SOCIOECONOMIC FACTORS AS DETERMINANTS OF QUALITY OF LIFE OF DIABETIC PATIENTS IN NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL NNEWI ANAMBRA STATE

SOCIOECONOMIC FACTORS AS DETERMINANTS OF QUALITY OF LIFE OF DIABETIC PATIENTS IN NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL NNEWI ANAMBRA STATE
CHAPTER ONE
INTRODUCTION
Background of the study
Diabetes Mellitus (DM) describes a group of metabolic diseases in which the person has high blood glucose (blood sugar), either because insulin production is inadequate, or because the body’s cells do not respond properly to insulin, or both (Nordqvist, 2013). Globally, the number of patients with diabetes is expected to increase from 285 million to 439 million by 2030 (Shaw, Sicree, & Zimmet, 2009). Currently, DM affects 246 million people worldwide (Levitt, 2008). According to Nwankwo, Nandy and Nwankwo (2010), the major part of this numerical increase will occur in developing countries. There will be an increase from 51-72 million in the developed countries and 84-228 million in the developing countries. Thus by the year 2025, greater than 75% of people with DM with will reside in developing countries.
The disease was previously thought to be rare in Africa, the population regarded as low and middle income; however, as a result of changes in the lifestyle, feeding patterns, and levels of physical activity among other factors, the prevalence has increased in many African countries over the past few decades. For example, the diabetic population in Uganda, estimated at about 98,000 in 2000, increased more than fifteen times (1.5 million) in a decade. Based on the country’s estimated population of 30 million people in 2010 (Nyanzi, Wamala & Atuhaire, 2014), the figure implies that about five percent of the country’s population was diabetic.
Nwankwo,et al (2010), posited that while it is estimated that 92% of Nigerians live under $2 a day, studies have shown that there has been a progressive increase in the prevalence of diabetes in Nigeria and the burden is expected to increase even further. According to World Health Organization, there are 1.71 million People living with diabetes in Nigeria and this figure is projected to reach 4.84 million by the year 2030 (WHO, 2009). Current prevalence rate estimates of diabetes in Nigeria have been tagged at 2.5% compared to its 2.2% rate in 2003, ( Nwankwo,et al,2010) .
Diabetes is associated with long-term complications that affect almost every part of the body (National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), 2014). The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes. According to Nwankwo, et al (2010), diabetes and its complications impose significant economic consequences on individuals, families, health systems and countries.
The threat is growing. The number of people, families and communities afflicted are increasing. This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries (WHO, 2009) and the economic burden is heavy. The upward trend in the number of diabetic patients points to the need for improved treatment and care for the disease. The fact that treatment for the disease and its associated complications are highly complex, a considerable patient education and medical monitoring are required. Thus, the patient is required to regulate blood sugars amidst required changes in lifestyle factors and the unpleasant medication that usually accompanies the disease in order to maintain a correct degree of metabolic control. The fact that these changes make the patients vulnerable to stress, their quality of life is highly bound to be affected.
Quality of life is a scientifically proven indicator of the quality of health experienced by a patient (Eckert, 2012). Due to insufficiency of traditional end points (which are mainly focused on the biologic and physiologic outcomes) in capturing the effects of interventions on patients’ health-related quality of life (HRQoL), a growing interest has emerged during the past decades for assessing determinant factors of patients HRQoL, especially in chronic diseases. Six studies, which examined the effect of diabetes on HRQoL, compared HRQoL in people with and without diabetes and reported negative effects of both type 1 and type 2 diabetes on HRQoL (Aliasghar, Baharak, & Mirmalek-Sani, 2013)
According to Nyanzi, et al (2014)  the predictors of quality of life of diabetic patients are identified by Imayama et al (2011)’s study as personal, medical, and lifestyle factors. Particularly, the study noted that old age, higher income, higher score on activity (personality) trait, not using insulin, having fewer comorbidities, lower body mass index (BMI), being a nonsmoker, and a higher physical activity level were significantly associated with better health related quality of life in adults with type 2 diabetes. . The findings of Aliasghar et al (2013) showed that people with diabetes had a lower HRQoL than healthy people. The findings also indicated that better socioeconomic status and better control of cardiovascular risk factors were associated with better HRQoL among patients with diabetes.
In line with these studies, there has been a resurgence of interest in the relation between health and socioeconomic position (SEP). SEP encompasses two important notions: the influence of the structural location of individuals and groups in a society and the cumulative effects of time. It addresses the context in which health-damaging exposures and health-protective resources act at different stages of the life course to influence adult health. Such an approach provides a broad framework in which to think about and understand how both recent and remote socioeconomic factors interact to affect adult health. A substantial body of literature demonstrates that in the general population, material and social deprivation are directly related to disease incidence and prevalence and inversely related to health status. According to Brown, (2014) various studies have addressed the relationship between lower SEP and mortality or the development of chronic conditions such as diabetes mellitus, cardiovascular disease, and cancer. Research on the relationship between SEP and health has often focused on individual characteristics such as income, wealth, education, and occupation. However, SEP encompasses not only current individual socioeconomic status but also social relationships and community-level characteristics (Brown, 2014).
Brown, (2014) further stated that although effective therapies are available for managing diabetes and preventing or treating its complications, these therapies are underutilized, particularly among persons of low socioeconomic status. For someone with diabetes, socioeconomic status such as educational level, income and culture may influence access to and quality of care, social support, and community resources. It may also influence diabetes-related knowledge, communication with providers, ability to adhere to recommended medication, exercise, and dietary regimens, and treatment choices. Socio-economic  factors  such  as income, education and neighborhood culture determine  how  people  are  born,  live grow  and progress  in life .They determine how people maintain good health. When  an individual is  poor  and ignorant  it  creates  barrier  in accessing  health  care  because  the individual  cannot  afford  the  cost . Besides  an  ignorant person  would  not  be  aware of the  ill health  and   would  not  seek  for  help  at the proper  time and place  when  the  need  arises.
The social status of persons with diabetes and the characteristics of their communities or culture may determine their risk of mortality and diabetes-related complications as well as their quality of life. Lower individual SEP, as measured by individual or household income, education, employment, occupation, or living in an underprivileged area, has been associated with poorer physical or emotional health, all-cause mortality or poor quality of life. In order words, poor socioeconomic factors affect the quality of life of an individual because   he may not be able to meet up with required need. At the same time with good socioeconomic status there is the need to use it properly as it may positively or negatively affect the quality of life of an individual.
In the light of the foregoing, the following question was posited: What role does socioeconomic status such as education, occupation; culture and income play in the quality of life of diabetic patients? This study is aimed at assessing how socioeconomic factors are determinant of the quality of life of diabetic patients in Nnamdi Azikiwe University Teaching Hospital.
Statement of the problem
DM is a serious disease and a cause for a growing public health concern in both developed and developing countries. This is because DM is an incurable chronic disease that patients live with their whole life; its complications are usually serious and problematic. There is also rapid increase in prevalence of DM globally and especially in developing countries. Current prevalence rate estimates of diabetes in Nigeria have been tagged at 2.5% compared to its 2.2% rate in 2003 (Nwankwo, et al, 2010). In NAUTH the prevalence of diabetes is noted to be increasing from the records of the endocrinology department (2013 = 780, 2014 = 811).
The prevalence of complications of DM such as nephropathy, diabetic foot ulcer and cardiovascular diseases in this population is high. Most of the patients only report to the hospital when complication has set in. In some cases the patients either sign against medical advice or they do not procure the prescribed drugs. All these may impact on the quality of life of individual. One wonders if socioeconomic factors such as education, income, occupation and culture are contributory. According to Majed (2013), several studies have demonstrated that DM has a strong negative impact on the HRQOL, especially in the presence of complications, though from literature there is paucity of information on quality of life of DM patients in Anambra state. Most of health care interventions are only concerned with eradication of symptoms and attempts to delay complications as much as possible. Health care is essentially a humanistic transaction where the patient’s well-being is a primary aim, therefore attention should be focused on QOL aspect of health from the need for commitment to the continued promotion of a holistic approach to health and health care, as emphasized in the WHO definition of health as “A state of physical, mental and social well-being, not merely the absence of disease and infirmity”. This study focused in assessing socioeconomic factors as determinants of quality of life of diabetic patients.
Purpose of study
The study is conducted to assess socioeconomic factors as determinant of the Quality of life (QoL) of diabetic patients in Nnamdi Azikiwe University Teaching hospital Nnewi, Anambra state.
Specifically, the study determined the QoL of the diabetic patients by domain and the educational, economic, occupational, religio-cultural and social / family factors as they relate to their QoL.
Research questions

