Structural equation modeling of the effects of psychological distress and a fear of coronavirus disease 2019 on diabetes care in Japan

doi:10.21203/rs.3.rs-1578334/v1

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Structural equation modeling of the effects of psychological distress and a fear of coronavirus disease 2019 on diabetes care in Japan

https://doi.org/10.21203/rs.3.rs-1578334/v1

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This study aimed to examine the effects of psychological distress and a fear of coronavirus disease 2019 (COVID-19) on diabetes care in Japan. We used data from a 2020 nationwide internet survey in Japan involving 28,000 respondents aged 15–79 years. The question items included psychological factors (Kessler psychological distress scale and fear of COVID-19), employment, trust in neighbors, informal caregiving, and history of diabetes care. After excluding respondents with comorbidities and those who had not visited the hospital, 625 patients with diabetes were analyzed. Statistical mediation was then examined through a path analysis using structural equation modeling. Discontinued diabetes care was independently associated with psychological distress (risk ratio = 1.44, 95% confidence interval [1.01–2.06]) and a fear of COVID-19 (1.41 [1.01–1.95]). The results of the structural equation modeling indicated that a fear of COVID-19, employment, trust in neighbors, and informal caregiving were indirectly associated with continued diabetes care via psychological distress. These findings suggest that a fear of COVID-19 is associated with continued diabetes care via psychological distress. COVID-19 pandemic may affect psychological distress and lead to refrained diabetes care among Japanese patients with diabetes. Moreover, employment, trust in neighbors, and family caregiving were also found to buffer refrained diabetes care. As psychological factors and socioeconomic status can affect diabetes care, a fear of COVID-19 should be considered in patients with diabetes to help ensure the continuation of diabetes treatment.

Diabetes care

Fear of COVID-19

Psychological distress

Structural equation modeling

Coronavirus disease 2019 (COVID-19) is a global public health emergency that began in 2020, resulting in numerous restrictions on the public around the world [1]. Psychological distress and socioeconomic status (SES) have been shown to be risk factors for a more severe chronic disease course [2, 3]. Among patients with diabetes, psychological distress and SES are greatly influenced by a fear of COVID-19, and may eventually be associated with discontinued diabetes care [4]. While the numbers of family caregivers are increasing because of the aging of the Japanese population, informal caregivers have been shown to experience more psychological distress than the general population, even before the COVID-19 pandemic [5]. Some studies have investigated the effects of a fear of COVID-19 and psychological distress among Japanese outpatients [6, 7]. To ensure continued diabetes care during the COVID-19 pandemic, many psychological effects need to be considered, even in patients without COVID-19.

To help prevent the spread of COVID-19, many countries have imposed lockdowns characterized by service closures and restrictions on outings. The Japanese government implemented a mild lockdown that was non-enforceable and non-punitive, accompanied by a declaration of a state of emergency, which attracted widespread attention [8], on April 7, 2020 for seven prefectures (Tokyo, Kanagawa, Osaka, Saitama, Chiba, Hyogo, and Fukuoka). Tokyo, the host of the 2020 Olympics, had the highest number of infections among the 47 prefectures, and the Tokyo Metropolitan Government imposed its own restrictions on citizens [9]. The state of emergency was expanded nationwide on April 16, 2020, and lifted in a phased manner on May 14, 2020. While many countries implemented lockdowns with penalties for violations, the Japanese policy for COVID-19 was unique as the government “requested” people to refrain from going out except for emergencies and temporarily closed certain businesses without penalties for violations. This mild lockdown significantly transformed all activities, including patients’ medical examination behaviors in Japan. For example, the number of monthly train users in April 2020 decreased by 45.5% compared with April 2019 [10]. Similar to the experience in other countries, the mild lockdown in Japan exerted a diverse range of effects on people’s lives, including changes in domestic circumstances (e.g., teleworking, school closures) and economic damage resulting from decreased income and job loss [11, 12]. In Japan, where the mortality rate from infectious diseases was relatively low before the COVID-19 pandemic, lifestyle and daily activities associated with noninfectious diseases have had a significant impact on health [13]. Even in patients not affected by COVID-19, various aspects of diabetes care became suboptimal, leading to poor outcomes in patients with diabetes; this should also be considered as an adverse effect of the pandemic. Examining the impact of COVID-19-related emergency declarations on diabetes care in Japan is a critical issue that could indirectly affect the mortality rate during the pandemic. In a study in the United States, HbA1c testing for outpatients decreased by up to 70% during the early months of the pandemic, and this decrease in testing was associated with an increase in abnormal HbA1c results [14]. In Japan, it has been suggested that patients with diabetes are more likely to become severely ill because of COVID-19 infection, and it is possible that such patients may have been discouraged from seeing a doctor [4]. While fear of infection could have adverse psychological consequences in vulnerable patients with preexisting conditions, little remains known about how diabetes care has changed during the pandemic in Japan [15]. Moreover, in a previous study, the level of education attained and financial status after adjusting for psychological distress were strong predictors of mortality among patients with diabetes [16]. However, the effects of these factors on patients with diabetes in Japan during the COVID-19 pandemic remain unclear.

