[Attitude of hemophilic adult individuals towards their disease]

The mental health of hemophilic individuals and their families play an important role on the integral treatment of the disease. The knowledge of the beliefs and attitudes perceived by the patients toward their disease will make possible a positive influence in their clinical improvement, their response to the treatment, as well as their quality of life. On the basis of the Azjen and Fishbein's Theory of Reasoned Action, a questionnaire was applied to 43 adult hemophilics to determine the salient beliefs about their disease. These beliefs permitted to elaborate a main structured questionnaire named Attitude Model in Patients with Hemophilia (Modelo de Actitud en Pacientes con Hemofilia, MAPACHE, in spanish), which was administered to the individuals and thus, the attitude toward their disease was obtained. Seventy two percent (72%) gave a major importance to the clinical aspects of the disease (hemorrhage, joint discomfort and trauma), 40% knew the general concepts of hemophilia (heredity, care and seriousness of the disease), 20% mentioned the implications of the psychosocial factors and only 18% had knowledge concerning the coagulation factors deficiency and the appropriate treatment. The MAPACHE showed a slightly positive score attitude (4.44 +/- 1.12 SEM) towards the disease in the majority of the groups (74.5%); with 26% of the hemophilics with a negative attitude. There were no significant differences between attitude and clinical parameters. It is recommended that a multidisciplinary team of caregivers should focus their efforts toward education and preventive measures in order to avoid the complications and consequences of the disease, to make possible a better quality of life in individuals with hemophilia.

[Adjustment patterns of illness process of people with hemophilia in Korea]

PURPOSE

The purpose of this study was to explore adjustment pattern of illness process of people with hemophilia in Korea.

METHOD

23 people with hemophilia had participated for this study. The data were collected through in-depth interviews and analyzed using Strauss & Corbin's grounded theory method.

RESULT

"would be free from" was emerged as a core category and it reflects that all participants wanted to be free from the constraints of the disease. The adjustment process was categorized into two stage, the 'unstable stage' and the 'stable stage'. In the process of "would be free from" four different patterns were identified: hopelessness type; appreciation type; challenge type; and transcendence type. These types were identified based on the degree of pursuing normal life and managing the disease, and social support. The most frequently occurring type was hopelessness type but the participants of this type suffered the most. The transcendence type was the most ideal type, but it occurred the least.

CONCLUSION

The results of this study indicate that people with hemophilia in Korea still suffer from the disease and they need supports. The results would be useful for health care professionals in establishing education and counseling program for the people with hemophilia.

Development of a new disease-specific quality-of-life questionnaire to adults living with haemophilia

A haemophilia-specific health-related quality-of-life questionnaire (named 'Hemofilia-QoL') was developed to assess quality-of-life in adults with haemophilia, and was psychometrically tested. Seventy-three interviews with haemophilia patients and health care professionals were used to generate the items included in the questionnaire, and expert ratings on the items formulated were used to screen them for potential omission. This was followed by psychometric testing in a sample of 35 patients. Preliminary psychometric testing of the revised questionnaire version, which contains 10 domains (physical health, physical role, joint damage, pain, treatment satisfaction, emotional role, mental health, social support), showed acceptable reliability (alpha = 0.94 for the Hemofilia-QoL total score) and validity, and this will be examined in a subsequent study with a larger patient sample.

Development and validation of a measure of disease-specific quality of life in young children with haemophilia

No disease-specific tool for measuring health-related quality of life (HRQL), an important outcome when assessing medical treatment, has been developed for children with haemophilia. The goal of this study was to develop a parent-administered questionnaire for evaluating quality of life (QOL) in paediatric haemophilia patients between 2 and 6 years of age. After interviewing physicians (5), nurses (5) and parents (10) of children with haemophilia aged between 2 and 6 years, 92 questions were developed and pilot-tested with parents (44) of children with haemophilia to create a 39-question instrument that assessed somatic symptoms, physical functioning, sleep disturbance, stigma, social functioning, fear/resentment, mood/behaviour, restrictions, treatment upset, haemophilia concern and energy level. Reliability and validity were evaluated with 103 parents of children with haemophilia and parents of 249 age- and gender-matched healthy children. Estimates of scale reliability (internal consistency) for eight multi-item scales ranged from 0.73 to 0.94. Results showed construct validity (correlations with age, severity of haemophilia, treatment type, days absent and days confined to bed) and correlated with two general, paediatric quality-of-life instruments (Impact on Family Scale and Functional Status II). Discriminant validity was demonstrated by comparing scores between patients receiving/not receiving prophylactic therapy and between haemophilia patients and healthy controls. This disease-specific HRQL measure should be of use in clinical trials and general practice to better understand disease and treatment impacts in young children with haemophilia.

