The Centers for Disease Control and Prevention's Healthy Days Measures - population tracking of perceived physical and mental health over time

Typologies of cannabis users and associated characteristics relevant for public health: a latent class analysis of data from a nationally representative Canadian adult survey

Cannabis is the most prevalently used illicit drug in Canada. Current policy consists primarily of universal use prohibition rather than interventions targeting specific risks and harms relevant for public health. This study aimed to identify distinct groups of cannabis users based on defined use characteristics in the Canadian population, and examine the emerging groups' associations with differential risk and harm outcomes. One thousand three hundred and three current (i.e. use in the past three months) cannabis users, based on data from the representative cross-sectional 2004 Canadian Addiction Survey (N = 13,909), were statistically assessed by a 'latent class analysis' (LCA). Emerging classes were examined for differential associations with socio-demographic, health and behavioral indicators on the basis of chi-square and analysis of variance techniques. Four distinct classes based on use patterns were identified. The class featuring earliest onset and highest frequency of use [22% of cannabis user sample or 2.2% (95% confidence interval (CI) = 1.8-2.7%) of the Canadian adult population] was disproportionately linked to key harms, including other illicit drug use, health problems, cannabis use and driving, and cannabis use problems. A public health framework for cannabis use is needed in Canada, meaningfully targeting effective interventions towards the minority of users experiencing elevated levels of risks and harms.

Predicting the EuroQol Group's EQ-5D index from CDC's "Healthy Days" in a US sample

BACKGROUND

Obtaining reliable preference-based scores from the widely used Healthy Days measures would enable calculation of quality-adjusted life years (QALYs) and cost-utility analyses in many US community populations and over time. Previous studies translating the Healthy Days to the EQ-5D, a preference-based measure, relied on an indirect method because of a lack of population-based survey data that asked both sets of questions of the same respondents.

METHOD

Data from the 2005-2006 National Health Measurement Study (NHMS; n = 3844 adults 35 years old or older) were used to develop regression-based models to estimate EQ-5D index scores from self-reported age, self-rated general health, and numbers of unhealthy days.

RESULTS

The models explained up to 52% of the variance in the EQ-5D. Estimated EQ-5D scores matched well to the observed EQ-5D scores in mean scores overall and by age, gender, race/ethnicity, income, education, body mass index, smoking, and disease categories. The average absolute differences were 0.005 to 0.006 on a health utility scale. After estimating mean EQ-5D index scores overall and for various subgroups in a large representative US sample of Healthy Days respondents, the authors found that these mean scores also closely matched the corresponding mean scores of EQ-5D respondents obtained from another large US representative sample with an average absolute difference of 0.013 points.

CONCLUSIONS

This study yielded a mapping algorithm to estimate EQ-5D index scores from the Healthy Days measures for populations of adults 35 years old and older. Such analysis confirms it is feasible to estimate mean EQ-5D index scores with acceptable validity for use in calculating QALYs and cost-utility analyses based on the overall model fit and relatively small differences between the observed and the estimated mean scores.

Associations between racial discrimination, limited English proficiency, and health-related quality of life among 6 Asian ethnic groups in California

OBJECTIVES

We examined the association of racial discrimination and limited English proficiency with health-related quality of life among Asian Americans in California.

METHODS

We studied Chinese (n = 2576), Filipino (n = 1426), Japanese (n = 833), Korean (n = 1128), South Asian (n = 822), and Vietnamese (n = 938) respondents to the California Health Interview Survey in 2003 and 2005. We assessed health-related quality of life with the Centers for Disease Control and Prevention's measures of self-rated health, activity limitation days, and unhealthy days.

RESULTS

Overall, Asians who reported racial discrimination or who had limited English proficiency were more likely to have poor quality of life, after adjustment for demographic characteristics. South Asian participants who reported discrimination had an estimated 14.4 more activity limitation days annually than South Asians who did not report discrimination. Results were similar among other groups. We observed similar but less consistent associations for limited English proficiency.

CONCLUSIONS

Racial discrimination, and to a lesser extent limited English proficiency, appear to be key correlates of quality of life among Asian ethnic groups.

Time trends and seasonal patterns of health-related quality of life among U.S. adults

OBJECTIVES

Although numerous studies have examined health-related quality of life (HRQOL) longitudinally, little is known about the impact of seasonality on HRQOL. We examined trend and seasonal variations of population HRQOL.

METHODS

We used data from the monthly Behavioral Risk Factor Surveillance System (BRFSS). We examined monthly observed mean physically and mentally unhealthy days from January 1993 to December 2006, using the structural time-series model to estimate the trend and seasonality of HRQOL.

RESULTS

We found overall worsening physical and mental health during the time period and a significant and regular seasonal pattern in both physical and mental health. The worst physical health was during the winter and the best physical health was during the summer. The mean number of physically unhealthy days in January was 0.63 days higher than in July. The worst mental health occurred during the spring and fall, but the magnitude of the seasonal effect was much smaller. The difference between the best and worst months of mentally unhealthy days was approximately 0.23 days. We found significant differences in unadjusted and season-adjusted unhealthy days in many counties.

CONCLUSIONS

Our findings can be used to examine time-varying causal factors and the impact of interventions, such as policies designed to improve population health. Our findings also demonstrated the need for calculating season-adjusted HRQOL scores when examining cross-sectional factors on the population HRQOL measures for continuous surveys or longitudinal data.

The Effects of a Physical Activity Program on Sleep-and Health-Related Quality of Life in Older Persons With Arthritis

Few studies have examined the effects of physical activity on sleep in older adults. The purpose of this study was to examine the short- and long-term effects of an 8-week, low-to-moderate-intensity physical activity program on improvements in sleep and health-related quality of life (HRQOL) in a sample of community-based older adults with arthritis ( N = 346). Participants were randomly assigned to an intervention group or control group that received the intervention on a delayed basis. Sleep and HROQL were assessed with self-report instruments at baseline and 8 weeks using intention-to-treat (ITT) and as-treated (AT) analyses. The intervention group was also assessed at 3 and 6 months. At 8 weeks, the intervention group reported fewer days waking up tired (ITT and AT results) and fewer days waking up at night and/or having poor mental health (AT results). Treatment effects were not maintained at 3 and 6 months.

