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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 

  

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Copyright ©2022 by Rahab Karanja 

 

 

 

 

 

 

 

 

 

 

 

  

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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) 
 

 

 

 

 

 

 

 

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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.  

 

 

 

  

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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 

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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 

 
  

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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 

 
 

 

 

 

 

 

  

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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 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

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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 

  

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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.    

 

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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. 

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CHAPTER ONE 

 INTRODUCTION AND BACKGROUND TO THE STUDY 

Introduction 

 This chapter gives the definition of diabetes, discusses its chronic implications on 

the individuals’ health and its global impact. The chapter also looks at the prevalence of 

depression and anxiety symptoms among diabetic patients. Moreover, the chapter 

explores the correlation between sociodemographic factors and symptoms of depression 

and anxiety among individuals with type 2 diabetes. Coping strategies used by patients 

with type 2 diabetes to cope with stressful situations is also explained. The researcher 

also discusses the intervention that was used for the treatment of depression and anxiety 

among patients with type 2 diabetes mellitus. The purpose, objectives, limitations, and 

delimitations of the study is also well discussed. 

 Diabetes is not a new phenomenon in the world. It can be traced back to Greece 

where it was referred to as passé which means ‘through’ and mellitus which refers to a 

sweet characteristic (Patlak, 2002). This is because the people who were diagnosed with 

diabetes mellitus urinated a lot and the urine attracted a lot of flies and bees (Patlak, 

2002).  The Chinese, on the other hand, could diagnose people with diabetes by 

observing whether ants were attracted to people’s urine or not. In contrast, during the 

medieval period, European doctors would taste the urine themselves to tell whether the 

individual had diabetes or not. Type 2 diabetes mellitus (T2DM) has been cited as a 

public health issue of concern for many years because the explanations of the illness have 

been found in papyrus dating back to 1500BC (Dods, 2013). Although many people 

would die one or two years after being diagnosed with diabetes before 1921, with the 

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development of technology, it has become possible for people with diabetes to live up to 

80 years and above (Zajac et al., 2010). In addition, a lot has been done in prevention and 

management of diabetes (Fonseca et al., 2012). Researchers are consistently trying to 

come up with faster acting insulin, improved insulin pumps and machines to test the 

blood glucose levels such as glucometers (Yeh et al., 2012). The device helps diabetes 

patients to test the levels of the blood sugars even at home without necessarily visiting 

hospitals. 

  The occurrence of diabetes mellitus is on the rise (Kharroubi & Darwish, 2015; 

Saeedi et al, 2019). Diabetes will reportedly rank as the seventh leading cause of 

mortality worldwide in 2030, according to Msopa and Mwanakasale (2019) and World 

Health Organization (2013). Diabetes was defined as a metabolic illness which is caused 

by inability of the pancreas to produce enough insulin or when the body cannot make use 

of the amount of insulin produced by the pancreas (WHO, 2013). In normal 

circumstances, the pancreas yields the appropriate amount of insulin automatically which 

assists the cells to absorb glucose that the body obtains from food (WHO, 2013). 

However, this is not normally the case for the diabetes patients because the process is 

disrupted leading to overly raised levels of glucose in the blood (American Diabetic 

Association, 2015; WHO, 2013).  

   The common types of diabetes mellitus include type 1, type 2, prediabetes, and 

gestational diabetes (International Diabetes Federation (IDF), 2013). Type 1 diabetes 

(T1DM) is referred to insulin-dependent diabetes mellitus which accounts for 5% to 10% 

of diabetes identified cases (Brunner & Suddarth, 2010; Oram et al., 2014). Brunner and 

his colleague added that people with T1DM do not generate sufficient insulin and 

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therefore they need insulin injections due to lack of beta-cells (Cantley & Ashcroft, 

2015). This is in line with IDF (2018), that T1DM is an autoimmune response where the 

body is not able to generate enough insulin. Gestational diabetes is another type of 

diabetes mellitus which normally develops in 2% to 5% of pregnant women but usually 

vanishes once pregnancy is over (Chatterjee et al., 2017). Individuals with gestational 

diabetes and their children are likely to develop T2DM later in life (IDF, 2018). 

Prediabetes is referred to as an intermediate state of hyperglycemic limits above usual but 

lower than the diabetes threshold (American Diabetes Association (ADA), 2012). T2DM 

is the most prevalent and IDF (2013) and World Health Organization (2018) reported 

90% to 95% of all diabetes cases worldwide. Even though T2DM is more prevalent in 

developing countries compared with developed countries, the variances in healthy results 

between nations can be accredited to differences in education program systems as well as 

economic growth (Clark & Utz, 2014; Dagenais et al., 2016; Nazir et al., 2016).  

 According to Amri and Yazdaribakhsh (2014), the occurrence of T2DM is on the 

rise despite the progression in medical sciences. There are three key factors that are 

known to cause hyperglycemia in people with T2DM worldwide (Inaishi & Saisho, 

2020).  Namely, insulin resistance, beta-cell dysfunction as well as too much hepatic 

glucose manufacture (Cantley & Ashcroft, 2015; Ignatavicius & Workman, 2016; Inaishi 

& Saisho, 2020; Lewis et al., 2014). Above and beyond insulin resistance, T2DM is 

linked with family history of diabetes, older age, obesity, genetic risk, lack of physical 

activities, poor diet, impaired glucose metabolic rate and ethnicity (Centre for Diabetes 

and Endocrinology (CDE), 2018; Ley et al., 2017). With regards to physical activity, 

Valliyot et al. (2013) observed that persons who are actively involved in the jobs they 

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perform are less likely to develop T2DM. In addition, studies report that people with 

gestational diabetes have 35-60% chance of developing diabetes mellitus later in life 

(National Diabetes Education Program, 2011). T2DM is a very complex chronic illness 

that requires long-term management so that the individuals may achieve best glycemic 

control as well as prevent its complications (ADA, 2010). This is in line with WHO 

(2016) and Socialstyrelsen (2015) who reported that T2DM is a lifestyle disease which is 

preventable by dealing with the risk factors. Unfortunately, T2DM has no observable 

indicators and because of deferred diagnosis many individuals miss the optimal time for 

treatment (WHO, 2016).  

  Diabetes mellitus is a health issue of concern today as 463 million (9.3%) 

individuals in 2019 were living with this condition globally (Worldwide toll of diabetes, 

2020) and this is likely to rise to 700 million by 2043 (IDF, 2020). However, according to 

IDF (2017), more than 415 million persons have diabetes in the world with more than 

35.4 million in the Middle East and North Africa region with expectation that the number 

will upsurge to 72.1 million persons by 2040 (IDF, 2017). Further, Kok et al., (2015) 

reported that diabetes claimed more than 1.5 million lives globally. World Health 

Organization (2017) cited that diabetes has rapidly increased and escalated and is said to 

be the sixth leading cause of death worldwide and in the developing countries. For 

instance, it was estimated that the persons with T2DM were 90% of the total population 

of people with diabetes (WHO, 2017). Unfortunately, majority of people with diabetes 

mellitus are financially unstable and 80% of these individuals live in low-income 

countries (IDF, 2015). 

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  The condition and its complications deplete family resources leading to poverty 

because a lot of money is used on diabetes drugs, follow-up clinics in addition to the diet 

of the patient (Oladeji & Gureje, 2013). IDF (2015) reported that a lot of money was 

spent on health expenses of persons with diabetes which amounted to 12% of the total 

health expenditure. Therefore, diabetes does not only affect the individuals who suffer 

from the condition, but its impact is also felt by the rest of the family members. Diabetes 

affects individuals’ mental functioning, and impacts on their quality of life particularly 

because of financial constraints (Lewko et al., 2012). The demands of diabetes such as 

lifestyle adjustment, adherence to diet and medication affects the treatment plan for the 

patients as well (Issa et al., 2007).     

  There are many complications that people with diabetes experience. These 

include sight problems, diabetes nephropathy which could worsen and cause blindness as 

well as kidney failure (Faselis et al, 2020; Shehab et al., 2015). This is in line with earlier 

study by Hatamloo et al. (2012) who reported that T2DM causes limb amputation, loss of 

sight, renal failure as well as heart disease. Additionally, Dagogo-Jack (2012) reported 

that diabetes normally goes along with numerous comorbidities that include 

hypertension, abnormal levels of lipids in the blood (dyslipidaemia) and cardiovascular 

issues.   

