Conceptualization, measurement, and application of quality of life for persons with intellectual disabilities: report of an international panel of experts

From a concept to a theory: The six eras of quality of life research and application

This article describes the evolution of the quality of life concept through the lens of six distinct eras. Each era reflects a shared process in which multiple stakeholders, including persons with intellectual and developmental disabilities and researchers, have played a significant role. Across these six eras, research on quality of life has evolved from operationalizing a concept to developing a theory. As described in the article, the first three eras resulted in formulating conceptualization, measurement, and application principles; developing quality of life conceptual and operational models; and constructing reliable and valid instruments to assess quality of life domains or domain-referenced indicators. The application era has focused on applying the concept of quality of life and its measurement, supports provision, conceptualization and theory, and systemic change. The final two eras have involved theory development and theory confirmation.

From assistive to inclusive? A systematic review of the uses and effects of technology to support people with pervasive support needs

BACKGROUND

Although particular technologies can enhance the quality of life (QoL) of people with profound intellectual and multiple disabilities (we use the term pervasive support needs), their objectives and outcomes are understudied. A systematic literature review was therefore conducted to explore this topic.

METHOD

A search of four databases yielded 64 studies. Data were extracted on their general characteristics, methods and sample characteristics as well as the technology types, QoL domains and application within ecological systems. A narrative synthesis was subsequently developed.

RESULTS

Most of the studies applied assistive technology (AT) and focused on personal development and self-determination on an individual level.

CONCLUSIONS

Technology can enhance the QoL of people with pervasive support needs. There are indications that although MT and UD-based technology are used in practice, few studies have examined these technologies. Therefore, there is a knowledge gap regarding the kinds of technology that are used in practice.

Psychological and social outcomes of befriending interventions for adults with intellectual disabilities: A systematic review

BACKGROUND

Befriending is an intervention intended to provide companionship and support to socially isolated populations. This review aimed to understand the key characteristics and psychological and social outcomes of befriending interventions for adults with intellectual disabilities.

METHODS

Systematic searches of electronic databases (PsycINFO, MedLine and Web of Science) identified 11 studies for inclusion. A narrative synthesis of the findings was completed, along with critical appraisal of study quality.

RESULTS

Increased community participation, positive changes to social networks and mood were frequently reported outcomes for befriendees. Increased knowledge, new experiences and opportunities to 'give back' were most reported for befrienders.

CONCLUSIONS

The review highlighted that existing research in this field is limited in scope and methodologically diverse. Future research should focus upon the effectiveness and long-term impact of befriending interventions, understanding the mechanisms of change, and eliciting the views of people with intellectual disabilities on their experiences.

The quality of life of individuals with intellectual disability: Differences between Denmark and Japan

Despite recent developments in measurement tools to assess the quality of life of individuals with intellectual disability, little is known about the cultural aspects that affect their quality of life. This study examined the universal and cultural characteristics of the quality of life of individuals with intellectual disability in Denmark and Japan through a factor analysis of the Personal Outcomes Scale and analysing qualitative comments in both self-report and report-of-others components of the scale. Factor analysis and qualitative comments in self-report showed that personal development and self-determination, as well as well-being and social participation, were experienced as important components of quality of life in Denmark. Conversely, personal development and self-determination were less frequently mentioned in Japan. The findings reflect the general characteristics of quality of life in each culture and the current conditions of independence and available support for individuals with intellectual disability in Denmark and Japan.

Effects of exercise on body mass index and waist circumference of individuals with intellectual and developmental disabilities: a systematic review with meta-analysis

Introduction/Methods: This systematic review with meta-analysis aims to assess the magnitude of the effects of physical exercise programs on body mass index (BMI) and waist circumference (WC) of individuals with Intellectual and Developmental Disabilities (IDD), metabolic and cardiovascular health markers. Results: Considering the eligibility criteria, a final sample of nine articles was obtained. For BMI, the Z-value obtained to test the null hypothesis (difference between means is zero), showed a Z = -2.176 and p = 0.03. The highest magnitude of the effect was from the intervention with combined training (difference in means: -0.399), with a value of Z = -1.815 and p = 0.07. For WC, the Z-value is zero, showing a Z = -3.306 and p = 0.001. The highest magnitude of the effect was from the intervention with continuous cardiorespiratory training of -0.786, with a value of Z = -2.793 and p = 0.005. Discussion: Physical exercise prevents increases in BMI and WC in individuals with IDD. Aerobic training seems to be more effective in promoting WC and combined training in BMI. Systematic Review Registration: [PROSPERO], identifier [CRD42021255316].

Quality of Life in Individuals with Intellectual and Developmental Disabilities: The Congruency Effect between Reports

Assessing quality of life (QoL) is important to provide personalized and individualized support plans with the purpose of improving personal outcomes. Based on the conceptual model of QoL, the aim of this study was to assess the congruence between the perceptions of institutionalized individuals with intellectual and developmental disabilities (IDD) and the perception of a third party, regarding QoL. Forty-two individuals participated in this study, including twenty-one with mild to severe IDD and their family members/caregiver/reference technician, who responded to the Personal Outcomes Scale (Portuguese version). Significant differences (p < 0.05) were found between reports in the personal development (t = -2.26; p = 0.024), emotional well-being (t = -2.263; p = 0.024), physical well-being (t = -2.491; p = 0.013) and total QoL (t = -2.331; p = 0.02). The results further show that most third-party reports tend to undervalue the QoL of the individual with IDD, and that there is no congruence in any of the QoL domains. The inclusion of self-reports in the QoL assessment is important. In addition to the assessment of third-party reports, the process of making decisions appropriate to the context and individual characteristics is equally important. On the other hand, the inclusion of third-party reports is an opportunity to promote communication among all stakeholders, recognize and discuss differences, and promote QoL, not only of individuals with IDD, but also of families.

Parent perspectives on the assessment of quality of life of their children with profound intellectual and multiple disabilities in the Netherlands

BACKGROUND

Assessing Quality of Life (QoL) of persons with profound intellectual and multiple disabilities (PIMD) is challenging, yet QoL plays an important role in medical decision-making processes concerning persons with PIMD. The perspectives of parents of children with PIMD on the assessment of their QoL have not been studied.

AIM

To explore the perspectives of parents on the assessment of QoL of their children.

METHODS

We conducted a qualitative study, forming three focus groups with 22 parents of children with PIMD to explore their views on what is necessary to assess QoL of their children and subsequently, who is best suited to assess QoL.

