Putting Wilson and Cleary to the test: analysis of a HRQOL conceptual model using structural equation modeling

Better and Healthier Together? The Mediation Effect of Positive Psychological Capital on the Relationship Between Perceived Social Support and Health-Related Quality of Life Among Older Adults

Objectives: This study aims to investigate the mediating effects of positive psychological capital (both as compound PsyCap and separate resources) in the relationship between social support and the two components of HRQoL: physical and mental health. Method: We conducted the current cross-sectional study on a sample of 319 participants (114 male; 205 female) aged 65 to 90. Results: The results indicated significant positive associations between social support, PsyCap, physical health and mental health. Compound PsyCap fully mediated the relationship between perceived social support and physical/mental health. Hope and optimism positively predicted physical health, while the same PsyCap resources, along with self-efficacy positively predicted mental health. Discussion: The retirees that perceived increased social support presented higher levels of PsyCap, which in turn increased their physical and mental health. Our results highlighted some new explanatory mechanisms regarding the relationships between variables that affect health-related quality of life among older adults.

Quality of life assessment in diabetic patients: validity of the creole version of the EQ-5D-5L in Reunion Island

Introduction

Due to the high prevalence of diabetes and its complications, evaluating the patient's quality of life is critical. EQ-5D-5L is a valid tool for assessing health-related quality of life (HRQOL) in chronic diseases, including diabetes. However, no psychometric measures have been validated in a Creole-speaking population. Therefore, this study aimed for the first time to validate and cross-culturally adapt Creole and French versions of EQ-5D-5L on Type II diabetes patients in Reunion Island.

Materials and methods

The Creole translation and cross-cultural adaptation process were based on the EUROQOL methods. Internal consistency and construct validity were determined using confirmatory factor analysis (CFA) of EQ-5D-5L for both versions. CFA model for HRQOL and global fit measures were calculated based on the EQ-5D-5L items using the maximum likelihood (ML) method.

Results

From November 2016 to October 2017, 148 patients were included in the Creole group and 152 in the French group. EQ-5D-5L measures were unidimensional for both versions. Cronbach's coefficient alpha was 0.76 for the Creole version and 0.81 for the French version in CFA models. The root mean square error of approximation (RMSEA) was 0.06 for the Creole version and 0.02 for the French version. The Comparative Fit Index (CFI) was closer to 1 for both versions. CFA models for both the Creole and French versions fit the data adequately.

Discussion

Overall, our findings provided evidence that both the Creole and French versions of EQ-5D-5L are suitable for assessing HRQOL in diabetes patients in Reunion Island. However, further research could be done to investigate French-Creole differences concerning the perception of health status, and a cultural adaptation of the French version will be considered.

Health-Related Quality of Life in People Living With HIV With Cognitive Symptoms: Assessing Relevant Domains and Associations

This study aimed to validate and assess a comprehensive set of illness-specific health-related quality of life (HRQL) domains in people living with HIV (PLWH) with cognitive symptoms. One hundred and three HIV patients with cognitive symptoms (n = 93 male, 90.3%) were identified from two UK HIV clinics and complete a series of validated scales measuring seven HRQL domains identified as important to HRQL by PLWH with cognitive impairment. These included: physical functioning, cognition, social connectedness, self-concept, HIV stigma, acceptance of and perceived control over cognitive health, and physical and mental health and wellbeing. Exploratory factor analysis confirmed that domain total scores loaded onto one main factor, representing HRQL. Scale cut-off scores revealed a significant proportion of patients scored outside the normal range on single domains (between 26.2% and 79.6%), and many patients on multiple domains (40.8% on 4 or more domains). We found evidence of poor HRQL across domains in the majority of PLWH with cognitive symptoms and identified domains driving these experiences. This provides targets for intervention development and clinical action to maintain or improve HRQL in PLWH with cognitive symptoms or impairment.

Personality traits and income inequalities in self-rated oral and general health

The association of low income with poor health is widely recognized, but why some low-income individuals do not experience poor health remains unclear. The aim of this study was to determine whether greater positive personality trait scores modify the association between income and oral and general health-related quality of life (OHRQoL and HRQoL) among a representative sample of the South Australian population. Cross-sectional self-rated questionnaire data from a sample of 3645 adults in 2015-2016 were used for secondary analysis. In four factorial ANOVA models, the main effects, interaction, and effect modification of personality traits [measured using the Ten-Item Personality Inventory (TIPI)] on the association between income and OHRQoL [measured using the Oral Health Impact Profile (OHIP-14)] and HRQoL [measured using the European Quality of Life indicator (EQ-5D-3L)] were assessed. In the low-income group, participants with greater TIPI scale scores had lower means for the OHIP-14 and the EQ-5D-3L (better OHRQoL and HRQoL). Greater emotional stability scores modified the association between low income and HRQoL and OHRQoL. Stronger positive personality traits, such as emotional stability, appear to ameliorate the adverse effect of income inequalities in health.

Tailoring prehabilitation to address the multifactorial nature of functional capacity for surgery

Mounting evidence suggests that recovery begins before the surgical incision. The pre-surgery phase of recovery - the preparation for optimal surgical recovery - can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson & Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualized and coordinated care from medical, nutritional, psychosocial, and exercise services. This article is protected by copyright. All rights reserved.

A philosophical perspective on the development and application of patient-reported outcomes measures (PROMs)

Questionnaires are a common method in healthcare and clinical research to collect self-reported data on patients' behaviour and outcomes rather than the clinician's perspective. As a consequence there is a plethora of questionnaires and rating forms developed to measure a range of concepts such as health-related quality of life and health status. Given that these measures have been developed within a nomothetic paradigm to enhance our understanding of peoples self-perceived health status by translating complex personal feelings and experiences into a simple numeric score, the patient's illness narrative is lost along the way. This commentary discusses the limitations of the nomothetic approach as completion of a questionnaire is a social and contextually orientated activity and that their development is best viewed within the philosophical tradition of pragmatism, based on sound qualitative methods and rigorous psychometric testing. The commentary discusses the philosophical orientation underpinning PROM development and argues the case for a pragmatic epistemology based on a mixed methods research paradigm which goes beyond the current practice of informing the content validity of a PROM in the early phase of its development but to work towards developing a more composite and holistic picture through mixed methods in the interpretation of a patient's PROM score. Therefore, it is argued that the quality of data obtained will be enhanced but, also importantly and rightly places the participant at the centre of the research.

Causal pathways to health-related quality of life in children with juvenile idiopathic arthritis: results from the ReACCh-Out cohort

OBJECTIVE

Structural equation modelling was applied to data from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) cohort to help elucidate causal pathways to decreased health-related quality of life (HRQoL) in children with JIA.

