GENDER MEDICINE/VoL. 5, No. 2, 2008

Gender Differences in Self-Rated Health, Quality of Life, Quality of Care, and Metabolic Control in Patients with Diabetes Anna-Lena Und6n, PhD1; Stig Elofsson, PhD2; Anna Andr6asson, MScl; Eva Hillered, BA3; Ingeborg Eriksson, BA1; and Kerstin Brismar, MD, PhD 3 1Center for Family and Community Medicine, Stockholm, Sweden; 2Department of Social Work, University of Stockholm, Sweden; and 3Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden

ABSTRACT Background: Because the projected increase in the number of diabetic patients is expected to strain the

capabilities of heal th care providers worldwide, we are challenged to find ways of reducing the burden of

diabetes. Maintaining and improving health-related quali ty of life (QoL) for diabetic patients may be

viewed as public heal th goals.

Objective: The aim of this cross-sectional study was to compare different aspects of health, QoL, and quality of care (QoC) between men and women with diabetes as a basis for p lanning and managing dia-

betes care.

Methods: All patients in 2 age groups (aged 20-30 years [younger age group] and aged 50-60 years

[middle-aged group]) who were registered with the Depar tment of Endocrinology, Metabolism, and

Diabetes at Karolinska University Hospital, Stockholm, Sweden, in October 2004, were recruited for a

survey. Questions were included about self-rated heal th (SRH), QoL, QoC, diabetes-related worries, occu-

pational status, physical activity level, living arrangements, and educational background. Glycosylated

hemoglobin (HbAlc) values were obtained from medical records.

Results: Of the 223 eligible patients (109 men, 114 women) in the younger age group, 49 m en and 74 women responded to the questionnaire; of the 300 eligible patients (170 men, 130 women) in the middle-

aged group, 120 men and 93 women responded. Middle-aged w o m en rated their mental well-being and

QoL as worse compared with men (P < 0.001 and P < 0.05, respectively). In bo th age groups, w o m en

reported more diabetes-related worries and less ability to cope (P < 0.05 for the younger age group and

P < 0.001 for the middle-aged group for bo th variables), thus the differences were more marked for middle-

aged women. Although there were no gender differences in metabolic control, middle-aged w o m en

reported less satisfaction with diabetes care (P < 0.001). Higher HbAlc was related to worse SRH in bo th

m e n and wome n when analyzing the age groups together (P < 0.05). This association was most p rominen t

in young women, in w h o m having more diabetes-related worries was also related to higher HbAlc (P <

0.01). Conclusion: In this study, women with diabetes appeared to have worse QoL and mental well-being

compared with men with diabetes. Therefore, identifying strategies to improve SRH and QoL among dia- betic patients, especially among women, is of great importance. (Gend Med. 2008;5:162-180) © 2008 Excerpta Medica Inc.

Key words: diabetes, self-rated health, metabolic control, gender differences, QoL.

Accepted for publication August 28, 2007. © 2008 Excerpta Medica Inc. All rights reserved.

doi:l 0.1016/j.genm.2008.05.003 1550-8579/$32.00

162

A.-L. UndOn et al.

INTRODUCTION The Internat ional Diabetes Federation, a coalit ion

of diabetes associations from >1S0 countries, esti-

mates that the prevalence of (mainly type 2) dia-

betes mellitus (DM) is rising relentlessly and now affects S.9% of people aged 20 to 79 years. 1,2

Diabetes accounts for N3.8 mill ion deaths a year, a

mortal i ty rate similar in magni tude to that f rom HIV/AIDS. 1

The goal of medical care is not only to alleviate

the physical complicat ions of a disease, but also to improve the patient 's overall quality of life (QoL).3

Thus, mainta ining and improving health-related

QoL for persons with diabetes may be considered

public heal th goals. People with diabetes often feel

challenged by the demands of day-to-day manage-

m e n t of the disease and by the fear of developing

complications. The psychosocial burden of living

with diabetes is of ten heavy, and this in turn may

affect QoL, self-care behavior, and ultimately, gly-

cemic control and the risk of developing long- term complications. 4 QoL may be measured by

physical and social funct ioning and perceived physical and mental well-being. 4

In past decades, global self-ratings of health as

well as different measures of QoL have been used

extensively in a variety of health-related studies

focusing on the impact of diabetes and its treat- ment on the daily functioning of diabetic patients.S,6

Self-rated health (SRH), measured with a single

question, correlates strongly with more complex health indices, 7 suggesting robust validity as well as

good test-retest reliability. 8,9 SRH has attracted spe-

cial at tent ion--studies have shown that it is a pow-

erful predictor of mortality, even after controlling

for a number of confounders including medical diagnoses and funct ional ability. 1°,11 Findings

regarding gender differences in predictive power

have been inconsistent. 12 Various studies have

reported that the association between SRH and mortali ty is stronger among men 1°,11,13,14; however,

similar associations for bo th sexes ls,16 and stronger

associations for women 17 have also been reported.

SRH captures a broad array of factors including

physical, social, mental , and psychosocial dimen- sions. 18 Men and women appear to consider simi-

lar factors whe n judging health. 18 Thus, SRH may

be a useful tool to provide a more complete view

of the summarized information about various areas

of health. Little is known about the biological

mechanisms underlying the association between SRH and mortality. In 2 recent studies, poor SRH

was found to be associated with higher levels of

inf lammatory cytokines in w o m en but no t in i n e n . 19,20

The projected increase in the number of dia-

betic patients is expected to strain the capabilities

of heal th care providers worldwide. It is therefore

a challenge to find ways of reducing the burden of

diabetes, prevent ing diabetes complications, and

improving diabetes care, which in turn m ay

improve SRH and QoL for patients. A recently

published review about gender-specific care of

diabetes patients emphasized the importance of

assessing gender-specific differences when analyz-

ing data. 21 The authors concluded that even when

bo th m en and w o m en were included in a study,

there was often no a t tempt to assess the impact of

gender-specific differences. The objective of the

present study was to investigate gender-specific

differences in the perception of health, QoL, and

diabetes-related problems such as worries, satisfac-

t ion with care, and diabetes control in young and

middle-aged m en and women.

SUBJECTS AND METHODS Study Group

All diabetic patients in 2 age groups, 20 to

30 years old (termed the younger age group) and S0 to 60 years old (termed the middle-aged group), who were registered with the Department of Endo-

crinology, Metabolism, and Diabetes, Karo- linska University Hospital, Stockholm, Sweden,

in October 2004, were recrui ted for this

study. All patients lived in an urban area with

close access to nurses and doctors specializing in

diabetes care. In the younger age group, 223 pa-

tients (109 men, 114 women) were identified, and

in the middle-aged group, 300 patients (170 men,

130 women) were identified. The patients were

asked to answer an 8-page quest ionnaire including

questions about perceived heal th status, QoL,

quali ty of care (QoC), problems and concerns with

having diabetes, occupat ional stares, physical

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Gender Medicine

activity level, l iving arrangements , and educa-

t ional background. The quest ionnaires were dis-

t r ibuted by postal mail at the end of November

2004, and a reminder was mai led in January 200S.

The s tudy protocol was devised in accordance

wi th the ethical standards of the local commi t t ee

on h u m a n exper imen ta t ion at the Karolinska

Universi ty Hospital, and informed consent was

ob ta ined f rom all participants.

Measurements

Sociodemographic Factors Educational achievement was classified accord-

ing to 3 levels ranging f rom manda to ry educat ion

to university educat ion (mandatory = 1, lower to

upper secondary = 2, university = 3). Living arrange-

ments (ie, cohabitat ion, which included living with

parents, or single status) were requested. The response

alternatives for occupational status were: work-

ing, studying, unemployed , sick leave, and retired.

Physical activity during leisure t ime was estimated

on a 4-point scale ranging f rom no activity = 1 to

hard training at least 3 times a week = 4 . 22

Self-Rated Health SRH was measured using the following 3 ques-

tions: (1) How would you rate your general heal th

status? Response alternatives were: very good,

quite good, nei ther good nor poor, quite poor, and

poor; (2) How would you assess your general

heal th status compared with that of others your

own age? Response alternatives were: m u c h better,

slightly better, nei ther better nor worse, slightly

worse, and m u c h worse; and (3) How do you regard

your health? Response alternatives ranged f rom

very poor = i to excellent, could not be better = 7.

