Health-Related Quality of Life of Adolescents and Children With Type 1 Diabetes in the Jazan Region of Saudi Arabia

Background: Type 1 diabetes mellitus (T1DM) is increasingly prevalent among Saudi Arabian youth, particularly in the Jazan region. This chronic condition necessitates lifelong insulin therapy and poses significant daily management challenges for affected adolescents. Despite the high incidence rates, there is a notable lack of research into how T1DM impacts the health-related quality of life (HRQoL) of these individuals. Objective: This study aimed to assess HRQoL and its demographic correlates in T1DM patients in the Jazan region of Saudi Arabia. Methods: In this cross-sectional study, 236 T1DM patients completed the Pediatric Quality of Life Inventory Diabetes Module 3.0 (PedsQL DM). The HRQoL across domains of diabetes symptoms, treatment barriers, adherence, worry, and communication was compared by gender, nationality, age, education, residence, and healthcare follow-up using t-tests and ANOVA. Multivariate regression identified predictors of overall HRQoL. Results: Most respondents were female (51.3%), 42.8% were between the ages of seven and 12 years, and 94.5% were Saudi nationals. Males reported better HRQoL than females, with fewer symptoms, treatment barriers, and better communication (all p<0.05). Non-Saudis had better treatment adherence, communication, and overall HRQoL than Saudis (all p<0.05). Older children (13-18 years) reported lower treatment barriers than younger children (three to six years) (p<0.05). Those with intermediate education had lower treatment barriers than those with preliminary education (p = 0.038). Only the female gender (-0.171, p = 0.009) independently predicted poorer overall HRQoL. Conclusion: This study revealed disparities in HRQoL among T1DM children and adolescents. Males, non-Saudis, older children, and those with more education had better HRQoL. Females were at particular risk for poorer outcomes. Targeted interventions are needed to address this region's demographic disparities in diabetes-related HRQoL.


Introduction
Diabetes is a global epidemic affecting 382 million people worldwide and is projected to rise to 582 million by 2035 [1].This public health crisis particularly impacts Saudi Arabia, where 24% of the population lives with the disease [2,3].The prevalence of type 1 diabetes mellitus (T1DM) is notably high among children and adolescents, having more than doubled in the past decade to an average incidence of 27.2 per 100,000 people [2,3].Type 1 diabetes mellitus is marked by chronic hyperglycemia due to complete insulin deficiency, requiring lifelong insulin replacement therapy [4,5].
Adolescents with T1DM face many daily challenges, such as stringent insulin therapy regimens, dietary restrictions, regular exercise, and frequent biochemical marker monitoring [6][7][8].Historically, T1DM management has concentrated on maintaining reasonable metabolic control to prevent long-term complications [9,10].Health-related quality of life (HRQoL) has emerged as a pivotal aspect of patient care [11,12].Health-related quality of life encapsulates the impact of an individual's health status on their life quality across physical, psychological, and social domains [11,12].The importance of HRQoL is particularly amplified in T1DM, where the disease can significantly impact adolescents undergoing complex physical,

Sampling method and sample size
The research utilized a simple random technique to guarantee equitable representation of the populace, minimizing sampling bias.The Raosoft calculator (Raosoft Inc., Seattle, WA) [19] was employed to ascertain the sample size.Based on a 95% confidence level, a margin of error of 5%, an anticipated response rate of 50%, and a total diabetic patient count of 39,000 in Jazan [20], the smallest required sample size was determined to be 381.

Data collection tools and processes
Information was gathered through an online, validated, self-administered survey facilitated by various data collectors.The questionnaire was based on the Pediatric Quality of Life Diabetes Module 3.0 (PedsQL DM) [21] and comprised the following sections: Diabetes symptoms (11 questions): This scale assesses common symptoms and complications associated with diabetes, such as frequent urination, extreme thirst, and fatigue; Treatment barriers (four questions): This scale addresses difficulties in managing diabetes treatment, such as remembering to take medication or checking blood glucose levels; Treatment adherence (seven questions): This scale assesses how well the child or adolescent follows their treatment plan, such as taking medication as prescribed and following dietary guidelines; Worry (three questions): This scale assesses concerns related to having diabetes, such as worrying about blood sugar levels or future complications; Communication (three questions): This scale assesses communication with healthcare providers, such as feeling comfortable asking questions or discussing concerns.
Each item is scored on a five-point scale from 0 (never a problem) to five (almost always a problem).The scores are then reversed and transformed into a scale, with higher scores indicating better HRQoL.Total HRQoL was calculated as the sum scores of diabetes symptoms plus treatment barriers plus treatment adherence plus worry plus communication

Ethical considerations
Jazan University's Scientific Research Ethics Committee (REC) in Jazan, Saudi Arabia, under approval number REC-44/07/544, granted ethical clearance on February 5, 2023.Participants were also given a digitally accessible information letter for their electronic consent.This was displayed as an initial page before starting the online questionnaire.The research process placed significant emphasis on respecting the dignity of all participants.

