2026 Jan; 3(1): 75-84. |
ISSN: 3005-6632 |
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2026 Jan; 3(1): 75-84. |
ISSN: 3005-6632 |
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*Mohammad Naim Safi 1,2, Aziz-ur-Rahman Niazi 1,3, Naseer Ahmad Durrani 1, Asad Ulla Arsalan Aslami 4
Received: 12 Nov, 2025 Accepted: 25 Dec, 2025 *Corresponding Author: E-mails: Safi MN, Niazi AR, Durrani NA, Aslami AA. Health‑Related Quality of Life in Type 2 Diabetes Mellitus: Cross‑Sectional Analytical Evidence from Wazir Akbar Khan Hospital, Kabul, Afghanistan. Afghanistan Journal of Basic Medical Sciences. 2026 Jan; 3(1): 75-84. DOI https://doi.org/10.62134/khatamuni.152 |
Diabetes mellitus (DM) is among the most common chronic metabolic disorders worldwide and remains a major contributor to global morbidity and mortality (1). It is characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Type 2 diabetes mellitus (T2DM), the predominant form of the disease, is defined by insulin resistance accompanied by a relative deficiency of insulin, leading to sustained elevations in blood glucose levels (2).
The etiology of T2DM is complex and multifactorial, arising from interactions between genetic predisposition and environmental and behavioral factors. Established risk factors include obesity, physical inactivity, smoking, unhealthy dietary patterns, excessive alcohol intake, advancing age—particularly beyond 45 years—and a family history of diabetes, especially among first-degree relatives. Several comorbid conditions further increase susceptibility to T2DM, including hypertension, dyslipidemia, polycystic ovary syndrome, and endocrine disorders such as Cushing’s syndrome (2,3). T2DM often remains clinically silent in its early stages, delaying diagnosis and increasing the risk of complications. When symptoms occur, they commonly include polyuria, polydipsia, polyphagia, fatigue, nocturia, and overweight. Diagnosis is based on standardized biochemical criteria, including fasting plasma glucose ≥126 mg/dL (7 mmol/L), HbA1c ≥6.5%, a two-hour plasma glucose level ≥200 mg/dL during a 75 g oral glucose tolerance test, or a random plasma glucose ≥200 mg/dL in the presence of classic hyperglycemic symptoms (2).
The overarching goals of diabetes care extend beyond glycemic regulation and include the prevention of acute metabolic emergencies—such as diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic syndrome—as well as the reduction of long-term microvascular and macrovascular complications. Effective disease management ultimately seeks to enhance patients’ quality of life and decrease diabetes-related mortality (1,4). Previous investigations in Middle Eastern populations have largely focused on clinical outcomes, including hypoglycemic episodes and the effects of intensive antidiabetic treatment regimens (5,6).
Despite the expanding literature on diabetes, limited attention has been given to the quality of life (QoL) of affected individuals, particularly in Afghanistan and its capital, Kabul. DM exerts a profound impact on QoL, not only through its medical complications but also by imposing substantial social, economic, and familial burdens, especially among patients with coexisting conditions (7). Recurrent hospital admissions can further exacerbate these challenges, contributing to financial hardship, employment instability, reduced social engagement, and psychological distress (8). QoL is a multidimensional construct defined by the WHO as an individual’s perception of their position in life within the context of their cultural and value systems and in relation to their goals, expectations, and concerns (9). This concept is shaped by an intricate interaction of physical health, psychological well-being, level of independence, social relationships, and environmental factors. In the context of diabetes, health-related quality of life (HRQoL) is commonly compromised by physical limitations resulting from disease-related complications, as well as by mental health disturbances such as fatigue and depressive symptoms associated with poor glycemic control (10).
Given the breadth and complexity of these influences, systematic assessment of HRQoL in patients with diabetes is essential. Accordingly, we aimed to evaluate health-related quality of life and its associated factors among patients with T2DM.
A hospital-based descriptive cross-sectional study was carried out in 2025 at Wazir Mohammad Akbar Khan National Hospital, Kabul, Afghanistan. This institution is a tertiary referral center that delivers specialized outpatient and inpatient services to patients with chronic non-communicable diseases, including diabetes mellitus.
The study population comprised adult patients diagnosed with diabetes mellitus who attended the hospital during the study period. A total of 298 participants were enrolled using a non-probability convenience sampling technique. Eligible participants were aged 18 years or older, had a physician-confirmed diagnosis of diabetes mellitus, and were capable of understanding and completing the study questionnaire. Patients were excluded if they had severe cognitive impairment, psychiatric disorders that could compromise reliable questionnaire responses, or acute medical conditions at the time of data collection.
