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Health Spiritual Med Ethics 2021, 8(2): 85-94 |
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Panahi T, shahabizadeh F, Mahmoudirad A. The Effects of Acceptance and Commitment Therapy With and Without Compassion on Spiritual Fatalism and Depression in Diabetic Patients. Health Spiritual Med Ethics 2021; 8 (2) :85-94
URL: http://jhsme.muq.ac.ir/article-1-417-en.html
URL: http://jhsme.muq.ac.ir/article-1-417-en.html
1- Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran
2- Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran ,f_shahabizadeh@yahoo.com
3- Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran, AND Department of Internal Medicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
2- Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran ,
3- Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran, AND Department of Internal Medicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
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| Rayhaneh Panahi1 , Fatemeh Shahabizadeh1* , Alireza Mahmoudi Rad1,2 1. Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran. 2. Department of Internal Medicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran. *Corresponding Author: Fatemeh Shahabizadeh, PhD. Address: Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran. Phone: +98 (915) 3319855 E-mail: f_shahabizadeh@yahoo.com Research Paper: The Effects of Acceptance and Commitment Therapy With and Without Compassion on Spiritual Fatalism and Depression in Diabetic Patients Background and Objectives: There exists a relationship between spirituality and depression. Moreover, psychological interventions are effective in this regard. Thus, this study aimed to investigate the effects of Acceptance and Commitment Therapy (ACT) with and without compassion on spiritual fatalism and depression in non-clinically depressed diabetic patients. Methods: This was a quasi-experimental study with a pre-test, post-test and follow-up and a control group design. The statistical population included all non-clinical depressed patients with type 2 diabetes in the welfare centers of Mashhad City, Iran, in 2020. To form 3 research groups using the purposive sampling method, 33 subjects were selected and randomly divided into the study groups. Moreover, after 2 months, a follow-up test was performed on the research groups. The research instruments included the Patient Health Questionnaire (Depression) by Arbi et al. and the Diagnosis Scale of Egede and Ellis Diabetes. Results: The repeated measures analysis of variance data suggested that the ACT approaches with and without compassion intervention were effective in increasing spiritual fatalism (P<0.05) and reducing depression (P<0.05) in the explored nonclinical depressed diabetic patients. Moreover, the follow-up data revealed the stability of the collected results (P<0.05). Conclusion:ACT, as an effective intervention can be used in medical centers to increase spiritual fatalism and reduce depression in diabetic patients with depression vulnerability. A B S T R A C T Keywords: Depression, Fate, Spirituality, Acceptance and Commitment Therapy, Compassion Please cite this article as Panahi R, Shahabizadeh F, Mahmoudi Rad A. The Effects of Acceptance and Commitment Therapy With and Without Compassion on Spiritual Fatalism and Depression in Diabetic Patients. Health, Spirituality and Medi cal Ethics Journal. 2021; 8(2):85-94. http://dx.doi.org/10.32598/hsmej.8.2.3 :http://dx.doi.org/10.32598/hsmej.8.2.3 Use your device to scan and read the article online Article info: Received: 22 Dec 2020 Accepted: 29 Jan 2021 Publish: 01 Jun 2021 |
| 86 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| Introduction iabetes significantly impacts the health care system and its prevalence is increas ing worldwide [1]. Furthermore, the risk of depression has been reported to be high in these patients [2]. Literature sig nifies the role of depression in exacerbat ing diabetes [3]. This is because diabetes management presents the patient with cognitive challenges, such as predicting premature death and depression [4]; accord ingly, it is more difficult for depressed diabetic patients to control their blood glucose levels than other patients [5]. Thus, psychological therapies are required in this respect. Along with other treatment approaches, these measures are essential in controlling diabetes [2, 6]. In addition to the significance of depression in diabetes, the combination of anxiety and depression has been estab lished in most studies [7, 8]. Considering the existence of depression in diabetic patients [3, 8] and the role of beliefs in its severity [9], diabetes might also affect nega tive thoughts, leading to depression [7]. Numerous studies evaluated the role of religious be liefs (trust & relationship with God) in disease control; however, there is no agreement on the positive or nega tive effects of spirituality in the form of fatalism; there fore, the definition of fatalism and its meaning remains unanimously stated [10]. Fatalism reflects that events oc cur without the human ability to affect them. Moreover, fatalism is a complex psychological cycle that manifests in the perception of despair, helplessness, and cognitive helplessness about disease control [10]. Accordingly, death with the onset of diabetes is inevitable and out of control [11]. In this sense, the fatalism of diabetes can increase poor self-care behaviors and negative emotions associated with diabetes [10]. Some studies suggested the direct role of diabetes fatalism [12] and the indirect role of fatalism by increasing depression [13] on reduc ing caring behaviors. However, the constant control of blood glucose is influenced by socio-cultural and psy cho-religious factors, including the spiritual fatalism of the patients with diabetes. In other words, destiny has different dimensions and one of its components is the spiritual dimension, i.e., associated with more caring be haviors [14]. Therefore, studies addressed fatalism; the role of spirituality in the perception of fatalism [10]. A relevant study reported that communication with God is among the main components of fatalism [15]. How ever, fatalism in the context of Islamic society is differ ent from that of other societies. Besides, Islamic texts and prayers, including the pilgrimage of Aminullah, emphasized the acceptance of divine fatalism and God’s pleasure. Therefore, in the control and treatment of dis eases, it is necessary to consider the effects of adaptive capacities, including disease acceptance [16]. Accep tance and Commitment Therapy (ACT) improves the patient’s relationship with the thoughts and feelings as sociated with the disease [17]. Thus, approach was very successful concerning serious physical illnesses. In some studies, the relationship between ACT and fatalism has been negatively evaluated [18, 19]; however, respect ing the concept of fatalism, the spiritual component was neglected in these investigations. In Destinyism without spirituality, it does not seem to have a fighting spirit [20]; however, in some studies, this relationship was evaluat ed to be positive [21]. Additionally, the activation of sup portive patterns in the patient increases self-compassion; thus, it is associated with reduced depression [22]. Fur thermore, studies reflected its effectiveness in reducing diabetes [23]. Moreover, there is a close relationship be tween compassion and acceptance [24]. Therefore, ACT combined with compassion seems to present a more de sirable influence; therefore, this method can reverse the negative evaluation and fatalism loop, i.e., prevent in de pressed diabetic patients. Therefore, this study aimed to investigate the effects of ACT with and without compas sion on depression and spiritual fatalism among patients with diabetes and depression vulnerability. Methods This was a quasi-experimental study with a pre-test, post-test and follow-up and control group. The statisti cal population included all non-clinical type 2 diabetic patients in the welfare centers of Mashhad City, Iran (13 centers with 230 types 2 diabetic patients) in 2020. To select the research sample, a purposive sampling method was used. Accordingly, among the study population, 100 patients who met the following inclusion criteria were selected. The inclusion criteria of the study included having diabetes, not receiving psychological treatment in the last 6 months, and not having a psychological disorderand at least two years have passed since having diabetes. The exclusion criteria of the study consisted of the occurrence of diabetes complications respecting dia betic eyes and feet and kidneys according to the patient’s records and the diagnosis of the treating physician, and receiving insulin-dependent treatment. In the second stage, among these patients, 33 individ uals who received a higher score in the patient health questionnaire (a score higher than the cut-off point of 1.1), indicating high depression symptoms in patients with type 2 diabetes [25], were selected. The study par ticipants were chosen according to the inclusion/exclu D |
