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 financial 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 significant.
The prevalence of 50.0% DRD in our setting is higher than the prevalence of DRD in some Asian countries (18–27%) , but lower than other Asian countries (54.5–63.7%) , . Factors such as demographic, socio-economic, biological, and behavioral characteristics are associated with differences in prevalence , 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, 22–24], “General Health Questionnaire”, and a variety of other methods to access DRD , which may also have contributed to differences in DRD prevalence [20, 25–27].
Our findings of women having higher ORs of DRD than men are in line with studies from China , Italy , and South Africa . 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 difficulties 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 [28–31]. Moreover, in Vietnam women are, more often than men, in charge of housework, and care of children and old people and other family members , 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 financial stress is associated with diabetes related costs such as medical expenses, travel expenses, and even daily activities, including costs for a particular diet . In addition, a qualitative study from Thai Binh, Vietnam, found that patients with T2D feel “guilty” when they feel that their diabetes status influences their family’s incomes and when they depend on others for help .
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 financial 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 . A study in India showed that the lack of encouraging discussion with family and friends made DRD worse . In terms of lack of financial 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 financial support and DRD may also reflect specific 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 find 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 significant 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 , and it has been demonstrated that poor adherence to dietary advice and medications were associated with DRD . 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 significantly associated with lower triglycerides, HbA1c, and cholesterol , which are major predictors of DRD . 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 findings 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 influenced by the economic situation of the household in which the person with T2D lived.
A strength of this study is that it is the first 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.