**2.1 A preliminary model of the factors conditioning HRQOL**

On the basis of previous research (Bidzan, 2008) a model has been developed for the assumed relationships between HRQOL and selected psychological measures (personality traits, quality of relationship, and coping styles). The pathways analysis method was used. In the opinion of many researchers (e.g. Cwalina, 2000; Gaul & Machowski, 2004) this method is distinctly superior to both the ANOVA approach and factor analysis in testing correlational and differential accuracy on the basis of a multi-feature, multi-method matrix. Pathway analysis, unlike other methods, provides not only quantitative indices of weight (the "feature factor" and the "method factor"), but also a model of the structure of the data acquired by means of a given instrument.

The model we are proposing, which is shown in Fig. 1, takes in both the variables that directly influence the quality of life and the indirect variables.

Fig. 1. Proposed model of relations between selected psychological measures and HRQOL in women patients with UUI

A Model of the Psychological Factors Conditioning Health

2. bidirectional arrows: covariance of variables;

model that would fit the data ideally).

regarded as indicative of a good fit.

not explained by the model).

can also affect HRQOL.

obtained:

a good fit.

dependencies between variables.

explains.

Related Quality of Life in Urodynamic Stress Incontinence Patients After TVT 137

dimensions from the NEO-FFI are the only two exogenous variables in the model. The variance of these exogenous variables is assumed to be 1 (standardized sizes). In addition to the personality variables, the model also incorporates three coping styles from the CISS: task-oriented, emotion-oriented, and avoidance. These coping styles have not previously been studied in women with urinary incontinence, though the literature refers to other kinds of strategies used by patients with urinary incontinence, such as making a toilet map, urinating "in advance," etc. The manner of coping in the face of a difficult situation depends, among other things, on previous experiences and personality traits. Health, in turn, is largely dependent on the process of coping (Makowska & Poprawa, 2001), which

In the course of further analysis the model has been modified in such a way as to maximize the agreement of the correlation matrix reproduced in the model with the correlation matrix observed in research. The calculations were done using the R statistical environment (www.r-project.org) and the SEM package for this environment (Structural Equations Modeling). From the diagrams we can read out the following parameters of the model thus

3. "reversed" bidirectional arrows: variance of error (additional variance of the variable

1. The value of the chi-squared statistic for the model. It was assumed that this value should not be statistically significant (i.e. the model does not differ significantly from a

2. The Goodness of Fit Index (GFI), in the range from 0 to 1. Values greater than 0.95 are

The value can be interpreted as the percentage of the observed covariance that the model

In order to test the proposed model for the factors conditioning HRQOL in a group of USI patients who have undergone TVT - that is, to check whether and how much it reflects the actual dependencies between the variables, to specify the causal effects, and to specify the degree to which it explains the variance in HRQOL, a pathways analysis was performed (Dolińska-Zygmunt, 2000). The results are presented below in tables. The results of the analysis indicate that the model is correctly constructed, i.e. it accurately reflects the

3. The Adjusted Goodness of Fit index (AGFI). A value of at last 0.9 indicates a good fit. 4. The Root Mean Square Error of Approximation (RMSEA). A value below 0.05 indicates

5. The Bentler-Bonett Normed Fit Index (NFI). Values above 0.90 are acceptable. 6. The Trucker-Lewis Non-Normed Fit Index (NNFI). Values above 0.95 are acceptable.

7. The Bentler Comparative Fit Index (CFI).A value of 0.9 is acceptable.

The proposed model displays a significant fit to the data.

1. unidirectional arrows: beta coefficients for linear regression equations;

The following factors were used to evaluate the compatibility of the model:

For purposes of the preliminary model, HRQOL was used as a latent variable. The value of this variable was indirectly observed by means of the DAS and the KHQ. It was assumed that HRQOL assumes a value on the same scale as the overall QOL score in the KHQ.

The categories incorporated in the model include two personality dimensions ("agreeability" and "neurotism") measured by the NEO-FFI Personality Inventory, the coping styles measured by the CISS, the overall QOL measured by the KHQ, and the overall quality of the marital or partner relationship, measured by the DAS.

Given the limitations of the pathways analysis method, only the foregoing variables were taken into account.