RESULTS

Parents describe a long-term relationship of the assessor with family (child and parents), with trust as an important aspect, as a requirement to assess QoL. Parents consider family members, preferably the parents themselves as the best assessors of QoL, followed by siblings. Professional caregivers, mostly mentioned by name, are considered the next alternative. Most parents thought that physicians do not know the child well enough to assess their QoL.

CONCLUSIONS

In conclusion, the parents of children with PIMD in our study consider trust and a long-term relationship essential for assessing QoL.

Effects of a 24-week exercise program on anthropometric, body composition, metabolic status, cardiovascular response, and neuromuscular capacity, in individuals with intellectual and developmental disabilities

Introduction: The prevalence of overweight and obesity has increased in the last decades, including in people with Intellectual and Developmental Disabilities (IDD). This is even more concerning when it is globally accepted that a low physical condition contributes to the deterioration of functionality and increases the risk of developing chronic diseases during life, with effective implications for health and well-being. The aim of the present study is to investigate the effects of two physical exercise intervention programs on institutionalized individuals with IDD. Methods: Twenty-one adults with IDD (43.04 ± 11.18 years) were split by convenience into three groups: i) an indoor training group (IG; N = 7; 24-week machine-based gym intervention), ii) an outdoor training group (OG; N = 7; 24-week outdoor intervention with low-content materials), and iii) a control group (CG; N = 7). Assessed outcomes included indicators of health and neuromuscular capacity. The ShapiroWilk (n < 50) and Levene tests were used to verify data normality and homoscedasticity. A Kruskal-Walli test was performed to understand if there were differences between the groups. For comparison purposes and to assess hypothetical differences between groups, the Wilcoxon signed-rank test and the Friedman test were used. The respective effect size was calculated, and the significance level was defined at 0.05. Results/Discussion: There was a difference in fat mass in OG (initial ≠ intermediate; Bonferroni corrected: t = 2.405; p = 0.048; W = 0.08 and initial ≠ final moments; Bonferroni corrected: t = 2.405; p = 0.048; W = 0.08). Indoor intervention programs seem to be more effective than outdoor intervention programs for reducing heart rate rest (t = -2.912; p = 0.011; W = -0.104) when compared with CG. Conclusion: A low-cost outdoor intervention in contact with nature appears to be more effective for fat mass reduction. The results for heart rate variability are not clear and robust. Finally, an indoor intervention using weight-training machines appears to be a good method to promote neuromuscular capacity.

Perceptions of direct care workers in two sustainable communities on services provided

Currently, outcomes for people with autism and intellectual disabilities are poor, leaving some needing optimal life-long services. Little is known regarding the services provided at sustainable communities. This study's purpose is to explore the make-up of sustainable communities, those participating in them, and the services provided. One survey containing demographic, descriptive, and quality of life questions was sent to sustainable communities. Survey results revealed that the two communities offer similar services, employ similar staff, and have a common central theme throughout their community. However, the two communities carry out services in very different ways. Quantitative results demonstrate participants achieving statistically similar mean quality of life scores. A correlation indicates that as the frequency of services increases, so does the quality of life. This research suggests these two communities deliver services leading to high levels of quality of life. Results should guide future avenues of research. We also make recommendations for sustainable communities and those considering sustainable communities.

Constructing a preliminary model of school belonging for students with intellectual disability

The construct of belonging has been studied in many marginalised student groups yet has been understudied among students with intellectual disability. The present study used a large dataset from the United States to quantitatively investigate the construct of belonging among 7^th to 12^th grade students with the educational classification of "intellectual disability" (n = 670) who responded to a set of questions related to belonging in a nationally representative survey. The purpose of the study was twofold: (1) to identify the latent factors of belonging among students with intellectual disability to create a preliminary model and (2) use the preliminary model to compare belonging among students with intellectual disability with different demographic factors (e.g., race, sex, English proficiency). Exploratory factor analysis revealed a four-factor model of belonging and confirmatory factor analysis suggested the model was a good fit for the data, χ2 = 622.81, p < .001, RMSEA = .049, CFI = 0.879, TLI = 0.868. The study has implications for future avenues of research, including measurement development, exploring the developmental pathway of belonging, and the consequences of not belonging.

Quality of Life and Family Impact in Down Syndrome, Autism Spectrum Disorder, and Co-occurring Down Syndrome and Autism Spectrum Disorder

OBJECTIVE

Families of children with neurodevelopmental disorders have developmental, behavioral, and social-emotional needs that affect quality of life (QoL). This study assesses the validity and utility of a caregiver QoL measure; characterizes QoL in families with children with Down syndrome (DS), autism spectrum disorder (ASD), and a dual diagnosis of DS and ASD (DS + ASD); and compares and explores differences in QoL based on diagnosis.

METHODS

Caregivers of children and adolescents with ASD (n = 610) and DS (n = 177) completed the Pediatric Quality of Life Inventory Family Impact Module 2.0, yielding overall, parent functioning, family functioning, and subscale scores, and a Parent Global Impression (PGI) rating. An ASD cohort (n = 177) was sex matched to the DS cohort (n = 177) to mitigate potential sex bias. Additional analyses compared these groups with children and adolescents with DS + ASD (n = 37).

RESULTS

Analyses showed that the Pediatric Quality of Life Inventory was valid and reliable in DS, ASD, and DS + ASD populations. No differences were reported in PGI ratings among groups. Caregivers in the DS group demonstrated higher QoL and family functioning compared with the ASD and DS + ASD groups. The DS group reported significantly better Emotional Functioning and Communication and less Worry than the ASD group. Compared with the ASD group, caregivers of the DS + ASD group indicated more concerns with Physical Functioning. Notably, the DS + ASD group had significantly lower levels of QoL than the DS group in nearly all caregiver functioning domains.

CONCLUSION

This study highlights differences in QoL within and between neurodevelopmental disorder groups, which may help identify families requiring additional support, advocacy, and community engagement.