METHODS

Based on published literature and clinical plausibility, a priori models were constructed with explicit root causes (disease activity, treatment intensity) and mediators (pain, disease symptoms, functional impairments) leading to HRQoL [measured by the Quality of my Life (QoML) scale and the Juvenile Arthritis Quality of Life Questionnaire (JAQQ)] at five disease stages: (i) diagnosis, (ii) 3-9 months after diagnosis, (iii) flare, (iv) remission on medications, (v) remission off medications. Following structural equation modelling, a posteriori models were selected based on data fit and clinical plausibility.

RESULTS

We included 561, 887, 137, 186 and 182 patients at each stage, respectively. In a posteriori models for active disease stages, paths from disease activity led through pain, functional impairments, and disease symptoms, directly or through restrictions in participation, to decreased QoML scores. Treatment intensity had detrimental effects through psychosocial domains; while treatment side effects had a lesser role. Pathways were similar for QoML and JAQQ, but JAQQ models provided greater specificity. Models for remission stages were not supported by the data.

CONCLUSION

Our findings support disease activity and treatment intensity as being root causes of decreased HRQoL in children with JIA, with pain, functional impairments, and participation restrictions being mediators for disease activity; they support psychosocial effects and side effects as being mediators for treatment intensity.

The association between birth weight and proxy-reported health-related quality of life among children aged 5 - 10 years old: A linked data analysis

Background

Birth weight has a substantial effect on children’s cognitive development, physical capability, and emotional development, which in turn impact on Health-Related Quality of Life (HRQoL). Generally, evidence indicates that children born with low birth weight tend to have poorer proxy-reported HRQoL, particularly at school age. However, there is limited evidence on whether variation in HRQoL exists across the entire range of possible birth weights. This study aimed to examine the association between birth weight and proxy-reported HRQoL among children aged 5–10 years old.

Methods

Data from the 1973–78 cohort of the Australian Longitudinal Study on Women’s Health were linked with state-based Perinatal Data Collections and the Mothers and their Children’s Health study for 1,589 mothers and 2,092 children aged 5 − 10 years old. Generalized estimating equations were used to model the association between birth weight and proxy-reported HRQoL measured by the Pediatric Quality of Life Inventory 4.0. Results are presented as odds ratios with 95 % confidence intervals.

Results

In this study, 15.61 % of children were at risk of impaired proxy-reported HRQoL. Each 100-gram increase in birth weight was associated with a 3 % reduction in the odds of impaired HRQoL (AOR = 0.97; 95 % CI: 0.94, 0.99). However, there was only limited evidence of an effect within the normal birth weight range (AOR = 0.97; 95 % CI: 0.94, 1.01).

Conclusions

The findings indicate that increased birth weight was protective against impaired HRQoL, although there was limited evidence of variability within the normal birth weight range. This study contributes to the existing literature by not only emphasizing the impact of low birth weight on children’s health and health-related outcomes but also by focusing on the variability within the normal birth weight range, particularly in a setting where low birth weight is less prevalent.

Validity and reliability of the Turkish version of the Child Perceptions Questionnaire 8-10

BACKGROUND

A reliable measurement tool is needed to gain more knowledge about Turkish children's oral health status that affects the quality of life.

AIM

To develop a translated version of CPQ_8-10 into Turkish language and evaluate its reliability, validity, and reproducibility.

DESIGN

The intra-class correlation coefficient (ICC) was used for the test-retest reliability in the 50 children. For the internal consistency, 418 children aged 8-10 years were evaluated using Cronbach's alpha Coefficient. Construct validity and discriminant validity were calculated using Spearman's correlation analysis, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) was also employed.

RESULTS

The mean CPQ_8-10 score was 13.3 ± 9.2. The translated Turkish version of CPQ_8-10 showed high test-retest reliability (ICC = 0.90) and internal consistency (Cronbach's alpha = 0.82). A statistically significant correlation was observed between the scores of the CPQ_8-10 and oral health and overall well-being, which revealed good construct validity (r = 0.50; P < .001 and r = 0.47; P < .001, respectively). Seven factors identified from EFA were statistically verified using CFA. Discriminant validity was supported by significant differences between CPQ and OHIS scores (P < .001).

CONCLUSIONS

The translated version of CPQ_8-10 to the Turkish language is reliable, valid, and reproducible for use in the Turkish culture in this age group.

Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France

BACKGROUND

Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help.

DESIGN AND INTERVENTION

We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months.

PARTICIPANTS

We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less.

OUTCOMES

We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries.

CONCLUSIONS

We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.

Quality of life in people living with HIV-associated neurocognitive disorder: A scoping review study

Quality of life (QoL) is recognized as an essential end point in the disease management of chronic conditions such as HIV with calls to include good QoL as a ‘fourth 90’ in the 90-90-90 testing and treatment targets introduced by World Health Organization in 2016. Cognitive impairments impact a broad spectrum of experiences and are a common issue effecting people living with HIV (PLWH). Despite this, few studies have examined QoL in PLWH who also have a cognitive disorder. This study aimed to synthesize and describe what is known about QoL in those living with HIV-associated neurocognitive disorders (HAND). A scoping review of peer-reviewed literature was conducted to identify how QoL has been investigated and measured in PLWH with HAND, and how PLWH with HAND report and describe their QoL. We searched PsychInfo, Medline, Scopus, and Web of Science along with hand-searching reference lists from relevant studies found. Included studies were those published in English after 1^st January 2003 which included PLWH with cognitive impairment not due to other pre-existing conditions. Fifteen articles met criteria for inclusion. Two studies measured QoL as a primary aim, with others including QoL assessment as part of a broader battery of outcomes. The MOS-HIV and SF-36 were the most commonly used measures of overall QoL, with findings generally suggestive of poorer overall QoL in PLWH with HAND, compared to PLWH without cognitive impairment. Studies which examined dimensions of QoL focused exclusively on functionality, level of independence, and psychological QoL domains. There is a considerable dearth of research examining QoL in PLWH with HAND. The initiatives which advocate for healthy aging and improved QoL in PLWH must be extended to include and understand the experiences those also living with cognitive impairment. Research is needed to understand the broad experiential impacts of living with these two complex, chronic conditions, to ensure interventions are meaningful to patients and potential benefits are not missed.

Analysis of quality of life in breast cancer survivors using structural equation modelling: the role of spirituality, social support and psychological well-being

BACKGROUND

To explore and characterize the inter-relationship between psychological well-being, spirituality, social support, comorbidity, demographic and lifestyle factors and quality of life (QoL).

