Health-Related Quality Of Life Of Diabetes Mellitus Patients And Non-Diabetics
Nigeria has the highest number of diabetics in Sub-Saharan Africa. As a chronic illness, diabetes mellitus (DM) places serious constraints on the people living with diabetes mellitus. The short-term and long-term complications affecting the physical, psychological and social functioning of diabetics can impinge on their health-related quality of life (HRQOL).
This study assessed and compared the HRQOL of diabetic patients and non-diabetics in Port Harcourt, Rivers State, Nigeria. Four objectives and two null hypotheses were formulated to guide the study. The study adopted a descriptive cross sectional survey design. It was conducted at the diabetic out- patient clinic of the University of Port Harcourt Teaching Hospital, Port Harcourt. Power analysis was used to determine the minimum sample size of 200 each for the diabetic and the non-diabetic comparison group.
The diabetics who met the inclusion criteria were purposively recruited, while the age and sex matched non-diabetics were recruited from Catholic Community of Mater Misericordiae Catholic Church, Rumumasi and Anglican Community of Anglican Church of Messiah, Elekahia Housing Estate, all in Port Harcourt. The World Health Quality of Life-Bref, (WHOQOL-BREF) a 26 item standardized questionnaire with 12 additional questions soliciting demographic and clinical data was used for data collection.
The reliability of the instrument was carried out using split-half method.The Cronbach’s alpha coefficient of reliability was 0.70 for physical domain, 0.76 for psychological domain, 0.78 for social domain and 0.70 for environmental domain.. Instrument was interviewer administered and data collected were subjected to descriptive and inferential statistics using Chi-square, student t-test and analysis of variance at alpha significant level of P<0.05.
There were no significant differences (p > 0.05) between the diabetics and the non-diabetics in their demographic variables. The mean scores for diabetics in the four domains of the WHOQOL-BREF were: physical 23.17 ± 3.39, Psychological 20.06 ± 3.32, social 10.20 ± 2.47 and environmental 28.00 ± 5.15. The mean scores for non-diabetics in the four domains were: physical 24.17 ± 2.42, psychological 21.53 ± 2.51, social 11.43 ± 1.87 and environmental 28.68 ± 5.044. The diabetic group had less HRQOL (p < 0.05) than the non- diabetic group in the physical, psychological and social domains. Out of the 200 diabetics, 92 reported co-morbidities.
The mean scores of diabetics with co-morbidities in the four domains were: physical 22.73 ± 3.30, psychological 19.63 ± 3.08, social 9.96 and environmental 27.41 ± 4.98. The mean scores of diabetics without co-morbidities in the four domains were: physical 23.55 ± 3.43, psychological 20.39 ± 3.48, social 10.40 ± 2.62 and environmental 28.50 ± 5.25.
There was no significant difference (p > 0.05) between the diabetic patients with co-morbidities and the diabetics without co-morbidities in all the four domains. The diabetics with post-secondary education had a significant higher mean score (3.93 ± 0.81) than those with secondary and primary education (3.75 ± 1.12 and 3.37 ± 1.06 respectively). In conclusion, DM impacts negatively on the HRQOL of the patients. Efforts to enhance diabetic HRQOL should be promoted
Background to the Study
Diabetes mellitus is defined as a group of metabolic diseases characterized by increased level of glucose in the blood resulting from defects in insulin secretion or insulin action or both [American Diabetic Association (ADA), (2004); Huang, Hwang, Wu, Lin, Leite & Wu, (2008)]. It is a devastating illness that has physical, social, emotional and economic implications. It impinges on the quality of life and overall health status of the individuals, as well as direct health care cost and indirect costs to the society when related to lost productivity. It is a chronic and distressing illness that makes demands on the individual by causing a lot of short-term and long-term complications that is life threatening. Diabetes mellitus is the leading cause of non-traumatic amputation and blindness in working age adults and the third leading cause of death from diseases primarily, because of the high rate of cardiovascular complications (myocardial infarction, stroke, and peripheral vascular disease) among people with diabetes (Smeltzer, Bare, Hinkle & Cheever, 2010).