| 87 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| sion criteria as well as experts’ opinions, i.e., conducted through interviews and examining patient records. This study was approved by Birjand University of Medi cal Sciences (Code: IRCT20191012045072N1) and the ethics code was obtained from the Ethics Commit tee of Birjand University of Medical Sciences (Code: IR.BUMS.REC.1398.001). Then, on 10/5/2020, after coordination with the relevant diabetes specialists, pa tients’ consent was obtained for cooperation. The first experimental group received eight 90-minute ACT; concurrently, the second experimental group received compassion-based ACT in sixteen 90-minute sessions (two sessions per week). However, the control group remained on the waiting list. Notably, although no in tervention was provided to the control group, to comply with the ethical principles, two sessions of educational intervention were performed in them after the follow-up period. Then, SPSS was applied for the statistical analy sis of the collected data. The following tools were em ployed to collect the required data in this research: The Patient Health Questionnaire (PHQ) (Depres sion): This 9-item questionnaire was developed by Erbe et al. [25] and is among the most appropriate tools for screening and diagnosing depression in chronic patients. The scores range between 0 and 3, i.e., answered on Likert-type scale. Concerning the mean score, the cut off point equals 1.1, indicating a high level of depressive symptoms in type 2 diabetic patients. Cronchia Sprinter and Williams [26] reported Cronbach’s alpha coefficient of 0.89 and sensitivity of 88% for this tool. In the study of Davis et al. [27], the convergent validity of depression with anxiety and depression in diabetes was significant and Cronbach’s alpha coefficient was calculated as 0.81, suggesting the appropriate reliability of the instrument. The Diabetes Fatalism Scale (DFS): This 12-item questionnaire consists of 3 subscales, answered on a 6-point Likert-type scale, i.e., 1) emotional disturbance (helplessness) (5 items, including 1, 2, 3, 4, 5), 2) spiritu al dimension (4 items, including 6, 7, 8, 9), and 3) ability to control diabetes (3 items, including, 10, 11, 12) [10]. In each subscale, the average of the total scores is cal culated. In each subscale, the score is between one and 6, and the higher score indicates the high value in that subscale. The validity of the questionnaire was assessed by the convergent method, suggesting that it has a posi tive and significant correlation with the questionnaire of self-management, problem management, and self-care ability. The Cronbach’s alpha coefficient for 12 items was calculated to be 0.80 [10]. Moreover, the question naire was translated into Persian, then back-translated into English, and finally, the initial questionnaire and the translated questionnaire were examined for content matching. The two-week test-retest reliability values for emotional distress, spiritual dimension, and self-efficacy perception were obtained as 0.5, 0.59, and 0.73, respec tively, i.e., significant. Cronbach’s alpha coefficient was obtained for each subscale of emotional distress (0.85), spiritual dimension (0.98), self-efficacy (0.74), and the whole questionnaire (0.64), which reflected the appropri ate reliability of the tool. In the present study, the spiritual component of diabetes fatalism of this tool was used. ACT sessions: In this study, ACT sessions were pre sented based on Estrosal and Hayes’s treatment protocol [28] 8 sessions according to Table 1. Compassion-based ACT: First, compassion interven tion and related techniques [29], then ACT intervention was performed in the group in sixteen 90-minute train ing sessions (twice a week). A summary of compassion based ACT sessions is listed in Table 2. Results The present study findings suggested that 75.8% of the research subjects were women and 24.2% were men. Furthermore, 63.6% of the ACT group members, 54.5% of the compassion-based ACT group, and 45.5% of the control group had a high-school diploma. The mean age of the study subjects was 41 years; their minimum and maximum age were 35 and 50 years, in sequence. Table 3 manifests the Mean±SD values of depression and spiri tual fatalism in the study groups at pre-test, post-test, and two-month follow-up stages. Multivariate repeated-measures Analysis of Variance (ANOVA) was used to analyze the obtained data on depression and spiritual fatalism concerning diabetes. To ensure normality, the Shapiro-Wilk test value was obtained per variable in the experimental and control groups at 3 non-significant evaluation steps (P>0.05). To evaluate the parity of covariance matrices, Box’s M statistics concerning diabetic depression (P<0.001, F 1471/19.21=3.52), equal to 110.67 and respecting spiritual fatalism (P<0.001, F2898/11.6=4.45) equal to 32.01 was ob tained, i.e., it did not confirm of the mentioned hypoth esis; thus, to investigate the interaction effect of time and group, the variable effect was used. Moreover, the re sults of which in each of the repeated-measures ANOVA revealed a significant interaction between the effects of time and group (P<0.05). To investigate the effect of the subjects, the assumption of Mauchly’s Test of Sphericity (Table 4) was explored |
