Perceived health in the Portuguese population aged ≥ 35

João Paulo de Figueiredo Salvador Massano Cardoso About the authors

Abstracts

OBJECTIVE

To evaluate the exploratory relationship between determinants of health, life satisfaction, locus of control, attitudes and behaviors and health related quality of life in an adult population.

METHODS

Observational study (analytical and cross-sectional) with a quantitative methodological basis. The sample was composed oy 1,214 inhabitants aged ≥ 35 in 31 civil parishes in the County of Coimbra, Portugal, 2011-2012. An anonymous and voluntary health survey was conducted, which collected the following information: demographic, clinical record, health and lifestyle behaviors; health related quality of life (Medical Outcomes Study, Short Form-36); health locus of control; survey of health attitudes and behavior, and quality of life index. Pearson’s Linear Correlation, t-Student, Wilcoxon-Mann-Whitney; One-way ANOVA; Brown-Forsythe’s F; Kruskal-Wallis; Multiple Comparisons: Tukey (HSD), Games-Howell and Conover were used in the statistical analysis.

RESULTS

Health related quality of life was shown to be lower in females, in older age groups, in obese/overweight individuals, widows, unassisted, those living alone, living in rural/suburban areas, those who did not work and with a medium-low socioeconomic level. Respondents with poor/very poor self-perceived health (p < 0.0001), with chronic disease (p < 0.0001), who consumed < 3 meals per day (p ≤ 0.01), who were sedentary, who slept ≤ 6 h/day and had smoked for several years revealed the worst health results. Health related quality of life was positively related with a bigger internal locus, with better health attitudes and behaviors (physical exercise, health and nutritional care, length of dependence) and with different areas of life satisfaction.

CONCLUSIONS

Better health related quality of life was associated with certain social, psychological, family and health characteristics, a satisfactory lifestyle, better socioeconomic conditions and a good internal locus of control over health attitudes and behaviors.

Health Status; Diagnostic Self Evaluation; Lifestyle; Health Behavior; Quality of Life Health Knowledge, Attitudes, Practice; Cross-Sectional Studies


INTRODUCTION

Society today is undergoing constant transformation (economic, political and social) and every day individuals are exposed to determinants that can influence their well-being, health and quality of life. It’s necessary to invest in health promotion in order to reduce the effects of certain factors responsible for morbidity and mortality.1111  Hespanhol AP, Couto L, Martins C. A medicina preventiva. Rev Port Clin Geral. 2008;24(1):49-64.,1515  Marteau TM, Hollands GJ, Fletcher PC. Changing human behavior to prevent disease: the importance of targeting automatic processes. Science. 2012;337(6101):1492-5. DOI:10.1126/science.1226918
https://doi.org/10.1126/science.1226918...
Health and disease determinants are developments or events that produce health alterations in a specific clinical situation. In the life cycle of populations, there has always been a constant seeking after health and well-being, to the detriment of disease. However, there are intrinsic (biological personal, immunological and genetic) factors which determine the individual’s susceptibility to contracting disease, and extrinsic factors (environmental, behavioral, physical and social habits, among others) that compete to expose the individual to it.1111  Hespanhol AP, Couto L, Martins C. A medicina preventiva. Rev Port Clin Geral. 2008;24(1):49-64.

