Advs Exp. Medicine, Biology - Neuroscience and Respiration (2015) 14: 19–30 DOI 10.1007/5584_2015_136 # Springer International Publishing Switzerland 2015 Published online: 28 May 2015
Socioeconomic Indicators Shaping Quality of Life and Illness Acceptance in Patients with Chronic Obstructive Pulmonary Disease Boz˙ ena Mroczek, Zygmunt Sitko, Katarzyna Augustyniuk, blewska, Joanna Pierzak-Sominka, Izabela Wro and Donata Kurpas Abstract
Quality of life (QoL) combined with the acceptance of illness reflects the efficiency of therapy and the level of patients’ satisfaction with medical care. Education, marital status, and place of residence were used as the socio-economic status indicators. The purpose of this study was to determine the relationship between the levels of QoL and acceptance of illness (AI) and the socio-demographic data in patients with chronic obstructive pulmonary disease (COPD). The study involved 264 adult COPD patients. The average duration of COPD was 9 years (Q1–Q3: 3.0–12.0). The duration of the disease was significantly shorter in patients from rural areas. QoL correlated positively with AI (r ¼ 0.69, p < 0.0001). The general QoL and AI were most strongly influenced by education, gender, and age. Education is a strong predictor of QoL and AI, and the latter correlate with the socioeconomic status of COPD patients. It is recommended that COPD patients with a low level of education have regular medical check-ups and are included in the preventive programs by general practitioners to improve their somatic status and QoL level.
B. Mroczek (*) Department of Humanities in Medicine, Faculty of Health Sciences, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland e-mail: [email protected]; [email protected] Z. Sitko Department of Thoracic Surgery and Transplantology, The Professor Alfred Sokołowski Specialist Hospital, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland K. Augustyniuk Department of Nursing, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland
J. Pierzak-Sominka Department of Public Health, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland I. Wr oblewska Health Sciences Faculty, Wroclaw Medical University, 5 Kazimierza Bartla St., 50-996 Wroclaw, Poland D. Kurpas Department of Family Medicine, Wroclaw Medical University, Wroclaw, Poland Opole Medical School, Opole, Poland 19
Boz˙ena Mroczek et al.
20
Keywords
Chronic disease • Family physician • Prevention • Socio-demographic data • Somatic status • WHOQOL-Bref
1
Introduction
Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory conditions. According to the forecasts of the World Health Organization (WHO), it will be the third leading cause of death in the world, after cardiovascular and neoplastic diseases in 2030 (WHO 2013). There are predictions that COPD will become the seventh cause of disability, expressed as lost disability-adjusted life years (DALYs, and one of the main contributors to chronic morbidity worldwide (GOLD 2013; Nurmatov et al. 2012; Aslani et al. 2007; Mannino and Buist 2007; Sta˚hl et al. 2005). At present, nearly 40 % of COPD patients are forced to draw sickness benefit (every second patient is younger than 65). These patients die 10–15 years earlier than those without COPD and the emphasis is put on the urgent need for prevention of the disease and research into possible improvements in quality of life (QoL) of COPD patients (Nurmatov et al. 2012; Aslani et al. 2007). Effective COPD management and prevention strategies include four elements: (1) evaluation and monitoring of disease, (2) reduction of risk factors, (3) stabilization, and (4) treatment of exacerbations (GOLD 2013). In COPD treatment, it is essential to improve QoL and general health. Sta˚hl et al. (2005) and Ferrer et al. (1998), who measured QoL in patients at various stages of COPD development, found that even those with moderate COPD (FEV1 > 50 % of predicted value) have significantly lower QoL levels. Engstro¨m et al. (2001), on the other hand, claim that the worsening of QoL in COPD patients only occurs when the FEV1 drops below 50 % of predicted value. QoL studies carried out among COPD patients are gaining an increasing importance as a valuable complement to the assessment of the
patient’s clinical status, effectiveness of therapy, education and prevention, and clinical evaluation of drugs (Ba˛k-Drabik and Ziora 2010; Maly and Vondra 2006). Prescott and Vestbo (1999) assert that QoL measurement may be used as a good indicator of health status treatment efficiency in COPD patients. WHO defines QoL as individuals’ perception of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. The QoL level and health status in chronic conditions are measured by both general and disease-specific questionnaires. COPD as a chronic illness has effects on social, psychological, and economic spheres of life. Maly and Vondra (2006) maintain that the use of general and disease-specific questionnaires together is probably the best approach to the evaluation of QoL and health status. Ba˛k-Drabik and Ziora (2010) demonstrated that QoL in COPD patients is lower than in the healthy population and it is particularly influenced by socioeconomic factors; the element being so far poorly described. Similar conclusions were drawn by Prescott and Vestbo (1999). In their opinion, even patients with mild COPD are not satisfied with their QoL which is adversely influenced by physical and psychological consequences of respiratory disease, including sleep disorders, low effort tolerance, and limited possibility of doing everyday activities. Socioeconomic status refers to the position of an individual in the society, which is mainly conditioned by education (Krieger et al. 1997; Laurent et al. 2008; Bacon et al. 2009), income, professional activity, and actual profession (Braveman et al. 2005). The level of education is often used as a main socioeconomic status indicator, because it is steady over time, whereas
Socioeconomic Indicators Shaping Quality of Life and Illness Acceptance in. . .
