- Email: [email protected]
Psychological Predictors (Personal Recourses) of Quality of Life for Heart Transplant Recipients
Psychological Predictors (Personal Recourses) of Quality of Life for Heart Transplant Recipients a,c skaa, _ I. Milaniaka,b,*, E. Wilczek-Ruzyczka , P. Przybyłowskia,d, K. Wierzbickia,d, J. Siwin a,d and J. Sadowski a John Paul II Hospital, Krakow, Poland; bFaculty of Health and Medical Science, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; cFaculty of Psychology and Humanities, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; and dCollegium Medicum UJ, Krakow, Poland
ABSTRACT Background. Heart transplantation (HTx) has a significant impact on all areas of the operation, adjustment, and quality of life (QOL) in patients after heart transplantation. In the process of healing and coping with the new situation, it is important to have personal resources. Aim. The main objectives of this study were to assess subjective QOL of patients after HTx and to determine the relationship between personal resources and QOL in this group of patients. Material and Methods. The study included 121 patients who received a heart transplant. A standardized instrument used to measure the quality of life was the World Health Organization (WHO) QOL Brief Questionnaire. The personal resources and deficits were determined using the following research techniques: Antonovsky’s Sense of Coherence (SOC), coping strategies for stress (Brief-COPE), Generalized Self Efficacy Scale (GSES), and Life Orientation Test (LOT-R). The data were analyzed statistically. Results. The patients gained an average level of QOL (13.75). The results indicate a positive relationship between the QOL in all its domains and personal resources: a sense of coherence (r ¼ 0.65; P < .05), optimism (r ¼ 0.55; P < .05), self-efficacy (r ¼ 0.58; P < .05), and strategies for coping (active coping [r ¼ 0.41; P < .05], planning [r ¼ 0.42; P < .05; P < .05], and positive revaluing [r ¼ 0.40; P < .05]). The regression model explained 56% of the predictors of QOL in patients after HTx. Applications. It is necessary to strengthen personal resources in this group of patients as well as to detect early and treat symptoms of depression and to cope with stress.
T
HE OUTCOME of heart transplantation (HTx) has been seen not only in terms of mortality and morbidity but also emphasis has been more toward assessing outcome in terms of patients’ perceptions of changes in their healthrelated quality of life (QOL). In addition to the physical consequences of transplantation, psychosocial factors are taken into account. The transplantation literature has highlighted that HTx may give rise to a new set of stressors, psychological challenges, and adaptive demands [1]. In the process of healing and coping with the new situation, it is important to have personal resources.
Positive psychology measures and nurtures the best values in human life. The fundamental goals of positive psychology are to foster the development of strengths in humans, their values and virtues, and to give the opportunity for a person to live their life to the fullest, to develop and to perfect themselves in the pursuit of happiness [2,3].
*Address correspondence to Irena Milaniak, MSN, CETC, MA, John Paul II Hospital, Cardiovascular Surgery and Transplantology Department, Pradnicka str 80, 31-202 Krakow, Poland. E-mail: [email protected]
ª 2014 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.026
Transplantation Proceedings, 46, 2839e2843 (2014)
2839
2840
QOL has long been used as an outcome measure in the evaluation of a diverse range of health and social care interventions. It is a multi-faceted concept, encompassing macro-societal and socio-demographic influences and also micro-concerns, such as individuals’ experiences, social circumstances, health, values, and perceptions [4]. Because it is subjective, it needs grounding in people’s own values and perceptions. The term “personal resources,” just as the term “the quality of life,” is interdisciplinary, and even multidisciplinary. Hobfoll [5], the author of Conservation of Resources Theory, understands resources as objects, conditions, personal possessions, and forms of energy, which are significant for experience or serve as a means of obtaining objects possessing the significance. The most common classifications of resources include the following spheres of human functioning: biological, psychological, social, and spiritual [6]. Personal resources and deficits, which are important from the point of view of human health and illnesses analysis, also constitute the basis of the high level of QOL. People actively strive to obtain, maintain, protect, and promote personal resources, because by means of these resources they are able to change reality, making it more satisfactory. QOL is contained in everyday experienceemodification of vital personal objectives is closely related to the modification of subjective meaning of the QOL [7]. Even successful curative surgery, considerable improvement in pharmacological treatment, and good prognosis leave the patient and his or her family with uncertainty due to the permanent threat. Research indicates that psychological and behavioral variables, such as personal resources (coping strategies, sense of coherence, optimism, and selfefficacy), have an impact on patients’ adjustment to live with a transplanted heart as well as QOL. The purpose of this study was to describe personal recourses influencing QOL for heart transplant recipients. METHODS Selection and Description of Participants
_ MILANIAK, WILCZEK-RUZYCZKA, PRZYBYŁOWSKI ET AL Table 1. Demographic Characteristics Variable
(N ¼ 121)
Age (y) Gender n (%) Male Female Education n (%) Elementary school Secondary school Higher education ND Work situation n (%) Old-age pension Sickness pension Working Marital status n (%) Single Married Divorced Widow/widower Living with a partner ND
55.01 (13.23); median, 58; from 18e77 91 (75.20) 30 (24.79) 16 (13.22) 84 (69.42) 19 (17.39) 2 109 (28.09) (61.98) 19 (15.70) 1 (0.82) 14 89 4 9 3 2
(11.57) (73.55) (3.30) (7.43) (2.47)
Abbreviation: ND, no data available.