Health related quality of life (HRQL) is a generic indicator of the state of health, integrating physical, psychological and social components. It enables the state of health to be characterized and predicted, relating it to different indicators.6 Ferreira PL, Santana P. Percepção de estado de saúde e de qualidade de vida da população activa: contributo para a definição de normas portuguesas. Rev Port Saude Publica. 2003;21(2):15-30. Evaluating HRQL goes beyond an objective medical clinical evaluation. It emphasizes the individual’s subjective perception of their own health. It is becoming increasingly common to evaluate individuals’ health behavior and control (locus of control)2121  Ribeiro JLP. Avaliação das intenções comportamentais relacionadas com a promoção e protecção da saúde e com a prevenção das doenças. Ana Psicol. 2004;22(2):387-97. whether to avoid disease or to promote day-to-day health.1212  Greene CA, Murdock KK. Multidimensional control beliefs, socioeconomic status, and health. Am J Healt Behav. 2013;37(2):227-37. DOI:10.5993/AJHB.37.2.10
https://doi.org/10.5993/AJHB.37.2.10...
The greater the individual’s level of personal control and capacity to decide about their own health (internal locus), the greater their satisfaction with HRQL. This condition will be inversely proportional to health related developments depending on “luck” or “powerful others” (external locus).2525  Timm LA, Argimon IIL, Wend GW. Correlação entre domínios de qualidade de vida e lócus de controle da saúde em idosos residentes na comunidade. Sci Med. 2011;21(1):9-13. Quality of life as an indicator of satisfaction with life seeks to understand how certain areas of life, valued by the individual, can influence the conditions of their health.3 Ferrans CE, Powers MJ. Psychometric assessment of the Quality of Life Index. Res Nurs Health. 1992;15(1):29-38.

The aim of this study was to analyze the relationship between health determinants, satisfaction with life, the locus of control and health related attitudes and behavior in an adult population.

METHODS

This was an observational study, of a cross-sectional analytical nature, with a population aged ≥ 35 in the County of Coimbra, totaling 143,396 residents in 31 parishes.a a Instituto Nacional de Estatística (Editors). Censos 2011 Resultados Definitivos – Região Centro. Instituto Nacional de Estatística. Lisboa, 2012. The selection strategy was incomplete (sample) and the observation unit was the individuals. The test for stratified samples1616  Martins GA. Estatística geral e aplicada. São Paulo: Atlas; 2006. was used, controlling the population parameter of “perceived state of health” (), total number of residents of the County (N),a a Instituto Nacional de Estatística (Editors). Censos 2011 Resultados Definitivos – Região Centro. Instituto Nacional de Estatística. Lisboa, 2012. total number of residents per stratum (parish) (wi)a a Instituto Nacional de Estatística (Editors). Censos 2011 Resultados Definitivos – Região Centro. Instituto Nacional de Estatística. Lisboa, 2012. with random error of (d2/Z2 = 0.05) and a 95% level of confidence. The final sample was 1,214 interviewees.

The study was based on collecting data using a health survey (self-reporting, anonymous and voluntary). The survey used was adapted from the IV Inquérito Nacional de Saúdeb b Instituto Nacional de Estatística; Instituto Nacional de Saúde Dr. Ricardo Jorge. Inquérito Nacional de Saúde 2005/2006. Lisboa; 2009. (IV National Health Survey), the result of various pre-tests with the population. The responses to the respective pre-tests led to some questions, words and terms being reformulated, the format being altered, redundant content eliminated and the topics being reorganized. A team of interviewers was trained to administer the questionnaire to the population. The survey included health indicators (demographic data, clinical inventory, health and lifestyle behavior) and indices seeking to capture, measure and qualify the state of health.

Perceived state of health on the MOS SF-36 Medical Outcomes Study, Short Form-36, Health Survey4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66.,5 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte II - Testes de validação. Acta Med Port. 2000;13(3):119-27.,a a Instituto Nacional de Estatística (Editors). Censos 2011 Resultados Definitivos – Região Centro. Instituto Nacional de Estatística. Lisboa, 2012. is described in eight health dimensions: Physical health measures (PHM), which include: physical functioning, physical performance and pain, which measure the limitations in performing activities of daily living, incapacity to execute everyday tasks due to physical problems and evaluate the severity of pain and resulting limitations;4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66. Mental health measures (MHM) including: social functioning, emotional performance and mental health. Social functioning and emotional performance evaluated perceived limitations/disabilities attributable to personal and emotional problems; mental health included anxiety, depression, loss of emotional/behavioral control and psychological well-being;4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66. Sensitive measures and physical and mental results included: individual’s vitality associated to energy levels and fatigue and general health with regards a holistic perception of health associated with current situation, resistance to disease and healthy aspect. Regarding the score (for each dimension): the “0” minimum value (worst perception) and the “100” maximum value (best perception of health).

