Authors: Ni Wayan Suniyadewi  ( Department of Nursing, Airlangga University, East Java, Indonesia. )
Yuni Sufyanti  ( Department of Nursing, Airlangga University, East Java, Indonesia. )
Ninuk Dian Kurniawati  ( Department of Nursing, Airlangga University, Surabaya, Indonesia. )
Ni Luh Putu Inca Buntari Agustini  ( Department of Nursing, InstituteofTechnologyand Health Bali, Indonesia. )
I Dewa Ayu Rismayanti  ( Department of Nursing, Stikes Buleleng, Bali, Indonesia. )

Objective: To review various quality of life questionnaires related to patients of type 2 diabetes mellitus.

 

Method: The systematic review comprised search on SAGE, PubMed, ProQuest, Ebsco and Google Scholar databases for studies using quality of life questionnaires related to patients of type 2 diabetes mellitus published between January 2012 and January 2022 in either English or Bhasha language. Data extraction and assessment was done in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist.

 

Results: Of the 25 studies reviewed, 23(92.2%) were in the English language. They were conducted in 17(51.5%) of the 33 provinces in Indonesia. The questionnaires used were 36-item Short Form 8(32%), EuroQol 5-dimension 5-level scale 6(24%), World Health Organisation Quality of Life-Brief version 6(24%), Diabetes Quality of Life 3(12%) and Diabetes Quality of Life Clinical Trial Questionnaire 2(8%). Variables associated with the quality of life of the diabetics included education, gender and age. The internal factors included glycaemic control, psychological condition, self-efficacy, perception of illness, self-care management, medication adherence, neutrophil-lymphocyte ratio and complications. The external factors included family support, medication counselling and pharmacists’ intervention.

 

Conclusions: Many instruments measure quality of life related to patients of diabetes mellitus. Countries with different socio-cultural forms have different quality of life perspectives, and the assessment tool should be picked accordingly.

 

Keywords: Diabetes mellitus, Glycaemic, Neutrophils, Pharmacists, Self-efficacy, Surgical mesh, Medication adherence, Lymphocytes. (JPMA 73: S-140 [Suppl. 2]; 2023)

 

DOI:https://doi.org/10.47391/JPMA.Ind-S2-33

 

Introduction

 

In Indonesia, the number of diabetes mellitus (DM) patients is rising and the issue is exacerbated by complications which arise due to various factors, including a lifelong treatment process that causes DM patients to feel tired and stressed, and the burden of life increases so that they experience disturbances in biological, psychological, social and spiritual aspects that ultimately reduce the patient’s quality of life (QOL).¹ Complications of DM can be classified as microvascular and macrovascular and they can worsen QOL of DM patients.²

In a study, male DM respondents felt better QOL compared to women, especially in the areas of vitality and pain. Patients with comorbidities (93.64%) had lower quality of life scores in all domains.³ In another study, DM patients were found to have port overall QOL.⁴ Decreased QOL in DM patients can cause discomfort, anxiety, more severe pain, impaired glycaemic control, loss of independence, loss of body function, premature death, and stress in the family.²

QOL is the perception of an individual’s position in life based on values and culture where they live in accordance with their purpose of life, expectations and standards. There are four QOL domains; physical health, psychological state, social relationships, and the environment. There are more than five instruments for assessing QOL.⁵ In addition to the complicating factors, the causes of decreased QOL in DM patients are anxiety, depression and sleep disorders.^6,7 The important predictors affecting QOL are age, gender, marital status, illness duration and fasting blood sugar (FBS) levels.⁸

The current systematic review was planned to analyse the use of various QOL questionnaires related to patients of type 2 DM (T2DM).

 

Material and methods

 

The systematic review comprised search on SAGE, PubMed, ProQuest, Ebsco and Google Scholar databases for studies using QOL questionnaires related to patients of T2DM published between January 2012 and January 2022. The eligibility of the studies was based on the patient, intervention, comparison, outcome and time (PICOT) framework.⁹ Key words used for the search were quality of life or QOL, life quality, or health-related quality of life, diabetes or diabetes mellitus type 2 or DM type 2, T2DM or type 2 diabetes.