Studies have shown that the incidence of diabetes is on the increase. The centre for Disease Control and Prevention (CDC) (2011), stated that in 2010, an estimated 79 million American adults aged 20years or older with pre-diabetes. In 2000, the world-wide estimate of the prevalence of diabetes was 171 million people, and by 2030, this is expected to increase to 366 million (Wild, Roglic, Green et al, 2004). The International Diabetes Federation (IDF) estimated that 194 million people had diabetes in the year 2003, and about two thirds of these people lived in developing countries of which Nigeria is one. The President of IDF (2006-2009), warned that if left unchecked, the number of people with diabetes will reach 380million in less than 20years. This will mean 1 out of 14 adults worldwide will have diabetes in the years 2025. The loss of earnings and life will be hard to bear.
Diabetes mellitus was once regarded as a disease of the affluent but is now vastly visible as a growing health problem in developing economies as almost 80% of diabetes deaths occur in low and middle income countries, of which Nigeria is one (Diabetes Atlas, 2006). Available data suggests that it is emerging as a major health problem in Africa, including Nigeria. In the African sub-region, diabetes is frequently undiagnosed. In most cases, it is diagnosed incidentally during routine check-up or when the patient presents with the complications (International Diabetes Federation, African Region, 2006). The World Health Organization (WHO) statistics indicates that Nigeria has the highest number of diabetics in Sub-Saharan Africa (Chinenye & Ogbera, 2013).
The incidence and prevalence of diabetes mellitus in Nigeria continues to increase despite great deal of research and resources. With current trend of transition from communicable to non-communicable disease, it is projected that non-communicable diseases will equal or even exceed communicable diseases in developing nations, including Nigeria thus culminating in double burden of disease(Chinenye & Ogbera, 2013).The crude prevalence rate of diabetes mellitus in Port Harcourt, Nigeria is 6.8% ( Nyenwe, Odia, Ihekwaba, Ojule & Babatunde, 2003).With the alarming growth in the number of people suffering from diabetes, efficient and quality care become imperative. The numerous complications of the disease and its management poses challenges on the quality of life of the individuals suffering from the disease, therefore the need to assess the quality of life (QOL) of these individuals becomes necessary.
Quality of life (Q0L) is a descriptive term that refers to people’s emotional, social and physical well-being and their ability to function in the ordinary task of living (Donald, 2010). Health related quality of life (HRQ0L) is preferred by health researchers because it is used to narrow the scope to aspects of functioning directly related to diseases and or medical treatment (Odili, Ugboka & Oparah, 2010).
Studies of quality of life are performed for two reasons. First, they are conducted to evaluate the psychosocial functioning of patient group and to identify specific problems and needs of patients at different stages of the disease process. Secondly, and most often, HRQOL studies are conducted to compare the impact of different regimens on the patient’s well-being and the treatment satisfaction (Snoek, 2000).
Researchers report lower HRQOL in people diagnosed with diabetes than for non-diabetic (Andayani, Ibrahim & Aside, 2010; Odili et al, 2010). In Nigeria, studies of HRQOL with diabetics have been carried out at the University of Benin Teaching Hospital (UBTH) (Odili et al., 2010) and University of Ilorin Teaching Hospital (UITH) (Issa & Baiyewu, 2006). UBTH study concluded that diabetes impacts on the lives of diabetic patients while UITH study concluded that lower income, lower education, low rated employment and physical complications adversely affect the HRQOL of patients with diabetes mellitus. Both studies dwelt on the psychosocial aspects of the diabetics. This study therefore assessed the HRQOL of patients with diabetes mellitus in Port Harcourt.
Statement of Problem
Diabetes mellitus is a chronically distressful illness with which to live. Polonsky, (2000) stated that for many patients the demand of self-care can be burdensome, frustrating and overwhelming. According to Kubler Ross, (1969), in Berman, Synder, Kozier & Erb, (2008), the individual has to pass through the stages of grief which are denial, anger, bargaining, depression and acceptance on diagnosis.
