Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 5 Issue: 1

Gender Differences in Health-Related Quality of Life: A Survey of Saudis with SCD

Anwar E. Ahmed1,2*, Ahmed S. Alaskar1,2,3, Donna K. McClish4, Yosra Z. Ali3, Ahmad M. Al-Suliman5, Mohammed H. Aldughither6, May Anne Mendoza2, Hafiz Malhan7
1King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
3King Abdulaziz Medical City, Riyadh, Saudi Arabia
4Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
5King Fahad Hospital, Hofuf, Saudi Arabia
6National Anti-Corruption Commission, Riyadh, Saudi Arabia
7King Fahad Hospital Central, Jazan, Saudi Arabia
Corresponding author : Anwar E. Ahmed, MSc., Ph.D
Director of Research Unit Associate Professor, Biostatistics, Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, MC 2350, P.O.Box 22490 Riyadh, 11426, Saudi Arabia
Tel: 00966114299999 Ext. 95415
E-mail: [email protected]; [email protected]
Received: January 20, 2015 Accepted: March 07, 2016 Published: March 12, 2016
Citation: Ahmed AE, Alaskar S, McClish DK, Ali YZ, Al-Suliman AM, et al.(2016) Gender Differences in Health-Related Quality of Life: A Survey of Saudis with SCD. J Womens Health, Issues Care 5:1 doi:10.4172/2325-9795.1000219

 

Abstract

Context: The literature provides limited evidence of the quality of life (QoL) distinctions between Saudi Arabian male and female patients with sickle cell disease (SCD).
Objectives: To compare SCD complications, symptoms, and individual items in the Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36) between Saudi adult males and females. Methods: A multi-center, cross-sectional study was conducted on 629 Saudi adults with SCD who attended King Fahad Hospital in Hofuf and King Fahad Central Hospital in Jazan.
Results: Gender differences were noted in terms of SCD-related complications, symptoms, daily activity, and pain. Saudi females with SCD reported significantly more fever (66.8% vs. 54.8%, P=0.003), more swelling (59.2% vs. 38.9%, P=0.001), and more frequent blood transfusion (88.5% vs. 80.6%, P=0.009). Males reported more physical exercising than females (41% vs. 23%, P=0.001), and having less family support (89.6% vs. 96.3%, P=0.001). Saudi females with SCD reported significantly higher percentages of daily activity limitations in lifting or carrying groceries (66.7% vs. 58%, P=0.031), climbing one flight of stairs (63.5% vs. 53.6%, P=0.016), and walking the length of one block (59.2% vs. 42.5%, P=0.001). Saudi females with SCD reported a higher percentage of bodily pain (94.3% vs. 87.1%, P=0.004). Conclusion: The study reveals that Saudi females with SCD experience SCD-related complications, symptoms, and pain differently than Saudi males with SCD. According to our data, females reported more limitations in daily activity, more pain, and less physical activity, than males. An interventional program is needed to address QoL among Saudi females with SCD.

Keywords: Sickle cell disease; SCD-related complications; Gender; Quality of life; SF-36; Saudi Arabia

Keywords

Sickle cell disease; SCD-related complications; Gender; Quality of life; SF-36; Saudi Arabia