Quality of Life To measure general well-being, the GOteborg

Quali ty of Life Ins t rumen t (GQLI) was employed. 23

The GQLI comprises ratings of social well-being

(home and family, housing, work situation, econ-

omy, leisure), physical well-being (hearing, vision,

memory , fitness, appeti te) , m en t a l well-being

(mood, energy, endurance, self-esteem, sleep), and

feelings of be ing appreciated wi th in and outside

the h o m e (social support). All i tems were rated on

Likert scales ranging f rom very poor = 1 to excel-

lent, could no t be bet ter = 7. A m e a n score was

calculated to express social, physical, and men ta l

well-being, wi th a higher score indicat ing bet ter

well-being; the internal consis tency for the 3 mea-

sures, according to the Cronbach ~ index, was

0.77, 0.73, and 0.86, respectively.

QoL was also measured with Cantril 's Ladder of

Life, a 10-point scale wi th which respondents rate

their current QoL, their QoL 1 year ago, and their

QoL 1 year f rom n o w (referred to as present, past, and future QoL). 24,2s To measure diabetes-specific

QoL, a 6-i tem scale was devised. The quest ions

focused on specific problems and concerns posed

by diabetes, as follows: General ly speaking, h o w

often during the past 2 weeks have you: (1) Wor-

ried because you have diabetes?; (2) Had diffi-

culty sleeping well at n ight because of your dia-

betes?; (3) Worried tha t your diabetes t r ea tment is

no t working?; (4) Avoided going to a d inner par ty

because of unsui table food?; (5) Felt generally frus-

t rated because of your diabetes?; and (6) Felt af-

fected by b lood sugar swings? Response alterna-

tives were: the whole t ime = 1; mos t of the t ime =

2; m u c h of the t ime = 3; somet imes = 4; no t very

of ten = 5; a lmost never = 6; and never = 7. A m e a n

sum score was calculated, wi th higher scores indi-

cat ing fewer worries. The scale had good reliabili-

ty, wi th a Cronbach ~ measure of internal consis-

t ency of 0.77. This scale was used to assess

diabetes-related worries.

Coping Ability Coping is a psychological concept , of ten used

regarding diabetic pat ients ' adap ta t ion to self-

care. 26 The ability to cope has been described as

"cons tant ly changing cognit ive and behavioral

efforts to manage specific external and /or internal

demands tha t are appraised as taxing or exceeding

the resources of a person. '27 Coping was measured

by a 7-item, 4-point Likert scale in which higher

values indicated better ability to cope. 28 The follow-

ing 7 statements were used: (1) There is really no

way I can solve m y problems; (2) Somet imes I feel

that I am being pushed around in life; (3) I have little

control over things tha t h a p p e n to me; (4) I of ten

feel helpless in dealing with the problems of life;

164

A.-L. Und4n et al.

(5) Wha t happens to me in the future mos t ly

depends on me; (6) There is a lot I can do to

change the impor t an t factors in m y life; and (7) I

can do just about any th ing I really set m y m i n d

to. For this scale, the Cronbach ~ measure of inter-

nal consis tency was 0.87.

Diabetes Control Patients were asked whe ther they had had their

a lbumin, urine protein, serum lipids, glycosylated

hemog lob in (HbAk) , b lood pressure, and eye and

foot status evaluated during the past 12 months .

The number of "yes" answers were summed to form

a score ranging f rom 1 to 7 for each i tem checked.

This scale was used to assess diabetes control.

HbA k was assayed by MonoS, a liquid chro-

matograph ic m e t h o d (Variant II, Bio-Rad Labora-

tories, Hercules, California). The MonoS m e t h o d

results in an HbA k tha t is N0.9% lower t han HbA k

obta ined f rom the Nat ional Glycoprote in Stan-

dardization Program: 0.92 x HbA k (MonoS) + 1:33.

These data were obta ined f rom medical records.

Patients were also asked whe ther they knew their

mos t recent HbA k level, and their answer was

compared with the value obta ined f rom their

medical records.

The prevalence of multiple diabetic complications

was obtained f rom medical records and was recorded

according to the Swedish version of the International Statistical Classification of Diseases and Related Health Problems, lOth Revision, code E10.7 or El l .7 . 29

Quality of Care To assess the pat ient 's op in ion about quali ty of

diabetes care, the following 8 quest ions were used:

(1) How well do you th ink diabetes care works at

the Depar tmen t of Endocrinology Metabolism,

and Diabetes of Karolinska Universi ty Hospital?

Response alternatives were: very well = 1, quite

well = 2, no t very well = 3, and poorly = 4; (2) Were

your quest ions answered by the person w h o you

saw on your last visit?; (3) Do you th ink tha t the

doctor l istened to h o w you perceived your health?;

(4) Do you have a say in choos ing visiting t imes

tha t suit you, wi thou t needing to phone and

change your appoin tment? ; (S) Is your diabetes

nurse an impor t an t e lement in h o w you experi-

ence your care? Response alternatives for the last

4 quest ions were: to a very great extent = 1, to a

great extent = 2, to a certain extent = 3, and not

at all = 4; (6) Do you th ink tha t the person w h o

saw you at your last visit gave you sufficient time?;

(7) Would you like more t ime to discuss wha t it is

like to have diabetes?; and (8) Do you have regular

contac t wi th your diabetes nurse? Response alter-

natives for the last 3 quest ions were: yes = 1 and

n o = 2 .

To de termine h o w to group the questions, all

were subjected to a principal c o m p o n e n t s analysis

wi th p r o m a x rotation. The analysis revealed one

clearly defined factor including quest ions 1, 2, 3,

and 4 wi th an eigenvalue of >1, factor loadings of

>0.60, and good psychometr ic properties (Cron-

bach ~ = 0.78). The m e a n score of the answers was

used to fo rm an index of QoC ranging f rom 1 to

4, wi th higher scores indicat ing worse perceived

QoC. The responses to quest ions S to 8 are report-

ed separately.

Patients were also asked the following S ques-

tions: (1) In the past S years, have you been

invited by your heal th service to a t tend a class on

diabetes educat ion? Response opt ions were "yes,

group educat ion," "yes, individual educat ion,"

or "no"; (2) Have you a t tended such a class? and

(3) Would you like to take part in such a class?

Response opt ions were "yes" or "no"; (4) Have

member s of your family or your par tner received

in fo rmat ion about diabetes f rom your heal th ser-

vices? Response opt ions were "yes," "no," and

"don ' t know"; and (S) Would you like your family

or par tner to be involved in your diabetes care?

Response opt ions were "yes, to a great extent ,"

"yes, to a certain extent ," and "no, no t at all."

Preferred Physician Characteristics To study what doctor characteristics the pat ients

preferred, the following S quest ions were includ-

ed: If you could choose your doctor today, h o w

impor t an t is it that (1) the doctor knows a lot

about diabetes?; (2) you know the doctor well?;

(3) the doctor is close to where you live or work?;

(4) the doctor is good at listening?; and (S) the

doctor talks in a way tha t is easy to unders tand?

The response alternatives were: very impor tan t = 1,

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Gender Medicine

impor t an t = 2, less impor t an t = 3, and no t at all

impor t an t = 4.

Statistical Methods Because we could not f ind validated quest ions

for all the domains , some quest ions were specifi-

cal ly devised for this survey. For these new

ques t ions /domains , we used factor analyses and

reliability measures (Cronbach ~) to investigate

construct and internal validity. The Cronbach

value is dependen t on bo th i tem intercorrelat ion

as well as the n u m b e r of i tems measur ing the attri-

bute. Values wi thin the range of 0.70 to 0.85 are

considered to be satisfactory. 3° To estimate con-

struct validity, the questions were reviewed by phy-

sicians wi th long-term experience in diabetes care.

The validity was also tested by allowing a group of

patients (N200) in the outpat ient clinic to answer,

and offer their opin ion on the relevance of, ques-

tions about diabetes care. The questions used had

high relevance for the patients. Depending on the

data level, a Student t or Z 2 test was used to com-

pare gender groups. In addition, multiple regres-

sion analysis was used to determine variables that

were primarily associated with SRH and well-being,

and the extent to which gender differences in these

variables could be "explained" by gender differences

in living arrangements , education, and diabetes-

related situation. These analyses were under taken

using 3 different models. In the first model, only

gender as an independent variable was used to

measure the original gender differences. All depen-

dent variables except coping were used in the sec-

ond model, and coping was included in the third

model. SAS version 6.3 software (SAS Institute Inc.,

Cary, North Carolina) was used to calculate data.

Reference Population For the SRH measures, the GQLI and the Ladder

of Life, data f rom diabetes pat ients were compared

wi th data for cor responding age groups f rom the

general popula t ion . 31 The cor responding data

comprised 540 w o m e n and 486 m e n in the young-

er age group, and 563 w o m e n and 533 m e n in the

middle-aged group. Demographic characteristics

were c o m p a r e d wi th data f rom the Swedish

Nat ional Public Heal th Report.

