Prevalence of depression, anxiety, and stress among internally displaced diabetic patients: Cross-sectional study, Kassala State, Sudan

Prevalence of depression, anxiety, and stress among internally displaced diabetic patients: Cross-sectional study, Kassala State, Sudan | 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 Article Prevalence of depression, anxiety, and stress among internally displaced diabetic patients: Cross-sectional study, Kassala State, Sudan Ismaeil Eldooma, Fakhreldin Yassin, Wadah Osman, Mahmood Basil A Al-Rawi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7594930/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 The recent ongoing Sudanese Armed Forces Conflict since 2023(SAFC2023) has led to substantial displacement of citizens. Displacement often causes psychological disorders of depression, anxiety, and stress (DAS). The DAS disorders could worsen the control of chronic diseases. Diabetes is one of the diseases that DAS could critically influence. Awareness about the prevalence of DAS among internally displaced diabetic patients (IDDPs) is crucial for mitigating the worsening of diabetes control. This study aimed to assess the prevalence of DAS among IDDPs during the SAFC2023. A total of 141 DDPs were included in this cross-sectional study conducted from July to August 2024 in eastern Sudan (Kassala State). An adapted and modified structured DAS questionnaire, comprising 21 questions (ADASQ-21), was used for data collection, with dichotomous open closed answers (Yes or No). The findings revealed a mean age of 48.5±17.3 years, with males accounting for 53.2%. University (36.1%) and secondary (35.5%) education levels are the most dominant. Most participants (49.6%) had a middle-income. However, the overall prevalence of DAS was 40.9% (depression 36.1%, anxiety 35.0%, and stress 51.6%). Remarkably, the prevalence rate is strikingly high compared to global reports (22.1%) in similar contexts. Moreover, the DAS severity grouping revealed a mild/moderate threshold to be most for depression (66.0%), and Stress (60.3%). In comparison, anxiety emerged with severe levels in 44.0% of patients. Nevertheless, the Chi-square test (χ2) revealed a statistically insignificant association and no differences in DAS prevalence between socio-demographic groups. However, the gender factor showed statistically significant differences with anxiety and depression (t-test, p=0.010 and p=0.023, at α=0.05, respectively). These findings among IDDPs highlighted the need for targeted psychological rehabilitation interventions, strengthening community support links, and encouraging policies to support displaced diabetic patients. Furthermore, the finding is scientific evidence for integrating psychological clinics into healthcare settings for better diabetes control among IDDPs. Health sciences/Diseases Health sciences/Endocrinology Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Introduction Armed conflict is a significant factor that usually causes internal and external population relocation (Mélanie 2012). The displacement could expose the affected populations to severe disruptions in their living conditions, access to healthcare, and social support. In 2020, an estimated 9.8 million individuals were displaced within their own countries due to violence and conflicts (McAuliffe and Triandafyllidou 2021). In Sudan, the ongoing Sudanese Armed Forces Conflict of 2023 (SAFC2023) has exacerbated this crisis, displacing over 10 million people (International Organization for Migration 2024). The prolonged history of conflict in Sudan has critically damaged healthcare infrastructure, leaving vulnerable groups, such as patients with chronic diseases, facing a high risk of losing their lives. Among these groups, diabetic patients are particularly affected. Diabetes is one of the chronic diseases that causes critical health complications for millions of people if not managed well due to uncontrolled elevated blood sugar(Usman et al. 2021). Among these complications, the psychological health of diabetic patients plays a crucial role in disease management outcomes and overall quality of life. Overall, diabetes complications caused 1.5 million deaths and 48% of all deaths before 70 years of age in 2012 worldwide (World Health Organization 2016). Between 1990 and 2019, in lower and middle-income countries, the mortality rate due to diabetes increased by 13%. (Liu et al. 2022) Depression, Anxiety, and Stress(DAS) conditions are common psychological issues that could significantly affect diabetic patients' treatment, adherence, and blood sugar control(Shahbaz et al. 2024). Studies on depression prevalence among diabetes mellitus patients in African countries revealed that depression prevalence among diabetes patients is high, with the North Africa region dominating in depression proportions. At the same time, rates in West Africa were found to be lower(Ogunsakin et al. 2021). Accordingly, it was rational to assess factors influencing blood sugar control in diabetic patients. The displacement has a substantial effect on diabetic patients, presenting in disrupted continuity of care and limited access to medications, including insulin. It undermines blood sugar control, thereby increasing the risks of morbidity and mortality (Shinan-Altman 2024b). Furthermore, to physiological health challenges, internally displaced diabetic patients (IDDPs) are exposed to psychosocial and emotional stressors. These stressors are represented as violence, uncertainty, security, loss of income, and life-threatening situations. These factors exacerbate the prevalence of DAS conditions and mortality risks (Arage et al. 2023; Restrepo and Padilla-Medina 2023). Globally, the World Health Organization (WHO) estimated that 20% of people in conflict-affected areas live with psychological or mental health disorders, with prevalence rates substantially higher than those in stable settings (Charlson et al. 2019). In the context of diabetes within the armed conflict areas, DAS disorders have critical implications because psychological distress could affect self-care behaviors, reduce treatment adherence and compliance, and worsen blood sugar control outcomes. Although there is a demonstrated prevalence of DAS conditions among dietetic patients, there are limited studies regarding the prevalence and severity levels of these conditions among IDDPs in conflict zones. In Sudan, the burden of psychological conditions among diabetic patients in everyday situations has been previously well documented (Omar et al. 2021). However, little is known about the prevalence and severity of DAS among IDDPs affected by SAFC2023. This knowledge gap is particularly concerning regarding the psychological impact resulting from the combined effects of limited routine healthcare access, medication shortages, displacement of uncertainty experiences, and increased vulnerability (Fussell and Lowe 2014). Assessing the prevalence and severity levels of DAS conditions among IDDPs is therefore essential for informing healthcare providers, policymakers, and humanitarian organizations, as well as for designing psychosocial support strategies tailored to this vulnerable population. This study aimed to assess the prevalence and severity levels of depression, anxiety, and stress among internally displaced diabetic patients in Kassala State, Sudan, during the ongoing armed conflict(2023). Accordingly, providing evidence of the importance of targeted psychological healthcare for appropriate diabetic management interventions in conflict-affected regions is crucial. Methods Study design and area: An observational, cross-sectional study was conducted from July to August 2024 in Kassala City, Sudan. Study population, inclusion, and exclusion criteria: Displaced diabetic patients who left their homes due to the SAFC 2023 and are living in Kassala City were included. However, diabetic patients under 20 years of age and city residents were excluded from the study. Sample size determination and sampling technique: A total of 141 participants were included in the study. A standard thumb rule method of (100–200) participants for determining a convenient sample size was adopted, since the study was to assess prevalence, and there was a lack of time and budget. The population consisted of patients attending health centres, clinics, and hospitals in Kassala City. The study employed a non-probability, simple convenience sampling method, selecting participants based on their availability and willingness to participate during the data collection period. Data collection tool: An adapted, translated (to Arabic), and modified self-administered questionnaire was used for data collection. The questionnaire was modified from the Depression, Anxiety, and Stress Scale (DASS-21), a 21-item tool that is reliable for collecting data on mental and emotional health status (Psychology Foundation of Australia 2025; Salihu et al. 2022). In this study, a modified Adapted Depression, Anxiety, and Stress Scale (ADASQ-21) (Appendix 1) was used. All participants provided the requested information on their gender, age, education, and income, followed by their agreement (yes) or disagreement (no) with statements that reflected their psychological and emotional feelings. The 21 constructs represent seven statements for each DAS condition. The DAS scale is a set of statements designed to measure the emotional states of DAS disorders. Each of the three DAS disorders has seven items. The depression statements assess dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia. However, the anxiety statements assess autonomic arousal, skeletal muscle effects, situational anxiety, and the subjective experience of anxious affect. Whereas, the stress statements are sensitive to levels of chronic nonspecific arousal, such as difficulty relaxing, nervous arousal, being easily agitated, irritable, or overreactive, and being impatient. The scores for DASQ-21 are calculated by summing the scores for the relevant items. This tool aims to assess the prevalence and severity of DAS disorders in individuals. The reference for psychological and emotional classification for the ADASQ-21 was the severity cutoff points for the DASS-21 classification cutoff points (the status is either Normal, Mild, Moderate, or Severe) according to Lovibond, S.H. & Lovibond, P.F. (1995) classification in their book " Manual for the Depression Anxiety & Stress Scales. (2nd Ed.) "(Appendix 1) (Sh 1995). Peer professionals and piloting confirmed the reliability and