 These comorbidities, together with stressful feelings connected with the diagnosis 

of diabetes mellitus, have been associated with the development of depression and 

anxiety among people with diabetes (Gonzalez et al., 2011; Yekta et al., 2010). The 

prevalence of depression is on the rise, and it has been linked to vascular damage which 

may induce cerebral pathology that creates susceptibility for depression and anxiety 

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(Sherina et al., 2004; Taylor et al., 2013). Persons with diabetes are vulnerable to 

depression and they are likely to have poor compliance to diabetes self-care regimes 

including controlling their blood sugar levels (Kaur et al., 2013).  

  According to World Federation for Mental Health (2010), about 43 million 

diabetic persons have symptoms of depression. Individuals diagnosed with diabetes, 

depression and anxiety frequently find it hard to adhere to diabetes treatment 

commendations and have deprived metabolic control (Kaveeshwar, 2014). In addition, 

depression can amplify the blood sugar levels and this can lead to low productivity, poor 

quality of life, increased mortality rates (Kaveeshwar, 2014) and greater levels of 

complications (Takasaki et al., 2016). Literature indicates that depression affects up to 

40% of persons with diabetes (Golden et al., 2017; Mushtame et al., 2016; Rajput et al., 

2016).  

   Anxiety, on the other hand, is defined as specific phobias, general fear which is 

often associated with muscle tightness and attentiveness in preparation for future threat or 

avoidant actions (American Psychiatric Association, 2013). Anxiety damages the 

metabolic procedures and is said to escalate the complications in diabetic patients 

(Bickett & Tapp, 2016). Individuals with diabetes may possibly experience clinical and 

subclinical anxiety with a prevalence of 14% and high symptoms of anxiety 40% 

(Grigsby et al., 2002). The symptoms of anxiety comprise of tension of the muscles, 

tenderness, restlessness, and low energy (Anxiety Disorders Association of America, 

2012; Allugander, 2006). These anxiety symptoms lead to wide interferences in peoples’ 

social as well as work-related functioning. Khuwaje et al. (2010) indicate that anxiety and 

its symptoms are related to deprived physical and medical conditions like chronic 

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illnesses such as diabetes mellitus. People with diabetes are reported to be at a greater 

risk of developing anxiety symptoms because of both physical warning signs associated 

with fears and anxieties of the advancement of the illness (Goldbacher & Matthews, 

2007).  

 The comorbidity of anxiety and T2DM may be due to struggles with painful 

experiences, unhealthy self-care practices and depression (Rosa et al., 2019; Settineri et 

al., 2019). The pathogenic link between anxiety and T2DM is thought to be due to stress-

induced release of hormone cortisol during inflammation as a result of apprehension 

(Black, 2003; Conti et al., 2016; Seematter et al., 2004; Stellar et al., 2015). Despite 

known risk factors, anxiety is less researched compared to depression even though it has 

similar effects on the dysregulation of metabolic and inflammatory systems (Young et al., 

2004) or cytokine-mediated autoimmune reactions (Hou & Baudwin, 2012). Research 

indicates that there is little attention on anxiety compared to depression in people with 

diabetes (Smith et al., 2013). Even if anxiety disorders are comorbid with depression, the 

probability of amplifying the risk of getting diabetes and its complications cannot be 

ruled out (Belzer & Schneier, 2004). 

 Earlier studies show that people with diabetes mellitus may experience anxiety 

symptoms when they are diagnosed with the disease (Cherrington et al., 2006; Deluhanty 

et al., 2007). The diagnosis of diabetes mellitus could contribute anxiety because people 

perceive that the illness will lead to unwanted daily life adjustments, diabetes-related 

complications such as neuropathy, sexual dysfunction, fear of losing control over their 

health as well as macrovascular complications (Pouwer, 2009). Furthermore, individuals 

with T2DM are shown to exhibit greater anxiety and depressive symptoms due to 

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diabetes complications and intensive daily management of the illness leading to the 

required lifestyle changes (Van Houtum et al., 2015; Sartorius, 2018). 

  To manage and control the diabetes condition, diabetes patients need to adjust 

their lifestyle. The demands for changes, adjustment to lifestyle and self-care routines 

cause emotional stress, which may interfere with individual’s inspiration to observe 

diabetes self-management (Fisher et al., 2012). Change of lifestyle includes change of 

diet which could add a burden to self and family and as a result they may end up being 

depressed (Mouwen et al., 2011). Even though adjustment to lifestyle is the most 

important self- management plan used for managing T2DM, a lot of individuals find it 

hard and may not comprehend why it is necessary (Inzucchi et al., 2012). This was 

further supported by Lipscombe et al. (2016) and Mondersir et al. (2015) who said that to 

prevent diabetes complications as well as minimize the risk of early mortality, there is 

need for adjustments of lifestyle behaviours. This involves adherence to medication and 

diet, self-monitoring of blood sugar levels and to an active lifestyle. 

  Diabetic people will benefit from a change of lifestyle together with medication. 

Adherence to medication together with psychological support is vital for people living 

with diabetes (Collins et al., 2009). In a Swedish institute study, 40 participants with 

diabetes were involved and the psychological intervention was administered to the 

experimental group (Hayes et al., 2013). The aim of this study was to assist individuals 

with diabetes to change their way of life, to increase adherence to drug and to add 

psychological intervention to help them manage their condition and any comorbidities. 

The study’s findings revealed that the individuals in the experimental group improved 

greatly in several areas like glycaemic control (p=0.05), diabetes related suffering and 

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health. The results also revealed that patients had improved as far as their perceived 

pressure (p=0.05), anxiety (p=0.05) and self-monitoring of blood sugar level was 

concerned compared to the diabetic patients in the control group who did not receive 

psychological intervention. This indicated that there was a statistically significant 

difference (p=0.05) registered with respect to non-severe blood glucose lower levels 

(Amsberg et al., 2009; Hayes et al., 2013). This agrees with Cox et al. (2001) and Katon 

et al. (2010) who observed that intervention on mental difficulties in persons with 

diabetes boosts their mental health. This may also lead to improvement of metabolic 

control of diabetes.  

   The burden of type 2 diabetic patients leads to low mood as well as irrational 

beliefs and unwanted thoughts about diabetes, which deteriorate diabetes self-care and 

impacts on medical decision making (Fulton et al., 2011). Such unwelcome thoughts and 

conducts can be identified and modified with Rational Emotive Behavioral Therapy 

(REBT) which to some extent improves mood and therefore blood glucose monitoring in 

persons with T2DM (Safren et al., 2014). As noted earlier, T2DM is a chronic illness that 

calls for long-term management which requires change of individual’s behaviour. This is 

because people who have been diagnosed with T2DM need to follow a dietary and 

medical regime. This means that it is a lifetime behavior change. Therefore, for T2DM 

patients to restructure their thoughts about dietary intake, adherence to medication and 

engage with self-care behaviours, REBT approach was the appropriate therapy to apply.   

 REBT is one of the key modalities of psychotherapy under the umbrella of 

cognitive behavioral approach which was pioneered by Albert Ellis in the 1990’s (Corey, 

2009). According to David et al. (2005), REBT is one of the most examined and well 

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applied treatment modalities in psychotherapy. In clinical setting, REBT is used with the 

understanding that the beliefs an individual embrace concerning failure, denial, and ill-

treatment, influence expressive reactions through arbitration of occurrence insights 

(Turnel et al., 2014). REBT assists people to examine their way of thinking which leads 

to emotional as well as behavioral difficulties. This is done through helping the patient to 

focus on unconditional self-acceptance and determinations to decrease demanding and 

negative beliefs (David et al., 2008). 

 REBT proposes that dysfunctional feelings like depression, and anxiety are a 

product of unbending and extreme beliefs associated with adverse events and are 

therefore referred to as irrational (Dryden, 2009). Therefore, people may think, feel, act, 

and react in a different way depending on what they tell themselves about the similar 

situation (Maclaren et al., 2016). In contrast, rational beliefs are regarded as flexible and 

are not extreme, which bring about functional expressive reactions like sadness, concern, 

and healthy anger (Dryden, 2009). REBT is based on the understanding that human 

thoughts and feelings are interconnected, because both influence each other (Komalasari 

et al., 2014). Komalasari and colleagues (2014) expounded that those thoughts and 

feelings play a substantial role in an individual’s self-talk that will make a positive affect 

when adjusting their feelings. During psychotherapy people are shown how to challenge 

their irrational beliefs with an objective of changing unqualified philosophies which are 

full of “must” with more flexible philosophies which are full of “preferences” (Dryden, 

2006).  