Are Americans feeling less healthy? The puzzle of trends in self-rated health

Although self-rated health is proposed for use in public health monitoring, previous reports on US levels and trends in self-rated health have shown ambiguous results. This study presents a comprehensive comparative analysis of responses to a common self-rated health question in 4 national surveys from 1971 to 2007: the National Health and Nutrition Examination Survey, Behavioral Risk Factor Surveillance System, National Health Interview Survey, and Current Population Survey. In addition to variation in the levels of self-rated health across surveys, striking discrepancies in time trends were observed. Whereas data from the Behavioral Risk Factor Surveillance System demonstrate that Americans were increasingly likely to report "fair" or "poor" health over the last decade, those from the Current Population Survey indicate the opposite trend. Subgroup analyses revealed that the greatest inconsistencies were among young respondents, Hispanics, and those without a high school education. Trends in "fair" or "poor" ratings were more inconsistent than trends in "excellent" ratings. The observed discrepancies elude simple explanations but suggest that self-rated health may be unsuitable for monitoring changes in population health over time. Analyses of socioeconomic disparities that use self-rated health may be particularly vulnerable to comparability problems, as inconsistencies are most pronounced among the lowest education group. More work is urgently needed on robust and comparable approaches to tracking population health.

Health-related quality of life, quality-adjusted life years, and quality-adjusted life expectancy in new york city from 1995 to 2006

We applied our previously developed estimation equation to predict EQ-5D index scores from the Centers for Disease Control and Prevention's Healthy Days measures for the New York City (NYC) adult population from 1995 to 2006 and compared these trends over time with the US general population. Such scores enabled us to examine the burden of disease attributable to smoking and overweight/obesity at both the local and national levels. We employed the estimation equation to the 1993-2007 Behavioral Risk Factor Surveillance System (BRFSS) data to obtain EQ-5D index scores for all survey respondents based on their age, self-rated health status, and overall number of unhealthy days. With the combination of mortality data, we calculated trends of quality-adjusted life years (QALYs), life expectancy (LE), and quality-adjusted life expectancy (QALE) as well as the percent of QALYs and QALE lost contributed by smoking and overweight/obesity. Mean EQ-5D index scores for NYC adults decreased from 0.874 to 0.852 but, more recently, have increased to 0.869. The LE of an 18-year-old living in NYC increased 4.7 years and QALE increased 2.6 years. The contribution of smoking to the proportion of QALYs lost decreased from 6.7% to 3.5%, while the contribution of overweight/obesity to the proportion of QALYs lost increased from 4.5% to 16.9%. The proportion of QALEs lost due to smoking decreased from 5.5% to 4.5%, while the proportion of QALEs lost due to overweight/obesity increased from 3.5% to 11.8%. Because the Healthy Days measures have been included in the BRFSS since 1993, translating Healthy Days Measures to a preference-based measure is a useful method for longitudinal tracking of population health at the local, state, and national level.

Geographic patterns of frequent mental distress: U.S. adults, 1993-2001 and 2003-2006

BACKGROUND

Mental illnesses and other mental health problems often lead to prolonged, disabling, and costly mental distress. Yet little is known about the geographic distribution of such mental distress in the U.S.

METHODS

Since 1993, the CDC has tracked self-perceived mental distress through the Behavioral Risk Factor Surveillance System (BRFSS). In 2007 and 2008, analysis was performed on BRFSS data reported by 2.4 million adults from 1993-2001 and 2003-2006 to map and describe the prevalence of frequent mental distress (FMD)-defined as having >or=14 mentally unhealthy days during the previous 30 days-for all states and for counties with at least 30 respondents.

RESULTS

The adult prevalence of FMD for the combined periods was 9.4% overall, ranging from 6.6% in Hawaii to 14.4% in Kentucky. From 1993-2001 to 2003-2006, the mean prevalence of FMD increased by at least 1 percentage point in 27 states and by more than 4 percentage points in Mississippi, Oklahoma, and West Virginia. Most states showed internal geographic variations in FMD prevalence. The Appalachian and the Mississippi Valley regions had high and increasing FMD prevalence, and the upper Midwest had low and decreasing FMD prevalence.

CONCLUSIONS

Geographic areas were identified with consistently high and consistently low FMD prevalence, as well as areas in which FMD prevalence changed substantially. Further evaluation of the causes and implications of these patterns is warranted. Surveillance of mental distress may be useful in identifying unmet mental health needs and disparities and in guiding health-related policies and interventions.

The PHQ-8 as a measure of current depression in the general population

BACKGROUND

The eight-item Patient Health Questionnaire depression scale (PHQ-8) is established as a valid diagnostic and severity measure for depressive disorders in large clinical studies. Our objectives were to assess the PHQ-8 as a depression measure in a large, epidemiological population-based study, and to determine the comparability of depression as defined by the PHQ-8 diagnostic algorithm vs. a PHQ-8 cutpoint > or = 10.

METHODS

Random-digit-dialed telephone survey of 198,678 participants in the 2006 Behavioral Risk Factor Surveillance Survey (BRFSS), a population-based survey in the United States. Current depression as defined by either the DSM-IV based diagnostic algorithm (i.e., major depressive or other depressive disorder) of the PHQ-8 or a PHQ-8 score > or = 10; respondent sociodemographic characteristics; number of days of impairment in the past 30 days in multiple domains of health-related quality of life (HRQoL).

RESULTS

The prevalence of current depression was similar whether defined by the diagnostic algorithm or a PHQ-8 score > or = 10 (9.1% vs. 8.6%). Depressed patients had substantially more days of impairment across multiple domains of HRQoL, and the impairment was nearly identical in depressed groups defined by either method. Of the 17,040 respondents with a PHQ-8 score > or = 10, major depressive disorder was present in 49.7%, other depressive disorder in 23.9%, depressed mood or anhedonia in another 22.8%, and no evidence of depressive disorder or depressive symptoms in only 3.5%.

LIMITATIONS

The PHQ-8 diagnostic algorithm rather than an independent structured psychiatric interview was used as the criterion standard.

