|Year : 2022 | Volume
| Issue : 3 | Page : 285-293
Evaluation of the association between social determinants and health-related quality of life among diabetic patients attending an outpatient clinic in the Warangal region, Telangana, India
Wajid Syed1, Muthukkaruppan Menaka1, Sundararajan Parimalakrishnan1, Vamshi Vishnu Yamasani2
1 Department of Pharmacy, Annamalai University, Annamalai Nagar, Tamil Nadu, India
2 Department of Pharmacy, Aurobindo College of Pharmacy, Warangal, Andhra Pradesh, India
|Date of Submission||10-May-2022|
|Date of Decision||08-Jul-2022|
|Date of Acceptance||19-Jul-2022|
|Date of Web Publication||26-Sep-2022|
Dr. Wajid Syed
Department of Pharmacy, Annamalai University, Annamalai Nagar, Tamil Nadu 608002
Source of Support: None, Conflict of Interest: None
Objective: The present study aims to evaluate the association between sociodemographic characteristics and health-related quality of life (HRQoL) among diabetic patients attending a clinic situated in the Warangal region of Telangana, India. Materials and Methods: A cross-sectional study was conducted for 8 months in the diabetes outpatients’ clinic in the Warangal region, Telangana, India. A total of 402 patients were included in that study. The patients were assessed for QoL using the HRQoL-8-dimensional scale, which covers mainly Role Restriction Due to Physical Illness (6 items), Strength and Stamina (6 items), Health in General (3 items), Satisfaction with the Treatment (4 items), Symptoms Botherless (3 items), Financial Worries (3 items), Mental Health (5-items), and Satisfaction with Diet (2 items). All the items were assessed on a five-point Likert scale. Results: The mean age of the patients was 52.39 ± 11.01 (mean±SD). There was a statistically significant association between education and physical health (P=0.015), treatment satisfaction (P=0.006), emotional health (P=0.038), and diet satisfaction domain of HRQoL (P=0.006). The type of medication is associated with treatment satisfaction, financial worry, emotional health, and diet satisfaction (P=0.001). The patient’s employment status is significantly different from the general health, financial, and emotional health of HRQoL (P=0.001). However, treatment satisfaction (P=0.044) alone was significantly associated with years of having diabetes. Conclusion: Adhering to treatment guidelines and provider recommendations helps patients to lead a healthy lifestyle.
Keywords: Diabetes mellitus, emotional health, quality of life, social factors, therapy factors
|How to cite this article:|
Syed W, Menaka M, Parimalakrishnan S, Yamasani VV. Evaluation of the association between social determinants and health-related quality of life among diabetic patients attending an outpatient clinic in the Warangal region, Telangana, India. J Diabetol 2022;13:285-93
|How to cite this URL:|
Syed W, Menaka M, Parimalakrishnan S, Yamasani VV. Evaluation of the association between social determinants and health-related quality of life among diabetic patients attending an outpatient clinic in the Warangal region, Telangana, India. J Diabetol [serial online] 2022 [cited 2022 Nov 30];13:285-93. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/3/285/357132
| Introduction|| |
The prevalence of diabetes mellitus (DM) is increasing worldwide. It is a global problem due to the sudden increase of common risk factors such as age, genetics, obesity, and chronic disease. While the quality of life (QoL) is an essential measure of how the disease affects patients’ everyday activities, it is evidenced that DM patients have decreased QoL when compared with healthy individuals.,, According to the World Health Organization (WHO), socio-economic factors are defined as the conditions in which individuals are born, grow, work, live, and age and the set of forces and systems shaping the conditions of daily life.,
Internationally, several studies estimated the factors contributing to deficiency in the QoL of diabetic patients.,,,, For instance, Huang et al. reported that DM is positively correlated with age, and hemoglobin levels were higher in males than in females. Similarly, Edelman et al. and Chia reported that the type of DM, use of insulin, age, complications, social level, ethnicity, and education interfere with these patients’ QoL. John et al. found a significant association among different domains of QoL concerning family history, hypertension, body mass index (BMI), educational status, marital status, income status, treatment, and complications. Similarly, another study from Karnataka state in India reported that the QoL of a person with diabetes is associated with gender, age, education status, occupation, duration of DM, HbA1c, type of medication, and the presence of comorbidities.
