Impact of peptic ulcer disease on the quality of life: A Cross Sectional Study

 

Sadeel A. Shanshal1*, Ali Saleh Noori2, Jaafar Atheer Ghazi2, Abdullah Tahseen Dahham2,

Abdulrahman Samer Mohamed Saleh2, Harith Kh. Al-Qazaz1

1College of Pharmacy, University of Mosul, Mosul, Iraq.

2Nineveh Health Directorate, Mosul, Iraq.

*Corresponding Author E-mail: sadeelshanshal@uomosul.edu.iq

 

ABSTRACT:

Background: Peptic ulcer disease (PUD) is a serious chronic medical condition. It is considered one of the most common illnesses worldwide. PUD has its own impact on the patients’ quality of life (QOL). Objectives: This study aimed to assess the QOL in patients with peptic ulcer disease in Mosul city, Iraq. Methods: A cross sectional study was carried out among 385 patients in a public general hospital and 5 local pharmacies in Mosul city during the period from 10th May to 5th August 2021. Data collection was performed using a face-validated SF-12v2 questionnaire assessing the patients’ physical, mental, and overall health. All the data were subjected to descriptive and inferential analyses. Results: Overall, only 8.6% of the participants reported that their general health is poor. The majority (40.8% and 38.4%) stated that peptic ulcer disease has no or little impact on their moderate daily physical activity. Significant differences were found in the physical, mental and overall QOL scores with socio-demographic characteristics. Conclusion: Quality of life assessment indicated that there are some negative impacts in the patients’ daily life caused either by the patients’ environmental aspects or peptic ulcer related symptoms.

 

KEYWORDS: Peptic ulcer, Quality of Life, Chronic disease, SF-12, Questionnaire.

 

 


INTRODUCTION:

Gastrointestinal tract (GIT) is considered one of the key aspects for the overall health of the human beings1. Along with its primary function which is the chemical and physical digestion and absorption of nutrients, GIT has its own vital defensive immunological role through the mucosal immune system which consists of the non-specific first line defense system, the innate immune system and adaptive immune system2,3. Therefore, the protection and management of infectious and noninfectious diseases affecting GIT is required, especially those affecting the GI mucosa in order to preserve its normal function4. One of the common GI illnesses is the peptic ulcer disease (PUD), sometimes called stomach ulcer or gastric ulcer5,6.

 

PUD is a distinctive breach (lesion) in the mucosa of GI tract, typically in the stomach (gastric ulcer) or duodenum (duodenal ulcer) as a result of the corrosive effect of both digestive acid and pepsin7. Helicobacter pylori (H. pylori) is considered one of the most common causes of PUD8. Other risk factors include long term use of some medications, especially non-steroidal anti-inflammatory drugs9, in addition to the increased intake of some gastric irritants like: caffeine and cigarette smoke10,11.

 

PUD represents a serious chronic medical condition12. If left untreated it could lead to life threatening complications like bleeding, perforation, obstruction, and cancer13. The lifetime risk estimation for developing peptic ulcer condition is about 10%14.

 

Although medications for PUD are well developed to be effective and they are well implemented in the guidelines depending on the identification of the main cause15; patients’ outcomes, the impact of certain chronic condition as well as other therapeutic interventions still need to be evaluated and improved16.

Quality of life (QOL) is considered one of the main goals in the management and prevention strategies of chronic illnesses17,18. It is characterized by its multidimensional model which includes personal assessments of both positive and negative characteristics of life19,20. Even though health is a major key domain in the overall QOL, other domains are considered to be no less important than health; for instance, physical functioning, social functioning, emotional functioning, and personal autonomy21.

 

Physicians have often used quality of life measurement to have an additional perception regarding the interference between an illness and patient’s day to day life as well as to better understand the consequences of their prescribed treatments22,23. Also, other healthcare professionals use quality of life assessment to measure the impact of various conditions and disabilities in different populations, which provides a clear identification of the subgroups with impaired mental or physical health24,25.

