The illusion of paradox: commentary on Albrecht, G.L. and Devlieger, P.J. (1998). The disability paradox: high quality of life against all odds. Social Science & Medicine 48, 977-988

An investigation of the longitudinal trajectory patterns of health-related quality of life among Australians with disabilities: explaining disability types and properties

BACKGROUND

Research on health-related quality of life (HRQoL) trajectory patterns for people with disabilities (PwD) is scant. Understanding the HRQoL trajectory patterns for PwDs and investigating their relationship with disability types and socioeconomic factors can have important implications for Australia's welfare policy.

METHODS

We analysed data from waves 11 to 21 of the Household, Income and Labour Dynamics in Australia (HILDA) survey of respondents aged 15 + years of the PwDs. The analytic sample consists of 3724 self-reported disabled individuals and 34,539 observations in total. The SF-6D utility score is our HRQoL measure. Group-based trajectory modelling was utilised to identify trajectory groups, and multinomial logistic regression was employed to determine the baseline factors associated with trajectory group membership.

RESULTS

The study identified four distinct types of HRQoL trajectories (high, moderate improving, moderate deteriorating and low HRQoL trajectories). Psychosocial disability types followed by physical disability types had a high Relative Risk Ratio (RRR) in the low group compared with high trajectory group membership of PwDs (psychosocial: 6.090, physical: 3.524). Similar, results followed for the moderate improving group albeit with lower RRR (psychosocial: 2.868, Physical: 1.820). In the moderate deteriorating group, the disability types were not significant as this group has a similar profile to high group at the baseline. Compared with males, females had a higher RRR in low and moderate versus high improving HRQoL trajectories (low: 1.532, moderate improving: 1.237). Comparing the richest class to the poorest class, socioeconomic factors (income and education) predicted significantly lower exposure for the richer class to the low and medium HRQoL trajectories groups (RRR < 1).

CONCLUSION

Different forms of disability, demographic and socioeconomic factors have distinct effects on the HRQoL trajectories of disabled individuals. Healthcare and economic resource efficiency might be improved with targeted government policy interventions based on disability trajectories.

Well-being and quality of life in people with disabilities practicing sports, athletes with disabilities, and para-athletes: Insights from a critical review of the literature

Global well-being (GWB) is a complex, multi-dimensional, and multi-faceted construct that can be explored from two different, but often overlapping, complementary perspectives: the subjective and the objective ones. The subjective perspective, in turn, is comprised of two dimensions: namely, the hedonic and the eudaimonic standpoints. Within the former dimension, researchers have developed the concept of subjective hedonic well-being (SHWB), whereas, within the latter, they have built the framework of psychological and social well-being (PSWB). Disabled people have poorer well-being due to their pathology and may more frequently suffer from anxiety and depressive disorders than their able-bodied counterparts. Sports participation is an essential way to cope with disability. On the other hand, compared with their able-bodied peers, athletes with disabilities and para-athletes undergo a unique series of stressors. Little is known in terms of hedonic and eudaimonic well-being and quality of life in this specific population. Here, we review the literature, with an emphasis on the current state-of-art and gaps in knowledge that need to be addressed by future research. High-quality, large-scale investigations are needed to have a better understanding of the self-perceived (hedonic) and objective (eudaimonic) well-being and quality of life of disabled people practicing sports, athletes with disabilities, and para-athletes.

Discrepancy between disability and reported well-being after traumatic brain injury

BACKGROUND

Following traumatic brain injury (TBI), the clinical focus is often on disability. However, patients' perceptions of well-being can be discordant with their disability level, referred to as the 'disability paradox'. We aimed to examine the relationship between disability and health-related quality of life (HRQoL) following TBI, while taking variation in personal, injury-related and environment factors into account.

METHODS

We used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury study. Disability was assessed 6 months post-injury by the Glasgow Outcome Scale-Extended (GOSE). HRQoL was assessed by the SF-12v2 physical and mental component summary scores and the Quality of Life after Traumatic Brain Injury overall scale. We examined mean total and domain HRQoL scores by GOSE. We quantified variance in HRQoL explained by GOSE, personal, injury-related and environment factors with multivariable regression.

RESULTS

Six-month outcome assessments were completed in 2075 patients, of whom 78% had mild TBI (Glasgow Coma Scale 13-15). Patients with severe disability had higher HRQoL than expected on the basis of GOSE alone, particularly after mild TBI. Up to 50% of patients with severe disability reported HRQoL scores within the normative range. GOSE, personal, injury-related and environment factors explained a limited amount of variance in HRQoL (up to 29%).

CONCLUSION

Contrary to the idea that discrepancies are unusual, many patients with poor functional outcomes reported well-being that was at or above the boundary considered satisfactory for the normative sample. These findings challenge the idea that satisfactory HRQoL in patients with disability should be described as 'paradoxical' and question common views of what constitutes 'unfavourable' outcome.

