Characteristics of persons with type II diabetes mellitus
There were 339 patients with T2DM that were enrolled in this study with the majority being females (64.3%). Of the 339 participants, 55.2% were between 41-65 years old with a mean age of 50.3±15.5 years. Forty percent were overweight (BMI; 25-29.9kg/m2) with a mean BMI of 26.6 ±5.5 kg/m2 (Table 2).
Table 2: QoL and Characteristics of persons with type II diabetes mellitus
Patient Characteristics (n=339)
|
N
|
%
|
Mean QoL (95% CI)
|
P-value
|
|
|
|
|
|
Total
|
339
|
100.0
|
63.91 (61.83-66.00)
|
|
Sex
|
|
|
|
0.63
|
Males
|
121
|
35.7
|
64.59(61.16-68.03)
|
|
Females
|
218
|
64.3
|
63.54(60.90-66.17)
|
|
Agegroups (years)
|
|
|
|
0.05
|
<40
|
92
|
27.1
|
61.64(57.52-65.76)
|
|
41-65
|
187
|
55.2
|
66.23(63.49-68.97)
|
|
>65
|
60
|
17.7
|
60.18(55.22-65.15)
|
|
BMI (kg/m²)
|
|
|
|
0.02
|
<18.5
|
21
|
6.2
|
53.86(45.70-62.01)
|
|
18.5-24.9
|
104
|
30.7
|
63.64(60.02-67.27)
|
|
25-29.9
|
135
|
39.8
|
62.97(59.73-66.21)
|
|
30+
|
79
|
23.3
|
68.56(64.05-73.07)
|
|
|
|
|
|
|
Treatment duration (years)
|
|
|
|
0.56
|
<5
|
137
|
40.4
|
64.74(61.47-68.02)
|
|
06-010
|
114
|
33.6
|
62.29(58.68-65.92)
|
|
>10
|
88
|
26.0
|
64.72(60.61-68.82)
|
|
|
|
|
|
|
Education level
|
|
|
|
0.005
|
None
|
39
|
11.5
|
58.21(51.81-64.60)
|
|
Primary
|
134
|
39.5
|
62.70(59.43-65.97)
|
|
Secondary
|
131
|
38.6
|
64.21(60.82-67.61)
|
|
Tertiary
|
35
|
10.3
|
73.8(68.56-79.04)
|
|
Marital status
|
|
|
|
0.87
|
Divorced
|
13
|
3.8
|
63.77(52.63-74.91)
|
|
Single
|
30
|
8.9
|
61.07(53.75-68.39)
|
|
Widowed
|
51
|
15.0
|
64.08(58.72-69.44)
|
|
Medical aid
|
|
|
|
0.005
|
No
|
322
|
95.0
|
63.24(61.10-65.38)
|
|
Alcohol drinking
|
|
|
|
0.49
|
No
|
329
|
97.1
|
63.79(61.67-65.90)
|
|
Yes
|
10
|
3.0
|
68.1(54.59-81.61)
|
|
No
|
339
|
100.0
|
63.91(61.83-66.00)
|
|
The mean diabetes duration was 8.1±6.5 years. Forty percent (n=134) of the participants had a diabetes history of less than 5 years. Forty percent of the participants had primary school education. Out of 339 participants, 73% were married, 5% were on health insurance, 98% reported no alcohol drinking and none of the participants reported a history of smoking.
Characteristics of interviewees and diarists
A total of 12 participants took part in the in-depth interviews and their ages ranged from 25 to 72 years of which 7 of them were females. Six of the interviewees were T2DM patients of which 3 were females.
Six of the interviewees were guardians of T2DM patients and 4 of them were females. Out of the 12 diaries that were distributed, 7 diarists were male. In the end, we managed to collect 8 diaries of which 5 were from males.
Definition of quality of life
Absence of disease
The participants referred to the absence of disease as not getting sick often and having a body that is resilient to illness.
“According to me the way I see quality life… is the one who is not falling sick often. Because when you become sick frequently, you cannot work to bring wealth to your family, and you can’t manage to work to have enough food for your family. So quality life let’s say it is someone who does not get sick frequently, that’s the one who has quality life, not just riches… no”. (69 years old male, guardian interviewee)
Independence
Quality of life also emerged as an act of independence over oneself. The participants felt that one needs to manage taking care of oneself, work satisfactorily and travel without any problems.