Association between employment status and quality of life for individuals with intellectual or developmental disability

The current study examined how employment conditions (competitive employment, work center employment, unemployment) are associated with the quality of life (QoL) for individuals with intellectual or developmental disabilities. Using the Comprehensive Quality of Life Scale - Intellectual/Cognitive Disability (5th Edition; ComQoL-I5; Cummins, 1997a) to measure objective QoL factors, and the PWI-ID (Personal Wellbeing Index - Intellectual Disability, 3rd Edition; Cummins & Lau, 2005b) to measure subjective well-being, participants answered self-reporting questions regarding the seven QoL domains. Kruskal-Wallis H for Oneway Analysis of Variance was used to determine statistical significance between comparison work conditions. Results indicate significant findings in the objective QoL domains of Material Well-Being, Productivity, and Safety between the work conditions for individuals with intellectual and developmental disabilities, with participants in the competitive-employment group reporting the highest QoL objective scores in these areas. Implications of these findings for practice and research are discussed.

Ableism, racism, and the quality of life of Black, Indigenous, people of colour with intellectual and developmental disabilities

BACKGROUND

Research indicates Black, Indigenous, people of colour (BIPOC) with intellectual and developmental disabilities face disparities in quality of life outcomes. This study's aim was to examine how ableism and racism impacted the quality of life of BIPOC with intellectual and developmental disabilities.

METHODS

Using a multilevel linear regression, we analysed secondary quality of life outcome data from Personal Outcome Measures® interviews with 1393 BIPOC with intellectual and developmental disabilities and implicit ableism and racism data from the 128 regions of the United States in which they lived (discrimination data came from 7.4 million people).

RESULTS

When BIPOC with intellectual and developmental disabilities lived in regions of the United States which were more ableist and racist, they had a lower quality of life, regardless of their demographics.

CONCLUSION

Ableism and racism are a direct threat to BIPOC with intellectual and developmental disabilities' health, wellbeing, and overall quality of life.

Effects of Physical Exercise Program in Adults with Intellectual and Developmental Disabilities-A Study Protocol

We developed a physical exercise (PE) program for people with Intellectual and Developmental Disabilities (IDD), aiming to determine the effects on physical fitness, health, cognitive ability, and quality of life (QoL). Using experimental methodology, this intervention study recruited 21 adults (18 to 65 years old), institutionalized and with no other associated pathology, who will be allocated to one of the different groups: (i) gym/indoor intervention group (using weight machines), (ii) outdoor intervention group (using low-cost materials), or (iii) control group (without specific intervention, who continue with their normal daily activities). Both intervention groups will engage in 45 min of training per session, twice a week, for 24 weeks. Assessments will be conducted at baseline (initial assessment), 3 months (mid-term assessment), and 6 months (final assessment). Variables assessed include anthropometrics, body composition, functional capacity, muscle strength, general health, cognitive ability, and QoL. The results of this study will assist in the development of more effective strategies, recommendations, and interventions to ensure better and greater adherence to PE by institutionalized individuals with IDD, namely, recommendations for assessment, prescription, and implementation of PE for this population. Additionally, we intend to make available two PE programs, if they are adapted and promote positive effects.

Understanding quality of life in people with complex and multiple communicative disabilities: A narrative overview of the empirical research literature

The fundamental characteristics of quality of life (QoL) are considered the same for all people. However, the relative importance of QoL domains may vary for specific populations. No studies have focused on understanding QoL for people with intellectual disabilities with additional communicative disabilities (developmental language disorder or hearing impairment), who experience complex and multiple communicative disabilities (CMCD). This study provides a narrative overview of QoL domains and indicators for this population, highlighting the role of communication. The 16 selected studies proved to be heterogeneous in study design, objective and conceptualization of QoL. The eight domains of QoL by Schalock and Verdugo (2002) are recognized, but few studies specify the importance of communication related to QoL for people with CMCD. The current overview attempts to emphasize not only the indirect role of communication for every QoL domain, but also the importance of acknowledging communication as a prerequisite for QoL in general.

Smart Continence Care for People With Profound Intellectual and Multiple Disabilities: Protocol for a Cluster Randomized Trial and Trial-Based Economic Evaluation

Background

People with profound intellectual and multiple disabilities (PIMD) cannot communicate the need to change their incontinence products. The smart continence care (SCC) product Abena Nova signals caregivers when change is needed. This provides the opportunity for more person-centered care, increased quality of life, and a decreased number of leakages. However, there is a need for evidence of the effectiveness and cost-effectiveness of such technology compared with regular continence care (RCC) for people with PIMD.

Objective

This paper presents the research protocol for an effectiveness and cost-effectiveness study with people with PIMD living in long-term care facilities in the Netherlands.

Methods

A cluster randomized trial will be conducted in 3 consecutive waves across 6 long-term care providers for people with disabilities and 160 participants with PIMD. Long-term care providers are randomized at a 1:1 ratio, resulting in an intervention group and a group continuing RCC. The intervention group will receive implementation guidance and use SCC for 3 months; the other group will continue their RCC as usual and then switch to SCC. This study consists of three components: effectiveness study, economic evaluation, and process evaluation. The primary outcome will be a change in the number of leakages. The secondary outcomes are quality of life, the difference in the number of changes, the work perception of caregivers, cost-effectiveness, and cost utility. Data collection will occur at T0 (baseline), T1 (6 weeks), T2 (12 weeks), and T3 (9-month follow-up) for the first 2 intervention groups. An intention-to-treat analysis will be performed. The economic evaluation will be conducted alongside the trial from the societal and long-term care provider perspectives. Qualitative data collection through interviews and field notes will complement these quantitative results and provide input for the process evaluation.

Results

This research was funded in December 2019 by ZonMw, the Netherlands Organization for Health Research and Development. As of June 2022, we enrolled 118 of the 160 participants. The enrollment of participants will continue in the third and fourth quarters of 2022.

Conclusions

This study will provide insights into the effectiveness and cost-effectiveness of SCC for people with PIMD, allowing long-term care providers to make informed decisions about implementing such a technology. This is the first time that such a large-scale study is being conducted for people with PIMD.

Trial Registration

ClinicalTrials.gov NCT05481840; https://clinicaltrials.gov/ct2/show/NCT05481840

International Registered Report Identifier (IRRID)

DERR1-10.2196/42555

Putting "ME" into measurement: Adapting self-report health measures for use with individuals with intellectual disability

BACKGROUND

Self-report is important for measuring health outcomes; however, most research in intellectual disability (ID) relies on proxy report. The lack of cognitively accessible measures is one barrier to accurate self-reporting by individuals with ID.

AIMS

This paper describes the process of adapting self-report measures of health status, health-related quality of life, and environment for use by individuals with ID and presents evidence on their usability (accessibility), usefulness (independent self-report), and reliability (internal consistency and test-retest).

