Association between Unmet Needs for Informal support and Diabetes-related Distress among People Living with Type 2 Diabetes in Vietnam: A Cross-sectional Study

Background: Diabetes-related distress (DRD) in people with type 2 diabetes (T2D) is associated with reduced quality of life. Lower levels of DRD were found in people who received informal support. The prevalence of T2D in Vietnam is rapidly increasing. Yet, the prevalence of DRD and its association with informal social support have not been investigated. The present investigate the prevalence of DRD and its association with unmet needs for informal support in people with T2D in Vietnam. Methods: A total of 806 people, age ³40 years, diagnosed with T2D in Thai Binh, Vietnam, completed a questionnaire-based cross-sectional survey. DRD was self-reported, based on the Problem Areas In Diabetes scale 5 (PAID 5). We assessed 6 types of unmet needs for informal support from family/friends/community including: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support. Multivariable logistic regression was used to model DRD as an outcome of each type of unmet need for informal support, and as an outcome of the number of unmet needs for informal support, adjusted for three sets of covariates. Results: The prevalence of DRD in people with T2D was 50.0%. Odds for DRD were higher among those who had unmet needs for emotional support and nancial support as compared to those with met needs (OR=2.59, CI95%: 1.19-5.63 and OR= 1.63, CI95%: 1.10 -2.40, respectively). People who had more than one type of unmet need was not a higher risk of DRD as compared to those with only one type of unmet need. Conclusions: Half of the people with T2D had DRD. DRD was associated with unmet needs for emotional and nancial support. The ndings suggest that in order to prevent or reverse DRD, family members and others providing informal support should be included in health programs and interventions targeting people with in and similar settings.

are associated with DRD and with increasing levels of need for support, including informal support [7][8][9][10][11][12]. Social support is understood as help provided by family, friends, neighbors, relatives, and other informal care givers, and includes different areas of assistance, such as informational, emotional, companionship, and practical help [13][14][15]. Unmet needs for informal support can be de ned as inadequate amount of help received from informal sources in relation to activities of daily living [16].
DRD is common in people with diabetes. Results of a meta-analysis including 55 studies from high-and middle-income countries showed that more than one-third of people with T2D had DRD [2], while a study conducted in 17 countries, including India and China, found that 45% of the people with diabetes had DRD [17]. In South-East Asia, a cross-sectional study of Malaysian adults with T2D, found that 50% had DRD [18], while a study from China showed that 23% of people with T2D had moderate DRD and 19% had a high level of DRD [19].
To assess the prevalence of DRD and investigate the associations with informal social support in a Vietnamese setting, we conducted a cross-sectional study among people with T2D .

Study population, setting, and recruitment
This cross-sectional survey collected self-reported questionnaire-based data from people with T2D in Thai Binh province, Vietnam, from December 2018 to February 2019, who had been diagnosed with T2D after the age of 40. Thai Binh is a rural province in the northern part of Vietnam and covers an area of 1,542 km², with a population of 1,860,447 people (2019). The province is divided into seven districts and one major city. Two of these districts, Quynh Phu district and Vu Thu district in the northern and southern parts of the province, respectively, were purposively selected for the present study. From a total of 68 communes in Quynh Phu district and Vu Thu district, we purposively selected four communes in each district as study areas. Two communes had the highest number of T2D people, while the two other communes were neighboring communes of the two selected communes, and convenient for data collection.
We recruited a total of 963 individuals, who resided in the eight selected communes and who were identi ed as having been diagnosed with or treated for T2D at three district hospitals in Vu Thu and Quynh Phu. Among them, 37 (3.8%) refused to participate, and 78 (8.1%) did not stay at the address reported to the hospital or had moved away by the period of data collection. A total of 848 people participated in the cross-sectional survey. Among these, 42 individuals were excluded from the data analysis because they were diagnosed with T2D before the age of 40 or did not remember when they were diagnosed. A total of 806 participants were eligible for the analyses.