 REBT has been applied in clinical and counselling settings by scholars to examine 

its effectiveness on mental diseases such as anger management, stress, depression, 

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anxiety, and addiction (David et al., 2008; Fuller et al., 2010). Its impact has also been 

investigated on treatment of adults and people living with disability, stress, and 

depression in chronic fatigue syndrome (Noonan et al., 2010). REBT was also found to 

be effective in treating conduct disorders. However, literature reviewed revealed that very 

little has been done in REBT and chronic health conditions. For instance, REBT has been 

applied in coping behavior in people with arthritis (Sciacchitano et al., 2009) and in 

management of pain in cancer (Mahigir et al., 2012). REBT has also been suggested for 

use in individuals with stroke (Alverez, 1997).   

 A cross sectional study was conducted by Thour et al. (2015) in endocrinology 

clinic of tertiary care hospital in Chandigarn, North India. The study was done in 

September 2014 and participants were T2DM patients aged 30 years and above. The 

study established that people in the rural setting were three times more likely to develop 

depression compared to those in the urban setting. However, anxiety was not measured in 

that study. The results showed that the prevalence rate of depression was 41% out of 

which, 3 (4%), 7 (10%) and 20 (27%) of the patients had severe, moderate, and mild 

depression respectively. The findings of this study revealed that depression was high 

among rural patients (57%) while urban patients had (31%) with a p=0.049. The current 

study was done in a rural setting in Murang’a County and T2DM patients exhibited 

depression and anxiety symptoms which seemed to be high compared to findings of the 

study done in Chandigarn in India. This was earlier noted by Ravishankar et al. (2014) 

that people with T2DM living in the rural context are more vulnerable to getting 

depression as compared to those in urban contexts. Although the efficacy of REBT in 

reducing symptoms of depression and anxiety is well documented in literature in a range 

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of population, its impact has not been investigated among T2DM patients in Kenya and 

more importantly in Murang’a County. Many studies done in Kenya focused on 

pharmacotherapy in management of diabetes mellitus especially in medium sized 

hospitals in urban centres.  

 A descriptive cross-sectional study was carried out in Murang’a District in 

Mathioya and Kangema constituencies where five community health centres were 

purposively sampled for the study. The participants in this study were aged between 14-

90 years and a total of 258 individuals were sampled. The study established that 15% of 

the participants indicated that they were diagnosed with diabetes mellitus (Mwangi & 

Gitonga, 2014). However, this study did not specify the prevalence of individuals who 

had T2DM. The prevalence of T2DM has been established in different studies in Kenya. 

For instance, 96% of T2DM cases from both Isiolo and Meru was reported while 94% 

from Thika was highlighted (Githinji et al., 2017).  This is consistent with IDF (2013) 

and WHO (2017) that T2DM is the most prevalent at 90% to 95% cases worldwide. 

 This study focuses on T2DM in Murang’a County. Although, it may be the first 

study on the prevalence of T2DM in the county, it is significant because it opens this area 

for future research. Studies have shown that individuals with T2DM experience health 

difficulties including psychiatric and mental problems that impact on their over-all health 

(Abbas et al., 2011). Diabetes mellitus diagnosis is associated with frustrations, 

hopelessness, anxiety, complications of diabetes in future as well as   early death. This 

predisposes an individual to anxiety and depression disorders that further aggravate the 

condition hence mental health management needs to be part of overall patient 

management in diabetes mellitus. In this regard, consideration should be concentrated on 

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psychological support for persons with diabetes and this suggests that psychotherapy is 

needed (Manderbacka et al., 2011).  

  So far, to the best of researcher’s knowledge, little is known regarding the 

prevalence of depression and anxiety symptoms among individuals with T2DM in rural 

communities particularly in Murang’a County and the efficacy of REBT in the 

management of these conditions. In Kenya, although we have national statistics and 

prevalence rates of T2DM, there seems to be limited information at the county level. This 

study, therefore, aims at providing prevalence rates, screening opportunities for 

depression and anxiety and the use REBT as an intervention on depression and anxiety 

symptoms among patients with T2DM in Kigumo and Kandara Sub-County Hospitals. 

The results of this study may contribute knowledge in the field of Psychology on the 

effective psychotherapy treatment for depression and anxiety symptoms in Kenya. The 

REBT model has been used in the management of different problems and found to be 

effective. 

 Effectiveness of REBT has been demonstrated as an intervention for treating 

various conditions such as Generalized Anxiety Disorder (GAD).  For example, a study 

carried out in Ge Palade University of Medicidne, Pharmacy, Sciences and Technology 

from Tirgu-Mures investigated the effectiveness of REBT on first year medical students 

who exhibited GAD. The sample of 40 students (33 females, 7 males) were involved and 

the average age was 19.22 (SD=1.04). Anxiety was assessed using Hamilton Anxiety 

Rating Scale (HARS). Those who presented with GAD were given eight REBT sessions. 

The symptoms of anxiety and irrational beliefs were assessed before and after 

intervention. The findings showed that there was a statistically significant difference 

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before and after treatment for the anxiety symptoms t=20.31, df=78, p=0.001 as well as 

irrational beliefs with t=3.45, df=77, p= 0.01. This implied that REBT was efficacious in 

enhancing emotional functioning in students pursuing a medical course (Schenk et al., 

2020). 

 A meta-analysis of effectiveness and efficacy of REBT as well as alleged 

mechanisms of alteration documented in 84 studies with 69 between-group and 39 for 

within-group and between-group analyses concluded that REBT is a sound psychological 

intervention (David et al., 2016). The study reported a medium effect size for REBT 

compared to other intervention on outcomes (d=0.58) and on irrational beliefs (d=0.070 

at post-test. The medium effects for both outcomes were (d=0.56) and irrational beliefs 

(d=0.061) for within-group analyses (David et al., 2016). Furthermore, REBT is 

empirically based psychotherapy in the field of psychology as pointed out by David et al. 

(2017). This conclusion was made after they examined effectiveness and efficacy of 

REBT as part of meta-analysis of 84 published studies. Medium effect sizes were shown 

to reduce anxiety symptoms after intervention was administered. Banks (2012) reported 

that REBT combines cognitive, emotive and behavioral strategies which in this case are 

significant in managing psychological illnesses such as depression and anxiety. This is 

what has impelled the researcher to conduct this study to assess the efficacy of REBT in 

treating depression and anxiety symptoms among patients with T2DM attending selected 

Sub-County hospitals in Murang’a County.  

Background to the Study 

  Depression is known to be a common comorbidity in persons with diabetes (Groh 

& Moran, 2016; Wang et al., 2016) that causes serious psychological illness with 

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negative effect on how people think, feel, and behave (APA, 2013). Literature shows that 

11% of people with diabetes meet the criteria for major depressive disorder (Chlebowy et 

al., 2018). Despite the reported prevalence of depression in adults with T2DM, it often 

goes undiagnosed, hence untreated (Echeverry et al., 2009; Hunter et al., 2018). As a 

result, this leads to poor adherence to diet, inactivity, and smoking which are reported to 

intensify the risk as well as sequence of obesity and diabetes (Hunter et al., 2018). This is 

in line with findings by Katon et al. (2013) that depression affects individuals with 

diabetes resulting in poor adherence to medication and severe hypoglycemic episodes. 

Depression among persons with diabetes is usually not diagnosed early and remains 

untreated until six months after diagnosis (Delamater et al., 2001). 

  A meta-analysis study that included 39 studies which was carried out by 

Anderson et al. (2001) found out that 11% of persons who suffered from diabetes met the 

diagnostic criteria for major depressive disorder (MDD) while 31% experienced 

significant symptoms of depression (Anderson et al., 2001). Furthermore, the prevalence 

of depression in persons with T2DM was statistically greater in women (28%) as 

compared to men with (18%) and this difference was statistically significant as indicated 

by the P=0.0001 (Anderson et al., 2001).   