 

Moreover, quality of life has been an important clinical research tool and highlighted as one of the aspects of effective patient care. Additionally, it has been used in the assessment of the existing differences between patients, and in the estimation of the consequences of disease treatment interventions26-28. Considering the lack of studies about quality of life and its related issues along with the low level of quality of life in developing countries like Iraq, the present study was conducted to assess quality of life and its related factors among the patients with peptic ulcer disease in Mosul.

 

METHODS:

Design and setting:

A cross-sectional study design was employed, and the study was carried out in a public general hospital and 5 local pharmacies in Mosul city (biggest city in the North of Iraq) from 10th May to 5th August 2021. Adult patients who were diagnosed with PUD for at least 6 months and treated with oral medications are considered the criteria for inclusion in this study.

 

Study instruments:

The questionnaire used consisted of two parts. The first part was about the personal socio-demographic characteristics such as gender, age, and occupation. The second part was the multipurpose SF-12 for the assessment of patients’ QOL, and the questions were combined in order to provide insights into physical and mental functioning of the patients in addition to the overall health-related-quality of life29-31. The first six questions in the SF-12 questionnaire assess the physical component while the last six questions evaluate the mental component. The scores ranged between 0 and 100; better physical and mental functioning is associated with higher scores32. The scoring was calculated and normalized based on published algorithms33.

 

Ethical approval:

This study received the ethical approval from the Department of Clinical Pharmacy at the College of Pharmacy in the University of Mosul. Moreover, an approval of the Medical Research Ethics Committee at University of Mosul was obtained. A written consent was signed by the participants before enrolling in the study.

 

Statistical analysis:

Descriptive and inferential statistics were performed accordingly by using IBM SPSS (Statistical Package for Social Science) Statistics for Windows, version 26 (IBM Crop., Armonk, NY). A P-value of less than 0.05 was used to indicate significant results.

 

RESULTS:

Basic demographic characteristics:

The age average of the 385 patients was 40.20±12.93 with a minimum and maximum age of 18 and 66 years respectively. In terms of gender, 61.8% were males and 38.2% were females. Other basic demographic data are shown in Table 1.

 

Table 1: Participants’ Basic Demographic Characteristics

ITEMS (N=385)

N

%

GENDER

Male

238

61.8

Female

147

38.2

PATIENTS RESIDENCE

Urban

334

86.8

Rural

51

13.2

EDUCATIONAL LEVEL

No formal education

51

13.2

Primary

88

22.9

Secondary

93

24.2

University

153

39.7

OCCUPATIONAL STATUS

Working

218

56.6

Not working

167

43.4

MONTHLY INCOME

 

 

Very low

18

4.7

Low

79

20.5

Medium

145

37.7

Good

111

28.8

Very good

32

8.3

SMOKING

Yes

133

34.5

No

252

65.5

SPICY FOOD

Yes

228

59.2

No

157

40.8

 

Quality of life aspects:

The participants’ responses to the questions assessing the different aspects of QOL are presented in table 2.


Table 2: Quality of life aspects of the participants

Quality of life aspects

Frequency of answers (%)

Quality of life aspects

Frequency of answers (%)

General health

Excellent (6%)

Very good (17.4%)

Good (37.9%)

Fair (30.1%)

Poor (8.6%)

Energetic time

All of the time (16.9%)

Most of the time (27%)

Some of the time (28.1%)

A little of the time (24.2%)

None of the time (3.9%)

Limited physical activity (moderate activities)

Yes, limited a lot (20.8%)

Yes, limited a little (38.4%)

No, not limited at all (40.8%)

Accomplished less in work (due to emotional status)

All of the time (4.7%)

Most of the time (28.3%)

Some of the time (39.7%)

A little of the time (22.6%)

None of the time (4.7%)

Limited physical activity (climbing stairs)

Yes, limited a lot (22.6%)

Yes, limited a little (32.2%)

No, not limited at all (45.2%)

Troubles with work

(due to emotional status)

All of the time (3.6%)

Most of the time (17.9%)

Some of the time (45.2%)

A little of the time (26.2%)

None of the time (7%)

Accomplished less in work (due to physical status)

All of the time (3.9%)

Most of the time (14.2%)

Some of the time (49.9%)

A little of the time (16.9%)

None of the time (15.1%)

Feeling calm and peaceful

All of the time (1.8%)

Most of the time (30.4%)