The health locus of control was constructed, adapted and validated for Portuguese.2020  Ribeiro JLP. Reconstrução de uma Escala de Locus-de-Controlo de Saúde. Psiquiat Clin. 1994;15(4):207-14. The scale was structured of 14 items, resulting in two dimensions: locus of control and powerful others. The highest score in the locus control dimension corresponded to the premise that health largely depends on our own control. The highest score for powerful others indicated that health is controlled by doctors and other health care professionals.2020  Ribeiro JLP. Reconstrução de uma Escala de Locus-de-Controlo de Saúde. Psiquiat Clin. 1994;15(4):207-14. To confirm the author’s decisions regarding validation, factorial analysis was used to analyze the principal components. This solution produced two components (dimensions) estimated using the Orthogonal Varimax Rotation: the first dimension explained 24.3% of the total variance; the second explained 17.2% of total variance (41.5% of common variance). Of the 14 items, eight belonged to the first dimension (locus of control) and six to the second (powerful others). In the evaluation of internal consistency, the Cronbach’s alpha statistics were 0.763 for the first dimension and 0.697 for the second.

The Health Attitudes and Behavior Questionnaire (HABQ), adapted and validated for Portuguese (list of classification containing 28 items), summarizes behavior related to health and disease.2121  Ribeiro JLP. Avaliação das intenções comportamentais relacionadas com a promoção e protecção da saúde e com a prevenção das doenças. Ana Psicol. 2004;22(2):387-97. Final classification varies between 28 and 140 points and the higher the score the greater the health protective behavior. The inventory in made up of five categories: physical exercise (pe); 2) nutrition (n); 3) self-care (sc); 4) motor safety; 5) drug or substance use.2121  Ribeiro JLP. Avaliação das intenções comportamentais relacionadas com a promoção e protecção da saúde e com a prevenção das doenças. Ana Psicol. 2004;22(2):387-97. This is not a scale but rather an inventory and does not assume a close relationship between the items. However, Pais Ribeiro2020  Ribeiro JLP. Reconstrução de uma Escala de Locus-de-Controlo de Saúde. Psiquiat Clin. 1994;15(4):207-14. suggested estimating internal consistency. In the physical exercise category (three items with Cronbach’s Alpha of 0.683); nutrition (five items with Cronbach’s Alpha of 0.784); AC (11 items with Cronbach’s Alpha of 0.643); motor safety (three items with Cronbach’s Alpha of 0.447); drug or substance use (six items with Cronbach’s Alpha of 0.512). The Cronbach’s Alpha values estimated in the study were slightly higher than those obtained by Pais Ribeiro.2121  Ribeiro JLP. Avaliação das intenções comportamentais relacionadas com a promoção e protecção da saúde e com a prevenção das doenças. Ana Psicol. 2004;22(2):387-97.

