Demographic, social, and clinical characteristics, personality traits, and quality of life
The demographic, social, and clinical characteristics of participants, as well as their personality traits and quality of life, are summarized in Table 1. A total of 300 participants were enrolled in the study. The median age of the participants was 63 years (IQR = 16 years). Approximately half of the participants were males (n = 158, 52.7%). More than half of the participants were Malays (n = 195, 65.0%) and a similar proportion of participants were Muslim (n = 199, 66.3%). Large proportion of the participants also agreed that they had regular religious practice (n= 237, 79.0%). The majority of participants were married (n = 231, 77.0%), and an almost equal proportion of participants received up to a secondary level of education (n = 133, 44.3%) or a tertiary level of education (n = 119, 39.7%). A minority of participants were retired (n = 123, 41%), and slightly more than half were earning less than RM 3000 per month (n = 166, 55.3%). The majority of participants perceived that they had good social support, with 80.3% (n = 241) of participants ‘agreeing’ with adequate social support. The majority of participants had never smoked (n = 216, 72.0%), had never consumed alcohol (n = 271, 90.3%), and had no history of recreational drug use (n = 294, 98%).
With regard to clinical characteristics, the majority of participants were diagnosed with type 2 diabetes mellitus (n = 269, 89.7%), while a minority had been diagnosed with type 1 diabetes mellitus (n = 22, 7.3%) or gestational diabetes mellitus (n = 6, 2.0%). The median duration of diabetes diagnosis was 14 years (IQR = 12 years), while the median HbA1C measurement was 7.6% (IQR = 2.7%). Almost half of the participants were on insulin therapy (n = 138, 46.0%). More than half of the participants perceived that they managed their illness well; in fact, 71.3% (n = 214) of participants ‘agreed’ with the statement ‘I am able to manage my diabetes well’. Almost half (49.0%, n = 147) of participants were overweight (BMI 25–30), while 26.0% (n = 78) were obese (BMI > 30).
Screening with the GAD-7 indicated that only a small proportion of the participants had anxiety (9%, n = 27), while BDI-II screening revealed that a relatively larger proportion of participants had depression (20%, n = 60). In BFI assessment, the median of extraversion was 3.38 (IQR = 0.75), agreeableness was 3.78 (IQR = 0.43), conscientiousness was 3.67 (IQR = 0.60), neuroticism was 2.50 (IQR = 0.73), and openness was 3.30 (IQR = 0.60). The WHOQOL-BREF screening revealed that the median of the physical health score was 14.29 (IQR = 3.43), the psychological score was 15.33 (IQR = 2.67), the social relationships score was 16.00 (IQR= 2.67), and the environment score was 15.00 (IQR = 2.50). The mean and standard deviation (SD) of the BFI subscale scores and the WHOQOL-BREF domain scores are summarized in Table S1 in Additional file 1 (supplementary information).
Table 1. Socio-demographic, social and clinical characteristics of the participants.
|
Variables
|
N
|
%
|
Age (N=300)
|
63a
|
16b
|
Gender
|
|
|
|
Male
|
158
|
52.7
|
|
Female
|
141
|
47.0
|
|
Missing
|
1
|
0.3
|
Ethnicity
|
|
|
|
Malay
|
195
|
65.0
|
|
Chinese
|
54
|
18.0
|
|
Indian
|
44
|
14.7
|
|
Others
|
7
|
2.3
|
Marital status
|
|
|
|
Married
|
231
|
77.0
|
|
Single
|
24
|
8.0
|
|
Divorced/widowed
|
43
|
14.3
|
Education
|
|
|
|
None
|
7
|
2.3
|
|
Primary
|
38
|
12.7
|
|
Secondary
|
133
|
44.3
|
|
Tertiary
|
119
|
39.7
|
|
Missing
|
3
|
1.0
|
Employment
|
|
|
|
Employed
|
80
|
26.7
|
|
Unemployed
|
94
|
31.3
|
|
Retired
|
123
|
41.0
|
|
Missing
|
3
|
1.0
|
Household income
|
|
|
|
<RM3,000
|
166
|
55.3
|
|
RM3,000-6,000
|
57
|
19.0
|
|
>RM6,000
|
61
|
20.3
|
|
Missing
|
16
|
