ArticlePDF Available

Health-Related Quality of Life, Gender, and Culture of Older People Users of Health Services in the Multicultural Landscape of the City of Ceuta (Spain): A Cross-Sectional Study


Abstract and Figures

Perceptions of health-related quality of life (HRQOL) are influenced by sociodemographic variables and by cultural-religious concepts of health, disease, and old age, among others. To assess the HRQOL of older people in a population with a long history of multiculturalism, the city of Ceuta (Spain), and to compare the results with Spanish reference values. A total of 372 individuals (55.4% females) were interviewed using the Spanish version of the Short Form-36 questionnaire. The subjects' mean age was 70.9 (SD = 5) years: 253 were Christians, 93 Muslims, and 26 Jews, representing the proportions in the overall population of these cultural-religious groups. HRQOL differs according to the cultural-religious affiliation, which specifically affects social and psychological dimensions. All groups obtained lower social function scores than the reference values, especially the Muslim and Jewish groups. Health care providers may consider integrating culturally sensitive interventions to improve HRQOL. © The Author(s) 2015.
Content may be subject to copyright.
Journal of Transcultural Nursing
1 –8
© The Author(s) 2015
Reprints and permissions:
DOI: 10.1177/1043659615597042
Assessing the health status of a population involves both the
measurement of objective parameters and the evaluation of
individual subjective perceptions, as individuals have differ-
ing levels of tolerance of disease or disability (Low &
Molzahn, 2007; Molzahn, Skevington, Kalfoss, & Makaroff,
2010). Health perceptions are derived not only from physical
symptoms like pain but also from the cultural-social setting
(Dragomirecka et al., 2008; Molzahn, Kalfoss, Makaroff, &
Skevington, 2011). The evaluation of health perception is
important in monitoring the effective use of health care
resources and in highlighting specific needs that might other-
wise go unrecognized. This issue is of special interest in rela-
tion to the elderly (Casas Anguita, Repullo Labrador, &
Pereira Candel, 2001; Fletcher, Guthrie, Berg, & Hirdes,
2010). Perceptions of health-related quality of life (HRQOL)
are influenced by sociodemographic variables and by cul-
tural concepts of health, disease, and old age, among others
(Dragomirecka et al., 2008; Yosef, 2008). In multicultural
societies, the task of determining HRQOL is further compli-
cated by differing attitudes among the population toward
these same concepts, which reflect perceptions of health, the
values assigned to the body, what is permitted, and what is
forbidden (Artigas-Lelong & Bennasar-Veny, 2009).
Sometimes problems related to cultural customs arise, such
as women not wishing to be examined by male doctors or
men not wishing to be seen by female doctors. Sometimes
illness is perceived as a punishment or as the result of des-
tiny. These cultural differences can hamper diagnosis, lead to
597042TCNXXX10.1177/1043659615597042Journal of Transcultural NursingOlmedo-Alguacil et al.
1Nursing Department, Faculty of Health Sciences, University of Granada,
Ceuta, Spain
2Faculty of Health Sciences, University of Granada, Granada, Spain
3Faculty of Economic Sciences, University of Granada, Granada, Spain
Corresponding Author:
Carmen Villaverde-Gutiérrez, Faculty of Health Sciences (Physiology),
University of Granada / PTS., Avda. de la Ilustración s/n. 18016-Granada,
Health-Related Quality of Life, Gender,
and Culture of Older People Users of
Health Services in the Multicultural
Landscape of the City of Ceuta (Spain):
A Cross-Sectional Study
Maria Milagrosa Olmedo-Alguacil, PhD1,
Jesús Ramírez-Rodrigo, PhD1, Carmen Villaverde-Gutiérrez, PhD2,
Maria Angeles Sánchez-Caravaca, PhD1, Encarnación Aguilar Ferrándiz, PhD2,
and Alberto Ruiz-Villaverde, PhD3
Introduction: Perceptions of health-related quality of life (HRQOL) are influenced by sociodemographic variables and by
cultural-religious concepts of health, disease, and old age, among others. Purpose: To assess the HRQOL of older people
in a population with a long history of multiculturalism, the city of Ceuta (Spain), and to compare the results with Spanish
reference values. Method: A total of 372 individuals (55.4% females) were interviewed using the Spanish version of the
Short Form-36 questionnaire. The subjects’ mean age was 70.9 (SD = 5) years: 253 were Christians, 93 Muslims, and 26
Jews, representing the proportions in the overall population of these cultural-religious groups. Results: HRQOL differs
according to the cultural-religious affiliation, which specifically affects social and psychological dimensions. Discussion and
Conclusions: All groups obtained lower social function scores than the reference values, especially the Muslim and Jewish
groups. Implications for Practice: Health care providers may consider integrating culturally sensitive interventions to
improve HRQOL.
quality of life, health, older people, gender, culture
by guest on July 29, 2015tcn.sagepub.comDownloaded from
2 Journal of Transcultural Nursing
misunderstanding, and produce lack of treatment adherence
and follow-up.
Cultural questions can have contradictory effects. On one
hand, HRQOL can be enhanced by the integration of indi-
viduals and through social cooperation networks. On the
other, cultural differences may be divisive, feeding social
imbalances that translate into differences in the conditions of
life and perceptions of its quality (Coons, Rao, Keininger, &
Hays, 2000; Molzahn et al., 2011).