consistency of ADASQ-21, with a Cronbach's Alpha test score of 0.708 (n = 26). Statistical analysis: The analysis method was conducted using IBM SPSS (version 26). Descriptive statistics for categorical data were presented and analysed using the Chi-square and Fisher-Freeman-Halton Exact Tests. However, for numerical data, the comparison of means and central tendency, along with standard deviations, was used for the t-test and ANOVA test. The statistics adopted were based on a 95% confidence level (p-value at α = 0.05, which is the cutoff point). The cutoff point for statistically significant results for associations and differences between variables was interpreted using the Fisher-Freeman-Halton Exact Test if more than 20% of cells contained a number less than 5 in the cross-tabulated data. For numerical data, a normal distribution was assumed because the sample was approximately large enough(greater than 30 participants, N = 141). The data variables: Independent variables : Gender (Male and Female), DAS conditions (Depression, Anxiety, and Stress), age groups, educational level, and Income Levels. Dependent variables : DAS scores, prevalence proportions, and severity levels (mild to moderate and severe to extremely severe). Ethical consideration: The Declaration of Helsinki principles were adopted before conducting this study. The study was non-interventional, so obtaining a signed written consent from participants was not crucial (according to Sudan guidelines). However, ethical approval was obtained from the Department of Research at the Ministry of Health in Kassala State, Sudan. Furthermore, another approval was obtained from the Igraa College's Ethical Committee at the College of Medicine Program (June 2024, Ref: 07–24). Each participant was well-informed after listening to a written informed consent document before completing the questionnaire. The informed consent form illustrated that the findings and recommendations from this study will help displaced diabetic patients and healthcare providers overcome diabetes complications and psychological impacts. Participants verbally agreed to contribute by saying "Yes" (approved by the ethical committees, as it was deemed acceptable for surveys and non-interventional studies in Sudan). Results Socio-demographic and prevalence proportions descriptive results: Table 1 Socio-demographic characteristics (N = 141): Variable Groups Frequency % Cumulative % Gender Female 66 46.8 46.8 Male 75 53.2 100.0 Income levels High 26 18.4 18.4 Low 45 31.9 50.4 Middle 70 49.6 100.0 Education Illiterate 10 7.1 7.1 Primary 30 21.3 28.4 Secondary 50 35.5 63.8 University 51 36.2 100.0 Age ≥ 18 to 45 56 39.7 39.7 46 to 60 64 45.4 85.1 61 to ≥ 75 21 14.9 100.0 Table 1 showed that 53.2% of diabetic patients were male, and 36.1% acquired a university degree. Also, 49.6% of participants had a middle income, while only 18.4% had a high income. Table 2 Prevalence of DAS conditions among participants (N = 141). DAS Conditions Sum of total scores Prevalence Anxiety 356 36.1% Depression 345 35.0% Stress 509 51.6% Grand Total 1210 40.9% Note: Each condition has seven items, of which the virtual score could equal 987 = (7 × 141). Table 2 shows the result of DAS prevalence among participants. The stress condition was the most prevalent psychological condition, affecting 51.6% participants. In comparison, depression prevailed among 35.0% of participants as the lowest percentage of the three DAS conditions. However, the overall prevalence of DAS conditions was 40.9%, highlighting a considerable burden of psychological health problems among the studied population. Table 3 Severity levels of DAS distribution statistics(N = 141). Variable Goups Frequency Percent Cumulative Percent Depression Normal 24 17.0 17.0 Mild or Moderate 93 66.0 83.0 Severe or Extremely severe 24 17.0 100.0 Anxiety Normal 25 17.7 17.7 Mild or Moderate 54 38.3 56.0 Severe or Extremely severe 62 44.0 100.0 Stress Normal 23 16.3 16.3 Mild or Moderate 85 60.3 76.6 Severe or Extremely severe 33 23.4 100.0 Total 141 100.0 Table 3 shows the distribution of DAS severity levels among DDPs(N = 141). The most prominent severity level is within Mild or Moderate for Depression 93 (66%), Stress 85(60.3%), while Anxiety emerged with the most severe prevalence 62(44.0%). DAS prevalence and severity levels analytical results: Table 4 Comparison of DAS prevalence proportions across gender groups. DAS Prevalence Statistics (t-test, α = 0.05) Variable Male(n = 75) Female(n = 66) M. diff Sig Mean ± St. Dev Prevalence Mean ± St. Dev Prevalence Depression 2.48 ± 0.991 12.2% 2.41 ± 1.067 11.0% 0.071 0.683 Anxiety 2.28 ± 1.034 12.1% 2.80 ± 1.292 12.0% -0.523 0.010 Stress 3.39 ± .999 17.5% 3.86 ± 1.402 16.9% -0.477 0.023 Total 8.76 ± 2.006 41.8% 8.38 ± 2.02 39.9% 0.381 0.265 Table 4 shows the comparison of depression, anxiety, and stress (DAS) prevalence across gender groups. The results showed a statistically insignificant difference in depression prevalence between males (12.2%) and females (11.0%) (M.diff = 0.071, p = 0.683 > 0.05). However, significant gender differences were observed in anxiety (M.diff = − 0.523, p = 0.010 < 0.05) and stress(M.diff = − 0.477, p = 0.023 0.05). Table 5 Comparison of the DAS prevalence proportions among age groups. DAS Prevalence among age groups statistics (One-way ANOVA). F Sig, Variable Statistics ≥ 18 to 45 (n = 56) 46 to 60 (n = 64) 61 to ≥ 75 (n = 21) Depression Mean ± SD 2.50 ± 0.972 2.42 ± 1.081 2.38 ± 1.024 0.136 0.873 % 12.6% 11.1% 10.9% Anxiety Mean ± SD 2.50 ± 1.079 2.53 ± 1.272 2.57 ± 1.248 0.029 0.971 % 11.7% 12.9% 10.0% Stress Mean ± SD 3.59 ± 1.233 3.78 ± 1.147 3.14 ± 1.352 2.203 0.114 % 16.9% 17.5% 17.0% Total Mean ± SD 2.45 ± 1.024 2.52 ± 1.187 3.61 ± 1.223 1.215 0.300 % 41.2% 41.5% 37.9% Table 5 shows the comparison of DAS prevalence across different age groups. There are statistically insignificant differences between groups(p-values > 0.05), as indicated by the ANOVA test results for stress (F = 2.203, p = 0.114), anxiety (F = 0.029, p = 0.971), and depression (F = 0.136, p = 0.873). Table 6 Comparing prevalence differences among income categories(ANOVA test). Variables Statistics High(n = 26) Medium(n = 70) Low(n = 45) F Sig Depression Mean ± SD 2.50 ± 949 2.33 ± .959 2.60 ± 1.156 1.005 0.369 % 18.1% 16.4% 17.9% Anxiety Mean ± SD 2.50 ± 1.241 2.60 ± 1.172 2.42 ± 1.196 0.311 0.733 % 12.8% 12.2% 11.3% Stress Mean ± SD 3.81 ± 1.096 3.60 ± 1.197 3.51 ± 1.342 0.485 0.617 % 11.7% 11.6% 11.6% Total Mean ± SD 8.96 ± 2.107 8.44 ± 2.083 8.58 ± 1.877 0.623 0.538 % 42.7% 40.2% 40.8% Table 6 represents the comparison of DAS prevalence across income groups using an ANOVA statistical test (α = 0.05). There are statistically insignificant differences between income groups regarding the prevalence of depression, anxiety, or stress conditions. Nevertheless, the total prevalence percentages were slightly higher in the high-income category (42.7%). In comparison, the medium-income group represented the lowest prevalence (40.2%). Accordingly, the differences were minimal and approximately equally distributed among the three income groups. Table 7 Comparison of DAS severity levels across gender groups using Chi-square statistical test(α = 0.05). Variable Severity levels Gender Total :n (%) X 2 value Sig.(2-sided) Male: n (%) Female: n (%) Depression Normal 11(14.7) 13(19.7) 24(17.0) 0.897 0.659 Mild or Moderate 52(69.3) 41(62.1) 93(66.0) Severe or Extremely severe 12(16.0) 12(18.2) 24(17.0) Anxiety Normal 15(20.0) 10(15.2) 25(17.7) 7.519 0.024 Mild or Moderate 35(46.7) 19(28.8) 54(38.3) Severe or Extremely severe 25(33.3) 37(56.1) 62(44.0) Stress Normal 13(17.3) 10(15.2) 23(16.3) 11.872 0.002 Mild or Moderate 53(70.7) 32(48.5) 85(60.3) Severe or Extremely severe 9(12.0) 24(36.4) 33(23.4) Total 75(53.2) 66(46.8) 141(100) Table 7 shows the comparison of depression, anxiety, and stress (DAS) severity levels across gender groups. For the depression condition, there is a statistically insignificant difference between males and females (χ² = 0.897, p = 0.659 > 0.05), with the majority in both groups falling into the mild-to-moderate category. In contrast, anxiety levels showed a significant gender difference (χ²=7.519, p = 0.024 < 0.05), where severe-to-extremely severe anxiety was more prevalent among females (56.1%) compared to males (33.3%). Similarly, stress levels were significantly associated with gender (χ² = 11.872, p = 0.002 < 0.05), with severe-to-extremely severe stress notably higher among females (36.4%) than among males (12.0%). Table 8 Comparing DAS severity and educational levels groups(Chi-Square test). Variable Level group Education Total: n(%) Sig Illiterate or Primary:n(%) Secondary or University:n(%) Depression Normal 6(15.0) 18(17.8) 24(17.0) 0.305 Mild or Moderate 24(60.0) 69(68.3) 93(66.0) Severe or Extremely severe 10(25.0) 14(13.9) 24(17.0) Anxiety Normal 7(17.5) 18(17.8) 25(17.7) 0.777 Mild or Moderate 17(42.5) 37(36.6) 54(38.3) Severe or Extremely severe 16(40.0) 46(45.5) 62(44.0) Stress Normal 5(12.5) 18(17.8) 23(16.3) 0.627 Mild or Moderate 24(60.0) 61(60.4) 85(60.3) Severe or Extremely severe 11(27.5) 22(21.8) 33(23.4) Total 40(28.4) 101(71.6) 141(100%) Table 8 shows the comparison of depression, anxiety, and stress (DAS) severity levels across educational groups. There are statistically significant associations between education level and psychological outcomes (Chi-square test, p > 0.05 for all three conditions). While both educational groups displayed similar patterns, the majority of participants in each group reported mild or moderate levels of depression (66.0%), anxiety (38.3%), and stress (60.3%). However, severe or extremely severe cases were also present but relatively balanced between groups. Discussion The psychological conditions of patients with chronic diseases are a critical risk concern. Depression, anxiety, and stress (DAS) are common emotional conditions that could significantly affect the management and progression of diabetes (Abbas et al. 2023; Lustman et al. 2000). In armed conflict-affected regions, DAS conditions often prevail with numerous severity levels that require appropriate interventions to resolve. Assessment of DAS prevalence among displaced people resulting from armed conflict can reveal important medical indicators. These indicators can serve as a valuable reference for psychological rehabilitation, appropriate medical treatment, and effective risk mitigation. In this research, the prevalence of DAS among DDPs in Kassala State during the ongoing SAFC2023 showed