CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

The direct and indirect costs of diabetes mellitus (DM) on individuals and households have sky-rocketed and increased globally as prevalence of the disease continues to increase especially in Africa as a whole and Cameroon in particular. In some households there are about 2 or more people living with diabetes mellitus. Life for people living with diabetes mellitus (PLWDM) needs constant awareness of the illness- and practical medical measures such as several insulin injections a day, constant intake of metformin and glibenclamide, a very strict diet, lots of exercise, frequent finger punctures to monitor the blood glucose level and concerns over complications which include loss of vision and ulcers (Shier et al., 2010).  These syndromes are due to complications in carbohydrate, protein and fat metabolism. This gives us a clue on the extent of disability and socioeconomic consequences that diabetes mellitus renders on individuals and households. 

DM can lead to a  great deal  of negative effects on patients’ health-related quality of life (HRQoL) because of its burden that results from its chronicity, complications, symptomology and expensiveness. In Sackett Reports on the effects of Diabetes on the HRQoL he reiterated that QoL is an important outcome of non-communicable diseases (NCDs) care, which can reflect an individual’s perceived physical, psychological, social and environmental health over time. Therefore, examining the Patients HRQoL as a measure of the therapeutic outcome of diabetes mellitus care, both directly and indirectly, its very important parts of evidence-based decision making in both clinical medicine and public health (Sackett D.L, 2000).

It should  be noted that,  evolution in medicines and self care approaches to diabetes  care despite  the increased incidence of DM,  has led to  a general decrease in its mortality rate which has led to an increase  in the number of diabetic survivors. This implies that diabetic patients now have opportunity to concentrate on QoL not only on mare survival. . As diabetes patients live longer, they incur greater Expenditures becuase of longer-term care.  Then results Catastrophic health spending followed by impoverishing. Financial burdens therefore  comes from the growing out-of-pocket (OOP) payments especially  in Africa associated with diabetes care to assist patients to live better lifes.

The financial cost related to DM for both individuals and states coupled with the high level of mortality from the disease in Africa is a clear obstacle to the attainment of the Sustainable Development Goals (SDGs) (Saligon et  al., 2016). Generally, NCDs especially  diabetes mellitus and their risk factors often prevent people from working or seeking employment, thus robbing families of income. In 2008, an analysis by the World Economic Forum estimated that countries such as Brazil, China, India and the Russian Federation lost more than 20 million productive life years annually to NCDs (World Economic Forum, 2008). On average, 10 days are lost per employee per year due to NCDs and injuries in the Russian Federation (Suhrcke et al., 2007).

 Annual income loss from NCDs, arising from days spent ill and in care-giving efforts, amounted to about $ 23 billion in India in 2004. In the Province of Taiwan, China, the probability of being in the labour force was reduced by 27% by cardiovascular disease and 19% by diabetes (Mete C. et al., 2002). One of the main risk factors of cardiovascular diseases is diabetes mellitus. Financial catastrophe due to health problems can occur in countries of all levels of development. Yet the problem is most severe in low- and middle-income countries (Xu et al. ., 2007).   It is worth noting that DM affects mostly working age people in Africa (Saligon et al., 2016).

Due to its adverse effect on peoples health, diabetes also imposes an economic burden on individuals and households affected as well as on healthcare systems (Seuring et al., 2015). The direct cost of diabetes borne by affected individuals and families is tremendous. In low-resource settings, treatment for cardiovascular diseases, cancer, diabetes mellitus or chronic lung disease can quickly drain household resources, driving families into impoverishment. NCDs increases social inequity because most payments for health care in low- and middle-income countries are private and out-of-pocket; such costs weigh more heavily on those least able to afford them, increasing the risk of impoverishment (WHO, 2010).

It is estimated that the cost of DM in the USA is at 327 billion dollars being 237 billion dollars for direct medical cost and 90 billion dollars for lack of productivity (Peterson, 2018). Little is known about the economic impact of diabetes in low and middle-income countries (LMIC). Available studies have been confined almost exclusively to high-income countries (HIC) (Jamayo et al., 2016). However, research by Seuring  and crew states that in LMICs—in stark contrast to HICs—a substantial part of the cost burden was attributed to patients payments through out-of-pocket treatment costs (Seuring et aI., 2015).It is very important that studies be done and estimates of the economic burden of DM be made in order to assist policy makers in decision making in the Bamenda Health District, Cameroon and Africa as a whole.

