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Social support and quality of life in patients with HIV infection
Apoyo social y calidad de vida en la infección por el VIH
E. Remora
a Department of Biological and Health Psychology, School of Psychology, Autonomous University of Madrid, Spain.
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    "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><hr></hr><p class="elsevierStylePara">Since the 1970s the phenomenon of social support is a topic that has attracted much attention from health science researchers&#46;<span class="elsevierStyleSup">1</span> Such interest arose empirically from data suggesting that social support might be useful for maintaining good health and improving the health of sick persons&#46; Specifically&#44; it was postulated that social support might be an important variable in the prevention of psychopathologies<span class="elsevierStyleSup">2&#44;3</span> and diseases in general&#44; through the so-called buffering hypothesis&#46;<span class="elsevierStyleSup">4&#44;5</span> In other words&#44; it has been argued that persons who enjoy social support are better at coping with stressful life conditions than are persons who do not have the benefit of such support&#46;</p><p class="elsevierStylePara">The relationship between social support&#44; depression&#44; coping and health appears to be especially important for persons who live with HIV&#46; For example&#44; a study by Zich &#38; Temoshok<span class="elsevierStyleSup">6</span> of 103 gay and bisexual men with AIDS or AIDS-related complex found evidence that HIV-positive persons with low social support had more physical symptoms&#44; more hopelessness and more depression than persons with high levels of social support&#46; Another study found that the lower availability of perceived social support was associated&#44; in HIV-positive men&#44; with the greater use of avoidance coping strategies and greater mood disorder&#44; including higher levels of self-reported depression and anxiety and lower levels of vigor&#46;<span class="elsevierStyleSup">7</span> Similarly&#44; another study of a sample of 50 men with AIDS reported that social support was related with physical and mental health&#46; Specifically&#44; instrumental or tangible help was the only variable that was significantly predictive of physical health scores and was significantly associated with mood disorders&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">Kaplan&#44; Patterson&#44; Kerner and Grant<span class="elsevierStyleSup">9</span> approached the relationship differently and tried to disentangle cause and effect&#46; These authors proposed an alternative explanation according to which low social support is a consequence&#44; rather than a cause&#44; of poor health status&#46; Their longitudinal study of a sample of 397 HIV-positive homosexual and heterosexual men found that the size of the subject&#180;s social network decreased as the disease worsened&#46; Moreover&#44; their data indicated that advancing disease preceded&#44; rather than followed&#44; a decline in social support&#44; and that in fact&#44; instrumental social support improved as the infection progressed&#46; In other words&#44; as the disease progressed&#44; HIV-positive men may have fewer people in their social network&#44; but can rely more on those who remain in the network than on those who drop out&#46; In the light of these results it was suggested that the relationship between social support and health or illness ought not to be conceptualized and studied as a predictor of health outcomes&#44; as changes in social support can also be a consequence &#40;rather than a cause&#41; of the disease&#46; Moreover&#44; the influence can be reciprocal&#44; that is&#44; bidirectional&#46; A cross-sectional study by Remor<span class="elsevierStyleSup">10</span> reported similar results&#58; the perception of support from the patient&#180;s partner and family increased as the disease progressed in terms of Centers for Disease Control criteria&#46;</p><p class="elsevierStylePara">The present study sets out to answer the following questions&#58; <span class="elsevierStyleItalic">a&#41;</span> is health-related quality of life &#40;HRQL&#41; worse in subjects with low social support than in those with normal social support&#63;&#44; and <span class="elsevierStyleItalic">b&#41;</span> what is the relative weight of social support in predicting quality of live in HIV-positive persons&#63;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Material and methods </p><hr></hr><p class="elsevierStylePara"><img src="27v30n03-13035263tab01.gif"></img></p><p