Data were obtained through structured, face-to-face interviews conducted by trained personnel, supplemented by a review of patients’ medical records. Collected sociodemographic information included age, sex, marital status, level of education, and place of residence. Clinical data focused primarily on disease-related variables, particularly the duration of diabetes.
HRQoL was evaluated using the 36-Item Short Form Health Survey (SF-36), a widely validated generic instrument. The SF-36 assesses eight health domains: Physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health. Scores for each domain were calculated following standard scoring algorithms and transformed to a scale ranging from 0 to 100, with higher scores reflecting better perceived health status. Composite indices were generated to summarize overall health dimensions: the physical component summary (PCS), derived from physical functioning, role physical, bodily pain, and general health; and the mental component summary (MCS), derived from vitality, mental health, role emotional, and social functioning.
Data analysis was performed using the SPSS, version 20 (IBM Corp., Armonk, NY, USA). The analytical approach was descriptive in nature, and no inferential statistical testing was undertaken. Continuous variables were reported as means with standard deviations, while categorical variables were expressed as frequencies and percentages. Mean scores and standard deviations were calculated for each SF-36 domain and descriptively interpreted as indicating poor or moderate HRQoL in accordance with established SF-36 interpretative frameworks and prior descriptive research in diabetes populations (11).
Composite PCS and MCS scores were computed to facilitate a descriptive comparison between physical and mental dimensions of health status. Gender-based differences in HRQoL were explored by comparing mean SF-36 domain scores between male and female participants and reporting observed directional trends. Age-related variations were examined by stratifying participants into three age categories (<40 years, 40–60 years, and >60 years) and comparing domain-level mean scores across these groups. Similarly, the influence of disease duration was assessed by categorizing participants according to diabetes duration (<5 years, 5–10 years, and >10 years) and identifying progressive or dose–response patterns in HRQoL scores.
The sociodemographic and clinical profile of the 298 participants is presented in Table 1. The study population included 153 men (51.3%) and 145 women (48.7%), reflecting an almost equal gender distribution. Participants had a mean age of 53.6 years (SD = 12.4), indicating that most were middle-aged or older adults. The majority were married (82.9%), whereas 17.1% reported being single, widowed, or divorced. Educational attainment was generally low. More than two-fifths of participants were illiterate (40.6%), while 24.8% had completed primary education, 20.5% secondary education, and only 14.1% had attained a university-level qualification. Most respondents resided in Kabul (84.2%), with a smaller proportion (15.8%) coming from provinces outside the capital. The mean duration of diabetes was 8.9 years (SD = 5.7), suggesting prolonged exposure to the disease among a substantial proportion of the sample (Table 1).
| Male | 153 | 51.3 | |
| Female | 145 | 48.7 | |
| Age (Mean ± SD) | 53.6 ± 12.4 | - | |
| Married | 247 | 82.9 | |
| Other marital status | 51 | 17.1 | |
| Illiterate | 121 | 40.6 | |
| Primary education | 74 | 24.8 | |
| Secondary education | 61 | 20.5 | |
| University education | 42 | 14.1 | |
| Kabul residence | 251 | 84.2 | |
| Other provinces | 47 | 15.8 |
Health-Related Quality of Life
Table 2 summarizes the mean scores of the SF-36 domains for the study participants. Overall, HRQoL was notably compromised, with the greatest impairments observed in physical health–related domains.
| Physical Functioning | 43.7 ± 11.2 | Poor |
| Role Limitation – Physical | 35.4 ± 13.6 | Poor |
| Role Limitation – Emotional | 51.9 ± 21.3 | Moderate |
| Social Functioning | 54.0 ± 18.2 | Moderate |
| Bodily Pain | 52.1 ± 16.8 | Moderate |
| Vitality / Mental Health | 46.8 ± 19.4 | Poor |
| General Health Perception | 44.5 ± 17.1 | Poor |
The lowest mean scores were recorded for role limitations due to physical problems (35.4 ± 13.6) and physical functioning (43.7 ± 11.2), both categorized as poor, indicating marked restrictions in physical activities and daily role performance attributable to health limitations. Perceptions of general health were similarly unfavorable, with the general health domain scoring 44.5 ± 17.1. Measures related to energy and psychological well-being, reflected in the vitality/mental health domain, also demonstrated poor status (46.8 ± 19.4). In contrast, relatively higher—though still suboptimal—scores were observed in role limitations due to emotional problems (51.9 ± 21.3), social functioning (54.0 ± 18.2), and bodily pain (52.1 ± 16.8), all of which were interpreted as indicating moderate levels of functioning (Table 2).
