The assessment of public knowledge on diabetes mellitus and patient reported outcomes measurement among patients with type 2 diabetes in thailand

THE ASSESSMENT OF PUBLIC KNOWLEDGE ON DIABETES MELLITUS AND PATIENT REPORTED OUTCOMES MEASUREMENT AMONG PATIENTS WITH TYPE DIABETES IN THAILAND TIPAPORN PONGMESA (B.Pharm (Hons.), Silpakorn University, Thailand) A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY DEPARTMENT OF PHARMACY NATIONAL UNIVERSITY OF SINGAPORE 2010 ACKNOWLEDGEMENTS This thesis would never have been accomplished without the involvement and support from many people I would like to take opportunity to express my deep and sincere gratitude to the following people My utmost gratitude goes to Prof Li Shu Chuen, one of my thesis supervisors, for his brilliant mentorship and supervision, as well as his kindness, understanding and continuous encouragements since the beginning of my postgraduate life Even after he left Singapore for Australia, he has always tried his best to pay attention to not only my studies but also non-studies related matters, especially my health I feel very fortunate to have him as my supervisor Likewise, I am immensely grateful to my main supervisor, Asst Prof Wee Hwee Lin, for her generosity in providing me her precious time, knowledge and invaluable advice during the past few years She has put hard efforts not only in making my studies go smoothly, but also in pushing me to be an independent thinker, careful researcher as well as a good scientific writer I wish to convey my special thanks to Ms Pranee Luckanajantachote, Ms Saifon Chaodeekornpun and their diabetes care team at Samut Sakhon Hospital in Thailand Without their excellent collaboration and active support, the studies conducted there would not have been successfully completed I am very grateful to the Royal Thai Government for the award of the Thai MOE-NUS PhD Scholarship; my employer, the Faculty of Pharmacy at Silpakorn University, for granting me a leave of absence for pursuing a PhD degree; and the Thai Ambassador to Singapore, His Excellency Nopadol Gunavibool and the staff at i the Royal Thai Embassy in Singapore for their effort and assistance in looking after the well-being of all Thai students in Singapore My sincere gratitude goes to the Department of Pharmacy at NUS for providing me an opportunity to experience postgraduate study; A/Prof Chan Sui Yung for her kindness and constant support; and my PhD thesis committees, A/Prof Paul Ho and Asst Prof Joyce Lee, for their invaluable advice and generous contribution Thanks are also due to all staffs at the department for their kind assistance in administrative issues The journey of my postgraduate study in Singapore would be tougher and boring without having lovely and helpful seniors and friends around I would like to thank my seniors, Sharon and Jin Jing, for providing me guidance and help I also cherish all my colleagues in S7 02-09, Yingjiao, Mandy, Hua Pey, Regine and Wei Ting, and my unit mates, Sureerat, Nichanan and Poonna, for their kind support and words of encouragement, as well as the wonderful and joyful moments we have spent together This thesis is dedicated to my parents and family members as well as my boyfriend for their unflagging love, consistent care and understanding Without their great encouragement and support throughout my studies, there is no doubt this thesis would not have been possible ii TABLE OF CONTENTS Acknowledgements………………………………………………………………….i Table of Contents…………………………………………………………………iii Summary………………………………………………………………………….vii List of Tables………………………………………………………………………ix List of Figures………………………………………………………………………xi List of Abbreviations………………………………………………………………xii Chapter Introduction……………………………………………………………1 1.1 The global burden of type diabetes mellitus (T2DM)………………………2 1.2 The role of disease management in containing the T2DM epidemic ………4 1.3 T2DM management in Thailand: the state of affairs………………………….5 1.4 Prevention: the cornerstone of T2DM management………………………….6 1.4.1 Knowledge of DM and its role in T2DM prevention…………………6 1.4.2 Factors associated with knowledge of DM …………………………7 1.5 Measuring the outcomes of T2DM management: the role of patient-reported outcomes (PROs)……………………………………………………………9 1.5.1 QoL as an outcome measure of T2DM management ……………… 1.5.2 Treatment satisfaction as an outcome measure of T2DM management…………………………………………………………… …12 1.5.3 Improving the external validity of PROs instruments: the role of cross-cultural adaptation………………………………………………… 14 1.6 Research objectives and thesis organization………………………………17 iii Chapter A Survey of Knowledge on Diabetes in the Central Region of Thailand………………………………………………………………………….…20 2.1 Introduction ………………………………………………………………21 2.2 Methods……………………………………………………………………23 2.3 Results……………………………………………………………………….28 2.4 Discussion…………………………………………………………………40 2.5 Conclusions…………………………………………………………………46 2.6 Acknowledgements…………………………………………………………46 Chapter A Comparison of Diabetes Knowledge among Residents in Bangkok and Other Central Provinces of Thailand……………………………………… 47 3.1 Introduction ………………………………………………………………48 3.2 Methods……………………………………………………………………50 3.3 Results………………………………………………………………………51 3.4 Discussion…………………………………………………………………57 3.5 Conclusions…………………………………………………………………61 Chapter Development of a Thai Version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL-19) Questionnaire: Linguistic and Psychometric Evaluation…………………………………………………………………………62 4.1 Introduction ………………………………………………………………63 4.2 Methods……………………………………………………………………65 4.3 Results……………………………………………………………………72 4.4 Discussion…………………………………………………………………89 4.5 Conclusions…………………………………………………………………93 4.6 Acknowledgements…………………………………………………………94 iv Chapter Psychometric Evaluation of a Thai Version of the Diabetes Treatment Satisfaction Questionnaire Status Version (DTSQs)………… … 95 5.1 Introduction ………………………………………………………………96 5.2 Methods……………………………………………………………………97 5.3 Results……………………………………………………………………101 5.4 Discussion…………………………………………………………………107 5.5 Conclusions………………………………………………………………110 5.6 Acknowledgements………………………………………………………111 Chapter Health Status, Quality of Life and Treatment Satisfaction among Patients with Diabetes in Thailand………………………………………………112 6.1 Introduction ………………………………………………………………113 6.2 Methods……………………………………………………………………115 6.3 Results……………………………………………………………………118 6.4 Discussion……………………………………………………………… 