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Quality of life in Asians with type-2 diabetes mellitus: development and validation of ethnic and language specific questionnaires, a cross-sectional study in Malaysia.

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posted on 01.03.2017, 02:52 by Goh, Giap Kah
Diabetes mellitus (DM) is a complex and chronic disease with multiple complications leading to increased mortality and poor quality of life. Current studies have shown that lowering glycosylated hemoglobin (HbA1c) confers protection against microvascular complications. However, evidence showed that with more intensive glucose control to achieve HbA1c of less than 6.5%, there is a significant increased risk of mortality and cardiovascular events. The current recommendation worldwide is for “tailoring” of DM management to risk and also quality of Life (QOL) which is a crucial component in determining the success or failure of DM management. In Asia, DM has become a health crisis but there is a lack of QOL assessment tool that is specific for Asians with wide spectrum of ethnicity, languages, religions and socio-economic differences. The primary aim of this study is to construct a type-2 diabetes mellitus specific quality of life (QOL) tool for Asian populations that is valid and reliable across different ethnicities, languages, and socio-economic backgrounds. The secondary aim is to study the perception of diabetes quality of life in a multi-ethnic Malaysian population with type- 2 diabetes and to determine the factors contributing to QOL in our study population. The tertiary aim is to determine whether cardiac disease will worsen sexual dysfunction (SD) in diabetes, and determine the factors causing SD in a multi-ethnic population. Methods: A focus group determined the domains affecting QOL in consultation with an expert group. A pilot study was conducted to validate the Asian Diabetes QOL (AsianDQOL) in English, Malay/Indonesian and Chinese- Mandarin. The World Health Organization Brief Quality of Life Questionnaire (WHOQOL-BREF) was used for comparison. Exploratory factor analysis (EFA), reliability analysis (RA) using Cronbach’s alpha and test-retest reliability, and confirmatory factor analysis (CFA) using structural equation modelling (SEM) was undertaken using the statistical software IBM SPSS Statistics version 20. In order to study the impact of westernization on the perception of QOL, a population based cross-sectional and longitudinal study were carried out in 3 different states in Malaysia. The Asian Diabetes Quality of Life (AsianDQOL) tool specific for Type 2 diabetes is the primary outcome tool for data gathering at 2 points of time. The subjects were tested 3 months apart. Stepwise multiple linear regression models were used for analysis. The Sexual Function Assessment in Diabetic Men (SAD-Men) tool specific for sexual dysfunction in men with diabetes is the primary outcome tool for data gathering. Chi-Squared test for independence was applied to evaluate for any significant differences in the three groups of participants. Stepwise multiple linear regression models were used for analysis. Results EFA with eigen values (>1) and factor loadings ≥ 0.3 for English and Malay language demonstrated 21 items and 5 components. CFA (English version) confirmed the model fit (CMIN 201.08, p-value 0.071, GFI 0.88, RMSEA 0.036, CFI 0.978). CFA (Malay version) confirmed the 5-factor model (CMIN 189.39, p-value 0.085, GFI 0.937, RMSEA 0.025, CFI 0.987). The corresponding Cronbach’s alpha scores (English version) were 0.917, 0.818, 0.816, 0.749 and 0.719, respectively. The Malay/Indonesian version scored 0.833, 0.819, 0.816, 0.775, 0.673, respectively whilst the Chinese/Mandarin version scored 0.890, 0.719, 0.826, 0.862 and 0.759, respectively. Test-retest reliability showed Spearman’s correlation of 0.664 (English version), 0.736 (Malay/Indonesian version) and 0.553(Chinese- Mandarin version). A scoring system was generated based on the 25th, 50th and 75th centiles for all the three languages. A total of 664 subjects of different ethnicity were recruited. Analysis shown the main contributors of QOL for English language group of different ethnicities were sexual dysfunction(-4.5), having visual problems (-3.7), female (-2.8) glycaemic control (-1.6). Sexual dysfunction was negatively correlated with QOL in Malay, Chinese and Indian ethnic groups. The predictors of QOL were different in the westernized group compared to the traditional group. As for the study of sexual dysfunction among men with diabetes and cardiovascular disease, a total of 424 subjects of different ethnicity were recruited. A total of 221 have diabetes only, 98 with cardiovascular disease without diabetes and 105 with diabetes and cardiovascular disease. The prevalence of SD in all subjects assessed using the SADMEN tool was 82%. The prevalence of SD in DM only group, CVD only group and DM plus CVD group was 80%, 78% and 91%, respectively. Those with DM and CVD experienced more severe SD compared to the other two groups. Regression model generated for SD score shows negative correlation of age (-0.4), duration of DM (-2.5), neuropathy (-3.5), retinopathy (-4.1), ischemic heart disease (-5.1) and depression symptoms (-6.3). Conclusion The AsianDQOL is a valid, reliable and stable tool for assessing QOL in multiethnic and multi-lingual T2DM Asian populations. The perception of QOL is different across the ethnic groups and language. Significant differences in the English-speaking group and the traditional Non-English speaking group were detected within the same ethnicity. Sexual dysfunction severely impact QOL in a multi-ethnic Asian population and remained an important determinant regardless of ethnicity and language. The predictors of sexual dysfunction and its components were different. There is a high prevalence of SD among men with diabetes in a multi-ethnic Malaysian population. Men with diabetes and CVD are at higher risk of developing moderate to severe sexual dysfunction compared to men with diabetes alone.


Principal supervisor

Rusli Nordin

Year of Award


Department, School or Centre

Jeffrey Cheah School of Medicine and Health Sciences (Monash University Malaysia)

Campus location


Degree Type



Faculty of Medicine Nursing and Health Sciences