Sense of coherence and quality of life in patients treated with antivitamin k oral anticoagulants: a cross-sectional study

International Journal of Environmental Research and Public Health Article Sense of Coherence and Quality of Life in Patients Treated with Antivitamin K Oral Anticoagulants: A Cross-Sectional Study Ana Anguas-Gracia 1,2,3 , Ana Belén Subirón-Valera 1,3,4 , Beatriz Rodríguez-Roca 1,Ángel Gasch-Gallén1,5,* , Isabel Antón-Solanas 1,5,* and Fernando Urcola-Pardo 1,3   Citation: Anguas-Gracia, A.; Subirón-Valera, A.B.; Rodríguez-Roca, B.; Gasch-Gallén, Á.; Antón-Solanas, I.; Urcola-Pardo, F. Sense of Coherence and Quality of Life in Patients Treated with Antivitamin K Oral Anticoagulants: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2021,18, 1668. https://doi.org/10.3390/ ijerph18041668 Academic Editors: Laura Galiana, JoséManuel, Tomás Miguel, Amparo Oliver and Patrícia Sancho Received: 21 December 2020 Accepted: 5 February 2021 Published: 9 February 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; [email protected] (A.A.-G.); [email protected] (A.B.S.-V.); [email protected] (B.R.-R.); [email protected] (F.U.-P.) 2Research Group Safety and Care (GIISA0021), Institute of Research of Aragón, 50009 Zaragoza, Spain 3Research Group Water and Environmental Health (B43_20R), University Institute of Research in Environmental Science of Aragón, University of Zaragoza, 50009 Zaragoza, Spain 4Research Group Sector III Healthcare (GIIS081), Institute of Research of Aragón, 50009 Zaragoza, Spain 5Research Group Nursing Research in Primary Care in Aragón (GENIAPA) (GIIS094), Institute of Research of Aragón, 50009 Zaragoza, Spain *Correspondence: [email protected] (Á.G.-G.); [email protected] (I.A.-S.) Abstract: The aim of this study was to analyze the correlation between the participants’ self-reported quality of life and their sense of coherence in a sample (n= 85) of patients on treatment with oral antivitamin K anticoagulants. A cross-sectional design was used. The measurement instruments included a questionnaire on sociodemographic variables, the Spanish version of the Abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-BREF), an oral-anticoagulanttreatment-specific quality-of-life questionnaire, and the sense-of-coherence (SOC) scale. We analyzed the correlations between the participants’ characteristics and the results from the quality-of-life and SOC scales. Age, level of education, employment status, living arrangement, and treatment length were the determinants of the quality of life in people treated with oral anticoagulants. We found a significant association between the four domains of the WHOQOL-BREF questionnaire and general treatment satisfaction (p< 0.01); no significant correlations were found between the SOC subscales and the oral-anticoagulant-treatment-specific quality of life in our sample. Women had a worse level of self-management than men. Nursing interventions should be tailored to the needs of the populations on treatment with oral anticoagulants in order to facilitate a higher level of self-management. Keywords: quality of life; anticoagulants; primary healthcare; self-efficacy; sense of coherence 1. Introduction Antivitamin K oral anticoagulants (AKOA) function by reducing plasma concentrations of the vitamin-K-dependent proteins (FII, FVII, FIX, FX, protein C, and protein S) and are crucial in the pharmacological treatment of cardiac and thromboembolic disorders, as well as atrial fibrillation [ 1 ]. In Spain, the most frequently prescribed AKOA are warfarin and acenocoumarol. The prevalence of the use of AKOA in Spain is 1.3%, with no significant differences between men and women [ 2 ]. Patients on treatment with these AKOA are generally older adults, with an average age of 76 (SD 11.4) [3]. Almost