Table 3 presents the composite scores for physical and mental health derived from the SF-36 assessment. The PCS, calculated from the domains of physical functioning, role limitations due to physical problems, bodily pain, and general health, yielded a low average score and was categorized as poor, reflecting pronounced limitations in physical aspects of health-related quality of life. In comparison, the MCS, which encompasses vitality, mental health, role limitations due to emotional problems, and social functioning, achieved a higher mean score than the PCS. Despite this relative difference, MCS values remained within the poor-to-moderate range, indicating that mental, emotional, and social well-being were also adversely affected. Collectively, these findings indicate that while physical health domains were more severely impaired than mental health domains, overall quality of life was substantially reduced among the study population (Table 3).
| Physical Health Component (PCS) | Physical Functioning, Role Physical, Bodily Pain, General Health | Poor |
| Mental Health Component (MCS) | Vitality, Mental Health, Role Emotional, Social Functioning | Poor–Moderate |
Table 4 illustrates gender-based differences in SF-36 domain scores among patients with diabetes. Male participants demonstrated higher mean scores across all domains when compared with female participants, suggesting a more favorable health-related quality of life among men.
| Physical Functioning | Higher | Lower | Female worse |
| Role Physical | Higher | Lower | Female worse |
| Role Emotional | Higher | Lower | Female worse |
| Social Functioning | Higher | Lower | Female worse |
| Bodily Pain | Higher | Lower | Female worse |
| Vitality / Mental Health | Higher | Lower | Female worse |
| General Health | Higher | Lower | Female worse |
Women consistently reported lower scores in domains related to physical health, particularly physical functioning and role limitations due to physical problems, indicating greater restrictions in routine physical activities. Gender disparities were also evident in psychosocial domains. Female participants exhibited poorer scores in role limitations due to emotional problems, social functioning, and vitality/mental health, reflecting increased emotional strain, diminished social participation, and reduced psychological well-being. Furthermore, lower scores among women in the bodily pain and general health domains suggest greater pain-related interference and less favorable perceptions of overall health status (Table 4).
Table 5 presents SF-36 domain scores across three age groups. A clear and consistent age-related trend was observed in both physical and mental health domains. Participants younger than 40 years reported the highest levels of physical functioning and role limitation due to physical problems, along with the least impairment related to bodily pain. This group also demonstrated better vitality/mental health and general health perception. Individuals aged 40–60 years exhibited intermediate scores across all domains. In contrast, participants older than 60 years showed the poorest outcomes, with the lowest physical functioning and role physical scores, the greatest degree of bodily pain, and markedly reduced vitality and general health perception. Overall, physical functioning, vitality, and general health declined progressively with increasing age, whereas bodily pain increased (Table 5).
| Physical Functioning | Highest | Moderate | Lowest | ↓ With age |
| Role Physical | Highest | Moderate | Lowest | ↓ With age |
| Bodily Pain | Least pain | Moderate pain | Most pain | ↑ With age |
| Vitality / Mental Health | Better | Reduced | Poor | ↓ With age |
| General Health | Better | Moderate | Poor | ↓ With age |
Table 6 presents SF-36 domain scores according to duration of diabetes, revealing a consistent and progressive decline in health-related quality of life as disease duration increased. Participants with a diabetes history of less than five years demonstrated the most favorable HRQoL profiles, with higher scores in physical functioning and role limitations due to physical problems, lower levels of pain-related impairment, and more positive perceptions of vitality and general health.
| Physical Functioning | Highest | Moderate | Lowest | Dose–response |
| Role Physical | Highest | Moderate | Lowest | Dose–response |
| Bodily Pain | Least | Moderate | Most | Progressive |
| Vitality / Mental Health | Better | Reduced | Poor | Progressive |
| General Health | Better | Moderate | Poor | Progressive |
Patients with an intermediate disease duration of 5–10 years showed moderate scores across all SF-36 domains, reflecting a transitional stage between early and long-standing disease. In contrast, those with diabetes for more than ten years experienced the greatest deterioration in quality of life, as evidenced by markedly reduced physical functioning and role performance, increased bodily pain, and substantial declines in vitality and overall health perception. Collectively, these findings indicate a dose–response relationship between longer diabetes duration and poorer HRQoL outcomes (Table 6).
Table 7 outlines the principal factors associated with diminished health-related QL in patients with diabetes and summarizes their impact across SF-36 domains. Advancing age emerged as a key determinant of reduced HRQoL, particularly affecting physical functioning, bodily pain, and general health domains. Older participants reported greater limitations in mobility, increased pain-related interference, and more negative perceptions of overall health, collectively contributing to declines in functional independence and daily activity performance. Female gender emerged as a significant determinant affecting both physical and mental health domains, indicating a higher overall disease burden among women. Longer duration of diabetes was linked to impairments in physical functioning, increased pain, and reduced vitality, reflecting the cumulative effects of chronic disease over time. Additionally, chronic pain was found to negatively influence physical, mental, and social domains, contributing to functional disability and limitations in daily activities. Emotional distress predominantly affected mental health, social functioning, and role limitation due to emotional problems, resulting in decreased productivity and social participation (Table 7).