Data collection
To collect data, we trained 16 village health workers from 8 selected communes at a 2-day workshop followed by 1-day eld-based training. For the interviews, participants with T2D were contacted by mobile phone or via a personal visit. After the oral and written outline of the project was explained, persons agreeing to participate were asked to sign a consent form. The interviewer conducted the interview faceto-face, using a structured questionnaire (eight domains, 176 questions, including questions about emotional distress and informal support). No other persons were allowed to participate in or observe the interview session. All the participants were interviewed in their home.
Outcome variable DRD was determined based on the short form of Problem Areas in Diabetes scale 5 (PAID 5) [20], containing ve questions: 1) Feeling scared when you think about living with diabetes; 2) Feeling depressed when you think about living with diabetes; 3) Worrying about the future and the possibility of serious complications; 4) Feeling that diabetes is taking up too much of your mental and physical energy every day; and 5) Coping with complications. Answers were scored at ve levels: not a problem (0 points), minor problem (1 point), moderate problem (2 points), somewhat serious problem (3 points), and serious problem (4 points). Thus, the total score can range from zero to 20, and DRD was de ned as a total score of ≥ 8 points [20].

Exposure variables
We chose 6 unmet needs hypothesized to be associated with diabetes distress as these needs are associated with management and requirements for diabetes [9,21]. Unmet needs for informal support were determined by asking 6 questions to people with T2D related to the extent they experienced support from family/friends/community regarding: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support related to any of the above-mentioned items. Answering options were: 1) I receive too little support: 2) I receive adequate support; and 3) I receive too much support. For each item, unmet need for the support was coded as a binary variable with "I receive too little support" coded 1, whereas the other answering options were coded as no unmet need for support, 0. We also created a variable for the total number of unmet needs, categorized as 1, 2, 3, ≥ 4 unmet needs.

Statistical analysis
The descriptive characteristics of people with T2D strati ed by DRD status are presented as frequencies.
Chi-square tests were performed to compare the frequency of DRD by demographic, socio-economic, and health-related characteristics. Statistical signi cance level p < 0.05 was used. We used logistic regression to model DRD as an outcome of each unmet need for informal support to manage diabetes, and as an outcome of total number of types of unmet needs for informal supports. All models were adjusted for age, sex, and household socio-economic status (model 1). As a next step, we further adjusted for selfreported physical health (model 2). Lastly, we also included adjusted for marital status and number of coresiding household members. Results are presented as odd ratios (OR) with 95% con dence interval (95%CI). Data analyses were performed using SPSS (IBM Statistical Package for Social Science software) version 22.

Results
Demographic, socio-economic, and health-related characteristics of people with diabetes-related distress Characteristics of the people with T2D strati ed by DRD status are presented in Table 1