The studies included were original articles having quantitative component published in English and Bahasa languages in peer-reviewed journals, and whose full text was available. Those not meeting the inclusion criteria as well as duplicates were excluded. The review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.¹⁰

 

Results

 

Of the 2082 articles initially found, 25(1.2%) were reviewed (Figure 1).^{9-16,19,21-24,26-31,34-36,39,47,48} Of them, 23(92.2%) were in the English language, and 22(88%) had a cross-sectional design. The studies were conducted in 17(51.5%) of the 33 provinces in Indonesia.

 

 

The questionnaires used were 36-item Short Form (SF-36) 8(32%), EuroQol 5-dimension 5-level (EQ5D5L) scale 6(24%), World Health Organisation Quality of Life-Brief version (WHOQOL-BREF) 6(24%), Diabetes Quality of Life (DQOL) 3(12%) and Diabetes Quality of Life Clinical Trial Questionnaire (DQOLCTQ) 2(8%) (Figure 2).

 

 

In 8(32%) studies, patients with lower levels of education and female gender had worse QOL scores. Variables associated with the QOL of T2DM patients included education, gender and age. The internal factors included glycaemic control, psychological condition, self-efficacy, perception of illness, self-care management, medication adherence, neutrophil-lymphocyte ratio (NLR) and complications. The external factors included family support, medication counselling and pharmacists’ intervention (Table).

 

 

Discussion

 

The systematic review found that 8 studies used SF-36 to assess QOL in T2DM patients^11-18. SF-36 is a generic instrument with good validity and reliability. The performance of component scores and each dimension can, however, vary depending on populations and research design.¹⁹ Dimensions of the SF-36 are physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). Many publications in reputable journals and international research have used SF-36 to measure QOL, but the validity of the total health-related score is questionable because it can give biased results.²⁰

There were 6 studies that used EQ5D5L scale.^21-26 The dimensions of the scale are mobility, self-care, pain/discomfort, and anxiety/depression, with ratings of ‘no problem’, ‘some problem’ and ‘extreme problem’. The EQ5D5L and EQ5D3L questionnaires have clear psychometric advantages across multiple dimensions.²⁷

Six of the studies used WHOQOL-BREF.^28-33 Its domains are physical health, psychological, social relationships and environment.³⁴ The validity score for all the domains is 0.93 and for each domain it ranges from 0.69 to 0.86, with total average score of 12.8.³⁵

Three of the studies used DQOL.^36-38 The revised version of the DQOL instrument was developed with satisfaction, impact and worry domains consisting of 13 items. Reliability is very good with satisfaction domain values 0.92 and 0.84, impact domain values 0.98 and 0.60 and worry domain values 0.99 and 0.57.³⁹ Indonesian Asian DQOL questionnaire is a valid and reliable tool to measure QOL of T2DM patients in Indonesia.⁴⁰

Two studies used DQLCTQ(24,41) which was developed by the United Kingdom Prospective Diabetes Study (UKPDS) to assess QOL in diabetes patients. The DQLCTQ consists of eight domains: physical function, energy/fatigue, health distress, mental health, satisfaction, treatment satisfaction, treatment flexibility, and symptoms frequency. Total scores ranges 0-100, with higher scores indicating a better QOL.⁴² The revised version (DQLCTQ-R) is a very suitable health-related QOL (HRQOL) instrument for evaluating the effectiveness of new diabetes treatments in type 1 and 2 patients, and it has been found to reliable, valid and comprehensive in multinational clinical trials²⁴.