Given this background, we hypothesized that a fear of COVID-19, psychological distress, and SES could affect diabetes care. Therefore, in this study, we investigated the effects of a fear of COVID-19, psychological distress, and SES on diabetes care among patients with diabetes in Japan.

Design, settings and participants

The Japan COVID-19 and Society Internet Survey (JACSIS) undertook an epidemiological approach to investigate the social and individual health situations related to the COVID-19 pandemic. In JACSIS, 28,000 respondents were investigated from among 224,389 qualified panelists selected through approximately 2.2 million panelists registered with a Japanese Internet survey agency (Rakuten Insight, Inc., Tokyo, Japan). The participants were recruited using a random sampling method to select a sample representative of the official demographic composition of Japan as of October 1, 2019, based on the categories of age, sex, and region of residence (i.e., all 47 prefectures). A cross-sectional design was used to detect changes in individual lifestyle and social factors before and after the COVID-19 pandemic. Web-based informed consent was obtained from all participants before they completed the online questionnaire.

Of the 28,000 respondents, 625 patients with diabetes (155 women and 470 men) were analyzed (Table 1). First, we excluded 2,518 participants who provided invalid responses. These measures to validate the quality of the data consistently were performed as described in previous studies [17-20]. Second, we excluded 23,917 participants without comorbid diabetes. Finally, we excluded participants who had not visited the hospital (n = 449) or had comorbidities (n = 490). In this survey, asthma, bronchitis, pneumonia, atopic dermatitis, otitis media, angina pectoris, myocardial infarction, stroke, chronic obstructive pulmonary disease, cancer, malignant tumors, chronic pain, depression, and mental disease (without depression) were defined as comorbidities.

The protocol for this research conforms to the provisions of the Declaration of Helsinki. This study was reviewed and approved by the Research Ethics Committee of the Osaka International Cancer Institute (No. 20084). In this study, the data used are not deposited in a public repository, due to confidentiality and restrictions being imposed by of data the Research Ethics Committee of the Osaka International Cancer Institute. Data inquiries should be addressed by data manager (Takahiro Tabuchi: [email protected]).

Measurements

The outcome variable was “refraining from visiting the hospital as scheduled between April and May 2020” by patients with diabetes. The outcome was obtained from a specific question: “Did you refrain from a planned hospital visit between April and May 2020?” The answer options were “yes”, “no”, and “not applicable (not planning on visiting the hospital)”. Patients with diabetes who answered “not applicable” were excluded from the analysis.

