The relative contributions of race/ethnicity, socioeconomic status, health, and social relationships to life satisfaction in the United States

Purpose  To evaluate racial/ethnic disparities in life satisfaction and the relative contributions of socioeconomic status (SES; education, income, employment status, wealth), health, and social relationships (social ties, emotional support) to well-being within and across racial/ethnic groups. Methods  In two cross-sectional, representative samples of U.S. adults (the 2001 National Health Interview Survey and the 2007 Behavioral Risk Factor Surveillance System; combined n > 350,000), we compared life satisfaction across Whites, Hispanics, and Blacks. We also evaluated the extent to which SES, health, and social relationships ‘explained’ racial/ethnic group differences and compared the magnitude of variation explained by life satisfaction determinants across and within these groups. Results  Relative to Whites, both Blacks and Hispanics were less likely to be very satisfied. Blacks were somewhat more likely to report being dissatisfied. These differences were reduced or eliminated with adjustment for SES, health, and social relationships. Together, SES and health explained 12–15% of the variation in life satisfaction, whereas social relationships explained an additional 10–12% of the variance. Conclusions  Racial/ethnic life satisfaction disparities exist for Blacks and Hispanics, and these differences are largest when comparing those reporting being ‘satisfied’ to ‘very satisfied’ versus ‘dissatisfied’ to ‘satisfied.’ SES, health, and social relationships were consistently associated with life satisfaction, with emotional support having the strongest association with life satisfaction.     

The Significance of Importance: An Evaluation of Ferrans and Powers’ Quality of Life Index

Ferrans and Powers’ Quality of Life Index (QLI) defines and assesses quality of life (QoL) in terms of importance-weighted life satisfaction. This study assessed the value of such weights and explored the relationship between weighted and unweighted (satisfaction only) scores and single-item rated overall life satisfaction (LS) and QoL. Data were collected by a postal survey to 81 Parkinson’s disease patients (88% response rate). Correlations between weighted and unweighted QLI scores were ≥0.96, except for one subscale (r_s = 0.85). Item non-response rates ranged between 4.2 and 45.1% and 1.4 and 38% for the weighted and unweighted QLI, respectively. Cronbach’s α exceeded 0.7 for weighted and unweighted versions of two out of the four subscales and the total score. Scaling success rates were similar for weighted and unweighted scores and did not support the current subscale structure. Unexpectedly, weighted total scores correlated stronger with LS than with QoL, and unweighted scores displayed the opposite pattern. This study found no advantages by using importance-weighted satisfaction scores. The correlational pattern with overall LS and QoL challenges the QLI approach to QoL, although these observations may relate to the use of multiplicative item weights. This study has implications also beyond the QLI regarding, e.g., the use of multiplicative weights and the relationship between life satisfaction and QoL.     

Quality of life and related factors: a questionnaire survey of older people living alone in Mainland China

Purpose

There is a growing population of older people living alone within the context of dramatic population ageing and changing living arrangements. However, little is known about the quality of life (QoL) of older people living alone in Mainland China. This study aimed to investigate QoL and its related factors among Chinese older people who live alone.

Methods

A stratified random cluster sample of 521 community-dwelling older people living alone in Shanghai completed a structured questionnaire through face-to-face interviews. QoL was measured using the Older People’s Quality of Life Questionnaire. Other data collected included self-rated health, physical health, cognitive function, depression, functional ability, loneliness, social support, physical activity, health services satisfaction, satisfaction with overall dwelling conditions and socio-demographic variables.

Results

Older people living alone in Mainland China rated social relationships and financial circumstances as sources of low satisfaction within their QoL. Multiway analysis of variance showed that satisfaction with overall dwelling conditions, self-rated health, functional ability, depression, economic level, social support, loneliness, previous occupation and health services satisfaction were independently related to QoL, accounting for 68.8 % of the variance. Depression and previous occupation had an interaction effect upon QoL.

Conclusions

This study identified nine factors influencing the QoL of older people living alone in Mainland China. Interventions to increase satisfaction with dwelling conditions, improve economic level, social support and functional ability, decrease loneliness and depression and improve health services satisfaction appear to be important for enhancing their QoL.     