Based on 25 studies, the current review found that T2DM reduces QOL. Most of the sociodemographic associations with a decrease in QOL related to low levels of education, female gender and older age. Other factors included glycaemic control, psychological condition, self-efficacy, perception of illness, self-care management, medication adherence, NLR and complications. External factors included family support, medication counselling and pharmacist intervention. In general, such related factors were in line with international reviews.^43,44

Social support and family support have a significant correlation with QOL⁴⁵ and similar is the case with pharmaceutical care programmes.⁴⁶ Health education plays an important role in the prevention and control of diabetes and its complications. Pharmacist-mediated patient counselling can greatly affect knowledge, attitude, practice, glycaemic control and, hence, can improve QOL.⁴⁷

The current review has limitations as it comprised <30 studies which were conducted in only 17 of the 33 provinces in Indonesia. Also, most of the studies reviewed had a cross-sectional design.

 

Conclusion

 

The most used questionnaire to assess QOL in T2DM patients in Indonesia was found to be the SF-36. In general, the association between variables and QOL in the reviewed Indonesia studies were in line with international reviews.

 

Limitation: The review was not registered with the Prospective Register of Systematic Reviews (PROSPERO), which is a limitation.

 

Acknowledgment: We are grateful to the Faculty of Nursing, Universitas Airlangga University and Stikes Buleng, College and University, Bali, Indonesia.

 

Disclaimer: None.

 

Conflict of Interest: None.

 

Source of Funding: STIKES Wira Medika, Bali, Indonesia.

 

References

 

1.      Kalra S, Jena BN, Yeravdekar R. Emotional and Psychological Needs of People with Diabetes. Indian J Endocrinol Metab 2018;22:696-704. doi: 10.4103/ijem.IJEM_579_17.

2.      Grant SF, Thorleifsson G, Reynisdottir I, Benediktsson R, Manolescu A, Sainz J, et al. Variant of transcription factor 7-like 2 (TCF7L2) gene confers risk of type 2 diabetes. Nat Genet 2006;38:320-3. doi: 10.1038/ng1732.

3.      Spasić A, Radovanović RV, Đorđević AC, Stefanović N, Cvetković T. Quality of Life in Type 2 Diabetic Patients. Acta Fac. med. Naiss 2014;3:193-200. DOI: 10.2478/afmnai-2014-0024.

4.      Khajebishak Y, Faghfouri AH, Molaei A, Rahmani V, Amiri S, Jafarabadi MA, et al. Investigation of the potential relationship between depression, diabetes knowledge and self-care management with the quality of life in diabetic patients–an analytical study. Nutr. Food Sci 2020;51:164-75. Doi: 10.1108/NFS-01-2020-0016

5.      World Health Organization (WHO), Division of Mental Health and Prevention of Substance Abuse. ‎WHOQOL: Measuring Quality of Life. Geneva, Switzerland: WHO Press; 1997.

6.      Rodríguez-Almagro J, García-Manzanares Á, Lucendo AJ, Hernández-Martínez A. Health-related quality of life in diabetes mellitus and its social, demographic and clinical determinants: A nationwide cross-sectional survey. J Clin Nurs 2018;27:4212-23. doi: 10.1111/jocn.14624

7.      Gebremedhin T, Workicho A, Angaw DA. Health-related quality of life and its associated factors among adult patients with type II diabetes attending Mizan Tepi University Teaching Hospital, Southwest Ethiopia. BMJ Open Diabetes Res Care 2019;7:e000577. doi: 10.1136/bmjdrc-2018-000577.

8.      Liu X, Haagsma J, Sijbrands E, Buijks H, Boogaard L, Mackenbach JP, et al. Anxiety and depression in diabetes care: longitudinal associations with health-related quality of life. Sci Rep 2020;10:8307. doi: 10.1038/s41598-020-57647-x.

9.      Riva JJ, Malik KM, Burnie SJ, Endicott AR, Busse JW. What is your research question? An introduction to the PICOT format for clinicians. J Can Chiropr Assoc 2012;56:167-71.

10.    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev2021;10:89. doi: 10.1186/s13643-021-01626-4.