| 88 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| in each of the variables, indicating that this assumption was not confirmed. Therefore, the Epsilon Greenhouse index was used. In total, the effect of time, as well as time and group interaction, was significant per study variable. In evaluating the equality of variance of time-variable error during the treatment, the results of Levene’s test for health variable (depression) for pre-test (P=0.96, F30.2= 0.03), post-test (P>0.001, F30.2=6.67), and follow-up (P>0.001, F30.2=7.85), at the level of 0.05 at the pre-test and the post-test at the level of 0.001 were non-signif icant, indicating the confirmation of the assumption. Additionally, Levene’s test results for spiritual fatal ism at pre-test (P=0.9, F30.2=0.09), post-test (P=7.17, F 30.2=0.003), and follow-up (P=0.007, F30.2=7.81) were observed to be non-significant (0.05), confirming the above hypothesis. Table 1. The contents of ACT sessions Session Contents First Complete understanding of the nature of diabetes and coping strategies. Determining the clients’ previous attempts to cope with anxiety, describing thoughts, and symptoms; presenting the metaphor of the hungry tiger. Second Control as a problem. Presenting the metaphor of a man in a pit, the metaphor of a chocolate cake, and paying attention to the passion of the clients. Third Address clients’ experiences and control recognition. Presenting the rope metaphor with the giant, the metaphor of the lie detector, emphasizes the importance of promoting and cultivating mindfulness. Fourth Create an orientation to develop mindfulness skills. Suggesting Polygraph metaphor, milk metaphor practice, passion as an alternative to control two-scale metaphor, the introduction of mindfulness through mindful breathing practice. Fifth Introduce the importance of values, distinguish them from goals, and set simple behavioral goals. Sixth Provide practical methods for breeding faults. The use of tombstone metaphors, and mindfulness skills instructions. Seventh Pay attention to the function of emotions, the habit of behavioral avoidance and distinguishing between vivid and vague emotions, controlling the emotional cycle, emotional avoidance, the metaphor of hot stove, vivid emotions versus vague emotions. Eighth Presenting the idea of commitment and strengthening choices to achieve those goals, gardening metaphor, obstacles to achieving goals and passions, bubble metaphor on the road, the metaphor of passengers on the bus, the metaphor of climbing the peak. Table 2. A summary of compassion-based ACT sessions Session The Content of the Sessions First Compassion, suffering, healing, and introducing the causes of human suffering. Second Introducing emotion regulation systems, introducing different types of human suffering, introducing different types of human needs, introducing the dimensions of compassion. Third Introducing logical reasoning and compassionate reasoning. Fourth Applying cognitive error techniques, weakening the good coalition of thoughts and emotions. Doing the practice of being kind and kind to others, performing the practice of playing the role of being kind yourself. Fifth Introducing the compassionate idea. Applying mindfulness techniques, illustration, and introducing kind human charac teristics. Sixth The contrast between experience and mind, introducing the skill of compassionate attention. Introducing different di mensions of compassionate attention, and introducing being non-judgmental. Seventh Introducing the skill of compassionate sensory experience. Demonstrating the dangers of focusing on results, discovering the practical values of life, retelling the characteristics of a kind person, introducing kind behavior, and introducing differ ent types of compassionate behavior. Eighth Determining the patterns of action commensurate with values, re-introducing kind behavior. |
| 89 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| In examining the between-group effects, Table 5 sug gests that the effect of the group was significant on both study variables in both analyses. To find the difference between the mean scores in the research groups, the Bonferroni post hoc test was used; the relevant data indicated no significant difference be tween the ACT and ACT/CFT groups for depression (P>0.05). However, there was a significant difference between the mean scores of ACT and ACT/CFT and the control groups for health (depression) (respectively, mean difference= -0.76, P<0.001; mean difference= -0.92, P<0.001); thus, it was effective in both interven tions. Regarding spiritual fatalism, the difference