METHODS

This cross-sectional study was conducted with 305 breast cancer survivors in northern Iran in 2017. The demographic and socio-economic data and physical activity were measured with a standard questionnaire. The standard European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL scale, a system-of-belief inventory questionnaire, the social support scale, the short form of the Hospital Anxiety and Depression Scale and the fatigue severity scale (FSS) were used in data collection. In structural equation modelling analysis, we used the maximum likelihood procedure to estimate the direct and indirect effects of relevant factors on QoL.

RESULTS

The median age (quartile 1 [Q1], quartile 3 [Q3]) of patients was 50 y (43, 55). The psychological factors designated by anxiety, depression and FSS had a negative significant direct effect on QoL (β=-0.62). Spirituality has a positive direct effect (β=0.089) but a negligible indirect effect (β=0.020) on QoL, while the direct association of social support was almost negligible.

CONCLUSIONS

The findings emphasized the unifying structure of the determinants of QoL and the mediating negative association of psychological factors with QoL. Thus the supportive education efforts should focus on improving psychological well-being along with standard treatment in breast cancer survivors.

Quality of life assessment in patients with heart failure: validity of the German version of the generic EQ-5D-5L™

BACKGROUND

Chronic heart failure patients typically suffer from tremendous strain and are managed mainly in primary care. New care concepts adapted to the severity of heart failure are a challenge and need to consider health-related quality of life aspects. This is the first psychometric validation of the German EQ-5D-5L™ as a generic instrument for assessing health-related quality of life (HRQOL) in a primary care heart failure patient sample.

METHODS

Confirmatory factor analysis (CFA) was performed on the baseline EQ-5D-5L™ data from the RECODE-HF study (responses to all items from n = 3225 of 3778 patients). Basic CFA models for HRQOL were calculated based on the EQ-5D-5L™ items using the maximum likelihood (ML) and the asymptotic distribution-free method. In an extended CFA, physical activity and depression were added. The basic CFA ML model was verified for the reduced number of cases of the extended CFA model (n = 3064). In analyses of variance the association of the EQ-5D-5L™ visual analogue scale (VAS) and both the German and the British EQ-5D-5L™ crosswalk index with the SF-36 measure of general health were examined. The discriminant validity was analysed using Pearson's chi-squared tests applying the New York Heart Association classification, for the VAS and indices analyses of variance were calculated.

RESULTS

In the basic CFA models the root mean square error of approximation was 0.095 with the ML method, and 0.081 with the asymptotic distribution-free method (Comparative Fit Index > 0.90 for both). Physical activity and depression were confirmed as influential factors in the extended model. The VAS and indices were strongly associated with the SF-36 measure of general health (partial eta-squared 0.525/0.454/0.481; all p <  0.001; n = 3155/3210/3210, respectively), also for physical activity and depression when included together (partial eta-squared 0.050, 0.200/0.047, 0.213/0.051 and 0.270; all p <  0.001; n = 3015/n = 3064/n = 3064, respectively). The discriminant validity analyses showed p-values < 0.001 and small to moderate effect sizes for all EQ-5D-5L™ items. Analyses of variance demonstrated moderate effect sizes for the VAS and indices (0.067/0.087/0.084; all p <  0.001; n = 3110/3171/3171).

CONCLUSION

The German EQ-5D-5L™ is a suitable method for assessing HRQOL in heart failure patients.

Comparative Longitudinal Study on the Impact Root Canal Treatment and Other Dental Services Have on Oral Health-related Quality of Life Using Self-reported Health Measures (Oral Health Impact Profile-14 and Global Health Measures)

INTRODUCTION

The literature assessing quality of life for subjects who have undergone root canal treatment (RCT) is scarce. The aim of this study was to compare the effect of RCT with other dental services (exodontia, restorative, prosthodontics, periodontics, and negative controls [preventative and scale and clean]) on oral health-related quality of life.

METHODS

A random sample of 3000 adults aged 30-61 years was obtained from the Australian electoral roll in 2009. Data were collected through questionnaires, dental service logbooks, and treatment receipts. The impact their dentition had at baseline and the 2-year follow-up for the Oral Health Impact Profile-14 and the self-rated dental health score followed by "global transition statement of change" (GTSC) was assessed. Binary regression models were used to compare the outcomes.

RESULTS

Responses were collected from 1096 respondents (response rate = 36.5%). After adjustment (for age, sex, household income, and reason for visit), the RCT group had significant differences (P ≤ .05) to other dental services at the 2-year follow-up using the Oral Health Impact Profile-14 (odds ratio = 0.34; 95% confidence interval, 0.12-0.96) and GTSC (odds ratio = 0.29; 95% confidence interval, 0.09-0.88) but not with individual treatment groups. Using the self-rated dental health score/GTSC, only the prosthodontic treatment group had a significant difference to the RCT group at baseline, whereas the negative controls (P ≤ .01) had significant differences to the RCT group with the odds for improved health 5 times higher, at 2-year follow-up.

CONCLUSIONS

The RCT group presented with similar oral health-related quality of life when compared with the other individual treatment groups; however, they consistently reported poorer oral health outcomes when the negative controls were included.

Self-management and psychological resilience moderate the relationships between symptoms and health-related quality of life among patients with hypertension in China

PURPOSE

To examine whether and how self-management and psychological resilience could moderate the relationships between symptoms and health-related quality of life (HRQoL) among hypertensive patients in China.

METHODS

This was a cross-sectional study of 220 participants recruited from January to May, 2018. Demographic and clinical information were obtained from medical records and by patient interview. The Chinese version of 17-item Hypertension-specific Symptom Scale, 21-item Self-Management Scale, and 10-item Connor-Davidson Resilience Scale (CD-RISC-10) as well as Short Form 12 Health Survey (SF-12) were used to collect information in this research. The moderation effects of self-management and psychological resilience were explored using the PROCESS macro for SPSS.

RESULTS

Among all patients, 128 (58.2%) were female, 106 (48.2%) had a bachelor degree or higher, and 133 (60.5%) had moderate to severe Charlson Comorbidity Index. Both self-management and psychological resilience were negatively correlated to symptoms (r = - 0.259, p < 0.001; r = - 0.282, p < 0.001) but positively correlated to physical (r = 0.316, p < 0.001; r = 0.344, p < 0.001) and mental (r = 0.273, p < 0.001; r = 0.309, p < 0.001) HRQoL. After controlling for potential covariates, self-management could moderate the associations between symptoms and physical HRQoL (p = 0.041, ΔR² = 0.010), while psychological resilience could moderate the relationships between symptoms and mental HRQoL (p = 0.02, ΔR² = 0.010).

CONCLUSIONS

For hypertension patients, HRQoL is dependent on the severity of symptoms, engagement of self-management behaviors, and psychological resilience, which should be carefully considered when to improve patients' HRQoL by health care providers.

