Abstract
Background:
Risk of diabetes continues to increase worldwide due to population growth, urbanization. Little is known regarding the health related quality of life (HRQoL) among diabetes mellitus in India. Identifying factors influencing HRQoL could help us to form strategies for better control of diabetes.
Material and Methods:
To measure the quality of life among men with type 2 diabetes mellitus residing in the rural field practice area of a teaching hospital in Coimbatore and to determine sociodemographic as well as diabetes and sexual related characteristics associated with poor quality of life. This study was conducted in the rural field catchment area by enrolling 443 adult males with type 2 diabetes mellitus. The data was collected from the blood investigation reports and by face-to-face interviews using a Semi-structured. Quality of Life was assessed using the European quality of life five-dimension scale (EQ 5D 3L). A question on erectile dysfunction was also included. Logistic regression models were used to investigate the factors associated with it.
Results:
Patients reported “some or extreme problems” most frequently in pain/discomfort (34.8%), and in anxiety/depression (27.7%) dimensions. Older age, long duration of diabetes, having co-morbid conditions were significantly associated (P < 0.05) with mobility, self-care, usual activities, and pain/discomfort of EQ 5D in the multivariate regression model. It is also observed that 60.9% of these patients had erectile dysfunction, which was found significantly associated with increasing blood sugar values (P < 0.001).
Conclusion:
The study results indicated that patients with diabetes suffer from a relatively poor quality of life. More attention should be paid to the determinants of the poor quality of life. It is recommended that factors leading to derangement of quality of life as well as causing sexual dysfunction have to be addressed by the primary health care providers for the improvement of the quality of life of diabetic patients attending the primary health care center.
Keywords: Diabetic patients, erectile dysfunction, quality of life
BACKGROUND
Diabetes is a complex chronic disease and a disease of major public health problem that causes a significant burden on patients and society in terms of morbidity, premature mortality, and quality of life.[1,2] This emerging pandemic is due to rapid urbanization, greater longevity, economic development, life standards improvement, lifestyle and diet changes, physical inactivity, and obesity.[3] Diabetes patients are known to have a worse quality of life than individuals without diabetes.[4] Health-related quality of life (HRQoL) is one of the most widely measured treatment outcomes to self-assess the effects of the management of chronic disease on health and monitor the physical, psychological, and social aspects of personal health. It is influenced by individual expectations, beliefs, perceptions, and experiences.[5] Many studies have shown that health-related quality of life (HRQoL) decreases with disease progression and complications.[6] In addition to diabetes-related complications, fear of hypoglycemia and change in lifestyle are the main causes of HRQoL diminution.[7] Erectile dysfunction (ED) is another common complication of diabetes; the reported prevalence of ED ranges from 35% to 70% globally, which also affects the quality of life.[8] However, today diabetes treatment is mainly aimed at treating the blood sugar level without recognizing the quality of life experienced by these patients. It is important to understand the factors associated with HRQoL among diabetes due to its chronic nature so that strategies can be formed to manage it in a better way in addition to the traditional measures.
There are only limited community-based studies to document the quality of patients with diabetes mellitus and to find the association of sociodemographic factors on Quality of life[8,9,10] and hence more studies are needed. The primary aim of the study was to find the health related quality of life and its associated sociodemographic and diabetes-related factors among type 2 diabetic males in the rural field practice area of Coimbatore and also to estimate the burden of erectile dysfunction among diabetic-affected males in the study area.
MATERIALS AND METHODS
A community-based cross-sectional study was carried out from October 2021 to July 2022 at the field practice area of the Rural Health Training Centre, Vedapatti attached to the Department of Community Medicine, Medical College in Coimbatore. The sample size was calculated based on an Indian study[11] where in HRQoL with regard to pain/discomfort dimension was affected among 54% of the study participants and in other regions it varied from 40% to 60%.[7,9,10,11] Assuming that 50% of the diabetic patients are having pain/discomfort, and with a relative precision of 5% and expected non-response rate of 10%, the required sample size was estimated as 440. The study was approved by the Institutional Human Ethics Committee (IHEC – Ref No PSG/IHEC/2020/Appr/Exp/136). Informed Consent was obtained from each participant. Confidentiality of the data was strictly maintained.
