Introduction

The overall burden of diabetes and hypertension are on a rise in third world countries especially Pakistan. In Pakistan, the incidence of diabetes is rising by 170 percent as compared to a less than 50 percent in developed countries.[1]  Main reasons are population growth, ageing, urbanization, increased prevalence of obesity and physical inactivity.[2] According to a report published by WHO in 2003, Pakistan is amongst the top countries with incidence of diabetes, on number 11.[3] The prevalence of diabetes in Pakistani men rural and urban is 6% and 6.9% respectively and in women rural and urban 3.5% and 2.5% respectively. [4] On the other hand, the finding of prevalence of hypertension in Pakistan has not been done on official level yet. However we have relied on different researches and surveys done in different parts of Pakistan. For instance in rural Punjab, 35.1% of the sample population was hypertensive with only 62.3% aware of their condition.[5] Similarly in a low-income area of Karachi, which as a matter of fact corresponds to our sample population, about 26% of the sample population was hypertensive with males having a prevalence of 34% and females 24%.[6]

Quality of Life (QOL) is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment. [7] The WHOQOL is a quality of life assessment developed by the WHOQOL Group with fifteen international field centers, simultaneously, in an attempt to develop a quality of life assessment that would be applicable cross-culturally. [8]

The reason for conducting our research is that comparison of QOL of Diabetes Mellitus and Hypertension has not been conducted before in Pakistan as per our review of literature. The need for a better understanding of the impact diseases have on patient QOL in our set up may perhaps facilitate improved patient management.

Methods

Cross-sectional, non-randomized Study was conducted for 4 months in general medicine, general surgery and orthopedics wards of 1900 bedded government sector tertiary care hospital (Civil Hospital Karachi Pakistan) [9]. Karachi is the provincial capital of Sindh, Pakistan; the largest and most populated city in Pakistan.[10] CHK caters to a large influx of patients from all over the province. Patients diagnosed with diabetes and/or hypertension on drug therapy for at least 6 months were included in our study. A total of 408(188 males, 220 females) people were interviewed using the WHOQOL-BREF questionnaire in addition to basic demographic information. Patient interviews were carried out by trained doctors with sound knowledge about the study and the professional skills required for it.  Quality of life of diabetics patients of hypertension and controls were compared using the whoqol bref scoring.

INCLUSION CRITERIA: All patients included were diagnosed with diabetes mellitus type 2 or hypertension according to the diagnostic criteria. A total of 95 were diabetics, 91 were patients of hypertension and 122 suffered from both diseases. They attended the primary health care units where the study was conducted All individuals had their diabetes and hypertension controlled with at least one form of medication. All individuals were in the age group between 40 to 70 years. The control population was those who did not have hypertension, diabetes or any other chronic disease, was between the age 40 and 70 and had a similar demographic profile to sample population. The people in hospital and those accompanying patients were selected as controls.

Individuals present at the Hospital were approached for consent and then interviewed individually in a closed setting.

EXCLUSION CRITERIA: Patients with uncontrolled hypertension/DM, pregnant women or individuals with other comorbid or other debilitating chronic disorders were excluded. The 4 month study period started in October 2016 and ended by February 2017.

Social and demographic data (gender, age, years of schooling, employment status, marital status and race), clinical data (duration of diabetes and hypertension, time of diagnosis of diabetes and hypertension, body mass index, and treatment) were inquired, in addition to comorbidities and risk factors such as smoking, obesity, depression, heart failure, family history of cardiovascular disease, history of stroke, and history of infarction. As confirmation past history was confirmed by patient medical records present in hospital vicinity.