indicate a better QOL. The psychological predictive variables (personal recourses) included: (1) Antonovsky’s Sense of Coherence (SOC-29), which contains 29 items measuring salutogenic factors (comprehensibility, manageability, and meaningfulness; every item is rated on a 7-point scale giving a maximum score of 203; a high score indicates a good SOC); (2) coping strategies for stress (Brief COPE; the brief COPE scale is a 28-item, which consists of 14 coping strategies, scoring from 0 to 3); (3) Generalized Self Efficacy Scale (GSES, which has 10 items; the higher the score the better the individual self-efficacy is recorded); and (4) optimism was assessed using the Life Orientation Test Revised (LOT-R; which is composed of 10 items with a Likert-type response format, scores from 0 to 24 points, the higher the score the higher the level of optimism reported). Approval to conduct the study was received from the institutional review board (KBET/246/B/2012). All patients who met criteria were invited to participate and informed consent was obtained during the routine health status evaluation.
Statistical Techniques
Participants of this study consisted of cardiac transplant recipients (n ¼ 121) from the Cardiovascular Surgery and Transplantology Department of John Paul II Hospital. Recipient inclusion criteria included: (1) 18 years, (2) 3 months after HTx, (3) agreement to participate in the study, and (4) with good cognitive and health status. Table 1 presents demographic characteristic of the sample. Participants in this study were primarily male (75.20%). Most were married and lived in the town. The mean age of participants was 55.01 (13.23) and time since transplantation was 10.54 years (5.24). Also, 75.26% participants reported not working.
The descriptive statistics of each question, facet, domain, and “Total” of WHO QOL Brief was calculated using Microsoft Excel. All statistical analyses were conducted using SPSS statistical software (version 17.0). Pearson or Spearman correlation was used to detect relationship between QOL and independent variables. Psychological approaches were entered together in a multivariate analysis to examine their independent predictive ability. Statistical significance was accepted at P < .05.
Technical Information/Instruments
RESULTS QOL
Data were collected using 5 patient-completed instruments: QOL was the dependent variable, measured using the World Health Organization Quality of Life (WHOQOL BREF). The WHOQOLBREF is composed of 26 questions - 2 questions on self-assessment of QOL and 24 issues representing each facet of WHOQOL-100. Each item is rated on a 5-point Likert scale. Higher score
The study population was satisfied with their overall QOL as well as health status (3.69 0.72 vs 3.70 0.80). In our study population, the highest QOL score was observed in the social relationships domain (15.044 2.40) followed by environment (14.159 2.43), psychological health
PSYCHOLOGICAL PREDICTORS OF QOL
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Table 2. Scores of Domains of QOL
Table 4. Significant Differences Between Level of SOC and QOL
Domain
Average
SD
Median
Min
Max
P
Physical Psychological Social relationship Environment Total QOL
13.035 13.046 15.044 14.159 13.75
1.549 1.100 2.404 2.437 1.44
13.14 13.33 16.00 14.00
9.14 9.33 9.33 8.50 10.46
16.00 15.33 20.00 20.00 17.08
<.001
Abbreviations: Min, minimum; Max, maximum.
(13.046 1.10), and physical domain QOL scores (13.035 1.54). There was a significant difference among domains (P < .01; Table 2). Psychological Predictors
The results for measurement of psychological predictors are presented in Table 3. Relationship Among QOL and Psychological Predictors
The analysis showed that participants with a high strength of SOC had a better QOL in comparison with those with weak SOC (Table 4). Respondents with a higher level of optimism and self efficacy compared with a lower level of these variable had also better QOL (P < .001). We obtained the same results between QOL domains and strength of SOC (P <.05), level of optimism (P < .05), and level of self-efficacy (P < .05). The bivariate correlations revealed a positive correlation among sense of coherence (r ¼ 0.66; P < .001), optimism (r ¼ 0.53; P < .001), self-efficacy (r ¼ 0.62; P < .001), as well as coping strategies like: active coping (r ¼ 0.421; P < .001), planning Table 3. Psychological Factors Psychological Variables
Possible Range
Sense of 1e203; (normalized score) coherence 130e160 CS 0e3 Self-distraction (1) Active coping (2) Denial (3) Substance use (4) Use of emotional support (5) Use of instrumental support (6) Behavioral disengagement (7) Venting (8) Positive reframing (9) Planning (10) Humor (11) Acceptance (12) Religion (13) Self-blame (14) Optimism 0e24
Self-efficacy
Results
Mean (SD) 131.41 (26.00) Mean (SD) 1.691 (0.787) 2.181 (0.578) 1.03 (0.73) 0.26 (0.45) 1.784 (0.684) 1.703 (0.664) 0.86 (0.65) 1.22 (0.63) 1.814 (0.606) 2.09 (0.64) 1.03 (0.74) 2.064 (0.656) 1.487 (0.986) 1.242 (0.679) Mean (SD) 15.17 (4.17) 1e4 sten-score e low optimism 22.31 % 7e10 sten-score e high optimism 38.02% 0e40 Mean (SD) 30.27 (4.77) 27.32 (normalized score)
Abbreviation: CS, coping strategies.