Some of the time (31.9%)

A little of the time (30.1%)

None of the time (5.7%)

Limited work

All of the time (6.3%)

Most of the time (20.5%)

Some of the time (35.8%)

A little of the time (25.5%)

None of the time (11.9%)

Feeling downhearted and blue

All of the time (7%)

Most of the time (26.8%)

Some of the time (29.9%)

A little of the time (27.3%)

None of the time (9.1%)

Pain-work interference

Extremely (7%)

Quite a bit (19%)

Moderately (39.2%)

A little bit (24.9%)

Not at all (9.9%)

Interference with social activities

All of the time (8.3%)

Most of the time (28.6%)

Some of the time (38.7%)

A little of the time (18.4%)

None of the time (6%)

 


Overall quality of life:

The means (SD) of physical and mental functioning scores for the participants were 53.80(21.63) and 49.41 (18.53) respectively, whereas the mean score of the overall quality of life was 51.34(17.62).

 

The relationships between demographic characteristics and physical, mental, and overall QOL scores were analyzed. Significant negative correlation was found between physical functioning scores and age (r= -0.287).

In terms of physical activity, significant differences were found with gender, educational level, occupational status, and monthly income of the participants. However, the educational level and employment showed significant variations in mental scores. Finally, there were significant differences in the overall QOL scores with gender, educational level, and the participants’ monthly income. Table 3 shows a summary of these results.


 

Table 3: Differences in QOL scores with demographic characteristics


ITEMS (N=385)

Physical

 

Mental

 

Overall QOL

 

Mean ± SD

P-value

Mean ± SD

P-value

Mean ± SD

P-value

GENDER*

Male

Female

 

56.20 ± 21.14

49.91 ± 21.90

0.005§

 

50.40 ± 16.72

47.80 ± 21.08

0.18

 

49.70 ± 18.08

53.99 ± 16.56

0.02§

PATIENTS RESIDENCE*

Urban

Rural

 

53.59 ± 21.53

55.15 ± 22.38

0.63

 

49.76 ± 18.03

47.06 ± 21.55

0.33

 

51.55 ± 17.52

49.92 ± 18.36

0.53

EDUCATIONAL LEVEL**

No formal education

Primary

Secondary

University

 

39.09 ± 19.99

51.28 ± 16.41

50.94 ± 20.58

61.89 ± 22.18

0.00§

 

40.87 ± 15.91

52.93 ± 14.28

46.41 ± 18.21

52.05 ± 20.54

0.00§

 

48.35 ± 16.38

54.58 ± 17.75

54.25 ± 13.47

48.70 ± 19.61

0.01§

OCCUPATIONAL STATUS*

Working

Not working

 

58.94 ± 21.31

47.08 ± 20.19

0.00§

 

51.14 ± 18.40

47.15 ± 18.49

0.03§

 

50.72 ± 18.42

52.14 ± 16.53

0.43

MONTHLY INCOME**

Very low

Low

Medium

Good

Very good

 

46.36 ± 13.48

47.31 ± 21.45

53.62 ± 20.35

58.45 ± 23.57

60.94 ± 18.03

0.00§

 

48.54 ± 16.79

51.76 ± 17.54

47.11 ± 17.45

49.08 ± 21.74

55.59 ± 12.24

0.12

 

36.51 ± 10.80

50.63 ± 18.80

50.85 ± 15.36

53.31 ± 18.72

56.78 ± 19.44

0.001§

SMOKING*

Yes

No

 

54.75 ± 25.04

53.30 ± 19.61

0.53

 

47.37 ± 18.09

50.48 ± 18.70

0.11

 

53.25 ± 14.98

50.33 ± 18.81

0.12

SPICY FOOD*

Yes

No

 

53.76 ± 23.21

53.86 ± 19.16

0.96

 

48.11 ± 19.24

51.29 ± 17.33

0.09

 

50.50 ± 16.39

52.56 ± 19.25

0.26

*Independent samples t-test, **One-way ANOVA

§P-value < 0.05 indicates significant result

 


DISCUSSION:

The rationale of QOL assessments is to explore for more than the disease and the severity of symptoms by examining how patients perceive and experience the effect of their condition on the wellbeing and daily life. Physicians, in addition to patients can benefit from these data to properly decide about treatments. Hence, the patient’s own assessment regarding quality of life (QOL) should be considered and well documented as well. This study provided  new information about the physical and mental status in patients who had been previously diagnosed with peptic ulcer disease by using SF-12 questionnaire.