This is a 26 item self-administered generic questionnaire. The WHOQOL-BREF is one of the most commonly used generic QOL questionnaire which was developed simultaneously across a broad range of member countries, ensuring that it could be used more multi-culturally and multi-linguistically than any other existing QOL tool. It emphasizes subjective response rather than objective life condition, with assessment made over the preceding two weeks. All items, on a five-point scale, could be classified into four domains: overall general health – global (two items), physical (seven items), psychological (six items), social relationships (three items) and environment (eight items). The response option ranges from 1 (very dissatisfied / very poor) to 5 (very satisfied / very good). The total raw score for these four dimensions is transformed into 0 (lowest) to 100(highest) with low score indicating poor QOL. [8]

The WHOQOL-BREF assessment tools were administered in one single interview for each patient. This study was approved by the ethics committee of the institution DUHS. Scores for each of the domains were computed and transformed into final scores as per the WHO BREF guidelines.  Fisher’s exact test was applied to the domain score groups and cross tabulated between Diabetics, patients of hypertension and control groups.

Statistical analysis was carried out using the SPSS version 16.0 for Windows software program. For the comparison between groups of score and the comorbid status (Diabetes, Hypertension, both or Control) of the sample Kruskal-Wallis test was used and P values < 0.05 were considered statistically significant. To find the significance between the 2 subgroups, 6 different Mann-Whitney u tests were conducted between different groups. (Control and diabetes, control and hypertension, control and dual, diabetes and hypertension, diabetes and dual, and hypertension and dual). The aim of this study was to compare the effects of diabetes and/or hypertension on patient’s quality of life.

Results

In this study, a total of 408 individuals were interviewed of which males were 188(45.91%) and females were 220(54.1%). Of the 408, 95(23.3%) were diabetics, 91(22.3%) were patients of hypertension and 122(29.9%) were diabetics plus hypertensive.  The mean age of the 408 participants was 56

±9.8 (mean

±SD). The three groups observed were hypertension (n=91), Diabetes (n=95) and hypertension plus diabetes (n=122) (Table 1).

The means for the whoqol bref were as follows (Table 2):

• Diabetes: Physical health mean 52.27(95%CI from 46.49 to 58.05); psychological health mean 54.54(95%CI from 50.79 to 58.29); social health mean 70.94(95% CI from 65.79 to 76.09) and environmental health mean 61.40(95% CI from 57.08 to 65.72)
• Hypertension: physical health mean 58.81(95% CI from 53.94 to 63.68); psychological health mean 60.31(95 CI from 56.97 to 63.65); social health mean 75.07(71.63 to 78.50); environmental health mean 68.13(95% CI interval from 64.50 to 71.76).
• Diabetics and Patients of Hypertension: physical health mean 50.88(95% CI from 46.38 to 55.38); psychological health mean 52.99(95 CI from 49.86 to 56.12); social health mean 76.09(72.40 to 79.78); environmental health mean 63.85(95% CI interval from 60.41 to 67.28).
• Control group: Physical health mean 70.36(95% CI from 66.49 to 74.23); psychological health mean 61.47(95% CI from 59.01 to 63.93); social health mean 67.07(62.99 to 71.16); environmental health mean; 71.74(95 CI from 68.67 to 78.81)

The Kruskal-Wallis test had p-values<0.05 indicating that there is a significant correlation between the subgroups and scores of the 4 domains. To note significant differences between all the 4 groups individually the Mann-Whitney test was used. It was interesting to note that patients of diabetes had no significant differences with co-morbids. (P>0.05) (Table 3)

It was seen that dual comorbids patient had the lowest physical health score, whereas control had the highest. However, we also noted that domain of physical health had no significant difference when comparing diabetics and dual comorbids (P=0.59, u=5547.50). (Table 4)

Similarly psychological health was also lowest in comorbids and highest in Control population. We also noted that the psychological health did not differ significantly in patients of Hypertension and control (P=0.98) also indicated by the psychological health of patients of hypertension being the 3^rd highest. Furthermore, a non-significant difference was also observed in patients of diabetes and dual comorbids.

