Multidimensionality of health status in an elderly population. Construct validity of a measurement battery

Using outcome measures to provide excellence in Alzheimer care

Outcome measures have been widely touted as a valuable tool to guarantee quality assurance in healthcare settings. Recently, a number offactors have conspired to make outcome-based measurement more feasible. This paper describes the advantages of utilizing outcome measures, continuous quality improvement methods and consumer based input to ensure excellence in long term care.

The impact of physical complaints, social environment, and psychological functioning on IBS patients' health perceptions: looking beyond GI symptom severity

OBJECTIVES

In the absence of a reliable biomarker, clinical decisions for a functional gastrointestinal (GI) disorder like irritable bowel syndrome (IBS) depend on asking patients to appraise and communicate their health status. Self-ratings of health (SRH) have proven a powerful and consistent predictor of health outcomes, but little is known about how they relate to those relevant to IBS (e.g., quality of life (QOL), IBS symptom severity). This study examined what psychosocial factors, if any, predict SRH among a cohort of more severe IBS patients.

METHODS

Subjects included 234 Rome III-positive IBS patients (mean age=41 years, female=78%) without comorbid organic GI disease. Subjects were administered a test battery that included the IBS Symptom Severity Scale, Screening for Somatoform Symptoms, IBS Medical Comorbidity Inventory, SF-12 Vitality Scale, Perceived Stress Scale, Beck Depression Inventory, Trait Anxiety Inventory, and Negative Interactions Scale.

RESULTS

Partial correlations identified somatization, depression, fatigue, stress, anxiety, and medical comorbidities as variables with the strongest correlations with SRH (r values=0.36-0.41, P values <0.05). IBS symptom severity was weakly associated with SRH (r=0.18, P<0.05). The final regression model explained 41.3% of the variance in SRH scores (F=8.49, P<0.001) with significant predictors including fatigue, medical comorbidities, somatization, and negative social interactions.

CONCLUSIONS

SRH are associated with psychological (anxiety, stress, depression), social (negative interactions), and extraintestinal somatic factors (fatigue, somatization, medical comorbidities). The severity of IBS symptoms appears to have a relatively modest role in how IBS patients describe their health in general.

Health status of independently living older adults in Romania

AIM

Aging is affecting health care all over Europe, but it is expected to have a much greater impact in Eastern Europe. Reliable data on various indicators of health of older adults in Eastern Europe are lacking. The objectives of the present study were to describe the health of older Romanian adults, and to examine its relationship with sociodemographic, psychological and social factors.

METHODS

This cross-sectional study used a stratified sample of 600 independent-living older Romanian adults from the great metropolitan area of Bucharest; 549 citizens aged ≥ 65 years participated. Data were collected by a mailed questionnaire and interviews. Measurements included self-rated health, the number of chronic conditions, the Short Form-20, the Eysenck Personality Questionnaire and Social support.

RESULTS

Romanian older adults rate their health as "fair". On average, they report three chronic conditions. They more frequently have problems in executing daily activities as compared with older adults from other European countries. Three components of health are identified: independent functioning, suffering from chronic diseases and psychological health. Regression analysis shows that age, education and social support are related to each component, and neuroticism and extraversion to two components of health.

CONCLUSIONS

A comparison with international data shows various indicators of health of older Romanian adults to be relatively worse. The three identified components of health offer opportunities for an integrated approach to deal with the health care needs of older citizens.

Determinants of self-rated health and the role of acculturation: implications for health inequalities

OBJECTIVES

Self-rated health (SRH) is an important indicator of overall health, predicting morbidity and mortality. This paper investigates what individuals incorporate into their self-assessments of health and how acculturation plays a part in this assessment. The relationship of acculturation to SRH and whether it moderates the association between indicators of health and SRH is also examined.

DESIGN

The paper is based on data from adults in the Boston Puerto Rican Health Study, living in the greater Boston area (n=1357) mean age 57.2 (SD = 7.6). We used multiple regression analysis and testing for moderation effects.

