INTRODUCTION
MATERIAL AND METHODS
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
 

QUALITY OF LIFE IN SAUDIS WITH DIABETES
Ensaf Saied Abdel-Gawad, Ph.D.

From the Community Health Sciences Department, College of Applied Medical Sciences, Riyadh, KSA. Address reprint requests to: Dr. Ensaf Saied Abdel-Gawad, Health Education and Behavioral Sciences, Community Health Sciences Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Kingdom of Saudi Arabia, Tel: (Off.) 4355392, Fax: 4355883

Diabetes is a devastatingly chronic disease that affects quality of life (QOL). The objective of this study is to assess diabetic Saudi patients' perceptions of their quality of life and its relation to some socio-demographic variables. Interview questionnaire was designed to collect data from 320 randomly selected patients in three main hospitals in Riyadh. Results showed that diabetes has affected QOL, the overall QOL impairment was in the mild to moderate range. Satisfaction with life in general was prevalent. However, much concern was noted, for health in future, complications, death and the great impact of diabetes on physical health and sex life. Higher satisfaction, less impact of diabetes and few worries were reported for social life and relationships within family and friends. Dissatisfaction and great impact of diabetes were evident with the necessary changes in routine lifestyles such as diet regimen, body weight, and physical activities. Some socio-demographic and diabetes-related variables were significantly related to either total measure or one of the scales of QOL such as age, sex, marital status, education, type of diabetes, treatment regimen and hospitalization. These findings help the planners of diabetes management and education programs for early identification of persons at risk of decreased QOL and tailoring preventive intervention that bring significant changes in patient's QOL.

Key Words: Diabetes, Quality of Life, Socio-Demographic Variables, Life Satisfaction

INTRODUCTION :
          Diabetes is a complex disorder associated with several potentially preventable disabilities, such as blindness, amputation, neuropathy, nephropathy, and cardiovascular disease. Diabetes-related morbidity and premature mortality impose a sizeable burden on individuals with diabetes and on society, signifying a major public health concern^1,2. The incidence of diabetes is increasing and its prevalence is approaching epidemic proportion in many developing countries in the Middle East including Saudi Arabia³. The prevalence of non-insulin dependant diabetes mellitus in Saudi population aged above 30 years is greater than 14% in each province⁴ and 49% for subjects aged 51-60 years in urban areas³.
          Diabetes as a chronic disease requires medical care and education to prevent acute and long-term complications. Diabetes education basically involves learning how to live with diabetes and aims to improve the QOL of all people affected by diabetes^5,6. There is increasing recognition that the impact of chronic illnesses and their treatment must be assessed in terms of their QOL in addition to more traditional measures of medical outcomes- morbidity and mortality^7-9. Studies of diabetes self-management education often include a single measure in each of two categories: a measure of patient knowledge and a measure of the glycosylated hemoglobin level. Although glycemic control is clearly relevant, patient functioning and QOL are also essential.
          QOL was defined as "the perceptions of individuals or groups that their needs are being fulfilled and that they are not being denied opportunities to achieve happiness and satisfaction". QOL is considered as a multi-dimensional entity incorporating both a cognitive component (satisfaction) and an emotional component (happiness)¹⁰. Assessment of QOL in a clinical trial must focus on a person's illness and treatment experience from his own perspective. This can include judgements about satisfaction with treatment, social functions, emotional wellbeing, and physical symptoms¹¹.
          QOL issues are crucially important in diabetes. Diabetes overwhelms (i.e., poor QOL) leads to dimi-nished self-care, worsen glycemic control, and increased risks of complications¹². The improvement in QOL not only benefits the patients but also reduces the health care cost related to readmission¹³. It is needed to know more about QOL among individuals with diabetes and about patients profile, disease status, health care system, and socio-environmental characteristics that put people at risk of decreased QOL¹⁴. Although an increasing amount of research is being devoted to the QOL of individuals with diabetes, there is still much to be learned about QOL of Saudis with diabetes. Therefore, the objective of this study is to assess diabetic Saudi patients' perceptions of their quality of life and its relationship to some socio-demographic variables.