The Social health was highest in duals, which is anomalous keeping in view the results, also the lowest mean score in social health was obtained by the Control group. Social health had significant differences when diabetes, hypertension and duals were compared with the control population. (P=0.40, P=0.15, P=0.50)

The environmental health mean was lowest in patients of diabetes and highest in the Control group. Significant differences were noted in the domain of environmental health between diabetics and non-diabetics (P=0.00), dual comorbids and controls (P=0.00) and diabetics and patients of hypertension (P=0.03

It was also noted that age, gender, marital status and employment had a significant effect on the quality of life of patients. (P<0.05) However it was a low income hospital, with 98 % muslim population and most of the people uneducated so it did not have a significant effect on quality of life and were considered constants after attempting independent t-tests. (P>0.05). As age increased, it tend to decrease the score in domains of physical, psychological and environmental health. Similarly an impact was also seen in gender with men having higher physical and psychological scores than women. Unmarried people had a lower social score than married couples and a statistically significant result was not seen in other domains. (P<0.05 Mann Whitney test, non-normal data)

Table 1: demographics of the sample population

Table 3: Scores of diabetes and/or hypertension and controls in all 4 domains

Table 4: Mann Whitney test between different groups with mean ranks. Mann Whitney is conducted for non-normal data. Mean ranks are used for Mann whitney test with Mann Whitney u values and used for data with different standard deviations and different distributions.

Discussion

More than 50 years ago, the World Health Organization stated that health was defined not only by the absence of disease and infirmity, but also by the presence of physical, mental, and social wellbeing. [11]The results of this research would help to analyze different aspects of health in diabetics, patients of hypertension and subjects without these comorbidities.

General Findings

An interesting finding of this study was that control population had lowest mean score of (61.20) in psychological health compared to its other three domains. Pakistan is a third world country where basic facilities are out of reach of ordinary population. This can also be related to the lack of recreational activities.[12] Amongst the four domains we see that control population had the highest environmental health, this can be due to the reason that their financial expenses are low since they do not need to spend on medications of diabetes or hypertension. Moreover control population also has the opportunity to participate in new activities since as mentioned above, diabetics may fear hypoglycemia and avoid new physical activities. This reflects the fact that having a disease lowers environmental score. However we would also like to refer to articles where it is stressed that environment might play a role in evolution of many non-communicable diseases along with obvious communicable diseases. [13]

Diabetes and Control

Diabetes having the lowest physical domain score (51.70) compared to the other 3 domains can be linked to the fact that medical support and strict treatment regime of twice or thrice daily especially pre and post-prandial affects their QOL. Patients are expected to modify their lifestyle catering to their disease. This may further impact their perception of QOL.  These patients have to face many adversities e.g. specific dietary regimen, changes in their body image, dependence on machines like Glucometers, blood pressure monitors and syringes which increases anxiety and affect QOL. [14]  Other factors are late diagnosis of diabetes and noncompliance to the regimens.

Hypertension and Control

Hypertension also had the worst physical score (58.9) compared to the other 3 domains. The issues on hand are underlining the predisposing factors (such as little or no knowledge of hypertension, non-compliance to the treatment regimen, inability of follow-ups, and financial constraints) and the need to find a solution as soon as possible [15] All these factors negatively impact the physical health domain. Hypertension also had the highest score in social domain (75.0659).as previously stated with diabetes. Good social scores are due to good social support family culture. A very important feature of a Muslim society is the importance that it gives to the family structure. Family is considered as a fundamental unit of a healthy and balanced society. [16]

Diabetics and patients of Hypertension

Psychological health in diabetics is significantly lower as compared to patients of hypertension and this may have multiple reasons. For instance, the food culture in Pakistan promotes sugar-rich and oil-rich foods coupled with huge consumption of sugar-filled beverages, a patient diagnosed with diabetes has to follow his non-pharmaceutical therapy avoiding his general food routine and thereby feeling deprived, whereas in patients of hypertension, doctors suggest avoiding salty items only. [17] Also, the medical equipment associated with day to day checkup of hypertension is lesser of an anxiety causing agent since only a sphygmomanometer is involved whereas as mentioned above, with diabetes, needles and glucometer are involved which may result in more anxiety or depression. Also, the fear of blood-glucose levels falling and its impact might be more worrisome for a patient than blood pressure rising extra-ordinary if regimen is strictly followed other than in times of stress. We also see that hypertension has a higher environmental score than diabetics. This can be attributed to the fact that treatment of diabetes is more expensive than hypertension and affects the financial environment of the patient that results in low environmental score. [18]