The international Diabetes Federation states that diabetes mellitus is spiraling out of control (IDF, 2021). According to their recent statistics, one in 10 adults is living with diabetes mellitus and almost half are undiagnosed. Three in four people  living with diabetes mellitus are from low and middle-income countries (International Diabetes Federation (IDF), 2021).

In 2011 diabetes was associated with 4.6 million deaths worldwide, causing more deaths than HIV and malaria combined and health expenditures on diabetes were rated at about 465 billion dollars just in health care resources (Saligon et al., 2016). .

The overall burden of diabetes has increased in recent decades and will continue to soar.  Recent findings depict that, the global burden of diabetes increased greatly from 1990 to 2017 and is predicted to rise by 2025. (Lin et al., 2020). Scientific predictions estimate that by 2025 three quarters of the worlds 300million people with DM especially type 2 will be from non-industrialized countries where more than 80% of diabetes-related deaths occur (Shariful et al., 2020).

 The overall burden of diabetes has increased in recent decades and will continue to soar.  Recent findings depict that, the global burden of diabetes increased greatly from 1990 to 2017 and is predicted to rise by 2025. (Lin et al., 2020). In 2011 diabetes was associated with 4.6 million deaths worldwide, causing more deaths than HIV and malaria combined and health expenditures on diabetes were rated at about 465 billion dollars just in health care resources (Saligon et al., 2016).

Among WHO regions, the Eastern Mediterranean, part of Asia and Africa have higher prevalence rates of diabetes compared to other countries. The International Diabetes Federation reports that an estimated 19.4 million adults from ages 20 to 79 were living with Diabetes in 2019 in Africa. Africa is the region with the highest undiagnosed diabetes with about 60% of adults currently living with Diabetes (International Diabetes Federation., 2021). It has also been projected that by 2030 82.5% of people living with Diabetes Mellitus will come from low and middle-income countries.  The burden of diabetes is increasing more and more in Africa (Lin et al., 2020). There is therefore a need to determine the prevalence and economic burden of the disease on quality  of life in different localities as this data will be useful to health economists who can advise the health authorities about  management strategies.

 In Cameroon, diabetes prevalence was estimated at around 6% in 2018.This prevalence has been increasing in the general population, rising from 2.0% in 1999 to 4.7% in 2002 and 6% in 2018 (Bigna et al 2018). There is also a regional disparity between rural and urban areas, with a rural prevalence of diabetes lower than the urban one but rising with time. Diabetes mellitus prevalence also seems to be increased in particular groups: patients with stroke (12.8%) and patients with end-stage renal disease (.5.9%) as reported by (Njounou et al. (2020). The burden of diabetes in Cameroon is not only high but is also increasing rapidly. Data in Cameroonian adults based on a three-cross sectional survey over a 10-year period reveals a 10 fold increase in diabetes prevalence. (Cameroon Diabetes and Hypertension Program, 2020).

A study conducted at the Bamenda Regional Hospital on the prevalence of diabetes and associated risk factors among patients with pulmonary tuberculosis depicts that the prevalence of type 2 DM among TB patients is 9.0% and this is thought to be far greater than the estimated prevalence among the general population in Cameroon which is at 6.82% (Garba et al., 2021).

This increased prevalence of DM is thought to be due to an increase in the prevalence of risk factors in the general population globally. The burden of diabetes is prominently associated with metabolic risks (i.e., high) and behavioral factors (i.e. poor diet, smoking, and low physical activity). In 2017, the leading three risk factors of diabetes mellitus in Africa were high BMI, dietary risks and ambient particulate matter pollution (Xiling et al., 2020).

Saligon and colleagues opined that this epidemiology transition has been caused by profound changes in life style around the world, with rampant urbanization, a rapid nutritional transition as well as an increase in sedentary behavior. They stated that these changes foster an increase in the number of risk factors for DM, high blood pressure and certain types of cancer (Saligon et al., 2016). They went further to explain that, in West Africa as well as Central Africa, it is estimated that more than 21% of the over 20s are overweight and a 5th of the over 15s in the sub region are sedentary (Saligon et al.,2016).

Most of the modifiable risk factors of diabetes are the same as the risk factors for other chronic diseases like cardiovascular diseases (CVD), tuberculosis and certain forms of cancer.  It is therefore common to find patients with diabetes suffering from two or more pathologies. It is however difficult to deal with two pathologies at the same time and treating diabetes needs a strict diet and lifestyle in order to avoid complications. The socioeconomic burden that DM renders on the family is inevitable and therefore needs to be investigated in the Bamenda Health District.