Good HRQOL is generally expressed in terms of satis-
faction, contentment, contentment, happiness, and the
ability to cope with life-changing events (Casas Anguita
et al., 2001; Hawthorne et al., 2006). Most systems for
measuring HRQOL consider dimensions related to physi-
cal capacity, physical and mental state of health, family
and social networks, and the economic situation (Fries,
1980; Hickey, Barker, McGee, & O’Boyle, 2005; La
Huerta, Borrel, Rodriguez-Sanz, Pérez, & Nebot, 2004;
Villaverde-Gutiérrez et al., 2006). These dimensions are
conditioned by the specific circumstances of each subject
(Low & Molzahn, 2007), including gender and culture
(Molzahn et al., 2011; Saxena, Carlson, Billington, &
Orley, 2001). Thus, perceptions of HRQOL are affected by
the different gender roles assigned and represented within
communities, and these may produce conditions of inequal-
ity (Rohlfs et al., 2000).
Europe’s population is increasingly older and more multi-
cultural; accordingly, more research is needed on how these
aspects may influence the quality of life. The present study
of HRQOL is based on a population with a long history of
multiculturalism and an aging pattern similar to that found
elsewhere in Western Europe. For these reasons, the study
population is very appropriate for this kind of study.
The study aim was to assess the HRQOL perceptions of
persons older than 65 year, resident in the city of Ceuta
(Spain), taking into account their gender and culture/reli-
gion, and to compare these perceptions with reference values
for the general Spanish population of the same age range, in
order to identify possible areas for interventions.
Research Design
A cross-sectional study was made of a representative sample
of the older population of Ceuta, who completed the Spanish
version (Alonso et al., 1998) of the Medical Outcomes Trust
Short Form-36 (SF-36) questionnaire.
According to the population census, 7,078 persons older
than 65 years (55.5% of whom are female) are resident in
Ceuta. We conducted a stratified random sampling with
allocation proportional to the size of each stratum,
considering the six health care districts of the city and the
percentage of men and women resident in each. The sample
size of 372 subjects (44.6% males and 55.4% females) was
established by using a calculation algorithm for the esti-
mates of proportions (p;q) in a random sample from a pop-
ulation of known size (N):
( 1)
z Npq
e N z pq
for a maximum variation in estimated proportions (e) of 5%
and a 95% confidence interval (p .05).
The stratification by cultural group was based on the
known proportions of these groups in the general population
of Ceuta. Accordingly, 68% of the study sample were
Christians, 25% Muslims, and 7% Jews. Because of the lack
of specific data on the religious affiliation of individuals,
members of each group were initially selected according to
their family name on the Public Health Register from which
the study sample was recruited. The individuals recruited
confirmed their membership of the religious-cultural group
before being included in the study. Strict confidentiality was
maintained on these and other personal data. The inclusion
criteria were 65 years or older, noninstitutionalization, and in
receipt of health care from the Ceuta Public Health Service.
The exclusion criteria were severe language difficulties or
major physical or psychological limitations hampering com-
pletion of the questionnaire. Informed consent was obtained
from all subjects. This study was approved by the research
ethics committee of the University of Granada and complied
with the usual ethical norms and applicable legislation for
this type of research.
The city of Ceuta shares a border with Morocco and is
home to people of diverse cultures and religions, belonging
to the different cultural groups that have settled in the city
throughout its history. In consequence, Ceuta forms a mul-
ticultural society, of Spanish nationality, whose primary
language is Spanish. The city extends over an area of 19.3
km2, and has a population older than 65 years of 7,078
people. Its religious and cultural groupings give a specific
identity to the different neighbourhoods, some with an
exclusively Muslim population and others exclusively
Christian (Olmedo-Alguacil, Ramírez-Rodrigo, Villaverde-
Gutiérrez, & Ruiz-Villaverde, 2014). The different commu-
nities coexist on an equal basis and may be considered an
example “multicultural citizenship” (Zapata-Barrero,
It has an equal society on descriptive terms, following a
model of equal interaction between the existing cultures,
where they all share an equal status in the public sphere, thus
coming under the category of multicultural citizenship
(Zapata-Barrero, 2003).
by guest on July 29, 2015tcn.sagepub.comDownloaded from
Olmedo-Alguacil et al. 3
Based on the definition of HRQOL proposed by the World
Health Organization, measurement instruments have been
developed and validated for the comprehensive assessment of
individuals and their health (Coons et al., 2000; Hickey et al.,
2005; Valderas, Ferrer, & Alonso, 2005). For the purposes of
this study, we applied the SF-36, a standardized instrument of
intercultural applicability, as adapted and validated for the
Spanish population. SF-36 has proven to be effective for
assessing HRQOL in adult populations (Alonso et al., 1998;
Alonso, Prieto, & Antó, 1995; Vilagut et al., 2005; Zúñiga,
Carrillo-Jiménez, Fos, Gandek, & Medina-Moreno 1999).
For the dependent variables, scores were recorded for the
eight HRQOL dimensions of the SF-36 questionnaire, on a
scale of 0 to 100 for each dimension: physical function (PF),
physical role (PR), body pain (BP), general health (GH), vitality
(VT), social function (SF), emotional role (ER), and mental
health (MH). For the comparison of each scale score with the
Spanish reference value for this age-group (Alonso et al., 1998),
the standardized difference (z) was calculated as scale value −
reference mean value/reference standard deviation (SD).