CONCLUSIONS

The PHQ-8 is a useful depression measure for population-based studies, and either its diagnostic algorithm or a cutpoint > or = 10 can be used for defining current depression.

The statewide burden of obesity, smoking, low income and chronic diseases in the United States

BACKGROUND

We developed an estimation equation of EuroQol EQ-5D index scores from the Healthy Days measures of the Centers for Disease Control and Prevention for use in burden of disease and cost-effectiveness studies in population subgroups. This study estimated EQ-5D scores, quality-adjusted life years (QALYs) and quality-adjusted life expectancy (QALE) for the USA and the individual states.

METHODS

We estimated the EQ-5D scores for respondents from the 2000-2003 Behavioral Risk Factor Surveillance System. We calculated QALYs and QALE lost to morbidity due to obesity/overweight, smoking, low income and chronic diseases.

RESULTS

The mean EQ-5D score for US adults was 0.870. The mean scores ranged from 0.826 (West Virginia) to 0.902 (Hawaii). Smoking contributed from 5.6 (Utah) to 12.3 (Kentucky) percent, obesity/overweight 5.4 (South Dakota) to 13.8 (Louisiana) percent, low income 16.6 (Hawaii) to 39.9 (South Carolina) percent and chronic diseases 8.7 (Minnesota) to 22.9 (Tennessee) percent of explainable QALYs lost. These risks contributed the greatest proportion of explainable QALYs and QALE lost in Kentucky, Tennessee and South Carolina.

CONCLUSIONS

We estimated the burden of disease contributed by selected risk factors. Currently, such data are unavailable but are needed to set targets for reducing modifiable health risks and eliminating health disparities among at-risk populations.

Serious psychological distress among persons with epilepsy based on the 2005 California Health Interview Survey

PURPOSE

To compare the prevalence of self-reported serious psychological distress using the Kessler 6 (K6) in persons with a history of epilepsy (PWE) to those without epilepsy from a population-based survey.

METHODS

Data were analyzed from adults aged >or=18 years (n = 43,020) who participated in the 2005 California Health Interview Survey (CHIS).

RESULTS

California adults with a history of epilepsy, after controlling for demographics and comorbidities, reported higher rates of feeling nervous [odds ratio (OR) 2.22], feeling hopeless (OR 1.35), feeling restless (OR 2.07), feeling depressed (OR 3.14), and feeling worthless (OR 2.57), and reported that everything has been an effort (OR 2.28) in the last 30 days. The K6 score showed that serious psychological distress is more common in PWE (OR 2.24). After adjusting for demographics, comorbidities, and serious psychological distress, PWE are more likely to report having 14 or more physical, mental, and general unhealthy days in the last 30 days.

DISCUSSION

PWE have significantly higher rates of serious psychological distress and poor health-related quality of life after controlling for demographics, comorbidities. These comorbid conditions need to be factored into any comprehensive treatment strategy for managing PWE to achieve optimum quality of life.

Associations between health-related quality of life and smoking status among a large sample of U.S. adults

OBJECTIVE

To examine the association between self-perceived health-related quality of life (HRQoL) and smoking status.

METHODS

We used data from 2006 Behavioral Risk Factor Surveillance System, USA participants in four states (n=17,800) to compare the HRQoL of current smokers who unsuccessfully attempted to quit (unsuccessful quitters), former smokers, and never smokers with the HRQoL of current smokers who made no attempts to quit (non-quitters).

RESULTS

Overall, unsuccessful quitters were more likely than non-quitters to report frequent mental distress, physical distress, and pain but not frequent depressive symptoms; former and never smokers were less likely than non-quitters to report frequent depressive symptoms. When study subjects were stratified by sex, these associations held true for men, but not for women. Among women, the prevalence of frequent mental and physical distress among former smokers and never smokers was not significantly different from the prevalence among non-quitters, whereas unsuccessful quitters were 2.4 times more likely to report frequent mental distress and 2.1 times more likely to report frequent physical distress than were non-quitters.

CONCLUSIONS

Certain HRQoL characteristics were worse among smokers who unsuccessfully attempted to quit and better among former smokers than among smokers who made no attempts to quit.

Health coaching via an internet portal for primary care patients with chronic conditions: a randomized controlled trial

BACKGROUND

Efforts to enhance patient-physician communication may improve management of underdiagnosed chronic conditions. Patient internet portals offer an efficient venue for coaching patients to discuss chronic conditions with their primary care physicians (PCP).

OBJECTIVES

We sought to test the effectiveness of an internet portal-based coaching intervention to promote patient-PCP discussion about chronic conditions.

RESEARCH DESIGN

We conducted a randomized trial of a nurse coach intervention conducted entirely through a patient internet-portal.

SUBJECTS

Two hundred forty-one patients who were registered portal users with scheduled PCP appointments were screened through the portal for 3 target conditions, depression, chronic pain, mobility difficulty, and randomized to intervention and control groups.

MEASURES

One-week and 3-month patient surveys assessed visit experiences, target conditions, and quality of life; chart abstractions assessed diagnosis and management during PCP visit.

RESULTS

Similar high percentages of intervention (85%) and control (80%) participants reported discussing their screened condition during their PCP visit. More intervention than control patients reported their PCP gave them specific advice about their health (94% vs. 84%; P = 0.03) and referred them to a specialist (51% vs. 28%; P = 0.002). Intervention participants reported somewhat higher satisfaction than controls (P = 0.07). Results showed no differences in detection or management of screened conditions, symptom ratings, and quality of life between groups.

CONCLUSIONS

Internet portal-based coaching produced some possible benefits in care for chronic conditions but without significantly changing patient outcomes. Limited sample sizes may have contributed to insignificant findings. Further research should explore ways internet portals may improve patient outcomes in primary care. ClinicalTrials.gov registration NCT00130416.