profession and income may change during a lifespan. Krieger et al. (1997) found that respondents were more eager to answer questions about education than questions about income, which often were left unanswered. The living environment is also an important indicator of socioeconomic status. There is evidence for the fact that health differences may depend on income, wealth, education, profession, and the socioeconomic features of the environment. Therefore, it seems sensible to analyze the influence of separate socioeconomic factors rather than general socioeconomic status (Braveman et al. 2005). Furthermore, O’Malley et al. (2007) and Bacon et al. (2009) indicate the necessity of considering socioeconomic status as a variable in QoL measurement. According to these authors, low socioeconomic status is associated with higher morbidity and mortality rates due to chronic diseases, including cardiovascular conditions, COPD, asthma and diabetes (Bacon et al. 2009; O’Malley et al. 2007). Braveman et al. (2005) prove that both in clinical and public health research, socioeconomic status is usually treated as a control variable, and less frequently as a response variable, which may have effects on the research results and their implications for health practice and health policy. Socioeconomic status seems to play a more important role in COPD than in other chronic diseases (Shavro et al. 2012). On the individual level (professional, social and economic status, education, and income per capita), low status may cause higher exposure both to harmful factors at home (indoor exposure, e.g. cockroach, dust, cigarette smoke, or mycotic fungi) and outside of it (outdoor exposure, e.g. the environmental pollution or not taking drugs because of high costs of treatment). Consequently, low socioeconomic level increases the risk of COPD exacerbations (Shavro et al. 2012; Laurent et al. 2008; Aslani et al. 2007). The knowledge of the relationship between COPD and particular socioeconomic elements is still insufficient, hence the need for research in this field.
21
An element that should be included in the research on QoL and health status in patients with chronic diseases is the measurement of the acceptance of illness (AI) as a sign of adaptation to limitations and disability caused by the disease (Juczynski 2009). High AI leads to a reduction of negative emotions associated with a chronic disease and its therapy. According to Nowicki and Ostrowska (2008), adaptation to the disease, manifested as acceptance of illness, plays an important role in the control, including selfcontrol of chronic diseases. AI modulates QoL: high AI level contributes to higher QoL, obedience to doctor’s orders, and coping better with disease-related limitations. There is evidence of some regularities in the influence on AI of socioeconomic status, which refers to sociodemographic and economic variables; notably the level of education and the place of residence (Kaczmarczyk 2010; Bacon et al. 2009; O’Malley et al. 2007; Krieger et al. 1997). The purpose of this study, was to establish how the QoL and AI levels are related to socioeconomic status of adult COPD patients. It was assumed that socio-economic status might correlate with both QoL and AI. Furthermore, the influence of socioeconomic variables on health care utilization was taken into account in the analysis.
2
Methods
The study was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki), and was approved by the Bioethical Commission of Wroclaw Medical University (no. KB 608/2011). The main inclusion criteria were: minimum 18 years of age, COPD diagnosis, and written consent of patients to participate in the study. The study included 264 COPD patients, mean age of 60.2 13.2 years, who were under care of 34 family doctors in Poland. Detailed sociodemographic data of the patients are shown in Table 1. The questionnaire was completed in the presence of the project executors; current spirometry results were attached to questionnaires.
Boz˙ena Mroczek et al.
