Gesundheitsbezogene Kontrollüberzeugung und Lebensqualität bei chronisch Kranken nach stationärer Behandlung mit Integrativer Medizin – eine Beobachtungsstudie

BACKGROUND

In 1999 the Clinic for Internal Medicine and Integrative Medicine was founded in Essen as a regular part of the German inpatient health care system. Integrative medicine (standard internal medicine, evidence-based complementary and alternative medicine combined with intensified lifestyle modification) aims to help patients with chronic illness to cope with their condition more effectively and to achieve a health-promoting lifestyle. Techniques include cognitive restructuring, the elicitation of the relaxation response, and lifestyle education. The goal is to increase health-related quality of life (QoL) as well as control beliefs and to reduce morbidity in later life.

AIM

To demonstrate changes in quality of life, lifestyle, and control beliefs after a two-week hospital stay.

METHODS

Uncontrolled prospective observational study with 557 consecutive hospital patients. Outcome parameters were quality of life (SF36), control beliefs (GKU), and daily health-related behavior (nutrition, physical activity, relaxation) on admission, at discharge, as well as 3 and 6 months after discharge.

RESULTS

Weekly physical activity increases by 29%, consumption of not recommendable foods decreases by 18%. The majority of patients (57%) engage in relaxation exercises 6 months after discharge (on admission 23%). The physical sum scale (SF36) increases from 33.9 (95% KI 32.5-35.3) on admission to 37.3 (35.8-38.9) 6 months after discharge, the mental sum scale from 41.2 (39.5-42.9) to 45.1 (43.5-46.7). The ratio internal/external control belief rises from 1.17 (95% KI 1.11-1.24) to 1.32 (1.24-1.40). Pretherapeutic ratio internal/external control belief and its increase are associated with rises in QoL.

CONCLUSIONS

After integrative medicine treatment a lasting increase in QoL and lifestyle changes can be achieved. Reinforcement of internal control beliefs and own competence is possible and enhances outcomes in chronically ill patients.

Leisure time physical activity and health-related quality of life: cross-sectional and longitudinal associations

Studies that relate change in physical activity to change in health-related quality of life in the general population are needed to confirm associations suggested by cross-sectional studies. In the present study, cross-sectional as well as longitudinal associations between leisure time physical activity and health-related quality of life were studied in an apparently healthy population. The present study showed cross-sectional associations between at least moderately intense leisure time physical activity and general health perceptions, vitality, physical functioning and role limitations due to physical health problems. No associations were present for total leisure time physical activity. Change in leisure time physical activity was associated with change in social functioning in men as well as in women, irrespective of the intensity of physical activity. Only in men, change in total leisure time physical activity was associated with change in vitality and general mental health. In our study, cross-sectional associations were not confirmed by longitudinal analyses. Cross-sectional associations were mainly found for physical components of health-related quality of life, whereas longitudinal associations were predominantly observed for mental components of health-related quality of life. Confirmation of our results by those of other studies is needed in order to quantify health promotion messages.

A unique opportunity for students: long-term therapeutic relationships with chronically ill clients

Because of a number of factors, fewer opportunities are available today for students to have independent clinical experiences with home care agencies. At York College of Pennsylvania, community health nursing faculty designed a home health clinical experience with chronically ill clients that would be meaningful to students, fill unmet client needs, and establish or strengthen the relationship between the nursing department and community/home health agencies. In addition to achieving the stated goals, these clinical experiences offered additional unanticipated benefits that resulted from the long-term nature of these client-student interactions.

[A questionnaire study on psychological problems in home medical care for children with chronic illness]

We performed a questionnaire study on psychological problems in home medical care, including mechanical ventilation, oxygen therapy, continuous ambulatory peritoneal dialysis and parenteral nutrition, for children with chronic illnesses in Osaka prefecture, Japan. One hundred two pediatricians (46%) answered the questionnaire. The majority of the doctors regarded psychological support for the children and their families as an important issue. In some cases, home medical care was interrupted because of psychological problems such as psychological burden, anxiety and stress of the children and/or their families. And some other cases, home medical care was impossible because of parental refusal to treatment and/or their child. The cases with mechanical ventilation and oxygen therapy mainly accounted for these cases. Since the number of cases undergoing home medical care is estimated to increase in the future, medical staff should be more aware of psychological support for the families as well as their children.