Health-related quality-of-life model in adolescents with different body composition

The purpose of the present study was to develop and evaluate a causal model of health-related quality of life (HRQoL) in adolescents with different body composition. The participants were 209 adolescents (107 women and 102 men) ranging from 10 to 15 years of age. A model based on that proposed by Wilson and Cleary (JAMA 273(1):59-65, 1995) was elaborated. The body composition of the participants was analyzed. They were asked to complete a battery of questionnaires composed of the following factors: biological status (BS; included body mass index and weight), symptomatic psychological status (SPS; included the variables of drive for thinness and food concerns), functional status (FS; composed of physical activity, food consumption estimation, and socioeconomic status), and HRQoL, which included the dimensions of psychological well-being, autonomy and relationship with parents, social support and peers, and the academic environment. Structural equation modeling produced a model, which obtained an adequate fit for the prediction of HRQoL (χ²(38) = 51.88, p = .07; NNFI = 0.97, CFI = 0.98, GFI = 0.95, and RMSEA = 0.04). The main outcome demonstrated the indirect effect of BS (0.44) and SPS (- 0.45) as well as a direct effect of FS (0.21) on HRQoL. In addition, a second path was observed, BS has an indirect effect on FS (0.34) and FS on HRQoL (0.21). These results provide empirical support for the evaluated model.Level of evidence: Level V, Descriptive study.

Correlates and aetiological factors associated with hedonic well-being among an ageing population of US men and women: secondary data analysis of a national survey

OBJECTIVE

To understand the gender-specific factors that uniquely contribute to successful ageing in a US population of men and women, 57-85 years of age. This was achieved through the examination of the correlates of subjective well-being defined by health-related quality of life (HRQoL), across several biological and psychosocial determinants of health.

DESIGN

Cross-sectional study.

SETTING

The National Social Life, Health and Ageing Project (NSHAP), 2010-2011 a representative sample of the US population.

PARTICIPANTS

3377 adults aged 57-85 (1538 men, 1839 women) from the NSHAP.

MAIN OUTCOME MEASURES

The biopsychosocial factors of biological/physiological function, symptom status, functional status, general health perceptions and HRQoL happiness.

METHOD

HRQoL was measured using the NSHAP wave 2 multistage, stratified area probability sample of US households (n=3377). Variable selection was guided by the Wilson and Cleary model (WCM) that classifies health outcomes at five main levels and characteristics.

RESULTS

Our findings indicate differences in biopsychosocial factors comprised in the WCM and their relative importance and unique impact on HRQoL by gender. Women reported significantly lower HRQoL than men (t=3.5, df=3366). The most significant contributors to HRQoL in women were mental health (B=0.31; 0.22, 0.39), loneliness (B=-0.26; -0.35, -0.17), urinary incontinence (B=-0.22; -0.40, -0.05) and support from spouse/partner (B=0.27; 0.10, 0.43) and family B=0.12; 0.03, 0.20). Men indicated mental health (B=0.21; 0.14, 0.29), physical health (B=0.17; 0.10, 0.23), functional difficulties (B=0.38; 0.10, 0.65), loneliness (B=-0.20; -0.26, -0.12), depression (B=-0.36; -0.58, -0.15) and support from friends (B=0.06; 0.10, 0.11) as significant contributors. Those with greater social support had better HRQoL (F=4.22, df=4). Lack of companionship and reliance on spouse/partner were significant HRQoL contributors in both groups.

CONCLUSION

Our findings offer insight into ageing, gender and subjective well-being. The results provide an opportunity to identify biopsychosocial factors to inform interventions to support successful ageing.

Medication Adherence and Diabetes Self-Care Activities Among Patients With Type 2 Diabetes Mellitus

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) is increasing at an alarming rate in developing countries. The accompanying complications of T2DM can be reduced by maintaining a good adherence to medication and self-care activities.

OBJECTIVES

To evaluate medication adherence and self-care behaviors among patients with T2DM.

METHODS

A total of 497 subjects with T2DM were recruited from three hospitals and a government clinic in the state of Selangor, Malaysia. Previously validated scales were used to measure medication adherence (Morisky Medication Adherence Scale) and diabetes self-care activities (Summary of Diabetes Self-Care Activities). Pearson correlation coefficient was used to investigate the relationship between the risk factors and medication adherence. Pearson χ² test of association was used to test significant association.

RESULTS

The mean age of the subjects was 55.5 years. The mean Morisky Medication Adherence Scale score was 5.65 ± 1.97, indicating a moderate adherence level to medication. Among the subjects who had low adherence level, 50.9% were Malays, followed by 34.2% Indians. The Pearson χ² test of association indicated a significant association (P = 0.000) between ethnicity and medication adherence. The subjects had better self-care behaviors in their general diet (mean 5.04 ± 1.88) and poor self-care behaviors in blood sugar testing (mean 2.13 ± 2.34).

CONCLUSIONS

The Malaysians had a moderate medication adherence level, whereas they were nonadherent to blood glucose testing. Emphasis on self-care activities and medication adherence is relevant to improve outcomes in the management of T2DM.

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30: factorial models to Brazilian cancer patients

Objective

To evaluate the psychometric properties of the seven theoretical models proposed in the literature for European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), when applied to a sample of Brazilian cancer patients.

Methods

Content and construct validity (factorial, convergent, discriminant) were estimated. Confirmatory factor analysis was performed. Convergent validity was analyzed using the average variance extracted. Discriminant validity was analyzed using correlational analysis. Internal consistency and composite reliability were used to assess the reliability of instrument.

Results

A total of 1,020 cancer patients participated. The mean age was 53.3±13.0 years, and 62% were female. All models showed adequate factorial validity for the study sample. Convergent and discriminant validities and the reliability were compromised in all of the models for all of the single items referring to symptoms, as well as for the “physical function” and “cognitive function” factors.

Conclusion

All theoretical models assessed in this study presented adequate factorial validity when applied to Brazilian cancer patients. The choice of the best model for use in research and/or clinical protocols should be centered on the purpose and underlying theory of each model.

How non-functioning pituitary adenomas can affect health-related quality of life: a conceptual model and literature review

After treatment for a non-functioning pituitary adenoma (NFA) health-related quality of life (HR-QoL) improves considerably. However, the literature about the normalization of HR-QoL after treatment is inconclusive. Some researchers described a persistently decreased HR-QoL compared to reference data, while others did not. Considering this variety in observed HR-QoL outcomes, the aim of the present review was to provide a literature overview of health outcomes in patients with a NFA, using a conceptual HR-QoL model. A concrete conceptualization of the health outcomes of patients with a NFA can be helpful to understand the observed variety in HR-QoL outcomes and to improve clinical care and guidance of these patients. For this conceptualization, the Wilson and Cleary model was used. This model has a biopsychosocial character and has been validated in several patient populations. In the present review, health outcomes of patients with a NFA were described at each stage of the model e.g. biological and physiological variables, symptom status, functional status, general health perceptions and overall HR-QoL. The Wilson-Cleary model elucidates that elements at each stage of the model can contribute to the impairment in HR-QoL of patients with a NFA, which explains the reported variety in the literature. Furthermore, by applying the model, potential interventions targeting these elements can be identified. While optimal biomedical treatment has always been the focus, it is clearly not sufficient for good HR-QoL in patients with a NFA. Further improvement of HR-QoL should be supported by a pituitary specific care trajectory, including psychosocial care (e.g. self-management training), to beneficially affect characteristics of the patient and the (healthcare) environment, with the utmost goal to optimize HR-QoL in patients after treatment.

