Original ArticleHealth-related quality of life and its predictors among outpatients with coronary heart disease in Singapore
Introduction
Coronary heart disease (CHD) continues to be a leading cause of morbidity and mortality among adults worldwide (Gough, 2011). In Singapore, CHD is the second leading cause of death (Health Fact Singapore, 2013), though a steady decline in morbidity and mortality rates is attributed to improved treatment and preventive measures (Mak et al., 2003).
Over the past decade, health-related quality of life (HRQoL) has assumed increasing prominence as an important measure of health outcome (Cepeda-Valery, Cheong, Lee, & Yan, 2011). HRQoL is a multi-faceted concept that measures the impact of disease and treatment on the individual's physical, psychological and social well-being, such as changes in symptoms, physical functioning and social roles (Stafford, Berk, Reddy, & Jackson, 2007). Symptoms such as chest pain and breathlessness and lifelong treatment regimes are contributing factors to poor HRQoL (Celano et al., 2012). Furthermore, outpatients with CHD report higher stress levels due to uncertainty in disease progression, and are at higher risk of experiencing anxiety and depression, which translates to poorer HRQoL (Celano et al., 2012). Patients with poor HRQoL, in turn report worsening disease progression and poorer health outcomes (Škodová et al., 2011).
Studies also identify several predictors of HRQoL in outpatients with CHD, such as demographic, clinical and psychosocial factors (Barry et al., 2006, Celano et al., 2012, Škodová et al., 2011, Rumsfeld et al., 2001). Individuals with higher socioeconomic status, higher education level, who are married and enjoy high levels of social support report better HRQoL (Barry et al., 2006, Barbareschi et al., 2009, Boersma et al., 2005). On the other hand, females, individuals with a high number of cardiac co-morbidities and those experiencing increased severity of disease, anxiety and depression report poorer HRQoL (Stafford et al., 2012, Wang et al., 2012). Age is an inverse predictor with elderly individuals reporting better mental health whilst younger individuals report better physical health (Ford et al., 2008, Kimble et al., 2011, Lee et al., 2012). These predictors would assist healthcare professionals in identifying individuals at risk for poor HRQoL and introducing tailored interventions to mitigate the negative impact of diminished HRQoL (Xie et al., 2008).
Although much is known about HRQoL of CHD patients and its predictors, research findings were limited in terms of generalisability as studies predominantly investigated the western population. There is limited knowledge of how Asian CHD outpatients perceive what supports or undermines their HRQoL, the extent of anxiety and depression post CHD and the influence of social support on HRQoL. There may be varied impact on HRQoL amongst the different ethnic groups that warrants attention given the presence of ethnic differences in CHD in Asian countries such as Singapore; with Indian residents facing higher risk of acute myocardial infarction compared to Chinese and Malay residents (Wong et al., 2012). In addition, there are limited studies that clearly investigate the relationship of HRQoL, anxiety and depression, social support, sociodemographic and clinical factors to CHD. This study aims to understand the relationship between these factors, in an attempt to provide healthcare professionals with a holistic overview of the health status of outpatients with CHD. Such information would assist healthcare professionals to select appropriate interventions based on the patient's needs in this rapidly burgeoning population, to better manage CHD and reduce dependency on the healthcare system (Poh, 2009).
Section snippets
Study design and sample
A correlational study was conducted among a convenience sample of 106 outpatients with CHD recruited from a heart clinic in a public hospital in Singapore during October 2012 to January 2013. Patients were clinically diagnosed with CHD including non-ST segment elevation myocardial infarction (NSTEMI), ST segment elevation MI (STEMI) and stable or unstable angina, aged 21 years and above and able to communicate in English and/or Mandarin. Individuals with a known history of major psychiatric
Results
Of 132 patients invited to participate over a 4-month period of data collection, 106 (80.3%) completed the questionnaires.
The demographic and clinical characteristics of the sample are summarized in Table 1. Ages ranged from 37 to 90 (M = 57.73, SD = 11.13) years. Most of the patients were male (89.6%) and married (89.6%). Nearly half of them had attained secondary education (43.4%), and earned below S$1,500 per month. Nearly half were Chinese, a third Malay and a fifth Indian. Most (n = 98, 92.5%)
Discussion
The HRQoL of the sample in this study appears to be relatively high compared to those conducted in China and the United States (US) using the SF-36 and SF-12 to evaluate HRQoL of CHD patients (Lee et al., 2012, Norris et al., 2008, Wang et al., 2013). The higher scores in this study may be attributable to the inclusion of only outpatients with CHD, whereas other studies included CHD patients with heart failure (Wang et al., 2013); and cardiac arrhythmias (Norris et al., 2008). In addition,
Implications and Conclusion
The use of convenience sampling strategy from a single tertiary hospital limits the generalisability and interpretation of the findings, and caution must be exercised when extrapolating these results to CHD outpatients in other settings. A more proportionate recruitment may be beneficial in future studies to enhance generalisability of findings and to better discern any differences in HRQoL status between major ethnic groups in Singapore. Moreover, the use of self-report questionnaire may have
Acknowledgment
The authors acknowledge and extend their gratitude to the patients who participated in this study, the doctors and nurses who provided support and Associate Professor Chan Moon Fai for guidance with the statistical analysis.
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