Disease related knowledge and quality of life: a descriptive study focusing on hypertensive population in Pakistan.

OBJECTIVE: This study aims to evaluate association between Health related quality of lifeand disease state knowledge among hypertensive population of Pakistan.
METHODS: A cross sectional descriptive study was undertaken with a representative cohort of hypertension patients. Using prevalence based sampling technique, a total of 385 hypertensive patients were selected from two public hospitals of Quetta city, Pakistan. Hypertension Fact Questionnaire (HFQ) and European Quality of Life scale (EQ-5D) were used for data collection. Statistical Package for the Social Sciences 16.0 was used to compute descriptive analysis of patients' demographic and disease related information. Categorical variables were described as percentages while continuous variables were expressed as mean ± standard deviation (SD). Spearman's rho correlation was used to identify the association between study variables.
RESULTS: The mean (SD) age of the patients was 39.02 (6.59), with 68.8% males (n=265). The mean (SD) duration of hypertension was 3.01 (0.93) years. Forty percent (n=154) had bachelor degree with 34.8% (n=134) working in private sector. Almost forty one percent (n=140) had monthly income of more than 15000 Pakistan rupees per month with 75.1% (n=289) having urban residency. The mean EQ-5D descriptive score (0.46±0.28) and EQ-VAS score (63.97±6.62) indicated lower HRQoL in our study participants. Mean knowledge score was 8.03 ± 0.42. Correlation coefficient between HRQoL and knowledge was 0.208 (p< 0.001), indicating a week positive association.
CONCLUSION: Results of this study highlight hypertension knowledge to be weakly associated with HRQoL suggesting that imparting knowledge to patients do not necessarily improve HRQoL. More attention should be given to identify individualized factors affecting HRQoL.

Introduction

Health Related Quality of Life (HRQoL)is defined as “person's perceived quality of life representing satisfaction in those areas of life likely to be affected by health status” [1]. The concept of HRQoL is being used by health care professionals to describe factors other than illness affecting human health and its status [2]. These different health dimensions help healthcare professionals to understand patient perceptions of illness [2].

The development of chronic conditions with established decreased life expectancies is very disturbing for the patients [3]. The composite nature of diseases has traumatic effect on social and economical status of the patients. Although categorized as “controlled”, feeling of being ill heavily imbalances HRQoL in patients suffering from chronic illnesses. This in return, results in decreased patients’ satisfaction with daily life activities. By the time, HRQoL has become an important tool for the assessment of treatment outcomes from patients perceptive [4].

Within the context of chronic diseases, hypertension (HTN) in particular is counted as a major factor in decreasing life expectancy and disability-accustomed life years [5]. An estimated one billion of world’s population was diagnosed with HTN in year 2000 and this fraction will be augmented to 29% by the year 2025 [6]. It is also estimated that around 7.1 million people die each year due to complications of HTN [7]. This rising frequency of HTN is becoming a major public health challenge for both developed and developing nations [8]. HTN is a serious apprehension because of its high incidence and risk of developing allied cardiovascular disorders [9]. HTN adversely affects patients’ every day activities and results in a decrease in self confidence [10], hence it is reported that hypertensive patients offer report less or poor HRQoL [11-13].

In recent years, a growing demand to educate patients with chronic disorders is reported in literature [14-16]. Several methods have been utilized to improve patient knowledge including patient groups, published literature, specialist clinics, and information technology [17]. Although the provision of disease-related information to patients has been considered a good practice, it is not clear whether disease related knowledge has any impact on their HRQoL [17]. Therefore, the study aimed to examine the association between disease related knowledge and HRQoL in patients with HTN.

Methods

Design and settings

This study was designed as descriptive cross sectional analysis. Patients being managed for HTN at the outpatient clinic of two tertiary care public hospitals of Quetta, Pakistan (Sandeman Provincial Hospital and Bolan Medical complex Hospital) were targeted [18]. A prevalence based sample of 385 HTN patients was selected from May to July 2010 [19]. Patients of age 18 years and above, with confirmed diagnosis of essential HTN, using antihypertensive agents for the last six months and familiarity with the national language of Pakistan (Urdu) [20] were included in the study. Patients aging below 18 and above 80 years, having co-morbidities, immigrants from other countries and pregnant ladies were excluded from the study.

