Health Related Quality of Life in Patients with Chronic Diseases

Copyright © 2020 Phcog.Net. This is an openaccess article distributed under the terms of the Creative Commons Attribution 4.0 International license. Cite this article : Mohamed AMAA, Isa HMA. Health Related Quality of Life in Patients with Chronic Diseases.. Int J Med Public Health. 2020;10(3):104-9. ABSTRACT Background: Chronic diseases impacted the different aspects of patients’ life. This study aimed to measure health-related quality of life (HRQOL) of patients with chronic diseases attending primary health care centres in Bahrain. Methods: This Cross-sectional study was conducted between September 2016 and January 2017 in five randomly selected primary health centres. Data was collected using a self-filled structured questionnaire (World Health Organization Quality of life-BREF (WHOQOL-BREF) questionnaire) to measure the HRQOL. Scores of HRQOL were calculated and relations between the scores and the sociodemographic data were explored using one-way ANOVA. Results: 337 questionnaires were received back with a response rate of 67.4%. 169 (50.1%) of the participants were females. The mean age (SD) was 52±11 years. Most of the participants were married (255 (78.2%)), retired (115 (34.1%)) and educated (309 (91.7%)). All the participants had at least three chronic diseases. The most prevalent chronic diseases were diabetes mellitus, dyslipidemia and hypertension. 161(48%) participants reported having good quality of life and were satisfied with their health. The mean HRQOL scores for physical, psychological, social and environmental domains were 63.8±18, 63.9±18, 67±22 and 64±16, respectively. Patients with diabetes, hypertension and hyperlipidemia tend to have the highest mean scores in all the domains. Patients with sickle cell disease and psychiatric diseases had the lowest mean scores in all the domains. Conclusion: Chronic diseases affect the HRQOL of patients. Some diseases had more impacts on the HRQOL than others. Patients with chronic diseases in Bahrain had an overall good quality of life.


INTRODUCTION
Worldwide, chronic diseases had increased significantly in the past decades. This was a result of improved living conditions and advances in medical treatment. Consequently, the number and the life expectancies of patients living with chronic diseases of have increased. 1,2 Chronic diseases in general have slow progression and prolonged duration requiring continuous medical care. In United States, more than 40% of patients seen in primary health care setting have multiple chronic illnesses. 3 Majority of chronic diseases have the potential to affect the overall health of patients and their quality of life. 1 Studies showed an adverse effect of these diseases on patient's quality of life. 1,4 One study even showed a larger effect on the quality of life with the presence of more than one disease. 5 In addition to multimorbidity, other factors might also affect the patient's quality of life like age, sex, educational level and associated psychiatric diseases. 6 Chronic diseases have impacts on different aspects of patients' life like perception of independence, social relationship, financial capacity and general wellbeing which are not measured routinely in health care visits. Understanding the relationship between quality of patient's life and their chronic diseases is important. 7,8 Quality of life was defined by the world health organization (WHO) as the persons' view of his position in life in his own cultural environment and within his own value regarding his own expectations and goals. Health-related quality of life (HRQOL) describes the effect that any health condition and/ or its' symptoms exhibit on the individual's life. 9,10 HRQOL questionnaires were used to measure the discrepancies between the objective health status and the one's subjective sense of health. 7 The WHO in collaboration with 15 centres around the world has developed two tools to measure the quality of life which are the World Health Organization Quality of life-100 (WHOQOL-100) and World Health Organization Quality of life-BREF (WHOQOL-BREF). 9 Centers for Disease Control and Prevention in the United States had also developed their own tool to measure quality of life. 3 Information gained from assessing the quality of life are of great value for public health and for health care systems. Assessment of patient's quality of life had become an established factor in assessing health care outcomes and in developing guidelines. 11 HRQOL questionnaires might reveal the public views to guide the health care policies and to observe the progress of national health targets. 11 The more we understand the effect of chronic diseases on patient's quality of life, the better will be the development of management strategies to control these diseases. 7 HRQOL had been studied in many developed countries across the globe. Yet, the concept of HRQOL is not familiar in the Middle East and measuring it is not a common practice as reflected by the scarcity of related studies in this part of the world. 12,13 Bahrain is an Arabic speaking country in the Middle East with a population of more than a million. 14 Over the last few decades, Bahrain has experienced a dramatic economic growth and life style changes. Sedentary life style and high caloric diet lead to an increase in the prevalence of chronic diseases in this country. 15 Chronic diseases are the major cause of mortality in Bahrain accounting for 79% of the overall deaths. The estimated prevalence of some chronic diseases like diabetes, hypertension and hyperlipidaemia in Bahrain were 13.5%, 38.2% and 40%; respectively. 16 Although there are well-structured non-communicable diseases (NCDs) clinics to care for patients with chronic diseases in Bahrain, measuring HRQOL is not incorporated in these clinics nor studied on a regular basis.
Although the prevalence of chronic diseases in Bahrain is high, studies about HRQOL are limited. Only few studies were published about quality of life in patient with kidney transplant, breast cancer, pulmonary diseases and sickle cell disease specifically. [17][18][19][20] The main objective of this study was to measure HRQOL of patients with chronic diseases attending NCDs clinics in the primary health care centres in Bahrain.