The main exposure variables were fear of COVID-19 and psychological distress. We used the Fear of COVID-19 scale (FCV-19S) to assess anxiety and fear of COVID-19. The FCV-19S has been validated in recent Japanese studies [6, 21, 22]. The FCV-19S is composed of seven statements, and the total score is calculated by adding up each item score (range = 7–35). The higher the score, the greater the fear of COVID-19. Total scores of 19–35 were defined as having a fear of COVID-19 (the cutoff score was defined as the median of patients with diabetes in this study). We used the 6-item Kessler Screening Scale for Psychological Distress (K6) to measure psychological distress. The total score on the K6 ranges from 0–24. We used a proven reliable and validated Japanese version of the K6 in this survey [23]. A K6 score ³5 was used to indicate the presence of mild psychological distress [24].

In a path analysis, psychological distress was considered a mediator of fear of COVID-19 to refrained diabetes care, as described below. In a previous study, COVID-19 pandemic-associated anxiety and fear were found to be positively correlated with perceptions of vulnerability to infection [25]. We adjusted for SES as follows: informal caregiving (categorized as “yes [providing care primarily] or yes [providing care, but not primarily]” or “no [not providing]”), educational attainment (categorized as “high school or lower” or “college or higher”) [26], employment (“employer”, “self-employed”, “regular employee”, “non-regular employee”, and “unemployed”) [27], trust in neighbors (categorized as “high [trust or moderately trust]” or “low [not trust or moderately not trust]”) [28], and income level (categorized by tertiles of household equivalent income in 2019 [low, <4 million JPY; intermediate, 4–7 million JPY; high, >7 million JPY; unknown or no answer]) [29].

Statistical analyses

A modified Poisson model was applied to calculate risk ratios (RRs) for the association between diabetes care and mental condition (fear of COVID-19 and psychological distress) during the COVID-19 pandemic (Table 2). We designed three models to assess the effects of psychological distress and a fear of COVID-19 on diabetes care. Model 1 included only psychological distress, model 2 included a fear of COVID-19, and model 3 included both psychological distress and a fear of COVID-19. All models were adjusted for age, sex, informal caregiving, income level, employment, trust in neighbors, and educational attainment.

To examine the statistical mediation effects, a path analysis using structural equation modeling (SEM) was performed. The SEM tested the direct effects from a fear of COVID-19 to continued diabetes care, and the indirect effects from a fear of COVID-19 to continued diabetes care via psychological distress. A fear of COVID-19 and psychological distress were modeled as continuous variables. Informal caregiving, employment, and trust in neighbors were included in the SEM as endogeneity of both fear of COVID-19 and psychological distress. Unstandardized profit regression coefficients with 95% confidence intervals (CIs) are reported with a root mean square error of approximation (RMSEA) ≤ 0.08 [30]. Good model fit was indicated by both a goodness-of-fit index (GFI) ³ 0.90 and an adjusted goodness-of-fit index (AGFI) ³ 0.90.

All statistical analyses were performed using STATA 12.0 (Stata Corp, College Station, TX, USA) and JMP ver. 16.1 (SAS Institute Inc. Cary, NC, USA). This study followed the STROBE guidelines for a cross-sectional study.

Table 1 summarizes the characteristics of the study participants (N = 625). The median age of the patients with diabetes was 67.0 years, and 24.8% (n = 155) were female. In total, 19.5% (n = 122) of the patients with diabetes discontinued diabetes care during the COVID-19 pandemic. In addition, 20.3% (n = 127) had psychological distress and 49.3% (n = 308) had a fear of COVID-19. More than 70% (n = 451) of the patients with diabetes had a trusted neighbor. In terms of employment, 14.7% (n = 92) were employers or self-employed, 21.9% (n = 137) were regular employees, 13.0% (n = 81) were non-regular employees, and 50.4% (n = 315) were unemployed.

Table 2 summarizes the RRs for discontinued diabetes care with psychological distress and a fear of COVID-19 during the COVID-19 pandemic after adjusting for SES according to the modified Poisson model. In model 1, a significantly higher prevalence of discontinued diabetes care with psychological distress (RR: 1.44 [1.01–2.06]) was observed after adjusting for age, sex, informal caregiving, and SES. In model 2, a significantly higher prevalence of discontinued diabetes care with a fear of COVID-19 (1.41 [95%CI = 1.01–1.95]) was found after adjusting for age, sex, informal caregiving, and SES. In model 3, slightly higher prevalences of discontinued diabetes care with both psychological distress (1.36 [0.95–1.94]) and a fear of COVID-19 (1.35 [0.97–1.87]) were found after adjusting for age, sex, informal caregiving, and SES.