MATERIAL AND METHODS :
          Study setting and population: The study was carried out in 3 hospitals: King Abdul- Aziz University Hospital, the Armed Forces Hospital, and King Khalid hospital. Data was collected by a trained interviewer for each hospital, where 5 diabetic patients were randomly selected from the daily list of outpatients for one month. The entry criteria were: age (20 years and over), generally good health, without advanced complications of diabetes and consent to participate in the study. The total sample size was 320.
          Methods: An interview questionnaire was designed to collect data about:
a) Socio-demographic data
b) Diabetes history: including type and duration of diabetes, treatment regimen, and previous hospitalization.
c) The 45 items Diabetes Quality of Life (DQOL) measure¹⁵. The DQOL measure has three primary scales that assess different aspects of quality of life (15 items for self satisfaction, 20 items for the impact generated by diabetes and 10 items for the worry about the anticipated effects of diabetes on health or social and vocational relations). The response of each item of satisfaction, impact and worry scales was rated from 5 (very satisfied, no impact and never worried) to 1 (very dissatisfied, strong impact and always worried). The scores of all items in each scale were summed giving total scale score, as well as the scores of all items of the three scales were summed to give grand measure score which ranged from 45 to 225. The grand measure score and each of the three total scale scores were divided by the number of their items to convert them to a score from 1-5 with higher scores for better QOL.
          Data was analyzed using SPSS computer software version 9 using 2-tailed t-test as a significance test.

RESULTS :
          Socio-demographic and clinical characteristics: The mean age of patients was 45.77 + 15.07, males constituted 56.9%, 89.1% were married, and 51.3% completed nine years of education or more. The mean income was 8100 1 5372 SR. Patients with type II diabetes were 54.1%, with 59.7% of patients had diabetes history of more than 5 years. 11.6% patients managed diabetes by diet only, while 44.3% and 44.1% were taking oral hypoglycemic agents and insulin respectively. About 71.6% of patients have no diabetes- related complications.
          Table 1 shows that the total score of DQOL measure was 3.768. The mean scores of both impact and worry scale were slightly higher (3.858 & 3.874). Satisfaction's mean score was the lowest (3.576).
          Focusing on different items of DQOL measure, Table 2 reveals that the highest mean scores of satisfaction scale was for satisfaction with social relationships and friendships and satisfaction with life in general (4.17 & 3.94). The patients were moderately satisfied with their
 

Table 1. Mean, standard deviation, median and range of scores of total DQOL measure and its scales among Saudis with diabetes

management of diabetes, work and household activities, knowledge about diabetes, sleep and burden of diabetes of family. Less satisfaction was shown with sex life, flexibility for food exchange, body weight and leisure time. The lowest mean score was for satisfaction with time patient spends exercising (2.55).
          Regarding the impact scale, Table 3 indicates that patients cited certain items to have greatest impact of diabetes: feeling physically ill, no improvement in health, feeling restricted by diet, teased because of frequent urination, effect on sex life, and having hypoglycemia (2.64 -3.58). On the other hand the least
 

 

Table 3. Mean, standard deviation and range of scores for impact of diabetes scale-QOL measure of Saudis with diabetes

impact items were for social situations; and interfering with driving, exercising, sleep, leisure-time activities, or missing work/ school/ household duties.
          Table 4 portrays that diabetic patients expressed much worry about their health in future, complications of diabetes and death (2.67 &3.28). Some worry was cited for marital relation (3.81). Fewer worries were shown for having children, education or work, treatment, family or social support and taking vacation or trip (score above 4.03).
          The mean scores of total DQOL measure and its scales as indicated in Table 5 was apparently higher among Saudi diabetics who are males, aged above forty years, married, and having higher income compared to females, aged < forty, not married, and lower income groups. However, not all the differences in mean scores were significant.