METHODS AND PROCEDURES

We used an inclusive research approach, in which we collaborated with adults with ID to revise, cognitively test, and pilot test cognitively accessible self-report measures. Technology supported the independent completion of measures. We assessed usability, usefulness, and reliability of these measures in 41 adults with ID.

OUTCOMES AND RESULTS

The resulting measures are useful (independently completed) and usable (elicit a range of responses), with modest reliability (internal consistency and test-retest).

CONCLUSIONS AND IMPLICATIONS

Self- report by adults with ID is feasible. A key element of this measure adaptation process was engaging adults with ID. More research is needed to understand the reliability and validity of the adapted measures and the characteristics of the population for whom they are most usable.

The potential for person-centred planning to support the community participation of adults with an intellectual disability

Person-centred planning (PCP) puts individuals with an intellectual disability at the centre of service and support planning, identifying how individuals wish to live their lives and what is needed to make that possible. PCP has been identified as having the potential to facilitate improved social inclusion and community participation. A mixed-methods approach combined quantitative analyses with qualitative case studies of individuals with severe-profound intellectual disability to assess the impact of PCP on community participation for adults with an intellectual disability at a disability service in Dublin. We conclude that PCP may provide a good basis to plan community participation and, with the right supports in place, may provide opportunities for people with complex needs to improve their community participation. Supports including familiar staff and family are critical to the success of PCP for people with complex needs, and their absence may undermine the best intentions of PCP for this population.

Anthropometric Indicators of the Cardiometabolic Risk, Muscle Strength, and Functional Capacity of Schoolchildren with Intellectual Disabilities during Lockdown in Chile

Lockdown due to the COVID-19 pandemic has negatively impacted the social, psychological, and physical well-being of the world population. In the case of people with intellectual disabilities, the impact of lockdown on their physical condition and functionality is not completely clear. This study aimed to determine the effects of COVID-19 lockdown on the anthropometric indicators of cardiometabolic risk, muscle strength, and functionality on schoolchildren with intellectual disabilities. The sample was composed of 132 students of both sexes (n = 74 pre-lockdown; n = 58 lockdown) belonging to two special education centers from the Metropolitan Region of Santiago, Chile. Our results showed significant reductions (p ≤ 0.05) in absolute and relative handgrip strength, as well as in functionality, when comparing pre-lockdown and lockdown measurements, with a greater loss in girls than boys. The design and implementation of physical exercise programs centered on strength training are necessary for the physical and functional reconditioning of this population. These programs need to be implemented in special education centers considering the general well-being, quality of life and work needs of people with intellectual disabilities.

Conceptualization of quality of life in autistic individuals

The present study examines to what extent two core characteristics of the quality of life (QoL) construct were incorporated in the field of autism: (1) its subjective nature; and (2) its multidimensionality. Therefore, we reviewed 174 articles examining QoL in individuals with autism. The review showed parents reporting a lower QoL compared with autistic individuals themselves, especially on internal domains. This may suggest different expectations about what a good QoL may entail. Such an underestimation of QoL by others is commonly observed in individuals with disabilities (the so-called 'disability paradox'). For the multidimensionality of the QoL construct, our findings suggest that the narrower (and more unidimensional) construct of health-related QoL is often measured instead of QoL. Additionally, a substantial proportion of items did not measure QoL, but they evaluated characteristics that may or may not have an impact on QoL. Researchers and clinicians should be aware that QoL domains are selected and operationalized differently by different instruments. QoL may benefit from an exclusive focus on subjective aspects, which can be measured alongside more normative, objective characteristics of individuals or their environment.

Improving quality of family life among Christian parents of children with low vision in Nsukka catholic diocese using rational emotive family health therapy

BACKGROUND

Most Christian parents living with children with low vision have reported to be experiencing psychological disturbances that are affecting the family health. As a result, the quality of family life is being impaired. The experience of parents catering for children with low vision is mainly influenced by psychosocial factors that could determine the quality of family life of such parents. This present study is to investigate the efficacy of rational emotive family health therapy in reducing poor quality of family life among Christian parents of children with low vision in Nsukka Catholic Dioceses.

METHOD

This is a randomized pretest and posttest control trial. Participants were 88 parents of children living with low vision in Nsukka Catholic Dioceses, Nigeria. The power of the sample size was determined using Gpower statistical software. The participants in rational emotive family health therapy programme-group were exposed to a 12-session treatment programme whereas their counterparts in waitlisted control group did not receive anything. A family quality of life scale was utilized in assessing the participants. Data analyses were performed using repeated measures ANOVA.

RESULTS

It was found that rational emotive family health therapy had a significant positive effect on increasing quality of family life among the study participants compared to those in the waitlisted control group.

CONCLUSION

This study contributed and validated the efficacy of rational emotive family health therapy in improving quality of family life among parents of children with low vision.

An international field study of the ICD-11 behavioural indicators for disorders of intellectual development

BACKGROUND

The World Health Organization (WHO) has approved the 11th Revision of the International Classification of Diseases (ICD-11). A version of the ICD-11 for Mental, Behavioural and Neurodevelopmental Disorders for use in clinical settings, called the Clinical Descriptions and Diagnostic Requirements (CDDR), has also been developed. The CDDR includes behavioural indicators (BIs) for assessing the severity of disorders of intellectual development (DID) as part of the section on neurodevelopmental disorders. Reliable and valid diagnostic assessment measures are needed to improve identification and treatment of individuals with DID. Although appropriately normed, standardised intellectual and adaptive behaviour assessments are considered the optimal assessment approach in this area, they are unavailable in many parts of the world. This field study tested the BIs internationally to assess the inter-rater reliability, concurrent validity, and clinical utility of the BIs for the assessment of DID.

METHODS

This international study recruited a total of 206 children and adolescents (5-18 years old) with a suspected or established diagnosis of DID from four sites across three countries [Sri-Lanka (n = 57), Italy (n = 60) and two sites in India (n = 89)]. Two clinicians assessed each participant using the BIs with one conducting the clinical interview and the other observing. Diagnostic formulations using the BIs and clinical utility ratings were collected and entered independently after each assessment. At a follow-up appointment, standardised measures (Leiter-3, Vineland Adaptive Behaviour Scales-II) were used to assess intellectual and adaptive abilities.

