The determinants of health-related quality of life in urban and rural isi-Xhosa-speaking people with disabilities

Improving health-related quality of life instrument translation into South African languages

Background

Most health-related quality of life (HRQoL) instruments have been created in English, which can influence their reliability and validity in non-English speaking populations. This study assessed the translation methodology of HRQoL instruments that have been used and translated into South African languages and which could be applied in cost-utility analyses (CUAs).

Methods

A 2019 systematic review was updated with searches conducted in Medline, the Web of Science^TM (WoS^TM) Core Collection and the South African SciELO collection via the WoS^TM Platform. Additional searches in Sabinet’s African Journals database and on instrument developers’ webpages were performed. Only HRQoL instruments suitable for CUAs were included. Articles reporting at least one element of the translation methods were included. Established good practice principles were used to evaluate the translation methodology.

Results

Within the 39 publications identified, a dozen translated instruments have been used in South Africa. All instruments used were translated from English and none had originally been created in South Africa. Instrument developers’ translations were used more than study investigators’ translations. Almost all instrument developer versions met the full translation criteria. No investigator translated instrument met the full translation criteria primarily because recommendations on forward and back translations were not followed. However, this analysis was hampered by a lack of methodological reporting details. The most used instruments, which also had the most translated versions available, were the EQ-5D-3L, SF-36 version 2 and EORTC QLQ-C30.

Conclusion

Instrument developers’ translations more often met recommended translation methodology compared with investigators’ versions. The EQ-5D-3L may be best suited for South African economic evaluations and for use in clinical practice, but further work may be needed.

Managing pain in HIV/AIDS: a therapeutic relationship is as effective as an exercise and education intervention for rural amaXhosa women in South Africa

Background

Pain is one of the most prevalent symptoms in people living with HIV/AIDS and is largely undermanaged. Both a peer-led exercise and education Positive Living programme (PL programme) and the PL programme workbook alone were previously found to be effective in reducing pain in urban amaXhosa Women Living With HIV/AIDS (WLWHA). A therapeutic relationship was hypothesised to have contributed to the efficacy of both interventions. The aim of the study was to determine the effectiveness of the PL programme and a therapeutic relationship, compared to a therapeutic relationship alone in managing pain amongst rural amaXhosa WLWHA on pain severity and pain interference, and secondary outcomes, symptoms of depression, health-related quality of life (HRQoL) and self-efficacy.

Methods

In this two-group, single-blind, pragmatic clinical trial with stratified convenience sampling, the PL programme and therapeutic relationship, was compared to a therapeutic relationship alone in rural amaXhosa WLWHA. The PL programme was a 6-week, peer-led intervention comprising education on living well with HIV, exercise and goal setting. The therapeutic relationship comprised follow-up appointments with a caring research assistant. Outcome measures included pain severity and interference (Brief Pain Inventory), depressive symptoms (Beck Depression Inventory), HRQoL (EuroQol 5-Dimensional outcome questionnaire) and self-efficacy (Self-efficacy for Managing Chronic Disease 6-Item Scale). Follow-up was conducted at 4, 8, 12, 24, and 48 weeks. Mixed model regression was used to test the effects of group, time, and group and time interactions of the interventions on outcome measures.

Results

Forty-nine rural amaXhosa WLWHA participated in the study: PL group n = 26; TR group n = 23. Both intervention groups were similarly effective in significantly reducing pain severity and interference and depressive symptoms, and increasing self-efficacy and HRQoL over the 48 weeks. A clinically important reduction in pain severity of 3.31 points occurred for the sample over the 48 weeks of the study. All of these clinical improvements were obtained despite low and suboptimal attendance for both interventions.

Conclusions

Providing a therapeutic relationship alone is sufficient for effective pain management amongst rural amaXhosa WLWHA. These findings support greater emphasis on demonstrating care and developing skills to enhance the therapeutic relationship in healthcare professionals working with rural amaXhosa WLWHA.

Trial registration

PACTR; PACTR201410000902600, 30th October 2014; https://pactr.samrc.ac.za.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10309-7.

Barriers to implementing clinical trials on nonpharmacological treatments in developing countries: lessons learnt from addressing pain in HIV

Supplemental Digital Content is Available in the Text.