5.3
|
Religion
|
|
|
|
Islam
|
199
|
66.3
|
|
Buddhism
|
37
|
12.3
|
|
Hindusim
|
35
|
11.7
|
|
Christianity
|
23
|
7.7
|
|
Others
|
4
|
1.3
|
|
Missing
|
2
|
0.7
|
Regular religious practice
|
|
|
|
Disagree
|
19
|
6.3
|
|
Neutral
|
43
|
14.4
|
|
Agree
|
237
|
79.0
|
|
Missing
|
1
|
0.3
|
Smoking
|
|
|
|
Never
|
216
|
72.0
|
|
Ex-smoker
|
64
|
21.3
|
|
Current smoker
|
20
|
6.7
|
Alcohol use
|
|
|
|
Yes
|
26
|
8.7
|
|
No
|
271
|
90.3
|
|
Missing
|
2
|
0.7
|
Recreational drug use
|
|
|
|
Yes
|
5
|
1.7
|
|
No
|
294
|
98.0
|
|
Missing
|
1
|
0.3
|
Perceived social support
Very poor
Poor
Neutral
Good
Very good
Missing
|
|
2
8
48
165
76
1
|
0.7
2.7
16.0
55.0
25.3
0.3
|
Diabetes type
|
|
|
|
Type 1
|
22
|
7.3
|
|
Type 2
|
269
|
89.7
|
|
Gestational
|
6
|
2.0
|
|
Missing
|
3
|
1.0
|
Duration of DM (years) (N=229)
|
14a
|
12b
|
Insulin therapy
|
|
|
|
Yes
|
138
|
46.0
|
|
No
|
114
|
38.0
|
|
Missing
|
48
|
16.0
|
HbA1c (%) (N=268)
|
7.6a
|
2.7b
|
Diabetic control
|
|
|
|
Good
|
92
|
30.7
|
|
Poor
|
208
|
69.3
|
"I am able to manage my diabetes well"
|
|
|
|
Disagree
|
15
|
5.0
|
|
Neutral
|
70
|
23.4
|
|
Agree
|
214
|
71.3
|
|
Missing
|
1
|
0.3
|
Obesity
|
|
|
|
BMI <25
|
65
|
21.7
|
|
BMI 25-30
|
147
|
49.0
|
|
BMI >30
|
78
|
26.0
|
|
Missing
|
10
|
3.3
|
Hypertension
|
|
|
|
Yes
|
222
|
74.0
|
|
No
|
78
|
26.0
|
Dyslipidaemia
|
|
|
|
Yes
|
152
|
50.7
|
|
No
|
148
|
49.3
|
Ischaemic heart disease
|
|
|
|
Yes
|
82
|
27.3
|
|
No
|
218
|
72.7
|
Stroke
|
|
|
|
Yes
|
27
|
9.0
|
|
No
|
273
|
91.0
|
Renal disease
|
|
|
|
Yes
|
53
|
17.7
|
|
No
|
247
|
82.3
|
Anxiety (GAD-7)
|
|
|
|
Yes
|
27
|
9.0
|
|
No
|
273
|
91.0
|
Depression (BDI)
|
|
|
|
No/minimal
|
240
|
80.0
|
|
Mild to moderate
|
41
|
13.7
|
|
Moderate to severe
|
17
|
5.7
|
|
Severe
|
2
|
0.7
|
WHOQOL-BREF
|
|
|
Overall perception of QOL
|
|
|
|
Very poor
|
3
|
1.0
|
|
Poor
|
5
|
1.7
|
|
Neither poor nor good
|
89
|
29.7
|
|
Good
|
162
|
54.0
|
|
Very good
|
41
|
13.7
|
Overall perception of health
|
|
|
|
Very dissatisfied
|
1
|
0.3
|
|
Dissatisfied
|
37
|
12.3
|
|
Neither satisfied nor dissatisfied
|
131
|
43.7
|
|
Satisfied
|
121
|
40.3
|
|
Very satisfied
|
10
|
3.3
|
WHOQOL-BREF domains (N=300)
|
|
|
|
Physical health
|
63.00a
|
19.00b
|
|
Psychological
|
69.00a
|
13.53b
|
|
Social relationships
|
75.00a
|
19.00b
|
|
Environment
|
69.00a
|
12.00b
|
BFI subscales (N=300)
|
|
|
|
Extraversion
|
3.38a
|
0.75b
|
|
Agreeableness
|
3.78a
|
0.43b
|
|
Conscienciousness
|
3.67a
|
0.60b
|
|
Neuroticism
|
2.50a
|
0.73b
|
|
Openness
|
3.30a
|
0.60b
|
a= Median; b= Interquartile range (IQR)
|
|
|
|
|
|
The association between demographic, social, and clinical characteristics, personality traits and quality of life, and anxiety among participants
The findings of the univariate logistic regression analyses examining associations between demographic, social, and clinical characteristics, personality traits, quality of life, and anxiety are summarized in Table 2. The demographic characteristics associated with anxiety (p < 0.25) were ethnicity, employment status, household income, and regular religious practice. There were no significant association between history of cigarette smoking, alcohol intake, and recreational drug use, and anxiety. On the contrary, there were several clinical characteristics, personality traits, and quality of life components which were associated with anxiety. The variables which were associated with anxiety include self-perceived diabetic management, depression, overall perception of QOL, overall perception of health, physical quality of life, psychological quality of life, social quality of life, environmental quality of life, extraversion, agreeableness, conscientiousness, neuroticism, openness scores, and the interaction between perceived social support and neuroticism.