People living with diabetes mellitus pass through a lot of stress in order to live. The disease, as a chronic illness, places serious constraints on the peoples’ activities due to its manifold demands. Individuals with diabetes have to think of what to eat and when to eat, exercise, decide whether to test plasma glucose and depending on the result, plan when to eat or take their drugs (insulin or tablets). They also carry along with them glucose drinks for fear of hypoglycaemia and usually stop to check the symptoms of hypo or hyperglycaemia. To crown it all, they are always gripped with the fear of complications especially foot complications and amputation. A good number of patients become frustrated, discouraged and/or engaged with a disease that often does not seem to respond to their best efforts. This, Rubin (2000), referred to as “diabetes overwhelmus”. Diabetes can exert an enormous negative impact on QOL in the area of social and psychological well-being, as well as physical ill-health and environmental health. As the disease progresses, psychosocial problems imernate from onset of complications, medical and self- management. To what extent do the disease and its management impact on the QOL of the patients? This study therefore assessed the HRQOL of patients with diabetes mellitus.
Purpose of the Study
The purpose of this study was to assess the health-related quality of life (HRQOL) of patients with diabetes mellitus attending the diabetic clinic of the University of Port Harcourt Teaching Hospital, and compare with that of non-diabetic persons resident in Port Harcourt. The non-diabetics are comparable normal persons drawn from the same catchment area of the hospital. They are matching group.
Objectives of the Study
The study objectives were to:
- Determine the HRQOL scores of patients with diabetes mellitus and the non-diabetic group in all the four domains of the WHOQOL-BREF.
- Compare the HRQOL scores of diabetes mellitus patients with non-diabetic group in all the four domains of the World Health Organization Quality Of Life-BREF (WHOQOL-BREF).
- Compare the HRQOL scores of DM patients with co-morbidities with the scores of DM patients without co-morbidities in the four domains of WHOQOL-BREF.
- Determine the influence of socio-demographic variables on the HRQOL overall mean score of the DM patients.
- There is no significant difference between the HRQOL scores of patients with diabetes mellitus and that of the non-diabetic group in the four domains of the Whoqol-Bref.
- There is no significant difference between the HRQOL scores of diabetic patients with co-morbidities and those without co-morbidities in all the four domains of the Whoqol-Bref.
Scope of the Study
This study was carried out at the University of Port Harcourt Teaching Hospital using diabetic patients attending the diabetic clinic that hold on Wednesdays. Only persons 30 years and above were recruited. The non-diabetic group was recruited from the Catholic community of Mater Misericordiae Catholic Church Rumumasi, Port Harcourt and Anglican community of the Anglican Church of Messiah, Port Harcourt. Anglican and Catholic churches are the two biggest churches in this area.
Significance of the Study:
Findings from the present study will reveal generally how diabetic patients cope with life, disease and treatment. The findings will specifically reveal quality of life of diabetic patients with regards to: physical domain, psychological domain, social domain and environmental domain.
Findings from the study will provide clinicians with important information needed to support clinical decision-making, taking both biomedical and psychosocial aspects into consideration in the management of diabetics. To the nurse in particular, a tailored education and management based on identified needs from the study will go a long way in helping the patient to lead a normal life and cope with the problems associated with the ailment.
Improved management based on the findings of this study will improve productivity and reduce the economic burden on the individual as well as the society in general. The quality of life of the individual will be improved. To policy makers, the findings of this study will stimulate them to address issues concerning diabetics e.g. insurance, employment, etc. This study will not only tell us about the patient’s subjective experience of living with diabetes, it will also elicit new and or better ways to improve on diabetes care.
Operational Definition of Terms
Health Related Quality of Life (HRQOL)
This is the impact of the disease (diabetes mellitus) on the individual’s subjective description of his/her various dimensions of human functioning and well-being. In this study, these functions will be measured using the four domain World Health Organization Quality of Life (WHOQOL-BREF) instrument. The domains are physical, psychological, social and environmental.
A group of diseases characterized by increased level of glucose in the blood, diagnosed medically if the fasting blood glucose is126mg/dl (7.0mmol/L) or higher, Random plasma, 2 hours post prandial glucose levels exceeding 200mg/dl (11.1mmol/L) and Glucose Tolerant Test result of 180mg/dl (11.1mmol/L) 2hours after glucose load.