class="elsevierStylePara">The study involved 100 persons of both sexes at different stages of HIV infection&#44; who were followed at the Internal Medicine Service and HIV Unit of the La Paz University Hospital in Madrid&#46; The criteria for inclusion in the sample were age older than 18 years and HIV-positivity&#46; The criteria for exclusion were drug use in the preceding 6 months and refusal to provide informed consent to participate&#46;</p><p class="elsevierStylePara">Measures and instruments</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Sociodemographic and clinical data</span>&#46; The participants provided information&#44; via a self-administered questionnaire&#44; on age&#44; sex&#44; sexual orientation&#44; socioeconomic level&#44; employment status&#44; educational level&#44; persons in the household and mode of transmission of HIV&#46; Information about clinical and immunological profile&#44; including Centers for Disease Control&#40;CDC&#41; classification&#44; viral load&#44; CD4 T lymphocyte count and months of HIV infection&#44; was obtained from the medical record&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Social support</span>&#46; Social support was evaluated with Duke-UNC-11 Functional Social Support Questionnaire<span class="elsevierStyleSup">11</span> validated for the general population<span class="elsevierStyleSup">12&#44;13</span> and the HIV-positive population<span class="elsevierStyleSup">14</span> in Spain&#46; The responses on this 11-item questionnaire are chosen from a 5-point Lickert scale where 1 represents &#171;as much a I would like&#187; and 5 represents &#171;much less than I would like&#187;&#46; The instrument consists of two subscales for <span class="elsevierStyleItalic">confidant</span> &#40;having persons to talk to&#41; and <span class="elsevierStyleItalic">affective</span> support &#40;manifestations of love&#44; affection and empathy&#41;&#46; The higher the total score&#44; the higher the level of social support&#46; Internal consistency of the scale &#40;Cronbach&#180;s alpha&#41; and two subscales &#40;confidant and affective support&#41; for the sample was 0&#46;91&#44; 0&#46;86 and 0&#46;87&#44; respectively&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Health-related quality of life &#40;HRQL&#41;</span>&#46; Health-related quality of life was evaluated with the a 30-item short form of the Medical Outcomes Study &#40;MOS&#41; Health Survey<span class="elsevierStyleSup">15</span> validated for HIV-positive population in Spain&#46;<span class="elsevierStyleSup">10&#44;16</span> This instrument is divided into 11 subscales that measure general perception of health&#44; bodily pain&#44; physical functioning&#44; social functioning&#44; mental health&#44; energy or fatigue&#44; limitations in physical activities because of health problems&#44; health distress&#44; cognitive functioning&#44; perceived quality of life and perceived change in health&#46; Each subscale was scored directly&#44; with higher scores on each subscale indicating better quality of life&#46; The total HRQL score&#44; obtained as the sum of the scores on each subscale&#44; ranged from a minimum of 0 &#40;worst possible quality of life&#41; to a maximum of 100 &#40;best possible quality life&#41;&#46;</p><p class="elsevierStylePara">Procedure</p><p class="elsevierStylePara">The study was done during the period from February to April 1999&#46; Four consecutive patients per day were chosen on the basis of the inclusion and exclusion criteria specified earlier&#46; This was repeated until the sample consisted of 100 participants&#46; Both questionnaires were administered by a psychologist at the end of the patient&#180;s regular visit with the physician&#46; The aims of the study were explained briefly to each patient&#44; and participation was voluntary&#46; Volunteers signed an informed consent declaration in which they agreed to the conditions of the study&#46; Only three of the patients we interviewed declined to participate&#46; Those who agreed to take part completed the questionnaires immediately thereafter&#44; in the presence of the interviewer&#46;</p><p class="elsevierStylePara">Analyses</p><p class="elsevierStylePara">An initial descriptive analysis of the sample was based on frequency analysis and calculation of mean and percent values for the variables considered in the study&#46; To evaluate the reliability of the Duke-UNC-11 scale for our sample we checked internal consistency &#40;Cronbach&#180;s alpha&#41; for each subscale and for all items globally&#46; To verify the differences in social support and HRQL associated