Poucos estudos têm avaliado a estrutura dimensional do Oral Health Impact Profile-14 (OHIP-14). Análise sobre a dimensionalidade e a adequação do OHIP-14 pode ajudar a melhorar a interpretação deste instrumento. Os objetivos desta tese foram avaliar a dimensionalidade e testar um modelo conceitual de qualidade de vida relacionada à saúde bucal utilizando a escala OHIP-14. A tese foi organizada em 3 manuscritos. O primeiro manuscrito "Comparison of two assessment instruments of the quality of life in older adults" teve como objetivo investigar se existe convergência entre as dimensões da versão abreviada do questionário da Organização Mundial da Saúde sobre Qualidade de vida (WHOQOL-Bref) e do questionário Perfil do Impacto de Saúde Bucal-14 (OHIP-14). Neste estudo, foram avaliados 872 idosos do sul do Brasil. As dimensões dos questionários WHOQOL-Bref e OHIP-14 foram correlacionas por afinidade. Todas as correlações analisadas apresentaram baixa magnitude. Apesar dos questionários WHOQOL-Bref and OHIP-14 apresentarem dimensões relacionadas, eles medem as relações físicas, sociais e psicológicas de maneira diferente. O segundo manuscrito "Oral Health Impact Profile-14: a Unidimensional Scale?" teve como objetivo investigar a estrutura dimensional do OHIP-14. As amostras foram provenientes de dois estudos realizados no Brasil, um no Rio de Janeiro (N=504) e o outro em Carlos Barbosa (N=872). Análises Fatoriais Confirmatória e Exploratória foram realizadas para identificar as dimensões do OHIP-14. As análises fatoriais confirmaram um fator para ambos os estudos. Nossos resultados sugerem que o OHIP-14 é uma escala unidimensional. O terceiro manuscrito "Testing the applicability of a conceptual model of oral health-related quality of life in community-dwelling older people" teve como objetivo testar o modelo conceitual de Wilson e Cleary em relação à qualidade de vida relacionada à saúde bucal. Uma amostra aleatória de 578 idosos do sul do Brasil foi avaliada.O modelo conceitual de Wilson e Cleary foi testado usando a modelagem de equações estruturais, incluindo: edentulismo, sintomas, estado funcional, percepção de saúde bucal, qualidade de vida relacionada à saúde bucal e variáveis sociodemográficas. No modelo final, o edentulismo foi correlacionado com a insatisfação da aparência dos dentes (r = -0,25). O pior estado funcional foi correlacionado com pior percepção de saúde bucal (r = 0,24). A idade teve um efeito direto no OHIP-14 (r = -0,15). Houve um efeito indireto do sexo no OHIP-14 através do estado funcional (r = 0,12).Os resultados apresentados mostram que, para idosos brasileiros, variáveis como sexo e idade desempenham um papel importante para o entendimento conceitual de qualidade de vida relacionada à saúde bucal. Nossos resultados sugerem que o OHIP-14 não avalia o impacto das condições bucais na qualidade de vida numa perspectiva multidimensional, mas em uma única dimensão. A presente tese demonstrou que há caminhos diretos e mediados entre as variáveis clínicas e não clínicas em relação à qualidade de vida relacionada à saúde bucal. / A few studies have evaluated the dimensional structure of Oral Health Impact Profile-14. Further analysis on the dimensionality and the adequacy of OHIP-14 can help improve the interpretation of this instrument. The objectives of this thesis were to assess the dimensionality and testing a conceptual model of oral health-related quality of life using the OHIP-14 scale. The thesis was organized in three manuscripts. The first manuscript "Comparison of two assessment instruments of the quality of life in older adults" aimed to investigate if there is convergent validity between the dimensions of World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-Bref) and Oral Health Impact Profile-14 (OHIP-14) questionnaires. In this study, 872 elderly Southern-Brazilians were evaluated. The dimensions of WHOQOL-Bref and OHIP-14 questionnaires were correlated by affinity. All correlations analyzed had a low magnitude. Despite the fact that WHOQOL-Bref and OHIP-14 instruments have related dimensions, they measure physical, psychological and social relations differently. The second manuscript "Oral Health Impact Profile-14: a Unidimensional Scale?" aimed to investigate the dimensional structure of the OHIP-14. Subjects were from Rio de Janeiro (N=504) and Carlos Barbosa (N=872) Studies in Brazil. Exploratory and Confirmatory Factor Analysis were performed to identify the dimensions of OHIP-14. The factor analysis confirmed one factor in both studies. Our findings suggest that the OHIP-14 is a unidimensional scale. The third manuscript "Testing the applicability of a conceptual model of oral health-related quality of life in community-dwelling older people" aimed to test Wilson and Cleary's conceptual model in relation to oral health-related quality of life. A random sample of 578 elderly Southern-Brazilians was evaluated. Wilson and Cleary's conceptual model was tested using structural equations modeling including: edentulism, symptom status, functional health, oral health perceptions, oral health-related quality of life, and sociodemographic variables. In the final model, edentulism was negatively correlated to dissatisfaction of appearance of their dental prostheses (r= -0.25). The worse functional status was correlated with poor oral health perception (r= 0.24). Age had a direct effect on OHIP-14 (r= -0.15). There was an indirect effect of sex on OHIP-14 via functional status (r= 0.12). The results showed that for elderly Brazilians variables such as sex and age are important in the conceptual understanding of oral health-related quality of life. Our findings suggest that the OHIP-14 may not evaluate the oral impact on quality of life on a multidimensional perspective, but in a single dimension. The present thesis demonstrates that there are direct and mediated pathways between clinical and nonclinical variables in relation to oral health-related quality of life.