RESULTS After the reminder was mailed in January 2005,

123 of the 223 pat ients (55%) in the younger age

group (49/109 [45%] men, 74/114 [65%] women)

and 213 of the 300 pat ients (71%) in the middle-

aged group (120/170 [71%] men, 93/130 [72%] wom-

en) responded to the quest ionnaire.

Study Group Characteristics Clinical and sociodemographic characteristics

for m e n and w o m e n in bo th age groups are pre-

sented in T a b l e I. There were no significant

gender differences in demographic factors in either

of the age groups. Educational level was similar

to that of the general populat ion. 32 However, few-

er w o m e n than m e n were employed, especially

in the younger age group. Because the pat ients

were recruited f rom an outpatient clinic in a univer-

sity hospital, most had type 1 DM: 100% of the

m e n and 92% of the w o m e n in the younger age

group, and 79% of the m e n and 86% of the w o m e n

in the middle-aged group. W o m e n in the middle-

aged group had a m e a n durat ion of diabetes of

27 years compared wi th 22 years for their male

counterpar ts (P < 0.05). T a b l e I also includes dis-

ease dura t ion a m o n g pat ien ts for b o t h age

groups.

Glycosylated Hemoglobin T a b l e I I shows the m e a n values and distribu-

t ion of HbAlc for m e n and w o m e n in bo th age

groups. In the younger age group, 53% of the m e n

and 65% of the w o m e n reported tha t they knew

their HbAlc value; in the middle-aged group, 65%

of the m e n and 70% of the w o m e n knew their

value. There were no gender differences in HbAlc ,

even if there was a t endency for younger m e n to

have lower m e a n HbAlc compared wi th younger

women . This was also apparen t for the distribu-

t ion of values, which showed tha t 52% of the

younger m e n and on ly 30% of the younger

w o m e n had values of <6.5%; however, the differ-

ences were nonsignif icant . Self-reported HbAlc

and values ob ta ined f rom medical records were for

the mos t part in accordance wi th each other. The

correlat ion be tween self-reported and medical-

record HbAlc levels was 0.93 and 0.88 for younger

166

A.-L. Und•n et al.

Table I. Clinical and sociodemographic characteristics by gender and age group.*

Aged 20 to 30 Years Aged 50 to 60 Years

Men Women Men Women Characteristic (n 49) (n 74) (n 120) (n 93)

Age, y, mean (SD) 26.8 (3.1) 27.2 (2.9) 56.9 (2.9) 56.8 (3.2)

Physical activity*, mean (SD) 2.8 (1.0) 2.6 (1.0) 2.2 (0.9) 2.2 (0.9)

Educational level, % Mandatory 13 6 22 37 Secondary 41 56 40 29 University 46 39 38 34

Married/cohabitating, % 69 69 73 73

Occupational status, % Working 70 53 72 62 Studying 19 18 0 0 Unemployed 6 17 2 3 Sick leave 2 11 9 13 Retired 2 2 17 22

Diabetes mellitus, % Type 1 100 92 79 86 Type 2 0 8 21 14

Duration of diabetes, y, mean (SD) 11.4 (7.6) 13.2 (7.4) 22.0 (14.0) 26.6 (15.4)

Duration of diabetes, % 0 14 y 54 47 34 24 1 5 ~ 9 y 46 53 38 37 >30 y 28 39

Patients with multiple diabetic complications, % 10 23 59 54

*To determine gender differences, t tests were used for age, physical activity, and mean duration of diabetes; in all other cases, Z 2 tests were used. All gender comparisons were nonsignificant except for duration of diabetes in the middle-aged group (aged 50 60 y), which was P < 0.05.

*Physical activity was estimated on a 4-point scale ranging from no activity 1 to hard training at least 3 times a week 4.

and middle-aged men , respectively, and 0.93 and

0.78 for younge r and middle-aged w o m e n , respec-

tively. Middle-aged w o m e n w h o repor ted tha t

they did no t know their HbA k had, on average,

h igher values t h a n those w h o did know their

HbA k (P < 0.0S) (in a compar i son of medical

records; data no t presented). Data f rom medical

records also showed tha t gender differences in

HbAlc a m o n g n o n r e s p o n d e r s were similar to

those for the responders. C o m p a r e d wi th the

responders , the non re sponde r s also had signifi-

can t ly h igher values for m e n in b o t h age groups

(P < 0.0S) and for w o m e n in the younge r age

group (P < 0.01).

Self-Rated Health Three measures of SRH are presented in T a b l e

l l l . In bo th age groups, w o m e n rated their heal th

as worse compared wi th men . This was valid for all

assessments (at least P < 0.0S, wi th the except ion

of the 7-grade SRH in the younger age group). The

differences were more p ronounced in the middle-

aged group for the 7-grade scale and in the young-

er age group for the global and age-related assess-

ments . A compar i son of these findings wi th those

of the general popula t ion indicates tha t bo th dia-

betic m e n and diabetic w o m e n rated their heal th

as worse t han tha t of the general populat ion. This

difference was significant (P < 0.001; global SRH

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Gender Medic ine

Table II. Glycosylated hemoglobin (HbAlc) values and distribution by gender and age group,* expressed as mean (SD unless otherwise noted.

HbAlc Value

Obtained from medical records

Distribution, % <6.5 6.5 7.5 >7.5

Reported on questionnaire

Corresponding from medical records

Did not know Obtained from medical records

Dropouts Obtained from medical records

Aged 20 to 30 Years Aged 50 to 60 Years

Men Women )~2/t* P Men Women

n 49 n 74 n 120 n 93 6.7 (1.5) 7.3 (1.6) 1.53 7.2 (1.2) 7.3 (1.4)

5.6

%2/t* P

0.64

0.3 52 30 27 24 21 32 37 37 27 38 36 39

n 26 n 48 n 78 n 65 6.3 (1.1) 7.2 (1.5) 2.64 <0.05 6.9 (1.2) 7.1 (1.2) 0.96

n 25 n 43 n 81 n 70 6.4 (1.1) 7.4 (1.9) 2.43 <0.05 7.1 (1.1) 7.1 (1.3) 0.35

n 23 n 26 n 39 n 23 7.2 (1.9) 7.0 (1.2) 0.41 7.4 (1.4) 7.8 (1.6) 0.96

n 60 n 40 n 50 n 37 7.2 (1.5) 8.4 (1.8) 3.51 <0.01 7.8 (1.7) 7.6 (1.7) 0.34

in the distribution of HbAlc; in all other cases, t tests were used. *Two-tailed X 2 tests were used to determine gender differences

Table III. Comparison of self-rated health (SRH) by gender and age group. Brackets denote values from the genera population.

Variable

Global SRH, % Very good 20.4 [35.8] 12.2 [30.9] Quite good 55.1 [46.5] 45.9 [52.2] Neither good nor poor 18.4 [15.0] 24.3 [12.4] Quite poor 6.1 [2.5] 14.9 [4.3] Poor 0.0 [0.2] 2.7 [0.29]

Age-related SRH, % Much better 6.3 [15.4] 2.7 [20.6] Slightly better 25.0 [10.0] 6.8 [20.2] Neither better nor worse 50.0 [63.8] 39.2 [50.8] Slightly worse 16.7 [8.59] 39.2 [7.09] Much worse 2.1 [2.1] 12.2 [1.4]

SRH, t mean (SD) 4.75 (1.44) 4.32 (1.45)

Aged 20 to 30 Years Aged 50 to 60 Years

Men Women Men Women (n 49) (n 74) )~2/t* P (n 120) (n 93) )~2/t*

5.4 <0.05 4.5

*Two-tailed t tests were used to determine gender differences tMeasured by a 7-point scale; higher values = better health.

15.3 <0.001

1.59 NS

16.1 [22.9] 5.5 [22.7] 47.5 [53.3] 42.9 [48.5] 13.6 [15.6] 28.6 [17.1] 22.0 [8.1] 19.8 [10.5]

0.8 [0.29] 3.3 [1.2]

3.4 [23.4] 4.3 [25.3] 24.8 [12.9] 14.1 [22.0] 40.2 [48.0] 34.8 [39.8] 22.2 [11.1] 28.3 [10.5]

9.4 [4.6] 18.5 [2.4]

4.48 (1.48) 3.62 (1.58)

in the 7-point scale; in all other cases, Z 2 tests were used.

5.2

4.05

P

<0.0

<0.05

<0.001

168

A.-L. Unde!n et al.

was P < 0.0S and age-related SRH was P < 0.01 in

younger men, and global SRH was P < 0.01 in

middle-aged men).

