Association between cognitive failure and health related quality of life indices

ABSTRACT

Context:There seems to be epidemiological associations between quality of life and cognitive failure yet, studies determining the relationship between quality of life indices and cognitive failure have been sparse. In addition, no studies examining this relationship have been carried out in Nigerian population.

Objective:To determine the association between quality of life indices and cognitive failure in a Nigerian sample.

Design, Setting, and Participants: A cross-sectional study of 1,338 participants with diverse age groups, ethnicity and socioeconomic levels from three different States and regions in Nigeria recruited from eleven public hospitals between May 2014 and August 2014.

Main Outcomes and Measures:Cognitive failure in relation to quality of life domains centring on physical and occupational functioning, perceptions about health status, psychological and social functioning were determined using linear and logistic regressions after adjusting for age, ethnicity, education, gender, marital status, family type, alcohol and smoking status.

Results:In the adjusted models, four of the indices for measuring quality of life domains were significantly associated with cognitive failures: worrying about health problems (adjusted odds ratio [AOR], 1.095; 95% CI, 1.05-1.14), health-related impairment in daily activities (AOR, 1.138; 95% CI, 1.09-1.93) and increased hospitalization (AOR, 1.55; 95% CI, 1.24-1.94) were associated with increased cognitive failures whereas showing care for one’s health (AOR, 0.93; 95% CI, 0.89-0.96) was associated with decreased levels of cognitive failure. Linear regression analysis on these data recapitulated these results.

Conclusions: Quality of life research appears to be vital for health needs assessment of populations and could have profound implications for cognitive failure and other health-related outcome assessment in biology, medicine and health services research.

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Health is a fundamental human right. Every human being is entitled to enjoy the highest attainable standard of health conductive for living a life in dignity (Cynthia et al., 2009).

According to World Health Organisation (WHO, 2010), health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Although a healthy life is the desire of everyone, the reality is that no one is absolutely healthy. An essential aspect of preserving health is to identify the factors that enable or prevent people from making healthy choices in either their life style or their use of medical care and treatment, the underlying assumption being that behaviour is best understood in terms of an individual perception of their social environment (Iyalomhe and Iyalomhe, 2012). Good health is regarded as the state of total effective physiological functioning (Adefolaju, 2011) while Lawanson (2009) reveals that health is one of the major components of human capital formation.

The Nigerian health status and medical care suffered several downfalls (HERFON, 2010; Asangansi and Shaguy, 2011). Despite Nigerians strategic position in Africa, the country is greatly underserved in medical care sphere. Health facilities (health centres, personnel and Medical care equipment) are inadequate in the country, especially in rural areas (HERFON, 2010).According to the Communiqué of Nigeria National Conference (2009) medical care system remain weak as evidenced by lack of coordination, fragmentation of services, dearth of resources and access to care and very deplorable quality of care. The communiqué further outlined the lack of clarity of roles and responsibilities among the different the level of government to have a compounded the situation (NNHCC, 2010). For a decade ago, communicable disease outbreak was a threat not only to lives of individuals but also to national security. Today it is possible to track outbreaks of diseases and step up medical treatment and preventive measure even before it spread over a large populace (Schiffbauer et al., 2008; Soteriade and Falagas, 2006). Medical and epidemiological surveillance, besides adequate health care delivery, are essential functions of public health agencies whose mandate is to protect the public from major health treats including communicable disease outbreak (Soteriade and Falagas, 2006). The Nigerian health care had suffered several infectious disease outbreaks year after year. Hence, there is need to tackle the problem (HERFON, 2010).

Several studies have been conducted on the supply of health care services in Nigeria (Ichoku, 2005) and few on the demand for these services (Ichoku and Leibrandt, 2003). Recognizing the importance of health indices and the poor states of these indices in Nigeria as compared with other developing countries, it is imperative to improve on these indices. Case et al., (2005) used data from many sources to examine health status and medical care. The health status output includes; a person’s height, body mass, disease incidence or severity, ability to function easily at a specific physical activities such as walking 1 kilometre and mortality while medical care as an input includes; use of health facilities, medication, nutrient intake such as calories, protein, iron, vitamins and minerals. Other is water and sanitation as a measure of exposure to pathogen (Alagbonsi et al., 2013).Medical care therefore, will always be sought by humans in an effort to live without the severity of illness as this affects their employment status; family life; wealth; social relationships, happiness and harmony with themselves (Akande and Owoyemi, 2009). Health care delivery continues to be limited, not efficient and does not meet the need of the majority of Nigerians. This is indication of high mortality rate, poor maternal care, very low life expectancy as at 2010, and outbreak of the diseases, as well as the long period of time spent for control of various outbreaks (HERFON, 2010). Ali and de Muynik (2005) revealed that individual were more willing to seek medical care based on severity of illness and if the illness interfaced with their normal social activities. Bourne (2009) noted that health care-seeking behaviour is even lower among the populace, suggesting that premature deaths are high among the population. WHO (2005) observed that chronic disease were in low and middle income countries and that of global mortality is caused by chronic illness (WHO, 2002; 2005) suggesting that illness interferes with poverty and vice versa, along with other social activities or social economic conditions.

According to Gupta et al., (2004) the goal of Primary Health Care (PHC) was to provide accessible health for all by the year 2000 and beyond. Unfortunately, this is yet to be achieved in Nigeria and seems to be unrealistic in the next two decades. The PHC aims at providing people of the world with the basic health services. Though PHC centres were established in both rural and urban areas. The rural population in Nigeria are seriously underserved when compared with their urban counterparts. About two- thirds of Nigerians reside in rural areas therefore they deserve to be served with all components of PHC. Primary Health Care, which is supposed to be the bedrock of the country’s health care policy, is currently catering for less than 20% of the potential patients (Gupta et al., 2004)

According to the WHO (2005), 80% of the deaths from chronic diseases occur in low-to-middle income countries and that 60% of global mortality is caused by chronic illness. This indicates that a proportion of mortality that is occurring in the developing nations is resulting in premature deaths. Poverty also influences many of the other social determinants of health such as income, education, employment status (WHO, 2008; Kelly et al., 2007; and Marmot, 2003) as well as biological conditions. Money is need in health care services, and so its non-access affects the treatment of care that the poor are likely to receive. A study by Lee Kim (2003) found that existing illness and ‘new health event’ were significantly correlated with the diminution of the wealth of elderly in United States. Therefore, the awareness of ill-health is not a sufficient driving force for people to seek medical care as they must balance the perception of severity with the affordability of health care. It is this fact that explains why purchased health insurance coverage allows the increase of health care demand.