Small-cell lung cancer patients are just ‘a little bit’ tired: response shift and self-presentation in the measurement of fatigue

Background Response shift has gained increasing attention in the measurement of health-related quality of life (QoL) as it may explain counter-intuitive findings as a result of adaptation to deteriorating health. Objective To search for response shift type explanations to account for counter-intuitive findings in QoL measurement. Methods Qualitative investigation of the response behaviour of small-cell lung cancer (SCLC) patients (n = 23) in the measurement of fatigue with The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) question ‘were you tired’. Interviews were conducted at four points during 1st line chemotherapy: at the start of chemotherapy, 4 weeks later, at the end of chemotherapy, and 6 weeks later. Patients were asked to ‘think aloud’ when filling in the questionnaire. Results Fifteen patients showed discrepancies between their answer to the EORTC question ‘were you tired’ and their level of fatigue spontaneously reported during the interview. These patients chose the response options ‘not at all’ or ‘a little’ and explained their answers in various ways. In patients with and without discrepancies, we found indications of recalibration response shift (e.g. using a different comparison standard over time) and of change in perspective (e.g. change towards a more optimistic perspective). Patients in the discrepancy group reported spontaneously how they dealt with diagnosis and treatment, i.e. by adopting protective and assertive behaviour and by fighting the stigma. They distanced themselves from the image of the stereotypical cancer patient and presented themselves as not suffering and accepting fatigue as consequence of treatment. Conclusion In addition to response shift, this study suggests that ‘self-presentation’ might be an important mechanism affecting QoL measurement, particularly during phases when a new equilibrium needs to be found.     

Neuroticism and extraversion in association with quality of life in patients with Parkinson’s disease

Purpose  Personality traits appear as determinants of quality of life (QoL) in most chronic diseases. The aim of this study is to explore whether neuroticism and extraversion contribute to the variance in QoL in patients with Parkinson’s disease (PD) when controlled for age, functional status and disease duration. Methods  The Parkinson’s Disease Quality of Life Questionnaire (PDQ-39) was used to assess QoL and the Unified Parkinson’s Disease Rating Scale (UPDRS) for disease severity. Neuroticism and extraversion were measured with the Eysenck Personality Questionnaire (EPQR-A). Multiple linear regression analysis was then used to assess the contribution of neuroticism and extraversion to QoL. Results  The sample consisted of 153 PD patients (48.4% women; 67.9 ± 9.3 years; mean disease duration 7.5 ± 5.8 years). Neuroticism was, after disease severity, the second most important variable associated with QoL in PD patients, in particular for domains associated with psychological processes: emotional well-being, social support, stigma and communication. A higher score in extraversion was significantly associated with better emotional well-being in males, but surprisingly, with worse emotional well-being in females. Conclusions  After functional status, personality traits were clearly associated with QoL in PD patients. Therefore, they should be taken into account by health-care professionals in their appraisal of patient complaints.     

General life satisfaction and domain-specific quality of life in chronic schizophrenic patients

Subjective quality of life (QOL) has often been assessed through questionnaires or structured interviews focusing on the person's satisfaction with various life domains. In particular, most QOL instruments for psychiatric patients are based on this concept. We report on a study casting some doubts on the rationale of this approach. We investigated the QOL of 48 chronic schizophrenic outpatients with a long-term disease history (at least 20 years) using a German version of the Lancashire QOL Profile. The interrelations between general life satisfaction, satisfaction with specific life domains, psychological well-being and psychopathology were studied using correlation analysis and multiple linear regression. Of the life domains assessed, only two, namely social relations and health, contributed significantly to the patients' general life satisfaction, while the others (including work, leisure, family relations and housing) did not. The subscales on psychological well-being (self-esteem, affective state) as well as psychopathology were found to be more closely associated with general life satisfaction than almost all life domains considered. The findings are discussed with regard to the specific situation of the group of patients investigated. They give indications that the life domain approach to measuring QOL has its limitations, in particular when applied to patients having adapted to a very restricted everyday life.     