| Older Age | Physical Functioning, Pain, General Health | Reduced mobility |
| Female Gender | Physical & Mental Domains | Higher disease burden |
| Longer Diabetes Duration | Physical, Pain, Vitality | Cumulative impairment |
| Chronic Pain | Physical, Mental, Social | Functional disability |
| Emotional Distress | Mental, Social, Role Emotional | Reduced productivity |
This study provides a comprehensive assessment of HRQoL among patients with diabetes in Kabul, Afghanistan, highlighting substantial impairments across both physical and mental health domains. Overall, the findings indicate that diabetes is associated with markedly reduced HRQoL, with physical health dimensions being more severely affected than mental and social domains. These results underscore the multidimensional burden of diabetes in low-resource and conflict-affected settings.
The lowest SF-36 scores were observed in role limitation due to physical problems and physical functioning, indicating profound restrictions in daily activities and occupational roles. This pattern is consistent with previous studies showing that diabetes-related complications, fatigue, and reduced mobility significantly impair physical functioning and role performance (12, 13). The poor general health perception observed in this study further reflects patients’ awareness of diabetes as a chronic, progressive condition with long-term consequences, a finding widely reported in international literature (14, 15).
The relatively poorer PCS compared with the MCS suggests that physical limitations represent the dominant contributor to reduced HRQoL in this population. Similar trends have been documented in studies from both high- and low-income countries, where physical symptoms and complications such as neuropathy, musculoskeletal pain, and cardiovascular comorbidities disproportionately affect quality of life (1, 11).
Although mental and social domains were comparatively less impaired than physical domains, they still fell within poor to moderate ranges. Reduced vitality/mental health scores indicate persistent fatigue, emotional distress, and reduced psychological well-being, which are common among individuals with diabetes and have been linked to suboptimal glycemic control and increased risk of depression (16). Moderate scores in social functioning and role limitation due to emotional problems suggest partial preservation of social roles, possibly supported by strong family structures; however, emotional burden remains clinically significant. Prior evidence demonstrates that emotional distress and diabetes-related depression negatively influence adherence, self-care behaviors, and overall outcomes (17).
A notable finding of this study is the consistently lower HRQoL scores among female patients across all SF-36 domains. This aligns with a robust body of evidence indicating that women with diabetes experience greater physical limitations, higher pain perception, and increased psychological distress compared with men (18, 19). Sociocultural factors, reduced access to healthcare, caregiving responsibilities, and lower health literacy may further exacerbate the disease burden among women in this context. These findings emphasize the need for gender-sensitive diabetes management strategies that address both biomedical and psychosocial determinants of health.
The observed age-related gradient, with progressively worse HRQoL among older participants, is consistent with prior research demonstrating declining physical function, increased pain, and reduced vitality with advancing age (20, 21). Older adults with diabetes are more likely to experience cumulative complications, comorbidities, and functional decline, which collectively impair both physical and mental health. The sharp deterioration in physical functioning and general health perception among participants older than 60 years highlights the importance of early intervention and age-specific care models.
The clear dose–response relationship between longer duration of diabetes and poorer HRQoL strongly supports the cumulative burden hypothesis. Patients with more than 10 years of disease duration exhibited the lowest scores across physical, pain, vitality, and general health domains. Similar findings have been widely reported, indicating that prolonged exposure to hyperglycemia and metabolic dysregulation increases the risk of complications, chronic pain, and functional impairment (22, 23). These results reinforce the importance of early diagnosis, sustained glycemic control, and long-term monitoring to preserve quality of life.
Chronic pain emerged as a central determinant affecting physical, mental, and social domains, contributing to functional disability and reduced daily activity. Pain-related impairment in diabetes has been closely linked to neuropathy, musculoskeletal disorders, and inflammatory mechanisms, all of which negatively influence HRQoL (24). Additionally, emotional distress was strongly associated with poorer mental health, social functioning, and role performance, consistent with evidence that psychological comorbidities significantly amplify the perceived burden of diabetes (25).
The findings highlight the urgent need for integrated, patient-centered diabetes care that extends beyond glycemic control to include pain management, mental health screening, and social support interventions. Targeted strategies for high-risk groups—particularly women, older adults, and patients with long disease duration—are essential. In resource-limited settings such as Afghanistan, incorporating HRQoL assessment into routine clinical practice may help identify vulnerable patients and guide holistic interventions aimed at improving long-term outcomes.
The authors would like to express their sincere gratitude to Kabul University of Medical Sciences and the Ministry of Public Health for their support. This research received no specific grant or financial support from any funding agency, commercial, or not-for-profit organization.
The authors declare that they have no conflicts of interest related to this work.
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