RESULTS

The strongest predictors of poor SRH were the number of existing medical conditions, functional problems, allostatic load and depressive symptoms. Poor SRH was also associated with being female, fewer years of education, heavy alcohol use, smoking, poverty, and low emotional support. More acculturated Puerto Rican adults rated their health more positively, which corresponded to better indicators of physical and psychological health. Additionally, acculturation moderated the association between some indicators of morbidity (functional status and depressive symptoms) and SRH.Self-assessments of overall health integrate diverse indicators, including psychological symptoms, functional status and objective health indicators such as chronic conditions and allostatic load. However, adults' assessments of overall health differed by acculturation, which moderated the association between health indicators and SRH. The data suggest that when in poor health, those less acculturated may understate the severity of their health problems when rating their overall health, thus SRH might thus conceal disparities. Using SRH can have implications for assessing health disparities in this population.

Measuring health status: self-, interviewer, and physician reports of overall health

OBJECTIVE

This study examines and compares respondent, interviewer, and physician ratings of overall health.

METHOD

Data are from the 2006 Social Environment and Biomarkers of Aging Study, a nationally representative survey of older adults in Taiwan. Ordered probit models are used to examine factors associated with self- and external assessments of health and discordant health ratings.

RESULTS

Our results suggest similarities and differences in factors influencing health ratings across evaluators but a high level of interevaluator disagreement in ratings. Discrepancies in ratings between physicians and both respondents and interviewers are associated with the greater weight given to functional limitations and psychological well-being in interviewer and respondent ratings and to the importance of clinical measures or risk factors of illness and mortality in physician assessments.

DISCUSSION

Interviewer and physician assessments may be complementary to self-assessed health measures. The importance and implications of these findings for future research are discussed.

Predicting caregiver burden from daily functional abilities of patients with mild dementia

OBJECTIVES

To assess the relationship between performance- and informant-based measures of activities of daily living (ADLs) in patients with early dementia and burden or psychological distress experienced by the patients' caregivers.

DESIGN

Descriptive study.

SETTING

Ambulatory center.

PARTICIPANTS

Thirty-four patient-caregiver dyads in which the patient had mild dementia (Mini-Mental State Examination score >17).

MEASUREMENTS

A performance-based ADL measure (the Direct Assessment of Functional Status (DAFS)) was administered to patients with mild dementia. Caregivers completed an informant-based measure of patient functional status (instrumental activities of daily living). Caregivers also completed the Caregiver Burden Inventory (CBI) and the Brief Symptom Inventory (BSI).

RESULTS

Significant correlations were found between the informant-based ADL measure and caregiver burden (CBI) and psychological distress (BSI) (correlation coefficient (r)=-0.34 to -0.71, all P<.05). Alternatively, fewer and weaker relationships were observed between the DAFS (performance-based) ADL measure and caregiver burden or distress ratings (r=-0.32 to -0.43, all P<.05). Of the seven tasks assessed using the DAFS, impairments in orientation, communication, financial, and transportation skills in patients were associated with greater time and developmental burden and greater hostility in caregivers. Impairment in financial skills in patients was the strongest predictor of time-dependence burden and hostility in caregivers, whereas impairment in patient transportation skills was the best predictor of developmental burden.

CONCLUSIONS

The ADL abilities of cognitively impaired patients can predict caregiver burden and psychological distress, with informant-based measures having the greatest association with patient impairment.

Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction

Self-rated health (SRH) is a useful summary measure of people's general health and was found to predict future health outcomes. Self-rated oral health (SROH) is a similarly useful summary measure of people's oral health. Both are related to quality of life, especially at old age. The objectives of the study were: (1) to assess the independent contribution of SROH to concurrent and future SRH of elderly people, controlling for sociodemographics and health measures, and, (2) to assess whether SROH adds unique information not captured by SRH by testing their independent associations with self-esteem and life satisfaction. Participants were 850 residents of a retirement community (mean age 73) interviewed in their homes at baseline and 5 years later. The interview included single-item self-ratings of general and oral health, self-reports of medical history, recent chronic diseases, medication usage, functional disability, self-esteem and life satisfaction. Multiple regression analyses showed that SROH had an independent effect on concurrent and future SRH, controlling for age and other measures of health status. Both SRH and SROH independently explained a significant amount of variance in concurrent ratings of self-esteem and life satisfaction. SROH has a unique role in people's perceptions of their overall health yet is not fully captured by SRH. Therefore, it should be considered by general health care providers in their assessments of the health status of older adults.

Do differences in methods for constructing SF-36 physical and mental health summary measures change their associations with chronic medical conditions and utilization?