Effect of intracranial bleeds on the health and quality of life of boys with hemophilia

OBJECTIVES

To compare the health, physical function, and quality of life (QoL) of boys with hemophilia with and without a history of intracranial hemorrhage (ICH).

STUDY DESIGN

Of 172 patients with hemophilia A or B, 18 (10%) had at least one episode of ICH. For outcome assessments, 16 of 18 (89%) boys with ICH and 32 controls, matched (1:2) for age and severity of hemophilia, were available. The outcome measures were neurologic function, physical function, and QoL.

RESULTS

The median age of the boys at the first ICH was 5.9 months (range, 1 day to 2.7 years). Boys with ICH had a higher incidence of inhibitors and lower mean household income. Neurologic examination was abnormal in seven of 16 (44%) boys with ICH and nine of 32 (28%) controls (P=.3). The mean physical function in boys with ICH was lower (82%+/-25%) compared with controls (93.5%+/-12%, P=.045). The QoL was decreased in boys with ICH compared with controls (6.8+/-3.2 vs 8.5+/-1.4, P=.02), whereas health-related QoL was not significantly different between groups.

CONCLUSION

The poorer long-term outcomes of boys with hemophilia appropriately treated for ICH, especially in the domain of QoL, suggest that new strategies to prevent ICH and to manage ICH effectively in this population are needed.

Development of a health-related quality of life measure for boys with haemophilia: the Canadian Haemophilia Outcomes - Kids Life Assessment Tool (CHO-KLAT)

Several measures of quality of life (QoL) are available for children with haemophilia. However, most are not disease-specific and few focus on children's perspectives. The purpose of this study was to develop a psychometrically sound measure of QoL that included the perspectives of boys with haemophilia. A list of potential items was developed from the literature, other measures, and input from five discussion sessions with adults with haemophilia, children with haemophilia and their parents and haemophilia nurses. The list was augmented with items generated by three focus groups with children and three focus groups with parents. These groups also prioritized items and recommended a domain structure. Supplemental information was gathered by surveying haematologists. Data from all sources were analysed to reduce the number of items using a two-step approach, based on rules that weighted the children's priorities most heavily. The remaining items were compiled into a questionnaire that was pilot tested with 10 children and their parents. The total item pool contained 228 potential items. Of these, 33 were removed based on three focus groups and survey responses, 72 were removed after the completion of all focus groups and 46 were removed due to redundancy. This resulted in a 77-item version of the CHO-KLAT. Pilot testing identified the need to subdivide two items, resulting in a 79-item CHO-KLAT. The CHO-KLAT is a promising disease-specific measure of QoL that reflects children's unique perspectives. This child-centric focus distinguishes the CHO-KLAT from alternative measures of QoL. Further research will assess the measurement properties of the CHO-KLAT.

Health status and health-related quality of life of children with haemophilia from six West European countries

