پریشانی دیابت و خصوصیات محله ای در افراد مبتلا به دیابت نوع 2

Objective Diabetes-specific distress is an important psychological issue in people with diabetes. The neighborhood environment has the potential to be an important factor for diabetes distress. This study investigates the associations between neighborhood characteristics and diabetes distress in adults with type 2 diabetes. Methods We used cross-sectional data from a community-based sample of 578 adults with type 2 diabetes from Quebec, Canada. Information on perceived neighborhood characteristics and diabetes distress was collected from phone interviews. We used factor analysis to combine questionnaire items into neighborhood factors. Information on neighborhood deprivation was derived from census data. We performed linear regressions for diabetes distress and specific domains of diabetes distress (emotional, regimen-related, physician-related and interpersonal distress), adjusting for individual-level variables. Results Factorial analysis uncovered 3 important neighborhood constructs: perceived order (social and physical order), culture (social and cultural environment) and access (access to services and facilities). After adjusting for individual-level confounders, neighborhood order was significantly associated with diabetes distress and all specific domains of distress; neighborhood culture was specifically associated with regimen-related distress; and neighborhood access was specifically associated with physician-related distress. The objective measure of neighborhood material deprivation was associated with regimen-related distress. Conclusions Neighborhood characteristics are associated with diabetes distress in people with type 2 diabetes. Clinicians should consider the neighborhood environment reported by their patients with diabetes when assessing and addressing diabetes-specific distress.

The prevalence of diabetes in Canada is estimated at 5.5% and is expected to increase steadily in coming years [1]. Individuals living with diabetes often face lifelong self-management regimens often involving significant changes in their lifestyle and adherence to complex medication procedures. Individuals with diabetes also need to prevent and manage diabetes complications, concurrent health problems and functional limitations [1] and [2]. Diabetes distress is a multi-domain construct which captures the worry, frustration and discouragement that may accompany life with diabetes. It encompasses regimen-related distress, physician-related distress, emotional burden and diabetes-related interpersonal distress [3], [4] and [5]. Distress over diabetes regimen relates to the worries and discouragements that patients may have about self-managing their disease, such as perceived difficulties in following their diet or maintaining their diabetes routine [6], [7] and [8]. Distress related to physician includes concerns about access to healthcare and quality of care, such as worries that recommendations provided by healthcare professionals may be incomplete [6] and [9]. Emotional burden is another source of diabetes distress that refers to the negative mental and emotional aspects of life with diabetes. This includes feelings such as despair, anger or fear when thinking about a lifetime with diabetes or feeling overwhelmed by the demands of diabetes. Finally, interpersonal distress such as lack of social support may contribute to diabetes distress by limiting emotional support or making it more difficult to maintain a healthy lifestyle [6]. Diabetes distress is a psychological issue distinct from depression and anxiety [10]. It has been found to be more common and persistent than depression in people with diabetes [5], [10] and [11]. It is associated with poorer glycemic control, self-care behaviors and medication adherence, even above and beyond depressive symptoms [12], [13], [14], [15] and [16]. Although diabetes distress is an important outcome for people with diabetes, relatively little is known of the predictors and correlates of diabetes distress. One study identified individual-level variables associated with diabetes distress, including a greater number of diabetes complications, negative life events or chronic stress, a history of depression and an unhealthy lifestyle [17]. The neighborhood where people live could be an important additional factor for diabetes distress. People with diabetes are often recommended to exercise more frequently and improve their diet. Living in a neighborhood with limited access to healthy food and safe places to exercise can be an important barrier for diabetes self-care [18] and may be a source of diabetes distress. A lack of community resources and support may also limit a person's ability to manage and function with their diabetes [19]. Neighborhood factors have further been linked to physical health outcomes and complications in people with diabetes [19] and [20], which could affect distress. Only one study investigated the link between neighborhood environment and mental wellbeing in people with diabetes [21]. Results showed an association between neighborhood socioeconomic status and depressive symptoms in a clinical sample of obese patients with type 2 diabetes. No study has specifically focused on neighborhood factors in diabetes distress. The primary objective of this study was to investigate the associations between a range of neighborhood characteristics and diabetes distress, in a representative sample of adults with type 2 diabetes. The secondary objective was to examine the association between neighborhood characteristics and the specific domains of diabetes distress (regimen-related, physician-related, emotional, interpersonal distress).