Persistent impaired emotional functioning in survivors of a myocardial infarction?

The quality of life (QoL) of survivors of a myocardial infarction (MI) remains lower than that of their peers long after the acute event. Previous research on this subject has indicated, however, that this difference might lessen somewhat over time for the dimension `emotional functioning' (as measured by the sickness impact profile (SIP): a generic instrument for QoL). The present study explores this phenomenon further using two instruments that specifically measure emotional functioning i.e. the hospital anxiety and depression scale (HAD) and the heart patients psychological questionnaire (HPPQ). Ninety-nine participants of a large population-based cohort (the Rotterdam study), who had been admitted to the hospital because of an MI in the previous 6–60 months, and 101 reference subjects, without a history of infarction of heart or brain, from the same age and gender-groups, were interviewed twice (at 1- to 3-year time intervals). The results of the present study confirm earlier findings that the emotional functioning (in terms of ‘anxiety’, ‘depression’, ‘well-being’, ‘feeling disabled’, and ‘displeasure’) of MI survivors is impaired when compared to their unaffected peers. Moreover, they did not show any improvement in ‘anxiety’, ‘depression’, ‘well-being’ and ‘displeasure’ over time in the MI survivors. The results did, however, show that the difference between MI survivors and referents became less in time in the dimension `feeling disabled'. This decrease was partly because MI survivors improved and partly because referents felt more disabled over time. One explanation for this might be that referents (51% aged 70 years and over) had difficulties in adapting emotionally to decreasing levels of physical functioning with increasing age, while the MI survivors tended to adjust to and accept the impairments they had contracted several years earlier. This revised version was published online in June 2006 with corrections to the Cover Date.     

Quality of life in patients with bladder carcinoma after cystectomy: First results of a prospective study

This study reports the changes in the quality of life (QoL) of 44 patients observed prospectively from pre-surgery to one year post-surgery. Two kinds of surgeries were compared: continent and incontinent urinary diversion. In most areas the QoL returned to the prior level within one year after surgery. However, patients were restricted in their physical activity, sexual activity, and emotional well-being. Using individual weights for different aspects of life (Fragen zur Lebenszufriedenheit – Module FLZ^M), QoL was higher than when using an unweighted measurement (Short Form 36, MOS). Two trends for the different developments in the QoL were established: general life satisfaction and social functioning tended to improve after a continent diversion but decreased after an incontinent diversion. The perceived global satisfaction with both kinds of diversion was high – 75% of the patients would choose the same kind of diversion again.     

Job Satisfaction and the Work Situation of Physicians: a survey at a German University hospital

Summary. Objective: Job demands and workload of hospital physicians are increasing. The object of this survey was to examine the factors that constitute job satisfaction and to analyse physicians’ work situation in the area of in-patient care. Methodology: 447 physicians at a German University Hospital received questionnaires with regard to work situation, job satisfaction and personal health. Data were analysed by MANOVA and multiple regression models. Results: A first regression model explained 53% of the variance in satisfaction with ‘work and profession’. Among the explanatory variables ‘superiors and hierarchy’ showed the highest beta-weight (β = −0.49). ‘Personal health’ also determined job satisfaction, for female physicians stronger (β = −0.31) than for male physicians (β = −0.11). In a second regression model on satisfaction with ‘Financial situation’ only 18% of the variance was explained, whereby ‘work condition on the ward’, ‘personal health’ and ‘collaboration between occupational groups’ showed the highest beta-weights. Discussion: Among resident physicians, work conditions, superiors, hierarchy, transparency and participation in decisions are very important variables for job satisfaction. Improvements in these aspects may improve job satisfaction and help to reduce physician shortage in hospitals. Submitted: 2 March 2005; Revised: 31 May, 29 August 2005, 15 November 2005; Accepted: 9 June 2006     

Is there an association between economic performance and public satisfaction in health care?