substantial proportions. The socio-demographic factors for 141 participants, of whom more than half (53.2%) were males and nearly half (49.6%) had a middle-income level, and attained educational levels varied from 36.2% (university degree), 56.8%(primary or secondary), and 7.1% illiterate, participated in this study (Table 1 ). DAS Prevalence proportions and severity levels among DDPs: The assessment of psychological burden faced by internally displaced diabetic patients (IDDPs) residing in armed conflict zones has medical and humanitarian importance regarding DAS prevalence and severity levels. In this current study, the findings reveal that stress is the most prevalent condition, affecting 51.6% of participants, followed by anxiety at 36.1% and depression at 35.0%(Table 2 ). Also, see supplementary material details for more details(Generated information). The overall prevalence of these psychological conditions among IDDPs is 40.9%, a figure that substantially exceeds the 22.1% prevalence reported by the World Health Organization (WHO) for comparable situations (Koshe et al. 2023). This disparity underlines the acute mental health crisis within this vulnerable group, necessitating immediate humanitarian and psychological healthcare interventions. However, stress prevalence dominated the prevalence of depression and anxiety. This result aligns with a previous systematic review, which indicated that stress disorders frequently exceed 50% prevalence within conflict-affected areas. Notably, the distribution of DAS severity levels among IDDPs reveals that depression and stress are most commonly experienced at mild to moderate levels (66% and 60.3%, respectively). Conversely, anxiety showed a higher proportion of severe to extremely severe cases (44%)(Table 3 ). This stress severity is consistent with findings from other conflict-affected populations, where the persistent insecurity factor exacerbated anxiety symptoms. For example, studies among Syrian (69.6%) and Southern Sudanese (24%) displaced populations have similarly identified anxiety as the most severe psychological condition(Mohsen et al. 2021; Tutlam et al. 2024). While no prior research has specifically examined DAS prevalence in IDDPs, the current findings are consistent with general studies of displaced populations in conflict zones, where anxiety often manifests at heightened severity levels. These results emphasize the urgent need for targeted psychological health support and interventions specifically designed for this unique, vulnerable population. Addressing these psychological burdens is critical not only for improving psychological outcomes but also for mitigating the complicated health risks associated with diabetes in conflict-affected settings. DAS Prevalence Across Socio-demographic Factors: DAS prevalence regarding the gender factor: The gender characteristics and prevalence of DAS among DDPs during SAFC 2023 revealed several key indicators (Table 4 ). The DAS prevalence across genders found statistically insignificant differences in depression between males and females (p = 0.683 > 0.05) and total distress scores (41.8% vs. 39.9%, p = 0.265 > 0.05). Conversely, there is a statistically significant gender difference due to higher anxiety (p = 0.010 < 0.05) and stress (p = 0.023 < 0.05) prevalence among females compared to males. This finding aligns with the broader DAS conditions in the literature, where results showed women often report greater prevalence levels of anxiety and stress (Chaplin et al. 2008; Maslakçı and Sürücü 2022). In clinical practice, the gender-specific patterns underscore the need for appropriate interventions because both gender groups may experience similar depressive symptoms. However, anxiety and stress prevalence levels necessitate the importance of developing gender-based strategies to mitigate stress and anxiety-focused management while utilizing social support systems that consider females' unique distress patterns. DAS prevalence regarding the age grouping factor: The findings from the DAS prevalence analysis regarding age groups revealed some clinically relevant patterns (Table 5 ). There is a depression prevalence similarity across age groups (12.6% vs 11.1% vs 10.9%; F = 0.136, p = 0.873). This result aligns with a study from an Asian population, suggesting that cultural protective factors in elder care may mitigate age-related effects (Partha 2024). However, there is a statistically insignificant stress difference in middle-aged participants (46–60 years: 17.5% vs 16.9% younger group). This result contradicts a previous study that reported increased depression rates with advancing age due to comorbidities (Smith et al. 2020). Accordingly, context-specific intervention strategies considering regional sociocultural dynamics are essential. The statistical insignificance (stress: F = 2.203, p = 0.114 > 0.05) despite the observed differences highlights the importance of interpreting clinical relevance beyond p-values. DAS prevalence regarding the income level factor: Numerous previous epidemiological studies worldwide have demonstrated that economically disadvantaged populations have higher DAS prevalence (Caron and Liu 2010; Hu and Umeda 2021). Clinically, it is significant when considered in the context of displaced diabetic patients from conflict zones. However, comparing findings between income level groups becomes essential for appropriately mitigating interventions. In the current study, although there are statistically insignificant income-based differences in DAS conditions prevalence (F = 0.623, p = 0.538 > 0.05), this finding appears to contradict the conventional literature, which emphasizes socioeconomic status as a determinant of mental health in chronic disease management. This pattern aligns with emerging studies showing homogenized psychological distress in war-affected populations regardless of income. The marginal difference in total DAS prevalence between the high-income group (42.7%) and the medium-income group (40.2%) may reflect the unique stressor situation (Table 6 ). Clinically, these findings support trauma-informed diabetes care models that incorporate income-based triaging, particularly in conflict zones. DAS severity levels distribution across socio-demographic factors: Comparing DAS severity levels in relation to socio-demographic factors is crucial for triaging patients to receive clinically appropriate interventions and rehabilitation. DAS severity levels regarding the gender factor: In this study, IDDPs emerged with depression severity did not differ significantly by gender, so both gender groups experienced mild-to-moderate depression, with 17% reporting severe symptoms (χ² = 0.897, p = 0.659 > 0.05). Conversely, anxiety and stress showed statistically significant differences with higher severity proportions among female patients than males(severe/extremely severe anxiety: 56.1% vs. 33.3%, χ² = 7.519, p = 0.024 < 0.05; and stress:36.4% vs. 12.0%, χ² = 11.872, p = 0.002 < 0.05). These patterns align with previous findings from conflict and war-related factors, which adversely impact mental health management among people with diabetes (Shinan-Altman 2024b; Shinan-Altman 2024a). Moreover, many studies found that people with diabetes reported a high prevalence of DAS even in populations without conflict situations (Abualhamael et al. 2024; Fisekovic Kremic 2020). The markedly elevated anxiety and stress among displaced females suggest an exacerbating effect of conflict and displacement, especially for women, beyond what is typically seen in stable settings. DAS severity levels and educational attainment factor: The prevalence of DAS severity levels among internally displaced persons within armed conflict zones shows medical and humanitarian indicators. Generally, educational attainment is a significant variable associated with the severity levels of DAS. In the literature, it is suggested that higher educational levels are associated with lower DAS severity levels. However, this association appears to be disrupted in areas of armed conflict. In the current study, the comparison of DAS severity levels across educational groups (illiterate/primary versus secondary/university) showed statistically insignificant differences (p > 0.05 for DAS variables) (Table 8 ). Exactly, the prevalence of mild to moderate depression ( 60.0% versus 68.3%) and anxiety (42.5% versus 36.6%). These findings indicate that educational level does not prevent the severity of DAS symptoms in conflict zones. This result aligns with studies highlighting the effects of conflicts and displacement on DAS severity among DDPs. For instance, studies conducted in Jordanian refugee camps have documented elevated rates of severe depression (73%) and anxiety (60%), illustrating the psychological burden of chronic illness and displacement on DAS symptoms thresholds (Gammoh et al. 2024). Similarly, our current study highlights that the DAS severity in internally displaced individuals is consistent across educational groups. The lack of significant differences in DAS severity levels among educational groups may be due to the nature of stressors associated with armed conflict. These other stressors, such as the loss of social support and the constant threat of violence, likely prevent the mitigating effects of education on mental health. Furthermore, diabetes itself may exacerbate stress and anxiety in resource-scarce conflict settings. In summary, the findings of this study underscore the resilience of mental health challenges in conflict-affected diabetic populations, regardless of educational attainment. Clinical and social significance: Clinically, the overall 65% DAS prevalence of the studied population is significant. The anxiety prevalence of 94.3% and 16.3% in the severe-extremely severe category is striking. The elevated rate of anxiety suggests a critical need for integrated mental health support alongside diabetes care. Furthermore, the evident gender-based significant differences necessitated special care for females and the need for routine psychosocial screening. Furthermore, targeted interventions for displaced diabetic populations are needed to prevent further complications of both mental health and diabetes management outcomes. Procedures to reduce DAS symptoms: Incorporating psychological interventions through integrated services, mobile psychological clinics, and educational programs may reduce symptoms of depression (Guérin et al. 2019). The integration of psychological health services should include cognitive