University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES SOCIO-ECONOMIC BURDEN OF TYPE-2 DIABETES AMONG PATIENTS ATTENDING PANTANG GOVERNMENT HOSPITAL BY MARGARET SERWAA AMOAKO (INDEX: 10637877) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, MARGARET SERWAA AMOAKO hereby declare that this dissertation is a result of my independent work. References to other works have been duly acknowledged. I further declare that this dissertation has not been submitted for award of any degree in that institution and other universities elsewhere. Signature ……………………… Date…………………………… MARGARET SERWAA AMOAKO (STUDENT) Signature …………………….. Date……………………..……… Dr. IRENE KRETCHY (ACADEMIC SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to my late parents, my supervisor and all my friends for their support in diverse ways including prayer and encouragement that has enabled me to reach this far. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENT First and foremost, I thank God who is the source of my knowledge, wisdom and strength with which I am able to accomplish this work. Secondly, I would like to extend my heartfelt acknowledgment to the authorities of Pantang Hospital for the assistance I received from officers in charge of doctors and the nurses at the outpatient divisions and various in-charges and the participants for their support during my data collection in the hospital. I am grateful to my supervisor Dr. IRENE KRETCHY from the School of Pharmacy, University of Ghana, Legon for her support and guidance. Also thank the Department of Social and Behavioral Sciences (SOBS) lecturers and all staff in the School of Public Health, University of Ghana, Legon. May God richly bless you all. Moreover, grateful thanks to the Chairman of the Ethical Committee, especially for their approval and support to allow me to collect my data. Thanks, directed to my friends and colleagues in the Social and Behavioral Science Department (2017-2018) with which I shared knowledge, experience and leisure time. Also, grateful thanks to Pastor E.P Mensah, Mr. Samuel Antwi, George Marfo, Pastor Danso, Mr and Mrs David Tuah and Dr Sarfo SPH, for their support, encouragement and for financing my education. May God bless you all. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction Type-2 Diabetes is fast attaining pandemic levels. Globally, it exerts a huge toll on patients and society, physical, financial and psychosocial burden. The objectives of the study include were the following: to estimate the direct treatment cost (consultation, lab test, treatments) of type-2 diabetes, to estimate the indirect treatment cost (working hours lost, lost wages) of type-2 diabetes, to determine intangible cost (physical pain, psychological pain, social isolation, anxiety, stress, depression, stigmatization, self-esteem etc.) associated with type-2 diabetes. Methods The study was a cross-sectional survey study which adopted the cost-of-illness approach to estimate the socio-economic burden of type-2 diabetes patients. The explanatory variables were direct, indirect and intangible costs (including socio-behavior factors) of type-2 diabetes. The study participants were patients with type-2 diabetes who sought care at the out-patient division of Pantang Government Hospital. The study relied on consecutive random sampling technique. Data were analyzed using STATA 13 and the excel version 2007. Results The overall total direct medical cost and direct non-medical cost of type-2 diabetics was estimated to be GHS 30,693.50 (USD$ 138, 910.95) with total direct average cost of GHS 4,384.79. With the indirect medical cost, the overall value of time absent from productive work within past month was estimated as GHS 1,268.08 (US$ 589.50). The mean indirect cost was GHS 93.67 (95% CI: 0-88.54). With the intangible medical cost, a higher percentage of complicated diabetic patients suffered severe physical pains (37.86%). The majority of the iv University of Ghana http://ugspace.ug.edu.gh patients also indicated that, they got fatigued due to diabetes. About 36.9% of the diabetic patients reported feeling depressed often while 26.7% were always depressed. Conclusion The analysis of estimated total treatment cost and related intangible burden of type-2 diabetes suggest that the disease posed socio-economic burden on individuals. The complexity of the disease requires constant and regular treatment regime to avoid complications and its associated cost burden. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGMENT................................................................................................................ iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ........................................................................................................................ x LIST OF ABBREVIATION .......................................................................................................... xi CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background of the study ....................................................................................................... 1 1.2 Statement of Problem ............................................................................................................ 3 1.3 Justification of the Study ....................................................................................................... 4 1.4 Research Question ................................................................................................................. 5 1.5 Aim and Objectives ............................................................................................................... 5 1.5.1 Aim ................................................................................................................................. 5 1.5.2 Specific Objectives ......................................................................................................... 5 CHAPTER TWO ............................................................................................................................ 9 LITERATURE REVIEW ............................................................................................................... 9 2.1 The Diabetes Disease ............................................................................................................ 9 2.2 Forms of diabetes .................................................................................................................. 9 2.3 Insulin Therapy ................................................................................................................... 12 2.4 Global Socio-Economic Burden of Type-2 Diabetes .......................................................... 14 vi University of Ghana http://ugspace.ug.edu.gh 2.4.1 Direct Cost of Diabetes Disease ................................................................................... 16 2.4.2 Direct Cost to individuals ............................................................................................. 16 2.4.3 Direct cost on governments .......................................................................................... 18 2.4.4 Indirect Cost of Diabetes Disease ................................................................................. 20 2.4.5 Intangible Cost of Diabetes Disease ............................................................................. 21 2.4.6 Socio-economic Status and Diabetes ............................................................................ 22 2.5 Risk Factors for Type-2 Diabetes ....................................................................................... 23 2.6 Conclusion ........................................................................................................................... 26 CHAPTER THREE ...................................................................................................................... 27 METHODOLODY ....................................................................................................................... 27 3.1 Study Design ....................................................................................................................... 27 3.2 Study Area ........................................................................................................................... 27 3.3 Study Variables ................................................................................................................... 28 3.4 Sampling.............................................................................................................................. 29 3.4.1 Study Population........................................................................................................... 29 3.4.2 Sample Size .................................................................................................................. 29 3.4.3 Sampling Procedure ......................................................................................................... 30 3.5 Data Collection Technique and Tools ................................................................................. 30 3.6 Quality Control .................................................................................................................... 30 3.7 Pre-testing of Questionnaire ................................................................................................ 30 3.9 Data Analysis ...................................................................................................................... 32 CHAPTER FOUR ......................................................................................................................... 34 RESULTS ..................................................................................................................................... 34 1.1 Introduction .................................................................................................................... 34 4.1 Demographic Background of the respondents .................................................................... 34 vii University of Ghana http://ugspace.ug.edu.gh 4.2 Direct Treatment Cost of Type-2 Diabetes ......................................................................... 36 4.2.1 Direct Medical Cost ...................................................................................................... 36 4.2.2 Direct Non-Medical Cost .............................................................................................. 37 4.2.3 Total Direct cost of Type-2 Diabetes ........................................................................... 38 4.2.4. Indirect treatment cost of type-2-diabetes ................................................................... 40 4.2.5  Intang ible Cost assoc iated w ith Type-2 D iabetes ....................................................... 43 CHAPTER F IVE .......................................................................................................................... 46 D ISCUSS ION .............................................................................................................................. 46 5.1 D irect Treatment Cost of Type-2 D iabetes......................................................................... 46 5.2  Ind irect Treatment Cost of Type-2 D iabetes ...................................................................... 48 5.3  Intang ible Cost Assoc iated w ith Type-2 D iabetes ............................................................ 50 5.4 L im itat ion of the Study ................................................................................................. 51 CHAPTER S IX............................................................................................................................. 52 CONCLUS IONS AND RECOMMEDAT IONS ......................................................................... 52 6.1 Conclusion  .......................................................................................................................... 52 6.2 Recommendation ................................................................................................................. 53 REFERENCE ................................................................................................................................ 55 APPENDIX ................................................................................................................................... 57 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Study Variables ............................................................................................................... 28 Table 2: Socio-demographic characteristics of study ................................................................... 35 Table 3: Direct Medical Cost ........................................................................................................ 37 Table 4: Direct Non-Medical Cost ................................................................................................ 38 Table 5: Total Direct Cost of Type-2 Diabetes ............................................................................. 39 Table 6: Total indirect cost of diabetes disease ............................................................................ 43 Table 7:  Intang ible cost (phys ical pa in, psycholog ical pa in, soc ial  isolat ion, anx iety, stress, Table depress ion, st igmat izat ion, self-esteem etc.) ..................................................................... 