1. Background
Diabetes is a common persistent disease and a severe health-related problem in the world (1). The Middle East and North Africa are known as regions with the highest age-adjusted prevalence of diabetes in adults in 2019, 2030, and 2045 (12.2%, 13.3%, and 13.9%, respectively). In 2019, China, India, and the United States of America were countries with the largest numbers of adults with diabetes. Globally, 463 million people had DM in 2019. A decade ago, in 2010, the global projection for diabetic cases in 2025 was 438 million. With over five years still to go, that prediction has already been surpassed by 25 million (2). The spread of diabetes mellitus in Iran is about 7.7%, accounting for about two million people, which is predicted to be 5.2 million cases in 2025 (3).
Diabetes has the potential to cause numerous debilitating health complications that can lower the quality of life and lead to an early death. Most often, complications are the results of unmanaged or poorly managed diabetes (4). Therefore, a healthy diet, regular physical activity, medicines, and blood sugar control are needed to prevent the complications accompanied by diabetes mellitus (5, 6). The quality of life (QoL) is a highly subjective measure of happiness and shows how much an individual is healthy, comfortable, and can participate in or enjoy life events (7). Type 2 diabetes can be managed with diabetes self-management skills. Self-care is the ability of the patient with the family, and the community to promote health, prevent illness, maintain health, and deal with the disease and disability with or without the help of health care providers (8). Diabetic patients have to change their behaviors and perform self-care activities. The aspects of life with diabetes that may affect the quality of life include the never-ending demands of diabetes care, such as eating carefully, exercising, monitoring blood glucose, and scheduling and planning. (9, 10). In recent years, controlling diabetes has been shown to improve the overall quality of life of patients with diabetes (11). For performing beneficial interventions to improve the quality of life, it is necessary to identify many factors that can increase the risk of complications and affect the quality of life. Studies show that the quality of life could rise with higher self-care behaviors among patients with type 2 diabetes mellitus (12, 13).
2. Objectives
The results of other similar studies have shown the impact of diabetes management on the quality of life of patients with diabetes. The current study aimed to survey the quality of life and self-care behavior among patients with type 2 diabetes mellitus (T2DM) in Mashhad in 2019.
3. Methods
A cross-sectional study was conducted on 140 patients with T2DM. The sample size was estimated using G*power software with a power of 0.95 and an SD of 1% at a two-tailed significance level. The sample was obtained from the diabetic clinic of Imam Reza hospital in Mashhad, Iran. From October to December 2019, a trained research assistant visited the outpatient diabetic clinic weekly on days scheduled by the hospital for providing care to outpatient diabetic patients to recruit patients for the study. The research assistant approached the patients while they were waiting for their medical consultation or after their consultation to introduce the study and seek their consent to participate. The Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.RES.1398.176) approved the study. The inclusion criteria were as follows: Age of 35 years or more, having medical records at the health center, T2DM diagnosed via the WHO criteria, known diabetes for one year, and ability to communicate in Farsi. The exclusion criteria included having other types of diabetes and unwillingness to participate in the study.
The applied tools in the study included two self-reporting questionnaires. The first questionnaire consisted of sociodemographic information and self-care behaviors (SDSCA) associated with diabetes (BG monitoring, dietary control, physical activity, foot care, and smoking). The reliability and validity of SDSCA were confirmed by Toobert et al. (14). The validity and reliability of the Persian version were obtained by Didarloo et al. (15) with α = 0.83. The second questionnaire was a standardized Persian version of the World Health Organization questionnaire for quality of life (WHOQOL-BREF-26). This tool assesses the quality of life in four aspects: Physical health (seven items), mental health (six items), social health (three items), and environmental health (eight items), along with two questions related to the overall quality of life. The reliability and validity of this questionnaire were approved by Nejat et al. (16) that reported Cronbach's alpha values of 0.70, 0.73, 0.55, and 0.84 for physical health, mental health, social health, and environmental health, respectively (16). The researchers were trained on moral issues such as informing the participants of the purpose of the study and obtaining consent forms.
