Health-Related Quality of Life and Activity Limitation -- Eight States, 1995

Since January 1993, CDC's Behavioral Risk Factor Surveillance System (BRFSS) has included four general questions concerning health-related quality of life (HRQOL) (1). The results of these HRQOL measures are useful for population health assessment, epidemiologic research, and policy development (2,3), but they are less useful for identifying specific public health interventions because they track general deficiencies such as poor health. Since 1995, state health departments have had the option of including in the BRFSS an expanded set of 14 HRQOL questions; these questions ask about specific types of activity limitation and common physical and emotional symptoms. This report summarizes preliminary findings from the eight states (i.e., Delaware, Indiana, Kansas, Mississippi, Missouri, New Mexico, North Carolina, * and Tennessee) in which these other questions were included in the 1995 BRFSS.

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized persons aged greater than or equal to 18 years in the United States. The surveillance system tracks the prevalence of key health- and safety-related behaviors. The 14 HRQOL questions ** ask about general self-rated health and the number of days during the preceding 30 days when physical health was not good, mental health was not good, and usual activities were limited. The questions also ask about the presence of any activity limitation resulting from an impairment or health problem and about the cause, duration, and severity of the limitation (e.g., requiring assistance to perform routine daily activities).

Other questions include the number of days during the preceding 30 days when respondents felt very healthy and full of energy (i.e., had "vitality") and the number of days health and activity were affected by pain, depression, anxiety, or sleeplessness. To allow comparisons among states and between individual states and all respondents, the results were weighted to account for the complex sample survey design (4).

In the eight states, 13,244 persons participated in the 1995 BRFSS (Table_1). During the 30 days preceding participation in the survey, respondents averaged 1.8 days of activity limitation because of poor physical or mental health, 2.8 days of poor mental health, 2.8 days of pain, 3.2 days of poor physical health, 3.2 days of depression, 5.4 days of anxiety, 7.8 days of sleeplessness, and 18.6 days of vitality. The range of state-specific means was less than 1 day for poor physical health, activity limitation, and depression; 1-2 days for mental health, pain, and anxiety; and greater than or equal to 2 days for sleeplessness and vitality. In comparison with men, women reported more days of poor health on every measure; the largest differences were for mental health, depression, anxiety, and vitality -- a finding that did not change when data were age-adjusted. Persons aged greater than or equal to 60 years reported more days of poor physical health, activity limitation, and pain than did persons aged less than 60 years; but persons aged less than 60 years reported more days of poor mental health, anxiety, and sleeplessness.

Compared with all respondents, persons whose annual household incomes were less than $10,000 reported at least twice as many days of activity limitation (4.8 days), pain (5.6 days), and poor physical health (6.9 days). Persons who identified their marital status as separated *** reported more than twice as many days of poor mental health (5.8 days) and depression (7.3 days).

For the eight states, the prevalence of any activity limitation ranged from 17% to 22% (overall mean: 19%). In each state, persons with differing severity of current activity limitation (i.e., ranging from no limitation to needing assistance with personal care) had progressively poorer HRQOL than persons with less severe limitations.

Compared with HRQOL for all respondents, HRQOL was poorer for persons who reported an activity limitation from particular common causes (Table_2). Persons with arthritis or rheumatism reported substantially more days of pain; persons with a back or neck problem, more days of pain and sleeplessness; persons who had had a stroke, more days of depression and anxiety; persons with diabetes, more days of poor physical health; persons with cancer, more days of poor physical and mental health and activity limitation; and persons with an emotional problem, more days of poor mental health, activity limitation, depression, anxiety, and sleeplessness. Limitations associated with the fewest days of vitality were emotional problems (4.0 days), diabetes (8.1 days), and cancer (8.1 days). In comparison with all respondents, persons who had been told by a physician that they had diabetes also reported low HRQOL (i.e., poor physical health, activity limitation, pain, and lack of vitality).

The internal consistency of the HRQOL results was demonstrated by several findings. In comparison with all respondents and other demographic subgroups, persons who reported being unable to work also reported low HRQOL, especially poor physical health (18.0 days), activity limitation (13.5 days), pain (15.5 days), depression (10.2 days), anxiety (11.7 days), and fewer days of vitality (8.0 days) (Table_1). For all respondents, as the gradient of excellent to poor self-rated health worsened, the number of days of poor HRQOL increased. Conversely, persons who rated their general health status as excellent had a greater number of days of vitality (22.4 days) than did persons who rated this status as poor (5.1 days). HRQOL is measured by validated survey methods. A comparison of the BRFSS measures and the widely used and validated Medical Outcomes Study Short Form 36 (SF-36) indicated that the 14-item HRQOL had acceptable construct, criterion, and known-groups validity (5).

Reported by the following state BRFSS coordinators: F Breukelman, Delaware; K Horvath, Indiana; M Perry, Kansas; D Johnson, Mississippi; T Murayi, PhD, Missouri; W Honey, MPH, New Mexico; K Passaro, PhD, North Carolina; D Ridings, Tennessee. J Jackson-Thompson, PhD, Missouri Dept of Health. Health Care and Aging Studies Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Quality of life includes health, level of activity, spirituality, social support, and satisfaction with personal accomplishments, resources, and life situa-tion (6). HRQOL focuses on self-perceived health and well-being and their determinants. Assessments of HRQOL in communities can assist in identifying vulnerable and underserved populations, motivating groups to act on health-related problems, guiding efforts to ensure that health resources match the needs of the community, and evaluating public health interventions.