Figure 1 summarizes the results of the path analysis using SEM to examine the associations among a fear of COVID-19, psychological distress, SES, and diabetes care. A directed acyclic graph of the analysis is shown in Figures 2. When a fear of COVID-19 and psychological distress were included in the path analysis model, a fear of COVID-19 via psychological distress was found to be indirectly associated with continued diabetes care. The results of the path analysis conducted with psychological distress as a mediator showed that a fear of COVID-19 was indirectly associated with not continued diabetes care among Japanese patients with diabetes. In addition, a fear of COVID-19 was positively associated with psychological distress (path coefficient = 0.233 [0.160–0.306]), and psychological distress was positively associated with diabetes care (path coefficient = 0.137 [0.057–0.218]). A fear of COVID-19 was indirectly associated with discontinued diabetes care via psychological distress (indirect effect = 0.032 [0.009–0.067]). These findings indicated that working was significantly associated with a lower fear of COVID-19 (b = –0.097) and higher psychological distress (b = 0.076). Higher trust in neighbors was significantly associated with a lower fear of COVID-19 (b = –0.084) and lower psychological distress (b = –0.098) among the patients with diabetes. In addition, being a family caregiver was significantly associated with higher psychological distress (b = 0.171). Indicators of the model fit were good (CFI = 0.946, RMSEA = 0.051, GFI = 0.997, AGFI = 0.977).

The results of this study suggested that a fear of COVID-19 was associated with discontinued diabetes care via psychological distress. Moreover, a fear of COVID-19 and psychological distress were affected by employment, trust in neighbors, and family caregiving. While patients with underlying illnesses may be more likely to become severely ill when infected with COVID-19 via their family, informal caregivers may be more likely to discontinued diabetes care and to avoid visiting the hospital [31].

To our knowledge, this is the first study to examine the association of a fear of COVID-19 on the refrained care among patients with diabetes in Japan. The results of the path analysis conducted with psychological distress as a mediator in the SEM showed that a fear of COVID-19 was indirectly associated with discontinued diabetes care among patients with diabetes in Japan. Patients with diabetes have been shown to be more susceptible to severe cases of COVID-19, and may avoid the risk of infection by not visiting the hospital [32]. Regarding the association between a fear of COVID-19 and discontinued diabetes care, diabetes and its associated comorbidities increase the risk of both a more severe case of COVID-19 and mortality [33]. Thus, patients with diabetes may have chosen to avoid outpatient treatment to help prevent COVID-19 infection rather than continued diabetes care. In addition, the psychological distress derived from a fear of COVID-19 may have reduced the motivation for diabetes care among these patients. Previous studies have suggested that psychological distress may be a barrier to diabetes care, which is consistent with our results [34, 35].

The findings of this study suggest that trust in neighbors affects a fear of COVID-19 and psychological distress among patients with diabetes. A Chinese study conducted before the COVID-19 pandemic reported that more attention should be paid to the mental health of critically ill patients and formal social, community, and governmental support, particularly in rural China [36]. The results of that study were consistent to the findings in the present study, in that trust in neighbors may have been associated with diabetes care during the COVID-19 pandemic. Medical treatment-based information and communication technology were more noticeable during the COVID-19 pandemic because of infection control and rural medicine. Telemedicine may be promising for continued diabetes care while reducing the risk of COVID-19 infection, given that the number of reimbursement codes for telemedicine use is still small in Japan (accounting for only 0.02% of all outpatient care services) [37]. Barone et al. reported that to protect communities, health systems, and the global economy, citizens should value the knowledge and experience gained from past outbreaks and the lessons learned from the COVID-19 pandemic, allowing them to take immediate action to protect the most vulnerable groups [38]. In addition, a recent study reported associations according to the number of risk factors between incident dementia, cognitive performance, and brain abnormalities among individuals with type 2 diabetes when compared with control subjects without diabetes [39]. While SES among patients with diabetes may be obscured or change rapidly because of the prolonged COVID-19 pandemic, attention should be paid to the patient’s background as they continue to receive diabetes care.