“Quality life means living without getting sick quite often, working satisfactorily, and also walking/travelling without any problem”. (35 years old male patient interviewee)
Assessment of quality of life among persons with type II diabetes mellitus
The mean QoL was 63.91±19.54 (95%CI: 61.83-66.00). QoL score <50 was poor, a score between 50-70 was moderate and a score more than 70 signified better QoL (Table 3). Forty-one percent of patients had QoL between 70-100 while the minority had QoL of less than 50 (Table 3).
Table 3: Assessment of quality of life among persons with type II diabetes mellitus
Quality of life categories
|
N
|
%
|
|
|
|
TOTAL
|
339
|
100
|
|
|
|
<50
|
82
|
24.2
|
50-70
|
117
|
34.5
|
70-100
|
140
|
41.3
|
Factors that inhibit the quality of life among diabetes patients
Some of the participants from the in-depth interviews explained that there are factors that contribute to the reduction of QoL among T2DM patients in addition to the presence of the disease itself. These factors are categorized under the following level the health system, family or societal factors, and individual.
Health system factors (drug shortages)
The participants complained that sometimes they are faced with a shortage of drugs at the hospital which requires them to buy from private pharmacies. This becomes a challenge as they reported that these drugs are expensive. As such, they become stressed over their ability to access the medicines.
“Sometimes we come to the hospital and we are told diabetes medicines are out of stock, and we are forced to go and buy at pharmacies. Maybe the government should look at that so that we can live in a diabetes-free world”. (25 years old woman guardian interviewee)
Family/societal factors
Some patients reported that they are labeled as selfish if they refuse to eat a certain type of food in communal gatherings for example at a funeral or a wedding. Some people may think that diabetics are nagging unnecessarily when they report getting hungry frequently, consequently limiting their travel and participation in social gatherings.
“This disease doesn’t allow us to eat good, soft, oily, and sweet food. This results in us being painted as selfish because most of our friends do not understand this disease. We eat m’gaiwa nsima so it is hard for family and friends to accept and assist us accordingly”. (Diarist male patient)
Individual factors
Participants highlighted stress as one of the factors that reduce QoL among diabetes clients. Stress may arise from the presence of diabetes itself and its complex nature. In addition, some patients may despise hospital advice like ignoring the prescribed food, medicine, and physical exercises. All of these may put them at risk of getting sick often hence enhancing instability in their lives and that of their relations.
“…. anxiety disturbs because just the fact that you are worried, your body is disturbed. This is in a way that the body doesn’t function properly. Because getting worried and the nature of diabetes do not go together”. (35 years old man patient interviewee)
“… That’s why if you just eat those fatty foods, for example at a funeral you have had those fatty foods, you just find that the body is not normal. Not that you are sick or you have general body pains but the body just lacks energy. Then you realize that ooooh I have made a mistake…” (69 years old woman patient interviewee)
Quality of life varied by demographic and behavioral characteristics
Patients who had tertiary education had a better QoL than those who had lower education levels (QoL score 73.8, 95%CI 68.56-79.04) (p-value 0.005). There was an increasing trend in the QoL by education level. Similarly, patients who had health insurance had a better QoL than those who did not have health insurance (QoL score76.71, 95%CI 69.22-84.19) (p-value 0.005). Furthermore, patients who were obese (BMI >30kg/m2) had a better QoL compared to those who were underweight, normal weight, and overweight (QoL score 68.56, 95%CI: 64.05-73.07, p-value 0.02) (Table 4).
Table 4: Quality of life varied by demographic and behavioral characteristics
Patient Characteristics (n=339)
|
N
|
%
|
Mean QoL (95% CI)
|
P-value
|
|
|
|
|
|
Total
|
339
|
100.0
|
63.91 (61.83-66.00)
|
|
BMI (kg/m²)
|
|
|
|
0.02
|
<18.5
|
21
|
6.2
|
53.86(45.70-62.01)
|
|
18.5-24.9
|
104
|
30.7
|
63.64(60.02-67.27)
|
|
25-29.9
|
135
|
39.8
|
62.97(59.73-66.21)
|
|
30+
|
79
|
23.3
|
68.56(64.05-73.07)
|
|
|
|
|
|
|
Education level
|
|
|
|
0.005
|
None
|
39
|
11.5
|
58.21(51.81-64.60)
|
|
Primary
|
134
|
39.5
|
62.70(59.43-65.97)
|
|
Secondary
|
131
|
38.6
|
64.21(60.82-67.61)
|
|
Tertiary
|
35
|
10.3
|
73.8(68.56-79.04)
|
|
Medical aid
|
|
|
|
0.005
|
No
|
322
|
95.0
|
63.24(61.10-65.38)
|
|
Yes
|
17
|
5.0
|
76.71(69.22-84.19)
|
|
Qualitatively, participants stated factors that are associated with promoting QoL among T2DM patients, and these were categorized under health system, family or societal and individual levels.