Sample and setting
This is a cross-sectional study which was conducted between September 2016 and January 2017. Patients from the 28 primary health care centres distributed across the five health governorates in Bahrain were gathered using a stratified random sampling method. Two health centres were randomly selected from each health governorate. In each of the selected health centres, there were specialized clinics to care for patients with chronic diseases; the NCDs clinics and the diabetic clinics. The sample size was estimated using an online sample size calculator at 95% confidence level and 5% confidence interval.
All eligible patients attending the NCDs and diabetic clinics during the study period were invited to participate. The eligibility criteria were being Bahraini, adult older than 18 years, competent in Arabic language and has one or more chronic diseases.

Data collection procedure
The data were gathered using a self-filled structured questionnaire, which was distributed to the patients by nursing staff who run the NCDs or the specialized diabetic clinics. The questionnaire consisted of two parts. The first part was related to sociodemographic data and inquired about the types of chronic medical conditions. The second part was the WHOQOL-BREF questionnaire which was used to collect the data about HRQOL. The WHOQOL-BREF is a self-filled structured questionnaire scored in a 5-point Likert scale with the highest score representing better HRQOL. The questionnaire contains 26 questions; two general questions and 24 items assessing the four HRQOL domains. The two general questions are asking about the overall quality of life and the overall health status of the patient. The four domains of HRQOL are the physical, the psychological, the social relationship and the environment domains. Each domain is measured by subscale and the sum of all the subscales gives the overall HRQOL. The raw scores for the domains were calculated by adding the score of the questions related to these domains. These scores are then transformed into a scale between 0-100 where zero is the lowest and 100 is the highest score. If more than two items of the domain questions were not answered, the domain score is discarded.

Ethical consideration
This study was conducted in accordance with the principles of Helsinki Declaration. The primary care medical research committee in ministry of health in Bahrain had approved this study. Participation in the study was voluntary and each patient has signed a written informed consent to be enrolled in the study. Patient's confidentiality was assured.

Data analysis
Statistical analysis was done using the statistical package for social science software (SPSS) version 20. Descriptive and inferential statistics were performed. Descriptive statistics were calculated for all the study variables. The frequency, mean, median, range and standard deviation (SD) were calculated. Summary of the scores were generated for the WHOQOL-BREF questionnaire by organizing the items into domains covered by the questionnaire. In computing the summary scores, patients with missing values were excluded from the analysis for that domain. One-way ANOVA was used to study the relationship between the four domains of the HRQOL and the sociodemographic variables. The Cronbach alpha test was used for all the 26 items in the HRQOL questionnaire to test for internal consistency. Statistical significance was set at P<0.05.