Regarding the impact of these findings on long-term diabetes care in relation to informal caregiving, there were two possible effects: (1) patients with diabetes could not undergo treatment because of insufficient time, and (2) patients had to cancel or postpone treatment because of infection control for their family (especially caregivers at home). During the COVID-19 pandemic, disruptions in the formal care system and medical care system have increased the need for more intense informal care at home [40]. The predicted effect of trust in neighbors on diabetes care is that people with higher trust in neighbors will be more likely to have access to accurate medical information about diabetes treatment. The findings of the present study suggest that a fear of COVID-19 is associated with discontinued diabetes care, but also that trust in neighbors and family caregiving buffer discontinued diabetes care.

The main strengths of this study are its assessment of various individual-level factors and the large-scale sample covering all 47 prefectures in Japan during the COVID-19 pandemic. On the other hand, this study had several limitations. First, we cannot clarify the direction of causality because this was a cross-sectional study. However, we assumed a plausible causal direction from a fear of COVID-19 to refrained diabetes care via psychological distress and estimated the effect based on this assumption. Second, the data used in this study were obtained from an internet survey, and the response rate was relatively low (12.5%). We adjusted as much as possible to account for possible biases in the collected sample using an external, nationally representative sample. Third, our findings may not be generalizable to the population with limited access/literacy to the internet because our study sample was collected through an internet survey. Finally, there was no medical diagnosis of diabetes, so we could not use an accurate measurement of diabetes intensity or care plan. Due to social distancing requirements, reduced mobility, and meeting restrictions, it was not possible to include certain measurements, which could have provided more relevant information regarding the risk factors of discontinued diabetes care. As the lockdown owing to the COVID-19 pandemic began around March 2020, there may have been a time lag of up to 5 months to when diabetes care was not maintained. Although it has been difficult for patients with diabetes to be observed and treated during the COVID-19 pandemic, the results of this study could provide valuable data in regard to diabetes care, psychological factors, and SES.

These findings suggest that a fear of COVID-19 may affect psychological distress and continued diabetes care among patients with diabetes in Japan, and that trust in neighbors and family caregiving may buffer discontinued diabetes care. As psychological factors and SES affect diabetes care, it is important to consider a fear of COVID-19 among patients with diabetes to maintain diabetes treatment.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AM, TS, and TT planned this study. AM, TS, TK, TY, and TT contributed to improving this study in a meaningful way. AM drafted the manuscript. TT performed the data collection. TS, TK, TY, and TT supported the draft of this manuscript. AM and TS contributed to the statistical analysis. AM, TS, TK, TY, and TT made substantial contributions to the conception of this study and the revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

This study was funded by the Japan Society for the Promotion of Science (JSPS) KAKENHI (grant Nos. 17H03589, 19K10671, 19K10446, 18H03107, and 18H03062), a JSPS Grant-in-Aid for Young Scientists (grant No. 19K19439), the Research Support Program to Apply the Wisdom of the University to Tackle COVID-19 Related Emergency Problems, University of Tsukuba, and Health Labour Sciences Research grants (Nos. 19FA1005 and 19FG2001).

Author details

¹ Department of Hygiene, Public Health and Preventive Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan

² Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki 305-8575, Japan

³ Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo 162-8655, Japan

⁴ Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo 162-8655, Japan

⁵ Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan

⁶ Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, Japan

⁷ Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima city, Fukushima, Japan

⁸ Center for Cancer Control and Statistics, Osaka Medical Cancer and Cardiovascular Diseases, Osaka Japan

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Tables 1 and 2 are available in the Supplementary Files section

No competing interests reported.

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Structural equation modeling of the effects of psychological distress and a fear of coronavirus disease 2019 on diabetes care in Japan

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