 (2), 113–120. https://doi.org/10.2217/cer-2018-0075 Basiri, R., Seidu, B., & Rudich, M. (2023). Exploring the interrelationships between diabetes, nutrition, anxiety and depression: Implications for treatment and prevention strategies. Nutrients , 15 (19). Article 4226. https://doi.org/10.3390/nu15194226 Chireh, B., Li, M., & D’Arcy, C. (2019). Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. Preventive Medicine Reports , 14 , 100822. https://doi.org/10.1016/j.pmedr.2019.100822 Chireh, B., Essien, S. K., D’Arcy, C., & Li, M. (2024). Severe disability and self-reported depression and anxiety among persons living with type 2 diabetes in Canada. Journal of Affective Disorders Reports , 16 , 100720. https://doi.org/10.1016/j.jadr.2024.100720 Cho, N. H., Shaw, J. E., Karuranga, S., Huang, Y., da Rocha Fernandes, J. D., Ohlrogge, A. W., & Malanda, B. (2018). IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Research and Clinical Practice , 138 , 271–281. Demirtaş, A., & Akbayrak, A. (2017). Development of an assessment scale for treatment compliance in type 2 diabetes mellitus in Turkish population: Psychometric evaluation. International Journal of Nursing Sciences , 4 , 244–252. Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus patients: A systematic literature review. Journal of Public Health Research , 10 (2). Article 2240. https://doi.org/10.4081/jphr.2021.2240 Erol, A., Yazıcı, F., & Toprak, G. (2018). Gender differences in psychological distress and its determinants in diabetes patients: A study from Turkey. Journal of Clinical Psychology in Medical Settings , 25 (3), 299–310. Fisher, L., Glasgow, R. E., Strycker, L. A., Delahanty, L. M., & Polonsky, W. H. (2010). The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes. Diabetes Care , 33 (5), 1034–1036. https://doi.org/10.2337/dc10-0178 Golden, S. H., Lazo, M., & Carnethon, M. (2022). Depression and diabetes: A review of current understanding. Psychological Medicine , 52 (4), 641–650. https://doi.org/10.1017/S0033291720000988 Kalra, S., Jena, B. N., & Yeravdekar, R. (2018). Emotional and psychological needs of people with diabetes. Indian Journal of Endocrinology and Metabolism , 22 (5), 696–704. https://doi.org/10.4103/ijem.IJEM_579_17 Kılıç, C. (1996). Genel sağlık anketi: Geçerlik ve güvenirlik çalışması. Türk Psikiyatri Dergisi , 7 (1), 3–9. Koekkoek, P. S., Biessels, G. J., Kooistra, M., Janssen, J., & Kappelle, L. J. (2015). Undiagnosed cognitive impairment, health status and depressive symptoms in patients with type 2 diabetes. Journal of Diabetes and Its Complications , 29 (8), 1217–1222. https://doi.org/10.1016/j.jdiacomp.2015.07.004 Lee, E. H., Lee, Y. W., & Moon, S. H. (2017). Impact of diabetes literacy on self-management behaviors and health outcomes in patients with type 2 diabetes. Journal of Korean Academy of Nursing , 47 (4), 462–472. Matud, M. P. (2004). Gender differences in stress and coping styles. Journal of Health Psychology , 9 (6), 805–820. https://doi.org/10.1177/1359105304046400 Meneghini, L. F., Liebl, A., & Abrahamson, M. J. (2007). Potential glycemic effects of switching to insulin analogs. Diabetes Technology & Therapeutics , 9 (1), 49–57. Rotella, F., & Mannucci, E. (2022). Depression and diabetes: A review of current understanding. Psychological Medicine , 52 (4), 641–650. Roy, T., & Lloyd, C. E. (2012). Epidemiology of depression and diabetes: A systematic review. Journal of Affective Disorders , 142 (Suppl), S8–S21. https://doi.org/10.1016/S0165-0327(12)70004-6 Xu, Z., Feng, J., Xing, S., Zhang, Y., & Liu, H. (2024). Global trends and spatial drivers of diabetes mellitus mortality, 1990–2019: A systematic geographical analysis. Frontiers in Endocrinology , 15 , 1370489. Xu, Z., Huang, F., & Zhang, X. (2024). Illness perception and psychological adjustment in type 2 diabetes: A structural equation model. Journal of Health Psychology , 29 (1), 49–61. https://doi.org/10.1177/13591053231123567 Zhou, H., Zhu, J., Liu, L., & Li, W. (2017). Depression and its relationship with quality of life in patients with type 2 diabetes mellitus. Journal of Diabetes Research , 2017 . https://doi.org/10.1155/2017/8454305 . Article 8454305. Zu, W., Chen, J., & Liu, H. (2024). Multimodal adherence assessment in type 2 diabetes: A call for objective and subjective integration. Journal of Health Psychology , 29 (2), 101–112. https://doi.org/10.1177/13591053231234567 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8575733","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583857342,"identity":"7ee2a90c-063b-45b2-9ecd-dcc5f897be2a","order_by":0,"name":"Özge Kısaoğlu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJADxgdAgoePFC3MBiAtbKRoYZMAk4SUyUdkp0n+qDksJ9+/+Fjl1xw7GTYG5oePbuDRYngjd5s0z7HDxowznqXdlt2WDHQYm7FxDj4tM4BaGNgOJzZLnDG7LbmNGaiFh02akBbJH/8OJ7ZJnP9WLLmtnrAWeYncbRK8bYcTe/h72Bg/bjtMWIsBz9vN1rx96cYSEmzG0ozbjvOwMRPwi3x77sabP75ZA0Ps8MOPP7dV2/OzNz98jNeWA2CqmYFBIoGBmQfEZsajHGxLA5iqY2DgP8DA+IOA6lEwCkbBKBiZAAAiMkXvPW77mAAAAABJRU5ErkJggg==","orcid":"","institution":"Sivas Cumhuriyet University","correspondingAuthor":true,"prefix":"","firstName":"Özge","middleName":"","lastName":"Kısaoğlu","suffix":""},{"id":583857343,"identity":"0122d665-04fc-4abd-81af-92a87b1f82bf","order_by":1,"name":"Meral Kelleci","email":"","orcid":"","institution":"Sivas Cumhuriyet University","correspondingAuthor":false,"prefix":"","firstName":"Meral","middleName":"","lastName":"Kelleci","suffix":""}],"badges":[],"createdAt":"2026-01-11 21:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8575733/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8575733/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104137459,"identity":"5b165eee-d65b-4177-993f-f1d5ff77aa62","added_by":"auto","created_at":"2026-03-07 15:39:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725501,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8575733/v1/9c8d3964-58b4-4907-9278-7ef100af25b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adherence to Treatment and Psychological States of Patients with Type 2 Diabetes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus is a chronic condition that places sustained psychological, behavioral, and emotional demands on individuals (Kalra et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Effective management requires continuous monitoring, medication use, and lifestyle changes to control the condition. In this context, a high level of illness acceptance understood as the cognitive and emotional adaptation to a chronic diagnosis is crucial for sustaining treatment and care (Xu et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Due to its chronic progression, diabetes requires patients to engage in long-term and multifaceted treatment regimens, encompassing continuous medical and lifestyle management.\u003c/p\u003e \u003cp\u003eIndividuals with diabetes who understand healthcare recommendations, adjust blood glucose levels or medication, and manage treatments like carbohydrate counting are more likely to engage in these behaviors. Such competencies are linked to higher self-efficacy, which is a psychological construct associated with better treatment adherence. These actions increase the frequency of utilizing healthcare services and strengthen patients' self-confidence. Improved diabetes-related health behaviors also indicate better adherence to disease management (Al Sayah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Al-Lawati, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn clinical practice, it is crucial for healthcare professionals to determine the treatment adherence and psychological state of individuals with diabetes, as these factors affect both holistic care and the patients' physical and psychological health (Ernawati et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Chireh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Diabetes mellitus (DM) has significant negative effects on all aspects of patients' lives, often creating physical and behavioral limitations, as well as impacting social interaction patterns related to the disease (Chireh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Cho et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These psychosocial stressors may exacerbate emotional burden and hinder effective disease management.\u003c/p\u003e \u003cp\u003eResearch shows that the risk of individuals in with diabetes is 1.5 to 2 times higher than in the general population (Roy \u0026amp; Lloyd, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additionally, more than 80% of patients with type 2 diabetes (T2DM) experience depressive and anxiety disorders (Chireh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Cho et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Babenko et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Previous studies have highlighted that psychological distress, including anxiety and depression, is significantly higher among individuals with type 2 diabetes compared to the general population (Chireh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Roy \u0026amp; Lloyd, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The burden of diabetes management, coupled with the fear of complications, can contribute to emotional distress, which in turn may affect adherence to treatment (Fisher et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Importantly, the relationship between psychological state and adherence may be bidirectional and mediated by multiple behavioral and clinical factors (Golden et al., 2008; Rotella \u0026amp; Manucci, 2022).\u003c/p\u003e \u003cp\u003eFurthermore, while self-reported adherence measures provide valuable insights, their reliability can sometimes be questioned due to response bias (Koekkoek et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This study aims to address this limitation by incorporating objective clinical measures such as HbA1c levels to cross-validate self-reported adherence data. This study contributes to the existing literature by exploring the impact of psychological states on treatment adherence and investigating whether self-reported adherence aligns with clinical indicators such as HbA1c levels. The findings of this research can help guide healthcare professionals in identifying high-risk patients and implementing targeted psychological interventions to improve adherence and overall diabetes management (Zu et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients who understand healthcare recommendations and know how to use healthcare services are better at maintaining diabetes-related health behaviors. Therefore, patients' psychological states can have a significant impact on treatment adherence. Given the chronic and burdensome nature of type 2 diabetes, investigating these psychological dimensions is critical for advancing person-centered care. This study was conducted to evaluate how the psychological state of individuals with diabetes affects their adherence to treatment.