Introduction

Sickle cell disease (SCD) is a genetic blood disorder affecting the red blood cells. It is one of the world’s most common blood disorders, affects millions of people, and is considered a major health problem in the Middle East, which has the highest frequency of SCD in the world [1]. It has been estimated that the prevalence of SCD in Saudi Arabia falls between 1 and 17% of the population [2-4], depending on the region of Saudi Arabia. The prevalence of SCD is known to be higher in the Eastern and Southern regions of Saudi Arabia [2,3]. In Bahrain, the pattern of sickle cell haemoglobin is similar to that of Saudi Arabia with a range from 7-18.1% of the general population [5-7]. In Qatar, SCD patients represent 7.5% of the general population [8,9]. SCD can lead to poor quality of life, impaired well-being, and limitations in daily activity due to its complications [10,11].
In clinical settings, quality of life has become an important standard assessment of patients’ health status. Several studies used the Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36) [11-14]. Studies have shown that SCD and its complications has a negative impact on patients’ QoL [11-18]. Results from previous studies found that females reported poorer QoL than that experienced by males [15-18], while other studies revealed that gender did not affect the QoL of patients with SCD [19-21].
Recent studies in Saudi Arabia investigated the QoL in patients with SCD [11,22]. Amr et al. [22] reported that male adolescents with SCD tend to show better physical functioning than female adolescents with SCD, while female adolescents with SCD tend to show poorer role limitations due to physical health, worsening pain, and general health.
When Ahmed et al. [11] assessed HR-QoL in Saudi adults with SCD, similar scores were found between males and females for all SF-36 subscales, except for the physical functioning subscale. According to the study, females reported higher scores on physical functioning than males [11]. There were no significant differences between females and males in the other subscales: role limitations due to physical health, role limitations due to emotional problems, vitality, emotional well-being, social functioning, pain, and general health. However, the findings related to patients’ gender differences in QoL or complications have not been addressed adequately in Saudi Arabia.
Gender differences are the primary focus of our current investigation. Specifically, this study describes gender differences on SCD-related complications, symptoms, and on individual SF-36 items across a variety of settings from carrying groceries to general health. Our research hypotheses is that Saudi females with SCD may experience more SCD-related complications and symptoms, and worse quality of life than males on several items of SF-36.

Methods

SCD sample characteristics
We conducted a multicenter, cross-sectional study in two sites in Saudi Arabia: King Fahad Hospital, Hofuf, Eastern region, and King Fahad Central Hospital, Jazan, Southern region. The study has been approved by the Ministry of Health with IRB Log No. 15- 247E, Kingdom of Saudi Arabia, and funded by the King Abdullah International Medical Research Center (KAIMRC), Research Protocol - RC12/127/R. Our target population consisted of patients who attended a Hematology Outpatient Clinic between June 1, 2015 and October 31, 2015. Adult SCD patients who were age 18 years or older were asked to participate in the study. Only patients who provided verbal agreement were asked to complete the questionnaire. We excluded patients who could not read or write. A total of 629 (N=629) surveys were completed and returned (823 surveys were administered with a 76.4% response rate). We collected patients’ demographic characteristics such as age/year, gender (male/female), and obesity (body mass index value ≥ 30). We asked the patients to report SCD-related signs, symptoms, and complications during the past three months such as fever (Yes/No), swelling (Yes/ No), skin redness (Yes/No), and blood transfusion (Yes/No). We asked the patients to report a history of anemia (Yes/No), ED visits during the past six months (frequent if ED visits ≥ 3), regular exercise (Yes/No), presence of other chronic diseases (Yes/No), and whether they are receiving family support (Yes/No). More details of the study can be found in Ahmed et al.[11].
Study instrument
The study compared the quality of life in male and female patients with SCD. We utilized the Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36) to measure the health status and patients’ perceptions towards their health outcomes [23]. The original version of the SF-36 was translated into Arabic [24]. The English and Arabic versions of the SF-36 were found to be equivalent in a convenient sample of bilingual Saudi citizens [24]. It was found that the Arabic version of the SF-36 was reliable in patients with SCD [11]. The SF-36 contains 9 different domains: physical function (10 items); physical role health (4 items); emotional role functions (3 items); vitality (4 items); emotional wellbeing (5 items); social function (2 items); bodily pain (2 items); general health (5 items), and health change (1item). The internal consistency of each subscale was assessed using Cronbach’s alpha. Five domains of the SF-36 had acceptable internal consistency: emotional role functions (alpha = 0.86); bodily pain (alpha=0.84); physical role health (alpha=0.84); physical function (alpha=0.81); and vitality (alpha=0.79). The other three domains had Cronbach’s alpha values lower than the ideal range: emotional wellbeing (alpha=0.67); social function (alpha=0.67); general health (alpha=0.60). The study participants rated their health status in terms of their feelings with respect to 36 different items. Missing responses were considered to be missing. For the purpose of the analysis, each item was classified based on the positive and negative responses. For instance, participants were asked to rate their health in general (poor, fair, good, very good, or excellent), and response was coded to (poor vs. fair to excellent). In another example, participants were asked to report any limitations (Yes, limited a lot; Yes, limited a little; No, not limited at all) in their daily activities such as lifting or carrying groceries, climbing several flights of stairs, walking more than a mile, walking one block, and bathing or dressing oneself. We recoded these items into (Yes, limited a lot or limited a little vs. not limited at all). Participants were asked to respond using “Yes/No” to several questions such as: have you cut down on the amount of time you spent on work or other activities or accomplished less than you would like; did you not do work or other activities as carefully as usual; were you limited to a specific kind of work or other activities; and did you have difficulty performing the work or other activities.
Statistical analysis
The data analyses were conducted using Windows (IBM SPSS Statistics 22; SPSS, Chicago, IL). Descriptive statistics such as means and standard deviation (mean ± SD) were used to describe age (Tables 1). Counts and percentages n (%) were used to describe SCD-related complications, symptoms, and individual items of SF- 36 (Table 1 and 2). The Chi-square test was used to compare the proportions between males and females. The following assumptions of the Chi-square test were met: large sample size and independence. The presence of SCD-related complications and symptoms were compared between males and females by Chi-square tests (Table 1). An independent sample t-test was used to compare age in males and females (Table 1). The following two assumptions of the independent sample t-test were met: age was normally distributed in males and females, independent samples, and homogeneity of variances. We compared each individual item of SF-36 between males and females by Chi-square tests (Table 2). In all analyses, P < 0.05 was considered significant.
Table 1: SCD patients’ characteristics by gender.
Table 2: RAND 36-Item Short Form Health Survey (SF-36) 1.0 questionnaire items by gender.