Health system factors (diabetes health talks)
Participants reported that the health education delivered at the facilities helps them lead a healthy life if they follow the protocols taught during the health talks. These health education sessions include aspects like pieces of advice on taking medication properly, the recommended diet, and allowable amount to consume, and avoiding a sedentary lifestyle.
“…But I believe that we can attain a good life if we follow the advice we are taught time and again. A while ago, there was a nurse who used to come before the start of each diabetes clinic to advise us. It was really good but these days she is nowhere to be seen. But if she is no longer here, can’t there be another nurse to encourage and help us reduce our stress so that we can have a good and long life if we can manage to take good care of ourselves?” (Diarist male patient)
Family/societal factors (supportive family, good relationships)
Having a supportive family and good relationships promotes the QoL of diabetes patients. The support that relatives render includes encouragement on following advice received from a hospital for example taking medication properly and following a recommended diet. Participants further reported that good relationships help them with psychological support.
“My relatives are good people and they are the only ones who understand my diabetes problem. They encourage me on the right diet as well as remind me when to take medicine. They always want to see me happy and stress-free”. (Diarist female patient)
In agreement with the participants, one guardian reported that supportive families and relationships are good for the patients.
“Because when we remind him to come to the hospital, there are also protocols concerning what kind of food he is supposed to eat and also being active most of the time so that his body should not be weak”. (36 years old man, guardian interviewee)
Individual factors
Some of the participants reported that avoiding stress and accepting their condition are key elements in life. They further indicated that when they accept, it is more likely that they follow hospital advice for example eating the right food as well as leading an active lifestyle.
“Most importantly, it is good not to be worried, no… accept the situation. And also when you accept, be settled so that you should not get sick quite often… because if you are not accepting, you are always worried as a result you may die faster”. (47 years old man patient interviewee)
Guardians corroborated with what the participants reiterated on the importance of accepting the condition and adherence to advice as key to leading a better life. Furthermore, one of the guardians indicated that it is possible to live in a diabetes-free world if diabetes management and preventive measures are followed.
“The way I see it, I think diabetes can be prevented. And I have heard other people recovered from it properly. It just requires a person to follow what the doctor says… so if he can follow instructions given at the hospital, we can live in a diabetes free-world”. (25 years old woman guardian interviewee)
Quality of life varied by comorbidities
QoL was further assessed based on the presence and absence of comorbidities as well as types of comorbidities (Table 5). In comparison with patients with comorbidities, those without comorbidities had a better QoL of 71.18 (95%CI: 66.69-75.67, p-value <0.0001). Specifically, patients without musculoskeletal diseases had a statistically significantly better QoL than those with musculoskeletal diseases and their QoL score was 66.01 (95%CI: 63.48-68.54) (p-value 0.002).