The objective of this paper was to investigate the associations between a range of neighborhood characteristics and diabetes distress in adults with type 2 diabetes. Results suggest that individuals who report living in neighborhood with better physical and social order had lower overall diabetes distress than those who reported less favorably on neighborhood order, even after adjusting for socioeconomic and health variables. A better perceived neighborhood social and cultural environment was also associated with lower diabetes distress for women but not for men. Evidence suggests that different aspects of the neighborhood are associated with different domains of diabetes distress. Neighborhoods with less material deprivation and better perceived cultural and social environment were specifically associated with lower regimen-related distress and neighborhoods with better perceived access to resources and services were associated with lower physician-related distress. Several studies have found a significant association between the neighborhood environment and psychological wellbeing in the general population [31] and [32] and in subgroups with diabetes and other chronic conditions [21] and [33]. Our study adds to this growing literature by being the first to examine aspects of the neighborhood associated with diabetes distress. It is the first to examine factors related to the specific sub-domains of diabetes distress. It is also the first to investigate a range of neighborhood characteristics that relate to mental health in people with diabetes. Perceived neighborhood physical and social order was associated with lower global and domain-specific diabetes distress in our sample. The concept of neighborhood disorder in social psychology suggests that areas characterized by physical disorder (such as deteriorated buildings, graffiti, noise and trash) and social disorder (such as crime and vandalism) instill fear and mistrust in residents, which in turn affects their mental well-being, their interactions with each other and their view of the environment [34] and [35]. Conversely, living in communities with high physical and social order might protect against diabetes-related interpersonal distress by providing opportunities for social connection and community support in a perceived safe environment [36]. Neighborhoods perceived as safe and orderly might also protect against regimen-related diabetes distress by facilitating outdoor physical activities such as walking or other forms of active transportation [37]. The perceived cultural and social neighborhood environment was particularly important for regimen-related distress. This neighborhood factor captures aspects of social cohesion and social norms of health in the community. Numerous studies have shown that social norms and values are determinants of self-efficacy and healthy behaviors [38], [39], [40] and [41]. In spite of good knowledge of diabetes self-care recommendations, people with diabetes might struggle to maintain a healthy lifestyle when their efforts are not valued by their community. Evidence suggests that social cohesion also relates to healthy behaviors such as adherence to treatment [42]. Social cohesion represents the ties, solidarity and connectedness among individuals living in the neighborhood. Socially cohesive neighborhoods could provide people with diabetes with a wider social network, greater social support and locally available assistance to help deal with the burden of managing their diabetes. Further, it is hypothesized that social cohesion facilitates sharing of information among community members, which could provide people with diabetes with better knowledge of available services and resources to self-manage their illness. In addition to regimen-related distress, we found that the perceived cultural and social neighborhood characteristics were relevant to global diabetes distress specifically in women. Others have also reported social elements of neighborhood to be more important in women than in men for mental health outcomes [43]. Women may be more sensitive to the social cues and norms of health behaviors in their neighborhood environment or may derive greater benefits from neighborhood social cohesion than men [44] and [45]. Perceived neighborhood access to services and resources was specifically associated with physician-related diabetes distress. Physician-related diabetes distress is a measure of satisfaction and trust in the diabetes-related services provided by the physician. Access to medical services in the neighborhood, or access to transportation to medical services outside the neighborhood, might allow patients with diabetes to seek satisfactory healthcare for their diabetes. Neighborhood deprivation was not associated with global diabetes distress, but material deprivation was related to regimen-related distress in our sample. Communities with more material resources may be better equipped to provide people with diabetes with the support that they need for their regimen. Because data in this study were cross-sectional, it is not possible to make inferences on the direction of causality. Although the neighborhood environment could be a potential risk factor for diabetes distress, it is also possible that people with higher levels of diabetes distress report worse neighborhood characteristics because they are distressed. Individuals with high general distress could also be more likely to report poor neighborhood environments and diabetes distress. Additional information on general distress would help to determine whether people are distressed because of their diabetes, or because they are distressed in general. Further, the association between poorly perceived neighborhood environment and diabetes distress could be a due to lack of knowledge about the available neighborhood resources for people with diabetes. For example, individuals with high levels of regimen-related diabetes distress could report fewer neighborhood resources to help with diabetes management because they are unaware of these services and facilities in their communities. All survey data were self-reported which has potential for measurement error. Perceived neighborhood characteristics may not reflect objective characteristics. For instance, some individuals may misestimate availability of healthy food in their neighborhood [46]. When measuring perceived neighborhoods, neighborhood geographic boundaries were defined by participants in the survey, which may depend on individual-level factors, such as physical mobility. This study focused on individuals living in urban and semi-urban areas and findings may therefore not be generalizable to rural areas. Finally, the list of neighborhood characteristics examined in this study was extensive but not exhaustive. Other elements of the neighborhood environment could be important to diabetes distress. This study is the first to investigate the neighborhood characteristics that relate to diabetes distress. It used a large representative sample of adults with type 2 diabetes and used both objective and subjective measures to characterize the neighborhood environment. We adjusted for important individual-level confounders. We carefully considered correlation issues in our analysis by combining items using factorial analysis and we accounted for missing data using multiple imputations in sensitivity analyses. Neighborhood characteristics are relevant to diabetes distress in adults with type 2 diabetes, above and beyond the characteristics of individuals. Findings from this study have important clinical and public health implications for the management of diabetes. Clinicians should consider the neighborhood environment of their patients when assessing and addressing diabetes distress. Namely, clinicians are encouraged to discuss available neighborhood resources to help their patients deal with the stress of life with diabetes. Clinicians should also consider potential barriers in the neighborhood environment of their patients to manage life with diabetes. For instance, patients that report living in an area that they perceive as unsafe or threatening could be referred to safer perceived neighboring community centers for the practice of physical activity. Perception of poor neighborhood resources could also be an indicator of diabetes distress. Policy-makers should also consider urban and community policies that enhance neighborhood physical and social capital to protect the mental wellbeing of individuals with diabetes. For example, evidence from this study suggests that diabetes distress could be reduced by improving physical order in neighborhoods, such as trash and graffiti clean-up and restoration of buildings and green spaces. Further research is recommended to elucidate the direction of causality between the neighborhood environment and diabetes distress and intervention studies may be warranted to investigate strategies by which to reduce diabetes distress under unfavorable neighborhood conditions.