 

The results demonstrated that only 8.6% of the participants reported having poor health whereas the majority (91.4%) had an overall better general health. One of the possible explanations is that most of our study participants (86.8%) reported that they live in the urban areas of Mosul city. The healthcare services in urban areas are characterized by being of high quality, more patient-centered and more accessible than those in the rural areas, the aspects that may positively impact the general health and well-being status of the patients34-36. Secondly, high proportion (65.5%) of the participants stated that they are non-smokers. As well known, smoking increases the risk of contribution through a wide range of diseases and conditions that could affect the general health like cancers (e.g. lung cancer), respiratory diseases (e.g. chronic obstructive lung disease) and cardiovascular diseases (e.g. coronary heart disease)37,38. Also, it inhibits the release of reactive oxygen species (ROS) which compromises neutrophils and the other cells of the immune system39,40, thus disturbing the immune system activity which is also considered another factor that affects the humans’ health and well-being. Therefore, being non-smoker could be one of the reasons behind the good general health of the study participants.

 

Another promising finding was that the majority (79.2%) of the participants stated that their condition (peptic ulcer) has no or little limitation on their moderate daily activity (e.g. moving a table). Referring back to the literature, we can easily notice that our finding is directly in line with the research which indicated that there is no effect of peptic ulcer disease on moderate physical activities41-43. In contrary, moderate physical activity could have a favorable impact on PUD through reducing gastric acid secretion, thus decreasing the acid overload on the mucosa as well as enhancing the patient’s immune system as both of these aspects could improve the patients’ overall condition44.             

 

Also, these results provided additional evidence regarding the relation between the emotional status, work productivity and the severity of PUD. The results demonstrated that high proportion of the participants feel downhearted as well as less peaceful and calm, which reflect the affected emotional status of the patients; specifically, being under stress. This could be due to the repetition of terrorism attacks that affected the infrastructure, economy and various important organizations in Mosul city, the point that may affect peoples’ social and psychological status. Consequently, the resulting stress can lead the elevation of cortisol hormone levels as a result of hypothalamus-pituitary-adrenal (HPA) axis activation -the main stress response pathway- the feature that may induce fatigue and depression45-47. This was manifested by the statement from a large proportion of the participants that their energy is affected, and their emotional status was limiting their work productivity. Moreover, they reported that pain was limiting their work performance. Referring back to the previously discussed explanation (stress), alteration in the cortisol levels will probably increase the secretions of gastric acid and pepsin that can induce the mucosal injury48,49. Also, the elevation in gastric acid and cortisol levels could restrain the normal inflammatory response of the gastrointestinal mucosa50, thus it may complicate the patients’ pain.

 

These findings cast the light on the impact of the chronic diseases and stress on the social functioning of the patients as most of the participants (75.6%) stated that their emotional or physical problems have affected their social activities. As per the previously discussed stress process and its potential to induce anxiety, depression and low level of energy, patients experiencing anxiety, depression or having a chronic condition could be less willing to perform any activity especially the social type, which represents the possible explanation of their limited social activities51,52.

 

 

Increasing age in this study was associated with lower physical and mental functioning scores and these results agreed with many other studies53-55. Concerning gender, the mental component showed higher scores in males than in females as observed in another study56. This could be attributed to the fact that women are more embarrassed and stressed to discuss their condition or disease with others, and this may be true in many populations and regarding different diseases57,58. Men are more active than women and this is probably why they scored higher than women in the physical component.

 

Lower educational level and lower monthly incomes were associated with lower physical, mental, and overall QOL scores and these results are in agreement with other studies54. A possible explanation is that spending longer time in education and receiving higher incomes will lead to better living conditions which will positively affect the QOL eventually.