Table 4. Mean, standard deviation and range of scores of worry scale of QOL measure of Saudis with diabetes

 

Table 5. Means and standard deviatons of total DQOL measure and its scales by some socio-demograhic variables. (2-tailed t-test)

Younger persons reported significantly better total QOL and fewer worries about diabetes. Males had significantly higher satisfaction. Married patients reported significantly higher scores on all QOL measures meaning having higher satisfaction, less impact, few worry and better total QOL. Less educated respondents reported significantly fewer worries than those of higher education.
          Table 6 shows that NIDDM patients had significantly better over all QOL and less impact of diabetes than did IDDM patients. Higher satisfaction and fewer worries were also expressed by NIDDM patients compared to IDDM patients without reaching statistical significance. Patients who reported previous hospitalization due to diabetes and followed medication regimen were significantly greatly impacted with diabetes than those never hospitalized and followed diet regimen. Patient with diabetes for <2 years and no complications showed little
 

bit better QOL than those suffer from diabetes for longer duration and complications but no significant difference was found on total DQOL measure or its scales.

DISCUSSION :

          Diabetes requires the patient to self-manage his or her disease and is a lifetime struggle to maintain QOL. Treatment plans that inherently improve or include strategies to enhance patients' QOL may increase compliance, thereby improving these patients' metabolic status^9,12. If one of the goals of health care is to improve QOL, then it seems important to understand how diabetes affects QOL¹. This study provides information about QOL and its assessment among Saudi diabetic patients. It is clear that diabetes affected the studied patients' QOL, the overall QOL impairment was in the mild to moderate range, with mean values for the total QOL measure and its three domains above 3.5. Little is known about the level of satisfaction, impact, and worry that could be considered as an indicator for the good or poor QOL.
          In the present study, diabetic patients were highly satisfied, less impacted and less worried with their social life, and relationships within family and friends. In addition, married patients had significantly better QOL, much satisfaction, less impact and fewer worries. This indicates that most patients experience a good support by the referent social network. This can be attributed to the cohesiveness of Saudi community, its cultural values and traditions about family ties and tolerant supportive attitudes towards caring the patients. Social support has beneficial effects on psychological and physical wellbeing, the domains of QOL. Social support helps the promotion of active coping and management behaviors, affects a person's perceptions of personal risk or of severity of illness, bolsters beliefs about his ability to cope with stressful situations and manage difficult emotions, so acts as "stress-buffering"^16,17.
          Satisfaction with life in general was prevalent among patients of this study, which might arise from our religious beliefs and faith in fate. Such satisfaction can serve as a mechanism for downward comparison- that is, a comparison between oneself and someone who worse off. Resultant self-esteem and self-efficacy from such comparison, in turn, can increase the likelihood of active coping strategies rather than avoidance¹⁷. Despite of their satisfaction with life, most of the studied patients experienced much worry about their health in future, complications and death, added to the great impact of diabetes on physical health and sex life. Interestingly, general measure of life satisfaction or happiness is not strongly related to the objective life circumstances as might be anticipated, and tends to be unstable. This may be partially due to the optimism of patients or the fact that people change their expectations and aspirations as circumstances change¹⁸.
          Most patients of the present study who were satisfied with their knowledge about diabetes and drug regimen, were dissatisfied with the necessary changes in their routine lifestyles such as diet regimen, body weight, and physical activities. This contrast can be attributed to over emphasis of health professionals for dispensing information about diabetes, its complications and the "dos" and "don'ts" in diabetes management, while ignoring educating patients how to change behavior¹⁹. Dispensing information is necessary step for behavior change but is alone not sufficient for that change¹⁰. This highlights an important challenge for health professionals and educators who should assess factors behind such behaviors and lifestyles (predisposing, enabling, and reinforcing factors) in order to tailor effective educational programs and apply behavior modification techniques to make patients acquire confidence and skills to change. Patients should play an active role during this process¹⁹. Indeed, one rationale for including QOL assessment in clinical trials is to provide patients with information and skills to help them choose treatment strategies consistent with their lifestyles. In essence, patients may recognize the impact on their lives and make continuous modifications in treatment objectives to match desirable QOL objectives¹¹. It should be noted that patients of the present study who follow diet regimen had better QOL, and less impacted with diabetes.
          Younger patients (<40 years) in this study, reported significantly better QOL and fewer worry about diabetes, probably because of short period of disease, better physical functioning and less complications. The present study, concurrently with Jacobson et al 1994, reveals that QOL was lower among patient with diabetes complications. It was suggested that future worry might be useful among younger patients especially adolescent before the onset of long-term complications⁹.