The inclusion of Neurotism in the model is justified both by the results previously obtained by the first author of the present study (Bidzan 2008), pointing to statistically significant differences in the level of Neurotism between groups of women with different forms and different intensities of urinary incontinence, and by previously published reports indicating the essential role of this trait in shaping HRQOL. To be sure, these latter reports did not deal with urinary incontinence; still, the overall regularities should be valid in this respect. The inclusion of Agreeability was also motivated by results obtained in a previous study by the first author of the present study (Bidzan 2008), indicating that this is the only personality trait besides Neurotism that differentiated the groups of women studied, with various forms of urinary incontinence (USI, MUI, UUI) and with varying degrees of intensity.

Apart from the direct impact of Agreeability and Neurotism on HRQOL, the model in question also assumes that these factors have an indirect impact, through the coping styles used by the individual. The quality of the marital or partner relationship (DAS overall) is associated with overall HRQOL according to King's Health Questionnaire.

#### **2.2 Verification of the preliminary model of factors conditioning HRQOL - pathways analysis**

The proposed model was then verified. The structural equations modeling technique was used. This makes it possible to ascertain dependencies, in terms of direction and strength, between the observed variables.

As mentioned above, the preliminary model used the latent variable "HRQOL," whose value was indirectly observed using the DAS and the KHQ. It was assumed that HRQOL takes on a value on the same scale1 as the QOL score on the KHQ. The connection between HRQOL thus defined and the DAS is also statistically significant (see the model). For the purposes of the model, then, the results for HRQOL were negatived, so that higher scores would mean a higher HRQOL, which makes it possible to make comparisons with results from other methods, especially the DAS.

Two dimensions from the NEO-FFI are incorporated in the model (Neurotism and Agreeability), since, as indicated by previous research, these have the greatest impact on the psychological functioning of patients with urinary incontinence, including the decision to undergo treatment, which can guarantee a change in HRQOL. These two

 1 The linear regression coefficient for the variable HRQOL and the overall score from the KHQ equals 1.

For purposes of the preliminary model, HRQOL was used as a latent variable. The value of this variable was indirectly observed by means of the DAS and the KHQ. It was assumed that HRQOL assumes a value on the same scale as the overall QOL score in the KHQ.

The categories incorporated in the model include two personality dimensions ("agreeability" and "neurotism") measured by the NEO-FFI Personality Inventory, the coping styles measured by the CISS, the overall QOL measured by the KHQ, and the overall

Given the limitations of the pathways analysis method, only the foregoing variables were

The inclusion of Neurotism in the model is justified both by the results previously obtained by the first author of the present study (Bidzan 2008), pointing to statistically significant differences in the level of Neurotism between groups of women with different forms and different intensities of urinary incontinence, and by previously published reports indicating the essential role of this trait in shaping HRQOL. To be sure, these latter reports did not deal with urinary incontinence; still, the overall regularities should be valid in this respect. The inclusion of Agreeability was also motivated by results obtained in a previous study by the first author of the present study (Bidzan 2008), indicating that this is the only personality trait besides Neurotism that differentiated the groups of women studied, with various forms

Apart from the direct impact of Agreeability and Neurotism on HRQOL, the model in question also assumes that these factors have an indirect impact, through the coping styles used by the individual. The quality of the marital or partner relationship (DAS overall) is

**2.2 Verification of the preliminary model of factors conditioning HRQOL - pathways** 

The proposed model was then verified. The structural equations modeling technique was used. This makes it possible to ascertain dependencies, in terms of direction and strength,

As mentioned above, the preliminary model used the latent variable "HRQOL," whose value was indirectly observed using the DAS and the KHQ. It was assumed that HRQOL takes on a value on the same scale1 as the QOL score on the KHQ. The connection between HRQOL thus defined and the DAS is also statistically significant (see the model). For the purposes of the model, then, the results for HRQOL were negatived, so that higher scores would mean a higher HRQOL, which makes it possible to make comparisons with results

Two dimensions from the NEO-FFI are incorporated in the model (Neurotism and Agreeability), since, as indicated by previous research, these have the greatest impact on the psychological functioning of patients with urinary incontinence, including the decision to undergo treatment, which can guarantee a change in HRQOL. These two

1 The linear regression coefficient for the variable HRQOL and the overall score from the KHQ equals 1.

of urinary incontinence (USI, MUI, UUI) and with varying degrees of intensity.

associated with overall HRQOL according to King's Health Questionnaire.

quality of the marital or partner relationship, measured by the DAS.

taken into account.