  The above notwithstanding, there is a bidirectional relationship between diabetes 

and depression (Park & Reynolds, 2015). This means that having diabetes mellitus 

increases the chances of developing depression and vice versa (Park & Reynolds, 2015). 

Depression is linked with a 60% risk for developing T2DM, with a general occurrence of 

depression with T2DM being 25% in African Americans (Mezuk et al., 2008; Rovner et 

al., 2014). The presence of T2DM comorbidity with depression and anxiety leads to 

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major adverse effects on glycemic control, quality of life, self-care as well as increase in 

treatment cost (Andreoulakis et al., 2012; Holt et al., 2014). 

  In Spain, the occurrence of depression in individuals with T2DM ranges between 

15% to 32% (Calvin et al., 2015). In Malaysia, a study that was carried out revealed that 

individuals with diabetes who had depression symptoms were 30.5% and those who had 

anxiety were 12.5% (Kaur et al., 2013). This shows that diabetes is a public health issue 

of concern in Malaysia. In another study done by Mohamed et al. (2015), a total of 480 

diabetic patients who were selected from six health clinics participated in the study. 

Every 10th individual on the follow up who was 18 to 59 years old and had been 

diagnosed with diabetes participated in the study. The study established that the 

prevalence of diabetes in Malaysia had increased from 11.6% in 2006 to 15.2% in 2011.  

  In Saudi Arabia, a researcher used quasi-experimental research design and 

sampled 70 diabetes patients as participants of the study (WHO, 2008). The study was 

carried out in Menoufia University Hospital. The findings indicated that the prevalence of 

anxiety was 35.3% compared to severe depression which was 13.6%. In Africa, the 

prevalence of depression among individuals with diabetes is also high. This was revealed 

by findings of a study that was done in a Nigerian teaching hospital which found that 

30% of the participants in the study who were diagnosed with diabetes had depression 

symptoms (James et al., 2010). A study carried out in South Africa, found that most of 

the people with chronic illnesses such as diabetes exhibited symptoms of depression as 

well as anxiety (Kogee, 2008).  

  Further, Pibernik-Okanovic et al. (2008) established that at baseline depressive 

symptoms, diabetes-related distress, social as well as physical quality of life 

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characteristics, and perpetuated depression after one year in diabetes patients with 

subthreshold depression. All the same, it is not clear about what factors predispose 

persons with diabetes from subthreshold depression to a major depressive disorder 

(MDD). Pouwer (2009) stated that screening for depression alone will not help much, but 

screening and monitoring activities each day for diabetic patients may be more effective. 

Monitoring on diet, physical activities as well as psychoeducation about psychological 

wellbeing with professionals (nurses, doctors, and psychologists), were found to be 

protective factors that improved mood in diabetic outpatients (Pouwer et al., 2001).  

 Furthermore, anxiety was cited as a risk factor for the occurrence of major 

depressive disorder. This clearly points out that anxiety was perceived as a possible 

predictor of major depressive disorder. This is congruent with King et al. (2009) who 

observed that anxiety disorder frequently precedes a major depressive episode. Moreover, 

Collins et al. (2009) observed that the anxiety rates are high among diabetic persons. 

There seems to be a relationship between the development of diabetes mellitus and 

depression. A study conducted by Carnethon et al. (2007) involved 4681 males and 

females from four United States communities at baseline. This Cardiovascular Health 

Study found that individuals aged between 65 years and above who reported greater 

depressive symptoms were more likely to develop diabetes as opposed to those that 

reported lower levels of symptoms of depression. Golden et al. (2008) also established a 

relationship between depressive symptoms and T2DM. Golden and his colleagues 

explained that baseline results were partially explained by lifestyle factors.  

 An earlier study that was cited in Greece by Sotiropoulus et al. (2008), found that 

33.4% of people with diabetes mellitus had elevated depression symptoms. Moreover, 

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Pibernik-Okanovic et al. (2008) observed that emotional factors were superior predictors 

for one-year perseverance of depression in diabetes individuals as compared with socio-

demographic variables. A cross-sectional study that involved 300 persons with T2DM 

attending primary health care centres in Erbill city, Iraq was carried out between July 

2016 and June 2017. The patients were individuals aged between 40 and 75 years old. 

PHQ-9 was used to screen for depression symptoms and the Diagnostic and Statistical 

Manual of Mental Disorders (DSM-5) was also applied as a diagnostic tool for both 

anxiety and depression. From the findings, the prevalence of depression was found to be 

at 58.7% and anxiety at 55.1%. There was no statistically significant difference found 

between sociodemographic characteristics and the prevalence of depression and anxiety 

(Yaseen & Dauod, 2018). 

 Regarding correlation between sociodemographic factors and depression and 

anxiety symptoms, a cross-sectional study done in two tertiary care hospitals of 

Rawalpindi and Islamabad in Pakistan is a good example. This study engaged 338 T2DM 

patients.  The study was carried out between August 2016 and February 2017. The results 

showed that 66.5% of the patients had mild levels of anxiety and 21.1% exhibited mild to 

moderate anxiety. The study also established that anxiety was significantly correlated 

with gender (OR=-0.308, 95% CI: 0.57-0.299; p=0.000), education level (p=0.010) and 

occupation as shown by p=0.000. In the same study, it was established that there was no 

statistically significant difference between anxiety and T2DM, individuals’ age, family 

history and lifestyle (Nawaz et al., 2017). 

 Another cross-sectional study was done in the National Guard Diabetic Clinic in 

Arar city in Saudi Arabia. Involved were 397 T2DM patients and the study was carried 

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out in January and March 2019. PHQ-9 was used to measure depressive symptoms.  The 

prevalence of depression was 37% and T2DM patients with low income (OR=3.78, 95% 

CI:1.4-10.2, P=0.006), low level of education (OR=2.05; 95% CI: 1.34-3.13; p=0.007) as 

well as long duration of disease (OR=5.83, 95% CI: 3.48-9.77; P=0.0001) were at risk of 

developing depression. The findings also showed that T2DM patients who were using 

oral drugs and insulin were more likely to exhibit depression compared with those on oral 

drugs (OR= 6.78, 95% CI: 4.1-11.2) and this was statistically significant as predicted by 

p=0.0001 (Alhunayni et al., 2020). 

 Individuals with diabetes mellitus use different coping styles to cope with the 

illness (Owens Gary et al., 2019).  People with T2DM have poor coping mechanisms 

caused by lack of mental, emotional, and social support which leads to development of 

depression and anxiety (Gonzales et al., 2011). This increases the likelihood of 

complications. However, adapting effective coping strategies could help in decreasing 

symptoms of depression and improving quality of life (Huang et al., 2016). In Kenya, 

IDF (2017) reported prevalence of diabetes mellitus at 2% though it is widely agreed that 

the comorbidity of diabetes and depression is more prevalent (IDF, 2017). This means 

that the people with diabetes mellitus are up to three times more likely to develop 

depression than those without (Andreoulakis et al., 2012).   

  In Murang’a County, a descriptive cross-sectional study was conducted in 

Mathioya and Kangema constituencies where five community health centres were 

purposively sampled for the study. The purpose of this descriptive study was to determine 

the perceptions of the use of the herbal remedies among patients with diabetes mellitus. 

The study also aimed to establish the correlation between patients’ perceptions and use of 

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herbal remedies. The study sampled a total of 258 individuals aged between 14-90 years. 

The results of the study revealed that 15% of the participants indicated that they were 

diagnosed with diabetes mellitus (Mwangi & Gitonga, 2014). In this case, depression 

increased the risk of developing T2DM, but as mentioned earlier, it is also linked with 

poor diabetes self-care. It is clear from these observations that greater intervention is 

needed to help reduce depressive and anxiety levels among the T2DM patients. This 

study aims at assessing the effectiveness of REBT in the treatment of depression and 

anxiety. 

