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Conceptual Frameworks of Health and Introduction to Conceptual Issues in Diverse Populations. Anita L. Stewart, Ph.D. Anna Nápoles -Springer, Ph.D. University of California, San Francisco Clinical Research with Diverse Communities EPI 222, Spring 2002. Overview.

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Conceptual frameworks of health and introduction to conceptual issues in diverse populations l.jpg

Conceptual Frameworks of Health and Introduction to Conceptual Issues in Diverse Populations

Anita L. Stewart, Ph.D.

Anna Nápoles-Springer, Ph.D.

University of California, San Francisco

Clinical Research with Diverse Communities

EPI 222, Spring 2002


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Overview

  • What are conceptual frameworks and why are they needed?

  • Conceptualizing health in general

  • How are variables related to health?

  • Issues of conceptualizing health and health-related concepts in diverse populations


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What is a Conceptual Framework?

  • A description of the research problem that:

    • Specifies and defines variables of interest (predictors, covariates and outcomes)

    • Describes the hypothesized relationships among variables to be tested

    • Is based on theory and/or empirical data


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Why do we Need Conceptual Frameworks? They …

  • Provide rationale and theoretical basis for research questions/hypotheses

  • Guide the variables/measures selected to address research question, the analysis plan, or program evaluation

  • Help identify potential covariates that need to be measured

  • Are critical for understanding complex relationships, as in health disparities


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Using Frameworks to Study Complex Processes That Can Affect Health

Helps you to:

  • Clearly and comprehensively define and operationalize the constructs of interest

  • Identify conditions under which specific constructs operate on health

  • Evaluate different aspects of constructs (e.g. control, social support) separately to determine what aspects (individual, organizational, environmental, or social) are important under various conditions


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Overview

  • What are conceptual frameworks and why are they needed?

  • Conceptualizing health in general

  • How are variables related to health?

  • Issues of conceptualizing health and health-related concepts in diverse populations


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Conceptualizing Health in General

  • Terminology

  • Conceptual frameworks

    • Categories of health

    • Relationships among health domains

  • Conceptualizing a health domain


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Terminology

  • Health status

  • Health indicators

  • Health outcomes

  • Functional status

  • Functioning and well-being

  • Quality of life

  • Health-related quality of life


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More Terminology: Functional Status and Functioning

  • Functional status

  • Functioning

  • Functional limitations

  • Disability

  • Handicap

  • Impairment

  • Physical fitness

  • Physical functioning

  • Major activity limitations


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Individual

Clinicianor Proxy

Anatomic, physiologic, biochemical X

Diagnosed physical/mental conditions XX

Severity of conditions XX

Functioning in daily life X

Well-being (emotional & physical) X

Perspectives on Health


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Functioning and Well-being: Healthfrom the Patient’s Perspective

  • Functioning: Ability to perform behaviors and activities of daily life Usually observable

  • Well-being: Internal, subjective feelings and perceptions Physical and emotional


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Conceptualizing Health in General

  • Terminology

  • Conceptual frameworks

    • Categories of health

    • Relationships among health domains

  • Conceptualizing a health domain


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World Health Organization Definition of Health Status

“…physical, mental, and social well-being…”

“…not merely the absence of disease or infirmity.”


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1. Symptoms

2. Functional status

3. Role activities

4. Social functioning

5. Emotional status

6. Cognition

7. Sleep and rest

8. Energy and vitality

9. Health perceptions

10. General life satisfaction

Conceptual Framework: Marilyn Bergner

Bergner M, Med Care, 1989;27:S148


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Medical Outcomes Study Framework

Physical Mental

Indicators

Physical functioningX

Pain X

Energy/fatigue X X

Sleep problems X X

Cognitive functioning X

Psychological distress/well-being X

Social activity limitations due to healthX X

Role limitations - physical health X

Role limitations - emotional problems X

Current health perceptions X X

Stewart AL, MOS Framework. In Stewart and Ware, 1992.


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Key Point: What Are Conceptual Frameworks of Health?

  • Are they just a lot of categories?