44 Table 8: Intang ible cost (phys ical pa in, psycholog ical pa in, soc ial  isolat ion, anx iety, stress, Table depress ion, st igmat izat ion, and self-esteem) ..................................................................... 45 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework ................................................................................................... 8 Figure 2: Number of days absent from work by Diabetes Pat ients .............................................. 40 Figure 3: Travelling times of Diabetes Patients ............................................................................ 41 Figure 4: Waiting times of Diabetes Patients ............................................................................... 42 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATION NCDs …………………………………................Non-communicable diseases CVD……………………………….......................Cardiovascular diseases WHO……………………………………………...World health organization GHS………………………………………………Ghana health service LMIC…………………………………………......Low middle-income countries GAR……………………………………................Greater Accra Region NPH……………………………….........................Neutral Protamine Hagedorn OPD ………………………………........................Out-patient Department RAPIA ………………………………....................Rapid Assessment Protocol for Insulin Access EU…………………………………………............Europe, Union USA………………………………………............United State of America NHIS…………………………….............................National Health Insurance Scheme CI……………………………………....................Confidence interval xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of the study Non-communicable diseases (NCDs) will be the leading cause of mortality worldwide by 2030 (Mather’s & Lon car, 2006). The contribution of cardiovascular disease (CVD) to overall disease burden is determined by the risk factors associated with diabetes and hypertension (Lon car, 2006). Diabetes is a chronic illness that occurs either when the patient does not produce enough insulin or when the insulin cannot be used. Insulin is a hormone that regulate sugar. Hyperglycaemia or raised blood sugar is a common symptom of uncontrolled diabetes, and overtime leads to serious damage of the body’s systems, especially the nerves and blood vessels. In 2014, 8.5% of adults aged 18 years and older had diabetes and the World Health Organization (WHO) projects that diabetes will be the sixth leading cause of death by the year 2030. Progressive globalization and industrialization have brought about changes in the environment and lifestyle. This has led to more deskbound jobs, increased availability and high consumption of drinks, foods with high sugar, fat and salt content which results in rapid increase of diabetes (Kolb & Mandrel-Poulsen, 2010). According to the International Diabetes Federation (2009), four out of every five people with diabetes will soon live in developing countries. Type-2 diabetes is much more common and accounts for 90% to 95% of people with diabetes in sub-Saharan Africa (Hall et al., 2011). Diabetes is a cardiovascular metabolism disease with characteristics of chronic high blood glucose levels (fasting glucose level 6.1 mom/L or 108 mg/dL and above) and a high risk of complications such as retinopathy (eyes damage), nephropathy (kidneys damage), neuropathy (nervous system damage), hearing impairment, 1 University of Ghana http://ugspace.ug.edu.gh Alzheima and CVD (Strine et al., 2005). In addition, adults with diabetes have two to three-fold increased risk of heart and strokes. Combined with reduce blood flow, there is an increase in damaged nerves in the feet, foot ulcer, infections and eventual limb amputation and kidney failure (Mathers CD, Loncar et al.,2006). The World Economic Forum (2009) reported that non-communicable disease burden is among the five most severe economic risk globally. Substantial economic losses in developing economies are as a result of reduced productivity caused by NCDs (Tunstall-Pekoe, 2006). To add to this burden of huge costs, diabetic patients and their families commonly go through various forms of psychological and emotional stress due to the chronic nature and complications associated with the disease (International Diabetes Federation, 2009). Abegunde et al. (2007) recommended that attention needs to be paid to the risk associated with chronic diseases, including diabetes in low and middle-income countries (LMICs) due to the huge socio-economic burden it poses. In Nigeria, diabetes was found to be among the top three non-communicable diseases reported at out-patient departments (Abegunde et al., 2007). Kumi- Ampofo (2015) reported that financial and non-financial household cost of diabetes mellitus in Ghana account for over two-thirds of household income. Diabetes is also associated with other economic cost (Kumi-Ampofo, 2015). These include direct cost comprising the cost of treatment. Indirect cost include lost wages due to diabetes and its accompanying complications and intangible costs such as physical, psychological (pains, stress, anxiety) and reduced quality of life (Brown et al., 2014; WHO, 2005). Notwithstanding the significant economic cost incurred by patients living with type-2 diabetes, there is limited study especially in sub-Saharan Africa on the socio-economic burden on people living with the disease. 2 University of Ghana http://ugspace.ug.edu.gh 1.2 Statement of Problem In Ghana, diabetes was among the top three non-communicable disease of recorded out-patient department (OPD) cases, increasing from 39,789 in 2005 to 156,076 in 2010 (NCDCP-Ghana, 2010). Cases of diabetes have been observed disproportionately among the poor who are most vulnerable to disease complications and mortality (GHS, 2014). Studies have shown that more than 50% of people living with diabetes are not aware of their condition. Although diabetes is common among adults, those aged 40 and over; recently, many cases of the disease among children have been recorded. This has been attributed to unhealthy personal behaviours or lifestyle. Abegunde et al. (2007) lamented about the implication of chronic diseases, including diabetes in LMICs. He asserted that the risk of chronic diseases such as diabetes and hypertension should be reduced considering their impact on economic production. Studies show that for every estimated 10% rise in NCD-related mortality, there is a decline in annual economic growth by 0.5% (Gameau et al., 2010). The costs associated with diabetes, especially its complications create a considerable socio-economic burden for patients, families, and society (Gilmer et al, 2005). The main driver of total cost is direct medical cost (Tague, 2012; Henriksen et al., 2000; Kirgizia et al., 2009). In order to aid stakeholders develop better and more effective strategies to ensure that diabetic patients live a longer and better life, there is a need to understand the socio-economic burden of diabetes and more importantly, its complications and comorbidities. This study therefore sought to estimate the socio-economic burden of type-2 diabetes among patients attending the Pantang Government Hospital while noting issues of complication and comorbidities. 3 University of Ghana http://ugspace.ug.edu.gh 1.3 Justification of the Study Diabetes is associated with great economic cost. These include direct costs (medical and non- medical cost of treatment), indirect (e.g. lost wages) and intangible costs such as physical and psychological pains, stress, anxiety and reduced quality of life (Brown et al., 2014). Furthermore, families with members who have complicated diabetes condition bear the brunt of higher out-of- pocket expenses which invariably reduce household earnings and lower quality of life (Dall et al., 2010). There are, however, limited studies in sub-Saharan Africa on the socio-economic burden of diabetes, of which Ghana is no exception. This is mainly due to unavailability of data, especially on the loss of income and productivity. Subsequently, even though a number of studies have been conducted in developed countries on diabetes, most of these studies have been on the type-1 diabetes. Studies on type-2 diabetes in sub-Saharan African countries is scarce despite its prevalence on the continent. In the Greater Accra Region of Ghana, for example, diabetes is one of the top five health condition (GHS-GRA,2012). Diabetic patients in Sub-Saharan Africa qhave greater risk of serious complications and the cost of treatment is high as well (Kirigia et al., 2009; Mbanya et al., 2014). Some complications include neural damage, foot ulcer leading to amputation, heart attack, kidney damage and blindness. Patients with diabetes also suffer from emotional distress, anxiety and physical and psychological pains. It is the number six cause of admission, accounting for 2.4% of all admissions and number nine cause of death, accounting for 2.8% of all death in the region (GHS- GRA, 2012). The attention of government, policy makers and other stakeholders must therefore be drawn to the relevance of affordable and accessible type-2 diabetes care. Estimating the socio- economic burden of this disease is a way to achieve this aim. 4 University of Ghana http://ugspace.ug.edu.gh This study will provide an overall view of the socio-economic burden of type-2 diabetes on the patient which may inform government and policy makers about the allocation of resources. The study may also be useful in strategic planning and budgeting to facilitate easy access to type-2 diabetes care in other health facilities. Aside from specifically estimating the socio-economic burden of type-2 diabetes disease at the Pantang Government Hospital, information gathered by this study may be relevant for future studies. 1.4 Research Question 1. What is the direct treatment cost (consultation, lab test, treatments) of type-2 diabetes? 2. What is the indirect treatment cost (working hours lost, lost wages) of type-2 diabetes? 3. What is the intangible cost (physical pain, psychological pain, social isolation, anxiety, stress, depression, stigmatization, self-esteem etc.) associated with type-2 diabetes? 1.5 Aim and Objectives 1.5.1 Aim The general objective of this study was to determine the socio-economic burden of type-2 diabetes among patients attending Pantang Government Hospital. 1.5.2 Specific Objectives 1. Estimate the direct treatment cost (consultation, lab test, treatments) of type-2 diabetes. 2. Estimate the indirect treatment cost (working hours lost, lost wages) of type-2 diabetes. 3. Determine intangible cost (physical pain, psychological pain, social isolation, anxiety, stress, depression, stigmatization, self-esteem etc.) associated with type-2 diabetes. 5 University of Ghana http://ugspace.ug.edu.gh 6 University of Ghana http://ugspace.ug.edu.gh Conceptual Framework of socio-economic burden of Type-2 Diabetes Figure 1 conceptual frame work shows the theoretical relationship between type-2 diabetes and its socio-economic burden on the people living with diabetes. The framework was based on the cost-of-illness concept. Many people living with diabetes suffer certain comorbidities and complications (e.g. neuropathy, nephropathy, retinopathy, foot ulcer, skin conditions, hearing impairment etc.) which exerts a heavy socio-economic burden on patients and households. Key among costs associated with treatment of diabetes complications are direct cost, indirect cost (i.e. lost productivity, income and assets) and intangible cost (i.e. pain, anxiety, stress, isolation etc.). The direct cost is made up of two components: medical and non-medical cost. Medical cost includes expenditure on medical product and services such as medication, hospitalization and other treatment. Non-medical direct cost includes cost of visits to the health facilities (e.g. transportation), diet and other subsistence expenses. Indirect cost in the conceptual framework were the severe complications, absenteeism, disability, premature retirement and premature mortality leading to productivity loss (WHO, 2015). Individuals suffering from diabetes complications also bear the brunt of pains and suffering in the form of anxiety, stress, and isolation, physical and psychological pains, all of which constitute intangible costs. Pain and suffering reduce quality of life of people living with diabetes. The sum of all of these costs constitutes the socio-economic burden of type-2 diabetes. 7 University of Ghana http://ugspace.ug.edu.gh Figure 1: Conceptual Framework 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW This chapter reviews available literature on type-2 diabetes. The review aims to provide insight into the cost burden associated with management of the disease. It focused on: diabetes and its related comorbidities and complications, and direct, indirect and intangible cost associated with the disease as documented in the scientific literature. 2.1 The Diabetes Disease Diabetes mellitus (or diabetes) is a chronic, metabolic, lifelong disease that affects the body's ability to use the energy found in food.  It occurs when the pancreas does not produce sufficient insulin, or when the body cannot effectively use the insulin it produces. Uncontrolled diabetes over time causes hyperglycaemia or raised blood sugar which leads to serious damage to some parts of the body such as the heart, blood vessels, eyes, k idneys, nerves etc. Type-1 diabetes also known as insulin-dependent diabetes usually occurs in children and it is a chronic condition in which the pancreas produces little or no insulin by itself. Most people w ith the type-1 diabetes also have the type-2 diabetes which is usually found in adults. It occurs when the body becomes resistant to insulin or does not make enough insulin. 