three-quarters of this population (72%) are managed in the community by primary healthcare professionals. This requires frequent follow-up visits in order to guarantee clinical safety through dose adjustment and close monitoring of patients’ sensitivity to treatment [ 4 ]. For instance, concomitant treatment with AKOA and antiplatelets such as nintedanib may result in side effects, including gastrointestinal bleeding and perforation [ 5 ]. In these cases, individual assessments of bleeding risks involving therapeutic Int. J. Environ. Res. Public Health 2021,18, 1668. https://doi.org/10.3390/ijerph18041668 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 1668 2 of 15 drug monitoring should be carried out regularly. However, the effectiveness of treatment with AKOA is also influenced by other factors such as treatment adherence and diseasecoping strategies. Health education is an important tool in the management of patients on treatment with AKOA and should include information related to dietary, absorptive, compliance, and pharmacological factors [ 6 ]. Furthermore, a correlation has been found between optimal AKOA treatment control and patients’ illness perception; that is, patients who accept their illness and understand the treatment is more likely to achieve better international normalized ratio (INR) control [ 7 ]. However, disease chronicity, impact of the disease on daily life, and the presence of other comorbidities can lead to a reduced quality of life (QoL) in people treated with AKOA, as well as their closest relatives and caregivers [8]. According to the World Health Organization (WHO), the QoL is defined as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [ 9 ]. Appraising a patient’s QoL allows healthcare professionals to identify health dimensions at risk and also to design individualized interventions to maintain and/or improve the patient/caregiver QoL during treatment with AKOA [ 10 , 11 ]. In addition, according to Antonovsky [ 12 ], a self-efficacy approach to health can lead to an improvement in the patients’ understanding, self-management, and meaningfulness of their life, thus generating a higher level of health. According to Antonovsky’s salutogenic model [ 12 ], appropriate use of the resources available from the environment provides opportunities for patients to face challenges and recover from adversity; the ability to make appropriate use of these resources and, subsequently, act constructively through life events is known as the sense of coherence (SOC) [ 13 ]. A good SOC has been found to be positively related to better health outcomes across a range of patient populations, including patients with cardiac disorders [14,15]. Previous studies have identified a significant association between the QoL and SOC in a range of chronic pathologies, namely cancer [ 16 ]; end-stage renal disease [ 17 ]; and cardiovascular disorders, including patients undergoing angioplasty procedures [18] and those with chronic heart failure [ 19 ], atrial fibrillation [ 20 ], and congenital heart disease [ 21 ]. A positive correlation between the QoL and SOC has also been established in communitydwelling older people [ 22 , 23 ]. However, less is known about the relationship between the general and specific QoL and SOC, considering the specific QoL as a measurement of QoL in patients on long-term treatment with AKOA. Therefore, the aim of this study was to analyze the relationship between the general and specific QoL and SOC in patients on long-term treatment with AKOA. 2. Materials and Methods 2.1. Design A cross-sectional design was used to investigate the correlation between the general and specific QoL and SOC in a sample of patients on treatment with antivitamin KOA. 2.2. Participants and Study Location This study was carried out in a primary