Enhancing the multi-dimensional assessment of quality of life: introducing the WHOQOL-Combi.

INTRODUCTION: We revisited the global concept of subjective quality of life (QoL) as assessed by the WHOQOL-BREF to investigate whether it could be elaborated into a conceptually more comprehensive instrument with good psychometric properties. Responding to a growing need for shorter QoL measures with broader social, spiritual and environmental contents, facets from WHOQOL international modules were examined for potential integration into the new WHOQOL-Combi. METHOD: Adults over 65 years, diagnosed with one or more chronic diseases (n = 2833), completed 41 WHOQOL items during the CLASSIC survey; each item represented a WHOQOL facet. This pool of specific QoL facets contained 24 from the WHOQOL-BREF (excluding general items), and 17 from recent international WHOQOL short-form modules, selected for their generic properties. Rasch modelling reduced the final item pool when assessing the WHOQOL-Combi's conceptual structure. Comparisons are made with the WHOQOL-BREF. RESULTS: Modelling confirmed the tenability of a 36-item solution scored as a five-domain profile, comprised of 24 WHOQOL-BREF facets and 12 new facets from modules. Social and psychological domains were strengthened by three facets, spiritual QoL by five, and physical QoL by one. The WHOQOL-Combi showed sound model fit, excellent internal consistency (α = .95), and scores discriminated between socio-demographic categories. Concurrent validity with the EQ-5D-5L was confirmed for physical and psychological domains. Performance was similar to the WHOQOL-BREF. CONCLUSION: The WHOQOL-Combi offers a contemporary, comprehensive, integrated, multi-dimensional subjective QoL instrument with enhanced evaluations of social, spiritual, psychological and physical QoL. Acceptable to older people, future research should evaluate younger age groups and other cultures.

Peer Mentors for People with Advanced Cancer: Lessons Learnt from Recruiting and Training Peer Mentors for a Feasibility Randomized Controlled Trial.

Peer mentors may offer distinctive forms of support to people with advanced cancer. Whilst peer mentor programmes are known, little is understood about recruiting and training peer mentors to support those with advanced cancer. The purpose of this study is to determine the feasibility of recruiting and training peer mentors for a novel peer mentor intervention to promote well-being in people with advanced cancer. Feasibility study testing proactive introduction to a trained peer mentor for 12 weeks in the context of a randomized controlled two-arm trial and nested qualitative process evaluation was used. Peer mentors have/had cancer, recruited via an open call. Two-day training included a new bespoke module on coping with cancer. Descriptive recruitment and training data were captured, supplemented by qualitative interviews, analysed thematically. Forty-eight people expressed interest, mostly female (69%), with breast cancer (32%), and recruited via social media (49%). Twelve people completed training, with attrition often due to availability or mentors' own health; many had advanced cancer themselves. They wanted to 'give something back', but also formed supportive bonds with fellow mentors. It is feasible to recruit and train people with lived experience of cancer to be peer mentors, but those with particular characteristics may predominate. Broad social media based recruitment may have merit in widening the pool of potential peer mentors.

Development of a measure for patients preparing to start dialysis and their partners: The Starting Dialysis Questionnaire (SDQ).

BACKGROUND: The transition onto dialysis is a stressful time that affects both patients and their partners. Research suggests that psychological and interpersonal characteristics within the couple are related to how well they adapt to dialysis. The aim of this multi-phase, mixed methods study was to develop a measure, the Starting Dialysis Questionnaire (SDQ), that is applicable to both patients and their partners and assesses their own thoughts and feelings about these constructs. METHODS: Data from semi-structured interviews with patients and their partners (n = 22 couples) were analysed using theoretical thematic analysis to identify and define constructs related to quality of life (QOL). Next, items addressing these constructs were derived from the interviews. Then, cognitive interviews were conducted with patients with chronic kidney disease and their partners (n = 5 couples) to assess the face validity and comprehensibility of the items. Lastly, preliminary psychometric properties were evaluated in a sample of patients preparing to start dialysis and their partners (n = 83 couples). RESULTS: Three themes related to QOL were identified, namely dialysis expectations, accepting dialysis and dyadic relationship characteristics. The cognitive interviews refined the SDQ and established its face validity. Psychometric assessments indicated that overall the items performed well and did not show significant floor or ceiling effects. Good internal consistency was found within the three domains, and items correlated within the domains. CONCLUSIONS: The SDQ is a measure (34 items) that assesses key psychological and interpersonal factors in patients and their partners as they start dialysis. It shows good preliminary psychometric properties; however, a large-scale field trial is needed to establish its validity. Once validated, it could offer a clinically useful tool to assist clinicians in preparing patients and partners for dialysis.