In Nigeria the education of an individual, affect the type of medical care provider, and type of person providing assistance during illness (Okeke, 2010). In addition illiteracy impacts upon negatively on the health status of rural dwellers. This is so because; it contributes to the higher incidence of ill-health among the uneducated and their lower capacity to take advantage of existing health facilities. Poverty is another major factor that impedes that health status of rural communities. Given the fact that the poor also tend to use the health services provided at the primary health care level, it can only be imaged that level of pressure that large number of poor people with a higher disease burden will place on the resources of primary health care facilities (Uzobo et al., 2014).

On the other hand, cognitive failures are defined as failure in perception memory and the motor function and social interaction, in which the action does not match the intention (Allahyari et al., 2008). Thus cognitive failure includes numerous types of execution lapses; lapses in attention (i.e. failure perception), memory (i.e. failure related to information retrieval) and motor function (i.e. performance of unintended action) (Victoir et al., 2005). Cognitive failure occurs frequently and many do not produce any serious consequences some-under specific circumstances will result in mental illness (Allahyari et al., 2008).

Diseases are a by-product of cognitive functioning of humans (Wallace and Vodanovich, 2003). Individual differences in cognitive ability can lead to different types of medical care they render for and rates of diseases that they commit among the populace. Wallace and Chen (2005) noted that some people were indeed prone to established diseases and were also likely to report a relative number of memory lapses and instances of inattention. Thus cognitive failure rates may be an indicator of misinformation processing capacity and could therefore influence the performance of individual in a population.

In general, these efforts indicated that cognitive failure had a major contribution to severity of illness and neglecting medical care (Wallace and Vodanovich, 2003).

1.2 AIMS OF THE STUDY

This study aimed at looking at measures of quality of life indices as correlates of cognitive failure in Nigerian population. The study may be fundamental for fostering health promotion strategies and advocacy in Nigeria.

CHAPTER TWO

LITERATURE REVIEW

2.1. MEANING OF HEALTH

The Oxford Advanced Learners Dictionary conceptualized health as a state of being physically and mentally healthy. For one to be healthy, his physical and mental ability should be in good condition which is necessary for production of goods and services. Health is important to us as individual and as a society. Babatude (2012) posited that poor health infrastructure, illness and diseased shorting the working lives of people thereby reducing their life time earnings. Good health is regarded as the state of total effective physiologic and psychological functioning. WHO (2010) defined health as a state of complete physical, mental and social well-being, and not merely the absence of diseases.

Schultz (1999) postulated that good health has positive impact on the learning ability of children which lead to better educational outcome, school completion rate, higher means of years schooling, achievement and increases the efficiency of human capital formation by individuals and households. Lawanson (2009) asserted that health is one of the major components of human capital formation. Adeoti and Awoyemi, (2014) asserted that, good health and productivity are important in the economy of any nation especially in the fight against poverty. Health enhances work effectiveness and productivity of an individual through increase in physical and mental capital which is necessary for economic growth. Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity (Awosika, 2005).

2.2 DETERMINANTS OF HEALTH STATUS

The determinants of an individual’s health usually are decisions made by the individual or the household in which he or she lives. Therefore a natural starting point is the determination of individual health at the household level (Adeoti and Awoyemi, 2014). The health status as outputs include examples such as a person's height, body mass (weight measured in kilograms/height, measured in metres), disease incidence or severity, or ability to function easily at specific physical activities such as walking for 1 kilometre or mortality. Examples of health inputs include use of health facilities, medications, immunizations ,nutrient intakes such as calories, proteins, iron, vitamins and minerals; type of feeding in the case of infants (e.g., sole breastfeeding, supplemented breastfeeding and so forth). Others are water and sanitation quality as a measure of exposure to pathogens; exposure to underlying disease conditions, for which one crude proxy may be rainfall (Adeoti and Awoyemi, 2014).

Currie and Stabile (2003) in their review found a vast literature documenting the relationship between socioeconomic status and health and emphasized that it has been difficult to determine whether the relationship exists primarily because health affects socioeconomic status, whether socioeconomic status has a direct impact on health, or whether both are affected by some third factor such as rate of time preferences. Case et al., (2002) used data from many sources to examine at the relationship between family income and overall health status, where health status is a categorical variable with values 1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, and 5 = Poor. The study found out that individual's health is positively related to household income, and that the relationship between household income and individual's health status becomes more pronounced as children grow older. The health of individual’s from families with lower incomes erodes faster with age. In explaining income-health relationship, it may be that higher income parents are better able to manage chronic health problems (Adeoti and Awoyemi, 2014).

Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact (Adeoti and Awoyemi, 2014).

The determinants of health include:

- The social and economic environment,
- The physical environment, and
- The person’s individual characteristics and behaviours.

Health production function is an application of economic concept of a production function to the field of health. It relates various inputs affecting health status (healthcare resources, life style factors, socio-economic factors to measure output including life expectancy at birth, mortality and under-5 (child) mortality (Anton and Onofrei, 2006; Joumard, 2008 and OECD, 2006). Thus, the various categories of input (factors) that determine the population health status include health care resources, education, life style factors, socio-economic factor, genetics, personal behaviour and coping skills, health services and gender. It can thus be reasonably suggested that income, consumer price index and literacy rate are perhaps significant determinants of health status in Nigeria. Thus, governmental implementation capacity in health sector is important in terms of provision of health facilities to the demand needs of Nigeria and improved their human capital development which will induce the nation’s economic growth.

2.3 LEVEL OF HEALTH SECURITY IN NIGERIA

The national health system is, in principal decentralized into three tiers which are primary, secondary and tertiary levels structure with responsibilities at the federal, state, local government levels. Currently, all three tiers are involved, to some extent, in all the major health system function; stewardship, financing and services provision (FMOH, 2004).

The federal level

More specifically, the federal ministry of health (FMOH) is responsible for policy and technical support of the overall health system, inter-national relation On health matters, national health management information system and the provision of health services through the tertiary and teaching hospitals and laboratories (FMOH, 2004) . The tertiary primary health care is provided by teaching hospitals and specialist hospitals. At this level, the federal government also works with voluntary and nongovernmental organizations, as well as private practitioners (Adeyemo 2005; Awosika 2005 and Akande 2004).

