Social determinants of health-related quality of life Francis Guillemin, Joelle Kivits EA 4360 Apemac, Inserm CIC-EC Université de Lorraine, CHU de Nancy
1
Health-Related Quality of Life WHO (1993) defines quality of life « as an individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. » « It is a broad ranging concept affected in a complex way by the person's condition and its relationship to salient features of its environment. » In the field of health and health care, this definition is restricted to health domains mainly covering physical health, psychological state, and social relationships of the individual. 2
Health-Related Quality of Life HRQoL measures the perspective and experience of the subject consequences of his/her health condition Like pain symptoms, measurement by an observer is not relevant => Subjective health, perception by the individual Self-assessment or by an interviewer Measurement using self-report standardized questionnaire Multidimensional in composite scores: physical, mental, social This endpoint can be assessed and monitored all along life span => People may adjust to various situations 3
Measurement and indicators Duke Health Profile 10 dimensions Score 0=worse to 100= best quality of life
SF-36 8 dimensions into 2 components summary Score 0=worse to 100= best quality of life Interpretation: minimum important difference at least 5 points
4
Investigating social determinants General population surveys Baromètre Santé 2005 (INPES) Random sample of households and individuals (phone) N=16326 individuals Adults 18 to 75 years Duke Health Profile Enquête décennale Santé 2002-03 (Insee) Random sample of households (home visits) N=20574 individuals Adults 18 years and over SF-36 5
Baromètre Santé 2005: overall and gender Duke Health Profile
mean
Female (compared to male)
Physical
71.7
-7.94
Mental
75.1
-6.69
Social
66.7
1.58
General
71.2
-4.34
Perceived health
71.4
-1.18
Self esteem
77.0
-2.85
Anxiety
69.2
-5.03
Depression
72.9
-6.96
Pain
64.7
-7.82 6
Baromètre Santé 2005: age
10 5
18-24 years 25-34 years
0
35-44 years 45-54 years
-5
55-64 years 65-75 years
-10
>75 ans
n
es te em Se lf-
De pr es sio
ty An xie
Pa in
he al th d
Pe rc ei ve
G en er al
l So cia
M en ta l
Ph ys i
ca l
-15
7
Décennale Santé: overall and gender SF 36
mean
Female (compared to male)
Physical functioning
85.3
-3.23
Role physical
82.2
-2.30
Bodily pain
73.0
-4.83
Mental health
66.7
-4.95
Role mental
82.0
-4.08
Social functioning
80.9
-3.74
Vitality
57.4
-4.44
General health
67.8
-1.07
Physical component summary
50.4
-0.72
Mental component summary
48.8
-2.28 8
ph ys i
P hy V ita si G ca lit e y ne lc om ra lh M po ea en ne lth ta n lc ts om um po m ar ne y nt su m m ar y
pa M in en ta lh ea lth R ol e S m oc en ia ta lf l un ct io ni ng
ca l
io ni ng
B od ily
R ol e
P hy si ca lf un ct
Décennale Santé: age 5
0
-5
-10 18-24 years
25-34 years
-15 35-44 years 45-54 years
-20 55-64 years
-25 65-75 years >75 years
-30
-35
-40
9
Baromètre Santé 2005: level of education 2 0 -2 > 2 years university
-4
2years university High school
-6
College No diploma
-8
ep re s
sio
n
ty xie D
An
lf e
st ee m
Pa in Se
l G en
er a
l cia So
en ta l M
Ph ys ic
al
-10
10
Baromètre Santé 2005: occupational status
4 3 2 1 0
Employed -1
Unemployed Inactive
-2 -3 -4 -5 Physical
Mental
General
Depression
Pain
Self esteem
11
Baromètre Santé 2005: income Zoom sur les scores de qualité de vie (Échelle de qualité de vie de 50 à 100 points – score Douleur non représenté)
100 95 90 85 Qualité de vie
80 75
HRQoL
70 65 60 55 50
=
7
0€ 60
4) =1 (n
Net monthly income per household score - percu Perceived
health
12
Baromètre Santé 2005: social indicators Physical
Mental
Social
Perceived health
General
70.6%
2
4,4
5,3
--
3,9
19.7%
0
0
0
0
0
2 years university
12.8%
-0,1
0,2
-0,5
-0,5
-0,2
High school
18.7%
0,3
-0,2
-2,3
-1,3
-0,8
College
40.8%
-2,2
-0,8
-5,1
-5,4
-2,8
8.0%
-4,6
-3,4
-8,9
-5,2
-5,7
0
0
--
--
0
1,1
-4
--
--
-1
1,5
-1
--
--
0,4
-2,6
-2,6
-5,5
-4,6
-3,6
-11,2
-6,2
-2
-19,2
-6,5