The impact of employment on quality of life for adults with brain injury

BACKGROUND: Employment is associated with greater quality of life (QOL) for people with disabilities. Yet, for individuals with traumatic brain injury (TBI), the benefits of work are not often realized given high rates of unemployment. OBJECTIVE: This study examined the unique impact of psychosocial variables and employment status (working vs. not working) on self-reported QOL among adults with TBI. METHODS: Participants included 116 adults with TBI between the ages of 18-65, recruited through state brain injury associations in the United States to complete an anonymous online survey. Hierarchical regression analysis was used to examine the incremental impact of psychosocial variables (sense of community, social support, social network, and problem-solving confidence) and employment status on QOL controlling for age and symptom severity. RESULTS: In the final model, employment status, informal and formal support network ties, problem-solving confidence, sense of community, and emotional support explained 59% of the variance in QOL, which is considered a large effect size. Employment status uniquely explained 5% of the variance in QOL. CONCLUSIONS: Findings support the positive benefits of work for adults with TBI. Rehabilitation services that emphasize vocational considerations and employment supports are needed to impact work status and ultimately QOL for individuals with TBI.

Interaction of Socio-demographic Characteristics on Acceptance of Disability Among Individuals With Physical Disabilities

This study aimed to investigate the interaction of sociodemographic characteristics on acceptance of disability among individuals with physical disabilities (IWPD). Data from the 8th Panel Survey of Employment for the Disabled in Korea (PSED) in the second wave were used. A sample concerning the first phase of disability was extracted using the one-step colony method to extract regions and was stratified based on the type of disability, disability grade, and age. To explore the association between acceptance of sociodemographic characteristics and of disability, we used a general linear model. A significant main effect was observed in employment, health status, degree of help, and subjective economic status. Regarding employment status, acceptance of disability in unemployment of IWPD with less than high school was lower as compared to those with more than high school. We observed that unemployed IWPD with low income or poor health status could be the group with the highest risk for acceptance of disability. Individuals in the low economic group were more religious than those in the high economic one. These findings indicate that specialized intervention programs that consider religion, economic status, employment, education, health, and their interactions would be effective for acceptance of disability. Interdisciplinary team members should consider the individual profiles of these populations and implement suitable support and rehabilitation programs.

Quality of Life Following Stroke: Negotiating Disability, Identity, and Resources

Residual physical and cognitive impairments following a stroke can pose a significant threat to a survivor’s quality of life. Yet, there is not always a direct one-to-one correlation between functional disability and subjective quality of life. This research investigated the complexity of factors that influence quality of life after stroke, using qualitative interviews. Results indicate that a stroke has a significant impact on the quality of life of survivors, but some individuals find ways to adapt to their functional disabilities and report a high quality of life. Common elements of this process consist of reordering priorities to focus on those activities considered most salient to an individual’s identity; then drawing on existing resources, including health services and social supports, to maintain a customary activity, even in a modified form, retaining salient aspects of the individual’s identity and maintaining a sense of continuity in his or her life.

Race differences in the association of spiritual experiences and life satisfaction in older age

OBJECTIVES

The primary objective of this study was to examine an African American 'faith advantage' in life satisfaction. Specifically, we sought to test the hypothesis that the positive relationship between spiritual experiences and life satisfaction is stronger among older African Americans than among older Whites.

METHOD

The data came from 6864 community-dwelling persons aged 65+ (66% African American) who participated in the Chicago Health and Aging Project. Life satisfaction was measured using a five-item composite and we used a five-item version of the Daily Spiritual Experiences scale.

RESULTS

In a regression model adjusting for age, sex, marital status, education, income and worship attendance, we found that African American race was associated with lower life satisfaction. We also found a positive association between spiritual experiences and life satisfaction. In an additional model, a significant race by spiritual experiences interaction term indicates that spiritual experiences are more positively associated with life satisfaction among African Americans.

CONCLUSION

The data suggest that at higher levels of spiritual experiences, racial differences in life satisfaction are virtually non-existent. However, at lower levels of spiritual experiences, older African Americans show modestly lower levels of life satisfaction than do older Whites. This pattern suggests that spiritual experiences are a positive resource - distinct from worship attendance - that enable older African Americans to overcome decrements in life satisfaction and, in fact, that lower spiritual experiences may be especially harmful for older African American's life satisfaction.