The quality of life index, geriatric version (III), is formed of 33 items (common to all validated versions and adapted for Portuguese) forming four domains: health and functionality; psychological and spiritual; and social, economic and family.1414  Kimura M, Silva JV. Índice de qualidade de vida de Ferrans e Powers. Rev Esc Enferm USP. 2009;43(N. Espec):1096-102. DOI:10.1590/S0080-62342009000500014
https://doi.org/10.1590/S0080-6234200900...
Factorial analysis was used to analyze the principal components using the Orthogonal Varimax Rotation to validate the four dimensions. The first dimension explained 24.3% of total variance; the second 8.0%, the third 4.7% and the fourth 4.2% (58.3% of common variance). Regarding internal consistency: health and functionality (13 items with Cronbach’s Alpha of 0.901); spiritual and psychological (seven items with Cronbach’s Alpha of 0.894); social and economic (eight items with Cronbach’s Alpha of 0.832); family (five items with Cronbach’s Alpha of 0.835). Items with higher values had a greater impact on the result (satisfaction with different areas of life) than those with lower values.3 Ferrans CE, Powers MJ. Psychometric assessment of the Quality of Life Index. Res Nurs Health. 1992;15(1):29-38.,1414  Kimura M, Silva JV. Índice de qualidade de vida de Ferrans e Powers. Rev Esc Enferm USP. 2009;43(N. Espec):1096-102. DOI:10.1590/S0080-62342009000500014
https://doi.org/10.1590/S0080-6234200900...
The instruments were chosen for their precision, conciseness and ease of use and evaluation.2424  Tabachnick B, Fidell L. Using multivariate statistics. 5.ed. Boston: Pearson International Edition; 2007.

Anthropometric data such as height (m) (according to the identity document); weight (kg) (according to the subject’s perception, referring to the most recent time they weighed themselves and maintaining the same physical condition; body mass index (BMI)c c World Health Organization. Global Database on Body Mass Index: an interactive surveillance tool for monitoring nutrition transition. Geneva; 2006 [cited 2013 May]. Available from: http://apps.who.int/bmi/index.jsp?introPage=intro_3.htm (underweight: < 18.50 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
, normal weight: 18.50 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
to 24.99 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
, overweight: 25.00 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
to 29.99 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
, obese: ≥ 30.00 kg/m2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
); waist and neck circumference measured using a tape measure. For men, risk of obesity according to waist circumference was ≤ 102 cm, normal risk and > 102 cm high risk, and for women ≤ 88 cm was normal risk and > 88 cm high risk.1313  Janssen I, Katzmarzyk P, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med. 2002;162(18):2074-9. DOI:10.1001/archinte.162.18.2074
https://doi.org/10.1001/archinte.162.18....
Chronic disease identifiedb b Instituto Nacional de Estatística; Instituto Nacional de Saúde Dr. Ricardo Jorge. Inquérito Nacional de Saúde 2005/2006. Lisboa; 2009. were re-grouped according the 10th revision of the International Classification of Disease (ICD).

Re-codified variables were: parishes classified as predominantly rural areas; predominantly urban areas and moderately urban areas.d d Portugal. Secção Permanente de Coordenação Estatística. 8ª Deliberação 2717/2009, de 6 de Agosto de 2009. Revisão da tipologia de áreas urbanas. Diario da Republica, 2ª Serie, n. 188, 28 set 2009; p.39246. Profession was defined according to the Portuguese Classification of Professione e Instituto Nacional de Estatística. Classificação Portuguesa das Profissões 2010. Lisboa; 2011. and social class (adapted Graffer Scale) was defined as class I (high), class II (upper middle), class III (middle), class IV (lower middle) and class V (low).

The following tests were used: the Student-t test for independent samples; the Wilcoxon-Mann-Whitney Test; the ANOVA test for one factor; the Brown-Forsythe F Test; the Tukey Multiple Comparisons Test; the Kruskal-Wallis Test; the Conover Multiple Comparisons Test and Pearson’s Coefficient of Linear Correlation. When r < 0.2, correlation was very low; [0.2 − 0.39] low correlation; [0.4 − 0.69] moderate correlation; [0.70 − 0.89] high correlation; [0.9 − 1.0] very high correlation.2424  Tabachnick B, Fidell L. Using multivariate statistics. 5.ed. Boston: Pearson International Edition; 2007. The statistical interpretation was conducted based on a level of significance of p ≤ 0.05 with a 95% confidence interval.

IBM SPSS Statistics and MedCalc Statistical Software was used.