BACKGROUND AND OBJECTIVE

Various approaches have been employed to derive physical health and mental health summary scores for the SF-36 and the RAND-36, but head-to-head comparisons of alternative scoring algorithms are rare. We determined whether the associations of the physical and mental health summary scores with chronic medical conditions and utilization would differ depending on the scoring algorithm used.

METHODS

We examined 5701 patients receiving medical care from an independent association of 48 physician groups located primarily in the western United States and compared SF-36 and RAND-36 scoring of physical health and mental health summary scores. Associations with the presence of diabetes, heart disease, and kidney disease, as well as with utilization of medical care and mental health care were compared using bivariate and multivariate analysis. To examine the relationship between SF-36 and RAND-36 scores, we regressed the SF-36 physical and mental health composite scores on the RAND-36 physical and mental health summary measures and vice versa.

RESULTS

We found that the SF-36 and RAND-36 summary scores generally yielded results similar to one another across measures of heart disease, diabetes, and kidney disease, as well as measures of utilization. However, for each chronic medical condition, the RAND-36 showed a slightly larger decrement in mental health than did the SF-36.

CONCLUSIONS

Differences between the two sets of summary scores were consistent with their respective conceptual and analytic approaches. Where comparisons of results between the SF-36 and RAND-36 summary scores are desirable in future studies, they can be estimated using the regression equations derived in this study.

Elderly people's ratings of the importance of health-related factors to their self-assessments of health

Identifying the bases for self-assessed health (SAH) has interested researchers in their attempts to understand its validity as a predictor of future health outcomes. Quantitative approaches typically used statistical methods to identify correlates of SAH while qualitative approaches asked people to elaborate on the reasons underlying their rating of health. The current study used a quantitative methodology, asking 487 elderly people to rate the importance of 42 health-related factors as bases for their SAH judgment. Factors indicating overall functioning/vitality were rated highly by all participants. Factors indicating current disease were rated highly by people reporting poor/fair SAH while risk factors and positive indicators were rated highly by those reporting good, very good, or excellent health. Thus, there seems to be a clear distinction between poor and fair SAH that reflect levels of illness, and higher levels of SAH that reflect levels of health.

Quality of life of low-vision patients and outcomes of low-vision rehabilitation

PURPOSE

The impact of low vision on self-reported quality of life and changes after low-vision intervention are investigated.

METHODS

Literature reports from 1990 to 2000 are reviewed.

RESULTS

Low vision is associated with increased risk for depression and decreased functional status and quality of life. Decreased visual acuity, visual field loss, and occasional blurred vision are also associated with decreased quality of life. Improvements in both functional status and quality of life occur after low-vision service delivery.

CONCLUSIONS

Self-reported quality of life is a significant outcome measure for low-vision rehabilitation. Questionnaires that are more sensitive to rehabilitation services provided as well as patient needs and goals are required to facilitate development of rehabilitation plans and to compare techniques, devices, and programs. Attention should be given to measurement properties, validity, and reliability of instruments used currently and in development of new instruments.

What outcomes matter to patients?

OBJECTIVE

This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status.

DESIGN

Cross-sectional data from quasi-experimental, prospective study.

SETTING

Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado.

PATIENTS

Consecutive adult outpatients (n = 16,689) visiting primary care providers.

MEASUREMENTS AND MAIN RESULTS

Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions.

CONCLUSIONS

Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.

Contrasting results between caregiver's report and direct assessment of activities of daily living in patients affected by mild and very mild dementia: the contribution of the caregiver's personal characteristics

OBJECTIVE

To determine the level of agreement between the primary caregiver's report on patient activities of daily living (ADLs) and ADLs assessed directly in a sample of patients affected by very mild and mild dementia and to assess whether this agreement is influenced by the caregiver's depressive symptoms and burden.

PATIENTS AND METHODS

Data were obtained from the baseline sample of the Mild Dementia Longitudinal Study, consisting of 111 consecutive patients affected by dementia with very mild to mild functional impairment (grades .5 and 1 on the Clinical Dementia Rating Scale). As is usual for patients referred to our Alzheimer's Unit, anamnestic, cognitive, functional and behavioral information are collected from the primary caregiver. Along with sociodemographic characteristics, caregivers' depressive symptoms (Beck Depression Inventory Scale) and burden (Nowak and Guest's Caregiver Burden Inventory Scale) were also evaluated. Patients underwent a performance-based assessment of the activities of daily living (DAFS) and direct assessment of physical function with the Physical Performance Test (PPT). Caregiver's report and direct observation have been compared for the following ADLs: dressing, toileting, walking, telephone use, shopping, and money use. Discriminant analyses were conducted to examine the degree of agreement between caregiver-report functional status and performance-based measures and whether additional agreement is attributable to caregiver's burden and depressive symptoms.