Does quality of life feedback promote seeking help for undiagnosed cancer?

PURPOSE: Diagnosing cancer early is an imperative, as help-seeking delays affect survival. Quality of life (QoL) deteriorates after diagnosis, but decline may start when cancer is suspected at the earliest stage of the pathway to treatment. This study examined whether offering guided feedback about personal QoL to adults with potential cancer symptoms, living in deprived communities, changes QoL and promotes help-seeking in primary care. METHODS: Visitors to a CRUK mobile cancer roadshow were recruited in 43 sites. A prospective longitudinal (2 × 2) repeated-measures design was applied. Where they presented a potential cancer symptom, and were 'signposted' to a GP, they were allocated to a symptom condition, or a lifestyle condition, if seeking cancer risk advice. Randomisation was to an Intervention group, who received feedback about personal QoL results (WHOQOL-BREF and WHOQOL importance measures), or a Control group who assessed QoL without feedback. Depression was screened. RESULTS: Of 107 participants, the mean age was 53; 50% were women, 57% were without tertiary education, 66% were unemployed and 45% were currently ill. Over 10 weeks, 54% of all those with symptoms sought help from a medical source and 42% specifically from a GP. Thirty-one completed all three assessments. With symptoms present, psychological, social and environmental QoL were poor, becoming poorer over time. When the symptoms group received feedback, psychological QoL increased, but GP visits were unaffected. However, feedback increased help-seeking from informal social contacts. Lifestyle groups reported consistently good psychological and social QoL. CONCLUSION: This early cancer research offers practical and theoretical implications for QoL interventions in deprived communities.

Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study.

BACKGROUND: Quality of life (QOL) is important to patients with end stage renal disease and their partners. Despite the first 12 weeks being a critical time in the treatment pathway, limited research exists which examines how the transition onto dialysis impacts QOL. In this study we measured QOL in patients and their partners at pre-dialysis and over the first 12 weeks on dialysis to investigate QOL during this crucial period. METHODS: Patients and their partners, recruited from 10 renal units in England, completed questionnaires at pre-dialysis (n = 166 participants, 83 couples), 6 weeks (n = 90 participants, 45 couples) and 12 weeks (n = 78, 39 couples) after starting dialysis. On each occasion participants completed a QOL questionnaire (WHOQOL-BREF). Multilevel modelling accommodated the nested structure of couples with repeated measures within participants. Three-level random intercept models estimated changes in WHOQOL general QOL and its four domains (Physical, Psychological, Social and Environment). Two-level random intercept models assessed the relationship between baseline clinical and socio-demographic variables with changes in general QOL. RESULTS: Patients reported positive changes in general QOL from pre-dialysis to 6 weeks (ß = 0.42, p < 0.001, 95% CI 0.19, 0.65) and from pre-dialysis to 12 weeks (ß = 0.47, p < 0.001, 95% CI 0.24, 0.71). Partners' general QOL decreased significantly from pre-dialysis to 6 weeks (ß = - 0.24, p = 0.04, 95% CI -0.47, - 0.01) but returned to its original level at 12 weeks. Patients reported improvements in the physical domain between pre-dialysis and 12 weeks (ß = 6.56, p < 0.004, 95% CI 2.10, 11.03). No other domains changed significantly in patients or partners. Only in patients were there significant associations between moderator variables and general QOL. High comorbidity risk level and diabetes were associated with poorer QOL at pre-dialysis whereas being female and having an arteriovenous fistula were linked with improvements in general QOL. CONCLUSIONS: Patients reported significant improvements in their general and physical QOL after starting dialysis. Partners' general QOL worsened after patients started dialysis but improved by 12 weeks. Both patients and partners may benefit from additional educational and counselling services in the lead up to, and immediately after starting dialysis, which could facilitate the transition onto dialysis and improve QOL in both. STUDY REGISTRATION: This study was adopted on the NIHR Clinical Research Network (UK). The details of this study are registered on the Research Registry website (www.researchregistry.com). The identifier for this study is researchregistry2574.