2.2 Forms of diabetes Generally, diabetes is categorized into three major forms: diabetes type-1, d diabetes type-2 and gestat ional diabetes. 9 University of Ghana http://ugspace.ug.edu.gh Type-1 Diabetes Diabetes Type 1 is not preventable with current knowledge and was previously referred to as insulin -dependent, juvenile or childhood-onset diabetes. The cause of diabetes type 1 isst ill not known. However, the risk for developing type 1 diabetes has been l inked to exposure to some viral infect ions or environmental factors. Also, the risk for developing the disease slightly increases if there is a family member with the disease (IDF, 2014). Diabetes type-1 is identified by the lack of insulin production by the pancreas and requires daily administration of insulin. Symptoms of type-1 diabetes include polyuria (excessive urine), polydipsia (excessive thirst), weight loss, changes in vision, tiredness and constant hunger (WHO, 2015).   Type-2 Diabetes Diabetes type-2, also known as non-insulin dependent or adult-onset diabetes, occurs as a result of the body’s ineffective insulin usage. The common causes of diabetes type-2 are unhealthy diet, lack of physical activity and obesity (overweight). Its symptoms are similar to that of diabetes type-1, except that they are less obvious. Hence, they are very difficult to be diagnosed in the early stages and as a result complication would have already arisen (WHO, 2015). Diabetes type-2 was previously observed only among adults but can now be diagnosed at any age, even among children.  It is not always, but usually it is associated with obese or overweight people with a sedentary lifestyle. Other risk factors that could lead to the development of diabetes type-2 include family history and history of gestational diabetes. It is often diagnosed when complications appear (e.g. kidney failure, blindness, lower limb amputation, cardiovascular disease) or when a routine blood or urine glucose test is done. 10 University of Ghana http://ugspace.ug.edu.gh During the early stages, diabetes type-2 can be managed through healthy diet and regular physical activity but as it progresses, there will be a need for oral drug or insulin ( IDF, 2014). Management and treatment of type-2 diabetes require monitoring the blood glucose level which can be done by a caregiver or the patients themselves. This helps caregivers and the patients to access and follow the efficiency of their glycemic control plan. Diabetes screening should be done for overweight children starting at the age of 10 and repeated every 2 years, same for adults with body mass index (BMI) of 25 and above, adults aged 45 years and above; repeating it every other 3 years. Every three months, examinations of blood pressure, eyes as well as skin and bones in feet and legs should be done to prevent diabetes- related complications. Gestational diabetes Gestational diabetes occurs to women during pregnancy.  It is indicated by hyperglycaemia with above normal blood glucose levels. When this happens, the risk of complications during pregnancy and at delivery is increased. Also, the possibility of having diabetes type-2 in the future is higher. Gestational diabetes is determined through prenatal screening instead of reported symptoms. (WHO, 2015a.). The thesis focuses on type-2 diabetes because it is becoming an increasingly common disease among all ages and it is riddled with poor management, leading to micro and macro vascular complications. These complications can minimize quality of life and increase morbidity and mortality rate (WHO, 2015a). 11 University of Ghana http://ugspace.ug.edu.gh 2.3 Insulin Therapy Insulin therapy was usually initiated by practitioners in the majority of type-2 diabetic patients in order to reach a desired and optimal glycaemia control (HbA1C <6) when the combination of non-insulin therapies and changes in lifestyle do not produce a satisfactory glycaemia control. Different kinds of individual factors such as type of diabetes, the patient’s degree of interest, patient needs, presence of diabetic complication (e.g. blindness), the patient’s job and financial situation may influence the decision to start insulin therapy and a final decision should be made only after having a full discussion with the patient. A potential insulin therapy’s side effect, hypoglycaemia, weight gain as well as patient’s own reluctance to monitor blood glucose in addition to needle phobia are the common reasons why some patients want to or try to avoid insulin therapy. Some patients also belive insulin therapy is a sign that they have failed their treatment and would rather prefer to live with poor glycaemia control instead of starting insulin inject ion. Therefore, it is the duty of the healthcare professional to educate and help patients to accept and start insulin therapy in order to succeed. Oral anti- diabetics such as metformin, sulfonylurea, sitagliptin and pioglitazone may still be continued or used while using insulin unless contraindicated (Morr is 2011, 496.)  Insulin therapy generally consists of three insulin regiments, namely basal, prandial, and premixed insulins Basal insulin is the most common starting point for insulin therapy initiation consisting of glargine, detemir and Neutral Protamine Hagedorn (NPH) and a dosage of once daily. They reduce pre-prandial glucose level, minimize the level of fasting glucose and weight gain with a low risk of both nocturnal and pre-breakfast hypoglycaem ia. This is achieved by basal insulin’s function of indicating the amount of insulin required to minimize the liver’s production of 12 University of Ghana http://ugspace.ug.edu.gh glucose and maintain good glucose levels between meals (Spollet, 2012). Basal insulin is usually started when the HbA1c level is less than about 9.5%. (Morr is, 2011). Prandial insulin (Rap id & short-acting insulin) according to Spollet (2012) is short-acting insulin administered as a bolus to regulate postprand ial hyperglycaemia.  It is given before meal as a replacement therapy for basal insulin, or as an add-on therapy to the basal insulin. This has a quicker onset effect with a shorter acting time. Hence, producing a great reduction in the glycaemia levels. The act ions of the prandial insulin could be fast and/or short. The fast/rap id acting prandial insulin should be taken during meals, while the short acting prandial insulin should be injected 30 minutes before meal. There is an increased risk of hypoglycaemia if prandial insulin is not injected at the right time. Types of prandial insulin analogues include:  insulin as part (novolog), glulisine (apidra) and lispro (Humalog) (Boyle, 2008). Morr is (2011) stated that this is given or intensified when basal insulin does not achieve the required glucose level or when the HbA1c level  is greater than 9.5%. Premixed Insulin therapy is a premixed combination of a fixed dose of basal and regular or analogue rap id-acting insulin used twice or thrice daily with meals if greater control is required. Patients may, however, switch back to the basal-bolus therapy if an excellent or desired glucose control is not achieved after two or three premix insulin injections. Premixed insulin also has a high risk of hypoglycemia if not used at the right time (Spollet, 2012). According to Nice (2009), pre-mixed insulin therapy should be considered if a patient’s HbA1C> = 9. For people with type-2 diabetes, keeping blood glucose levels at normal (fasting glucose level below 6.1 moll/L or 108 mg/ld.) levels depends on release and functioning of insulin from the 13 University of Ghana http://ugspace.ug.edu.gh pancreas. However, the targeted cells of people with type-2 diabetes are not reactive to insulin effect thereby resulting in large amount of glucose circulation. Certain lifestyle factors like smoking, sedentariness, and high dietary fat intake promote the development of insulin resistance by the targeted cells. Insulin is a commonly used medication for the treatment of type-2 diabetes. For people living with diabetes, access to affordable treatment as well as insulin is critical to their survival. Long standing evidence shows that early insulin treatment has a significant effect in delaying or preventing complications (Solar, 2010; American Diabetes Association, 2010). 2.4 Global Socio-Economic Burden of Type-2 Diabetes Diabetes is a growing global challenge for both developed and developing countries and healthcare systems. Cost estimates from literature reviewed highlight the substantial burden that diabetes imposes on society. Diabetes substantially causes premature mortality and the situation is projected to worsen, particularly in low and middle- income countries. Prevalence of type-2 diabetes  is projected to  increase by 69%  in adults  in low and middle- income countries and 20%  in developed countries between 2010 and 2030 (Relic & Unwin, 2010). Whiting et al. (2011) further reported that majority of people with diabetes live in low and middle- income countries, and by 2030 these countries will witness the highest increase. Hence, there is urgent need to invest in prevent ion to mitigate the burden (Shaw et al., 2010). In 2007, medical costs attributed to diabetes include $27 b ill ion for care to directly treat diabetes, $58 b ill ion to treat the port ion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs. American Diabetes Association (2008) reported that the estimated cost of diagnosed diabetes was $174 b ill ion, which comprised of $116 b ill ion in excess medical expenditures and reduced national 14 University of Ghana http://ugspace.ug.edu.gh productivity of $58 b ill ion in 2007. Furthermore, annual medical costs per person on type-2 diabetes is US$9,677 (Dell et al., 2010). Dall et al. (2010) estimated productivity loss due to higher levels of work absentee ism, disability and early mortality to be US$65 b ill ion. In addition, families with members who have complicated diabetes condition bear the burden of higher out-of-pocket expenses and reduced earnings as well as low quality of life.  In sub-Saharan Africa, risk of diabetes complications is great and costly (Hall et al., 2011; Ortegon et al., 2012). These include emotional distress (Aikins, 2005; Brown et al., 2014), stroke (Kengne et al., 2005), neural damage leading to amputation, heart attack, kidney damage and blindness (Nisar et al., 2015), and also reduced life expectancy (WHO, 2005).  It is estimated that one-third of the world’s population lacks consistent access to necessary medications partly due to the high price in the private market (WHO, 2005).  In LM ICs of sub- Sahara Africa, diabetes management is a challenge because many people do not have access to a reliable, affordable supply of insulin. Despite  initiatives from  insulin-producing companies, including Novo Nordisk that have attempted to  improve  insulin supply by  introducing price differentials, the price of  insulin to the user  is usually  inflated along the distribution chain. A number of initiatives to improve the situation have been advanced by the International Insulin Foundation. This  includes a practical guide called Rap id Assessment Protocol for  Insulin Access (RAP IA) that enables evaluation of access that diabetics have to both diabetes care and  insulin (Beran et al., 2005). The RAP IA have been piloted in Mozambique, Zambia, Mali and Nicaragua (Diabetes Leadership Forum - Africa, 2010). 15 University of Ghana http://ugspace.ug.edu.gh 2.4.1 Direct Cost of Diabetes Disease The direct costs of diabetes disease to individuals and their families include medical care, drugs, insulin and other supplies.  In add it ion to these, in some countries, patients may also bear other personal costs, such as increased payments for health, life and automobile insurance (WHO, 2015). Also, there is direct costs to the healthcare sector which include hospital services, physician services, laboratory tests and the daily management of diabetes by use of products such as insulin, syringes, oral hypoglycemic agents and blood-testing equipment (WHO, 2015). Direct cost of diabetes ranges from relatively low-cost items such as primary-care consultations to very high-cost items such as long hospitalization for treatment of complications (WHO, 2015). The direct cost of diabetic healthcare is estimated between 2.5% and 15% of yearly healthcare budgets depending on the local diabetes prevalence, complications and difficulty of treatment accessibility (WHO, 2013). Direct costs of diabetes disease management were generally found to be higher than indirect costs globally (Seurin & Suhrcke, 2015). 