Table 2. The association between individual socio-demographic, social and clinical characteristics, and anxiety among participants.
Variables
|
Crude OR (95% CI)
|
p-value
|
Age
Gender:
Male
Female
Ethnicity:
Non-Malays
Malays
Marital status:
Married
Not married
Education:
Secondary & below
Tertiary
Employment:
Employed
Unemployed
Retired
Household income:
<RM3,000
RM3,000-6,000
>RM6,000
Regular religious practice:
Disagree
Neutral
Agree
Perceived social support:
Poor
Neutral
Good
Cigarette smoking:
Non-smoker
Smoker
Alcohol:
No
Yes
Recreational drug use:
No
Yes
Obesity:
BMI <25
BMI 25-30
BMI >30
Diabetes mellitus type:
Type I or gestational diabetes
Type II diabetes
Insulin therapy:
No
Yes
Good self-perceived diabetic management:
Disagree
Neutral
Agree
Diabetic control:
Good
Poor
Depression:
No depression
Depression
Overall perception of QOL:
Poor/very poor
Neutral
Good/very good
Overall perception of health:
Poor/very poor
Neutral
Good/very good
WHOQOL-BREF domains:
Physical health
Psychological
Social relationships
Environment
BFI subscales:
Extraversion
Agreeableness
Conscientiousness
Neuroticism
Openness
Neuroticism x perceived social support
|
0.99 (0.96- 1.02)
1
0 .75 (0 .34- 1.68)
1
0 .39 (0.18- 0.88)
1
1.73 (0.58- 5.17)
1
1.05 (0.47- 2.35)
1
0.53 (0.20- 1.36)
0.34 (0.13- 0.91)
1
0.41 (0.12-1.42)
0.38 (0.11-1.32)
1
0.18 (0.03-1.06)
0.34 (0.10-1.11)
1
1.05 (0.19-5.76)
0.26 (0.05-1.36)
1
1.58 (0.69-3.61)
1
0.38 (0.05-2.93)
1
2.59 (0.28-24.01)
1
1.99 (0.64-6.14)
1.33 (0.36-4.94)
1
2.74 (0.36-21.00)
1
1.51 (0.64-3.57)
1
0.19 (0.05-0.69)
0.10 (0.03-0.31)
1
1.61 (0.63-4.13)
1
36.68 (12.00-112.06)
1
0.10 (0.02-0.48)
0.03 (0.01-0.14)
1
0.18 (0.07-0.46)
0.09 (0.03-0.27)
0.72 (0.61-0.85)
0.48 (0.38-0.62)
0.61 (0.51-0.74)
0.60 (0.48-0.56)
0.38 (0.17-0.85)
0.20 (0.07-0.54)
0.52 (0.22-1.23)
16.84 (6.16-40.01)
1.91 (0.85-4.29)
1.24 (1.06-1.46)
|
0.585
0.485
0.022*
0.331
0.905
0.186*
0.032*
0.158*
0.127*
0.058*
0.074*
0.953
0.311
0.276
0.354
0.403
0.254
0.667
0.333
0.350
0.011*
< 0.001*
0.322
< 0.001*
0.004*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
0.018*
0.001*
0.135*
< 0.001*
0.119*
0.009*
|
* p-value < 0.25
The association between demographic, social, and clinical characteristics, personality traits and quality of life, and depression among participants
The findings of the univariate logistic regression analyses examining the associations between demographic, social, and clinical characteristics, personality traits, quality of life, and depression among participants are summarized in Table 3. There were four demographic characteristics associated with depression (p < 0.25), such as age, employment status, household income, and regular religious practice. There were no significant associations between social characteristics and depression among participants. Several clinical characteristics, personality traits, and quality of life components were associated with depression. The variables which were associated with depression include self-perceived diabetic management, anxiety, overall perception of QOL, overall perception of health, physical quality of life, psychological quality of life, social quality of life, environmental quality of life, extraversion, agreeableness, conscientiousness, neuroticism scores, and the interaction between perceived social support and neuroticism.