A multicentre, international, cross-sectional study was carried out in the frame of field testing of the first haemophilia-specific quality-of-life (QoL) questionnaire (Haemo-QoL). The aim of this paper is to describe health status and health care and their impact on QoL in haemophilic children in Western Europe. Children aged 4-16 years with severe haemophilia without inhibitors were enrolled by 20 centres in France, Germany, Italy, the Netherlands, Spain and the United Kingdom. Clinical information was collected by the physicians with a medical documentation form. Health-related QoL (HRQoL) of children was assessed with Haemo-QoL, available for three age groups. Clinical data were available in 318 patients, 85.5% with haemophilia A. The mean age at first bleeding was 11 months, at first joint bleed 25 months. Functional joint impairments were found in 11.3%. Prophylaxis treatment was given to 66.7% of children in whom breakthrough bleeds occurred 0.4 times a month compared to 1.1 bleeds in children receiving on-demand treatment. A significantly higher factor consumption was found only in the two younger age groups of prophylaxis patients compared to on-demand patients. HRQoL was satisfactory in this cohort: young children were impaired mainly in the dimension 'family' and 'treatment', whereas older children had higher impairments in the so-called 'social' dimensions, such as 'perceived support' and 'friends'. Health care of children in Western Europe is progressively improving with a large diffusion of home treatment and prophylaxis. This provides a high level of health status and HRQoL, being better in haemophilic adolescents on prophylaxis.

Development and testing of an instrument to assess the Quality of Life of Children with Haemophilia in Europe (Haemo-QoL)

In spite of an increased interest in the assessment of quality of life (QoL) in children, so far no instrument for children with haemophilia is available. Because of the low prevalence of the condition, such an instrument should also be cross-culturally applicable. In the study presented, a (QoL) assessment instrument for children with haemophilia (the Haemo-QoL questionnaire) was developed and tested in six countries (France, Germany, Italy, the Netherlands, Spain and the United Kingdom) for psychometric properties in 339 children with haemophilia and their parents. The Haemo-QoL is a self-reported questionnaire for children in the age ranges 4-7 (I: 21 items), 8-12 (II: 64 items), 13-16 years (III: 77 items) as well as for parent rating containing 9-11 subscales (depending on age-group versions). Psychometric testing involved the examination of reliability and validity. The three age-group versions of the Haemo-QoL had acceptable internal consistency and retest reliability values, as well as possessing sufficient discriminant and convergent validity. However, in young children when compared to older children, these indicators were less satisfactory. The Haemo-QoL full version is now available for children of three age groups and their parents and is ready for use in clinical research.

Quality of life assessment in haemophilia

Quality of life (QoL) is a recent focus of research in haemophilia. It can be defined--in analogy to the World Health Organization (WHO) definition of health--as patient-perceived wellbeing and function in terms of physical, emotional, mental, social and behavioural life domains. The paper describes conceptual, methodological and practical foundations of QoL research in adults and children at an international level. It then proceeds to review the QoL literature in the field of haemophilia. With regard to assessment of QoL in haemophilia patients, both generic and very recently targeted instruments have been applied. Recent publications have focused on describing QoL in adults, showing specific impairments in terms of physical function (arthropathy) and mental wellbeing (HIV infection) as well as focusing on the cost-benefit (QoL) ratio of haemophilia care. In paediatric haemophilia, research has suggested the beneficial QoL outcomes with prophylaxis and stressed the role of the family for patients' wellbeing and function. QoL research is a relevant area for haemophilia research which should be pursued further.

Frequency and causes of hospitalization in HIV-negative children and adolescents with haemophilia A or B and its effect on academic achievement

The aim of the study is to determine the causes and frequency of hospitalization in HIV-negative boys and adolescents with haemophilia and evaluate their impact on academic achievement. One hundred and twenty-six HIV-negative boys and adolescents were followed prospectively from 1989-96, at 14 comprehensive haemophilia treatment centres. One hundred and fifteen participants with haemophilia A or B were included in the investigation. These participants contributed an average of 57.8 months of follow-up. There were 203 hospitalizations in 65 participants and 50 participants were never hospitalized. Haemarthroses and soft tissue bleeds accounted for 46 and 44 causes of hospitalization. Central line infection was the third most common cause. Participants with inhibitor had the majority of central line infections and hospitalizations. Intracranial haemorrhage resulted in five hospitalizations in two participants. Other causes of bleeding accounted for 22% of hospitalizations. The median number of hospitalizations per year was 0.18. Duration of hospital stay was significantly related to lower spelling scores. Acute and chronic joint problems and soft tissue bleeds still account for the majority of hospitalizations. Positive inhibitor status was associated with higher numbers of hospitalizations and central line infections. Academic achievement was affected, to some degree, by length of hospital stay.

