Evaluación evolutiva de la salud percibida según las etapas del cambio del modelo transteórico en el tabaquismo

OBJETIVO: Evaluar la salud percibida en fumadores de cigarrillos según las etapas del cambio. METODOLOGIA: Se estudiaron 253 personas mediante el cuestionario de salud SF-36 cada 6 meses durante dos años. RESULTADOS: Después del abandono del tabaco mejora la Evolución Declarada de la Salud y las percepciones de salud del componente físico y mental. Los fumadores que siguen fumando pero progresan en las etapas del cambio experimentan un descenso en Función Física, Salud General y en el Componente Sumario Físico. La recaída en el tabaquismo se asocia a peor Vitalidad y Salud Mental, y a considerar el consumo de tabaco como causa del deterioro actual de la salud. CONCLUSIONES: Se observa una peor percepción de salud física al plantearse el abandono del consumo de tabaco a medio plazo, una mejoría global de la salud percibida al dejar de fumar y una peor salud emocional en la recaída.

Arterial access through the right subclavian artery in surgery of the aortic arch improves neurologic outcome and mid-term quality of life

BACKGROUND: We have shown that selective antegrade cerebral perfusion improves mid-term quality of life in patients undergoing surgical repair for acute type A aortic dissection and aortic aneurysms. The aim of the study was to assess the impact of continuous cerebral perfusion through the right subclavian artery on immediate outcome and quality of life. METHODS: Perioperative data of 567 consecutive patients who underwent surgery of the aortic arch using deep hypothermic circulatory arrest have been analyzed. Patients were divided into three groups, according to the management of cerebral protection. Three hundred eighty-seven patients (68.3%) had deep hypothermic circulatory arrest with pharmacologic protection with pentothal only, 91 (16.0%) had selective antegrade cerebral perfusion and pentothal, and 89 (15.7%) had continuous cerebral perfusion through the right subclavian artery and pentothal. All in-hospital data were assessed, and quality of life was analyzed prospectively 2.4 +/- 1.2 years after surgery with the Short Form-36 Health Survey Questionnaire. RESULTS: Major perioperative cerebrovascular injuries were observed in 1.1% of the patients with continuous cerebral perfusion through the right subclavian artery, compared with 9.8% with selective antegrade cerebral perfusion (p < 0.001) and 6.5% in the group with no antegrade cerebral perfusion (p = 0.007). Average quality of life after an arrest time between 30 and 50 minutes with continuous cerebral perfusion through the right subclavian artery was significantly better than selective antegrade cerebral perfusion (90.2 +/- 12.1 versus 74.4 +/- 40.7; p = 0.015). CONCLUSIONS: Continuous cerebral perfusion through the right subclavian artery improves considerably perioperative brain protection during deep hypothermic circulatory arrest. Irreversible perioperative neurologic complications can be significantly reduced and duration of deep hypothermic circulatory arrest can be extended up to 50 minutes without impairment in quality of life.

Level of incongruence during cardiac rehabilitation and prediction of future CVD-related hospitalizations plus all-cause mortality

Independent of traditional risk factors, psychosocial risk factors increase the risk of cardiovascular disease (CVD). Studies in the field of psychotherapy have shown that the construct of incongruence (meaning a discrepancy between desired and achieved goals) affects the outcome of therapy. We prospectively measured the impact of incongruence in patients after undergoing a cardiac rehabilitation program. We examined 198 CVD patients enrolled in a 8–12 week comprehensive cardiac rehabilitation program. Patients completed the German short version of the Incongruence Questionnaire and the SF-36 Health Questionnaire to measure quality of life (QoL) at discharge of rehabilitation. Endpoints at follow-up were CVD-related hospitalizations plus all-cause mortality. During a mean follow-up period of 54.3 months, 29 patients experienced a CVD-related hospitalization and 3 patients died. Incongruence at discharge of rehabilitation was independent of traditional risk factors a significant predictor for CVD-related hospitalizations plus all-cause mortality (HR 2.03, 95% CI 1.29–3.20, p = .002). We also found a significant interaction of incongruence with mental QoL (HR .96, 95% CI .92–.99, p = .027), i.e. incongruence predicted poor prognosis if QoL was low (p = .017), but not if QoL was high (p = .74). Incongruence at discharge predicted future CVD-related hospitalizations plus all-cause mortality and mental QoL moderated this relationship. Therefore, incongruence should be considered for effective treatment planning and outcome measurement.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

BACKGROUND & AIMS Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis. METHODS We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures. RESULTS A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups. CONCLUSIONS Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.