The rural health centre (RHC) catchment area includes 14 villages. As per the census collected by the field workers of RHC, these 14 villages have 4,154 households. The adult population of more than 18 years was around 9,978 and out of these adults 10.1% (i.e.,1012) were diabetic. The diabetic condition has been enumerated either by self-reporting as either previously diagnosed/taking treatment for diabetes or those with previous blood reports as either fasting blood glucose >126 mg/dl or postprandial blood sugar of >200 mg/dl.
For the purpose of the study, we chose only Type 2 diabetic males which amounted to 494 who were contacted two to three times by telephone and some by a direct home visit by the field staff and were requested to visit the health center in small batches to measure their fasting and postprandial blood sugar values. Out of 494 identified male diabetic patients 443 were enrolled in the present study who were permanent residents (residing for more than 1 year in the study area) aged more than 18 years. The remaining 51 them were excluded; because 39 of them did not turn up to have their blood sugar levels checked, seven of them were not living with their partner during the past six months (due to either family commitments, separation, or death) and five of them were not willing to take part in the study.
Data were collected by the medical officer (First author) during the outpatient time 11 am to 1 pm using the questionnaire which was in the local language by face-to-face interview which had the components; of sociodemographic details and quality of life after ensuring privacy. The interview took approximately 15 minutes for each participant after getting their blood investigation report. The quality of life was assessed by using the validated HRQoL questionnaire – European quality of life five dimension scale EQ 5D 3L[12]: A multi-attribute utility instrument, which helps to measure five components, each assessing one of 5 dimensions of the HRQoL (Mobility (MO), Self-Care (SC), Usual Activities (UA), Pain/Discomfort (P/D) and Anxiety/Depression (A/D). EQ-5D-3L instrument is a widely used preference-based outcome measure in the type 2 diabetes context, validated in the Indian Scenario.[10,11] It is used in several countries as it is simple and easy to apply with reasonable validity[13] and reliability[14] and responsiveness in type 2 diabetes.[15] Each dimension has to be answered on a three-level scale with a score of 1 to 3 i.e. no problems with a score of 1, some or moderate problems with a score 2, and extreme problems with a score of 3. An additional question on erectile dysfunction was asked on how frequently they experience difficulty in getting/maintaining an erection under five categories (problem during erection - never, fewer times, many/most of the times, every time of sexual activity, did not have a sexual relationship in the past 6 months). Blood sugar level was estimated prior to and after breakfast.
Statistical analysis
The data were entered in Microsoft Excel and analyzed using SPSS software (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). The categorical values were expressed in terms of frequency and percentage whereas the continuous variables were expressed as mean ± standard deviation. The association between the categorical values was assessed by the Chi-square test and for the continuous variable by the student t-test. ANOVA was used to find the difference between the mean values if there were more than two groups in a category. For all 5 dimensions, levels 2 and 3 on EQ-5D dimensions was merged and thus dichotomized to ‘no problem’ or ‘ some or extreme problem’. Bivariate analysis was initially performed and those variables that were statistically significant in the bivariate analysis (P < 0.05) were further subjected to multivariate logistic regression analysis. Adjusted odds ratio and 95% confidence intervals were thus estimated. P < 0.05 was considered a statistically significant.
RESULTS
The demographic and clinical profiles of the study participants are shown in Table 1. Diabetes-related hospitalization in the past year was 2.9% Mean age (in years) of the study participants was 57.55 ± 11.55. A higher proportion of them was employed (67.3%) and educated below 12th standard (83.1%). Around 26.4% were on lifestyle modification (diet and physical activity) and the remaining were on diabetic medication along with lifestyle modification. The mean duration of diabetes was 6 ± 1.34 years.
Table 1.
