Prevalence and Clinical Correlates of Sexual Dysfunction among Primary Care Diabetes Mellitus Enrollees attending National Health Insurance Scheme (NHIS) Clinic in Uyo, South-South, Nigeria

Female sexual dysfunction are disorders of sexual desire, arousal, orgasm and sexual pain which lead to significant personal distress...

satisfying sex lives [3]. Female sexual dysfunctions though common are often underreported [4]. Sexual dysfunction causes numerous deleterious effects on victims and their families such as loss of self esteem, poor selfconcept, mental stress, disorders in interpersonal relationships as well as problems with partners thus making sexual dysfunction a qualityoflifeissue [4,5]. Diabetes mellitus (DM) is a chronic metabolic disease caused by a variable combination of two pathogenic factors namely Insulin deficiency and Insulin resistance.
It is characterized by high blood sugar (glucose) levels that result from defects in insulin secretion or its action, or both [6]. Elevated levels of glucose (hyperglycaemia) produce the classical symptoms of polyuria, polydipsia and polyphagia. In diabetes mellitus, there is disordered utilization and storage of proximate nutrients (carbohydrates, protein and fats) and reduced energy production.
Hyperglycaemia is its easily measured laboratory marker and the liability for chronic degenerative diseases in almost all body tissues. The mechanisms of sexual dysfunction among diabetes mellitus patients are complex and multifactorial and include both organic and psychological factors. According to report, Insulin resistance and the metabolic syndrome as well as visceral adiposity which are distinctive clinical traits of type 2 diabetes mellitus are associated with the development of sexual dysfunction especially in overweight and obese diabetic patients [7]

Location of the Study
The study was carried out at the National Health Insurance  [12]. Nigeria is divided into six geopolitical zones as follows: North-East, NorthWest, SouthEast, SouthWest and SouthSouth. The SouthSouth geopolitical zone is otherwise referred to as the NigerDelta region. It is one of the major oils producing areas in Nigeria.
An average of 100 patients are treated in the NHIS clinic every day, thus about twelve thousand patients patronize the clinic in 6months. About one thousand four hundred (1400) female diabetic patients were projected to attend the clinic during the period of study which was between January and June 2018. This projection followed unpublished record obtained from the Health records department of the hospital concerning the number of female diabetic patients who attended the clinic during the same period in the previous year. These comprised all newly registered patients as well as those who returned for followup care. A total of 162 female diabetic patients who attended the NHIS clinic between January and June 2018 were recruited for the study. Sample Size for this study was calculated using the formula Z 2 pq/d 2 where 'N' is standard normal deviation set at 95% confidence level which corresponds to 1.96, 'p' is the reported prevalence of sexual dysfunction among female diabetics (88.0%)9, 'd' is the precision which at 95% confidence interval is 5%.
The calculated sample size was 162. They were sampled from the 1400 female diabetic patients who attended the clinic during the study period. They were recruited by systematic sampling method with a sampling interval of nine. Numbers ranging from one to nine were assigned to the first nine respondents who met the inclusion criteria. The first respondent was chosen by simple balloting which was done by randomly picking one of the numbers from a basket containing the assigned numbers. Thereafter every ninth (9th) respondent was recruited for the study. Their case notes were marked to forestall duplication of entry. Inclusion criteria included willingness to take part in the study as well as those aged between 18 years and above. Exclusion criteria included diabetic females who were pregnant, or those with emergency diabetic complications who needed urgent intervention as well as those who were below 18 years of age. Ethical approval for this study was obtained from UUTH institutional review committee. A pretest of the research questionnaire was performed in order to determine its applicability, experience and logistic problems. This was a prospective crosssectional study conducted between January and June 2018.
A semistructured and pretested intervieweradministered questionnaire was used to obtain information about socio demographic characteristics of the respondents such as age, marital status, highest level of education attained, income (in Nigeria Naira denomination) using the approved wage structure in the Nigerian public service [13]. Weight of respondents was measured in kilograms(kg) to the nearest 0.5kg using a hannacalibrated bathroom scale, model BR 9011. Each subject was weighed wearing light clothing without shoes or stocking. The height of each subject was measured using an improvised wooden stadiometer mounted on vertical wall with the respondent standing erect against the wall on a horizontal floor without shoes. The head was placed so as to ensure that the external auditory meatus and the angle of the eye were on a horizontal line. The height was measured in meters to the nearest 0.1cm. Body mass index (BMI) was calculated [14]. Normal weight was defined as BMI of 18.0 -24.9 kg/m2, overweight as BMI of 25.0-29.9kg/m2 while obesity was defined as BMI of > 30.0 kg/ m2 [15,16].  [18]. Neuropathy was diagnosed following American Academy of Neurology criteria [19]. Hypertension was defined as having a previous physician's diagnosis of hypertension or persistent elevation of Blood pressure of greater than 140/90 mmHg. Sexual dysfunction among the female respondents was assessed using the female sexual function index [FSFI] questionnaire. The FSFI is a brief 19item selfreport measure of female sexual function [20]. It was designed to assess the key dimensions of female sexual function in clinical practice.
The FSFI provides scores in six domains of sexual function namely desire, subjective arousal, lubrication, orgasm, satisfaction and pain [20]. Based on the Female sexual function index (FSFI), the range of score for sexual desire is 210, a score of 24 denotes dysfunction in sexual desire while a score of 510 denotes no dysfunction; the range of score for sexual arousal is 020, a score of 010 denotes dysfunction in sexual arousal while a score of 1120 means there is no dysfunction in sexual arousal; the range of score for vaginal lubrication is 020, dysfunction is said to occur with a score of 010 while a score of 1120 denotes no dysfunction with vaginal lubrication. The range of score for orgasm is 015, a score of 0 8 denotes orgasmic dysfunction, while a score of 915 means that there is no dysfunction with orgasm. The range of score for sexual satisfaction is 215, a score of 28 denotes dysfunction with sexual satisfaction while a score of 915 denotes no dysfunction. The range of score for sexual pain is 015, a score of 010 denotes the presence of sexual pain while a score of 1115 denotes absence of sexual pain [8]. The female sexual function index has been used to study female sexual function in many countries including Nigeria [810,2123].