[Present and expected role of the nurse in Japanese hemophilia care: result of a questionnaire survey of hemophiliacs and their families]

Since 1970, many hemophilia centers have been opened in the United States and Western Europe. In these centers, nurse coordinators (NCs) play an important role as key persons in improving the QOL of hemophiliacs with a variety of problems. On the other hand, NCs have not been stationed in most Japanese hemophilia centers, although many doctors and nurses in charge of hemophilia care desire that NCs participate in hemophilia treatment. Therefore, a survey of hemophiliacs and their families was conducted to clarify the role of the nurse in Japanese hemophilia care. The results obtained from the analysis of responses concerning 393 patients indicated that about two thirds of the respondents had never consulted with nurses in regard to their disease. Although the total number of items of care and support which were offered by nurses to the patients was 739, the total number of these items which were expected to be offered from nurses to the patients was 1078. These results indicate that the introduction of NCs is necessary for hemophilia care in Japan.

Quality of life in children and families with bleeding disorders

Quality of life (QoL) in children and adolescents with bleeding disorders and their families is a relatively new topic. It is important to understand more about QoL in this patient population to evaluate and if necessary to improve the care patients receive. To achieve this aim, a questionnaire to assess patients' QoL in hemophilia was developed and psychometrically tested. Three hundred twenty hemophiliac children and adolescents from six European countries and their families were asked to fill out a questionnaire regarding different aspects of their well-being and functioning, as well as their views on hemophilia care. Generic QoL questionnaires showed that children with hemophilia have a higher QoL than other patients with chronic disease, such as asthma/atopic dermatitis and obesity. Several determinants affected patients' QoL (e.g., number of bleeds, social support). Parents' and children's assessments differed with regard to social and emotional aspects of QoL. The study showed that variations in QoL can be explained by clinical and psychosocial factors and suggested that QoL can be assessed and enhanced both by medical and non-medical (e.g., psychological) interventions.

Psychological aspects and coping in haemophilic patients: a case-control study

Although enormous progress has been made in recent years in the field of haemophilia, some problems still await solution, such as the risk of sudden haemorrhage, the sequelae of haemophilic arthropathy and social activities. We, therefore, carried out a case-control study in which some psychological dimensions (social expectations, tendency to depression, state of anxiety and self-esteem) were evaluated in a group of 60 haemophiliacs. A control group was formed of 78 healthy subjects matched for age, socio-economic class and level of education. The methodology used was the administration of self-assessment questionnaires which investigate and provide a quantitative measure of psychological dimensions. The results can be subjected to statistical analysis. Three self-assessment questionnaires were used: (i) the Marlowe-Crowne scale, (ii) the Beck Inventory version modified by Cusinato and (iii) the S.T.A.I.-form. Our aim was to evaluate: (i) whether there are significant differences in the considered psychological aspects between haemophiliacs and healthy subjects; (ii) whether there is a significant correlation between the psychological dimensions considered in the haemophiliacs and in the healthy subjects. The results showed that the haemophiliacs have a good psychological adaptation to their disease with the exception of their greater tendency to have less self-esteem than do the healthy subjects. As far as concerns the second aim, we found than self-esteem correlated with all the psychological variables investigated. This information could indicate the enormous importance that the psychological variable 'self-esteem' plays in haemophiliacs with respect to whether or not they develop depressive disorders and/or anxiety states.

Is attention deficit hyperactivity disorder over-represented among HIV-seronegative boys with haemophilia? Preliminary results from our centre

Haemophilia care providers report anecdotally that many boys under their care bear the diagnosis of attention deficit hyperactivity disorder (ADHD). This study investigated the hypothesis that ADHD is over-represented among boys with haemophilia. All the boys with haemophilia, aged 5-14 years, who receive their comprehensive care at our centre were solicited to participate in this study. Of the 78 eligible boys, 34 (44%) were successfully contacted and agreed to participate. All participants were HIV-negative on both serological and PCR-based assays. The presence of ADHD symptoms was established via a parent- and teacher-completed standardized rating instrument. On the parent-rating scale, 26% of the participants exceeded the cut-off for inattentive ADHD, 18% for hyperactive/impulsive ADHD, and 18% for combined. On the teacher rating scale, 4% of the participants exceeded the cut-off for inattentive ADHD, but no participants were rated as having extreme hyperactive/impulsive or combined ADHD symptoms. Retrospectively, 29% of the participants had previously been diagnosed with ADHD, all treated with stimulant medications. Of note, 38% of our participants were enrolled in special education programmes. All of the above were more common in boys with haemophilia compared with national controls. A chart review of non-participating patients from the same clinic suggested that sampling bias is unlikely to account for these differences. These results provide the first empirical evidence that ADHD may be over-represented among boys with haemophilia.