Correction to: Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study.

An amendment to this paper has been published and can be accessed via the original article.

Peer support to maintain psychological wellbeing in people with advanced cancer: findings from a feasibility study for a randomised controlled trial.

BACKGROUND: Advanced cancer affects people's lives, often causing stress, anxiety and depression. Peer mentor interventions are used to address psychosocial concerns, but their outcomes and effect are not known. Our objective was to determine the feasibility of delivering and investigating a novel peer mentor intervention to promote and maintain psychological wellbeing in people with advanced cancer. METHODS: A mixed methods design incorporating a two-armed controlled trial (random allocation ratio 1:1) of a proactive peer mentor intervention plus usual care, vs. usual care alone, and a qualitative process evaluation. Peer mentors were recruited, trained, and matched with people with advanced cancer. Quantitative data assessed quality of life, coping styles, depression, social support and use of healthcare and other supports. Qualitative interviews probed experiences of the study and intervention. RESULTS: Peer mentor training and numbers (n = 12) met feasibility targets. Patient participants (n = 12, from 181 eligible who received an information pack) were not recruited to feasibility targets. Those who entered the study demonstrated that intervention delivery and data collection were feasible. Outcome data must be treated with extreme caution due to small numbers, but indicate that the intervention may have a positive effect on quality of life. CONCLUSIONS: Peer mentor interventions are worthy of further study and researchers can learn from these feasibility data in planning participant recruitment and data collection strategies. Pragmatic trials, where the effectiveness of an intervention is tested in real-world routine practice, may be most appropriate. Peer mentor interventions may have merit in enabling survivors with advanced cancer cope with their disease. TRIAL REGISTRATION: The trial was prospectively registered 13.6.2016: ISRCTN10276684 .

Impact of Dialysis on the Dyadic Relationship Between Male Patients and Their Female Partners.

The objective of this study was to explore the impact of three early phases of renal dialysis, namely pre-dialysis, starting dialysis, and establishing dialysis, on dyadic relationships. Twenty UK-based dyads (20 male patients and their female partners) participated in semi-structured interviews and discussed the effects of dialysis on themselves and their relationship. Dyadic thematic analysis, facilitated by dyadic-level charting, integrated participants' experiences and enabled identification of patterns across dyads. We found that dialysis had positive and negative influences on identity, social relationships, and mental health, forming the themes: Prioritizing the Patient, Carrying the Burden, and Changing Identities. The final theme, Managing the Relationship, described how dyads prevented dialysis from negatively impacting their relationship. Dyadic-level charting provided a systematic examination of individual and dyadic experiences. These findings indicate that access to informational and support services for dyads as they prepare to start dialysis may minimize negative effects on their relationship.

Undiagnosed cancer symptoms in the community: does poor quality of life influence the decision to seek help?

PURPOSE: Although a cancer diagnosis is linked with decrements to quality of life (QoL), it is unknown exactly when QoL starts to deteriorate, and whether this occurs during the pre-diagnostic pathway. This study aimed to examine QoL during this phase, and in addition investigate whether QoL levels influence decisions about seeking professional help. This is important, because early diagnosis is linked to lower cancer mortality rates. METHODS: Working alongside a Cancer Research UK Roadshow in socially deprived communities, the recent QoL of adult visitors was assessed, before attending primary care. Using a cross-sectional design, we compared QoL in those presenting a potential cancer symptom/sign, with others seeking lifestyle advice to reduce cancer risk. Self-reported QoL (WHOQOL-BREF), and intention to seek help, were measured. RESULTS: Of 107 recruited, 50% were men. The potential cancer symptom group reported significantly poorer general QoL and psychological QoL, than lifestyle controls. Prior poorer physical QoL predicted stronger intentions to consult a general practitioner (GP) in the next 2 weeks, when controlling for symptom presence. CONCLUSIONS: QoL is poorer for those with potential cancer symptoms, before they first seek advice from primary care. Poorer physical QoL is associated with stronger intentions to make a GP appointment. An implication for longer term health is that if public awareness about the impact of symptoms on QoL was raised, this could provide an impetus to seek help.

