Journal of Preventive Medicine

Introduction
The aging population is increasing in the countries worldwide due to the decrease in mortality and the progress of medical sciences, health, education, and the increase in life expectancy. The elderly people are prone to many chronic diseases, including type 2 diabetes (T2D). People react differently to a chronic disease such as diabetes such as having stress and anxiety in coping with it. For a person who is under stressful conditions, it is important to evaluate stress levels and how to deal with the conditions. High, continuous and long-term stress can lead to incompatibility in the person and cause physical and emotional problems. In addition to perceived stress, self-efficacy is also affected in older people with diabetes. Studies have shown that self-efficacy is a key psychological factor in adapting to chronic diseases, especially diabetes; therefore, promoting self-efficacy can be effective in improving self-care. Insomnia is other common disorders in the elderly, especially those with diabetes. Sleep disorders in the elderly may lead to depression, falls, memory disorders, problems in concentration, excitability, low quality of life, dementia, fatigue, unstable mood and anxiety. This study aims to evaluate the effect of emotion regulation training on reducing perceived stress and increasing self-efficacy and quality of sleep in the elderly with T2D.
Methods
This is a quasi-experimental study with a pre-test/post-test/ follow-up design using a control group. The study population includes all older people with T2D living in Kish Island in Iran in 2021, 30 of whom were selected using a purposive sampling method and randomly assigned to two training and control groups. Participants were selected based on the inclusion criteria and conducting a clinical interview based on the diagnostic criteria of DSM-5. The inclusion criteria were no history of participation in the emotional regulation training programs, no history of mental disorder and other specific and chronic physical diseases, while the exclusion criteria were the absence from more than two training sessions and having severe complications leading to hospitalization. A written informed consent was obtained from all participants. They were free to leave the study at any time. Emotion regulation training was conducted at 8 sessions, two sessions per week, each for 90 minutes. Then, the participants were evaluated in three phases: pre-test, post-test, and follow-up (2 months) using the Perceived Stress Scale of Cohen et al. (2004), General Self-Efficacy Scale by Scherer et al. (1989), and Pittsburgh Sleep Quality Index developed by Pittsburgh (1989). Data analysis was conducted using repeated measures analysis of variance in SPSS v. 26 software.
Results
The Mean±SD of the age was 70.40±4.50 in the intervention group and 70.40±4.89 in the control group. In the intervention group, 9 (60%) were men and 6 (40%) were women. In the control group, there were 7 men (46.6%) and 8 women (53.4%). The results of the Shapiro-Wilk test showed that the assumption of normal data distribution was established. The assumption of sphericity was also confirmed. The results showed that the interaction effect of group and time on perceived stress (F(4, 84)=42.065, P=0.001, η2=0.667), self-efficacy (F(4, 84)=91.845, P=0.001, η2=0.814), and sleep quality (F(4, 84)=5.410, P=0.001, η2=0.205) were significant (P<0.001) (Table 1).


Discussion
Based on the findings, emotional regulation training was effective in reducing perceived stress, and improving self-efficacy and sleep quality of older people with T2D. The cognitive emotion regulation strategies are among the methods that determine the ways of accepting or coping with stressful situations and events. Executive functions based on the consistent use of cognitive processes might help the elderly solve problems, plan, act, regulate and monitor their emotions and thus have reduced perceived stress. As a behavioral and cognitive ability, it can stabilize a person's relationship with the environment by coordinating mental, biological and motivational processes, and equip her/him with efficient and appropriate responses in dealing with situations, increase the feeling of control over affairs, strengthen the belief in influencing situations, and improve the self-efficiency. Emotion regulation training made effective use of positive emotion regulation strategies by the elderly. Therefore, in facing problems, they turn their minds to positive activities and experiences, emphasize the positive aspects of the unfortunate events, and reduce their importance and seriousness. So, positive emotion regulation could improve their sleep quality. The results of this study cannot be generalized to the entire elderly people in Iran, but it paves the way for other studies that can verify the use of emotion regulation strategies for different aspects of mental health in the elderly and improve their quality of life.