The results presented in this report are subject to at least four limitations. First, data from only eight states might not be representative of all adults in the U.S. population. Second, the BRFSS excludes households without telephones. Third, the BRFSS may underrepresent persons who are at a low level of health and functioning, because time and functional capacity are needed to complete the survey. Fourth, because this analysis describes, rather than explains, the relations between HRQOL and demographic factors, the evaluation did not adjust for possible confounding variables, such as age.

Despite these limitations, the HRQOL measures provide information about the association between mental and physical health, behavioral and demographic characteristics, and disease and disability (7,8). This information will assist state and community efforts in measuring and assessing changes in the proportion of adults reporting good health and in the number of reported days when physical or mental health was not good (i.e., two of the 25 Community Profile Indicators recommended by the Institute of Medicine {9}).

Previous reports have indicated that a large segment of the U.S. population (i.e., approximately 41 million persons aged greater than or equal to 18 years in 1994) is composed of persons who have disabilities and that these persons are at increased risk for other physical or psychological conditions (7,10). These findings were confirmed by results from the 14 HRQOL questions in the 1995 BRFSS. Persons who have chronic health conditions or disabilities are especially vulnerable to pain, depression, anxiety, sleeplessness, and lack of vitality. Secondary prevention strategies, such as providing improved access to treatment for pain and depression for persons who have disabilities, are needed to address these public health problems.

References

1. Hennessy CH, Moriarty DG, Zack MM, Scherr PA, Brackbill R. Measuring health-related quality of life for public health surveillance. Public Health Rep 1994;109:665-72.

2. CDC. Quality of life as a new public health measure -- Behavioral Risk Factor Surveillance System, 1993. MMWR 1994;43:375-80.

3. CDC. Health-related quality-of-life measures -- United States, 1993. MMWR 1995;44:195-200.

4. Shah BV. SUDAAN user's manual, release 6.0. Research Triangle Park, North Carolina: Research Triangle Institute, 1992.

5. Newschaffer CJ. Validation of BRFSS HRQOL measures in a statewide sample. Atlanta: US Department of Health and Human Services, CDC, 1998.

6. Diener E, Suh E. Measuring quality of life: economic, social, and subjective indicators. Soc Indicators Res 1997;40:189-216.

7. Pope AM, Tarlov AR, eds. Disability in America: toward a national agenda for prevention. Washington, DC: National Academy Press, 1991.

8. Burman ME. Daily symptoms and responses in adults: a review. Public Health Nurs 1996;13:294-301.

9. Durch J, Bailey LA, Stoto MA, eds. Improving health in the community: a role for performance monitoring. Washington, DC: National Academy Press, 1997.

10. Adler M. People with disabilities: who are they? Beyond the water's edge: charting the course of managed care for people with disabilities. Washington, DC: US Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, 1996.

* In North Carolina, the HRQOL questions were included only during June-August 1995.

TABLE 1. Health-related quality-of-life measures, by selected characteristics -- eight states, Behavioral Risk Factor
Surveillance System, 1995
===================================================================================================================================================
                                                                             Mean no. of days *
                                   -------------------------------------------------------------------------------------------------------------
                                             Physical     Mental       Usual                                                        Very healthy
                                              health      health      activity                                                      and full of
Characteristic                      No. +    not good    not good    limited &    Pain     Depression   Anxiety    Sleeplessness       energy
------------------------------------------------------------------------------------------------------------------------------------------------
State
 Delaware                           2,042       3.0         2.9          1.8       3.0         2.8         5.0           7.4            19.9
 Indiana                            2,270       3.5         3.6          1.7       3.4         3.4         6.1           9.0            18.4
 Kansas                             1,744       3.1         3.0          1.7       2.8         2.9         5.7           7.8            18.8
 Mississippi                        1,470       3.3         2.6          2.2       3.2         3.5         4.7           6.7            20.2
 Missouri                           1,488       2.9         3.1          1.7       2.6         2.9         5.3           7.9            18.5
 New Mexico                         1,250       3.7         2.8          2.1       2.3         3.0         5.4           7.2            20.3
 North Carolina @                   1,289       2.8         1.8          1.4       2.2         2.9         4.2           6.9            17.5
 Tennessee                          1,689       3.6         2.5          1.8       2.5         3.5         5.6           7.6            17.7

Sex
 Men                                5,417       2.8         2.2          1.6       2.6         2.5         4.7           7.2            19.3
 Women                              7,827       3.6         3.5          2.0       3.0         3.8         6.0           8.3            17.9

Age group (yrs)
 18-39                              5,587       2.1         3.1          1.2       1.7         3.2         6.2           9.8            18.3
 40-59                              4,191       3.3         3.1          1.9       3.2         3.3         5.5           7.5            19.0
 60-74                              2,394       5.1         1.9          2.2       3.8         3.0         3.7           4.2            19.1
  >=75                              1,030       6.6         2.2          3.7       5.3         3.5         3.6           4.0            17.2