Earlier studies on the association between health systems’ economic performance and public satisfaction were based on between-countries comparisons. This approach can be challenged as it ignores the fact that subjective measures like ‘satisfaction’ might be relative. Cohort analysis is a way of dealing with this issue as it focuses on within-countries comparisons. The association between change in satisfaction with health care systems and change in economic performance, determined by an output-orientated constant returns to scale DEA Malmquist model over the period 1995 to 2000/2002 using OECD data, is explored. The results show that a health care systems’ economic performance is not associated with public satisfaction.     

Is a Generic Quality of Life Instrument Helpful for Evaluating Women with Urinary Incontinence?

Objectives: The aim of this study was to determine whether a generic health outcome instrument would be helpful for evaluating women with stress urinary incontinence (UI) combined with or without urge UI. Methods: A total of 109 women with UI and 80 controls participated in the study. Health-related quality of life (QOL) was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) and the Incontinence Quality of Life (I-QoL) questionnaire. Results: Among eight domains of the SF-36 questionnaire, only four domains, namely, ‘role-physical functioning’ (p<0.05), ‘vitality’ (p<0.05), ‘mental health’ (p<0.05) and ‘bodily pain’ (p<0.05) were significantly different between the groups. Comparing the I-QoL sores in the two groups, patients with UI had significantly poorer subscale scores of I-QoL than the controls (p<0.05 for all domains). When women with UI were subdivided into groups of stress and mixed UI, only 2 domains of the SF-36 questionnaire, ‘role-physical functioning’ (p<0.05) and ‘bodily pain’ (p<0.05), were significantly different. The mixed UI group had higher scores only on these two domains compared to the stress UI group. In the ‘role-physical functioning’ domain, there was no significant difference between the mixed UI group and the controls. In ‘bodily pain’ domain, there was no significant difference between the stress UI group and the controls. The mixed group had the highest scores observed. Patients with mixed UI had significantly lower total scores compared to those with stress UI, including the subscale score of ‘avoidance behavior’ of the I-QoL. Among eight domains of the SF-36, only ‘physical functioning’ (r = 0.281, p<0.01) and ‘social functioning’ (r = 0.239, p<0.05) were weakly correlated with ‘psychological impact’ of the I-QoL. Conclusion: Our findings show that the generic QOL instrument is not sensitive measure of QOL in women with UI.     

Quality-of-life outcome after hallux valgus surgery

Objective To assess the quality of life before and after hallux valgus surgery. Methods A longitudinal study with 94 consecutive patients undergoing hallux valgus surgery. Assessments were made preoperatively and at 12 month postoperatively. Measures used were the quality of life (QoL) according to SF-36, a disease specific score (the American Orthopaedic Foot and Ankle Society’s clinical rating system for the hallux), the severity of the deformity, the possibility of wearing the preferred choice of shoes and satisfaction with the treatment. The pre- and postoperative QoL scores were compared with the score in the general population. Results QoL outcomes improved significantly postoperatively regarding bodily pain, vitality, mental health and the mental component summary. The correction of the deformity did not affect the QoL. Regardless of the extent of correction, the choice of shoeware and the degree of satisfaction with surgery were associated with a better QoL. Conclusions Hallux valgus patients have worse pain than the general population. Surgery produces a significant improvement in the quality of life. The severity of the deformity did not influence the QoL, however; the free choice of shoeware and the degree of satisfaction with the surgery had a positive effect on the QoL outcome. SF-36 is a relevant tool for evaluating outcome in hallux valgus surgery.     

Clarifying quality of life assessment: do theoretical models capture the underlying cognitive processes?