2.4.2 Direct Cost to individuals Sickness and poor health burdens the individual economically in the short term and in the long term for chronic diseases like diabetes. A study by Kanavos et al. (2012) indicated that total direct cost burden of people with diabetes in five EU countries (i.e. France, Germany, Italy, Spa in, and the UK) was €90 b ill ion. Per patient direct medical costs for Spain is estimated as €1,708 and that of Germany was estimated as €5,899 in 2010. Also, treatment of diabetes related complications accounted for significant port ion of inpatient direct costs. People living with diabetes, especially those with complications in sub-Saharan Africa often face all kinds of difficulties (financial etc.)  in undertaking regular access to treatment (Lamr i et al., 2014). De-Graft (2010) and Lamr i et al., (2014) reported that medical 16 University of Ghana http://ugspace.ug.edu.gh treatment is often expensive, irrationally prescribed and inconsistent. Hence, many people with diabetes often turn to traditional herbal healers whose treatment cost is less. Also, more often than not ethnomedical and pharmaceutical treatments are combined. However, many return to inconsistent medical care as and when they can afford (Lamr i et al., 2014). The estimated direct cost of diabetes care per person is about 25% of the estimated annual income for the richest countries in sub-Saharan Africa, and almost 125% for the region’s poorest countries (Kir igia et al., 2009). Mbanya (2014) and his colleagues reported that the huge financial cost diabetes pose to society and individuals  is predicted to  increase  in sub-Saharan Africa over the next 20 years due to rap id urbanization and the ageing population. The estimated total economic cost (direct and indirect) of diabetes in the WHO's Africa region in 2000 was US$8836 per person with diabetes per year (Kirigia et al., 2009). Furthermore, Kiriga et al. (2009) estimated the direct cost of treating diabetes in 2000 to range from US$2302 to US$3207 per person. Since the 1990s, the burden on people living with non-communicable diseases (NCDs) has been worsened due to change in Ghana’s health pol icy. Thus, in 1992 the  introduction of user fees  in all public health facilities resulted  in a reduction  in subsidies on all health services  in the country as well as full cost pricing of drugs and pharmaceuticals (Jehu-Appiah et al., 2010; Tagoe, 2012). Furthermore, the existing national health insurance scheme (NH Is) does not cover all non- communicable diseases.  Ironically, the introduction of the national health insurance scheme in Ghana reduced government’s percentage budget expenditure on health by 39% in 2003 and increased household healthcare costs. Tagoe (2012) reported that average healthcare expenditure for households with respondent currently living with non-communicable diseases is 49% more than households with healthier respondents. 17 University of Ghana http://ugspace.ug.edu.gh This according to him places undue stress on households due to the relatively high direct cost of treating illness and the associated high indirect burden of illness. He further established significant difference in the mean household healthcare expenditure between household with a member having NCD(s) (GH¢13.09) and household with non-NCD(s) members (GH¢8.76) representing a 49% higher cost with a p-value (0.007). Another study in Sweden reported that averagely, 60% of annual medical cost of type-2 diabetes in a study conducted in Sweden was attributable to diabetes (Henriksson et al., 2000). Beran (2005) in a study conducted  in Malawi found that one month of insulin treatment cost to a patient was almost 20 days’ wages. 2.4.3 Direct cost on governments Chronic non-communicable disease like diabetes severely impact on the economic development of nations (Mayer-Foulkes, 2011). Diabetes is a chronic and progressive disease which if not treated over time leads to complications that are costly to treat. Hence, avoiding complications through preventive policies and proper treatment saves money in the long term. However, many government especially in sub-Sahara Africa find it difficult balancing treatment with prevent ion (Beran & Yudk in, 2006). Cost of diabetes to national economies though hard to estimate can be very significant. Annual direct cost estimates recently quoted for Brazil was US$ 3.9 bill ion), Argentina was US$ 0.8 b ill ion and Mexico was US$ 2.0 b ill ion and these costs were rising as diabetes prevalence increased. This implies that a rise in diabetes prevalence is associated with a concurrent increase in the direct healthcare cost from the disease (WHO, 2015). Generally, the diabetes share of direct healthcare costs ranges from 2.5% to 15% annual healthcare budgets, depending on local diabetes prevalence and the sophistication of the treatment available (WHO, 2015). Kanavos et 18 University of Ghana http://ugspace.ug.edu.gh al. (2012) reported that estimated direct annual cost was €5.45 b ill ion for Spa in and €43.2 b ill ion for Germany in 2010. Likewise, Sweden’s annual direct medical cost of drugs per patient averagely accounted for 27% of total direct cost of treating the disease (Henriksson et al., 2000). The UN Resolution 61/225 recognized “…diabetes is a chronic, debilitating and costly disease associated with severe complications which pose severe risks for families, [UN] Member States and the entire world and serious challenges to the achievement of internationally agreed development goals including the Millennium Development Goals …”  In 2006 African Diabetes Declaration called on all stakeholders and partners  in diabetes and particularly governments of African countries to prevent diabetes and  its related chronic complications, to  improve quality of life and reduce morbidity and premature mortality from diabetes. Beran et al. (2008) reported that medication, insulin and equipment like syringes needed for diabetic management are commonly in short supply in many countries. Furthermore, in countries where they are available, often they are unaffordable due to limited access to subsidized medicine or unavailability of subsidy. Substantial difference exist  in the availability and price of  insulin obtained through the private and public sectors due to a combination of taxes, mark-ups etc. Due to these reasons, since 2001 a differential insulin price are offered by Novo Nordisk to the world’s less developed countries, of which 33 are  in sub-Saharan Africa (UN Least developed countries). Novo Nordisk’s differential pricing for insulin supplied  is targeted basically at the UN least developed countries where insulin is sold at a maximum 20% of the average price for Europe, USA, Canada and Japan. Annually, insulin is offered at a differential price to all 49 governments of the Least Developed Countries defined by the UN84. 19 University of Ghana http://ugspace.ug.edu.gh 2.4.4 Indirect Cost of Diabetes Disease The majority of diabetic patients with complications may not be able to continue working or work effectively as they used to prior to the onset of their condition. Severe complications, absentee ism, disability, premature retirement or premature mortality could cause productivity loss (WHO. 2015). Though the estimation of cost to society in relation to productivity loss could be complex in many cases where estimates have been made, the costs may be as great or even greater than direct healthcare costs. Also, families suffer loss of earnings as a result of diabetes and its complications (WHO. 2015). Health conditions curtail people’s ability to engage in economic activity. Schof ield (2014) reported that when this happens, individuals bear the cost of lost income in add it ion to the burden of the diabetes disease, the impacts of lost productivity and income taxation revenue  is endured by Government. These national costs are in add it ion to the government's direct healthcare costs. Brown and h is colleagues (2014) showed that 15% of family members of patients with diabetes had to stop work to care for a family member with diabetes, and 20% had to cut back on work. Also, since in sub-Sahara Africa, family members often endure the primary responsibility for care, the effect on the family exceeds monetary costs. Patients and affected family members are hugely burdened in instances where home-based care is required. Apart from the fact that people with diabetes have to pay for medication, consultation, treatment and transport to treatment centers, they also suffer from loss of earnings due to days off work thereby risking losing their job. Thus, in add it ion to the direct cost associated with diabetes and complications, the disease affects not only patients but their families and by extension their community. 20 University of Ghana http://ugspace.ug.edu.gh Beran (2005) in a study conducted in Malawi found that affected families often suffer economic loss through giving up work to provide nursing care for family members suffering diabetes  illness causes (Diabetes Leadersh ip Forum Africa, 2010) A study conducted  in Ghana by Tagoe (2012) showed that households with respondents currently living with non-communicable diseases and were not working was about 59% more than households with healthier respondents. Eleven percent of the respondents attributed their unemployment status to their health. Due to limited support networks for people living with NCDs in Ghana, especially  in rural areas (Aik ins, 2005), patients had to depend on household members, friends and social groups to support treatment and management of disease condition (Tagoe, 2012). 2.4.5 Intangible Cost of Diabetes Disease There is a higher risk of mood and anxiety disorders among individuals with diabetes relative to those without the disease (WHO, 2015). These risks which affect quality of life are termed as intangible cost. Pain, anxiety, discrimination at workplace and difficulty in obtaining jobs due to complications, stigmatization and other factors also decrease quality of life (WHO, 2015). Prevalence of depress ion among diabetic patients varies by lower and higher income countries although there is disproportionate evidence base for countries (Egede Ell is, 2010). High risk of complications such as retinopathy (eyes damage), nephropathy (kidneys damage), and neuropathy (nervous system damage), hearing impairment, Alzheimer and CVD burden a person suffering from diabetes with emotional, physical and psychological pains (Strine et al., 2005). Common symptoms of diabetes neuropathy are pain in extremities. Symptoms of CVD associated with diabetes include chest pain to leg pain, to confusion and paralysis. Abbas and Archibald (2007) reported that significantly long-term disability and premature mortality have 21 University of Ghana http://ugspace.ug.edu.gh association with foot ulceration and infect ion. Regular and proper care of the foot is needed to prevent amputations which can lead to psychological pain and limited mobility. 2.4.6 Socio-economic Status and Diabetes Studies from high income countries have reported that depress ion among diabetic patients has association with socio-economic status, marital status, physical activity and chronic somatic diseases (Engum et al., 2005; Safraj et al., 2012). There is a relationship between psychosocial factors (including social isolation or support, coping styles, behav iour and job stress or strain), socio-economic status and depress ion as a result of diabetes (Lustman & Clouse, 2005; Golden et al., 2008). Studies had attributed higher risk to people w ith lower socio-economic status, also known as inverse social gradients (Engum et al., 2005; Knol et al., 2007). Nevertheless, there may be variations in the relationship depending on the socio-economic context of the particular country. For  instance,  in low- income countries L ICs, higher socio-economic status may be related to higher levels of chronic disease risk factors while the poor experience a double burden of  infectious and chronic diseases accord ing to the protracted polar ized model of ep idem iolog ical trans it ion (Fle ischer et al., 2008). Stud ies show association between socio-economic status at the individual level (e.g. unemployment and education) and psychological comorbidity due to diabetes (Acosta et al., 2010; Yang et al., 2009; Youssef et al., 2013). A study conducted in Syr ia by K ilz ieh et al. (2008) showed that depress ion comorbidity w ith any chronic disease increase w ith lower socio- economic status. Yang et al. (2009) also reported significant associations between unemployment and psychological pa in in diabetic patients. A study further shows that households with low income were more likely to be depressed due to diabetes complications compared to households who were wealth ier (K ilz ieh et al., 2008). 22 University of Ghana http://ugspace.ug.edu.gh Furthermore, stud ies suggest an association between lower education and depress ion among diabetic patients. For  instance, M ier et al. (2008) reported statistically significant associations between diabetic patients who were educated up to secondary level and depress ion, with diabetic having less than 5 years of education  being more depressed (Zhang et al., 2008). Also, diabetic patients in Thailand with less than 12 years education were significantly more likely to be depressed (Thaneerat et al., 2010). F inally, Yekta et al. (2010) reported that non-depressed diabetic patients  in  Iran were more educated than depressed diabetic patients. From Thailand, Thaneerat et al. (2010) reported statistically significant association between poor social support (especially support) and diabetes- depress ion among people living with diabetes. Furthermore, Zhang et al. (2008) reported negative correlation between depressive symptoms and social support  in China. 