Statement of the Problem 

 The number of individuals with T2DM globally is projected to escalate from 

405.6 million in 2018 to 510.8 million in 2030 (Basu et al., 2018). Of   all diabetic cases, 

T2DM is the most prevalent at 90% to 95% of all diabetes cases worldwide (IDF, 2013; 

WHO, 2018). In Africa, it was reported that 14.2 million people had diabetes as at 2015 

(IDF, 2015). In Kenya, the prevalence of diabetes stood at 3.3% in 2011(IDF, 2017) and 

according to Kenya Ministry of Health, annual cases of T2DM in the country runs up to 

9.42% of all lifestyle diseases (MOH, 2015). At the county level, a cross-sectional study 

carried out in Murang’a County in Mathioya and Kangema constituencies found that 15% 

of the participants were diagnosed with diabetes mellitus (Mwangi & Gitonga, 2014). 

This increase in prevalence is consistent with information from the Sub-County hospitals 

which indicated that the number of people who attend the diabetic clinic increased from 

40-50 patients per month to over 60 patients and the majority had been diagnosed with 

T2DM. (Nduati, Personal Communication, November 29, 2019). With such kind of 

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current and projected high numbers of diabetics, the aspect of diabetes psychological 

comorbidities cannot be ignored. 

 Literature shows that depression affects up to 40% of patients with diabetes 

mellitus (Golden et al., 2017; Mushtaque et al., 2016; Rajput et al., 2016). Globally, 

depression is estimated to affect 322 million people every year and individuals with 

depression are 18% likely to develop T2DM (Graham et al., 2020; WHO, 2020). 

Depression occurrence is two to three times higher in people with diabetes mellitus, but 

majority of cases remain under diagnosed and untreated (Bădescu et al., 2016). As 

reported by Chen et al. (2016), there is evidence that the prevalence of depression is 

markedly increased in the previously diagnosed diabetes patients compared to normal 

glucose metabolism individuals. According to Bicket and Tapp (2016) individuals with 

T2DM exhibit clinical and subclinical symptoms of anxiety more frequently than people 

without diabetes mellitus.  

 However, majority of the guidelines on diabetes care focus on the medical aspects 

of the disease without addressing the psychological needs of the patients using 

psychotherapy (Kalra et al., 2013). Therefore, there is need for screening and 

management of psychological problems that are likely to affect persons with T2DM. 

Although there are several studies in relation to co-occurrence of diabetes, depression and 

anxiety, there is scarce research done on depression and anxiety symptoms that has 

utilized REBT intervention among diabetes patients in Murang’a County. This study 

focused on the screening for depression and anxiety symptoms among type 2 diabetic 

patients in the said county and intervening for the same by use of REBT. Ellis (2003) 

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demonstrated his successful experience of using REBT psychotherapy with his clients 

who had physical illnesses including diabetes.   

Purpose of the Study 

 The purpose of this study was to assess the efficacy of Rational Emotive 

Behavioral Therapy in reducing symptoms of depression and anxiety in persons 

diagnosed with type 2 diabetes mellitus in selected Sub-County Hospitals in Murang’a 

County, Kenya. 

  

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Objectives of the Study 

Broad Objective 

 To assess the efficacy of Rational Emotive Behavioral Therapy in reducing 

symptoms of depression and anxiety symptoms among type 2 diabetes patients in 

selected Sub-County Hospitals in Murang’a County. 

Specific Objectives 

The specific objectives were to: 

1. Determine the prevalence of type 2 diabetes mellitus among diabetes patients in 

selected Sub-County hospitals in Murang’a County, Kenya. 

2. Establish the prevalence of depression and anxiety among type 2 diabetes patients in 

selected Sub-County hospitals in Murang’a County, Kenya. 

3. Determine the correlation between sociodemographic characteristics and depression 

as well as anxiety among type 2 diabetic patients in selected Sub-County hospitals in 

Murang’a County, Kenya. 

4. Determine the strategies used by patients with type 2 diabetes to cope with stressful 

situations in selected Sub-County hospitals in Murang’a County, Kenya. 

5. Assess the efficacy of Rational Emotive Behavioral Therapy in reducing depression 

and anxiety levels among type 2 diabetic patients in selected Sub-County hospitals in 

Murang’a County, Kenya. 

Research Questions 

The researcher aimed to answer the following questions: 

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1. What was the prevalence of type 2 diabetes mellitus among diabetes patients in 

selected Sub-County hospitals in Murang’a County? 

2. What was the prevalence of depression and anxiety among type 2 diabetic patients 

in selected Sub-County hospitals in Murang’a County?  

3. Was there a correlation between sociodemographic characteristics and depression 

as well as anxiety among type 2 diabetic patients in selected Sub-County hospitals 

in Murang’a County, Kenya? 

4. What were the strategies used by patients with type 2 diabetes to cope with 

stressful situations in selected Sub-County hospitals in Murang’a County, Kenya? 

5. Was REBT effective in reducing depression symptoms and anxiety levels among 

type 2 diabetes patients in selected Sub-County hospitals in Murang’a County?  

Hypothesis of the Study 

Ho REBT was not effective in reducing depression and anxiety symptoms among type 2 

diabetes patients in selected Sub-County hospitals in Murang’a County.  

Ha REBT was effective in reducing depression and anxiety symptoms among type 2 

diabetes patients in selected Sub-County hospitals in Murang’a County. 

Justification for the Study 

 Depression and T2DM are two leading global health issues of concern due to high 

morbidity and mortality rates (Marcus et al., 2012; WHO, 2012) which affect individuals, 

families, and communities (Egede & Ellis, 2010; Molosankwe et al., 2012). T2DM 

affects more than 9% people worldwide while depression affects 5% of the global 

population every year (Marcus et al., 2012; WHO, 2012). For every four individuals with 

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T2DM, one experiences depression at an occurrence of five times greater than what is 

perceived in the entire population (Semenkorich et al., 2015).  

 This is consistent with an earlier study that reported that one out of four people 

with T2DM had high depressive symptoms. Similarly, 11% of people had been diagnosed 

with depression disorder (Holt et al., 2014). According to WHO (2016), the 

corresponding prevalence of anxiety disorders is 3.6% worldwide which is equivalent to 

264 million people. A qualitative study conducted in Central Greece using interpretive 

phenomenological approach involved nine (9) women and six men (6). The participants 

were people aged between 36 to 81 years who were insulin dependent. The findings of 

this study indicated that insulin-dependent person’s express fears and unmet desires 

concerning healthcare and encounter problems with diabetes self-management 

(Papaspurou et al., 2015). 

  Individuals with diabetes face a lot of stress such as inability to control the 

disease, inability to adhere to treatment schedules, diet plans, and experience complex as 

well as extreme financial constrains occasioned by expensive health care (Zahrakar, 

2012). This is in line with 62 studies that were reviewed by Molosankwe et al. (2012) 

which found out that individuals with diabetes and depression were expected to spend an 

exorbitant amount of money on their health care. Egede and Ellis (2010) had earlier 

reported that the patients with depression and diabetes mellitus devote more of their time 

in health expenditures. Moreover, this agrees with Egede et al. (2015) that diabetes 

combined with a comorbid psychological health condition is linked with significantly 

increased cost of care. Integration of psychotherapy and pharmacotherapy in the 

management of depression and diabetes improves clinical outcomes and reduces costs of 

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healthcare (Doty et al., 2012). People with diabetes also experience challenges in 

interpersonal relationships, in sexual function, have worries about their future and lack of 

productivity in their workplace which could intensify the symptoms of depression, 

anxiety, and stress (Zahrakar, 2012). Depression and T2DM escalates the rates of 

morbidity as well as mortality which affect individuals themselves, their families, and 

their community (Egede & Ellis, 2010; Molosankwe et al., 2012).  Hence the importance 

of this study. 

  The burden of T2DM also leads to low mood and unwanted thoughts about 

diabetes which deteriorate individual’s self-care (Safren et al., 2014). According to Knaus 

(2006), REBT is an interactive therapy which has been found to be effective in managing 

depression and its comorbid illnesses. Knaus explained that it could open ways for 

averting depressive thoughts and other unwelcomed thoughts from recurring. REBT’s 

primary hypothesis is that feelings stem from beliefs which then impact on assessments 

as well as interpretations of life events (Corey, 2013).  

 REBT is the appropriate intervention because it teaches people to think more 

systematically to prevent and eradicate rigid and illogical thoughts that lead to emotional 

disturbances such as depression and anxiety (DiGiuseppe, 2002). REBT strategies target 

peoples’ belief system, attitudes, and thought procedures as the mechanism of change 

because they play substantial roles in how REBT put forth its clinical treatment effects 

(American Addiction Centre, 2018). The individual’s perception, which is formed in the 

first months after diagnosis of the illness, as well as positive re-examination plays a 

significant role in increasing positive cognitive emotional style that impacts on 

individual’s health and quality of life (Li et al., 2015).   