Are patients 30years and above, diagnosed and attending diabetes mellitus clinic at University of Port Harcourt Teaching Hospital, Port Harcourt.
They are persons 30years and above, clinically healthy and have never been told or known to have diabetes mellitus or any other chronic diseases such as Asthma, Hypertension, Congestive Cardiac Failure, Arthritis, Pulmonary Tuberculosis, Duodenal or Stomach ulcer, HIV/AIDS and cancers. In this environment, there is no existing norm data using the WHOQOL-BREF. So, those who met the inclusion criteria for the study were recruited from the area of the study.
Discussion of Major Findings
This chapter presented the discussion of major findings, implications of the findings, limitation of the study, suggestions for further studies, summary of the study, conclusion and recommendations
Difference between the HRQOL of patients with diabetes mellitus and the non-diabetic group in the physical domain
In general the study found that the overall perception of HRQOL of patients with diabetes mellitus was lower when compared with the non- diabetic group. The patients with diabetes mellitus were also less satisfied with their health in comparison with the non-diabetic group. Patients with diabetes mellitus had a lower mean score than the non-diabetic persons in the physical functioning. This lower mean score could be attributed to the impact of the disease and its management on the individuals. This domain assesses pain, energy, sleep, mobility, activities, medication and work. The factor analysis of this study revealed that all the sub-scale items are involved in the low quality of life found in the patients. Similarly, Eljide, et al (2006) who also used WHOQOL-BREF found that HRQOL was lower in diabetics than the non-diabetic group in all the domains with the largest difference in the physical, psychological and social domains. The finding is also similar to that of Odili, Ugboka & Oparah (2010), Eljedi, Mikolajczyk, Kraemer and Laaser (2006), Fevzi, Yildrim, Gozu, et al (2008), which reported lower mean HRQOL, scores in the diabetics. The diabetic patients should therefore be closely monitored by all members of the health team involved in their management. They should be encouraged to follow treatment modalities and must be involved in their management.
Differences between the HRQOL of patients with diabetes mellitus and non-diabetic group in the psychological domain
The analysis also revealed a statistically significant lower mean health-related quality of life score among the diabetics in the psychological domain. The diabetics had a mean score and standard deviation of 20.06±3.32, while the non-diabetic group scored 21.53±2.51. It was also found to be statistically significant (t -5.001, df 398, and p0.000). The psychological domain evaluated positive feelings, cognitions, self-esteem, body-image, negative-feelings, and spirituality. These sub-domains were all statistically significant as shown in table 7. In this study, 97(48.5%) of the diabetics had developed complications due to diabetes. The researcher found problems in financial resources, social support and personal relationships. These complications and the other problems could have contributed to the decrease in the HRQOL due to its impact on psychological functions. The finding is in line with that of Eljedi, et al(2006) and Al-Sheheri, Taha, Banhnassy & Salah, (2009) who reported lower HRQOL in the type 2 diabetics than in the non-diabetics with a mean mental component score of 47.8±9.1 in cases vs. 51.5±9.4 in non diabetics (p<.001). The diabetics should be followed up by clinical psychologist to elicit and solve psychological problems early enough. They should be encouraged to join groups that have similar problems e.g. Diabetic Association of Nigeria with its different chapters where they can share ideas.
Differences in the HRQOL of patients with diabetes mellitus and that of the non-diabetic group in the social domain
The social domain evaluates personal relations, social support and sex. The analysis revealed that the patients with diabetes mellitus had a lower mean score than the non-diabetic group with scores of 10.20±2.47 and 11.43±1.87 respectively (t -5.640, df 398 and p0.000).This study revealed that personal relationship and social support were significant while sex was not significant. Other studies emphasized on poor sexual activities among the diabetics but they did not analyze the sub-scales as was done in this study. They argued that changes in sexual activities come with age, and it is worse in people with diabetes mellitus because diabetes mellitus predisposes patient to sexual dysfunction. This therefore is a serious implication for healthcare providers. The need to provide social support team and emergency services cannot be over emphasized. This study agrees with the findings of Odili et al (2010). Significant others have to be involved in the management of the diabetics and educated on the social aspects so that they can give good support to the diabetics.