The following independent variables were determined: sex;
age (years), weight (kg), height (cm), body mass index (BMI,
kg/m2), systolic and diastolic blood pressure (mmHg), glyce-
mia (mg/dL), and blood levels of total cholesterol (mg/dL),
triglycerides (mg/dL), high-density lipoprotein (HDL, mg/dL),
and low-density lipoprotein (LDL, mg/dL). These data were
obtained during the subjects’ most recent visit to the health
center. The data with respect to religious culture (Christian,
Muslim, or Jewish) were obtained from the subjects’ medical
records and later confirmed in person.
Data Analysis
SPSS software, Version 15.0 (SPSS, Chicago, IL) was used
for the statistical analysis, applying nonparametric tests after
application of the Kolmogorov–Smirnov test demonstrated
the distribution of the data. The Mann–Whitney test was
used to analyze differences between men and women and
between the different religious-cultural groups. When more
than two factors were considered, the Kruskal–Wallis test for
k unpaired samples was applied. Tables 1 and 2 summarize
the data for each group, and give the mean values and SD as
additional information (despite the nonapplication of para-
metric tests). p . 05 was considered significant in all tests.
Sample Characteristics
The anthropometric characteristics and clinical data for the
372 individuals studied are shown in Table 1 (55.4%
females); 68% were Christians, 25% Muslims, and 7% Jews.
The mean age was 70.9 (SD = 5.03) years, and was slightly
lower for the women 70.5 (SD = 4.95) years, than for the
men 71.5 (SD = 5.09) years. Glycemia and triglyceride levels
were significantly higher and HDL cholesterol levels signifi-
cantly lower in the men. BMI and systolic blood pressure
levels were significantly higher in the Muslim group than in
the other religious/cultural groups, while levels of triglycer-
ides were significantly higher in the Christians.
Health-Related Quality of Life
The mean score for the SF-36 dimensions was 62.7 (SD =
6.5), ranging from 52.5 for general health to 71.2 for physi-
cal role (Table 2). Physical function and mental health scores
were significantly lower in the women than in the men. The
Muslims recorded significantly lower scores for general
health, vitality, social function, emotional role, and mental
health dimensions in comparison with the other two groups.
Comparison of the SF-36 scores in our sample with the
reference values for the general Spanish population of the
same age (Alonso et al., 1998), revealed lower social function
and emotional role scores for both sexes and lower body pain
and mental health scores for the females versus reference val-
ues (Figure 1). All of the religious/cultural groups recorded
lower social function scores versus the reference values.
With respect to the reference values, the Christians
recorded similar or higher values for the other dimensions,
the Muslims scored higher for physical function and physical
role but lower for all other dimensions, while the Jewish
group recorded lower scores for body pain, emotional role,
mental health, and social function (Figure 2).
Our study sample matched the age and sex profile of the
older population of this city, according to official census
data. Most of the subjects were under medical treatment for
chronic disease, mainly cardiovascular diseases and diabe-
tes, as expected in this age-group, according to the 2011-
2012 Spanish National Health Survey (Pujol Rodríguez &
Abellán García, 2013).
Of the three cultural-religious groups, the Muslims
recorded the highest BMI (p < .001), systolic blood pressure
(p < .010) and glycemia (p < .050), implying a poorer control
of chronic conditions, in comparison with the Christians and
Jews. Unlike the case described by Yosef (2008), where the
Muslim minority in America faces severe obstacles in access-
ing the U.S. health care system, elderly Muslim residents in
Ceuta are Spanish citizens and are fully entitled to the Spanish
health care system. On the other hand, we agree with Yosef
(2008) that cultural factors arising from religious beliefs and
practices can have a profound impact on health and should be
taken into consideration when health care is provided.
Cardiovascular risk factors were greater and levels of
glycemia, triglycerides, and HDL were significantly
by guest on July 29, 2015tcn.sagepub.comDownloaded from
Table 1. Sample Characteristics.
Groups Age, years BMI, kg/m2SBP, mmHg DBP, mmHg GLY, mg/dL CHOL, mg/dL TRIG, mg/dL HDL, mg/dL LDL, mg/dL
Males (n = 166), M (SD) 71.5 (5.1) 29.8 (4.3) 144.3 (23.3) 79.5 (11.9) 124.3 (52.9) 190.6 (44.5) 127.3 (67.1) 47.1 (20.4) 126.2 (45.2)
Females (n = 206), M (SD) 70.5 (4.9) 30.7 (8.7) 141.4 (23.9) 77.9 (12.1) 108.1 (30.5) 195.6 (49.0) 112.9 (61.2) 54.8 (24.7) 126.5 (39.0)
Christian (n = 253), M (SD) 70.9 (5.0) 29.0 (4.7) 139.4 (21.5) 77.9 (10.9) 112.2 (35.8) 194.4 (46.0) 124.7 (66.4) 50.7 (20.6) 126.9 (40.6)
Muslim (n = 93), M (SD) 70.6 (5.2) 33.2 (9.4) 150.6 (27.9) 80.2 (14.7) 128.0 (59.3) 188.7 (51.6) 112.1 (60.5) 53.0 (30.6) 123.6 (46.5)
Jewish (n = 26), M (SD) 72.4 (4.9) 32.5 (12.2) 146.9 (21.2) 79.6 (10.7) 100.8 (16.8) 200.8 (39.8) 93.4 (46.0) 51.8 (15.0) 130.7 (36.5)
Total (n = 372), M (SD) 70.9 (5.0) 30.3 (7.1) 142.7 (23.7) 78.6 (12.0) 115.3 (42.7) 193.4 (47.1) 119.4 (64.2) 51.4 (23.2) 126.4 (41.9)
Differences: gender p < .050 p < .010 p < .010 p < .010
Differences: culture p < .001 p < .010 p < .050 p < .050
Note. BMI = body mass index; SBP/DBP = systolic and diastolic blood pressure; GLY = glycemia; CHOL = total cholesterol; TRIG = triglycerides; HDL: high-density lipoprotein; LDL: low-density
by guest on July 29, 2015tcn.sagepub.comDownloaded from
Olmedo-Alguacil et al. 5
higher in the male subjects (Table 1). However, the men
had a similar profile to the women in most HRQOL dimen-
sions, except for the dimensions of physical function and
mental health (Table 2). These results corroborate
Hawthorne et al. (2006) and Casas Anguita et al. (2001),
who concluded that people are reconciled to their health
problems and do not consider it to have a major impact on
their daily lives.