Data Analysis
Statistical analysis was done using statistical package for social sciences (SPSS) version 21.0. Frequency distribution and cross tabulation were generated, chisquare was used to compare proportions. The corresponding pvalues were used to determine the level of statistical significance. The p-value of 0.05 was used to determine the level of statistical significance.

Results
One hundred and sixtytwo (162) adult female diabetes mellitus patients were recruited for the study. The average age of respondents in this study was 32.4+5.3 years. Respondents between the age bracket of 2645 years accounted for 67.9% of respondents.  (Table 1). Table 2 shows the clinical characteristics, treatment options as well as presence of complications among diabetic respondents with or without sexual dysfunction. The mean age at onset of diabetes mellitus among respondents with sexual dysfunction was 43.6+6.1 compared to 39.3+4.3 among those without sexual dysfunction. This was statistically significant (p= 0.04). Fortyeight (80.0%) respondents with sexual dysfunction had suffered from diabetes mellitus for ten years and above compared to twelve [20.0%] respondents without sexual dysfunction who also suffered from diabetes mellitus for the same duration and this was statistically significant (p=0.011).    It is higher than the prevalence of 53.5% reported among female respondents in a university community in Enugu, South East Nigeria. The differences in the reported prevalence rates among different workers might be due to differences in the study design as well as the population studied. Whatever might be the reason, it is important to note that sexual dysfunction is common among women with diabetes mellitus due perhaps to organic impairment or fears arising from nonacceptance of the disease condition [8,10,24].
Duration of diabetes mellitus as well as the presence of its complications were significant contributors to sexual dysfunction among respondents in this study. This is in agreement with reports from other studies. [25,26]. Sexual dysfunction occurs among diabetes mellitus patients due to metabolic and neurovascular factors that occur frequently among diabetics. Increase in body mass index (BMI) significantly contributed to sexual dysfunction among respondents in this study. This finding should, however, be interpreted with caution since large body frame in itself is a risk factor for many other health problems including sexual dysfunction.
Pain was the commonest sexual dysfunction among respondents in this study. This is in agreement with reports from other studies [8,27]. Many reasons have been given by various workers and these include the fact that hyperglycaemia among diabetic women reduces hydration of the vaginal mucus membrane resulting in poor vaginal lubrication thus leading to sexual pain dysfunction [28]. It is further reported that clinically silent vaginal inflammation occurs very frequently in diabetic women thus giving rise to pain during sexual intercourse.

Conclusion
In conclusion, our study shows that diabetes mellitus is associated with sexual dysfunction. Primary care givers should explore the presence of sexual dysfunction among female diabetic patients with a view to addressing this issue during consultations so as to offer adequate treatment and counselling as may be required. This is particularly important since sexual dysfunction can exert a huge psychological burden on the patient with consequent negative impact on the marital relationship, family and quality of life of the patient. The limitation of this study is that potential confounders such as psychogenic factors and blood pressure medications were not addressed in this study. Moreover, because of lack of facilities it was impossible to characterize the respondents into type 1 or type 2 diabetics.