 

Significant differences were found in physical and mental scores between participants who work and those who do not, the higher scores observed in the working patients. This may be because working is associated with higher monthly incomes which in turn improve the living conditions and result in better QOL59. Moreover, being busy at work may reduce the psychological stress that could contribute to higher scores in the mental component.

 

This study could be considered as the first study assessing the quality of life of patients with peptic ulcer in Mosul city which may provide an important novel reference for the healthcare policy makers. On the other hand, one of the limitations of this investigation is the design of the study that may affect the generalizability of the results. However, results of this work provide evidence that more studies concentrating on patients’ quality of life with other chronic diseases are required. Moreover, results may help physicians to give more attention on health-related quality of life in choosing the better management options.

 

CONCLUSION:

Quality of life assessment indicated that the patients’ daily life is negatively affected either by the patients’ environmental aspects or peptic ulcer related symptoms. Communication with patients needs to be improved along with the involvement of other healthcare providers in addition to the physicians like pharmacists and psychologists in order to achieve more enhanced decision-making process regarding chronic disease management.

 

 

 

ACKNOWLEDGMENT:

As authors of this paper our gratitude is extended to the patients participated in the study. The University of Mosul, and specifically the College of Pharmacy deserve special thanks for their efforts.

 

REFERENCES:

1.      Cires MJ, Wong X, Carrasco-Pozo C, et al. The gastrointestinal tract as a key target organ for the health-promoting effects of dietary proanthocyanidins. Frontiers in Nutrition. 2017; 3 57.

2.      Nauta AJ, Engels F, Knippels LM, et al. Mechanisms of allergy and asthma. European Journal of Pharmacology. 2008; 585(2–3): 354–60.

3.      Vieira WA, Pretorius E. The impact of asthma on the gastrointestinal tract (GIT). Journal of Asthma and Allergy. 2010; 3 123–30.

4.      Ramanan D, Cadwell K. Intrinsic defense mechanisms of the intestinal epithelium. Cell Host and Microbe. 2016; 19(4): 434–41.

5.      Ramakrishnan K, Salinas RC. Peptic ulcer disease. American Family Physician. 2007; 76(7): 1005–12.

6.      Chan HL-Y, Wu JC-Y, Chan FK-L, et al. Is non-Helicobacter pylori, non-NSAID peptic ulcer a common cause of upper GI bleeding? A prospective study of 977 patients. Gastrointestinal Endoscopy. 2001; 53(4): 438–42.

7.      Ifeanyi OE, Sunday AG. Some haematological and biochemical parameters in peptic ulcer patients in umudike, Abia state, Nigeria. World J Pharm Pharm Sci. 2014; 3(4): 294–302.

8.      Mahurkar N, Sayeed Ul Hasan SM. Synergistic Antiulcer Effect of Melatonin and Esomeprazole Combination in Pylorus Ligation, Ethanol, Aspirin induced Peptic Ulcers. Asian Journal of Pharmaceutical Research. 2015; 5(1): 10–4.

9.      Yuan Y, Padol IT, Hunt RH. Peptic ulcer disease today. Nature Clinical Practice Gastroenterology and Hepatology. 2006; 3(2): 80–9.

10.   Farsakh NAA. Risk factors for duodenal ulcer disease. Saudi Medical Journal. 2002; 23(2): 168–72.

11.   Venkatesan H. Retrospective Analytical Case Series Study on the Acid Peptic Disorders treated with Homoeopathic Medications. Research Journal of Pharmacology and Pharmacodynamics. 2020; 12(2): 97–100.

12.   Huh CW, Kim B-W. Clinical significance of risk factors for asymptomatic peptic ulcer disease. Clinical Endoscopy. 2017; 50(6): 514–5.

13.   Milosavljevic T, Kostić-Milosavljević M, Jovanović I, et al. Complications of peptic ulcer disease. Digestive Diseases. 2011; 29(5): 491–3.

14.   Snowden FM. Emerging and reemerging diseases: a historical perspective. Immunological Reviews. 2008; 225(1): 9–26.

15.   Boparai V, Rajagopalan J, Triadafilopoulos G. Guide to the use of proton pump inhibitors in adult patients. Drugs. 2008; 68(7): 925–47.