RESULTS

The BIs had excellent inter-rater reliability (intra-class correlations ranging from 0.91 to 0.97) and good to excellent concurrent validity (intra-class correlations ranging from 0.66 to 0.82) across sites. Compared to standardised measures, the BIs had more diagnostic overlap between intellectual and adaptive functioning. The BIs were rated as quick and easy to use and applicable across severities; clear and understandable with adequate to too much level of detail and specificity to describe DID; and useful for treatment selection, prognosis assessments, communication with other health care professionals, and education efforts.

CONCLUSION

The inclusion of newly developed BIs within the CDDR for ICD-11 Neurodevelopmental Disorders must be supported by information on their reliability, validity, and clinical utility prior to their widespread adoption for international use. BIs were found to have excellent inter-rater reliability, good to excellent concurrent validity, and good clinical utility. This supports use of the BIs within the ICD-11 CDDR to assist with the accurate identification of individuals with DID, particularly in settings where specialised services are unavailable.

The Impact of Health and Social Services on the Quality of Life in Families of Adults with Autism Spectrum Disorder (ASD): A Focus Group Study

Background: Autism spectrum disorder (ASD) is a complex developmental condition that affects the whole family. The gap between childrens’ needs and their satisfaction, especially regarding what concerns the presence of social and healthcare services, is still a source of burden, particularly after the transition to adulthood. Our study aimed to gather a comprehensive view on how parents of adults with ASD perceive (and interact with) health and social services, and how the provision of care impacts family quality of life with the aim to advise ASD intervention programs. The goal is to identify specific areas of change useful to influence autism intervention strategies so that they more effectively meet the needs of young people with autism and their families. Methods: We conducted two focus groups with parents of young adults with ASD. A semi-structured focus group methodology was adopted. The QoL conceptual framework guided data collection and analysis as part of a directed theory-driven content analysis approach. Results: The lack of structured care pathways and the low level of integration of different services were the main limits reported by parents during the focus group, while a shared positive perception of the experience conducted together as caring families emerged. Conclusions: The experience here reported claims for a greater role of the institutions in order to facilitate the building of networks that are really inclusive for persons with autism in society and to support the implementation of innovative solutions for the welfare system. Furthermore, parents stressed the need for the provision of support to the family.

From Deinstitutionalization to Community-Based Urban Development: Investigating Accessibility of Urban Systems in Calabria through Network Analytics

Community-based urban development is an inclusive approach for local service provision and management centered on the proactive partnerships between urban communities and local governments. Rooted in the deinstitutionalization of public services, the European Union and national policy effort is pushing towards the organization of community-based alternatives in response to the evolving needs of local communities. As the pandemic has shown, service accessibility has proven to be a key concern element that needs to be addressed to increase communities’ and cities’ resilience. In this direction, the paper aims to propose data-driven alternative approaches to assess urban systems’ accessibility and connectivity as an element of leveraging the resilience-oriented planning process and facilitating community-based development. The methodological approach focuses on the case of the Calabria region, where community-based alternatives for the provision of public services found difficulties to be operationalized through an integrated planning approach. The case study is explored by experimenting on the spatial connections of two purposefully selected clusters to assess the accessibility and connectivity of urban systems within the region through network analysis visualization tools: health and social-related services and transportation and logistics. The analytical approach outlines the accessibility level of urban systems in the region examined, proving its relevance in detecting social, economic, and environmental dynamics. This approach shows how using non-traditional data-driven perspectives can detect development dynamics—which affect local community’s needs—and their limitations in the organization of community-based development alternatives.

The Impact of Human Service Provider Quality on the Personal Outcomes of People With Intellectual and Developmental Disabilities

Background

Quality of life is multidimensional—influenced by individual, organizational, and environmental factors. As such, when examining personal outcomes, it is also important to consider meso and macro factors that contribute to people with intellectual and developmental disabilities' (IDD's) quality of life. While it is widely acknowledged that organizational factors contribute to people's quality of life, there is less research directly examining how the quality of human service providers contributes to people with IDD's personal outcomes. For these reasons, the aim of this study was to explore the relationship between provider quality and people with IDD's personal quality of life outcomes.

Methods

Using a multilevel linear regression we analyzed secondary Personal Outcome Measures® (personal outcomes) and Basic Assurances® (provider quality) data from 2,900 people with IDD served by 331 human service providers.

Results

People with IDD's personal outcomes, regardless of their support needs or other demographics, were significantly impacted by the quality of the human service providers they received services from—the higher the quality of the provider, the more personal outcomes they had present. In addition, the following demographic covariates were correlated with personal outcomes: gender; race; complex support needs; residence type; and organizations that offered therapy services.

Discussion

While quality improvement initiatives may require a great deal of cost and time commitment from providers, our findings suggest the effort translates to improved personal outcomes among people with IDD. The ultimate goal of service providers should be improvement of quality of life among those they support.

The perspectives of professional caregivers on quality of life of persons with profound intellectual and multiple disabilities: a qualitative study

Persons with Profound Intellectual and Multiple Disabilities (PIMD) are supported by professional caregivers for a large part of their lives. However, the perspectives of professional caregivers on good or poor Quality of Live (QoL) of persons with PIMD have hardly been explored. To explore the perspective of professional caregivers on QoL of persons with PIMD, we performed a qualitative study, conducting semi-structured interviews with eleven professional caregivers and thematically analysed them. In the interviews, these professional caregivers described examples of good and poor QoL. Good QoL was mostly described in emotional terms such as happiness, pleasure and enjoying things. Poor QoL was mostly described in physical terms such as pain, sickness and shortage of breath. The capability of persons with PIMD to influence the environment was described as an element of good QoL. Furthermore, these professional caregivers described how they assessed QoL. They 'sensed' QoL, they tested it (trial and error) and discussed QoL of persons with PIMD with colleagues. Participants emphasized the dependency of persons with PIMD on professional caregivers. Furthermore, these professional caregivers described feelings of failure and powerlessness if they could not assess or fulfil the needs of persons with PIMD. We conclude that these professional caregivers use their (tacit) knowledge to understand QoL of persons with PIMD. The relationship between QoL of persons with PIMD and professional caregivers needs more investigation, because of its consequences both for the persons with PIMD and the professional caregivers.

