This was a cross-sectional study conducted in Shandong province in eastern China between August and December 2017. Shandong contains 17 prefectures and 140 counties (districts) and has a population of nearly 99 million (7.2% of mainland China) in 2016. There are an estimated 980,000 T2DM patients in the province in 2013 (prevalence: 9.3%).27 Nearly 30% of T2DM patients were enrolled in the Essential Public Health Services - Non-communicable Disease Management System (EPHS- NDMS) in 2016. For our study, we employed a multi-stage, stratified, randomized sampling to select participants from the EPHS-NDMS, as described in detail in a previous study.28 A total of 2520 diabetes patients in the sampling communities or villages were recruited to the survey, and 2166 diabetic patients for whom a complete dataset were available were included in the analysis. The inclusion criteria were registration in EPHS-NDMS; diagnosis of T2DM based on WHO criteria for more than 6 months;29 aged under 80 years and ability to communicate and understand instructions.

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