Ethical Considerations
Compliance with ethical guidelines
Ethical considerations included receiving a written informed consent form to participate in the research stating that the participation in the research was voluntary, the right to withdraw from the study at any time, taking care of the sample, his rights and health. The subject was assured that he would be informed of any new information that would affect his cooperation.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Writing, conceptualization, editing, implementation of experimental intervention and statistical analysis: Badri Omidi; Conceptualization, editing and validation: Mehrdad Sabet; Management, validation and editing: Hassan Ahadi; Management and editing: Hamid Nejat.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We are grateful to the elderly participants in the research who patiently helped us in conducting this research.
 

References

1. Li W-P, Neradilek MB, Gu F-S, Isquith DA, Sun Z-J, Wu X, et al. Pregnancy-associated plasma protein-A is a stronger predictor for adverse cardiovascular outcomes after acute coronary syndrome in type-2 diabetes mellitus. Cardiovasc Diabetol. 2017; 16(1):1-11. [DOI:10.1186/s12933-017-0526-6] [PMID] [PMCID]
2. Jafari Z, Mehrdad N, Sharifi F, Haghani H, Nikpour S. Fall related factors in the type 2 diabets older adults: A case-control study on older adults referring the hospital. Iran J Diabet Metab. 2016; 15(4):258-66. [Link]
3. American Diabetes Association. 2 Classification and diagnosis of diabetes: Standards of medical care in diabetes-2020. Diabetes Care. 2020; 43(Suppl 1):S14-31. [DOI:10.2337/dc20-S002] [PMID]
4. Delevatti RS, Schuch FB, Kanitz AC, Alberton CL, Marson EC, Lisboa SC, et al. Quality of life and sleep quality are similarly improved after aquatic or dry-land aerobic training in patients with type 2 diabetes: A randomized clinical trial. J Sci Med Sport. 2018; 21(5):483-8. [DOI:10.1016/j.jsams.2017.08.024] [PMID]
5. Burger K, Samuel R. The role of perceived stress and self-efficacy in young people's life satisfaction: A longitudinal study. J Youth Adolesc. 2017; 46(1):78-90. [DOI:10.1007/s10964-016-0608-x] [PMID]
6. Rönnlund M, Åström E, Adolfsson R, Carelli MG. Perceived stress in adults aged 65 to 90: Relations to facets of time perspective and COMT Val158Met polymorphism. Front Psychol. 2018; 9:378. [DOI:10.3389/fpsyg.2018.00378] [PMID] [PMCID]
7. Chen Y, Liang Y, Zhang W, Crawford JC, Sakel KL, Dong X. Perceived Stress and cognitive decline in chinese-american older adults. J Am Geriatr Soc. 2019; 67(S3):S519-24. [DOI:10.1111/jgs.15606]
8. Enns A, Eldridge GD, Montgomery C, Gonzalez VM. Perceived stress, coping strategies, and emotional intelligence: A cross-sectional study of university students in helping disciplines. Nurse Educ Today. 2018; 68:226-31. [DOI:10.1016/j.nedt.2018.06.012] [PMID]
9. Schwarzer R, Antoniuk A, Gholami M. A brief intervention changing oral self-care, self-efficacy, and self-monitoring. Br J Health Psychol. 2015; 20(1):56-67. [DOI:10.1111/bjhp.12091] [PMID]
10. Skaalvik EM, Skaalvik S. Teacher stress and teacher self-efficacy as predictors of engagement, emotional exhaustion, and motivation to leave the teaching profession. Creative Education. 2016; 7(13):1.785-99. [DOI:10.4236/ce.2016.713182]
11. Kang H, Lee H, Lee W, Oh H, Lim W, Koo H, et al. Octave bandwidth Doherty power amplifier using multiple resonance circuit for the peaking amplifier. IEEE Trans. Circuits Syst I: Regular Papers. 2018; 66(2):583-93. [DOI:10.1109/TCSI.2018.2869905]
12. de Sousa APS, Ferreira HR, José, Filho F, Baker J, Brock S, et al. Dermatoglyphic profile and hand grip strength of the finalists athletes in the Brazilian paracanoe championship. J Exerc Physiol. 2016; 19 (1). [Link]