SOC
N
Mean
SD
Median
Min
Max
P
TOTAL QOL <130 (low SOC) 58 12.897 1.220 12.769 10.462 15.385 <.001 130e160 49 14.327 1.154 14.154 11.846 17.077 (normal SOC) >160 pkt 14 15.297 0.836 15.231 14.000 16.769 (high SOC)
(r ¼ 0.437; P < .001), positive reframing (r ¼ 0.410; P < .001), and “total” QOL. Negative correlation was found among coping strategies like: behavioral disengagement (r ¼ 0.344; P < .001), self-blame (r ¼ 0.267; P ¼ .004), and “total” QOL. Psychological factors were significantly associated with QOL and accounted for between 28% and 44% of the variance. Optimism, sense of coherence, and self-efficacy were the good predictors of QOL. Multiple regression models included sense of coherence, optimism, self-efficacy, and coping strategies. Next step multiple linear regression analysis with backward elimination revealed that only sense of coherence (P < .001), self-distraction (P ¼ .031), and self-blame (P ¼ .004) were associated with QOL. The final model accounted for 66.7% of variance in heart transplant recipients’ QOL (R2 ¼ 0.667; adjusted R2 ¼ .634, Test F(4.341); P < .05). We also saw that all variables were associated with each domain of QOL. The results indicated that there was a significant positive association between personal recourses: sense of coherence, selfefficacy, optimism, positive coping strategies, and QOL (Table 5 and Table 6). The results from the multiple regression analysis for predicting domain of QOL using the psychological variables are presented in Table 7. These were the principle results we obtained: (1) sense of coherence, optimism, and self-efficacy predicts a better QOL in all the domains; and all predictive variables were the weakest in the psychological domains.
Table 5. Association Between the Domain of QOL and Predictive Variable
Physical Pearson Significance N Social Spearman Significance N Psychological Spearman Significance N Environmental Pearson Significance N
SOC
Optimism
Self-Efficacy
0.512 0.000* 121
0.454 0.000* 121
0.448 0.000* 121
0.559 0.000* 121
0.412 0.000* 121
0.507 0.000* 121
0.263 0.004* 121
0.221 0.015* 121
0.282 0.002* 121
0.540 0.000* 121
0.424 0.000* 121
0.523 0.000* 121
*Bivariate correlation, P < .01.
_ MILANIAK, WILCZEK-RUZYCZKA, PRZYBYŁOWSKI ET AL
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Table 6. Correlations Between Coping Strategies and QOL Domain Variables
Coping Strategies (CS)
QOL domains
1 CS
2 CS
3 CS
4 CS
5 CS
6 CS
7 CS
8 CS
9 CS
10 CS
11 CS
12 CS
13 CS
14 CS
Physical (D1) Psychological (D2) Social (D3) Environmental (D4)
0.372* 0.246* 0.374* 0.352*
0.409* NS 0.361* 0.412*
0.346* NS 0.382* 0.341*
0.232* NS 0.319* 0.354*
NS NS NS NS
NS NS NS NS
0.271* NS 0.386* 0.279*
0.243* NS 0.276* 0.238*
NS NS NS NS
NS NS NS NS
NS NS NS NS
0.242* NS 0.199* NS
0.419* 0.184* 0.316* 0.284*
0.201* NS 0.362* NS
*Spearman bivariate correlation, P < .01.
DISCUSSION
Our objective was to evaluate the QOL as well as its psychosocial predictors among patients after HTx. Based on our results, there appears to be a substantial impairment to QOL in our population. All components of QOL were low. The most heavily affected domains being physical and psychological function. The results from our study are comparable with those from other studies [8e12]. Our second objective was to identify the psychological variables that could be significant predictors of QOL. Focusing on sense of coherence, optimism, selfefficacy, and positive coping strategies as personal recourses, we found that they were the predictors with positive correlations with QOL, accounting for from 28% to 44% of variance total QOL. The final model for this population revealed that sense of coherence (P < .001), self-distraction (P ¼ .031), and selfblame (P ¼ .004) were associated with total QOL. The final model accounted for 66.7% of variance in heart transplant recipients QOL. Table 7. Effect of Personal Recourses on QOL QOL Domains Personal recourses
Physical
Psychological
Optimism Self-efficacy Sense of coherence Coping strategies 1 2 3 4 5 6 7 8 9 10 11 12 13 14 R2 F (df ¼ 17.98)
0.03 0.07 0.36*
0.03 0.09 0.20
0.02 0.15 0.10 0.06 0.01 0.06 0.09 0.12 0.05 0.11 0.06 0.13 0.20 0.05 0.42 4.24†
0.06 0.06 0.04 0.01 0.02 0.06 0.13 0.07 0.21 0.02 0.01 0.12 0.05 0.10 0.17 1.23‡
*P ¼ .001. † P < .001. ‡ P < .25. § P < .05.