Descriptive statistics such as central tendencies (mean and standard deviation) and frequency distributions were carried out for quantitative variables. To compare the equality of two mean values in qualitative variables, the Mann-Whitney test was adopted. The ANCOVA test was used to assess the relationship between the demographic variables and self-care behaviors towards the quality of life of patients. It was performed by the Backward elimination (or backward deletion) method in which all the independent variables were first entered into the equation, and then they were deleted one at a time if they did not contribute to the regression equation. Data were analyzed by SPSS ver. 22.
4. Results
In our study, 140 patients with diabetes were attended. The mean age of them was 58.41 ± 8.91 years, and 67.14% of them were female. The education level of all patients was below a high school diploma. In addition, most participants were married (87.1%). No significant difference was seen between males and females in terms of demographic data (Table 1). The mean scores of patients' overall self-care were 43.32 ± 10.93 in males and 39.93 ± 9.94 in females (P-value = 0.069). The mean scores of self-care behaviors were not statistically different between male and female patients, although, a statistically significant difference was observed in physical activity (P = 0.005) (Table 2). The mean scores of the dimensions of quality of life were 61.29 ± 15.66 for physical health, 60.62 ± 13.70 for mental health, 68.67 ± 11.63 for social health, and 61.54 ± 14.88 for environmental health. The demographic characteristic (except for the duration of disease, family history, and age) had significant relationships with all dimensions of the quality of life (Table 3). Furthermore, younger patients had better physical health among the dimensions of quality of life (P = 0.03). To predict the patients' quality of life, ANCOVA was performed (Table 4), which showed physical activity was a predictor of the quality of life. There was a positive relationship between the quality of life and self-care behaviors but was not linear (P = 0.005, Rs = 0.44).
Table 1.Distribution of Demographic Characteristics Among Patients with Type 2 Diabetes Mellitus
| Variables | Male | Female | P-Value |
|---|---|---|---|
| Age group | 0.002 | ||
| 35 - 55 | 11 (23.9) | 49 (52.1) | |
| > 55 | 35 (76.1) | 45 (47.9) | |
| Education level | < 0.001 | ||
| Illiterate | 8 (17.4) | 26 (27.7) | |
| Under diploma | 20 (43.5) | 55 (58.5) | |
| Diploma | 18 (39.1) | 13 (13.8) | |
| Marital status | 0.008 | ||
| Single | 1 (97.8) | 17 (18.1) | |
| Married | 45 (2.2) | 77 (81.9) | |
| Occupational status | < 0.001 | ||
| Employed | 38 (82.6) | 3 (3.2) | |
| Unemployed | 8 (17.4) | 91 (96.8) | |
| Duration of disease, y | 0.796 | ||
| < 5 | 11 (23.9) | 22 (23.4) | |
| 5 - 10 | 16 (34.4) | 28 (29.8) | |
| ≥ 10 | 19 (41.3) | 44 (46.8) | |
| Medical condition | 0.310 | ||
| Tablet | 17 (37.0) | 43 (45.7) | |
| Tablet and insulin | 2 (4.3) | 8 (8.5) | |
| Insulin | 27 (58.7) | 43 (45.7) | |
| Family history | 0.232 | ||
| Yes | 23 (50.0) | 57 (60.6) | |
| No | 23 (50) | 37 (39.4) |
Table 2.Gender and Self-care Behaviors in Diabetic Patients
| Variables | Male | Female | P-Value |
