quality of life def instruments of measuring QOL ...ETC

1. Quality of Life
By
Prof. Dr Mona Aboserea
Faculty of medicine
Zagazig University

2.  Review health determinants,
spectrum
 Define quality of life, its importance
 Understand and calculate measures of
QOL
Learning objectives

3. Revision
 Health is the state of complete physical, mental
and social well-being and not merely absence of
disease or infirmity (WHO,1948).
 Spiritual was added to the definition in 1984
“Optimal health is defined as a balance of physical,
emotion, social, spiritual and intellectual health”.

4. Determinants of
Population Health
• Employment and occupational
• Biology of disease
• Education
• Socioeconomic status
• Psychosocial factors
• Environment, natural and built3
• Public health services
• Health care services
Over the lifespan

5. Health Spectrum
Positive health Clinical disease Complications
Promotion 1ry
prevention
(treatment)
2dry
prevention
rehabilitation
3ry
prevention
At
risk

6. Negative Health Terms
•Impairment: any
loss or
abnormality of
psychological,
physiological or
anatomical
structure or
function.
•Disability : any
restriction or lack
of ability to
perform an activity
in the manner or
within the range
considered normal
for human being
(resulting from an
impairment ).
•Handicap:
disadvantage for a
given individual, that
limits or prevents the
fulfilment of a role that
is normal ( depending
on age, sex and social
and cultural factors for
that individual
resulting from an
impairment or
disability.

7. Health & disease measurement
Morbidity
indices &
data
Mortality
indices
& data
Quality
of life
indices
Physiological
indicators
Functional
indicators
Risk
factors
Nutritional
status
Work,
school
Daily
activity

8. Health data collection
 Records ….(What are their types?)
 ….(What is vital record
linkage?)
 Health reports..
 Surveys
 Surveillance...(definition- purpose- cycle)
 Epidemiological studies


9. Quality of life
Quality Life

10.  A peculiar or
essential character
 A degree of
excellence
 A social status
 A distinguishing
attribute
Quality

11.  State or mode of living
 Experience of being alive
 Quality that distinguishes a
vital & functional being from
a dead body
 Course of existence
 Biological
◦ Motion
◦ Reproduction
◦ Metabolism
◦ Consumption & growth
◦ Stimulus response
 Philosophical/religious
◦ Being
◦ Purpose and significance
◦ “Why are we here?”
What is Life?

12. Quality of life (QOL) versus
life tables& life expectancy
“Add life into years “
not only
“add years into life”

13. The average number of years an
individual of a given age is
expected to live if current mortality
rates continue.
Life expectancy

14. Quality of Life
Feeling, function & future of happiness,
health & hope
3Fs
for
3 Hs

15. With increase life expectancy all over the
world,
the aim of health services is to make these
added life years of good quality

16. (QOL)(QOL)
WHOWHO was defined QOL as “an individual’swas defined QOL as “an individual’s
perception of their position in life in theperception of their position in life in the
context of the cultural and value systems incontext of the cultural and value systems in
which they live and in relation to their goals,which they live and in relation to their goals,
expectations, standards and concerns”.expectations, standards and concerns”.
 WHOWHO alsoalso defined QOL as “the degree ofdefined QOL as “the degree of
well being, satisfaction and standardizedwell being, satisfaction and standardized
living”.living”.

18.  QOL: The degree to which a person
enjoys the important possibilities of
his/her life
 Subjective QOL is about feeling
good and being satisfied with things
in general.
 Objective QOL is about fulfilling
the societal and cultural demands
for material wealth, social status,
and physical well-being
Definitions

19. Quality of Life
Objective Subjective
Behavioral Competence
leisure and discretionary activities
Environmental Quality
structure and process of care
Perceived QOL
time, friends, family
Psychological Well Being
satisfaction, affect

20. QOL multiple domains:
 Being is comprised of physical,
psychological and spiritual dimensions;
• Spiritual
 Belonging is comprised of social,
community, and ecological dimensions
• Community
 Becoming is constituted by personal
growth, leisure, and practical.
• Growth

21. Assessment of Quality ofAssessment of Quality of
lifelife
 QuestionnaireQuestionnaire
 TestsTests
 InstrumentsInstruments
Which must be:
Valid
Accurate
Adequate
Reliable