Comorbidity, health screening, and quality of life among persons with a history of epilepsy

Previous population surveys outside the United States have found an increased prevalence of comorbid conditions in persons with epilepsy. However, the effect of comorbid conditions on health-related quality of life (HRQOL) has not been previously examined in the epilepsy literature from the United States. Results from the California Health Interview Survey (CHIS) indicate an increased prevalence of comorbid conditions in persons with a history of epilepsy compared to those without epilepsy. After controlling for demographics and comorbid conditions, persons with a history of epilepsy were significantly more likely to report poor HRQOL. Although seizure freedom should continue to be a primary clinical goal, optimal care should also include primary and secondary prevention of comorbid conditions, especially cardiovascular and pulmonary diseases. Prevention, early identification, and treatment of comorbid conditions may reduce mortality risk and improve health outcomes in persons with epilepsy.

Health-related quality of life in adults from 17 family practice clinics in North Carolina

INTRODUCTION

We examined health-related quality of life (HRQOL) in white and African American patients based on their own and their community's socioeconomic status.

METHODS

Participants were 4,565 adults recruited from 17 family physician practices in urban and rural areas of North Carolina. Education was used as a proxy for individual socioeconomic status, and the census block-group poverty level was used as a proxy for community socioeconomic status. HRQOL measures were the 12-Item Short Form Survey Instrument, physical component summary (PCS) and mental component summary (MCS), and 3 Centers for Disease Control and Prevention HRQOL healthy days measures. Multilevel analyses examined independent associations of individual and community poverty level with HRQOL, adjusting for demographics and clustering by family practice. Analyses were stratified by race and were conducted on subgroups of arthritis and cardiovascular disease patients.

RESULTS

Among whites, all 5 HRQOL measures were significantly associated with the lowest individual socioeconomic status, and 4 HRQOL measures were associated with the lowest community socioeconomic status (MCS being the exception). Among African Americans, 4 HRQOL measures were significantly associated with the lowest individual socioeconomic status and the lowest community socioeconomic status (PCS being the exception). Arthritis and cardiovascular disease subgroup analyses showed generally analogous findings.

CONCLUSION

Better HRQOL measures generally were associated with low levels of community poverty and high levels of education, emphasizing the need for further exploration of factors that influence health.

Propensity for intimate partner abuse and workplace productivity: why employers should care

It has been demonstrated that intimate partner violence (IPV) victimization is costly to employers, but little is known about the economic consequences associated with employing perpetrators. This study investigated propensity for partner abuse as a predictor of missed work time and on-the-job decreases in productivity among a small sample of male employees at a state agency (N=61). Results suggest that greater propensity for abusiveness is positively associated with missing work and experiencing worse productivity on the job, controlling for level of education, income, marital status, age, and part-time versus full-time employment status. Additional research could clarify whether IPV perpetration is a predictor of decreased productivity among larger samples and a wider variety of workplace settings. Employers and IPV advocates should consider responding to potential IPV perpetrators through the workplace in addition to developing victim-oriented policies and prevention initiatives.

Patterns of health-related quality of life and patterns associated with health risks among Rhode Island adults

Background

Health-related quality of life (HRQOL) has become an important consideration in assessing the impact of chronic disease on individuals as well as in populations. HRQOL is often assessed using multiple indicators. The authors sought to determine if multiple indicators of HRQOL could be used to characterize patterns of HRQOL in a population, and if so, to examine the association between such patterns and demographic, health risk and health condition covariates.

Methods

Data from Rhode Island's 2004 Behavioral Risk Factor Surveillance System (BRFSS) were used for this analysis. The BRFSS is a population-based random-digit-dialed telephone survey of adults ages 18 and older. In 2004 RI's BRFSS interviewed 3,999 respondents. A latent class regression (LCR) model, using 9 BRFSS HRQOL indicators, was used to determine latent classes of HRQOL for RI adults and to model the relationship between latent class membership and covariates.

Results

RI adults were categorized into four latent classes of HRQOL. Class 1 (76%) was characterized by good physical and mental HRQOL; Class 2 (9%) was characterized as having physically related poor HRQOL; Class 3 (11%) was characterized as having mentally related poor HRQOL; and Class 4 (4%) as having both physically and mentally related poor HRQOL. Class 2 was associated with older age, being female, unable to work, disabled, or unemployed, no participation in leisure time physical activity, or with having asthma or diabetes. Class 3 was associated with being female, current smoking, or having asthma or disability. Class 4 was associated with almost all the same predictors of Classes 2 and 3, i.e. older age, being female, unable to work, disabled, or unemployed, no participation in leisure time physical activity, current smoking, with having asthma or diabetes, or with low income.

Conclusion

Using a LCR model, the authors found 4 distinct patterns of HRQOL among RI adults. The largest class was associated with good HRQOL; three smaller classes were associated with poor HRQOL. We identified the characteristics of subgroups at higher-risk for each of the three classes of poor HRQOL. Focusing interventions on the high-risk populations may be one approach to improving HRQOL in RI.

Clustering of cardiovascular disease risk factors and health-related quality of life among US adults

OBJECTIVE

To assess the association of clusters of multiple cardiovascular disease (CVD) risk factors with health-related quality of life (HRQOL) among US adults aged 18 years or older in 2003.

METHODS

Data from the 2003 Behavioral Risk Factor Surveillance System were analyzed. The four HRQOL questions developed by the Centers for Disease Control and Prevention were used. The CVD risk factors included diabetes, hypertension, high cholesterol, obesity, and current smoking.

RESULTS

The adjusted odds ratios of having four or more CVD risk factors were 14.0 (95% confidence interval [CI] 12.4-16.0) for poor or fair health, 6.4 (95% CI 5.6-7.3) for 14 or more physically unhealthy days, 4.8 (95% CI 4.2-5.6) for 14 or more mentally unhealthy days, and 8.0 (95% CI6.8-9.3) for 14 or more impaired activity days compared to having none of the five risk factors. A greater number of CVD risk factors was significantly associated with an increasing likelihood of having poor or fair health (P(1) < 0.0001 for linear trend, P(2) < 0.0001 for quadratic trend), 14 or more physically unhealthy days (P(1) < 0.0001, P(2) < 0.0001), 14 or more mentally unhealthy days (P(1) < 0.0001, P(2) = 0.02), and 14 or more impaired activity days (P(1) < 0.0001, P(2) < 0.0001).