Ethical approval

There is no human ethical committee for non clinical studies in the institutes where the research was conducted. Therefore, permission from the respective medical superintendent was taken to conduct the study (EA/FS/1021-2).Written consent was also taken prior to data collection.

Data abstraction

Hypertension Fact Questionnaire (HFQ) and European Quality of Life scale (EQ-5D) were used for data collection. Demographic and disease related information was also taken into account. All instruments were pre tested for their reliability and validity. Data from the pre-test evaluation was not considered for the final analysis. Four pharmacists were trained to use HFQ and EQ-5D by the principal researcher. Group discussions were continuously held among the pharmacists and principal researcher to maintain the reliability of the data collection process. The data obtained were verified and scrutinize for its accuracy and precision for analysis.

Assessment of Health related quality of life (HRQoL)

EQ-5D is a standardized instrument for use as a measure of health outcome and provides a simple descriptive profile and a single index value for health status [21]. It is composed of two portions. EQ-5D descriptive consists of five domains (mobility, self-care, usual activities, pain/discomfort, anxiety/depression). The responses record three levels of severity (no problems/some or moderate problems/extreme problems) within a particular EQ-5D dimension. Second portion of EQ-5D consists of a 20 cm health thermometer with two distinct end points, the best imaginable health state (score of 100) and the worst imaginable health state (score of 0) and is known as the VAS (visual analog scale) [21]. The Urdu version of EQ-5D was provided by Euroqol and the study was registered with Euroqol.

Assessment of knowledge towards HTN

HFQ was originally constructed in English and translated into Urdu by an independent professional translator. The translation was reconfirmed by a professor stationed at an academy of languages. As the originality and constancy of the instruments was stabilized, the final version were reviewed and approved by the researchers. HFQ consisting of 15 items was used for assessment of patients’ knowledge towards causes, treatment and management of hypertension. The instrument was constructed after an intensive literature review [22, 23] and measured knowledge with a cut off level of < 8 as poor, 8-12 average and 13-15 as an adequate knowledge [24]. Mean knowledge of the cohort was calculated for the final analysis.

Statistical analysis

SPSS version 16.0 (SPSS Inc., Chicago, IL) [25] was used to compute descriptive analysis of patients’ demographic and disease related information. Categorical variables were measured as percentages while continuous variables were expressed as mean ± standard deviation. EQ-5D was scored using values derived from the UK general population survey reported in 1995 [26]. Spearmen’s rank correlation was used to establish correlation between knowledge and HRQoL. Correlations were interpreted using the following criteria: 0–0.25 = weak correlation, 0.25–0.5 = fair correlation, 0.5–0.75 = good correlation and greater than 0.75 = excellent correlation [27].

Results

The demographic characteristics of the study patients are presented in table 1, including the frequency distribution and disease related information. Mean age (SD) of patients was 39.02 (6.59), with 68.8% of males dominating the cohort. The mean (SD) duration of hypertension was 3.01±0.93 years. Forty percent (n=154) had bachelor level of education with 75% (n=289) having urban residency. Forty one% (n=160) had monthly income of more than 15000 Pakistan rupees.

Table 2 reflects the HRQoL scores among study patients. Mean EQ-5D descriptive score was 0.46±0.28 and EQ-Vas score 63.97±6.62. A total of 29 different EQ-5D health states were described by the patients. Majority of the participants (n=112, 29.1%) indicated no problems in the second and third domain while moderate problems in first, fourth and fifth. There was not a single patient who stated no problem in all five domains as shown in Table 3.

Table 4 reflects the knowledge of patients towards HTN. Mean knowledge score was 8.03±0.42 and median score was 8. From the cohort, 146 (37.9%) were within poor knowledge range, 236 (61.3%) moderate and only 3 patients (0.8%) adequate general knowledge about HTN. Poor knowledge was evident in responses to questions relating to onset, management (questions 3 and 5) and dietary control of HTN (questions 11, 12 and 13). Correct answers to these questions were 27.8, 30.4, 13.5, 20.5 and 23.6 %, respectively.

