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)
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
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).
The systematic review found that 8 studies used SF-36 to assess QOL in T2DM patients11-18. 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.
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.
Conflict of Interest: None.
Source of Funding: STIKES Wira Medika, Bali, Indonesia.
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