DISCUSSION
Quality of life is an important topic in the care of patients with chronic diseases. In literature, there is a growing attention focusing on HRQOL of chronically ill patients because it can affect the patients' attitude toward the disease and its' treatment. 1 In Bahrain, chronic diseases account for 83% of deaths annually. This study found that patients followed in the chronic disease clinics suffers from at least three chronic diseases. This might indicate the high prevalence of comorbidities among patients with chronic diseases and might explain the mortality statistics in Bahrain which showed that chronic diseases are the leading cause of mortality in the country. The high prevalence of comorbidities was also reflected in a study done on diabetic patients in Bahrain and found that two third of them had hyperlipidemia and one third had hypertension in addition to their diabetes. 21 Similarly, a study to detect cardiovascular risk factors on workplace in Bahrain found high prevalence of diabetes, hyperlipidaemia  and environmental domains when compared to general population of Hong Kong. 27 They also scored higher in environmental domain when compared to Pakistani general population. 28 Several studies showed differences in the HRQOL scores by sex. Males usually had better scores than females. Some domains were more affected than other by the sex of the patients. In physical, psychological and social domains males tend to score higher than females which was comparable to the result of the current study. 25,26 However, other study showed better quality of life among females. 5 Level of education is known to improve the HRQOL scores. In this study, educated patients had better scores in all domains compared to non-educated patients which is similar to other studies. 23,26 In the current study, retired patients showed better overall quality of life and better scores in the social domain. This could be explained by that retired patients had more free time to socialize than do working individuals. On the other hands, the working participants had better scores on the physical domains. This could be explained by the presence of differences in the mean age of both groups and on the sex distribution. Working participants had lower mean age of 47 years than retired participants who had mean age of 58.9 years. Most of the working participants are males and generally males had better physical score than females. Some chronic diseases had more negative impacts on the HRQOL than others and their effects on the domains varies by the type of disease. For example, mental disorders had shown to have the worst effect on the psychological and social domains. 23 Though, in another study, the negative effect of the mental disorders had shown to affect all the domains. 29 Similarly, in this study, the patients with mental disorders had lower scores in all domains. Respiratory diseases had the worst effect on the environmental domains, which is in line with the result of this study, where asthma patients had lower scores compared to other diseases. 23 In relation to smoking status, smoking was found to negatively affect the HRQOL scores across the four domains when compared to non-smokers which is similar to the results of studies done in Brazil and United States. 30 This study is limited by being conducted only among Bahraini patients attending the chronic disease clinics. This could explain why all the and hypertension. 22 In contrast, a study about comorbidities and quality of life in European countries showed a lower rate of comorbidities of only 27%. 23 Despite the comorbidities, the study population rated their quality of life as good and their HRQOL scores were relatively high when compared to similar studies in other countries. Participants of this study had HRQOL scores of 63.8 ±18, 63.9 ±18, 67 ±22 and 64±16 for physical, psychological, social and environmental domains respectively. However, a study from Gaza province on diabetic patients showed mean scores of 36.7, 34.8, 52.4 and 23 for physical, psychological, social and environmental domains respectively which were far lower than those of the present study. 24 This could explain why poor health does not usually equate poor quality of life as some people are able to overcome limitations generated by the presence of their illnesses. 5 HRQOL scores of the current study participants were good enough to be compared with scores of the general population in other countries (Table 7). Yet, a study on Kuwaiti general population showed a better score in physical domain but comparable scores on other domains. 25 Furthermore, general population in Indonesia had higher scores in physical and psychological domains but lower scores in the social and environmental domains when compared to the present study population. 26 Participants in the current study had higher scores in social  (18) DM = diabetes mellites, SD = standard deviation, SCD = sickle cell disease. patients had more than one chronic disease. Another limitation is that the patients who are followed in primary care chronic disease clinics are less likely to have complications than those followed in secondary care clinics which might limit the generalization of this study results. Despite these limitations, this study is one of few studies about HRQOL among patients with chronic disease in Bahrain. It can form basis for further studies in the same field.

CONCLUSION
Chronic diseases affect HRQOL of patients. Some diseases had more impacts on HRQOL than others. Patients with chronic diseases in Bahrain had relatively good HRQOL. However, this field in research is relatively new in Bahrain. Further studies tackling the same topic using different HRQOL measurement instruments will help in enriching this field.