Original articlesRelationship of Health-Related Quality of Life to Symptom Severity in Diabetes Mellitus: A Study in Trinidad and Tobago
Introduction
Non-insulin-dependent diabetes mellitus has emerged as an important health problem in middle-income countries. Many studies have now documented the prevalence of diabetes mellitus and impaired glucose tolerance in different populations [1] but less is known about the health consequences of diabetes in different communities [2]. Evaluating health consequences of diabetes is critical to understanding populations' needs for health care, evaluating the effectiveness of different interventions and ultimately informing resource allocation decisions, which are particularly important in middle and low income countries. Measures of mortality and morbidity have been used traditionally as measures of the health impact of chronic illnesses like diabetes, but these have practical limitations. Routinely available statistics are known to underestimate mortality from diabetes by up to two thirds [3] and methods for assessing clinical complications of diabetes are costly, poorly standardised and difficult to apply in the field [4]. Over the past few years, self-rated measures of health status have attracted increasing attention and it has been suggested that measures of health-related quality of life should be used to inform resource allocation decisions [5]. Interpretation of data describing health-related quality of life requires an understanding of the quantitative relationship between health-related quality of life scores and the underlying severity of illness. Deriving severity-specific quality of life reference data could provide a starting point for evaluating the effectiveness of interventions in economic evaluation.
In Trinidad and Tobago, diabetes mellitus affects between one in five and one in four adults [6], the condition now accounts for some 13% of deaths [7] and diabetes is an important and costly cause of hospital utilisation [8]. In an exploratory study we found that self-reported symptoms and morbidity were common among primary care attenders with diabetes in Trinidad and Tobago [9]. Higher levels of morbidity showed expected associations with older age and longer duration of diabetes but were also associated with indicators of lower socio-economic status including the level of educational attainment, employment status and whether there was a piped water supply in the home 9, 10. In the present study we wanted to extend these observations by evaluating the impact of diabetes-related symptoms on health-related quality of life.
Section snippets
Selection of Subjects and Sample Size
We aimed to recruit a representative sample of subjects with diabetes attending government health centres in Trinidad and Tobago. In Trinidad and Tobago there are just over 100 government primary care health centres distributed throughout the country. We took an initial random sample of 29 health centres in Trinidad, stratified according to eight administrative counties. At each health centre we recruited patients form the “chronic disease clinic” which is usually held on a fixed day of the
Results
Of the initial sample of 29 health centres, one health centre proved too remote to visit and was replaced. Because of low attendance rates at six of the other health centres, a nearby health centre was studied in addition, thus the final sample included 35 health centres. Very few patients who were invited to be interviewed declined to participate. There were 2117 subjects in the final sample, of these 2040 (96%) had complete scores for the diabetes symptom checklist, 1939 (92%) had complete
Discussion
When a health measurement scale is used in a cultural setting which differs from the one in which it was developed, the properties of the instrument should be re-evaluated. Although Trinidad and Tobago is part of the English-speaking Caribbean, cultural beliefs and vernacular forms of spoken English differ from those of Europe and North America. Three types of evidence suggest that the DSC may be used appropriately in Trinidad and Tobago. First, the total DSC score and its subscales show
Acknowledgements
We thank the Chief Medical Officer of Trinidad and Tobago for permission to report this work. We are grateful to the developers of the Diabetes Symptom Checklist for making this instrument available for us to use. We also thank the staff of the Nutrition Division and the Community Services of the Ministry of Health in Trinidad and Tobago for their assistance in data collection. The work was supported in part by a grant from the Special Trustees of Guy's Hospital, London, UK.
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