Dual Comorbid with isolated comorbid and control population

Patients with both hypertension and diabetes had a significant difference in all 4 domains of quality of life. This is in line with multiple researches that have been conducted, for example a study that was conducted in Korea recently in 2014 by Young Ran Chin indicated that comorbid patients tend to have a lower quality of life score than patients with either hypertension or diabetes.[19] The patients with both hypertension and diabetes had lower physical scores as compared to controls, however no significant difference was seen when comparing their score with diabetics. A significant difference as compared to patients of hypertension and none seen with diabetics indicate that effect of diabetes on physical scores is significantly higher than patients of hypertension. If a comparison was made between diabetics and hypertension was made, the difference would not have been observed. The probable reason is that decline in physical quality of life is greater in diabetes and hypertension. The reason for this difference maybe the fact that diabetics need to change their lifestyle to a greater extent in order to control their glucose, since even acute hypoglycemia can result in unconsciousness making them conscious about their physical activities.  Hypertension on the other hand has a detrimental effect that is chronic in nature and tends to be overlooked by patients who are recently diagnosed with it. This is in contradiction with a similar study conducted in Turkey by Hakan Tüzün and et al. in 2015. [20] The difference in results can be attributed to the fact that the study was conducted in two very different settings, the severity of disease may be different in both studies and duration of hypertension may also vary. Another important reason is that the inclusion criteria of our study was people of age above 40 whereas in the study mentioned above, any person of age eighteen or above could participate in the survey. It is suggested that age plays a very important role in calculation of QOL of a person.[21]

Similarly, patients suffering from both hypertension and diabetes had a significant difference in psychological health when compared with patients of hypertension. This is again attributed to the fact that diabetes has a higher effect on psychological health as compared to the patients of hypertension. This has been discussed when comparing patients of hypertension and diabetes.

A peculiar finding was very low social scores of the control population and high social scores of patients suffering from both the diseases. This, however can be attributed to the fact that the control population was selected from people accompanying the patients for the purpose of making other factors like demographics constant. However, it was not foreseen that the attendees might have low social scores because of the incidence of disease in their family. The controls were not suffering from hypertension and diabetes but both hypertension and diabetes has a hereditary link and multiple family members might be suffering from it. [22, 23]This puts a burden of medication and other health related expenses on the attendees and the patients if they are earning upto 3.2 times in a study conducted in UAE. [24] Since, the sample population was from low income group of Sindh, it is suggested that they might be working harder to meet their ends, compromising their social life.

Limitations of the Study

The presence of chronic disease based on the self-report of participants may be a limitation of this study. However, it was necessary to use an alternative source since the records of chronic diseases registered at PHCs were insufficient. The reported diseases were grouped according to the ICD codes for evaluations. Although they may be of the same group, different diseases can affect QoL in different ways. Therefore, a comparison based on the specific diagnoses of disease would be more informative.

In addition, we believe an increase in the size of sample would have further validated the study and yielded results that would be more precise and accurate.

Furthermore, we think that our research could have widened its scope by including more diseases prevalent in the society like osteoporosis, asthma and mental illnesses like depression. A thorough comparison of these different comorbities could have given a greater insight of QoL of general population and diseases that require proper physical and mental rehab.

Another limitation of the study is the setting of the research. The research was conducted at Civil Hospital Karachi, which mostly caters to the low socioeconomic class of the society which did not allow us to take in account the impact of socioeconomic status on the QoL.  Targeting populations from different hospitals could have eliminated this limitation.

Conclusion

In a comparison of diabetics, patients of hypertension and control, we see that diabetics had the lowest score as a whole and also domain wise. The exact reasons are unclear, but the decrease in QOL of these patients is of immense importance to not only doctors but also other stakeholders like Primary, Secondary and tertiary health care providers. One way in which higher scores might be achieved is by promoting the psychological health sector in Pakistan which does not seem to be very developed till now. Low scores of psychological health of control population, additionally, is of particular interest.

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