Results

Characteristics of the study population
More than half of the 629 sample (59.6%) were males: 374 males and 253 females with SCD were included in the analysis. Two participants were excluded from the analysis because they did not report their gender. The final sample analyzed was 627. The mean age of the sample was 28.96 ± 9.7 years. Approximately two-thirds of the sample reported frequent visits to the ED in the past six months. The clinical signs and symptoms of SCD were commonly reported as follows: 33.4% redness, 47.1% swelling, 83.9% blood transfusion, and 90.2% family history of anemia. One-third reported physical exercise and 92.3% reported receiving family support. Table 1 reports demographic and clinical characteristics in males and females. Females tend to report more fever (66.8% vs. 54.8%, P=0.003), more swelling (59.2% vs. 38.9%, P=0.001), more blood transfusion (88.5% vs. 80.6%, P=0.009), and more family support (96.3% vs. 89.6%, P=0.002) than males. However, females reported less family history of anemia (87.2% vs. 92.4%, P=0.035) and less physical activity (23% vs. 41%, P=0.001) than males.

Survey results

Approximately 9.7% of the respondents reported poor health in general and 19.6% rated their health much worse to somewhat worse compared to one year ago. A total of 83.1% reported limitation of vigorous activities, such as running, lifting heavy objects, and participating in strenuous sports, while 73.3% reported limitation of moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf. Further, 61.6% reported limitation in lifting or carrying groceries, 81.2% reported limitation in climbing several flights of stairs, 57.5% reported limitation in climbing one flight of stairs, 53.6% reported limitation when bending, kneeling, or stooping, 76.3% reported limitation when walking more than a mile, 62.5% reported limitation when walking several blocks, 49.3% reported limitation when walking one block, and 35.3% reported limitation when self-bathing or dressing. Other SF-36 items are described in Table 2.
The sub-group analysis (Table 2) showed 12% of the males reported poor health in general, while 6% of the females reported poor health in general (P=0.014). The analysis revealed that 66.7% of the females reported limitation in lifting or carrying groceries compared to 58% of males (P=0.031), 63.5% of the females reported limitation in climbing one flight of stairs compared to 53.6% of males (P=0.016), 59.2% of the females reported limitation in walking one block compared to 42.5% males (P=0.001). Fully 94.3% of the females reported very mild to very severe bodily pain during the past four weeks compared to 87.1% of the males (P=0.004). However, 10.4% of the males reported seldom to always feeling full of pep compared to 5.3% of the females (P=0.026).