2.5 Risk Factors for Type-2 Diabetes Decades of research have shown that much of the burden of chronic disease is attributable to modified lifestyle factors working collectively. Proximate risk factors for type-2 diabetes are obesity, family history, insufficient physical activity, raised cholesterol, tobacco use, and harmful use of alcohol, unhealthy diets and hypertension. Studies have also shown a l ink between NCDs and stress (Er iksson et al. 2008, Er iksson et al. 2013). Lindenberg, Ostergren and colleagues have cited a close association between psychosocial stress and exhaust ion with disease ( Lindeberg et al. 2011). Because all these factors are modifiable, NCDs are to an extent preventable (M iranda et al. 2008). Personal lifestyle measures to reduce risk of type-2 diabetes have been known for decades (Stuckler and Siegel 2011, Lagerros and Rossner 2013, Schellenberg et al. 2013). They include healthy diets, physical activity and regular monitoring of health parameters (body weight, blood sugar, blood pressure, blood lipids and adherence to 23 University of Ghana http://ugspace.ug.edu.gh therapy) (Pan et al. 1997; Booth et al. 2013). Others are cessation of smoking and harmful alcohol intake (Stuckler and S iegel 2011). While sedentariness is highest in HICs, high levels are now increasingly seen in some LMICs (WHO 2011c). Smoking is still low in many LICs but data from 23 high burdened LMICs show that it is increasing (Alwan et al. 2010). Adult per capita consumption of alcohol is highest HICs, but nearly as high in some LMICs, especially of local potent brew (WHO 2011c). Dangerous alcohol consumption has also been l inked to other lifestyle diseases (Choudhry et al. 2014). Unhealthy diets are rising in lower-resource settings.  In some countries in sub-Saharan Africa (e.g. Ghana, South Africa and Cameroon), hypertension has increased to epidemic proportions (Fezeu et al. 2006, Thorogood et al. 2007, Bosu 2010). Overweight has tripled in sub-Saharan Africa over the last two decades (Hossain et al. 2007). A synopsis of the distribution of risk factors for type-2 diabetes in sub-Saharan Africa is presented in three systematic reviews: (Addo et al. 2007, Dalal et al. 2011, Kengne et al. 2013a). According to these reviews, prevalence of risk factors varies considerably between countries, urban-rural gradients and gender. Obesity rates ranged from 0.4 to 43%; smoking from 0.4% to 71%. Hypertension is the most frequently reported cardiovascular risk factor  in Africa, with prevalence ranging from 4% to 65% across contexts (Dalal et al. 2011; Kengne et al. 2013a). Hypertensio  is consistently equal  in men and women, higher  in urban areas, and  increases with age (Dalal et al. 2011). Less than 40% of people with hypertension have been detected and of those detected, less than 30% were on treatment. For those on treatment, less than 20% are controlled (Dalal et al., 2011). Most evidence on cross-linkages between risk factors for type-2 diabetes is from high income countries (Mendis et al., 2004) and may not apply to other contexts (M iranda et al. 2008). For 24 University of Ghana http://ugspace.ug.edu.gh example, contrary to wha  is observed  in Europe, obesity in Africa is predominant among women compared to men, but smoking is higher in men (Dalal et al. 2011). More than half of the LM ICs are in the early stage of the nutritional transition (Abrahams et al. 2011). The distribution of overweight in such countries is still socially segregated with wealthier persons being more likely to be obese (Fezeu et al. 2006, Subraman ian et al. 2009). Some data, however, show that in transitioning countries obesity is increasingly occurring in low socio-economic status groups (Hossa in et al. 2007). Some transitioning countries face the paradox of families in which the children are underweight and the adults are overweight (Hossa in et al. 2007). The degenerative models of NCD causation pay little attention to processes that build up to the optimal phenotypic state leading to disease (M iranda et al. 2008). Known proximate risk factors are in reality underlined or modified by other context specific factors. Yet, only few studies explore these relationships. Effective prevention requires unravelling these root causes of risk (M iranda et al. 2008). These underlying causes are often deeply rooted in a society, in complex causal pathways, act across an individual’s life course, driven by societal norms (Penn et al. 2013), to create the optimal phenotypic state for type-2 diabetes – “developmental hypotheses” (Miranda et al. 2008). Societies’ people are born, live and age may increase their risks for chronic diseases, of which indiviudals for little choice (Stuckler & S iegel 2011). Studies on the distribution of type-2 diabetes related risk factors in sub-Saharan Africa are patchy, with many contexts especially the rural areas insufficiently explored (Dalal et al. 2011). Fewer studies have assessed the cross-linkages between risk factors and latent factors which is important in contextualizing interventions. Three population-based studies on the prevalence of CVD risk factors in Uganda and another  in Cameroon focused on demographic correlates of either hypertension or abnormal glucose regulation ((Lasky et al. 2002, Fezeu et al. 2006, 25 University of Ghana http://ugspace.ug.edu.gh Wamala et al. 2009, Maher et al. 2011) nut did not include behavioural correlates. The lack of a holistic assessment of socio-behavioural risk factors is not noticeable in other studies in sub- Saharan Africa (Addo et al. 2007, Mbanya et al. 2010, Dalal et al. 2011, Hall et al. 2011). Likewise, very few studies have explored community perception about risk and preventive behaviour. Therefore, while the recommended behav iour are well known, there  is  inadequate  information on forms of these behav iour that are feasible within the normative contexts of communities  in sub-Saharan Africa (Whyte 2012). Lifestyle measures ought to be relevant to the context in which they are applied (Carmo i et al. 2008). 2.6 Conclusion It was apparent that the direct consequences that diabetes and its accompanying complications place on people living with the disease cannot be underestimated. The disease places a lot of socio-economic burden on individuals and affects their quality of life. It could be observed from the literature review that studies cited were mainly from developed countries. There are limited studies on the burden posed by type-2 diabetes mellitus on individuals living with the disease, especially in Low and Middle-Income Countries (LMIC). This study therefore becomes relevant as it will not only bridge the knowledge gap in the area but also provide useful information on the socio-economic burden of type-2 diabetes mellitus in Ghana for individuals and policy makers in the health sector. Cost-of-illness approach is considered appropriate for this study. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLODY 3.1 Study Design The study was a cross-sectional study which adopted the cost-of- illness analytical approach to estimate the socio-economic burden of type-2 diabetes on patients who were seeking treatment at the Pantang Government Hospital. Bryman (2012) defines quantitative research as, a research strategy the essentially focuses on quantification in both the collection and analysis of data. In other words, quantitative research method places emphasis on measuring a phenomenon in the social world. Nonetheless, findings in a quantitative research paradigm are likely to be generalised to a whole population or a sub-population. 3.2 Study Area The Pantang General Hosp ital is situated on the Accra-Aburi road. It boast of facilities which are comparable to those available at the principal sanatorium in Accra. The Pantang hospital was the brainchild of Ghana’s first President Dr. Kwame Nkrumah.  It was built to cater for psychiatric care in the West African sub-region and its facilities include an excellent facility for medical and psychiatric needs as well as a nursing training school. The hospital is situated on the outskirts of Pantang Township and serves as a health facility for those who live in the environs. The hospital vision is to take care of the mentally challenged patients as well as those with other types of diseases. The Pantang Hospital has a lot of departments in operations (medical, surgical, emergency, OPD etc.). With the except of the medical department, the hospital administration department takes in charges of all internal and external activities comprising compilations of medical bills, data collection, preparations of bills and the like. 27 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Variables The outcome variable is the socio-economic burden of type-2 diabetes. The explanatory variables are direct, indirect and intangible costs of type-2 diabetes. Table 1 shows the variables of interest for this study. Table 1: Study Variables COST TYPE COST VARIABLE COST DESCRIPTION DIRECT COST Medical 1 Cost of consultation 2 Cost of diagnostic 3 Cost of treatment 4 Cost of medication Non-medical 1 Travel cost 2 Cost of diet 3 Other substantial expenses INDIRECT COST Productivity lost 1 Work hours lost 2 Lost wages INTANGIBLE COST Intangible burden 1 Physical pain 2 Psychological pain 3 Social isolation 4 Anxiety 5 Stress 6 Depression 7 Stigmatization 8 Self-esteem 9 Quality of life measure 28 University of Ghana http://ugspace.ug.edu.gh 3.4 Sampling 3.4.1 Study Population The study population will be made up of all type-2 diabetes patients who sought care at the OPD of Pantang Government Hospital  between May and July, 2017. 3.4.2 Sample Size A sample of 206 type-2 diabetes patients were selected for the study. The prevalence of Type-2 diabetes in Ghana was last measured in 2012 at 159 per 100,000 population (MOH, 2013). Using a Z-value of 1.96, prevalence (p) of 0.159, a q value of 0.841 and a precision of 0.05 due to limited resources and time of data collection. The sample size for the type-2 diabetes type-2 diabetes patient was calculated using the people living with type-2 diabetes of d = allowable error of 5% following formula (Naing et al, 2006): Z 2 p(1 p) pe N  2 2 d Where: N = sample size, Z =is the standard score for the confidence interval of 95% P= proportion N 1.96 2 0.1590.841  0.052  205.57796  206 Therefore, the sample size determined for this study was approximately 206. 29 University of Ghana http://ugspace.ug.edu.gh 3.4.3 Sampling Procedure The study relied on consecutive random sampling technique. The first random number selected between 1 and 2 was 1. Hence, the sample selected each day for data collection was 1, 3, 5, 7, 9 etc. That is, on each diabetic clinic day within the period of data collection, approximately half of diabetes patients waiting in a queue for treatment were recruited in a manner such that every second patient was excluded. When a selected patient did not meet the inclusion criteria or refused to participate, the next eligible patient was recruited. 3.5 Data Collection Technique and Tools Researcher-administered questionnaire was used to collect the data. The questionnaire had both open and closed ended questions covering relevant information on patients’ demographic information, employment status and occupation. Another aspect of the questionnaire was the cost incurred by patients as a result of the surgery done, therapy sessions, stage of diagnosis and duration of treatment and their time lost in a month to seek treatment (direct and indirect costs). 3.6 Quality Control Several mechanisms where be put in place to ensure and guarantee data accuracy and quality devoid of biases. These included training of research assistants, pre-testing of questionnaires and supervised data entry and processing. The research assistants were monitored on daily bas is. Completed questionnaires were validated and entered daily after which data was cleaned. 3.7 Pre-testing of Questionnaire The questionnaire was pre-tested with two research assistants before the actual administration was done. Pre-testing included patients with type-2 diabetes. The principal investigator held meetings daily with the research assistants to cross-check and validate all completed 30 University of Ghana http://ugspace.ug.edu.gh questionnaires and discussed matters that cropped up. This helped in correcting errors and planning for the subsequent days. Reliability: The general criterion of acceptability was quite high, with Cronbach’s alpha of .90. Validity: The construct validity was used to determine the psychological concept the Determine intangible cost (physical pain, social isolation, anxiety, stress, depression, stigmatization, self-esteem etc.) associated with type-2 diabetes. Divergent validity score on a measure of self -esteem was negatively correlated with measures of insecurity and anxiety. A depression scale was able to discriminate between people with type-2 diabetes who were depressed and those who were not. The test was valid and reliable, and described how data was collected as well as the process of analysis. The study ensured validity by reducing subject or participant error, subject or participant bias, observer error and observer bias. 3.8 Ethical Consideration Ethical approval was sought from the Ethical Review Committee of the Ghana Health Service. Permission from the Administrator of Pantang Government Hospital was sought.  