\u003c/p\u003e"},{"header":"Study Design and Participants","content":"\u003cp\u003eThis descriptive and cross-sectional study was conducted with individuals diagnosed with type 2 diabetes at a research hospital's diabetes outpatient clinic in XXX between January 15 and April 15, 2021. The inclusion criteria were: a) voluntary participation, b) age 18 or older, and c) at least one year of documented follow-up with a confirmed diagnosis of type 2 diabetes. An a priori power analysis was conducted using G*Power version 3.1 for multiple linear regression. Assuming a small effect size (f\u0026sup2; = 0.02), an alpha level of 0.05, a power of 0.90, and two predictors in the model, the minimum required sample size was approximately 500 participants. The study sample consisted of 753 participants. The data were collected through face-to-face structured interviews conducted by trained researchers in a private setting to ensure confidentiality and data integrity.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Tools\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eThe Patient Information Form\u003c/strong\u003e \u003cp\u003eThe Patient Information Form was developed based on a review of the relevant literature and consisted of 11 questions assessing the sociodemographic and disease-related characteristics of individuals with Type 2 diabetes (Alzahrani et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Babenko et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Kalra et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Information on the HbA1C value was obtained from the latest laboratory result sheet upon the consent of the patient. Adherence was evaluated using both self-reported scores from the scale and HbA1c levels for objective validation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eType 2 Diabetes Mellitus Treatment Adherence Scale\u003c/em\u003e: This scale, developed by Demirtaş and Akbayrak (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), consists of seven sub-dimensions and 30 items scored on a five-point Likert scale. It includes 13 positive and 17 negative statements. Total scores range from 30 to 150, with lower scores indicating better adherence (30\u0026ndash;54: good adherence, 55\u0026ndash;125: moderate adherence, 126\u0026ndash;150: poor adherence). The original study reported a Cronbach\u0026rsquo;s alpha of 0.77, and the internal consistency in this study was also high (α\u0026thinsp;=\u0026thinsp;0.76). In addition to self-reported adherence, objective glycemic control was assessed via participants\u0026rsquo; most recent HbA1c values (within the last 3 months).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eGeneral Health Questionnaire-12 (GHQ-12)\u003c/strong\u003e \u003cp\u003eDeveloped by David Goldberg, this scale identifies common psychological disorders through 12 items rated on a four-point Likert scale. Kılı\u0026ccedil; (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) validated the Turkish version. Scores below 2 indicate low psychological distress, scores between 2 and 3 indicate moderate, and scores of 4 or more indicate high distress. The Cronbach\u0026rsquo;s alpha coefficient for the in this study was 0.92, indicating excellent internal reliability. The scale assesses symptoms such as anxiety, insomnia, social dysfunction, and somatic complaints, making it suitable for detecting general psychological distress beyond depression alone.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Evaluation\u003c/h3\u003e\n\u003cp\u003eThe data were analyzed using IBM SPSS V23, and IBM AMOS V24. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to assess normality. Due to non-parametric data distribution, the Mann-Whitney U test, Kruskal-Wallis test, Post hoc Dunn test. The effect of the general health score on treatment adherence and HbA1C values was examined using a path analysis. Quantitative data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median (minimum\u0026ndash;maximum), while categorical variables are shown as frequency and percentage. All analyses were conducted with a 95% confidence interval, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was approved by the university ethics committee (Date: 09.12.2020; Decision No: 218) and conducted in accordance with the principles of the Declaration of Helsinki. Participants were informed both verbally and in writing about the study\u0026rsquo;s objectives, procedures, and confidentiality safeguards, and written informed consent was obtained before data collection.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 753 individuals diagnosed with type 2 diabetes. Among the participants, 51.1% were male, 93.4% were married, 63.2% had completed secondary education, 59.6% received oral and insulin treatment, and 94.7% reported having a moderate economic status. Additionally, 42.9% had comorbid conditions, and 40.8% had diabetes-related complications, and 39.8% had poor treatment compliance. The mean age was 57.79 years (range: 30\u0026ndash;85), and the average duration of diabetes was 7.01 years. The mean HbA1c value was 8.94%, indicating poor glycemic control overall. The mean adherence score, based on the Type 2 Diabetes Mellitus Treatment Adherence Scale, was 90.6 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2), which falls within the moderate adherence range (55\u0026ndash;125). The mean GHQ-12 score was 6.29 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4), suggesting a high level of psychological distress across the sample. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA statistically significant difference in adherence scores was found between women (median\u0026thinsp;=\u0026thinsp;88.00) and men (median\u0026thinsp;=\u0026thinsp;92.00), with men demonstrating higher adherence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Individuals with comorbid conditions also showed lower adherence scores compared to those without (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No statistically significant differences were observed in adherence scores based on age, marital status, education, or economic status. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patient adherence scale scores by demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u0026thinsp;\u0026plusmn;\u0026thinsp;SS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian (Min\u0026ndash;Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e368 (48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.92\u0026thinsp;\u0026plusmn;\u0026thinsp;7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.00(70.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e50695.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e385(51.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.00(64.00\u0026ndash;112.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e703(93.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.65\u0026thinsp;\u0026plusmn;\u0026thinsp;7.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.00(64.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19061.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(71.00\u0026ndash;111.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e270(35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.01\u0026thinsp;\u0026plusmn;\u0026thinsp;7.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.00(71.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4.740 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondry\u003c/p\u003e \u003cp\u003eeducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e476(63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(64.00\u0026ndash;112.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.00(91.00\u0026ndash;98.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEconomic Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.18\u0026thinsp;\u0026plusmn;\u0026thinsp;10.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.00(71.00\u0026ndash;112.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.417 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e713(94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.58\u0026thinsp;\u0026plusmn;\u0026thinsp;7.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(64.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.00(76.00\u0026ndash;102.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbid condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e323 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.00(64.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e79185.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e430(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.80\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(70.00\u0026ndash;105.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes-related complication status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e307 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.68\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(64.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e67802.500 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.822\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e446 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.54\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.00(71.00\u0026ndash;106.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes-related complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(64.00\u0026ndash;117.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.435 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetinopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.39\u0026thinsp;\u0026plusmn;\u0026thinsp;8.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.00(70.00\u0026ndash;110.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.83\u0026thinsp;\u0026plusmn;\u0026thinsp;10.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.50(74.00\u0026ndash;109.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e1\u003c/sup\u003eMann Whitney U testi. \u003csup\u003e2\u003c/sup\u003eKruskall Wallis H testi. a-b: There is no difference between groups with the same letter\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding psychological distress, women had significantly higher GHQ-12 scores than men (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Individuals with comorbid conditions and complications had significantly higher GHQ-12 scores. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of general health questionnaire scores by demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (Min\u0026ndash;Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e98274.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e16238.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(1.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2.445 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondry\u003c/p\u003e \u003cp\u003eeducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00(2.00\u0026ndash;10.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEconomic Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00(1.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4.356 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.30\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbid condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e117278.500 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes-related complication status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.15\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e106167.000 \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.00(0.00\u0026ndash;10.