RESULTS

The strength of the association between the caregiver's report and performance-based measures of ADLs is high for motor performance (walking), moderate to good for dressing, but only moderate for telephone, money use, and shopping. No association was found for toileting. The discrepancies between caregiver report and performance-based assessment were influenced substantially by the burden caused by demands and restrictions on a caregiver's time.

CONCLUSIONS

With the exception of motor performance (walking), the caregiver's report and the performance-based assessment of functional status measure different aspects of a patient's functional status. Contrasts between the caregiver's report and observed ADL performance in mildly and very mildly demented patients are influenced by the caregiver's burden.

Gender role orientation as a correlate of perceived health, health behavior, and qualitative well-being in older women

This study investigated the relationships of gender role orientations (Feminine, Masculine, & Androgynous) with self-perceived health status, health behavior, and qualitative well-being experience in a simple random sample of community-dwelling older women (N = 70). Instruments used were The Bem Sex Role Inventory (Bem, 1974); The Seniors' Lifestyle Inventory (Schwirian, 1991); and The Integration Inventory (Ruffing-Rahal, 1991). Findings revealed the greatest number of significant positive correlations with the Feminine orientation; Androgyny was significantly linked with qualitative well-being and with a positive self-comparison in relation to peers and Masculinity was positively linked with health behavior. Findings are interpreted in light of successful aging issues for older women.

Use of structural equation modeling to test the construct validity of the SF-36 Health Survey in ten countries: results from the IQOLA Project. International Quality of Life Assessment

A crucial prerequisite to the use of the SF-36 Health Survey in multinational studies is the reproduction of the conceptual model underlying its scoring and interpretation. Structural equation modeling (SEM) was used to test these aspects of the construct validity of the SF-36 in ten IQOLA countries: Denmark, France, Germany, Italy, the Netherlands, Norway, Spain, Sweden, the United Kingdom, and the United States. Data came from general population surveys fielded to gather normative data. Measurement and structural models developed in the United States were cross-validated in random halves of the sample in each country. SEM analyses supported the eight first-order factor model of health that underlies the scoring of SF-36 scales and two second-order factors that are the basis for summary physical and mental health measures. A single third-order factor was also observed in support of the hypothesis that all responses to the SF-36 are generated by a single, underlying construct--health. In addition, a third second-order factors, interpreted as general well-being, was shown to improve the fit of the model. This model (including eight first-order factors, three second-order factors, and one third-order factor) was cross-validated using a holdout sample within the United States and in each of the nine other countries. These results confirm the hypothesized relationships between SF-36 items and scales and justify their scoring in each country using standard algorithms. Results also suggest that SF-36 scales and summary physical and mental health measures will have similar interpretations across countries. The practical implications of a third second-order SF-36 factor (general well-being) warrant further study.

Developing a summary measure of medical status

Health status surveys and assessments typically obtain detailed information on specific physical health conditions. While such specific details are important, it is frequently also valuable to have a summarized evaluation of medical conditions which can be used to compare subjects, or for statistical analyses. Using data from the Duke Established Populations for Epidemiologic Studies of the Elderly survey, we indicate how to obtain a weighted sum of chronic medical conditions. Like the sum of the same conditions, it explains variance in selected measures of health service use and health status, in some instances making a contribution beyond that of the summed measure. It is a significantly better predictor of mortality within six years.

Pain beliefs. What do elders believe?

The purpose of this descriptive study was to better understand elders' beliefs regarding chronic pain. The research questions were (a) What are the pain beliefs of elders experiencing nonmalignant chronic pain (NMP) and chronic pain associated with malignancy with the hope for recovery (MHR)? (b) Are there differences in pain beliefs between the NMP group and the MHR group? and (c) Do elders have similar or different pain beliefs? Sixty adults age 65 or older, all cognitively intact, completed the Pain Beliefs Questionnaire; 30 had arthritis and 30 had cancer. Of the total, 60% responded that pain is the result of damage to the body--either often, almost always, or always. Another 13% believed that pain was rarely or never the result of such damage, and 15% rarely or never saw pain as a sign of illness. In all, 68% responded that depression makes pain seem worse.