Discussion
In this study, we found that 50.0% of adults with T2D in Thai Binh, Vietnam, had DRD. Prevalence of DRD varied by sex, marital status, occupation, economic situation of household, and physical health. Those with unmet needs for emotional support or nancial support had higher odds of DRD than those with no unmet needs. The study also showed that ORs of DRD increased with increasing number of unmet needs, but after adjustments for socio-economic characteristics, the association was no longer statistically signi cant.
The prevalence of 50.0% DRD in our setting is higher than the prevalence of DRD in some Asian countries (18-27%) [22], but lower than other Asian countries (54.5-63.7%) [23], [24]. Factors such as demographic, socio-economic, biological, and behavioral characteristics are associated with differences in prevalence [25], which may explain the differences in DRD between Asian settings. In addition, in the present study, we assessed DRD through the short form of PAID 5 while other studies used the "Diabetes Distress Scale" [18, [22][23][24], "General Health Questionnaire", and a variety of other methods to access DRD [2], which may also have contributed to differences in DRD prevalence [20,[25][26][27].
Our ndings of women having higher ORs of DRD than men are in line with studies from China [10], Italy [12], and South Africa [11]. Further, in our Vietnamese setting, the difference between men and women may be partly explained by marriage and kinship practices: due to marriage arrangements, women in Vietnam often move far away from their own family to live with their husband's family [28,29]. This could mean that they have fewer relatives to share di culties with, including health related problems. Previous research has shown that living far from one's family can often generate feelings of loneliness and discomfort, making women more susceptible to distress [28][29][30][31]. Moreover, in Vietnam women are, more often than men, in charge of housework, and care of children and old people and other family members [28], which may also add to the feeling of distress.
Those who were unemployed or farmers had higher ORs of DRD than those working in small trade business/worker/government employee/private company, or those who were retired. Studies have shown that nancial stress is associated with diabetes related costs such as medical expenses, travel expenses, and even daily activities, including costs for a particular diet [22]. In addition, a qualitative study from Thai Binh, Vietnam, found that patients with T2D feel "guilty" when they feel that their diabetes status in uences their family's incomes and when they depend on others for help [30].
Five out of six types of unmet needs for informal support were associated with increased ORs of DRD. However, after adjusting for household socio-economic status, only unmet needs for emotional and nancial support were associated with DRD suggesting that most needs are mediated by socio-economic status. Studies shows that emotional support is important for people with diabetes, especially for those with DRD: people with diabetes often want to get help and support in handling their feelings about diabetes [8,32]. Further, the more social support people with diabetes report to receive, including support in handling their feelings about diabetes, the less likely they are to report experiencing emotional distress [6]. A study in India showed that the lack of encouraging discussion with family and friends made DRD worse [4]. In terms of lack of nancial support, other studies have found that patients with T2D can feel that they are a burden for the family, which may contribute to the DRD [8,9].
The observed association between unmet needs for emotional or nancial support and DRD may also re ect speci c contextual family-related social characteristics -rather than a possible causal link between unmet needs for informal support and DRD. Being a member of a family with a low level of positive social interactions and thereby a concurrent high level of unmet needs for support may increase risk of DRD. If so, the observed association is more likely to mirror a link between family dysfunctional aspects and distress rather than contributing to an understanding of the role of unmet needs for support.
After adjustment for household socio-economic status, we did not nd an association between unmet needs for transport and company when visiting health facilities, reminders to take medication, purchase and preparation of food, and reminders to engage in physical exercise, and DRD. In contrast, other studies found that reminders to take medication, diet maintenance, food preparation, support for getting adequate physical exercise, assistance for accessing health services, including transportation to the healthcare center, are signi cant informal support needs for diabetes control in people living with diabetes [8,9]. Another study showed that increase in social support was associated with high medication adherence [33], and it has been demonstrated that poor adherence to dietary advice and medications were associated with DRD [5]. Other studies showed that lower levels of DRD are seen in people who received social support for following a diet, taking medicine, and exercising [6,7]. Lastly, a study from India showed that support from family in cooking most meals was signi cantly associated with lower triglycerides, HbA1c, and cholesterol [34], which are major predictors of DRD [24]. In our study, the people with T2D were outpatients at district hospitals, which in Vietnam means that they were not having severe diabetes-related complications and co-morbidities. Therefore, family members and relatives may have thought the person with T2FD are able to take care of themselves and not in need of informal support related to the needs assessed in this study.
Our ndings showed that increasing number of unmet needs increased the ORs of DRD, which is in line with the result of the studies from other countries that demonstrated that increasing social support and satisfaction with these were associated with lesser DRD [7,8,35]. However, we also found that this association was in uenced by the economic situation of the household in which the person with T2D lived.
A strength of this study is that it is the rst quantitative study in Vietnam assessing DRD, and of the association between unmet needs for informal support and DRD. In addition, we had a high response rate (83.7%). However, the study had some limitations. First, participants were recruited from the list of outpatients at three district hospitals in two districts in Thai Binh province. Therefore, we did not include inpatients, or outpatients from province hospitals, or the national referral hospital, where people with more severe diabetes receive treatment. Therefore, the prevalence of DRD in our study may be lower than if these patients been included. Second, unmet needs for informal support were assessed using six questions, whereas the associations between unmet needs for informal support and DRD may have had other dimensions, such as unmet needs for support for ordinary daily activities or unmet needs for guidance in performing self-management.

Conclusions
This study from Thai Binh, Vietnam, found that 50% of people living with diabetes have DRD. Unmet needs for emotional and nancial support from family and/or relatives increased the odds of DRD. Thus, our research suggests that enhanced informal support may contribute to prevent or reverse DRD.

Declarations
Ethics approval and consent to participate The study followed ethical guidelines developed by CIOMS (Council for International Organization of Medical Sciences). Both oral and written informed consent were obtained from all research participants and con dentiality was guaranteed. Ethical approval of the project was granted by the Ethics Committee for Biomedical Research of Thai Binh University of Medicine and Pharmacy (decision 11/2018, 23rd November 2018).

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.