Baseline characteristics of the study participants (n=443)
| Variable | Category | Frequency | Percentage |
|---|---|---|---|
| Age | 18–60 years | 252 | 56.9 |
| More than 60 years | 191 | 43.1 | |
| Educational status | College and above | 75 | 16.9 |
| Up to 12th standard | 368 | 83.1 | |
| Employment status | Employed | 298 | 67.3 |
| Unemployed | 145 | 32.7 | |
| Treatment for diabetes | Diet and physical activity alone | 117 | 26.4 |
| Oral hypoglycemic agent | 286 | 64.6 | |
| Insulin Alone or with OHA | 40 | 9.0 | |
| Diabetes-related Hospitalization in the past year | Yes | 13 | 2.9 |
| No | 430 | 97.1 | |
| Duration of diabetes | Less than 5 years | 246 | 55.5 |
| 5–10 years | 128 | 28.9 | |
| More than 10 years | 69 | 15.6 | |
| Hypertension | Yes | 137 | 30.9 |
| No | 306 | 69.1 | |
| CVS Comorbidity | Yes | 30 | 6.8 |
| No | 413 | 93.2 | |
| Nephropathy | Yes | 14 | 3.2 |
| No | 429 | 96.8 | |
| Retinopathy | Yes | 27 | 6.1 |
| No | 416 | 93.9 | |
| Neuropathy | Yes | 23 | 5.2 |
| No | 420 | 94.8 |
The quality of life of the diabetic males is shown in Table 2. The people having mild to severe problems in the different dimensions are as follows: mobility (16.5%), self-care (11.3%), usual daily activities (11.5%), the pain/discomfort (34.8%) and the anxiety/depression dimension (27.8%). It was observed that those who have higher blood sugar values have reduced quality of life with regard to all five different dimensions. In our study, the post-prandial blood sugar did not show a significant association with pain/discomfort and anxiety/depression dimensions.
Table 2.
Quality of life of the diabetic male patient and their association with blood sugar values
| Variable | Category | Frequency (Percentage) | FBS Mean±SD |
P | PPBS Mean±SD |
P |
|---|---|---|---|---|---|---|
| Mobility | I have no problem in walking about | 370 (83.5) | 144.83±56.66 | <0.05 | 230.12±77.41 | 0.004 |
| I have some problems in walking about | 65 (14.7) | 160.93±63.42 | 236.62±86.09 | |||
| I am confined in bed | 8 (1.8) | 162.63±64.70 | 256.75±74.89 | |||
| Self-care | I have no problem with self-care | 393 (88.7) | 104.50±18.77 | <0.001 | 190.50±35.44 | <0.05 |
| I have some problems washing or dressing myself | 46 (10.4) | 152.17±54.75 | 235.61±69.62 | |||
| I am unable to wash or dress myself | 4 (0.9) | 159.90±63.55 | 246.14±86.45 | |||
| Usual Activities | I have no problems with performing my usual activities | 392 (88.5) | 143.65±41.79 | <0.001 | 224.09±62.86 | <0.001 |
| I have some problems with performing my usual activities | 46 (10.4) | 160.26±63.96 | 236.87±86.69 | |||
| I am unable to perform my usual activities | 5 (1.1) | 165.60±104.08 | 247.80±95.13 | |||
| Pain/Discomfort | I have no pain or discomfort | 289 (65.2) | 125.83±36.45 | <0.001 | 231.67±57.18 | 0.86 |
| I have moderate pain or discomfort | 148 (33.4) | 139.15±63.05 | 235.01±89.42 | |||
| I have extreme pain or discomfort | 6 (1.4) | 158.84±62.56 | 237.11±75.70 | |||
| Anxiety/depression | I am not anxious or depressed | 320 (72.2) | 122.40±45.45 | <0.001 | 224.40±83.57 | 0.76 |
| I am moderately anxious or depressed | 118 (26.6) | 149.11±59.34 | 224.09±81.59 | |||
| I am extremely anxious or depressed | 5 (1.1) | 162.66±63.611 | 239.80±85.491 |
Factors determining the HRQoL are shown in Table 3. Bivariate analysis showed that various dimensions of quality of life are affected by factors like higher age more than 60 years, unemployed males, longer duration of diabetes, and those on insulin management. It was also observed that HRQoL deteriorated if they had associated comorbidity like nephropathy, retinopathy, and neuropathy and who had diabetes-related hospitalization in the past year.
