**4. HRQoL indicators for prevalent diseases and functional disability**

Measurement tools for health and HRQoL in the field of disease have developed considerably and are generally associated with the most prevalent problems present in the population, and therefore in those with most patients. Among these the following can be highlighted:

#### **4.1 Quality of life profile for the chronically ill (PECVEC)**

This standardised tool of measurement was developed in 1996 to assess somatic, emotional and social components as well as functioning and well-being in clinical practice [29, 56]. Therefore it may be used in diverse risk groups and when assessing therapeutic measures and analysing the progression of chronicity. It is composed of 40 questions with a Likert-type response scale with 5 scores, from nothing to a great deal. It is a multidimensional assessment involving the following aspects: Physical Capacity (8 items), Psychological Functioning (8 items), Positive Mood (5 items), Negative Mood (8 items), Social Functioning (6 items) and Social Welfare (5 items). Range of scores is 0 to 4 in all items and the highest score corresponds to the highest quality of life in the patient, with the same weight given to physical and psychological aspects and differentiating between social functioning and social well-being. It has been used successfully in epidemiological studies in the general population and in patients with various chronic diseases such as hypertension, DM, rheumatic disease and acute myocardial infarction. It can be selfadministered (preferable) or by an interviewer or interviewers in patients with difficulties, such as persons with visual or intellectual disabilities. It is Grade A for its psychometric criteria, generalisability for comparisons, and utility in assessments of patient perception of their own health status and the consequences of diseases and circumstances on patient quality of life.

#### **4.2 EUROQOL-5D**

EQ-5D is a measure of self-perceived health which originated with the desire of integrating the five dimensions considered most relevant to HRQoL: mobility, selfcare, habitual activates, pain/discomfort, and anxiety/depression [57]. It is a generic, standardised, self-administered questionnaire, easy to answer and with low cognitive and intellectual load. EQ-5D is widely used around the world, and is available in more than 170 languages, including several versions in Spanish after a rigorous translation process [58, 59]. It is available in multiple formats: paper and electronic. According to the author, EQ-5D's potential in Spain, not merely as a measure of health but also as a basis for economic assessment, would increase if it were systematically incorporated into clinical information [60, 61] and primary care, and were validated for patients with constipation [62]. This can only occur if

*Modifiers of Health-Related Quality of Life by Biological, Psychological and Social… DOI: http://dx.doi.org/10.5772/intechopen.97451*

healthcare professionals consider that patient-submitted information on HRQoL outcomes is relevant to the management of their clinical work. EuroQol was developed with the aim of making a generic instrument for measuring HRQoL which could be used in applied, clinical and public health research, and which allowed comparisons among countries, but which was also capable of detecting and quantifying changes in health status and quality of life. The test was designed to obtain and provide descriptive information on quality of life based on various dimensions, a global value and a value indicating patient preference for a certain desired state of health. It produces a profile of social values which together with years of life create a measure of the outcomes of medical interventions: quality-adjusted life years (QALY) [63].

EuroQol was developed simultaneously in five European countries: England, the Netherlands, Norway, Sweden and Denmark. The content was obtained from a review of the dimensions of the SIP and the Nottingham Health Profile, based on the experience of the researchers who participated in the project. The tool consist of three parts. The first is devoted to *description of health status* according to 5 dimensions (mobility, personal care, daily activities, pain/discomfort, and anxiety/ depression). These dimensions are rated 1 to 3, 1 No problems, 2 Some problems, and 3 Many problems. In the second part of the test, the patient scores their state of health on a millimetre scale analogous to a 20 mm thermometer (EVA) whose extremes go from 0 (Worst State) to 100 (Best State). This EVA score can be used as a quantitative indicator of state of health. The third part is designed to obtain individual scores of preference for states designed in the descriptive part, with 14 possible states scored from 1 to 3, and in which the patient is also asked where they would place the status "death". The tool is designed to be self-administered (preferable) or through an interviewer or interviewers in patients with difficulties such as persons with visual or intellectual disabilities. It is Grade A for its psychometric criteria, for generalisability which allows studies in diverse diseases and clinical settings, and for utility of the index value in cost-effectiveness studies and especially in the allocation of clinical and care resources [29]. This questionnaire is available at http://www.euroqol.org.

