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Bradley H, Zhu Y, Duan X, Kang H, Qu B. HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties. JMIR Public Health Surveill 2022; 8:e39015. [PMID: 36222289 PMCID: PMC9782451 DOI: 10.2196/39015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/03/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS. OBJECTIVE The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. METHODS This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation. RESULTS A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation). CONCLUSIONS This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.
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Affiliation(s)
| | - Yaxin Zhu
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, China
| | - Xiyu Duan
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, China
| | - Hao Kang
- Administration Department of Nosocomial Infection, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Bo Qu
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, China.,School of Public Health, China Medical University, Shenyang, China
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Wen H, Yang Z, Zhu Z, Han S, Zhang L, Hu Y. Psychometric properties of self-reported measures of health-related quality of life in people living with HIV: a systematic review. Health Qual Life Outcomes 2022; 20:5. [PMID: 35012574 PMCID: PMC8744327 DOI: 10.1186/s12955-021-01910-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/14/2021] [Indexed: 01/31/2023] Open
Abstract
Objective To identify and assess the psychometric properties of patient-reported outcome measures (PROMs) of health-related quality of life (HRQoL) in people living with HIV (PLWH). Methods Nine databases were searched from January 1996 to October 2020. Methodological quality was assessed by using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) Risk of Bias Checklist. We used the COSMIN criteria to summarize and rate the psychometric properties of each PROM. A modified Grading, Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. Results Sixty-nine studies reported on the psychometric properties of 30 identified instruments. All studies were considered to have adequate methodological quality in terms of content validity, construct validity, and internal consistency. Limited information was retrieved on cross-cultural validity, criterion validity, reliability, hypothesis testing, and responsiveness. High-quality evidence on psychometric properties was provided for the Medical Outcomes Study HIV Health Survey (MOS-HIV), the brief version of the World Health Organization's Quality of Life Instrument in HIV Infection (WHOQoL-HIV-BREF), 36-Item Short Form Survey (SF-36), Multidimensional Quality of Life Questionnaire for Persons with HIV/AIDS (MQoL-HIV), and WHOQoL-HIV. Conclusions The findings from the included studies highlighted that among HIV-specific and generic HRQoL PROMs, MOS-HIV, WHOQoL-HIV-BREF, SF-36, MQoL-HIV, and WHOQoL-HIV are strongly recommended to evaluate HRQoL in PLWH in research and clinics based on the specific aims of assessments and the response burden for participants. Supplementary Information The online version contains supplementary material available at 10.1186/s12955-021-01910-w.
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Affiliation(s)
- Huan Wen
- Fudan University School of Public Health, Shanghai, China
| | - Zhongfang Yang
- School of Nursing, Fudan University, Shanghai, China.,Fudan University Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, 305 Fenglin Rd, Shanghai, 200032, China
| | - Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China. .,Fudan University Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, 305 Fenglin Rd, Shanghai, 200032, China.
| | - Shuyu Han
- Peking University School of Nursing, Beijing, China
| | - Lin Zhang
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Yan Hu
- School of Nursing, Fudan University, Shanghai, China. .,Fudan University Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, 305 Fenglin Rd, Shanghai, 200032, China.
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3
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Olliges E, Bührlen B, Fischer F, Boesecke C, Kümmerle T, Schneider J, Weidlich S, Cordes C, Heiken H, Stellbrink HJ, Krznaric I, Scholten S, Jensen BEO, Wolf E, Ronel J, Spinner CD, On Behalf Of The Dualis Study Group. Health-related quality-of-life in people living with HIV after switching to dual therapy with ritonavir-boosted darunavir + dolutegravir: a DUALIS sub-study. AIDS Care 2021; 34:698-707. [PMID: 33896276 DOI: 10.1080/09540121.2021.1916873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The DUALIS study demonstrated efficacy and safety of switching to dolutegravir plus ritonavir-boosted darunavir (DRV/r) (2DR) as compared to standard-of-care-therapy with two nucleoside reverse transcriptase inhibitors + DRV/r (3DR) in pretreated people living with HIV (PLWH), 48 weeks after switching. This DUALIS sub-study investigates health-related-quality-of-life (HrQoL) in this study-population. The Hospital Anxiety and Depression Scale (HADS) and the Medical Outcome Survey-HIV (MOS-HIV) were used assessing anxiety and depression symptoms, respectively HrQoL. Data were collected at baseline, 4, 24, and 48 weeks after randomization. Outcome scores were dichotomized and used as criteria in longitudinal models identifying differential developments. Odds ratios (ORs) with 95% confidence intervals (CIs) were computed as main measures of effects. ORs<1 indicate better results for HADS, and worse for MOS-HIV scores in the 2DR compared to 3DR group. In total, 263 subjects were randomized and treated (2DR n=131, 3DR n=132; median age 48 years). Significant different progressions could only be found for HADS-Depression scores (OR=.87, 95% CI: .78, .98, p=.02). While HADS-Depression scores decreased in the 2DR group, they increased in 3DR group. This sub-study showed no disadvantages regarding HrQoL in PLWH after switching to DTG+DRV/r. Considering lifelong requirements for antiretroviral medication, close attention to HrQL is required.