care center in the Zaragoza City Center, Spain, which serves a population of 32,862 adult inhabitants (16,659 men and 20,557 women). The target population comprised all the patients on treatment with AKOA (n= 244) who met the selection criteria. The sample size was determined following Mira Tamayo’s recommendations for the application of the Spanish version of the WHO quality-of-life scale (WHOQOL-BREF) [24], resulting in a minimum sample of 75 participants. A total of 85 patients on treatment with AKOA were recruited to participate in this study. The inclusion criteria to take part in this investigation were (1) community-dwelling adults (aged 18 or over), (2) on treatment with AKOA, (3) managed at the study location, (4) and adherent to treatment as measured by the Morisky Medication Adherence Scale in its Spanish version [ 25 ]. We excluded patients who had commenced treatment with Int. J. Environ. Res. Public Health 2021,18, 1668 3 of 15 AKOA less than 90 days before data collection, those who had difficulty communicating in Spanish, and those who refused to give informed consent. We did not exclude any patients based on the number of comorbidities. 2.3. Instruments of Data Collection We designed an ad hoc questionnaire on sociodemographic and clinical characteristics, including the following variables: sex, age, level of education, employment status, marital status, living arrangement, participation in housework activities, and time since treatment with AKOA. We used the Spanish version of the WHOQOL-BREF to measure the general QoL in our sample [ 26 ]. This scale comprises 24 items classified into four domains, namely physical, psychological, social relationships, and environmental QoL, and two questions to measure the respondents’ self-perceptions of their QoL (item 1) and of their general health (item 2). It is measured on a 5-point Likert scale, with higher scores indicating a higher self-perception of the QoL. The OA-treatment-specific QoL questionnaire was originally developed by Sawicki [ 27 ] in 1999 and was translated and validated for use in a Spanish population by Sánchez González et al. [ 28 ] in 2004. This tool measures the QoL in a population on treatment with OA and comprises 32 items divided into five dimensions: (1) treatment satisfaction, (2) self-management, (3) psychological distress, (4) limitations in daily activities, and (5) impact on social activities. The OA-treatment-specific QoL questionnaire is self-administered and is measured on a 6-point Likert scale, with response options ranging from 1 (total disagreement) to 6 (total agreement). Higher mean scores indicate a better QoL in dimensions 1 and 2, and lower mean scores indicate a worse QoL in dimensions 3, 4, and 5. This questionnaire showed good internal consistency for the total scale ( α = 0.82) and for each dimension separately [28]. The SOC scale is a self-assessment questionnaire originally developed by Antonovsky [ 29 ] to measure the global orientation of the personality, which facilitates an adaptive response to daily-life problems and stressful situations. In this study, we used the Spanish version of the SOC scale validated by Virués-Ortega et al. [ 30 ] in 2007. It consists of 13 items classified into three dimensions: (1) comprehensibility (5 items), (2) manageability (4 items), and (3) meaningfulness (4 items). This questionnaire is selfadministered, and it is measured on a 7-point Likert scale ranging from 1 (never or rarely) to 7 (very often or always). 