16.   Tinker A. How to improve patient outcomes for chronic diseases and comorbidities. Health Catalyst. 2017;

17.   Eiser C, Morse R. A review of measures of quality of life for children with chronic illness. Archives of disease in childhood. 2001; 84(3): 205–11.

18.   Bala M, Kalia R, Kaur J, et al. Assessment of Quality of Life among Diabetic Patients Visiting Medical Out Patient Department at Selected Health Care Facilities at Punjab. International Journal of Advances in Nursing Management. 2017; 5(4): 327–30.

19.   Group W. The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Social Science and Medicine. 1995; 41(10): 1403–9.

20.   Tripathi N, Balai MK. A Study to assess the Quality of life among Persons living with Hypertension, Diabetes Mellitus and Arthritis in selected Village of Ludhiana, Punjab. International Journal of Nursing Education and Research. 2018; 6(4): 379–82.

21.   Connell J, O’Cathain A, Brazier J. Measuring quality of life in mental health: are we asking the right questions? Social Science and Medicine. 2014; 120: 12–20.

22.   Megari K. Quality of life in chronic disease patients. Health Psychology Research. 2013; 1(3): e27.

23.   Prabha SL. Assess the Quality of Life (QOL) of patients undergoing Haemodialysis in Vinayaka Mission Hospital, Salem, Tamilnadu. International Journal of Advances in Nursing Management. 2015; 3(3): 197–9.

24.   Geurink KV. Community Oral Health Practice for the Dental Hygienist-E-Book. (Elsevier Health Sciences, 2014).

25.   Batra K, Sharma S. A Descriptive Study to Assess the Quality of Life in ESRD (End Stage Renal Disease) Patients Undergoing Hemodialysis in Selected Hospital of Mohali, Punjab. International Journal of Nursing Education and Research. 2018; 6(1): 31–6.

26.   Baghery H, Memarian R, Alhani F. Evaluation of the effect of group counselling on post myocardial infarction patients: determined by an analysis of quality of life. Journal of Clinical Nursing. 2007; 16(2): 402–6.

27.   Selai CE, Trimble MR, Rossor MN, et al. Assessing quality of life in dementia: Preliminary psychometric testing of the Quality of Life Assessment Schedule (QOLAS). Neuropsychological Rehabilitation. 2001; 11(3–4): 219–43.

28.   Bullinger M, Quitmann J. Quality of life as patient-reported outcomes: principles of assessment. Dialogues in Clinical Neuroscience. 2014; 16(2): 137.

29.   Salyers MP, Bosworth HB, Swanson JW, et al. Reliability and validity of the SF-12 health survey among people with severe mental illness. Medical Care. 2000; 1141–50.

30.   Burdine JN, Felix MR, Abel AL, et al. The SF-12 as a population health measure: an exploratory examination of potential for application. Health Services Research. 2000; 35(4): 885.

31.   Lacson E, Xu J, Lin S-F, et al. A comparison of SF-36 and SF-12 composite scores and subsequent hospitalization and mortality risks in long-term dialysis patients. Clinical Journal of the American Society of Nephrology. 2010; 5(2): 252–60.

32.   Ware J, Kisinski M, Keller S. How to Score SF-12 Physical and Mental Health Summary Scales. (The Health Institute, New England Medical Center, 1995).

33.   Ware Jr JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care. 1996; 220–33.

34.   Chaney P. Wellness in the Urban Workplace: Strategies for Keeping Your Workforce Healthy. https://thebenefitsguide.com/ wellness-in-the-urban-workplace-strategies-for-keeping-your-workforce-healthy/ (2018).

35.   Galea S, Freudenberg N, Vlahov D. Cities and population health. Social science and medicine. 2005; 60(5): 1017–33.

36.   Conway P, Favet H, Hall L, et al. Rural health networks and care coordination: health care innovation in frontier communities to improve patient outcomes and reduce health care costs. Journal of Health Care for the Poor and Underserved. 2016; 27(4A): 91.

37.   Lee PN. The effect of reducing the number of cigarettes smoked on risk of lung cancer, COPD, cardiovascular disease and FEV1–A review. Regulatory Toxicology and Pharmacology. 2013; 67(3): 372–81.