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Affiliation(s)
- Elisabeth Olliges
- Department of Psychosomatic Medicine and Psychotherapy, Klinik Barmelweid AG, Barmelweid, Switzerland
| | - Bernhard Bührlen
- Psymeta GmbH, Clinical Research Organisation, Schafisheim, Switzerland
| | - Franz Fischer
- Psymeta GmbH, Clinical Research Organisation, Schafisheim, Switzerland
| | | | | | - Jochen Schneider
- School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Simon Weidlich
- School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | | | | | | | | | | | - Joram Ronel
- Department of Psychosomatic Medicine and Psychotherapy, Klinik Barmelweid AG, Barmelweid, Switzerland.,Department of Psychosomatic Medicine and Psychotherapy, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph D Spinner
- School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
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Khademi N, Zanganeh A, Saeidi S, Teimouri R, Khezeli M, Jamshidi B, Yigitcanlar T, Salimi Y, Almasi A, Gholami Kiaee K. Quality of life of HIV-infected individuals: insights from a study of patients in Kermanshah, Iran. BMC Infect Dis 2021; 21:203. [PMID: 33622262 PMCID: PMC7903600 DOI: 10.1186/s12879-021-05908-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Quality of life (QOL) is one of the major factors to assessing the health and wellbeing of People living with HIV (PLWH). Likewise, improved QOL is among the prominent goals of patient treatment. This study was conducted to investigate the QOL of PLWH in Kermanshah, Iran. Methods This cross-sectional study was conducted on 364 PLWH of Kermanshah between 2016 and 2017. Outpatients were selected as the sample through the convenience sampling method from HIV Positive Clients of Kermanshah Behavioral Diseases Counseling Center. The reasons for the selection of outpatients include: (a) some patients were substance users, homeless or did not have a fixed address to follow-up; (b) addresses and personal details that were registered on the first admission were incorrect or incomplete; (c) due to financial issues, some were forced to relocate frequently and were difficult to track; (d) some patients were convicts or prisoners, making it hard to find them after their release; (e) some of them were from other provinces, where managing access was not easy/possible. Data was collected using WHOQOL-HIV BREF questionnaire (Persian Version). Data also analyzed with STATA 14, and SPSS 23 using T-test and multiple regression. Results This study showed that mean (SD) age of PLWH was 40.21 (10.45) years. Females had better QOL than males except for spirituality, religion and personal beliefs. The gender differences disappeared in multivariate results. A significant association was observed between education and the independence, environment, and spirituality domains of QOL. In addition, being married was correlated with overall QOL, psychological and social relationships domains of QOL of PLWH. Drug use was a behavioral factor with negative influence on the QOL. Conclusion This study found that marital status and drug use were the main predictors of various domains of QOL. Drug use was a behavioral factor with a negative influence on the QOL. Hence, it is recommended that health professionals, planners, and policymakers take effective measures to improve the status quo.
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Affiliation(s)
- Nahid Khademi
- Vice Chancellery for Disease Prevention and Control, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Zanganeh
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Shahram Saeidi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Raziyeh Teimouri
- UniSA Creative, University of South Australia, Adelaide, Australia
| | - Mehdi Khezeli
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Babak Jamshidi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tan Yigitcanlar
- School of Built Environment, Queensland University of Technology, Brisbane, Australia
| | - Yahya Salimi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Almasi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kobra Gholami Kiaee
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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O'Brien KK, Kietrys D, Galantino ML, Parrott JS, Davis T, Tran Q, Aubry R, Solomon P. Reliability and Validity of the HIV Disability Questionnaire (HDQ) with Adults Living with HIV in the United States. J Int Assoc Provid AIDS Care 2020; 18:2325958219888461. [PMID: 31769326 PMCID: PMC6880031 DOI: 10.1177/2325958219888461] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To assess measurement properties of the HIV Disability Questionnaire (HDQ) among adults with HIV in the United States. METHODS We administered the HDQ, World Health Organization Disability Assessment Schedule II (WHODAS 2.0), and a demographic questionnaire. For internal consistency reliability, we calculated Cronbach α and Kuder-Richardson-20 (KR-20) statistics for disability and episodic scores, respectively (≥0.80 acceptable). For test-retest reliability, we calculated intraclass correlation coefficients (>0.8 acceptable). For construct validity, we tested 15 a priori hypotheses assessing correlations between HDQ and WHODAS 2.0 scores. RESULTS Of the 128 participants, the majority were males (68%), median age 51 years, taking antiretroviral therapy (96%). Cronbach α ranged from 0.88 (social inclusion) to 0.93 (uncertainty). The KR-20 ranged from 0.86 (cognitive) to 0.96 (uncertainty). Intraclass correlation coefficients ranged from 0.88 (physical, cognitive, social inclusion) to 0.92 (mental-emotional). Of the 15 hypotheses, 13 (87%) were confirmed. CONCLUSIONS The HDQ demonstrates internal consistency reliability, test-retest reliability, and construct validity when administered to a sample of adults with HIV in the United States.