behavioural therapy to help patients change negative attitudes. Furthermore, physical activities such as walking in safe spaces within camps are beneficial, as daily walking has been shown to improve psychological well-being (Kelly et al. 2018; Marciano et al. 2024). Social support programs are also crucial in overcoming diabetic complications (Rad et al. 2013). Nevertheless, implementing these strategies requires coordination from healthcare providers, community leaders, non-governmental organisations, and policymakers to create supportive strategies for the psychological and physical health needs of DDPs. Conclusion There is a striking overall depression, anxiety, and stress prevalence among displaced diabetic patients, with anxiety being widespread and often reaching moderate to severe levels. Anxiety and stress were significantly higher in females and individuals with lower socioeconomic and educational status. These results showed a clinically significant psychological burden on displaced diabetic patients in Sudan. There is an urgent need for integrated mental health support in diabetic care programs alongside humanitarian interventions, especially for women, the poor, and less educated diabetic patients. Further longitudinal studies are needed to understand the long-term psychological outcomes in this vulnerable group of displaced diabetic patients. Limitations: A cross-sectional design, which restricts causal interpretations of these associations. Furthermore, the reliance on self-reported data and convenient sampling may introduce bias, especially regarding sensitive mental health conditions. Abbreviations DAS: Depression, Anxiety, and Stress; IDDPs: Internally Displaced Diabetic Patients; ADASQ-21: Adapted Depression Anxiety and Stress Questionnaire (comprising 21 statements); SAFC2023: Sudanese Armed Forces Conflict started in 2023. Declarations Funding declaration: This study was supported by the Ongoing Research Funding Program (ORF), King Saud University, Riyadh, Saudi Arabia, under grant number [ORF-2025-1099]. All authors declare that the funding body had no role in the design of the study, collection, analysis, and interpretation of data, or in writing the manuscript. 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"Meta-analysis of studies on depression prevalence among diabetes mellitus patients in Africa." Heliyon 7(5): e07085 http://doi.org/10.1016/j.heliyon.2021.e07085 Omar S M, Musa I R, Idrees M B and Adam I (2021). "Prevalence of depression and associated factors among patients with type 2 diabetes mellitus in eastern Sudan." BMC Psychiatry 21(1): 336 http://doi.org/10.1186/s12888-021-03357-1 Partha I S (2024). "Cultural Considerations in Healthcare for Older Asian Indian US Adults." The American Journal of Medicine 137(5): 399-405 http://doi.org/10.1016/j.amjmed.2024.01.001 Psychology Foundation of Australia. (2025, 9/01/ 2025). "Depression Anxiety Stress Scales - DASS." Retrieved May/15, 2025,available from https://www2.psy.unsw.edu.au/dass/. Rad G S, Bakht L A, Feizi A and Mohebi S (2013). "Importance of social support in diabetes care." J Educ Health Promot 2: 62 http://doi.org/10.4103/2277-9531.120864 Restrepo M T and Padilla-Medina D (2023). "Armed conflict exposure and mental health: examining the role of imperceptible violence." Med Confl Surviv 39(3): 199-221 http://doi.org/10.1080/13623699.2023.2222360 Salihu D, Wong E M L, Kwan R Y C, Ho G W K, Chutiyami M, Surajo K S, Bello U M, Ibrahim A A, Ali M U, Wang S, Bashir K, Jalo H A, Haddad M M, Suleiman A D, Ajio D K, Ali G M and Leung D Y P (2022). "Anxiety, depression and stress among internally displaced persons and host community in an armed conflict region: A comparative study." Psychiatry Res 315: 114700 http://doi.org/10.1016/j.psychres.2022.114700 Sh L (1995). Manual for the depression anxiety stress scales. Sydney Psychology Foundation. Shahbaz K, Alamgeer, Paudyal V, Zubair M, Safdar M Z, Tahir M, Akram L and Ali S (2024). "Prevalence and Impact of Psychological Disorders on Pharmacotherapy of Diabetic Patients in Low Resource Settings: A Prospective Assessment in Primary Healthcare Settings." Patient Prefer Adherence 18: 1939-1948 http://doi.org/10.2147/ppa.S463133 Shinan-Altman S (2024a). "Challenges faced by internally displaced diabetes patients in managing their health during a conflict: a qualitative study." Confl Health 18(1): 60 http://doi.org/10.1186/s13031-024-00625-1 Shinan-Altman S (2024b). "Challenges faced by internally displaced diabetes patients in managing their health during a conflict: a qualitative study." Conflict and Health 18(1): 60 http://doi.org/10.1186/s13031-024-00625-1 Smith M L, Steinman L E and Casey E A (2020). "Combatting Social Isolation Among Older Adults in a Time of Physical Distancing: The COVID-19 Social Connectivity Paradox." Front Public Health 8: 403 http://doi.org/10.3389/fpubh.2020.00403 Tutlam N T, Chang J J, Byansi W, Flick L H, Ssewamala F M and Betancourt T S (2024). "War-Affected South Sudanese in Settings of Preflight, Flight, and Resettlement: a Systematic Review and Meta-analysis of Trauma-Associated Mental Disorders." Glob Soc Welf 11(3): 193-210 http://doi.org/10.1007/s40609-022-00227-w Usman M S, Khan M S and Butler J (2021). "The Interplay Between Diabetes, Cardiovascular Disease, and Kidney Disease." ADA Clinical Compendia 2021(1): 13-18 http://doi.org/10.2337/db20211-13 World Health Organizations (2016) Global report on diabetes. Geneva, Switzerland; 2016. https://iris.who.int/bitstream/handle/10665/204871/9789241565257_eng.pdf?sequence=1. Additional Declarations No competing interests reported. Supplementary Files SublimentaryinformationDataGenerated.docx SuplementaryinformationDataCollected.xlsx ADASS21.docx 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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The displacement could expose the affected populations to severe disruptions in their living conditions, access to healthcare, and social support. In 2020, an estimated 9.8\u0026nbsp;million individuals were displaced within their own countries due to violence and conflicts (McAuliffe and Triandafyllidou 2021). In Sudan, the ongoing Sudanese Armed Forces Conflict of 2023 (SAFC2023) has exacerbated this crisis, displacing over 10\u0026nbsp;million people (International Organization for Migration 2024). The prolonged history of conflict in Sudan has critically damaged healthcare infrastructure, leaving vulnerable groups, such as patients with chronic diseases, facing a high risk of losing their lives. Among these groups, diabetic patients are particularly affected. Diabetes is one of the chronic diseases that causes critical health complications for millions of people if not managed well due to uncontrolled elevated blood sugar(Usman et al. 2021). Among these complications, the psychological health of diabetic patients plays a crucial role in disease management outcomes and overall quality of life. Overall, diabetes complications caused 1.5\u0026nbsp;million deaths and 48% of all deaths before 70 years of age in 2012 worldwide (World Health Organization 2016). Between 1990 and 2019, in lower and middle-income countries, the mortality rate due to diabetes increased by 13%. (Liu et al. 2022) Depression, Anxiety, and Stress(DAS) conditions are common psychological issues that could significantly affect diabetic patients' treatment, adherence, and blood sugar control(Shahbaz et al. 2024). Studies on depression prevalence among diabetes mellitus patients in African countries revealed that depression prevalence among diabetes patients is high, with the North Africa region dominating in depression proportions. At the same time, rates in West Africa were found to be lower(Ogunsakin et al. 2021). Accordingly, it was rational to assess factors influencing blood sugar control in diabetic patients.\u003c/p\u003e\u003cp\u003eThe displacement has a substantial effect on diabetic patients, presenting in disrupted continuity of care and limited access to medications, including insulin. It undermines blood sugar control, thereby increasing the risks of morbidity and mortality (Shinan-Altman 2024b). Furthermore, to physiological health challenges, internally displaced diabetic patients (IDDPs) are exposed to psychosocial and emotional stressors. These stressors are represented as violence, uncertainty, security, loss of income, and life-threatening situations. These factors exacerbate the prevalence of DAS conditions and mortality risks (Arage et al. 2023; Restrepo and Padilla-Medina 2023). Globally, the World Health Organization (WHO) estimated that 20% of people in conflict-affected areas live with psychological or mental health disorders, with prevalence rates substantially higher than those in stable settings (Charlson et al. 2019).\u003c/p\u003e\u003cp\u003eIn the context of diabetes within the armed conflict areas, DAS disorders have critical implications because psychological distress could affect self-care behaviors, reduce treatment adherence and compliance, and worsen blood sugar control outcomes. Although there is a demonstrated prevalence of DAS conditions among dietetic patients, there are limited studies regarding the prevalence and severity levels of these conditions among IDDPs in conflict zones.\u003c/p\u003e\u003cp\u003eIn Sudan, the burden of psychological conditions among diabetic patients in everyday situations has been previously well documented (Omar et al. 2021). However, little is known about the prevalence and severity of DAS among IDDPs affected by SAFC2023. This knowledge gap is particularly concerning regarding the psychological impact resulting from the combined effects of limited routine healthcare access, medication shortages, displacement of uncertainty experiences, and increased vulnerability (Fussell and Lowe 2014). Assessing the prevalence and severity levels of DAS conditions among IDDPs is therefore essential for informing healthcare providers, policymakers, and humanitarian organizations, as well as for designing psychosocial support strategies tailored to this vulnerable population.\u003c/p\u003e\u003cp\u003eThis study aimed to assess the prevalence and severity levels of depression, anxiety, and stress among internally displaced diabetic patients in Kassala State, Sudan, during the ongoing armed conflict(2023). Accordingly, providing evidence of the importance of targeted psychological healthcare for appropriate diabetic management interventions in conflict-affected regions is crucial.