    • With different investigators defining different categories?

  • Is there some order among the categories?

  • Most are static

    • no flow or dynamic pattern of relationships

  • Very few conceptual frameworks of relationships among variables


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Functional

Limitations

Pathology

Impairments

Disability

The Disablement ProcessVerbrugge and Jette

Diagnoses

of diseases,

injury,

congenital,

development-

al condition

Abnormalitiesin specific

body systems

Restrictions

in basic

physical and

mental actions

Difficulty

doing activities

of daily lifedue to a health

problem

Soc Sci Med, 1994;38:1-14


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Biological

and

Physio-

logical

Variables

Symptom

Status

Functional

Status

General

Health

Percep-

tions

Overall

Quality of

Life

Conceptual Model of Patient Outcomes:Wilson and Cleary

Wilson, IB and Cleary, PD, JAMA, 1995


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Conceptualizing HRQL in General

  • Terminology of HRQL

  • Conceptual frameworks of HRQL

    • Categories of health

    • Relationships among health domains

  • Conceptualizing a HRQL domain


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Defining a Domain of Health-Related Quality of Life Involves Specifying

  • Content area

    • of domains and subdomains

  • Response dimensions

  • Time frame


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Sample Content Area: Physical Functioning Domain

  • Walking

  • Running

  • Climbing stairs, hills

  • Bending, stooping

  • Turning head

  • Lifting, reaching, carrying

  • Getting in/out of a chair, car

  • Dexterity


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Content Areas of Physical Functioning in Four Measures

AIMS MOS HAQSIP

Walking . . . . . . . . . . . . . X X X X

Climbing stairs, steps . . X X X X

Bending, kneeling . . . . . X X X X

Lifting, carrying . . . . . . . X

Getting out of bed . . . . . X

Bathing . . . . . . . . . . . . . . X X X

Running errands . . . . . . . . . X

Opening jars . . . . . . . . . . . . X

Vigorous activities . . . . . . . X X X


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State/level

Evaluative

Comparative

State or level of behavior of feeling

- Frequency of pain

- Amount of difficulty walking

Value attached to level or state

- Satisfaction with health

- Bothersomeness of symptom

Comparison to prior time, other persons

Types of Response Dimensions


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State/level

Evaluative

Able/unable to do

Extent of limitation

Amount of difficulty

Need for help

Speed of completing defined task

Satisfaction with level

Possible Response Dimensions for Physical Functioning


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Example: State/Level Responses for Three Physical Functioning Measures

Do you have any trouble... walking one block… ? (AIMS)

Yes or No

Does your health limit you… in walking one block? (MOS)

Yes, limited a lot

Yes, limited a little

No, not limited at all

Are you able to… walk one block? (HAQ)

Without any difficulty

With some difficulty

With much difficulty

Unable to do


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Past:

Present:

No time frame:

Average experience over some

previous time period (6 months,

3 months, 4 weeks, etc)

Current status, how they are now

Time frame not specified

(assumes “in general”)

Specify Time Frame


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Activities in Which a Person Might be Limited

  • Self careBathing, dressing, eating, using toilet

  • InstrumentalShopping, laundry, cooking, work around the house, getting around the community

  • RoleWork, caregiving, volunteeringfamily roles

  • SocialGetting together with others

  • PhysicalWalking, exercise, sports

  • RecreationalHobbies, recreational activities, going outdoors


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Ability to Perform Activities: Interaction Between HRQL and Nature of Activities

Functioning and well-being

  • Physical functioning

  • Cognitive functioning

  • Psychological distress/well-being

  • Fatigue

  • Pain

    Ability to perform complex activities

    Nature of activities

  • Location

  • Complexity

  • Opportunity to do them


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What’s In A Name?

  • Domain or variable label may not mean what you think it means

  • Essential to examine content areas of a measure with any label to see how that measure is defined


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Summary of Issues Conceptualizing Health

  • Much variation in definitions of health and health-related concepts

    • don’t judge a measure by its label

  • Content and response dimensions are part of definition

  • Clarify conceptual framework and concept definitions prior to beginning any study

  • Consider contextual factors that may affect domains and subdomains of interest

  • Consider interrelationships among variables


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Overview

  • What are conceptual frameworks and why are they needed?