Social
Environmental
0.002 0.01 0.39†
0.09 0.25 0.35*
0.06 0.08 0.12 0.03 0.06 0.12 0.26§ 0.07 0.17 0.03 0.04 0.001 0.003 0.22§ 0.52 6.49†
0.06 0.07 0.01 0.03 0.05 0.05 0.19 0.13 0.11 0.03 0.02 0.02 0.03 0.10 0.44 4.64†
Sense of coherence was a strong predictor of QOL of heart transplant recipients. Other studies have found similar association between SOC and QOL [13e16]. Self-efficacy was positively and statistically significantly correlated with QOL. The associations between self-efficacy and QOL were similar to previous findings [17e19]. Supporting previous research on the predictive ability of psychosocial factors on patients’ QOL post-transplantation, we also found that optimism predicted better QOL [20,21]. To conclude, the results of our study suggest that intervention in several psychological aspects may be useful for improving QOL in heart transplant recipients. Our results indicate an important role of personal recourses: sense of coherence, self-efficacy, and optimism, which can be improved and strengthened through cognitive behavioral therapy. REFERENCES [1] Cupples S, Dew MA, Grady KL, et al. Report of the Psychosocial Outcomes Workgroup of the Nursing and Social Sciences Council of the International Society for Heart and Lung Transplantation: present status of research on psychosocial outcomes in cardiothoracic transplantation: review and recommendations for the field. J Heart Lung Transplant 2006;25(6):716e25. [2] Seligmann MEP. Positive psychology. In: Czapi nski J, editor. Positive psychology. Study of happiness, health, strength and man’s virtues. Warsaw: Scientific Publishing PWN; 2005. pp. 359e79. [3] Kobau R, Seligmann MEP, Petersom Ch, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health 2001;101:8e19. [4] Bowling A, Iliff S. Psychological approach to successful ageing predicts future quality of life in older adults and. Health & Quality of Life Outcomes 2011;9:13. [5] Hobfoll, SE. Stress, Culture, and Community. The Psychology and Philosophy of Stress. Gdansk: GWP; 2006. p. 71e103. [6] Chodkiewicz J. To struggle against the world. The meaning of personal resources, www.psychologia.net.pl/artykul.php?level¼136.; 2011 [accessed 09.10.11; in Polish]. [7] Dziurowicz-Kozłowska A. Around the quality of life definition. Psychol Quality Life 2002;2:77e99. [8] Aguiar M, Farias DR, Pinheiro ML, et al. Quality of life of patients that had a heart transplant: application of Whoqol-Bref scale. Arq Bras Cardiol 2011;96(1):60e7. [9] Martín-Rodríguez A, Pérez-San-Gregorio MA, DíazDomínguez R, et al. Health-related quality of life evolution in patients after heart transplantation. Transplant Proc 2008;40(9): 3037e8. [10] Politi P, Piccinelli M, FusarPoli P, et al. Ten years of “extended” life: quality of life among heart transplantation survivors. Transplantation 2004;78:257e63. [11] Fusar-Poli P, Martinelli V, Klersy C, et al. Depression and quality of life in patients living 10-18 years beyond heart transplantation. J Heart Lung Transplant 2005;24(12):2269e78.
PSYCHOLOGICAL PREDICTORS OF QOL [12] Saeed I, Rogers Ch, Murday A. Health-related quality of life after cardiac transplantation: results of a UK national survey with norm-based comparisons. J Heart Lung Transplant 2008;27(6): 675e81. [13] Guldvog B. Can patient satisfaction improve health among patients with angina pectoris? Int J Qual Care 1999;11:233e40. [14] Kattinen E, Merilainen P, Sintonen H. Sense of coherence and health related quality of life among patients undergoing coronary artery bypass grafting or angioplasty. Eur J Cardiovasc Nurs 2006;5:21e30. [15] Wrzesniewski K, Włodarczyk D. Sense of coherence as a personality predictor of the quality of life in men and women after myocardial infarction. Polish Cardiol 2012;70(2):157e63. [16] Tuszewska M, Tuszewski B, Stachowiak C. Quality of life and sense of coherence in patients with ulcerative colitis. Med News 2002;71(4-5):207e11.
2843 [17] Luszczynska A, Scholz U, Schwarzer R. The general selfefficacy scale: multicultural validation studies. J Psychol 2005;139(5): 439e57. [18] Hamplon NZ. Self-efficacy and quality of life in people with spinal cord injuries in China. Rehabilitaion Counselling Bull 2000;42:66e74. [19] Brekke M, Hjortdai P, Kvien TK. Changes in self-efficacy and health status over 5 years: a longitudinal observational study of 306 patients with rheumatoid arthritis. Arthritis Rheum 2003;49: 342e8. [20] Myaskovsky L, Dew MA, McNulty ML, et al. Trajectories of change in quality of life in 12-month survivors of lung or heart transplant. Am J Transplant 2006;6:1939e47. [21] Evangelista LS, Doering L, Dracup K. Meaning and life purpose: the perspectives of post-transplant women. Heart Lung 2003;32:250.