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and area:\u003c/h2\u003e\u003cp\u003eAn observational, cross-sectional study was conducted from July to August 2024 in Kassala City, Sudan.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population, inclusion, and exclusion criteria:\u003c/h3\u003e\n\u003cp\u003eDisplaced diabetic patients who left their homes due to the SAFC 2023 and are living in Kassala City were included. However, diabetic patients under 20 years of age and city residents were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eSample size determination and sampling technique:\u003c/h3\u003e\n\u003cp\u003eA total of 141 participants were included in the study. A standard thumb rule method of (100\u0026ndash;200) participants for determining a convenient sample size was adopted, since the study was to assess prevalence, and there was a lack of time and budget. The population consisted of patients attending health centres, clinics, and hospitals in Kassala City. The study employed a non-probability, simple convenience sampling method, selecting participants based on their availability and willingness to participate during the data collection period.\u003c/p\u003e\n\u003ch3\u003eData collection tool:\u003c/h3\u003e\n\u003cp\u003eAn adapted, translated (to Arabic), and modified self-administered questionnaire was used for data collection. The questionnaire was modified from the Depression, Anxiety, and Stress Scale (DASS-21), a 21-item tool that is reliable for collecting data on mental and emotional health status (Psychology Foundation of Australia 2025; Salihu et al. 2022). In this study, a modified Adapted Depression, Anxiety, and Stress Scale (ADASQ-21) (Appendix 1) was used. All participants provided the requested information on their gender, age, education, and income, followed by their agreement (yes) or disagreement (no) with statements that reflected their psychological and emotional feelings. The 21 constructs represent seven statements for each DAS condition. The DAS scale is a set of statements designed to measure the emotional states of DAS disorders. Each of the three DAS disorders has seven items. The depression statements assess dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia. However, the anxiety statements assess autonomic arousal, skeletal muscle effects, situational anxiety, and the subjective experience of anxious affect. Whereas, the stress statements are sensitive to levels of chronic nonspecific arousal, such as difficulty relaxing, nervous arousal, being easily agitated, irritable, or overreactive, and being impatient. The scores for DASQ-21 are calculated by summing the scores for the relevant items. This tool aims to assess the prevalence and severity of DAS disorders in individuals. The reference for psychological and emotional classification for the ADASQ-21 was the severity cutoff points for the DASS-21 classification cutoff points (the status is either Normal, Mild, Moderate, or Severe) according to Lovibond, S.H. \u0026amp; Lovibond, P.F. (1995) classification in their book \"\u003cem\u003eManual for the Depression Anxiety \u0026amp; Stress Scales. (2nd Ed.)\u003c/em\u003e\"(Appendix 1) (Sh 1995). Peer professionals and piloting confirmed the reliability and consistency of ADASQ-21, with a \u003cem\u003eCronbach's Alpha\u003c/em\u003e test score of 0.708 (n\u0026thinsp;=\u0026thinsp;26).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis:\u003c/h2\u003e\u003cp\u003eThe analysis method was conducted using IBM SPSS (version 26). Descriptive statistics for categorical data were presented and analysed using the Chi-square and Fisher-Freeman-Halton Exact Tests. However, for numerical data, the comparison of means and central tendency, along with standard deviations, was used for the t-test and ANOVA test. The statistics adopted were based on a 95% confidence level (p-value at α\u0026thinsp;=\u0026thinsp;0.05, which is the cutoff point). The cutoff point for statistically significant results for associations and differences between variables was interpreted using the Fisher-Freeman-Halton Exact Test if more than 20% of cells contained a number less than 5 in the cross-tabulated data. For numerical data, a normal distribution was assumed because the sample was approximately large enough(greater than 30 participants, N\u0026thinsp;=\u0026thinsp;141).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eThe data variables:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIndependent variables\u003c/b\u003e: Gender (Male and Female), DAS conditions (Depression, Anxiety, and Stress), age groups, educational level, and Income Levels.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDependent variables\u003c/b\u003e: DAS scores, prevalence proportions, and severity levels (mild to moderate and severe to extremely severe).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical consideration:\u003c/h3\u003e\n\u003cp\u003eThe Declaration of Helsinki principles were adopted before conducting this study. The study was non-interventional, so obtaining a signed written consent from participants was not crucial (according to Sudan guidelines). However, ethical approval was obtained from the Department of Research at the Ministry of Health in Kassala State, Sudan. Furthermore, another approval was obtained from the Igraa College's Ethical Committee at the College of Medicine Program (June 2024, Ref: 07\u0026ndash;24). Each participant was well-informed after listening to a written informed consent document before completing the questionnaire. The informed consent form illustrated that the findings and recommendations from this study will help displaced diabetic patients and healthcare providers overcome diabetes complications and psychological impacts. Participants verbally agreed to contribute by saying \"Yes\" (approved by the ethical committees, as it was deemed acceptable for surveys and non-interventional studies in Sudan).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSocio-demographic and prevalence proportions descriptive results:\u003c/h2\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\u003eSocio-demographic characteristics (N\u0026thinsp;=\u0026thinsp;141):\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=\"char\" char=\".\" 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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCumulative %\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIncome levels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e63.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;18 to 45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e39.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 to 60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 to \u0026ge;\u0026thinsp;75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed that 53.2% of diabetic patients were male, and 36.1% acquired a university degree. Also, 49.6% of participants had a middle income, while only 18.4% had a high income.\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\u003ePrevalence of DAS conditions among participants (N\u0026thinsp;=\u0026thinsp;141).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDAS Conditions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSum of total scores\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e356\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e509\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrand Total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Each condition has seven items, of which the virtual score could equal 987\u0026thinsp;=\u0026thinsp;(7 \u0026times; 141).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the result of DAS prevalence among participants. The stress condition was the most prevalent psychological condition, affecting 51.6% participants. In comparison, depression prevailed among 35.0% of participants as the lowest percentage of the three DAS conditions. However, the overall prevalence of DAS conditions was 40.9%, highlighting a considerable burden of psychological health problems among the studied population.\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\u003eSeverity levels of DAS distribution statistics(N\u0026thinsp;=\u0026thinsp;141).\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\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGoups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCumulative Percent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the distribution of DAS severity levels among DDPs(N\u0026thinsp;=\u0026thinsp;141). The most prominent severity level is within Mild or Moderate for Depression 93 (66%), Stress 85(60.3%), while Anxiety emerged with the most severe prevalence 62(44.0%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDAS prevalence and severity levels analytical results:\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of DAS prevalence proportions across gender groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDAS Prevalence Statistics (t-test, α\u0026thinsp;=\u0026thinsp;0.05)\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMale(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eFemale(n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eM. diff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;St. Dev\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;St. Dev\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.991\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.067\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.292\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.523\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.402\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.477\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.265\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the comparison of depression, anxiety, and stress (DAS) prevalence across gender groups. The results showed a statistically insignificant difference in depression prevalence between males (12.2%) and females (11.0%) (M.diff\u0026thinsp;=\u0026thinsp;0.071, p\u0026thinsp;=\u0026thinsp;0.683\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, significant gender differences were observed in anxiety (M.diff\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.523, p\u0026thinsp;=\u0026thinsp;0.010\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and stress(M.diff\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.477, p\u0026thinsp;=\u0026thinsp;0.023\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, the overall DAS prevalence was statistically insignificant among males (41.8%) compared to females (39.9%) (p\u0026thinsp;=\u0026thinsp;0.265\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the DAS prevalence proportions among age groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDAS Prevalence among age groups statistics (One-way ANOVA).