Quality of life instruments in studies of menorrhagia: a systematic review

BACKGROUND: The use of quality of life (QoL) instruments in menorrhagia research is increasing but there is concern that not enough emphasis is placed on patient-focus in these measurements, i.e. on issues which are of importance to patients and reflect their experiences and concerns (clinical face validity). The objective was to assess the quality of QoL instruments in studies of menorrhagia. STUDY DESIGN: A systematic review of published research. Papers were identified through MEDLINE (1966-April 2000), EMBASE (1980-April 2000), Science Citation Index (1981-April 2000), Social Science Citation Index (1981-April 2000), CINAHL (1982-1999) and PsychLIT (1966-1999), and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with menorrhagia for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for quality of their QoL instruments, using a 17 items checklist including 10 items for clinical face validity (issues of relevance to patients' expectations and concerns) and 7 items for measurement properties (such as reliability, responsiveness, etc.). RESULTS: A total of 19 articles, 8 on instrument development and 11 on application, were included in the review. The generic Short Form 36 Health Survey Questionnaire (SF36) was used in 12/19 (63%) studies. Only two studies developed new specific QoL instruments for menorrhagia but they complied with 7/17 (41%) and 10/17 (59%) of the quality criteria. Quality assessment showed that only 7/19 (37%) studies complied with more than half the criteria for face validity whereas 17/19 (90%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). CONCLUSION: Among existing QoL instruments, there is good compliance with the quality criteria for measurement properties but not with those for clinical face validity. There is a need to develop methodologically sound disease specific QoL instruments in menorrhagia focussing both on face validity and measurement properties.

Quality of life instruments in studies of menorrhagia: a systematic review

BACKGROUND: The use of quality of life (QoL) instruments in menorrhagia research is increasing but there is concern that not enough emphasis is placed on patient-focus in these measurements, i.e. on issues which are of importance to patients and reflect their experiences and concerns (clinical face validity). The objective was to assess the quality of QoL instruments in studies of menorrhagia. STUDY DESIGN: A systematic review of published research. Papers were identified through MEDLINE (1966-April 2000), EMBASE (1980-April 2000), Science Citation Index (1981-April 2000), Social Science Citation Index (1981-April 2000), CINAHL (1982-1999) and PsychLIT (1966-1999), and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with menorrhagia for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for quality of their QoL instruments, using a 17 items checklist including 10 items for clinical face validity (issues of relevance to patients' expectations and concerns) and 7 items for measurement properties (such as reliability, responsiveness, etc.). RESULTS: A total of 19 articles, 8 on instrument development and 11 on application, were included in the review. The generic Short Form 36 Health Survey Questionnaire (SF36) was used in 12/19 (63%) studies. Only two studies developed new specific QoL instruments for menorrhagia but they complied with 7/17 (41%) and 10/17 (59%) of the quality criteria. Quality assessment showed that only 7/19 (37%) studies complied with more than half the criteria for face validity whereas 17/19 (90%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). CONCLUSION: Among existing QoL instruments, there is good compliance with the quality criteria for measurement properties but not with those for clinical face validity. There is a need to develop methodologically sound disease specific QoL instruments in menorrhagia focussing both on face validity and measurement properties.

Sex differences in quality of life in stroke survivors. Data from the Tinzaparin in Acute Ischaemic Stroke Trial (TAIST)

Introduction: Female sex is predictive of poor functional outcome in stroke, even after correction for prognostic factors. Poor quality of life (QoL) is observed in stroke survivors, with lower scores seen in the most disabled patients. We used data from the TAIST trial to assess the relationship between sex and QoL after ischaemic stroke. Methods: TAIST was a randomised controlled trial assessing the safety and efficacy of tinzaparin versus aspirin in 1,484 patients with acute ischaemic stroke. QoL was measured at 180 days post randomisation using the short-form 36 health survey which assesses QoL across eight domains. The relationship between sex and each domain was assessed using ordinal regression, both unadjusted and adjusted for key prognostics factors. Results: Of the 1,484 patients randomised into TAIST, 216 had died at 180 days post randomisation. 1,268 survivors were included in this analysis, 694 males (55%), 574 females (45%). Females tended to score lower than males across all QoL domains (apart from general health); statistically significant lower scores were seen for physical functioning (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72), vitality (OR 0.79, 95% CI 0.64-0.98) and mental health (OR 0.75, 95% CI 0.61-0.93). The results for physical functioning and mental health remained significant after adjustment for prognostic variables (OR 0.73, 95% CI 0.58-0.92; OR 0.76, 95% CI 0.60-0.95 respectively). Conclusions: QoL, in particular physical function and mental health domains, is lower in female patients after stroke. This difference persists even after correction for known prognostic factors such as age and stroke severity.