CONCLUSIONS

A greater number of multiple CVD risk factors may be associated with more detrimental impairment of HRQOL. Preventing or reducing the clustering of multiple CVD risk factors to improve HRQOL is needed among adults.

Estimating EuroQol EQ-5D scores from Population Healthy Days data

BACKGROUND

Preference-based assessments of population health, which may be used for cost-utility analyses, are lacking for most states and communities. With adequate population data, preference-based values can be estimated from non-preference-based health-related quality of life (HRQOL) data. This study estimates scores on the EuroQol EQ-5D, a preference-based measure, from the Healthy Days

MEASURES

METHODS

No data set from the US population asks both the Healthy Days and EQ-5D questions for the same respondents. Therefore, estimates for EQ-5D scores were obtained indirectly by matching cumulative distributions of the 2 measures. These distributions were estimated from the 2000- 2002 Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditure Panel Survey (MEPS). The validity of estimates was examined by comparing the mean estimated and observed scores across particular population subgroups. A simulation study was conducted to compare the performance of the proposed method to the regression method.

RESULTS

The overall mean observed EQ-5D index was 0.871 and the mean estimated EQ-5D index was 0.872. In the majority of examined subgroups, the mean scores demonstrated a good match according to sociodemographic variables and health-related conditions and, with the exception of the most impaired health states, the differences tended to be less than 0.04.

CONCLUSIONS

This study provided preliminary estimates of EQ-5D scores from the Healthy Days Measures and demonstrated acceptable validity of the estimates. Because the Healthy Days Measures have been included in many state and local surveys, preliminary cost-utility analyses and determination of burden of disease might be able to be conducted at the national, state, and community levels as well as over time.

Women's childhood and adult adverse experiences, mental health, and binge drinking: the California Women's Health Survey

BACKGROUND

This study examined sociodemographic, physical and mental health, and adult and childhood adverse experiences associated with binge drinking in a representative sample of women in the State of California.

MATERIALS AND METHODS

Data were from the 2003 to 2004 (response rates of 72% and 74%, respectively) California Women's Health Survey (CWHS), a population-based, random-digit-dial annual probability survey sponsored by the California Department of Health Services. The sample was 6,942 women aged 18 years or older.

RESULTS

The prevalence of binge drinking was 9.3%. Poor physical health, and poorer mental health (i.e., symptoms of PTSD, anxiety, and depression, feeling overwhelmed by stress), were associated with binge drinking when demographics were controlled, as were adverse experiences in adulthood (intimate partner violence, having been physically or sexually assaulted, or having experienced the death of someone close) and in childhood (living with someone abusing substances or mentally ill, or with a mother vicimized by violence, or having been physically or sexually assaulted). When adult mental health and adverse experiences were also controlled, having lived as a child with someone who abused substances or was mentally ill was associated with binge drinking. Associations between childhood adverse experiences and binge drinking could not be explained by women's poorer mental health status in adulthood.

CONCLUSION

Identifying characteristics of women who engage in binge drinking is a key step in prevention and intervention efforts. Binge drinking programs should consider comprehensive approaches that address women's mental health symptoms as well as circumstances in the childhood home.

Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the United States with asthma, 2006

BACKGROUND

Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma.

METHODS

We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma).

RESULTS

Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety.

CONCLUSION

This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.

Health-related quality of life and hypertension status, awareness, treatment, and control: National Health and Nutrition Examination Survey, 2001--2004

OBJECTIVE

We examined health-related quality of life measures by hypertension status, awareness, treatment, and control.

METHODS

Five unfavorable health-related quality of life measures were analyzed among 8303 adults aged 20 years or older who participated in the 2001--2004 National Health and Nutrition Examination Survey. Multivariable logistic regression analyses examined differences in health-related quality of life with adjustment for age, race, sex, healthcare coverage, and other medical conditions.

RESULTS

The 30% of respondents with hypertension were more likely to report fair or poor health status (adjusted odds ratio 1.72, 95% confidence interval 1.44-2.05), 14 or more unhealthy days in the past 30 days (1.23, 1.06-1.43), 14 or more physically unhealthy days (1.39, 1.15-1.67), and 14 or more activity-limited days (1.55, 1.17-2.04) than those without hypertension. Among adults with hypertension, the 73.2% who were aware of their condition were more likely to report fair or poor health status (2.19, 1.54-3.12), 14 or more unhealthy days (1.53, 1.12-2.09), 14 or more physically unhealthy days (1.49, 1.10-2.03), 14 or more mentally unhealthy days (1.70, 1.05-2.75), and 14 or more activity-limited days (2.38, 1.39-4.05) than those who were unaware. Among those aware they had hypertension, 14 or more physically unhealthy days (0.50, 0.28-0.90) was associated with current treatment. Health-related quality of life measures did not differ by blood pressure control status.

CONCLUSIONS

Having hypertension and being aware of it was related to lower health-related quality of life. Antihypertensive medication was associated with more physically unhealthy days, while there were no differences in health-related quality of life by control status. Further study is needed to examine these differences including: disease severity, sex and racial/ethnic differences, comorbidities not examined, and impact of health-related quality of life and its changes on outcomes.

Use of complementary and alternative therapies in community-dwelling older adults

OBJECTIVES

Although complementary and alternative medicine (CAM) use is becoming increasingly prevalent in the United States, knowledge regarding complementary and alternative therapy use in older adults is limited. The purposes of this study were to (1) assess the prevalence and patterns of CAM use in a probability-based sample of older adults; (2) describe the characteristics of older CAM users; and (3) identify factors associated with complementary and alternative medicine use/nonuse.

METHODS

A cross-sectional survey design was used. An age-stratified sample of community-dwelling adults ages>or=65 (N=1200) was randomly selected from the Minnesota Driver's License/Identification Tape using names from the Twin Cities seven-county metropolitan area. The mailed questionnaire included items on demographics, health status, health care utilization, CAM modality use, reasons for use, costs, and complementary and alternative therapy use satisfaction. Descriptive statistics, chi-square tests, and regression analysis were performed.

