EFFICACY OF RATIONAL EMOTIVE BEHAVIORAL THERAPY IN REDUCING SYMPTOMS OF DEPRESSION AND ANXIETY AMONG TYPE 2 DIABETIC PATIENTS IN SELECTED SUB-COUNTY HOSPITALS IN MURANG’A COUNTY, KENYA by Rahab Karanja A dissertation presented to the School of Applied Human Sciences of Daystar University Nairobi, Kenya In partial fulfilment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Clinical Psychology October 2022 Daystar University Repository Library Archives Copy ii APPROVAL EFFICACY OF RATIONAL EMOTIVE BEHAVIORAL THERAPY IN REDUCING SYMPTOMS OF DEPRESSION AND ANXIETY AMONG TYPE 2 DIABETIC PATIENTS IN SELECTED SUB-COUNTY HOSPITALS IN MURANG’A COUNTY, KENYA by Rahab W. Karanja (14-2528) In accordance with Daystar University policies, this Dissertation is submitted in partial fulfilment for the requirements of Ph.D. in Clinical Psychology Degree. Date _______________________ _______________________ Stella Nyagwencha, Ph.D., Supervisor _______________________ _______________________ George Kimathi, Ph.D., Supervisor _______________________ _______________________ Alice Munene, Psy.D., Coordinator, Ph.D. Program _______________________ _______________________ Kennedy Ong’aro, Ph.D., Dean, School of Applied Human Sciences Daystar University Repository Library Archives Copy 3 Copyright ©2022 by Rahab Karanja Daystar University Repository Library Archives Copy 4 DECLARATION EFFICACY OF RATIONAL EMOTIVE BEHAVIORAL THERAPY IN REDUCING SYMPTOMS OF DEPRESSION AND ANXIETY AMONG TYPE 2 DIABETIC PATIENTS IN SELECTED SUB-COUNTY HOSPITALS IN MURANG’A COUNTY, KENYA I declare that this dissertation is my original work and has not been submitted to any other college or University for academic credit Signed: ___________________ Date: ___________________ Rahab W. Karanja (14-2528) Daystar University Repository Library Archives Copy 5 ACKNOWLEDGEMENTS I thank the Almighty God for his love, care, protection, faithfulness, mercies and grace that have been sufficient for me throughout the entire writing of this research. Thank you to Dr. George Kimathi and Dr. Stella Nyagwencha my supervisors for your support, mentorship, and encouragement throughout the entire writing of this dissertation study. I also thank my parents, Julius and Magdaline, and my siblings for the support and encouragement they accorded to me. I am thankful to Drs. Jane Kuria and Caroline Mwendwa for their patience, assistance, and support during field work process and data analysis. I would also like to thank Prof. Winnie Mucherah from Ball State University (Carnegie Fellow-Africa Diaspora) for your support, guidance, and mentorship during data analysis and interpretation. I register my special appreciation to all medical Superintendent and staffs in Kigumo and Kandara, Maragua and Kirwara for their help and cooperation during data collection process. My appreciation goes to Prof. Alice Munene (Coordinator, Ph.D. in Clinical Psychology Program) and PhD faculty for their instructional empowerment, support and guidance throughout the dissertation writing process. I appreciate all PhD students in Daystar who always inspired, motivated, encouraged me with their prayers, and moral support. God bless you all for being true friends in a time of need. Special gratitude goes to Higher Education Loans Board (HELB) for the award of postgraduate scholarship in 2019/2020. Daystar University Repository Library Archives Copy 6 TABLE OF CONTENTS APPROVAL ................................................................................................................................... ii DECLARATION ........................................................................................................................... iv ACKNOWLEDGEMENTS ............................................................................................................ v TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ....................................................................................................................... viii LIST OF FIGURES ....................................................................................................................... ix LIST OF ABBREVIATIONS AND ACRONYMS ....................................................................... x ABSTRACT ................................................................................................................................... xi DEDICATION .............................................................................................................................. xii CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION AND BACKGROUND TO THE STUDY ...................................................... 1 Introduction ................................................................................................................................. 1 Background to the Study ........................................................................................................... 14 Statement of the Problem .......................................................................................................... 20 Purpose of the Study ................................................................................................................. 21 Objectives of the Study ............................................................................................................. 22 Research Questions ................................................................................................................... 22 Justification for the Study ......................................................................................................... 23 Significance of the Study .......................................................................................................... 26 Assumptions of the Study ......................................................................................................... 28 Scope of the Study..................................................................................................................... 29 Limitations and Delimitations of the Study .............................................................................. 30 Definition of Terms ................................................................................................................... 31 Summary ................................................................................................................................... 32 CHAPTER TWO .......................................................................................................................... 34 LITERATURE REVIEW ............................................................................................................. 34 Introduction ............................................................................................................................... 34 Theoretical Framework ............................................................................................................. 