Reliability and validity of using EQ-5D-5L among healthy and adolescents with major mental health disorders in Ethiopia

The feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone

OBJECTIVES

To assess the feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone, the first psychometric assessment of the EQ-5D-3L to be conducted in patients with stroke in Sub Saharan Africa.

METHODS

A prospective stroke register at two tertiary government hospitals recruited all patients with the WHO definition of stroke and followed patients up at seven days, 90 days and one year post stroke. The newly translated EQ-5D-3L, Barthel Index (BI), modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS), a measure of stroke severity, were collected by trained researchers, face to face during admission and via phone at follow up. Feasibility was assessed by completion rate and proportion of floor/ceiling effects. Internal consistency was assessed by inter item correlations (IIC) and Cronbach's alpha. Repeatability of the EQ-5D-3L was examined using test-retest, EQ-5D-3L utility scores at 90 days were compared to EQ-5D-3L utility scores at one year in the same individuals, whose Barthel Index had remained within the minimally clinical important difference. Known group validity was assessed by stroke severity. Convergent validity was assessed against the BI, using Spearman's rho. Responsiveness was assessed in patients whose BI improved or deteriorated from seven to 90 days. Sensitivity analyses were conducted using the UK and Zimbabwe value sets, to evaluate the effect of value set, in a subgroup of patients with no formal education to evaluate the influence of patient educational attainment, and using the mRS instead of the BI to evaluate the influence of utilising an alternative functional scale.

RESULTS

The EQ-5D-3L was completed in 373/460 (81.1%), 360/367 (98.1%) and 299/308 (97.1%) eligible patients at seven days, 90 days and one year post stroke. Missing item data was low overall, but was highest in the anxiety/depression dimension 1.3% (5/373). Alpha was 0.81, 0.88 and 0.86 at seven days, 90 days and one year post stroke and IIC were within pre-specified ranges. Repeatability of the EQ-5D-3L was moderate to poor, weighted Kappa 0.23-0.49. EQ-5D-3L utility was significantly associated with stroke severity at all timepoints. Convergent validity with BI was strong overall and for shared subscales. EQ-5D-3L was moderately responsive to both improvement Cohen's D 0.55 (95% CI:0.15-0.94) and deterioration 0.92 (95% CI:0.29-1.55). Completion rates were similar in patients with no formal education 148/185 (80.0%) vs those with any formal education 225/275 (81.8%), and known group validity for stroke severity in patients with no formal education was strong. Using the Zimbabwe value set instead of the UK value set, and using the mRS instead of the BI did not change the direction or significance of results.

CONCLUSIONS

The EQ-5D-3L for stroke in Sierra Leone was feasible, and responsive including in patients with no formal education. However, repeatability was moderate to poor, which may be due to the study design, but should add a degree of caution in the analysis of repeated measures of EQ-5D-3L over time in this population. Known group validity and convergent validity with BI and mRS were strong. Further research should assess the EQ-5D in the general population, examine test-retest reliability over a shorter time period and assess the acceptability and validity of the anxiety/depression dimension against other validated mental health instruments. Development of an EQ-5D value set for West Africa should be a research priority.

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda

BACKGROUND

The war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent.

METHODS

A parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat.

DISCUSSION

CHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery.

TRIAL REGISTRATION

ISRCTN ISRCTN10360385. Registered on 30 January 2023.

@ease peer-to-peer youth walk-in centres in The Netherlands: A protocol for evaluating longitudinal outcomes, follow-up results and cost-of-illness

AIM

Innovative youth mental health services around the globe vigorously work on increasing highly needed mental health care accessibility but their service users and care effectiveness have rarely been studied. The Dutch youth walk-in centres of @ease opened in 2018, with currently 11 locations at which free anonymous peer-to-peer counselling is offered to young people aged 12-25. The aim of this protocol is to outline the to-be-conducted research at @ease.

METHODS

Three studies are outlined: (1) an outcome evaluation of @ease visits using hierarchical mixed model analyses and change calculations, (2) a cost-of-illness study using calculations for costs of truancy and care usage among these help-seeking young people, with regression analyses for risk group identification, and (3) a follow-up evaluation at three, six and 12 months to assess long-term effects after ending @ease visits. Data provided by young people include demographics, parental mental illness, truancy, past treatment, psychological distress (CORE-10) and health-related quality of life (EQ-5D-5L). Social and occupational functioning (SOFAS), suicidal ideation and need for referral are rated by the counsellors. Questionnaires are filled out at the end of every visit and at follow-up via e-mail or text, provided permission is given.