Informed consent was obtained from the sampled diabetic patients and confidentiality/privacy assured before their engagement in the study. They were informed about the purpose, procedures, risks and benefits of participating in the study. Study participants were informed about the minimal risk involved in participating in the study. The participants were, however, informed of possible minor discomforts in answering certain questions for which they may choose not to answer. For participants. For participants who could not read, the consent form was read out and explained to them in the presence of an independent witness. Only participants who agreed to be part of the 31 University of Ghana http://ugspace.ug.edu.gh study were recruited for the study and required to sign or thumbprint a consent form as an indication of their willingness to participate. The participants were informed that there would be no consequences of forfeiting healthcare or other benefit if they chose to withdraw from the study. Study participants were given sugar free biscuits at the completion of the researcher-administered questionnaire as a token of appreciation for the time spent answering the research quest ions. Data collected for the study was kept confidential and used solely for the purpose indicated for the study. Data files were password protected. Hard copy and electronic data were stored securely in locked file cabinets without the names of the participants, and access was limited to the Principal Investigator and the supervisors of the study. Extract ion of data from patients’ records were done only by trained Research Assistants and Principal  Investigator. 3.9 Data Analysis Cost data were entered into Microsoft Excel version 2013. Responses to intangible burden associated with diabetes were entered into Epi.  Info Version 7. The entries was done by two independent data entry clerks. To prevent data entry errors, the completed questionnaires were coded, double entered and cleaned. Detected discrepancies were resolved by consulting the original completed questionnaires. Direct medical cost, direct non-medical cost and indirect cost incurred by diabetic patients were estimated using Microsoft Excel version 2017 and STATA version 13. Total direct cost was estimated by summing total direct medical cost and total direct non-medical cost.  Indirect cost was estimated by multiplying productive work hours lost and average lost wage. Total cost was estimated by summing direct and indirect cost. All costs data was 32 University of Ghana http://ugspace.ug.edu.gh presented in total aggregates, averages, median and percentage share of cost profile. The Likert scale responses to intangible burden associated with diabetes were analyzed using STATA version 13 and expressed in percentages. The results were presented using charts, graphs and figures. Results of patients’ assessment of qual ity of l ife were presented in a radar chart. For study participants’ socio-economic status (SES) determination, wealth index was constructed from household asset data using principal components analysis. By this, categorical variables used for assets ownership were transformed into separate dichotomous (0-1) indicators. Common factor score for each participant was produced based on the asset indicators. Wealth quintiles ( i.e. lowest, second, middle, fourth and highest) was then obtained by assigning score to each respondent, ranking each study participant by his or her score, and then dividing the ranking  into five equal categories, each comprising 20 percent of the total patients. Total direct and indirect treatment cost of diabetics was then sorted and classified by wealth quintiles or socio-economic status with the aid of STATA version 1. 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 1.1 Introduction This chapter presents the study results. The chapter has these sections: background characteristics of study patients, health state of study patient; direct treatment cost of type-2 diabetes; indirect treatment cost of type-2 diabetes; intangible cost associated with type-2 diabetes; and total treatment cost of type-2 diabetes by socio-economic status. 4.1 Demographic Background of the respondents According to table 2, the majority of the type-2 diabetes patients who responded to the questionnaire were female, constituting 59.7%. Out of the total sample of 206 patients, most of the type-2 diabetes patients who responded to the questionnaire were between 41 - 60 years, representing 30.6%. The least age group of patients was above 60 years, constituting 11.2 %. Furthermore, most of the patients had completed JSS/JHS education (21.8%). About 37.9% of the patients were married whilst 22.3% were divorced. More than half of the patients (65%) were employed. For those unemployed, it was ma inly due to diabetes (35%). Most of the patients representing 28.2 % earned between GHS 401-500 (USD 445.5) monthly and 16.8% earned between GHS 501-1000 (USD 2245.5). More than 16% earned above GHS 1001. However, most of the patients reported that their medical bill was sponsored by two family members 33.5 %. 34 University of Ghana http://ugspace.ug.edu.gh Table 2: Socio-demographic characteristics of study Variable Category Frequency Percentage N=206 (%) Sex Male 83 40.3 Female 123 59.7 Age category Less than 20 years - - 20-30 years 14 6.8 31-40 years 49 23.8 41-50 years 63 30.6 51-60 years 57 27.7 Above 60 years 23 11.2 Level of education No education 23 11.2 Primary 30 14.6 Middle 28 13.6 JSS/JHS 45 21.8 Secondary/Vocational 29 14.2 SSS/SHS 31 15 Higher 20 9.7 Marital Status Married/living together 78 37.9 Divorced/ Separated 48 23.3 Widow 42 20.4 Never married 38 18.4 Employment Status Employed 134 65 Unemployed 72 35 35 University of Ghana http://ugspace.ug.edu.gh Table 2 continued. Variable Category Frequency N=206 Percentage (%) Average Monthly income (salary plus other sources) 001-100 - GH 101-200 24 11.7 GH 201-300 33 16 GH 301-400 27 13.1 GH 401-500 58 28.2 GH 501-1000 34 16.5 GH 1001 and above 34 16.5 Numbers of people supporting the Patients 1 40 19.4 2 69 33.5 3 47 22.8 4 28 13.6 5 and above 22 10.7 US$1.00 equivalent to GHS4.50 (Bank of Ghana average monthly interbank exchange rate, July 2018) 4.2 Direct Treatment Cost of Type-2 Diabetes The direct cost was made up of two main components i.e. estimated direct medical and direct non-medical cost incurred by the diabetic patient. 4.2.1 Direct Medical Cost The components of direct medical costs were consultation, laboratory test, medicine and other treatment. Table 3 shows distribution of direct medical cost by diabetes. Medicine cost constituted a bulk of total direct medical cost profile of diabetes healthcare (71.9%). Patients spent an estimated GHS18, 540.00 on medicine with a mean medicine costs of GHS 90.00 (95% 36 University of Ghana http://ugspace.ug.edu.gh CI: 0-90.00). Consultation cost recorded the second highest share of the cost profile with a mean of GHS18.00 (95% CI: 18.20-20.00). The total direct medical cost estimated was GHS3,708.00 (USD 16, 686). The overall estimated direct medical cost for the year was GHS25, 801.00 (USD 38,563.2) with a yearly average cost of GHS 6,450.00. Table 3: Direct Medical Cost D iabetes Pat ient N=206 Cost  item Cost Mean Med ian Cost Prof it (GHS) (95% C. I) (%) Consultat ion 3,708.00 18.00 19.1 14.4 (18.20-20.00) Lab tests 1,596.50 4.50 7.75 6.2 (5.50-10.00) Treatment 1,957.00 9.50 15 7.6 (10.50-20.00) Med ic ine 18,540.00 90.00 85 71.9 (0-90.00) Total cost est imates 25,801.00 41.60 126.85 100 Total average cost (6,450.00) * *US$1.00 equ ivalent to GHS 4.50 (Bank of Ghana average monthly interbank exchange rate, 2018) 4.2.2 Direct Non-Medical Cost The components of direct non-medical costs were travel cost, food cost and miscellaneous. Distribution of direct medical cost among diabetes patients  is presented  in table 4. Less than half of the total non-medical cost profile composed of travel cost (41.1%). The yearly total food cost estimated for type-2 diabetics constitute 35.8% with a cost of GHS 1,751.00 and a mean value of 8.50 (95% C I: 1.50-10.00). 37 University of Ghana http://ugspace.ug.edu.gh Table 4: Direct Non-Medical Cost D iabetes Pat ient N=206 Cost  item Cost Mean Med ian Cost (GHS) (95% C. I) Prof it (%) Travel cost 2,008.50 9.75 10.00 41.1 (0.19.50) Food cost 1,751.00 8.50 8.00 35.8 (1.50-10.00) M iscellaneous 1,133.00 5.50 5.00 23.2 (0-5.50) Total cost 4,892.50 23.75 23.00 100 est imates Total average cost (1,630.83) * *US$1.00 equ ivalent to GHS 4.50 (Bank of Ghana average monthly  interbank exchange rate, 2018) Total average cost (1,630.83) * 4.2.3 Total Direct cost of Type-2 Diabetes The total direct cost estimate was made up of direct medical and non-medical costs.  It is the sum of total direct medical cost and total direct non-medical cost. Table 5 presents an amalgamation of the direct medical and non-medical costs estimated table 3 and 4. The overall yearly total  direct medical cost and direct non-medical cost of type-2 diabetics  is estimated to be GHS 30,693.50(USD$138,910.95) with total direct average cost of the GHS 4,384.79. 38 University of Ghana http://ugspace.ug.edu.gh Table 5: Total Direct Cost of Type-2 Diabetes D iabetes Pat ient N=206 Cost  item Cost Mean Med ian Cost (GHS) (95% C. I) Prof it (%) Consultat ion 3,708.00 18.00 19.1 14.4 (18.20-20.00) Lab tests 1,596.50 4.50 7.75 6.2 (5.50-10.00) Treatment 1,957.00 9.50 15 7.6 (10.50-20.00) Medicine 18,540.00 90.00 85 71.9 (0-90.00) Sub-total cost 25,801.00 41.60 126.85 100 est imate Sub-total average (6,450.00) * cost Cost  item Cost Mean Med ian Cost (GHS) (95% C. I) Prof it (%) Travel cost 2,008.50 9.75 10.00 41.1 (0.19.50) Food cost 1,751.00 8.50 8.00 35.8 (1.50-10.00) M iscellaneous 1,133.00 5.50 5.00 23.2 (0-5.50) Sub-total cost 4,892.50 23.75 23.00 100 est imates Sub-total average (1,630.83) * cost Total d irect cost 30,693.50 65.35 149.85 100 Total d irect average cost (4,384.79) * *US$1.00 equ ivalent to GHS 4.50 (Bank of Ghana average monthly interbank exchange rate, 2018) 39 University of Ghana http://ugspace.ug.edu.gh 4.2.4. Indirect treatment cost of type-2-diabetes The indirect cost estimated the productive working days lost due to diabetes by using the human capital approach. Figure 2 shows the percentage distribution of total working days patients were absent. Most of the patents representing 36.4% were absent from work for one day. This  is followed by patients who were absent from work for two days and more than five days also constituting 20.9% and 14.6% respectively. Patients who were also absent from work for three days and four days also constituted 18% and 10.1% respectively. WORK ABSENTEEISM 80 70 60 50 40 30 20 10 0 1 day 2 days 3 days 4 days above 5 days Figure 2: Number of days absent from work by Diabetes Pat ients The indirect cost estimated the productive work hours lost due to diabetes by using the human capital approach. Figure 3 shows the percentage distribution of total time spent travelling to and from diabetic clinic by both employed and unemployed diabetics.  It was realized that most of the patients spent 11-20 minutes in travelling from their homes to the clinic representing 24.8%. Some of them also indicated that they spent 1-10 minutes and 41-50 minutes in travelling from the clinics to their home, constituting 19.4% and 11.2% respectively. 40 University of Ghana http://ugspace.ug.edu.gh TRAVELLING TIME above 2 houres 11% 1-10 minutes 2 hours 19% 7% 51-60 minutes 14% 11-20 minutes 13% 41-50 minutes 21-30 minutes 12% 12% 31-40 minutes 12% Figure 3: Travelling times of Diabetes Patients The indirect cost est imated the productive work hours lost due to diabetes by using the human capital approach. F igure 4 shows the percentage distribution of the total waiting time spent at the d iabetes clin ic seek ing healthcare by both employed and unemployed diabet ics. Most of the pat ients  ind icated that they spent between 40-50 m inutes  in the hosp ital before they are served, constitut ing 19.9%. Some of them also  ind icated that they spend between 51-60 m inutes and between 31-40 m inutes  in the hosp ital before they are served const itut ing 14.6% and 12.1% respect ively. 41 University of Ghana http://ugspace.ug.edu.gh WAITING TIME 45 40 35 30 25 20 15 10 5 0 1-10 11-20 21-30 31-40 41-50 51-60 2 hours above 2 minutes minutes minutes minutes minutes minutes houres Figure 4: Waiting times of Diabetes Patients The total  ind irect cost est imat ion was done for only product ively engaged (employed) d iabet ics. The total product ive days lost by employed type-2 d iabet ics was 131. The valuat ion of product ive t ime lost to pat ient rel ied on the nat ional m in imum wage per day of GHS9.68 as at July, 2018 (M in istry of F inance and Econom ic Plann ing, July 2018). The total product ive days lost by d iabet ics was 281 days. Overall, the value of t ime absent from product ive work w ith in past month was est imated as 1,268.08 (US$589.5). The mean  ind irect cost was GHS93.67 (95% C I: 0-88.54). 