CONCLUSION :
          Overall, diabetic patients reported mild to moderate QOL, which appears to be related to demographic, medical history and management regimens. These findings of the present study provide useful information to the planners of diabetes management and education programs. It is needed to include and control for socio-demographic and medical-history factors in diabetes education research to bring significant changes in patient's QOL. The study allows early identification of persons at risk of decreased QOL for preventive intervention. Responses to specific items of QOL could provide clues for further discussions between patients and their medical provider about personal experiences of diabetes, treatment and lifestyles. Increasing provider understanding of patient's perspective can improve the therapeutic alliance and the patient's participation in self-management, lifestyle changes leading to better QOL.

REFERENCES :

1. Krein SL, Klamerus ML: Michigan diabetes outreach networks: A public health approach to strengthening diabetes care. Journal of Community Health 2000;25(6):495-511.

2. Wu SY, Fryback DG, Sainfort F, Klein R, Tomar RH, et al: Development and application of a model to estimate the impact of type 1 diabetes on health related quality of life. Diabetes Care 1998;21(5):725-31.

3. Al-Nuaim AR: Prevalence of glucose intolerance in urban and rural communities in Saudi Arabia. Diabet-Med 1997;14(7):595-602.

4. Khoja TA, Farid SM: Family Health Survey: Principle report. Riyadh, MOH 2000.

5. Roman SH, Harris MI: Management of diabetes mellitus from a public health perspective. Endocrinol Metab Clin North Am 1997;26:443-474.

6. Mensing C, Boucher J, Cypress M, Weinger K, Mulcahy K, et al: National standards of diabetes self-management education. Diabetes Care 2001;24(supplement 1):126-49.

7. Nakache R, Tyden G, Groth G: Long-term quality of life in diabetic patients after combined pancreas-kidney transplantation or kidney transplantation. Transplantation Proceedings 1994;26(2):510-511.

8. Secchi A, Martinenghi S, Castoldi D, Giudici D, Di Carlo, Pozza G: Effects of pancreas transplantation on QOL in type 1 diabetic patients undergoing kidney transplantation. Transplantation Proceedings 1998;30:339-341.

9. Jacobson AM, Samson JA, Groot M:The evaluation of two measures of QOL in patients with type 1 and type 11 diabetes. Diabetes Care 1994;17(4):264-274

10. Green LW, Kreuter MW: Health promotion planning: An educational and ecological approach. 3rd edition. London: Mayfield Publishing Co. 1999; 54.

11. The DCCT Research Group. Influence of intensive diabetes treatment on quality of life outcomes in the Diabetes Control and Complications Trial. Diabetes Care 1996;19(3):195-202.

12. Kotsanos JC, Marrfero D, Vignati JG, Mathias AD, Huster W, et al: Health-related quality of life results from multinational clinical trials of insulin lispro. Diabetes Care 1997;20(6):948-58.

13. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L: Quality of life and associated characteristics in a large national sample of adults with diabetes. Diabetes Care 1997;20(4):562-567.

14. Di Iorio A, Longo AL, Mitidieri Costanza S, Bandinelli S, Capasso S, Giante M, et al: Characteristics of geriatric patients related to early and late readmission to hospital. Aging (Milano) 1998;10:339-46.

15. DCCT Research Group. Reliability and validity of a diabetes quality of life measure for the diabetes control and complications trial (DCCT ). Diabetes care 1988;11(9):725-732.

16. Perry CL, Baranowski T, Parcel GC: How individuals, environments, and health behavior interact: Social learning theory. In: Glanz K, Lewis FM, Rimer BK(eds): Health behavior and health education: Theory, research and practice. San Francisco: Jossey-Bass 1990;161-186.

17. Ogden J: Health psychology. Trowbridge: Redwood Books 1996;36-57.

18. Wilson IB, Cleary PD: Linking clinical variables with health related Quality of life. JAMA 1995;273(1):59-65.

19. Redman BK: The process of patient education. 7th ed. London: Mosby Year Book 1993;16-41.