The study was approved by the Ethics Commission of the Faculdade de Medicina da Universidade de Coimbra (Record 04-CE-09, 2009). Participants signed an informed consent form.

RESULTS

The majority of inhabitants in the study were female and lived in parishes classified as predominantly urban; 40.3% were aged 35-45 and 31.5% 45-55 years old; 25.0% had higher education and 23.2% secondary education. The majority of interviewees were Portuguese, Caucasian, married or in a stable relationship, cohabited, had religious beliefs but were not practicing, owned their own home and were middle class. With regards profession, 76.6% were working, of whom 87.5% had a permanent contract. The average length of retirement was 10 years (SD = 7.48 years) and unemployment of two years (SD = 3.39 years). Around 47.1% classified their health as “good” and 38.2% as “reasonable”; 78.1% considered it approximately the same as one year before. Mean height and weight were 1.65 m (SD = 0.08 m) and 71.65 kg (SD = 12.83 kg). Mean waist and neck circumference were 90.93 cm (SD = 15.50 cm) and 36.96 cm (SD = 5.51 cm), respectively.

The majority was overweight or obese and used the health center or hospital for health care; 61.2% reported that they had not been to a doctor in the preceding three months. The location of the most recent appointment was the health center (62.0%) or the GP (72.1%). The majority had consulted a health care professional or received health care in the preceding 12 months. The majority reported being in the habit of controlling arterial tension and cholesterol and 25.5% had had a flu vaccination.

Those who smoked, 20.8%, had been smoking for 25.6 years, on average (SD = 9.14 years) and ex-smokers for 20.0 (SD = 11.0 years); 43.4% said they had regularly or occasionally drunk alcohol for 31.5 years (SD = 11.97 years). The majority was sedentary, slept between seven and eight hours/day, had a Mediterranean diet, had between three and five meals a day, never changed their eating habits, drank less than one liter of water/day and worked a 35-40 hour week; 34.1% spent their working day “standing and walking, also walking up stairs and lifting objects”, 32.1% spend most of their time “sitting down”. The most representative group from the Portuguese Classification of Profession was “services” (19.9%), a group that includes salesmen and those who work in personal services, care and similar areas, those who work in protection/security an “unqualified” individuals (18.4%) encompassing those who worked as cleaners, agricultural workers, animal, forest and fishery workers, extraction industries, construction, industry and transport, among others. Of the 38.6% of individuals who reported having chronic disease, 70.9% had one or two (Table 1).

Table 1
Socio-biographical characterization, profile and health care of the population. County of Coimbra, Portugal, 2011-2012.

Behavioral performance was significantly lower in women and they also showed greater disability and expressed more discomfort in activities of daily living compared with males regarding PHM. A similar pattern was observed in the ≥ 65 and 55-65 years old age groups compared with younger individuals. The interviewees with lower educational achievement had worse results for physical health than those with more schooling. The health indices were better in those who were single and those who were married/ in a stable relationship than those who were widowed. There was a similar pattern for those who lived alone. Regarding MHM, females, those aged ≥ 55, those with low levels of educational attainment and individuals who were widowed or living alone had worse health indices, with the exception of present or absent fathers (p > 0.05). The well-being of females, those with low schooling, widows and those with a father present was significantly worse at a health level and they had less energy in the general health and vitality measure. Those living in areas which were predominantly urban, those living in apartments and who paid monthly had better HRQL than those who lived in predominantly rural and moderately urban areas, those who lived in houses and those who owned their own homes. Those with a religion had worse physical functioning (p = 0.016) and mental health (p = 0.037) compared with those who had no religion. Those who were practicing had worse HRQL compared with non-practicing individuals. Low levels of HRQL were found in those who were inactive, and a similar pattern was found in those whose employment was precarious regarding physical performance, pain and vitality, with the exception of physical functioning (p = 0.450) and general health (p = 0.421).The lower middle class has a greater health deficit in terms of physical function (p = 0.002) and general health (p < 0.0001). However, MHM and vitality did not differ according to social class (Table 2).