#### **4.3 Duke activity status index (DASI)**

This tool was designed to analyse and assess functional capacity in cardiovascular patients based on the patient's ability to perform activities of daily living (ADLs). A version adapted to gravely hospitalised patients was also developed, based on the SUPPORT [29] study, and more recently its use was recommended as a predictor of postoperative morbidity and mortality by assessing tolerance to exercise and thus improving the planning and outcome of surgery [64]. The original questionnaire consisted of 12 items which collect information on the possibilities of performing activities of daily living (ADLs) such as personal care, mobility, household tasks and sexual functioning in the last two weeks; the reduced version does not include sexual functioning. Scores for each item range from 3 (activity performed without difficulty), 2 (activity performed with difficulty) and 1 (activity not performed for reasons of health). If a surveyed patient does not perform the activity for reasons other than health, this question is given the same score as the previous item, as it is assumed that the patient had at least the same difficulty in performing the activity. Each item has a value ranging between 1 and 2.5, such that the score ranges from 11.5 (minimum capacity) to 33 (maximum capacity). The test is designed to be selfadministered (preferable because this eliminates bias) or through an interviewer or interviewers in patients with difficulties such as persons with visual or intellectual

disabilities [13]. It is Grade A for its psychometric criteria of validity, reliability and sensitivity, and permits studies on cardiovascular diseases and conditions, which are among the most prevalent and primary causes of death in developed countries. Additionally, it is predictive in patients with cardiovascular disease.

#### **4.4 General health questionnaire (GHQ)**

The aim in developing this measuring tool was the detection of patients suffering from non-psychotic psychiatric disorders. It was validated for patients who requested primary care services from General Practitioners in the UK, to aid these practitioners in detecting psychiatric cases, and was later applied to epidemiological studies in the general population [29]. The questionnaire is based on the multidimensional model of the Biopsychosocial Health Model [7] and specifically for mental disorders. The author wished to distinguish between minor mental conditions and greater disorders which lead to loss of normality in connection with daily living. The tool consists of 140 items and a short 60-item form; further short forms were later developed, of which the 28-item version is the most frequently used. This last is composed of four subscales of 7 items which assess somatic symptoms of psychological origin, anxiety, difficulties in performing daily activities, and subjective perception of depression. The score for these items is 0 in responses better or equal to normal and 1 in responses worse or much worse than normal. The test is designed to be self-administered (preferable because this eliminate bias) and can be completed in under 5 minutes.

It is Grade A for its psychometric criteria of validity, reliability and sensitivity, and the 28-question version has become widely used due to the short time to administer, ease of scoring and good acceptance. Its main weakness is that it is not designed to screen for psychiatric conditions and for minor non-psychotic psychological conditions [29].

#### **4.5 Psychological general well-being index**

This survey was developed in the USA for use in community epidemiological studies as an indicator to reveal subjective feelings of well-being or psychological discomfort, i.e. for studies in the general population. The questionnaire consists of 18 items which cover 6 dimensions. The first 14 items have Likert-type answers, with six categories representing degrees of intensity or frequency which may range from 1 to 6 or from 6 to 1 depending on type of item; the remaining four items are scored on a visual analogue scale. The assessed dimensions are: anxiety, depression, positive mood, vitality, self-control and overall health. A global assessment of severe discomfort can be obtained with the lowest score, and of positive well-being with the highest. Scores can also be obtained for each dimension. A 22-item version of the tool exists which was developed by Dupay [65] for use in cardiovascular disease, and whose score ranges from 22 (patients with severe discomfort) to 132 (patients with positive well-being), which has been translated and adapted into Spanish by experts on methodology and HRQoL measurement tools [66]. It is designed to be self-administered (preferable because this eliminates bias). It is Grade A for its psychometric criteria of validity, reliability and sensitivity to change. Its main weakness is the establishing of cut-off points when differentiating between degrees of well-being: positive, negative, and severe discomfort [29].

To summarise and facilitate the analytical analysis and decision-making when choosing an instrument, these are presented in the following **Table 3**.


*Modifiers of Health-Related Quality of Life by Biological, Psychological and Social… DOI: http://dx.doi.org/10.5772/intechopen.97451*

> **Table 3.**

*Summary of the characteristics of the selected HRQoL instruments.*
