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Individuals with diabetes face many multifaceted issues when integrating their plan of care into their daily lives, which can become burdensome and lead to inadequate diabetes control. Due to the persistent demands of diabetes management, screening for psychosocial factors that can impact control, such as depression, anxiety, and diabetes-related distress (DRD) should occur routinely (American Diabetes Association [ADA], 2017). DRD is distinctly different from depression in that the focus is on the burden experienced due to the rigorous treatment regimen associated with diabetes. DRD focuses on the self-management demands, complications, comorbidities, and lack of perceived social support (ADA, 2019). DRD can affect treatment compliance and lead to negative health outcomes, including more frequent hospitalizations and higher healthcare costs. Therefore, early screening and detection of psychosocial factors influencing management is essential to prevent health complications and deterioration. The purpose of this practice improvement project was to implement DRD screening in a rural North Dakota clinic. Rural providers were educated on DRD and the use of an evidenced-based screening tool called the Problems Areas in Diabetes (PAID) scale. This self-report scale allows providers to make appropriate referrals to diabetes educators, dieticians, and mental health professionals, which may result in individualized treatment plans and improved outcomes. The project implementation was comprised of an educational session focused on DRD that included a pre- and post-test, as well as return skill demonstration where attendees were asked to score a mock patient’s PAID scale. Following the educational session, the PAID scale was implemented at diabetic appointments for a three-month period. Positive PAID scale results were monitored to determine if the positive screenings resulted in a referral or additional resources. Twenty-four scales were completed by patients during the project, resulting in 30 referrals for additional support. Additionally, an increase in healthcare provider knowledge related to DRD evaluation and management was identified. The provision of DRD education and implementation of the PAID scale in this rural primary care clinic enabled patients within the community to receive evidence-based, individualized care, which may potentially reduce complications, as well as improve diabetes control and overall patient health.

This thesis reviews and augments existing evidence surrounding the psychosocial aspects of living with Type 2 diabetes. There is a specific emphasis on the factors which underpin diabetes distress in individuals with Type 2 diabetes, which pertains also to the influence of partners or spouses on psychological adjustment to diabetes. This research develops and presents a conceptual framework of the key determinants of diabetes distress, providing focus and content for an intervention to address distress among couples living with Type 2 diabetes. Chapter 1 introduces the concept of diabetes distress; including prevalence, clinical relevance, and the cognitive, interpersonal and behaviour factors which are believed to drive this condition-specific distress. There is also an emphasis on existing strategies to improve both psychological and medical outcomes in Type 2 diabetes, which identified a need to evolve psychosocial support for individuals who are struggling to manage diabetes. Importantly, this chapter provided a rationale and direction for the studies reported in prospective chapters. Chapter 2 broadens the focus of psychosocial support in diabetes, to consider also the importance of considering partners or spouses in interventions to improve health outcomes in the context of different chronic physical conditions. This systematic review conveys the benefits of partner inclusion in interventions and highlights a number of shortcomings pertaining to couples intervention work. In particular, the review identifies a scarcity of couples intervention work in the context of Type 2 diabetes. The cross-sectional questionnaire study in Chapter 3 captures the predictive influence of illness perception clusters, coping styles, and relationship quality on diabetes distress in individuals with Type 2 diabetes. Of note, this work identifies negative belief and coping patterns which coincide and exacerbate distress, and presents a novel method of distinguishing those most at risk of elevated diabetes distress. Chapter 4 investigates the influence of partners’ diabetes beliefs on diabetes distress over time. This study demonstrates the moderating influence of partners’ illness perceptions on the association between persons with Type 2 diabetes illness perceptions and diabetes distress, and reveals that such effects persist overtime. Furthermore, Chapter 5 explores narratives of diabetes distress among couples living with Type 2 diabetes and among healthcare professionals, by means of individual semi-structured interviews and focus groups. Expanding on the findings of Chapters 3 and 4, this qualitative work compares experiences of distress from the perspectives of individuals with diabetes and those who support them in a personal and professional capacity, in an attempt to understand how communication and interpersonal conflicts might emerge in day to day life. Importantly, Chapter 5 discerns a perceived need for an intervention to reduce diabetes distress in individuals with Type 2 diabetes and their loved ones, and provides direction for the design and implementation of an intervention of this nature. Chapter 6 draws upon existing and primary evidence pertaining to the cognitive, interpersonal, and behavioural factors which underpin diabetes distress, and provides recommendations for the design and implementation of an intervention to address diabetes distress in couples living with Type 2 diabetes. The feasibility study described in Chapter 7 assesses the acceptability, potential effectiveness, and practical implementation of a brief psychoeducational intervention to address diabetes distress in people with Type 2 diabetes and their partners or family members. The findings of Chapter 7 highlight important strengths and shortcomings of providing an intervention of this nature, which are expanded on in the main discussion in Chapter 8. Chapter 8 provides a broad overview of the rationale for this PhD research and reflects on the primary work undertaken to date. Crucially, this discussion chapter provides recommendations on how key strengths of the feasibility study described in Chapter 7 can be enhanced and how observed shortcomings can be addressed in future studies. Finally, there is consideration of how aspects of the intervention described in Chapters 6 and 7 may feasibly be incorporated into existing programmes of diabetes support.