What Do U.K. Orthopedic Surgery Patients Think About PROMs? Evaluating the Evaluation and Explaining Missing Data.

The NHS routinely evaluates the quality of life of patients receiving hip or knee replacement surgery using patient-reported outcome measures (PROMs), but some hospital completion rates are only 30%, restricting data usefulness. Statistics limit insights into how and why data are missing, so qualitative methods were used to explore this issue. Observation periods preceded semistructured interviews with 34 preoperative patients attending an orthopedic outpatient clinic. Interview themes covered: completion time/timing, orientation, setting, measures, and practicalities. Triangulated against observations, pragmatic barriers, and facilitators were considered. Refined themes included completion conditions, patient support, and national delivery. Simple improvements (e.g., quiet zone) could improve completion rates and reducing missing data. Reorganizing preoperative leaflets and their systematic distribution via standardized procedures could reassure patients, enhancing PROMs acceptance, while reducing inquiries and subsequent staff burden. Findings have implications for interpreting national statistics. They indicate that further debate about mandating preoperative PROMs is due.

Effect of health literacy on the quality of life of older patients with long-term conditions: a large cohort study in UK general practice.

PURPOSE: The levels of health literacy in patients with long-term conditions (LTCs) are critical for better disease management and quality of life (QoL). However, the impact of health literacy on QoL in older adults with LTCs is unclear. This study examined the association between health literacy and domains of QoL in older people with LTCs, investigating key socio-demographic and clinical variables, as confounders. METHODS: A prospective cohort study was conducted on older adults (n = 4278; aged 65 years and over) with at least one LTC, registered in general practices in Salford, UK. Participants completed measures of health literacy, QoL, multi-morbidity, depression, social support, and socio-demographic characteristics. Multivariate linear regressions were performed to examine the effects of health literacy on four QoL domains at baseline, and then changes in QoL over 12 months. RESULTS: At baseline, poor health literacy was associated with lower scores in all four QoL domains (physical, psychological, social relationships and environment), after adjusting for the effects of multi-morbidity, depression, social support and socio-demographic factors. At 12-month follow-up, low health literacy significantly predicted declines in the physical, psychological and environment domains of QoL, but not in social relationships QoL. CONCLUSIONS: This is the largest, most complete assessment of the effects of health literacy on QoL in older adults with LTCs. Low health literacy is an independent indicator of poor QoL older patients with LTCs. Interventions to improve health literacy in older people with LTCs are encouraged by these findings.

Evaluating a new methodology for providing individualized feedback in healthcare on quality of life and its importance, using the WHOQOL-BREF in a community population.

PURPOSE: We conducted an evaluation to find out how a novel quality of life (QoL) intervention containing guided individualized feedback was appraised. The importance of QoL was matched with QoL assessment for each subjective dimension, using graphical feedback. We examined whether this information was acceptable, feasible and valued beyond the clinical context, among the community. METHODS: Using a mixed-methods cross-sectional design, the intervention was piloted with 129 participants from communities and registered in primary care. WHOQOL-BREF and WHOQOL Importance scores were graphically matched by dimension. Results were inspected and interpreted with directed guidance to identify good and poor QoL. We report the post-intervention evaluation of feedback, including qualitative themes. Follow-up interviews among those expecting feedback to be helpful explored potential self-management and healthcare uses. RESULTS: After feedback, 65 % reported changes in thoughts and perceptions of QoL, often describing insights as self-affirming. Goals or expectations changed for 34 %, and motivation to change was reported. Over 50 % evaluated the feedback as helpful in the short term or for the future. Follow-up interviews endorsed the value of the feedback and its usefulness in sharing with a healthcare professional (92 %), suggesting it would facilitate professionals' understandings of patients and enable health advice to be targeted. CONCLUSIONS: The benefits of using this novel feedback can be extended to the general population, as directed guidance aids interpretation, thereby saving health service costs. This complex pilot intervention needs testing in a blinded fully randomized controlled trial. Beyond independent self-management, graphs could be used during clinical decision-making.