Table 3. The association between socio-demographic, social and clinical characteristics, and depression among participants.
Variables
|
Crude OR (95% CI)
|
p-value
|
Age
Gender:
Male
Female
Ethnicity:
Non-Malays
Malays
Marital status:
Married
Not married
Education:
Secondary & below
Tertiary
Employment:
Employed
Unemployed
Retired
Household income:
<RM3,000
RM3,000-6,000
>RM6,000
Regular religious practice:
Disagree
Neutral
Agree
Perceived social support:
Poor
Neutral
Good
Cigarette smoking:
Non-smoker
Smoker
Alcohol:
No
Yes
Recreational drug use:
No
Yes
Obesity:
BMI <25
BMI 25-30
BMI >30
Diabetes mellitus type:
Type I or gestational diabetes
Type II diabetes
Insulin therapy:
No
Yes
Good self-perceived diabetic management:
Disagree
Neutral
Agree
Diabetic control:
Good
Poor
Anxiety:
No anxiety
Anxiety
Overall perception of QOL:
Poor/very poor
Neutral
Good/very good
Overall perception of health:
Poor/very poor
Neutral
Good/very good
WHOQOL-BREF domains:
Physical health
Psychological
Social relationships
Environment
BFI subscales:
Extraversion
Agreeableness
Conscientiousness
Neuroticism
Openness
Neuroticism x social support
|
0.98 (0.96- 0.99)
1
0.76 (0.43- 1.34)
1
0.84 (0.47- 1.50)
1
1.05 (0.53- 2.08)
1
0.85 (0.48- 1.53)
1
0.91 (0.46- 1.81)
0.42 (0.20- 0.87)
1
0.96 (0.41-1.97)
0.36 (0.14-0.89)
1
0.24 (0.07-0.78)
0.22 (0.08-0.58)
1
2.40 (0.46-12.57)
0.79 (0.16-3.87)
1
1.13 (0.61-2.10)
1
0.50 (0.14-1.71)
1
0.98 (0.11-9.10)
1
1.32 (0.64-2.75)
1.02 (0.44-2.39)
1
1.11 (0.40-3.06)
1
0.83 (0.46-1.47)
1
0.49 (0.16-1.53)
0.20 (0.07-0.59)
1
1.42 (0.74-2.70)
1
36.68 (12.00-112.06)
1
0.14 (0.03-0.73)
0.05 (0.01-0.28)
1
0.46 (0.21-0.98)
0.20 (0.09-0.46)
0.66 (0.58-0.76)
0.58 (0.49-0.61)
0.68 (0.59-0.77)
0.66 (0.56-0.78)
0.50 (0.28-0.89)
0.36 (0.18-0.73)
0.33 (0.17-0.63)
5.54 (3.02-10.18)
1.23 (0.70-2.17)
1.19 (1.06-1.33)
|
0.030*
0.341
0.545
0.890
0.596
0.788
0.019*
0.916
0.027*
0.018*
0.002*
0.300
0.773
0.700
0.268
0.988
0.454
0.962
0.840
0.513
0.218*
0.004*
0.289
< 0.001*
0.019*
< 0.001*
< 0.045*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
< 0.001*
0.018*
0.004*
0.001*
< 0.001*
0.476
0.004*
|
* p-value < 0.25
Stepwise multiple logistic regression analyses between various factors and anxiety among participants
The findings of stepwise multiple logistic regression analyses between demographic characteristics (ethnicity, employment, household income, and practice of religion), clinical factors (co-morbid depression), personality traits (extraversion, agreeableness, neuroticism, conscientiousness, openness, and the interaction between perceived social support and neuroticism), quality of life (overall perception of QOL, overall perception of health, physical, psychological, social, and environmental QOL), and anxiety among participants are summarized in Table 4. There were only a few factors predictive of anxiety among participants. Participants who were depressed (adjusted OR = 9.89, 95% CI = 2.63- 37.14, p = 0.001) with higher neuroticism scores (adjusted OR = 11.66, 95% CI = 2.69-50.47, p = 0.001) had higher odds of having anxiety. On the contrary, lower odds of anxiety was associated with higher psychological scores on the quality of life questionnaire (adjusted OR = 0.47, 95% CI = 0.29-0.75, p = 0.002) and higher conscientiousness scores (adjusted OR = 0.45, 95% CI = 0.23-0.80, p = 0.004). Other demographic characteristics, personality traits, and QOL components were not significant predictors of occurrence of anxiety among the participants. The logistic regression model reported a Cox and Snell R2 of 0.29 (p < 0.001), Hosmer-Lemeshow goodness-of-fit test was not significant (p = 0.843) and the area under the ROC curve (AUC) of 0.949 (95% CI= 0.912-0.986, p < 0.001), indicating acceptable fit of the model to discriminate participants with presence and absence of anxiety.