A quality of life supports model: Six research-focused steps to evaluate the model and enhance research practices in the field of IDD

In the field of intellectual and developmental disabilities (IDD) the constructs of quality of life and supports have been combined into a Quality of Life Supports Model (QOLSM) that is currently used internationally for supports provision, organization transformation, and systems change. With the model's increasing and widespan use in research and practice, there is a need to evaluate the model's impact at the individual, organization, and systems levels. The purpose of this article is to outline six specific research-focused evaluation steps that allow researchers to evaluate the model and thereby enhance research practices is the field of IDD. These steps involve: (1) operationalizing components of the QOLSM; (2) relating QOLSM components to the type of research planned and intended outcome indicators; (3) gathering evidence and establishing its credibility; (4) interpreting and communicating the results; (5) implementing research outcomes at the level of the microsystem, mesosystem and macrosystem; and (6) judging the impact of the model. These steps delineate a research framework that is based on a systematic approach to evidence-based practices and enhanced research practices in the field of IDD.

Perceptions of parents of the impact of autism spectrum disorder on their quality of life and correlates: comparison between mothers and fathers

PURPOSE

To compare mothers and fathers perceptions of the impact of autism spectrum disorder on their Quality of Life (QoL), we used the Parental-Developmental Disorders-Quality of Life scale (Par-DD-QoL).

METHOD

The perception of QoL of mothers and fathers was compared for 130 pairs of parents of children with ASD and the associated variables were investigated.

RESULTS

Mothers perceived a significantly greater impact of ASD on their QoL than fathers. Parents perceived a higher impact of ASD on global QoL when their child's adaptive skills were low and when the level of aberrant behaviors was high. More precisely, the perception of QoL by the mothers was negatively associated with their child's internalized disorders, whereas the perception of QoL by the fathers was negatively associated with their child's externalized disorders. Neither the mothers' nor the fathers' perception of the impact on QoL was associated with their children's age or the severity of their autistic symptoms. Some parental factors, such as being members of a family association, having benefited from training in ASD and having experienced a disruption in professional activity were associated with a greater impact on their QoL.

CONCLUSION

Our finding that the perceived impact of ASD on QoL differed between mothers and fathers argues for individualized psychosocial support. Moreover, the strong correlation between the child's clinical characteristics and the perception by parents of a higher impact of ASD on QoL should be seen as red flag concerning the needs of the parents in terms of social and educational support.

TRIAL REGISTRATION NUMBER

NCT02625116 (October 2015).

Health-Related Quality of Life in People Living with HIV in Southwest Iran in 2018: A Cross-Sectional Study

Health-related quality of life (HRQoL) is one of the most important indicators in assessing the health and well-being of HIV-positive patients. The present study investigated the HRQoL of HIV patients referred to Abadan's Voluntary Counseling and Testing (VCT) center in 2019. In this cross-sectional study, a total of 134 HIV⁺ patients referred to Abadan's VCT center were selected through convenience sampling. Demographic information was collected through a researcher-made checklist; the patients' status and health information were collected through electronic medical records of HIV⁺ patients and their records at the VCT center. The HRQoL index was assessed using the World Health Organization (WHOQOL-BREF) questionnaire. Data analysis was carried out using simple and multiple linear regression as well as a t-test in SPSS software. A P value < 0.05 was considered as the significance level in all tests. The mean of the HRQoL in all the participating patients was 56.42 ± 22.66. The highest and lowest mean scores of HRQoL domains were related to social relationships (57.53 ± 24.73) and environmental health (53.68 ± 19.07). There was a positive significant relationship between the marital status, residency, years of education, duration of infection, transmission route, and antiretroviral (ARV) therapy with the score of the HRQoL. The results showed a moderate score for the mean HRQoL and its domains. The present study revealed the necessity of improving HIV⁺ patients' living conditions, employment status, health education, and mental health care.

The positive psychology constructs of parents of children with intellectual and developmental disabilities in Turkey

BACKGROUND

The purpose of this exploratory study was to examine positive psychology constructs (life orientation/optimism, life satisfaction, happiness, psychological well-being and personal well-being) that may predict the family quality of life (FQOL) of parents of children with intellectual and developmental disabilities (IDD) in Turkey.

METHODS

Data were obtained from a convenience sample of 660 parents of children with IDD who responded to six assessments, including a measure of FQOL. An analysis using stepwise multiple regression was conducted to identify predictors of FQOL as rated by parents.

RESULTS

The four constructs including personal well-being, psychological well-being, life orientation (optimism) and life satisfaction significantly explained 60% of the total variance of FQOL. The amount of explained variance, beta scores and correlations suggests that these positive psychology constructs are significant predictors of FQOL of parents of children with IDD in Turkey.

CONCLUSION

The study findings suggested that positive psychological constructs at the individual level were positively related to FQOL at the group level. Personal well-being was the strongest predictor of FOQL of parents who have children with IDD in Turkey. The results also indicated that other constructs including psychological well-being, an optimistic life orientation and life satisfaction contribute significantly to the FQOL of parents of children with IDD.

An 88.8-kb Novel Deletion of 19q13.2 Encompassing the ATP1A3 Gene Detected by Array CGH in a Patient with Delayed Psychomotor Development, Generalized Hypotonia and Macrocephaly

Many neurodevelopmental disorders are caused by the presence of CNVs. Chromosome microarray technology is widely used to accurately detect CNVs. We report the case of a male, aged 3 years, presenting with delayed psychomotor development, generalized hypotonia, encephalopathy, delayed myelination in the central nervous system, and poor motor coordination. The array CGH revealed an interstitial deletion of chromosome 19q13.2 with a size of 88.8 kb involving 3 OMIM genes: RABAC1, ARHGEF1, and ATP1A3. Heterozygous mutations in the ATP1A3 gene are associated with delayed psychomotor development, alternating hemiplegia of childhood type 2 (AHC2), dystonia type 12, and cerebellarataxia-areflexia-pes cavus-optic atrophy-sensorineural hearing loss syndrome, also called CAPOS syndrome. The phenotypic expression of partial ATP1A3 deletion is, however, poorly described in the literature. The deletion was confirmed by MLPA, and we identified a hitherto undescribed novel deletion of exons 3b-21 of the ATP1A3 gene. Our data suggest that the deletion of the ATP1A3 gene is a causative factor of the AHC2 phenotype in the patient.