Electronic Quality of Life Assessment Using Computer-Adaptive Testing.

BACKGROUND: Quality of life (QoL) questionnaires are desirable for clinical practice but can be time-consuming to administer and interpret, making their widespread adoption difficult. OBJECTIVE: Our aim was to assess the performance of the World Health Organization Quality of Life (WHOQOL)-100 questionnaire as four item banks to facilitate adaptive testing using simulated computer adaptive tests (CATs) for physical, psychological, social, and environmental QoL. METHODS: We used data from the UK WHOQOL-100 questionnaire (N=320) to calibrate item banks using item response theory, which included psychometric assessments of differential item functioning, local dependency, unidimensionality, and reliability. We simulated CATs to assess the number of items administered before prespecified levels of reliability was met. RESULTS: The item banks (40 items) all displayed good model fit (P>.01) and were unidimensional (fewer than 5% of t tests significant), reliable (Person Separation Index>.70), and free from differential item functioning (no significant analysis of variance interaction) or local dependency (residual correlations < +.20). When matched for reliability, the item banks were between 45% and 75% shorter than paper-based WHOQOL measures. Across the four domains, a high standard of reliability (alpha>.90) could be gained with a median of 9 items. CONCLUSIONS: Using CAT, simulated assessments were as reliable as paper-based forms of the WHOQOL with a fraction of the number of items. These properties suggest that these item banks are suitable for computerized adaptive assessment. These item banks have the potential for international development using existing alternative language versions of the WHOQOL items.

A systematic review to quantitatively evaluate 'Stepping Stones': a participatory community-based HIV/AIDS prevention intervention.

This first independent systematic review examined evidence for the effectiveness of the stepping stones intervention in HIV prevention. To reduce HIV transmission it addresses gender roles and promotes equitable relationships. Biomedical, behavioural and psychosocial outcomes extracted from six databases and 'grey' literature identified eight reports of seven studies (n = 14,630) from India, Gambia, S. Africa, Ethiopia, Angola, Tanzania, Uganda and Fiji. Infection incidence tested in the only RCT showed no significant reduction in HIV, although HSV-2 decreased. Condom use increased (two countries out of eight). Risk reduction results were mixed for declining alcohol misuse (two studies in three) and multiple partners (one in two). Communicating HIV information to partners, family or community improved (three studies from seven). Gender inequity was reduced in India (one in five), but stigma decreased in four studies. Future investigations of diverse cultures and older adults should select high quality biomedical and quality of life measures.

Introducing the WHOQOL-SRPB BREF: developing a short-form instrument for assessing spiritual, religious and personal beliefs within quality of life.

PURPOSE: The aim was to develop and conduct preliminary testing of a short-form measure to assess spiritual, religious and personal beliefs (SRPB) within quality of life (QoL). METHODS: Existing data from the 132 items of the WHOQOL-SRPB (n = 5087) obtained in 18 cultures were first analysed to select the 'best' performing item from each of the eight SRPB facets. These were integrated with the 26 WHOQOL-BREF items to give 34 items in the WHOQOL-SRPB BREF. A focus group of hospital chaplains reviewed this new short-form. The WHOQOL-SRPB BREF was administered to a UK community sample (n = 230) either with an adapted WHOQOL-SRPB Importance measure or the SWBQ. A subset received both WHOQOL measures twice. RESULTS: Completed in 8 mins, the WHOQOL-SRPB BREF was acceptable and feasible; Importance 5.5 mins. Good internal consistency reliability was found overall (α = 0.85), for the SRPB domain (α = 0.83), and Importance (α = 0.90). Domains were moderately correlated. Domain test-retest reliability was acceptable in both WHOQOL measures, except for SRPB Importance. Sleep was linked with religious beliefs. Hope and wholeness were widely associated with non-spiritual facets. Factor analysis (maximum likelihood) of items largely confirmed the WHOQOL domain structure, adding SRPB as a significant fifth domain. Internally, SRPB distinguished religious from existential beliefs, and was validated by association with personal and transcendental well-being from the SWBQ. CONCLUSION: Preliminary evidence shows that the WHOQOL-SRPB BREF is sound for use in, and beyond health care. Extracted from a measure already available in 18 languages, this short-form can be immediately used where such translations exist.