• What is the QoL of diabetic patients in NAUTH by domain?
• What association is there between diabetic patient’s educational levels and their quality of life?
• How is diabetic patient’s economic status associated with their quality of life?
• What is the association between diabetic patient’s occupation and their quality of life?
• How are diabetic patient’s religio-cultural practices in the management of DM associated with their quality of life?
• What is the association between diabetic patients social / family supports and there quality of life.

Research Hypotheses

1. There is significant association between diabetic patient’s educational levels and their quality of life.
2. There is significant association between diabetic patient’s economic status and their quality of life.
3. There is significant association between diabetic patient’s occupation and their quality of life.
4. There is significant association between diabetic patient’s religio-cultural practices in the management of DM and their quality of life.
5. There is significant association between diabetic patient’s social /family supports and their quality of life.

Significance of the study
This study will provide much needed information about the socioeconomic factors that affect the life of diabetic patients. Knowledge of this will be of great benefit to the diabetic patients, health care providers, the general public, other future researchers, and the country as a whole.
Knowledge of this will assist health care providers to know areas to focus on during health care education, and it will help them to plan and provide effective and efficient health education for the patients. When patients are adequately educated and empowered, they are able to take care of themselves better, thereby reducing complications and fostering improved quality of life free of disabilities.
It will inform those tasked with health rationing or anyone involved in the decision making process. The outcome may be economic and social security policies that have positive impact on the lives of people with diabetes, thereby improving their quality of life.
The general public will also benefit as there will be reduction in health care cost, improved quality of life of diabetic patients, and improved economic productivity of the country and reduction in morbidity and mortality rate due to diabetes complications. It will also be of help to other researchers who may wish to work in this field in future.
Scope of the study
The study is delimited to diabetic patients, who are receiving treatment at the diabetic clinic at NAUTH .It is also delimited to the association between socioeconomic factors such as education, income, occupation, religious-cultural practices, family/social support and the quality of life of diabetic patients in NAUTH.
Operational Definition of Terms
Quality of life
In this study the researcher has adapted the WHO’s definition of QOL which identifies it as a multidimensional concept and defines it as “individuals’ perceptions of their position in life in the context of the culture and value system in which they live and in relation to their goals, standards, and concerns” (WHO 1993). The definition includes six broad domains: physical health, psychological state, level of independence, social relationships, environmental features, and spiritual concerns.    It will be assessed using adapted WHO-SRPB field test instrument, covering overall quality of life and aspects related to spirituality, religiousness and personal beliefs. Each item is scored on a point likert scale 1(low) -5(high) and a mean score calculated for each domain. Respondents with scores below 3 are rated with low QoL and those with scores above 3 are rated with high QoL. The mean score of items within each domain is used to calculate the domain score.
Diabetic patients