Concept development of family resilience: a study of Korean families with a chronically ill child

AIMS

To clarify and delineate the concept of family resilience in the context of the chronic illness of a child. This study also investigated the concept of family resilience in relation to family functioning in order to compare and contrast family resilience and family functioning.

DESIGN AND METHOD

Three phases of the hybrid model of concept development were applied: theoretical, fieldwork and final analytical. In the theoretical phase, a working definition of family resilience was developed by a literature review. The fieldwork phase comprised in-depth interviews with 11 parents with a chronically ill child, in the paediatric oncology unit of a university hospital in South Korea. The qualitative data obtained from the interviews were analysed to find attributes of family resilience. The final analytical phase compared and interpreted the findings from the theoretical and fieldwork phases in order to clarify and refine the concept of resilience.

RESULTS

The definition of family resilience was of an enduring force that leads a family to change its functioning dynamics in order to solve problems encountered. Twenty-one conceptual attributes of family resilience emerging from this study were differentiated into four dimensions: (i) intrinsic family characteristics, (ii) family member orientation related to family characteristics, (iii) responsiveness to stress and (iv) external orientation.

CONCLUSIONS

Family resilience is an enduring force that leads a family to change its dynamics of functioning in order to solve problems associated with stresses encountered. This conceptualization led to the development of a model of family coping that incorporates both family resilience and family functioning, as the property and as the process of change, respectively.

RELEVANCE TO CLINICAL PRACTICE

In order to build a family that functions better under stress, it is necessary for nurses to focus more attention on family resilience, especially in terms of the development of intervention strategies to strengthen family resilience.

Psychometric properties of the WHO Quality of Life questionnaire (WHOQOL-100) in patients with chronic diseases and their caregivers in China

OBJECTIVE

To evaluate the psychometric properties of the WHO Quality of Life questionnaire (WHOQOL-100), a multi-dimensional, conceptualized, 100-item quality-of-life instrument.

METHODS

A total of 460 patients in China with chronic diseases (including hypertension, schizophrenia, stroke, end-stage renal disease, head and neck cancer and breast cancer) and 418 family members who were their caregivers were assessed at baseline and one year later.

FINDINGS

The WHOQOL-100 had acceptable internal consistency (alpha = 0.76-0.90 across domains). There were strong correlations between the domains of WHOQOL-100 and the dimensions of the General Quality of Life Inventory (alpha = 0.72-0.82 across related domains). Within domains most facet correlations were satisfactory, although some facets correlated more strongly with a domain other than that to which they had been assigned. Principal component analysis produced four factors accounting for 61% of the total variance.

CONCLUSION

The WHOQOL-100 was able to discriminate between the different groups of patients and was sensitive to clinical change in patients' conditions. It proved to be a reliable and valid instrument for assessing the quality of life of patients with chronic diseases and their caregivers in China.

Improving drug concordance in patients with chronic conditions

A significant proportion of patients with chronic illnesses fail to take their medication as prescribed (Barber et al, 2004). Failure to adhere to medication regimens is a widespread problem that has serious implications for patients and the health service. However, to improve concordance, health care professionals need to understand patients' reasons for not taking their medication as prescribed. While in many cases these reasons are relatively straightforward, others are complex and difficult to identify. In addition, the concept of informed choice means that, provided they have been given all the relevant information about the treatment options, patients have the right to refuse the treatment recommended to them.