Social, emotional, and behavioral functioning of children with hemophilia

This study examines the social, emotional, and behavioral functioning of children with hemophilia. Data were collected in the homes and schools of 40 boys with hemophilia and 40 comparison boys of the same race and age. Data on social, emotional, and behavioral functioning were collected from teachers, classmates, parents, and the participants. Children with hemophilia scored comparably with comparison peers in all areas of social functioning but reported more difficulties with emotional well-being, including more depressive symptomatology and lower self-perceptions. Parent report also indicated more difficulties with emotional well-being. Parents did not report significant differences in externalizing behavior problems. In conclusion, children with hemophilia were not found to be at increased risk of social or behavioral difficulties. However, both children with hemophilia and their parents identified more difficulties with emotional well-being. Nevertheless, approximately all mean scores for both groups remained within the normal range.

Psychological aspects of hematologic diseases

This article focused on two hematologic diseases that have received significant attention in the pediatric literature: sickle cell anemia and hemophilia. As the data indicate, these illnesses present lifelong challenges to individuals afflicted. With advances in medical interventions, many children with these hematologic diseases are living longer and with fewer serious complications. Intervention efforts only recently have begun to consider issues related to quality of life and increased psychological adjustment, including active coping strategies by children and their parents and necessary social support for all family members. Theoretical models [54] have highlighted the multiple factors that play a role in illness adjustment and the complex interactions of these factors. Individual, family, and community characteristics are impacted by and, in turn, impact on illness-related characteristics. The notion that illness severity is predictive of psychological adjustment has been discarded in favor of a model that recognizes multiple influences and multiple outcomes. Child coping, parent coping, social support, adaptive functioning, treatment compliance, and illness severity are being considered to better understand and influence overall psychological functioning. The field of pediatric psychology has made tremendous advances in improving knowledge of illness and its impact on development. Even with these advances, however, there remains much to be discovered. To date, pediatric psychology research has focused primarily on individual illness categories, making comparisons across illness types difficult. By considering different illnesses within the same study, characteristics that are crucial to improved adjustment and common across illnesses can be identified. As we continue to work for cures for these debilitating illnesses, our goal remains to improve quality of life for children.

Communication about carrier testing within hemophilia A families

Genetic diseases are family diseases. Although there is considerable research on how individuals decide to have genetic testing and their individual reactions to testing, there is limited research on the familial context of genetic testing. In the present study, we focus on three aspects of the family context of genetic testing for hemophilia A carrier status among women at risk to be carriers. We look at the extent to which there was discussion of carrier testing for hemophilia before we offered DNA-based carrier testing to these at-risk women; with which family members these tested women communicated the results of their carrier testing; and concerns these women had about communicating their carrier test results with relatives, including their children. Data suggest that members of families with hemophilia discussed carrier testing prior to study participation, that the communication of testing information within families was selective, not universal, largely following gender lines for this X-linked disorder, and that there was limited concern about communicating carrier status information to children and other relatives. These data reinforce observations that families are social systems, and within these systems information is selectively communicated. A more complete understanding of how families communicate genetic test information will enable providers to develop more effective means of assisting individuals in handling the familial communication aspects of genetic testing.