Table 5: Assessment of quality of life based on comorbidities
Comorbidities
|
N
|
%
|
Mean qol (95%CI)
|
P-value
|
|
|
|
|
|
Total
|
339
|
100
|
63.91(61.83-66.00)
|
|
Comorbidities
|
|
|
|
<0.0001
|
Absent
|
92
|
27.1
|
71.18(66.69-75.67)
|
|
Present
|
247
|
72.9
|
61.21(58.97-63.45)
|
|
Cardiovascular diseases
|
|
|
|
0.07
|
No
|
283
|
83.5
|
64.77(62.49-67.06)
|
|
Yes
|
56
|
16.5
|
59.57(54.54-64.60)
|
|
Musculoskeletal diseases
|
|
|
|
0.002
|
No
|
238
|
70.2
|
66.01(63.48-68.54)
|
|
Yes
|
101
|
29.8
|
58.98(55.48-62.48)
|
|
Urologic diseases
|
|
|
|
0.79
|
No
|
335
|
98.8
|
63.88(61.78-69.99)
|
|
Yes
|
4
|
1.2
|
66.5(52.67-80.33)
|
|
Reproductive system diseases
|
|
|
|
0.32
|
No
|
329
|
97.4
|
64.10(61.97-66.22)
|
|
Yes
|
10
|
3.0
|
57.9(46.85-68.95)
|
|
Endocrine diseases
|
|
|
|
1
|
No
|
330
|
97.4
|
63.92(61.80-66.03)
|
|
Yes
|
9
|
2.7
|
63.89(49.56-78.22)
|
|
Neurology diseases
|
|
|
|
0.13
|
No
|
267
|
78.8
|
64.75(62.34-67.17)
|
|
Yes
|
72
|
21.2
|
60.81(56.84-64.78)
|
|
Ophthalmic diseases
|
|
|
|
0.26
|
No
|
267
|
78.8
|
64.54(62.16-66.91)
|
|
Yes
|
72
|
21.2
|
61.61(57.26-65.96)
|
|
Findings from the qualitative component on existing comorbidities also corroborated with those from the quantitative component. In the qualitative component, some participants reported having body weakness frequently. They also reported that diabetes results in different conditions such as problems with eye-sight, wounds that are difficult to heal which may end up in loss of limbs through surgery, sudden death, burning sensations, lack of sexual desire, and numbness, especially in the legs and feet. The patients reported that due to all these problems, they become stressed as they feel that their lives are unstable. They also stated that sometimes stress is caused by loss of independence and failure in taking care of their families.
“I hear some people saying that a diabetes patient dies suddenly when their sugar drops extremely. And also when you are diagnosed with diabetes when you are young, you have never been married, and I heard that you lack sexual desire. And also when you have a wound or a sore, it is difficult to get healed and it takes a long time. For example, if you got injured on your leg or toe/finger, in the end, they may remove that part. As a result, I am stressed a lot, furthermore, I heard that diabetes may destroy eyes”. (Diarist female patient)
Some family members also observed the impact diabetes has on their patients. They reported that diabetes patients feel weak most of the time, they have various problems like poor/loss of eyesight and also feel stressed because of their disabilities as well as loss of independence.
“When he was diagnosed with diabetes in 2016 his life was not very healthy. He used to be sick always to the extent of being amputated. So you can understand that after amputation there was nothing he could do, he doesn’t do anything… but he has a lot of thoughts that he has failed to provide for his family. So that’s what I see affects him that as a father is supposed to provide for his family unfortunately he doesn’t”. (25 years old female guardian interviewee)
Physical challenges faced by patients with type II diabetes mellitus
Of the 73% that had comorbidities, the most common comorbidities reported by patients were cardiovascular diseases (16.5%), musculoskeletal diseases (29.8%), neurologic conditions (21.2%), and ophthalmic conditions (21.2%). A few patients reported having urologic diseases (2.7%), reproductive (3%), and endocrine system conditions (1.2%) (Table 5).
In addition to the above physical challenges, participants pointed out that diabetes demands multiple changes in someone’s life for example loss of independence in that in most cases, they rely on someone to help them with activities of daily living as well as failing to earn a living.
“Everything has to be done for her… for example cooking for her. She can’t manage to cook maybe what she wants but maybe we have to cook for her. Maybe washing for her, giving her water to bath. Everything. She has just reached a level whereby it’s like we are taking care of a baby now…” (49 years old female guardian)
In addition, the participants stated that they are restricted from eating a variety of foods as a result they feel stressed as they are always searching for their recommended foods. This also restricts them from travelling freely as they are not sure whether they will be able to find the right food as they travel. The participants further reported that food restrictions prevent them from participating in social gatherings.
“…Sometimes, I may be stressed as diabetes demands to eat frequently. Sometimes I might feel hungry when I am in a group of people, I am required to do something according to how I feel… sometimes for example when I am going to a funeral, I don’t go thinking that something bad might happen while I am there. Eeeeee maybe how will I explain to people that I am hungry or maybe for me to leave my friends and tell them that I am going home temporarily to eat? They may say; why is she acting like she is the only one having the disease?” (49 years old female patient interviewee)