Psychotic symptoms in patients with medical disorders

Psychotic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. They may be a part of an independent psychiatric illness associated with the underlying medical condition or induced by substance use or medications. The presence of psychotic symptoms can contribute to misdiagnosis or complicate the management of the comorbid medical illness. Psychiatrists must be familiar with the assessment and management of psychotic disorders in patients with comorbid medical disorders. Medications that may be used to treat psychosis include antipsychotic agents, benzodiazepines, or possibly certain anticonvulsants. Selecting the appropriate medication requires knowledge of the pharmacokinetics of different agents and their side effect profile. Understanding the neuropsychiatric effects of medications and drug-drug interactions may help in preventing psychotic symptoms.

Seeking the Patient's Perspective: A Qualitative Assessment of EuroQol, COOP-WONCA Charts and MYMOP

An outcome questionnaire that is patient-centred should encompass the aims, values and treatment effects that are prioritised by individuals, and should enable each individual to provide an unambiguous assessment of change over time. There is little evidence about how well outcome questionnaires perform in this regard. This paper describes how interviews that combined in-depth enquiry and cognitive techniques were used to explore patients' experiences of completing three outcome questionnaires over a 6 month period. The 23 interviewees all had chronic disease and were receiving acupuncture treatment for the first time. Many of the problems uncovered by this study can be ameliorated by attention to questionnaire design. For example, by the provision of at least five response options, by being explicit about including co-morbidity, and by measuring medication change as a separate outcome. The study also highlighted more fundamental conceptual difficulties, such as response shift and the respondent's conflict between scoring external function and internal distress (what they did, vs. what they felt). These issues relate to the co-existence of different perspectives and the impossibility of reducing health status to one 'single truth'. The study concludes that qualitative evaluations have an important role to play in questionnaire design and development and are likely to lead to more modest and realistic appraisals of outcome questionnaire performance.

The Effects of Depressed Affect on Functional Disability Among Rural Older Adults

This study investigates functional disability among some of the nation's most vulnerable older adults: rural Medicaid recipients. Data were provided by 221 older adults (mean age = 75.9 years; 82% women) who were receiving community-based long-term care services through Medicaid. Participants self-reported functional ability involving the completion of six basic activities of daily living (BADLs), three cognitive instrumental activities of daily living (IADLS), and four physical IADLs. Self-reports of depressed affect and the number of physical health conditions were also obtained. Path analysis was used to examine all of the associations among age, gender, number of chronic health conditions, depressed affect and functional disability. The tested model was significant [chi2 (DF = 3, n = 221) = 5.052, p = 0.168; TLI = 0.945; CFI = 0.992; RMSEA = 0.056] and explained 45.1% of the variance in BADL disability. Depressed affect significantly predicted disability in cognitive IADLs and physical IADLs, which predicted disability in BADLs. Age and gender had indirect effects on BADL, through their association with cognitive IADLs and physical IADLs. The number of chronic health conditions exerted both indirect and direct effects on BADL disability. Results are discussed within the context of the growing literature that suggests the importance of psychological variables as predictors of functional disability. Moreover, we discuss whether community-based long-term care is appropriate for older adults with high levels of functional disability.

Arthritis and Heart Disease as Risk Factors for Major Depression

BACKGROUND

Major depression in later life is highest among people with chronic illness. Identifying amenable factors that mediate the relationship between known risk factors such as arthritis and heart disease with major depression is important to the design of clinical and public health strategies to reduce depression and its consequences.

OBJECTIVE

This study investigates factors amenable to clinical and public health intervention that could mediate the relationship between chronic illness and major depression.

DESIGN

Population-based national sample.

SETTING

United States preretirement age (54-65) adults.

PARTICIPANTS

A total of 7825 participants from the 1996 Health and Retirement Survey.

MEASUREMENT

The outcome is major depression based on standardized assessment. Independent variables include sociodemographics chronic illness profile, functional limitation, health and medical access.

RESULTS

A substantial burden of major depression is related to chronic illness, particularly arthritis (attributable risk [AR], 18.1%; 95% confidence interval [CI], 9.9-25.6) and heart disease (AR, 17.6%; 95% CI, 13.4-21.7). Functional limitation is the strongest investigated factor associated with depression (AR, 34.4%; 95% CI, 24.8-42.7) and attenuates the associations of arthritis and heart disease with depression.