Pain affects over half of the people living with HIV/AIDS (LWHA), and pharmacological treatment has limited efficacy. Preliminary evidence supports nonpharmacological interventions. We previously piloted a multimodal intervention in amaXhosa women LWHA and chronic pain in South Africa with improvements seen in all outcomes, in both intervention and control groups. A multicentre, single-blind randomised controlled trial with 160 participants recruited was conducted to determine whether the multimodal peer-led intervention reduced pain in different populations of both male and female South Africans LWHA. Participants were followed up at weeks 4, 8, 12, 24, and 48 to evaluate effects on the primary outcome of pain, and on depression, self-efficacy, and health-related quality of life. We were unable to assess the efficacy of the intervention due to a 58% loss to follow-up (LTFU). Secondary analysis of the LTFU found that sociocultural factors were not predictive of LTFU. Depression, however, did associate with LTFU, with greater severity of depressive symptoms predicting LTFU at week 8 (P = 0.01). We were unable to evaluate the effectiveness of the intervention due to the high LTFU and the risk of retention bias. The different sociocultural context in South Africa may warrant a different approach to interventions for pain in HIV compared with resource-rich countries, including a concurrent strategy to address barriers to health care service delivery. We suggest that assessment of pain and depression need to occur simultaneously in those with pain in HIV. We suggest investigation of the effect of social inclusion on pain and depression.

Improvements in health-related quality of life and function in middle-aged women with chronic diseases of lifestyle after participating in a non-pharmacological intervention programme: A pragmatic randomised controlled trial

Background

Musculoskeletal diseases consume a large amount of health and social resources and are a major cause of disability in both low- and high-income countries. In addition, patients frequently present with co-morbid chronic diseases of lifestyle. The area of musculoskeletal disease is restricted by a lack of epidemiological knowledge, particularly in low- and middle-income countries.

Objectives

This pragmatic randomised controlled trial assessed the benefits of a 6-week physiotherapy intervention for middle-aged women with musculoskeletal conditions compared to usual care.

Method

A weekly 2-h educational programme utilising a workbook, discussion group and exercise class was presented for the intervention group, while the control group received usual care. The primary outcome was health-related quality of life. Parametric and non-parametric data were used to determine the equivalence between the groups.

Results

Twenty-two participants were randomised to the intervention and 20 to the control group. The control group demonstrated no within-group improvement in health-related quality of life items, compared to significant improvements in two items in the intervention group. The change in median utility score within the intervention group was twice as large as the change in the control group. With regard to self-efficacy, the intervention group demonstrated significant within-group changes in perceived management of fatigue and discomfort.

Conclusion

The positive impact of the intervention on the participants suggests that the programme should continue at the clinic in question, but should be presented at a more convenient time for participants who work, as recruitment to the study was less than anticipated. Primary health care systems in South Africa urgently need to put structures in place for effective management of the functional impact of chronic diseases of lifestyle and musculoskeletal conditions. It is time for physiotherapists and possibly other health care professionals to participate in the development of appropriate community level interventions to address the functioning and quality of life of individuals living with the diseases.

The perceived needs-access gap for health services among persons with disabilities in a rural area within South Africa

Purpose: Health should be a universal phenomenon. However, little is known about the relationship between disability status and health issues - particularly in rural areas. This study looks at health issues of persons with disabilities in Madwaleni, a rural impoverished area in South Africa in 2011, and compares them to persons with no disabilities. Materials and Methods: Standardized questionnaires were used in the survey to assess disability and health status. The sample comprised of 773 individuals - 322 persons with disability and 451 comparisons (without disability) - covering 527 households. Children under the age of five were excluded from the sample. We used purposive sampling. Results and Conclusion: This study found that persons with disabilities have poorer reported health outcomes than persons with no disabilities. There is also an association between disability severity and mental health issues as assessed by the GHQ-12. A significantly higher percentage of persons with disability did not get health care when needed. Persons with disabilities also have less favorable attitudes toward competence of health care workers. This study has shown greater health needs and less satisfaction with services, which strongly indicates insufficient access for persons with disabilities in a rural impoverished are within South Africa. Implications for rehabilitation Persons with disabilities in rural South Africa have poorer reported health outcomes. Persons with disabilities have less favorable attitudes towards competence of health care workers in rural South Africa. Better access to health care for persons with disabilities is needed in rural South Africa.