Statistical analysis
The study utilized the IBM Statistical Package for the Social Sciences (SPSS) software for data analysis (IBM Corp., Armonk, NY).Initially, data were gathered from participants via Google Forms (Google Inc., Mountainview, CA), documenting characteristics such as age, gender, nationality, education level, place of residence, and health center follow-up status.After data collection, the responses were transferred to Microsoft Excel (Microsoft Corp., Redmond, WA) for cleaning and coding and subsequently imported into SPSS for comprehensive statistical analysis.Descriptive analysis was performed to generate participant demographics, followed by independent t-tests to determine significant differences in diabetes-related experiences and HRQoL based on gender, nationality, living place, and health center follow-ups.A one-way ANOVA was employed to examine differences based on age groups and education levels.In cases of significant results, Tukey post hoc tests were conducted to pinpoint the specific groups with significant differences.The study also utilized multiple linear regression analysis to identify the factors predicting HRQoL, considering the total HRQoL score as the dependent variable and age, gender, nationality, education level, living place, and health center follow-up status as independent variables.A p-value <0.05 was considered indicative of statistical significance for all the tests carried out.The results, including mean scores and standard deviations for various PedsQL DM scales, were then meticulously reported in the study's results section.

Results
This study included 236 participants, of whom the majority were female (51.3%).Regarding age, 14.8% of participants were between three and six years old, 42.8% were between the ages of seven and 12, and 42.4% were between the ages of 13 and 18.Most participants were Saudi nationals (94.5%), with 5.5% being non-Saudi.Regarding education level, 12.7% had a preliminary education, 36.0%had a primary education, 29.2% had an intermediate education, 17.8% had a secondary education, 3.4% had a collegiate education, and 0.8% were illiterate.The sample was predominantly from villages (76.7%), with 23.3% living in cities.Finally, most participants (92.4%) reported being followed up at a health center, while 7.6% did not (Table 1).Analysis revealed significant gender differences in several areas of the PedsQL DM.For the diabetes symptoms scale, males reported a higher mean score (29.77 ± 6.73) than females (27.89 ± 7.05), indicating that males perceive fewer diabetes-related symptoms.This difference was statistically significant (p = 0.038).Regarding the treatment barrier scale, male participants also reported a higher mean score (11.28 ± 3.67) than their female counterparts (10.03 ± 3.62).This result suggests that males experience fewer barriers to treatment, and this difference was statistically significant (p = 0.009).For the treatment adherence scale, although males had a slightly higher mean score (21.51 ± 4.83) than females (20.20 ± 5.75), the difference was not statistically significant (p = 0.059).On the worry scale, the mean score for males was 7.03 ± 3.22, and for females, it was 6.79 ± 2.94.This indicates similar levels of worry between male and female participants about their diabetes, with no significant difference (p = 0.562).In the communication scale, males had a significantly higher mean score (9.82 ± 2.82) than females (8.94 ± 3.34), suggesting that males are better able to communicate about their diabetes (p = 0.031).Lastly, when it comes to the overall HRQoL, male participants reported a significantly higher mean score (79.40 ± 14.65) than females (73.86 ± 16.43), indicating that males have a better perceived HRQoL (p = 0.007).
The differences in diabetes-specific quality of life based on nationality using the PedsQL DM are shown in Table 3.  Independent sample t-tests revealed no significant difference between Saudi and non-Saudi participants on the diabetes symptoms scale (p = 0.114), the treatment barrier scale (p = 0.718), or the worry scale (p = 0.592).However, statistically significant differences were found on the treatment adherence scale (p = 0.   Independent sample t-tests revealed no significant differences between participants from city and village on any of the PedsQL, which were diabetes symptoms (p = 0.555), treatment barriers (p = 0.125), treatment adherence (p = 0.793), worry (p = 0.545), communication (p = 0.531), or total HRQoL (p = 0.441).Participants living in cities had similar mean scores for all diabetes modules as those living in villages.
Independent sample t-tests revealed no significant differences between those who did versus did not follow up at a health center on any of the PedsQL DM scales: diabetes symptoms (p = 0.610), treatment barriers (p = 0.529), treatment adherence (p = 0.312), worry (p = 0.615), communication (p = 0.322), or total HRQoL (p = 0.314).Total HRQoL was comparable between those who did (M = 76.86,SD = 15.43) and did not (M = 72.94,SD = 19.96)follow up at a health center (  A one-way ANOVA was conducted to examine differences in diabetes-specific quality of life based on age group (three to six years, seven to 12 years, and 13-18 years) using the PedsQL DM.There were no significant differences between the age groups on the diabetes symptoms, treatment adherence, worry, communication, and total HRQoL scales.However, a significant difference emerged for the treatment barrier scale.Post-hoc analyses revealed that 13-18-year-olds (M = 11.33) reported significantly lower treatment barriers and better quality of life than three-to six-year-olds (M = 8.40, p = 0.000).Additionally, three-to six-year-olds reported significantly higher treatment barriers and worse quality of life than seven-to 12year-olds (M = 10.73,p = 0.003) (Table 6).A one-way ANOVA was conducted to examine differences in diabetes-specific quality of life based on education level using the PedsQL DM.There was no significant effect of education level on diabetes symptoms (p = 0.230), treatment adherence (p = 0.905), worry (p = 0.274), communication (p = 0.729), or total HRQoL (p = 0.767).However, education level significantly affected treatment barriers (p = 0.030).Tukey's post hoc test revealed that there was a significant difference between the intermediate education group and the preliminary education group for the dependent variable treatment barrier (p = 0.038).The intermediate education group had significantly lower treatment barriers than the preliminary education group (Table 7).A multiple linear regression analysis was conducted to determine factors predicting HRQoL in the sample.The dependent variable was the total HRQoL score.The independent variables included in the analysis were age, gender, nationality, education level, living place, and whether participants were followed up at a health center.Of the predictor variables, only gender had a significant association with HRQoL.Being female was associated with a 5.403 lower HRQoL score than being male (β = -0.171,p = 0.009).Age, nationality, education level, living situation, and following up at a health center did not significantly predict HRQoL (p > 0.05) (Table 8).