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Affiliation(s)
- Kelly Kathleen O'Brien
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,School of Rehabilitation Science (RSI), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - David Kietrys
- School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Mary Lou Galantino
- Physical Therapy Program, School of Health Sciences, Stockton University, Galloway, NJ, USA.,Perelman School of Medicine, Clinical Center for Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Physiotherapy, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - James Scott Parrott
- School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Tracy Davis
- School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Quang Tran
- School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Rachel Aubry
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Patricia Solomon
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
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6
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Amini A, Peyman A, Hatami M. Effect of Self-Care Education Based on Virtual Networks on Quality of Life in HIV-Positive Patients. JOURNAL OF EDUCATION AND COMMUNITY HEALTH 2020. [DOI: 10.29252/jech.7.3.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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7
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Gebremichael DY, Hadush KT, Kebede EM, Zegeye RT. Gender difference in health related quality of life and associated factors among people living with HIV/AIDS attending anti-retroviral therapy at public health facilities, western Ethiopia: comparative cross sectional study. BMC Public Health 2018; 18:537. [PMID: 29688853 PMCID: PMC5913892 DOI: 10.1186/s12889-018-5474-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 04/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Though HIV/AIDS has multidimensional consequences on quality of life, there is a gap in measuring and monitoring health related quality of life of HIV/AIDS patients. Hence, this study intended to measure health related quality of life domains and associated determinants among people living with HIV/AIDS in western Ethiopia. Methods A comparative cross-sectional study was conducted among 520 HIV/AIDS patients on anti-retroviral therapy in public health facilities in West Shoa Zone, Western Ethiopia from April to May, 2016. Participants were selected using simple random sampling method. Quality of life was measured using WHOQOL-HIV BREF and depression was assessed using Beck Depression Inventory, Second Edition (BDI-II). Data were analyzed using SPSS version 22. An independent sample t-test was used to compare quality of life domains between men and women and logistic regression analysis was used to determine independent predictors. Results Females had significantly lower quality of life in physical, psychological, independence and environmental domains as compared with males except social relationship and spiritual domains. Depressed HIV patients had significantly lower quality of life in all domains as compared with HIV infected patients without depression in both genders. Malnutrition and anemia were significantly associated with poor physical, psychological, independence and environmental domains. Anemic women had 1.9 times lower independence quality of life compared with women who had no anemia (AOR = 1.9, 95%CI: 1.4, 3.5). Tuberculosis was also predictor of physical, psychological, independence and social domains in both genders. TB/HIV co-infected females had 2.0 times poorer environmental health compared to only HIV infected females (AOR = 2.0, 95%CI: 1.2, 3.5). Family support, education and occupation were also independent significant predictors of QOL domains in both genders. In females, residence was significantly associated with independence (AOR = 1.8, 95%CI: 1.2–3.8) and environmental (AOR = 1.5, 95%CI: 1.1–3.2) domains. Conclusions Females had significantly lower quality of life compared with males. The findings indicted poor socio-economic status and co-infections significantly associated with poor quality of life among HIV/AIDS patients. So, due emphasis should be given to improve socio-economic status and enhance integrated early detection and management of malnutrition, depression, tuberculosis and anemia among HIV/AIDS patients in Ethiopia.
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Affiliation(s)
- Delelegn Yilma Gebremichael
- College of medicine and health sciences, Department of Public Health, Ambo University, P.O. Box 19, Ambo, Ethiopia.
| | - Kokeb Tesfamariam Hadush
- College of medicine and health sciences, Department of Public Health, Ambo University, P.O. Box 19, Ambo, Ethiopia
| | - Ermiyas Mulu Kebede
- College of medicine and health sciences, Department of Public Health, Ambo University, P.O. Box 19, Ambo, Ethiopia
| | - Robel Tezera Zegeye
- College of medicine and health sciences, Department of Public Health, Ambo University, P.O. Box 19, Ambo, Ethiopia
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Federici S, Bracalenti M, Meloni F, Luciano JV. World Health Organization disability assessment schedule 2.0: An international systematic review. Disabil Rehabil 2016; 39:2347-2380. [PMID: 27820966 DOI: 10.1080/09638288.2016.1223177] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument. METHOD Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases. RESULTS We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry). CONCLUSIONS The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.