ABSTRACT Background. Heart transplantation (HTx) has a significant impact on all areas of the operation, adjustment, and quality of life (QOL) in patients after heart transplantation. In the process of healing and coping with the new situation, it is important to have personal resources. Aim. The main objectives of this study were to assess subjective QOL of patients after HTx and to determine the relationship between personal resources and QOL in this group of patients. Material and Methods. The study included 121 patients who received a heart transplant. A standardized instrument used to measure the quality of life was the World Health Organization (WHO) QOL Brief Questionnaire. The personal resources and deficits were determined using the following research techniques: Antonovsky’s Sense of Coherence (SOC), coping strategies for stress (Brief-COPE), Generalized Self Efficacy Scale (GSES), and Life Orientation Test (LOT-R). The data were analyzed statistically. Results. The patients gained an average level of QOL (13.75). The results indicate a positive relationship between the QOL in all its domains and personal resources: a sense of coherence (r ¼ 0.65; P < .05), optimism (r ¼ 0.55; P < .05), self-efficacy (r ¼ 0.58; P < .05), and strategies for coping (active coping [r ¼ 0.41; P < .05], planning [r ¼ 0.42; P < .05; P < .05], and positive revaluing [r ¼ 0.40; P < .05]). The regression model explained 56% of the predictors of QOL in patients after HTx. Applications. It is necessary to strengthen personal resources in this group of patients as well as to detect early and treat symptoms of depression and to cope with stress.
T
HE OUTCOME of heart transplantation (HTx) has been seen not only in terms of mortality and morbidity but also emphasis has been more toward assessing outcome in terms of patients’ perceptions of changes in their healthrelated quality of life (QOL). In addition to the physical consequences of transplantation, psychosocial factors are taken into account. The transplantation literature has highlighted that HTx may give rise to a new set of stressors, psychological challenges, and adaptive demands [1]. In the process of healing and coping with the new situation, it is important to have personal resources.
Positive psychology measures and nurtures the best values in human life. The fundamental goals of positive psychology are to foster the development of strengths in humans, their values and virtues, and to give the opportunity for a person to live their life to the fullest, to develop and to perfect themselves in the pursuit of happiness [2,3].
*Address correspondence to Irena Milaniak, MSN, CETC, MA, John Paul II Hospital, Cardiovascular Surgery and Transplantology Department, Pradnicka str 80, 31-202 Krakow, Poland. E-mail: [email protected]
ª 2014 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.026
Transplantation Proceedings, 46, 2839e2843 (2014)
2839
2840
QOL has long been used as an outcome measure in the evaluation of a diverse range of health and social care interventions. It is a multi-faceted concept, encompassing macro-societal and socio-demographic influences and also micro-concerns, such as individuals’ experiences, social circumstances, health, values, and perceptions [4]. Because it is subjective, it needs grounding in people’s own values and perceptions. The term “personal resources,” just as the term “the quality of life,” is interdisciplinary, and even multidisciplinary. Hobfoll [5], the author of Conservation of Resources Theory, understands resources as objects, conditions, personal possessions, and forms of energy, which are significant for experience or serve as a means of obtaining objects possessing the significance. The most common classifications of resources include the following spheres of human functioning: biological, psychological, social, and spiritual [6]. Personal resources and deficits, which are important from the point of view of human health and illnesses analysis, also constitute the basis of the high level of QOL. People actively strive to obtain, maintain, protect, and promote personal resources, because by means of these resources they are able to change reality, making it more satisfactory. QOL is contained in everyday experienceemodification of vital personal objectives is closely related to the modification of subjective meaning of the QOL [7]. Even successful curative surgery, considerable improvement in pharmacological treatment, and good prognosis leave the patient and his or her family with uncertainty due to the permanent threat. Research indicates that psychological and behavioral variables, such as personal resources (coping strategies, sense of coherence, optimism, and selfefficacy), have an impact on patients’ adjustment to live with a transplanted heart as well as QOL. The purpose of this study was to describe personal recourses influencing QOL for heart transplant recipients. METHODS Selection and Description of Participants
_ MILANIAK, WILCZEK-RUZYCZKA, PRZYBYŁOWSKI ET AL Table 1. Demographic Characteristics Variable
(N ¼ 121)
Age (y) Gender n (%) Male Female Education n (%) Elementary school Secondary school Higher education ND Work situation n (%) Old-age pension Sickness pension Working Marital status n (%) Single Married Divorced Widow/widower Living with a partner ND
55.01 (13.23); median, 58; from 18e77 91 (75.20) 30 (24.79) 16 (13.22) 84 (69.42) 19 (17.39) 2 109 (28.09) (61.98) 19 (15.70) 1 (0.82) 14 89 4 9 3 2
(11.57) (73.55) (3.30) (7.43) (2.47)
Abbreviation: ND, no data available.