CONCLUSION

Functional limitation mediates the association of arthritis and heart disease with major depression. This relationship offers potential clinical and public health strategies to reduce major depression in older adults through intervention and management of functional limitation. Alternatively, it might be possible to reduce functional loss through screening for depression, particularly among people with functional limitation, and effective mental health treatment. The importance for clinical management of depression, comorbidity, and functional limitation spectrum supports the value of systems-based medicine.

Improving transition: a qualitative study examining the attitudes of young people with chronic illness transferring to adult care

Transition is a process that attends to the medical, psychosocial and educational needs of young people as they transfer to adult-orientated care. With a growing population of adolescents surviving with chronic illness well into adulthood, it is remarkable that empirical research has paid little attention to transition. This qualitative study examined the attitudes of young people with chronic illness who were facing transition, considering what young people wanted from a transition service and the ways in which provision could be improved from a service-user's perspective. A purposive sample of seven adolescents (aged 14-17) attending a hospital youth club were interviewed. To increase the likelihood of successful transition, strategies need to be informal, flexible, highly individualized and prepare adolescents steadily for adult services.

The Relative Contribution of Domains of Quality of Life to Overall Quality of Life for Different Chronic Diseases

This study examined the contribution of the quality of life (QoL) domains physical, social and psychological functioning to the explanation of overall QoL. Various disorders may differentially affect QoL domains due to disease-specific factors and, consequently, the relationship between QoL domains and overall QoL may vary between diseases. We therefore studied this relationship for several diseases as well as the differential impact of these diseases on QoL. The present study had a cross-sectional design. We selected patients (aged 57 years and older) with one of the following eight chronic medical conditions: lung disorder, heart condition, hypertension, diabetes mellitus, back problems, rheumatoid arthritis, migraine, or dermatological disorders. The total group of respondents included 1457 patients and 1851 healthy subjects. Regression analyses showed that the domain of psychological functioning contributed to overall QoL for all disorders, whereas physical and social functioning contributed to overall QoL for some disorders. Differences were found between most patient groups and healthy subjects with respect to physical functioning; with respect to social and psychological functioning some groups differed from the healthy group. Explanations for the findings and implications for clinical practice are discussed.

[Quality-of-life scales for patients with drug-resistant partial epilepsy]

Epilepsy is a chronic condition with numerous social and psychological consequences. Research on quality of life in epilepsy is characterized by different kind of methodology. Quality of life is worse in epileptic patients than in the general population. Quality of life is also comparable or worse in epileptic patients than in patients with other chronic conditions. But quality of life in well-controlled epileptic patients is similar to quality of life in healthy persons. Frequency of seizures seems to be one of the most relevant determinants of poor quality-of-life scores. Being seizure free is a necessary but not sufficient condition to have a good quality of life. Quality of life is worsened by the co-existence of depression. The impact of surgical treatment on quality of life is positive, in all ages, in correlation with seizure control. It is difficult to analyze the impact of drug therapy on quality of life. Because of the lack of a standardized approach summarizing the literature in the field remains extremely difficult.

Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents

Adolescents with chronic pain also report severe disability and emotional distress. A clinical sample of 80 adolescents and accompanying parents were investigated to first measure the extent of distress, and second to investigate the relationships between adolescent distress, parental distress and adolescent coping. Measures of pain intensity, anxiety, depression, disability and coping were obtained from adolescents. Parents completed measures including their own anxiety, depression and parenting stress. Overall, adolescents reported high levels of disability, depression and anxiety, and parents reported high levels of depression, anxiety and parenting stress. Multiple regression analyses revealed that the best predictors of adolescent emotional distress were the extent to which the adolescents catastrophize and seek social support to cope with the pain. There were no clear predictors of parental anxiety or depression but the specific pattern of parenting stress was best predicted by the younger age of the adolescent, the greater the chronicity of the problem, and the greater the extent of adolescent depression. These findings suggest that emotional coping is a critical variable in the distress associated with adolescent chronic pain. It is argued that adolescent emotional coping may best be understood within a relational context of seeking emotional support.