Previous reports revealed that HRQoL is significantly decreased due to the influence of multiple social and economic determinants.,,,, Furthermore, socio-economic factors can be considered the root cause of the disease process and serve as a direct problem for some chronic diseases. For example, smoking and alcohol consumption were associated with multiple lifelong conditions such as diabetes and other cardiovascular conditions., In contrast, education, employment status, ethnicity, and eating habits affect a patient’s living status, which are significantly associated with the increased risk prevalence of various chronic diseases.,,
Furthermore, international studies on the association between social determinants and health-related QoL (HRQoL) among diabetic patients are limited. Evaluating diabetes patients’ effects of social determinants using different methods is required. In addition, leading a healthy lifestyle and adopting endocrinologist’s recommendation among diabetic patients is another challenge. The research focussed on the association between HRQoL and the effects of social determinants that can provide an overall picture of the QoL for healthcare providers in India and worldwide. Additionally, a comprehensive study on factors influencing the QoL will render valuable discernment for the endocrinologist to improve the QoL of patients. Nevertheless, there is a scarcity of studies assessing the factors affecting the QoL of diabetes patients in developing countries, including India. Hence, this study aspired to evaluate the association between sociodemographic characteristics of diabetics with the QoL domain of HRQoL questionnaires.
| Materials and Methods|| |
A cross-sectional study was conducted among diabetic patients for 8 months, from June 2019 to January 2020. This study was conducted in the endocrinology outpatient clinic in Warangal, Telangana, India. The diabetes patients who had a regular follow-up with the endocrinologist at the study center were between 18 and above; both type-1 and type-2 diabetics were asked to enroll in the study. At the same time, patients with diabetes during pregnancy and psychiatric patients were excluded from the study.
This study used a convenient sampling technique to compute the required sample size. The sample size was calculated by using the Epitools-Epidemiology calculator. (https://epitools.ausvet.com.au/oneproportion) with a 95% confidence level and a 5% margin of error. The present study has assumed that the response distribution for each question would be equal to 50%. The calculated sample size was 385 patients. However, 423 patients were selected for the present study to avoid selection bias. A total of 402 diabetic patients successfully completed this study.
For patients who met the inclusion criteria and after obtaining the informed consent, the demographic details including age, gender, marital status, education level, employment status, BMI, social habits such as smoking habits and alcohol habits, frequency of physician visits, years of having diabetes, and glycosylated hemoglobin levels (HbA1c) were assessed. The patients’ QoL was assessed using the QoL Instrument for Indian Diabetes Patients (HRQoL)., Before using the original HRQoL questionnaires, a pilot study was conducted to check the accuracy of the content and length of interview time; upon the results of the pilot study, the original HRQoL questionnaires were subjected to reliability analysis. After removing 3 items, Cronbach’s alpha value was found to be 0.83. The modified 31 items based on validity were included in the final study. The HRQoL items cover mainly Role Restriction Due to Physical Illness (6 items), followed by Strength and Stamina (5 items), Health in General (3 items), Satisfaction with the current Treatment (4 items), Symptoms Botherless (3 items), Financial Worries (3 items), Mental Health (5 items), and Satisfaction with Diet (2 items). The questionnaires were assessed on a five-point Likert scale where 1 indicates poor QoL, whereas 5 indicates excellent QoL. The total HRQoL was calculated in three levels. The poor HRQoL in one patient was <25% (percentile), patients who scored between 26% and 50% (percentile) are moderate HRQoL, and patients who scored <75% (percentile) are considered a good HRQoL.