Access to health care for persons with disabilities in rural South Africa

BACKGROUND

Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa.

METHODS

The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis.

RESULTS

Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age.

CONCLUSIONS

This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.

Community stakeholders' perspectives on the role of occupational therapy in primary healthcare: Implications for practice

BACKGROUND

Primary healthcare (PHC) is central to increased access and transformation in South African healthcare. There is limited literature about services required by occupational therapists in PHC. Despite policy being in place, the implementation of services at grassroots level does not always occur adequately.

OBJECTIVES

This study aimed at gaining an understanding of the challenges of being disabled and the services required by occupational therapists (OTs) in rural communities in order to better inform the occupational therapy (OT) training curriculum.

METHOD

An exploratory, descriptive qualitative design was implemented using purposive sampling to recruit 23 community healthcare workers from the uGu district. Snowball sampling was used to recruit 37 members of the uGu community, which included people with disability (PWD) and caregivers of PWDs. Audio-recorded focus groups and semi-structured interviews were used to collect data, which were thematically analysed. Ethical approval was obtained from the Biomedical and Research Ethics Committee of the University of KwaZulu-Natal (BE248/14).

RESULTS

Two main themes emerged namely: firstly, the challenges faced by the disabled community and secondly appropriate opportunities for intervention in PHC. A snapshot of the social and physical inaccessibility challenges experienced by the community was created. Challenges included physical and sexual abuse, discrimination and marginalisation. Community-based rehabilitation and ideas for health promotion and prevention were identified as possible strategies for OT intervention.

CONCLUSION

The understanding of the intervention required by OT in PHC was enhanced through obtaining the views of various stakeholders' on the role. This study highlighted the gaps in community-based services that OTs should offer in this context.

Should additional domains be added to the EQ-5D health-related quality of life instrument for community-based studies? An analytical descriptive study

Background

There is increasing interest in monitoring the health-related quality of life (HRQoL) of populations as opposed to clinical populations. The EQ-5D identifies five domains as being most able to capture the HRQoL construct. The question arises as to whether these domains are adequate within a community-based population or whether additional domains would add to the explanatory power of the instrument.

Methods

As part of a community-based survey, the responses of 310 informants who reported at least one problem in one domain filled in the EQ-5D three-level version and the WHOQOL-BREF (World Health Organization Quality of Life Scale – Abbreviated version). Using the EQ-5D visual analogue scale (VAS) of rating of health as a dependent variable, the five EQ-5D and four selected WHOQOL-BREF items were entered as dummy variables in multiple regression analysis.

Results

The additional domains increased the explanatory power of the model from 52 % (EQ-5D only) to 57 % (all domains). The coefficients of Self-Care and Usual Activities were not significant in any model. The most parsimonious model included the EQ-5D domains of Mobility, Pain/Discomfort, Anxiety/Depression, Concentration, and Sleep (adjusted r² = .57).

Conclusions

The EQ-5D-3L performed well, but the addition of domains such as Concentration and Sleep increased the explanatory power. The user needs to weigh the advantage of using the EQ-5D, which allows for the calculation of a single summary index, against the use of a set of domains that are likely to be more responsive to differences in HRQoL within community living respondents. The poor predictive power of the Self-Care and Usual Activities domains within this context needs to be further examined.

Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya

BACKGROUND

Depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained settings.

OBJECTIVE

To assess the validity/reliability of PHQ-9 and PHQ-2.

DESIGN

Observational, two occasions 7 days apart.

PARTICIPANTS

A total of 347 patients attending psychosocial support groups.

MEASUREMENTS

Demographics, PHQ-9, PHQ-2, general health perception rating and CD4 count.