Discussion
This study delves into HRQoL assessment among adolescents and children diagnosed with T1DM in the Jazan region of Saudi Arabia, unearthing several significant findings.One salient observation was the existence of distinct HRQoL disparities based on gender, nationality, and age.An intriguing pattern emerged wherein male participants reported superior HRQoL compared to their female counterparts, echoing the outcomes of earlier studies [22][23][24][25][26].This divergence could be attributed to the heightened perception of symptoms, communication challenges, and treatment hurdles that females encounter.Girls face additional stressors such as concerns over body image, self-esteem, and societal acceptance.Moreover, a fear of hypoglycemia can induce anxiety and restrict their activities, detrimentally impacting their quality of life [27].Hormonal fluctuations that affect blood glucose levels exacerbate this fear, particularly for girls, impeding their participation in sports and other social events [28].These factors collectively contribute to increased stress and diminished quality of life in females [27,29,30].
The data also revealed significant differences in HRQoL between Saudi and non-Saudi participants, with the latter group reporting improved treatment adherence, communication, and overall HRQoL.This intriguing finding necessitates further exploration to discern whether cultural discrepancies or socioeconomic factors underpin these disparities [30].Age-wise, the research indicated that older adolescents aged 13-18 years (M = 11.33) reported significantly lower treatment barriers than younger age groups, indicating a better quality of life.The youngest group of children (three to six years, M = 8.40) experienced the highest treatment barriers, significantly more than the seven-to-12-year-olds (M = 10.73).These results align with studies suggesting that older adolescents may become more adept at managing their condition and more resilient in the face of treatment-related challenges [31].On the other hand, the youngest children (three to six years) who reported the highest treatment barriers might be more reliant on their caregivers for diabetes management and therefore perceive greater barriers.This is supported by research indicating that younger children may feel more overwhelmed by the daily demands of diabetes care [32].However, it is essential to note that no significant differences were found between the age groups regarding diabetes symptoms, treatment adherence, worry, communication, and total HRQoL scales.
Regarding education, the study highlighted that those in the intermediate education group faced fewer treatment barriers compared to the preliminary education group.This suggests that fostering a more comprehensive understanding of diabetes care in the intermediate stage could help reduce treatment barriers [33][34][35].Contrary to some earlier studies [35,36], our research found no discernible differences in HRQoL based on the place of residence (city vs. village) and regular health center follow-ups, despite the traditionally perceived lower HRQoL in rural areas due to limited healthcare access [35][36][37].
The analysis of multiple linear regression has pinpointed gender as the primary significant predictor of HRQoL, revealing that girls tend to report lower HRQoL scores compared to boys.This observation is in harmony with the outcomes of the t-test, underscoring the pivotal influence of gender on the management and treatment approaches for adolescent diabetes.The insights derived from this study are particularly valuable for understanding the HRQoL among children and adolescents with T1DM in the Jazan region.These insights lay the groundwork for designing interventions that are tailored to improve HRQoL within this specific population.There is a clear need for increased attention to bolster the quality of life for the groups identified as high-risk in this research.By doing so, healthcare providers and policymakers can work towards ensuring that these vulnerable groups receive the support they need to lead better-quality lives while managing their conditions.