with sociodemographic variables &#40;regrouped as dichotomous variables&#41;&#44; we used Student&#180;s <span class="elsevierStyleItalic">t</span> test &#40;n&#62;30&#41; and Mann-Whitney&#180;s U test &#40;n&#60;30&#41;&#46; To identify the differences in level of social support &#40;i&#46;e&#46;&#44; low or normal&#41; associated with HRQL dimensions as the dependent variable&#44; we used the nonparametric Mann-Whitney U test&#59; this approach was used because of the dissimilar size of the groups and the ordinal nature of the variables&#46; The cutoff point was chosen on the basis of criteria established in the course of validation of the instrument for the Spanish population&#46;<span class="elsevierStyleSup">13</span> Simple linear regression analysis was used to study the ability of social support to predict HRQL&#46; All analyses were done with the Statistical Package for Social Sciences &#40;SPSS&#44; v&#46; 9&#46;0 for Windows&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Results  </p><hr></hr><p class="elsevierStylePara">The sociodemographic data are summarized in Table 1&#46;</p><p class="elsevierStylePara"><img src="27v30n03-13035263tab02.gif"></img></p><p class="elsevierStylePara">Mean score on the Duke-UNC-11 was 40&#46;89 &#40;SD 10&#46;20&#44; range 16-55&#41;&#44; and the median score was 42&#46; On the confidant support subscale&#44; mean score was 25&#46;47 &#40;SD&#44; 6&#46;70&#59; range&#44; 10-35&#41;&#44; and the median score was 26&#46; On the affective support subscale&#44; mean score was 15&#46;42 &#40;SD&#44; 4&#46;12&#59; range&#44; 4-20&#41;&#44; and the median score was 16&#46; No significant differences were found for social support associated with the socioeconomic variables sex&#44; age&#44; persons in the household&#44; occupation and socioeconomic level&#59; however&#44; the level of social support differed between patients with no formal education or primary level education &#40;mean score 38&#46;40&#41; and those with secondary level education &#40;mean score&#44; 43&#46;58&#59; t&#61;2&#46;608&#59; df&#61;98&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;01&#41;&#46;</p><p class="elsevierStylePara">Mean score for HRQL was 66&#46;39 &#40;SD&#44; 13&#46;58&#59; range&#44; 30-99&#41;&#44; with a median of 69&#46; We found no significant differences in HRQL associated with the sociodemographic variables age&#44; sex&#44; persons in the household&#44; educational level or socioeconomic level&#59; however&#44; HRQL was significantly higher in employed &#40;mean&#44; 71&#46;63&#41; vs&#46; unemployed participants &#40;mean&#44; 63&#46;93&#59; t&#61;2&#46;730&#59; df&#61;98&#59; <span class="elsevierStyleItalic"> P</span>&#61;&#46;008&#41;&#46;</p><p class="elsevierStylePara">To determine the differences in social support &#40;low&#44; normal or high&#41; on the basis of HRQL as the dependent variable&#44; Mann-Whitney&#180;s nonparametric U test was used &#40;Table 2&#41;&#46; To determine the relative weight of social support in predicting HRQL&#44; simple linear regression analysis yielded figures for the relation between these factors&#44; as shown schematically in Figure 1&#46;</p><p class="elsevierStylePara"><img src="27v30n03-13035263tab03.gif"></img></p><p class="elsevierStylePara"><img src="27v30n03-13035263tab04.gif"></img></p><p class="elsevierStylePara">Fig 1 Scheme of the relationship yielded by linear regression analysis with health-related quality of life as the criterion &#40;R<span class="elsevierStyleSup">2</span>&#61;0&#46;139&#41;&#46; HRQL&#61;health-related quality of life</p><p class="elsevierStylePara">Social support was a predictor of HRQL in HIV-positive subjects at different stages of HIV infection &#40;F&#61;15&#46;883&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#46; However&#44; although the relationship found with the regression model was statistically significant&#44; this result should be regarded with caution as the results indicated that the ability of the model to predict HRQL from a single variable was discreet&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Discussion  </p><hr></hr><p class="elsevierStylePara"><img src="27v30n03-13035263tab05.gif"></img></p><p class="elsevierStylePara">Mean score for social support in the HIV-positive participants of this study was 40&#46;89&#44; a figure higher than the mean score reported in the first validation study for the Spanish population &#40;35&#46;55&#41;<span class="elsevierStyleSup">12</span> and slightly lower than the mean score in the second Spanish validation study &#40;42&#46;73&#41;&#46;<span class="elsevierStyleSup">13</span> It should be noted