2.4. Data Analysis A descriptive analysis was conducted using the mean and standard deviation (SD) for the quantitative variables and frequencies and percentages for the qualitative variables. The differences between groups were analyzed using Student’s t-test and Mann–Whitney U test, applying the Bonferroni correction for multiple comparisons. A correlation analysis of the measurement instruments, using the Pearson correlation coefficient, was applied. Finally, stepwise multiple regressions were performed in order to determine the relationship between the significant predictor values for each WHOQOL-BREF dimension. Data codification, processing, and analysis were completed using the software Statistical Package for the Social Science (SPSS) version 22 for Windows (IBM Corp., Chicago, IL, USA), accepting a level of significance of p< 0.05. 2.5. Ethical Considerations The investigation adhered to the principles outlined in the Declaration of Helsinki [ 31 ]. All the participants included in the study were informed about the study’s aims and procedures and gave their informed consent to participate. The research protocol was authorized by the directive managers of Aragón’s Primary Care Department and was approved by the Clinical Research Ethics Committee of Aragón (C.P.—C.I. PI18/0177). Int. J. Environ. Res. Public Health 2021,18, 1668 4 of 15 3. Results A total of 85 patients completed the questionnaires. The sociodemographic characteristics of our sample are described in Table 1. The majority of our participants were men (60%), with a mean age of 76.24 years (SD: 10.7 years). Nearly half of our participants were educated to the primary school level; the remaining participants were educated to the secondary school or university level, and only five of our patients said that they had not studied. Most of our patients were retired (90.6%), and just over half of our sample were married. With regard to their living arrangements, 22.4% of our patients lived alone, 43.5% lived with their partners, and 31.8% lived with relatives other than their partners. Almost half (47.1%) of our participants said that they contributed to housework tasks. The mean number of months on treatment with AKOA was 74.08 (SD: 62.53). Table 1. Sociodemographic characteristics (n= 85). Variable Category n(%) Sex Male 51 (60%) Female 34 (40%) Age Less than 80 years 44 (51.8%) 80 years or more 41 (48.2%) Level of education Primary school or below 47 (55.3%) Secondary school or above 38 (44.7%) Employment status Retired 77 (90.6%) Employed 8 (9.4%) Marital status Married 45 (52.9%) Single or widowed 40 (47.1%) Living arrangement Living with partner 37 (43.5%) Living alone or with relatives other than partner 48 (56.5%) Participation in housework Yes 40 (47.1%) No 45 (52.9%) Length of treatment with AKOA Less than 5 years 43 (50.6%) 5 years or more 42 (49.4%) The associations between the sociodemographic characteristics of our participants and the results from the WHOQOL-BREF questionnaire are presented in Table 2. We observed that the patients aged less than 80 years and those who were educated to at least the secondary school level presented a higher QoL in the physical domain (p< 0.01). A higher QoL in the psychological domain was observed in patients aged less than 80 years old (p< 0.01), married patients (p< 0.05), and those who lived with their partners (p< 0.01). People who were unemployed reported a lower QoL in the social domain (p< 0.05). In the environmental domain, the participants who were married (p< 0.05), those who did not perform any housework tasks (p< 0.05), and those who had been on treatment for less than five years presented a higher QoL (p< 0.05). It is important to note that after applying the Bonferroni correction, only the association between age and the QoL in the psychological domain remained significant. The results from the OA-treatment-specific QoL questionnaire are presented in Table 3 . We observed significant differences in the self-management domain, with better results for the men (p< 0.01), the participants who were educated to the secondary school