[Similarities and differences between self-rated and proxy-rated health in extreme old age]

Especially in old age, the global well-being of persons is strongly influenced by their health situation. Due to functional limitations, research on the development of persons in extreme old age often uses proxy ratings of health instead of self-ratings common in younger age groups. However, it is not known whether self- and proxy-ratings provide comparable information about the health status of extremely old persons. The current study with 53 centenarians and 53 proxies examines similarities and differences between self and proxy-ratings of health. The results indicate a high degree of similarity in some health ratings, an overestimation of ADL capacities by the centenarians, and that self-ratings to a large degree reflect the current mood levels of individuals. Findings are discussed with respect to the differences in the kind of information used for general health ratings.

Needs for care of chronic schizophrenic patients in long-term community treatment

BACKGROUND

Specific problems of long-term community care of chronic schizophrenic patients are an under-researched area interesting for the provision of regional mental health care.

METHODS

This study focuses on a 4 1/2-year prospective assessment of normative needs for care in a cohort (initially N = 115) living in the Dresden care region (Germany). At six time-points, normative needs for care were assessed with the Needs for Care Assessment (NFCAS).

RESULTS

The total number of problems did not change significantly over the study period. The average number of met needs was lower at the longer-term follow-up assessments,due particularly to a decrease in the social section. This trend is also demonstrated for the average number of unmet needs. In contrast, the mean number of "unmeetable needs" increased. Consistently, 70-80% of the patients exhibit problems in positive psychotic and negative symptoms, household affairs and recreational activities. Communication, occupation and recreational activities constitute a trio of social needs not met for nearly one-third of the patients disabled in these respects. Logistic analyses of regression could not identify a predictive model for the total needs development within the 4 1/2-year community treatment.

CONCLUSION

The rather stable pattern of needs for care seems to define clear long-lasting tasks for community mental health services. For chronic schizophrenic patients, services should especially focus on social skills training and psychoeducational approaches. Due to a wide range of possible factors of influence, however, planning long-term context-dependent processes of care in the community lacks a clear evidence base.

Selbsthilfe und Beratung im Internet

Using e-health portals to the internet seeking information about one's illness and to exchange experience with other sick persons can result in more self-responsible patients and in a more partnership-based physician-patient relationship. Especially with serious and chronic diseases like cancer, HIV infection, eating disorders, and depression, concerned patients may find support by accessing web pages and by using internet communication like message boards, mailing lists, and chat rooms. In an online questionnaire, internet users with eating disorders stated that they felt understood by their internet peers and, therefore, were encouraged to start therapy. Physicians may fear their advance in knowledge to decrease, resulting in an overprotective attitude to the informed patient. Nevertheless, they will recognize, by active participation, that the medical internet may promote an earlier start of expert-guided therapy, improved compliance, aftercare, and basic care independent of place and time. However, further evaluation of internet-supported treatment is required.

Construction and validation of a quality of life instrument for young adults

Assessment of quality of life (QOL) in young adults has become an increasingly important field of research as information on the QOL of children and adults accumulates. The purpose of this study is to report on the development of the Young Adult Quality Of Life (YAQOL) instrument, a measure of QOL for young adults aged 18-25. The YAQOL, which is comprised of 14 multi-item scales that assess physical health and aspects of psychological well-being, social relationships, role function, and environmental context, was administered to a general population sample of 751 young adults. Scale structure was confirmed by item-internal consistency, item discriminant validity, and inter-scale correlations. Reliability coefficients ranged from 0.88 to 0.63 across scales (mean = 0.73). Eight YAQOL scales discriminated clearly between young adults with and without chronic physical conditions, 12 scales discriminated between young adults with and without personality disorder, and negative associations were demonstrated between YAQOL scale scores and psychiatric disorder symptoms. Demographic differences in the YAQOL scales were consistent with theoretical expectations and previous empirical work. Overall, findings support the reliability and utility of the YAQOL as a measure of QOL in young adults in the general population. Additional psychometric properties will continue to be evaluated as more data become available.