RESULTS

Rates for PHQ-9 DSM-IV major depressive disorder (MDD), other depressive disorder (ODD) and any depressive disorder were 13%, 21% and 34%. Depression was associated with female gender, but not CD4. Construct validity was supported by: (1) a strong association between PHQ-9 and general health rating, (2) a single major factor with loadings exceeding 0.50, (3) item-total correlations exceeding 0.37 and (4) a pattern of item means similar to US validation studies. Four focus groups indicated culturally relevant content validity and minor modifications to the PHQ-9 instructions. Coefficient alpha was 0.78. Test-retest reliability was acceptable: (1) intraclass correlation 0.59 for PHQ-9 total score, (2) kappas 0.24, 0.25 and 0.38 for PHQ-9 MDD, ODD and any depressive disorder and (3) weighted kappa 0.53 for PHQ-9 depression severity categories. PHQ-2 > or =3 demonstrated high sensitivity (85%) and specificity (95%) for diagnosing any PHQ-9 depressive disorder (AUC, 0.97), and 91% and 77%, respectively, for diagnosing PHQ-9 MDD (AUC, 0.91). Psychometrics were also good within four gender/age (18-35, 36-61) subgroups.

CONCLUSIONS

PHQ-9 and PHQ-2 appear valid/reliable for assessing DSM-IV depressive disorders and depression severity among adults living with HIV/AIDS in western Kenya.

Health-related quality of life (HRQoL) domains most valued by urban IsiXhosa-speaking people

PURPOSE

The aim of the study was to investigate and identify aspects of health-related quality of life (HRQoL) that are most valued by IsiXhosa-speaking people resident in underresourced areas of Cape Town, South Africa.

METHODOLOGY

Fifty-seven domains of HRQoL were identified as important through group discussions with IsiXhosa-speaking people. Participants randomly selected from the community (n = 601) and from individuals seeking medical attention at a local clinic (n = 102) graded the domains on a visual analogue scale (VAS) ranging from 0 for "not at all important" to 10 for " very important". The domains were then mapped to the categories of the International Classification of Functioning, Disability and Health.

RESULTS

The domains regarded as being most important were Food availability [9.5, standard deviation (SD) = 1.52), Owning a brick house (9.4, SD = 1.57), Access to medical services (9.4, SD = 1.55) and Family safety (9.4, SD = 1.7). Having no bodily pain ranked 40th. Environmental Factors were valued significantly more than the other two categories, and those related to Body Functions were valued higher than domains in the category of Activity and Participation.

DISCUSSION AND CONCLUSION

Despite being asked specifically to answer the questions in relation to their health status, the participants apparently did not differentiate between general quality of life (QoL) and specific HRQoL. It appears that members of an underresourced community regard socioeconomic and service delivery aspects of their lives as integral to their perceived state of health. It may be that it is not possible to separate out factors relating to general QoL from those specifically related to HRQoL in an underresourced population, and such populations might not be suitable for inclusion in certain clinical trials where an improvement in HRQoL is the required outcome. Alternatively, if an HRQoL instrument is to be used to monitor the impact of medical interventions, the inclusion of Environmental Factors should be considered.

Health-related quality of life (HRQoL) domains most valued by urban isiXhosa-speaking people

PURPOSE

The aim of the study was to investigate and identify aspects of health-related quality of life (HRQoL) that are most valued by isiXhosa-speaking people resident in under-resourced areas of Cape Town.

METHODOLOGY

Fifty-seven domains of HRQoL were identified as important through group discussions with isiXhosa-speaking people. Participants randomly selected from the community (n = 601) and from individuals seeking medical attention at a local clinic (n = 102) graded the domains on a visual analogue scale (VAS) ranging from 0 as "not at all important" to 10 as " very important". The domains were then mapped to the categories of the International Classification of Functioning, Disability, and Health.

RESULTS

The domains regarded as being most important were food availability (9.5, SD = 1.52), owning a brick house (9.4, SD = 1.57), access to medical services (9.4, SD = 1.55), and family safety (9.4, SD = 1.7). Having no bodily pain was ranked 40th. Environmental factors were valued significantly more than the other two categories and those related to body functions were valued more highly than domains in the category of activity/participation.

DISCUSSION AND CONCLUSION

Despite being asked specifically to answer the questions in relation to their health status, the participants apparently did not differentiate between general quality of life (QoL) and specific HRQoL. It appears that members of an under-resourced community regard socioeconomic and service delivery aspects of their lives as integral to their perceived state of health. It may be that it is not possible to separate factors relating to general quality of life from those specifically related to HRQoL in an under-resourced population and such populations might not be suitable for inclusion in certain clinical trials where improvement in HRQoL is the required outcome. Alternatively, if a HRQoL instrument is to be used to monitor the impact of medical intervention, the inclusion of environmental factors should be considered.