The state level

The state ministries of health (SMOH) are responsible for secondary hospitals and for regulation and technical support for primary health care services. Patients at this level are often referred from the primary health care. This is the first level of specialty services and is available at different divisions of the state. The state primary health care comprises laboratory and diagnostic services, rehabilitation, etc.

The local government level

Primary Health Care is the responsibility of the local government where health services are organised through the ward (Adeyemi et al; 2001). Each local government is subdivided to 7-15 wards. ). The primary health care system is managed by the 774 local government areas (LGAs), with support from their respective state ministries of health as well as private medical practitioners (Adeyemo 2005). The primary health care has its sublevel at the village, district, and LGA.

2.3.1 Indicators of health in Nigeria

In spite of the huge development in the health system in relation to the last decades, much is still needed to be done in the health system (Adeyemo, 2005 and Omoruan et al., 2009).Although the total expenditure in health amounts to 4.6% GDP(Omoruan et al., 2009) financial managerial competency, besides inadequate funding, remains a major problem. Current statistics show that health institutions rendering health care in Nigeria are 33,303 general hospitals, 20,278 primary health centres’ and posts, and 59 teaching hospital and federal medical centres (Omoruan et al., 2009). This represents a huge improvement in regards to the last decades; nonetheless, health care institution continues to suffer shortage.

2.3.2 Nigerian health insurance scheme

As an effort by the federal government to revitalize the worsening state of health, the Nigerian health insurance scheme (NHIS) that was established in 2005 by Decree 35 of 1999 provided for the establishment of a governing council with the responsibility of managing the scheme (NHIS).

The objectives of the scheme were to:

1. Ensure that every Nigerian has access to good health care services
2. Protect Nigerians from the financial burden of medical bills
3. Limit the rise in the cost of health care services
4. Ensure efficiency in health care services
5. Ensure equitable distribution of health care costs among different income groups; equitable patronage of all levels of health care
6. Maintain high standard of health care delivery services within the scheme
7. Improve and harness private sector participation in the provision of health care services
8. Ensure adequate distribution of health facilities within the Federation
9. Ensure the availability of funds to the health sector for improved services.

The objectives and functions of the NHIS (Akande 2004) according to this present review have hardly attained any height as health care delivery continues to be limited; not equitable and does not meet the needs of the majority of the Nigerian people. This is indicative of the high infant mortality rate/poor maternal care, very low life expectancy as at 2010, and periodical outbreak of the same disease, as well as the long period of time spent for control of the various outbreaks. At its present state, it is true that the scheme does not adequately account for the needs of the Nigerian people (Okaro et al., 2010).

2.3.3 Healthcare financing and health outcomes in Nigeria

In Nigeria, the major sources of health financing have been identified as through (i) the tax-based public sector that comprises Local, State and Federal Governments (ii) the private sector (including the not-for-profit sector) financing which is done, directly or indirectly through health insurance of their employees (iii) households, through out-of-pocket expenditures, including user fees paid in public facilities; (iv) other insurance-social and community-based; and (v) external financing (through grants and loans) from donor organizations(Hodo and Emmanuel, 2012).

Despite the health financing options so identified in Nigeria, there still exist disproportions in health system financing. For instance, Olaniyan and Lawanson (2010) observed severe budgetary constraints and uneven distribution of resources among the urban and rural areas with the rural areas mostly affected by inequitable budgetary health expenditure allocation. Ichoku and Fonta (2009) had also noticed a catastrophic healthcare financing in Nigeria which eventually has led to further impoverishment of the poor. According to Ichoku and Fonta (2009) Nigeria’s health financial arrangement has shifted from health provisioning by government as a normal good towards a competitive market where greater proportion of health services are provided by ability to pay through out of pocket expenses (often referred to as user fee). Furthermore, excessive reliance on the ability to pay through Out-Of-Pocket payment (OOP) reduces health care consumption, exacerbates the already inequitable access to quality care, and exposes households to the financial risk of expensive illness at a time when there are both affordable and effective health financing instruments to address such problems in low income settings (O’Donnell, et al., 2005). Summarily, it could be argued that the system of health care financing in Nigeria is disproportionate, such that, it pushes the burden and risk of obtaining health services to the poor.

The budgetary allocation for health in 2003 and 2004 represented 2% and 1.2% respectively, out of the total budgetary estimates for those years. This allocation falls below the World Bank recommendation of 15%. Budgetary allocation to the health sector since then has not exceeded 2%. There is uneven distribution of finance and facilities, especially in the primary health care. Despite the budgetary provision for health, many of the health institutions still lack adequate personnel and facilities to provide quality care for the citizenry. There is gross inadequacy in the number of these facilities, and the few available are unevenly distributed (Hodo and Emmanuel, 2012)

2.3.4Health sector reform programme(HSRP)

The HSRP is the government‘s response to dealing with the outline organizational system and financial challenges facing the national health system (Idogbo, 2006). The comprehensive reform is structured along five strategic thrusts;

1. Improving the stewardship of government
2. Strengthening the nation health system and it management
3. Reduction of disease burden
4. Improving availability of health resources
5. Improving access to quality health services.

2.3.5 Drug supply management

Drug procurement in the public sector is decentralised and fragmented mist state drug stores are general well organised but do not fulfil a central procurement function as this is done directly by individuals hospitals and local government authorities. Drug supply is especially inadequate at the PHC level (WHO, 2005).

In 2006, out of the 746 facilities visited in 202 local governments, 46% had less than half of essential drugs 54% had experienced out of stock and tertiary and secondary hospitals in general have more reliable drug supplies compared to PHC facilities. However, their supplies are not always sufficient to meet needs of their patients (Abiodun et al., 2010).

2.3.6 Distance to the health care centre

The health system indicated that 71% of household in Nigeria were within 5km of a primary health centre (PHC) facility. The distribution of PHC facilities is better in urban area compare to rural area. Unfortunately, many of these clinics are not functioning. They are poorly equipped and lack essential supplies and qualified staff (WHO, 2005). Reducing the distance health consumer’s travel to the health service delivery point is another objective of health sector reform programme. The health consumer not only bears the cost of health services but also transport cost of facility (FMOH, 2002). In addition to financial factor, the three critical factors that determine access to health care are distance of the health care perceived quality of care type and severity of the illness.