level or above (p< 0.05), and those who were married (p< 0.05). The patients who lived with their partners, as opposed to those living alone or with relatives other than their partners, experienced fewer limitations in daily activities (p< 0.05). We did not find any significant differences between groups for the treatment satisfaction, impact on social activities, and psychological distress domains. After the Bonferroni correction, none of the associations remained significant. Int. J. Environ. Res. Public Health 2021,18, 1668 5 of 15 Table 4shows the results from the SOC scale. We found a significant association between the length of treatment with AKOA (less than five years) and the manageability (p< 0.01) and meaningfulness dimensions (p< 0.05). We did not identify any additional significant differences between groups in the manageability dimension. However, we observed that the patients who were aged 80 years or less achieved better results in the meaningfulness dimension (p< 0.01). Significant differences were observed in the comprehensibility dimension, with married patients (p< 0.05), those who lived with their partners (p< 0.01), and those who did not take part in housework tasks (p< 0.01) achieving better results. All of the associations remained significant with the exception of marital status–comprehensibility and treatment length–meaningfulness after the Bonferroni correction. We analyzed the correlations between the three questionnaires (Table 5). The four domains of the WHOQOL-BREF were associated with the OA-treatment-specific QoL questionnaire dimension treatment satisfaction. We did not find any significant associations between the WHOQOL-BREF and the SOC dimensions. We identified a positive correlation between the self-management domain from the OA-treatment-specific QoL questionnaire and the psychological domain from the WHOQOL-BREF questionnaire; self-management was also positively correlated with the comprehensibility dimension from the SOC scale. With regard to the impact on social activities, as measured by the OAtreatment-specific QoL questionnaire, we identified significant inverse correlations with the physical, psychological, and social WHOQOL-BREF domains and with the manageability and comprehensibility SOC subscales. Limitations in daily activities and psychological distress were inversely correlated with the four domains of the WHOQOL-BREF questionnaire and the three SOC subscales. We observed a significant positive association between the WHOQOL-BREF’s physical, psychological, and environmental domains and the SOC scale. Multivariate regression was performed to predict the values of each WHOQOL-BREF dimension (Table 6). For the physical domain, the significant equation was predicted by OA-treatment-specific QoL-General Treatment Satisfaction (GTS), SOC-Comp, level of education, SOC-Meaning, and SOC-Man (r 2 = 0.49), while the psychological domain equation was based on SOC-Comp, OA-treatment-specific QoL-Distress (OAQoL-D), and age (r 2 = 0.54). For the social domain, the significant equation was based on OAQoL-D and employment (r 2 = 0.25), and the predictor model for the environmental dimension was based on the values of SOC-Meaning, SOC-Comp, and OAQoL-GTS (r2= 0.30). Int. J. Environ. Res. Public Health 2021,18, 1668 6 of 15 Table 2. Associations between the participants’ sociodemographic characteristics and the results from the World Health Organization quality-of-life scale (WHOQOL-BREF) questionnaire. Variable Category n(%) WQ-Ph WQ-Psy WQ-Social WQ-Env Mean (SD) df ppBMean (SD) df ppBMean (SD) df pBCorrected Mean (SD) df ppB Sex 1Male 51 (60%) 13.17 (2.08) 83 0.08 0.48 14.56 (1.78) 83 0.14 0.70 13.15 (2.07) 83 0.15 0.72 14.73 (1.66) 83 0.71 0.99 Female 34 (40%) 12.18 (3.01) 13.88 (2.51) 13.88 (2.55) 14.59 (1.77) Age 