SF-36 summary scores: are physical and mental health truly distinct?

OBJECTIVES

Data from 536 primary care patients initiating antidepressant treatment were used to examine the performance of the Medical Outcomes Study SF-36 Physical Component and Mental Component summary scores.

METHODS

The SF-36 was administered at baseline and readministered after 1 month and 3 months (n = 482).

RESULTS

At the baseline assessment, patients reported modest impairment on the Physical Function, Role--Physical, Bodily Pain, and General Health Perceptions subscales (0.10 to 0.68 standard deviations below national norms), but the Physical Component summary (mean = 51) indicated no impairment based on a population norm of 50. During 3 months of follow-up evaluation, the Physical Function, Role--Physical, Bodily Pain, and General Health Perceptions subscales all showed moderate and statistically significant improvement (range from 0.28 to 0.49 standard deviation units), whereas the Physical Component summary score was essentially unchanged (mean = 50 at both 1-month and 3-month assessments). This pattern of results is a natural consequence of the assumptions and methods used to calculate these summary scores-orthogonal factor rotation and negative scoring coefficients.

CONCLUSIONS

These findings suggest caution in the interpretation of Mental Component Summary and Physical Component Summary scores when the condition or treatment of interest has strong effects on scales with negative scoring coefficients (Mental Health and Role--Emotional for the Physical Component; Physical Function, Role--Physical, and Bodily Pain for the Mental Component).

Examining emotional, physical, social, and spiritual health as determinants of self-rated health status

PURPOSE

To determine whether individuals' perceptions of their emotional, physical, social, and spiritual health constitute elements of their self-rated health status operationalized with a commonly employed single indicator.

DESIGN

Secondary analysis of cross-sectional survey data. Structural equation modeling with LISREL was used.

SETTING

The Yukon Health Promotion Survey, Yukon Territory, Canada, 1993.

SUBJECTS

The population-based sample was made up of 742 women and 713 men between 15 and 90 years of age; 80.3% responded.

MEASURES

Self-rated health status was operationalized with the "excellent, good, fair, poor" indicator derived from the question: "In general, compared to other people your age, would you say your health is...." Social, spiritual, emotional, and physical health status were also self-rated from excellent to poor.

RESULTS

The model's fit of the data was acceptable. Only physical health status significantly contributed to the variance in self-rated health status (55.1% of the variance was explained). Emotional, social, and spiritual health were found to have no effect on individuals' ratings of their health status.

CONCLUSIONS

Although recent conceptualizations have broadened in much of the theoretical and political discourse about health, especially in health promotion, the self-rated health status indicator measures only physical health status.

Reliability and validity of physical and mental health summary scores from the Medical Outcomes Study HIV Health Survey

OBJECTIVES

Health-related quality of life measures are used to evaluate patient outcomes in clinical trials of new treatments for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Summary index scores, rather than profiles of scale scores, would simplify data analysis and interpretation of findings from clinical trials and comparison across studies.

METHODS

Baseline MOS HIV Health Survey scores from two clinical trials of new antiretroviral medications in HIV/AIDS patients (total n = 2253) and an observational study (n = 162) were used to develop physical health summary (PHS) and mental health summary (MHS) scores. Exploratory and confirmatory factor analysis were used to identify the factor structure of the summary scores based on MOS HIV Health Survey scales. Physical health summary and MHS scores were derived and the factor structure proved invariant across the two groups.

RESULTS

Reliability of the PHS score was 0.90 to 0.92 and MHS score was 0.91 to 0.94. Mean PHS and MHS scores differed in patient groups defined by HIV disease stage, HIV disease severity, Karnofsky performance status scores, and global ratings of health status. Mean PHS and MHS scores in patient reporting worsening health status were significantly lower than scores of patients reporting stable or improving health status.

CONCLUSIONS

The PHS and MHS were reproducible across different samples of HIV/AIDS patients and are reliable and valid measures for demonstrating treatment impact on patient functioning and well-being.