2.4 STATE OF NIGERIAN HEALTH CARE SYSTEM

A well-functioning health care system requires a robust financing mechanism; a well- trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality medicines and technologies (WHO 2012).Its provision in Nigeria is a concurrent responsibility of the three tiers of government in the country (Alagbonsi et al., 2013). However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals, Federal Medical Centres (Tertiary Health Care) while the state government manages the various general hospitals (Secondary Health Care) and the local government focus on dispensaries (Primary Health Care), (FMC Abeokuta, 2011).

Increasing access to affordable, accessible and quality healthcare which is a major contributor to human capital development, increased employability and higher labour productivity, was part of the planned strategies to reduce poverty and inequality. This was done by the introduction of a national primary healthcare strategy, the reinvigoration of the federal Primary Health Care Development Agency (PHCDA) and the pioneering of a National Health Insurance System (NHIS). Despite the various reforms in the health sector, the progress of the impacts of the reforms on health and child poverty was reported to be slow on infant mortality rate, malaria prevalence rate and tuberculosis prevention rate; and worsening number of child orphaned by HIV/AIDS, total population with access to safe drinking water, maternal mortality ratio, just to mention a few (MDG, 2008).

2.5 PRIMARY HEALTH CARE IN NIGERIA

The Nigerian government is committed to quality and accessible public health services through provision of primary health care (PHC) in rural areas as well as provision of preventive and curative services (Nigeria Constitution, 1999). PHC is provided by local government authority through health centres and health posts and they are staffed by nurses, midwives, community health officers, heath technicians, community health extension workers and by physicians (doctors) especially in the western part of the country. The services provided at these PHCs include: prevention and treatment of communicable diseases, immunization, maternal and child health services, family planning, public health education, environmental health and the collection of statistical data on health and heath related events (Adeyemo, 2005 and FMH, 2004). However, in spite of these increase, the Nigerian health care system, comprising of Primary Health Care (PHC), Secondary Health Care and Tertiary Health Institutions are generally characterized by inadequate infrastructure, lack of basic amenities, inaccessibility to the vulnerable groups especially the poor and people living in the rural and undeveloped areas, which adversely influenced their health outcomes (Agbatogun and Taiwo, 2010).

2.5.1. Current status and gaps in PHC services in Nigeria

PHC centres are filtering units for those who require specialized services at the higher levels of care. Specialized medical services such as radiotherapy, orthopaedic procedures and surgeries are completely absent. There are many variations in the ways that medical care is given to rural people. The psychosocial health of rural dwellers is a neglected aspect of services provided (Abiodun et al., 2010).

2.6 FACTORS INFLUENCING ACCESS AND AVAILABILITY OF MEDICAL CARE IN NIGERIA

- Lack ofuniversal health careorhealth insurancecoverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Majority groups in Nigeria lack insurance coverage at higher rates (KCMU, 2003)
- Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Minority groups in Nigeria are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care.
- Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Nigerian, the impact on access appears to be greater for minority populations.
- Legalbarriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs.
- Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.
- The health care financing system. The Institute of health in Nigeria says fragmentation of the Nigeria health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.
- Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities.[
- Linguistic barriers. Language differences restrict access to medical care for majority in Nigeria who are not English-proficient.
- Healthliteracy.This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in urban area than in rural area due to socioeconomic and educational factors.
- Age.Age can also be a factor in health care system for a number of reasons. As many older Nigerians exist on fixed incomes which make paying for health care expenses difficult? Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically.

2.7 FACTORS INFLUENCING HEALTH CARE AND HEALTH-SEEKING BEHAVIOUR

Community ideas and attitudes toward health and illness affect the way they utilize health services. This is because these ideas and attitudes provide ideological basis for the healthcare system (WHO, 2002; Omotosho, 2010). In Nigeria, and in many developing countries, the factors that commonly affect the way rural dwellers shop for health includes:

Religious Beliefs

Everywhere, the quest for health easily shades into issues of morality and religion because the latter plays a significant aspect of social life. They believe that the doctor knows all and can cure all provided the right conditions are fulfilled. Hence, treatment of diseases classified as “common” or “ordinary” is diffused using either traditional or allopathic medicines while those classified as “severe” or “extraordinary” usually require special (traditional) attention (Olujimi, 2006; Ewhrudjakpor, 2007;Omotosho, 2010).

The basic explanatory theory is that in serious illness, there is an underpinning of the supernatural. ill health and other misfortunes can result from a disturbance in the relationship between man and his social cum spiritual environment, or from forces directed by witches, wizards, sorcerers, evil spirits or angered ancestors because of infraction of totemic principles (Iyalomhe and Iyalomhe, 2012 ). The popular notion is that “people do not just suffer illness by chance” therefore, serious illness is believed to have its origin in a primary supernatural cause. There is no difficulty, however, in accepting biomedical explanations based on the presence of viruses, bacteria, parasites, cancer or high blood pressure; these are simply seen as secondary causes. The idea of primary causation provides an explanation as to why a particular individual, and not others in the group, is afflicted by these infectious agents (Iyalomhe and Iyalomhe, 2012).

Illiteracy

Illiteracy has impacts upon negatively on the health status of rural dwellers. This is so because, it contributes to the higher incidence of ill-health among the uneducated and their lower capacity to take advantage of existing health facilities. According to reports from (UNDP, 2000), illiteracy is not only related to poverty; it also has implications for malnutrition, high infant and child mortality. It has been suggested, for example, that the probability of death among illiterate mothers is two times as high as those born to literate mothers. There is also a strong correlation between education and life expectancy at birth (UNDP, 2005). In Nigeria, an uneducated person tends to have more health problems and therefore to experience the need to access primary health care facilities. They also tend to have a lower capacity to access existing health care facilities (Okeke, 2010).

Povertyis another major factor that impedes the health status of rural communities. Given the fact that the poor also tend to use the health service provided at the primary health care level, it can only be imagined the level of pressure that large numbers of poor people with a higher disease burden will place on the resources of primary health care facilities (Uzobo, et al., 2014). The theory of social suffering collapses the historical distinction between what is health problem and what is a social problem, by framing conditions that are both and that require both health and social policies, such as in urban slums and Shanty towns where poverty, broken families, and a high risk of violence are also the settings where depression, suicide, post-traumatic stress disorder, and drug misuse cluster (Kleinman, 2011).