Quality of Life and Psychosocial Well-Being In T a b l e IV, m e n and w o m e n are compared

wi th respect to different measures of QoL and gen-

eral well-being. For the measures represent ing

social and physical well-being, there were rela-

t ively few significant differences be tween m e n

and women . Middle-aged m e n were more satisfied

wi th their m e m o r y (P < 0.01) and appet i te (P <

0.01) t han were middle-aged women . Several of

the measures of men ta l well-being showed signifi-

cant differences be tween m e n and w o m e n in bo th

age groups, indicat ing worse men ta l well-being for

women . However, the combined measure of men-

tal well-being showed significant gender differ-

ences on ly for the middle-aged group (P < 0.001).

W o m e n in the middle-aged group also reported

lower present (P < 0.0S), past (P < 0.0S), and future

(P < 0.01) QoL. In bo th age groups, w o m e n report-

ed more diabetes-related worries and less ability to

cope (P < 0.0S in the younger age group and P <

0.001 in the middle-aged group for b o t h vari-

ables). Younger w o m e n perceived less support

outside the h o m e compared with m e n in the same

age group (P < 0.0S). Thus, diabetic w o m e n appear

Table IV. Comparison of quality of life and psychosocial well-being by gender and age group.*

Aged 20 to 30 Years Aged 50 to 60 Years

Men Women Men Women Variable (scale) (n 49) (n 74) t P (n 120) (n 93) t P

Social well-being (1 7) 4.6 (1.1) 4.5 (1.2) 0.64 5.0 (1.0) 4.8 (1.1) 1.51 Home/family 5.2 (1.5) 5.1 (1.6) 0.32 5.3 (1.4) 5.0 (1.5) 1.57 Housing situation 4.9 (1.7) 5.1 (1.5) 0.89 5.8 (1.1) 5.7 (1.3) 0.59 Work 4.5 (1.7) 3.9 (1.8) 1.72 4.4 (1.9) 4.2 (2.0) 0.83 Economy 4.0 (1.7) 3.7 (1.7) 0.83 4.8 (1.6) 4.5 (1.7) 1.02 Leisure 4.5 (1.5) 4.5 (1.6) 0.19 4.9 (1.5) 4.6 (1.5) 1.44

Physical well-being (1 7) 5.1 (1.0) 5.1 (0.9) 0.11 4.8 (0.9) 4.4 (1.0) 2.68 <0.01 Hearing 5.7 (1.5) 5.8 (1.2) 0.54 5.2 (1.4) 4.9 (1.5) 1.44 Vision 5.2 (1.6) 5.2 (1.5) 0.20 4.4 (1.5) 4.2 (1.5) 0.74 Memory 4.8 (1.7) 4.9 (1.4) 0.44 5.0 (1.3) 4.5 (1.4) 2.63 <0.01 Fitness 4.4 (1.4) 4.2 (1.4) 0.54 3.9 (1.5) 3.6 (1.4) 1.54 Appetite 5.5 (1.4) 5.3 (1.4) 1.05 5.5 (1.2) 5.0 (1.3) 3.03 <0.01

Mental well-being (1 7) 4.5 (1.3) 4.2 (1.2) 1.84 4.7 (1.2) 4.1 (1.2) 4.03 <0.001 Mood 4.7 (1.4) 4.3 (1.4) 1.72 4.9 (1.3) 4.3 (1.5) 3.23 <0.01 Energy 4.4 (1.6) 3.8 (1.5) 2.12 <0.05 4.3 (1.5) 3.7 (1.4) 3.29 <0.01 Endurance 4.7 (1.6) 4.0 (1.4) 2.66 <0.01 4.6 (1.4) 4.1 (1.6) 2.46 <0.05 Self-esteem 5.0 (1.5) 4.3 (1.6) 2.30 <0.05 5.1 (1.5) 4.4 (1.5) 3.43 <0.01 Sleep 4.1 (1.5) 4.5 (1.8) 1.18 4.8 (1.8) 4.0 (1.8) 3.26 <0.01

Support (1 7) Outside home 5.4 (1.0) 4.8 (1.6) 2.32 <0.05 5.0 (1.5) 4.7 (1.4) 1.46 Within home 5.5 (1.2) 5.4 (1.6) 0.57 5.3 (1.5) 5.1 (1.5) 1.18

Ladder of Life (1 10) Present 6.2 (2.0) 6.0 (2.2) 0.38 6.5 (2.0) 5.7 (2.0) 2.57 <0.05 Past 5.5 (2.2) 5.3 (2.5) 0.61 6.4 (1.9) 5.8 (2.1) 2.25 <0.05 Future 7.2 (1.8) 7.3 (2.1) 0.27 6.9 (2.1) 6.1 (2.3) 2.77 <0.01

Coping (1~l) 3.1 (0.5) 2.9 (0.6) 2.36 <0.05 3.0 (0.6) 2.7 (0.5) 4.54 <0.001

Diabetes-related worries (1 7) 5.5 (1.2) 4.9 (1.2) 2.61 <0.05 5.6 (1.1) 5.0 (1.2) 3.64 <0.001

*Higher values on the item/scales indicate greater well-being. Gender differences were determined by t tests.

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Gender Medicine

to have a worse si tuat ion with respect to QoL and

men ta l well-being compared wi th diabetic men.

Comparison with Values from the General Population

In the f i g u r e , the summar ized measures of

mental , physical, and social well-being and the

Ladder of Life are compared be tween diabetic m e n

and w o m e n and the general populat ion. Sig-

nificance tests of the m e a n differences showed

tha t bo th diabetic m e n and diabetic w o m e n in

b o t h age groups perceived their well-being to be

significantly worse t han the general popula t ion

for all 4 measures (P < 0.001 for mos t compar i -

sons; physical well-being was P < 0.01 and QoL

was P < O.OS in younger men; social well-being,

physical well-being, and QoL were P < 0.01 in

middle-aged men). In the general popula t ion,

A

Mental wel l -being

Physical wel l -being

Social wel l -being

GQLI

I I I I 2 3 4 5

Mental I wel l -being ]

Physical wel l -being

I Social J I wel l -being

I I 6 7

Aged 20 to 30 Years

Ladder of Life

• Men (N) [ ] Women (N) [ ] Men (D) [ ] Women (D)

I I I I I I 2 3 4 5 6 7

Aged 50 to 60 Years

Past

Present

Future

I i Past

Present

i Future

I I 8 9

I I

I J

I I I I I I I I I I I 3 4 5 6 2 3 4 5 6 7 8 9

Aged 20 to 30 Years Aged 50 to 60 Years

Figure. Quality of life by gender, age group, and reference population, according to (A) the G6teborg Quality of Life Instrument (GQLI) and (B) the Ladder of Life. D diabetic; N general population.

170

A.-L. Unde!n et al.

younger w o m e n rated their men ta l well-being sig-

nif icantly lower t han did younger m e n (P < 0.01);

however, the gender difference was no t as large as

it was for the diabetic group. No significant gender

differences were found in the general popula t ion

for physical or social well-being. In the middle-

aged group, there were no significant gender dif-

ferences in men ta l or social well-being; however,

w o m e n reported better physical well-being t han

did m e n (P < 0.001).

Diabetes Control and Quality of Care In response to the question about how diabetes

care works at the Depar tment of Endocrinology,

Metabolism, and Diabetes most patients (N85%)

answered "very well" or "quite well." There were,

however, some gender differences indicating that

w o m e n in bo th age groups reported significantly less

satisfaction compared with their male counterparts

(P < 0.0S for the younger age group and P < 0.01 for

the middle-aged group). The responses to this ques-

t ion and 3 other questions were combined to deter-

mine a summarized score for QoC. In T a b l e g dif-

ferent measures of QoC and diabetes control were

compared between m e n and women. Middle-aged

w o m e n perceived their QoC as significantly worse

than did men (P < 0.001), and they wanted more

t ime with their doctor or nurse to discuss what it is

like to have diabetes than did men (P < 0.001). In

response to the question about whether they would

like to take part in a class for diabetes education,

more younger w o m e n ($2°/o) than younger men

Table V. Comparison of perceived diabetes control and quality of care by gender and age group.