\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig,\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;18 to 45\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 to 60\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61 to \u0026ge;\u0026thinsp;75\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.972\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.873\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.248\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.971\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.300\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.9%\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the comparison of DAS prevalence across different age groups. There are statistically insignificant differences between groups(p-values\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as indicated by the ANOVA test results for stress (F\u0026thinsp;=\u0026thinsp;2.203, p\u0026thinsp;=\u0026thinsp;0.114), anxiety (F\u0026thinsp;=\u0026thinsp;0.029, p\u0026thinsp;=\u0026thinsp;0.971), and depression (F\u0026thinsp;=\u0026thinsp;0.136, p\u0026thinsp;=\u0026thinsp;0.873).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparing prevalence differences among income categories(ANOVA test).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedium(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSig\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;949\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;.959\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.369\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.172\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.311\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.733\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.096\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.342\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.485\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.617\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.623\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.538\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40.8%\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e represents the comparison of DAS prevalence across income groups using an ANOVA statistical test (α\u0026thinsp;=\u0026thinsp;0.05). There are statistically insignificant differences between income groups regarding the prevalence of depression, anxiety, or stress conditions. Nevertheless, the total prevalence percentages were slightly higher in the high-income category (42.7%). In comparison, the medium-income group represented the lowest prevalence (40.2%). Accordingly, the differences were minimal and approximately equally distributed among the three income groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of DAS severity levels across gender groups using Chi-square statistical test(α\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSeverity levels\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGender\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e:n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig.(2-sided)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale:\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFemale:\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13(19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24(17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.659\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52(69.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41(62.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93(66.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24(17.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25(17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e7.519\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35(46.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19(28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54(38.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37(56.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62(44.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13(17.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23(16.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e11.872\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53(70.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32(48.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85(60.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(36.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33(23.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75(53.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66(46.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e141(100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e shows the comparison of depression, anxiety, and stress (DAS) severity levels across gender groups. For the depression condition, there is a statistically insignificant difference between males and females (χ\u0026sup2; = 0.897, p\u0026thinsp;=\u0026thinsp;0.659\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with the majority in both groups falling into the mild-to-moderate category. In contrast, anxiety levels showed a significant gender difference (χ\u0026sup2;=7.519, p\u0026thinsp;=\u0026thinsp;0.024\u0026thinsp;\u0026lt;\u0026thinsp;0.05), where severe-to-extremely severe anxiety was more prevalent among females (56.1%) compared to males (33.3%). Similarly, stress levels were significantly associated with gender (χ\u0026sup2; = 11.872, p\u0026thinsp;=\u0026thinsp;0.002\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with severe-to-extremely severe stress notably higher among females (36.4%) than among males (12.0%).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparing DAS severity and educational levels groups(Chi-Square test).\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\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLevel group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal: n(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIlliterate or Primary:n(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSecondary or University:n(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24(17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.305\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69(68.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93(66.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14(13.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24(17.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25(17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.777\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17(42.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37(36.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54(38.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16(40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46(45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62(44.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23(16.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.627\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild or Moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61(60.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85(60.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere or Extremely severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(27.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22(21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33(23.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40(28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e101(71.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e141(100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e shows the comparison of depression, anxiety, and stress (DAS) severity levels across educational groups. There are statistically significant associations between education level and psychological outcomes (Chi-square test, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all three conditions). While both educational groups displayed similar patterns, the majority of participants in each group reported mild or moderate levels of depression (66.0%), anxiety (38.3%), and stress (60.3%). However, severe or extremely severe cases were also present but relatively balanced between groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe psychological conditions of patients with chronic diseases are a critical risk concern. Depression, anxiety, and stress (DAS) are common emotional conditions that could significantly affect the management and progression of diabetes (Abbas et al. 2023; Lustman et al. 2000). In armed conflict-affected regions, DAS conditions often prevail with numerous severity levels that require appropriate interventions to resolve. Assessment of DAS prevalence among displaced people resulting from armed conflict can reveal important medical indicators. These indicators can serve as a valuable reference for psychological rehabilitation, appropriate medical treatment, and effective risk mitigation. In this research, the prevalence of DAS among DDPs in Kassala State during the ongoing SAFC2023 showed substantial proportions. The socio-demographic factors for 141 participants, of whom more than half (53.2%) were males and nearly half (49.6%) had a middle-income level, and attained educational levels varied from 36.2% (university degree), 56.8%(primary or secondary), and 7.1% illiterate, participated in this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDAS Prevalence proportions and severity levels among DDPs:\u003c/h2\u003e\u003cp\u003eThe assessment of psychological burden faced by internally displaced diabetic patients (IDDPs) residing in armed conflict zones has medical and humanitarian importance regarding DAS prevalence and severity levels. In this current study, the findings reveal that stress is the most prevalent condition, affecting 51.6% of participants, followed by anxiety at 36.1% and depression at 35.0%(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Also, see supplementary material details for more details(Generated information). The overall prevalence of these psychological conditions among IDDPs is 40.9%, a figure that substantially exceeds the 22.1% prevalence reported by the World Health Organization (WHO) for comparable situations (Koshe et al. 2023). This disparity underlines the acute mental health crisis within this vulnerable group, necessitating immediate humanitarian and psychological healthcare interventions. However, stress prevalence dominated the prevalence of depression and anxiety. This result aligns with a previous systematic review, which indicated that stress disorders frequently exceed 50% prevalence within conflict-affected areas. Notably, the distribution of DAS severity levels among IDDPs reveals that depression and stress are most commonly experienced at mild to moderate levels (66% and 60.3%, respectively). Conversely, anxiety showed a higher proportion of severe to extremely severe cases (44%)(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This stress severity is consistent with findings from other conflict-affected populations, where the persistent insecurity factor exacerbated anxiety symptoms. For example, studies among Syrian (69.6%) and Southern Sudanese (24%) displaced populations have similarly identified anxiety as the most severe psychological condition(Mohsen et al. 2021; Tutlam et al. 2024).