Care, compassion, or cost: redefining the basis of treatment in ethics and law

There are in two assumptions inherent in this issue's theme, both inimical to the traditional goals of medicine and to the standards of care it proposed. First, the idea that treatment must be limited for some (but not others) on the basis of cost was born in the early literature of bioethics. Second, that there is a quantifiable and diagnostically predictable period at the "end-of-life" where treatment is "futile," and therefore not worth supporting in a context of scarcity grew out of bioethics's construction of allocative protocols in the 1990s. This paper traces the history of these ideas as constructs grounded in neither natural scarcity nor in firm diagnostic categories. Their relation to issues of care is therefore suspect.

Aging and disability: biopsychosocial perspectives

Understanding the complex trajectories of disability and aging requires a biopsychosocial approach that considers disability in the broader context of later adulthood. Although disability service researchers and gerontologists have many shared interests and a similar mission, the fields are relatively new to one another and have had little historical interaction. The purpose of this article is to increase and improve collaboration among investigators in these fields by providing some background in social gerontology to the disability researcher, and by applying key theories in aging to the issue of growing older with physical disability. The article discusses particular problem areas for older adults, including social support, and also discusses the parallel paradoxes of aging and disability.

Self-perception of quality of life by adolescents with neuromuscular diseases

PURPOSE

Little is known about quality of life of adolescents with neuromuscular diseases or the factors that influence it. We searched whether physical impairment, physical disability, and medical complications were predictors of low quality of life.

METHODS

Motor function, health, orthopedic status, and rehabilitation were assessed in 43 adolescents with neuromuscular diseases (mean age, 13.8 years, standard deviation 1.7 year; sex ratio 2.9/1). Quality of life was measured with the VSP-A ("Vécu Santé Perçu par l'Adolescent"; self-perceived health state in adolescents), a validated health-related quality of life self-perception test. A mixed linear regression related quality of life to impairment, disability, and respiratory status. Comparisons were made with results from an age/sex-matched nondisabled group.

RESULTS

On the average, the VSP-A scores in physically disabled adolescents were: (1) similar to those of the nondisabled group with regard to vitality, body image, relationships with parents and friends, and physical and psychological well-being; (2) higher with regard to school performance (score 68 vs. 52.8) and relationships with teachers (67.4 vs. 43.2); and (3) lower with regard to leisure activities (43.9 vs. 60.9). Physical disability and physical impairment were not negatively associated with seven of the nine VSP-A dimensions, but physical impairment was negatively associated with leisure activities and vitality (p < .001 and p < .01, respectively). Adolescents with ventilatory support did not express lower scores than adolescents not requiring ventilatory support (67.7+/-11 vs. 62.9+/-15, p=.39).

CONCLUSIONS

These surprising results should lead us question our medical, educational, and rehabilitation practices. Already well-managed disabled adolescents should benefit from less compassionate but more daring and dynamic interpersonal contacts.

Quality of life after stroke in old age: comparison of persons living in nursing home and those living in their own home

AIM

To determine the differences in subjective quality of life between elderly people living in a nursing home and those living in their own homes after brain stroke, and to determine the contribution of demographic variables and different quality of life domains to the explanation of self-assessed quality of life.

METHODS

The study included 60 elderly men and women, 30 living in their own homes (median age, 81; range, 72-90) and 30 living in a nursing home (median age, 81; range, 72-86). Both groups received care (stationary or ambulatory) from the same nursing home. World Health Organization Quality of Life Questionnaire-short version, self-assessed quality of life questionnaire, and demographic questionnaire were used to collect data on subjective quality of life. The participants completed self-report questionnaires individually.

RESULTS

Quality of life scores were significantly higher in the elderly living in a nursing home than in the elderly living in their own home (mean +/- standard deviation, 78.7 +/- 12.8 vs 59.3 +/- 17.3 out of maximum 100, P < 0.001). Also, the elderly living in the nursing home scored significantly higher than those living in their own home on all 4 quality of life domains (maximum 100 for each domain): physical (28.5 +/- 3.3 vs 17.2 +/- 5.0), psychological (22.3 +/- 3.7 vs 16.3 +/- 5.0), social relationships (11.4 +/- 1.6 vs 8.3 +/- 1.7), and environment (32.8 +/- 4.6 vs 24.0 +/- 6.1) domain (P < 0.001 for all). All predictive variables together explained 51.9% of quality of life variance, with self-assessed health being the most significant predictor.

CONCLUSION

Quality of life of the elderly in a nursing home was significantly higher than that of their peers living in their own home, which may be related to better care in specially organized settings.

Disability and Psychosocial Outcomes in Old Age

Objective: This article explores psychosocial variables associated with illness and age-related losses during old age. Method: The study is cross-sectional and comprised 999 people aged 65 and older. The variables included health problems and limitations, self-perceptions of health, optimism, and quality of life. Results: In general, people aged 80+ years show high prevalence of health problems and disability, good self-perception of health, and quality of life. However, among the oldest age group, those in better health were more optimistic, but more problems meant lower self-perception of health, quality of life, and optimism. Discussion: This does not fully confirm the disability paradox (high disability and high optimism and self-perception of quality of life). The dual-process coping model helps to understand the results of our study: First is an attempt to avoid losses; afterward, people lower goals and standards to meet constraints and foster adaptation.