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes-related complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.751 \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.687\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetinopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00(0.00\u0026ndash;12.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.50(1.00\u0026ndash;11.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003eMann Whitney U testi. \u003csup\u003e2\u003c/sup\u003eKruskall Wallis H testi. a-c: There is no difference between groups with the same letter.\u003c/p\u003e \u003cp\u003eThe general health questionnaire had no effect on patient adherence (p\u0026thinsp;=\u0026thinsp;0.596). The general health questionnaire score had a positive effect on HbA1c, with a one-unit increase in the general health questionnaire score increasing the HbA1c value by 0.029 units (p\u0026thinsp;=\u0026thinsp;0.002). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamination of the effect of general health questionnaire scores on treatment adherence and hba1c levels using path analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ (Standardized)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ (Unstandardized)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eR\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGHQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGHQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eβ\u003csup\u003e1\u003c/sup\u003e: Standardized beta coefficient. β\u003csup\u003e2\u003c/sup\u003e: Unstandardized beta coefficient\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings confirmed that women and individuals with comorbid conditions exhibited significantly higher psychological distress and lower adherence to treatment. This pattern is in line with prior findings suggesting that women may report poorer adherence, although results vary depending on measurement instruments and population characteristics. To our knowledge, few studies have used the Type 2 Diabetes Mellitus Treatment Adherence Scale specifically to examine gender differences. Future studies comparing across adherence scales are warranted to validate these differences.\u003c/p\u003e \u003cp\u003eThis study also showed that comorbid conditions and diabetes-related complications may increase the risk of psychological distress. Although the average adherence scores indicated moderate adherence, the psychological well-being of patients appeared compromised, as reflected in scores. While means reflect the general patient profile, it is important to recognize individual variability in psychological and behavioral responses. Basiri et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) noted that psychological issues such as depression and anxiety are common in individuals with diabetes and that these conditions can negatively affect treatment adherence. For instance, Zhou et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) demonstrated that elevated HbA1c levels are associated with increased depressive symptoms in individuals with diabetes, reinforcing the importance of glycemic control in mental health outcomes. This interplay may exacerbate difficulties in diabetes management and subsequently impair treatment adherence.\u003c/p\u003e \u003cp\u003eMoreover, studies suggest that individuals with poor psychological well-being are more likely to experience difficulties in adhering to their treatment regimens. Koekkoek et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) found that undiagnosed psychological distress can contribute to decreased adherence, making it imperative for healthcare providers to incorporate mental health screenings as part of routine diabetes care.\u003c/p\u003e \u003cp\u003eThe high average HbA1c levels in this study reflect suboptimal diabetes control. Elevated HbA1c levels can increase the long-term risk of complications and reduce quality of life. Assessments using tools such as the General Health Questionnaire-12 (GHQ-12), validated by Kılı\u0026ccedil; (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1996\u003c/span\u003e), can provide important insights into patients\u0026rsquo; psychological status. These data can assist clinicians in tailoring individualized treatment plans. The observed positive correlation between GHQ-12 scores and HbA1c values may suggest that psychological distress contributes to poor glycemic outcomes. Further research is needed to explore the underlying mechanisms and determine how general health perceptions influence diabetes outcomes.\u003c/p\u003e \u003cp\u003eWhen comparing scores by demographic characteristics, significant differences were found based on gender, comorbid conditions, and diabetes-related complications. No significant differences were found for marital status, education level, or type of diabetes treatment. These findings are consistent with the literature and suggest that psychosocial vulnerabilities differ by demographic and clinical variables (Alzahrani et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Erol et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) noted that women are more prone to psychological issues, possibly explaining their higher GHQ-12 scores. Both biological and sociocultural factors may underlie these gender-based differences. Some studies also suggest that longer duration of diabetes may adversely affect perceived health and psychological outcomes.