The scores for all dimensions were significantly lower for
the women than for the men, with respect to the Spanish ref-
erence population, while men’s perceptions of their physical
function were higher than among the reference population
and (Figure 1).
In the joint analysis of physical function and physical
role, carried out to assess the subjects’ capacity to carry
out daily tasks and activities, a convergence between the
sexes was observed (Table 2); thus, the women, despite
having a worse perception of their physical function, gave
a higher rating of their performance of daily activities.
This may because the women, as they grow older, con-
tinue to perform the same housework they have done all of
their lives, whereas the men are more likely to experience
a radical change in their daily activities following retire-
ment. The gender difference found in mental health is also
present in the Spanish population (Alonso et al., 1998;
Pujol Rodríguez & Abellán García, 2013), with women
showing more signs of anxiety, depression, and lack of
control over their emotional behavior. These results are in
line with what some authors have described as a differen-
tial characteristic of female aging, that is, the major
Table 2. Dimensions of the SF-36 (Scale 0-100).
Males (n = 166), M (SD) 69.9 (26.9) 70.6 (42.3) 60.5 (29.1) 52.9 (17.6) 56.8 (22.3) 67.3 (29.5) 66.9 (43.0) 66.3 (22.4)
Females (n = 206), M (SD) 62.9 (28.9) 71.7 (41.4) 55.5 (25.7) 52.2 (19.2) 55.2 (20.4) 66.3 (25.1) 66.8 (43.5) 61.2 (21.0)
Christian (n = 253), M (SD) 66.3 (27.6) 73.5 (40.9) 59.7 (27.3) 54.2 (18.6) 57.8 (21.2) 70.3 (27.2) 75.9 (38.6) 66.9 (21.6)
Muslim (n = 93), M (SD) 66.1 (30.0) 65.1 (43.0) 54.5 (27.3) 46.9 (17.7) 51.3 (20.6) 58.9 (25.6) 45.2 (46.0) 55.4 (19.7)
Jewish (n = 26), M (SD) 63.3 (27.9) 71.2 (44.5) 50.0 (26.0) 56.4 (16.7) 53.6 (22.1) 60.1 (24.5) 56.4 (46.9) 59.2 (22.4)
Total (n = 372), M (SD) 66.0 (28.2) 71.2 (41.8) 57.7 (27.3) 52.5 (18.5) 55.9 (21.2) 66.7 (27.1) 66.8 (43.2) 63.5 (21.7)
Differences: gender p < .050 p < .050
Differences: culture p < .010 p < .050 p < .001 p < .001 p < .001
Note. SF-36 = Short Form-36 health survey; PF = physical function; PR = physical role; BP = body pain; GH = general health; VT = vitality; SF = social
function; ER = emotional role; MH = mental health.
Figure 1. Gender differences with standardized reference values.
Note. PF = physical function; PR = physical role; BP = body pain; GH = general health; VT = vitality; SF = social function; ER = emotional role; MH =
mental health. The vertical axis represents the standard values for Spain. The different deviations are shown as positive or negative values. We highlight
the negative deviations in SF and ER for both sexes.
*p < .050.
by guest on July 29, 2015tcn.sagepub.comDownloaded from
6 Journal of Transcultural Nursing
physical, psychological, and social changes following the
menopause (Brown, 2001; Menditto, Cassese, & Balbi,
1999). This event is believed to significantly raise the
prevalence of psychopathology in women (Villaverde-
Gutiérrez et al., 2006). The lower mental health scores
recorded by the women in our study, in comparison with
the Spanish reference population (Figure 2) suggest that
these factors have an especially marked effect on elderly
women in Ceuta.
We observed important differences in HRQOL depending
on the religious-cultural group to which the subject belonged,
especially with regard to the mental dimension of the SF-36
instrument. The poorer scores for general health and vitality
in the Muslim group are consistent with the poorer health
control evidenced by the clinical data.
The lowest values with respect to the reference values were
observed for social function, emotional role, and mental
health. The capacity to develop social activities was notably
worse in all three cultural/religious groups than in the Spanish
reference population, especially in the Muslim and Jewish
groups. This suggests that there is a need to promote a more
satisfactory social role among these groups (Fernández-
Ballesteros et al., 2004). In the Muslim group and to a lesser
extent in the Jewish and Christian groups, the scores for the
general health, vitality, social function, emotional role, and
mental health dimensions of the SF-36 survey were poorer
than those obtained by the reference Spanish population.
Perceptions of HRQOL are influenced not only by pain and
other symptoms but also by sociodemographic variables and
by cultural concepts such as health, disease, and old age
(Dragomirecka et al., 2008; Molzahn et al., 2011; Yosef, 2008).