Table 4. Stepwise multiple logistic regression model between various factors and anxiety among participants.
Variables
|
Adjusted ORa (95% CI)
|
p-value
|
Depression:
No depression
Depression
Psychological domain of WHOQOL-BREF
Conscientiousness
Neuroticism
|
1
9.89 (2.63- 37.14)
0.47 (0.29-0.75)
0.45 (0.23-0.80)
11.66 (2.69-50.47)
|
0.001*
0.002*
0.004*
0.001*
|
*Statistical significance at p < 0.05, a The stepwise logistic regression model indicated ethnicity, employment, household income, practice of religion, perceived diabetic management, overall perception of QOL, overall perception of health, physical, social relationship and environment domains of QOL, extraversion, agreeableness, openness personality traits, and neuroticism x perceived social support were not significantly associated with anxiety among the participants. The model reported reported Cox and Snell R2 = 0.29, p < 0.001, Hosmer-Lemeshow goodness-of-fit test (p = 0.843), and the area under the receiver operating characteristic curve (AUC) = 0.949 (95% CI= 0.912-0.986, p < 0.001).
Stepwise multivariate logistic regression analyses between various factors and depression among participants
The findings of stepwise multivariate logistic regression analyses between demographic characteristics (age, employment, household income, and practice of religion), clinical factors (co-morbid anxiety and perceived diabetic management), personality traits (extraversion, agreeableness, conscientiousness, neuroticism, and the interaction between perceived social support and neuroticism), quality of life (overall perception of QOL and health, physical, psychological, social, and environmental QOL), and depression among participants are summarized in Table 5. The only clinical factor associated with higher odds of depression was anxiety, which increased the occurrence of depression by almost 20-fold (adjusted OR = 19.83, 95% CI = 5.63- 69.92, p < 0.001). On the contrary, older age (adjusted OR = 0.96, 95% CI = 0.93-0.98, p = 0.002), higher physical health quality of life scores (adjusted OR = 0.69, 95% CI = 0.58-0.83, p < 0.001), and higher social quality of life scores (adjusted OR = 0.84, 95% CI = 0.71- .0.99, p = 0.047) were associated with lower odds of occurrence of depression. Perceived diabetic management, other demographic characteristics, personality traits, and QOL components did not significantly predict depression among the participants. The logistic regression model reported a Cox and Snell R2 of 0.294 (p < 0.001), Hosmer-Lemeshow goodness-of-fit test was not significant (p = 0.447) and the area under the ROC curve (AUC) of 0.851 (95% CI= 0.793-0.909, p < 0.001), indicating acceptable fit of the model to discriminate participants with presence and absence of depression.
Table 5. Stepwise multiple logistic regression model between various factors and depression among participants.
Variables
|
Adjusted ORa (95% CI)
|
p-value
|
Age
Anxiety:
No
Yes
Physical domain of WHOQOL-BREF
Social relationship domain of WHOQOL-BREF
|
0.96 (0.93-0.98)
1
19.83 (5.63- 69.92)
0.69 (0.58-0.83)
0.84 (0.71- .0.99)
|
0.002*
< 0.001*
< 0.001*
0.047*
|
*Statistical significance at p < 0.05, a The stepwise logistic regression model indicated employment, household income, practice of religion, perceived diabetic management, overall perception of QOL, overall perception of health, psychological and environment domains of QOL, extraversion, agreeableness, conscientiousness, neuroticism personality traits, and neuroticism x perceived social support were not significantly associated with depression among the participants. The model reported reported Cox and Snell R2 = 0.294, p < 0.001, Hosmer-Lemeshow goodness-of-fit test (p = 0.447), and the area under the receiver operating characteristic curve (AUC) = 0.851 (95% CI= 0.793-0.909, p < 0.001).