  • Conceptualizing health in general

  • How are variables related to health?

  • Issues of conceptualizing health and health-related concepts in diverse populations


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How are VariablesRelated to Health?

  • A predictor or independent variable can be:

    • unrelated to the outcome variable

    • directly related to the outcome variable

    • indirectly related to the outcome variable

    • jointly related with another variable to the outcome variable

    • confounded by a covariate


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Mediators

  • Mediator variable

  • Is on the “causal pathway” between the independent and dependent variable

  • The independent variable causes the mediating variable, which then causes the outcome


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Mediators

AC

A is directly related to C

B

AC

A is indirectly related to C

B mediates the relationship between A and C


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Test of 3 equations:

A B

AC

A

C

B

To assess mediation hypothesis (A B C) A must independently predict B & C and B must predict C

Compare effects of A on C when B is, and is not, controlled

Effects of A on C when controlling for B should be substantially less than when not controlling for B

Assessing Mediation with Regression


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Why Assess Potential Mediators?

  • Most available population data on health determinants usually involve distal (removed) causes of illness (e.g. income, education)

  • Distal determinants exert their effects through more proximate determinants (mechanisms)

  • Proximate determinant may provide greater potential for interventions


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Distal Social Determinant (poverty)

Health Outcome (infectious disease)

Proximate Determinant (malnutrition)

Distal Social Determinant (poverty)

Health Outcome (infectious disease)

Distal and Proximate Determinants of Health: Identifying Mechanisms


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Distal Social Determinant (poverty)

Health Outcome (infectious disease)

Why Assess Potential Mediators?

  • Improperly adjusting for the effects of proximate determinants may result in underestimating the effects of the distal determinants

Proximate Determinant (malnutrition)


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Moderators

  • Moderator variable

  • Affects the relationship between 2 variables

    • the effect of the independent variable on the dependent variable depends on the level of a third variable, the moderator

  • A significant interaction effect between the independent variable and the moderator variable is evidence of a moderator effect


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Moderators

B moderates the relationship between A and C

B1: AC

B2: A C


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Why Assess Interactions (Moderators)?

  • Researchers often simply compare ethnic groups on risk of outcome relative to whites, controlling for covariates (e.g. age, SES, risk factors) and provide odds ratios of outcome relative to whites

    • focus is on direct (main) effects only

  • Example: What is the effect of ethnicity on CVD risk, controlling for other covariates including smoking?


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Why Assess Interactions? (cont.)

  • Does not address mechanisms by which the groups might differ on the risk of outcome.

  • By testing interaction terms (moderator effects), can assess if relative importance of a risk factor is the same (or differs) by ethnic group

  • Example: Are the effects of cigarette smoking on CVD risk the same for African Americans compared to whites?

    • Assess ethnicity x smoking interaction term


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Testing for Interaction (Moderator) Effects Using Regression Approach

  • Regression approach:A (predictor) and B (moderator) are entered first (main effects) followed by the interaction term A x B (interaction effects)

  • Example:Enter ethnicity and smoking followed by ethnicity x smoking interaction term

    • If interaction is significant, effect of smoking on CVD risk differs across ethnic groups


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Testing for Interaction (Moderator) Effects

  • Plot regression lines and assess significance of interaction term

African Americans

Risk of CVD

Whites

Cigarettes/day


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Example: Job Strain Model

Moderation: Effects of stress on smoking (or CVD) depends on race, level of social support and decision making authority

Mediation: Part of the effects of perceived stress on CVD are explained by level of smoking

Modifying Factors

Individual Social Environmental

(race, age) (social support) (latitude to make decisions)

Long-term health

(cardiovascular health)

Short term response

(smoking)

Perceived stress


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Overview

  • What are conceptual frameworks and why are they needed?

  • Conceptualizing health in general

  • How are variables related to health?