Thesis advisor: Judith A. Vessey / Significance of Problem: Emerging adults (ages 18-30) with type 1 diabetes (T1D) are a specific group that experiences worse glycemic control, more frequent severe hypoglycemia and more frequent diabetic ketoacidosis (DKA) than any other age group. The multiple transitions and stressors associated with the developmental stage of emerging adulthood can magnify and exacerbate the diabetes specific emotional burden of living with T1D, resulting in increased diabetes distress (DD). However, there is no measure of DD specific to the developmental stage of emerging adulthood. Purpose: The purpose of this program of research is to explicate the need for a developmental stage-specific measure of DD, as well as to develop, refine and psychometrically validate a new measure of DD in emerging adults. Method: This multi-phase study employed methods grounded in both item response theory (Rasch analysis) and classical test theory to reduce, refine and validate a new measure of DD in emerging adulthood, entitled the Problem Areas in Diabetes-Emerging Adult version (PAID-EA). In phase 1, data were collected from emerging adults with T1D using a cross-sectional online survey strategy. Rasch methodology was used to reduce and refine the PAID-EA. In phase 2, an additional cross-sectional online survey was conducted using the refined PAID-EA. Classical test theory-based approaches were employed to examine the psychometric properties of the refined measure. Finally, the relationships between scores on the PAID-EA and related constructs and clinical variables were explored. Conclusions: Collectively, this work advances the science by providing insight into how the challenges of emerging adulthood impact life with T1D during this developmental stage and providing a new measure to accurately and validly capture this experience for both clinical and research purposes. / Thesis (PhD) — Boston College, 2021. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Aims: Work-related diabetes distress (WRDD) can be defined as the combination of anxiety and exhaustion to combine work with diabetes in working life and this is a current problem. The aims of this study were to assess the prevalence of WRDD and covariation between WRDD and working life variables relevant to occupational health among professionals diagnosed with type 1 diabetes in Sweden. Method: This is a quantitative cross-sectional study in the form of a survey. The sample was a closed group on Facebook for people with type 1 diabetes, all members were offered to answer a questionnaire with validated questions about psychosocial working conditions, work requirements, work ability, diabetes acceptance and blood sugar levels. To investigate the occurrence of WRDD, descriptive analyses and cross-tabulation were carried out. Logistic regression analysis was used to investigate associations between the dependent variable (WRDD) and the independent variables (psychosocial working conditions, work requirements, work ability, diabetes acceptance and blood sugar levels). Main result: The survey was answered by 191 respondents. The incidence of WRDD in the sample was 71.7%. The multiple logistic regression analysis showed a significant relationship (p <0.05) between the independent variables work ability, blood sugar level, diabetes acceptance, and the dependent variable WRDD. The odds of having WRDD were three times higher in those individuals who experienced poorer work ability, had difficulty accepting their diabetes or maintained a higher blood sugar level at work. Conclusions: The results showed that WRDD is a problem causing working life consequences and should be given more attention both in healthcare and working life. Increased knowledge and understanding of the challenges WRDD can cause for people with type 1 diabetes in working life is necessary to be able to prevent WRDD. / Syfte: Work-related diabetes distress (WRDD) kan definieras som en kombination av oro för och utmattning av att förena arbete med diabetes i arbetslivet och är ett aktuellt problem. Studiens syfte var att studera förekomsten av WRDD och samvariationen mellan WRDD och andra arbetsrelaterade variabler relevanta för arbetshälsa bland yrkesverksamma diagnostiserade med typ 1 diabetes i Sverige. Metod: Studien var en kvantitativ tvärsnittsstudie i form av en enkätundersökning riktad till yrkesverksamma personer med typ 1 diabetes. Urvalet var en sluten grupp på Facebook för personer med typ 1 diabetes, alla medlemmar i gruppen fick erbjudande om att svara på en enkät innehållande validerade frågor om psykosociala arbetsförhållanden, arbetskrav, arbetsförmåga, diabetesacceptans och blodsockernivå. För att undersöka hur förekomsten av WRDD såg ut genomfördes deskriptiva analyser och korstabulering. Logistisk regressionsanalys användes för att undersöka om det fanns samband mellan den beroende variabeln (WRDD) och de oberoende variablerna (psykosociala arbetsförhållanden, arbetskrav, arbetsförmåga, diabetesacceptans och blodsockernivå). Huvudresultat: Enkäten besvarades av 191 respondenter. Förekomsten av WRDD hos de svarande var 71,7%. Den multipla logistiska regressionsanalysen visade ett signifikant samband (p <0.05) mellan arbetsförmåga, blodsockernivå, diabetesacceptans och WRDD. Oddsen för att ha WRDD var tre gånger högre hos de individer som upplevde sämre arbetsförmåga, hade svårt att acceptera sin diabetes eller höll en högre blodsockernivå på arbetet. Slutsatser: Resultaten visade att WRDD är ett problem med arbetslivskonsekvenser som behöver uppmärksammas mer både inom vården och i arbetslivet. Ökad kunskap och förståelse för de utmaningar WRDD kan medföra för personer med typ 1 diabetes i arbetslivet är nödvändigt för att kunna förebygga WRDD.