Aged 20 to 30 Years Aged 50 to 60 Years

Men Women Men Women (N 55) (N 71) z2/t * (N 119) (N 94)

4.2 (2.1) 4.4 (1.9) 0.42 5.7 (1.5) 5.4 (1.7)

1.9 (0.7) 2.1 (0.6) 0.94 1.7 (0.5) 2.0 (1.6)

Variable P Z2/t * P

Diabetes control (scale: 1 7) 1.32

Qual i ty of care (scale: 1~l) 4.64 <0.001

Sufficient t ime with doctor/nurse at latest visit, % 71 68 4.9 84 72 5.4

Would like more t ime to discuss living with diabetes, % 36 53 2.21 33 57 10.6 <0.001

Diabetes nurse Regular contact, % 46 52 0.58 46 39 0.4 Importance to care, % 1.8 3.4

To a very great extent 30 36 25 20 To a great extent 41 33 35 30 To a certain extent 18 24 25 26 Not at all 11 7 15 24

Invited to attend a class about diabetes, % 60 61 41 48

Attended a class in the past 5 years, % 47 30 2.7 56 61 0.7

Would like to take part in a class, % 24 52 7.4 <0.05 42 46 1.0

Family received information about diabetes 38 36 4.7 29 13 9.4 <0.05

Would like family/partner to be involved in diabetes care, % 3.4 4.4

To a great extent 18 18 26 22 To a certain extent 52 60 39 47 Not at all 26 15 16 9 Not applicable 4 7 19 22

*Two-tailed t tests were used to determine gender differences in diabetes control and quality of care; in all other cases, Z 2 tests were used.

171

Gender Medic ine

(24%) replied "yes" (P < 0.0S). To a greater extent,

middle-aged men (29%) reported that their family

had received information about diabetes, compared

with their female counterparts (13%) (P < 0.05).

There were no significant gender differences in dia-

betes control (urine tests of microalbuminuria,

blood tests of creatinine, serum lipids, HbAk, blood

pressure, foot and eye examinations).

Is Duration of Diabetes Associated with Quality of Life?

An impor tan t quest ion in diabetes research is

whether durat ion of disease or age at diagnosis

affects diabetes control or QoL and well-being. As

expected, a strong correlation was found between

age at diagnosis and diabetes duration, with a cor-

relation coefficient between 0.90 and 0.9S. In

T a b l e VI, we have used diabetes durat ion as a

cont inuous variable to analyze associations with

heal th and QoL measures. Few significant differ-

ences were noted. In younger men, longer dura-

t ion was significantly associated with worse physi-

cal well-being (P < 0.0S) and more diabetes-related

worries (P < 0.0S), whereas longer durat ion in

middle-aged m en was associated with worse self-

rated age-related heal th (P < 0.0S). There were no

significant associations between diabetes durat ion

and HbAlc in any of the analyses.

Is Glycemic Control Associated with Quality of Life?

T a b l e VII presents the correlations between

HbAlc and heal th and QoL measures. Higher

HbAlc values were significantly associated with

worse global SRH in younger women (P < 0.01)

and in middle-aged m en (P < 0.05). A combined

analysis of bo th age groups by gender yielded a

significant association between SRH (global and

7-grade) and HbAlc for bo th m en and w o m en (P <

0.01) (data not presented). In younger women,

worse disease-specific QoL, measured by the

diabetes-related worries scale, was significantly

associated with higher HbAlc (P < 0.01). Only

weak associations were noted between the generic

QoL assessments (physical, social, and mental

well-being; Ladder of Life) and HbAlc. Among

middle-aged men, higher educat ion was signifi-

cant ly associated with lower HbAlc (P < 0.0S).

Table VI. Association of diabetes duration and gender with different measures of quality of life.*

Aged 20 to 30 Years Aged 50 to 60 Years

Variable (scale, if indicated) Men Women Men Women

(N 49) (N 74) (N 120) (N 93)

Physical activity (1~l) 0.12 0.22 0.01 0.03 Educational level (1 3) 0.00 0.06 0.14 0.02 HbAlc 0.15 0.02 0.02 0.11 Global SRH (1 5) 0.10 0.22 0.09 0.01 Age-related SRH (1 5) 0.03 0.08 0.24 t 0.12 7-Grade SRH (1 7) 0.02 0.13 0.07 0.06 Physical well-being (1 7) 0.37 t 0.21 0.09 0.10 Social well-being (1 7) 0.13 0.17 0.09 0.03 Mental well-being (1 7) 0.11 0.12 0.15 0.04 Diabetes-related worries (1~l) 0.31 t 0.12 0.02 0.10 Ladder of Life--present (1 10) 0.24 0.04 0.16 0.07 Qual i ty of care (1~l) 0.19 0.26 0.13 0.03 Coping (1~l) 0.26 0.34* 0.16 0.08

HbAlc glycosylated hemoglobin; SRH self-rated health. *Values are shown as product-moment correlations. Higher values better situation, except for global SRH, age-related SRH, and quali- ty of care.

*P < 0.05. *P < 0.01.

172

A.-L. Und•n et al.

Table VII. Associations with glycemic control, assessed using HbAlc levels, by gender and age group.*

Aged 20 to 30 Years Aged 50 to 60 Years

Variable (scale, if indicated) Men Women Men Women

(N 49) (N 74) (N 120) (N 93)

Age 0.07 0.25 + 0.15 0.01 Physical activity (1 ~l) 0.12 0.05 0.12 0.02 Educational level (1 3) 0.18 0.04 0.22 t 0.14 Duration of diabetes 0.15 0.02 0.02 0.11 Global SRH (1 5) 0.24 0.37* 0.20 t 0.15 Age-related SRH (1 5) 0.01 0.24 t 0.13 0.19 7-Grade SRH (1 7) 0.11 0.27 t 0.19 t 0.07 Physical well-being (1 7) 0.12 0.05 0.12 0.02 Social well-being (1 7) 0.12 0.11 0.03 0.09 Mental well-being (1 7) 0.07 0.06 0.10 0.00 Diabetes-related worries (1 7) 0.25 0.32* 0.10 0.07 Ladder of Life, present (1 7) 0.05 0.11 0.00 0.11 Qual i ty of care (1~l) 0.26 0.13 0.03 0.05 Coping (1~l) 0.04 0.07 0.08 0.05

HbAlc glycosylated hemoglobin; SRH self-rated health. *Values are shown as product-moment correlations. Higher values better situation, except for global SRH, age-related SRH, and quali- ty of care.

*P < 0.05. *P < 0.01.

What "Explains" Gender Differences? In both age groups, men reported better health

and QoL than did women, but is this gender dis- parity explained by gender differences in other diabetes-related factors? To examine this possibili- ty, SRH, mental well-being, and QoL as deter- mined by the Ladder of Life were used as depen- dent variables in regression analyses. All these measures (together with social well-being, diabetes- related worries, and coping) were strongly corre- lated to each other (correlation coefficients of 0.S0-0.60). We chose to present the results with global SRH as a dependent variable. Tab le VIII shows the results from these analyses using gen- der, living arrangements, education, type of diabe- tes, duration, multiple complications, diabetes- related worries, QoC, HbAk, social well-being, and coping as independent variables. These analyses were undertaken using the 3 different models described in the Methods section. The bivariate regression, with gender as a single dependent vari- able (model I), revealed gender differences that were significant in both age groups (P < 0.0S).

The gender differences, however, disappeared when all the independent variables were included, suggesting that these gender differences in health may be explained by factors such as multiple dia- betic complications, diabetes-related worries, social well-being, coping abilities, and HbAlc , which emerged as significant explanatory variables in the regression analyses. The results differed slightly between age groups. In both age groups, fewer diabetes-related worries (P < 0.01), better social well-

being (P < O.OS), better coping abilities (P < 0.001), and lower HbAlc (P < 0.01 in the younger age group and P < O.OS in the middle-aged group) were sig- nificantly related to better health. In the younger age group, higher education (P < O.OS) and not hav- ing multiple diabetic complications (P < 0.001) were significantly associated with better health.

Analyses with QoL and mental well-being as dependent variables (data not presented) did not significantly affect the results (ie, diabetes-related worries, social well-being, coping, and presence of multiple problems were still the predominant explanatory variables).

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Gender Medic ine

Table VIII. Associations with self-rated health, determined with multiple regression analyses by age group, standardized 13-coefficients, and explained variance.

Aged 20 to 30 Years Aged 50 to 60 Years

Variable MI* MII Mil l MI* MII Mil l

Gender 0.21 * 0.03 0.01 0.15* 0.04 0.03 Living arrangements 0.00 0.03 0.08 0.06 Education 0.19 f 0.15 f 0.05 0.02 Type of diabetes 0.03 0.01 0.11 0.09 Duration 0.11 0.09 0.01 0.01 Mult iple diabetic complications 0.28* 0.26* 0.06 0.08 Diabetes-related worries 0.38* 0.295 0.34* 0.235 Quali ty of care 0.06 0.07 0.01 0.01 HbAlc 0.325 0.215 0.13 f 0.12 f Social well-being 0.32* 0.21 * 0.32* 0.18* Coping 0.28* 0.36* R2ad j 3.6 49.3 53.7 1.7 34.3 41.0

M model; HbAlc glycosylated hemoglobin; R2adj explained variance adjusted for degrees of freedom. *In model I, only gender as an independent variable was used to measure the original gender differences. All dependent variables except coping were used in model II, and coping was included in model III.