A systematic review of the application of Wilson and Cleary health-related quality of life model in chronic diseases

Background

A conceptual model approach to clarify the elements of health-related quality of life (HRQL), their determinants and causal pathways is needed to aid researchers, health practitioners and policy makers in their bid to improve HRQL outcomes in patients. The aim of this systematic review was to appraise empirical evidence on the performance of the Wilson and Cleary Model of HRQL.

Methods

We conducted a search of MEDLINE, Science Direct, PsyARTICLES and CINAHL databases to identify articles that used Wilson and Cleary model to examine HRQL in chronic diseases. A narrative synthesis was employed in the review of the articles.

Results

Evidence supports linkages between adjacent concepts and between non-adjacent concepts of the Wilson and Cleary model indicating that in practice there is a need to examine relationships among constructs - or to consider interventions in terms of - both with and without mediators. Symptoms status has the highest magnitude of relative impact on health-related quality of life.

Conclusion

The Wilson and Cleary model demonstrated good features suitable for evaluating health-related quality of life in chronic diseases.

Testing a model of health-related quality of life in women living with HIV infection

PURPOSE

The purpose of this secondary analysis was to test Ferrans et al.'s (J Nurs Scholarsh 37(4):336-342, 2005) revised model of health-related quality of life (HRQoL) (2005) modified from the Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model on women living with HIV. The primary aim was to test this model, examining the relations among the five central components (biological function, symptoms, functional status, general health perceptions, and HRQoL). The secondary aim was to explore the individual (age, children, race, marital status, education) and environmental (HIV-related stigma, social support) characteristics that may impact the main components of the model.

METHODS

This study employed a cross-sectional correlational design using baseline data from 178 women living with HIV/AIDS who participated in one of the two independent randomized controlled trials designed to enhance HIV medication adherence. Path analysis using structural equation modeling was used to examine the hypothesized multivariate relations proposed in the revised Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model of HRQoL.

RESULTS

While the revised model did not fit, exploratory post hoc modified models with a path from depressive symptoms to overall general health had an adequate model fit. Women with lower depressive symptoms (r = -.457, p < .01), lower HIV-related stigma (r = -.462, p < .01), higher social support (r = .413, p < .01), higher physical functioning (r = .350, p < .01), and higher general health perceptions (r = .537, p < .01) had higher overall HRQoL.

CONCLUSIONS

The results of this study have the potential to assist healthcare professionals in improving HRQoL for women living with HIV/AIDS.

Hearing Loss and Quality of Life (QOL) among Human Immunodeficiency Virus (HIV)-Infected and Uninfected Adults

OBJECTIVE

Research has established that human immunodeficiency virus (HIV) causes hearing loss. Studies have yet to evaluate the impact on quality of life (QOL). This project evaluates the effect of hearing loss on QOL by HIV status.

METHODS

The study participants were from the Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV study (WIHS). A total of 248 men and 127 women participated. Pure-tone air conduction thresholds were collected for each ear at frequencies from 250 through 8000 Hz. Pure-tone averages (PTAs) for each ear were calculated as the mean of air conduction thresholds in low frequencies (i.e., 250, 500, 1000 and 2000 Hz) and high frequencies (i.e., 3000, 4000, 6000 and 8000 Hz). QOL data were gathered with the Short Form 36 Health Survey and Medical Outcome Study (MOS)-HIV instrument in the MACS and WIHS, respectively. A median regression analysis was performed to test the association of PTAs with QOL by HIV status.

RESULTS

There was no significant association between hearing loss and QOL scores at low and high pure tone averages in HIV positive and negative individuals. HIV status, HIV biomarkers and treatment did not change the lack of association of low and high pure tone averages with poorer QOL.

CONCLUSION

Although we did not find a statistically significant association of hearing loss with QOL by HIV status, testing for hearing loss with aging and recommending treatment may offset any presumed later life decline in QOL.

Does the EQ-5D capture the effects of physical and mental health status on life satisfaction among older people? A path analysis approach

PURPOSE

To examine the extent to which EQ-5D utility scores capture the effect of mental and physical health status on life satisfaction (LS) in older adults.

METHODS

Retrospective cohort study of 884 patients aged ≥70 years from 15 general practices in Ireland, including medical records, pharmacy claims, and self-completion questionnaire. Path analysis was used to evaluate the direct and indirect effects of: (1) chronic disease burden (based on medications data); (2) activity limitation (basic and instrumental activities of daily living); (3) anxiety symptoms and; (4) depressive symptoms (Hospital Anxiety and Depression Scale) on LS (Life Satisfaction Index Z), via a utility score based on responses to the EQ-5D scale. Utility scores were calculated using UK time trade-off utility weights. Covariates included age and socioeconomic status.

RESULTS

The final path model fitted the data well (goodness of fit χ² = 7.5, df (7), p = 0.37). The direct effects of chronic disease burden and disability on LS were not statistically significant and were excluded from the final model, indicating that EQ-5D score mediated 100% of the total effect on LS. The direct and indirect effects of anxiety and depression on LS were statistically significant, but the size of the indirect effect was small (4% of the total effect for anxiety and 6% of the total effect for depression).

CONCLUSION

The EQ-5D does not adequately capture the effects of anxiety and depression on LS among older adults, suggesting that it may lead to inaccurate assessments of the effectiveness of interventions in this cohort.

Health-Related Quality of Life During the Menopausal Transition: Testing a Theoretical Model

The purpose of this study was to test the hypothetical model of health-related quality of life (HRQOL) during the menopausal transition. The model was developed to test specific components of the Wilson and Cleary's model for HRQOL. A cross-sectional, correlational study was carried out using self-report questionnaires on a convenience sample of 162 Korean women in the menopausal transition. The model was tested by a path analysis using Analysis of Moment Structure (AMOS) program. The path analysis showed that 5 affecting variables explained 69% of the variance in HRQOL during the menopausal transition. Based on the results, the Wilson and Cleary's model may be useful in explaining HRQOL during the menopausal transition. Symptoms, functional status, and health perceptions mediated the effect of individual and environmental characteristics on HRQOL. However, the results suggest that some paths need to be added or modified in the model. To date, most research using Wilson and Cleary's model has been conducted in the United States, Africa, and Europe (e.g., Austria, Norway, and Spain). This study shows the applicability of the model in Asian people.

