Original articleA study on the subjective well-being and its influential factors in chronically ill inpatients in Changsha, China☆
Introduction
According to the U.S. National Center for Health Statistics (Stedman, 1995), chronic illness is defined as any illness with a duration of at least 3 months. Chronic diseases are the largest cause of death in the world, causing 29 million deaths worldwide in 2002 (Yach, Hawkes, Gould, & Hofman, 2004). Cardiovascular disease is the number one killer among chronic illnesses, followed by cancer, chronic lung diseases, and diabetes mellitus, respectively. In the Western world, chronic diseases are a major threat to quality of life (Rijken, van Kerkhof, Dekker, & Schellevis, 2005). In China, chronic diseases affect 0.16 billion chronic ill-health patients, yielding a morbidity rate of 15.11% computed by cases, and a morbidity rate of 12.33% computed by patients (total population of China is 1.30 billion) (Ministry of Health People's Republic of China [MHPRC], 2004). In 2001, the three leading causes of mortality were cardiovascular disease (38.02%), cancer (20.93%), and chronic pulmonary heart disease (13.36%), respectively (MHPRC, 2006). Chronic diseases lead to impairments in daily activities, social functioning, psychological functioning, and recreational activities (Kunik et al., 2005). Knowing that patients with chronic illnesses are at higher risk for comorbid psychiatric problems (Katon & Sullivan, 1990), it is important to extend the existing knowledge about subjective well-being (SWB) of chronically ill patients. Due to high-prevalence rates of chronic illness in China, this study focused on assessing the SWB of chronic patients with hypertension and coronary heart disease, diabetes mellitus, and chronic pulmonary heart disease.
SWB refers to the global assessment of all aspects of a person's life, including affective and cognitive components (Diener, 1984). These cognitive and affective reactions to a person's life can be understood within the matrix of personality (Diener & Diener, 1996). The World Health Organization defines health as “a state of complete physical, mental and social well- being,” but traditionally clinical staff has given precedence to promoting physical well-being and ignoring the importance of emotional well-being for health. Increasing evidence suggests that the promotion of physical health without paying attention to mental and social well-being is an inadequate strategy. As for chronically ill patients suffering from hypertension (Klocek & Kawecka-Jaszcz, 2003), chronic respiratory disease (Carone & Donner, 2005), and diabetes, a considerable number of studies reveal that patients' SWB declined markedly compared to general population. These results are consistent with Chinese samples (Han, et al., 2003, Lei & Yu, 2005, Mei & Bao, 2004).
Investigations of determinants of psychological well-being have been the major focus of health sociology for at least three decades (Fuller, Edwards, Vorakitphokatorn, & Sermsri, 1996). In the past 30 years, many studies have examined internal, demographic, and other external correlates of SWB. Among foreign populations of chronically ill patients, an overwhelming amount of evidence shows that SWB is strongly and positively related to income (Shirai et al., 2006), social support (Han et al., 2003), physical fitness (Hessert, Gugliucci, & Pierce, 2005), and memory function. Diabetes mellitus patients with long-term complications (e.g., cardiovascular diseases and nephrosis) reported significantly lower psychological well-being compared to subjects without long-term complications (Pouwer, van der Ploeg, Ader, Heine, & Snoek, 1999). A meta-analysis of gender differences in psychological well-being in elderly populations showed that older women reported significantly lower SWB than older men (Pinquart & Sorensen, 2001). The impact of age on SWB also showed cross-cultural diversity. For example, age identities played a role in more varied aspects of psychosocial adaptation in the United States than in Germany (Westerhof & Barrett, 2005). Married individuals reported greater happiness than married but divorced, separated or widowed, and never-married individuals (Mookherjee, 1998). The effect of education on SWB is not strong (Jones, Rapport, Hanks, Lichtenberg, & Telmet, 2003). According to the existing literature, studies have found similar results for Chinese samples, with means of payment for treatment expenditures being one of the most influential factors (Zheng, Ling, & Zhang, 2004). In general, these means can be divided into three kinds: paid by oneself, partly paid by medical care, and entirely paid by medical care. In China, the Medicare System or similar coverage does not cover individuals. In urban and suburban areas, 44.8% of individuals do not benefit from medical care coverage, whereas this percentage rises to 79.1% in rural areas (MHPR, 2004).
