1er Colloque de l’ITMO Santé Publique (Aviesan)Déterminants sociaux de la santé : les apports de la recherche en santé publique Paris, 26 octobre 2012Social determinants of health-related quality of lifeLes déterminants sociaux de la qualité de vie liée à la santé
Introduction
Perspective of patient is today favoured in health care. Considering patient's perspective as an essential component of the health care relationship is now an evidence and a source of rights, but this is the result of a long-lasting changing process of the medical framework [1], [2]. Patient's perspective implies to recognise the centrality of the person, who becomes a care element, and to divert the medical gaze [3] from the bodily symptoms towards the patient and her/his daily environment. The concept of health-related quality of life (HRQoL) encounters this concern, as it represents “a relocation of illness to the patient's social world” [1].
HRQoL is assimilated to a set of existing tools measuring health. In this concept, patient's perspective becomes part of medical practice, and the question is to know how to make it an element of cure and care. The last three decades have seen, in that sense, the development of tools aimed at measuring the perspective of the patient. These tools mainly respond to the necessity to improve health care systems and quality of care [4], as chronic illness has become the 21st century medical challenge. These tools are nowadays gathered as patient-reported outcomes (PRO) and they include all HRQoL indicators and tools.
More specifically, HRQoL measures the perspective of the person and his/her experience in life, particularly the consequences of his/her health condition, making HRQoL measures an original, important and topical issue. As it is assessed by patients themselves, the impact of disease on daily activities becomes part of the diagnosis and treatment; patient's perspective as caught by HRQoL tools is therefore a way, for medical professionals, to read otherwise the “manifestations of disease” [1].
This tools-orientated view of HRQoL is somewhat distanced from the definition of quality of life (QoL) given by the WHO [5], as “individuals” perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. Unlike the HRQoL tools described above, the WHO framework focuses more on measuring well-being, than on clinical measures which aim at helping medical decision and care. Within the WHO framework, HRQoL enters the health promotion field as an approach for measuring well-being but, more importantly, as a disposition for promoting health: “to enable everyone, individually and collectively, to benefit of a material and social environment, and lifestyle favorable to well-being and health” [6]. Quality of life means, in this perspective, living in good health as long as possible and becomes a goal in itself to be achieved through health promotion interventions.
From a clinical tool to a health promotion perspective, HRQoL aims at integrating in health care, the everyday living of patients in the case of medical care of persons, and populations in the case of health promotion. The part of the everyday life actually concerned is not a priori defined. Between clinical and health promotion perspectives, this part is alternatively more individual or more environmental, but constantly refers to the social aspects of health and illness.
One may assume that differences exist in patients reporting their health, which can be qualified as social differences. Education, professional status, gender are suspected to be influencing factors on health self-perception and reporting. Sociological literature, although not directly discussing HRQoL, has shown and still shows how health perceptions are indeed socially differentiated. Health inequalities are more than ever a public health priority and HRQoL undoubtedly contributes at producing data to estimate inequalities in coping with health and illness. Mechanisms leading to health inequalities may also be disentangled by studying HRQoL. So far however, HRQoL is rarely used in a health inequality perspective. Social aspects of HRQoL are somehow underexplored.
The objective of this paper is twofold. It firstly presents a secondary analysis of epidemiological HRQoL data issued from two national surveys, interrogating social determinants of HRQoL. Secondly, it discusses social aspects of HRQoL, in the light of the analysis and literature.
Section snippets
Measuring health-related quality of life
As well as measurement of pain and other subjective symptoms, measurement of HRQoL by an observer is not relevant. It is all about subjective health – that is to say the perception by the individual of her/his own health. This deserves a self-assessment or assessment by an interviewer of the individual. The measurement mainly uses self-report standardized multiple items questionnaires. They are multidimensional and reported in composite scores in the more frequent dimensions being physical,
Results
According to these two cross-sectional surveys, we observe some demographic effect, already observed in many surveys in the literature.
Discussion
The analysis of data showed the existence of social determinants of HRQoL and indicated that social environment – looked through social determinants’ lens – impacts on health and quality of life perception. This study has more specifically demonstrated that four social indicators are determinants of HRQoL namely living in couple, level of education, occupational status and net income per household, independently of age and gender known effect.
This secondary data analysis is the occasion to
Conclusion
Social determinants of quality of life highlight health inequalities in subjective health assessment and in social environment. Data based on two French national studies had shown that there is a place for monitoring quality of life in addressing health inequalities. Because health perception can be measured repeatedly over life span, health quality of life indicators may become an inequality indicator. Moreover, HRQoL indicators allows measuring effect of social intervention or effect of
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgments
INPES: Baromètre Santé 2005.
Insee: Enquête Décennale Santé 2002–03.
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