Objective  To develop an analysis scheme capturing the cognitive processes underlying QoL assessment to increase our understanding on how to interpret responses to QoL items. Tourangeau et al.’s (The psychology of survey response, 2000) and Rapkin and Schwartz’ (Health Qual Life Outcomes 2:14, 2004) cognitive process models form the basis for this analysis scheme. Methods  We conducted think aloud interviews with six cancer patients prior to and following radiotherapy to elicit the cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Content analysis was carried out by two to four researchers independently. Eighty text fragments were analyzed inductively and combined in an iterative process with deductive analyses based on both models. Results  We have developed a comprehensive analysis scheme feasible for analyzing the cognitive processes underlying QoL assessment qualitatively. All cognitive components of both models could be distinguished in our data. The cognitive component ‘reporting and response selection’ needed extension to fully capture the cognitive processes used. Conclusion  The two models combined are useful in describing the cognitive processes cancer patients use in answering QoL items, and as such facilitate insight into patients’ self-reported QoL assessments. Interestingly, the content of the cognitive processes not only differed between patients but also between items within patients and over time.

Predictors of Quality of Life in HIV-infected Rural Women: Psychometric Test of the Chronic Illness Quality of Life Ladder

The Chronic Illness Quality of Life Ladder (CIQOLL) underwent psychometric testing in a sample of 278 women with HIV disease. The CIQOLL, a self-anchoring striving scale based on Cantril’s Ladder, measures seven domains (physical , emotional, financial, family and friends, spiritual well-being, peace of mind, and overall life satisfaction) across four time periods (present, past, future, life without a diagnosis of HIV). The domains were derived from focus groups with persons with HIV disease. Women with a diagnosis of HIV Infection, age 18 or older, residing in rural areas in the southeastern United States, completed questionnaires that measured physical functioning, HIV related symptom frequency and distress, depressive symptoms, social support, and quality of life. Procedures used to assess reliability included item–item, item–total, and subscale–subscale correlations, and Chronbach’s coefficient α. Criterion-related (concurrent) validity was assessed by correlating the CIQOLL with HIV symptoms, functional status and social support. Construct validity was estimated using factor analysis and predictive modeling. Results provide preliminary evidence that the CIQOLL is a reliable and valid scale that may provide meaningful information about persons living with a chronic illness, such as HIV disease, especially low literacy and unacculturated populations. Additional research is needed to weight the domains, test the sensitivity of the scale to changes over time, and explore the usefulness of discrepancy scores.     

Is Psychometric Scoring of the McNew Quality of Life After Myocardial Infarction Questionnaire Superior to the Clinimetric Scoring? A Comparison of the Two Approaches

Objective: ‘Clinimetric’ and ‘psychometric’ approaches are currently used to develop health related quality of life questionnaires. The Quality of Life after Myocardial Infarction questionnaire (QLMI) was originally developed using ‘clinimetric’ criteria; it was subsequently modified (McNew QLMI) and a new domain structure was defined using factor analysis. The objective of this study was to compare the measurement properties of the McNew QLMI scores when both approaches for scoring are used. Methods: The McNew QLMI and SF-36 were administered to patients 2 weeks and 2 months after myocardial infarction. Two sets of scores for the McNew QLMI were computed using the original ‘clinimetric’ and the subsequent ‘psychometrically’ derived scoring systems. Reliability statistics for the two sets of domains were compared and construct validity was assessed by establishing a priori hypotheses on the expected correlation between each score and the dimensions of the SF-36. Results: Both sets of scores had similar reliability (Cronbach’s α between 0.64 and 0.93) and responsiveness (SRMs between 0.17 and 0.87) while validity was better for the ‘clinimetric’ set of scores (concordance between observed and expected correlations was moderate for the ‘clinimetric’ scores and fair for the ‘psychometric’ scores). Conclusion: Since overall measurement properties of the ‘clinimetrically’ scored McNew QLMI are better than the ‘psychometrically’ scored version, we suggest that either the original ‘clinimetric’ system is used or that an improved ‘psychometric’ version is developed.     

Measurement accuracy in assessing patient’s quality of life: to weight or not to weight domains of quality of life

Purpose  Health-related quality of life (HRQOL) measures typically do not incorporate patients’ preferences for domains such as physical, emotional, functional and social/family well-being, which may compromise precision. Method  A forced-choice domain-preference measure was developed to assess the importance of HRQOL domains. About 194 cancer patients completed the domain-preference measure, along with measures of HRQOL, coping, adjustment, and life satisfaction. Results  Patients ranked emotional well-being as most important and the loss of social-family well-being as the most difficult to do without. A weighting algorithm revealed no advantage to incorporating individuals’ domain preferences in HRQOL assessment; however, preliminary evidence suggested that HRQOL measurement may be more accurate in predicting outcomes for individuals with no distinct domain preferences than those with distinct preference profiles. Conclusion  This study provides preliminary evidence for the validity of current measures of HRQOL, which may inherently take into account patients’ domain preferences.     