*P < 0.05. *F < 0.001. ~F < 0.01.

Separate regression analyses by gender and age

group (data not presented) revealed a somewha t

different association pa t te rn for m e n and women .

For younger women , educat ion (P < 0.01), mult i-

pie compl ica t ions (P < 0.001), diabetes-related

worries (P < 0.0S), social well-being (P < 0.001),

and HbAlc (P < 0.01) were significant explanatory

variables, whereas for younger men, on ly coping

(P < 0.01) was significantly related to SRH. In the

middle-aged group, only coping (P < 0.01) was

significantly associated with global SRH a m o n g

women, whereas diabetes-related worries (P < 0.0S),

social well-being (P < 0.0S), and coping (P < 0.01)

were significantly associated a m o n g men.

DISCUSSION QoL assessment in diabetic pat ients cont inues to

contr ibute to our unders tand ing of the disease

and its t r ea tment effects on daily funct ioning. 4

Such compara t ive assessments are impor t an t in

ident ifying the u n m e t needs of m e n and w o m e n

so tha t targeted efforts can be under taken to

improve diabetes care.

Most of the part icipants had type 1 DM, which

means the results pr imari ly concern this group of

patients. The power would be too low to analyze

the type 2 DM group separately. However, we have

also per formed the analyses presented wi thou t

type 2 DM participants. This did not change the

results and, therefore, we decided to analyze the

groups together. In the mult ivariate analysis, we

used type of diabetes as a control variable.

QoL has become a generally accepted te rm for a

set of measures tha t a im at captur ing an individu-

al's percept ion of physical, emotional , and men ta l

well-being. 4 The correlations be tween heal th and

QoL in this s tudy were strong, wi th correlat ion

coefficients of 0.S0 to 0.60, indicat ing tha t there

were significant intercorrelat ions be tween SRH,

social and men ta l well-being, diabetes-related

worries (which could be viewed as a measure of

disease-specific QoL), and QoL according to the

Ladder of Life. The debate on the use of different

QoL ins t ruments is discussed in an article by

Bradley, 33 w h o emphasizes the impor tance of dif-

ferentiat ing heal th status f rom QoL, because these

174

A.-L. Und6n et al.

measures are not necessarily in accordance with

each other. Poor heal th or low well-being is no t

necessarily correlated wi th low QoL. Even if this is

true, our data indicated tha t in mos t cases, good

heal th was associated with h igh QoL. It is, how-

ever, clear tha t the causal relat ionships be tween

heal th and QoL are complex and often reciprocal.

For example, QoL m a y affect diabetes self-efficacy,

self-care behavior, SRH, glycemic control, and dis-

ease complicat ions, just as each of these variables

m a y affect each other and QoL. In this study, we

have focused on SRH as it is extensively used, n

wi th good psychometr ic properties. 8,9 SRH cap-

tures a broad array of factors 18 and is a powerful

predictor of morb id i ty and mortality.11

The h igh d ropout rate is a l imi ta t ion of this

study. In addition, mos t likely there is underrepre-

sen ta t ion of diabetic pa t ients w h o have no t

achieved glycemic control , but this should no t

affect the results of the gender compar isons in this

study. Most of the results are based on self-reports;

thus, we canno t exclude recall bias (ie, the report-

ed data m a y be either overes t imated or underest i-

mated). However, we believe tha t there is no rea-

son w h y recall bias would influence the gender

differences. Similar results are also conf i rmed by

o ther studies.

Glycosylated Hemoglobin Similar to wha t has been no ted in o ther stud-

ies, 34-36 we found no significant gender differ-

ences in HbA k values in the middle-aged group.

According to the Nat iona l Diabetes Register,

wh ich includes N40% of all diabetic persons in

Sweden, the med i an value of HbA k was 7.0% in

2005. 37 The med i an value in the current s tudy

was 7.15%. There was a t endency for the younge r

w o m e n to have h igher m e a n HbA k (P < 0.05), a

f inding also observed in the Nat ional Diabetes

Register.

The f inding tha t pat ients who either did no t

know their HbA k values or did not respond to the

quest ionnaire had higher HbA k emphasizes the

impor tance of ident ifying these individuals, w h o

likely have worse SRH and worse coping abilities.

Higher HbA k values have been shown to be asso-

ciated with worse coping abilities. 26

Self-Rated Health and Quality of Life We have found that w o m e n rated their health and

well-being as worse compared with men. Similar

results with respect to QoL were also found in 2 pre- vious studies. 3,38 Furthermore, a study of adolescents

with diabetes reported significantly increased wor-

ries, less satisfaction, and a wider perception of poor

health in girls compared with boys. 39

We canno t exclude tha t some of the gender dif-

ferences no ted in our s tudy reflect those found in

the general popula t ion, in which m e n often report

bet ter heal th and QoL than do women . 18 However,

the gender differences were greater for people wi th

diabetes t han for the general popula t ion. According

to the Ladder of Life, m e n and w o m e n with diabe-

tes in bo th age groups reported worse SRH; worse

physical, social, and menta l well-being; and worse

QoL compared with the general populat ion. Lower

QoL for people wi th diabetes compared with the

general popula t ion has also been no ted in o ther

studies4,4°; however, QoL was higher for diabetic

pat ients t han for those wi th o ther chronic diseases

such as congestive heart failure, myocardia l infarc-

tion, arthritis, chronic lung problems, gastrointes-

tinal disorders, back problems, and angina. 41

In a recent study, adults with diabetes were

>3 times more likely to report fair or poor health

than persons wi thout diabetes. 2 The impor tance of

assessing SRH in diabetic patients was emphasized

in another study which suggests that for diabetic

individuals who perceive their heal th as poor, there

m a y be a lack of concordance between pat ient and

physician ratings of health. 6 These patients m a y be

more negative and difficult to treat, and m a y there-

fore need an alternative t rea tment approach.

No specific differences were identified in a com-

parison of our f indings wi th similar studies in

o ther countries, suggesting tha t the effect of dia-

betes, especially type 1 DM, on heal th and QoL

m a y be the same, irrespective of culture and popu-

lat ion studied. Whe the r this is the effect of meta-

bolic control , lifestyle restrictions, or diabetes-

related worries is not known.

Quality of Care HbAlc levels are considered evidence-based per-

fo rmance measures for QoC. 42 We found no gen-

175

Gender Medicine

der differences in ei ther QoC as assessed by levels

of HbA k or in s tandard of care as assessed by dia-

betes control.

Patient satisfaction wi th inpat ien t and outpa-

t ient t r ea tment has assumed increasing impor-

tance as a measure of the QoC provided by hospi-

tals or heal th care systems. 43 We found tha t even

if mos t m e n and w o m e n were very satisfied or

satisfied wi th different aspects of their care, there

was a gender difference indicat ing tha t women ,

especially those older, were less satisfied. Middle-

aged w o m e n also reported tha t they would like

more t ime with the doctor or nurse to discuss

wha t it is like to have diabetes. Other studies have

also observed tha t w o m e n seem to be less satisfied

wi th t r ea tment and experience a higher diabetes burden. 43A4 However, in a s tudy by Wright et a143

using quest ions similar to those we used, some of

the gender differences disappeared or became

smaller after adjust ing for covariates.

Another aspect of QoC is the oppor tun i ty to

a t tend classes and in fo rmat ion sessions. Men and

w o m e n in bo th age groups reported to the same

extent tha t they had been invited to a t tend a class

for diabetes education. More younger w o m e n

than younger m e n reported tha t they wanted to

a t tend such a class, and fewer middle-aged w o m e n

than middle-aged m e n reported tha t their family

had received in fo rmat ion about diabetes.

In a recent review of 39 studies, w o m e n were

found to be significantly more satisfied wi th care

in 6 of the studies, m e n were more satisfied in

7 studies, and the differences were nonsignif icant

in the others. 4s Our findings, indicat ing less sup-

por t outside the h o m e and less ability to cope,

suggest tha t w o m e n m a y need addi t ional sup-

por t f rom heal th care organizations; this support

m a y improve their SRH and metabol ic control and

prevent complicat ions. A study by Gafvels and

Wandell, 26 in which the authors suggest tha t more

a t t en t ion be paid to a pat ient ' s ability to cope with

diabetes, emphasizes the impor tance of coping

strategies for successful self-care and t rea tment .