Moreover, urban development and demographic changes over
the past few decades may have contributed to altering customs
and habits among younger generations. Such changes may
have had a negative effect on older residents, especially in the
Muslim and Jewish communities, due to their greater influence
of cultural tradition (Olmedo-Alguacil et al. 2014). These
changes may also affect the emotional and psychological
dimensions of the SF-36 survey, which would account for the
lower scores obtained by the Muslims and Jews.
Although the multicultural context of Ceuta matches the
definition of “multicultural citizenship” proposed by Zapata-
Barrero (2003), in which different cultural identities coexist
harmoniously, evidently there exists a Christian majority that
is culturally recognized by the Spanish authorities and is tra-
ditionally viewed as a dominant and culturally homogeneous
identity. Furthermore, despite their forming part of the same
system of rights and duties, Muslims do not enjoy similar
levels of freedom and equality in practice. In this respect, the
elderly are the most affected by inequalities arising from
their social relations with other cultures and from a lifetime
of harsh working conditions. These factors have a clear
impact on health, both objectively and in the subjects’ own
view, as citizens (Coons et al., 2000; Molzahn et al., 2011).
*** ***
Figure 2. Cultural group differences with standardized references values.
Note. PF = physical function; PR = physical role; BP = body pain; GH = general health; VT = vitality; SF = social function; ER = emotional role; MH =
mental health. The vertical axis represents the standard values for Spain. Deviations are reported as positive or negative values. The Muslim and Jewish
communities show most negative deviations.
*p < .050. **p < .010. ***p < .001.
by guest on July 29, 2015tcn.sagepub.comDownloaded from
Olmedo-Alguacil et al. 7
The sample selection was calculated to be in proportion to the
composition and size of each cultural group. Sampling took
place for each health district, and was representative of different
neighborhoods and social strata, although specific data regard-
ing the economic status of the study subjects were not compiled.
In our opinion, life adversity in general and economic adversity
in particular have a major influence on the elderly, namely, the
subjects of this study, and these factors leave their mark in terms
of education and professional qualifications, low income in old
age, housing issues, and so on. All of these areas remain to be
examined in greater detail in subsequent research.
The HRQOL perceptions of older people in Ceuta differ
according to their gender and cultural-religious affiliation.
The Muslims generally presented a poorer clinical situation
than the other cultural groups, with high levels of blood pres-
sure and glycemia in many cases. By sex, the men had a
poorer health status, with higher blood pressure and glucose
levels than the women. Subjectively, all the survey dimen-
sions addressed obtained lower scores in the Muslim group,
except for physical function, which was even lower in the
Jewish group. With respect to the dimensions of body pain,
general health, vitality, social function, emotional role, and
mental health, the survey showed scores to be lower than in
the reference Spanish population, especially in the Muslim
group. Physical function and mental health scores were sig-
nificantly lower for the female subjects than for the men, and
the women also recorded lower values for body pain, emo-
tional role, and mental health than the reference values. All
religious-cultural groups, for both male and female subjects,
had lower social function scores than the reference values.
Implications for Practice
The Spanish population of Ceuta has a long history of multicul-
turalism. According to the objective data, the Muslim subjects
presented the most divergent clinical and general health param-
eters. The subjective values for HRQOL are influenced by
health and also by sociocultural concepts, which specifically
affect social and psychological dimensions. This finding
suggests that a more satisfactory social role should be played.
Various authors have highlighted the importance of social
networks to support the HRQOL of the elderly (La Huerta
et al., 2004). These results should be taken into account in
the development of policies aimed at creating specific col-
laboration spaces (Merriam & Kee, 2014) and support net-
works for all elderly residents in the city, regardless of their
religion or culture. Health care providers need to be aware of
religious and cultural factors in order to provide culturally
appropriate health promotion services for this population
(Pucci, Rech, Fermino, & Reis, 2012). Furthermore, both
doctors and nurses need to take account of social aspects in
their interventions in order to provide appropriate care and
motivate health-promoting behavior.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
Alonso, J., Prieto, L., & Antó, J. M. (1995). The Spanish version
of the SF-36 health survey: A measure of clinical outcomes.
Medicina Clinica (Barcelona), 104, 771-776. (Article in
Alonso, J., Regidor, E., Barrio, G., Prieto, L., Rodriguez, C., & De
la Fuente L. (1998). Population reference values of the Spanish
version of the Health Questionnaire SF-36. Medicina Clínica
(Barcelona), 111, 410-416.
Artigas-Lelong, B., & Bennasar-Veny, M. (2009). Healthcare in
the 21st century: The challenge of multicultural care. Index de
Enfermeria, 18, 42-46.
Brown, C. S. (2001). Depression and anxiety disorders. Obstetrics
and Gynecology Clinics of North America, 28, 241-268.
Casas Anguita, J., Repullo Labrador, J. R., & Pereira Candel, J.
(2001). Measurements of quality of life related with health:
Basic concepts and cultural adaptation. Medicina Clínica
(Barcelona), 116, 789-796.
Coons, S. J., Rao, S., Keininger, D. L., & Hays, R. D. (2000). A
comparative review of generic quality-of-life instruments.
PharmacoEconomics, 17, 13-35.
Dragomirecka, E., Bartonova, J., Eisemann, M., Kalfoss, M.,
Kilian, R., Martiny, K., . . . Schmidt, S. (2008). Demographic
and psychosocial correlates of quality of life in the elderly
from a cross-cultural perspective. Clinical Psychology &
Psychotherapy, 15, 193-204.