DISCUSSION

Research regarding the visitors and effectiveness of the @ease services is fully original. It offers unique insights into the mental wellbeing and cost-of-illness of young people who may otherwise remain unseen while suffering from a high disease burden. The upcoming studies shed light on this unseen group, inform policy and practice and direct future research.

Economic evaluations of non-communicable diseases conducted in Sub-Saharan Africa: a critical review of data sources

BACKGROUND

Policymakers in sub-Saharan Africa (SSA) face challenging decisions regarding the allocation of health resources. Economic evaluations can help decision makers to determine which health interventions should be funded and or included in their benefits package. A major problem is whether the evaluations incorporated data from sources that are reliable and relevant to the country of interest. We aimed to review the quality of the data sources used in all published economic evaluations for cardiovascular disease and diabetes in SSA.

METHODS

We systematically searched selected databases for all published economic evaluations for CVD and diabetes in SSA. We modified a hierarchy of data sources and used a reference case to measure the adherence to reporting and methodological characteristics, and descriptively analysed author statements.

RESULTS

From 7,297 articles retrieved from the search, we selected 35 for study inclusion. Most were modelled evaluations and almost all focused on pharmacological interventions. The studies adhered to the reporting standards but were less adherent to the methodological standards. The quality of data sources varied. The quality level of evidence in the data domains of resource use and costs were generally considered of high quality, with studies often sourcing information from reliable databases within the same jurisdiction. The authors of most studies referred to data sources in the discussion section of the publications highlighting the challenges of obtaining good quality and locally relevant data.

CONCLUSIONS

The data sources in some domains are considered high quality but there remains a need to make substantial improvements in the methodological adherence and overall quality of data sources to provide evidence that is sufficiently robust to support decision making in SSA within the context of UHC and health benefits plans. Many SSA governments will need to strengthen and build their capacity to conduct economic evaluations of interventions and health technology assessment for improved priority setting. This capacity building includes enhancing local infrastructures for routine data production and management. If many of the policy makers are using economic evaluations to guide resource allocation, it is imperative that the evidence used is of the feasibly highest quality.

Insulin injection practice and health related quality of life among individuals with diabetes at Tikur Anbessa Specialized Hospital, Ethiopia: a cross-sectional study

BACKGROUND

Insulin therapy can be inconvenient, painful, burdensome, and restrict patients' daily activities and health related quality of life (HRQOL) due to improper injection techniques or the nature of administration.

OBJECTIVE

This study aimed to assess insulin injection practice, HRQOL and predictors among patients treated with insulin at Tikur Anbessa Specialized Hospital (TASH).

METHODS

An institutional-based cross-sectional study was conducted among diabetes patients on insulin therapy from May to June 2022. A structured questionnaire was used to collect patient characteristics and insulin injection practice. The validated Amharic version of an EQ-5D-5L tool was used to assess the HRQOL. The data was analyzed using SPSS version 26. The patient data were summarized using descriptive statistics. One-way ANOVA using Kruskal-Wallis H tests was used to assess factors that predict insulin handling practice scores. Multivariate linear regression analysis was used to assess factors affecting HRQOL among diabetes patients treated with insulin. The EQ5D-5L utility scores of the patients were calculated using disutility coefficients taken from the Ethiopian general population. Statistical significance was declared at p-value < 0.05.

RESULTS

Of 319 patients who agreed and completed the survey, 51.1% of them were males. Almost half of the participants (n = 158) were > 50 years of age. Among the study participants, 62.1% were only on intermediate acting insulin. A significantly higher proportion of participants 291(91.2%) in this study were taking insulin two times per day. Most of the participants 234(73.4%) had fair practice with a median insulin handling practice score of 38 out of 56. Patient characteristics such as age, educational status, occupation, disease duration, and type of diabetes were significantly association with insulin injection practice (p < 0.05). The mean ± SD utility score of patients were 0.89 ± 0.19 (ranged from -0.04 to 1). Being female (β = -5.42, 95%CI:-8.63,-2.21, p = 0.001) and treated for type-I diabetes mellitus (β =  + 9.04, 95%CI: 4.23,13.85, p-value < 0.0001) were significantly associated with HRQOL of patients on insulin therapy.