38.   Godtfredsen NS, Prescott E. Benefits of smoking cessation with focus on cardiovascular and respiratory comorbidities. The Clinical Respiratory Journal. 2011; 5(4): 187–94.

39.   Mehta H, Nazzal K, Sadikot RT. Cigarette smoking and innate immunity. Inflammation Research. 2008; 57(11): 497–503.

40.   Qiu F, Liang C-L, Liu H, et al. Impacts of cigarette smoking on immune responsiveness: Up and down or upside down? Oncotarget. 2017; 8(1): 268.

41.   Rosenstock S, Jørgensen T, Bonnevie O, et al. Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish Adults. Gut. 2003; 52(2): 186–93.

42.   Cheng Y, Macera CA, Davis DR, et al. Does physical activity reduce the risk of developing peptic ulcers? British Journal of Sports Medicine. 2000; 34(2): 116–21.

43.   Cheng Y, Macera CA, Davis DR, et al. Physical activity and peptic ulcers. Western Journal of Medicine. 2000; 173(2): 101.

44.   Shephard RJ. Peptic ulcer and exercise. Sports Medicine. 2017; 47(1): 33–40.

45.   Stephens MAC, Wand G. Stress and the HPA axis: Role of glucocorticoids in alcohol dependence. Alcohol Research: Current Reviews. 2012; 34(4): 468–83.

46.   Bartolomucci A, Leopardi R. Stress and depression: preclinical research and clinical implications. PloS One. 2009; 4(1): e4265.

47.   Gheena S. Cortisol in saliva of uncontrolled diabetes patients and Adrenal stress index. Research Journal of Pharmacy and Technology. 2016; 9(10): 1786–8.

48.   Brown ES, Varghese FP, McEwen BS. Association of depression with medical illness: does cortisol play a role? Biological Psychiatry. 2004; 55(1): 1–9.

49.   Di Mario F, Goni E. Gastric acid secretion: changes during a century. Best Practice and Research Clinical Gastroenterology. 2014; 28(6): 953–65.

50.   Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy. 2014; 94(12): 1816–25.

51.   Centers of Disease Control and Prevention (CDC). Mental Health Conditions: Depression and Anxiety. https://www.cdc.gov/ tobacco/campaign/tips/diseases/depression-anxiety.html.

52.   Saris IMJ, Aghajani M, van der Werff SJA, et al. Social functioning in patients with depressive and anxiety disorders. Acta Psychiatrica Scandinavica. 2017; 136(4): 352–61.

53.   Wensing M, Vingerhoets E, Grol R. Functional status, health problems, age and comorbidity in primary care patients. Quality of Life Research. 2001; 10(2): 141–8.

54.   Wen Z, Li X, Lu Q, et al. Health related quality of life in patients with chronic gastritis and peptic ulcer and factors with impact: a longitudinal study. BMC Gastroenterology. 2014; 14(1): 1–10.

55.   Rayyani M, Malekyan L, Forouzi MA, et al. Self-care self-efficacy and quality of life among patients receiving hemodialysis in South-East of Iran. Asian Journal of Nursing Education and Research. 2014; 4(2): 165–71.

56.   Pezzilli R, Morselli-Labate AM, Frulloni L, et al. The quality of life in patients with chronic pancreatitis evaluated using the SF-12 questionnaire: a comparative study with the SF-36 questionnaire. Digestive and Liver Disease. 2006; 38(2): 109–15.

57.   Apolone G, Mosconi P, Ware JE. Questionario sullo stato di salute SF-36: manuale d’uso e guida all’interpretazione dei risultati. (Guerini, 1997).

58.   Dasgupta P, Dubey K. Factors Affecting Stress Level of Married Working Women in Dual Income Family. Asian Journal of Management. 2015; 6(4): 265–75.

59.   Indra V. Health-Promoting Factors related to lifestyle among nursing students in University of Hail. Asian Journal of Nursing Education and Research. 2018; 8(4): 535–7.

 

 

 

 

 

Received on 24.10.2021           Modified on 17.12.2021

Accepted on 12.01.2022         © RJPT All right reserved

Research J. Pharm. and Tech. 2022; 15(7):3267-3272.

DOI: 10.52711/0974-360X.2022.00548