in the mean values between the groups of ACT and ACT/CFT was insignificant (P>0.05); however, regarding the dif ference in the mean scores between the ACT and con trol groups (mean difference= 2.06, P=0.001), as well as the ACT/CFT and the control groups (mean difference= 2.21, P<0.001) it was significant, indicating the effec tiveness of both provided interventions. To evaluate the stability of efficacy and changes in each experimental Table 4. Mauchly’s test of sphericity and the between-group effects Intragroup Effect Effect Mauchly Squared Chi- df P Effect Squares Sum of df Mean of Squares F P Squared Eta Spiritual fatalism Time 0.01 117.41 2 0.0001 Time 11.64 1.01 11.45 42.76 0.0001 0.58 Greenhouse Index 0.51 Time × Group 4.88 2.01 2.41 8.96 0.001 0.37 Error 8.16 3.62 0.27 Depression Time 0.03 98.27 2 0.0001 Time 10.16 1.02 9.91 136.47 0.0001 0.82 Greenhouse Index 0.509 Time× Group 3.39 2.05 1.65 22.80 0.0001 0.60 Error 2.23 30.75 0.07 Table 3. The descriptive indicators of depression and spiritual fatalism in different study groups and assessment steps Steps Group Mean±SD Patient Health (Depression) The Spiritual Destiny of Diabetes Pre-test ACT 2.13±0.42 3.90±1.125 ACT & CFT* 1.87±0.47 3.72±0.98 Control 2.30±0.53 2.27±0.84 Total 2.10±0.49 3.30±1.21 Post-test ACT 1.11±0.19 4.66±0.85 ACT & CFT 1.00±0.001 4.99±0.02 Control 2.22±0.52 2.34±0.84 Total 1.44±0.64 4.00±1.37 Follow-up ACT 1.09±0.16 4.69±0.83 ACT & CFT 1.00±0.001 5.00±0.001 Control 2.11±0.56 2.45±0.85 Total 1.40±0.60 4.05±1.33 *CFT: Compassion-Focused Therapy |
| 90 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| group in the assessment stages, the results of the Bonfer roni test are reported in Table 6. Respecting the groups of ACT and ACT/CFT, the mean scores in the post-test and follow-up stages were significantly different from those of the pre-test; these changes were maintained until the follow-up step. Discussion This study evaluated the effects of ACT with and with out compassion on spiritual fatalism and depression in non-clinical depressed diabetic patients.The present study results suggested that ACT with and without com passion was effective in increasing spiritual fatalism and reducing depression in the study subjects. Moreover, this effect remained stable over time (two-month follow-up). Studies reported that fatalism was associated within creased glucose index [15]. In some studies, a negative relationship was expressed between ACT and fatalism, i.e., in contrast to other studies [18, 19, 21]. Notably, the scale used in the present study was spiritual fatalism, while in previous studies, the overall score of fatalism was studied regardless of the subscale of spiritual fatal ism, addressing the compulsion and fatalism of the times. ACT, by increasing acceptance of the disease along with trusting in God and attempting to control the disease in diabetic patients, could increase spiritual fatalism. In ex amining the effectiveness of ACT on increasing spiritual fatalism, there was no difference between the interven tions with and without compassion, suggesting the sig nificance of ACT. In other words, ACT emphasizes the intrapersonal acceptance of functional forms, especially the natural reactions of body and mind [30]; therefore, it can increase spiritual fatalism in patients [14], i.e., a kind of active coping strategy, by creating acceptance without surrender. Furthermore, the study data outlined that ACT with and without compassion was effective in reducing depression in diabetic patients. This finding Table 5. The between-group effects data Spiritual fatalism Width of origin 1418.10 1 1418.10 850.8 0.0001 0.96 group 100.96 2 50.48 30.28 0.0001 0.66 Error 50.00 30 1.66 Depression Width of origin 269.79 1 269.79 715.32 0.0001 0.960 group 16.08 2 8.04 21.31 0.0001 0.587 Error 11.31 30 0.37 Table 6. Bonferroni test data of the studied groups at pre-test, post-test, and follow-up steps Variable Time ACT ACT/CFT Mean Difference SE P Mean Difference SE P Spiritual fatalism Pre-test Post-test -0.75 015 0.001 -1.27 0.29 0.004 Follow-up -0.79 0.16 0.002 -1.28 0.3 0.005 Post-test Follow-up -0.03 0.01 0.36 -0.01 0.01 0.99 Health (Depression) Pre-test Post-test 1.02 0.09 0.0001 0.87 0.14 0.0001 Follow-up 1.05 0.1 0.0001 0.87 0.14 0.0001 Post-test Follow-up 0.03 0.01 0.08 0.00 0.001 0.0001 ACT: Compassion Focused Therapy; CFT: Acceptance and Commitment Therapy; SE: Standard Deviation |
Variable Source Sum of Squares
Type 4 df Mean of Squares F P Squared Eta
| 91 Panahi R, et al. The Effects of ACT With Compassion on Spiritual Fatalism. Health Spiritual Med Ethics J. 2021; 8(2):85-94. |