Objective: Diabetes mellitus is a known epidemic that is increasing throughout the United States and if current trends continue, it is estimated that as many as one in three U.S. adults could have diabetes by 2050. Considerable evidence has been found to link the presence of depression and or Diabetes Distress Syndrome with type two diabetes mellitus. Current studies demonstrate that lack of treatment of Diabetes Distress Syndrome may result in a decrease in medication adherence, participation in diabetic group meetings, and quality of life. The purpose of this study was to examine nurse practitioners (NPs') knowledge, perceptions and attitudes in utilizing behavioral therapy in TTDM management. Research Design and Methods: A total of 20 NPs completed the survey using Qualtrics. Results: suggest that there is a lack of knowledge in regards to Diabetes Distress Syndrome. Current practice for behavioral services in TTDM treatment is also deficient, however, NPs' are willing to learn more and use it as a treatment modality in their practice.

Type 2 diabetes mellitus self-management is a challenging process that brings forward a variety of emotional responses. The purpose of this work was to explore relationships between diabetes distress, self-efficacy and resilience and outcomes of glycosylated hemoglobin, quality of life and health status. A cross sectional descriptive design was used for this pilot study of 78 individuals enrolled from an Endocrine clinic in the Midwest United States and a Primary Care clinic in the southeast United States. Data were analyzed using descriptive statistics to characterize the sample and model variables. Spearman’s correlation was completed to identify relationships among variables. A stepwise building approach was used to identify significant interactions and determine predictors of the study outcomes. The results of this study confirm the presence of facilitators and barriers in type 2 diabetes mellitus self-management and their relationships with distal outcomes. The findings demonstrate that diabetes distress is a predictor of health status and quality of life. The findings of this study provide a link to other facilitator and barrier variables such as provider collaboration, diabetes self-management education, treatment regimen, ethnicity and years since diagnosis which can be incorporated into the comprehensive theoretical model. This study contributes to the understanding of the emotional aspect of diabetes as it relates to self-management of T2DM. Continuing this work will allow researchers to examine and better understand important factors of self-management. This ongoing work will hopefully lead to improved support in self-management efforts and better outcomes.