Selected demographic group
 Less than high school education    2,031       6.2         3.5          3.7       5.4         5.2         6.4           8.0            15.9
 =2 occasions)
 Smoke cigarettes                   3,259       3.6         4.1          2.4       3.4         4.8         7.6          10.0            17.0
 Severely obese &&                    603       5.4         4.5          3.4       5.8         5.0         7.9           9.4            14.7

General health status
 Excellent                          2,934       0.9         1.7          0.5       0.9         1.8         3.9           6.8            22.4
 Very good                          4,386       1.3         2.2          0.6       1.3         2.2         4.5           7.4            20.5
 Good                               3,749       2.6         2.9          1.3       2.6         3.2         5.5           7.9            17.8
 Fair                               1,469       7.8         4.9          4.2       6.3         5.8         8.1           9.2            12.1
 Poor                                 648      22.2         8.3         13.9      15.7        11.1        11.6          11.3             5.1

Activity limitation @@
 None                              10,698       1.6         2.3          0.7       1.1         2.4         4.6           7.3            20.2
 Limited but no help needed         1,710       7.7         4.2          3.8       7.7         5.4         7.8           9.2            13.0
 Need help with routine needs         512       15.9        7.7         11.3      15.7         8.5        10.9          11.0             7.7
 Need help with personal care         295       18.4        9.0         15.9      18.0        11.3        13.4          11.6             7.0

Total                              13,244       3.2         2.8          1.8       2.8         3.2         5.4           7.8            18.6
------------------------------------------------------------------------------------------------------------------------------------------------
*  During the 30 days preceding the survey.
+  Weighted to account for different probabilities of selection and to adjust for the age, sex, and racial distribution of the population in each state (4).
   Persons for whom data was missing were excluded from the analysis.
&  A value of 0 was imputed for all respondents who reported no days when their physical or mental health was not good.
@  Survey conducted during June-August 1995.
** Persons who were married but no longer living at the same residence (e.g., legally separated).
++ Women who reported having had breast cancer as the reason for their last mammogram or clinical breast examination.
&& Body mass index >=35.0
@@ Based on response to the question, "Are you limited in any way in any activities because of an impairment or health problem?"
===================================================================================================================================================

TABLE 2. Health-related quality-of-life measures, by cause of activity limitation * -- eight states, Behavioral Risk Factor
Surveillance System, 1995
==============================================================================================================================================================
                                                                         Mean no. of days +
                                 ------------------------------------------------------------------------------------------------------------
                                          Physical     Mental       Usual                                                        Very healthy
                                           health      health     activity                                                       and full of
Cause of activity limitation     No. &    not good    not good    limited @      Pain   Depression   Anxiety    Sleeplessness       energy
---------------------------------------------------------------------------------------------------------------------------------------------
Arthritis or rheumatism           416        9.9         3.4         4.9         13.7       5.1         7.2          8.9             10.7
Back or neck problem              477       10.4         6.4         7.8         13.7       7.8         9.6         12.4             10.5
Fractures,bone or joint injury    239        9.2         5.1         5.6         12.4       5.9         8.9          9.9             13.9
Walking problem                   187        8.6         3.5         5.3         10.9       4.5         7.5          6.4             13.2
Lung or breathing problem         188       13.6         5.6         7.8          5.9       6.9         9.5          9.4              9.6
Hearing problem                    23        2.8         3.5         1.2          2.3       3.6         7.5         10.6             13.6
Eye or vision problem              82        7.8         5.0         2.7          3.7       5.6         6.0          6.8             18.2
Heart problem                      223      11.7         4.1         7.1          7.5       5.7         8.1          9.4             10.2
Stroke                             47       14.5         3.8         8.0         11.2      10.5        11.4          7.4              8.3
Hypertension
  or high blood pressure           31       10.1         5.2         8.7          8.4       7.6         7.5          6.9              9.8
Diabetes                           73        15.0        5.1         7.3          8.6       8.7         8.7          9.3              8.1
Cancer                             44        18.3        8.2        12.6          8.9       7.6        10.1         11.3              8.1
Depression,anxiety,
  or other emotional  problem      44        9.4        17.5        12.2          7.8      22.1        23.1         16.7              4.0
Other impairment
  or problem                      413       10.9         7.1         7.7          9.7       7.2        10.3         10.2             11.7
---------------------------------------------------------------------------------------------------------------------------------------------
* Main causes of reported limitation were classified into these 14 categories by BRFSS interviewers.
+ During the 30 days preceding the survey.
& Includes data from Delaware, Indiana, Kansas, Mississippi, Missouri, New Mexico, North Carolina, and Tennessee. Weighted to account for different
  probabilities of selection and to adjust for the age, sex, and racial distribution of the population in each state (4). Persons for whom data were missing
  were excluded from the analysis.
@ A value of 0 days was imputed for all respondents who reported no days when their physical or mental health was not good.
==============================================================================================================================================================

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