indicate a better QOL. The psychological predictive variables (personal recourses) included: (1) Antonovsky’s Sense of Coherence (SOC-29), which contains 29 items measuring salutogenic factors (comprehensibility, manageability, and meaningfulness; every item is rated on a 7-point scale giving a maximum score of 203; a high score indicates a good SOC); (2) coping strategies for stress (Brief COPE; the brief COPE scale is a 28-item, which consists of 14 coping strategies, scoring from 0 to 3); (3) Generalized Self Efficacy Scale (GSES, which has 10 items; the higher the score the better the individual self-efficacy is recorded); and (4) optimism was assessed using the Life Orientation Test Revised (LOT-R; which is composed of 10 items with a Likert-type response format, scores from 0 to 24 points, the higher the score the higher the level of optimism reported). Approval to conduct the study was received from the institutional review board (KBET/246/B/2012). All patients who met criteria were invited to participate and informed consent was obtained during the routine health status evaluation.
Statistical Techniques
Participants of this study consisted of cardiac transplant recipients (n ¼ 121) from the Cardiovascular Surgery and Transplantology Department of John Paul II Hospital. Recipient inclusion criteria included: (1) 18 years, (2) 3 months after HTx, (3) agreement to participate in the study, and (4) with good cognitive and health status. Table 1 presents demographic characteristic of the sample. Participants in this study were primarily male (75.20%). Most were married and lived in the town. The mean age of participants was 55.01 (13.23) and time since transplantation was 10.54 years (5.24). Also, 75.26% participants reported not working.
The descriptive statistics of each question, facet, domain, and “Total” of WHO QOL Brief was calculated using Microsoft Excel. All statistical analyses were conducted using SPSS statistical software (version 17.0). Pearson or Spearman correlation was used to detect relationship between QOL and independent variables. Psychological approaches were entered together in a multivariate analysis to examine their independent predictive ability. Statistical significance was accepted at P < .05.
Technical Information/Instruments
RESULTS QOL
Data were collected using 5 patient-completed instruments: QOL was the dependent variable, measured using the World Health Organization Quality of Life (WHOQOL BREF). The WHOQOLBREF is composed of 26 questions - 2 questions on self-assessment of QOL and 24 issues representing each facet of WHOQOL-100. Each item is rated on a 5-point Likert scale. Higher score
The study population was satisfied with their overall QOL as well as health status (3.69 0.72 vs 3.70 0.80). In our study population, the highest QOL score was observed in the social relationships domain (15.044 2.40) followed by environment (14.159 2.43), psychological health
PSYCHOLOGICAL PREDICTORS OF QOL
2841
Table 2. Scores of Domains of QOL
Table 4. Significant Differences Between Level of SOC and QOL
Domain
Average
SD
Median
Min
Max
P
Physical Psychological Social relationship Environment Total QOL
13.035 13.046 15.044 14.159 13.75
1.549 1.100 2.404 2.437 1.44
13.14 13.33 16.00 14.00
9.14 9.33 9.33 8.50 10.46
16.00 15.33 20.00 20.00 17.08
<.001
Abbreviations: Min, minimum; Max, maximum.
(13.046 1.10), and physical domain QOL scores (13.035 1.54). There was a significant difference among domains (P < .01; Table 2). Psychological Predictors
The results for measurement of psychological predictors are presented in Table 3. Relationship Among QOL and Psychological Predictors
The analysis showed that participants with a high strength of SOC had a better QOL in comparison with those with weak SOC (Table 4). Respondents with a higher level of optimism and self efficacy compared with a lower level of these variable had also better QOL (P < .001). We obtained the same results between QOL domains and strength of SOC (P <.05), level of optimism (P < .05), and level of self-efficacy (P < .05). The bivariate correlations revealed a positive correlation among sense of coherence (r ¼ 0.66; P < .001), optimism (r ¼ 0.53; P < .001), self-efficacy (r ¼ 0.62; P < .001), as well as coping strategies like: active coping (r ¼ 0.421; P < .001), planning Table 3. Psychological Factors Psychological Variables
Possible Range
Sense of 1e203; (normalized score) coherence 130e160 CS 0e3 Self-distraction (1) Active coping (2) Denial (3) Substance use (4) Use of emotional support (5) Use of instrumental support (6) Behavioral disengagement (7) Venting (8) Positive reframing (9) Planning (10) Humor (11) Acceptance (12) Religion (13) Self-blame (14) Optimism 0e24
Self-efficacy
Results
Mean (SD) 131.41 (26.00) Mean (SD) 1.691 (0.787) 2.181 (0.578) 1.03 (0.73) 0.26 (0.45) 1.784 (0.684) 1.703 (0.664) 0.86 (0.65) 1.22 (0.63) 1.814 (0.606) 2.09 (0.64) 1.03 (0.74) 2.064 (0.656) 1.487 (0.986) 1.242 (0.679) Mean (SD) 15.17 (4.17) 1e4 sten-score e low optimism 22.31 % 7e10 sten-score e high optimism 38.02% 0e40 Mean (SD) 30.27 (4.77) 27.32 (normalized score)
Abbreviation: CS, coping strategies.