Discussion

This study reports QoL subscales and gender differences in a large sample of Saudi adults with SCD attending the Hematology Outpatient Clinic at two sites, King Fahad Hospital, Hofuf, Eastern region and King Fahad Central Hospital, Jazan, Southern region, Saudi Arabia. The male sample consisted of 374 (59.6%) SCD patients and the female sample consisted of 253 (40.4%). The sample was relatively young at age 28.96 (SD ±9.7) years. Gender differences were noted in SCD complications and symptoms: females reported experiencing more fever, swelling, and blood transfusion than males. These findings confirm those of Lionnet et al., who showed that SCD complications were often observed in female patients [25]. Similarly, Dauphin-McKenzie et al. reported that females with SCD experienced multiple complications [26].
Our study demonstrated that females tend to have more limitations lifting or carrying groceries than males. This may have been due to cultural differences, as it is a common practice that Saudi males carry more groceries than Saudi females. We found that Saudi females have less tendency to climb one flight of stairs or walk one block. The issue of gender differences in lifting or carrying groceries, climbing one flight of stairs, or walking one block is complex and could be related to cultural differences. Saudi females were less likely to carry groceries and walk one block. Cultural considerations should be given much attention by modifying the SF-36 to fit the Saudi population and other conservative Muslim populations.
According to our study, Saudi males were more likely to report having energy than Saudi females. This was consistent with a study that reported that the female gender tends to have worse physical QoL [17]. Another study reported that the female gender tends to have diminished vitality scale scores [18].
We noted females were more likely to report bodily pain than males. Several studies were consistent with our findings. For instance, more intense pain was observed among females [27]. Another study reported that pain intensity in hospitalized patients with acute, painful sickle-cell episodes was higher among females [28]. A study investigating HR-QoL among adolescents with SCD in Saudi Arabia revealed that HR-QoL scores were negatively associated with the female gender [22]. However, a study conducted in eastern Saudi Arabia identifying the differences between gender groups in sicklecell pain crisis suggests that the male gender tends to have more acute SCD pain crises than females [29].

Limitations and Suggestions

There are some limitations to our study. The target sample recruited from Hematology Outpatient Clinics is not necessarily representative of the larger SCD population. We did not assess gender differences in the presence of confounding factors such as age. The ratio of male to female was not equal to 1. The results are derived from a self-rated survey. The methodology used in this study does not allow causality statements. Thus, the findings must be interpreted carefully, given the subjectivity of the questionnaire. Large epidemiological studies using objective measures are warranted to investigate the key differences between genders and the reasons QoL tends to be poorer among females than males. Routine screening of females with SCD is recommended regarding pain, SCD related-complications, and symptoms.

Conclusions

We observed that there were significantly more limitations in daily activities among Saudi females with SCD. The study also reports that Saudi females with SCD experience SCDrelated complications, symptoms, and pain differently than Saudi males with SCD. According to our data, females reported more fever, swelling, and less physical activity than males. An interventional program is needed to address QoL among Saudi females with SCD.

Acknowledgment

This research is supported by the King Abdullah International Medical Research Center (RC12/127/R, PI: Anwar Ahmed).

Informed consent

Informed consent was obtained from all individual participants included in the study. The ethical approval for this study was gained by verbal consent with the IRB Log No-15-247E. Permission and assent was obtained from parents of all children and teenagers involved in the study (9 to 17 years old).

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