Differences in the HRQOL of patients with diabetes mellitus and the non-diabetic group in the environmental domain
The data analysis revealed that the patients with diabetes mellitus had a lower mean score than the non-diabetic group in the environmental domain with the diabetics’ scoring 28.00±5.51 and the non-diabetics28.68±5.04, but there was no statistically significant difference (t -1.325, df389 and p0.186). In this domain, the following were evaluated: safety and security, home environment, finance, health/social care, information, leisure, physical environment and transport. The contributory factor analysis showed that the financial resources are statistically significant. Although the mean score for the diabetic is slightly lower than that of the non-diabetics and not significant, both scored highest in this domain meaning a better quality of life in this domain. The environmental domain does not impact differently on diabetics as it does on non-diabetics. The findings are in line with findings of Eljide et al (2006) andOdili et al (2010) that also used the WHOQOL-BREF.
Differences between the HRQOL of life scores of diabetes mellitus patients with co-morbidities and those without co-morbidities
The analysis revealed that there was no statistically significant difference in health-related quality of life in all the domains when compared with diabetic patients without co-morbidities. This shows that other chronic illnesses impact on the individuals the same way as diabetes mellitus and this is where elimination of any person with other chronic illness among the non-diabetics comes to play as in the exclusion criteria. Another reason for these finding may be that all our respondents in the diabetic group were stable. Hypertension was the co-morbidity many of the respondents reported on and a few others, and they were being controlled. This finding supports that of Odili et al (2010), who did not find any significant difference between the HRQOL of diabetes mellitus patients with complications and co-morbidities and diabetes mellitus patients without co-morbidities.
Socio-Demographic Relationship on HRQOL
The analysis revealed that there was no significant difference in the demographic variables of the diabetics and the non-diabetics. Studies carried out in Nigeria and in other countries reported lower HRQOL in women than in men (Odili et al 2010, Raiz et al 2012, and Al-Shehri, et al 2009). This, they attributed to obesity and gender differences. This study did not pay attention to weight and did not take note of obese patients among the respondents. The analysis also showed that the HRQOL of the educated patients was better than the HRQOL of less educated patients among the diabetic group. This is in line with the findings of Issa & Baiyewu, (2006), who also used the WHOQOL-BREF. The implication of this finding is in intensifying diabetes education because it is a factor in understanding self-care management of diabetes, glycaemic control and self-concept.
Implication of the Findings
Diabetes mellitus is a chronic disease that has no cure for now and a complicated disease to manage as it involves asking patient to make a lot of life style modifications for life. Nurses are closer to the patients than any other healthcare team member.
- Therefore, nurses should be involved in diabetic education which should address the following: diet and exercise, monitoring glucose levels, implications of smoking, method of administration and storage of insulin; foot, skin and dental care; healthcare system and community resources as well as social support group e.g. Diabetic Association of Nigeria with its different chapters.
- Nurses should also be on the lookout for complications.
- Patients have confidence in nurses and therefore nurses should get closer and study the lived experiences of these patients as this will help in better management of the patients and improvement in their quality of life.
Limitations to the Study
The researcher only used patients registered and attending clinic in a tertiary hospital and whose condition is under control. Worse cases might be in the communities and not utilizing health facilities.
Data collection lasted for three months because patients do not attend clinic the same day. They are given appointment for one week, two, four, six or more weeks depending on the patient’s condition. This made the data collection to last long and therefore considered as a limitation to the study.
Suggestion for Further Studies
Specific diabetic HRQOL instrument should be used to assess patients as it is more sensitive to the disease condition than a generic instrument.
- Based on the findings from this study, the researcher recommends that healthcare personnel should educate diabetics on physical care and prevention of complications that will impact negatively on physical health. Improvement on HRQOL can be achieved through increasing patients’ knowledge and giving them diabetic education which among other benefits improve overall health and well-being. Education that will acknowledge cultural background and their ability to understand information on health will improve their ability to follow treatment modalities.