Covert-overt prejudices towards the intellectual disabilities at school: A study on teachers and non-teachers of southern Italy

Intellectual Disabilities (ID) is a neurodevelopmental disorder with considerable individual variability in type and severity. Due to overt and covert prejudices around ID, however, society tends to generalize this condition. Also, in schools, teachers’ attitudes toward students with IDs often differ from those toward regular students. The purpose of this study is to examine the levels of overt and covert prejudices toward ID of curricular and support teachers and non-teachers, in a sample of Southern Italian citizens, by evaluating age, gender and socioeconomic differences, as well as the associations of prejudice with education about and contact with ID. Six hundred and sixty-four participants (484 F; 38% teachers), 18–70 years old (M = 38.72; SD = 14.79) participated in the study. The Modern and Classical Prejudices Scale was administered in paper and online forms. Sociodemographic measures, as well as measures around ID education and contact with people with ID were collected. The results show that teachers had higher levels of classical prejudices compared to non-teacher participants. Teachers of primary schools showed higher levels of classical and modern prejudices. No gender and socioeconomic status (SES) differences were found in the whole sample. The entry of children with Intellectual Disabilities into primary school can be strongly influenced by teachers’ prejudices. Therefore, the need for teachers’ information and training on Intellectual Disabilities is evident.

The use of Oral Health Impact on Daily Living (OHIDL) transition scale in measuring the change in oral health-related quality of life among older adults

Background

This longitudinal study aimed to evaluate the longitudinal validity and reliability of the Oral Health Impact on Daily Living (OHIDL) transition scale and measure the perceived change in oral health-related quality of life (OHRQoL) after dental treatments among older adults.

Methods

OHIDL was administered to older adults who sought dental treatments. Participants were asked to assess changes in impact for each OHIDL item retrospectively compared with that before the treatment. The responsiveness, minimal clinically important difference (MCID), internal consistency and test–retest reliability of the OHIDL transition scale were evaluated. Multiple linear regression was employed to predict the change in oral health impacts after dental treatment. Beta coefficients (β) and 95% confidence intervals (CI) were reported.

Results

One hundred and seventy-six participants were followed-up with upon completing their dental treatments. The follow-up rate was 70.4% (176/250). The OHIDL transition score strongly correlated with the global rating of change (r_s = 0.76, P < 0.01). MCID was determined by participants who reported “a little improved” in the perceived oral health impacts, and their mean transition score was 3.3. Cronbach’s alpha of the transition scale was 0.87, and many items had a test–retest correlation of at least 0.60. Patients who perceived more oral health impacts at baseline as measured by the total intensity score (β = 0.32, 95% CI: 0.20, 0.44, P < 0.001) and those who had received endodontic treatment (β = 8.04, 95% CI: 4.36, 11.71, P < 0.001) would have more improvement in perceived oral health impacts.

Conclusions

The OHIDL transition scale has good psychometric properties and is sensitive to change over time. After receiving dental treatment, most of the study’s older adults perceived a lower intensity of OHIDL.

Clinical relevance

The OHIDL transition scale is a valid and reliable instrument to measure the change in OHRQoL after dental treatments.

Participation in daily life for adults with profound intellectual (and multiple) disabilities: How high do they climb on Shier's ladder of participation?

Participation is the goal of Swedish disability policy, but it is difficult to achieve for adults with profound intellectual (and multiple) disabilities (PI(M)D). Since these adults are dependent on others in every aspect of their lives, others control their ability to participate in everyday life decisions. This study used observations, analyzed with Shier's ladder of participation, to elucidate and describe participation in daily life for adults with PI(M)D living in a group home. The results showed that the adults often reached the first three levels of Shier's ladder, one adult reached the fourth level once, and no one reached the fifth level. Participation on a higher level, therefore, seems hard to reach for adults. Staff members' attitudes toward the adults' capability can also be a barrier to participation. Applying Shier's ladder of participation can provide valuable information that might lead to increased participation in daily life for adults with PI(M)D.

Quality of life and vocational education service quality in students with intellectual disability

The aim of the study was to investigate the relation between subjective quality of life and quality of vocational education services from the view of students with intellectual disability who participate in public special vocational education schools in Greece. The level of quality of life and quality of special vocational education services was explored. The article presents a functional description of service quality in special vocational education and operationalizes quality of life for students with disability. Instruments were developed and adapted in line with the participatory research paradigm. Convenience sampling was used. Data was gathered from 131 students with intellectual disability. All measures showed good evidence of internal consistency and construct validity. The findings suggest relationship between quality of life and quality of special vocational education services received by students with intellectual disability. Low levels of self-determination are highlighted. Practical implications concerning the application of the instruments in special education settings as measures for the quality assessment and the evaluation of educational interventions are discussed.

Defining quality of life for individuals with neurodevelopmental disorders: Challenges within an inpatient population

PURPOSE

The concept of Quality of Life (QoL) for people with neurodevelopmental disorders primarily focuses on deinstitutionalisation and community inclusion. This population, however, often presents with comorbid diagnoses and is sectioned to treatment facilities under the Mental Health Act. The aim of this paper is to review the existing literature on QoL and discuss the consideration of this specialised population and the environment when measuring QoL.

METHODS

Databases were searched using specific inclusion and exclusion criteria to ensure literature reviewed was relevant to the defined population. The challenges identified from the literature were categorised into interpersonal and intrapersonal factors.

RESULTS

A total of 30 articles were retrieved and considered in this review.

CONCLUSIONS

This paper discusses how these individuals present with different behaviours and opportunities, which subsequently make it difficult to apply existing knowledge of QoL. The need to further examine the QoL in this specific population is discussed.

Family Variables and Quality of Life in Children with Down Syndrome: A Scoping Review

The purpose of this scoping review was to identify the family and child quality of life variables that have been studied in relation to one another in children with Down syndrome, the frequency with which different relationships have been studied, and the extent to which family variables were the focus of the research aims. A literature search was conducted to find studies published between January 2007 and June 2018. The initial search yielded 2314 studies; of these, 43 were selected for a final review. Researchers most often addressed family resources and family problem-solving and coping concerning child personal development and physical well-being. Little attention to child emotional well-being was observed, with none considering family appraisal of child emotional well-being. The relationship between family variables and child QoL rarely was the primary focus of the study. Methodologically, most reviewed studies used cross-sectional designs, were conducted in North America and based on maternal report. From future research considering the issues found in this review, healthcare providers can obtain an in-depth understanding of relationships between children and family variables.

Participation in employment and day care for adults with intellectual disabilities: Equal access for all?

BACKGROUND

The employment rate for people with intellectual disabilities is low. This study aims to increase the knowledge about the association between age, gender, diagnosis, functional level, educational level, and daily activities for adults with intellectual disabilities.