22 Table 1 Sociodemographic data of COPD patients (n ¼ 263)
Gender Women Men Age 24 and below 25–44 45–64 65–84 85 and above Place of residence Village Below 5,000* 5,000–10,000* 10,000–50,000* 50,000–100,000* 100,000–200,000* Over 200,000* Education Incomplete primary – below 8 years Primary – 8 years Vocational – 10 years Secondary – 12 or 14 years Higher – 17 or above 17 years Marital status Single Married Separated Divorced Widowed Smoking Non-smokers Smokers
n
%
123 140
46.8 53.2
4 20 151 78 9
1.5 7.6 57.6 29.8 3.4
136 56 7 35 19 4 6
51.7 21.3 2.6 13.3 7.2 1.5 2.3
1 60 85 96 21
0.4 22.8 32.3 36.5 8.0
21 185 4 12 41
8.0 70.3 1.5 4.6 15.6
75 53
28.4 20.1
Mean SD Q1–Q3
Chi2 p 1.1 0.29
60.2 13.2 53.0–70.0
298.7
Socioeconomic Indicators Shaping Quality of Life and Illness Acceptance in Patients with Chronic Obstructive Pulmonary Disease Boz˙ ena Mroczek, Zygmunt Sitko, Katarzyna Augustyniuk, blewska, Joanna Pierzak-Sominka, Izabela Wro and Donata Kurpas Abstract
Quality of life (QoL) combined with the acceptance of illness reflects the efficiency of therapy and the level of patients’ satisfaction with medical care. Education, marital status, and place of residence were used as the socio-economic status indicators. The purpose of this study was to determine the relationship between the levels of QoL and acceptance of illness (AI) and the socio-demographic data in patients with chronic obstructive pulmonary disease (COPD). The study involved 264 adult COPD patients. The average duration of COPD was 9 years (Q1–Q3: 3.0–12.0). The duration of the disease was significantly shorter in patients from rural areas. QoL correlated positively with AI (r ¼ 0.69, p < 0.0001). The general QoL and AI were most strongly influenced by education, gender, and age. Education is a strong predictor of QoL and AI, and the latter correlate with the socioeconomic status of COPD patients. It is recommended that COPD patients with a low level of education have regular medical check-ups and are included in the preventive programs by general practitioners to improve their somatic status and QoL level.
B. Mroczek (*) Department of Humanities in Medicine, Faculty of Health Sciences, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland e-mail: [email protected]; [email protected] Z. Sitko Department of Thoracic Surgery and Transplantology, The Professor Alfred Sokołowski Specialist Hospital, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland K. Augustyniuk Department of Nursing, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland
J. Pierzak-Sominka Department of Public Health, Pomeranian Medical University, 11 Chlapowskiego St., 70-204 Szczecin, Poland I. Wr oblewska Health Sciences Faculty, Wroclaw Medical University, 5 Kazimierza Bartla St., 50-996 Wroclaw, Poland D. Kurpas Department of Family Medicine, Wroclaw Medical University, Wroclaw, Poland Opole Medical School, Opole, Poland 19
Boz˙ena Mroczek et al.
20
Keywords
Chronic disease • Family physician • Prevention • Socio-demographic data • Somatic status • WHOQOL-Bref
1
Introduction
Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory conditions. According to the forecasts of the World Health Organization (WHO), it will be the third leading cause of death in the world, after cardiovascular and neoplastic diseases in 2030 (WHO 2013). There are predictions that COPD will become the seventh cause of disability, expressed as lost disability-adjusted life years (DALYs, and one of the main contributors to chronic morbidity worldwide (GOLD 2013; Nurmatov et al. 2012; Aslani et al. 2007; Mannino and Buist 2007; Sta˚hl et al. 2005). At present, nearly 40 % of COPD patients are forced to draw sickness benefit (every second patient is younger than 65). These patients die 10–15 years earlier than those without COPD and the emphasis is put on the urgent need for prevention of the disease and research into possible improvements in quality of life (QoL) of COPD patients (Nurmatov et al. 2012; Aslani et al. 2007). Effective COPD management and prevention strategies include four elements: (1) evaluation and monitoring of disease, (2) reduction of risk factors, (3) stabilization, and (4) treatment of exacerbations (GOLD 2013). In COPD treatment, it is essential to improve QoL and general health. Sta˚hl et al. (2005) and Ferrer et al. (1998), who measured QoL in patients at various stages of COPD development, found that even those with moderate COPD (FEV1 > 50 % of predicted value) have significantly lower QoL levels. Engstro¨m et al. (2001), on the other hand, claim that the worsening of QoL in COPD patients only occurs when the FEV1 drops below 50 % of predicted value. QoL studies carried out among COPD patients are gaining an increasing importance as a valuable complement to the assessment of the
patient’s clinical status, effectiveness of therapy, education and prevention, and clinical evaluation of drugs (Ba˛k-Drabik and Ziora 2010; Maly and Vondra 2006). Prescott and Vestbo (1999) assert that QoL measurement may be used as a good indicator of health status treatment efficiency in COPD patients. WHO defines QoL as individuals’ perception of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. The QoL level and health status in chronic conditions are measured by both general and disease-specific questionnaires. COPD as a chronic illness has effects on social, psychological, and economic spheres of life. Maly and Vondra (2006) maintain that the use of general and disease-specific questionnaires together is probably the best approach to the evaluation of QoL and health status. Ba˛k-Drabik and Ziora (2010) demonstrated that QoL in COPD patients is lower than in the healthy population and it is particularly influenced by socioeconomic factors; the element being so far poorly described. Similar conclusions were drawn by Prescott and Vestbo (1999). In their opinion, even patients with mild COPD are not satisfied with their QoL which is adversely influenced by physical and psychological consequences of respiratory disease, including sleep disorders, low effort tolerance, and limited possibility of doing everyday activities. Socioeconomic status refers to the position of an individual in the society, which is mainly conditioned by education (Krieger et al. 1997; Laurent et al. 2008; Bacon et al. 2009), income, professional activity, and actual profession (Braveman et al. 2005). The level of education is often used as a main socioeconomic status indicator, because it is steady over time, whereas
Socioeconomic Indicators Shaping Quality of Life and Illness Acceptance in. . .