SOC
N
Mean
SD
Median
Min
Max
P
TOTAL QOL <130 (low SOC) 58 12.897 1.220 12.769 10.462 15.385 <.001 130e160 49 14.327 1.154 14.154 11.846 17.077 (normal SOC) >160 pkt 14 15.297 0.836 15.231 14.000 16.769 (high SOC)
(r ¼ 0.437; P < .001), positive reframing (r ¼ 0.410; P < .001), and “total” QOL. Negative correlation was found among coping strategies like: behavioral disengagement (r ¼ 0.344; P < .001), self-blame (r ¼ 0.267; P ¼ .004), and “total” QOL. Psychological factors were significantly associated with QOL and accounted for between 28% and 44% of the variance. Optimism, sense of coherence, and self-efficacy were the good predictors of QOL. Multiple regression models included sense of coherence, optimism, self-efficacy, and coping strategies. Next step multiple linear regression analysis with backward elimination revealed that only sense of coherence (P < .001), self-distraction (P ¼ .031), and self-blame (P ¼ .004) were associated with QOL. The final model accounted for 66.7% of variance in heart transplant recipients’ QOL (R2 ¼ 0.667; adjusted R2 ¼ .634, Test F(4.341); P < .05). We also saw that all variables were associated with each domain of QOL. The results indicated that there was a significant positive association between personal recourses: sense of coherence, selfefficacy, optimism, positive coping strategies, and QOL (Table 5 and Table 6). The results from the multiple regression analysis for predicting domain of QOL using the psychological variables are presented in Table 7. These were the principle results we obtained: (1) sense of coherence, optimism, and self-efficacy predicts a better QOL in all the domains; and all predictive variables were the weakest in the psychological domains.
Table 5. Association Between the Domain of QOL and Predictive Variable
Physical Pearson Significance N Social Spearman Significance N Psychological Spearman Significance N Environmental Pearson Significance N
SOC
Optimism
Self-Efficacy
0.512 0.000* 121
0.454 0.000* 121
0.448 0.000* 121
0.559 0.000* 121
0.412 0.000* 121
0.507 0.000* 121
0.263 0.004* 121
0.221 0.015* 121
0.282 0.002* 121
0.540 0.000* 121
0.424 0.000* 121
0.523 0.000* 121
*Bivariate correlation, P < .01.
_ MILANIAK, WILCZEK-RUZYCZKA, PRZYBYŁOWSKI ET AL
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Table 6. Correlations Between Coping Strategies and QOL Domain Variables
Coping Strategies (CS)
QOL domains
1 CS
2 CS
3 CS
4 CS
5 CS
6 CS
7 CS
8 CS
9 CS
10 CS
11 CS
12 CS
13 CS
14 CS
Physical (D1) Psychological (D2) Social (D3) Environmental (D4)
0.372* 0.246* 0.374* 0.352*
0.409* NS 0.361* 0.412*
0.346* NS 0.382* 0.341*
0.232* NS 0.319* 0.354*
NS NS NS NS
NS NS NS NS
0.271* NS 0.386* 0.279*
0.243* NS 0.276* 0.238*
NS NS NS NS
NS NS NS NS
NS NS NS NS
0.242* NS 0.199* NS
0.419* 0.184* 0.316* 0.284*
0.201* NS 0.362* NS
*Spearman bivariate correlation, P < .01.
DISCUSSION
Our objective was to evaluate the QOL as well as its psychosocial predictors among patients after HTx. Based on our results, there appears to be a substantial impairment to QOL in our population. All components of QOL were low. The most heavily affected domains being physical and psychological function. The results from our study are comparable with those from other studies [8e12]. Our second objective was to identify the psychological variables that could be significant predictors of QOL. Focusing on sense of coherence, optimism, selfefficacy, and positive coping strategies as personal recourses, we found that they were the predictors with positive correlations with QOL, accounting for from 28% to 44% of variance total QOL. The final model for this population revealed that sense of coherence (P < .001), self-distraction (P ¼ .031), and selfblame (P ¼ .004) were associated with total QOL. The final model accounted for 66.7% of variance in heart transplant recipients QOL. Table 7. Effect of Personal Recourses on QOL QOL Domains Personal recourses
Physical
Psychological
Optimism Self-efficacy Sense of coherence Coping strategies 1 2 3 4 5 6 7 8 9 10 11 12 13 14 R2 F (df ¼ 17.98)
0.03 0.07 0.36*
0.03 0.09 0.20
0.02 0.15 0.10 0.06 0.01 0.06 0.09 0.12 0.05 0.11 0.06 0.13 0.20 0.05 0.42 4.24†
0.06 0.06 0.04 0.01 0.02 0.06 0.13 0.07 0.21 0.02 0.01 0.12 0.05 0.10 0.17 1.23‡
*P ¼ .001. † P < .001. ‡ P < .25. § P < .05.