Unavailability of health human resources

Unavailability of health human resources has also been a problem to rural people in terms of them trying to access health personnel. Available data shows that there are shortages of health professionals across most of the rural areas with the shortage being highest among doctors, nurses, laboratory scientists and radiologists in rural Nigeria communities. In fact, in most rural communities in Nigeria, there are only two doctors assigned to a WHO general hospital with few nurses and one or none of the other health professionals. Hence, patients wait tirelessly in trying to seek medical help. Some get discouraged and never sought for further medical process when they become ill again (UNDP, 2005 and Iyayi, 2007).

2.8 COGNITIVE FAILURE

Cognitive failures are defined as failure in perception memory and the motor function and social interaction, in which the action does not match the intention (Allahyari et al., 2008). Thus cognitive failure includes numerous (i.e. failure perception), memory (i.e. failure related to information retrieval) and motor function (i.e. performance of unintended action. Theoretically the absence of cognitive control can lead to an increase in the frequency of cognitive failures and this general lack of cognitive control leads to overall increases in all different types of failures rather than specific failures being due to failures of specific processing component (i.e. retrospective memory failures as a result of failures in retrospective memory processes cognitive tasks). Each failure can be classified as an attention failure, a retrospective memory failure, or a prospective memory failure.

Attention failure– A failure of focusing mental effort that results in poor performance on any task

1. Distraction – W hen task-irrelevant information captures your attention, thus keeping you from focusing on your task (i.e., your roommates cell phone keeps ringing).
2. Absentmindedness – When you forget to pay attention to an important component of a task (i.e., leaving your drink on top of your car).
3. Mind wandering – When you find yourself lost in thoughts which are totally unrelated to a task (i.e., day dreaming in class).

Retrospective memory failure– A failure of retrieving information from memory.

1. Short-term – When you are trying to remember something over a brief period of time and you forget it (i.e., forgetting the name of newly introduced person).
2. Personal – When you cannot remember information personal to you (i.e., forgetting names, where you left your keys, a message you were told, or event from your past).
3. Fact-based – When you cannot remember factual information for quizzes, tests, or trivia (i.e., forgetting the president’s name during the Civil War).

Prospective memory failure– A failure of remembering to do something in the future.

1. Activity – When you fail to remember to do something after completing a different activity (i.e., forgetting to attach a document when you finish writing an email).
2. Time – When you fail to go to meeting or appointment at a predefined time (i.e., forgetting to be at the doctor’s office exactly at 10:15).
3. Event – When you fail to attend an event, or when you fail to remember to do something tied to an environmental event (i.e., forgetting to go to your friend’s birthday party).

2.9.1 CAUSES OF CONGNITIVE FAILURE

Cognitive failure can be caused by all sorts of brain problems including:

TUMOUR: tumours are masses of growing cell that grow and infiltrate the body. These masses of cell can be benign or malignant. Both tumours in the brain causes impaired cognitive functioning.

STROKES:disruption in the blood supply to the brain are one of the most common causes of brain damage lead to impaired memory, language difficulties and paralysis.

CLOSE HEAD INJURIES:are blows to the head that do not penetrate the skull, concussion, hematomas and traumatic brain injuries all types of closed head injuries. The severity and types of cognitive failure caused by closed head injuries.

INFECTION:can also cause cognitive failure, both bacteria and viruses can disrupt brain functioning. One of the most common forms of brain infection is meningitis cause deafness, other forms of cognitive failure and in several cases, death.

GENETIC MAKE UP:for instance, individuals with Down syndrome have an extra 21st chromosome. People with this syndrome often have mental retardation (intellectual function that is significantly below average).

2.9.2 RISK FACTORS CONTRIBUTING TO COGNITIVE FAILURE

2.9.2.1 PSYCHOLOGICAL FACTORS

Life Extension Foundation:Cognitive failure does not affect all individuals equally; clear associations exist between the rate and severity of cognitive failure and a variety of factors, including oxidative stress and free radical damage, chronic low-level inflammation, declining hormone levels, endothelial dysfunction, excess body weight, suboptimal nutrition, lifestyle, social network, other medical conditions and various biomarkers (Lovell and Markesbery, 2007). Fortunately, many of these factors are modifiable to a significant extent, and proactive lifestyle changes, cognitive training, and nutritional interventions have been shown to decrease the rate of intellectual decay and potentially reverse age-related cognitive failure (Butterfield and Sultana, 2007).

The Aging Brain:The aging process profoundly impacts the brain in ways that can be observed on multiple levels, ranging from sub-cellularly to macro-structurally. On a diminutive scale, aging causes deterioration of neuronal and mitochondrial membranes, which leads to the loss of cellular integrity and impaired neuronal function Specifically, even in healthy individuals, aging accounts for volume variances of 37% in the thalamus, which is involved in sight, hearing, and the sleep-wake cycle; 36% in the nucleus accumbens, which plays a major role in mood regulation (e.g. pleasure, fear, reward); and 33% in the hippocampus, a critical site for consolidation of short-term to long-term memory (Lovell and Markesbery, 2007).

2.9.2.2 BIOLOGICAL FACTORS

Oxidative Stress

The brain is particularly susceptible to oxidative damage since it consumes roughly 20% of the oxygen used by the entire body, and because it contains high concentrations of phospholipids, which are especially prone to oxidative damage in the context of high metabolic rate (Lovell and Markesbery, 2007).

Inflammation

The inflammatory process in the brain is unique in that the blood-brain barrier (BBB) (tight layer of endothelial cells that separates the brain from regular systemic circulation), during healthy conditions, prevents the infiltration of inflammatory agents and allows only select nutrients and small molecules into the central nervous system (CNS) (Di Domenico, 2010).

Hormonal Imbalance

Distributed throughout the brain are steroid hormone receptors which function to regulate the transcription of a vast array of genes involved in cognition and behaviour. Adequate steroid hormone receptor activation in the brain is a fundamental determinant in many aspects of our lives that we take for granted. When hormonal imbalances or deficiencies disrupt receptor activation, cognitive deficits and emotional turmoil are the result (Mani, 2009).

Estrogens

Animal models indicate that experimentally-induced alterations in the levels of steroid hormones, particularly estradiol, in the brain cause significant behavioural changes observable within minutes, leading some researchers to conclude that steroid hormones actually have the capacity to function directly as neurotransmitters in the central nervous system (Ryan, 2010).

Testosterone

Maintaining optimal levels of testosterone can help preserve cognitive ability as well. In a study involving over 500 aging men and women, higher levels of testosterone were linked with better performance on the Mini-Mental State Examination at baseline. Men with the lowest levels of testosterone at the beginning of the study period were more likely to exhibit a sharp failure in cognitive ability over the following two-year period as well (Ryan, 2010).