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Affiliation(s)
- Stefano Federici
- a Department of Philosophy, Social & Human Sciences and Education , University of Perugia , Perugia , Italy
| | - Marco Bracalenti
- a Department of Philosophy, Social & Human Sciences and Education , University of Perugia , Perugia , Italy
| | - Fabio Meloni
- a Department of Philosophy, Social & Human Sciences and Education , University of Perugia , Perugia , Italy
| | - Juan V Luciano
- b Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan De Déu , St. Boi De Llobregat , Spain.,c Primary Care Prevention and Health Promotion Research Network (RedIAPP) , Madrid , Spain
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9
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Lalanne C, Chassany O, Carrieri P, Marcellin F, Armstrong AR, Lert F, Spire B, Dray-Spira R, Duracinsky M. A reduced factor structure for the PROQOL-HIV questionnaire provided reliable indicators of health-related quality of life. J Clin Epidemiol 2015; 72:116-25. [PMID: 26548542 DOI: 10.1016/j.jclinepi.2015.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 10/13/2015] [Accepted: 10/26/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify a simplified factor structure for the PROQOL-human immunodeficiency virus (HIV) questionnaire to improve the measurement of the health-related quality of life (HRQL) of HIV-positive patients in clinical care and research settings. STUDY DESIGN AND SETTING HRQL data were collected using the eight-dimension PROQOL-HIV questionnaire from 2,537 patients (VESPA2 study). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) validated a simpler four-factor structure and assessed measurement invariance (MI). Multigroup analysis assessed the effect of sex, age, and antiretroviral therapy (ART) on the resulting factor scores. Correlations with symptom and Short Form (SF)-12 self-reports assessed convergent validity. RESULTS Item analysis, EFA, and CFAs confirmed the validity [comparative fit index (CFI), 0.948; root mean square error of approximation, 0.064] and reliability (α's ≥ 0.8) of four dimensions: physical health and symptoms, health concerns and mental distress, social and intimate relationships, and treatment-related impact. Strong MI was demonstrated across sex and age (decrease in CFI <0.01). A multiple-cause multiple-indicator model indicated that HRQL correlated as expected with sex, age, and the ART status. Correlations of HRQL, symptom reports, and SF-12 scores evidenced convergent validity criterion. CONCLUSION The simplified factor structure and scoring scheme for PROQOL-HIV will allow clinicians to monitor with greater reliability the HRQL of patients in clinical care and research settings.
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Affiliation(s)
- Christophe Lalanne
- University Paris Diderot, Paris Sorbonne Cité, EA 7334 (REMES), Patient-Centered Outcomes Research, Paris, France; AP-HP, Hôtel-Dieu Hospital, URC ECO, 1 Place du Parvis Notre-Dame, 75004, Paris, France.
| | - Olivier Chassany
- University Paris Diderot, Paris Sorbonne Cité, EA 7334 (REMES), Patient-Centered Outcomes Research, Paris, France; AP-HP, Hôtel-Dieu Hospital, URC ECO, 1 Place du Parvis Notre-Dame, 75004, Paris, France
| | - Patrizia Carrieri
- Inserm UMR 912 (SESSTIM), 23, rue Stanislas Torrents, 13006, Marseille, France; University Aix Marseille, IRD, UMR 912, 58 bd Charles Livon, 13284, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 23, rue Stanislas Torrents, 13006, Marseille, France
| | - Fabienne Marcellin
- Inserm UMR 912 (SESSTIM), 23, rue Stanislas Torrents, 13006, Marseille, France; University Aix Marseille, IRD, UMR 912, 58 bd Charles Livon, 13284, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 23, rue Stanislas Torrents, 13006, Marseille, France
| | - Andrew R Armstrong
- University Paris Diderot, Paris Sorbonne Cité, EA 7334 (REMES), Patient-Centered Outcomes Research, Paris, France; Australian Institute of Family Studies, 485 La Trobe St, Melbourne, VIC 3000, Australia
| | - France Lert