1Less than 80 years 44 (51.8%) 13.36 (2.58) 83 0.025 0.18 14.89 (1.75) 83 0.006 0.047 13.73 (2.38) 83 0.23 0.87 14.86 (1.68) 83 0.28 0.93 80 years more 41 (48.2%) 12.14 (2.33) 13.64 (2.29) 13.14 (2.16) 14.46 (1.70) Level of education 1Primary school or below 47 (55.3%) 12.16 (2.76) 83 0.009 0.07 14.13 (2.34) 83 0.43 0.99 13.70 (2.35) 83 0.25 0.89 14.65 (1.81) 83 0.89 1 Secondary school or above 38 (44.7%) 13.53 (1.98) 14.49 (1.80) 13.12(2.18) 14.70 (1.57) Employment 2Retired 77 (9.4%) 12.55 (2.37) -0.08 0.49 14.18 (2.05) -0.28 0.92 13.23 (2.13) -0.029 0.20 14.58 (1.58) -0.22 0.86 Employed 8 (90.6%) 14.93 (3.14) 15.33 (2.52) 15.50 (2.85) 15.56 (2.53) Marital status 1Married 45 (52.9%) 13.17 (2.16) 83 0.13 0.67 14.80 (1.86) 83 0.017 0.13 13.36 (2.00) 83 0.74 115.04 (1.49) 83 0.030 0.21 Single or widowed 40 (47.1%) 12.33 (2.85) 13.72 (2.25) 13.53 (2.59) 14.25 (1.83) Living arrangement 1Living with partner 37 (43.5%) 13.24 (2.22) 83 0.13 0.67 14.97 (1.77) 83 0.008 0.06 13.51 (1.89) 83 0.79 115.05 (1.49) 83 0.06 0.39 Not living with partner 48 (56.5%) 12.42 (2.70) 13.76 (2.22) 13.39 (2.56) 14.28 (1.80) Participation in homework activities 1 Yes 40 (47.1%) 12.54 (2.29) 83 0.43 0.98 13.92 (1.78) 83 0.12 0.64 13.00 (2.33) 83 0.09 0.52 14.28 (1.64) 83 0.042 0.29 No 45 (52.9%) 12.98 (2.73) 14.62 (2.34) 13.84 (2.19) 15.02 (1.68) Treatment length 1Less than 5 years 43 (50.6%) 13.18 (2.80) 83 0.13 0.67 14.70 (1.94) 83 0.07 0.44 13.83 (2.54) 83 0.11 0.61 15.07 (1.75) 83 0.027 0.19 5 years or more 42 (49.4%) 12.35 (2.16) 13.87 (2.22) 13.05 (1.94) 14.26 (1.55) Total 85 (100%) 12.77 (2.52) - 14.29 (2.11) - 13.44 (2.28) - 14.67 (1.69) - 1 Student’s t-test; 2 Mann–Whitney’s U test; WQ-Ph: physical domain; WQ-Psy: psychological domain; WQ-Social: social domain; WQ-Env: environmental domain; p: raw p-value; p B :p-value after the Bonferroni correction. Int. J. Environ. Res. Public Health 2021,18, 1668 7 of 15 Table 3. Associations between the participants’ sociodemographic characteristics and the results from the oral anticoagulant (OA)-treatment-specific QoL questionnaire. Variable Category n(%) Treatment Satisfaction Self-Management Psychological Distress Limitations in Daily Activities Impact on Social Activities Mean (SD) df ppBMean (SD) df ppBMean (SD) df ppBMean (SD) df ppBMean (SD) df ppB Sex 1Male 51 (60%) 4.79 (0.76) 83 0.25 0.89 4.71 (0.61) 83 0.009 0.069 1.96 (0.66) 83 0.94 12.09 (0.67) 83 0.12 0.64 3.00 (0.66) 83 0.10 0.57 Female 34 (40%) 4.57 (0.96) 4.26 (0.93) 1.97 (0.90) 2.36 (0.92) 3.30 (0.99) Age 1Less than 80 years 44 (51.8%) 4.77 (0.86) 83 0.42 0.98 4.48 (0.88) 83 0.55 0.99 2.02 (0.75) 83 0.48 0.99 2.26 (0.79) 83 0.44 0.99 3.11 (0.75) 83 0.93 1 80 years or more 41 (48.2%) 4.63 (0.82) 4.58 (0.66) 1.90 (0.77) 2.13 (0.78) 3.13 (0.88) Level of education 1 Primary school or below 47 (55.3%) 4.70 (0.87) 83 0.99 14.36 (0.92) 83 0.029 0.21 2.04 (0.86) 83 0.28 0.92 2.10 (0.72) 83 0.21 0.85 3.04 (0.85) 83 0.32 0.95 Secondary school or above 38 (44.7%) 4.70 (0.82) 4.73 (0.51) 1.87 (0.61) 2.32 (0.85) 3.22 (0.76) Employment 2Retired 77 (9.4%) 4.71 (0.82) - 0.87 14.49 (0.80) - 0.15 0.72 1.99 (0.78) - 0.39 0.98 2.18 (0.75) - 0.60 0.99 3.08 (0.82) - 0.26 0.91 Employed 8 (90.6%) 4.60 (1.14) 4.91 (0.40) 1.70 (0.49) 2.43 (1.09) 3.47 (0.73) Marital status 1Married 45 (52.9%) 4.75 (0.73) 83 0.57 0.99 4.68 (0.58) 83 0.049 0.33 1.97 (0.62) 83 0.93 12.10 (0.78) 83 0.19 0.81 3.02 (0.74) 83 0.23 0.88 Single or widowed 40 (47.1%) 4.65 (0.96) 4.35 (0.93) 1.96 (0.90) 2.32 (0.78) 3.24 (0.89) Living arrangement 1 Living with partner 37 (43.5%) 4.83 (0.72) 83 0.19 0.81 4.67 (0.61) 83 0.12 0.64 1.95 (0.60) 83 0.90 11.98 (0.63) 83 0.020 0.14 2.95 (0.71) 83 0.09 0.53 Not living with partner 48 (56.5%) 4.60 (0.92) 4.42 (0.88) 1.97 (0.87) 2.37 (0.85) 3.25 (0.87) Participation in housework tasks 