Psykisk ohälsa är vanligare hos personer med diabetes än befolkningen i stort. Forskning visar att det finns många olika anledningar till denna psykiska ohälsa och lyfter behov av differentiering av allmänna psykiatriska tillstånd och psykisk ohälsa kopplat till diabetesen. Ett begrepp som fångar hur personen förhåller sig till sin diabetes är diabetesrelaterad stress. Studier rapporterar att personer med diabetes upplever skam och självkritik kopplat till sin sjukdom. Självmedkänsla är ett fält inom psykologin som riktar sig specifikt mot skam och självkritik. I denna studie användes enkäter för att undersöka om det finns ett samband mellan grad av självmedkänsla och upplevd diabetesrelaterad stress samt om det finns skillnad i upplevd diabetesrelaterad stress mellan grupper med låg, medel och hög grad av självmedkänsla. Vidare undersöktes om självmedkänsla kunde förutsäga diabetesrelaterad stress, även när psykiskt välmående inkluderades. En enkät publicerades i Facebookgrupper kopplade till diabetes i Sverige och på den svarade 239 personer. Deltagarna var mellan 18 och 75 år, övervägande antalet deltagare var kvinnor. För att analysera data användes korrelationsanalys, ANOVA och Multipla linjära regressioner. Resultaten visade på ett starkt negativt samband mellan självmedkänsla och diabetesrelaterad stress. Gruppjämförelser visade att de grupper som hade högre självmedkänsla hade lägre diabetesrelaterad stress. Detta är i linje med tidigare forskning kring självmedkänsla och hantering av kroniska sjukdomar. Det starka sambandet och gruppjämförelsernas resultat motiverar att undersöka detta område ytterligare. Interventionsstudier i syfte att undersöka eventuell påverkan av självmedkänsla på diabetesrelaterad stress skulle vara relevant, för att i förlängningen utforma riktad behandlingsrekommendationer för just diabetesrelaterad stress. / Mental health problems are more common among people with diabetes than in the population in general. Research shows that there could be several reasons to this, and calls for more clarity regarding causes. Diabetes Distress is a concept that captures how a person handles the demands of living with diabetes. Studies reports that people living with diabetes experiences shame and self-blame regarding their disease. Self-Compassion is a concept which addresses shame and self-blame specifically. This study used questionnaires to investigate if there is a correlation between levels of Self-Compassion and Diabetes Distress, and if there is a difference regarding Diabetes Distress between groups with low, moderate, and high levels of Self-Compassion. The study also examined if Self-Compassion could predict Diabetes Distress, even when mental wellbeing was accounted for. Participants were recruited via Facebook groups connected to diabetes in Sweden and 239 people replied. The participants were between 18 and 75 years old, the majority were female. Correlation, ANOVA and multiple linear regression was used to analyze the collected data. The result showed a strong negative correlation between Self-Compassion and Diabetes Distress. Group comparisons showed that those with higher Self-Compassion had lower Diabetes Distress. This confirms previous research regarding Self-Compassion and coping with chronic illness. The strong correlation and the group comparisons results suggest that further research within this field should be performed. To investigate if Self-Compassion training could affect levels of Diabetes Distress studies including Self-Compassion interventions would be of interest. More research could lead to development of recommendations and care adjusted for those who are experiencing Diabetes Distress.

Literature review part of this thesis focuses on the diabetes mellitus diagnosis and its negative effects on mental health and social relationships of diagnosed patients in form of diabetes distress. The research part investigates change of diabetes distress measured by Diabetes distress scale (DDS) and glycated haemoglobin HbA1c in the beginning, at the end and 6 months after the end of the group educational course. The group consisted of 66 Czech people diagnosed with type 2 diabetes (mean age 62 years, SD = 9,77; median = 63,5). Increased diabetes distress (DDS value ≥ 2) in the 1st measurement of DDS was reported by 15 people out of 52 (29%). There was a significant decrease in HbA1c from the beginning to the end of the course (χ2 (2) = 22.5; p <0,001) and this low level was maintained even after 6 months after the course. A non-significant reduction in diabetes distress between 1st and 2nd measurement was observed in 45 subjects (W = 509; p = 0,098). A statistically significant reduction in diabetes distress was observed between the 1st and 2nd DDS measurement only in those 23 subjects (χ2 (2) = 9,50; p = 0,002) who also participated in 3rd DDS measurement - further research in this area would be appropriate. In our sample, no significant difference was found between the sexes, DDS and HbA1c,...

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