- Inserm UMR 1018, Centre de recherche en épidémiologie et santé des populations, Hôpital Paul Brousse, 16 avenue Paul Vaillant Couturier 94807 Villejuif, France; University Versailles Saint-Quentin-en-Yvelines, UMR 1018, 16 avenue Paul Vaillant Couturier 94807 Villejuif, France
| | - Bruno Spire
- Inserm UMR 912 (SESSTIM), 23, rue Stanislas Torrents, 13006, Marseille, France; University Aix Marseille, IRD, UMR 912, 58 bd Charles Livon, 13284, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 23, rue Stanislas Torrents, 13006, Marseille, France
| | - Rosemary Dray-Spira
- Department of Social Epidemiology, Pierre Louis Institute of Epidemiology and Public Health, Inserm UMR 1136, 27 rue Chaligny 75012 Paris, France; Department of Social Epidemiology, Pierre Louis Institute of Epidemiology and Public Health, Inserm UMR 1136, Sorbonne University, UPMC University Paris 06, 27 rue Chaligny 75012 Paris, France
| | - Martin Duracinsky
- University Paris Diderot, Paris Sorbonne Cité, EA 7334 (REMES), Patient-Centered Outcomes Research, Paris, France; AP-HP, Hôtel-Dieu Hospital, URC ECO, 1 Place du Parvis Notre-Dame, 75004, Paris, France; Internal Medicine and Clinical Immunology, Bicêtre Hospital, AP-HP, 78, avenue du Général Leclerc 94270 Le Kremlin-Bicêtre, France
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10
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O'Brien KK, Solomon P, Bergin C, O'Dea S, Stratford P, Iku N, Bayoumi AM. Reliability and validity of a new HIV-specific questionnaire with adults living with HIV in Canada and Ireland: the HIV Disability Questionnaire (HDQ). Health Qual Life Outcomes 2015; 13:124. [PMID: 26263898 PMCID: PMC4542093 DOI: 10.1186/s12955-015-0310-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 07/20/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Our aim was to assess internal consistency reliability, construct validity, and test-retest reliability of the HDQ with adults living with HIV in Canada and Ireland. METHODS We recruited adults 18 years of age or older living with HIV from hospital clinics and AIDS service organizations in Canada and Ireland. We administered the HDQ paired with reference measures (World Health Organization Disability Assessment Schedule, SF-36 Questionnaire, Medical Outcomes Study Social Support Survey), and a demographic questionnaire. We calculated HDQ disability presence, severity and episodic scores (scored from 0-100). We calculated Cronbach's alpha and Intraclass Correlation Coefficients (ICC) (Canada only) for the disability severity and episodic scores and considered coefficients >0.80 and >0.70 as acceptable, respectively. To assess construct validity, we tested 40 a priori hypotheses of correlations between scores on the HDQ and reference measures and two known group hypotheses comparing HDQ presence and severity scores based on age and comorbidity. We considered acceptance of at least 75% of hypotheses as demonstrating support for construct validity. RESULTS Of the 235 participants (139 Canada; 96 Ireland), the majority were men (74% Ireland; 82% Canada) and were taking antiretroviral therapy (88% Ireland; 91% Canada). Compared with Irish participants, Canadian participants were older (median age: 48 versus 41 years) and reported living with a higher median number of comorbidities (4 versus 1). Cronbach's alpha for Irish and Canadian participants were 0.97 (95% confidence interval (CI): 0.97-0.98) and 0.96 (95 % CI: 0.95-0.98), respectively, for the severity scale and 0.98 (95 % CI: 0.97-0.98) and 0.96 (95 % CI: 0.95-0.98), respectively, for the episodic scale. Of the 40 construct validity correlation hypotheses, 32 (80%) and 22 (55%) were supported among the Canadian and Irish samples respectively; both (100%) known group hypotheses were also supported. ICC values for Canadian participants ranged from 0.80 (95 % CI: 0.71, 0.86) in the cognitive domain to 0.89 (95 % CI: 0.83, 0.92) in the social inclusion domain. CONCLUSIONS The HDQ demonstrates internal consistency reliability and a variable degree of construct validity when administered to adults living with HIV in Canada and Ireland. The HDQ demonstrates test-retest reliability when administered to adults with HIV in Canada. Further validation of the HDQ outside of Canada is needed.