|---|---|---|---|
| Dietary control | 21.52 ± 4.07 | 21.01 ± 4.59 | 0.719 |
| Physical activity | 8.10 ± 4.96 | 5.32 ± 5.12 | 0.005 |
| SMBG | 3.08 ± 3.00 | 2.65 ± 2.54 | 0.291 |
| Foot caring | 10.60 ± 3.24 | 11.04 ± 2.92 | 0.413 |
Table 3.Association of the Dimensions of Quality of Life with Sociodemographic Characteristics of Study Participants
| Characteristics | Physical Health | Mental Health | Environmental Health | Social Health | ||||
|---|---|---|---|---|---|---|---|---|
| Mean ± SD | P-Value | Mean ± SD | P-Value | Mean ± SD | P-Value | Mean ± SD | P-Value | |
| Gender | 0.011 | 0.015 | 0.019 | 0.021 | ||||
| Female | 59.18 ± 15.70 | 58.82 ± 13.91 | 67.17 ± 11.35 | 59.79 ± 14.96 | ||||
| Male | 65.60 ± 14.83 | 64.28 ± 12.64 | 71.73 ± 11.72 | 65.08 ± 14.23 | ||||
| Age group, y | 0.037 | 0.141 | 0.276 | 0.145 | ||||
| 30 - 55 | 64.58 ± 15.95 | 62.53 ± 14.75 | 69.98 ± 11.45 | 63.25 ± 15.49 | ||||
| > 55 | 58.82 ± 15.07 | 59.18 ± 12.77 | 67.68 ± 11.73 | 60.28 ± 14.39 | ||||
| Education level | 0.007 | <0.001 | 0.006 | 0.006 | ||||
| Illiterate | 56.17 ± 14.47 | 55.20 ± 12.11 | 63.91 ± 11.38 | 56.11 ± 13.25 | ||||
| Under diploma | 60.84 ± 16.30 | 60.21 ± 14.15 | 68.81 ± 11.23 | 61.86 ± 14.78 | ||||
| Diploma | 68.00 ± 13.17 | 67.54 ± 11.47 | 73.54 ± 11.06 | 66.74 ± 15.27 | ||||
| Marital status | < 0.001 | 0.003 | 0.043 | 0.011 | ||||
| Single | 48.83 ± 12.27 | 51.83 ± 11.28 | 63.00 ± 11.74 | 54.55 ± 9.32 | ||||
| Married | 63.13 ± 15.30 | 61.91 ± 13.59 | 69.50 ± 11.42 | 62.58 ± 15.30 | ||||
| Occupation | 0.001 | 0.001 | 0.006 | 0.002 | ||||
| Employed | 67.63 ± 13.34 | 66.17 ± 11.83 | 72.53 ± 11.19 | 66.92 ± 13.60 | ||||
| Unemployed | 58.66 ± 15.85 | 58.32 ± 13.82 | 67.07 ± 11.48 | 59.29 ± 14.88 | ||||
| Duration of disease, y | 0.085 | 0.194 | 0.383 | 0.766 | ||||
| < 5 | 65.12 ± 16.80 | 63.30 ± 15.65 | 70.63 ± 14.06 | 63.06 ± 16.65 | ||||
| 5 - 10 | 62.59 ± 13.87 | 61.84 ± 12.64 | 68.86 ± 10.43 | 62.00 ± 13.25 | ||||
| ≥ 10 | 58.38 ± 15.91 | 58.36 ± 13.18 | 67.50 ± 11.05 | 60.44 ± 15.11 | ||||
| Medical condition | 0.001 | 0.006 | 0.006 | 0.004 | ||||
| Tablet | 65.53 ± 14.66 | 62.93 ± 13.45 | 70.40 ± 11.00 | 64.44 ± 14.77 | ||||
| Tablet and insulin | 46.40 ± 12.30 | 47.60 ± 13.34 | 56.40 ± 10.96 | 45.00 ± 17.46 | ||||
| Insulin | 59.78 ± 15.51 | 60.50 ± 13.08 | 68.94 ± 11.35 | 61.47 ± 13.15 | ||||
| Family history | 0.942 | 0.449 | 0.290 | 0.599 | ||||
| Yes | 61.28 ± 16.84 | 61.11 ± 13.89 | 69.60 ± 11.42 | 61.90 ± 15.31 | ||||
| No | 61.27 ± 14.20 | 59.61 ± 13.36 | 67.20 ± 11.84 | 61.06 ± 14.41 | ||||
Table 4.Factors Identified as Predictors of Quality of Life among Patients
| Variables | Beta | SE | P-Value a |
|---|---|---|---|
| Age group, y | |||
| 30 – 55 | 10.25 | 7.93 | 0.199 |
| > 55 | Reference | ||
| Education level | |||
| Illiterate | -14.18 | 11.74 | 0.230 |
| Under diploma | -9.27 | 9.77 | 0.344 |
| Diploma | Reference | ||
| Marital status | |||
| Single | Reference | ||
| Married | 9.87 | 11.63 | 0.397 |
| Occupational status | |||
| Employed | Reference | ||
| Unemployed | 16.11 | 9.00 | 0.076 |
| Self-care 1 | 1.13 | 0.76 | 0.138 |
| Self-care 2 | 2.42 | 0.82 | 0.006 |
| Self-care 3 | 3.05 | 1.42 | 0.034 |
| Self-care 4 | 0.56 | 0.73 | 0.444 |
aP-value was calculated based on ANCOVA.