Surrogate assessment of coronary artery disease patients' functional capacity

An investigation of the surrogate assessment of coronary artery disease (CAD) patients' functional capacity was conducted using 193 patient and surrogate rater dyads. Mean age of patients and surrogate raters were 60.4 and 54.4 years, respectively. Patients and surrogates independently completed a brief questionnaire that assessed health and psychosocial factors. The Duke Activity Status Index (DASI) was contained in the patients' questionnaire, while a similar form modified to assess patients' functional capacity was imbedded in the surrogates' questionnaire. Results indicated similar psychometric characteristics and clinical validity for patients' self-report and surrogates' ratings, suggesting that the Surrogate Rating Form of the Duke Activity Status Index (DASI-SRF) is a reliable and valid proxy method of assessing patient's functional capacity when this information may not be obtained directly from the patient. Further, while there were no effects of surrogates' health and psychological characteristics on their ratings of patients' functional capacity, in comparison with other surrogates, spouses were more likely to rate patients higher in functional capacity. Exploration of the patient/care provider relationship via concurrent use of the DASI and DASI-SRF is discussed.

A cross-national study of quality of life factors associated with patterns of elderly disablement

This study examines individual-level data of non-institutionalized elderly from Bahrain, Burma, DPR Korea, Egypt, Indonesia, Jordan, Sri Lanka, Thailand and Tunisia. The Grade of Membership multivariate procedure is used to determine profiles of disablement, based upon functional disability and depression items, and to examine socio-demographic and quality of life covariates associated with such profiles. The analysis yielded six profiles or types of disablement: functionally and emotionally healthy, functionally healthy with some depressive symptoms, some strength problems, severely depressed, mobility problems and functionally frail. The healthy profile had higher probabilities associated with males, whereas the very depressed, and those with physical strength limitations, and mobility problems were more likely to be female. There is a strong positive association between age and functional disabilities. The more depressed profiles, however, tended to be among the younger age categories, and the depressed had higher probabilities associated with being not married. The examination of quality of life covariates indicates that the functional and emotional limitations generally are correlated with a lower quality of life. The more functionally disabled and the depressed profiles had more negative self-assessments of health and lower morale scores. The very depressed had less instrumental social support in terms of available kin. Also, the functionally and emotionally disabled profiles expressed less satisfaction of visits with family and friends. Country-specific patterns of elderly disablement indicate a possible disability transition such that as countries become more developed there may be an increase in the prevalence of disabled elderly. However, there are exceptions to this trend, and these may be due to both cultural factors and data limitations.

Psychosocial and health status in stroke survivors after 14 years

BACKGROUND AND PURPOSE

Most studies of long-term survival and assessment of health status in survivors of stroke are hospital based and are often based only on a relatively short follow-up. This study was aimed at evaluating survival of acute stroke after 14 years. We also assessed psychosocial and health status among the long-term stroke survivors.

METHODS

This study is a follow-up of the Finnish part of the collaborative World Health Organization Stroke Study that took place during 1972 through 1974. All survivors were interviewed by telephone after being sent a structured questionnaire approximately 14 years after the initial stroke attack. Information on clinical history, socioeconomic situation, self-reported functional capacity, psychosomatic status, perceived mental status, and perceived health was collected.

RESULTS

Of the 1241 persons who had been entered in the stroke register from 1972 through 1974, 241 (19.4%) were still alive after 14 years. Participation rate in the telephone interview was 83.4%. Over 80% of all stroke survivors lived at home or with relatives at the time of interview. Functional capacity was good in about two thirds of the stroke survivors. Only 10% to 15% of all respondents felt depressed. About half of both men and women aged 64 years or younger perceived their health as good, while only 25% of men aged 65 years or over did.

CONCLUSIONS

Most stroke survivors did not need institutionalized care in the long term. Although a large proportion of them suffered from various somatic diseases, their functional capacity was found to be good.