11.    Rias YA, Kurniasari MD, Traynor V, Niu SF, Wiratama BS, Chang CW, et al. Synergistic Effect of Low Neutrophil-Lymphocyte Ratio With Physical Activity on Quality of Life in Type 2 Diabetes Mellitus: A Community-Based Study. Biol Res Nurs 2020;22:378-87. doi: 10.1177/1099800420924126.

12.    Sari Y, Isworo A, Upoyo AS, Taufik A, Setiyani R, Swasti KG, et al. The differences in health-related quality of life between younger and older adults and its associated factors in patients with type 2 diabetes mellitus in Indonesia. Health Qual Life Outcomes 2021;19:124. doi: 10.1186/s12955-021-01756-2.

13.    Harahap AW, Nasution MS. Comparison quality of life patients treated with insulin and oral hypoglycemic drugs. IOP Conf. Ser: Earth Environ. Sci 2018;125:1-7. doi:10.1088/1755-1315/125/1/012166.

14.    Amelia R, Wahyuni AS, Ariga RA, Felicia, Preveena. Relationship between family support with quality of life among type 2 diabetes mellitus patients at Amplas primary health care in Medan, Indonesia. J Phys Conf Ser 2018; 1116:1-6. doi:10.1088/1742-6596/1116/5/052004

15.    Syarifuddin S, Nasution A, Dalimunthe A, Khairunnisa. Impact of Pharmacist Intervention on Improving the Quality of Life of Patients with Type 2 Diabetes Mellitus. Open Access Maced J Med Sci 2019;7:1401-5. doi: 10.3889/oamjms.2019.140.

16.    Al-Kayyis HK, Perwitasari DA. Illness perception and quality of life in type 2 diabetes mellitus patients in Lampung, Indonesia. Glob J Health Sci 2018;10:136-40. doi:10.5539/gjhs.v10n7p136.

17.    Adikusuma W, Nopitasari BL. The Effect of Outcome Therapy to the Quality of Life Type 2 Diabetes Mellitus Patient on West Nusa Tenggara Hospital, Indonesia. J Young Pharm 2019;11:297-9. |doi:10.5530/jyp.2019.11.59.

18.    Rumana NA, Sitoayu L, Sa’pang M. Korelasi Kadar Gula Darah Puasa Terhadap Kualitas Hidup Pasien Diabetes Mellitus Type 2 di Puskesmas Jakarta Barat Tahun 2018. Indonesian of Health Information Management Journal (INOHIM) 2018;6:41-5.

19.    CADTH. CDR Clinical Review Report for Xultophy. [Online] 2019 [Cited 2022 February 07]. Available from URL: https://www.ncbi.nlm.nih.gov/books/NBK554824/

20.    Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med 2016;4:e2050312116671725. doi: 10.1177/2050312116671725.

21.    Alfian SD, Annisa N, Iskandarsyah A, Perwitasari DA, Denig P, Hak E, et al. Emotional Distress is Associated with Lower Health-Related Quality of Life Among Patients with Diabetes Using Antihypertensive and/or Antihyperlipidemic Medications: A Multicenter Study in Indonesia. Ther Clin Risk Manag 2021;17:1333-42. doi: 10.2147/TCRM.S329694.

22.    Arifin B, Idrus LR, van Asselt ADI, Purba FD, Perwitasari DA, Thobari JA, et al. Health-related quality of life in Indonesian type 2 diabetes mellitus outpatients measured with the Bahasa version of EQ-5D. Qual Life Res 2019;28:1179-90. doi: 10.1007/s11136-019-02105-z.

23.    Faridah IN, Perwitasari DA, Pusfita M, Jasman H. Relationship between emotional distress and quality of life on type 2 diabetes mellitus patients in Meranti island regency hospital. IOP Conf Ser Mater Sci Eng 2017;259:1-7. doi:10.1088/1757-899X/259/1/012002.