42 University of Ghana http://ugspace.ug.edu.gh Table 6: Total indirect cost of diabetes disease D iabetes Pat ients Employed (N=134) Category  Item Product ive days lost Valued product ive days lost (GHS) Health seek ing Travell ing t ime (3hrs * 30 days) - (per month) 90 Wa it ing t ime (2hrs * 30 days) - 60 Work absentee ism Absent from work 131 1,268.08 Total 281 1,268.08 (US $ 589.50) * 𝑚𝑒𝑎𝑛 = 93.67; 95% 𝐶𝐼 (0 − 𝑀𝑒𝑑𝑖𝑎𝑛 = 90 88.54); ***Est imat ion done for only employed d iabet ics based on work absentee ism **Nat ional m in imum wage per day of GHS9.68 was used to value lost product iv ity (M in istry of F inance, July,2018) *US$1.00 equ ivalent to GHS4.50 (Bank of Ghana average monthly  interbank exchange rate, June 2016) 4.2.5  Intang ible Cost assoc iated w ith Type-2 D iabetes The  intang ible cost assesses the  incalculable burden – usually phys ical and psycholog ical pa in and suffer ing - assoc iated w ith the d iabetes d isease. The elements assessed was categor ized  into phys ical and psycholog ical effect, soc ial effect, and qual ity of l ife assessment. Phys ical, psycholog ical and soc ial effect H igher percentage of complicated d iabet ics (37.86%) (n = 78) suffered severe phys ical pa ins. Furthermore, 25.7% (n = 53) d iabet ics felt very severe phys ical pa ins, about 16% (n = 33) of pat ients  ind icate they felt moderate pa ins. About 36.9% (n = 76) of d iabet ics’ pat ient very often felt depressed wh ile 26.7%(n = 55) always felt depressed due to type-2 d iabetes. However, a smaller percentage of d iabet ics (17%) (n = 35) seldom often felt depressed. About 37.9% (n = 78) sa id they always felt uncomfortable when  insulin  inject ion was adm in istered to them. Moreover, 30.6% (n = 63) pat ients  ind icated that they often felt uncomfortable w ith  insulin 43 University of Ghana http://ugspace.ug.edu.gh  inject ion wh ile 5.8% (n = 12) sa id they seldom felt uncomfortable. Also, h igher percentage of d iabet ics (37.9%) (n = 78) who used  insul in very often felt stressed out. Also, h igher percentage of d iabet ics (34%) (n = 70) who used  insul in always often felt stressed out , wh ile a s ign if icant percentage (2.4%) (n = 5) sa id they never felt stressed out  in  issu ing  insul in. Table 7:  Intang ible cost (phys ical pa in, psycholog ical pa in, soc ial  isolat ion, anx iety, stress, Table depress ion, st igmat izat ion, self-esteem etc.) Variable (N=206) (N, %) How much physical pain do you suffer as a result of diabetes? None 13(6.3) Very little 29(14) Moderate 33(16) Severe 78(37.9) Very severe 53(25.7) How often do you feel depressed by the fact that you have diabetes? Always 55(26.7) Very Often 76(36.9) Quite often 31(15) Seldom 35(17) Never 9(4.3) How often do you feel uncomfortable when you administer insulin injection? Always 78(37.9) Very Often 63(30.6) Quite often 45(21.8) Seldom 12(5.8) Never 8(3.9) How often do you feel stressed out when you have to administer insulin injection? Always 70(34) Very Often 78(37.9) Quite often 33(16) Seldom 20(9.7) Never 5(2.4) If married, how has diabetes affected your marriage? No effect 136(66) Divorced 34(16.5) Separated 39(18.9) 44 University of Ghana http://ugspace.ug.edu.gh Qual ity l ife assessment Accord ing to table 4.3, major ity of the d iabetes pat ients  ind icated that, they get fat igue due to d iabetes represent ing a mean of 2.391 and a standard dev iat ion of 1.076. Moreover, they also  ind icated that d iabetes has made them not enjoy  the ir hobb ies. Therefore, mak ing the ir qual ity of l ife look ing m iserable, const itut ing a mean value of 2.361 and a standard dev iat ion of 0.964. Also, pat ients  ind icated that the st igmat izat ion have made them avo id company of others because of d iabetes cond it ion hav ing a mean of 2.274 and a standard dev iat ion of 1.230. Table 8: Intang ible cost (phys ical pa in, psycholog ical pa in, soc ial  isolat ion, anx iety, stress, Table depress ion, st igmat izat ion, and self-esteem) Variable N=206 Mean Standard Deviation I am not able to enjoy my hobbies as I did prior to the 2.361 0.964 diagnosis of the disease? I have sleepless nights because of diabetes condition? 1.622 0.665 I have low self-confidence because of diabetes condition 1.578 0.512 I have low self-esteem because of diabetes condition 1.522 0.512 I avoid company of others because of my diabetes 2.274 1.230 condition I easily get fatigued because of my diabetes condition 2.391 1.076 I have to change diet because of diabetes 2.044 0.928 I easily get irritated because of my diabetes condition 2.057 0.767 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER F IVE D ISCUSS ION Th is chapter presents the d iscuss ions of the study. The outl ine  is based on the object ives of the research.  It  includes summary and d iscuss ion of the key f ind ings of the study and relates  it to publ ished l iterature on cost burden of type-2 d iabetes mellitus treatment as well as physical and psycholog ical pa in assoc iated w ith the d isease. 5.1 D irect Treatment Cost of Type-2 D iabetes The d irect non-med ical cost contr ibutes an  inapprec iable proport ion (10.7%) to the total d irect cost prof ile compared to d irect med ical cost (71.9%). Th is  is contrary to f ind ing by Chatterjee (2011) wh ich reported relat ively substant ial contr ibut ion of 40% d irect non-med ical cost to total d irect cost prof ile among d iabetes pat ients. Med ic ine cost const ituted a bulk of total d irect med ical cost prof ile of d iabetes healthcare was 71.9% (GHS18,540.00). D iabet ics pat ients spent an est imated GHS18,540.00 on med ic ine w ith a mean med ic ine costs of GH¢90.00 (95% C I: 0- 90.00). Consultat ion cost recorded the second h ighest share of the cost prof ile w ith a mean of GHS18.00 (95% C I: 18.20-20.00). The total d irect med ical cost est imated was GHS3,708.00 (USD16,686). The overall est imated d irect med ical cost was GHS25,801.00(USD38,563.2) w ith an average cost of GHS 6,450.00. The h igh percentage share of d irect cost est imated  in th is study conf irms f ind ings by Amer ican D iabetes Assoc iat ion (2013), where the d irect cost of d iabet ic healthcare formed about 71.8% of the total cost of d iabet ic healthcare. L ikew ise, results from a study conducted by K ir ig ia et al. (2009) showed that the d irect cost of d iabet ic healthcare (56%) 46 University of Ghana http://ugspace.ug.edu.gh formed a greater port ion of the total cost of d iabet ic healthcare. However, f ind ings of th is study are  in sharp contrast to study results obta ined by Barceló et al (2003) wh ich concluded that the d irect cost of d iabet ic healthcare const ituted a lesser proport ion (16%) of the total cost of d iabet ic healthcare. Th is study’s est imates of h igh percentage share of d irect cost over total treatment cost can largely be ascr ibed to the  influence of cost of med icat ions prescr ibed for treatment of d iabet ics and  its related compl icat ions/comorb id it ies. Med icat ion cost alone accounts for 67.2% of the total cost prof ile. The same f ind ing was observed by the Amer ican D iabetes Assoc iat ion (2013) wh ich found that the largest proport ion of the d irect cost of d iabet ic healthcare was attr ibutable to the percentage share of med ic ine cost (18%). S im ilarly, th is study’s result  is corroborated by the study f ind ings of Barceló et al. (2003), wh ich also concluded that med icat ions cost formed the h ighest proport ion of the d irect cost of d iabet ic healthcare (41%). Notw ithstand ing the  influence of med ic ine cost wh ich resulted  in h igh percentage share of d irect cost over total treatment cost prof ile, the real effect of cost of med icat ions  is poss ibly underest imated. Th is  is due to the fact that most of the med icat ions used  in d iabetes treatment were covered under the Nat ional Health  Insurance Scheme (NH IS) (NH IS med icat ion Tar iffs, 2012) and major ity of the study pat ients are NH IS subscr ibers. Type-2 d iabet ics unl ike type-1 d iabet ics are str ictly supposed to be non- insulin dependent. Measures used to manage the d isease  include oral med icat ion, regular exerc ise and adherence to d ietary plan. However, more than half of the stud ied d iabet ics (51.2%) are  insul in dependent. 47 University of Ghana http://ugspace.ug.edu.gh Reasons attr ibuted to pat ient’s rel iance on  insul in are: (1) study hosp ital’s standard of pract ice to use  insul in to normal ize severely h igh glucose levels of type-2 d iabet ics; (2) pat ients’ res istance to med icat ion over t ime (e.g. the average years pat ients had been d iagnosed w ith type-2 d iabetes  in th is study was 8years); and (3) to supplement pat ient’s med icat ion  in order to keep glucose at normal levels and prevent compl icat ion r isk. Th is study’s f ind ings part ially d isprove Beran et al. (2008) study report that med icat ion,  insul in etc. needed for management of the d isease are frequently  in short supply  in many countr ies and where they are ava ilable, often they are unaffordable due to lack of subs id ies. Th is study f inds that though there  is constant supply of  insul in, the NH IS d id not cover the ent ire cost and thus pat ients are made to pay about 20% of h igh pr ice med ic inal products l ike  insul in. 5.2  Ind irect Treatment Cost of Type-2 D iabetes The cost burden of manag ing type-2 d iabetes goes beyond d irect spend ing on med ical products and commod it ies.  It extends to other  ind irect cost elements. Th is  is expressed as loss of product iv ity result ing from absentee ism and pat ient’s  inab il ity to engage  in product ive act iv it ies. Accord ing to WHO (2013), due to the chronic and complex nature of the d isease, d iabet ic pat ients may e ither be unable to work or effect ively work as they could pr ior to the onset of the d isease. Th is study’s f ind ings reveal that d iabet ics w ith compl icat ions and those w ithout compl icat ions lost over 70% of the est imated product ive work t ime due to work absentee ism. WHO (2013) further reported  ind irect cost est imates for type-2 d iabetes management  in many countr ies may be as great as or even greater than the d irect healthcare cost.  In th is study, due to cultural factors which  inh ibit people from reveal ing correct  informat ion about the ir  income, 48 University of Ghana http://ugspace.ug.edu.gh Ghana’s m in imum wage as of July 2016 (GHS 9.68)  is used to est imate  ind irect cost of all employed d iabet ics. Th is approach may have b iased the cost est imat ion and thus conf irms WHO’s stance. Also, th is was ev ident  in the study results of Barceló et al. (2003)  in wh ich the percentage share of total  ind irect cost const ituted about 82% of the total cost of d iabet ic care. Furthermore, a survey conducted by Kapur (2007) on the cost of d iabetes mell itus  in  Ind ia reported that the  ind irect cost burden  in the management of d iabetes mell itus d isease formed more than half of the total healthcare expend iture. However,  in contrast to the f ind ing of Kapur’s (2007),  ind irect cost est imated  in th is study const itute less than 10% of the total treatment cost. Aga in, th is f ind ing  is  in sharp contrast w ith study results of K ir ig ia et al. (2009), who  in a standard cost-of- illness study  in the WHO Afr ican reg ion reported that the  ind irect cost burden of type-2 d iabetes d isease management was s ign if icantly not d ifferent from the d irect cost result ing from the d isease ( i.e. d irect cost was 57% and  ind irect cost was 43%). Nonetheless, cons istent w ith th is study was a research by Chatterjee et al. (2011) wh ich reported that the  ind irect cost of d iabet ic healthcare formed less than half of the total cost of d iabet ic healthcare. L ikew ise, Amer ican D iabetes Assoc iat ion (2013) reported that  ind irect cost of d iabetes mellitus d isease management const ituted less than 30% of the total healthcare expend iture. Accord ing to Amer ican D iabetes Assoc iat ion (2013) report wh ich documented the extent of econom ic loss from absentee ism and low product iv ity due to d iabetes care, d iabet ic management leads to more than 7%  increase  in absentee ism. 49 University of Ghana http://ugspace.ug.edu.gh 5.3  Intang ible Cost Assoc iated w ith Type-2 D iabetes The burden assoc iated w ith manag ing type-2 d iabetes further extends to phys ical and psycholog ical pa in, stress and anx iety wh ich adversely affect the quality of l ife of d iabet ics. F ind ings of th is study shows that a substant ial number (37.9%) of type-2 d iabet ics who used  insul in often felt d iscomfort and stressed dur ing  its adm in istrat ion. Th is corroborates WHO (2013) report wh ich observed that the management of the d isease espec ially by  insul in  inject ion may be  inconven ient, t ime-consum ing and a potent ial source of psycholog ical stress. K ir ig ia et al. (2009)  in a study emphas ized the point that  intang ible burden suffered due to d iabetes contr ibutes s ign if icantly to the overall cost burden. The major ity of patients suffer var ious degrees of depress ion and phys ical pa ins rang ing from moderate to very severe. S im ilarly, a study by Anderson et al (2001) showed that people w ith d iabetes had tw ice the odds of depression compared to those w ithout depress ion. Diabet ics must be encouraged to regularly engage  in phys ical act iv it ies and hobb ies  in order to prevent stress and depress ion assoc iated w ith the d iabetes mellitus d isease. Trovato et al. (2006) reported an assoc iat ion between d iabetes and psycholog ical stress. Sim ilarly, Donald et al. (2012) exam ined the cost of d iabetes and concluded that about 37.9% of d iabet ics l ived w ith pa in and d iscomfort. The lower levels of phys ical pa in among d iabet ics can be attr ibuted to the ir constant adherence to treatment schedule as a result of NH IS membersh ip. Donald et al (2012) stated that less than a th ird of study pat ients had problems w ith mob il ity and ab il ity to undertake usual act iv it ies w ith ease. Th is  is s im ilar to f ind ings of th is study  in wh ich even lower proport ion of pat ient report of  inab il ity to enjoy hobb ies. WHO (2015) reported that pa in, anx iety, d iscr im inat ion at workplace, d iff icult  in obta in ing jobs was ma inly due to 50 University of Ghana http://ugspace.ug.edu.gh compl icat ions, st igmat izat ion and other factors wh ich decrease qual ity of l ife.  