Prevalence and Associated Factors of Psychological Distress among Diabetic Patients at Thyolo District Hospital in Malawi: Hospital-Based Cross-Section Study [Response to Letter]

Dear editor

Thank you, Mohamed Jayte, for taking the time to provide insightful comments on our recently published research article titled “Prevalence and Associated Factors of Psychological Distress Among Diabetic Patients at Thyolo District Hospital in Malawi: A Hospital-Based Cross-Sectional Study”. We sincerely appreciate your thorough examination and commendation of our work.

Your recognition of the significance of our study in addressing a critical gap in the literature concerning the prevalence and determinants of psychological distress among diabetic patients in Malawi is greatly appreciated. We acknowledge the importance of further discussion and exploration to enhance the standard of care for diabetic patients, particularly within resource-constrained settings such as Thyolo District Hospital.

Furthermore, we agree with you on the importance of implementing systematic screening protocols for diabetes-related distress and advocating for the integration of mental healthcare professionals into the multidisciplinary framework of diabetes management. To further concur with you, in Malawi, researchers at Saint John of God College of Health Sciences such as Chima, Mkwinda, and Machaya (2023),¹ Chima, Mkwinda, Kumwendaet al, (2023),² Masulani-Mwale et al, (2019),³ Ng’oma et al, (2022)⁴ both emphasized in their studies independently on the need for incorporating Psychosocial counselling interventions in holistic life care. These measures hold promise for addressing the psychological needs of diabetic patients comprehensively and improving overall health outcomes and quality of life.

Your recommendations for future research directions are valuable. Expanding investigations beyond Thyolo District Hospital to encompass diverse geographic regions within Malawi would undoubtedly provide a more comprehensive understanding of psychological distress among diabetic populations.

Your points regarding the limitations of our study are well-taken. We acknowledge that the exclusive focus on patients attending the Diabetes Clinic at Thyolo District Hospital may limit the generalizability of our findings to the broader diabetic population in Malawi. Additionally, the use of a cross-sectional study design and reliance on self-reported questionnaires may at times introduce potential biases that warrant consideration.

However, it is also important to bring to your attention, Mohamed Jayte, that the Longitudinal studies that you have suggested may also have some major limitations. In this case, longitudinal studies are prone to attrition. Attrition can result from a range of factors, some of which are unavoidable, where participants may drop out of the study over time.⁵ Unavoidable attrition might be caused by a participant dying, or emigrating. Furthermore, in a setting such as Thyolo District Hospital, where patients may face various socioeconomic challenges, including limited access to transportation, retaining participants over the long duration of the study could be particularly challenging. Attrition is problematic for two main reasons. First, attrition reduces the size of the sample, and if the sample becomes too small, it jeopardises statistical power. Second, if attrition is not random, it can lead to non-response bias which compromises the validity of the study findings.⁶

Apart from that, much as longitudinal studies allow for the examination of changes over time, they do not inherently establish causality.⁷ Although temporal sequencing can be observed, other variables may confound the relationship between psychological distress and diabetes. Without experimental manipulation, establishing causal relationships becomes challenging. To this end, it is crystal clear that longitudinal studies may also present unique and key challenges, including prolonged data collection periods, therefore, a cross-sectional design was more appropriate, practical, and feasible for the current study.

Once again, we appreciate your thoughtful feedback, and your recommendations will be duly considered in our future research directions. We are always open to constructive feedback and look forward to more such valuable input from you, Mohamed Jayte.