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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 expectancy can be disturbing for the patients [3]. The composite nature of diseases has a traumatic effect on social and economic status of patients. Although categorized as "controlled", the feeling of being ill heavily imbalances HRQoL in patients suffering from chronic illnesses. This in return, results in decreased patient satisfaction with daily life activities. HRQoL has become an important tool for the assessment of treatment outcomes from a patient perspective [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 the world's population was diagnosed with HTN in year 2000 and this fraction is estimated to increase 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 countries [8]. Hypertension is apprehension significant chronic disease because of its high incidence and risk of developing associated 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 have reduced HRQoL scores [11][12][13].
In recent years, a growing demand to educate patients with chronic disorders has been reported in the literature [14][15][16]. Several methods have been utilized to improve patients' knowledge including; patient groups, published literature, specialist clinics, and the uptake of information technology [17]. Although the provision of disease-related information to patients has been considered good practice, it is not clear whether disease related knowledge has any impact on patients' HRQoL scores [17]. Therefore, the study aimed to examine the association between disease related knowledge and HRQoL in patients with HTN in Pakistan.

Design and settings
This study was designed as a 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 enrolled [18]. A prevalence based sample of 385 HTN patients was selected from May to July 2010 [19]. Patients18 years of age and above, with confirmed diagnosis of essential HTN, who had been using antihypertensive agents for the previous six months and were fluent in the national language of Pakistan (Urdu) [20] were included in the study. Patients aged below 18 and above 80 years, having co-morbidities, immigrants from other countries and pregnant women were exclusion criteria.

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 obtained in-order to conduct the study (EA/FS/1021-2).Written consent was obtained from participants prior to data collection.

Data abstraction
The Hypertension Fact Questionnaire (HFQ) and the European Quality of Life scale (EQ-5D) were used for data collection. Demographic and disease related information was also collected. All instruments were pre-tested for reliability and validity. Data from the pre-test evaluation was not included in the final analysis. Four pharmacists were trained by the principal researcher in how to administer the HFQ and EQ-5D. Group discussions were held among the pharmacists and principal researcher to ensure trustworthiness of the data collection process. The data obtained were verified and scrutinized for completeness and accuracy.

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. The EQ-5D tool consists of five domains (mobility, selfcare, usual activities, pain/discomfort, and anxiety/depression). Three levels of severity (no problems/some or moderate problems/extreme problems) are able to be selected from within a particular EQ-5D dimension. The second portion of the EQ-5D consists of a 20 cm health virtual analogue scale 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 translated Urdu version of EQ-5D was provided by Euroqol and the study was registered with Euroqol.

Assessment of knowledge about HTN
The HFQ was originally constructed in English and translated into Urdu by an independent professional translator. As the process of development and validation was completed, the final version was reviewed and approved by the researchers. The HFQ consists of 15 items which was used to assess patients' knowledge towards causes, treatment and management of HYT. The instrument was constructed after an intensive literature review [22,23] and measured knowledge with a cut off scores of < 8 as poor, 8-12 average and 13-15 as an adequate knowledge [24]. The 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 the descriptive analysis of patient demographics and disease related information. Categorical variables were measured as percentages, while continuous variables were expressed as mean ± standard deviation. The EQ-5D was scored using values derived from the United Kingdom (UK) general population survey from 1995 [26]. Spearman's rank correlation was used to explore any correlations 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. The mean age (SD) of patients was 39.02 (6.59) years, with 68.8% of the study population being male. The mean (SD) duration of hypertension was 3.01±0.93 years. Forty percent (n=154) had bachelor's degrees and 75% (n=289) resided in urban areas. Forty one% (n=160) had a monthly income of more than 15000 Pakistan rupees. Table 2 reports the HRQoL scores among study patients. The 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. The largest single group of 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.

Discussion
Results from the present study highlight that HTN knowledge is weakly associated with HRQoL. To the best of our knowledge, and from extensive literature review, the relationship between HTN knowledge and HRQoL has not been explored. In other disease conditions such as inflammatory bowel disease (IBD), it has been reported that even though 64% of study patients were well informed about their disease, over 90% had some impairment in their reported Quality of Life (QOL) [17]. The authors reported no significant correlation between diseaserelated patient awareness and QOL scores (r=0.3). This is supported by the current study 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][29][30], however there has been no attempt to associate the relationship between HTN knowledge and HRQoL.
In the present study, the correlation between knowledge and  [31]. In a similar study of IBD patients with high anxiety levels, patients declared no benefit in terms of reduced anxiety or improved HRQOL after participating in an educational program partially supporting the earlier hypothesis [32].
Within the context of developing countries like Pakistan, the HRQoL has been underused as one example of a tool borrowed from the social sciences and applied to this sort of work. Pakistan faces a severe shortage in numbers of professionals and health care facilities [33]. Furthermore, there is a huge gap in income disparity and living status between population subgroups [34]. All these factors may have a profound impact on patients HRQoL scores [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 a weak yet positive association between disease-related knowledge and HRQoL scores. Adding to current knowledge, this is the first study that has been reported from Pakistan. The weak association between knowledge and quality of life is likely to be influenced by the many other factors which this study suggests. 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.

Authors' contributions
Fahad Saleem and Noman ul Haq conducted the survey and drafted the initial manuscript. Mohamed Azmi Hassali and Asrul Akmal Shafie designed and supervised the study. Muhammad Atif and Hisham Aljadhey helped in statistical analysis, interpretation and manuscript revision. All authors read and approved the final manuscript.