\u003c/p\u003e \u003cp\u003eAdditionally, discrepancies between self-reported adherence and objective indicators such as HbA1c should be addressed. Fisher et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) emphasized the need to integrate both types of measures to achieve more accurate assessments of adherence.\u003c/p\u003e \u003cp\u003eGiven these findings, it is essential to address psychological components in diabetes management. Interventions such as cognitive-behavioral therapy (CBT) and diabetes self-management education (DSME) have been shown to improve both mental health and treatment adherence (Ernawati et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Al-Lawati, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). By incorporating psychosocial support into diabetes care plans, healthcare providers can enhance patient outcomes and quality of life (Chireh et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Lee EH et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMeneghini et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) stated that longer duration of diabetes may increase the risk of complications, which can negatively influence individuals\u0026rsquo; perceived health. This reinforces the potential impact of disease duration on general health perception and calls for a multidimensional evaluation approach. Future studies should consider integrating various psychological, behavioral, and clinical factors to offer more robust insights. Overall, these results highlight the importance of providing psychosocial support particularly for high-risk groups\u0026mdash;to improve diabetes outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study found that individuals with comorbid conditions and women are at higher risk for psychological issues and generally have lower treatment adherence.\u003c/p\u003e \u003cp\u003eNo significant differences in treatment adherence or psychological state were found based on age, marital status, education level, or economic status.\u003c/p\u003e \u003cp\u003eA weak but statistically significant correlation was observed between HbA1c levels and psychological distress, suggesting that glycemic control may be influenced by mental health factors, though the exact mechanisms require further exploration.\u003c/p\u003e \u003cp\u003eIn addition, the presence of diabetes-related complications and comorbidities emerged as important risk factors for poor psychological outcomes.\u003c/p\u003e \u003cp\u003eThese findings highlight the necessity of incorporating psychological assessment into routine diabetes care. By identifying high-risk groups particularly women and individuals with comorbid conditions interventions can be tailored more effectively.\u003c/p\u003e \u003cp\u003eFurthermore, the combined use of subjective and objective (e.g., HbA1c) indicators is recommended for a more accurate assessment of patients\u0026rsquo; adherence and mental well-being.\u003c/p\u003e \u003cp\u003eThis multidimensional approach may also help clinicians personalize treatment strategies and prioritize psychosocial support. By addressing psychological factors in diabetes management strategies, healthcare professionals can improve both mental well-being and treatment adherence, ultimately leading to better health outcomes. Gender-specific coping differences, as discussed by Matud (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), further underscore the need for personalized psychosocial strategies. Routine incorporation of mental health evaluations and targeted psychological strategies into diabetes care may enhance patient adherence and promote more favorable health trajectories.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical statement\u003c/h2\u003e \u003cp\u003e The study was approved by the university ethics committee (Approval date: 09 Dec 2020; Approval number: 218). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding statement\u003c/h2\u003e \u003cp\u003eThe authors have declared no funding specifically requested for this project.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.K. and \u0026Ouml;.K. conceptualized and designed the study. M.K. conducted data collection and performed the statistical analyses. M.K. and \u0026Ouml;.K. wrote the main manuscript text. \u0026Ouml;.K. critically revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Lawati, J. A. (2017). Diabetes mellitus: A local and global public health emergency. \u003cem\u003eOman Medical Journal\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(3), 177\u0026ndash;179. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5001/omj.2017.34\u003c/span\u003e\u003cspan address=\"10.5001/omj.2017.34\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Sayah, F., Majumdar, S. R., Williams, B., Robertson, S., \u0026amp; Johnson, J. A. (2013). Health literacy and health outcomes in diabetes: A systematic review. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e, 444\u0026ndash;452. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11606-012-2241-z\u003c/span\u003e\u003cspan address=\"10.1007/s11606-012-2241-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlzahrani, O., Fletcher, J. P., \u0026amp; Hitos, K. (2023). Quality of life and mental health measurements among patients with type 2 diabetes mellitus: A systematic review. \u003cem\u003eHealth and Quality of Life Outcomes\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eArticle 27. https://doi.org/10.1186/s12955-023-02063-5\u003c/span\u003e\u003cspan address=\"Article 27. 