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Affiliation(s)
- Kelly K O'Brien
- Department of Physical Therapy, University of Toronto, 500 University Avenue, Room 160, Toronto, ON, M5G 1V7, Canada. .,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada. .,School of Rehabilitation Science, McMaster University, 1400 Main Street West, Room 408, Hamilton, ON, L8S 1C7, Canada.
| | - Patricia Solomon
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Room 408, Hamilton, ON, L8S 1C7, Canada.
| | - Colm Bergin
- Department of Genito Urinary Medicine and Infectious Diseases, Hospital 5, St. James's Hospital, James's Street, Dublin 8, Ireland. .,Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Siobhán O'Dea
- Department of Genito Urinary Medicine and Infectious Diseases, Hospital 5, St. James's Hospital, James's Street, Dublin 8, Ireland.
| | - Paul Stratford
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Room 408, Hamilton, ON, L8S 1C7, Canada.
| | - Nkem Iku
- Department of Physical Therapy, University of Toronto, 500 University Avenue, Room 160, Toronto, ON, M5G 1V7, Canada.
| | - Ahmed M Bayoumi
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada. .,Centre for Research on Inner City Health, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Degroote S, Vogelaers D, Vandijck DM. What determines health-related quality of life among people living with HIV: an updated review of the literature. ACTA ACUST UNITED AC 2014; 72:40. [PMID: 25671112 PMCID: PMC4323115 DOI: 10.1186/2049-3258-72-40] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 08/13/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND As infection with the Human Immunodeficiency Virus (HIV) has evolved to a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. Literature discusses different factors influencing HRQoL in this population, however, currently no consensus exists about the main determinants. In this review a clear, up-to-date overview of the determinants influencing HRQOL among people living with HIV is provided. METHODS All studies published before July 2013 that identified determinants of HRQoL among people living with HIV in high-income countries, were considered in this narrative review. PubMed, Web of Science and The Cochrane Library were consulted using the keywords 'determinants', 'quality of life', 'HIV' and 'AIDS'. To be included, studies should have reported overall health and/or physical/mental health scores on a validated instrument and performed multivariable regression analyses to identify determinants that independently influence perceived HRQoL. RESULTS In total, 49 studies were included for further analysis and they used a variety of HRQoL instruments: Medical Outcomes Study Short Form-36 or variants, Medical Outcomes Study-HIV, HIV Cost and Services Utilization Study measure, Multidimensional Quality of Life Questionnaire, HIV targeted quality of life instrument, Functional Assessment of Human Immunodeficiency Virus Infection, HIV Overview of Problems Evaluation System, EuroQol, Fanning Quality of Life scale, Health Index and PROQOL-HIV. In this review, the discussed determinants were thematically divided into socio-demographic, clinical, psychological and behavioural factors. Employment, immunological status, presence of symptoms, depression, social support and adherence to antiretroviral therapy were most frequently and consistently reported to be associated with HRQoL among people living with HIV. CONCLUSIONS HRQoL among people living with HIV is influenced by several determinants. These determinants independently, but simultaneously impact perceived HRQoL. Most HRQoL instruments do not capture all key determinants. We recommend that the choice for an instrument should depend on the purpose of the HRQoL assessment.
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Affiliation(s)
- Sophie Degroote
- Department of General Internal Medicine, Infectious Diseases and Psychosomatics, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium ; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Dirk Vogelaers
- Department of General Internal Medicine, Infectious Diseases and Psychosomatics, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium ; Department of Internal Medicine, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Dominique M Vandijck
- Department of General Internal Medicine, Infectious Diseases and Psychosomatics, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium ; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium ; Department of Economics, Faculty of Business Economics, Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium
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Activity limitation and participation restrictions of breast cancer patients receiving chemotherapy: psychometric properties and validation of the Chinese version of the WHODAS 2.0. Qual Life Res 2012; 22:897-906. [DOI: 10.1007/s11136-012-0212-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2012] [Indexed: 11/26/2022]
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Pereira M, Canavarro MC. Gender and age differences in quality of life and the impact of psychopathological symptoms among HIV-infected patients. AIDS Behav 2011; 15:1857-69. [PMID: 21431413 DOI: 10.1007/s10461-011-9928-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to determine gender and age differences and interaction effects on the quality of life (QoL) domains in a sample of Portuguese HIV-positive patients, and to examine to what degree psychopathological symptoms are associated with QoL in addition to sociodemographic and clinical variables. The sample consisted of 1191 HIV-positive patients, and measures included the WHOQOL-HIV-Bref and the Brief Symptom Inventory. Controlling for clinical status, there was a significant effect of gender on QoL. Women reported lower scores of Psychological and Spirituality QoL. Younger patients reported higher scores on Physical and Level of Independence domains. Age by gender interactions emerged on all domains of QoL except on the Level of Independence domain. Overall, women over 45 years old showed lower QoL scores. Psychopathological symptoms contributed significantly to the variance of all QoL domains. Gender differences in the association of HIV infection with QoL and psychopathological symptoms seemed to be modulated by age. Understanding gender and age differences (and their interaction) may provide potentially useful information for planning interventions to improve QoL and mental health among people infected with HIV/AIDS, especially among older women.