Table 2
Relationship between individual, religious, social and professional characteristics and the perception of health status (Short Form-36 Scale). County of Coimbra, Portugal, 2011-2012.

Those who perceived their own health as reasonable, poor/very poor had worse HRQL. Those who were overweight and obese had lower HRQL at the physical level, and there was a similar pattern regarding waist circumference (presence of risk). Obese individuals had similar mean values for social function (p = 0.100), but worse performance for emotional and mental health compared with the other BMI groups. Being obese or overweight showed worse general health and vitality indices and there was a similar pattern regarding waist circumference, with the exception of vitality (p = 0.082). Those who consumed three to five or more meals a day had better PHM, MHM and general health. Regular/occasional alcohol drinkers perceived their physical function to be better, with the exception of physical performance (p = 0.081) and pain (p = 0.139). Concerning mental health, consumers revealed better emotional (p = 0.024) and mental health (p = 0.008) compared with those who did not drink, with the exception of social function and vitality. Significantly poorer health conditions were observed in smokers and ex-smokers who had smoked for a long time. This pattern was not present in MHM. Individuals who were sedentary, who slept ≤ 6h or fewer had worse HRQL.

Those who had seen a doctor in the preceding three months (health care) had a significant physical and mental health deficit, although the type of appointment (General/Specialty) was not a differentiator. Those who had taken prescribed medication in the preceding two weeks had worse PHM and mental health (p = 0.032), with the exception of social function and emotional performance. Those who had taken non-prescription medicine did not differ with regards HRQL measures. The physical functioning, physical performance and pain of those who had had a doctor’s, dentist’s or other appointment did not differ from those who had not seen any of those professionals (p > 0.05). However, the former indicated better quality of life in terms of mental and general health and vitality. Those who reported having seen a health professional in the ≤ 12 months tended to have worse HRQL indices compared with those whose last consultation had been more than 12 months before. Worse HRQL was observed, in the majority of indices, in those who had had a mammogram or a flu vaccination and those who controlled high blood pressure and cholesterol (Table 3).

Table 3
Relationship between state of health and quality of life related to the population’s health perception and care. County of Coimbra, Portugal, 2011-2012.

The most prevalent chronic diseases were: arterial hypertension (15.5%), rheumatic diseases (11.2%), depression (8.8%), allergies and rhinitis (7.7%). HRQL indices were worse in the presence of a chronic disease and its frequency were evaluated (Table 4).

Table 4
Relation between “Health Status and Quality of Life” in relation with clinical features. County of Coimbra, Portugal, 2011-2012.

Those with worse physical health conditions had a proportionally worse state of mental health, a lower indices for general health and vitality and vice-versa when the inter-relationship between the different measures and HRQL was evaluated. Those who considered that their health depended on their personal health behavior (locus of control) had better indices of physical functioning, physical performance and general health, although not of MHM. However, those who believed that their health depended more on external entities (powerful others) had worse HRQL indices. As for the HABQ, those who sought a better physical condition (physical exercise) and took more care with their diet (nutrition) had higher indices of HRQL. A pattern of positive correlation was observed with the development of better preventative behavior (self-care) and avoided accidents/injuries (motor safety) in terms of measures of mental health. Lower dependence on chemical substances (e.g., drugs) correlated positively with mental health. As for the quality of life index, the more satisfied the individual was with life in general (general index), health and functionality, social relationships and economic conditions (social and economic), belief and psychological well-being (spiritual and psychological) and family support (family) the higher the indices were for HRQL (Table 5).

Table 5
Relationship between “state of health and quality of life” and indices of locus of control, health attitudes and health behavior questionnaire and rate of quality of life of the inhabitants. County of Coimbra, Portugal, 2011-2012.