Table 3.
Quality of life among male diabetic patients and their association with sociodemographic and clinical characteristics of diabetes
| Variable | n | Mobility |
Self-Care |
Usual Activities |
Pain/Discomfort |
Anxiety/Depression |
|||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| With any problems n (%) | OR (95% CI) | With any problems n (%) | OR (95% CI) | With any problems n (%) | OR (95% CI) | With any problems n (%) | OR (95% CI) | With any problems n (%) | OR (95% CI) | ||
| Age | |||||||||||
| 18 to 60 years | 252 | 27 (10.7) | 1(Ref) | 17 (6.7) | 1(Ref) | 16 (6.3) | 1 (Ref) | 75 (29.8) | 1(Ref) | 63 (25.0) | 1 (Ref) |
| More than 60 years | 191 | 46 (24.1) | 1.178 (1.07-1.29)*** | 33 (17.3) | 1.12 (1.04-1.21)** | 35 (18.3) | 1.14 (1.06-1.23)*** | 79 (41.4) | 1.19 (1.03-1.38)** | 60 (31.4) | 1.09 (0.97-1.23) |
| Education | |||||||||||
| Up to 12th standard | 376 | 62 (16.5) | 1.02 (0.92-1.13) | 43 (11.4) | 1.008 (0.92-1.09) | 45 (12.0) |
1.04 (0.97-1.13) | 133 (35.4) | 1.02 (0.86-1.22) | 102 (27.1) | 0.97 (0.83-1.14) |
| College and above | 67 | 11 (16.4) | 1 (Ref) | 7 (10.4) | 1 (Ref) | 6 (9.0) | 1 (Ref) | 21 (31.3) | 1(Ref) | 21 (31.3) | 1 (Ref) |
| Employment Status | |||||||||||
| Employed | 298 | 35 (11.7) | 1 (Ref) | 25 (8.4) | 1 (Ref) | 24 (8.1) | 1 (Ref) | 101 (33.9) | 1 (Ref) | 79 (26.5) | 1 (Ref) |
| Unemployed | 145 | 38 (26.2) | 1.19 (1.07-1.33)*** | 25 (17.2) | 1.10 (1.02-1.20)** | 27 (18.6) | 1.13 (1.03-1.23)** | 53 (36.6) | 1.04 (0.89-1.20) | 44 (30.3) | 1.05 (0.92-1.19) |
| Treatment | |||||||||||
| Diet and Physical Activity | 117 | 17 (14.5) | 1(Ref) | 5 (4.3) | 1(Ref) | 9 (7.7) | 1 (Ref) | 32 (27.4) | 1 (Ref) | 28 (23.9) | 1 (Ref) |
| OHA | 286 | 43 (15.0) | 2.83 (1.22-6.54)* | 33 (11.5) | 3.2 (1.52-7.07)** | 30 (10.5) | 3.6 (1.68-7.93)** | 106 (37.1) | 1.13 (0.57-2.22) | 78 (27.3) | 1.97 (0.9-3.88) |
| Insulin alone or with OHA | 40 | 13 (32.5) | 2.71 (1.29-5.66)** | 12 (30.0) | 9.6 (3.12-29.4)*** | 12 (30) | 5.14 (1.97-13.4)** | 16 (40.0) | 1.17 (0.83-3.75) | 17 (42.5) | 2.34 (1.10-5.01)* |
| Duration of Diabetes | |||||||||||
| Less than 5 years | 246 | 32 (13) | 1 (Ref) | 18 (7.3) | 1 (Ref) | 20 (8.1) | 1 (Ref) | 78 (31.7) | 1 (Ref) | 55 (22.4) | 1 (Ref) |
| 5 to 10 years | 128 | 20 (15.6) | 2.34 (1.16-4.7)* | 15 (11.7) | 2.46 (1.14-5.30)* | 15 (11.7) | 2.27 (1.04-4.94)* | 42 (32.8) | 1.98 (1.09-3.62)* | 43 (33.6) | 1.12 (0.61-2.07) |
| More than 10 years | 69 | 21 (30.4) | 2.92 (1.55-5.51)** | 17 (24.6) | 4.14 (1.99-8.57)** | 16 (23.2) | 3.41 (1.65-7.02)** | 34 (49.3) | 2.09 (1.21-3.6)** | 25 (36.2) | 1.97 (1.11-3.5)* |
| Diabetes Related Hospitalization in the past year | |||||||||||
| Yes | 13 | 5 (38.5) | 1.36 (1.01-2.10)* | 5 (38.5) | 1.45 (1.09-2.23)** | 49 (30.8) | 1.28 (1.04-1.85)* | 8 (61.5) | 1.71 (1.09-3.42)* | 5 (38.5) | 1.17 (0.76-1.81) |
| No | 430 | 68 (15.8) | 1 (Ref) | 45 (10.5) | 1 (Ref) | 47 (10.9) | 1 (Ref) | 146 (34.0) | 1 (Ref) | 118 (27.40 | 1 (Ref) |
| Cardiovascular Comorbidity | |||||||||||
| Yes | 30 | 12 (40.0) | *1.42 (1.05-1.90)** | 11 (36.7) | 1.43 (1.08-1.88)*** | 9 (30.0) | 1.28 (1.01-1.62)** | 19 (63.3) | 1.83 (1.14-2.95)** | 14 (46.7) | 1.38 (1.01-1.93)* |