Social
Environmental
0.002 0.01 0.39†
0.09 0.25 0.35*
0.06 0.08 0.12 0.03 0.06 0.12 0.26§ 0.07 0.17 0.03 0.04 0.001 0.003 0.22§ 0.52 6.49†
0.06 0.07 0.01 0.03 0.05 0.05 0.19 0.13 0.11 0.03 0.02 0.02 0.03 0.10 0.44 4.64†
Sense of coherence was a strong predictor of QOL of heart transplant recipients. Other studies have found similar association between SOC and QOL [13e16]. Self-efficacy was positively and statistically significantly correlated with QOL. The associations between self-efficacy and QOL were similar to previous findings [17e19]. Supporting previous research on the predictive ability of psychosocial factors on patients’ QOL post-transplantation, we also found that optimism predicted better QOL [20,21]. To conclude, the results of our study suggest that intervention in several psychological aspects may be useful for improving QOL in heart transplant recipients. Our results indicate an important role of personal recourses: sense of coherence, self-efficacy, and optimism, which can be improved and strengthened through cognitive behavioral therapy. REFERENCES [1] Cupples S, Dew MA, Grady KL, et al. Report of the Psychosocial Outcomes Workgroup of the Nursing and Social Sciences Council of the International Society for Heart and Lung Transplantation: present status of research on psychosocial outcomes in cardiothoracic transplantation: review and recommendations for the field. J Heart Lung Transplant 2006;25(6):716e25. [2] Seligmann MEP. Positive psychology. In: Czapi nski J, editor. Positive psychology. Study of happiness, health, strength and man’s virtues. Warsaw: Scientific Publishing PWN; 2005. pp. 359e79. [3] Kobau R, Seligmann MEP, Petersom Ch, et al. Mental health promotion in public health: perspectives and strategies from positive psychology. Am J Public Health 2001;101:8e19. [4] Bowling A, Iliff S. Psychological approach to successful ageing predicts future quality of life in older adults and. Health & Quality of Life Outcomes 2011;9:13. [5] Hobfoll, SE. Stress, Culture, and Community. The Psychology and Philosophy of Stress. Gdansk: GWP; 2006. p. 71e103. [6] Chodkiewicz J. To struggle against the world. The meaning of personal resources, www.psychologia.net.pl/artykul.php?level¼136.; 2011 [accessed 09.10.11; in Polish]. [7] Dziurowicz-Kozłowska A. Around the quality of life definition. Psychol Quality Life 2002;2:77e99. [8] Aguiar M, Farias DR, Pinheiro ML, et al. Quality of life of patients that had a heart transplant: application of Whoqol-Bref scale. Arq Bras Cardiol 2011;96(1):60e7. [9] Martín-Rodríguez A, Pérez-San-Gregorio MA, DíazDomínguez R, et al. Health-related quality of life evolution in patients after heart transplantation. Transplant Proc 2008;40(9): 3037e8. [10] Politi P, Piccinelli M, FusarPoli P, et al. Ten years of “extended” life: quality of life among heart transplantation survivors. Transplantation 2004;78:257e63. [11] Fusar-Poli P, Martinelli V, Klersy C, et al. Depression and quality of life in patients living 10-18 years beyond heart transplantation. J Heart Lung Transplant 2005;24(12):2269e78.
PSYCHOLOGICAL PREDICTORS OF QOL [12] Saeed I, Rogers Ch, Murday A. Health-related quality of life after cardiac transplantation: results of a UK national survey with norm-based comparisons. J Heart Lung Transplant 2008;27(6): 675e81. [13] Guldvog B. Can patient satisfaction improve health among patients with angina pectoris? Int J Qual Care 1999;11:233e40. [14] Kattinen E, Merilainen P, Sintonen H. Sense of coherence and health related quality of life among patients undergoing coronary artery bypass grafting or angioplasty. Eur J Cardiovasc Nurs 2006;5:21e30. [15] Wrzesniewski K, Włodarczyk D. Sense of coherence as a personality predictor of the quality of life in men and women after myocardial infarction. Polish Cardiol 2012;70(2):157e63. [16] Tuszewska M, Tuszewski B, Stachowiak C. Quality of life and sense of coherence in patients with ulcerative colitis. Med News 2002;71(4-5):207e11.
2843 [17] Luszczynska A, Scholz U, Schwarzer R. The general selfefficacy scale: multicultural validation studies. J Psychol 2005;139(5): 439e57. [18] Hamplon NZ. Self-efficacy and quality of life in people with spinal cord injuries in China. Rehabilitaion Counselling Bull 2000;42:66e74. [19] Brekke M, Hjortdai P, Kvien TK. Changes in self-efficacy and health status over 5 years: a longitudinal observational study of 306 patients with rheumatoid arthritis. Arthritis Rheum 2003;49: 342e8. [20] Myaskovsky L, Dew MA, McNulty ML, et al. Trajectories of change in quality of life in 12-month survivors of lung or heart transplant. Am J Transplant 2006;6:1939e47. [21] Evangelista LS, Doering L, Dracup K. Meaning and life purpose: the perspectives of post-transplant women. Heart Lung 2003;32:250.