CONCLUSION

The study participants had fair practices in insulin handling, storage, and administration techniques, and it was seen that male and type one diabetes patients have a better quality of life compared to their counterparts.

Examining the psychometric properties of a split version of the EQ-5D-5L anxiety/depression dimension in patients with anxiety and/or depression

PURPOSE

This study explored differences in self-reported responses and the psychometric performance of the composite EQ-5D-5L anxiety/depression (A/D) dimension compared with a split version of the dimension where 'anxiety' and 'depression' are measured separately.

METHODS

People with anxiety and/or depression who visited the Amanuel Mental Specialized Hospital in Ethiopia completed the standard EQ-5D-5L with the added subdimensions. Correlation analysis was used to examine convergent validity with validated measures of depression (PHQ-9) and anxiety (GAD-7), while ANOVA was used to assess known-groups' validity. Agreement between ratings for composite and split dimensions was compared using percent agreement and Cohen's Kappa, while the proportion of 'no problems' reports was compared using the chi-square test. Discriminatory power analysis was undertaken using the Shannon index (H') and Shannon Evenness index (J'). Open-ended questions explored participants' preferences.

RESULTS

Of the 462 respondents, 30.5% reported no problems with the composite A/D, while 13.2% reported no problems on both subdimensions. Agreement between ratings for composite and split dimensions was highest for respondents with comorbid anxiety and depression. The depression subdimension had higher correlation with PHQ-9 (r = 0.53) and GAD-7 (r = 0.33) than the composite A/D dimension (r = 0.36 and r = 0.28, respectively). The split subdimensions and composite A/D could adequately differentiate respondents based on their severity of anxiety or depression. Slightly better informativity was observed in EQ-4D-5L + anxiety (H' = 5.4; J' = 0.47) and EQ-4D-5L + depression (H' = 5.31; J' = 0.46) than EQ-5D-5L (H' = 5.19; J' = 0.45).

CONCLUSIONS

Adopting two subdimensions within the EQ-5D-5L tool appears to perform slightly better than the standard EQ-5D-5L.

Health-related quality of life and its determinants among patients with diabetes mellitus: a multicentre cross-sectional study in Northwest Ethiopia

OBJECTIVES

This study assessed the health-related quality of life (HRQoL) and its determinants in patients with diabetes.

DESIGN AND SETTING

An institutional-based multicentre prospective cross-sectional study design was conducted in diabetes follow-up clinics of selected hospitals in Northwest Ethiopia from April to July 2022.

PARTICIPANTS

All eligible adult patients with diabetes at the selected facilities.

MAIN OUTCOME MEASURES

HRQoL was measured using EuroQol 5-dimensions 5-levels (EQ-5D-5L) and the EuroQol-Visual Analogue Scales (EQ-VAS) instruments. A lower EQ-5D-5L utility mean score for each dimension and/or an overall lower utility score of EQ-5D-5L and EQ-VAS scores are intended to show poor HRQoL. Linear regression analysis was used to identify the association of HRQoL and other variables.

RESULTS

Out of the 422 samples approached, 402 (95.3%) participated in the study. Most of the participants (>85%) reported having moderate-to-severe problems in all five EQ dimensions. The overall EQ-5D-5L utility and EQ-VAS scores were 0.56 (±0.11) and 56.7 (±10.1), respectively. A higher body mass index (BMI) (p < 0.001), a higher number of medications (p = 0.037), a high level of blood glucose (p < 0.001), the presence of comorbidities and/or complications (p = 0.031), hypoglycaemia (p = 0.043) and taking insulin (p < 0.001) were associated with worsened HRQoL, whereas practicing self-monitoring of blood glucose (p = 0.002) and taking aspirin (p = 0.008) had a significant association with increased HRQoL.

CONCLUSION

This study concluded that the HRQoL of patients was compromised in all five measuring dimensions. The EQ-5D-5L utility and EQ-VAS scores were far lower than other findings. Clinical and medication-related variables, such as a higher BMI, a higher number of medications, the presence of comorbidities and/or complications, hypoglycaemia and insulin use were associated with poor HRQoL in patients with diabetes. As a result, interventions should be individualised and focused on determinant factors.