24.    Perwitasari DA, Urbayatun S. Treatment Adherence and Quality of Life in Diabetes Mellitus Patients in Indonesia. SAGE Open 2016;6:1-7. DOI: 10.1177/2158244016643748

25.    Perwitasari DA, Urbayatun S, Faridah IN, Masyithah N. Relationship of therapeutic outcome with quality of life on type 2 diabetes mellitus patients in Abdul Azis Singkawang hospital. IOP Conf Ser Mater Sci Eng 2017;259:1-7. doi:10.1088/1757-899X/259/1/012023.

26.    Fajriansyah, Iskandarsyah A, Puspitasari IM, Lestari K. Impact of pharmacist counseling on health-related quality of life of patients with type 2 diabetes mellitus: a cluster randomized controlled study. J Diabetes Metab Disord 2020;19:675-82. doi: 10.1007/s40200-020-00528-x.

27.    Jankowska A, Młyńczak K, Golicki D. Validity of EQ-5D-5L health-related quality of life questionnaire in self-reported diabetes: evidence from a general population survey. Health Qual Life Outcomes 2021;19:138. doi: 10.1186/s12955-021-01780-2.

28.    Susy P, Dilo R. Quality of Life among Patients with Type 2 Diabetic Mellitus in Out Patient Department, General Public Hospital, West Java. Int J Caring Sci 2021;14:753-9.

29.    Amelia R. The Model of Self Care Behaviour and the Relationship with Quality Of Life, Metabolic Control and Lipid Control of Type 2 Diabetes Mellitus Patients in Binjai City, Indonesia. Open Access Maced J Med Sci 2018;6:1762-7. doi: 10.3889/oamjms.2018.363.

30.    Amelia R, Lelo A, Lindarto D, Mutiara E. Quality of life and glycemic profile of type 2 diabetes mellitus patients of Indonesian: a descriptive study. IOP Conf. Ser.:Earth Environ. Sci 2018;125:1-5. doi:10.1088/1755-1315/125/1/012171.

31.    Putra MM, Mariani KS, Ratnadi NNA. Religious Coping, Medication Adherence and Quality of Life for Diabetes Mellitus Patients. Indonesian J. Community Health Nurs 2021;6:18-21. Doi:10.20473/ijchn.v6i1.26663.

32.    Ulfani D, Safruddin, Sudarman. Relationships Between Family Support and Self-Care ToThe Quality of Life of Patients With Type II DiabetesMellitus at Puskesmas Kabaena Barat, Bombana, 2020. STRADA Jurnal Ilmiah Kesehatan 2021;10:86-93. DOI: 10.30994/sjik.v10i1.601.

33.    Estuningsih Y, Rochmah TN, Andriani M, Mahmudiono T. Effect of Self-Regulated Learning for Improving DietaryManagement and Quality of Life in Patients with Type-2Diabetes Mellitus at Dr. Ramelan Naval Hospital,Surabaya, Indonesia. Kesmas: National Public Health Journal 2019;14:51-7. DOI: 10.21109/kesmas. v14i2.2257.

34.    Wong FY, Yang L, Yuen JWM, Chang KKP, Wong FKY. Assessing quality of life using WHOQOL-BREF: a cross-sectional study on the association between quality of life and neighborhood environmental satisfaction, and the mediating effect of health-related behaviors. BMC Public Health 2018;18:1113. doi: 10.1186/s12889-018-5942-3.

35.    Gholami A, Azini M, Borji A, Shirazi F, Sharafi Z, Zarei E. Quality of Life in Patients with Type 2 Diabetes: Application of WHOQoL-BREF Scale. Shiraz E-Med J 2013;14: 162-71.