Many studies have shown that the psychological status of chronically ill patients is very low, with a high prevalence of depression and anxiety symptoms in clinical settings (Cramer, et al., 2005, Peruzza, et al., 2003, Ried, et al., 2006). Psychological aspects are inherent to SWB. Ried, Tueth, Handberg, and Nyanteh (2006) indicated that excellent SWB was associated with fewer depressive symptoms. Anxiety disorders influence SWB (Cramer et al., 2005) and trait anxiety has been shown to be strongly associated with SWB (Vazquez et al., 2005).
The literature on SWB is very rich for chronic patients in Western countries. However, very few studies have focused on non-Western countries, and China is no exception. Major cultural differences between China and Western countries prevent us from generalizing on SWB in Western countries to Chinese populations. According to the literature, SWB is influenced by sociodemographic and psychological factors, but it remains unknown which factors most influence SWB, what are the significant predictors of SWB, and how they influence chronic patients' SWB. Using person-centered nursing (McCormack, 2004) as the conceptual framework, this study assessed factors (including sociodemographic and psychological factors) influencing the SWB of chronically ill inpatients in China.
Five research questions were addressed in this study:
- 1.
Is the SWB of chronically ill inpatients lower than normal people and varied among different diseases in China?
- 2.
Do sociodemographic factors such as age, gender, marital status, occupation, education level, duration of diseases, complication, and means of payment influence the SWB of inpatients in China?
- 3.
Are psychological factors such as depression, anxiety, and trait anxiety predicators of SWB in China?
- 4.
What are the significant predictors of SWB among sociodemographic and psychological factors?
- 5.
What we can do in nursing care based on patients' suggestions and the findings of the study?
Section snippets
Study site and sample
Three hundred fifty participants were recruited from 14 wards of four top hospitals (three affiliated hospitals of Central South University and the People's Hospital of Hunan Province) in Changsha (a middle income area of China in terms of economic growth, overall family income, etc.), Hunan Province, China between July 2002 and January 2003. The wards included cardiovascular medical wards (n = 5), endocrine medical wards (n = 5), and respiratory medical wards (n = 4). Inclusionary criteria
Results
In our study, 350 patients agreed to participate, 28 respondents withdrew for various reasons, and 32 respondents were excluded for omitting 20% or more of the questions. In all, 290 persons (123 females and 167 males), aged between 17 and 90 years (59.7 ± 0.9) participated in the study. The effective response rate was 82.9%. Scores of SWB ranged from 2.85 to 14.7, with a mean of 10.51 ± 0.13. The demographic characteristics and SWB scores are presented in Table 1. A one-way ANOVA yielded
Discussion
The results showed that patients with chronic pulmonary heart disease, diabetes, and cardiovascular disease reported lower levels of SWB compared with the general population in the finding of Campbell et al. (1976). Various reasons may explain this result. One of them is related specifically to the chronic diseases from which participants suffer. The somatic nature of chronic conditions and life distress associated with chronic illnesses are important factors that influence SWB (Hessert et al.,
Implications for practice
Kitwood (1997) defines person-centeredness as “a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being”. It implies recognition, respect, and trust. McCormack (2004) extracted four core concepts from it as the heart of person-centered nursing: being in relation, being in a social world, being in place, and being with self. The concept makes explicit the need for nurses to move beyond a focus on technical competence and requires
Study limitations
There were several limitations to this study. First, a sampling bias exists as the results were obtained from only four institutions in Hunan, All these hospitals were teaching hospitals and ranked as first class hospitals in Hunan. Patients in these hospitals are potentially more seriously ill. Second, the sampling bias may also be due to the category of diseases selected. As only three categories of diseases were collected, this limits our ability to provide a global perspective of all
Conclusion
In general, patients with chronic pulmonary heart disease, diabetes, and cardiovascular disease reported lower levels of SWB. The main influential factors of SWB are trait anxiety, anxiety, means of paying medical expenses, depression, income, and age. Trait anxiety, anxiety, and means of paying medical expenses are predictors of SWB. Because psychological problems are important in predicting SWB, nurses should pay attention to the psychological status of their patients and help them reduce
Acknowledgments
The authors gratefully acknowledge the support and funding received from the Health Department of Hunan Province in China (series number: ZD02-01), the modification by Gabrielle Pagé (Department of Psychology, McGill University, 1205 Dr. Penfield Avenue, Montreal, Qc, Canada H3A 1B1) and the help of the head nurses of these wards, who extended their assistance in the data collection of the study. We are also grateful to all the parents who participated in this study.
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Cited by (0)
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Study design: JPZ, closely supervised by SQY; Data collection: JPZ, with supervision by SQY; Data analysis: JPZ, SQY, MY and HSH; and manuscript preparation: JPZ, SQY, MY HSH, GPH, and XHL.