that the latter two studies included HIV-negative subjects&#46; The median score in a study by Revilla et al&#46;<span class="elsevierStyleSup">14</span> of intravenous drug users &#40;IVDU&#41; who were HIV-positive was 33&#44; a figure much lower than the score of 42 we obtained for this subpopulation&#46; Because this study did not include information on other variables&#44;<span class="elsevierStyleSup">14</span> it was not possible to perform further comparisons&#46;</p><p class="elsevierStylePara">The differences between mean and median scores may have arisen from cultural&#44; socioeconomic or demographic differences between the populations in each study&#46; Taking as an example a common indicator such as age&#44; mean age of the participants in the present study was 37&#46;3 years&#44; whereas in the studies mentioned above<span class="elsevierStyleSup">12-14</span> mean age was 46&#44; 50&#46;6 and 29&#46;4 years&#46; With regard to HIV-positive populations we note that use of drugs during the 6 months prior to recruitment was an exclusion criterion&#44; whereas the 1994 study<span class="elsevierStyleSup">14</span> investigated active IVDU&#46; The results indicate the need for standardized psychometric variables for specific age groups&#44; educational levels and the presence or absence of disease&#46; In view of the present findings and the overall results of earlier studies&#44; the degree of social support can vary depending on the subject&#180;s age&#44; educational level or presence of certain diseases&#46; These analyses might be of key importance for future research with the Duke-UNC-11&#46;</p><p class="elsevierStylePara">The main aims of this study were&#58; <span class="elsevierStyleItalic">a&#41;</span> to determine how social support and HRQL are related&#44; and whether low social support implied worse quality of life&#44; and <span class="elsevierStyleItalic">b&#41;</span> to establish the relative weight of social support in predicting HRQL&#46; Therefore we first investigated whether subjects with low social support have a worse HRQL than subjects with normal social support&#46; Our findings show that the answer to this question is &#171;Yes&#187;&#46; Subjects with low social support &#40;defined as a score below the cutoff recommended by the most recent Spanish validation study<span class="elsevierStyleSup">13</span>&#41; had worse perceived health&#44; more pain&#44; worse physical functioning&#44; greater difficulties with daily activities&#44; more health-related distress&#44; worse cognitive functioning&#44; worse perceived quality of life&#44; worse physical and emotional health than in the preceding month&#44; and&#44; in overall terms&#44; worse HRQL than participants with a normal or high level of social support&#46;</p><p class="elsevierStylePara">Because an individual&#180;s HRQL can vary depending on his or her social support&#44; what relative weight does social support have for predicting the quality of life in persons who are HIV-positive&#63; The linear regression equation indicates that social support is able to predict 13&#37; of the variance in HRQL&#59; this indicates that persons who are more satisfied with their social support also enjoy a better HRQL&#46; Similar results were found in a study of hospitalized hemato-oncological patients&#58; social support&#44; together with the degree of comprehension of the information received and satisfaction with the health care team&#44; was a predictor of the patient&#180;s well-being&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">The results of the present study raise the question of how primary care can contribute to extend social support to persons with HIV infection&#44; and how it can improve their HRQL&#46; All such patients can potentially benefit from one key tool&#58; counseling &#40;nondirected assessment&#41;&#46; By using assertive communication and active listening&#44; we can help to better inform our interlocutors&#44; indicating and educating them in ways to seek potential social and community resources&#44; and helping them to extend their support network&#46; As we help them to express emotions and train them in communicating clearly and openly with the persons in their environment&#44; we can facilitate the development of their personal resources so that they can use their self-determination to work toward developing confidant and affective support in their relationships&#46; Lastly&#44; health professionals who are able to establish this type of helping relationship with their patients will help improve the amount and quality of social support these persons receive&#44; in