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 In Murang’a County, Kenya, where this study was carried out, data for depression 

and anxiety prevalence has not been determined. This may probably affect diabetes 

treatment outcome, self-management, and regime adherence. Hence, people with diabetes 

are prone to getting long-term complications. The present study aimed at assessing the 

depression and anxiety symptoms and treating the symptoms using REBT to resolve 

psychological problems faced by T2DM patients. This may add to the body of knowledge 

particularly in rural setting. Additionally, identification of depressive and anxiety 

symptoms among T2DM patients is significant to alleviate the destructive personal 

consequences and understand cost-savings in healthcare. 

Significance of the Study 

 The T2DM patients who were found presenting with anxiety and depressive 

symptoms or both benefited because they were treated using REBT therapy. By 

addressing psychological problems, this would possibly lead to improved individual’s 

self-care, reduce mortality and morbidity rates. This would also reduce risks of T2DM 

patients developing diabetes-related complications and the end product may be improved 

quality of life. The patients may also be empowered to adhere to medication and to seek 

psychological help whenever they are distressed. Additionally, when the psychological 

problems such as depression and anxiety are addressed, the individuals with T2DM are 

likely to have their blood sugars controlled. They may as well be able to cope with 

negative side effects of insulin, and other drugs, and most likely be more productive in 

their work, hence have improved quality of life. Persons with diabetes would also have 

improved intrapersonal, interpersonal relationships and cost of health would be reduced 

because complications may be minimal. This simply means that patients would be able to 

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get holistic management of diabetes which is significantly associated with depression and 

anxiety.  

  In the same line, the results of this study may inform healthcare providers in 

various diabetic clinics to have appraisal of contemporary practices and to introduce 

protocol for screening for depression and anxiety when people with diabetes go for 

follow-up clinics. This will be informative because it will be so clear that it is important 

to incorporate psychotherapy in treatment of T2DM to deal with psychological 

challenges. Regular screening for depression and anxiety will be vital because it will 

prevent medical complications that are made worse by anxiety and depression. 

Identifying individuals with T2DM with symptoms of depression and anxiety and 

incorporating REBT in this study will be geared towards facilitating improved mental 

health care outcomes (Petersen et al., 2012). 

  Moreover, the results of this study will possibly guide health care providers, 

clinicians, and policy makers in the country. First, the findings of this study may 

contribute to the body of knowledge particularly because of integrating psychotherapy in 

the clinical management of T2DM in a Kenyan context to deal with psychological 

disorders like depression and anxiety. The findings of this study may help to inform 

curriculum and modules that address assimilated management of physical and mental 

health (Jenkins et al., 2010; Othieno et al., 2014). Also, the findings of this study 

regarding the correlation between social demographic characteristics and depression or 

anxiety among T2DM patients in a Kenyan setting, can inspire many scholars to do more 

research on health seeking conducts. This would further be a foundation for further 

research linked to assimilation of psychological and pharmacological health care which 

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are necessary to improve general health results (Khasakhala et al., 2012; Ndetei et al., 

2009; Ndetei et al., 2010). The results may guide the government on resource allocation 

by focussing on vulnerable people. The finding of the study may also be used by 

International Diabetes Federation and other relevant bodies that develop policies to 

improve healthcare in relation to diabetes management. 

Assumptions of the Study 

The researcher had the following assumptions in mind as she embarked on the study: 

1. The participants of the study were willing to honestly answer the questionnaires 

and other assessment tools. 

2. Participants would accept to participate in the study. During the study, the 

participants were actively involved in the study. 

3. There were patients diagnosed with T2DM among diabetes patients who attend 

diabetes clinics in selected Sub-County Hospitals in Murang’a County. This 

assumption was confirmed in that there were patients diagnosed with T2DM in 

the said Sub-County. 

4. There were patients diagnosed with T2DM who exhibited with depression and 

anxiety symptoms in selected Sub-County Hospitals in Murang’a County. This 

was found to be so since the assessments done using BDI-II and BAI revealed that 

diabetes patients had depression and anxiety symptoms.  

5. There would be correlation between sociodemographic characteristics and 

depression as well as anxiety symptoms among patients with T2DM in selected 

Sub-County Hospitals in Murang’a County. In the course of data analysis, a 

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logistic regression revealed which factors predicted significant depressive and 

anxiety symptoms, hence, asserting this assumption. 

6. The current study assumed that patients with T2DM would use different coping 

strategies in coping with stressful events in life. For instance, this study assumed 

that men would use problem-focused coping strategies while women would use 

emotional-focused coping strategies. However, males and females with T2DM 

used similar coping mechanisms.   

7. Rational Emotive Behavioral Therapy (REBT) would be effective in reducing 

symptoms of depression and anxiety among type 2 diabetic patients in selected 

Sub-County Hospitals in Murang’a County, Kenya. Data collected and analysed 

at baseline, midline and endline revealed that REBT was efficacious in reducing 

symptoms of depression and anxiety among patients with T2DM. 

Scope of the Study 

  Simon and Goes (2013) observe that scope of a study is the compass of a 

research. There are four Sub-County hospitals in Murang’a County that have diabetes 

clinics. This includes Kigumo, Kandara, Maragua and Kirwara Sub-County hospitals. 

Murang’a referral hospital also has a diabetes clinic but being a referral hospital excludes 

it for this study because it does not have similar characteristics with Sub-County 

hospitals. This study was carried out in Kigumo and Kandara Sub-County hospitals in 

Murang’a County. The two mentioned Sub-County Hospitals have large numbers of 

people with diabetes mellitus as compared to the other two. The participants were 

patients diagnosed with diabetes who have been going for the follow-up clinics before the 

commencement of the study. The participants of the study were males and females with 

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T2DM aged between 30-70 years. T2DM is the most prevalent type of diabetes mellitus 

and is frequently seen in individuals aged 30 years and above (Mabaso & Oduntan, 2016; 

Ralineba et al., 2015). T2DM occurs to any age including children and adolescents but 

frequently in middle-age and older persons (Glasgow & Nutting, 2004; Temneanu et al., 

2016; Tryggestad & Willi, 2014). For this reason, T2DM patients aged between 30-70 

years were chosen to participate in the study. The study took place between October 2020 

and May 2021. 

Limitations and Delimitations of the Study 

     Some diabetes patients may not have been willing to share the required 

information about their experiences from the time they were diagnosed with the 

condition. This is due to the stigma associated with the disease, perceived pressure, self-

monitoring challenges and chronic implications. To overcome this challenge, the 

researcher reassured the participants of privacy and confidentiality of the information 

they gave during assessment and or therapy and while filling in the questionnaire. 

Secondly, during the time of study the participants may have failed to reveal the absolute 

truth. The researcher overcame this challenge by explaining to the participants the 

purpose and the benefits of the study. Thirdly, patients with T2DM could experience 

other psychological challenges associated with diabetes mellitus like delirium, mental 

distress, eating disorders and schizophrenia. However, the current study focused only on 

depression and anxiety symptoms among T2DM patients. Furthermore, the study was 

limited to males and females with T2DM aged between 30 and 70 years’ old who 

presented with symptoms of depression and anxiety. 

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  Fourthly, although there are other psychological interventions such as Cognitive 

Behavioural Therapy, Motivational Therapy, Problem Solving Therapy, coping skills 

training and Family Behaviour Therapy used to treat depression and anxiety symptoms, 

this study focused on REBT. Additionally, the current study was limited to only two Sub-

County hospitals in Murang’a County. So, if the same study is carried out in other 

counties in Kenya there is a possibility of having similar findings. This is due to the fact 

that epidemiologically, depression and diabetes mellitus have comparable environmental 

factors and biological factors. This means that the presence of one condition may 

accelerate the prevalence of the other. 

Definition of Terms 

Anxiety: It is defined as a particular phobias and overall fear and worry associated to 

caregiving (APA, 2014). It is frequently linked with muscle tightness and vigilance in 

preparation for future threat or avoidant actions (APA, 2013). This study adopts this 

definition of anxiety.  