2.9.2.3 PSYCHOANALYTICAL FACTORS

Anxiety and Stress:Anxiety has shown that, compared to non-anxious control subjects, those with high-anxiety levels must exert greater effort (dedicate more brain resources) to maintain the same level of performance on cognitive tests. More severe anxiety is also predicative of earlier conversion from mild cognitive impairment to Alzheimer’s disease. In men, even subclinical (low-level) anxiety is tied to cognitive impairment. Excessive stress leads to cognitive dysfunction as well (Gold, 2003). This indicates that “psychological stress had an independent inverse association with cognition…”

Depression:An intimate relationship exists between depression and cognitive dysfunction. Many studies have closely examined this link and allude to the intertwinement of these two conditions, rather than a causal effect of one on the other. Interestingly, depression seems to worsen cognitive dysfunction, but poorer cognitive health predisposes aging individuals to depression as well (Gold, 2003). The conclusion drawn from this evidence was that “late-life depression is characterized by slowed information processing, which affects all realms of cognition.”

Social Network and Personal Relationships:Several studies have suggested that maintaining a large network of friends and other personal relationships, and regularly engaging in social and productive activities is associated with a decreased risk of cognitive failure (Gold, 2003). Conversely, social disengagement, defined as having very few or no social relationships, is a strong risk factor for cognitive failure.

2.9.3 ASSOCIATIONS WITH COGNITIVE FAILURE

Body mass index (BMI) and cognitive failure:Adipose tissue secretes molecules that directly influence multiple functions within the brain. There is a clearly reciprocal relationship between adiposity (amount of body fat) and overall brain volume and cognitive function. In other words, as bodyweight increases, brain volume drops and cognitive function worsens. Investigators identified a strong correlation between higher BMI and brain volume deficits in the frontal, temporal, parietal, and occipital lobes (Kemnitz, 2011).

Dietary and cognitive failure:the relationship between dietary and cognition is a dynamic changing over the life span. Dietary pattern with high intakes of saturated fat and refined carbohydrate can damage the brain system and induce impairment in the brain can affect learning, memory and cognition (Tucker et al; 2012). High intakes of vegetables, fish, nuts, and lower intakes of meat, high fat dairy and sweets seem to be associated with lower odds of cognitive failure (Joseph et al., 2009).

Physical activity and cognitive failure:physical exercise contributes to the reduction of cardiovascular risk factor is positively associated with biomarkers of brain health and improved cognitive performance (WHO, 2011). Resistance exercise also appears to influence underlying mechanism of cognitive health. Although, adult performing aerobic exercise improved in attention processing speed, executive function and memory, individual that failed to demonstrate physical exercise has a positive effect on cognitive performance (craft et al., 2013).

Other diseases and cognitive failure

Hypertension

Small, delicate capillaries, like those that perpetuate the flow of blood throughout the brain, are particularly susceptible to damage caused by elevated blood pressure. Chronic hypertension leads to the breakdown of cerebrocapillaries, a condition associated with the development neurodegenerative diseases and cognitive impairment.

Homocysteine

Homocysteine is an endogenous amino acid derivative which damages the endothelial cells that line the inside of blood vessels and contributes to the pathogenesis of atherosclerosis and vascular dysfunction. Elevated homocysteine has been linked with reduced blood flow to the brain, memory impairment, poorer global cognitive function, smaller overall brain volume, and increased silent brain infarcts (Kemnitz, 2011).

Dehydroepiandrosterone (DHEA)

Age-associated decline in levels of the adrenal hormone dehydroepiandrosterone (DHEA), which is very active in the central nervous system, are also tied to worsening cognitive performance. Moreover, those individuals with the lowest levels of DHEA-s at baseline displayed greater cognitive failure over time than those with higher initial levels and levels of DHEA-S correlated positively with superior executive function, concentration, and working memory (Marinho, 2008).

Alzheimer’s disease

Alzheimer’s disease, and age-matched healthy controls, revealed that patients with Alzheimer disease displayed markedly increased oxidative damage. Subjects with mild cognitive impairment or Alzheimer’s disease exhibited increased protein oxidation (protein carbonyls) and decreased levels of glutathione, a powerful endogenous antioxidant (Whitney, 2009).

Dementia

Dementia can have numerous causes: genetics, brain trauma, stroke, and heart issues. The main causes are diseases such as Parkinson disease and Huntington diseases because they affect or deteriorate brain functions (Cicerelli, 2005)

Amnesia

Amnesia can be caused by concussions, traumatic brain injuries, post-traumatic stress, and alcoholism. Many problems are caused by damage to major memory encoding parts of the brain such as the hippocampus (Torypy, 2008)

CHAPTER THREE

3.0 Research Methodology

3.1. Participants

In total 1338 people participated in the survey. The participants consisted of 807 females and 531 males. The mean age was 32 years (age range was 18–87 years). People were recruited to participate from three different States and regions in the South West of Nigeria namely; Lagos state, Ogun state and Oyo state and were selected across eleven public hospitals between May 2014 and August 2014. Letters were also sent to the necessary units within these hospitals. An information sheet was sent out with the questionnaires. This included a description about the aims of the project. All participants signed informed consent .

3.2. Procedure

The questionnaires were returned anonymously with no identifiers attached therefore no reminders or follow ups were completed.

3.3. Materials

The questionnaire was designed to examine health and health-related behaviours, dietary intake and cognitive failures. Measures relevant to the present article are described below.

3.4. Cognitive Failures

This measure was derived using the well-established Cognitive Failures Questionnaire (Broadbent, Cooper, FitzGerald Parkes, 1982). Developed in 1982, the CFQ is a 25-item self-report measure of failures in attention, perception, memory, and action. Participants are asked to indicate on a 5-point scale how often they have experienced each failure in the past months, from 0 (never) to 5 (very often). Examples of CFQ items include #2, “Do you forget why you went from one part of the house to the other?” and #19, “Do you daydream when you ought to be listening to something?” One study determined that CFQ’s reliability is high, possessing an internal consistency (Cronbach’salpha) ranging from .85 to .89 (Broadbent et al., 1982; Merckelbach et al., 1999). It also has high test–retest reliability. Broadbent et al. (1982) reported values of r = .82 and r = .80 over an extended period of up to 2 years. Broadbent claimed that the CFQ should be used only to assess the single construct of cognitive failure. He supported his claim by stating the high internal consistency of the scale. We validated this scale in Nigerian sample and confirmed that it thus loads on a single factor using explorative and confirmatory factor analyses respectively (data not shown). High and low cognitive failures were determined based on median split.