| No | 413 | 61 (14.8) | 1 (Ref) | 39 (9.4) | 1 (Ref) | 42 (10.2) | 1 (Ref) | 135 (32.7) | 1 (Ref) | 109 (26.4) | 1 (Ref) |
| Nephropathy Comorbidity | |||||||||||
| Yes | 14 | 9 (64.3) | 2.38 (1.17-4.81)*** | 6 (42.9) | 1.57 (1.01-2.47)*** | 7 (50.0) | 1.79 (1.06-3.03)*** | 10 (71.4) | 2.32 (1.01-5.33)** | 10 (71.4) | 2.57 (1.12-5.91)*** |
| No | 429 | 64 (14.9) | 1 (Ref) | 44 (10.3) | 1 (Ref) | 44 (10.3) | 1 (Ref) | 144 (33.6) | 1 (Ref) | 113 (26.3) | 1 (Ref) |
| Retinopathy Comorbidity | |||||||||||
| Yes | 27 | 12 (44.4) | 1.53 (1.09-2.15)*** | 9 (33.3) | 1.35 (1.03-1.76)*** | 9 (33.3) | 1.34 (1.03-1.76)*** | 19 (70.4) | 2.28 (1.27-4.09)*** | 7 (25.9) | 0.97 (0.77-1.22) |
| No | 415 | 61 (14.7) | 1 (Ref) | 41 (9.9) | 1 (Ref) | 42 (10.1) | 1 (Ref) | 135 (32.5) | 1 (Ref) | 116 (27.9) | 1 (Ref) |
| Neuropathy | |||||||||||
| Yes | 23 | 11 (47.8) | 1.29 (1.02-1.75)*** | 9 (39.1) | 1.14 (1.01-1.41)*** | 9 (39.1) | 1.21 (1.03-1.54)*** | 16 (69.6) | 3.22 (1.81-7.02)*** | 6 (26.1) | 1.29 (0.89-1.850 |
| No | 420 | 62 (14.8) | 1 (Ref) | 41 (9.8) | 1 (Ref) | 42 (10.0) | 1 (Ref) | 138 (32.9) | 1 (Ref) | 117 (27.9) | 1 (Ref) |
*P<0.05 ** P<0.01 ***P<0.001
Multivariate logistic regression analysis [Table 4] showed that the quality of life regarding the mobility dimension was lower among older aged diabetic males more than 60 years (AOR: 1.51, 95%CI 1.13–2.96), if their duration of diabetes is 5 to 10 (AOR: 1.74, 95% CI: 1.21–3.77), if their diabetic duration more than 10 years (AOR: 1.89 95% CI: 1.27–3.94). Mobility dimension also showed a significant association and was much affected if the diabetic males have complications like nephropathy (AOR: 4.77, 95% CI: 2.18–7.71), retinopathy (AOR: 3.21, 95%CI: 1.31–5.85) and neuropathy (AOR: 1.73, 95%CI: 1.01–2.90). Higher odds of poor quality of life in regard to self-care dimension were observed among those aged more than 60 years (AOR: 2.15, 95%CI: 1.52–4.99), if their duration of diabetes 5–10 years (AOR: 1.75, 95%CI: 1.03–4.17), if diabetic duration more than 10 years (AOR: 2.71, 95%CI: 1.15–6.40). Self-care among the participants was affected if they had complications like nephropathy (AOR: 5.74, 95%CI: 1.51–11.92), retinopathy (AOR: 3.13, 95%CI: 1.18–8.26), and neuropathy (AOR: 1.71, 95%CI: 0.14–2.52).
Table 4.
Multivariate logistic regression comparing the sociodemographic and clinical characteristics of diabetic males with EQ-5D items (Adjusted odds ratios and 95% Confidence interval)
| Variable | Category | EQ 5 dimensions |
||||
|---|---|---|---|---|---|---|
| Mobility AOR (95%CI) | Self-care AOR (95%CI) | Usual Activities AOR (95%CI) | Pain/Discomfort AOR (95%CI) | Anxiety/Depression AOR (95%CI) | ||
| Age | 18 to 60 years | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | - |
| More than 60 years | 1.51 (1.13-2.96)* | 2.15 (1.52-4.99)* | 2.33 (1.01-5.33)* | 1.72 (1.02-2.92)* | ||
| Employment status | Employed | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | - | - |
| Unemployed | 1.51 (0.77-2.96) | 1.05 (0.47 – 2.35) | 1.14 (0.52-2.50) | |||