Spearman rank correlation was used to measure association between the study variables. Correlation coefficient between HRQoL and knowledge was 0.208 (p< 0.001), indicating a weak yet significant association between the study variables.

Discussion

Results from the present study highlights that HTN knowledge is weakly associated with HRQoL. To the best of our knowledge, and from extensive literature review, relationship between HTN knowledge and HRQoL has not been explored. In other disease conditions such as inflammatory bowel disease (IBD), it was reported that even though 64% of study patients were well informed about their disease, over 90% had some impairment in their Quality of Life (QOL) reporting [17]. The authors reported no significant correlation between disease-related patient awareness and QOL scores (r=0.3). This is supported by the current study results where despite having average knowledge, HRQoL in the study population was poor.

A number of studies have reported significant reduction in HRQoL with HTN [28-30] however the authors did not attempt to associate the relationship between HTN knowledge and HRQoL. In the present study, the correlation between knowledge and HRQoL is 0.208 which is less than what was reported by Verma et al. in their study among IBD patients [17]. Therefore we can predict that knowledge towards disease has no or less impact on HRQoL in patients suffering with HTN.

The reasons for this prediction can be multi-factorial. It is hypothesized that an increase in disease related knowledge can actually decrease HRQoL. It is a logical observation that as patients are informed about their conditions, the apprehension of developing further abnormalities especially in cases of chronic conditions likes HTN and diabetes affects psychological domains which disturbs the overall HRQoL. Unfortunately, after an extensive literature review, there was no data available from hypertensive patients supporting our hypothesis. However, Borgaonkar et al. in their study concluded that addition of educational booklets to IBD patients during an educational intervention decreases HRQoL of the patients [31]. In a similar study focusing IBD patients with a high anxiety level, patients declared no benefit in terms of reduced anxiety or improved HRQOL after participating in an educational program which is again in concordance to the hypothesis that was made earlier [32].

Furthermore, HRQoL recapitulates a wide range of physical, communal, and emotional behaviors, which are vital in the management of diseases. HRQoL is extremely difficult to measure impartially, as it depends on many preexisting and irreversible factors such as economic status, intelligence, personality, socio-political conditions, nature and duration of disease [17].

Within the context of developing countries like Pakistan, HRQoL is one part of social sciences that is often neglected. Pakistan faces a severe shortage in number of professionals and health care facilities [33]. Furthermore, there is a huge gap in income disparity and living status between the population subgroup [34]. All these factors may have a profound impact on HRQoL [17]. Besides that, lack of basic health facilities and recourses inversely affect health status and HRQoL of the population in general and specifically for patients suffering from chronic diseases like HTN.

Conclusion

The current study reported weak yet positive association between disease-related knowledge and HRQoL. Adding to current knowledge, this is the first study that has been reported from Pakistan. It is hereby concluded that recommending educational interventions and improving patient education is not always necessarily beneficial for the patients. Studies focusing on in depth psychosocial profile using either an in depth qualitative exploration or multivariate analysis are recommended to get a clearer view of individualized factors affecting HRQoL.

Conflict of interest

The authors declare no conflict of interest.

Table 1. Characteristics of survey respondents (n=385)

Characteristics	Frequency	Percentage
Age (39.02 ±.59 years)
18-2728-3738-47>48	4818612823	12.548.333.26.0
Gender
MaleFemale	265120	68.831.2
Education
IlliterateReligiousPrimaryMatricIntermediateBachelorsMasters	9627515115451	2.316.11.813.213.240.013.2
Occupation
JoblessGovernment JobPrivate JobBusinessman	977813476	25.220.334.819.7
Income[*]
Nil< Pakistan Rupees (Pk Rs) 50005000-100001000-15000> 15000	97222104160	25.20.55.727.041.6
Locality
UrbanRural	28996	75.124.9
Duration of disease (3.01±.939 years)
Less than 1 year1-3 years3-5 years> 5 years	2689124146	6.823.132.237.9