34 Conceptual Framework ........................................................................................................... 116 Discussion ............................................................................................................................... 117 Summary ................................................................................................................................. 118 CHAPTER THREE .................................................................................................................... 119 RESEARCH METHODOLOGY................................................................................................ 119 Introduction ............................................................................................................................. 119 Research Design ...................................................................................................................... 119 Study Site ................................................................................................................................ 120 Target Population .................................................................................................................... 122 Sample Size ............................................................................................................................. 124 Sampling Procedure ................................................................................................................ 126 Data Collection Instruments .................................................................................................... 130 Data Collection Procedure ...................................................................................................... 136 Pretesting ................................................................................................................................. 148 Data Analysis Plan .................................................................................................................. 150 Ethical Considerations............................................................................................................. 152 Daystar University Repository Library Archives Copy 7 Summary ................................................................................................................................. 156 CHAPTER FOUR ....................................................................................................................... 157 DATA PRESENTATION, ANALYSIS, AND INTERPRETATION ....................................... 157 Introduction ............................................................................................................................. 157 Analysis and Interpretation ..................................................................................................... 157 Summary of Key Findings ...................................................................................................... 198 CHAPTER FIVE ........................................................................................................................ 202 DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS ........................................... 202 Introduction ............................................................................................................................. 202 Discussions of Key Findings ................................................................................................... 202 Recommendations ................................................................................................................... 245 Recommendations for Further Research ................................................................................. 250 Summary ................................................................................................................................. 251 REFERENCES ........................................................................................................................... 252 APPENDICES ............................................................................................................................ 318 Appendix A: Ethical Clearance ............................................................................................... 318 Appendix B: Introduction Letter from Daystar University ..................................................... 319 Appendix C: Diabetes Data Collection Approval Letter ........................................................ 320 Appendix D: Research Permit ................................................................................................. 321 Appendix E: Research Authorization from Murang’a County ............................................... 322 Appendix F: Sub-County Education Office Approval Letter ................................................. 323 Appendix G: Kigumo Sub-County Hospital Approval Letter ................................................ 324 Appendix H: Kandara Sub-County Hospital Letter ................................................................ 325 Appendix I: Deputy County Commissioner Kigumo Sub-County Letter ............................... 326 Appendix J: Introduction Letter .............................................................................................. 327 Appendix K: Murang’a County Sub-County Hospitals Letter................................................ 328 Appendix L: Consent to Participate Form (Control Group) ................................................... 329 Appendix M: Consent to Participate Form (Experimental Group) ......................................... 331 Appendix N: Fomu za Idhini Tambulishi ............................................................................... 333 Appendix O: Fomu ya gùìtìkìra (consent form Gikuyu Version) ........................................... 337 Appendix P: Debriefing Form ................................................................................................. 339 Appendix Q: Socio Demographic Questionnaire .................................................................... 340 Appendix R: Socio Demographic Questionnaire-Swahili Version ......................................... 347 Appendix S: Beck Depression Inventory-II ............................................................................ 353 Appendix T: Becks Anxiety Inventory ................................................................................... 359 Appendix U: Rational Emotive Behavior Therapy Model...................................................... 361 Appendix V: Pleasure Predicting ............................................................................................ 367 Appendix W: Map of Murang’a County ................................................................................. 