3.5. Covariates

This section contained a number of standardized measures.

3.5.1. Quality of Life Indices

Quality of life domains involving physical and occupational functioning, perceptions about health status, psychological and social functioning were determined using a standardised questionnaire.

3.5.2. Other Health-Related Behaviours

Smoking, alcohol consumption were assessed and used as covariates.

3.5.3. Demographics

Items referring to age, gender, education, ethnicity and marital status were included in this section. Age and gender were related to the outcomes and used as covariates.

3.5.4. Statistical Analysis

Backward step binary logistic regression was used to analyze the data including covariates. Regression models were used in order to examine whether measures of quality of life indices exhibit any effects on cognitive failure when other health related behaviours and demographics are taken into consideration. Goodness of fit statistics were examined (Hosmer-Lemeshow) along with standardized residuals (Cooks, Leverance and DFBetas). Linear regression was also used to analyse the data and to test for evidence of collinearity. Unless otherwise stated all of these values were normal and did not warrant any further exploration. All analyses were implemented in SAS version 9.2.

CHAPTER FOUR

This chapter described the analysis the analysis of data collected from the study and the discussion of findings.

4.1 PRESENTATION OF RESULT

Table 1: Basic characteristics of participants in the study

Abbildung in dieser Leseprobe nicht enthalten

N= 1299; categorical data are presented in percentages and assessed for differences using chi-square; continuous measures are presented in means ±SD and assessed for differences using ANOVA.

Table1: shows basic characteristics of the respondents with respects to cognitive failure. It is observed that the level of participants with high cognitive failure are more likely to be female and older, and more likely to suffer more from fatigue, pain shortness of breath, and worry more from daily activities.

Most of the respondents were Yoruba (70.6%), with high cognitive failure, Hausa (6.2%), Ibo (20.0%) and other ethnic group (3.2%) were with high level of cognitive failure. However, respondents with no education with low cognitive failure (1.7%), primary (4.3%), High schools (13.4%), College/Poly/ NCE, (27.9%) and university/ BSC/ HND (52.8%) with low cognitive failure compare with those with high cognitive failure in university (43.4%). Majority of the respondents from different level of various marital status in this study had low level of cognitive failure named (51.6%), compare with single (44.2%), separated (1.0%), Divorce (1.1%) and widower (2.1%). The associations were statistically significant (P<.0.05).

Regarding the Age of the population, almost 18-44 with high cognitive failure (85.5%), 44 - 65 year (13.5%) while the least (1.0%) with high cognitive failure range of 65years above. Most of the respondent were from nuclear family (72.2%), with low cognitive failure and extended family (13.9%), while polygamous family (14.47) with high cognitive failure. Most of the respondents, Alcohol status, larger percentage of the respondents never involved in taking of alcohol (51.9%) and former involved (14.3%) while currently involving (33.8%) with low cognitive failure. None of the association were significantly (P>0.05).

Most of the respondents never engaged in smoking of cigarette (84.0), while (7.9%) former engaged in smoking and (8.0%). Currently involved or engaged in smoking with low cognitive failure. Majority of the respondents has High of cognitive failure with Good health status (40.7%), less respondents (6.3%) with excellent health status and high cognitive failure. The associations were statistically significant (P<0.05).

The Age range from 18-87 years, with the mean age of 32.2 ±11.9years,Majority of the respondents belonging to 18-44 years age group with high cognitive. The mean of respondents Fatigue, Shortness of Breath, Pain, Daily Activities, Physician Visit, Hospitalization, Hospital Night (3.6 ± 2.9 ), (3.8 ± 2.6), (2.2 ±2.7 ), (3.0 ±2.7), (3.3 ± 2.8 ), (3.7 ± 2.7), (2.6 ±3.2 ), (4.5± 3.5), (4.9 ± 3.8 ), (5.1±3.3) (1.2 ± 1.8 ), (1.5 ± 2.0 ), (0.3 ± 0.5), (0.6 ± 0.8), (0.6 ± 1.6), (1.3 ± 2.3) respectively. The association were statistically significant (P>0.05) with cognitive failure. The mean of medical care (4.9 ± 3.8, 5.1±3.3) show no significant.

Table 2.Show logistic regression result from association between cognitive failure and health related quality of life.

Odds ratio estimation

Abbildung in dieser Leseprobe nicht enthalten

Model fitX[2] = 136.3252, P<0001

Hosmer and Lemeshow Goodness of Fix TestX[2] = 9.492, P<0.3025

Table 2 shows information on the explanatory factors of Health related qualities of life accounted 76% of the explained variability of cognitive failure (P<0.05). The respondents that were discouraged of the health problems were 10% likely to have cognitive failure. These implies that the more fearful of health problems the more individual go for health care services respondents that health interfered with normal social activities, family, friends, neighbours or groups were 14% likely to have cognitive failure, while Respondents that visit doctor regularly were 7% likely to have cognitive failure. Respondents that were hospitalized for one night or longer were 45% likely to have cognitive failure.

Table 3: Linear regression: Association between cognitive failure and others characteristic by health status.

Abbildung in dieser Leseprobe nicht enthalten

Table 3: Presents information on the explanatory variables which account for cognitive failure. Five variables emerged as significant determinants of health related quality of life. This implies that Increase in health problems, fatigue, Daily Activities, Hospitalization lead to increase in cognitive failure of the respondents. While increase in medical care of the respondents lead to decrease in the level of cognitive failure.

4.2 DISCUSSION OF FINDINGS

The sociodemographic profiles of one thousand three hundred and thirty eight (1338) participants in the study showed that majority of the participants (88.2%) belonged to the age group of 18-44years. The age range was 18-87 years with the mean of 31.8 ±10.3 years. This is similar to 19-67 years with the mean of 39±13 years found in previous study on adult TB patients with cognitive failure (Mekonnen, 2002) and the reported majority (70%) of participants belonging to 20-39 years age group in similar study in India (Mekonnen, 2002). It also confirms to the assertion that cognitive failure is common among the adolescents and the young adult in developing countries while it is commoner among elderly patients in developed countries (WHO, 2009).