profession and income may change during a lifespan. Krieger et al. (1997) found that respondents were more eager to answer questions about education than questions about income, which often were left unanswered. The living environment is also an important indicator of socioeconomic status. There is evidence for the fact that health differences may depend on income, wealth, education, profession, and the socioeconomic features of the environment. Therefore, it seems sensible to analyze the influence of separate socioeconomic factors rather than general socioeconomic status (Braveman et al. 2005). Furthermore, O’Malley et al. (2007) and Bacon et al. (2009) indicate the necessity of considering socioeconomic status as a variable in QoL measurement. According to these authors, low socioeconomic status is associated with higher morbidity and mortality rates due to chronic diseases, including cardiovascular conditions, COPD, asthma and diabetes (Bacon et al. 2009; O’Malley et al. 2007). Braveman et al. (2005) prove that both in clinical and public health research, socioeconomic status is usually treated as a control variable, and less frequently as a response variable, which may have effects on the research results and their implications for health practice and health policy. Socioeconomic status seems to play a more important role in COPD than in other chronic diseases (Shavro et al. 2012). On the individual level (professional, social and economic status, education, and income per capita), low status may cause higher exposure both to harmful factors at home (indoor exposure, e.g. cockroach, dust, cigarette smoke, or mycotic fungi) and outside of it (outdoor exposure, e.g. the environmental pollution or not taking drugs because of high costs of treatment). Consequently, low socioeconomic level increases the risk of COPD exacerbations (Shavro et al. 2012; Laurent et al. 2008; Aslani et al. 2007). The knowledge of the relationship between COPD and particular socioeconomic elements is still insufficient, hence the need for research in this field.
21
An element that should be included in the research on QoL and health status in patients with chronic diseases is the measurement of the acceptance of illness (AI) as a sign of adaptation to limitations and disability caused by the disease (Juczynski 2009). High AI leads to a reduction of negative emotions associated with a chronic disease and its therapy. According to Nowicki and Ostrowska (2008), adaptation to the disease, manifested as acceptance of illness, plays an important role in the control, including selfcontrol of chronic diseases. AI modulates QoL: high AI level contributes to higher QoL, obedience to doctor’s orders, and coping better with disease-related limitations. There is evidence of some regularities in the influence on AI of socioeconomic status, which refers to sociodemographic and economic variables; notably the level of education and the place of residence (Kaczmarczyk 2010; Bacon et al. 2009; O’Malley et al. 2007; Krieger et al. 1997). The purpose of this study, was to establish how the QoL and AI levels are related to socioeconomic status of adult COPD patients. It was assumed that socio-economic status might correlate with both QoL and AI. Furthermore, the influence of socioeconomic variables on health care utilization was taken into account in the analysis.
2
Methods
The study was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki), and was approved by the Bioethical Commission of Wroclaw Medical University (no. KB 608/2011). The main inclusion criteria were: minimum 18 years of age, COPD diagnosis, and written consent of patients to participate in the study. The study included 264 COPD patients, mean age of 60.2 13.2 years, who were under care of 34 family doctors in Poland. Detailed sociodemographic data of the patients are shown in Table 1. The questionnaire was completed in the presence of the project executors; current spirometry results were attached to questionnaires.
Boz˙ena Mroczek et al.
22 Table 1 Sociodemographic data of COPD patients (n ¼ 263)
Gender Women Men Age 24 and below 25–44 45–64 65–84 85 and above Place of residence Village Below 5,000* 5,000–10,000* 10,000–50,000* 50,000–100,000* 100,000–200,000* Over 200,000* Education Incomplete primary – below 8 years Primary – 8 years Vocational – 10 years Secondary – 12 or 14 years Higher – 17 or above 17 years Marital status Single Married Separated Divorced Widowed Smoking Non-smokers Smokers
n
%
123 140
46.8 53.2
4 20 151 78 9
1.5 7.6 57.6 29.8 3.4
136 56 7 35 19 4 6
51.7 21.3 2.6 13.3 7.2 1.5 2.3
1 60 85 96 21
0.4 22.8 32.3 36.5 8.0
21 185 4 12 41
8.0 70.3 1.5 4.6 15.6
75 53
28.4 20.1
Mean SD Q1–Q3
Chi2 p 1.1 0.29
60.2 13.2 53.0–70.0
298.7
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