Categorical data are presented as frequency and percentage. Continuous variables are presented as mean and standard deviation. The association between the categorical variables (two-group) and HRQoL domain scores was assessed using the Mann–Whitney U-test. The association between the categorical variables (more than two groups) and HRQoL domain scores was assessed using the Kruskal–Wallis test. P-value of less than 0.05 was considered statistically significant. The data were analyzed using SPSS version 26.0. The Participants Information Sheet (PIS) was on the first page of the questionnaire, which included the risks and benefits of diabetes to the study participants. Before the start of the study, consent was obtained from all the study participants, and they agreed to complete the questionnaire.
| Results|| |
A total of 423 people with diabetes were approached in this study, and 21 (4.9%) questionnaires were excluded because of incomplete data and dropouts. Among the respondents, 402 diabetic patients completed the questionnaire, corresponding to a response rate of 95%. Among the enrolled patients in the study, more than half (64.4%) were males, whereas one-third (35.6%) were females. Their mean age was 52.39 ± 11.01 (mean±SD).
In this study, majority of the patients were older [males 127 (49%); females 72 (50.3%)], and 32.8% (n = 85) of the males were aged between 43 and 52 years. About 15.8% (n = 41) of the male patients were middle-aged. Majority of both males and females were married [males 83% (n = 215); females 84.6% (n = 121)]. About 21% of the interviewed males and 36.4% of the females who had DM were illiterates, and the majority of the male and female diabetics were under normal weight. In contrast, slightly more than half of the male diabetics were smokers [55.6% (n = 144)], whereas the majority were alcoholics [86.1% (n = 223)]. There was a significant association between males and females concerning educational and alcoholic status. Demographics are presented in [Table 1].
[Figure 1] describes the type of medication taken by patients. These findings reported that approximately 52% (n = 208) of interviewed diabetic patients were on oral therapy followed by a combination of diet, exercise, and tablets [29% (n = 117)], whereas 18% (n = 74) were on both injection and tablets [Figure 2]. The mean score of physical health was 18.8 ± 2.91 (range 0–28), whereas physical endurance was 16.3 ± 2.46, followed by general health at 9.02 ± 1.41, treatment satisfaction at 12.7 ± 1.92, and symptom botherless at 9.04 ± 1.44. The detailed mean score for the domains is given in [Table 2].
|Figure 1: Absolute frequency of different treatments in the outpatients’ sample|
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|Figure 2: Levels of health-related quality of life among outpatients’ sample|
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|Table 2: Summary statistics on quality of life of outpatients’ sample (n=402)|
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The total good HRQoL in this study was 46.8% (n = 188), whereas (n = 100) 24.9% had moderate HRQoL and 28.4% (n = 114) had poor HRQoL [Figure 2]. The mean score for physical health and physical endurance was higher among females 19.09 ± 2.94 and 16.48 ± 2.62, in comparison to male patients, 18.77 ± 2.89 and 16.22 ± 2.37. No statistically significant difference was observed between the two groups of the patients (P= 0.201 and P= 0.435). The scores for treatment satisfaction 12.81 ± 1.90 and symptom botherless 9.11 ± 1.42 were higher among males in comparison to those of females 12.66 ± 1.96 and 8.92 ± 1.48 (P=0.398 and 0.237), indicating no statistically significant difference concerning the above domains of HRQoL. Diabetic patients with young age (<32 years) scored a higher value for physical health and physical endurance domain of HRQoL (19.10 ± 2.37 and 16.70 ± 2.21) in comparison to patients aged between 33 and 42, 43 and 52 years, and more than 53-year-old patients (18.38 ± 3.05 and 16.40 ± 2.42). However, the score of physical health was higher among older patients (43 and above) (mean =18.96) in comparison to middle-aged patients (mean = 18.38) (P=0.541).
Concerning general health, the score was higher among patients above 33 years (9.05 ± 1.52) than younger patients (8.80 ± 1.39). The treatment satisfaction was higher among patients above 53 years, 12.91 ± 1.97, compared with patients aged between 43 and 52 years (12.52 ± 1.82). The symptoms bother similar in the aged groups of patients, and there was no statistically significant difference among the different age groups of patients (P = 0.873). Similarly, there were no significant differences or associations between the age groups for financial worry, emotional health, and diet satisfaction (P=0.05). Despite it, the mean score differed in different age groups of diabetic patients, particularly in the financial worry domain. The patients aged between 33 and 42 years scored higher at 9.25 ± 2.37 when compared with other age groups (P = 0.478).