10.1186/s12955-023-02063-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBabenko, A. Y., Mosikian, A. A., Lebedev, D. L., Khripko, O. P., \u0026amp; Skorodumova, E. A. (2019). Mental state, psychoemotional status, quality of life and treatment compliance in patients with type 2 diabetes mellitus. \u003cem\u003eJournal of Comparative Effectiveness Research\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(2), 113\u0026ndash;120. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2217/cer-2018-0075\u003c/span\u003e\u003cspan address=\"10.2217/cer-2018-0075\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasiri, R., Seidu, B., \u0026amp; Rudich, M. (2023). Exploring the interrelationships between diabetes, nutrition, anxiety and depression: Implications for treatment and prevention strategies. \u003cem\u003eNutrients\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(19). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eArticle 4226. https://doi.org/10.3390/nu15194226\u003c/span\u003e\u003cspan address=\"Article 4226. 10.3390/nu15194226\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChireh, B., Li, M., \u0026amp; D\u0026rsquo;Arcy, C. (2019). Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. \u003cem\u003ePreventive Medicine Reports\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e, 100822. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pmedr.2019.100822\u003c/span\u003e\u003cspan address=\"10.1016/j.pmedr.2019.100822\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChireh, B., Essien, S. K., D\u0026rsquo;Arcy, C., \u0026amp; Li, M. (2024). Severe disability and self-reported depression and anxiety among persons living with type 2 diabetes in Canada. \u003cem\u003eJournal of Affective Disorders Reports\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e, 100720. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jadr.2024.100720\u003c/span\u003e\u003cspan address=\"10.1016/j.jadr.2024.100720\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho, N. H., Shaw, J. E., Karuranga, S., Huang, Y., da Rocha Fernandes, J. D., Ohlrogge, A. W., \u0026amp; Malanda, B. (2018). IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. \u003cem\u003eDiabetes Research and Clinical Practice\u003c/em\u003e, \u003cem\u003e138\u003c/em\u003e, 271\u0026ndash;281.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemirtaş, A., \u0026amp; Akbayrak, A. (2017). Development of an assessment scale for treatment compliance in type 2 diabetes mellitus in Turkish population: Psychometric evaluation. \u003cem\u003eInternational Journal of Nursing Sciences\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e, 244\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErnawati, U., Wihastuti, T. A., \u0026amp; Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus patients: A systematic literature review. \u003cem\u003eJournal of Public Health Research\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eArticle 2240. https://doi.org/10.4081/jphr.2021.2240\u003c/span\u003e\u003cspan address=\"Article 2240. 10.4081/jphr.2021.2240\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErol, A., Yazıcı, F., \u0026amp; Toprak, G. (2018). Gender differences in psychological distress and its determinants in diabetes patients: A study from Turkey. \u003cem\u003eJournal of Clinical Psychology in Medical Settings\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 299\u0026ndash;310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisher, L., Glasgow, R. E., Strycker, L. A., Delahanty, L. M., \u0026amp; Polonsky, W. H. (2010). The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes. \u003cem\u003eDiabetes Care\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(5), 1034\u0026ndash;1036. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2337/dc10-0178\u003c/span\u003e\u003cspan address=\"10.2337/dc10-0178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolden, S. H., Lazo, M., \u0026amp; Carnethon, M. (2022). Depression and diabetes: A review of current understanding. \u003cem\u003ePsychological Medicine\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(4), 641\u0026ndash;650. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291720000988\u003c/span\u003e\u003cspan address=\"10.1017/S0033291720000988\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalra, S., Jena, B. N., \u0026amp; Yeravdekar, R. (2018). Emotional and psychological needs of people with diabetes. \u003cem\u003eIndian Journal of Endocrinology and Metabolism\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(5), 696\u0026ndash;704. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/ijem.IJEM_579_17\u003c/span\u003e\u003cspan address=\"10.4103/ijem.IJEM_579_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKılı\u0026ccedil;, C. (1996). Genel sağlık anketi: Ge\u0026ccedil;erlik ve g\u0026uuml;venirlik \u0026ccedil;alışması. \u003cem\u003eT\u0026uuml;rk Psikiyatri Dergisi\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 3\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoekkoek, P. S., Biessels, G. J., Kooistra, M., Janssen, J., \u0026amp; Kappelle, L. J. (2015). Undiagnosed cognitive impairment, health status and depressive symptoms in patients with type 2 diabetes. \u003cem\u003eJournal of Diabetes and Its Complications\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(8), 1217\u0026ndash;1222. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jdiacomp.2015.07.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jdiacomp.2015.07.