Validating the generic quality of life tool "QOL10" in a substance use disorder treatment cohort exposes a unique social construct

Background

Generic quality of life (QoL) instruments provide important measures of self-reported wellbeing that can be compared across healthy and clinical populations. The aim of this analysis is to validate the ten-item QoL instrument “QOL10”, as well as to confirm the validity of the embedded “QOL5” questionnaire and single-item “QOL1” in measuring overall QoL among adults in a substance use disorder treatment study.

Methods

We used exploratory factor analysis and measured internal and convergent validity of the QOL10 against the gold standard measure of the WHOQOL-BREF, in a subsample of 107 participants in a substance use disorder treatment study.

Results

The QOL10 displayed internal and convergent validity to the gold standard measure. Factor analysis revealed a two-factor structure that can be interpreted as “social QoL”, containing items about relationships and social functioning, and “global QoL”, comprised of items about health, working ability, self-evaluation, and an overall QoL estimation.

Conclusions

The QOL10 provides clinically useful and valid measures of social-related QoL and global QoL via two subscales. Interestingly, the QOL10’s social QoL measure, from the current sample, had little relationship to the analyzed groups previously reported to have differential global QoL: social QoL appears to be not only conceptually distinct from global QoL, but also to be less influenced by typical substance- and treatment-specific factors.

The PaArticular Scales - A new outcome measure to quantify the impact of joint contractures on activities and participation in individuals in geriatric care: Development and Rasch analysis

BACKGROUND

Joint contractures are frequent conditions in individuals in geriatric care settings and are associated with activity limitations and participation restrictions. As such, relevant intervention programs should address these aspects, and the effectiveness of such programs should be determined by assessing improvement in activities and participation. However, no patient-centred and psychometrically sound outcome measures for this purpose are available so far.

OBJECTIVES

The objectives of this study were to develop and to validate a new outcome measure, the PaArticular Scales, to quantify activities and participation in older individuals with joint contractures. Specific aims were (A) to operationalize the content of an International Classification of Functioning, Disability and Health-based standard set towards meaningful questions and to combine them to a questionnaire and (B) to assess the psychometric properties of the developed questionnaire, in detail to evaluate test-retest reliability, objectivity, internal consistency reliability and criterion validity.

DESIGN

Operationalization was reached by an expert consensus conference and a subsequent expert Delphi survey. Psychometric properties were assessed in a cross-sectional study.

SETTINGS

Nursing homes, geriatric rehabilitation facilities.

PARTICIPANTS

23 experts (nurses, physicians, physical and occupational therapists) participated in the consensus conference and the Delphi survey. A total of 191 individuals with joint contractures (as confirmed by physician, nurse or physical therapist) between 65 and 102 years, living in nursing homes or as patients in geriatric rehabilitation were enrolled in the cross-sectional study.

METHODS

Rasch Partial Credit Modelling.

RESULTS

The consensus conference and Delphi survey resulted in a questionnaire with 86 items of the International Classification of Functioning, Disability and Health. Test-retest-reliability among those was acceptable (Cohen's weighted kappa: 0.779). The Rasch analysis revealed two independent interval-scaled scales with 24 items for the Activities scale and 11 items for the Participation scale with high internal consistency reliability. Cronbach's alpha was 0.96 for the Activities scale and 0.92 for the Participation scale. Criterion validity was -0.40 and -0.30 for the Activities scale and for the Participation scale, respectively.

CONCLUSIONS

The PaArticular Scales, a new patient-centred and psychometric sound outcome measures to comprehensively assess the impact of joint contractures in geriatric care, are available now. These developed scales will serve as primary outcomes in a scheduled evaluation of a complex intervention to improve participation and quality of life in nursing home residents with joint contractures.

Testing the applicability of a model of oral health-related quality of life

The aim of this study was to test Wilson & Cleary's conceptual model of the direct and mediated pathways between clinical and non-clinical variables in relation to oral health-related quality of life. A random sample of 578 older people was evaluated. Wilson & Cleary's conceptual model was tested using structural equations modeling including: biological variables, symptom status, functional health, oral health perceptions, oral health-related quality of life. Oral health-related quality of life was assessed with the Oral Health Impact Profile-14 (OHIP-14). In the final model, edentulism was negatively correlated to dissatisfaction of appearance of their dental prostheses (r = -0.25). Worse functional status was correlated with poor oral health perception (r = 0.24). Being aged over 68 (r = 0.25), being a female (r = 0.39) and living in rural areas (r = 0.15) had a direct effect on the edentulism. Age had a direct effect on OHIP-14 (r = -0.15). There was an indirect effect of sex on OHIP-14 via functional status (r = 0.12). The present findings partially support Wilson & Cleary's model framework.

Patient experiences of burn scars in adults and children and development of a health-related quality of life conceptual model: A qualitative study

PURPOSE

The aim of this study was to understand the impact of burn scars on health-related quality of life (HRQOL) from the perspective of adults and children with burn scars, and caregivers to inform the development of a conceptual model of burn scar HRQOL.

METHOD

Twenty-one participants (adults and children) with burn scars and nine caregivers participated in semi-structured, face-to-face interviews between 2012 and 2013. During the interviews, participants were asked to describe features about their (or their child's) burn scars and its impact on everyday life. Two coders conducted thematic analysis, with consensus achieved through discussion and review with a third coder. The literature on HRQOL models was then reviewed to further inform the development of a conceptual model of burn scar HRQOL.

RESULTS

Five themes emerged from the qualitative data: 'physical and sensory symptoms', 'impact of burn scar interventions', 'impact of burn scar symptoms', 'personal factors' and 'change over time'. Caregivers offered further insights into family functioning after burn, and the impacts of burn scars and burn scar interventions on family life. In the conceptual model, symptoms (sensory and physical) of burn scars are considered proximal to HRQOL, with distal indicators including functioning (physical, emotional, social, cognitive), individual factors and the environment. Overall quality of life was affected by HRQOL.

CONCLUSION

Understanding the impact of burn scars on HRQOL and the development of a conceptual model will inform future burn scar research and clinical practice.