Avaliação dos problemas músculo-esqueléticos como preditores do estado de saúde em atletas de hóquei em patins

OBJETIVOS: Avaliar a prevalência de problemas músculo-esqueléticos (PM-E) em atletas praticantes de Hóquei em Patins (HP); comparar e correlacionar o estado de saúde (ES), o grau de dificuldade sentida no desempenho do HP e a intensidade da dor com os PM-E; estimar as diferentes contribuições dos PM-E para a variação no ES, grau de dificuldade sentida no desempenho do HP e a intensidade da dor. MATERIAIS E MÉTODOS: Foram inquiridos 289 atletas, a competir nos campeonatos nacionais e locais de HP em Portugal na época 2011/2012. Foi registada a prevalência de PM-E e o seu impacto no ES dos atletas nos últimos 12 meses. Todos os participantes responderam a um Questionário de PM-E relativo a 10 regiões anatómicas e ao Short Form-36 Health Survey Questionnaire. RESULTADOS: As áreas com maior prevalência de PM-E são o punho/mãos (31.1%), ancas/coxas (24.6%) e região lombar (24.2%). Grande parte dos atletas que reportaram problemas, apesar de experienciarem dor e limitação durante a sua participação, não interromperam a prática desportiva. As queixas físicas são prevalentes entre os atletas que reportaram PM-E e, predominantemente, resultantes de lesões por sobrecarga. Os PM-E afetaram as subescalas mais relacionadas com a dimensão física da saúde (p ≤ 0.05), diminuíndo, na generalidade, o ES dos atletas. Esta diminuição foi acompanhada de um aumento da dificuldade sentida no desempenho do HP e da intensidade de dor. A análise de regressão múltipla stepwise revelou que os PM-E explicam 1.4% a 28% da variância dos resultados das subescalas do ES. Quanto ao grau médio de dificuldade no desempenho do HP, os PM-E explicam 27.1% da variância dos resultados, assim como, explicam 21.3% da variância dos resultados da intensidade média de dor. CONCLUSÃO: Os PM-E são prevalentes em atletas praticantes de HP e estão associados a um menor ES, a um aumento da dificuldade no desempenho do HP e uma maior intensidade de dor; estes explicam uma proporção moderada da variação no ES, grau de dificuldade sentida no desempenho do HP e intensidade de dor. A ocorrência de problemas ao longo da época, diminuíu o rendimento e a participação desportiva, estendendo-se, estas limitações, para além do terreno de jogo, interferindo com as atividades diárias dos atletas.

Health and demographic characteristics of respondents in an Australian national sexuality survey: comparison with population norms

Study objective: To assess the representativeness of survey participants by systematically comparing volunteers in a national health and sexuality survey with the Australian population in terms of self reported health status (including the SF-36) and a wide range of demographic characteristics. Design: A cross sectional sample of Australian residents were compared with demographic data from the 1996 Australian census and health data from the 1995 National Health Survey. Setting: The Australian population. Participants: A stratified random sample of adults aged 18-59 years drawn from the Australian electoral roll, a compulsory register of voters. Interviews were completed with 1784 people, representing 40% of those initially selected (58% of those for whom a valid telephone number could be located). Main results: Participants were of similar age and sex to the national population. Consistent with prior research, respondents had higher socioeconomic status, more education, were more likely to be employed, and less likely to be immigrants. The prevalence estimates, means, and variances of self reported mental and physical health measures (for example, SF-36 subscales, women's health indicators, current smoking status) were similar to population norms. Conclusions: These findings considerably strengthen inferences about the representativeness of data on health status from volunteer samples used in health and sexuality surveys.

Health Related Quality of Life after Childhood Cancer - A Finnish Nationwide survey