23. Components of QOL

24. Quality of Life Assessment
DomainDomain Facets incorporated within domainsFacets incorporated within domains
1. Physical1. Physical
HealthHealth
Energy & Mobility / Activities of dailyEnergy & Mobility / Activities of daily
living / Work capacityliving / Work capacity
2.Psychological2.Psychological
Feelings, fear, depression / Self-esteem /Feelings, fear, depression / Self-esteem /
Thinking, learning, memory andThinking, learning, memory and
concentration.concentration.
3. Spirituality3. Spirituality Religion/ Personal internal powerReligion/ Personal internal power
4. Social4. Social
RelationsRelations
Personal relationships / Social support /Personal relationships / Social support /
Sexual activitySexual activity
5. Environment5. Environment Physical , chemical & biological environmentPhysical , chemical & biological environment
(pollution, noise, traffic, and climate) /(pollution, noise, traffic, and climate) /
Transport/ home environment.Transport/ home environment.

25. Why measuring QOL?
1. To evaluate the effects of health (and other)
services on citizen’s life. The higher the score of
QOL the better is the promotion services.
2. To classify health hazards according to their effect
on QOL (in putting priorities)
3. To evaluate the effects of different lines of
treatment on patients & patient satisfaction.
4. To evaluate the rehabilitation methods used by
handicapped.
5. To calculate amount of money to compensate for
disability

26. Quality of life measures
Specific
This type of instrument evaluates a series of
health dimensions specific to a disease. E.g.
For DM, HIV......
Generic
These instruments can be used with any
population. They generally cover perceptions
on overall health and also questions on social,
emotional and physical functioning, pain and
self-care.

27. How to assess QOL?
I) By using questionnaires
1- physical aspects (domain)
2- psychological aspects
3- spiritual aspects
4- social aspects
5- environmental aspects

28. Assess QOL (burden of disease)
II) Indicators of QOL:
 QALY= quality adjusted life years
 DALY=disability adjusted life years
 YLL= years of life lost
 YLD=years lost due to disability

29. Instruments for
Assessment of Health
Related Quality of Life
AssessAssess years lived with high qualityyears lived with high quality ofof
health without disability or prematurehealth without disability or premature
death.death.
It’s used in economic evaluationIt’s used in economic evaluation
especiallyespecially cost utility analysiscost utility analysis..
1. Quality Adjusted Life Years
(QALY)

30. QALY
 1 year in perfect health = 1year x 1 utility =1
QALY
 Any year lived with less than optimal health
= less than one
e.g. For two years bed ridden (utility = 0.5)
QALY = 2 x 0.5 = 1 year

31.  Disability : any restriction or lack of ability to
perform an activity in the manner or within the
range considered normal for human being
 WHO consider DALYs as a measure of the global
burden of disease.
 DALY= YLL+YLD
 YLL: years of life lost due to premature death
 YLD: years lost due to living with disability of
a specific health condition
2-Disability adjusted life
years “DALYs”

32. Disability adjusted lifeDisability adjusted life
yearsyears
(DALYs)(DALYs)
WHO considered DALYs as a measure of theWHO considered DALYs as a measure of the
global burden of diseaseglobal burden of disease..
It is theIt is the international quantitative indicatorinternational quantitative indicator ofof
burden of disease as itburden of disease as it sums the years lostsums the years lost
(PYLL)(PYLL) because of premature mortality andbecause of premature mortality and
years lived with disability (YLD)years lived with disability (YLD) adjusted for theadjusted for the
severityseverity of the disabilityof the disability..
DALY= PYLL+YLD
One DALY=one lost year of healthy life

33. DALYs due to early death
(Red area measures DALYs. Red + white is a standard life)
NO
DISABILITY
82,5 YEARS
e.g. Premature death from a myocardial infarction, say at age 50,
would produce the DALY-loss as depicted by the red area in the figure.
This patient’s loss is 32.5 years.
No adjustment is made for disability because the patient dies.