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

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

Factors that impede the discharge of long-term schizophrenic inpatients

The aim of the present study was to explore factors that impede the discharge of long-term schizophrenic inpatients, and it was focused on the patients' subjective views. Semi-structured interviews based on the Occupational Self Assessment (OSA) of 73 long-term inpatients with schizophrenia and 24 schizophrenic patients who had been discharged from hospitals after a long-term stay were conducted. Logistic regression analysis was performed. The results revealed that the factors that impeded the discharge of schizophrenic patients from hospitals were advanced age, severe mental symptoms, and higher rating of one's own capabilities in daily living. These results suggest that schizophrenic long-term inpatients require occupational interventions that help patients to have a realistic image of their daily life after discharge and that invite them to update their self-assessments of competence related to the skills needed for daily life.     

Bipolar Disorder and Quality of Life: A Patient-Centered Perspective

Objectives: Several quantitative studies have now examined the relationship between quality of life (QoL) and bipolar disorder (BD) and have generally indicated that QoL is markedly impaired in patients with BD. However, little qualitative research has been conducted to better describe patients’ own experiences of how BD impacts upon life quality. We report here on a series of in-depth qualitative interviews we conducted as part of the item generation phase for a disease-specific scale to assess QoL in BD. Methods: We conducted 52 interviews with people with BD (n=35), their caregivers (n=5) and healthcare professionals (n=12) identified by both convenience and purposive sampling. Clinical characteristics of the affected sample ranged widely between individuals who had been clinically stable for several years through to inpatients who were recovering from a severe episode of depression or mania. Interviews were tape recorded, transcribed verbatim and analyzed thematically. Results: Although several interwoven themes emerged from the data, we chose to focus on 6 for the purposes of this paper: routine, independence, stigma and disclosure, identity, social support and spirituality. When asked to prioritize the areas they thought were most important in determining QoL, the majority of participants ranked social support as most important, followed by mental health. Conclusions: Findings indicate that there is a complex, multifaceted relationship between BD and QoL. Most of the affected individuals we interviewed reported that BD had a profoundly negative effect upon their life quality, particularly in the areas of education, vocation, financial functioning, and social and intimate relationships. However, some people also reported that having BD opened up new doors of opportunity.     

Changes in quality of life in chronic psychiatric patients: A comparison between EuroQol (EQ-5D) and WHOQoL

It has often been postulated that simple, short questionnaires are unable to reflect complex changes in well-being of individuals with chronic psychiatric disorders. To investigate these assumptions we included two recently developed instruments to measure quality of life (the WHOQoL-Bref and the EuroQoL EQ-5D) in a randomised control trial (RCT) in which two treatment conditions were compared. Aims of the study were to assess the sensitivity and validity of these quality of life (QoL)-instruments, to establish their relationship and to examine the predictors of changes in QoL. Subjective changes in QoL were measured on three assessments waves in a period of 18 months and compared to objective changes in psychopathology and social functioning in a sample of 76 chronic schizophrenic patients who participated in the RCT. Results indicated that both WHOQoL-Bref and EuroQoL EQ-5D are capable of detecting changes in QoL over time in physical and psychological well-being. The instruments partly measure the same aspects of QoL, indicated by 50% common variance on total scores. Reduction of positive psychotic symptoms appeared to be the most important factor in improving QoL. The weighted TTO-score of EuroQoL-5D, which is often used as an index in economic evaluations of health care, did however not correspond with these changes, which indicates that it is less sensitive to changes in social and psychological well-being. Its use as the core measure in (economic) health evaluation in the field of psychiatry therefore seems less appropriate.