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Canavarro MC, Pereira M, Simoes MR, Pintassilgo AL. Quality of life assessment in HIV-infection: validation of the European Portuguese version of WHOQOL-HIV. AIDS Care 2011; 23:187-94. [PMID: 21259131 DOI: 10.1080/09540121.2010.498870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The assessment of quality of life (QOL) in HIV infection has emerged as being vital to research and clinical practice. This assessment is also a challenge due to the specific characteristics of the infection, the increased availability of therapeutics, as well as the epidemiological variability inherent to HIV infection. The purpose of this study was to investigate the psychometric properties of the European Portuguese version of the World Health Organization's QOL Instrument in HIV Infection (WHOQOL-HIV) and to test its performance in a sample of HIV-infected patients. The European Portuguese version of WHOQOL-HIV was administered in a sample of 200 HIV-positive patients. The patients also completed the Portuguese versions of Beck Depression Inventory (BDI) and Brief Symptom Inventory (BSI). The WHOQOL-HIV showed quite an acceptable internal consistency (Cronbach's α ranged from 0.86 to 0.95 across domains). Convergent validity with BDI and BSI was satisfactory for all domains (all r>0.50; p<0.001). Moreover, correlations between domains and between domains and overall QOL were all statistically significant (p<0.001). The reliability and validity studies of the European Portuguese version of the WHOQOL-HIV revealed good psychometric characteristics, which allows for the use of this version of WHOQOL in our country, and cross-cultural comparability.
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Pettersson I, Törnquist K, Ahlström G. The effect of an outdoor powered wheelchair on activity and participation in users with stroke. Disabil Rehabil Assist Technol 2009; 1:235-43. [PMID: 19260171 DOI: 10.1080/17483100600757841] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Persons with disabilities after stroke are often restricted in activity and participation in society because of mobility limitations. An outdoor powered wheelchair may be one among other interventions in a rehabilitation programme. The aim of this study was to describe and compare activity limitations and participation restrictions in persons with stroke from their own perspective, before and after using an outdoor powered wheelchair. METHOD At baseline and follow-up two instruments were used: Individually Prioritized Problem Assessment (IPPA) and World Health Organization Disability Assessment Schedule II (WHODAS II). RESULTS The results indicated that the powered wheelchair has a great positive effect on activity and participation assessed with IPPA. The results also showed that most of the participants' problems could be categorised as belonging to the domain of 'Community, social and civic life' according to the International Classification of Functioning, Disability and Health (ICF), and the effect size in this domain was large (2.4) after the participants had used the wheelchair. CONCLUSION An outdoor powered wheelchair is an essential device for persons with disability after stroke with regard to overcoming activity limitations and participation restrictions in everyday life.
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Schroecksnadel K, Sarcletti M, Winkler C, Mumelter B, Weiss G, Fuchs D, Kemmler G, Zangerle R. Quality of life and immune activation in patients with HIV-infection. Brain Behav Immun 2008; 22:881-9. [PMID: 18261883 DOI: 10.1016/j.bbi.2007.12.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 12/25/2007] [Accepted: 12/27/2007] [Indexed: 01/28/2023] Open
Abstract
Depression and impaired quality of life (QoL) are frequently observed in patients suffering from HIV-infection. As an enhanced degradation of the serotonin precursor tryptophan is well documented in HIV-infected patients, disturbances in tryptophan metabolism may be causally linked to HIV-related depression. In this study, the relationship between QoL, depression, various laboratory parameters and tryptophan metabolism was investigated. To estimate QoL and mood, 152 HIV-infected patients (classified according to CDC-criteria) were requested to complete the following psychological questionnaires: BDI and MQoL-HIV. Disease progression was monitored by determination of viral load (VL), CD4(+) cell counts, haemoglobin and urinary/plasma neopterin, tryptophan and kynurenine concentrations. Increasing VL, decreasing CD4(+) cell counts, and enhanced tryptophan degradation reflected disease progression. Forty-one patients presented with mild, 22 with moderate and 14 with severe depression. BDI and MQoL scores were associated strongly with each other (rs=-0.838; p<0.001). Patients without depression had significantly lower plasma neopterin concentrations, higher CD4(+) cell counts and haemoglobin concentrations and better QoL scores (all p<0.01) than depressive patients. Furthermore, they showed lower rates of tryptophan degradation (p<0.05). Significant associations were observed between tryptophan degradation and immune activation. Haemoglobin and viral load were predictive for impaired QoL, while high urinary neopterin concentrations and low haemoglobin were the best predictors for depression. In HIV-infected patients, depressive mood and impaired QoL appear to be related to clinical parameters like immune activation, haemoglobin values and viral load.