RESULTS

Overall, 62.9% (N=445) of the respondents reported use of one or more complementary and alternative medicine modalities with an average of three modalities (SD+/-1.9, range 1-11). The top five CAM modalities used were nutritional supplements (44.3%), spiritual healing/prayer (29.7%), megavitamins (28.3%), herbal supplements (20.7%), and chiropractic (17.8%). Maintaining health and treating a health condition were the primary reasons for CAM use. The most common conditions treated were arthritis (44.4%) and chronic pain (23.5%). Demographic variables were not significantly different between CAM users and nonusers. CAM users reported more unhealthy days than nonusers did. Overall satisfaction with CAM use was high (80%). Symptoms of a health problem and desire for personal control over health motivated CAM use. The main barriers to CAM use were lack of reason to use and knowledge about CAM. Only 53% of users disclosed CAM use to their primary care providers.

CONCLUSIONS

CAM use is common in older adults, especially those with health problems. The widespread use of oral supplements combined with not disclosing CAM use to primary care providers is a concern.

The associations between life satisfaction and health-related quality of life, chronic illness, and health behaviors among U.S. community-dwelling adults

The primary purpose of this article was to examine the associations between life satisfaction level and health-related quality of life (HRQOL), chronic illness, and adverse health behaviors among adults in the U.S. and its territories. Data were obtained from the 2005 Behavioral Risk Factor Surveillance System, an ongoing, state-based, random-digit telephone survey of the noninstitutionalized U.S. population aged >or=18 years. An estimated 5.6% of U.S. adults (about 12 million) reported that they were dissatisfied/very dissatisfied with their lives. As the level of life satisfaction decreased, the prevalence of fair/poor general health, disability, and infrequent social support increased as did the mean number of days in the past 30 days of physical distress, mental distress, activity limitation, depressive symptoms, anxiety symptoms, sleep insufficiency, and pain. The prevalence of smoking, obesity, physical inactivity, and heavy drinking also increased with decreasing level of life satisfaction. Moreover, adults with chronic illnesses were significantly more likely than those without to report life dissatisfaction. Notably, all of these associations remained significant after adjusting for sociodemographic characteristics. Our findings showed that HRQOL and health risk behaviors varied with level of life satisfaction. As life satisfaction appears to encompass many individual life domains, it may be an important concept for public health research.

Health-related quality of life and health behaviors by social and emotional support. Their relevance to psychiatry and medicine

BACKGROUND

Social and emotional support is an important construct, which has been associated with a reduced risk of mental illness, physical illness, and mortality. Despite its apparent relevance to health, there have been no recent state or national population-based U.S. studies regarding social and emotional support. In order to better address this issue, we examined health-related quality of life (HRQOL) and health behaviors by level of social and emotional support in community-dwelling adults in the United States and its territories.

METHODS

Data were obtained from the Behavioral Risk Factor Surveillance System, an ongoing, state-based, random digit telephone survey of the noninstitutionalized U.S. population aged > or =18 years. In 2005, one social and emotional support question, four HRQOL questions, two disability questions, one life satisfaction question, and four health behavior questions were administered in the 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. An additional five HRQOL questions were administered in two states.

RESULTS

An estimated 8.6% of adults reported that they rarely/never received social and emotional support; ranging in value from 4.2% in Minnesota to 12.4% in the U.S. Virgin Islands. As the level of social and emotional support decreased, the prevalence of fair/poor general health, dissatisfaction with life, and disability increased, as did the mean number of days of physical distress, mental distress, activity limitation, depressive symptoms, anxiety symptoms, insufficient sleep, and pain. Moreover, the prevalence of smoking, obesity, physical inactivity, and heavy drinking increased with decreasing level of social and emotional support. Additionally, the mean number of days of vitality slightly decreased with decreasing level of social and emotional support; particularly between those who always/usually received social and emotional support and those who sometimes received support.

CONCLUSIONS

These findings indicate that the assessment of social and emotional support is highly congruent with the practice of psychiatry. Assessment of social and emotional support, both in psychiatric and medical settings, may identify risk factors germane to adverse health behaviors, and foster interventions designed to improve the mental and physical health of at risk segments of the population.

A psychosocial self-management program for epilepsy: a randomized pilot study in adults

OBJECTIVE

The goal of the work described here was to develop and pilot a theoretically based self-management intervention in adults with epilepsy.

METHODS

A randomized, controlled trial examined intervention effectiveness of a 6-week psychosocial intervention designed to improve self-efficacy and quality of life for 61 adults with diagnosed epilepsy. Measures included the Quality of Life in Epilepsy-89 inventory (QOLIE-89), the Washington Psychosocial Seizure Inventory (WPSI), a locus of control scale (LOC), and the Epilepsy Self-Efficacy Scale-2000 (ESES). Group differences were examined between groups using analysis of covariance.

RESULTS

There was a significant improvement in the QOLIE-89 Role Limitations-Emotional score in the treatment group at follow-up, but no significant differences in overall quality of life. Strong and significant correlations were observed between outcome measures.

CONCLUSION

Although the intervention had little effect on improving overall quality of life, we observed promising trends in postintervention group comparisons linking self-efficacy and other psychosocial factors with quality of life. Intervention material can be modified for stage-based behavior change and retested in another study.

Adverse health effects of low levels of perceived control in Swedish and Russian community samples

Background

This cross-sectional study of two middle-aged community samples from Sweden and Russia examined the distribution of perceived control scores in the two populations, investigated differences in individual control items between the populations, and assessed the association between perceived control and self-rated health.

Methods

The samples consisted of men and women aged 45–69 years, randomly selected from national and local population registers in southeast Sweden (n = 1007) and in Novosibirsk, Russia (n = 9231). Data were collected by structured questionnaires and clinical measures at a visit to a clinic. The questionnaire covered socioeconomic and lifestyle factors, societal circumstances, and psychosocial measures. Self-rated health was assessed by standard single question with five possible answers, with a cut-off point at the top two alternatives.

Results

32.2 % of Swedish men and women reported good health, compared to 10.3 % of Russian men and women. Levels of perceived control were also significantly lower in Russia than in Sweden and varied by socio-demographic parameters in both populations. Sub-item analysis of the control questionnaire revealed substantial differences between the populations both in the perception of control over life and over health. Logistic regression analysis revealed that the odds ratios (OR) of poor self-rated health were significantly increased in men and women with low perceived control in both countries (OR between 2.61 and 4.26).