Apathy is associated with lower mental and physical quality of life in persons infected with HIV

HIV infection is associated with lower health-related quality of life (HRQoL), which is influenced by immunovirological factors, negative affect, neurocognitive impairment, and functional dependence. Although apathy is a common neuropsychiatric sequela of HIV infection, emerging findings regarding its unique role in lower HRQoL have been mixed. The present study was guided by Wilson and Cleary's (1995), model in examining the association between apathy and physical and mental HRQoL in 80 HIV+ individuals who completed a neuromedical examination, neuropsychological assessment, structured psychiatric interview, and a series of questionnaires including the SF-36. Apathy was measured using a composite of the apathy subscale of the Frontal Systems Behavioral Scale and the vigor-activation subscale of the Profile of Mood States. Independent of major depressive disorder, neurocognitive impairment, functional status, and current CD4 count, apathy was strongly associated with HRQoL. Specifically, apathy and CD4 count were significant predictors of physical HRQoL, whereas apathy and depression were the only predictors of mental HRQoL. All told, these findings suggest that apathy plays a unique role in HRQoL and support the importance of assessing and managing apathy in an effort to maximize health outcomes among individuals with HIV disease.

The Colorado Collaborative for Nursing Research: nurses shaping nursing's future

Nurses in the present health care environment have been reduced too often to being providers of safe, competent care rather than quality care. In response, the Institute of Medicine has recommended that nurses become more involved in making changes to the health care system and use data more effectively. If nursing intends to follow these recommendations, the profession needs (a) fresh perspectives to assist in making health care system changes, (b) partnerships between nurse scientists and nurse clinicians to generate and implement data, and (c) capture of the proper value of nursing as distinct from other elements of health care delivery. The Colorado Collaborative for Nursing Research is an effort to meet the recommendations of the Institute of Medicine. The Colorado Collaborative for Nursing Research has a three-arm structure: a research forum where nurse academicians and nurse clinicians can launch collaborative projects; a research support services arm from which nurse collaborators can obtain help with modeling, statistics, writing, and funding; and a data extraction/data sharing mechanism to inform the decision making of nurse leaders.

Oral health impacts on self-rated general and oral health in a cross-sectional study of working age adults

OBJECTIVES

The aims were to assess the joint effects of oral health and general health functional problems on self-ratings of general and oral health among adults.

METHODS

Data were collected from adults aged 30-61 years in Australia by mailed survey in 2009-2010. Self-rated health of 'very good/excellent' was analysed by oral health impact (OHIP-14) and number of health problems (EQ-5D) controlling for socio-demographics.

RESULTS

Responses were collected from n = 1093 persons (response rate = 39.1%). General health self-ratings were higher in the high-income group (prevalence ratio [PR] = 1.06, 1.00-1.12) but lower for those with a higher number of health problems (PR = 0.84, 0.76-0.93). The interaction of health problems with oral health impact indicated that self-rated general health was worst when both the number of health problems and OHIP score were higher. Oral health self-ratings were lower for males (PR = 0.92, 0.87-0.98), those aged 50-61 years (PR = 0.92, 0.85-0.99), for those with more health problems (PR = 0.82, 0.71-0.95) and higher oral health impact scores (PR = 0.54, 0.46-0.64).

CONCLUSIONS

For working age adults, oral health impact was associated with general health for those with more health problems indicating those in worse health suffer more impact from oral health problems.

Definitions of quality of life: what has happened and how to move on

BACKGROUND

Quality of life (QOL) is an important outcome in spinal cord injury (SCI) rehabilitation, but it is unclear how to define and measure it.

OBJECTIVE

The aims of this article are to (a) show how the concepts of QOL and health-related quality of life (HRQOL) have evolved over time, (b) describe the various ways QOL has been defined and measured, and (c) provide recommendations on how to be as clear and consistent as possible in QOL research.

METHOD

A narrative review of the QOL literature was performed.

RESULTS

Roots of the term "quality of life" in health care can be traced back to the definition of health by the World Health Organization in 1948. The use of the word "well-being" in this definition is probably a main factor in the continuing confusion about the conceptualization of QOL. Within the field of SCI rehabilitation, the Dijkers's QOL model, distinguishing between utilities, achievements, and subjective evaluations and reactions, has been very influential and the basis for several reviews and databases. Nevertheless, literature shows that it is still difficult to consistently use the term "quality of life" and categorize QOL measures. Several aspects of QOL that are specific for individuals with SCI have been identified.

CONCLUSIONS

Researchers should be as specific and clear as possible about the concept and operationalization of QOL in their studies. Readers should not take the term "quality of life" for granted, but should inspect the topic of the study from the actual measures used.

Pediatric health-related quality of life: a structural equation modeling approach

Objectives

One of the most referenced theoretical frameworks to measure Health Related Quality of Life (HRQoL) is the Wilson and Cleary framework. With some adaptions this framework has been validated in the adult population, but has not been tested in pediatric populations. Our goal was to empirically investigate it in children.

Methods

The contributory factors to Health Related Quality of Life that we included were symptom status (presence of chronic disease or hospitalizations), functional status (developmental status), developmental aspects of the individual (social-emotional) behavior, and characteristics of the social environment (socioeconomic status and area of education). Structural equation modeling was used to assess the measurement structure of the model in 214 German children (3–5 years old) participating in a follow-up study that investigates pediatric health outcomes.

Results

Model fit was χ2 = 5.5; df = 6; p = 0.48; SRMR  = 0.01. The variance explained of Health Related Quality of Life was 15%. Health Related Quality of Life was affected by the area education (i.e. where kindergartens were located) and development status. Developmental status was affected by the area of education, socioeconomic status and individual behavior. Symptoms did not affect the model.

Conclusions

The goodness of fit and the overall variance explained were good. However, the results between children' and adults' tests differed and denote a conceptual gap between adult and children measures. Indeed, there is a lot of variety in pediatric Health Related Quality of Life measures, which represents a lack of a common definition of pediatric Health Related Quality of Life. We recommend that researchers invest time in the development of pediatric Health Related Quality of Life theory and theory based evaluations.

Application of a health-related quality of life conceptual model in community-dwelling older Chinese people with diabetes to understand the relationships among clinical and psychological outcomes

AIMS/INTRODUCTION

The present study applied the Wilson-Cleary model of health-related quality of life (HRQOL) by using the structural equation modeling (SEM) approach to understand the interrelationships among clinical, sociodemographic and psychological characteristics in older people with diabetes.

MATERIALS AND METHODS

This was a cross-sectional study with 452 Chinese older people with diabetes recruited from three primary care clinics. A series of assessments were made, including four instruments: the Chinese version of the Short Form 36 Health Survey, Older American Resources and Services Multidimensional Functional Assessment Questionnaire, Rand Mental Health Inventory and Medical Outcomes Study Social Support Survey; and clinical outcomes (diabetes-related characteristics and physiological data).

RESULTS

In the present study, we identified six patient individual and environmental characteristics, namely, age, sex, physical activity, psychological distress, social support and adequacy of income, that significantly influence HRQOL directly or by way of physical functional status and general health perception.