METHOD

A multinomial logistic analysis was applied to registry data on 12,735 adults with intellectual disabilities from the Norwegian Information System for the Nursing and Care Sector (IPLOS) and Statistics Norway (SSB).

RESULTS

Higher likelihood of employment and day care participation were associated with younger age but differed between genders and diagnoses. High functional level and lack of a registered functional level decreased the likelihood for employment. Educational level was not associated with employment.

CONCLUSIONS

The systematic differences in employment and day care participation among people with intellectual disabilities indicate that actions are needed to prevent inequalities. Improved individual assessment of personal resources and wishes might promote participation in employment and day care.

Factor Structure and Psychometric Properties of the Family Quality of Life Questionnaire for Children With Developmental Disabilities in China

The purpose of this study was to explore the factor structure and psychometric properties of the Chinese version of Family Quality of Life Questionnaire (Chinese FQoL-Q) for children with developmental disabilities (CDD) under the background of Chinese culture. The item analysis, exploratory factor analysis, confirmatory factor analysis, and reliability test were carried out on survey data from a sample of 845 families of CDD. It was found that the Chinese FQoL-Q involved seven factors with 35 items, including economy and leisure, physical and mental health, parenting, family communication, support from others, professional support, and career development. The measurement model of Chinese FQoL-Q reflected traditional Chinese culture and parents’ perception of education or rehabilitation for CDD in China. The Chinese FQoL-Q is reliable and valid for assessing the quality of life for family members with developmental disabilities.

Social Interaction Skill Intervention for Autistic Adults with Intellectual Disability and Limited Language: A Pilot of the SKILL Program

There is a dearth of research that focuses on social intervention efforts for adults on the autism spectrum with intellectual disability and limited conversational language. Using a multiple baseline experimental design, this pilot investigation of the Socialization Knowledge for Individuals with Limited Language (SKILL) program evaluated a novel peer-facilitated group program specifically designed to target social interaction skills for this population. Findings from five pilot participants yielded evidence of social improvements across specific verbal skills (on-topic conversational contributions and responses) and nonverbal behaviors (eye-contact, active listening), as evidenced by coded social conversation probes and parent-report measures. These findings demonstrate the promise of a socialization intervention for a population that has historically been neglected in the social intervention research literature.

Intervention effects on professionals' attitudes towards the participation of adults with visual and severe or profound intellectual disabilities

Background

We investigated the effects of the “Care for Participation+” (CFP+) intervention on direct support professionals’ (DSPs’) attitudes regarding the participation of adults with visual and severe or profound intellectual disabilities (VSPID).

Methods

We implemented a pilot non‐randomized controlled trial with two control groups to compare DSPs’ attitudes towards CFP+ using the Attitudes towards Participation Questionnaire (APQ) and DSPs’ written profiles of adults with VSPID.

Results

CPP+ and the Participation Mind Map control group showed a positive trend for the “leisure/recreation,” “social relations,” and “ability to act” APQ domains compared to the usual care control group. The CFP+ group described significantly fewer disabilities at 6 months, reflecting a more positive attitude than controls.

Conclusion

CFP+ had positive effects on DSPs’ attitudes towards the participation of adults with VSPID. The small sample size, ceiling effects, measurement instruments used, and implementation difficulties may have hampered understanding the full potential of CFP+.

The Relationship Between Spiritual Life and Quality of Life in People with Intellectual Disability and/or Low-Functioning Autism Spectrum Disorders

Spirituality seems to represent a relevant domain in the person-centred care planning and outcome assessment for persons with intellectual disability and low-functioning autism spectrum disorder. Despite this, the impact of spirituality on subjective well-being and quality of life (QoL) has been scarcely investigated. The aim of the present study was to map the international scientific literature in order to identify the reasons of such misconsideration and the key points for future research and practice implementation. The relationship between spirituality and QoL depends on a complexity of factors, ranging from QoL theoretical models to services' organisation. Personal attitude, family members, health and social-care personnel, training, faith and life communities, and even different religions seem to deserve an in-depth analysis.

Pediatric Quality of Life Inventory (PedsQL) in Fragile X Syndrome

To date, health related quality of life (QoL) has not been systematically evaluated in youth with fragile X syndrome (FXS), the most common single gene cause of autism and the most common inherited form of developmental disability. We describe QoL data gathered using the Pediatric Quality of Life Inventory (PedsQL) completed online by 364 parents of youth with FXS. Parents consistently reported across all gender and age groups that their children experienced the highest QoL in Physical functioning and the lowest QoL in Cognitive functioning. Overall, older children with FXS had increase QoL ratings in the domains of School and Cognitive function.

An initial validation of a new quality of life measure for adults with intellectual disability: The Mini-MANS-LD

There is an appropriate increasing focus on the need to ensure the voices of people with intellectual disability are captured as part of assessing individuals' quality of life; however, there remains a lack of a consensus on ways to achieve this. This article describes the development of a self-report measure of quality of life for people with intellectual disability, the 'Mini-MANS-LD', based on the concepts of Maslow's hierarchy of needs. Following use with 33 individuals with intellectual disability, the Mini-MANS-LD was found to have acceptable psychometric properties, including moderate congruent validity and acceptable internal consistency. Administrators' feedback suggested good acceptability and feasibility, and the measure was relatively quick to administer, easy to use and acceptable to service users. Despite a small sample size, this initial study suggests that the Mini-MANS-LD may present a conceptually relevant, feasible and acceptable self-report measure of quality of life for people with intellectual disability.

Dimensions of group home culture as predictors of quality of life outcomes

Background

Research has shown that there is variability in quality of life (QOL) outcomes for people with intellectual disabilities who live in group homes. The aim was to examine dimensions of group home culture as predictors of QOL outcomes.

Method

The Group Home Culture Scale (GHCS) was used to measure staff perceptions of culture in 23 group homes. QOL data were available from 98 people with intellectual disabilities. Multilevel modelling was used to examine the associations between the GHCS subscales and four QOL‐dependent variables.

Results

Of the GHCS subscales, Effective Team Leadership and Alignment of Staff with Organizational Values significantly predicted residents’ engagement in activities. Supporting Well‐Being significantly predicted residents’ community involvement. None of the GHCS subscales significantly predicted domestic participation and choice making.

Conclusions

The findings suggest that strategies to improve Effective Team Leadership and Supporting Well‐Being dimensions of culture may contribute to enhancing certain QOL outcomes.