129 6.5 Conclusions……………………………………………………………….132 6.6 Acknowledgements………………………………………………………132 Chapter Association between Polypharmacy and Quality of Life in Patients with Type Diabetes in Thailand………………………………………………134 7.1 Introduction……………………………………………………………….135 7.2 Methods……………………………………………………………………137 7.3 Results……………………………………………………………………139 7.4 Discussion…………………………………………………………………148 7.5 Conclusions………………………………………………………………150 7.6 Acknowledgements………………………………………………………151 v Chapter Conclusions and Recommendations for Future Studies…………152 8.1 Contributions to new knowledge…………………………………………153 8.1.1 Public knowledge of DM in Thailand……………………………153 8.1.2 The measurement of health status, QoL and treatment satisfaction among patients with DM in Thailand……………………………………154 8.1.3 Polypharmacy in patients with T2DM in Thailand………………158 8.2 Main limitations……………………………………………………………159 8.3 Recommendations for future studies………………………………………159 Bibliography …………………………………………………………………….162 vi SUMMARY The prevalence of type diabetes mellitus (T2DM) is rising at an alarming rate, making DM a major health problem worldwide A multifaceted approach is taken in the battle against T2DM, with prevention being an important cornerstone Other important components of T2DM management include DM education and measurement of patient-reported outcomes (PROs) However, currently, the impact of these approaches among Asian populations is relatively unexplored The evaluation of their impact on T2DM management is of particular importance in view of the much less abundant availability of healthcare resources in Asia Based on the afore-mentioned reasons, this thesis therefore focused on various approaches, especially health outcomes assessment, in T2DM management in Asia In our studies, Thailand was chosen as an illustrating example based on the following considerations First, T2DM is one of the most prevalent chronic diseases there, and Thailand is among the top ten countries in Asia with the highest number of adults with T2DM Second, there are limited numbers of published studies concerning this topic in the Thai population Third, Thailand is a country with a mix of rural and cosmopolitan areas which may allow further generalization of the results to other countries with similar socioeconomic compositions This thesis is broadly organized into two sections We started by evaluating DM knowledge among the general population in central Thailand and found this to be generally fair indicating the existence of a foundation for further improvement Interestingly, we found that the residents in other provinces outperformed those in the vii capital demonstrating that easier access to health information may not translate into better health knowledge Further, we identified differing factors associated with DM knowledge between the two groups highlighting the need for different emphasis in future health promotion and education This was followed by our cross-culturally adapting and validating a Thai version of the Audit of Diabetes-Dependent Quality of life (ADDQoL-19), a DMspecific QoL instrument, among DM patients in Thailand and found it to be a promising tool We also evaluated the psychometric properties of a Thai version of the Diabetes Treatment Satisfaction Questionnaire status version (DTSQs), a DMspecific treatment satisfaction instrument, and the results suggested that further improvements may be required for this instrument to be used in routine clinical setting Further, we assessed health status, quality of life (QoL) and treatment satisfaction of DM patients in Thailand We found that DM had little effect on the patients‟ perceived health status but major negative impact on their QoL while their treatment satisfaction was high We also found that the factors associated with these PROs were not identical In addition, we evaluated the association between polypharmacy and QoL and found no significant association Overall, these results would provide some insights to healthcare providers in designing more holistic intervention strategies for DM management In conclusion, our studies would at least fill a knowledge gap in DM management in Thailand (if not beyond) and would serve as a foundation for further studies in more cost-effective approach in managing DM viii LIST OF TABLES Table 2.1 Characteristics of respondents 29 Table 2.2 The respondents‟ scores in each section of the questionnaire 31 Table 2.3 The respondents‟ scores in each item 33 Table 2.4 The list of other risk factors of DM as mentioned by the respondents 36 Table 2.5 The list of other treatments for DM as mentioned by the respondents 36 Table 2.6 Evaluation of potential factors associated with knowledge on DM of the respondents ……………………………………………………………39 Table 2.7 Multiple linear regression analysis of factors assiciated with knowledge of DM .40 Table 3.1 Sociodemographic characteristics of the respondents in the Bangkok and the other central provinces groups 52 Table 3.2 Overall DM knowledge scores and scores in each section of the respondents in each group 53 Table 3.3 Factors associated with DM knowledge of the respondents in each group in univariate analyses 55 Table 3.4 Multiple linear regression analyses of factors associated with knowledge of DM (separate analyses for residents of Bangkok only, residents of other provinces only and combined sample) 56 Table 3.5 Major sources of DM information of the two groups 57 Table 4.1 Characteristics of interviewees in cognitive debriefing interviews 74 Table 4.2 Characteristics of respondents in psychometric evaluation 78 Table 4.3 Distribution of responses to the Thai ADDQoL-19 80 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39(4):57-73 153 American Diabetes Association Standards of medical care in diabetes 2008 Diabetes Care 2008;31 Suppl 1:S12-54 154 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC report JAMA 2003; 289(19):2560-72 179 ... perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”(49) In PRO research, the. .. associated with knowledge of DM  compare the level of DM knowledge among the residents in Bangkok (the capital and the largest city in Thailand) and that of the residents in other central provinces The. .. 33 32 30 30 28 27 24 21 20 18 17 20 12 10 10 10 -2 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 overall score According to the grading criteria established, 26 .9%, 58.8% and