Health-related quality of life in patients with advanced prostate cancer: a multinational perspective

To explore the value of antiandrogen therapy for advanced prostate cancer, two clinical trials of similar design were recently conducted in six countries throughout Europe. A total of 550 patients with previously untreated metastatic prostate cancer were randomized either to treatment with an antiandrogen or castration. While time to treatment failure, objective tumour response and survival were expected to be similar between study treatments, their effects on health-related quality of life (HRQOL) were expected to differ and were therefore a focus of concern in this trial. To assess these effects, we developed a brief self-administered patient questionnaire covering 10 domains of HRQOL (general health perceptions, pain, emotional well-being, vitality, social functioning, physical capacity, sexual interest, sexual functioning, activity limitation and bed disability), which we translated from English into several other languages. In this paper, we describe the development, content and translation of this survey instrument and report on its reliability and validity in six countries based on data collected for the first 487 patients to complete questionnaires at study entry.

Psychometric considerations in evaluating health-related quality of life measures

How does one determine if a measure of health-related quality of life (HRQL) is adequate for clinical trials? Psychometric methods are frequently used to answer this question. What is psychometrics all about? In this paper we address these questions, discussing common psychometric evaluation procedures applied to HRQL measures. Specifically, we discuss issues regarding the evaluation of reliability and validity (including responsiveness).

French-language validation of the DACL and MAACL-R

The objective of this methodological pilot study was to make a contribution to the French-language validation of the Depressive Adjective Check List (DACL) Set 2 of Forms, E, F, G trait version (Lubin, 1981) and to that of the Multiple Affect Adjective Check List (MAACL-R; Zuckerman & Lubin, 1985). The importance of the study was to validate the French-language translation of these instruments to assess nonclinical depression or dysphoria and affect in two French- and English-speaking convenience sample groups. The Check Lists were administered to 183 Canadian subjects 60 years of age and over of both sexes from rural areas in the provinces of Quebec and Ontario, Canada. In order to ensure that the words chosen carried the same connotation as in the English language, a translation-retranslation technique was used. The data collected from this study suggest that the DACL Form G would be most valid to use with either language and/or site in the protocol for future studies.

The California Family Health Project: VII. Summary and integration of findings

In a series of reports, we have observed the relationships between four domains of family life (World View, Emotion Management, Structure/Organization, Problem Solving), and the health of husbands and wives in a community-based sample of 225 families. In this final article of the series, we provide an overview and summary of the results, by gender, including the structure and patterning of variables both within each family domain and among all four family domains analyzed together. In addition, we review the associations between each family domain and adult health (unidomain analyses), and among all four family domains taken together and adult health (multidomain analyses). Prominent differences in family and health relationships based on gender are described from the perspective of socially and culturally supported sex-role expectations and behavior. The results support the use of a multidimensional family assessment framework in health research that can lead to the further development of empirically based models of family process.

Measuring quality of life in stroke

BACKGROUND AND PURPOSE

Little attention has been focused on quality of life in stroke outcome research. The purpose of this review is to outline the meaning of the concept, describe important methodological issues and methods of assessment, review existing quality of life measures, and discuss criteria for selecting an appropriate instrument.

SUMMARY OF REVIEW

The following 10 quality of life instruments were reviewed: COOP Charts; Euroqol; Frenchay Activities Index; Karnofsky Performance Status Scale; McMaster Health Index Questionnaire; Medical Outcomes Study 20-Item Short-Form Health Survey; Nottingham Health Profile; Quality of Life Index; Quality of Well-being Scale; and the Sickness Impact Profile. They were evaluated in terms of length, time needed to complete, content, scoring, and psychometric characteristics.

CONCLUSIONS

Emphasis should be placed on further psychometric evaluation of existing quality of life measures rather than on generating new instruments. There is particular need for supplementary data on the responsiveness of the instruments to changes in patients' clinical status over time. The choice of a suitable quality of life instrument should be based not only on psychometric properties but also on careful consideration of the research question, the relevance to the objectives of the study, the feasibility of the instrument, and the specific characteristics of the stroke patients under investigation.

Technology assessment in healthcare: a means for pursuing the goals of biomedical engineering

The goals of biomedical engineering include the improvement of health and life quality of mankind. However, the contribution of biomedical engineering to those worthy ends must be more clearly related. Biomedical engineers should become more active in demonstrating to policymakers and other parties in healthcare the value of the contributions of healthcare technology. Technology assessment (TA) is a form of investigation designed to identify and evaluate the implications of technologies so as to inform policymaking. Among the important trends in TA that should be of special interest to biomedical engineers are the increasingly higher methodological standards for accepting evidence from clinical investigations, and the use of quality-of-life measures for determining how technologies affect people's lives.