Background
Functional dyspepsia is defined as the presence of symptoms thought to originate in the gastroduodenal region, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms [
1]. Dyspepsia symptoms are commonly seen in the community and in clinical practice [
2]. The prevalence of functional dyspepsia in Asian populations is 7–20% [
3]. Several Asian hospitals have also reported that 50–80% of patients with dyspepsia are found to have functional dyspepsia [
2,
4].
HRQOL describes health status based on patients’ perceptions. It consists of physical, psychological, and social function domains [
5,
6]. Functional dyspepsia is not associated with increased mortality so HRQoL assessment is important to understand the impact of disease and treatments on patients [
7‐
9]. Previous studies have demonstrated impaired HRQoL in patients with functional dyspepsia [
10‐
16]. Inside factors such as the type of illness, the nature and severity of symptoms, any comorbidities, health knowledge, anxiety, and depression can influence HRQoL. It is also affected by outside factors such as socioeconomic status, social support, culture, demographic and medical care quality and access [
17]. Studies in patients with functional dyspepsia have found the contribution of clinical factors such as symptom severity, psychosocial factors such as anxiety, and depression, and demographic factors such as age and gender in decreasing the patients’ HRQoL [
10,
12‐
14]. However, studies on factors associated with HRQoL in patients with functional dyspepsia are rare and have been limited to Western populations [
10,
12‐
14], eventhough there are differences in clinical and epidemiological characteristics between Asian and Western patients [
18]. Previous studies have also not evaluated the relationship between education level and ethnicity on the quality of life of patients with functional dyspepsia.
The objectives of this study were to assess the impact of functional dyspepsia on HRQoL among patients in a tertiary hospital in Indonesia. We also aimed to determine the contribution of clinical, psychosocial, and demographic factors to the HRQoL of such patients.
Discussion
Our study confirms previous studies that showed a decrease in the HRQoL in patients with functional dyspepsia [
10,
13‐
15]. We also found that functional dyspepsia mainly affected the physical components rather than mental components of HRQoL. This finding is consistent with two reported studies in Western populations [
10,
12].
Several studies have reported bodily pain as one of the most disrupted domains in patients with functional dyspepsia [
11,
12,
27]. A recent publication by Shetty et al. using the EuroQol Group EQ-5D questionnaire also demonstrated that 308 of 311 patients with functional dyspepsia complained of impairment in the pain dimension [
28]. In our study, the bodily pain scale score was the second lowest among the SF-36 physical component domains. Its scale score was almost whole SD value below the general population norms.
Vitality was the only domain with a scale score above the population norms but role-emotional was the lowest scale score domain. These findings suggest that functional dyspepsia may inhibit our patients from performing their work, but do not cause loss of their life enthusiasm and energy. In contrast to our findings, earlier studies in Western population reported decreased vitality domain value to population norms [
11,
12]. Aro et al. also reported vitality as the most affected domain in patients with functional dyspepsia [
11].
Impaired HRQoL occurs not only in those functional dyspepsia, but also in other functional GI disorders. Gralnek et al. found HRQoL reduction in patients with irritable bowel syndrome (IBS) [
29]. Nevertheless, compared with our study, patients with IBS had a more negative impact on mental components. Decreased HRQoL was also demonstrated in patients with gastroesophageal reflux disease (GERD) [
30]. However, the overall HRQoL in patients with GERD was better than the patients with functional dyspepsia in our study.
Female patients with functional dyspepsia generally have lower HRQoL mainly in the physical components compared with male patients [
31]. These HRQoL differences are not surprising given data from previous studies reporting that female patients tend to complain of symptoms of dyspepsia than male patients [
32]. Here, we found that the HRQoL of female patients was worse than among male patients. Multivariate analysis also demonstrated association between gender and SF-36 PCS and MCS results. However, this latter finding differs from previous studies that showed an association of gender only with PCS [
10,
13].
Our study confirms a previous study demonstrated an association between increased age and decreased physical components of HRQoL [
10]. The increased prevalence of chronic disease in old age is thought to be closely related to this [
33]. Our study did not find any association between employment status and HRQoL. However, this finding needs to be interpreted carefully as most (64%) of the patients in this study were unemployed. In contrast to our research, Oudenhove et al. showed a trend between employment status and PCS [
12]. A study in patients with inflammatory bowel disease also demonstrated an association between being unemployed patients with worse HRQoL and more severe anxiety and depression symptoms [
34].
In this study, symptom severity was associated with both PCS and MCS. These findings are in line with results from previous studies [
10,
13]. Talley et al. also reported different impact on HRQoL for different dyspepsia symptoms [
10]. Haag et al. further showed differences in HRQoL between patients with postprandial distress syndrome and those with epigastric pain syndrome [
13]. In general, anxiety and depression adversely influence the HRQoL in patients with functional GI disorders [
35]. Our study confirms previous research finding association between anxiety and depression and the mental components of HRQoL. However, in contrast to our study, Haag et al. also showed the impact of depression on the physical component of HRQoL [
14]. The more significant effect of the psychological factor on HRQoL in that study related to more severe symptoms of anxiety and depression than in our research.
Previous studies in patients with asthma and multiple sclerosis reported an association of education level with HRQoL [
36,
37]. Our study also found a similar finding, i.e., a lower level of education was associated with a worse HRQoL in these patients with functional dyspepsia. The differences in HRQoL between low-to-mid and high education level patients might be related to a stronger disease awareness and better coping ability with the challenges of better chronic diseases among patients with higher levels of education [
37].
Indonesia comprises a variety of peoples, religions, and languages, with over 600 ethnic groups; the Javanese ethnic group is the largest at 40% of the national population [
38]. We believe that sociocultural differences among ethnic groups might have impacts on HRQoL. However, in this study, we found there were no HRQoL differences between Javanese and non-Javanese patients with functional dyspepsia. Nevertheless, most of our patients were living in the same urban area (Jakarta) and not in their area of origin. We hypothesize that living in the same environment will lead to eliminating sociocultural differences between ethnic groups. Our results do not confirm the results of HRQoL studies of coronary heart disease and cancer that showed HRQoL differences among ethnic groups in the United States [
39‐
41]. Those discrepancies were associated with differences in patient perception and knowledge of the disease, medication adherence, and utilization of health facilities between groups [
42].
To the best of our knowledge, this is the first study in an Asian population to assess factors associated with HRQoL in patients with functional dyspepsia. We also analyzed factors that have never been studied before, such as education level and ethnicity. We measured HRQoL using the SF-36 norm-based scoring method to enable comparisons with other HRQoL studies.
There were several limitations to this study. One was a potential bias caused by errors in answering the question because we only used self-reporting questionnaires. Another limitation was the cross-sectional design that did not allow us to determine any causal relationships between variables.
Finally, although the decreased HRQoL in patients with functional dyspepsia was clear, further research efforts are still needed in this area. For example, we need to evaluate the potential role of other factors in such patients, such as social supports, household income, financial burdens, religious coping, and comorbidities with other functional gastroduodenal diseases.