Majority of the participants (48.6%) of the patient were fairly satisfied with their health while (40.7%) were highly satisfied. Most of the patients (88.3%) indicate good health status similar (90%) found in Ethiopian study and (80%) reported in New York (Isaa et al., 2007).

Based on this research, it could be concluded in support of Philbin et al., (2001) association between quality of life of patients with Cognitive Failure with previously characterised general population and those with other chronic diseases. Authors concluded that the total Cognitive failure sample was characterised by significant reduced quality of life. Patients with cognitive failure showed the same pattern reduced in quality of life. It could be confirmed that patients with high cognitive failure have impact on quality of life; however patients with high cognitive failure had more occurrence in symptoms, fatigue, hospitalization and general health than the low cognitive failure population.

This study consistent the notion that high cognitive failure patients may perceive their health status to be poorer and underestimate their functional status. The high incidence of fatigue, hospitalization and symptom is due to the high cognitive failure perception, poor functional status and the expectation. Also Gottlieb et al., (2004) studied the prevalence of fatigue in an out patients were evaluated with the cognitive failure questionnaires and the Beck Depression Inventory (BOI). A total of 45% of the patients with severe fatigue and high cognitive failure significantly worse than patients with low cognitive failure on all components of the questionnaire measuring quality of life. In this study fatigue was observed more commonly among younger than older patients.

Furthermore, this research work agree to the work of Fava (1999) who concluded that association between psychosocial factors and medical care in patients with cognitive failure, reduction in medical care of patients, lead to failure in perception of memory and decline in the quality of life. An increase in medical care of patients produced masked improvement in quality of life and outcomes in patient with low cognitive failure.

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATION

5.1 SUMMARY

The study examined the association between cognitive failure and health related quality of life indices, while relevant literature were theoretically reviewed in chapter two with a view to showing it relevance to the present study

For the collection of the data, two forms of questionnaires were used; chronic disease questionnaires and cognitive failure questionnaires. They were designed and used for data collection, Although the questionnaires were analysed using linear regression for continuous data and logistic regression for dichotomous data with the significant level formulated and tested at <0.05 level of significant.

5.2 CONCLUSION

Cognitive problems are an important health challenges for a poor-resource country like Nigeria where most of the populace are within the vulnerable age group. Quality of life research appears to be vital for health needs assessment of population and could have profound implications for cognitive failure and other health-related outcome assessment in biology, medicine and health services research.

5.3 RECOMMENDATION

Based on the research findings of this study, the following recommendations were proffered.

i. Government and health policy makers should improve collection and monitoring of health data and also educate people on prevailing health problems and method to preventing and controlling them.
ii. More involvement of international donor agencies in the health intervention programmes of the country. Nigeria still requires the support of foreign partners in fighting the scourge of disease within and around the country
iii. The communities should awaken to a shared sense of responsibilities, through the establishment of community health insurance schemes.
iv. Government should improve on immunization programs; promote treatment of epidemic diseases, food supply and nutrition.
v. The government should encourage the establishment of wards development committee whose responsibilities should include taking initiative to assist government in building health post, maintenance of established health facilities. Provision of logistics during health campaign and monitoring of health workers activities at the health facilities.

The above recommendations if undertaken have the capacity to turn around and reduce the incidence of cognitive failure rate in Nigeria as well improving the health related quality of life of the population.

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Appendix 1

The Cognitive Failures Questionnaire

The following questions are about minor mistakes which everyone makes from time to time, but some of which happen more often than others. We want to know how often these things have happened to you in the past 6 months. Please circle the appropriate number.

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Appendix 2

Questionnaire on chronic diseases

1. Today’s date: ______________________________ (dd/mm/yyyy)

2. Sex:

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3. Parity: If you are a female, how many times have you given birth? ___________times

4. Date of birth:dd/mm/yyyy ________________

5. Ethnicity (tick only one):

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6. Education: Please circle the highest level of education you obtained

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(Primary) (JSS) (SSS) (College)(University/Polytechnic)(Postgraduate)

7. Marital status:

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8. Family type:

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9. Number of people in your family:

Please circle one 1 2 3 4 5 6 7 8 9 10 above

10. What is your height (metres): _____________________m
11. What is your weight (Kilograms): _________________kg
12. Waist circumference (Metres): ____________________m
13. Systolic blood pressure: _________________________
14. Diastolic blood pressure: ________________________
15. Alcohol consumption: Do you take alcoholic drinks?

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16. Cigarette/ Tobacco consumption: Do you smoke?

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17. Please indicate below which of these health problems you have now or have had in the past:

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18. In general, would you say your health is: (Tick one)

1. Excellent 2. Very good 3. Good 4. Fair 5. Poor

19. Symptoms

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20.We are interested in learning whether or not you are affected by fatigue. Please circle the number below that describes yourfatiguein thepast 2 weeks:

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21. We are interested in learning whether or not you are affected by shortness of breath.

22. Please circle the number below that describes yourshortness of breathin thepast 2 weeks:

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23. We are interested in learning whether or not you are affected by pain. Please circle the number below that describes yourpainin thepast 2 weeks.

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24. Physical Activities

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25. Daily Activities

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26. Medical care

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27.

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In the past 6 months, how many times did you visit a physician?

(Donotinclude visits while in the hospital or the hospital emergency department) ______ visits

28.In the past 6 months, how many times did you go to ahospitalemergency department?_______ times
29.In the past 6 months, how many TIMES were you hospitalized for one night or longer? _______ times
30. How many totalNIGHTSdid you spend in the hospitalin the past 6 months?________ nights
31. Were any of these hospitalizations at a skilled nursing facility,convalescent hospital, or other minimum care facility? (circle) Yes No

Confidence about doing things

For each of the following questions, please circle the number that corresponds with yourconfidencethat you can do the tasks regularly at the present time.

32.How confident are you that you can…

i. Keep the fatigue caused by your disease from interfering with the things that you want to do?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

ii. Keep the physical discomfort or pain of your disease from interfering with the things you want to do?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

iii. Keep the emotional distress caused by your disease from interfering with the things you want to do?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

iv. Keep any other symptoms or health problems you have from interfering with the things you want to do?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

33. How confident are you that you can…

i. Do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

ii. Do things other than just taking medication to reduce how much your illness affects your everyday life?

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Not at all confident 1 2 3 4 5 6 7 8 9 10Totally confident

Thank you for your help!

[...]