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Affiliation(s)
- K Schroecksnadel
- Department of General Internal Medicine, Clinical Immunology and Infectious Diseases, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Smith Fawzi MC, Kaaya SF, Mbwambo J, Msamanga GI, Antelman G, Wei R, Hunter DJ, Fawzi WW. Multivitamin supplementation in HIV-positive pregnant women: impact on depression and quality of life in a resource-poor setting. HIV Med 2007; 8:203-12. [PMID: 17461847 PMCID: PMC6276367 DOI: 10.1111/j.1468-1293.2007.00454.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The primary objective of this study was to examine the effect of vitamin supplementation on health-related quality of life and the risk of elevated depressive symptoms comparable to major depressive disorder (MDD) in HIV-positive pregnant women in Dar es Salaam, Tanzania. METHODS From April 1995 to July 1997, 1078 HIV-positive pregnant women were enrolled in a randomized controlled trial. We examined the effects of vitamin supplementation on quality of life and the risk of elevated depressive symptoms, assessed longitudinally every 6-12 months. RESULTS A substantial prevalence of elevated depressive symptoms (42%) was observed in HIV-positive pregnant women. Multivitamin supplementation (B-complex, C and E) demonstrated a protective effect on depression [relative risk (RR)=0.78; P=0.005] and quality of life [RR=0.72 for social functioning (P=0.001) and vitality (P=0.0001); RR=0.70 for role-physical (P=0.002)]; however, vitamin A showed no effect on these outcomes. CONCLUSIONS Multivitamin supplementation (B-complex, C and E) resulted in a reduction in risk of elevated depressive symptoms comparable to MDD and improvement in quality of life in HIV-positive pregnant women in Tanzania.
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Affiliation(s)
- M C Smith Fawzi
- Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA.
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Eriksson LE, Bratt GA, Sandström E, Nordström G. The two-year impact of first generation protease inhibitor based antiretroviral therapy (PI-ART) on health-related quality of life. Health Qual Life Outcomes 2005; 3:32. [PMID: 15871738 PMCID: PMC1173133 DOI: 10.1186/1477-7525-3-32] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 05/04/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Protease inhibitor based antiretroviral therapy (PI-ART) was introduced in 1996 and has greatly reduced the incidence of HIV-related morbidity and mortality in the industrialised world. PI-ART would thus be expected to have a positive effect on health-related quality of life (HRQL). On the other hand, HRQL might be negatively affected by strict adherence requirements as well as by short and long-term adverse effects. The aim of this study was to assess the influence of two years of first generation PI-ART on HRQL in patients with a relatively advanced state of HIV-infection. Furthermore, we wanted to investigate the relation between developments in HRQL and viral response, self-reported adherence and subjective experience of adverse effects in patients with PI-ART. METHODS HRQL was measured by the Swedish Health-Related Quality of Life Questionnaire (SWED-QUAL). Sixty-three items from the SWED-QUAL forms two single-item and 11 multi-item dimension scales. For this study, two summary SWED-QUAL scores (physical HRQL composite score and emotional HRQL composite score) were created through a data reduction procedure. At the 2-year follow-up measurement (see below), items were added to measure adherence and subjective experience of adverse effects. Demographic and medical data were obtained from specific items in the questionnaires and from the medical files. Seventy-two patients who were among the first to receive PI-ART (indinavir or ritonavir based) responded to the questionnaire before the start of PI-ART. Of these, 54 responded to the same instrument after two years of treatment (13 had died, four had changed clinic and one did not receive the questionnaire). RESULTS The main findings were that the emotional HRQL deteriorated during two years of PI-ART, while the physical HRQL remained stable. Multiple linear regression analyses showed that experience of adverse effects contributed most to the deterioration of emotional HRQL. CONCLUSION In this sample of patients with relatively advanced state of HIV-infection, our data suggested that a negative development of physical HRQL had been interrupted by the treatment and that the emotional dimension of HRQL deteriorated during two years after start of PI-ART. Subjective experience of adverse effects made a major contribution to the decrease in emotional HRQL. The results underline the importance of including HRQL measures in the evaluation of new life prolonging therapies.
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Affiliation(s)
- Lars E Eriksson
- Department of Nursing, Karolinska Institutet, 23300, SE-141 83 Huddinge, Sweden
- Department of Venhälsan, South Stockholm General Hospital, SE-118 83 Stockholm, Sweden
- Department of Virology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - Göran A Bratt
- Department of Venhälsan, South Stockholm General Hospital, SE-118 83 Stockholm, Sweden
| | - Eric Sandström
- Department of Venhälsan, South Stockholm General Hospital, SE-118 83 Stockholm, Sweden
| | - Gun Nordström
- Department of Nursing, Karolinska Institutet, 23300, SE-141 83 Huddinge, Sweden
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