Social adjustment in three cultures: data from families affected by chronic blood disorders. A sibling study

This study explores the rate of psychosocial dysfunction in affected and unaffected children from families with haemophilia or beta-thalassaemia, as part of a cross-sectional, multicentre study into the resilience of 115 families with blood disorders. Sociodemographic and developmental data were collected from the parents using a standardized and semi-structured interview format, and medical data were obtained from the clinician. The children's social functioning over the year prior to the assessment was assessed with The Social Adjustment Scale adapted for school-aged children. Children with beta-thalassaemia showed significantly higher rates of social dysfunction than their unaffected siblings or children with haemophilia and their siblings. Older children showed significantly higher social dysfunction at school. The high rate of social dysfunction in children with beta-thalassaemia compared with unaffected siblings is likely to have a basis in the negative experiences associated with their medical problems. In contrast, the therapeutic advances in haemophilia allows boys to lead an almost normal life. Overall, the rates of social dysfunction in families with both these disorders proved commoner than reported in population surveys, but with the unavailability of local population controls, caution needs to be exercised in the interpretation of this finding.

Hemophilia Growth and Development Study: caregiver report of youth and family adjustment to HIV disease and immunologic compromise

OBJECTIVE

To assess differences in caregiver report of youth and family psychosocial adjustment associated with HIV infection and greater immune compromise in youths with hemophilia.

METHODS

Caregivers of 162 boys with hemophilia 8 to 20 years old completed three youth and family questionnaires (Personality Inventory for Children, Revised [PIC-R]; Questionnaire on Resources and Stress [QRS]; Family Environment Scale).

RESULTS

Caregivers of HIV positive (HIV+) youths reported greater health concerns, social withdrawal (PIC-R), physical and adaptive limitations associated with illness (QRS) in their sons, and more pessimism about their sons' future and negative attitudes about parenting (QRS). Caregivers of HIV+ youths with greater immune compromise reported greater concerns about their sons' health and greater pessimism about their futures, as well as lower levels of family integration and more limited family opportunities.

CONCLUSIONS

Results suggest caregivers perceive psychosocial problems in HIV+ youths with hemophilia and their families; some problems are specifically associated with greater immune compromise.

Promoting safer sex among HIV-positive youth with haemophilia: theory, intervention, and outcome

The goal of the project was to develop and evaluate theory-based interventions designed to change sexual behaviour and promote safer sex practices of HIV seropositive young men and adolescents with haemophilia to prevent transmission to sexual partners and offspring. Safer sex was defined as abstinence, consistent condom use, or 'outercourse' (intimate, non-intercourse sexual behaviour). This project utilized the Transtheoretical Model developed by Prochaska and DiClemente, which describes behaviour change as an incremental, stage-based process. The 1-year intervention protocol consisted of two individual sessions and two peer-centred activities. One hundred and four adolescents, residing in 22 states, participated. Pre- and post-intervention evaluations were conducted to measure stage progression for participants. The number who were in the action or maintenance stage of change for safer sex was significantly greater at post-test than at pre-test (79 vs. 62%, P < 0.0001). Participants also reported an increased use of outercourse. In addition, significant increases in self-efficacy and knowledge regarding safer sex were demonstrated. Following these stage-based interventions, participants were significantly more likely to be engaging in safer sex behaviours than they were previously. These intervention activities can be adapted for use with other adolescent populations and for other behaviour change goals in adolescents with haemophilia.

Analgesic use and pain coping among patients with haemophilia

Pain is an important consequence of bleeding episodes in haemophilia. Previous research has included pain frequency and severity among measures of illness-related disability and quality of life in haemophilia, but little systematic evidence exists about analgesic use and pain coping in haemophilia. This paper reports cross-sectional findings from a national survey of patients with severe haemophilia type A and type B. Respondents provided information about pain frequency, pain coping strategies (using the haemophilia-adapted CSQ), use of analgesics and other drugs, and described any concerns they had about their drug use. Participants registered with comprehensive care haemophilia centres did not differ from the rest of the sample on any of the factors recorded. Over one-third of participants expressed concerns about their drug use, the most frequent of which were about dependence on prescribed analgesics. Pain frequency was the most important predictor of analgesic use, but pain coping, and specifically negative thoughts about pain, was associated with concerns about drug use independently of other factors, including analgesic use and pain frequency. Further research will be needed to evaluate possible interventions to promote more effective pain coping in haemophilia, and to examine the possible effects of pain coping on illness outcomes beyond analgesic use, such as well-being and quality of life.