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 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 [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:

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

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:

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, 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.