Fernández-Ballesteros, R., Zamarrón, M. D., Rudinger, G.,
Schroots, J. J., Hekkinnen, E., Drusini, A., . . . Rosenmayr,
L. (2004). Assessing competence: The European Survey on
Aging Protocol (ESAP). Gerontology, 50, 330-347.
Fletcher, P. C., Guthrie, D. M., Berg, K., & Hirdes, J. P. (2010).
Risk factors for restriction in activity associated with fear
of falling among seniors within the community. Journal of
Patient Safety, 6, 187-191.
Fries, J. F. (1980). Aging natural death, and the compression of
morbidity. New England Journal of Medicine, 303,130-135.
Hawthorne, G., Davidson, N., Quinn, K., McCrate, F., Winkler, I.,
Lucas, R., . . . Molzahn, A. (2006). Issues in conducting cross-
cultural research: Implementation of an agreed international
protocol designed by the WHOQOL Group for the conduct of
focus groups eliciting the quality of life of older adults. Quality
of Life Research, 15, 1257-1270.
Hickey, A., Barker, M., McGee, H., & O’Boyle, C. (2005).
Measuring health-related quality of life in older patient popula-
tions: A review of current approaches. PharmacoEconomics,
23, 971-993.
by guest on July 29, 2015tcn.sagepub.comDownloaded from
8 Journal of Transcultural Nursing
La Huerta, C., Borrel, C., Rodriguez-Sanz, M., Pérez, K., & Nebot,
M. (2004). The influence of the social network on mental
health in the elderly. Gaceta Sanitaria, 18, 83-91.
Low, G., & Molzahn, A. E. (2007). Replication of a quality of life
model for older adults. Research in Nursing & Health, 30,
Menditto, A., Cassese, E., & Balbi, C. (1999). Climateric and qual-
ity of life. Minerva Ginecologica, 51(3), 83-89.
Merriam, S. B., & Kee, Y. (2014). Promoting community well-
being: The case for lifelong learning for older adults. Adult
Education Quarterly, 64, 128-144.
Molzahn, A., Skevington, S. M., Kalfoss, M., & Makaroff, K. S.
(2010). The importance of facets of quality of life to older
adults: An international investigation. Quality of Life Research,
19, 293-298.
Molzahn, A. E., Kalfoss, M., Makaroff, K. S., & Skevington, S.
M. (2011). Comparing the importance of different aspects of
quality of life to older adults across diverse cultures. Age and
Ageing, 40, 192-199.
Olmedo-Alguacil, M., Ramírez-Rodrigo, J., Villaverde-Gutiérrez,
C., & Ruiz-Villaverde, A. (2014). Quality of Life and mul-
ticulturalism of elderly people in the city of Ceuta (Spain).
Procedia: Social and Behavioral Sciences, 132, 701-707.
Pucci, G. G., Rech, C. R., Fermino, R. C., & Reis, R. S. (2012).
Association between physical activity and quality of life in
adults. Revista Saúde Pública, 46, 1-12.
Pujol Rodríguez, R., & Abellán García, A. (2013). Elders in the
National Health Survey 2011-2012: Some outcomes. Retrieved
Rohlfs, I., Borrell, C., Anitua, C., Artazcoz, L., Colomer, C.,
Escribá, V., . . . Valls-Llobet, C. (2000). The importance of
the gender perspective in health interview surveys. Gaceta
Sanitaria, 14, 146-155.
Saxena, S., Carlson, D., Billington, R., & Orley, J. (2001). The
WHO quality of life assessment instrument: The importance of
its items for cross-cultural research. Quality of Life Research,
10, 711-721.
Valderas, J. M., Ferrer, M., & Alonso, J. (2005). Health-related
quality of life instruments and other patient-reported outcomes.
Medicina Clínica (Barcelona), 125(Suppl. 1), 56-60.
Vilagut, G., Ferrer, M., Rajmil, L., Rebollo, P., Permanyer-Miralda,
G., & Quintan, J. M. (2005). The Spanish version of the Short
Form 36 Health Survey: A decade of experience and new
developments. Gaceta Sanitaria, 19, 135-150.
Villaverde-Gutiérrez, C., Araujo, E., Cruz, F., Roa, J. M., Barbosa,
W., & Ruiz-Villaverde, G. (2006). Quality of life of rural
menopausal women in response to a customized exercise
programme. Journal of Advanced Nursing, 54, 11-19.
Yosef, A. R. (2008). Health beliefs, practice, and priorities for
health care of Arab Muslims in the United States: Implications
for nursing care. Journal of Transcultural Nursing, 19,
Zapata-Barrero, R. (2003). Citizenship in multicultural con-
texts: Process of changes of paradigms Anales de la Cátedra
Francisco Suárez, 37, 173-199.
Zúñiga, M., Carrillo-Jiménez, G. T., Fos, P. J., Gandek, B., &
Medina-Moreno, M. C. (1999). Evaluation of health status
using Survey SF-36: Preliminary results in Mexico. Salud
Pública de Mexico, 41, 110-118.
by guest on July 29, 2015tcn.sagepub.comDownloaded from
Full-text available
Introduction: rates of health problems related to a chronic lack of energy in pregnant women in Indonesia remain prevalence. This study aimed to develop community empowerment and supplementary feeding on health status and nutritional status among pregnant women. Methods: the sample included 189 pregnant women living in the six villages in the Jember District. The research used a cluster random sampling technique. The variables included community empowerment, supplementary feeding, health status, and nutritional status of pregnant women. Data analysis was performed using structural equation modeling (SEM) with parameter data estimation using software (Analysis of Moment Structures (AMOS) version 21). Results: estimations of the direct effects were as follows: community empowerment on health status (0.224), supplementary feeding on health status (0.169), health status on nutritional status of pregnant women (0.001), community empowerment on nutritional status of pregnant women (2.857), supplementary feeding on nutritional status of pregnant women (-0.537), community empowerment on nutritional status of pregnant women through health status (0.000), supplementary feeding on nutritional status of pregnant women through health status (0.000), community empowerment on health status (0.224), supplementary feeding on health status (0.169). Conclusion: community empowerment remains an important key in improving the engagement of women in maternal health issues. Combined intervention with supplementary feeding based on locality may improve the health outcomes.