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee, E. H., Lee, Y. W., \u0026amp; Moon, S. H. (2017). Impact of diabetes literacy on self-management behaviors and health outcomes in patients with type 2 diabetes. \u003cem\u003eJournal of Korean Academy of Nursing\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(4), 462\u0026ndash;472.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatud, M. P. (2004). Gender differences in stress and coping styles. \u003cem\u003eJournal of Health Psychology\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(6), 805\u0026ndash;820. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1359105304046400\u003c/span\u003e\u003cspan address=\"10.1177/1359105304046400\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeneghini, L. F., Liebl, A., \u0026amp; Abrahamson, M. J. (2007). Potential glycemic effects of switching to insulin analogs. \u003cem\u003eDiabetes Technology \u0026amp; Therapeutics\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(1), 49\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRotella, F., \u0026amp; Mannucci, E. (2022). Depression and diabetes: A review of current understanding. \u003cem\u003ePsychological Medicine\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(4), 641\u0026ndash;650.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoy, T., \u0026amp; Lloyd, C. E. (2012). Epidemiology of depression and diabetes: A systematic review. \u003cem\u003eJournal of Affective Disorders\u003c/em\u003e, \u003cem\u003e142\u003c/em\u003e(Suppl), S8\u0026ndash;S21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0165-0327(12)70004-6\u003c/span\u003e\u003cspan address=\"10.1016/S0165-0327(12)70004-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu, Z., Feng, J., Xing, S., Zhang, Y., \u0026amp; Liu, H. (2024). Global trends and spatial drivers of diabetes mellitus mortality, 1990\u0026ndash;2019: A systematic geographical analysis. \u003cem\u003eFrontiers in Endocrinology\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 1370489.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu, Z., Huang, F., \u0026amp; Zhang, X. (2024). Illness perception and psychological adjustment in type 2 diabetes: A structural equation model. \u003cem\u003eJournal of Health Psychology\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(1), 49\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/13591053231123567\u003c/span\u003e\u003cspan address=\"10.1177/13591053231123567\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, H., Zhu, J., Liu, L., \u0026amp; Li, W. (2017). Depression and its relationship with quality of life in patients with type 2 diabetes mellitus. \u003cem\u003eJournal of Diabetes Research\u003c/em\u003e, \u003cem\u003e2017\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2017/8454305\u003c/span\u003e\u003cspan address=\"10.1155/2017/8454305\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Article 8454305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZu, W., Chen, J., \u0026amp; Liu, H. (2024). Multimodal adherence assessment in type 2 diabetes: A call for objective and subjective integration. \u003cem\u003eJournal of Health Psychology\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(2), 101\u0026ndash;112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/13591053231234567\u003c/span\u003e\u003cspan address=\"10.1177/13591053231234567\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Treatment, adherence, psychological state, type 2 diabetes, adult","lastPublishedDoi":"10.21203/rs.3.rs-8575733/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8575733/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDiabetes mellitus exerts a broad impact on individuals, influencing not only physical health but also behavioral patterns and interpersonal relationships. These physiological and behavioral disruptions may lead to psychological consequences, such as increased emotional distress. This descriptive and cross-sectional study aimed to examine the association between psychological state and adherence to treatment using both subjective and objective indicators. The study was conducted with 753 patients attending a diabetes outpatient clinic in XX. Data were collected using Patient Information Form, the Type 2 Diabetes Mellitus Treatment Adherence Scale, the General Health Questionnaire-12, and recent HbA1c values. Group comparisons were performed using the Mann\u0026ndash;Whitney U test and Kruskal\u0026ndash;Wallis test with Dunn post hoc analysis. Path analysis was conducted to assess the effect of psychological state on treatment adherence and HbA1c levels. Treatment adherence was generally moderate, glycemic control was poor. Although psychological distress had no significant direct effect on treatment adherence, higher GHQ-12 scores were significantly associated with increased HbA1c levels. Women and individuals with comorbidities exhibited higher psychological distress and lower adherence. These findings underscore the necessity of integrating routine psychological screening into diabetes care to support individualized treatment planning and improve glycemic outcomes.\u003c/p\u003e","manuscriptTitle":"Adherence to Treatment and Psychological States of Patients with Type 2 Diabetes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 05:33:48","doi":"10.21203/rs.3.rs-8575733/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a9a653b-0b01-4060-a9d1-609729d67d11","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-07T15:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 05:33:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8575733","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8575733","identity":"rs-8575733","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}