**analysis** 

between the observed variables.

from other methods, especially the DAS.

dimensions from the NEO-FFI are the only two exogenous variables in the model. The variance of these exogenous variables is assumed to be 1 (standardized sizes). In addition to the personality variables, the model also incorporates three coping styles from the CISS: task-oriented, emotion-oriented, and avoidance. These coping styles have not previously been studied in women with urinary incontinence, though the literature refers to other kinds of strategies used by patients with urinary incontinence, such as making a toilet map, urinating "in advance," etc. The manner of coping in the face of a difficult situation depends, among other things, on previous experiences and personality traits. Health, in turn, is largely dependent on the process of coping (Makowska & Poprawa, 2001), which can also affect HRQOL.

In the course of further analysis the model has been modified in such a way as to maximize the agreement of the correlation matrix reproduced in the model with the correlation matrix observed in research. The calculations were done using the R statistical environment (www.r-project.org) and the SEM package for this environment (Structural Equations Modeling). From the diagrams we can read out the following parameters of the model thus obtained:


The following factors were used to evaluate the compatibility of the model:


The value can be interpreted as the percentage of the observed covariance that the model explains.

The proposed model displays a significant fit to the data.

In order to test the proposed model for the factors conditioning HRQOL in a group of USI patients who have undergone TVT - that is, to check whether and how much it reflects the actual dependencies between the variables, to specify the causal effects, and to specify the degree to which it explains the variance in HRQOL, a pathways analysis was performed (Dolińska-Zygmunt, 2000). The results are presented below in tables. The results of the analysis indicate that the model is correctly constructed, i.e. it accurately reflects the dependencies between variables.

A Model of the Psychological Factors Conditioning Health

HRQOL CISS

CISS emotion

DAS overall

CISS task

CISS emotion

CISS avoidCISS avoid

DAS overall

Observed covariance

Covariance matrix replicated by the

model

matrix

Table 2. Coefficients for the model

Table 3. Observed covariance matrix

NEO.FFI Agree

NEO.FFI agree

Table 4. Covariance matrix replicated by the model

Related Quality of Life in Urodynamic Stress Incontinence Patients After TVT 139

avoid 0.27 0.18 1.51 0.13

CISS task 0.12 0.11 1.11 0.27

HRQOL 0.71 0.41 1.71 0.09

CISS task 0.83 0.24 3.46 **0.001**

CISS emotion 0.33 0.09 3.46 **0.001**

DAS overall 0.84 0.25 3.41 **0.001** KHQKHQ 0.68 0.20 3.41 **0.001**

> CISS avoid

> CISS avoid

NEO.FFI agree 1.00 -0.56 -0.42 0.20 -0.39 0.18 0.25 CISS emotion -0.56 1.00 0.15 -0.20 0.77 -0.23 -0.32 CISS avoid -0.42 0.15 1.00 -0.04 0.04 0.09 0.13 CISS task 0.20 -0.20 -0.04 1.00 -0.40 -0.21 -0.29 NEO.FFI neuro -0.39 0.77 0.04 -0.40 1.00 -0.12 -0.17 DAS overall 0.18 -0.23 0.09 -0.21 -0.12 1.00 0.22 KHQ 0.25 -0.32 0.13 -0.29 -0.17 0.22 1.00

CISS. task

NEO.FFI agree 1.00 -0.56 -0.42 0.20 -0.39 0.21 0.23 CISS emotion -0.56 1.00 0.25 -0.20 0.77 -0.35 -0.22 CISS avoid -0.42 0.25 1.00 -0.12 0.04 -0.03 0.21 CISS task 0.20 -0.20 -0.12 1.00 -0.40 -0.19 -0.33 NEO.FFI neuro -0.39 0.77 0.04 -0.40 1.00 -0.18 -0.13 DAS overall 0.21 -0.35 -0.03 -0.19 -0.18 1.00 0.18 KHQ 0.23 -0.22 0.21 -0.33 -0.13 0.18 1.00

CISS emotion

CISS emotion

Coefficient SD z value *Compatibility*

0.81 0.23 3.46 **0.001**

CISS task

NEO.FFI Neuro

NEO.FFI neuro

DAS

DAS

overall KHQ

overall KHQ