Discrepancies between self-ratings of and satisfaction with oral health in two older adult populations

OBJECTIVES

General health perceptions, usually measured by means of single-item indicators, are commonly included in health and oral health surveys. The aim of the study reported here was to assess the relationship between self-rated oral health and satisfaction with oral health in two studies of older adult populations.

METHODS

Participants in Study 1 were aged 50 years and over, the majority of whom had multiple chronic medical conditions and disabilities and lived within a multi-level geriatric care setting. They were recruited when attending a clinic in that setting for their annual dental screening. Participants in Study 2 were somewhat healthier community dwelling individuals, also aged 50 years and older, who took part. They were originally recruited by means of a telephone survey based on random-digit dialing. For Study 1, data were collected by means of personal interviews and a review of dental clinic charts, while for Study 2 personal interviews, clinical examination and self-completed questionnaires were used. Measures included self-rated oral health, satisfaction with oral health, oral health-related quality of life (OHRQoL) and tooth loss.

RESULTS

Data were obtained from 225 persons in Study 1 and 541 in Study 2. In both studies there was a significant association between self-ratings of oral health and satisfaction with oral health. However, also in both studies there was a discrepancy between the measures: approximately 10% of those with favourable oral health ratings were dissatisfied while approximately half of those with unfavourable ratings were satisfied. Those with apparently discordant responses had significantly higher scores on OHRQoL measures such as the GOHAI and the OHIP-14 than those with concordant responses. In Study 2, a similar discrepancy between self-rated general health and satisfaction with general health was also observed.

CONCLUSIONS

There is degree of discordance between self-ratings of and satisfaction with both oral and general health status in the older adult populations studied here. This may be because of the expectations concerning health in later life. More needs to be known about the frames of reference people use in constructing their responses to questions designed to assess health perceptions.

Is quality of life a healthy concept? Measuring and understanding life experiences of older people

The concept of quality of life has received considerable attention as an inclusive notion of health and as a basis for health interventions. The authors' argument in this article is that notwithstanding this attention, little consensus exists as to definition of the term. In addition, a focus on measurement has led to the neglect of wider aspects of quality of life. Such difficulties are particularly relevant to the study of quality of life of older people. Analysis of interview data suggests that older people's understandings of quality of life are not readily measurable and should be viewed in terms of phenomenological experience. The authors discuss the implications for studying quality of life of this group and difficulties for the concept itself.

Selecting human health metrics for environmental decision-support tools

Environmental decision-support tools often predict a multitude of different human health effects due to environmental stressors. The accounting and aggregating of these morbidity and mortality outcomes is key to support decision making and can be accomplished by different methods that we call human health metrics. This article attempts to answer two questions: Does it matter which metric is chosen? and What are the relevant characteristics of these metrics in environmental applications? Three metrics (quality adjusted life years (QALYs), disability adjusted life years (DALYs), and willingness to pay (WTP)) have been applied to the same diverse set of health effects due to environmental impacts. In this example, the choice of metric mattered for the ranking of these environmental impacts and it was found for this example that WTP was dominated by mortality outcomes. Further, QALYs and DALYs are sensitive to mild illnesses that affect large numbers of people and the severity of these mild illnesses are difficult to assess. Eight guiding questions are provided in order to help select human health metrics for environmental decision-support tools. Since health metrics tend to follow the paradigm of utility maximization, these metrics may be supplemented with a semi-quantitative discussion of distributional and ethical aspects. Finally, the magnitude of age-dependent disutility due to mortality for both monetary and nonmonetary metrics may bear the largest practical relevance for future research.

Future states: the axioms underlying prospective, future-oriented, health planning instruments

Proscriptive planning exercises are critical to and generally accepted as integral to health planning at varying scales. These require specific instruments designed to predict future actions on the basis of present knowledge. At the macro-level of health economics, for example, a number of future-oriented Quality of Life Instruments (QL) are commonly employed. At the level of individual decision making, on the other hand, Advance Directives (AD's) are advanced as a means by which healthy individuals can assure their wishes will be carried out if at some future point they are incapacitated. As proscriptive tools, both instrument classes appear to share an axiomatic set whose individual parts have not been rigorously considered. This paper attempts to first identify and then consider a set of five axioms underlying future oriented health planning instruments. These axioms are then critiqued using data from a pre-test survey designed specifically to address their assumptions. Results appear to challenge the validity of the axioms underlying the proscriptive planning instruments.