Diabetes Duration and Quality of Life Does dura t ion of diabetes or age at diagnosis

affect diabetes control or QoL and well-being? We

found on ly a few significant associations, bu t

these differed be tween m e n and women . Whereas

longer dura t ion was associated wi th worse physi-

cal well-being and more diabetes-related worries

in younger men, it was associated with bet ter per-

ceived QoC and better coping in younger women .

This suggests tha t diagnosis at an earlier age m a y

lead to bet ter coping strategies in w o m e n but m a y

be more stressful for men.

Findings regarding the relat ionships be tween

QoL and dura t ion of diabetes have been inconsis- tent. 4 Two studies indicated no association. 46,47

The lack of an association be tween QoL and dis-

ease dura t ion m a y have resulted f rom the com-

b ined assessment of older and younger groups.

This migh t partially explain the absence of signifi-

cance, especially if there was a wide range in age

at diagnosis in the study popula t ion. Other studies

found tha t bet ter QoL was associated wi th shorter

dura t ion of disease. 3A8 In a s tudy of diabetic m e n

and w o m e n aged <30 years, the authors concluded

tha t individuals who were younger at diagnosis

rated their heal th as bet ter t han did those w h o

were older at diagnosis. 49 This m a y be due to bet-

ter adapta t ion to coping wi th diabetes a m o n g

individuals w h o receive their diagnosis at young-

er ages. None of the studies focused on gender

differences.

Glycemic Control and Quality of Life Of the different heal th and QoL measures, SRH

p redominan t ly had a significant association with

glycemic control . In younger women , hav ing

more diabetes-related worries (used as measure of

diabetes-related QoL) was associated with higher

HbAlc. The relat ionship be tween glycemic control

and QoL is the subject of debate, s° Published

results generally have suggested tha t bet ter glyce- mic control favors bet ter QoL. 4,3%47,sl Evidence

seems to be stronger w h e n using diabetes-specific

QoL instruments , t hough null f indings using gen-

eral measures have of ten been reported, se-s4 It has

also been suggested tha t the relat ionship m a y be

curvilinear. 4 In a s tudy of young people wi th dia-

betes, bet ter glycemic control was associated with

bet ter SRH in m e n and w o m e n aged <30 years. 49

Coping abilities have also been associated with

176

A.-L. Und4n et al.

bet ter glycemic control. 26 Our findings suggest

tha t SRH is an impor t an t factor to consider w h e n

establishing glycemic control in diabetic patients.

Coping strategies m a y improve b o t h SRH and gly-

cemic control.

It could be argued that our results m a y have been

influenced by selection bias (ie, those who respond-

ed to the questionnaire had worse metabolic con-

trol); however, the dropouts had even worse meta-

bolic control. Therefore, we believe that the w o m e n

who responded to our questionnaire were represen-

tative of young diabetic women.

Summary of Multivariate Analyses In the univariate analyses, we found that dia-

betic w o m e n had a disadvantage over diabetic

m e n in SRH and QoL. Multiple regression analyses

revealed tha t these gender differences disappeared

w h e n control l ing for o ther factors such as educa-

tion, living arrangements , social well-being, cop-

ing abilities, and heal th factors related to diabetes.

This f inding implies tha t the gender differences in

heal th for the mos t part m a y be explained by

some of these factors. Diabetes-related worries,

social well-being, coping abilities, and glycemic

control were all significantly associated wi th SRH

in b o t h age groups. Thus, more diabetes-related

worries and less ability to cope m a y explain the

worse perceived heal th in women . In the younger

age group, it is also possible tha t the somewha t

higher f requency of mult iple compl ica t ions a m o n g

w o m e n m a y be of impor tance in explaining gen-

der differences. Only in this group of younger

w o m e n was a significant i ndependen t association

found be tween mult iple compl ica t ions and SRH.

Separate regression analyses by age and gender

indicated significant associations be tween glyce-

mic control and SRH. The association was stron-

gest a m o n g younger women , weak a m o n g young-

er men, and modera te a m o n g middle-aged m e n

and women .

Because this was a cross-sectional study, it is no t

possible to analyze causal links or directions.

However, it is likely tha t the associations studied

are reciprocal and m a y also be dependen t on indi-

vidual and personal i ty factors. We have focused

on SRH and used it as a dependen t variable in the

analyses, because SRH is f requent ly used in medi-

cal as well as behavioral studies, is well defined,

and suggests robust validi ty as well as good tes t -

retest reliability. Heal thy People 2010 also includes

SRH as 1 of 3 surveillance tools tha t can be used to

measure heal th-related QoL. 1

SRH m a y be a useful tool to provide a summa-

rized view of various aspects of health. We per-

fo rmed the mult ivar ia te analyses wi th QoL (accord-

ing to the Ladder of Life) and men ta l well-being as

dependen t variables and achieved results similar

to those for SRH: factors such as diabetes-related

worries, mul t ip le complicat ions, and glycemic

control were also found to be associated with QoL

and men ta l well-being.

These findings suggest the impor tance of dis-

cussing SRH, men ta l and social well-being, coping

abilities, and diabetes-related worries in clinical

settings, and of including SRH as an integral part

of rout ine medical care. We r e c o m m e n d that spe-

cific a t ten t ion be paid to the m a n a g e m e n t of

w o m e n with diabetes. Further prospect ive studies

should be designed to examine which factors are

impor t an t to the percept ion of good QoC and

QoL for diabetic m e n and w o m e n at different

ages.

CONCLUSIONS In this s tudy of gender differences in the heal th

and care of pat ients wi th diabetes, we found tha t

diabetic w o m e n reported hav ing a worse heal th

si tuat ion compared with diabetic men, wi th re-

spect to SRH, QoL, and to a certain extent, per-

ceived QoC. The gender differences were greater

for people wi th diabetes than for the general

popula t ion. Diabetes m a y thus be experienced dif-

ferently by m e n and women .

Besides the worse heal th si tuat ion for diabetic

women , we found tha t b o t h diabetic m e n and

diabetic w o m e n had worse heal th compared with

the general populat ion. We also found tha t higher

HbA k was related to worse SRH in bo th m e n and

women , w h e n analyzing the age groups together.

The association was mos t marked in younger

w o m e n in w h o m having more diabetes-related

worries was also related to higher HbA k. Multi-

variate analyses indicated that the gender differences

177

Gender Medicine

may be attributed to factors such as diabetes- related worries, diabetes-related multiple compli- cations, and coping skills.

REFERENCES 1. Mayor S. Diabetes affects nearly 6% of the world's

adults. BMJ. 2006;333:1191.

2. Centers for Disease Control (CDC). Self-rated

fair or poor health among adults with diabetes--

United States, 1996-2005. MMWR Molt) Mortal Wkly

Rep. 2006;55:1224-1227.

3. Lloyd CE, Orchard TJ. Physical and psychological

well-being in adults with Type 1 diabetes. Diabetes

Res Clin Pract. 1999;44:9-19.

4. Rubin RR, Peyrot M. Quality of life and diabetes.

Diabetes Metab Res Rev. 1999;15:205-218.

5. Dasbach EJ, Klein R, Klein BE, Moss SE. Self-rated

health and mortality in people with diabetes. Am J

Public Health. 1994;84:1775-1779.

6. Linn MW, Linn BS, Skyler JS, Harris R. The impor-

tance of self-assessed health in patients with dia-

betes. Diabetes Care. 1980;3:599-606.

7. Rowan K. Global questions and scores. In:

Jenkinson C, ed. Measuring Health and Medical

Outcomes. London, UK: UCL Press; 1994:54-67.

8. Lundberg O, Manderbacka K. Assessing reliability

of a measure of self-rated health. ScandJ Soc Med.

1996;24:218-224.

9. Martikainen P, Lahelma E, Aromaa A, for the Mini-

Finland Research Group. Perceived health and

mortality. A fol low-up study. Paper presented at:

The 6th Biennial Conference of the European

Society of Health and Medical Sociology; August

29-31, 1996; Budapest, Hungary.

10. Benyamini Y, Leventhal EA, Leventhal H. Gender

differences in processing information for mak-

ing self-assessments of health. Psychosom Mecl.

2000;62:354-364.

11. Idler EL, BenyaminiY. Self-rated health and mortal-

ity: A review of twenty-seven community studies.

J Health Soc Behav. 1997;38:21-37.

12. Deeg DJ, Bath PA. Self-rated health, gender, and

mortality in older persons: Introduction to a spe-

cial section. Gerontologist. 2003;43:369-371.

13. Hays JC, Schoenfeld D, Blazer DG, Gold DT. Global

self-ratings of health and mortality: Hazard in

the North Carolina Piedmont. J Clin Epidemiol.