DISCUSSION

The majority of the different indicators/indices monitored (personal, clinical, health behavior, life styles and satisfaction with life) were shown to have significant impact on the HRQL of our inhabitants.

The personal characteristic with the greatest impact on HRQL was the biological factor, gender. Thus, as in the literature, women tend to be the group with the highest rates of morbility and worse HRQL in both physical and mental terms.7 Ferreira PL, Ferreira LN. A medição de preferências em saúde na população portuguesa. Rev Port Saude Publica. 2006;24(2):5-14.,1717  Mausner JS, Kramer S. Introdução à epidemiologia. 4.ed. Lisboa: Fundação Calouste Gulbenkian; 2007. They also make more use of health care.4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66.,7 Ferreira PL, Ferreira LN. A medição de preferências em saúde na população portuguesa. Rev Port Saude Publica. 2006;24(2):5-14. Age was shown to be an important marker in understanding a population’s HRQL.4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66. HRQL deteriorates as age increases, as seen in the literature.4 Ferreira PL. Criação da versão Portuguesa do MOS SF-36. Parte I - Adaptação cultural e linguística. Acta Med Port. 2000;13(1-2):55-66.,7 Ferreira PL, Ferreira LN. A medição de preferências em saúde na população portuguesa. Rev Port Saude Publica. 2006;24(2):5-14.,2525  Timm LA, Argimon IIL, Wend GW. Correlação entre domínios de qualidade de vida e lócus de controle da saúde em idosos residentes na comunidade. Sci Med. 2011;21(1):9-13.

In the inhabitants studied, the perception of HRQL was also negatively influenced by the conjugal situation and area of residence,7 Ferreira PL, Ferreira LN. A medição de preferências em saúde na população portuguesa. Rev Port Saude Publica. 2006;24(2):5-14. by characteristics of the residence and type of ownership, as well as the socioeconomic conditions and work status.2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
,8 Fleck MPA, Lima AFBS, Louzada S, Schestasky G, Henriques A, Borges V, et al. Associação entre sintomas depressivos e funcionamento social em cuidados primários à saúde. Rev Saude Publica. 2002;36(4):431-8. DOI:10.1590/S0034-89102002000400008
https://doi.org/10.1590/S0034-8910200200...
,2525  Timm LA, Argimon IIL, Wend GW. Correlação entre domínios de qualidade de vida e lócus de controle da saúde em idosos residentes na comunidade. Sci Med. 2011;21(1):9-13.,b b Instituto Nacional de Estatística; Instituto Nacional de Saúde Dr. Ricardo Jorge. Inquérito Nacional de Saúde 2005/2006. Lisboa; 2009.

Extrinsic determinants gained more importance and weight in characterizing and understanding the health profile of a population. HRQL deteriorates in individuals who are outside of the “norm” (overweight/obese, sedentary, with a poor diet, smokers, type of alcohol intake, fewer hours of sleep, among others).2 Burkert NT, Freidl W, Muckenhuber J, Stronegger WJ, Rasky E. Self-perceived health, quality of life, and health-related behavior in obesity: is social status a mediator? Wien Klin Wochenschr. 2012;124(7-8):271-5. DOI:10.1007/s00508-012-0160-y
https://doi.org/10.1007/s00508-012-0160-...
,1818  Mota J, Ribeiro JL, Carvalho J, Matos MG. Atividade física e qualidade de vida associada à saúde em idosos participantes e não participantes em programas regulares de atividade física. Rev Bras Educ Fis Esp. 2006;20(3):219-25.,1919  Nies MA, Kershaw TC. Psychosocial and environmental influences on physical activity and health outcomes in sedentary women. J Nurs Scholarsh. 2002;34(3):243-9. DOI:10.1111/j.1547-5069.2002.00243.x
https://doi.org/10.1111/j.1547-5069.2002...
,2323  Santos R, Pereira J. O peso da obesidade: avaliação da qualidade de vida relacionada com a saúde em utentes de farmácias. Rev Port Saude Publica. 2008;26(1):25-37.