WHOQOL Pain and Discomfort Module: development and validity testing of the Italian version.

BACKGROUND: The World Health Organization Quality of Life scale Pain and Discomfort Module (WHOQOL PDM) was designed to assess quality of life (QoL) in adults with chronic pain. It comprises 16 items covering four facets of pain: relief, anger/frustration, vulnerability/fear/worry, and uncertainty. AIM: The purpose of this study was to validate the Italian version of the WHOQOL PDM. METHODS: Chronic pain was assessed in 400 patients using the WHOQOL PDM and other pain scales, together with scales measuring associated symptoms, depression, anxiety, and QoL. RESULTS: The WHOQOL PDM shows good internal consistency, concurrent validity (it was significantly associated with all the WHOQOL BREF domains), construct validity (it was significantly associated with other pain scales), and discriminant validity (there were significant differences among different groups of patients). CONCLUSIONS: The Italian version of the WHOQOL PDM is a brief, useful, and valid tool for assessing chronic pain and its impact on patients' QoL.

An international quality of life instrument to assess wellbeing in adults who are HIV-positive: a short form of the WHOQOL-HIV (31 items).

Few cross-cultural measures are available to assess quality of life (QoL) in HIV/AIDS. A short form of the WHOQOL-HIV-the WHOQOL-HIV BREF-was developed and tested. Survey data from 1,923 HIV-positive adults (selected for age, gender and disease stage) were collected in 8 culturally diverse centres. The 'best' HIV-specific item was extracted from five HIV facets of the WHOQOL-HIV long form using information about item correlations with QoL, health and domains, item discriminant validity and centre problems. The five identified items were then integrated with the WHOQOL-BREF to complete the 31 item WHOQOL-HIV BREF. This short form shows good internal consistency reliability and discriminant validity for 'known' disease stages. Confirmatory Factor Analysis showed an overall good fit for a six domains model (Comparative Fit Index = 0.97), supporting scoring. Quality of life in different cultures is reported. A value of the WHOQOL-HIV short form is in monitoring QoL in multi-national clinical trials, and in clinical practice.

Expecting a good quality of life in health: assessing people with diverse diseases and conditions using the WHOQOL-BREF.

BACKGROUND AND OBJECTIVES: Fulfilling patient expectations is central to defining a good quality of life (QoL) in health. The WHOQOL-BREF was developed using novel, person-centred methods and is a generic patient-reported outcomes measure (PROM). However, without robust psychometric performance, PROMs cannot be relied upon to assess individuals. This study investigated the WHOQOL-BREF (UK), with this use in mind. DESIGN: Cross sectional with nested repeated measures. SETTING AND PARTICIPANTS: Twenty-seven disease groups or health conditions and healthy people were recruited at 38 UK sites, in a wide range of settings (n = 4628). INTERVENTIONS: 'Treatment as usual'; new and alternative interventions. OUTCOME MEASURES: WHOQOL-BREF (UK); SF-36. RESULTS: Respondent burden was low, as acceptability and feasibility were high. Internal consistency was excellent (0.92) and test-retest reliability good. Distinctive QoL profiles were found for diverse conditions. Musculoskeletal, psychiatric and cardiovascular patients reported the poorest QoL and also improved most during treatment. Overall, QoL was good, and best for healthy groups, supporting discriminant validity. Compared with the SF-36, WHOQOL physical and psychological domains showed good concurrent validity, although social was weak. Small or moderate effect sizes confirmed responsiveness to change in specified domains for certain conditions and interventions. Age had a small impact on reporting QoL. DISCUSSION AND CONCLUSION: The WHOQOL-BREF is found to be a high quality patient-centred generic tool suited to individual assessment in clinics, for research, and audit.