5. Discussion
This study aimed to measure the quality of life, its determinants, and self-care behaviors in patients with type 2 diabetes. In the present study, gender, education, marital status, occupational status, and medical condition had significant relationships with all dimensions of the quality of life. The findings showed that age had a significant association with patients' physical health. In the dimensions of quality of life, mental health had a lower score than other dimensions. In a similar study, Mohammad pour et al. (17) reported that demographic characteristics had significant associations with the patients' quality of life. In addition, the result of the study by Wang in China showed that the lowest score belonged to emotional functioning and the highest mean score belonged to physical functioning (18).
In the current study, evidence implied that older patients generally had undesirable physical health. In this regard, a study conducted by Tang et al. reported a poor level of physical health among patients who were older (19). Our findings indicated that four dimensions of the quality of life were associated with a higher education level. This result was in line with reported results by Zagozdzon et al. (20) that showed a direct relationship between patients’ higher education and the level of quality of life. It confirms that a higher education level is useful for health.
Marital status has a positive effect on the quality of life. Indeed, patients who are married have a better quality of life. Arslantas et al. reported that marriage improved the patient’s quality of life (21). Our result showed a significant association between the quality of life and employment status. This finding is in agreement with Genga et al., who showed the impact of having a job on the physical and social health of males and females with diabetes (22). The quality of life score was independently related to gender. Therefore, men had a higher quality of life than had women. Similar to the findings of the present study, Alrub et al. confirmed that males had a significantly higher score than had females, indicating a better health-related quality of life in them (23).
Based on the results of this study, the self-care among participants in this study was moderate in all dimensions. Males had better self-care behaviors than females. Among self-care dimensions, physical activity was positively correlated with gender (P = 0.005). Participants reported practicing self-care nutrition as the most common behavior and blood glucose testing as the least frequent behavior. These findings were comparable to those of Tharek et al. (10), which found similar a level of self-care behavior, and blood glucose testing was also found to be the least frequently reported self-care behavior in their participants.
In this study, we found that the self-care behavior of physical activity was a significant predictor of the quality of life in adults with diabetes. In a study conducted by Saleh et al. (9), exercise had a significant relationship with all domains of QoL. Lukacs et al. showed that increasing physical activity could improve the quality of life (24). Due to the direct connection between them, it is necessary to promote physical activity among T2DM patients. The strength of the present study is utilizing the interview method instead of self-reporting. However, the limitations of this study included potential confounding factors that were not controlled for in the study, such as social support and diabetes knowledge.
5.1. Conclusion
Diabetes is one of the fast-growing health challenges of the 21st century. Diabetes and its complications, if not well managed, can lead to frequent hospital admissions and decrease the patients’ quality of life. In the present study, we concluded that the quality of life of patients was not satisfactory. Thus, it should be a priority for health care managers to train self-care behaviors in people with T2DM. Our findings showed that the physical dimension of self-care assessment was most affected by the predictor. However, the physical activity of patients was not satisfactory. Furthermore, regular exercise programs are necessary for patients with diabetes. However, the physical activity of patients was not satisfactory. Furthermore, regular exercise programs are necessary for patients with diabetes.
