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Use of the SF36 to assess postnatal health and well-being at 4 and 12 months

Use of the SF36 to assess postnatal health and well-being at 4 and 12 months. Debra Bick on behalf of the IMPaCT Study Team, University of Birmingham. The SF36. Introduction to SF36; use in postnatal care trial (IMPaCT)

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Use of the SF36 to assess postnatal health and well-being at 4 and 12 months

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  1. Use of the SF36 to assess postnatal health and well-being at 4 and 12 months Debra Bick on behalf of the IMPaCT Study Team, University of Birmingham

  2. The SF36 • Introduction to SF36; use in postnatal care trial (IMPaCT) • Health Insurance Experiment (HIE) (Ware et al 1980), Medical Outcomes Study (Tarlov et al 1989) • Short-form instrument – SF36 (Ware et al 1992) • Self complete or interviewer administered • Used to measure range of health outcomes - menorrhagia (Coulter et al 1994) - back pain (Ruta et al 1994) - sleep apnoea (Smith and Sheerson 1995)

  3. The SF36 • Measures three aspects of health; functional status; well-being; overall evaluation of health • Eight multi-item dimensions; physical functioning; social functioning; role limitations (emotional problems); role limitations (physical problems); mental health; energy/vitality; pain; general health perception • One unscaled single item ‘health change during last 12 months’ • Minor word modifications to USA version for UK use

  4. The SF36 • For each variable item, scores coded and summed to provide eight scores between ‘0’ (worst possible health state) to ‘100’ (best possible health state) • Data presented in means (SD) – but could camouflage information – dimension scores rarely normally distributed • Presentation of quartiles and median scores more appropriate (Jenkinson et al 1996)

  5. The SF36 • Physical (PCS) and Mental Component Summary Scores (MCS) derived from eight dimensions • Algorithm aggregates relevant components of questionnaire • Reduce statistical comparisons and possibility of chance testing hypotheses about health outcomes (Jenkinson et al 1996) • Reliability estimates from general population studies high for internal consistency and test re-test methods • Validity high from UK and USA general population studies (Ware et al 1994, Jenkinson et al 1999)

  6. IMPaCT Study Team Project Director Christine MacArthur Senior Lecturer Heather Winter Research Staff Research Fellow in Midwifery Debra Bick Research Midwife Helena Knowles Economist Clive Belfield Support Anne Walker PhD Student (Psychology) Deborah Biggerstaff Other team members Richard Lilford Christine Henderson Robert Lancashire Harry Gee David Braunholtz Funded by the NHS R&D Health Technology Assessment Programme (the views & opinions expressed herein are those of the authors, not the funders)

  7. Implementing Midwifery-led Postnatal Care Trial • Aims: to develop a new model of care - which could be implemented - and to examine the effects of this on women • Cluster RCT of new model of midwifery-led care compared with current care • 36 general practice clusters in West Midlands; 19 control, 17 intervention • 80 midwives; 42 intervention, 38 control. • 2064 women recruited

  8. Study outcomes Process. • Evaluation of implementation of the intervention Primary. • Physical & psychological health at 4 & 12 months. PCS and MCS scores of SF36, Edinburgh Postnatal Depression Scale. Secondary. • Views of postnatal care • Reported morbidity at 12 months • Health service usage during the first p/n year • ‘Good practice’ indicators • Health professional’s views of care

  9. The SF36 • No index of health status available for postnatal population • Sensitive to health changes within a general population. Simple to complete • Used in other postnatal studies (Morrell et al 2000, Reid et al 2002) • One question modified – relate current health to health prior to pregnancy (original – relate current health to health one year previously)

  10. The SF36 • SF36 scores standardised to mean of 50 • Standardisation based on US general population data (M/F, different age groups, range of health status) • Needed to standardise for p/n population, but no specific data available • Used population data for women of approximate childbearing age (18 – 54) from large community study to standardise (Jenkinson et al 1996)

  11. Effects of intervention - women’s health and well-being at 4 months

  12. Mean of cluster means (unweighted) PCS MCS EPDS EPDS 13+ (OR) Mean of cluster means Control 47.84 47.54 8.06 21.25% Intervention 46.68 50.50 6.40 14.39% Diff (95% CI) -1.17 (-2.52 to 0.19) 2.96 (1.16 to 4.77) -1.66 (-2.49 to -0.83) -6.85% (-11.99 to -1.7 P-Value 0.089 0.002 0.001 0.010

  13. The SF36 • Direction of effect for MCS same as for EPDS • Difference in MCS score larger than estimate used in power calculations • Distribution of MCS scores by cluster show effect general • PCS scores suggest no benefit to physical health - Resolution more difficult - Interaction with psychological well-being

  14. Mean cluster PCS scores with 95% confidence intervals

  15. Mean cluster MCS scores with 95% confidence intervals

  16. Mean cluster EPDS scores with 95% confidence intervals

  17. Effects of intervention - women’s health & well-being at 12 months • SF 36 and EPDS scores in both groups improved at 12 months postpartum • Statistically significant differences in MCS and EPDS between intervention and control groups still present

  18. Use of SF36 for postnatal health and well-being • Implications of 3.03 point increase in MCS at 4 months difficult to gauge • Close to range of differences associated with other health conditions (2.5 – 3 points) • Multi-level models showed effect of low (relative to high) level of social support associated with similar size MCS effect (3.11 points) • Only P/N trial to find effect - evaluated care given as standard to all women - delivered by standard midwives - multi-faceted intervention - undertaken through health region

  19. Conclusion • Psychological health effect same direction as EPDS, a specific p/n tool • Sensitivity to capture p/n physical well-being? • A generic measure. No variable on sexual functioning; sleep patterns; family functioning; cognitive functioning • Need to supplement use of SF36 to ‘tap’ variables or condition under study • Implications of findings for health service provision

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