The current study results found no significant association between the mean score of smokers and different domains of the HRQoL (P > 0.05), except for the diet satisfaction domain, in which patients with smoking habits scored higher 6.92 ± 1.81, in comparison to non-smokers, 6.56 ± 1.54 (P< 0.020). There was no significant difference between alcoholic and non-alcoholic patients for different HRQoL domains (P > 0.05). Moreover, the mean scores for the physical endurance domain of HRQoL were significantly associated with the patient’s insurance status. The diabetic patients with health insurance scored higher at 16.78 ± 2.63 compared with lack of insurance at 16.1 ± 2.36 (P< 0.017). Concerning education, patients with university degrees scored higher for the physical health domain at 19.32 ± 2.87, followed by patients with no education who scored higher at 19.14 ± 3.41 [Table 3].
|Table 3: Association between demographics and health-related quality of life|
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There was a statistically significant association between education and the physical health domain of HRQoL (P= 0.015). Moreover, there was no significant association between physical endurance and general health of diabetic patients for patient education status (P = 0.05). The diabetic treatment satisfaction was significantly associated with patient education (P = 0.006), in which patients with secondary school (13.19 ± 2.17) and university graduates (12.85 ± 1.97) scored higher mean values in comparison to other education such as patients with schooling (12.34 ± 1.48) and no education (12.47 ± 1.78). The domains of HRQoL, such as Symptoms of botherless and Financial worries, did not show any significant difference in the mean score of the patients concerning education levels (P = 0.05); however, Emotional health (P = 0.038) and Diet satisfaction (p = 0.006) showed the difference in the mean scores that regards educational levels.
In this current study, HRQoL was not significantly associated with the marital status of the patients in all domains (P = 0.05) except for the diet satisfaction domain, in which divorced or widowed diabetic patients got higher diet satisfaction scores in comparison to married and single diabetic patients (P = 0.005).
The patient’s employment status is significantly different while concerned with the general health, financial, and emotional health domains HRQoL. The diabetic patients with self-employed status were found to have a higher mean score in general health (p =0.035) in comparison to employed and retired patients. In contrast, in the financial domain, patients with self-employment scored a higher mean value of 9.39 ± 2.46 (P =0.025); similarly, unemployed diabetics scored a higher mean in the emotional health domain of HRQoL in comparison to other categories (P = 0.003). This study also reported a significant association between types of treatment for diabetic patients for treatment satisfaction, financial worry, emotional health, and diet satisfaction (P =0.0001). The patients who used a combination of tablets and injections scored a higher mean score of 13.64 ± 1.98 for treatment satisfaction. The patients with diet and exercise scored a higher value of 10.0 ± 1.22 in financial worries than those with other medication therapies (P =0.005). The patient’s BMI was not significantly associated with the HRQoL of diabetic patients (P = 0.05). However, the number of physician visits per year was significantly associated with physical health (P=0.027), treatment satisfaction (P=0.015), emotional health (P =0.019), and diet satisfaction (P =0.015) of the HRQoL. However, treatment satisfaction (P= 0.044) alone was significantly associated with years of having diabetes. Interestingly, in this study, no significant difference was observed in the domains of HRQoL of diabetic patients concerning HbA1c levels (P = 0.05).
| Discussion|| |
There was evidence that socio-economic factors are potent elements of the clinical outcomes of chronic disease.,,,, As of now, there is a lack of studies or no study has examined the relationship between social, economic, and disease-related factors among diabetes patients in the Warangal region of Telangana; therefore, this study result would serve as the reference for future studies at both national and international levels. The present study’s findings revealed that socio-economic factors, namely, patient education, employment, frequency of physician visits, type of medication, years of having diabetes, presence of insurance, and current or former smokers, were associated with HRQoL of diabetes patients. Consistent with the previous finding carried out among type-2 diabetes patients from Maharashtra state, it has been reported that aging is not significantly associated with diabetes QoL. However, another similar study in the Karnataka region of India reported that age significantly affects self-confidence, future worries, financial situations, freedom to eat, enjoyment of food, and freedom to drink in QoL domains of diabetes. However, previous studies reported that age is a significant factor that disturbs the HRQoL of chronic disease patients, resulting in increased disability and hospitalization, which increases healthcare costs.