1996;49:969-979.

14. Idler EL, Russell LB, Davis D. Survival, functional

limitations, and self-rated health in the NHANES I

Epidemiologic Follow-up Study, 1992. First National

Health and Nutrition Examination Survey. Am J

Epidemiol. 2000;152:874-883.

15. Jylh~i M, Guralnik JM, Ferrucci L, et al. Is self-rated

health comparable across cultures and genders?

J Gerontol B Psychol Sci Soc Sci. 1998;53:$144-$152.

16. Strawbridge WJ, Wallhagen MI. Self-rated health

and mortality over three decades: Results from

a t ime-dependent covariate analysis. Res Aging.

1999;21:402416.

17. GrantMD, PiotrowskiZH,Chappell R.Self-reported

health and survival in the Longitudinal Study of

Aging, 1984-1986. J Clin Epidemiol. 1995;48:375-

387.

18. Unden AL, Elofsson S. Do different factors explain

self-rated health in men and women? Gend Med.

2006;3:292-294.

19. Lekander M, Elofsson S, Neve IM, et al. Self-rated

health is related to levels of circulating cytokines.

Psychosom Med. 2004;66:559-563.

20. Unden AL, Andreasson A, Elofsson S, et al.

Inflammatory cytokines, behaviour and age as

determinants of self-rated health in women. Clin

Sci (Lond). 2007;112:363-373.

21. Legato MJ, Gelzer A, Goland R, et al, for the

Writing Group for The Partnership for Gender-

Specific Medicine. Gender-specific care of the

patient with diabetes: Review and recommenda-

tions. Gend Med. 2006;3:131-158.

22. Grimby G, Wilhelmsen L, Bj6rnstorp P, et al.

Habitual physical activity. Aerobic power and

blood lipids. In: Pernow B, Saltin B, eds. Muscle

Metabolism During Exercise. NewYork, NY: Plenum

Press; 1971:469481.

23. Tibblin G, Tibblin B, Peciva S, et al. "The G6teborg

quality of life instrument ' --an assessment of well-

being and symptoms among men born in 1913 and

1923. Methods and validity. Scand J Prim Health

Care Suppl. 1990;1:33-38.

24. Andrews G, Tennant C, Hewson DM, Vaillant GE.

Life event stress, social support, coping style, and

risk of psychological impairment. J Ner Ment Dis.

1978;166:307-316.

178

A.-L. Und(!n et al.

25. Cantril H. The Pattern of Human Concerns. New

Brunswick, N J: Rutgers University Press; 1965.

26. G~ifvels C, W~indell PE. Coping strategies in men

and women with type 2 diabetes in Swedish pri-

mary care. Diabetes Res Clin Pract. 2006;71:280-289.

27. Lazarus RS, Folkman S. Stress, Appraisal, andCoping.

New York, NY: Springer Publishing; 1984.

28. Derogatis LR, Lipman RS, Covi L, Rickels K.

Neurotic symptom dimensions. As perceived by

psychiatrists and patients of various social classes.

Arch Gen Psychiatry. 1971;24:454464.

29. International Statistical Classification of Diseases

an d Related Health Problems, 10th Revision. 2 n d ed.

Geneva, Switzerland: World Health Organization;

2004.

30. Cronbach LJ. Coefficient alpha and the internal

stru ctu re of tests. Psychometrika. 1951;16:297-334.

31. Eriksson I, Und~n AL, Elofsson S. Self-rated health.

Comparisons between three different measures.

Results from a population study. Int J Epidemiol.

2001 ;30:326-333.

32. Socialstyrelsen. Folkh~ilsorapport 2005.2005: Stock-

holm. http://www.socialstyrelsen.se/Pu blicerat/2005/

8707/2005-111-2. htm. Accessed March 25, 2008.

33. Bradley C. Importance of differentiating health

status from quality of life. Lancet. 2001;357:7-8.

34. Naar-King S, Idalski A, Ellis D, et al. Gender dif-

ferences in adherence and metabolic control in

urban youth with poorly controlled type 1 diabe-

tes: The mediating role of mental health symp-

toms. J Pediatr Psychol. 2006;31:793d302.

35. Stadler M, Auinger M, Anderwald C, et al. Long-

term mortality and incidence of renal dialysis and

transplantation in type 1 diabetes mellitus. J Clin

Endocrinol Metab. 2006;91:3814-3820.

36. Tseng CL, Sambamoorthi U, Rajan M, et al. Are

there gender differences in diabetes care among

elderly Medicare enrolled veterans? J Gen Intern

Med. 2006;21 (Suppl 3):$47-$53.

37. Nationella Diabetesregistret.)krsrapport2006.2006:

G6tebo rg. https://www.n d r.n u/pdf/Arsrappo rt_N DR_

2006.pdf. Accessed March 25, 2008.

38. Graue M, WentzeI-Larsen T, Hanestad BR, et al.

Measuring self-reported, health-related, quality of

life in adolescents with type 1 diabetes using both

generic and disease-specific instruments. Acta

Paed iatr. 2003;92:1190-1196.

39. Hoey H, Aanstoot HJ, Chiarelli F, et al. Good

metabolic control is associated with better quality

of life in 2101 adolescents with type 1 diabetes.

Diabetes Care. 2001 ;24:1923-1928.

40. W~indell PE. Foreign- and Swedish-born diabetic

patients--medical situation and quality of life.

Scand J Prim Health Care. 1999;17:158-163.

41. Stewart AL, Greenfield S, Hays RD, et al.

Functional status and well-being of patients with

chronic conditions. Results from the Medical

Outcomes Study [published correction appears in

JAMA. 1989;262:2542]. JAMA. 1989;262:907-913.

42. Thompson W, Wang H, Xie M, et al. Assessing

quality of diabetes care by measuring lon-

gitudinal changes in hemoglobin A lc in the

Veterans Health Administration. Health Serv Res.

2005;40:1818-1835.

43. Wright SM, Craig T, Campbell S, et al. Patient

satisfaction of female and male users of Veterans

Health Administration services. J Gen Intern Med.

2006;21 (Suppl 3):$26-$32.

44. Peyrot M, Rubin RR, Lauritzen T, et al. Patient and

provider perceptions of care for diabetes: Results

of the cross-national DAWN Study. Diabetologia.

2006;49:279-288.

45. Crow R, Gage H, Hampson S, et al. The measure-

ment of satisfaction with healthcare: Implications

for practice from a systematic review of the litera-

tu re. Health Technol Assess. 2002;6:1-244.

46. Parkerson GR Jr, Connis RT, Broadhead WE, et al.

Disease-specific versus generic measurement of

health-related quality of life in insulin-dependent

diabetic patients. Med Care. 1993;31:629-639.

47. Wikblad K, Leksell J, Wibell L. Health-related qual-

ity of life in relation to metabolic control and late

complications in patients with insulin dependent

diabetes mellitus. Qual Life Res. 1996;5:123-130.

48. ElbagirMN, Etayeb NO, Eltom MA, etal. Health-related

quality of life in insulin-treated diabetic patients

in the Sudan. Diabetes Res Clin Pract. 1999;46:65-73.

49. Huang GH, Palta M, Allen C, et al, for theWisconsin

Diabetes Registry. Self-rated health among young

people with type 1 diabetes in relation to risk

factors in a longitudinal study. Am J Epidemiol.

2004;159:364-372.

50. Camacho F, Anderson RT, Bell RA, et al. Investigating

correlates of health related quality of life in a low-

179

Gender Medicine

income sample of patients with diabetes. Qual

Life Res. 2002;11:783-796.

51. Van der Does FE, De Neeling JN, Snoek FJ, et al. Symptoms and well-being in relation to glyce- mic control in type II diabetes. Diabetes Care.

1996;19:204-210.

52. Ahroni JH, Boyko EJ, Davignon DR, Pecoraro RE. The health and functional status of veterans with diabetes. Diabetes Care. 1994;17:318-321.

53. Anderson RM, Fitzgerald JT, Wisdom K, et al. A comparison of global versus disease-specific

quality-of-life measures in patients with NIDDM. Diabetes Care. 1997;20:299-305.

54. Weinberger M, Kirkman MS, Samsa GP, et al. The relationship between glycemic control and

health-related quality of life in patients with non- insulin-dependent diabetes mellitus. Med Care.

1994;32:1173-1181.

Address correspondence to: Anna-Lena Und6n, PhD, Center for Family and Community Medicine, Alfred

Nobels All6 12, SE-141 83 Huddinge, Stockholm, Sweden. E-mail: anna-lena.unden@ki.se

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