In th is study, d iabet ics w ith compl icat ions have sl ightly lower qual ity of l ife (we ighted mean score of 3.3) compared to pat ients w ithout compl icat ions (we ighted mean score of 3.5) 5.4 L im itat ion of the Study 1. The study was conducted  in only one fac il ity and the sample s ize used was m in imal compared to other stud ies. Hence, f ind ings could not be general ized to the larger populat ion of d iabet ic pat ients. 2. Intang ible cost could not be valued  in monetary terms due to methodolog ical l imitat ions. Therefore, these were descr ibed but not added to the total cost. 3. The d irect and  ind irect cost  incurred as well as the number of product ive hours lost by the pat ient was solely based on recall wh ich may not be accurate. 4. T ime lost by accompany ing relat ives was not accounted for s ince there was no data collected on the ir occupat ional backgrounds. 51 University of Ghana http://ugspace.ug.edu.gh CHAPTER S IX CONCLUS IONS AND RECOMMEDAT IONS This chapter summarizes the significance and implication of the study and makes recommendations which aims to inform policies and programmes targeted at improving the current management of the diabetes mellitus  disease  in order to  mitigate the economic burden associated with the disease. 6.1 Conclusion  This study aimed at assessing the cost of living with diabetes type-2 in Ghana, precisely among patients who visit Pantang Government Hospital. From the results of the study it became apparent that the cost of treatment across various dimensions studied was moderately to highly expensive for people living with diabetes. The cost of medicine was a huge burden on diabetes type-2 patients, which totaled 71.9% (representing GHS 18,540) of total direct medical cost. Beyond the direct medical cost, travel and food cost figured prominently in participants burden. It is also apparent from the study that the diseased also posed a significant burden on the productive lifestyle of the patients. Many of the patients reported absenteeism from work as well as the combined problem for long travel times to and waiting times at the diabetic clinics. The burden of living with diabetes type-2 was not only limited to finance or the economy of the patients but the disease also posed significant physical and psychosocial problems. Severe physical pains and depressed feeling were mostly reported by the patients. The discomfort and stress associated with insulin administration were also burdensome to the patients. Although the economic and psychosocial impact of the disease on the patients was worrying, it did not appear to affect the marriages. Most of the patients reported no effect of the condition on their 52 University of Ghana http://ugspace.ug.edu.gh marriages. Moreover, certain intangible costs including the impact of the disease on hobbies, sleep, confidence and social participation were not impacted much. As can be seen thus far the impact of the condition spans the individual, family and societal levels. Thus, diabetes type-2 requires a multilevel intervention to reduce some of the burden associated with living with the disease. The next section will delineate some recommendations targeted at various stakeholders. 6.2 Recommendation The study makes the follow ing recommendat ion: The Government To the extent that d irect cost const itutes the major cost  incurred by the type-2 d iabetes pat ients, there  is the need for a pol icy on d iabetes treatment w ith the a im of subs id iz ing the d irect cost components of treat ing d iabetes. Th is could be done through effect ive advocacy and collaborat ion w ith pr ivate sector partners and  interest group to ra ise the needed resources for reduc ing the d irect treatment cost of d iabetes. The M in istry of Health Serv ices for d iabetes management should be decentral ized by M in istry of Health s ince  it costs pat ients a lot of money travell ing  in and out of treatment centers. Bes ides the money spent on transportat ion, t ime spent travell ing  is also another source of loss to pat ients and the ir accompany ing relat ives. 53 University of Ghana http://ugspace.ug.edu.gh The Support ing Groups Cons ider ing the  intang ible cost borne by women (59.7%) w ith d iabetes, the support groups or the hosp ital should be encouraged  in order to ass ist pat ients psycholog ically as well as reduce the st igma assoc iated w ith the d isease.  Ind iv idual pat ients’ d iabetes Based on the study results pat ients should be encouraged to adhere to the ir d ietary plan, undertake regular phys ical act iv it ies and exerc ises. Th is would  increase  insul in sens it iv ity  in order for the cells to better be able to ut il ize  insul in and keep glucose at normal level thereby  improv ing the ir health and thus prevent compl icat ions and  its assoc iated costs. 54 University of Ghana http://ugspace.ug.edu.gh REFERENCE Abegunde, D. O., Mathers, C. D., Adam, T., Ortegon, M., & Strong, K. (2007). The burden and costs of chronic diseases in low-income and middle-income countries. The Lancet, 370(9603), 1929-1938. Aikins, A. d.-G. (2005). Healer shopping in Africa: new evidence from rural-urban qualitative study of Ghanaian diabetes experiences. Bmj, 331(7519), 737. American Diabetes Association. (2010). Standards of medical care in diabetes—2010. Diabetes care, 33(Supplement 1), S11-S61. Beran, D., Yudkin, J. S., & De Courten, M. (2005). Access to care for patients with insulin- requiring diabetes in developing countries case studies of Mozambique and Zambia. Diabetes care, 28(9), 2136-2140. Dall, T. M., Zhang, Y., Chen, Y. J., Quick, W. W., Yang, W. G., & Fogli, J. (2010). The economic burden of diabetes. Health Affairs, 29(2), 297-303. Geneau, R., Stuckler, D., Stachenko, S., McKee, M., Ebrahim, S., Basu, S., . . . Alwan, A. (2010). Raising the priority of preventing chronic diseases: a political process. The Lancet, 376(9753), 1689-1698. Gilmer, T. P., O’Connor, P. J., Rush, W. A., Crain, A. L., Whitebird, R. R., Hanson, A. M., & Solberg, L. I. (2005). Predictors of healthcare costs in adults with diabetes. Diabetes care, 28(1), 59-64. Hall, V., Thomsen, R. W., Henriksen, O., & Lohse, N. (2011). Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review. BMC public health, 11(1), 564. Kilzieh, N., Rastam, S., Maziak, W., & Ward, K. D. (2008). Comorbidity of depression with chronic diseases: a population-based study in Aleppo, Syria. The International Journal of Psychiatry in Medicine, 38(2), 169-184. Kolb, H., & Mandrup-Poulsen, T. (2010). The global diabetes epidemic as a consequence of lifestyle-induced low-grade inflammation. Diabetologia, 53(1), 10-20. doi:10.1007/s00125-009-1573-7 Kumi-Ampofo, G. (2015). Household Cost of Seeking Diabetic Healthcare in the Tano North 55 University of Ghana http://ugspace.ug.edu.gh District of the Brong Ahafo Region. Mayer-Foulkes, D. A. (2011). A survey of macro damages from Non-communicable chronic diseases: another challenge for global governance. Global Economy Journal, 11(1). MedicineNet.com (2015). http://www.medicinenet.com/diabetes/focus.htm. Nisar, M. U., Asad, A., Waqas, A., Ali, N., Nisar, A., Qayyum, M. A., . . . Jamil, M. (2015). Association of Diabetic Neuropathy with Duration of Type-2 Diabetes and Glycemic Control. Cureus, 7(8). Roglic, G., & Unwin, N. (2010). Mortality attributable to diabetes: estimates for the year 2010. Diabetes research and clinical practice, 87(1), 15-19. Shaw, J. E., Sicree, R. A., & Zimmet, P. Z. (2010). Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes research and clinical practice, 87(1), 4-14. Stolar, M. (2010). Glycemic control and complications in type-2 diabetes mellitus. The American journal of medicine, 123(3), S3-S11. Strine, T. W., Okoro, C. A., Chapman, D. P., Beckles, G. L., Balluz, L., & Mokdad, A. H. (2005). The impact of formal diabetes education on the preventive health practices and behaviors of persons with type-2 diabetes. Preventive Medicine, 41(1), 79-84. Tagoe, H. (2012). Household burden of chronic diseases in Ghana. GHANA MEDICAL JOURNAL, 46(2 Suppl), 54. Thaneerat, T., Tangwongchai, S., & Worakul, P. (2010). Prevalence of depression, hemoglobin A1C level, and associated factors in outpatients with type-2 diabetes. Asian Biomed, 3(4), 383-390. Tunstall-Pedoe, H. (2006). Preventing Chronic Diseases. A Vital Investment: WHO Global Report. Geneva: World Health Organization, 2005. Pp 200. CHF 30.00. ISBN 92 1563001. Also published on http://www. Who. Int/chp/chronic_disease_report/en. International Journal of Epidemiology, 35(4), 1107-1107. Zhang, C.-X., Chen, Y.-M., & Chen, W.-Q. (2008). Association of psychosocial factors with anxiety and depressive symptoms in Chinese patients with type-2 diabetes. Diabetes research and clinical practice, 79(3), 523-530. 56 University of Ghana http://ugspace.ug.edu.gh APPENDIX UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH Dear Respondent, I am Amoako Margaret, a student of the above-mentioned school, undertaking a master’s programme in public health. I am researching on the topic:” SOCIO-ECONOMIC BURDEN OF TYPE-2 DIABETES AMONG PATIENTS ATTENDING PANTANG GOVERNMENT HOSPITAL” and would be grateful if you could take some time to answer the below question to enable the completion of this research. All answers provided would be treated with the utmost confidentiality. Please kindly indicate your answer with a tick (√) or write in the space provided. Qn. No. Questions Response Questionnaire No. ……………………. Section Socio-demographic information 1 1 What is your sex 1. Male 2. Female 2 What is your age in years (i.e. age at last birthday)? Years 3 What is the highest level of school you attended? 1. No education 2. Primary 3. Middle 4. JSS/JHS 5. Secondary/Vocational 6. SSS/SHS 7. Higher 4 What is your current marital status? 1. Married/living together 2. Divorced/ Separated 3. Widowed 4. Never married 57 University of Ghana http://ugspace.ug.edu.gh 5 What is your employment status? 1. Unemployed 2. Employed If unemployed, go to Qn 7 6 If employed, what is your occupation, that is, ……………………………. what kind of work do you mainly do? ……………………….. 7 If unemployed, reason for not being employed? 1. Student 2. Housewife 3. Retired 4. Unable due to diabetes 5. Other (please specify) ..……………………… 8 What is your average monthly income? (salary plus other monies from other sources) 9 How many people are supported on this income? Section Direct cost information 2 Direct medical cost information How much money (GHS) did you spend for: (a)Consultation? 10 (b)Lab test? (c)treatments? 11 Direct non-medical cost information How much money did you spend for? (GHS) (a)travel cost (b)food cost (c)other cost Section Indirect cost information 3 How many days have you absent from work 12 (if applicable) in the last month because of Days diabetes (i.e. treatment, recovery)? 58 University of Ghana http://ugspace.ug.edu.gh 13 How many minutes did you spend travelling to and from the diabetic clinic? Minutes 14 How many minutes did you spend at the diabetic clinic? Minutes 15 Does anyone accompany you to the clinic? 1. Yes 2. No If No, go to Qn 17 16 What is his/her employment status? 1. Unemployed 2. Employed 17 Any other information on expenses incurred due to diabetes? ……………………………………. Section Intangible Cost information 4 How much physical pain do you suffer as a result of diabetes? 18 1. None 2. Very little 3. Moderate 4. Severe 5. Very severe How often do you feel depressed by the fact that you have diabetes? 19 1. Always 2. Very Often 3. Quite often 4. Seldom 5. Never 20 If employed by another person or organization, are you side-lined at work because of diabetes? 1. Yes 2. No 3. Not employed 21 If retired, was the retirement as a result of the diabetes? 1. Yes 2. No 3. Not applicable 22 How often do you feel uncomfortable when you adm in ister  insul in  inject ion? 1. Always 2. Very Often 59 University of Ghana http://ugspace.ug.edu.gh 3. Qu ite often 4. Seldom 5. Never 23 How often do you feel stressed out when you have to adm in ister  insul in  inject ion? 1. Always 2. Very Often 3. Qu ite often 4. Seldom 5. Never 24  If marr ied, how has d iabetes affected your marr iage? 1. No effect 2. D ivorced 3. Separated 4. Other (please spec ify) ……..…………………. 25  I am not able to enjoy my hobb ies as  I d id pr ior to the d iagnos is of the d isease? 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 26  I have sleepless n ights because of my d iabet ic cond it ion? 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 27  I have low self-conf idence because of my d iabet ic cond it ion. 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 28  I have low self-esteem because of my d iabet ic cond it ion. 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 60 University of Ghana http://ugspace.ug.edu.gh 29  I avo id company of others because of my d iabet ic cond it ion. 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 30  I eas ily get fat igued because of my d iabet ic cond it ion. 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 31  I have to change d iet because of d iabetes 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 32  I eas ily get  irr itated because of my d iabet ic cond it ion 1. Strongly d isagree 2. D isagree 3. Neutral 4. Agree 5. Strongly agree 33 On a scale of one to f ive, how would you rate your qual ity of l ife? Very Poor Ne ither poor Good Very poor nor good good 61