Duke Health Profile dimensions* Living in couple Level of education > 2 years university
No diploma Occupational status Employed Unemployed Inactive
59.0% 7.4% 33.6%
Income < 230€ Chronic condition
23.3%
* Multivariate linear regression models adjusted on age and sex
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Décennale Santé: level of education
1 0 -1 -2 -3 -4 -5 -6
> 2years university 2 years university High school College No diploma
po n
G
en
en
ts
er a
um
lh
m
ar y
ea lth
lity Vi ta
l ta m en Ro
le
lh en ta M
Bo d
ily
pa
ea l th
al
Ro
le
ph ys
ic
ti o ni ng nc fu al
Ph
ys
ica
lc
om
Ph y
sic
in
-7 -8 -9
14
P hy si V ca ita G e lc lit y om ner a M po lh en n en eal ta th lc ts om um po m ne ar y nt su m m ar y
Ph ys ic al fu nc tio ni ng R ol e ph ys ic al B od ily pa M in en ta lh ea l th R ol e S m oc en ia ta lf l un ct io ni ng
Décennale Santé: occupational status
2
1
0
-1
-2 Employed
Unemployed
-3 Inactive
-4
-5
-6
-7
15
PF RP BP MH RE SF
00 €
80 €
50 0€
VT GH
>=
-7
7
0€
)
)
(n
=3 3)
n= 23 9)
n= 89 3)
n= 10 22
n= 14 10
)
)
)
20 )
n= 34 23
0€ [(
60
60
50
n= 33 42
0€ [(
0€ [(
0€ [(
0€ [(
n=
n= 27 85
[(
0€ [(
50
00
40
00
50
-4
-3
-2
-2
-1
0€
5)
1)
49 )
=4 0
=1 2
=1 5
(n
(n
(n
0€ [(
00
20
-1
€[
€[
0€
80
00
-3
-6
-1
00 0€
40 0€
00 0€
50 0€
20 0€
00 0€
[4
Revenus mensuels nets par UC [3
[2
[2
[1
[1
[1
[6
[3
30 €
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Qualité de vie
HRQoL
[2
2 years university
12.5%
0
--
2 years university
13.6%
-0.4
--
High school
17.0%
-0.2
--
College
43.0%
-1.3
--
No diploma
13.9%
-3.1
--
58.7%
0
0
6.1%
-0.4
-1.5
35.2%
-1.2
-0.8
-2.9
-0.8
-4
-3.1
SF36 *
Living in couple Level of education
Occupational status Employed Unemployed Inactive Income per household < 230€ Chronic condition
40.0%
* Multivariate linear regression models adjusted on age and sex
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Discussion (1) Social determinants of HRQoL : why is it important ? We know that health perception impacts on health care recourse Data show the existence of social determinants in HRQoL indicate that social environment – as being understood through social determinants’ lens – impacts on health perception questions the role of social environment in health perception and health-related quality of life => Can we identify social mechanisms governing the impact of social determinants on HRQoL? 18
Discussion (2)
Exploring social mechanisms governing the impact of social determinants in HRQoL implies
1.
a pluridisciplinary approach Epidemiology, through HRQoL instruments, studies a part of health perception Psychology examines how chronically ill individuals adapt to their social environment Sociology highlights the social environment of individuals’ life 2. a multilevel approach of health perception Population health status Social environment Individual situations 19
Discussion (3) 3.
an individual – structural approach, mobilizing the concept of agency “the ability for people to deploy a range of causal powers… the ability to produce an effect” (Frolich et al. 2001, 2002) “make a difference to a pre-existing state of affairs or course of events” (Giddens, 1984) In public health, an agent is an individual engaging with social environment Linking individual and structural components of health Considers structural roots of social determinants
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Conclusion Social determinants of HRQoL highlights health inequalities in subjective health assessment in social environment Place of monitoring HRQoL in addressing health inequalities ? Health perception can be measured over life span => HRQoL may become an inequality indicator HRQoL allows measuring effect of social intervention / of public health intervention on social determinants
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Acknowledgments INPES: Baromètre Santé 2005 Insee: Enquête Décennale Santé 2002-03 Marie-Line Erpelding, biostatistician (Inserm CIC-EC)
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