Conclusion

Although the cross-sectional design does not allow causal inference, these results support the view that perceived control influences health, and that it may mediate the link between socioeconomic hardship and health.

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS

OBJECTIVES

We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS.

METHODS

Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive.

RESULTS

At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables.

CONCLUSIONS

Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.

Prevalence of Active Epilepsy and Health-Related Quality of Life among Adults with Self-Reported Epilepsy in California: California Health Interview Survey, 2003

PURPOSE

To examine the prevalence of self-reported epilepsy and active epilepsy, associated burden of impaired health-related quality of life, risk factors, and access to care in adults with self-reported epilepsy, and those classified as having active epilepsy with and without recent seizures.

METHODS

We analyzed data from adults aged >or=18 years (n = 41,494) who participated in the 2003 California Health Interview Survey (CHIS).

RESULTS

In California, 1.2% of adults reported ever being told they had epilepsy or seizure disorder, and 0.7% were classified as having active epilepsy. About three-fourths of adults with active epilepsy with recent seizures reported fair or poor health status. Adults with active epilepsy with recent seizures reported almost two weeks of poor physical or mental health and activity limitation days compared with two to 4 days per month in those without epilepsy. Among adults with active epilepsy and recent seizures, about one-quarter reported not taking any medicine to control their seizure disorder or epilepsy. About one-third reported physical disability/unable to work compared to a small proportion of the general population. The majority of adults with active epilepsy reported having a regular source of medical care.

CONCLUSION

Our findings highlight the burden of epilepsy among adults in California. CHIS serves as a model demonstrating the value of including questions about epilepsy on public health surveillance systems to ascertain the burden of the disorder and to guide intervention research and public policy to improve HRQOL in people with epilepsy.

Clustering of multiple healthy lifestyle habits and health-related quality of life among U.S. adults with diabetes

OBJECTIVE

We sought to examine the association between clustering of multiple healthy lifestyle habits (HLHs) and health-related quality of life (HRQOL) among adults with diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the representative sample of the civilian, noninstitutionalized U.S. population aged > or = 18 years with diabetes using data from the 2005 Behavioral Risk Factor Surveillance System (n = 16,428). Four HRQOL measures were general health rating, physically unhealthy days, mentally unhealthy days, and impaired activity days. Three HLHs included not smoking, engaging in adequate leisure time physical activity, and consuming five or more servings of fruits and vegetables per day.

RESULTS

The proportion of having 0, 1, 2, and 3 HLHs was 10.5, 44.7, 32.9, and 11.9%, respectively. The age-adjusted prevalence rates of poor or fair health, > or = 14 physically unhealthy days, > or = 14 mentally unhealthy days, and > or = 14 impaired activity days were 43.07, 27.61, 17.22, and 18.87%, respectively. After adjustment for potential confounders and comparison with none of the three HLHs, people with all three HLHs were less likely to report poor or fair health (adjusted odds ratio 0.49 [95% CI 0.33-0.71]), > or = 14 physically unhealthy days (0.56 [0.39-0.80]), > or = 14 mentally unhealthy days (0.35 [0.23-0.55]), or > or = 14 impaired activity days (0.35 [0.23-0.56]).

CONCLUSIONS

Accumulation of multiple HLHs was significantly associated with better HRQOL among people with diabetes.

Epidemiology and consequences of women's revictimization

This study uses Kraemer's approach for nonrandom comorbidity to identify the parameters of revictimization among women, using a diverse, population-based sample. Participants (n = 11,056) are from the California Women's Health Survey. Women were asked about childhood and adult violence and current symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety. Logistic regressions adjusted for age, ethnicity, education, and poverty indicate that women who experienced childhood physical or sexual abuse were 5.8 (95% confidence interval, 5.2-6.4) times more likely to experience adult physical or sexual victimization. Revictimization affected 12% of women, and these women were substantially more likely to report current symptoms of anxiety, depression, and PTSD than women exposed to violence only in childhood or only as an adult. Revictimization is a methodologically distinct concept and is a potent risk factor for adult mental health problems. Prevention should target women exposed to both physical and sexual assault.

Lifestyle behaviors and mental health of American adults

The purpose of this study was to test the hypothesis that individuals reporting healthy lifestyle behaviors would also report better self-rated mental health. Logistic regression analyses were conducted utilizing SUDAAN on the Behavioral Risk Factor Surveillance Survey data set. This descriptive analysis suggests that persons reporting poor mental health were more likely to report unhealthy lifestyle behaviors. This set of findings encourages careful design of experimental studies of empirically based associations of mental health and life style, using psychometrically sound measures. Then public health programs focused on change of health-related behaviors might be more suitably devised.

U.S. State-Level Social Capital and Health-Related Quality of Life: Multilevel Evidence of Main, Mediating, and Modifying Effects

PURPOSE

The aim of this study was to investigate the relation between state-level social capital and adult health-related quality of life (HRQOL) in the United States.

METHODS

Using data from the 2001 Behavioral Risk Factor Surveillance System survey and other surveys and administrative sources, we conducted a two-level, multivariable analysis of 173,236 adults in 48 U.S. states to estimate the associations of state-level social capital (along two scales) with individual-level self-rated general health and the numbers of recent days of poor physical health, poor mental health, and activity limitation.

RESULTS

For each social capital scale, living in a state intermediate or high (vs. low) in social capital was each associated with 10% to 11% lower odds of fair/poor health. Higher state-level social capital also predicted fewer recent days of poor physical and mental health and activity limitation. Differential returns of social capital to HRQOL according to state-level mean income and individual-level age and race/ethnicity were observed. Furthermore, evidence was found compatible with mediation by social capital of income inequality effects on HRQOL.

CONCLUSIONS

This study yields new evidence consistent with protective effects of state-level social capital on individual HRQOL. Promoting social capital may provide a means of improving the health-related quality of life of Americans.

