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1
Social determinants ofhealth-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 complexway by the person's condition and its relationship to salient features of its environment. »
� In the field of health and health care, this definition isrestricted to health domains mainly covering� physical health, � psychological state, � and social relationships of the individual.
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 notrelevant=> 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 atleast 5 points
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
-7.8264.7Pain
-6.9672.9Depression
-5.0369.2Anxiety
-2.8577.0Self esteem
-1.1871.4Perceived health
-4.3471.2General
1.5866.7Social
-6.6975.1Mental
-7.9471.7Physical
Female(compared to male)
meanDuke Health Profile
7
Baromètre Santé 2005: age
-15
-10
-5
0
5
10
Physic
al
Men
tal
Socia
l
Gener
alPer
ceive
d he
alth
Pain
Anxie
ty
Depres
sion
Self-e
steem
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
-2.2848.8Mental component summary
-0.7250.4Physical component summary
-1.0767.8General health
-4.4457.4Vitality
-3.7480.9Social functioning
-4.0882.0Role mental
-4.9566.7Mental health
-4.8373.0Bodily pain
-2.3082.2Role physical
-3.2385.3Physical functioning
Female(compared to male)
meanSF 36
9
Décennale Santé: age
-40
-35
-30
-25
-20
-15
-10
-5
0
5
Physic
al fu
nctio
ning
Role
phy
sical
Bodily
pain
M
enta
l hea
lth
Role m
enta
l
Social
func
tioni
ng
Vitality
Gen
eral
hea
lth
Physic
al co
mpo
nent
sum
mar
y
Men
tal c
ompo
nent
sum
mar
y 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
Physic
al
Ment
al
Social
Genera
l
PainSelf
este
em
Anxiet
yDep
ress
ion
> 2 years university
2years university
High school
College
No diploma
11
Baromètre Santé 2005: occupational status
-5
-4
-3
-2
-1
0
1
2
3
4
Physical Mental General Depression Pain Self esteem
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=2
26)
[230
€ -
380€
[ (n=
333)
[380
€ - 6
00€[ (
n=11
11)
[600
€ - 1
000€[ (
n=32
35)
[1000€
- 1
200€[
(n=2
008)
[1200€
- 1
500€[
(n=2
082)
[1500€
- 2
000€[
(n=2
477)
[200
0€ -
2400€[
(n=5
92)
[2400€
- 3
000€[
(n=1
204)
[300
0€ -
4500€[
(n=6
32)
[450
0€ -
7600€[
(n=1
19)
>= 7 600
€ (n=
14)
Revenus mensuels nets par UC
Qua
lité
de v
ie
score - physique score - mental score - social score - general score - percu
score - estime de soi score - anxiete score - depression score - incapacite
Net monthly incomeper household
HRQoL
PhysicalSelf esteem
MentalAnxiety
SocialDepression
GeneralDisability
Perceived health
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%
-5,7-5,2-8,9-3,4-4,6No diploma
-2,8-5,4-5,1-0,8-2,2College
-0,8-1,3-2,3-0,20,3High school
-0,2-0,5-0,50,2-0,12 years university
00000> 2 yearsuniversity
-6,5-19,2-2-6,2-11,2Chronic condition
-3,6-4,6-5,5-2,6-2,6< 230€
Income
0,4-----11,5Inactive
-1-----41,1Unemployed
0----00Employed
Occupational status
Level of education
3,9--5,34,42Living in couple
GeneralPerceivedhealth
SocialMentalPhysicalDuke 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
Physica
l functi
oning
Role phy
sical
Bodily p
ain M
ental h
ealth
Role menta
l
Vitality
Genera
l hea
lth
Physica
l compo
nent sum
mary
> 2years university
2 years university
High school
College
No diploma
15
Décennale Santé: occupational status
-7
-6
-5
-4
-3
-2
-1
0
1
2
Phys
ical f
uncti
onin
g Rol
e ph
ysic
alBo
dily
pain
M
enta
l hea
lth
Role
men
tal
Socia
l fun
ction
ing
Vita
lity
Gen
eral
hea
lth
Phys
ical c
ompo
nent
sum
mar
y
Men
tal c
ompo
nent
sum
mar
y Employed
Unemployed
Inactive
16
50
55
60
65
70
75
80
85
90
95
100
< 23
0€ (n
=121
)
[230
€ -
380€
[ (n=
405)
[380
€ -
600€
[ (n=
1549
)
[600
€ -
1000
€[ (n
=502
0)
[100
0€ -
120
0€[ (
n=27
85)
[120
0€ -
150
0€[ (
n=33
42)
[150
0€ -
200
0€[ (
n=34
23)
[200
0€ -
240
0€[ (
n=14
10)
[240
0€ -
300
0€[ (
n=10
22)
[300
0€ -
450
0€[ (
n=89
3)
[450
0€ -
760
0€[ (
n=23
9)>=
7 6
00€
(n=3
3)
Revenus mensuels nets par UC
Qua
lité
de v
ie
PF RP BP MH RE SF VT GH
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 incomeper household
HRQoL
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 *
-3.1-4Chronic condition
-0.8-2.9< 230€
Income perhousehold
-0.8-1.2Inactive
-1.5-0.4Unemployed
00Employed
Occupational status
---3.1No diploma
---1.3College
---0.2High school
---0.42 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 beingunderstood through social determinants’ lens –impacts on health perception
� questions the role of social environment in healthperception and health-related quality of life
=> Can we identify social mechanisms governing the impact of social determinants on HRQoL?
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 individualsadapt to their social environment
� Sociology highlights the social environment ofindividuals’ 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
Conclusion
�� Social Social determinantsdeterminants of of HRQoLHRQoL highlightshighlights healthhealthinequalitiesinequalities�� in subjective in subjective healthhealth assessmentassessment�� in social in social environmentenvironment
�� Place of monitoring Place of monitoring HRQoLHRQoL in in addressingaddressing healthhealthinequalitiesinequalities ? ?
�� HealthHealth perception perception cancan bebe measuredmeasured over life over life spanspan=> => HRQoLHRQoL maymay becomebecome an an inequalityinequality indicatorindicator
�� HRQoLHRQoL allowsallows measuringmeasuring effecteffect of social intervention of social intervention / of public / of public healthhealth intervention on social intervention on social determinantsdeterminants
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