\u003c/p\u003e\u003cp\u003eWhile no prior research has specifically examined DAS prevalence in IDDPs, the current findings are consistent with general studies of displaced populations in conflict zones, where anxiety often manifests at heightened severity levels. These results emphasize the urgent need for targeted psychological health support and interventions specifically designed for this unique, vulnerable population. Addressing these psychological burdens is critical not only for improving psychological outcomes but also for mitigating the complicated health risks associated with diabetes in conflict-affected settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eDAS Prevalence Across Socio-demographic Factors:\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eDAS prevalence regarding the gender factor:\u003c/h2\u003e\u003cp\u003eThe gender characteristics and prevalence of DAS among DDPs during SAFC 2023 revealed several key indicators (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The DAS prevalence across genders found statistically insignificant differences in depression between males and females (p\u0026thinsp;=\u0026thinsp;0.683\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and total distress scores (41.8% vs. 39.9%, p\u0026thinsp;=\u0026thinsp;0.265\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Conversely, there is a statistically significant gender difference due to higher anxiety (p\u0026thinsp;=\u0026thinsp;0.010\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and stress (p\u0026thinsp;=\u0026thinsp;0.023\u0026thinsp;\u0026lt;\u0026thinsp;0.05) prevalence among females compared to males. This finding aligns with the broader DAS conditions in the literature, where results showed women often report greater prevalence levels of anxiety and stress (Chaplin et al. 2008; Maslak\u0026ccedil;ı and S\u0026uuml;r\u0026uuml;c\u0026uuml; 2022). In clinical practice, the gender-specific patterns underscore the need for appropriate interventions because both gender groups may experience similar depressive symptoms. However, anxiety and stress prevalence levels necessitate the importance of developing gender-based strategies to mitigate stress and anxiety-focused management while utilizing social support systems that consider females' unique distress patterns.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eDAS prevalence regarding the age grouping factor:\u003c/h2\u003e\u003cp\u003eThe findings from the DAS prevalence analysis regarding age groups revealed some clinically relevant patterns (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). There is a depression prevalence similarity across age groups (12.6% vs 11.1% vs 10.9%; F\u0026thinsp;=\u0026thinsp;0.136, p\u0026thinsp;=\u0026thinsp;0.873). This result aligns with a study from an Asian population, suggesting that cultural protective factors in elder care may mitigate age-related effects (Partha 2024). However, there is a statistically insignificant stress difference in middle-aged participants (46\u0026ndash;60 years: 17.5% vs 16.9% younger group). This result contradicts a previous study that reported increased depression rates with advancing age due to comorbidities (Smith et al. 2020). Accordingly, context-specific intervention strategies considering regional sociocultural dynamics are essential. The statistical insignificance (stress: F\u0026thinsp;=\u0026thinsp;2.203, p\u0026thinsp;=\u0026thinsp;0.114\u0026thinsp;\u0026gt;\u0026thinsp;0.05) despite the observed differences highlights the importance of interpreting clinical relevance beyond p-values.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eDAS prevalence regarding the income level factor:\u003c/h2\u003e\u003cp\u003eNumerous previous epidemiological studies worldwide have demonstrated that economically disadvantaged populations have higher DAS prevalence (Caron and Liu 2010; Hu and Umeda 2021). Clinically, it is significant when considered in the context of displaced diabetic patients from conflict zones. However, comparing findings between income level groups becomes essential for appropriately mitigating interventions. In the current study, although there are statistically insignificant income-based differences in DAS conditions prevalence (F\u0026thinsp;=\u0026thinsp;0.623, p\u0026thinsp;=\u0026thinsp;0.538\u0026thinsp;\u0026gt;\u0026thinsp;0.05), this finding appears to contradict the conventional literature, which emphasizes socioeconomic status as a determinant of mental health in chronic disease management. This pattern aligns with emerging studies showing homogenized psychological distress in war-affected populations regardless of income. The marginal difference in total DAS prevalence between the high-income group (42.7%) and the medium-income group (40.2%) may reflect the unique stressor situation (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Clinically, these findings support trauma-informed diabetes care models that incorporate income-based triaging, particularly in conflict zones.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eDAS severity levels distribution across socio-demographic factors:\u003c/h2\u003e\u003cp\u003eComparing DAS severity levels in relation to socio-demographic factors is crucial for triaging patients to receive clinically appropriate interventions and rehabilitation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eDAS severity levels regarding the gender factor:\u003c/h2\u003e\u003cp\u003eIn this study, IDDPs emerged with depression severity did not differ significantly by gender, so both gender groups experienced mild-to-moderate depression, with 17% reporting severe symptoms (χ\u0026sup2; = 0.897, p\u0026thinsp;=\u0026thinsp;0.659\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Conversely, anxiety and stress showed statistically significant differences with higher severity proportions among female patients than males(severe/extremely severe anxiety: 56.1% vs. 33.3%, χ\u0026sup2; = 7.519, p\u0026thinsp;=\u0026thinsp;0.024\u0026thinsp;\u0026lt;\u0026thinsp;0.05; and stress:36.4% vs. 12.0%, χ\u0026sup2; = 11.872, p\u0026thinsp;=\u0026thinsp;0.002\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These patterns align with previous findings from conflict and war-related factors, which adversely impact mental health management among people with diabetes (Shinan-Altman 2024b; Shinan-Altman 2024a). Moreover, many studies found that people with diabetes reported a high prevalence of DAS even in populations without conflict situations (Abualhamael et al. 2024; Fisekovic Kremic 2020). The markedly elevated anxiety and stress among displaced females suggest an exacerbating effect of conflict and displacement, especially for women, beyond what is typically seen in stable settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eDAS severity levels and educational attainment factor:\u003c/h2\u003e\u003cp\u003eThe prevalence of DAS severity levels among internally displaced persons within armed conflict zones shows medical and humanitarian indicators. Generally, educational attainment is a significant variable associated with the severity levels of DAS. In the literature, it is suggested that higher educational levels are associated with lower DAS severity levels. However, this association appears to be disrupted in areas of armed conflict. In the current study, the comparison of DAS severity levels across educational groups (illiterate/primary versus secondary/university) showed statistically insignificant differences (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for DAS variables) (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Exactly, the prevalence of mild to moderate depression ( 60.0% versus 68.3%) and anxiety (42.5% versus 36.6%). These findings indicate that educational level does not prevent the severity of DAS symptoms in conflict zones. This result aligns with studies highlighting the effects of conflicts and displacement on DAS severity among DDPs. For instance, studies conducted in Jordanian refugee camps have documented elevated rates of severe depression (73%) and anxiety (60%), illustrating the psychological burden of chronic illness and displacement on DAS symptoms thresholds (Gammoh et al. 2024). Similarly, our current study highlights that the DAS severity in internally displaced individuals is consistent across educational groups. The lack of significant differences in DAS severity levels among educational groups may be due to the nature of stressors associated with armed conflict. These other stressors, such as the loss of social support and the constant threat of violence, likely prevent the mitigating effects of education on mental health. Furthermore, diabetes itself may exacerbate stress and anxiety in resource-scarce conflict settings. In summary, the findings of this study underscore the resilience of mental health challenges in conflict-affected diabetic populations, regardless of educational attainment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eClinical and social significance:\u003c/h2\u003e\u003cp\u003eClinically, the overall 65% DAS prevalence of the studied population is significant. The anxiety prevalence of 94.3% and 16.3% in the severe-extremely severe category is striking. The elevated rate of anxiety suggests a critical need for integrated mental health support alongside diabetes care. Furthermore, the evident gender-based significant differences necessitated special care for females and the need for routine psychosocial screening. Furthermore, targeted interventions for displaced diabetic populations are needed to prevent further complications of both mental health and diabetes management outcomes.