Those with worse HRQL believe that it does not depend solely upon themselves (locus of control), as has been shown in other studies,9 Fuscaldi FS, Balsanelli ACS, Grossi SAA. Lócus de controle em saúde e autoestima em portadores de diabetes mellitus tipo 2. Rev Esc Enferm. USP. 2011;45(4):855-61. DOI:10.1590/S0080-62342011000400009
https://doi.org/10.1590/S0080-6234201100...
,1212  Greene CA, Murdock KK. Multidimensional control beliefs, socioeconomic status, and health. Am J Healt Behav. 2013;37(2):227-37. DOI:10.5993/AJHB.37.2.10
https://doi.org/10.5993/AJHB.37.2.10...
,2525  Timm LA, Argimon IIL, Wend GW. Correlação entre domínios de qualidade de vida e lócus de controle da saúde em idosos residentes na comunidade. Sci Med. 2011;21(1):9-13. and therefore seek health care more frequently.8 Fleck MPA, Lima AFBS, Louzada S, Schestasky G, Henriques A, Borges V, et al. Associação entre sintomas depressivos e funcionamento social em cuidados primários à saúde. Rev Saude Publica. 2002;36(4):431-8. DOI:10.1590/S0034-89102002000400008
https://doi.org/10.1590/S0034-8910200200...
,1010  Henshaw EJ, Freedman-Doan CR. Conceptualizing mental health care utilization using the health belief model. Clin Psychol (New York). 2009;16(4):420-39. DOI:10.1111/j.1468-2850.2009.01181.x
https://doi.org/10.1111/j.1468-2850.2009...
Suffering from chronic disease and its frequency suggest a negative impact on HRQL.1 Aranha LLM, Mirón Canelo JA, Alonso Sardón M, Del Pino Montes J, Sáenz González MC. Qualidade de vida relacionada à saúde em espanholas com osteoporose. Rev Saude Publica. 2006;40(2):298-303. DOI:10.1590/S0034-89102006000200016
https://doi.org/10.1590/S0034-8910200600...
,2222  Santos ECM, França Junior I, Lopes F. Qualidade de vida de pessoas vivendo com HIV/Aids em São Paulo. Rev Saude Publica. 2007;41(Supl. 2):64-71. DOI:10.1590/S0034-89102007000900011
https://doi.org/10.1590/S0034-8910200700...

Individuals who have worse results for physical health also tend to have worse results for mental health.8 Fleck MPA, Lima AFBS, Louzada S, Schestasky G, Henriques A, Borges V, et al. Associação entre sintomas depressivos e funcionamento social em cuidados primários à saúde. Rev Saude Publica. 2002;36(4):431-8. DOI:10.1590/S0034-89102002000400008
https://doi.org/10.1590/S0034-8910200200...
However, the presence of better habits and health related behaviors and more satisfaction with the various areas of life promoted better HRQL indices in our population.

The limitations of the study concerned weight, height and presence of chronic disease, time spent doing exercise/day, identifying and quantifying food intake, as these were self-reported. The investigation was limited to generalizing the results based on cross-sectional data.

These indicators call for pertinent “reflections” on public health policies and the performance of different health care professionals to promote/develop new strategies and decision making instruments and actions to alter the impact of risk factors on the population’s health. A step has been taken towards creating a new study in the definition/prediction of health profiled in the adult population in the present and how these profiles may be grounded in determinants for the future (adolescence).

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  • Article based on the doctoral thesis of Figueiredo JP, entitled: “Comportamentos de Saúde, Costumes e Estilos de Vida – Indicadores de Risco Epidemiológicos na Avaliação de Estados de Saúde e Doença”, to be presented to the Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal.

Publication Dates

  • Publication in this collection
    June 2014

History

  • Received
    14 Nov 2013
  • Accepted
    26 Feb 2014
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br