In this study, gender was not significantly associated with the HRQoL of people with diabetes. The previous study among type 2 diabetes patients reported that men were experiencing poor HRQoL compared with women. Another similar study reported apposite findings that females were found to have good HRQoL than males. However, Papazafiropoulou et al. and Spasic et al. reported that males had higher HRQoL than females., Our results were comparable to a previous study by John et al., who reported no significant association between HRQoL and gender. The difference in the current findings, as well as previous results, might be due to the nature of the study, the type of instrument and measurements used, and the difference in ethnicity, as reported by earlier findings.
Several previous studies also reported that the marital status of a person with diabetes is associated with good QoL., The earlier study by Prasanna Kumar et al. among people with type 2 diabetes reported no significant association between the QoL and marital status of the patients. However, in the current study, the marital status of the person with diabetes is associated with the diet satisfaction domain of the QoL. The married participants have been informed that they need psychological and mental support. In this study, HRQoL concerning general health, financial worries, and emotional health was significantly associated with the employment status of diabetic patients. According to the current findings, patients with self-employed status scored higher mean values in the various HRQoL domains than homemakers, employed, and unemployed diabetics. However, Prasanna Kumar et al. reported that poor QoL was significantly associated with the patient’s unemployment status. Similarly, two other studies also reported an association between QoL and unemployment., This might be due to the fact or belief that lower-income, lower treatment, and lower lifestyle are reducing the QoL.
The current study reported that an overall good HRQoL was 46.8%, and similar results were found in Gupta and Kapoor among diabetes patients in other regions in India. Similarly, in Arabic countries, it was evidenced that 21% of the diabetic patients reported perfect health, and half of them found moderate HRQoL. Several studies reported various factors responsible for poor HRQoL; among those, age, education, and socioeconomic characteristics were the potential to affect the QoL., Additionally, the mean duration of diabetes and physician follow-up are the other factors that brought the differences in the levels of HRQoL in the current study than in other studies.
In this study, one-third of the people with diabetes were current smokers (36.8%) (n = 402). It is found that diseased populations with a smoking history were found to have higher mortality rates than nonsmokers. The current study reported a significant association between smoking and the diet satisfaction domain of HRQoL. Some studies reported that smoking is not associated with chronic diseases. However, according to the United States Food and Drug Administration Act (USFDA), smokers are more likely to develop diabetes; nicotine from smoke causes difficulty in regulating insulin levels, causing severe injuries including heart disease, blindness, damage to nerves, and blood vessels, renal failure.
Although the use of alcohol among people with diabetes in this study is 63.2%, earlier reports suggested a causal relationship between alcohol consumption and disease-related injuries. However, it leads to esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epilepsy, and motor vehicle accidents., Although all these studies have varied methodologies and populations, the current findings are essential in the following significant respects.
Although some limitations are associated with this study, first, this study employed only diabetic patients in the selected facility of the Warangal region; therefore, causation cannot be inferred, and the results cannot be generalized to other regions. Secondly, we included both type-1 and type-2 diabetes patients, but we did not differentiate between the types of diabetes. Lastly, the cross-sectional nature of the study design and the absence of longitudinal data do not allow to exclude a reciprocal relationship between HRQoL and diabetes determinants.
| Conclusion|| |
The results revealed that socio-economic factors associated with the DM were patient education, employment, frequency of physician visits, type of medication, years of having diabetes, presence of insurance, and current or former smokers, which were associated with HRQoL of diabetes patients. These findings can inform public health strategies on national and international levels because some determinants are modifiable or treatable. Future longitudinal research must confirm this relationship by examining the critical factors for diabetes, improving glycemic control, and leading an everyday life similar to healthy individuals.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]