36.    Sitorus N, Suriani O, Suryaputri IY, Purba FD, Hanafi AS. Association between Blood Pressure and Quality of Life of Patients with Diabetes Mellitus Type 2 in the Bogor City Indonesia. Open Access Maced J Med Sci 2022;10:136-40. Doi: 10.3889/oamjms.2022.8172

37.    Nurvitasari RI, Tamtomo DG, Lanti Y, Dewi R. Path Analysis on the Biopsychosocial and Economic Determinants of Quality of Life in Patients with Type II Diabetes Mellitus : Evidence from Surakarta , Central Java. Journal of Epidemiology and Public Health(JEPH) 2020;5:281–92. Doi: 10.26911/jepublichealth.2020.05.03.03

38.    Sasmiyanto. The Relationship of Health Behavior with the Area of Sugar Content and Quality of Life of Diabetes Patients. Jurnal Kesehatan Primer(JKP) 2019;4:114–23. DOI: 10.31965/jkp

39.    Bujang MA, Adnan TH, Mohd Hatta NKB, Ismail M, Lim CJ. A Revised Version of Diabetes Quality of Life Instrument Maintaining Domains for Satisfaction, Impact, and Worry. J Diabetes Res 2018; 2018:e5804687. doi: 10.1155/2018/5804687

40.    Permana H, Liem MV, Soetedjo NNM. Validation of the Indonesian Version of the Asian Diabetes Quality of Life Questionnaire. Acta Med Indones 2021;53:143-8.

41.    Restinia M, Anggriani Y, Kusumaeni Y. Sociodemographic Characteristic and Health Related Quality of Life in Outpatients of Type 2 Diabetes Mellitus Under JKN. J Sains Farm Klin 2016;3:91-8. DOI:10.29208/jsfk.2016.3.1.105

42.    Shen W, Kotsanos JG, Huster WJ, Mathias SD, Andrejasich CM, Patrick DL. Development and validation of the Diabetes Quality of Life Clinical Trial Questionnaire. Med Care 1999;37:AS45-66. doi: 10.1097/00005650-199904001-00008.

43.    Saleh F, Ara F, Mumu SJ, Hafez MA. Assessment of health-related quality of life of Bangladeshi patients with type 2 diabetes using the EQ-5D: a cross-sectional study. BMC Res Notes 2015;8:497. doi: 10.1186/s13104-015-1453-9.

44.    Alsuwayt S, Almesned M, Alhajri S, Alomari N, Alhadlaq R, Alotaibi A. Quality of life among type II diabetic patients attending the primary health centers of King Saud Medical City in Riyadh, Saudi Arabia. J Family Med Prim Care 2021;10:3040-6. doi: 10.4103/jfmpc.jfmpc_ 175_21.

45.    Mousavi SA, Vahedi Z, Kiaea Z, Rahimi MA. The relationship between family social support and quality of life in female patients with diabetes referred to Kermanshah diabetes research center. J Health Res 2017;7:712-8. DOI: 10.18869/acadpub.jrh.7.2.712

46.    Sriram S, Chack LE, Ramasamy R, Ghasemi A, Ravi TK, Sabzghabaee AM. Impact of pharmaceutical care on quality of life in patients with type 2 diabetes mellitus. J Res Med Sci 2011;16:S412-8

47.    Lavu C, Gonnabathula MP, Murakonda SK, Challa SR, DUMMALAPATI S, SAJJA S, NALLA KS. Effect of Pharmacist Mediated Counselling on Knowledge, Attitude and Practice (KAP), Health Related Quality of Life (HR-QoL) and Glycaemic Control in Diabetic Patients on Insulin Therapy. J. Clin. Diagnostic Res 2018;12:5-10.

48.    Arifin B, Idrus LR, van Asselt ADI, Purba FD, Perwitasari DA, Thobari JA, et al. Health-related quality of life in Indonesian type 2 diabetes mellitus outpatients measured with the Bahasa version of EQ-5D. Qual Life Res 2019;28:1179-90. doi: 10.1007/s11136-019-02105-z.

49.    Perwitasari DA, Faridah IN, SupadmiW,Yulistika M, Soltief SN, Sianturi EI, et al. Distress Adherence and Quality of Life of Type 2 Diabetes mellitus patients in Indonesia. International Journal of Medical Science and Innovative Research (IJMSIR) 2018;3:23-31.