| Treatment | Diet and Physical Activity | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | - | - |
| OHA | 2.2 (0.86 – 3.61) | 2.34 (0.97-5.67) | 1.64 (0.69-3.89) | |||
| Insulin alone or with OHA | 2.1 (0.92-3.78) | 2.76 (0.3-3.7) | 2.21 (0.95-5.12) | |||
| Duration of diabetes | Less than 5 years | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) |
| 5 to 10 years | 1.74 (1.21-3.77)* | 1.75 (1.03-4.17)* | 3.11 (1.31-7.39)** | 1.77 (1.23-3.38)* | 1.81 (1.3-3.69)* | |
| More than 10 years | 1.89 (1.27-3.94)* | 2.71 (1.15-6.40)** | 4.62 (1.58-13.51)** | 1.81 (1.17-3.32)** | 2.29 (1.03-5.09)* | |
| Diabetes Related Hospitalization in the past year | Yes | 1.85 (0.51 – 3.15) | 2.81 (0.71 – 5.7) | 1.98 (0.49-8.064) | 1.97 (0.57-6.77) | - |
| No | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | ||
| Cardiovascular Comorbidity | Yes | 1.45 (0.55-3.82) | 1.92 (0.69-5.37) | 1.11 (0.37-3.25) | 2.25 (0.95-5.30) | 1.22 (0.51-2.91) |
| No | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | |
| Nephropathy Comorbidity | Yes | 4.77 (2.18-7.71)*** | 5.74 (1.51 –11.92)*** | 3.11 (2.25-5.16)** | 3.43 (0.95-12.325) | 1.32 (0.387-4.51) |
| No | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | |
| Retinopathy Comorbidity | Yes | 3.21 (1.31 – 5.85)*** | 3.13 (1.18 – 8.26)*** | 2.93 (1.11-7.68)** | 4.30 (1.76-10.52)** | - |
| No | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | ||
| Neuropathy Comorbidity | Yes | 1.73 (1.01-2.90)** | 1.71 (0.14-2.52) | 1.72 (1.17-4.11)** | 2.26 (1.26.-5.32)* | - |
| No | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | 1.0 (Ref) | ||
*P<0.05 ** P<0.01 ***P<0.001*
Usual activities dimension was affected for individuals more than 60 years (AOR: 2.33, 95%CI: 1.01-5.33), with a duration of diabetes 5–10 years (AOR: 3.11, 95%CI: 1.31–7.39) with diabetic duration more than 10 years (AOR: 4.62, 95%CI: 1.58-13.51), having nephropathy (AOR: 3.11, 95%CI: 2.25–5.16), retinopathy (AOR: 2.93, 95%CI: 1.11–7.68) and neuropathy (AOR: 1.72, 95%CI: 1.17–4.11). Pain/discomfort dimension was affected for participants with age more than 60 years (AOR: 1.72, 95%CI: 1.02-2.92), duration of diabetes 5 to 10 years (AOR: 1.77, 95%CI: 1.23–3.38), diabetic duration more than 10 years (AOR: 1.81, 95%CI: 1.17–3.32), presence of retinopathy (AOR: 4.3, 95%CI: 1.76–10.52) and neuropathy (AOR: 2.26, 95%CI: 1.26–5.32). Anxiety/depression dimension was affected for participants having a duration of diabetes 5–10 years (AOR: 1.81, 95%CI: 1.3-–3.69) and duration more than 10 years (AOR: 2.29, 95%CI: 1.03–5.09). It is also observed that 60.9% of the patients had erectile dysfunction, which ranged from fewer times to many times in a month [Table 5]. It was also found that an uncontrolled higher sugar level was positively associated with erectile dysfunction (P < 0.001).
Table 5.
Characteristics of erectile dysfunction and their Blood sugar levels
| Erectile Dysfunction | Numbers (Percentage) | FBS Mean±SD |
P | PPBS±SD | P |
|---|---|---|---|---|---|
| No problem | 173 (39.1) | 142.72±46.646 | <0.001 | 207.77±68.037 | <0.001 |
| Once per month | 130 (29.3) | 170.89±67.473 | 256.97±84.288 | ||