- Nurses can also make home visits, accompany patients to hospitals and refer patients to support groups such as Diabetic Associations and Non-governmental
Organizations that can provide funds.
This study assessed the HRQOL of diabetes mellitus patients and non-diabetic persons in Port Harcourt, Rivers State, Nigeria. The specific objectives were to: (i) determine the HRQOL scores of patients with DM and non-diabetic group in the four domains of the World Health Organization Quality of Life-BREF (WHOQOL-BREF), (ii) compare the HRQOL scores of DM patients with the non-diabetics in the four domains of the WHOQOL-BREF, (iii) compare the HRQOL scores of DM patients with co-morbidities and the scores of DM patients without co-morbidities in four domains of WHOQOL – BREF. (iv) determine the influence of socio-demographic variables on the HRQOL overall mean score of DM patients.
The study adopted a descriptive cross sectional survey design. It was conducted at the diabetic out- patient clinic of the University of Port Harcourt Teaching Hospital, Port Harcourt. Power analysis was used to determine the minimum sample size of 200 each for the diabetic and the non-diabetic comparison group. The diabetics who met the inclusion criteria were purposively recruited, while the age and sex matched non-diabetics were recruited from Catholic Community of Mater Misericordiae Catholic Church, Rumumasi and Anglican Community of Anglican Church of Messiah, Elekahia Housing Estate, all in Port Harcourt. A 26 item standardized WHOQOL-BREF questionnaire with known psychometric properties was adopted for this study with 12 additional questions soliciting demographic and clinical data of the respondents. The researcher’s supervisor and two experts from the Department of Nursing Sciences, University of Nigeria Enugu Campus, validated the instrument. The reliability of the instrument was carried out using split-half method and analyzed using Chronbach’s alpha, which gave a coefficient of 0.70 for physical domain, 0.76 for psychological domain, 0.78 for social domain and 0.70 for environmental domain. Data were subjected to descriptive statistics and analyzed using Chi-square, student t-test and analysis of variance (ANOVA). Probability value less than 0.05 was considered statistically significant.
The HRQOL mean scores for DM patients in the four domains of the WHOQOL-BREF were: physical domains 23.17 ± 3.39, Psychological domain 20.06 ± 3.32, social domain 10.20 ± 2.47 and environmental domain 28.00 ± 5.15. The HRQOL mean scores for non-diabetics were: physical domain 24.17 ± 2.42, psychological domain 21.53 ± 2.51, social domain 11.43 ± 1.87 and environmental domain 28.68 ± 5.044. There was significant difference (p < 0.05) in the scores of the diabetic group in the physical, psychological and social domains when compared with the non-diabetics. Out of the 200 diabetics, 92 reported co-morbidities. The HRQOL mean scores of DM patients with co-morbidities were: physical domain 22.73 ± 3.30, psychological domain 19.63 ± 3.08, social domain 9.96 ± 2.28 and environmental 27.41 ± 4.98. The HRQOL mean scores of patients without co-morbidities were: physical domain 23.55 ± 3.43, psychological domain 20.39 ± 3.48, social domain 10.40 ± 2.62 and environmental domain 28.50 ± 5.25. There was no significant difference (p > 0.05) between the diabetic patients with co-morbidities and the patients without co-morbidities in all the four domains of the WHOQOL-BREF. There were no significant differences (p > 0.05) between the diabetics and the non-diabetics in their demographic variables. The diabetics with post-secondary education had a higher mean score (3.93 ± 0.81) than those with secondary and primary education (3.75 ± 1.12 and 3.37 ± 1.06 respectively). There was significant difference (p < 0.05) between the mean score of diabetics with post secondary education and those with secondary and primary education. In conclusion, the outcome of the study revealed that diabetes mellitus impact negatively on the HRQOL of the individuals in all the domains, with largest effect on the physical domain.
The study revealed that diabetes mellitus impact negatively on the HRQOL of diabetic patients in the four domains of WHOQOL-BREF as compared with non-diabetic persons in Port Harcourt, Rivers State of Nigeria. It also showed that diabetic patients with higher level of education scored higher in the HRQOL than those that are less educated.
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