Full-text available
A population-based cross-sectional study aimed to examine sex differences in health-related quality of life (HRQoL) of older adults, and investigate whether the relation patterns between HRQoL and its correlates differed between sexes. A stratified proportional and representative sample included 802 volunteers, aged 60–79. HRQoL (36-item Short Form Health Survey), functional fitness (Senior Fitness Test), physical activity (PA) (Baecke questionnaire), demographic information and health features (questionnaires) were assessed. Men showed significantly higher HRQoL ( P <0.001). Body mass index, body strength, aerobic endurance, PA, depressive symptoms, falls, and living alone were significantly related to HRQoL. With sex as moderator, these relations were not significant, except for PA ( β =0.12, P =0.004). A significant interaction of sex with PA on HRQoL ( β =0.08, P =0.037) was found, indicating that this relation was higher in men. A similar relation pattern was found for HRQoL physical component. HRQoL and its correlates differed between sexes, demanding a sex specific approach to promote HRQoL.
Full-text available
OBJECTIVE Analyzing the relationship between social support, quality of life and depression in patients eligible for palliative care at Primary Health Care of a municipality in the interior of Minas Gerais, Brazil. METHOD A correlational cross-sectional study carried out with patients treated in six primary health care units. Data were submitted to descriptive statistical analysis, tests for differences between averages and medians, and correlation tests. The significance level was 0.05. RESULTS The sample consisted of 115 participants, and it was identified that the higher the social support, the better the global quality of life (p<0.001) and functional quality of life (p=0.035); the greater the presence of physical symptoms, the lower the level of social support (p=0.012) and the higher the level of depression (p<0.001); the higher the symptoms of depression, the worse the global quality of life (p<0.001), functional quality of life (p<0.001) and the lower the levels of social support (p<0.001). CONCLUSION Levels of quality of life, social support and depression of patients eligible for palliative care are influenced by socioeconomic factors such as marital status, gender, age, income, education and presence of a caregiver.
Background Identifying the factors influencing breastfeeding attitude is significant for the implementation of effective promotion policies and counselling activities. To our best knowledge, no previous studies have modelled the relationships among breastfeeding attitude, health-related quality of life and maternal obesity among multi-ethnic pregnant women; the current study attempts to fill this research gap. Objectives This study investigated the relationships among maternal characteristics, health-related quality of life and breastfeeding attitude amidst normal weight and overweight/obese pregnant women using a multi-group structural equation modelling approach. Design Exploratory cross-sectional design was used. Setting Antenatal clinics of a university-affiliated hospital Participants Pregnant women were invited to participate; 708 (78.8%) agreed to participate in the study. Methods We examined a hypothetical model on the basis of integrating the concepts of a breastfeeding decision-making model, theory of planned behaviour-based model for breastfeeding and health-related quality of life model among 708 multi-ethnic pregnant women in Singapore. The Iowa Infant Feeding Attitude Scale and Medical Outcomes Study Short Form Health Survey were used to measure breastfeeding attitude and health-related quality of life, respectively. Results Two structural equation models demonstrated that better health-related quality of life, higher monthly household income, planned pregnancy and previous exclusive breastfeeding experience were significantly associated with positive breastfeeding attitude among normal and overweight/obese pregnant women. Among normal weight pregnant women, those who were older with higher educational level were more likely to have positive breastfeeding attitude. Among overweight/obese pregnant women, Chinese women with confinement nanny plan were less likely to have positive breastfeeding attitude. No significant difference existed between normal weight and overweight/obese pregnant women concerning estimates of health-related quality of life on breastfeeding attitude (Critical Ratio = −0.193). The model satisfactorily fitted the data (Incremental Fit Index = 0.924, Tucker–Lewis Index = 0.905, Comparative Fit Index = 0.921 and Root Means Square Error of Approximation = 0.025). Health-related quality of life was found to affect breastfeeding attitude in multi-ethnic pregnant women. Conclusions This relationship implied the importance of early culturally specific interventions to enhance health-related quality of life for improving positive breastfeeding attitude among pregnant women across different ethnic groups.
Full-text available
Community wellbeing is a function of many factors working in concert to promote an optimal quality of life for all members of a community. It is argued here that the promotion of lifelong learning among older adults can significantly contribute to community wellbeing. The aging society is a worldwide phenomenon presenting both opportunities and challenges to community wellbeing. Research suggests that the more active, healthier, and educated older adults are, the less drain they are on family and community resources and services. At the same time, active and healthy elders contribute to community wellbeing through their accumulated life experience, expertise, and service. The relationship between lifelong learning and community wellbeing is argued from a social capital perspective. This framework contends that formal, nonformal, and informal learning activities of older adults promote an active and engaged lifestyle that helps create and preserve community. Issues of access and opportunity are also addressed.
Full-text available
The study in the quality of life of old people is seen as having a special interest in order to detect specific needs which otherwise would go unnoticed. This is even more important in multicultural societies, where religious and cultural perspectives are understood as decisive. The main objective of this study was to identify factors which affect the quality of life of the elderly belonging to different religions (Christian, Muslim and Jewish), living together in Ceuta (Spain), on the border of Morocco. Between 2006 and 2009, an ethnographic study was made in the city of Ceuta amongst people aging from 65 to 80 years (n: 372; N: 7078), different religious beliefs (7% Jewish; 68% Christians; 25% Muslims; 7% Jewish), both genders (55% female; 45% male), with no invalidating/disability pathologies and who had lived in Ceuta for at least 20 years within any of the six different districts in which the city is divided. The indicated population underwent a survey, from which three different dimensions emerge. These dimensions are submitted to reliability and validity criteria: Isolation (α=0,73), Multiculturality (=0,65), and Border Security (α=69). These results lead us to the elaboration of a model of the reality of the elderly in a multicultural context.
Full-text available
The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work.The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor.Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities.This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.
Full-text available
Multi-centre and cross-cultural research require the use of common protocols if the results are to be either pooled or compared. All too often adherence to protocols is not discussed in reports and where it is reported poor adherence is frequently noted. This paper discusses the use of international guidelines developed by WHOQOL Field Centres to conduct and report focus groups aimed at eliciting key concepts of quality of life among older adults. This was the first step in the development of the WHOQOL-OLD instrument. Although there was overall adherence to the agreed guidelines, there were some differences in the level of reporting, even after participating Field Centres had the opportunity to explain their reports. The reasons for these discrepancies are reported. It is concluded that because of local situations, it is difficult to achieve identical implementation of multi-centre cross-cultural protocols and that the highest standards of auditing are required if findings are to be compared. Suggestions for how such protocols can be improved are given.
The purpose of this paper is to reflect on the challenge that the Spanish Health System must face in tackling the issue of healthcare in a multicultural society like ours. At the same time, it also aims to analyse the different situations and difficulties that immigrants encounter in gaining access to the health system and meeting their health-related needs. Given the changes that our society is undergoing, professionals must be aware what our attitude and position are with regard to cultural diversity. This will help us understand, respect and value the importance of nursing training in cultural skills.
BACKGROUND: The present study, performed within the International Quality of Life Assessment project (including researchers from 15 countries) presents preliminary results of the process of adaptation of the SF-36 to be used in Spain. METHODS: The adaptation was based on the translation/back-translation methodology. Meetings of translators, researchers and patients were organized in order to produce successive versions. A study involving 47 individuals was carried out to assess the relative value (through a visual analogue scale) of each response choice of the questionnaire items. Finally, internal consistency and reproducibility of the Spanish version of the SF-36 was assessed by administering the questionnaire to 46 patients with stable coronary heart disease in two different occasions 2 weeks apart. RESULTS: The average ratings of equivalence of the translated version with the original were high regardless of the difficulty of translation. The rank ordering of mean scores for each responses choice agreed with the ranking assigned in the questionnaire in all cases. Cronbach's Alpha was higher than 0.7 for all dimensions (range: 0.71-0.94) except for Social Functioning scale (alpha = 0.45). Intraclass correlation coefficients between both administrations of the questionnaire ranged from 0.58 to 0.99. CONCLUSIONS: The adaptation process of the SF-36 has concluded with an instrument apparently equivalent to the original and with an acceptable level of reliability. Nevertheless, other basic characteristics of the adapted questionnaire (i.e. validity and sensitivity to changes) should be also assessed.
Objective: The Short Form-36 Health Survey (SF-36) is one of the most widely used and evaluated generic health-related quality of life (HRQL) questionnaires. After almost a decade of use in Spain, the present article critically reviews the content and metric properties of the Spanish version, as well as its new developments. Methods: A review of indexed articles that used the Spanish version of the SF-36 was performed in Medline (PubMed), the Spanish bibliographic databases IBECS and IME. Articles that provided information on the measurement model, reliability, validity, and responsiveness to change of the instrument were selected. Results: Seventy-nine articles were found, of which 17 evaluated the metric characteristics of the questionnaire. The reliability of the SF-36 scales was higher than the suggested standard (Cronbach's alpha) of 0.7 in 96% of the evaluations. Grouped evaluations obtained by meta-analysis were higher than 0.7 in all cases. The SF-36 showed good discrimination among severity groups, moderate correlations with clinical indicators, and high correlations with other HRQL instruments. Moreover, questionnaire scores predicted mortality and were able to detect improvement due to therapeutic interventions such as coronary angioplasty, benign prostatic hyperplasia surgery, and non-invasive positive pressure home ventilation. The new developments (norm-based scoring, version 2, the SF-12 and SF-8) improved both the metric properties and interpretation of the questionnaire. Conclusions: The Spanish verion is a suitable instrument for use in medical research, as well as in clinical practice.
In the last few years, many different instruments assessing health-related quality of life and the broader concept of Patient-Reported Outcomes (PRO) have been developed. Following the recommendations of the Scientific Advisory Committee of the Medical Outcomes Trust, the ePRO checklist provides a modular assessment for PRO instruments based on eight key attributes: conceptual and measurement model, reliability, validity, responsiveness, interpretability, respondent and administrative burden, alternative forms, and cross-cultural adaptation. Selected criteria describing each attribute in detail are also listed. The availability of explicit guidelines is expected to promote the development of better PRO measurement instruments.