HEALTH-RELATED QUALITY OF LIFE OF DIABETES MELLITUS PATIENTS AND NON-DIABETICS

1.1 Introduction

Diabetes mellitus (DM) is a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both (WHO, 2011). The prevalence of diabetes and its complications are major public health issues globally, regionally and locally. Inadequate knowledge of diabetes, negative attitude and perception about diabetes is usually the root causes of diabetes complications and consequences. Developments in diabetes care and management have greatly evolved over the last several decades (American Diabetes Association, 2018).

High prevalence of diabetes and high mortality observed in patients with diabetes consequent upon late diagnosis and poor control result in huge costs in managing diabetes in Nigeria, sub-Saharan Africa and the rest of the developing world. These costs very likely far outweigh the cost of effective primary and secondary preventive measures which should form the focus and future of diabetes care.

As a prelude to other parts of this study, this chapter will discuss the background upon which this study was initiated, the statement of problems that led to this study, the Aim and Objectives of the study. Others are Significance of the study, Scope of work, Research hypothesis and questions, Limitation of the study and Definition of terms.

1.2 Background of Study

Diabetes mellitus is regarded 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.

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 et al., 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.

Therefore, in Nigeria where the research was carried out, the activities that was conducted is to assess the Health-Related Quality of Life of Diabetes Mellitus Patients and Non-Diabetics.

1.3 Statement of Problems

Investigation revealed that 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 et al., (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 emanate from onset of complications, medical and self-management. This study therefore assessed the HRQOL of patients with diabetes mellitus.

1.4 Purpose of the Study

The purpose of this research is 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.

1.5 Aim and Objectives of Study

The aim of the study is to assess the Health-Related Quality of Life of Diabetes Mellitus and Non-Diabetics Patients using University of Port Harcourt Teaching Hospital as a case study. Specifically, the objectives needed to achieve the aim or purpose of this research, are stated as follows to:

1. 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).
2. Determine the HRQOL scores of patients with diabetes mellitus and the non-diabetic group in all the four domains of the 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.

1.6 Research Questions

The study came up with research questions so as to be able to ascertain the above stated objectives. The specific research questions for the study are stated below as follows:

• What are the HRQOL scores of patients with diabetes mellitus and the non-diabetic group in all the four domains of the WHOQOL-BREF?
• What are 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)?
• What are 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?
• What is the influence of socio-demographic variables on the HRQOL overall mean score of the DM patients?

1.7 Research Hypothesis

In order to pursue the objective of this study, the following generalized statements have been designed to guide and aids in obtaining the result for the experiment to be conducted. For this work, the null hypothesis will be represented with H0 while the alternative hypothesis will be represented with hypothesis H1.

• H₀1: 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.
• H₀2: 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.

1.8 Significance of Study

The 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.

1.9 Scope of Study

The scope of the research is focused on the Health-Related Quality of Life of Diabetes Mellitus Patients and Non-Diabetics.

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 21 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.

1.10 Limitations of the Study

During the course of this study, there were some problems encountered which stood as limitations to the research work. Some of the limitations include:

1. Time Constraint: The time frame given to accomplish this project was very short due to school academic calendar and it was carried out under pressure which made the researcher not to implement some necessary features.
2. Research Material: availability of research material is a major setback to the scope of the study.
3. Financial Constraint: Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).
4. Initial Cooperation Delay from Respondents: A particular limitation of this work came as a result of the respondent refusal to offer their cooperation at the initial time they were contacted. This contributed in making the success of this research study difficult.

1.11 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, 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.

Diabetes:

Diabetes is a group of metabolic diseases or a chronic disease characterized by high sugar in the blood.

Knowledge:

A factual information that a person knows or skills required to perform an act acquired through education, training or via experience.