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2.0 Generic Instruments


2.1 Physical, Emotional
and Social Functioning

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            According to Post (2014), the evaluation of
health-related quality of life (HRQoL) usually incorporates four health dimensions:

Physical health,
which include sensation, sign and symptoms of the disease and adverse effect of
the treatment.

Mental health, which
includes the state of emotional and psychological well-being. It can be ranging
from a positive sense of well-being to negative sense of distress.

Social health, involved
the ability to form interpersonal relationships and social engagement which as
be evaluate quantitatively and qualitatively.

Functional health,
involved the ability to perform physical activity and social role- functioning.


The generic instruments
that use to measure the HRQoL include Quality of Life Enjoyment and Satisfaction
Questionnaire (Q-LES-Q), Short-Form 36 Health Survey (SF-36) and
Patient-Reported Outcome Measurement Information System (PROMIS). Q-LES-Q was
developed for measurement of satisfaction experienced by respondents in daily
living. It assesses respondent’s physical health, social relationships, subjective
feelings, general and recreational activities and work, school or household
duties. SF-36 is the most commonly used generic instrument for the measurement
of functioning and well-being for Medical Outcomes Study. It includes eight
domains which are physical and social functioning, physical and emotional role
limitations, mental health, general health perceptions, vitality and pain. From
these eight domains, Physical Component Summary (PCS) and Mental Component
Summary (MCS) can be generated. PROMIS is used for the assessment of physical,
mental and social functioning and consists of three major domains which is
physical, mental and social health. (Revicki et al., 2014)




Framework for PROMIS






Satisfaction with
participation in social roles



Satisfaction with
social roles and activities

Pain intensity


Ability to
participate in social roles and activities


Positive psychological

Social support

Behaviour and

Cognitive function

Social isolation

Sleep function


Sexual function


Table 1: Domain Framework for PROMIS.


            In a study of HRQoL among student in Malaysia with the
age range from 5 to 18 years old, using PedsQoL 4.0 which assess the physical,
emotional, social and school functioning of paediatric respondents, it was
found that schoolchildren with Thalassaemia has a QoL 10% to 24% lower than
healthy schoolchildren. Besides that, their emotional functioning is also lower
when compared with schoolchildren with other chronic illness such as acute
lymphocytic leukaemia, lymphoma and brain tumour. Absenteeism of students with
Thalassemia for blood transfusion in hospital is the major cause of lower
school functioning. (Ismail et al.,

            A study conducted in Singapore with respondents aged
above 18 years old by using SF-36 and EQ-5D self-reported questionnaire,
reported that patients with early stage hepatitis B have a similar HRQoL,
especially their physical health with healthy people, unlike hepatitis C
patients who show significant reduction in their HRQoL. They do not have any
significant physical role limitation. Despite of less affected physical health,
the effect of hepatitis B on mental health is higher, as more anxiety and
depression was reported. (Ong., 2006)






2.2 Visual Impairments

            Visual impairment is one of the top ten disabilities in
United State. About 20% of population with the age mare than 60 years old has
visual impairment. Many studies done in Asia Pacific countries reported that
quality of life is affected by visual impairment, especially in geriatric
population. (Brown & Barrett, 2011)

            A survey was done at 2010 in United State to determine
the correlation of visual impairment and health-related quality of life (HRQoL)
in geriatric population with age more than 65 years. By using “Healthy days
measures” which developed by the Centers of Disease Control and Prevention
(CDC), the physical and mental health as well as physical role limitation of
the respondents was assessed. It was found that visual impairment result in a
significant reduction in HRQoL when compared with those without visual
impairment. The reduction of HRQoL is proportional to the severity of visual
impairment. This is due to the greater physical and mobility limitations in
patients with more severe visual impairment. However, there is no significant relationship
between the reduction in mental health and severity of visual impairment. Patients
with mild visual impairment have a mental health score similar to that with
severe visual impairment. The mental health is less affected by visual impairment
when compared with other chronic conditions. (Li et al., 2011)

            On the other hand, the HRQoL of paediatric population
also affected by visual impairment. A study done in children aged between 3 to
16 years using Low Vision Quality of Life Questionnaire reported that the HRQoL
was reduced by 35.6% in children with visual impairment in comparison with
healthy children. The reduction in HRQoL is affected by the age of the
children. Older children have poorer HRQoL than younger children, probably due
to the increased demand of visual system, such as to drive and read more and smaller
words. (Chadha & Subramanian, 2010)

            According to Brown and Barrett (2011), the poorer HRQoL
and lower life statisfaction in people with visual limitation is associated

activity limitations.
People with visual impairment face difficulty even in doing daily tasks like
bathing and dressing. Besides that, they also not able to perform instrumental
activities like housekeeping and cooking.

economic resources.
People with visual impairment usually has lower income and facing financial
problem due to lower employment.

social resources. They
often receive sympathy and pity from society which lower their self-esteem. Furthermore,
they will face problem of social avoidance due to inability to participate in
social activities.

resources. Visual impairment diminishes one’s self-efficacy. They are unable to
control their life circumstances and often required help from others.


In addition, relationship
between the HRQoL in people with visual impairment and their level of physical
activity was study in 2015 by using WHO-Quality of Life (WHO-QOL-BREF). It was
found that visually impaired patients who have perform physical activity regularly
have a better HRQoL compared to those who are not. Regular physical activity
increases mental strength development and thereby, increases level of
happiness. Patients with regular physical activity have higher life satisfaction
ad motivation, although they face lots of difficulties in daily living. They tend
to think less about their disability than those who have a sedentary lifestyle.
(Kamelska & Mazurek, 2015)


2.3 Bodily Pain

            According to International Association for the Study of
Pain, pain is defined as an unpleasant physical sensation and emotional
experience associated with actual or potential tissue damage. For most of the
chronic diseases such as AIDS and cancer, pain is one of the major concern.
(Houlihan et al., 2004)

            From a study conducted in United State, it was found that
pain has a great impact of patients’ HRQoL. Patients experience chronic pain
has much lower HRQoL than healthy population with a lower SF-36 score, especially
in the physical component score. Patients experience bodily pain has a lower
score for physical functioning and physical role limitation. Pain greatly affected
their physical activities and mobility in daily life. (Georges et al., 2006)

            A study done on paediatric patients experiencing pain
with age range from 5 to 18 years old to evaluate their HRQoL from parents’
prospective using the patient-report Child-Health Questionnaire (CHQ). It is
reported that children experiencing pain have severe effect on their social and
school functioning. This is due to the high rate of absenteeism of children
with chronic pain and the inability to participate in school and family activities.
(Houlihan et al., 2004)

            In 2014, there was a research conducted to study the
correlation between the intensity of pain with the HRQoL in elderly patient.
From the score obtained from SF-36 questionnaire, the HRQoL is inversely
proportional to the intensity of pain. There is significant correlation between
the intensity of pain with the decrease in both physical and mental functioning
of the patient. Besides physical and mental function, patients with chronic
pain have poorer sleep quality compared to people without pain. Thus, obese
patients have more negative impact on their HRQoL. The poor physical and mental
functioning is due to the effect of poor quality of sleep, as it will
negatively affect the cognition, memory and attention of the patient. Worse sleep
quality also results in higher level of fatigue and aggressiveness. Furthermore,
for patients with chronic pain who are obese, they experience higher intensity
of pain in comparison with patient with normal body weight. In order to improve
the HRQoL of patients, treatment for pain should be considered.

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