| Almost every week | 81 (18.3) | 183.22±78.234 | 277.93±100.538 | ||
| More than once per week/Not having an active sexual life | 59 (13.3) | 184.24±52.159 | 272.54±68.088 |
DISCUSSION
To our knowledge, not many community-based studies have been done to investigate the health-related quality of life of patients with type 2 diabetes in our country. We measured the quality of health status by EQ-5D to investigate the relationship between EQ-5D dimensions and the demographic and clinical characteristics of the patients. In the literature, many studies have used EQ-5D to measure the HRQOL of diabetic patients.[10,16,17,18] The shorter completion time compared with other generic instruments is an added advantage of EQ 5D. In our study, we observed that the various dimensions of quality of life among diabetic males were significantly poor with older ages except anxiety/depression dimension. The possible reason could be as age increases the comorbidity also increases which might deteriorate the quality of life. Many studies have reported the same tendency.[19,20,21] However in another study it was observed that increased age was significantly associated with better quality of life among diabetic patients and contradicts our findings.[22]
In our study the diabetic males had reduced HRQoL in the entire five dimensions; however, the most affected dimensions are pain/discomfort (35%) and anxiety/depression (28%). Our finding is similar to previous studies[10,19,20] where pain/discomfort was the most common among the five domains. Several studies have demonstrated that diabetes has a strong negative impact on quality of life especially in the presence of complications[21,23] and it is obvious that as the blood sugar level increases, the quality of life decreases. Older people had complaints and problems with regard to the majority of dimensions, which was consistent with other reported studies.[16,24,25] Duration of diabetes plays a crucial role and affects the quality of life negatively in our study. This finding was consistent with other studies finding wherein as the duration of diabetes increases, health of the person gradually worsen depending on control of diabetes.[17,24,26] Conversely few studies have shown that there is no association between disease duration and quality of life.[16,18,24]
In the present study presence of complications of diabetes namely nephropathy, neuropathy, and retinopathy was associated with lower quality of life among type 2 diabetes patients. These results are in accordance with findings reported from other studies.[10,24,26,27] Our study reiterates that diabetic patients have mobility problems, find it difficult to take self-care like problems with washing or dressing themselves, usual activities are disturbed, and suffer chronic pain and discomfort if their sugar values are higher compared with their counterparts. Further multi-centric studies on diabetic males using different study designs could pave the way to identify the cause of poor quality of life thereby we can plan programs for better management of diabetes.
