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

22

Acknowledgments

� INPES: Baromètre Santé 2005

� Insee: Enquête Décennale Santé 2002-03

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