Cognitive behaviour therapy: Is a generic term which refers to psychotherapies that 

include both the conduct interventions as well as psychological interventions (Beck & 

Beck, 2011). The use of the word CBT in this study is the same. 

Diabetes:  Is said to be disruption of carbohydrates, fat and protein absorption which is 

due to a reduction in the discharge of insulin from the pancreas (Institute of Public 

Health, 2011). The same definition will be used in this study.  

Depression: According to Shams (2009) depression is a psychoneurotic disorder 

characterized by feelings of sadness, empty or irritable mood, inactivity, difficulty in 

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concentration, reduction or increase in appetite, sleep changes, fatigue, hopelessness, 

helplessness and at times suicidal ideations. All these affect a person’s abilities to 

function. This definition fits very well in this research and is used to mean the same. 

Efficacy: In the health field, it is a measure of output from those health services that 

contribute towards reducing the dimension of a problem or improving an unsatisfactory 

situation (Wojtczak, 2002). This is the same meaning assigned in this study.  

Insulin: Is defined as a hormone that controls the blood sugar by transferring it from the 

bloodstream into the person’s cells (WHO, 2013). This definition means the same in this 

study. 

Rational Emotive Behavior Therapy (REBT): Is a form of cognitive behavioral therapy 

that has emphasis on the individual’s descriptions as well as interpretations of events in 

life that lead to the way they feel and behave (McLeod, 2019). The use of this term in this 

study means the same. 

Type 2 diabetes mellitus (T2DM):  This is a condition associated with high blood sugar, 

insulin resistance and advanced Beta-cell failure (Petznick, 2011) as well as disruption in 

the metabolic rate of lipids, protein, and carbohydrates (Degeling & Rock, 2012).  The 

use of the word T2DM in this study means the same. 

Summary 

 This chapter has extensively discussed the background to the study which 

provides a basis for the statement of the problem, purpose and objectives of study. The 

study was done in Kigumo and Kandara Sub-County Hospitals and justification of the 

study was articulated. It has succinctly demonstrated the significance of the study and 

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presented assumptions of the study which were aligned with the objectives of the study. 

Regarding limitations and delimitations of study, there are other psychological problems 

associated with diabetes but this study focused on depression and anxiety. Additionally, 

there are other psychological intervention used to treat depression and anxiety but this 

study focused on REBT. Definition of operational terms was articulated. Chapter two 

deals with the literature review related to the topic of this study. 

 

 

 

 

 

 

  

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CHAPTER TWO 

LITERATURE REVIEW 

Introduction 

  This chapter discusses the theoretical framework and literature reviewed 

according to objectives of the study. This includes the prevalence of type 2 diabetes 

mellitus (T2DM), and the occurrence of depression and anxiety among T2DM patients. 

The sociodemographic correlation of depression and anxiety among T2DM patients and 

coping strategies used by patients with T2DM to cope with stressful situations in life was 

also discussed. In addition, the efficacy of Rational Emotive Behavioral Therapy in 

reducing symptoms of depression and anxiety has also been looked into as well as the 

Conceptual framework. 

Theoretical Framework 

  Jones (2010) defined theoretical framework as the structure that supports a 

research theory and give details of why the current research topic and problem is being 

studied. This study was guided by Rational Emotive Theory pioneered by Albert Ellis 

and Theory of Planned Behavior founded by Icek Ajzen. The two theories have been 

found to be appropriate for this study. 

Rational Emotive Behavioral Theory 

  Albert Ellis developed rational emotive behaviour theory (REBT) in the 1950s 

which is one of the original forms of Cognitive Behavioural Therapy (CBT) (Ellis, 1962). 

Initially, Ellis had named his REBT approach as Rational Therapy (RT) because his main 

emphasis was on thoughts (Dryden & Neenan, 2006). Later in 1961, he renamed his 

treatment Rational Emotive Therapy (RET) after he realized that he underrated the role of 

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feelings (Ellis, 1994). Finally, Ellis incorporated behaviour in his treatment because 

behavioral factors constitute a central element of these treatment strategies and named it 

Rational Emotive Behavioral Therapy (REBT) (Ellis, 1995).   

  As a trained clinical psychologist, he was not satisfied with results presented by 

traditional psychoanalytic therapy (Ellis, 1991). The idea of rational emotive theory and 

therapy came after realizing the insufficiency of the techniques of psychoanalytic and 

behaviourism. He argued that even though his patients were conscious of the underlying 

difficulties, their conduct did not change (Ellis, 1962). Early in 1955, Ellis formed REBT, 

and this was after he joined humanistic, philosophical as well as behavioural therapy 

(Corey, 2005). REBT upholds some uniqueness (Hollon & DiGiuseppe, 2010).   

  REBT is founded on the basis that humans bother themselves by the thought of 

what happens and not necessarily what happens (Ellis & Harper, 1975). The aim of 

REBT is to assist people change illogical beliefs and negative thinking patterns to 

overcome psychological problems and mental suffering (Ellis, 1991). On the other hand, 

Faw (1995) observed that a person’s beliefs are often irrational, do not line up with the 

facts of one’s life perceptions, are distorted and the individual often reacts to problems in 

self-defeating ways. Accordingly, the answer lies in coming to perceive challenging 

situations in more accurate and realistic ways. REBT stresses on the role of social interest 

in determining psychological wellbeing (Corey, 2005). It is therefore clear that the origin 

of one’s emotions or feelings is the beliefs, evaluations, interpretations, and reactions to 

life conditions. It is during therapy that clients gain skills that help identify and dispute 

irrational beliefs learnt and currently being perpetuated by self-indoctrination (Corey, 

2005). 

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   People acquire irrational beliefs after interacting with important people during 

childhood and then they generate irrational beliefs and superstitions by themselves 

(Corey, 1991). The result is that people actively support self-defeating dogmas through 

the process of auto suggestion and self-repetition as well as acting as though they are 

helpful. It is during therapy that clients learn how not to be depressed even when they are 

not recognized and treasured by the significant others (Corey, 1991). REBT is grounded 

on the ABCDE theory of psychopathology (Ellis, 1991). The main idea is that the 

activating event (A) may be something that happens in the environment around diabetes 

patients. For example, the activating event here is the patient’s diagnosis with T2DM. 

This does not directly cause emotional and behavioural consequences (C) which may be 

depression or anxiety. The beliefs (B) a person holds about the activating events are the 

greatest cause of feelings and actions. The individuals with diabetes mellitus may 

therefore hold negative beliefs due to the condition they may be in. For instance, T2DM 

will ruin my life and no one can stand having T2DM. Other patient’s may have a 

negative belief that “no one” can be contented if one has T2DM. 

 The beliefs lead to emotional and behaviour consequences (C). Therefore, what 

disturbs the patients is not diabetes mellitus or its chronic implications but the beliefs 

they hold about themselves, others, and the future. Ellis also added D and E. D is the 

disputes or arguments against irrational beliefs. E on the other hand, is the new outcome 

or the more effective feelings and conducts that result from new, more rational thinking 

about the original event (Ellis, 1991). Some of the most frequently and strongly held onto 

disturbed beliefs are known as core irrational beliefs (Sherin & Caiger, 2004). 

  

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Source: (Ellis, 1994) 

  REBT was used in this study to explain and provide a framework for 

understanding reasons that cause psychological problems for diabetes patients. The 

patients may develop irrational thinking because of the diagnosis of the condition.  Some 

of the irrational beliefs include; T2DM will ruin my life, no one can enjoy life if one has 

been diagnosed with T2DM and no one can be able to manage T2DM.  As a result, they 

isolate themselves from their parents or family members, perceive the problem as beyond 

their control, feel angry, sad, and worthless. This makes individuals vulnerable to 

depression, anxiety, and negative self-image (Corey, 2005). REBT theory expounds and 

offers a framework for understanding the origins of mental problems and negative 

thinking patterns, emotions and behaviour for people with diabetes.  

