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 comorbidities
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 comorbidities
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
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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
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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 noncommunicable
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
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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.
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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.
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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
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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.