addition to enhancing their quality of life&#46; These steps will ultimately help to improve the quality of health care&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Acknowledgments </p><hr></hr><p class="elsevierStylePara">The author thanks the staff of the HIV Unit of the Internal Medicine Service&#44; coordinated by Dr&#46; J&#46;M&#46; Pe&#241;a&#44; at the La Paz Hospital in Madrid&#44; for their help in providing access to the sample of patients this study is based on&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Correspondence&#58; Eduardo Remor&#46; Departamento de Psicolog&#237;a Biol&#243;gica y de la Salud&#46; Facultad de Psicolog&#237;a&#46; Universidad Aut&#243;noma de Madrid&#46; Ciudad Universitaria de Cantoblanco&#46; 28049 Madrid&#46; Espa&#241;a&#46; E-mail&#58; eduardo&#46;remor&#64;uam&#46;es</p>"
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        "resumen" => "Objectives&#46; To verify the relationship between social support and health related quality of life &#40;HRQoL&#41;&#44; specifically if a low level of social support implies in worse results in the HRQoL&#44; and to establish the relative weight of the social support in the prediction of the HRQoL in a sample of patient with HIV infection&#46; Design&#46; Cross sectional study&#44; descriptive and correlation study&#46; Setting&#46; Urban university hospital&#46; Participants&#46; 100 patients were evaluated draw from the HIV Unit of the university hospital&#44; by self-report questionnaires&#46; Measurements&#46; Social support questionnaire Duke-UNC-11&#44; HRQoL questionnaire MOS-SF30&#46; Results&#46; It has been detected significant differences in the QoL of people with HIV infection according to the level of social support that they presented&#59; in short&#44; those with a low level of social support had presented a worse perceived health&#44; more pain&#44; a worse physical functioning&#44; more difficulties in the daily activities&#44; higher health related distress&#44; worse cognitive functioning and they experienced worse physical and emotional health that in the previous month&#46; On the whole the HRQoL was worse in those subjects with a low level of social support&#46; In the same way&#44; the lineal regression equation&#44; show that the level of social support was predictor of the HRQoL&#46; Conclusions&#46; The social support is an important variable in the understanding of the well-being and QoL in people with HIV infection&#44; address efforts for the development of this personal resource contributes directly for improvement of the QoL&#46;"
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        "resumen" => "Objetivos&#46; Verificar&#44; por una parte&#44; la relaci&#243;n entre apoyo social y calidad de vida relacionada con la salud &#40;CVRS&#41;&#44; espec&#237;ficamente si un bajo apoyo social implica peores resultados en la CVRS&#44; y por otra&#44; establecer el peso relativo del apoyo social en la predicci&#243;n de la CVRS en una muestra de pacientes con infecci&#243;n por el virus de la inmunodeficiencia humana &#40;VIH&#41;&#46; Dise&#241;o&#46; Transversal&#44; descriptivo y correlacional&#46; Emplazamiento&#46; Hospital universitario urbano&#46; Participantes&#46; Se evalu&#243; a 100 pacientes adscritos a la unidad VIH de un hospital universitario mediante cuestionarios autoaplicados&#46; Mediciones principales&#46; Cuestionario de apoyo social Duke-UNC-11&#44; cuestionario de CVRS MOS-SF30&#46; Resultados&#46; Se han detectado diferencias significativas en la calidad de vida de las personas con infecci&#243;n por el VIH seg&#250;n el nivel de apoyo social que presentaban&#59; en concreto&#44; aquellos con un bajo apoyo social han presentado una peor salud percibida&#44; m&#225;s dolor&#44; un peor funcionamiento f&#237;sico&#44; una mayor dificultad en las actividades diarias&#44; mayor distr&#233;s relacionado con la salud&#44; peor funcionamiento cognitivo y experimentaban peor salud f&#237;sica y emocional que en el mes anterior&#46; En conjunto la CVRS fue peor en aquellos sujetos con un nivel de apoyo social bajo&#46; <br /> En el mismo sentido&#44; a trav&#233;s de la ecuaci&#243;n de regresi&#243;n lineal&#44; el nivel de apoyo social ha demostrado ser una variable predictora de la CVRS&#46; Conclusiones&#46; El apoyo social es una variable importante en la comprensi&#243;n del bienestar y calidad de vida de las personas con infecci&#243;n por el VIH&#46; Dirigir esfuerzos para la mejora de este recurso personal contribuye directamente a un aumento de la calidad de vida de estos pacientes&#46;"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos