ContextPeople with mental disorders can acquire long-term disabilities, which could impair their functioning and quality of life (QoL), requiring permanent care and social support. Systematic data on QoL and functioning, which could support a better management of these people, were not available.ObjectiveTo analyze the QoL, level of functioning and their association with sociodemographic and clinical factors of people with mental disorders who underwent deinstitutionalization using assisted living facilities.MethodsA Cross-sectional study was conducted between July 2018 and July 2019, through interviews (...) using the World Health Organization Quality of Life (WHOQOL-BREF) to determine the QoL scores, and the World Health Organization Disability Assessment Schedule (WHODAS 2.0) to determine the level of functioning. All adults (≥18 years old) with mental disorders, who underwent deinstitutionalization, users of assisted living facilities and assisted by the Psychosocial Assistance Centers III, in a city in the state of São Paulo, Brazil, were selected. For statistical analysis of the associated factors, Student’st-test was used for dichotomous variables and ANOVA for polynomial variables. Pearson correlation coefficient was used to measure the association between QoL and functioning scores.ResultsOut of 359 people who underwent deinstitutionalization with mental disorders, 147 met the eligibility criteria. The mean total score for the WHOQOL-BREF was 66.5 ± 13.4 and the mean score for WHODAS 2.0 was 10.4 ± 7.6. An association was found between people who were studying (n= 65.8; 95%CI, 63.5–68.1vs. n= 73.9; 95%CI, 67.5–80.3;p= 0.04) and better WHOQOL-BREF QoL scores or WHODAS 2.0 levels of functioning (n= 10.9; 95%CI, 9.6–12.2vs. n= 5.1; 95%CI, 2.5–7.7;p= 0.01). A weak negative correlation (r= 0.41) emerged between higher QoL scores and functioning improvement.ConclusionThis study indicates that the QoL of the sample is associated by their functioning levels, which, in turn, may reflect on their social interactions. Public policies that favor interventions increasing socialization of this population can result in better health outcomes. The QoL and functioning scores provide valuable insights to develop public policies more suited to this population profile. (shrink)

In recent years, there has been a growing emphasis on researching quality of life,particularly within families that include members with disabilities. Family Quality ofLife (FQOL) has gained prominence in special education as researchers seek to understandand improve the well-being of these families. This study aims to present findingson the quality of life of parents raising children with disabilities.Using a quantitative research approach and the validated BCFQOL tool, wesurveyed 205 parents. The results were unexpectedly positive, showing generally higherlevels (...) of quality of life among participants. However, challenges were identified in specificdimensions such as “Emotional well-being,” and “Material well-being”. (shrink)

The aim of the present paper is to describe three different attempts, which have been made by philosophers, to define what quality of life is; and to spell out some of the difficulties that faces each definition. One, Perfectionism, focuses on the capacities that human beings possess: capacities for friendship, knowledge and creative activity, for instance. It says that the good life consists in the development and use of these capacities. Another account, the Preference Theory, urges that satisfying one's (...) preferences, or desires, is what improves one's quality of life. And a third account, Hedonism, sees life-quality as consisting in the enjoyment of pleasure and the avoidance of pain. The paper describes and evaluates objections to each of these views, thereby displaying their weaknesses and strengths. Since no view comes out as the right one there is a choice to be made. At the end of the paper it is being discussed how well each of the views cohere with different methodologies used in quality of life research. Also it is suggested that considerations about what the research is to be used for are relevant. (shrink)

This study was aimed at examining the impacts of the Sharing economy on the individual and community Quality of Life and wellbeing by looking at their associated influencing factors using Village Savings and Loans Associations as a model of sharing economy in Malawi. An online community-based cross-sectional study design was conducted from November 2020 through January 2021. In the survey, 402 Village Savings and Loans Associations members from the Mzuzu City area participated, recruited using snowball and respondent-driven sampling techniques. (...) The sample size was computed using a single population proportion using the Yamane formula. Descriptive statistics and ordinal logistic regression model techniques were also employed. Additionally, we used the Chi-Square test, two-way ANOVA, and Ordinal regression model to determine statistical associations between socioeconomic data and QOL and wellbeing variables with a 5% level of significance. On the aspect of community wellbeing, the findings of our study indicated that income provided members with options to live a better QOL and wellbeing within the community by either facilitating payment for better education, eating healthier foods, acquiring assets, etc. Further, the absence of discrimination provided a platform for voice, inclusion, and social trust, enhancing freedom of expression. We also found that education facilitated better earnings and knowledge of public health-related issues. As for the contribution to the sharing economy, our study has emphasized the role played by trust in enhancing sharing economy. We recommend and encourage people to join these VSLAs so as to improve their QOL and wellbeing. However, there is a need to replicate the study on a larger scale to validate our study findings for effective policy formulation and implementation geared to improving the overall quality of people’s lives. Based on these findings, we further recommend that authorities reinstate programs like National Strategy for Financial Inclusion 2016–2020 and Savings and Loan Groups Best Practice Guidelines 2016–2017 that could further enhance the future of VSLAs, which are vital for QOL and community wellbeing of the people in developing countries like Malawi. (shrink)

Engagement with the historical and theoretical underpinnings of measuring quality of life (QoL) and patient‐reported outcomes (PROs) in healthcare is important. Ideas and values that shape such practices—and in the endgame, people's lives—might otherwise remain unexamined, be taken for granted or even essentialized. Our aim is to explicate and theoretically discuss the philosophical tenets underlying the practices of QoL assessment and PRO measurement in relation to the notion of person‐centredness. First, we engage with the late‐modern history of the concept (...) of QoL and the act of assessing and measuring it. Working with the historical method of genealogy, we describe the development of both QoL assessments and PRO measures (PROMs) within healthcare by accounting for the contextual conditions for their possibility. In this way, the historical and philosophical underpinnings of these measurement practices are highlighted. We move on to analyse theoretical and philosophical underpinnings regarding the use of PROMs and QoL assessments in clinical practice, as demonstrated in review studies thereof. Finally, we offer a critical analysis regarding the state of theory in the literature and conclude that, although improved person‐centredness is an implied driver of QoL assessments and PROMs in clinical practice, enhanced theoretical underpinning of the development of QoL assessments is called for. (shrink)

Quality of life is part of many different discourses and has been used in a variety of meanings ranging from purely descriptive (as in some medical contexts) to distinctly evaluative meanings (as in some social science and political contexts). The paper argues that there are good normative reasons to make the concept as descriptive as possible at least in its medical applications and, furthermore, to reconstruct it in a thoroughgoing subjectivist way, making the reflexive self-evaluation of the subject him- (...) or herself the ultimate standard. Attention is drawn to the fact that only few of the measures of quality of life applied in present-day medicine correspond to these requirements. (shrink)

Richard Kraut presents a new theory of human well-being. Kraut's principal idea, Aristotelian in spirit, is that 'external goods' have at most an indirect bearing on the quality of our lives. A good internal life - one with quality emotional, intellectual, social, and perceptual experiences - is what well-being consists in.

The COVID-19 pandemic has had unprecedented effects on our daily lives. This study aimed to assess the quality of life at two time points during the COVID-19 pandemic with lockdown restrictions according to gender, age, and urbanization level. Qualtrics® recruited representative Austrian population samples in April 2020 and December 2020/January 2021. ANOVAs and the Bonferroni-corrected post-hoc tests were conducted to investigate differences between April and December 2020 and to compare with pre-pandemic data. Although the quality of life changed (...) from pre-pandemic to April 2020, there were no significant changes between April and December. Living location, gender, and age showed an effect on the quality of life. All domains of quality of life have decreased since the onset of the pandemic, and this decline has been maintained over the course of the first year of the pandemic. Creative measures should be implemented to assist people in improving one or more areas of quality of life, within the lockdown restrictions to improve the overall wellbeing of the population. (shrink)

The basic work for this book was carried out during the spring of 1989 in Edinburgh, where I had been granted a research position at The Institute for Advanced Studies in the Humanities. I should like to express here my indebtedness to the Institute for the opportunity thus afforded me. I should also like to say how very grateful I am for the stimulating conversations I had there with Professor Timothy Sprigge and Dr. Elizabeth Telfer. Dr. Telfers’s own treatise Happiness (...) has been a major influence on my view of the questions involved. The basic view of health and illness presented in this book is more fully set out in my On the Nature of Health. As in the case of my previous larger projects, I have received a great amount of support and may wise comments from Professor Ingmar Pörn, Helsinki. Three Danish experts – Anton Aggernaes, Erik Ostenfeld and Peter Sandøe – have made valuable comments. Professor Heng ten Have, Nijmegen, has improved my reading of the philosophy of Jeremy Bentham. I should also like to thank my colleagues at the Department of Health and Society, University of Linköping, for helping me to avoid a number of the pitfalls that can so easily stumble into when it comes to a treatise like this. Especially I should like to mentioned Per-Erik Liss, Ingemar Nordin and Bo Petersson, all three of whom have read and commented on the entire manuscript. A Swedish version of this book, Livskvalitet och hälsa, came out in 1991. I have been made quite a number of corrections and additions, one type of addition being replies to critical points made in reviews of the Swedish version. I should like to thank Malcolm Forbes for valuable help putting my English into publishable condition. Linköping, May 1993 Lennart Noredenfelt. (shrink)

Introduction. Cities play a key role in the development of countries and regions. The authors of the article emphasize the importance of the largest cities’ development, which is based on an industrial model that has not exhausted its potential. The authors show possibilities of urban development on the basis of the industrial sector effective functioning in order to improve the citizens’ welfare, meet their needs and improve the life quality. In this regard, the authors formulate a hypothesis that the (...) largest Russian cities developing according to the industrial model have and are able to realize their potential in order to improve the life quality, preserve and increase the population on their territory. The authors set a goal: to identify the possibilities for developing industrial-type megalopolises to improve the population’s life quality of the (PLQ). Methods. The authors use the following information base: strategic documents of different levels, statistical data, scientific literature, analytical documents, and expert assessments of the megalopolises’ development. The authors also use an industrial model for developing the largest cities; they determine conditions under which the potential of megacities can be realized to improve the citizens’ life quality and carry out an analysis of the demographic and social situation in the largest Russian industrial cities. The authors evaluate some approaches and theses of the study as exemplified by the following cities with a million-plus population: Yekaterinburg, Krasnoyarsk, Chelyabinsk, and Omsk and they group the cities according to the signs of growth and decline, which is illustrated by favorable or unfavorable demographic trends. To confirm the identified trends and problems of the largest cities, the authors provide the results of expert assessments on the population’s life quality and the state of the urban environment and emphasize the need for a systemic integrated development of the largest cities of industrial type to improve the life quality of the population of megalopolises. The scientific novelty of the study consists in substantiating the prospects for the socio-economic development of the largest industrial cities of Russia on the basis of an industrial model that provides for the technological transformation of the economy, the use of agglomeration effects, the formation of a friendly urban environment for residents and the achievement of socialization of urban space. Results and conclusions. As a result of the analysis and typology of the largest cities by functional specialization, two groups of cities were identified: one group with signs of demographic growth, the second with signs of decline. The cities of the first group have a greater economic potential, opportunities for agglomeration, provide more comfortable living and consolidation of the population on their territory. On the contrary, cities with signs of decreasing have fewer opportunities (resources), are less diversified, the urban environment in them is less comfortable, which is reflected in the citizens’ life quality and is accompanied by the population’s outflow. At the same time, it was revealed that all analyzed cities actively use digital technologies, realizing, in particular, the concept of a «smart city». At the same time, cities with signs of decreasing show high IQ indicators of cities. Taking into account the identified problems, the authors propose promising directions for the development of industrial megalopolises with signs of decline. (shrink)

Quality of life is a difficult concept to define and to measure. An hypothesis is proposed which suggests that the quality of life measures the difference, or the gap, at a particular period of time between the hopes and expectations of the individual and that individual's present experiences. Quality of life can only be described by the individual, and must take into account many aspects of life. The approach is goal-orientated, and one of task analysis. The hypothesis (...) is developed in a diagramatic way, and several methods of testing the hypothesis suggested. (shrink)

Purpose: This article aims to highlight key indicators of residents' quality of life in a specific contemporary building in Kruja, Albania. -/- Design/Method/Approach: A questionnaire with 30 questions was prepared for the inhabitance, and the Binary or Tobit probabilistic models were taken into consideration as part of the methodology, to conclude. The study will further analyze the implications of the inhabitants and their behavior in a specific contemporary building in the city of Kruja. It was examined the statistical significance (...) of each variable (questions) in the models elaborated with EViews 8 software. The stable models that are associated with the “Log-likelihood” statistics were statistically significant at a significance level of p < 5%, or with 95% confidence, based on the model tests. -/- Findings: The study concluded that the most statistically significant quality of life indicators part of the questionnaire is related to the typology of the apartments, methods of cooling during summer, present living conditions, apartment improvement, apartment orientation, and time spent in the living room. Furthermore, the study reveals that most of the quality-of-life indicators (part of the questionnaire) are not statistically important, so they will not be considered part of the models created in the article. The study reveals that increasing the living space and improving orientation is crucial to enhance the satisfaction of apartment inhabitants. When apartment sizes increase and orientation is improved, residents are more likely to opt for fans over air conditioners to reduce electricity costs and avoid installing additional cooling facilities during summer. They believe that better living conditions require larger apartments, additional water supply, increased electrical costs, and more time spent in the living room. The inhabitants also emphasize the importance of reducing moisture levels, decreasing window opening frequency, and increasing time spent with family. Interestingly, a one-degree improvement in summer cooling methods (e.g., switching from air blowers to air conditioning) corresponds to a one-degree improvement in winter heating methods (e.g., switching from gas to electricity), leading to a heightened need for clean electric heating. Overall, the study emphasizes the importance of meeting the physical and spatial needs of the residents to enhance their overall satisfaction and quality of life. Urban policies significantly impact housing affordability, quality, transport systems, environmental sustainability, and social equity, affecting overall living standards and economic growth. Cities must create well-designed policies that consider residents' needs and study findings to ensure sustainable development and citizen welfare. -/- Theoretical Implications: Gujarati’s (Basic Economics) theory was developed in the article. -/- Practical Implications: This study will serve as an indicator to analyze the further improvements that might occur in the specific building (not just in the city of Kruja), considering the main quality of life indicators. -/- Originality/Value: The article will serve as a base for further analysis of resident’s behavior and their social impact in the community in order to be aware of their needs for further developments in the construction field. -/- Research Limitations/Future Research: The findings depend profoundly on the type of building the residents are living in. The research stream that can be inspired by the research is strongly related to mathematical regression models, statistics, and probability. -/- Paper Type: Empirical . (shrink)

The outcome of very preterm infants is marked by the development of complications that can have an impact on the quality of life of the children and their families. The concept of quality of life and its evaluation in the long term raise semantic and ethical problems for French physicians in perinatal care. Our reflection aims to gain a better understanding of the representations surrounding quality of life in neonatal medicine.

Illustrates how the concept of current well‐being can be put to work on the contemporary world. I draw upon evidence from the contemporary world's poorest countries to suggest that, interestingly, the three constituent spheres of citizenship may well be synergistically related to one another. The findings indicate that democracy and civil liberties are not only intrinsically valuable, but may even be instruments for bringing about material progress in poor countries. The fact remains though that, within democratic countries, there are enormous (...) differences in people's life chances. Democracies in poor regions harbour malnourished people. It is argued that the malnourished are caught in poverty traps. In order to explain the findings, we are led to study institutions and the role they play in determining the allocation of resources. (shrink)

sirRavenscroft and Bell's study of end-of-life decision making in intensive care1 provides valuable evidence ….

Meaning in life has been widely recognized as a hallmark of psychological well-being and positive youth development. The goal of this study was to validate the Korean version of the Meaning in Life in Children Questionnaire utilizing the framework suggested by the Standards for Educational and Psychological Testing. Data were obtained from 277 fifth graders aged 10–11 in three elementary schools in Seoul and Gyeonggi through a paper-and-pencil survey. We translated the MIL-CQ, a 21-item self-report measure developed based on Frankl’s (...) “meaning triangle,” into Korean. Psychological well-being measures were also assessed. Validity and reliability data were collected. The content of domains and items was appropriate for measuring MIL among children. A three-factor model consisting of attitude, creativity, and experience pathways was extracted via exploratory factor analysis, and a three-factor hierarchical model including attitude, creativity, and experience as first-order factors and MIL as a second-order factor was confirmed via confirmatory factor analysis. Higher levels of MIL were related to higher levels of satisfaction with life, self-esteem, positive affectivity, and lower levels of negative affectivity. All item fit statistics were acceptable based on the Rasch model. The analysis of the measurement invariance of each item showed that the responses to one item varied by gender, suggesting that additional items might facilitate better measurement of MIL in children. This study provides validity and reliability evidence that K-MIL-CQ is appropriate for measuring MIL among South Korean elementary school students. (shrink)

The odds of encountering a senior citizen selling on the street have increased. The claim that they have no choice but to work and sell on the street, despite the dangers, illnesses, and psychological issues they may face, to provide for their family’s needs is very evident. Therefore, this study explores the quality of life, lived experiences, challenges, and coping mechanisms of senior citizen street vendors in Bulacan, Philippines. The study employed Heideggerian Phenomenology and Interpretative Phenomenological Analysis (IPA). Moreover, (...) the following themes arise (1) Golden years, (2) Socially connected, and (3) Unknown journey. These themes highlighted the experiences and challenges faced by the participants. Moreover, it is highly suggested that local government agencies enhance and strictly monitor the existing program that alleviates mental and physical health concerns and senior citizens' safety and financial assistance. (shrink)

ObjectivesQuality of life has been the focus of increasing interest in oncology. QoL assessment instruments implicitly assume that each QoL domain has the same meaning for each patient. The objective of this study was to analyze the importance of and the satisfaction with QoL domains and to analyze the relationship between the two.MethodsA sample of 308 breast cancer survivors was examined twice with a three-month time interval. The women completed the two QoL questionnaires Questions of Life Satisfaction, which measures participants' (...) satisfaction with eight QoL domains and the subjective importance of those domains to them, and the EORTC QLQ-C30. A sample of 1,143 women from the general population served as controls.ResultsCompared with the general population sample, the patients were less satisfied with their health and more satisfied with all other QoL domains. The subjective importance of health was lower in the patients' sample. Satisfaction with health and importance of health were slightly positively correlated. The effect of QoL domain importance on general QoL was small, and interaction effects between domain importance and satisfaction on the prediction of global QoL were negligible.ConclusionIn addition to satisfaction with QoL dimensions, the subjective importance of these dimensions is relevant for psychooncological research and treatment. Health is not the only relevant QoL domain in breast cancer survivors, other domains such as finances also deserve health care providers' attention. (shrink)

Quality improvement mechanisms increasingly use outcome measures to evaluate health care providers. This move toward outcome measures is a radical departure from the traditional focus on process measures. More radical still is the proposal to shift from relatively simple and proximal measures of outcome, such as mortality, to complex outcomes, such as quality of life. While the practical, scientific, and ethical issues associated with the use of outcomes such as mortality and morbidity to compare health care providers have (...) been well rehearsed, the specific concerns associated with the use of quality of life measures in quality of care research have received little attention. As with much research on quality of life there is a tendency to assume that the disadvantages are outweighed by the general virtue of “listening” to patients. In this paper we disagree with this assumption and argue that quality of life is a process, not an outcome. (shrink)

Health-related quality of life measures aim to assess patients’ subjective experience in order to gauge an increasingly wide variety of health care issues such as patient needs; satisfaction; side effects; quality of care; disease progression and cost effectiveness. Their popularity is undoubtedly due to a larger initiative to provide patient-centered care. The use of patient perspectives to guide health care improvements and spending is rooted in the idea that we must respect patients as self-determining agents. In this paper (...) I look at the two main orientations to quality of life measurement: standardized and individualized measures. I argue that while these measures are attempts to provide for patient self-determination, they both fail to do so. In their place I suggest a new approach which overcomes their respective difficulties: a dialogic approach. (shrink)

As a consequence of industrialization, we face unprecedented pressures on the carrying capacity of the earth. Desertification, pollution and global climate changes can only increase these pressures, and will cause vast increases in the number of refugees and widespread risks to human health. Increasing inequalities between rich and poor nations are potential causes of conflict. Since the industrial countries are mainly responsible for our economic problems, they must give a lead in global arrangements to alleviate them. A major change in (...) our habitual patterns of thought is essential, in which we reassess how we perceive values, and how we measure wealth and well-being. This must be accompanied by governmental action: on population numbers and the refugee problem; on the efficient use of energy; on new methods of land use, and on regulation of damaging industrial activities. To act in these ways, governments must reorganize their domestic policies and increase international co-operation. (shrink)

The main measure of quality of life is well-being. The aim of this article is to compare insights about well-being from contemporary philosophy with the practice-related opinions of palliative care professionals. In the first part of the paper two philosophical theories on well-being are introduced: Sumner’s theory of authentic happiness and Griffin’s theory of prudential perfectionism. The second part presents opinions derived from interviews with 19 professional palliative caregivers. Both the well-being of patients and the well-being of the carers (...) themselves are considered in this empirical exploration. In the third part the attention shifts from the description of “well-being” to prescriptions for the promotion of well-being. Our interview data are analysed in light of the theories of Sumner and Griffin for clues to the promotion of “well-being.” The analysis (1) underscores the subject-relativity of well-being, (2) points out that values that are considered important in every life still seem to be relevant (at least in palliative care practice), and (3) shows the importance of living a certain sort of life when aiming to enhance dying patients’ well-being. (shrink)

This paper examines a model of income and quality of life that controls the love of money, job satisfaction, gender, and marital status and treats employment status (full-time versus part-time), income level, and gender as moderators. For the whole sample, income was not significantly related to quality of life when this path was examined alone. When all variables were controlled, income was negatively related to quality of life. When (1) the love of money was negatively correlated to (...) job satisfaction and (2) job satisfaction was positively related to both income and quality of life, income was negatively related to quality of life for full-time, high-income, and male employees. When these two conditions failed to exist, income was not related to quality of life for part-time, median- or low-income, and female employees. This model provides new insights regarding the impact of the love of money and job satisfaction on the income–quality of life relationship. (shrink)

This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cases where quality of life suffers because of (...) disability-focused exclusion or injustice differently from cases where lower quality of life results from laws of nature, resource scarcity, or appropriate tradeoffs. Decisionmakers should ignore quality-of-life losses that result from injustice or exclusion when ignoring them would improve the prospects of individuals with disabilities; in contrast, they should consider quality-of-life losses that are unavoidable or stem from resource scarcity or permissible tradeoffs. On this proposal, while health systems should not amplify existing injustice against individuals with disabilities, they are not required to altogether ignore the potential effects of disability on quality of life. (shrink)

The Quality of Life: Aristotle Revised, by KrautRichard. Oxford: Oxford University Press, 2018. Pp. x + 249.

ObjectivesThe breast cancer stigma affects Health-related quality of life, while general resilience resources, namely, sense of coherence, social support, and coping skills, are thought to alleviate this effect. The study aimed to explore the mediating/moderation role of GRRs in the relationship between stigma and HRQoL and its dimensions in Iranian patients with breast cancer.MethodsIn this cross-sectional study, Stigma Scale for Chronic Illness 8-item version, SOC-13, Medical Outcome Survey- Social Support Scale, Brief COPE, and Functional Assessment of Cancer Therapy-Breast were (...) investigated in a convenience sample of Iranian women with confirmed non-metastatic breast cancer. Following the establishment of correlations using Pearson’s correlation, single and parallel mediation analysis and moderation analysis were conducted to determine the extent to which each GRR might be impacted by stigma or decrease the adverse impact of stigma on HRQoL.ResultsAn analysis of 221 women with the mean age of 47.14 showed that stigma was negatively correlated to all HRQoL’s dimensions, SOC, social support, and the bulk of coping skills. In the single mediation analysis, stigma affected all facets of SOC, all subscales of social support, and positive reframing, which partially reduced breast cancer HRQoL. Stigma affects general HRQoL through damaging meaningfulness, social support, and positive reframing. Meaningfulness was marked as the most impacted GRR in terms of all domains of HRQoL. In parallel mediation, reduced meaningfulness, total social support, and positive reframing were highlighted as the pathways of diminished breast cancer HRQoL. Moderation analysis indicated the higher levels of humor, behavioral disengagement, and use of instrumental support behaviors to be functional in protecting different dimensions of HRQoL, while the results were mixed for venting, especially in patients with mastectomy surgery.ConclusionWhile GRRs may be impacted by stigma, they exert a relatively small protective effect against the impact of stigma on HRQoL. This study provides some novel findings, but longitudinal studies are needed to further verify these before any causal conclusion or recommendations for health policy can be drawn. (shrink)