It is noted that no significant difference was found in the dimensions of quality of life score for men with different levels of education, employment status, treatment modality, and cardiovascular co-morbidity. In contrast, studies have shown that education has a linear relationship with quality of life, as education increases they have a better understanding of the disease and take the needed precautions to avoid complications.[14,24] Studies have shown that cardiovascular co-morbidity is another factor that influences the quality of life. Treatment modality also influences quality of life and in a few studies those who took oral drugs have QoL significantly higher than that for Insulin users[26] This is because Insulin is the final treatment weapon when the oral hypoglycemic agents have become ineffective.
The EQ-5D dimensions seem capable of capturing the consequences of diabetes-related complications and such complications may have a substantial impact on several dimensions of health-related quality of life. The strongest determinants of reduced quality of life in people with diabetes were older age, longer duration of diabetes, and complications like nephropathy, neuropathy, and retinopathy. Regular evaluation for quality of life as a routine clinical practice could potentially improve necessary communication among the health care providers and their patients thereby identifying the complications and helping them with long-term care resulting in improving their health status.[28]
It is also observed that the diabetic males experience the erectile dysfunction problems.[29] On many such occasions, those males who seek health care for diabetes do not discuss their erectile dysfunction (ED) because it is considered a taboo in our society and hence it is under-reported and under-diagnosed. The prevalence of ED is difficult to establish accurately because of limitations related to the populations screened, the unwillingness of subjects to participate, and the unreliability of the answers due to personal embarrassment. Uncontrolled diabetes can cause erectile dysfunction which can disrupt marital harmony and can also affect the quality of life. Further Multi-centric comparative cohort studies on diabetic males and healthy individuals could pave the way to identify the cause of the poor quality of life over a period of time as well as the reason for erectile dysfunction, thereby we can plan programs for better management of diabetes.
Strengths of the study
The study has been done among male diabetics in a rural community using a validated tool to measure the quality of life.
Limitation
Our study did not capture the quality of life in undiagnosed diabetes patients. The study findings were based on self-reported health state by participants which cannot be completely relied upon. Our study was performed at one point in time, and variations can likely alter the quality of life. Another limitation is that our study was cross-sectional in nature and hence cause-effect relationship cannot be established. Besides we have not compared the HRQoL between diabetic males and healthy individuals.
CONCLUSIONS
The study revealed that the quality of life of diabetic patients with regard to all five dimensions i.e Mobility, self-care, usual activities, pain/discomfort, and anxiety/depression are reduced when they have higher blood sugar values. Among these dimensions pain/discomfort was the predominant one to have a poor quality followed by the anxiety/depression dimension. The factors contributing to reduced quality of life are higher age, longer duration of diabetes, and the presence of diabetes-related complications. We also observed that due to poor diabetes control, the patients are having erectile dysfunction. Therefore more attention should be paid to the main determinants of the quality of life and implement appropriate policies for achieving better management of diabetes and ultimately improving the quality of life in the region. Our results also emphasize that primary healthcare providers who treat diabetic patients should also address sexual dysfunction issues to get good quality of life in these patients.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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