Study limitations
In assessing the HRQoL of children and adolescents with T1DM in Saudi Arabia's Jazan region, this study revealed discernible disparities across various demographic groups.Contrasting male and female experiences, males reported higher HRQoL, perceived fewer diabetes symptoms, encountered fewer treatment barriers, and showed superior communication ability.When nationality was considered, non-Saudi participants presented better overall HRQoL outcomes compared to their Saudi counterparts.The study also observed a notable age-related disparity, where older children (13-18 years) faced fewer treatment barriers and demonstrated higher HRQoL than their younger counterparts (three to six years).Education emerged as another significant factor, with those with an intermediate education level encountering fewer treatment barriers than those with only a preliminary education.Interestingly, the living situation and frequency of healthcare follow-ups did not significantly impact HRQoL.However, gender was the predominant predictor of HRQoL, with female participants scoring significantly lower.The evidence of disparities in HRQoL outcomes among these groups signifies the need for targeted interventions, particularly for high-risk demographics such as females, younger children, Saudis, and those who are less educated.Future research should also explore other factors influencing the HRQoL of T1DM patients.
Altogether, this study offers critical baseline data for understanding the disparities in HRQoL among children and adolescents with T1DM in the Jazan region of Saudi Arabia.

Conclusions
This study found that among children and adolescents with T1DM in the Jazan region of Saudi Arabia, males reported a higher HRQoL than females, with fewer symptoms, treatment barriers, and better communication.Non-Saudis also had better HRQoL outcomes compared to Saudis.Interestingly, older children (13-18 years) faced fewer treatment barriers and had a higher HRQoL than younger children (three to six years).Those with intermediate education also had fewer treatment barriers than those with preliminary education.Gender was the main predictor of overall HRQoL, with females having significantly lower scores.No differences were seen based on the living situation or healthcare follow-up.These results indicate disparities in diabetes-related HRQoL, with males, non-Saudis, older children, and those with more education faring better.The findings highlight the need for targeted interventions to improve HRQoL among high-risk demographic groups like females, younger children, Saudis, and those with less education.Further research should explore additional factors influencing T1DM patients' lives.Overall, this study provides important baseline data on disparities in HRQoL in T1DM among Saudi children and adolescents in the Jazan region.

TABLE 2 : Analysis of the PedsQL DM with gender
N: number; PedsQL DM: Pediatric Quality of Life Inventory Diabetes Module; SD: standard deviation; HRQoL: health-related quality of life; p < 0.05 is considered significant

TABLE 3 : Analysis of the PedsQL DM with nationality
N: number; PedsQL DM: Pediatric Quality of Life Inventory Diabetes Module; HRQoL: health-related quality of life; SD: standard deviation; p < 0.05 is considered significant

Table 4
shows differences in diabetes-specific quality of life based on the place of residence (city vs. village) using the PedsQL DM.

TABLE 4 : Analysis of the PedsQL DM with the place of residence
N: number; PedsQL DM: Pediatric Quality of Life Inventory Diabetes Module; SD: standard deviation; HRQoL: health-related quality of life; p < 0.05 is considered significant

TABLE 5 : Analysis of the PedsQL DM with the participants' follow-up status at the health center
PedsQL DM: Pediatric Quality of Life Inventory Diabetes Module; HRQoL: health-related quality of life; N: number; SD: standard deviation; p < 0.05 is considered significant

TABLE 6 : Analysis of the PedsQL DM with age groups
PedsQL DM: Pediatric Quality of Life Inventory Diabetes Module; HRQoL: health-related quality of life; p < 0.05 is considered significant

TABLE 8 : The dependent variable in regression analysis for all models is the total HRQoL
SD. error (B): standard error of the unstandardized regression coefficient B; T: t-statistic; CI: confidence interval; HRQoL: health-related quality of life; p < 0.05 is considered significant.