The purpose of this Finnish epidemiological nationwide cross-sectional study was to evaluate the Health Related Quality of Life (HRQL) of young people that have survived childhood cancer at least four years after cancer diagnosis. The study aims were (1) to increase knowledge and understanding about the relationship between childhood cancer and its treatment and HRQL of childhood cancer survivors and (2) to identify survivors who need and could benefit from ongoing long-term follow-up, as well as (3) to identify what kind of aftercare the childhood cancer survivors will possibly need. HRQL and fatigue of currently still young survivors of extracranial childhood malignancies were evaluated with self-reports and parent proxy reports. HRQL was measured with age-appropriate generic instruments: PedsQL™, SF-36, 15D, 16D and 17D. Fatigue for children and adolescents aged below 18 years was measured with the PedsQL™ Multidimensional Fatigue Scale Finnish version. PedsQL™ parent-proxy and the PedsQL™ Multidimensional Fatigue Scale Parentproxy instruments were used to assess the perception of the parents on HRQL and fatigue of their children and adolescents. Postal-survey questionnaires were mailed to 852 childhood cancer survivors aged 11-27 years and their randomly selected gender-, age and living-place matched controls, as well as under 18-year-old children´s parents. A total of 474 survivors, 595 controls, 209 survivor’s parent and 253 control’s parent replied. The mean age of survivors at the time of the study was 18.4 years. The mean length of survival was 12.3 years, and the mean age at diagnosis 5.5 years. The most of the Finnish childhood cancer survivors evaluated that their HRQL as good. Survivors rated their HRQL equal or higher than their controls. The only dimension where the survivors scored poorer than the controls was the 15D mobility dimension. Survivors of childhood cancer did not suffer from significant fatigue. There were subgroups of childhood cancer survivors who had poorer level of HRQL, and suffered from fatigue more than the reference group. The demographic factors that associated with poorer HRQL were female gender, greater weight, living alone, need of remedial education, an additional non-cancer diagnosis, survivors with siblings, and self-reported unhappiness. Disease-related factors that associated with poorer HRQL were higher age at the time of diagnosis, the diagnosis of Wilms tumor, neuroblastoma, or osteosarcoma, and treatment with stem cell transplantation. The factors associated with more fatigue in survivors were male gender, older age at evaluation, the need of remedial education at school, lower overall average grade in the latest school marks report, length of survival more than 10 years, lower HRQL-scores, and a sarcoma diagnosis. However, all the used demographic and disease related factors explained only about one third of the variation in the HRQL scores. In open questions, the survivors were most worried about their physical health, but were also worried about their mental health, cancer inheritance, late-effects, and fertility and relapse issues. It seems that there are subgroups of survivors who need and could benefit from ongoing long-term follow-up. In the future, the survivors of childhood cancer need more information about their physical and mental health, as well as on their cancer inheritance, possible late-effects including fertility issues, and on the risk of relapse.

Iron deficiency, general health and fatigue: Results from the Australian Longitudinal Study on Women's Health

Associations between self-reported 'low iron', general health and well-being, vitality and tiredness in women, were examined using physical (PCS) and mental (MCS) component summary and vitality (VT) scores from the MOS short-form survey (SF-36). 14,762 young (18-23 years) and 14,072 mid-age (45-50 years) women, randomly selected from the national health insurance commission (Medicare) database, completed a baseline mailed self-report questionnaire and 12,328 mid-age women completed a follow-up questionnaire 2 years later. Young and mid-age women who reported (ever) having had 'low iron' reported significantly lower mean PCS, MCS and VT scores, and greater prevalence of 'constant tiredness' at baseline than women with no history of iron deficiency [Differences: young PCS = -2.2, MCS = -4.8, VT = -8.7; constant tiredness: 67% vs. 45%; mid-age PCS = -1.4, MCS = -3.1, VT = -5.9; constant tiredness: 63% vs. 48%]. After adjusting for number of children, chronic conditions, symptoms and socio-demographic variables, mean PCS, MCS and VT scores for mid-age women at follow-up were significantly lower for women who reported recent iron deficiency (in the last 2 years) than for women who reported past iron deficiency or no history of iron deficiency [Means: PCS - recent = 46.6, past = 47.8, never = 47.7; MCS - recent = 45.4, past = 46.9, never = 47.4; VT - recent = 54.8, past = 57.6, never = 58.6]. The adjusted mean change in PCS, MCS and VT scores between baseline and follow-up were also significantly lower among mid-age women who reported iron deficiency only in the last 2 years (i.e. recent iron deficiency) [Mean change: PCS = -3.2; MCS = -2.1; VT = -4.2]. The results suggest that iron deficiency is associated with decreased general health and well-being and increased fatigue.

A note on the decomposition of the health concentration index

In recent work, the concentration index has been widely used as a measure of income-related health inequality. The purpose of this note is to illustrate two different methods for decomposing the overall health concentration index using data collected from a Short Form (SF-36) survey of the general Australian population conducted in 1995. For simplicity, we focus on the physical functioning scale of the SF-36. Firstly we examine decomposition 'by component' by separating the concentration index for the physical functioning scale into the ten items on which it is based. The results show that the items contribute differently to the overall inequality measure, i.e. two of the items contributed 13% and 5%, respectively, to the overall measure. Second, to illustrate the 'by subgroup' method we decompose the concentration index by employment status. This involves separating the population into two groups: individuals currently in employment; and individuals not currently employed. We find that the inequality between these groups is about five times greater than the inequality within each group. These methods provide insights into the nature of inequality that can be used to inform policy design to reduce income related health inequalities. Copyright (C) 2002 John Wiley Sons, Ltd.