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

Concerns about patient safety have prompted studies of adverse surgical events (ASEs), but descriptive classification of errors and malpractice claims have overshadowed qualitative investigations into the processes that lead to expert errors and their solutions. We studied consultant surgeon's perspectives on how and why events occurred through semi-structured interviews about general and specific events. The sample contained heterogeneous cross-section of ages, gender and specialists, with >2 years consultant status and working within a 25-mile radius. Overarching findings included (1) pressures to work harder, faster and beyond capability within a blaming culture; (2) optimism bias from over-confidence and complacency; and (3) multiple pressures to 'finish' an operation or list, resulting in completion bias. Seven high order themes were identified on the healthcare system, adverse event types, contributing factors, emotions, cognitive processes, error detection, and strategies, solutions and barriers. The process of classifying event types guided solution selection, and the decision about whether to formally report it. How serious consequences were for patients and their temporal effects, defined an adversity continuum. Minor events arose routinely i.e. technical discrepancies, side-effects. More problematic were sub-optimal outcomes and avoidable events. Despite their expertise, consultants were vulnerable to unavoidable, uncontrollable events which were major concerns. Most serious were near-misses, errors and mistakes. However, major errors did not inevitably lead to a catastrophe and minor errors could be extremely serious. A 'cascade' of minor events exacerbated by negative emotions can precipitate major events, and interception methods need investigation. Consultants felt powerless and helpless to change environmental, organisational and systemic problems; new communication and action channels are desirable. Confidence building in team leadership would promote 'flatter' hierarchies, facilitating appropriate warnings. Although implementing the WHO Checklist averts important problems, social, environmental and organisational contributing factors are largely overlooked here and in existing models.

Prospective Evaluation of Positivity Rates of Aspergillus-Specific IgG and Quality of Life in HIV-Negative Tuberculosis Patients in Lagos, Nigeria.

BACKGROUND: Pulmonary tuberculosis (PTB) often results in residual anatomical and functional changes despite microbiological cure and may be complicated by chronic pulmonary aspergillosis (CPA). In this study, we determined the perceived health-related quality of life (HRQoL) of patients during and after PTB therapy and compared it with their quantitative Aspergillus-specific IgG positivity rates. METHODOLOGY: We conducted a longitudinal study among TB patients attending two directly observed therapy short-course (DOTS) clinics in Lagos, Nigeria. Two hundred and four confirmed TB patients were recruited over 9 months, with five visits at baseline and 3, 6, 9, and 12 months. They were all acid-fast bacilli smear, GeneXpert, or culture positive for Mycobacterium tuberculosis. Two HRQoL questionnaires translated into Yoruba were self-administered. Chest X-ray and Aspergillus IgG were collected at each visit. RESULTS: A total of 204 participants were recruited into this study. Most (70.6%) were age 18-39 years, and only 3.9% were above 60 years; 66.7% of all participants were males. A total of 189 (92.6%) participated in the 3-month assessment, 174 (85.3%) at 6 months, 139 (68.1%) at 9 months, and 99 (48.5%) at 12 months. At baseline, only 60.9% scored "good" or "very good" QoL and health on the WHOQOL-Bref, which improved to 77% at 6 months. At baseline, 10.4% had positive Aspergillus IgG levels, 15.1% at 3 months, 11.5% at 6 months, 16.7% at 9 months, and 19.3% at 12 months. Those with a positive Aspergillus IgG at 6 months had worse physical health (p = 0.001), psychological state (p = 0.002), social relationships (p = 0.006), and environmental QoL (p = 0.001) domains of the WHOQOL-Bref. Probable CPA was 10.4% at baseline and 19.3% at 6 months post-PTB therapy. Thirty-eight (18.6%) relocated after 6 months of treatment, 16 (7.8%) were lost to follow-up, and 11 (5.4%) died. CONCLUSION: Our findings reveal a significant relationship between the QoL and Aspergillus IgG levels of TB patients. Further follow-up studies and additional imaging are required to determine when patients develop CPA and its clinical impact.