1.2 Statement of the Problem

Diabetes Mellitus, once referred to in our local village communities as a rich man’s illness, has become very common and now affects even poor and under privileged communities. People living with the disease often run the risk of having complications like gangrene on the foot, blindness and many others. They are also more vulnerable to infectious diseases due to the fact that bacteria thrive more in sugary environments, (Walker et al., 2016).

Unfortunately, the risk factors of type 2 DM correlate with the risk factors of other diseases like, tuberculosis, and even cancer. So, it’s very common to see diabetic patients having two or more other pathologies.

Consequently, the direct cost of treatment for diabetes is very high and impoverishing especially in the Cameroon setting where most payments are done out of pocket (Oop). Even the cost of prevention of complications is relatively very high. For example, one vial of insulin costs 6500 XAF.  Similarly, the cost of other drugs for DM is high and out of the reach for the average person.

Interestingly, the dietary rules and regulations are tough and expensive especially in a culture where the most stable food contains high levels of carbohydrates and drinking alcoholis an essential part of relaxation and friendship. It is also a culture where most favorite beverages present a risk to DM. The social and economic consequences of DM therefore need to be investigated in order to inform health professionals to adopt proper management strategies for the affected population.

The indirect cost of DM includes loss of productivity and this is paramount.  The disability that presents with diabetes cannot be over emphasized.  The worst is when complications set in. Productivity is completely lost as the patient can live with disability for the rest of his/her life.

This research poses a problem of, inefficiency and ineffectiveness present interventions of diabetes  treatment  because  hight cost of care that has led to financial  catastrophes plaguing  families in the North West  Region  of Cameroon.

Africa including Cameroon has a dual nutritional burden which is: malnutrition and over nutrition. It has been reported that a baby exposed to malnutrition at its intrauterine life or early childhood, will tend to adapt to this shortage, but at the expense of a greater vulnerability to non-communicable diseases in adulthood especially if the environment is conducive to a diet and lifestyle that fosters over weight (Saligon et al., 2016). Lack of knowledge of this biological phenomenon means that there is a real time bomb called diabetes mellitus especially in Africa, Cameroon and Bamenda with its dual nutritional burden (malnutrition and over nutrition).

Despite all these, most of our local population is not yet aware of diabetes mellitus and the burden it presents. Many people in Cameroon still expose themselves to modifiable risk factors because of no knowledge. They only go to get medical help when complications set in thereby increasing cost and economic consequences on households. Many locals still perceive that diabetes is a rich man’s disease.

Lastly PLWDM face both financial and geographical inequity. Unfortunately, only urban settings have diabetic clinics. Most of those in villages have no access to essential medicines, health education and diagnostic services that can help them know and regularize their blood sugar levels.

Unfortunately, the government has laid more interest in communicable diseases like COVID 19 and HIV/AIDS, neglecting the silent killer, DM. If something is not done, the prevalence of DM and even complications will rise far more than predicted.

 To make things worse, medication and diagnostic services for diabetes mellitus are very expensive for the average household. Two interventions shall be compared in this study. Interventions on treatment and Interventions on risk factor  control in relation  to cost  effectiveness  evaluated through health related  quality  of  life.  This research provides a more cost effective way in tackling diabetes which if implemented by stakeholders   the attainment  of universal  health  coverage  in the treatment  of diabetes  mellitus will be a dream  come true.

1.3 Research Questions

1.3.1 Main Question

What is the impact of the financial burden (Catastrophic expenditures) and risk factors on the quality of life of diabetic patients in the Bamenda Health District using out of pocket direct health expenditures and socio-demographic/ economic characteristics.

1.3.2 Specific Questions

1. what are the Socio-demographic and Socioeconomic characteristics of people living with diabetes mellitus in the Bamenda Health District?
2. How does catastrophic health spending on diabetes affect the quality of life of patients with diabetes mellitus in the Bamenda Health District?
3. What is the effect of risk factors on the the quality of life of patients with diabetes mellitus in the Bamenda Health District?

1.4 Research Objectives

1.4.1 Main Objective

To examine the impact of the financial burden and risk factors of diabetes mellitus on the quality of life of diabetic patients in the Bamenda Health District.

1.4.2 Specific Objectives

1. To describe the sociodemographic and Socioeconomic characteristics of people living with diabetes mellitus
2. 2. To examine the impact of the Financial burden of PLWDM on the quality of life of patients with diabetes mellitus in the Bamenda Health District
3. 3. To investigate the effect of risk factors on the the quality of life of patients with diabetes mellitus in the Bamenda Health District