1 Yes 40 (47.1%) 4.63 (0.95) 83 0.49 0.99 4.38 (0.91) 83 0.10 0.57 2.09 (0.90) 83 0.14 0.70 2.36 (0.82) 83 0.07 0.44 3.19 (0.88) 83 0.49 0.99 No 45 (52.9%) 4.76 (0.74) 4.66 (0.62) 1.84 (0.58) 2.05 (0.73) 3.06 (0.76) Treatment length 1Less than 5 years 43 (50.6%) 4.74 (0.90) 83 0.64 0.99 4.42 (0.92) 83 0.20 0.83 1.86 (0.64) 83 0.19 0.81 2.12 (0.78) 83 0.36 0.97 3.09 (0.82) 83 0.69 0.99 5 years or more 42 (49.4%) 4.66 (0.79) 4.64 (0.60) 2.07 (0.85) 2.28 (0.78) 3.16 (0.81) Total 85 (100%) 4.70 (0.84) - 4.53 (0.78) - 1.96 (0.76) - 2.20 (0.78) - 3.12 (0.81) - 1Student’s t-test; 2Mann–Whitney’s U test; p: raw p-value; pB:p-value after the Bonferroni correction. Int. J. Environ. Res. Public Health 2021,18, 1668 8 of 15 Table 4. Associations between the participants’ sociodemographic characteristics and the results from the sense-of-coherence (SOC) scale. Variable Category n(%) SOC-Manageability SOC-Comprehensibility SOC-Meaningfulness Mean (SD) df ppBMean (SD) df ppBMean (SD) df ppB Sex 1Male 51 (60%) 5.14 (0.86) 83 0.79 1 5.08 (0.90) 83 0.06 0.39 5.09 (0.83) 83 1 1 Female 34 (40%) 5.08 (1.16) 4.67 (1.05) 5.09 (1.93) Age 1Less than 80 years 44 (51.8%) 5.12 (0.88) 83 0.96 1 4.84 (1.06) 83 0.45 0.99 5.37 (0.88) 83 0.003 0.024 80 years or more 41 (48.2%) 5.11 (1.09) 5.00 (0.89) 4.79 (0.85) Level of education 1Primary school or below 47 (55.3%) 5.15 (1.10) 83 0.71 0.99 4.91 (1.11) 83 0.98 1 4.94 (0.90) 83 0.09 0.53 Secondary school or above 38 (44.7%) 5.07 (0.82) 4.92 (0.80) 5.27 (0.90) Employment 2Retired 77 (9.4%) 5.13 (1.00) -0.59 0.99 4.92 (0.97) -0.99 1 5.05 (0.87) -0.11 0.61 Employed 8 (90.6%) 5.00 (0.83) 4.88 (1.10) 5.50 (1.23) Marital status 1Married 45 (52.9%) 5.19 (0.94) 83 0.43 0.98 5.16 (0.80) 83 0.014 0.11 5.24 (0.74) 83 0.11 0.61 Single or widowed 40 (47.1%) 5.03 (1.03) 4.65 (1.09) 4.92 (1.05) Living arrangement 1Living with partner 37 (43.5%) 5.22 (0.99) 83 0.38 0.97 5.26 (0.76) 83 0.003 0.024 5.07 (0.68) 83 0.89 1 Not living with partner 48 (56.5%) 5.03 (0.98) 4.65 (1.05) 5.10 (1.06) Participation in housework tasks 1Yes 40 (47.1%) 4.99 (0.93) 83 0.29 0.93 4.61 (1.06) 83 0.005 0.039 5.19 (0.84) 83 0.34 0.96 No 45 (52.9%) 5.22 (1.02) 5.20 (0.81) 5.00 (0.97) Treatment length 1Less than 5 years 43 (50.6%) 5.40 (1.03) 83 0.006 0.047 5.07 (1.06) 83 0.15 0.73 5.31 (0.91) 83 0.023 0.17 5 years or more 42 (49.4%) 4.82 (0.85) 4.76 (0.87) 4.86 (0.86) Total 85 (100%) 5.11 (0.98) - 4.92 (0.98) - 5.09 (0.91) - 1Student’s t-test; 2Mann–Whitney’s U test; p: raw p-value; pB:p-value after the Bonferroni correction. Int. J. Environ. Res. Public Health 2021,18, 1668 9 of 15 Table 5. Pearson’s correlations between the assessed dimensions. WQ-Ph WQ-Psy WQSocial WQ-Env OAQoLGTS OAQoL-SE OAQoLSSN OAQoLDH OAQoL-D SOC-Man SO-Comp SOMeaning WQ-Ph - WQ-Psy 0.601 ** - WQ-Social 0.429 ** 0.500 ** - WQ-Env 0.575 ** 0.634 ** 0.534 ** - OAQoL-GTS 0.453 ** 0.299 ** 0.356 ** 0.303 ** - OAQoL-SE 0.263 * 0.176 0.043 0.143 0.025 - OAQoL-SSN −0.349 ** −0.231 * −0.253 * −0.184 −0.535 ** −0.090 - OAQoL-DH −0.322 ** −0.341 ** −0.314 ** −0.261 * −0.647 ** −0.161 0.660 ** - OAQoL-D −0.395 ** −0.509 ** −0.363 ** −0.322 ** −0.571 ** 0.059 0.557 ** 0.688 ** - SOC-Man 0.232 * 0.458 ** 0.187 0.257 * 0.178 0.057 −0.405 ** −0.398 ** −0.384 ** - SOC-Comp 0.436 ** 0.524 ** 0.253 * 0.383 ** 0.126 0.357 ** −0.256 * −0.364 ** −0.249 * 0.663 ** - SOC-Meaning 0.373 ** 0.431 ** 0.185 0.392 ** 0.087 −0.041 −0.076 −0.072 −0.253 * 0.340 ** 0.251 * - WQ-Ph: physical domain; WQ-Psy: psychological domain; WQ-Social: social domain; WQ-Env: environmental domain; OAQoL-GTS: general treatment satisfaction; OAQoL-SE: self-efficacy; OAQoL-SSN: strained social network; OAQoL-DH: daily hassles; OAQoL-D: distress; SOC-Man: manageability; SOC-Comp: comprehensibility; SOC-Meaning: meaningfulness; * p< 0.05; ** p< 0.01.