            Although REBT helps diabetes patients to dispute irrational beliefs for them to 

learn different ways of analysing situations, Corey (1991) observed that the theory does 

not clarify why people tend to re-indoctrinate themselves with irrational beliefs or why 

they hold on to those beliefs. This agrees with Belkin (1980) who noted that the cause of 

his client’s emotional problems and psychological misperceptions was due to a 

B (Belief)  
-Evaluations 
/Appraisal 

-Rational /Irrational 

A 
Activating Event 

C 
Consequences 
Emotions 
behaviours 
cognitions 
 

D 
Disputing or 

arguments against 
irrational beliefs 

 

E 
New effect or more 

effective feelings and 
conducts 

 

Figure 2.1: Rational Emotive Behavioural Theory Chart 

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continuous reflection on their lives rather than what had happened in the past. REBT 

theory therefore assists people to examine their illogical beliefs and negative thinking 

patterns that cause psychological problems and suffering although they are not consistent 

with reality.  

          Davice (2006) asserted that there is a relationship between irrational beliefs and 

psychological distress. Illogical as well as maladaptive cognition might lead to 

psychological difficulties like anxiety or great fear, depression, anger as well as social 

fear among others. The detrimental consequences of irrational beliefs might lead to 

negative effects on the control and management of blood glucose. REBT theory explains 

that irrational thoughts and beliefs affect persons to a degree of triggering harmful sound 

effects and how these thoughts act as obstacles to a joyful self-fulfilling life (Mukangi, 

2010).  

 REBT theory has been criticized as being too simple, arguing that just a few 

rational and irrational beliefs cannot elaborate the great difference of mental disorders 

(Ellis, 2003, Padesky & Beck, 2003). In response to this criticism, David et al. (2005) 

stated that REBT theory includes the cognitive content particularly hypothesis of 

cognitive therapy theory. Riskind (2004) added that the benefit of a reductionist method 

preferred by REBT is the capacity to elaborate the growth of numerous mental disorders 

in terms of the relations between just few irrational beliefs’ processes. Another 

shortcoming is that it overlooks the role played by person’s differences bearing in mind 

that each person has his or her own verge for submitting to these irrational thoughts 

(DiGiuseppe, 1996). Furthermore, the role of diathesis stress model is also ignored 

(Bennett, 2003; Ridgway, 2007).  

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 As a result of REBT shortcomings, the theory of planned behaviour which was 

developed by Icek Ajzen was used. This theory helps in expounding as well as 

understanding the effectiveness of self-efficacy on conducts. In other words, theory of 

planned behaviour is applied in this study for behavioral clarifications and predictions. It 

considers the expectations that people have when deciding to engage in or avoid a certain 

behavior. Harvey and Lawson (2009) reports that theory of planned behavior being one 

of the health belief theories they reviewed, helps in explaining patient demeanour and the 

influence of conduct in diabetes self-management. Therefore, when diabetes beliefs are 

identified, REBT intervention will be applied to counter beliefs that may hinder positive 

behavior. 

Theory of a Planned Behaviour 

  Theory of planned behaviour (TPB), by Icek Ajzen, denotes a model established 

by social psychologists which has been extensively utilized in the understanding of a 

range of conducts (Ajzen, 1991; Armitage & Conner, 2001). The theory of planned 

behaviour summaries the factors that define a person’s verdict to follow a certain conduct 

(Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). TPB has its basis on the 

understanding of reasoned action which failed to elaborate conducts that were not under 

the direct control of individual. According to the theory of reasoned action (TRA), the 

conduct taken by a person needs to be intentional (Ajzen, 2011). The attitude towards a 

given conduct as well as subjective norm is the component that leads to these intentions 

(Ajzen, 2011). It was later discovered that intentions can only perfectly predict conduct 

when the conduct is under the person’s volitional control (Ajzen, 2011). For this reason, 

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Azjen added the concept of perceived behaviour control in the TRA and named the new 

model as Theory of Planned Behaviour (TPB) (Ajzen, 2011; Azjen, 1991).  

  This theory TPB was coined by Azjen who indicated that the predictors of 

intention to perform behaviour incorporated attitudes, subjective norm as well as 

perceived behavioural control (Ajzen, 1991; Lee at al., 2012). Intentions, in this case, are 

the antecedent of conduct because it is in-between components in the middle of the other 

three components to the real conduct (Ajzen, 2011; Rise et al., 2003; Schiffer & Ajzen, 

1985). Attitudes to adherence treatment are individual’s evaluative sentiments, both 

constructive and unwanted of the result of a conduct (O’Boyle et al., 2001; Ogden, 2000). 

Individual’s attitude towards their illness impact on how they manage day to day life in a 

more practical way and negative perception can hinder people with T2DM from 

monitoring their blood sugar (Svenningsson et al., 2011). Subjective norms are a person’s 

appraisal of how their loved ones and friends will act in a certain situation (O’Boyle et 

al., 2001).  

  The premise of the concept of subjective norm is that social pressure influences 

people to behave in ways that are anticipated by society, and that in turn, people are 

compelled to act in ways that are expected by society (Ogden, 2000). Intentions to engage 

in healthy behavior have been shown to be strongly predicted by subjective norms 

(Finlay et al., 1997). Perceived behaviour control on the other hand, involves person’s 

conviction that he or she can engage in a particular conduct, taking into account both 

internal and external aspects that are related to previous conduct or experiences (Povey et 

al., 2000). According to Povey et al. (2000), internal factors refer to individual’s abilities 

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and skills, whereas external factors are opportunities or challenges that an individual 

experience. 

  

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Figure 2.2: Theory of the Planned Behaviour 

Source: Ajzen (1994) 
   

Individuals’ primary judgments are influenced by their beliefs about the need for 

treatment as well as awareness of the related benefits and dangers (Hampson & Glasgow, 

1996; Hampson et al., 1995). Additionally, if individuals believe their risk to be greater 

for a specific illness, they are expected to be involved in healthy conducts to lessen that 

risk (Fischhoff et al., 2002). This agrees with Clyton and Griffith (2008), that the more 

positive or constructive the attitude and subjective norms together with perceived 

behaviour control, the stronger should be people’s intention to carry out a given conduct. 

  Some researchers observe that theory of planned behaviour as well as other social 

cognitive models should be stretched out to include volitional variables such as self-

regulatory approaches (Gollwitzer, 1993; Sheeran, 2002). For them, this would inspire 

enactment of individuals’ aim to support in the prediction of conduct (Gollwitzer, 1993; 

Sheeran, 2002). In support of this, Norman and Conner (2005) cited that planning is a 

Behaviour 
Belief  

Normative 
Beliefs  

Control 
Beliefs  

Attitude 
towards 

behaviour 

Subjective 
Norm 

Perceived 
Behaviour 

control 

Behaviour Intention 

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crucial volitional variable that can assist in changing from intention to conduct. Norman 

and Conner added that stipulating where, when, and how behaviour is to be conducted 

may possibly warrant those strong meanings are decoded in conduct. In the same vein, 

empirical data supports addition of a variable like past conduct, autonomy, ethical norms, 

self-identity, societal support, and emotional beliefs to the theory of planned behaviour 

(Armitage & Conner, 1998). On the other hand, Courneya et al. (2000) suggested that 

subjective norm needs to be replaced with societal support based on findings of their 

study that revealed societal support to be greater than subjective norm in envisioning 

physical exercise intention. 

  Theory of planned behaviour has been applied to envisage physical undertakings 

as well as healthy diet for individuals diagnosed with T2DM (Boudreau & Godin, 2009; 

Plotnikoff et al., 2010; White et al., 2010). In the same vein, several studies have 

described application of TPB in healthy conduct changes such as eating heathy diet 

(Omondi et al., 2010; 2011; Rahmati-najarkolaei et al., 2017) and carrying out physical 

activities for individuals with type 2 diabetic patients (Kurnia et al., 2017; Kurnia et al., 

2015, Masoud et al., 2016; White et al., 2012). 

  Lack of physical exercise will increase the risk of getting non-communicable 

diseases like obesity, diabetes, and stroke (Garland et al., 2011; Lee et al., 2012). 

According to Ajzen (1991), theory of planned behaviour puts more emphasis on intention 

as a locus of control and is widely applied to study health related conduct. According to 

Akbar et al. (2015), persons with robust intention can act more rapidly than a person with 

weak intention. Ajzen (1991) acknowledged that TPB fails to elaborate conduct 

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exclusively. This was supported by Sniehotta (2009) who said that TPB does not account 

for determined conduct inconsistencies. 

  This theory fits very well in the current study because it provides a good 

description of the factors which are linked to self-care conducts