| was consistent with those of other studies [23, 31] con ducted in diabetic patients. In explaining this alignment, we can consider the relationship between spiritual fatal ism and depression. Studies on the role of low scores of the spiritual component of fatalism in increasing depres sion are more important than other components of fatal ism; namely, the emotional distress of diabetes [32] and disease control (another component of fatalism) [33]. These data highlight the importance of the role of fatal ism spirituality in reducing depressive symptoms among diabetic patients [34, 35]. Moreover, the present study findings revealed the effectiveness of ACT on increasing spiritual fatalism and reducing depression. Therefore, considering the relationship between fatalism and reduc ing depression [13], it is expected that ACT indirectly reduces depression by increasing spiritual fatalism. Al though in this study, this finding was not directly exam ined, due to the effectiveness of ACT on both and con cerning the relationship between depression and spiritual fatalism, this possibility can be raised. In the ACT, mind fulness, acceptance, and cognitive skills are used to in crease psychological adjustment; accordingly, they can reduce learning-related depression by recognizing these strategies [30]. In this intervention, the individual be comes aware of diabetes and its consequences; accepts unpleasant thoughts and feelings related to diabetes, and shapes his/her behavior in line with their values and not based on diabetes [2]. In addition, studies demonstrated that this intervention increases the tolerance of suffering and encourages the patient to seek treatment [36]. This is because reducing commitment to the disease increases vulnerability [37]. Furthermore, it is necessary to accept the difficult conditions of compassion because there is a close relationship between compassion and acceptance; however, compassion can be introduced as an adapted form of acceptance. It indicates the degree of acceptance and its aspects. It is also unfavorable for itself and life [8], and is at the heart of ACT intervention; thus,compassion could not increase the effectiveness of ACT intervention. In other words, the effectiveness of ACT without com passion was significant in this regard. It is suggested that the effectiveness of ACT with compassion intervention be re-examined in other clinical examples. Howeve r, follow-up should be regarded. Additionally, in the pres ent study, self-report questionnaires were used. Conclusion The present study data revealed the effectiveness of ACT with and without self-compassion intervention on reducing depression and increasing spiritual fatal ism. Thus, ACT can reduce the associated psychological symptoms of diabetes, including depression. It can pro vide the patient with a level of effective psychological and behavioral function through positive fatalism; ac cordingly, this attention helps the patient to find health related pathways by focusing on health-related behav iors rather than focusing on illness and disability [38]. In other words, ACT without compassion can be effective in reducing depression and increasing spiritual fatalism. Ethical Considerations Compliance with ethical guidelines This study was approved by Birjand University of Medical Sciences (Code: IRCT20191012045072N1) and the ethics code was obtained from the Ethics Com mittee of Birjand University of Medical Sciences (Code: IR.BUMS.REC.1398.001). Funding This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. Authors' contributions Study design and idea: Fatemeh Shahabizadeh; Scien tific advisor: Fatemeh Shahabizadeh and Alireza Mah moudi Rad; Data collection and analysis: Reyhaneh Pa nahi and Fatemeh Shahabizadeh; Preparing, compiling, and editing the educational program: Reyhaneh Panahi, Fatemeh Shahabizadeh; Writing, compiling and editing the article: Fatemeh Shahabizadeh and Reyhaneh Panahi Conflict of interest The authors declared no conflict of interest. References [1] American Diabetes Association. Standards of medical care in diabetes - 2016 Abridged for primary care providers. Clin Diabetes. 2016; 34(1):3-21. [DOI:10.2337/diaclin.34.1.3] [PMID] [PMCID] [2] Saito J, Shoji W, Kumano H. The reliability and validity for Japanese type 2 diabetes patients of the Japanese version of the acceptance and action diabetes questionnaire. Biopsycho soc Med. 2018; 12:9. [DOI:10.1186/s13030-018-0129-9] [PMID] [PMCID] [3] Mikaliūkštienė A, Žagminas K, Juozulynas A, Narkauskaitė L, Sąlyga J, Jankauskienė K, et al. Prevalence and determi nants of anxiety and depression symptoms in patients with |
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Type of Study: Original Article |
Subject:
Special
Received: 2020/12/22 | Accepted: 2021/07/4 | Published: 2021/11/10
Received: 2020/12/22 | Accepted: 2021/07/4 | Published: 2021/11/10
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