368 Appendix X: Scheduling Form .............................................................................................. 369 Appendix Y: Worksheet for A-B-C-D Method....................................................................... 370 Appendix Z: Plagiarism Report............................................................................................... 371 Daystar University Repository Library Archives Copy 8 LIST OF TABLES Table 3. 1: Diabetes Patients in two selected Sub-County Hospitals (Estimates)……………….128 Table 4.1: Types of Diabetes Mellitus in Selected Sub-County Hospitals .................................. 158 Table 4.2: Prevalence of Depression and Anxiety among Participants ..................................... 159 Table 4.3: Severity of Depression and Anxiety among T2DM Patients ..................................... 160 Table 4.4:Depression & Anxiety in Relation to Sociodemographic Characteristics ................. 162 Table 4.5: Logistic Regression for Depression........................................................................... 165 Table 4.6: Logistic Regression for Anxiety ................................................................................. 166 Table 4.7: Sociodemographic Characteristics of Participants and Depression and Anxiety…..168 Table 4.8: Overall Coping Strategies used by T2DM Patients .................................................. 176 Table 4.9:Coping Strategies Used by T2DM Patients Categorized into Two Distinct Groups . 177 Table 4.10:Strategies Used by T2DM Patients in the Experimental and Control Groups......... 178 Table 4.11: Use of Coping Strategies Per Age Groups .............................................................. 179 Table 4.12: Gender Differences in the Coping Strategies .......................................................... 180 Table 4.13: Coping Strategies Used by T2DM Patients According to their Religion ................ 181 Table 4.14: Coping Strategies Used by Participants According to their Occupations .............. 182 Table 4.15: Coping Strategies Used as per the Education Level ............................................... 183 Table 4.16: Coping Strategies Used as per the Marital Status of the Participants ................... 184 Table 4.17:Distribution of Socio-Demographic Characteristics of Participants at Baseline .... 185 Table 4.18: BDI-II Mean Scores at Baseline, Midline and Endline ........................................... 189 Table 4.19: Difference-in-Difference Estimates of REBT in Depression ................................... 191 Table 4.20: Mean Score Difference in Depression ..................................................................... 192 Table 4.21: Shows Cohen’s d Effect Sizes for the Control and Experimental Group ................ 193 Table 4.22: Distribution of BAI Scores at Baseline, Midline and Endline ................................. 193 Table 4.23: Difference-in -Difference Estimates of REBT in Reducing Anxiety Symptoms ....... 196 Table 4.24: Sample of Paired T-test ........................................................................................... 196 Table 4.25: Overall Effect Sizes………………….…………………………………………….197 Daystar University Repository Library Archives Copy 9 LIST OF FIGURES Figure 2.1: Rational Emotive Behaviour Theory Chart………………..……………………………..37 Figure 2.2: Theory of Planned Behaviour…….....……………………………………………………..41 Figure 2.3: Cognitive Processing ............................................................................................... 115 Figure 2.4:Conceptual Framework ............................................................................................ 116 Figure 3.1: Data Collection Flow Chart……………………………………………………………….140 Figure 4.1: BDI-II Scores for Both Experimental and Control Groups ..................................... 189 Figure 4.2: Mean BAI (anxiety) Scores in Control and Experimental Group............................ 194 Daystar University Repository Library Archives Copy 10 LIST OF ABBREVIATIONS AND ACRONYMS ADA American Diabetic Association APA American Psychiatric Association BAI Becks Anxiety Inventory BDI Becks Depression Inventory CBT Cognitive Behavioral Therapy CDC Centre for Disease Control DMS Daily Mood Scale DTR Daily Thought Record ICBT Internet-Cognitive Behavioral Therapy IDF International Diabetes Federation REBT Rational Emotive Behavioural Therapy SSPS Statistical Package for Social Sciences TAU Treatment as usual T2DM Type 2 diabetes mellitus TPB Theory of Planned Behaviour TRA Theory of Reasoned Action WHO World Health Organization WHO-5 World Health Organization-5 wellbeing scale Daystar University Repository Library Archives Copy 11 ABSTRACT Type 2 diabetes mellitus (T2DM) is a complex metabolic disease that calls for long term management. People who have T2DM are reported to experience depression and anxiety symptoms compared to those who do not have. The purpose of this study was to assess the efficacy of Rational Emotive Behavioural Therapy (REBT) in reducing symptoms of depression and anxiety in people diagnosed with T2DM in selected Sub-County Hospitals in Murang’a County. This study was based on Rational Emotive Behavioural Theory and Theory of Planned Behaviour. The study used quasi-experimental research design utilizing quantitative methods of data collection. The participants of the study were type 2 diabetic patients aged between 30-70 years. To sample the T2DM participants, purposive sampling method was applied. The study screened 161 patients with T2DM. The data collection instruments included socio-demographic questionnaire, Becks Depression Inventory (BDI-II) to screen for depression symptoms and Becks Anxiety Inventory (BAI) for anxiety. Out of a sample of 161 patients with T2DM, 121 exhibited mild and moderate symptoms of depression and anxiety. The study established a high prevalence of depression and anxiety at 85.1% and 95.7% respectively. Moreover, the study found that the mean scores for depression and anxiety symptoms decreased from baseline to endline in the experimental group indicating that REBT intervention was effective in reducing the symptoms. Regular screening for depression and anxiety among patients with T2DM needs to be done and an integration of medication and REBT be provided accordingly in the Kenyan context. Daystar University Repository Library Archives Copy 12 DEDICATION I dedicate this work to my lovely nieces and nephews: Joy Jotham, Daniel Jotham, David Jotham, Joanna Jotham, Doreen Simon, Blessings Simon, Julius Thompson, and Newton Thompson. I thank each of you very sincerely for being there for me both physically and morally and, for encouraging me all through my academic journey. In addition, I dedicate this work to all men and women with diabetes mellitus including my mother. Daystar University Repository Library Archives Copy APPROVAL DECLARATION ACKNOWLEDGEMENTS TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES LIST OF ABBREVIATIONS AND ACRONYMS ABSTRACT DEDICATION