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(1)

1

Social determinants of

health-related quality of life

Francis Guillemin, Joelle Kivits

EA 4360 Apemac, Inserm CIC-EC

Université de Lorraine, CHU de Nancy

(2)

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.

(3)

3

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

(4)

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

(5)

5

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

(6)

Baromètre Santé 2005: overall and gender

-7.82 64.7

Pain

-6.96 72.9

Depression

-5.03 69.2

Anxiety

-2.85 77.0

Self esteem

-1.18 71.4

Perceived health

-4.34 71.2

General

1.58 66.7

Social

-6.69 75.1

Mental

-7.94 71.7

Physical

Female

(compared to male) mean

Duke Health Profile

(7)

7

Baromètre Santé 2005: age

-15 -10 -5 0 5 10

Physical

Mental

Social

General

Perceived health

Pain

Anxiety

Depression

Self-esteem

18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-75 years

>75 ans

(8)

Décennale Santé: overall and gender

-2.28 48.8

Mental component summary

-0.72 50.4

Physical component summary

-1.07 67.8

General health

-4.44 57.4

Vitality

-3.74 80.9

Social functioning

-4.08 Role mental 82.0

-4.95 66.7

Mental health

-4.83 Bodily pain 73.0

-2.30 82.2

Role physical

-3.23 85.3

Physical functioning

Female

(compared to male) mean

SF 36

(9)

9

Décennale Santé: age

-40 -35 -30 -25 -20 -15 -10 -5 0 5

Physical functioning

Role physical

Bodily pain

Mental health

Role mental

Social functioning

Vitality

General health

Physical com

ponent sum mary

Mental com

ponent sum mary

18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-75 years

>75 years

(10)

Baromètre Santé 2005: level of education

-10 -8 -6 -4 -2 0 2

Physical

Mental

Social

General

Pain

Self esteem

Anxiety

Depression

> 2 years university 2years university High school College No diploma

(11)

11

Baromètre Santé 2005: occupational status

-5 -4 -3 -2 -1 0 1 2 3 4

Physical Mental General Depression Pain Self es teem

Employed Unemployed Inactive

(12)

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)

50 55 60 65 70 75 80 85 90 95 100

< 230€ (n=226)

[230 - 380€[ (n=333)

[380 - 600€[ (n=1111)

[600 - 1000€[ (n=3235)

[1000€ - 1200€[ (n=2008)

[1200€ - 1500€[ (n=2082)

[1500€ - 2000€[ (n=2477)

[2000€ - 2400€[ (n=592)

[2400€ - 3000€[ (n=1204)

[3000€ - 4500€[ (n=632)

[4500€ - 7600€[ (n=119)

>= 7 600(n=14)

Revenus mensuels nets par UC

Quali de vie

score - physique score - mental score - social score - general score - percu

Net monthly income per household

HRQoL

Physical Mental Social General Perceived health

(13)

13

Baromètre Santé 2005: social indicators

23.3%

33.6%

7.4%

59.0%

8.0%

40.8%

18.7%

12.8%

19.7%

70.6%

-5,7 -5,2

-8,9 -3,4

-4,6 No diploma

-2,8 -5,4

-5,1 -0,8

College -2,2

-0,8 -1,3

-2,3 -0,2

0,3 High school

-0,2 -0,5

-0,5 0,2

-0,1 2 years university

0 0

0 0

0

> 2 years university

-6,5 -19,2

-2 -6,2

-11,2 Chronic condition

-3,6 -4,6

-5,5 -2,6

-2,6

< 230€

Income

0,4 --

-- -1

1,5 Inactive

-1 --

-- -4

1,1 Unemployed

0 --

-- 0

0 Employed

Occupational status Level of education

3,9 --

5,3 4,4

2 Living in couple

General Perceived

health Social

Mental Physical

Duke Health Profile dimensions*

* Multivariate linear regression models adjusted on age and sex

(14)

Décennale Santé: level of education

-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1

Physical functioning

Role physical

Bodily pain

Mental health

Role mental

Vitality

General health

ysical component summary

> 2years university 2 years university High school College No diploma

(15)

15

Décennale Santé: occupational status

-7 -6 -5 -4 -3 -2 -1 0 1 2

Physical functioning

Role physical

Bodily pain

Mental health

Role mental

Social functioning

Vitality

General health

Physical com

ponent sum mary

Mental com

ponent sum mary

Employed Unemployed Inactive

(16)

50 55 60 65 70 75 80 85 90 95 100

< 230€ (n=121)

[230 - 380€[ (n=405)

[380 - 600€[ (n=1549)

[600 - 1000€[ (n=5020)

[1000€ - 1200€[ (n=2785)

[1200€ - 1500€[ (n=3342)

[1500€ - 2000€[ (n=3423)

[2000€ - 2400€[ (n=1410)

[2400€ - 3000€[ (n=1022)

[3000€ - 4500€[ (n=893)

[4500€ - 7600€[ (n=239)

>= 7 600(n=33)

Revenus mensuels nets par UC

Quali de vie

Décennale Santé: income

Zoom sur les scores de qualité de vie (Échelle de qualité de vie de 50 à 100 points – score HT non représenté)

Net monthly income per household

HRQoL

(17)

17

Décennale Santé: social indicators

40.0%

35.2%

6.1%

58.7%

13.9%

43.0%

17.0%

13.6%

12.5%

71.6%

SF36 *

-3.1 -4

Chronic condition

-0.8 -2.9

< 230€

Income per household

-0.8 -1.2

Inactive

-1.5 -0.4

Unemployed

0 0

Employed

Occupational status

-- -3.1

No diploma

-- -1.3

College

-- -0.2

High school

-- -0.4

2 years university

-- 0

> 2 years university Level of education

1.5 --

Living in couple

Mental component

summary Physical component

summary

* Multivariate linear regression models adjusted on age and sex

(18)

Discussion (1)

Social Social determinantsdeterminants of of HRQoLHRQoL : : whywhy isis itit important ? 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?

(19)

19

Discussion (2)

ExploringExploring social mechanisms governing the social mechanisms governing the impact of social determinants in

impact of social determinants in HRQoLHRQoL impliesimplies

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

(20)

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

(21)

21

Conclusion

Social determinantsSocial determinants of HRQoLof HRQoL highlightshighlights healthhealth inequalities

inequalities

in subjective healthin subjective health assessmentassessment in social environmentin social environment

Place of monitoring HRQoLPlace of monitoring HRQoL in addressingin addressing healthhealth inequalities

inequalities ? ?

HealthHealth perception perception cancan bebe measuredmeasured over life spanover life span

=>

=> HRQoLHRQoL maymay becomebecome an inequalityan inequality indicatorindicator

HRQoLHRQoL allowsallows measuringmeasuring effecteffect of social intervention of social intervention / of public

/ of public healthhealth intervention on social intervention on social determinantsdeterminants

(22)

Acknowledgments

INPES: Baromètre Santé 2005

Insee: Enquête Décennale Santé 2002-03

Marie-Line Erpelding, biostatistician (Inserm CIC-EC)

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