* 1 Pk Rs = 0.0118 US$

Table 2. HRQoL scores in hypertensive patients

Description	N	Mean EQ-5D Score	Std Deviation	MeanEQ-VASScore	StdDeviation
Age
18-2728-3738-47>48	4818612823	0.59130.50070.41040.2576	0.184010.257060.314910.28444	66.8164.6859.8763.97	5.6525.8627.1606.621
Gender
MaleFemale	265120	0.46770.4669	0.281940.29107	64.0363.84	6.4666.978
Education
IlliterateReligiousPrimaryMatricIntermediateBachelorsMasters	9627515115451	0.25430.30050.55830.43710.52310.52930.4835	0.335540.346370.180480.287440.259060.231710.28105	59.4460.6363.5764.5965.0664.8464.59	6.5216.7442.9927.2455.7746.1307.119
Occupation
JoblessGovernment JobPrivate JobBusinessman	977813476	0.43370.47960.52950.3886	0.298820.276880.237610.32602	63.2464.4465.1662.36	7.0777.0115.5037.080
Income
Nil< Pk Rs 50005000-1000010000-15000> 15000	97222104160	0.43370.42100.56280.52310.4392	0.298820.332340.198530.238560.30643	63.2465.0065.6865.2563.34	7.0777.0716.5495.8416.735
Locality
UrbanRural	28996	0.51130.3356	0.254660.32713	64.9760.98	6.1567.089
Duration of disease
Less than 1 year1-3 years3-5 years> 5 years	2689124146	0.58850.51580.47380.4110	0.182030.255820.267770.31733	67.0465.3364.3562.28	4.9766.3356.1067.074
Total Sample	385	0.4674	0.28444	63.97	6.621

The mean HRQoL score was 46.74 ± 28.44 with VAS score 63.97 ± 6.621 indicting poor status of life in our study respondents.

Table 3. Frequency of self-reported (EQ-5D) Health States

Health State	N	% Total
11112	1	0.3
11122	21	5.5
11123	4	1.0
11222	39	10.1
11223	8	2.1
11232	2	0.5
11233	1	0.3
12122	12	3.1
12222	6	1.6
21112	6	1.6
21121	1	0.3
21122	112	29.1
21123	12	3.1
21132	8	2.1
21212	1	0.3
21222	37	9.6
21223	13	3.4
21232	18	4.7
21233	9	2.3
22122	11	2.9
22123	5	1.3
22212	1	0.3
22222	17	4.4
22223	8	2.1
22231	1	.3
22232	11	2.9
22233	18	4.7
22322	1	0.3
22323	1	0.3
Total	385	100

Within 29 different health states, majority (n=112, 29.1%) stated moderate difficulty in the first, fourth and fifth domain respectively, where as they stated no difficulty in the second and third domain[*].

* [(Mobility, self-care, usual activities, pain/discomfort and anxiety/depression) Domains of HRQoL in order]

Table 4: Responses to HTN knowledge questions

HTN knowledge item	Yes(%)	No(%)	Don't know(%)
Do you know the normal values of blood pressure?	77.9	22.1	0.0
Elevated BP is called HTN.	52.2	17.7	30.1
HTN is a condition which can progress with age.	27.8	70.1	2.1
Both men and women have equal chance of developing HTN.	20.3	79.	0.8
HTN is a treatable condition.	30.4	68.1	1.6
The older a person is, the greater their risk of having HTN.	67.3	31.2	1.6
Smoking is a risk factor for HTN.	96.4	3.4	0.3
Eating fatty food affects blood cholesterol level which is a risk factor for developing HTN.	41.0	48.6	10.4
Being overweight increases risk for HTN.	92.5	7.5	0.0
Regular physical activity will lower a person's chance of getting HTN.	42.1	56.4	1.6
Eating more salt has no effect on blood pressure.	86.5	13.5	0.0
Dietary approaches to reduce HTN do no good.	20.5	78.7	0.8
White meat is as good as red meat in HTN.	23.6	75.6	0.8
Medication alone can control HTN.	39.2	59.0	1.8
HTN can lead to other life-threatening diseases.	85.7	11.7	2.6

Knowledge was assessed by giving 1 to correct answer and 0 to the wrong answer. The “don’t know“ response was also taken as 0. The scale measured knowledge from maximum 15 to minimum 0. Scores < 8 were taken as poor, 8 - 12 average, and 13 - 15 adequate knowledge of hypertension. Mean knowledge was 8.03 ± 0.415.