34. DALYs due to disability and
premature death combined.
NO
DISABILITY
82,5 YEARS

35. Surprisingly, different cultures agreeSurprisingly, different cultures agree
at what is considered mild, moderateat what is considered mild, moderate
or severe disabilityor severe disability

36. Disability Classes and WeightsDisability Classes and Weights
Disability
Class
Severity
weights
Indicator conditions
11 0.00 – 0.020.00 – 0.02 Vitiligo on face, weight–for–heightVitiligo on face, weight–for–height
less than 2 standard deviationsless than 2 standard deviations
22 0.02 – 0.120.02 – 0.12 Watery diarrhea, severe sore throat,Watery diarrhea, severe sore throat,
severe anemiasevere anemia
33 0.12 - 0.240.12 - 0.24 Radius fracture in a stiff cast,Radius fracture in a stiff cast,
infertility, erectile dysfunction,infertility, erectile dysfunction,
rheumatoid arthritis, anginarheumatoid arthritis, angina
44 0.24 – 0.360.24 – 0.36 Below – the – knee amputation,Below – the – knee amputation,
deafnessdeafness
55 0.36 – 0.500.36 – 0.50 Rectovaginal fistula, mild mentalRectovaginal fistula, mild mental
retardational, Down syndromeretardational, Down syndrome
66 0.50 – 0.700.50 – 0.70 Unipolar major depression,Unipolar major depression,
blindness, paraplegiablindness, paraplegia
77 0.70 – 1.000.70 – 1.00 Active psychosis, dementia, severeActive psychosis, dementia, severe
migraine, quadriplegiamigraine, quadriplegia

37. Calculation of total DALY for a
disease in population:
PYLL= number of deaths X years lost
from expectancy
YLD= number of cases X disability percent
X average duration of disability till cure or
death.
DALY = PYLL + YLD (+ PYLL after
death from disability)

38. Example for “DALY”
calculation
In 16 years old adolescents : due to accident
100 deaths (consider life expectancy = 60 years)
70 with disability divided into:
60 with disability 25% for 4 years till cure
10 with disability 30% for 3 years then died

39. In 16 years old adolescents accident :
- 100 deaths
- 70 with disability divided into: 60 with disability 25% for 4 years till cure
10 with disability 30% for 3 years then died
 PYLL= number of deaths x years lost from expectancy =100
x (60-16)= 4400 years
 YLD= number of cases x disability percent x average
duration of disability till cure or death
= (60 x 25 x 4 = 6000 years) + (10 x 30 x 3 = 900 years)
 DALY = PYLL + YLD
 DALY =4400+6000+ 900= 11300 years
 (+ PYLL after death from disability = 10 x (60-19) = 410
years)
 DALY =4400+6000+ 900+410= 11710 years

41. Factor considered in DALY
calculation
Life expectancy?
Worth of years in
adulthood versus old
age?
Importance of people?
How to sum PYLL, YLD?

42. QALY & DALY
 QALY assess years lived with highassess years lived with high
quality.quality.
 DALY assess years lost of healthyassess years lost of healthy
life.life.
 They are completing each other.They are completing each other.

43. Example
 A woman live for 50 years with deafness (since birth) & utility of
deafness = 0.67 & considering life expectancy =80 years,
calculate QALY& DALY.
 QALY = years x utility = 50 x 0.67 = 33.5 years
 DALY = PYLL+YLD == PYLL+YLD =
 PYLL= years lost from expectancy =80 – 50 = 30 years
 YLD= disability (1- utility) x years = (1- 0.67) x 50 =(1- 0.67) x 50 =
0.33 x 50 = 16.5 years
 DALY = 30 + 16.5 = 46.5 years
 DALY + QALY = 46.5 +33.5 = 80 years
loss utility expectancy

44. 0.0
Quality of life 1.0

45. Relation between QALYs and DALYs
DALYs = healthy years lost (it should be minimized)
QALYs = healthy years gained (it should be maximized)
NO
DISABILITY
82,5 YEARS

46. 47 47
DALY / QALY
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 10 20 30 40 50 60 70 80 90
Life years
Adjusmentfactor
DAL
Y
QAL
Y

49. Conclusion
•Community medicine teach
how to keep the whole
community healthy
•Quality of life is as importantQuality of life is as important
as its lengthas its length
•DALY allows us to assessDALY allows us to assess
global burden of diseasesglobal burden of diseases
considering both mortality &considering both mortality &
morbiditymorbidity