The effect of early virological response in health-related quality of life in HCV-infected patients

Twenty-nine HCV-infected patients were treated with pegylated interferon alpha. Diagnosis was based on serum HCV RNA-PCR positive results and liver biopsy. All patients had elevated serum levels of alanine aminotransferase at the time of the study, but liver disease was compensated. Patients were evaluated at baseline treatment and after 4 and 12 weeks of antiviral treatment with the Medical Outcomes Study 36-item Short-Form Health Survey. The Mini-International Neuropsychiatric Interview was used to exclude previous or current psychiatric diagnoses. Both patients and psychiatrists were blind to the HCV RNA status, and serum HCV RNA test results only became available after the visit at week 12. After antiviral treatment, 16 patients (55.2%) were classified as nonresponders and 13 (44.8%) were classified as responders. When compared to nonresponders, responders had a greater improvement in the HRQOL scores for the mental health domain (P<.019). Differences in other domains were not significant. The present study confirms that active viral infection is one possible reason for the poor Health-Related Quality of Life in this population.

Validação do "King's Health Questionnaire" para o português em mulheres com incontinência urinária

OBJETIVO: Traduzir e adaptar para o português o questionário de qualidade de vida denominado "King's Health Questionnaire" (KHQ) em mulheres com incontinência urinária. MÉTODOS: Cientes dos objetivos da pesquisa científica, dois tradutores brasileiros prepararam duas versões do KHQ para o português, as quais foram retro-traduzidas por outros dois tradutores ingleses. As diferenças foram harmonizadas e pré-testadas em um estudo piloto. As versões finais do KHQ e de outro questionário, o "Short-Form Health Survey" (SF-36), já vertido e publicado em português, foram simultaneamente administradas a 156 e 119 pacientes, respectivamente. Foram testadas as propriedades psicométricas do KHQ como confiabilidade (consistência interna e teste-reteste) e validade de constructo. O reteste foi realizado em um período de duas semanas, a partir da primeira entrevista. RESULTADOS: O processo de adaptação cultural não alterou a versão em português do KHQ comparado ao original, exceto no modo de administração para pacientes com baixo grau de alfabetização. Neste caso, o questionário mudou de auto-avaliação para ser lido para as pacientes durante entrevista com o pesquisador. Para as outras pacientes, o KHQ foi auto-administrado. O alfa de Cronbach padronizado do KHQ foi de 0,87 e avaliado por seus domínios variou de 0,49 a 0,92. A confiabilidade, medida pelo índice de correlação intraclasses (ICC) foi considerada de moderada a forte em todos os domínios e na escala de medidas de gravidade, variando de 0,53 a 0,81. O coeficiente de correlação de Pearson entre o KHQ e o SF-36 foi considerado de fraco a moderado na maioria dos domínios afins, variando de -0,27 a -0,53. CONCLUSÕES: A versão para o português do KHQ, traduzida e adaptada para seu uso em mulheres brasileiras com queixas de incontinência urinária. Representa um importante instrumento para a avaliação de mulheres incontinentes em pesquisa clínica.

Health-related quality of life and working conditions among nursing providers

OBJECTIVE: To evaluate working conditions associated with health-related quality of life (HRQL) among nursing providers. METHODS: Cross-sectional study conducted in a university hospital in the city of São Paulo, Southeastern Brazil, during 2004-2005. The study sample comprised 696 registered nurses, nurse technicians and nurse assistants, predominantly females (87.8%), who worked day and/or night shifts. Data on sociodemographic information, working and living conditions, lifestyles, and health symptoms were collected using self-administered questionnaires. The following questionnaires were also used: Job Stress Scale, Effort-Reward Imbalance (ERI) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Ordinal logistic regression analysis using proportional odds model was performed to evaluate each dimension of the SF-36. RESULTS: Around 22% of the sample was found to be have high strain and 8% showed an effort-reward imbalance at work. The dimensions with the lowest mean scores in the SF-36 were vitality, bodily pain and mental health. High-strain job, effort-reward imbalance (ERI>1.01), and being a registered nurse were independently associated with low scores on the role emotional dimension. Those dimensions associated to mental health were the ones most affected by psychosocial factors at work. CONCLUSIONS: Effort-reward imbalance was more associated with health than high-strain (high demand and low control). The study results suggest that the joint analysis of psychosocial factors at work such as effort-reward imbalance and demand-control can provide more insight to the discussion of professional roles, working conditions and HRQL of nursing providers.