Design of the Coordinated Anxiety Learning and Management (CALM) study: innovations in collaborative care for anxiety disorders

BACKGROUND

Despite a marked increase in the number of persons seeking help for anxiety disorders, the care provided may not be evidence based, especially when delivered by nonspecialists. Since anxiety disorders are most often treated in primary care, quality improvement interventions, such as the Coordinated Anxiety Learning and Management (CALM) intervention, are needed in primary care.

RESEARCH DESIGN

This study is a randomized controlled trial of a collaborative care effectiveness intervention for anxiety disorders.

SUBJECTS

Approximately 1040 adult primary care patients with at least one of four anxiety disorders (generalized anxiety disorder, panic disorder, posttraumatic stress disorder or social anxiety disorder) will be recruited from four national sites.

INTERVENTION

Anxiety clinical specialists (ACSs) deliver education and behavioral activation to intervention patients and monitor their symptoms. Intervention patients choose cognitive-behavioral therapy, antianxiety medications or both in "stepped-care" treatment, which varies according to clinical needs. Control patients receive usual care from their primary care clinician. The innovations of CALM include the following: flexibility to treat any one of the four anxiety disorders, co-occurring depression, alcohol abuse or both; use of on-site clinicians to conduct initial assessments; and computer-assisted psychotherapy delivery.

EVALUATION

Anxiety symptoms, functioning, satisfaction with care and health care utilization are assessed at 6-month intervals for 18 months.

CONCLUSION

CALM was designed for clinical effectiveness and easy dissemination in a variety of primary care settings.

Changes in symptoms and health-related quality of life in a nationally representative sample of adults in treatment for HIV

Patient-centered measures of functioning and well-being are needed to monitor and improve health for HIV-infected persons. We estimated the associations between HRQOL and symptoms over time in HIV-infected persons, adjusting for demographic and clinical characteristics using a longitudinal study of a nationally representative cohort of 2267 patients in care for HIV infection surveyed in 1996 and again in 1998. We used two global measures of HRQOL (overall health and overall quality of life) scored to have a mean of 50 and standard deviation of 10 in the sample. The total number of symptoms decreased (-1.29, p<0.001 for the difference), and overall health (1.09, p<0.001 for the difference) and overall quality of life (1.31, p<0.001 for the difference) improved over the period. Controlling for baseline symptoms and HRQOL, each additional symptom at follow-up (B=-1.14, p<0.001) was associated with worsened overall health and worsened overall quality of life (B=-0.95, p<0.001). The association of two additional symptoms with lower global HRQOL was similar in magnitude to the effect of having significant depressive symptoms or the diagnosis of AIDS. In conclusion, among HIV-infected patients, symptoms are significantly related to HRQOL over time. The functioning and well-being of patients with HIV is inextricably linked to the symptoms they experience.

Black-white differences in health-related quality of life among older adults

Very little information exists on racial differences in quality of life among older adults. In this paper, we examine black-white differences in health-related quality of life (HRQOL) and identify factors that may account for these differences. The participants were 5,986 community-dwelling persons age 65+ (62% black at baseline) from the Chicago Health and Aging Project. Poor HRQOL was defined as having 14 or more self-reported physically or mentally unhealthy days over the past 30 days. A higher proportion of blacks (11.0%) than whites (9.7%) reported poor HRQOL. After adjusting for age and sex, blacks had increased odds of reporting poor HRQOL compared with whites (odds ratio [OR] = 1.72; 95% CI: 1.50-1.98). The black-white differences in HRQOL tended to increase with age (p < 0.05) and were greater among females (p < 0.05). Lifetime socioeconomic status, summary measures of medical conditions, and cognitive function accounted for most of the black-white difference (OR = 1.06; 95% CI: 0.89-1.27). Our results suggest that racial differences in HRQOL are associated with the combined effects of social disadvantage, poor physical health, and lower cognitive function.

Starting Early: Promoting the Mental Health of Women and Girls Throughout the Life Span

The importance of mental health in the promotion of lifelong health among men and women alike cannot be overstated. However, mental health remains under-addressed within general public health and community health programs. In this report, we focus primarily on the mental health of women and discuss risk factors that can affect the well-being of women throughout the life span. The literature reviewed demonstrates a strong relationship between social and environmental risk factors, such as abuse and family dysfunction in childhood, to health risk behaviors and poor mental health in adulthood. We concluded that adverse childhood experiences (ACEs) and poor adult mental health could contribute to cycles of intergenerational transmission of risks leading to poor mental and physical health in children of ACEexposed parents. Also, we argue that public health communities can make a difference in women's lifelong health by improving early recognition and treatment of mental health concerns, seeking opportunities to prevent exposures to known risk factors in childhood, and developing targeted parenting interventions. Promoting healthy psychological states and coping mechanisms before, during, and after exposure to adverse events throughout life is also critical. Perhaps such efforts will help to reduce or even break cycles of risk exposure specifically for women and their children. Finally, existing prevention activities and opportunities for promoting the mental health of girls and women are discussed. Ultimately, this report challenges the women's health and public health communities to take action because mental health can have a serious impact on lifelong well-being.

Health-related quality of life, health risk behaviors, and disability among adults with pain-related activity difficulty

OBJECTIVES

We examined the association between pain-related activity difficulty (PRAD) in the past 30 days and health-related quality of life, health behaviors, disability indices, and major health impairments in the general US population.

METHODS

We obtained data from 18 states in the 2002 Behavioral Risk Factor Surveillance System, an ongoing, cross-sectional, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged 18 years or older.

RESULTS

Nearly one quarter of people in the 18 states and the District of Columbia reported at least 1 day of PRAD in the past 30 days. PRAD was associated with obesity, smoking, physical inactivity, impaired general health, infrequent vitality, and frequent occurrences of physical distress, mental distress, depressive symptoms, sleep insufficiency, and anxiety symptoms. Moreover, a general dose-response relationship was noted between increased days of PRAD and increased prevalence of impaired health-related quality of life, disability indices, and health risk behaviors.

CONCLUSION

Pain negatively influences various domains of health, not only among clinical populations, but also in the general community, suggesting a critical need for the dissemination of targeted interventions to enhance recognition and treatment of pain among adult community-dwellers.