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eProcedures to reduce DAS symptoms:\u003c/h2\u003e\u003cp\u003eIncorporating psychological interventions through integrated services, mobile psychological clinics, and educational programs may reduce symptoms of depression (Gu\u0026eacute;rin et al. 2019). The integration of psychological health services should include cognitive behavioural therapy to help patients change negative attitudes. Furthermore, physical activities such as walking in safe spaces within camps are beneficial, as daily walking has been shown to improve psychological well-being (Kelly et al. 2018; Marciano et al. 2024). Social support programs are also crucial in overcoming diabetic complications (Rad et al. 2013). Nevertheless, implementing these strategies requires coordination from healthcare providers, community leaders, non-governmental organisations, and policymakers to create supportive strategies for the psychological and physical health needs of DDPs.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere is a striking overall depression, anxiety, and stress prevalence among displaced diabetic patients, with anxiety being widespread and often reaching moderate to severe levels. Anxiety and stress were significantly higher in females and individuals with lower socioeconomic and educational status. These results showed a clinically significant psychological burden on displaced diabetic patients in Sudan. There is an urgent need for integrated mental health support in diabetic care programs alongside humanitarian interventions, especially for women, the poor, and less educated diabetic patients. Further longitudinal studies are needed to understand the long-term psychological outcomes in this vulnerable group of displaced diabetic patients.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eLimitations:\u003c/h2\u003e\u003cp\u003eA cross-sectional design, which restricts causal interpretations of these associations. Furthermore, the reliance on self-reported data and convenient sampling may introduce bias, especially regarding sensitive mental health conditions.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDAS: Depression, Anxiety, and Stress; IDDPs: Internally Displaced Diabetic Patients; ADASQ-21: Adapted Depression Anxiety and Stress Questionnaire (comprising 21 statements); SAFC2023: Sudanese Armed Forces Conflict started in 2023.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003ch2\u003e\u0026nbsp;Funding declaration:\u003c/h2\u003e\n\u003cp\u003eThis study was supported by the Ongoing Research Funding Program (ORF), King Saud University, Riyadh, Saudi Arabia, under grant number [ORF-2025-1099]. All authors declare that the funding body had no role in the design of the study, collection, analysis, and interpretation of data, or in writing the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest regarding this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbbas Q, Latif S, Ayaz Habib H, Shahzad S, Sarwar U, Shahzadi M, Ramzan Z and Washdev W (2023). \u0026quot;Cognitive behavior therapy for diabetes distress, depression, health anxiety, quality of life and treatment adherence among patients with type-II diabetes mellitus: a randomized control trial.\u0026quot; BMC Psychiatry 23(1): 86 http://doi.org/10.1186/s12888-023-04546-w\u003c/li\u003e\n\u003cli\u003eAbualhamael S A, Baig M, Alghamdi W, Gazzaz Z J, Al-Hayani M and Bazi A (2024). \u0026quot;Quality of life, stress, anxiety and depression and associated factors among people with type 2 diabetes mellitus in Western region Saudi Arabia.\u0026quot; Frontiers in Psychiatry Volume 14 - 2023http://doi.org/10.3389/fpsyt.2023.1282249 \u003c/li\u003e\n\u003cli\u003eArage M W, Kumsa H, Asfaw M S, Kassaw A T, Dagnew E M, Tunta A, Kassahun W, Addisu A, Yigzaw M, Hailu T and Tenaw L A (2023). \u0026quot;Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study.\u0026quot; BMC Public Health 23(1): 2078 http://doi.org/10.1186/s12889-023-16983-z\u003c/li\u003e\n\u003cli\u003eCaron J and Liu A (2010). \u0026quot;A descriptive study of the prevalence of psychological distress and mental disorders in the Canadian population: comparison between low-income and non-low-income populations.\u0026quot; Chronic Dis Can 30(3): 84-94 http://doi.org/doi.org/10.24095/hpcdp.30.3.03\u003c/li\u003e\n\u003cli\u003eChaplin T M, Hong K, Bergquist K and Sinha R (2008). \u0026quot;Gender differences in response to emotional stress: an assessment across subjective, behavioral, and physiological domains and relations to alcohol craving.\u0026quot; Alcohol Clin Exp Res 32(7): 1242-1250 http://doi.org/10.1111/j.1530-0277.2008.00679.x\u003c/li\u003e\n\u003cli\u003eCharlson F, Van Ommeren M, Flaxman A, Cornett J, Whiteford H and Saxena S (2019). \u0026quot;New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis.\u0026quot; The Lancet 394(10194): 240-248 http://doi.org/10.1016/S0140-6736(19)30934-1\u003c/li\u003e\n\u003cli\u003eFisekovic Kremic M B (2020). \u0026quot;Factors associated with depression, anxiety and stress among patients with diabetes mellitus in primary health care: Many questions, few answers.\u0026quot; Malays Fam Physician 15(3): 54-61 http://doi.org/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7735874/\u003c/li\u003e\n\u003cli\u003eFussell E and Lowe S R (2014). \u0026quot;The impact of housing displacement on the mental health of low-income parents after Hurricane Katrina.\u0026quot; Soc Sci Med 113: 137-144 http://doi.org/10.1016/j.socscimed.2014.05.025\u003c/li\u003e\n\u003cli\u003eGammoh O, Sayaheen B, Alsous M, Al-Smadi A, Al-Jaidi B and Aljabali A (2024). \u0026quot;The Prevalence and Correlates of Depression, Anxiety, and Insomnia among Camp Residing Palestinian Women Migrants during the Outbreak of the War on Gaza: A Cross-Sectional Study from Jordan.\u0026quot; Medicina 60: 1228 http://doi.org/10.3390/medicina60081228\u003c/li\u003e\n\u003cli\u003eGu\u0026eacute;rin E, Jaafar H, Amrani L, Prud\u0026apos;homme D and Aguer C (2019). \u0026quot;Intervention Strategies for Prevention of Comorbid Depression Among Individuals With Type 2 Diabetes: A Scoping Review.\u0026quot; Front Public Health 7: 35 http://doi.org/10.3389/fpubh.2019.00035\u003c/li\u003e\n\u003cli\u003eHu Q and Umeda M (2021). \u0026quot;Stress, Anxiety, and Depression for Chinese Residents in Japan during the COVID-19 Pandemic.\u0026quot; Int J Environ Res Public Health 18(9)http://doi.org/10.3390/ijerph18094958\u003c/li\u003e\n\u003cli\u003eInternational Organization for Migrations (2024) SUDAN CRISIS AND NEIGHBOURING COUNTRIES. ^17 Route des Morillons, 1211 Geneva 19, Switzerland. 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Geneva, Switzerland; 2016. https://iris.who.int/bitstream/handle/10665/204871/9789241565257_eng.pdf?sequence=1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"","lastPublishedDoi":"10.21203/rs.3.rs-7594930/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7594930/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"The recent ongoing Sudanese Armed Forces Conflict since 2023(SAFC2023) has led to substantial displacement of citizens. Displacement often causes psychological disorders of depression, anxiety, and stress (DAS). The DAS disorders could worsen the control of chronic diseases. Diabetes is one of the diseases that DAS could critically influence. Awareness about the prevalence of DAS among internally displaced diabetic patients (IDDPs) is crucial for mitigating the worsening of diabetes control. This study aimed to assess the prevalence of DAS among IDDPs during the SAFC2023. A total of 141 DDPs were included in this cross-sectional study conducted from July to August 2024 in eastern Sudan (Kassala State). An adapted and modified structured DAS questionnaire, comprising 21 questions (ADASQ-21), was used for data collection, with dichotomous open closed answers (Yes or No). The findings revealed a mean age of 48.5±17.3 years, with males accounting for 53.2%. University (36.1%) and secondary (35.5%) education levels are the most dominant. Most participants (49.6%) had a middle-income. However, the overall prevalence of DAS was 40.9% (depression 36.1%, anxiety 35.0%, and stress 51.6%). Remarkably, the prevalence rate is strikingly high compared to global reports (22.1%) in similar contexts. Moreover, the DAS severity grouping revealed a mild/moderate threshold to be most for depression (66.0%), and Stress (60.3%). In comparison, anxiety emerged with severe levels in 44.0% of patients. Nevertheless, the Chi-square test (χ2) revealed a statistically insignificant association and no differences in DAS prevalence between socio-demographic groups. However, the gender factor showed statistically significant differences with anxiety and depression (t-test, p=0.010 and p=0.023, at α=0.05, respectively). These findings among IDDPs highlighted the need for targeted psychological rehabilitation interventions, strengthening community support links, and encouraging policies to support displaced diabetic patients. Furthermore, the finding is scientific evidence for integrating psychological clinics into healthcare settings for better diabetes control among IDDPs.","manuscriptTitle":"Prevalence of depression, anxiety, and stress among internally displaced diabetic patients: Cross-sectional study, Kassala State, Sudan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-19 08:35:48","doi":"10.21203/rs.3.rs-7594930/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":"3e603052-1151-4e01-a45a-ff013889d762","owner":[],"postedDate":"September 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54793260,"name":"Health sciences/Diseases"},{"id":54793261,"name":"Health sciences/Endocrinology"},{"id":54793262,"name":"Health sciences/Health care"},{"id":54793263,"name":"Health sciences/Medical research"},{"id":54793264,"name":"Biological sciences/Psychology"},{"id":54793265,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-03-25T06:56:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-19 08:35:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7594930","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7594930","identity":"rs-7594930","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}