  • Issues of conceptualizing health and health-related concepts in diverse populations


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Types of Diverse Groups

  • Health disparities research focuses on:

    • Minority vs. non-minority

    • Low income vs. others

    • Low education vs. others

    • Limited English skills vs. others

    • Vulnerable vs. non-vulnerable


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Diverse Groups Underrepresented in Research

  • Racial/ethnic minorities, older persons, and low SES groups underrepresented

  • Little or no information on treatment effectiveness or pathways to health in diverse groups

    • e.g., little research on moderator effects - are treatments equally effective across ethnic groups?

  • Most research findings may not generalize to the underrepresented groups


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Health Research Beginning to Include Minority and Other Diverse Groups

  • New focus on research to understand and reduce health disparities

    • conduct epidemiological studies of determinants of health disparities

    • examine treatment disparities

    • compare treatment effectiveness across ethnic groups

    • intervene to reduce health disparities


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Measurement Implications

  • Most health-related concepts and measures were developed in mainstream population groups (white, middle class)

    • Subgroup analysis of measures (e.g., by ethnicity) has been rare

  • Question: Are existing measures relevant, appropriate, reliable, and valid in these other groups?

  • Very little research or published information on measurement qualities in diverse groups


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Measurement Adequacy vs. Measurement Equivalence

  • Making group comparisons requires conceptual and psychometric adequacy and equivalence

  • Adequacy - within a group

    • concepts are appropriate

    • psychometric properties meet minimal criteria

  • Equivalence - between groups

    • conceptual and psychometric properties are comparable


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Conceptual and Psychometric Adequacy and Equivalence

Conceptual

Concept meaningful

within one group

Concept equivalent

across groups

Adequacyin 1 Group

Equivalence

Across Groups

Psychometric properties

meet minimal standards

within one group

Psychometric properties

invariant (equivalent)

across groups

Psychometric


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Summary of U.S. HRQL Literature

  • Almost no qualitative studies of conceptual adequacy or equivalence

Stewart AL & Nápoles-Springer A. HRQL assessments in diverse population groups in the US. Med Care, 2000;38(Suppl II):102.


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Conceptual Adequacy in One Group

Conceptual

Concept meaningful

within one group

Concept equivalent

across groups

Adequacyin 1 Group

Equivalence

Across Groups

Psychometric properties

meet minimal standards

within one group

Psychometric properties

invariant (equivalent)

across groups

Psychometric


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Conceptual Adequacy

  • Is a concept being applied to a group relevant, meaningful, and acceptable?

  • Is it defined in a way that corresponds to how the group thinks about the concept?


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Example of Inadequate Concept

  • Patient satisfaction is typically conceptualized in mainstream populations as having several domains, e.g.,

    • access, technical care, communication, continuity, interpersonal style

  • In minority and low income groups, “discrimination by health professionals” is a crucial domain of care

    • missing from standard frameworks


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Conceptual Equivalence Across Groups

Conceptual

Concept equivalent

across groups

Concept meaningful

within one group

Adequacyin 1 Group

Equivalence

Across Groups

Psychometric properties

meet minimal standards

within one group

Psychometric properties

invariant (equivalent)

across groups

Psychometric


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Determining Conceptual Equivalence

  • Is the concept relevant, familiar, and acceptable to all subgroups?

  • Is the concept defined the same way in all subgroups?

    • Are all relevant “subdomains” included (none are missing)

  • Are any parts of the original concept inappropriate for some subgroups?


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Examples of Group Differences in Concept Definition: Depression

  • Mainstream concept expressed and reported via affect, somatic symptoms, behavior, thought patterns

  • In Asian Americans

    • public expression of self-reflection is discouraged

    • saving face and self-sacrifice are powerful forces in molding behavior and expression


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Overall Summary

  • Overall conceptual framework of research question is essential first step

    • Incorporating moderators, mediators, covariates

  • Need separate conceptual framework of any health or health-related measures

  • In diverse population studies, need to consider conceptual adequacy and equivalence


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