13. McRae K, Rhee SH, Gatt JM, Godinez D, Williams LM, Gross JJ. Genetic and environmental influences on emotion regulation: A twin study of cognitive reappraisal and expressive suppression. Emotion. 2017; 17(5):772. [DOI:10.1037/emo0000300] [PMID]
14. Sabzaligol M, Kazemi AS. [Comparing cognitive emotion regulation in two male groups; suffering from cancer and cancer free subjects (Persian)]. Med Sci. 2017; 26(4):256-63. [Link]
15. Zangi Abadi M, Sadeghi M, Ghadampour E. [The effect of teaching emotional processing strategies on academic emotion and academic self-efficacy among high school female students in Kerman (Persian)]. J Psyc Sci. 2018; 17(67):399-406. [Link]
16. Cameron LD, Carroll P, Hamilton WK. Evaluation of an intervention promoting emotion regulation skills for adults with persisting distress due to adverse childhood experiences. Child Abuse Negl. 2018; 79:423-33. [DOI:10.1016/j.chiabu.2018.03.002] [PMID]
17. Palmer CA, Alfano CA. Sleep and emotion regulation: An organizing, integrative review. Sleep Med Rev. 2017; 31:6-16. [DOI:10.1016/j.smrv.2015.12.006] [PMID]
18. Hom MA, Stanley IH, Rogers ML, Tzoneva M, Bernert RA, Joiner TE. The association between sleep disturbances and depression among firefighters: Emotion dysregulation as an explanatory factor. J Clin Sleep Med. 2016; 12(2):235-45. [DOI:10.5664/jcsm.5492] [PMID] [PMCID]
19. Vantieghem I, Marcoen N, Mairesse O, Vandekerckhove M. Emotion regulation mediates the relationship between personality and sleep quality. Psychol Health. 2016; 31(9):1064-79. [DOI:10.1080/08870446.2016.1171866] [PMID]
20. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983; 24(4):385-96. [DOI:10.2307/2136404] [PMID]
21. Hashemi Z, Eyni S. Perceived stress in the elderly: [The role of spiritual intelligence, self-compassion, and psychological hardiness (Persian)]. Aging Psychol. 2020; 5(4):289-99. [DOI:10.22126/JAP.2020.4836.1381]
22. Buysse DJ, Reynolds III CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res. 1989; 28(2):193-213. [DOI:10.1016/0165-1781(89)90047-4]
23. Heidari A, Ehteshamzadeh P, Marashi M. [The relationship between insomnia intensity, sleep quality, sleepiness and mental health disorder with educational performance in female adolescences of Ahwaz city (Persian)]. 2010; 1(4):65-76. [Link]
24. Gratz KL, Gunderson JG. Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behav Ther. 2006; 37(1):25-35. [DOI:10.1016/j.beth.2005.03.002] [PMID]
25. Szczygieł D, Buczny J, Bazińska R. Emotion regulation and emotional information processing: The moderating effect of emotional awareness. Pers Individ differ. 2012; 52(3):433-7. [DOI:10.1016/j.paid.2011.11.005]
26. Nasrolahi B, Pour SNR. [Social adjustment and problem-solving in the elderly: The role of cognitive emotion regulation (Persian). Aging Psychol. 2019; 5(2):143-55. [DOI:10.22126/JAP.2019.1122]
27. Yu Y, Peng L, Tang T, Chen L, Li M, Wang T. Effects of emotion regulation and general self-efficacy on posttraumatic growth in Chinese cancer survivors: Assessing the mediating effect of positive affect. Psychooncology. 2014; 23(4):473-8. [DOI:10.1002/pon.3434] [PMID]
28. Mouton A, Hansenne M, Delcour R, Cloes M. Emotional intelligence and self-efficacy among physical education teachers. J Teach Phys Educ. 2013; 32(4):342-54. [DOI:10.1123/jtpe.32.4.342]
29. Garnefski N, Kraaij V. Specificity of relations between adolescents’ cognitive emotion regulation strategies and symptoms of depression and anxiety. Cogn Emot. 2018; 32(7):1401-8. [DOI:10.1080/02699931.2016.1232698] [PMID]
30. Jokar E, Rahmati A. [The effect of stress inoculation training on anxiety and quality of sleep of pregnant women in third trimester (Persian)]. J Fundamentals Ment Health. 2015; 2(17):62-66. [DOI:10.22038/jfmh.2015.3985]