Cost‐effectiveness analysis of a psychosocial web‐based intervention for adolescents distressed by a visible difference: Results from a randomized controlled trial in Norway

Adolescents with a visible difference to the face or body (e.g., due to a congenital condition, illness, or injury), may be at risk of elevated psychological distress. Young Person's Face IT (YPF), a web-based psychosocial intervention, has displayed effectiveness, but no previous study has specifically evaluated its cost-effectiveness. The aim of our study was to investigate whether YPF could be a cost-effective alternative for psychosocial support to adolescents distressed by a visible difference, relative to care-as-usual (CAU). Within the context of a randomized controlled trial in Norway, 102 participants (43% boys) were allocated to intervention (n = 55) or waiting list control group (n = 47). Mean age was 13.9 years (SD = 1.71; range 11-18), and all self-identified as experiencing distress related to a visible difference. Participants answered questionnaires including measures of health-related quality of life and social anxiety at baseline and 3-month follow-up. A health economic evaluation using the method of cost-utility analysis was performed, including quality-adjusted life-years (QALYs). Results indicated that the incremental cost-effectiveness of YPF was 63,641 Norwegian kroner per QALYs gained, which is well within the acceptability threshold in the Norwegian healthcare sector. Hence, YPF could potentially be considered a cost-effective intervention for adolescents experiencing distress related to a visible difference, but more research is needed that includes comparisons of YPF to other health- and societal resources and long-term follow-ups. Our study also constitutes an addition to research as, compared to interventions for somatic diseases, there is a lack of studies exploring the cost-effectiveness of psychological interventions.

The effect of percutaneouS vs. cutdoWn accEss in patients after Endovascular aorTic repair (SWEET): Study protocol for a single-blind, single-center, randomized controlled trial

Background

Endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have become the first-line treatment for aortic diseases, but current evidence is uncertain regarding whether a percutaneous approach has better outcomes than cutdown access, especially for patient-centered outcomes (PCOs). This study is designed to compare these outcomes of percutaneous access vs. cutdown access after endovascular aortic repair.

Method

The SWEET study is a randomized, controlled, single-blind, single-center non-inferiority trial with two parallel groups in two cohorts respectively. After eligibility screening, subjects who meet the inclusion criteria will be divided into Cohort EVAR or Cohort TEVAR according to clinic interviews. And then participants in two cohorts will be randomly allocated to either intervention groups receiving percutaneous access endovascular repair or controlled groups receiving cutdown access endovascular repair separately. Primary clinician-reported outcome (ClinRO) is access-related complication, and primary patient-centered outcome (PCO) is time back to normal life. Follow-up will be conducted at 2 weeks, 1 month, 3 months postoperatively.

Discussion

The choice of either percutaneous or cutdown access may not greatly affect the success of EVAR or TEVAR procedures, but can influence the quality of life and patient-centered experience. Given the very low evidence for ClinROs and few data for PCOs, comparison of the percutaneous vs. cutdown access EVAR and TEVAR is essential for both patient-centered care and clinical decision making in endovascular aortic repair.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100053161 (registered on 13th November, 2021).

Health-Related Quality of Life in Spanish Schoolchildren and Its Association with the Fitness Status and Adherence to the Mediterranean Diet

Background: Health-related quality of life (HRQoL) allows knowing the subject’s feelings in distress and well-being, as well as perception of current and future health. Objective: To assess associations between health-related quality of life, fitness status, and adherence to the Mediterranean diet in Spanish children and adolescents. Methods: A cross-sectional study was carried out in a sample of 305 (47.2% women) children and adolescents aged between 8 and 16 years, in the primary and secondary schools of the province of Ávila (central Spain) (NCT05380674). Subjects were classified according to their quality of life: group 1 (highest quality of life) > group 2 (medium quality of life) > group 3 (lowest quality of life). Results: More participants in group 1 showed higher adherence to Mediterranean diet (70.8%) than other groups (group 2: 55.0%; group 3: 43.4%). It was less likely to find optimal levels of muscle strength as quality of life decreased (OR; 95% CI: group 2: 0.535; 0.303−0.955; and group 3: 0.424; 0.234−0.768). Similar trends were found for speed and agility, but only group 3 showed significant results (OR; 95% CI: group 3: 0.297; 0.162−0.545). Flexibility was also the worst in groups 2 and 3 (OR; 95% CI: G2: 0.403; 0.213−0.762; and group 3: 0.520; 0.282−0.958). Conclusion: High fitness status and adherence to the Mediterranean diet were associated with improved health-related quality of life in schoolchildren of central Spain.