CONCLUSIONS

Improving social and financial support as well as providing interventions to promote physical activity and to cope with psychological distress in this patient population might be effective to eventually enhance their HRQOL. The present findings add to the literature the underlying complex biological and psychological processes of HRQOL, and take the body of knowledge in HRQOL of older people with diabetes to a theoretical level, and provide insights for development of appropriate strategies to optimize their HRQOL.

Development of a situation-specific theory for explaining health-related quality of life among older South Korean adults with type 2 diabetes

The purpose of the study was to develop a situation-specific theory for explaining health-related quality of life (QOL) among older South Korean adults with type 2 diabetes. To develop a situation-specific theory, three sources were considered: (a) the conceptual model of health promotion and QOL for people with chronic and disabling conditions (an existing theory related to the QOL in patients with chronic diseases); (b) a literature review using multiple databases including Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, and two Korean databases; and (c) findings from our structural equation modeling study on health-related QOL in older South Korean adults with type 2 diabetes. The proposed situation-specific theory is constructed with six major concepts including barriers, resources, perceptual factors, psychosocial factors, health-promoting behaviors, and health-related QOL. The theory also provides the interrelationships among concepts. Health care providers and nurses could incorporate the proposed situation-specific theory into development of diabetes education programs for improving health-related QOL in older South Korean adults with type 2 diabetes.

Conceptual, classification or causal: models of health status and health-related quality of life

Instruments intended to assess health-related quality of life (HRQOL) and health status are widely used in research and clinical practice, but with little conceptual guidance there is some uncertainty about what it is that these instruments are actually tapping. Causal models have the potential to provide the required conceptual guidance, not only placing commonly discussed health concepts on a firm scientific foundation, but also allowing medical and psychosocial interventions to be developed in a more focused and efficient manner. Several models, some postulating causal relations, have been proposed over many years, and some have been supported by data. The development and validation of these models has, however, been conducted in a piecemeal fashion. The imperative to develop tailored, cost-effective interventions requires a synthesized approach to developing and testing causal models.

Self-rated dental health and dental insurance: modification by household income

Background

Previous studies have reported that socioeconomically disadvantaged Australians have poorer self-rated dental health (SRDH), are less likely to be insured for dental services and are less likely to have regular dental visits than their more advantaged counterparts. However, less is known about the associations between dental insurance and SRDH. The aim of this study was to examine the associations between SRDH and dental insurance status and to test if the relationship was modified by household income.

Methods

A random sample of 3,000 adults aged 30–61 years was drawn from the Australian Electoral Roll and mailed a self-complete questionnaire. Analysis included dentate participants. Bivariate associations were assessed between SRDH and insurance stratified by household income group. A multiple variable model adjusting for covariates estimated prevalence ratios (PR) of having good to excellent SRDH and included an interaction term for insurance and household income group.

Results

The response rate was 39.1% (n = 1,093). More than half (53.9%) of the participants were insured and 72.5% had good to excellent SRDH. SRDH was associated with age group, brushing frequency, insurance status and income group. Amongst participants in the $40,000– < $80,000 income group, the insured had a higher proportion reporting good to excellent SRDH (80.8%) than the uninsured (66.5%); however, there was little difference in SRDH by insurance status for those in the $120,000+ income group. After adjusting for covariates, there was a significant interaction (p < 0.05) between having insurance and income; there was an association between insurance and SRDH for adults in the $40,000– < $80,000 income group, but not for adults in higher income groups.

Conclusions

For lower socio-economic groups being insured was associated with better SRDH, but there was no association for those in the highest income group. Insurance coverage may have the potential to improve dental health for low income groups.

Health-related quality of life and income-related social mobility in young adults

Background

To assess the association of income-related social mobility between the age of 13 and 30 years on health-related quality of life among young adults.

Methods

In 1988-89 n = 7,673 South Australian school children aged 13 years were sampled with n = 4,604 children (60.0%) and n = 4,476 parents (58.3%) returning questionnaires. In 2005-06 n = 632 baseline study participants responded (43.0% of those traced and living in Adelaide).

Results

Multivariate regressions adjusting for sex, tooth brushing and smoking status at age 30 showed that compared to upwardly mobile persons social disadvantage was associated (p < 0.05) with more oral health impact (Coeff = 5.5), lower EQ-VAS health state (Coeff = -5.8), and worse satisfaction with life scores (Coeff = -3.5) at age 30 years, while downward mobility was also associated with lower satisfaction with life scores (Coeff = -1.3).

Conclusions

Stable income-related socioeconomic disadvantage was associated with more oral health impact, and lower health state and life satisfaction, while being downwardly mobile was associated with lower life satisfaction at age 30 years. Persons who were upwardly mobile were similar in health outcomes to stable advantaged persons.

Systematic review of outcomes used to evaluate enhanced recovery after surgery

BACKGROUND

Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies.

METHODS

A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge).

RESULTS

A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission.

CONCLUSION

Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.

Relationships between dimensions of disability experienced by adults living with HIV: a structural equation model analysis

As individuals age with HIV it is increasingly important to consider the health-related consequences of HIV and multiple morbidities, known as disability. We assessed relationships between four dimensions of disability among adults living with HIV. We conducted a structural equation modeling analysis using data from 913 participants in the Ontario HIV Treatment Network Cohort Study to determine relationships between four latent variables of disability in the Episodic Disability Framework: physical symptoms and impairments, mental health symptoms and impairments, difficulties with day-to-day activities, and challenges to social inclusion. Results indicated that physical symptoms and impairments, mental health symptoms and impairments and difficulties with day-to-day activities directly or indirectly predicted challenges to social inclusion for adults living with HIV. Challenges to social inclusion were directly predicted by mental health symptoms and indirectly by physical health symptoms via (mediated by) having difficulties carrying out day-to-day activities and mental health symptoms and impairments. These findings provide a basis for conceptualizing disability experienced by people living with HIV.

A Longitudinal Approach to Understanding the Relationship Between Symptom Status and QOL

This study demonstrates how a variant of growth curve modeling known as longitudinal parallel-process modeling can yield an understanding of the effect of symptoms on quality of life (QOL). A two-level hierarchical linear model with random intercepts and slopes was implemented within a structural equation modeling approach. The data (N = 367) comes from a large database of persons with HIV-associated illness. Twenty-three symptoms based on the Sign and Symptom Checklist for Persons with HIV disease and items measuring QOL from the general health status scales were used. Each respondent completed from 1 to 11 questionnaires. The number of reported symptoms had a significant association with patient QOL over time. These findings suggest that appropriate symptom management has the potential to improve patient QOL. This study demonstrates how a state-of-the-art longitudinal modeling technique evaluates the relationship between concurrent rates of change in measurements of two relevant variables.