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HEALTH-RELATED
QUALITY OF LIFE OF DIABETES MELLITUS PATIENTS AND NON-DIABETICS
ABSTRACT
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
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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
CHAPTER ONE
INTRODUCTION
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
12
[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
13
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
14
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
15
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:
1. Determine the HRQOL scores of patients with
diabetes mellitus and the non-diabetic group in all the four domains of the
WHOQOL-BREF.
16
2. 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).
3. 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.
4. Determine the influence of socio-demographic
variables on the HRQOL overall mean score of the DM patients.
Hypotheses
1. 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.
2. 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:
17
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.
Diabetes
Mellitus- 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,
18
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.
Diabetic
Patients- are patients 30years and above, diagnosed and attending diabetes
mellitus
clinic at
University of Port Harcourt Teaching Hospital, Port Harcourt.
Non-Diabetics
- 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.
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