O objetivo principal deste estudo foi avaliar a associação do enfrentamento religioso-espiritual na qualidade de vida relacionada à saúde (QVRS) dos pacientes em pré-operatório de cirurgia de câncer de cabeça e pescoço. Estudo descritivo, correlacional, transversal, desenvolvido em enfermaria de cabeça e pescoço de um hospital público do interior do estado de São Paulo. As entrevistas individuais foram realizadas pela pesquisadora após a internação do paciente em seu período pré-operatório. Foram utilizados os seguintes instrumentos para a coleta de dados: roteiro estruturado para caracterização da amostra; o Functional Assessment Câncer Therapy-Head and Neck (FACT-H&N), para avaliar a QVRS em pacientes com câncer de cabeça e pescoço; a Escala de Coping Religioso-Espiritual (CRE), para avaliação do enfrentamento e da espiritualidade. Os dados foram analisados de forma quantitativa, utilizando-se dos princípios da estatística descritiva e inferencial. Participaram da investigação 55 pacientes, predominantemente do sexo masculino, com idade média de 57,1 anos. Todos participantes acreditavam em Deus e, em sua maioria, consideravam-se católicos (87,3%). Com relação ao enfrentamento religioso-espiritual, as médias das variáveis da Escala CRE foram satisfatórias, assim como as variáveis do instrumento FACT H&N. No entanto, não foram encontradas diferenças estatisticamente significantes entre as médias de CRE Total comparadas com grupos etários, sexo e com as medianas dos domínios do FACT-H&N. Embora seja possível deduzir uma correlação entre os constructos CRE e QVRS, não detectamos associação entre a Escala CRE e FACT H&N. Não obstante, encontrou-se diferença estatisticamente significante entre as correlações nos grupos que apresentaram CRE Total Alto e Médio da Escala CRE e os altos e baixos escores nos domínios do instrumento FACT H&N, indicando que aquele que apresenta alta utilização do enfrentamento religioso-espiritual apresenta melhores índices nos domínios da qualidade de vida relacionada à saúde. Ressalta-se que tal correlação não implica em causa e efeito, ainda são complexas as relações entre a espiritualidade, religiosidade e seus benefícios para a saúde, mas este assunto tem merecido grande destaque em meios científicos. / The main goal of this study was to assess the association between religious-spiritual coping and the health-related quality of life (HRQoL) of patients in the preoperative phase of head and neck cancer surgery. A descriptive correlational and cross-sectional study was developed at a head and neck ward of a public hospital in the interior of São Paulo State, Brazil. The researcher held individual interviews after the patient\'s hospitalization in the preoperative phase. The following data collection instruments were used: structured script for sample characteristics; the Functional Assessment Cancer Therapy-Head and Neck (FACT-H&N), to assess the HRQoL in head and neck cancer patients; the Religious Spiritual Coping Scale (CRE), to assess coping and spirituality. The data were subject to quantitative analysis, using the principles of descriptive and inferential statistics. Research participants were 55 patients, predominantly male, with a mean age of 57.1 years. All participants believed in God and the majority considered they were Catholic (87.3%). Concerning religious-spiritual coping, the mean scores for the CRE Scale variables were satisfactory, as well as the FACT H&N variables. No statistically significant differences were found, though, between the mean scores of the Total CRE compared with age groups, gender and median scores for the FACT-H&N domains. Although a correlation can be deduced between the CRE and HRQoL constructs, we did not detect and association between the CRE and FACT H&N Scales. Nevertheless, a statistically significant difference was found between the groups with High and Medium total CRE on the CRE Scale and high and low scores in the FACT H&N domains, indicating that patients with high usage rates of religious-spiritual coping present better scores in the health-related quality of life domains. It is highlighted that this correlation does not imply cause and effect. Relations among spirituality, religiosity and their benefits for health remain complex, but this topic has received great attention in the scientific context.

Approximately 34% of adolescents are overweight or obese which can be accompanied by physical, psychosocial, and economic consequences. Increasingly, pediatric overweight/obesity research has focused on Health Related Quality of Life (HRQoL) as a health outcome. This study examined differences in HRQoL across weight categories in adolescents, specifically, the sensitivity of using a general versus condition-specific measure. Further, the influence of gender was explored. Data were extracted from Wave 2 of Team Up for Healthy Living, a school-based obesity prevention program targeting adolescents in Southern Appalachia. Participants (N = 918; 50% Female; 93% Caucasian; 90% 9th graders) completed the Pediatric Quality of Life (PedsQL) Inventory (general) and PedsQL Multidimensional Fatigue Scale (condition-specific) measures as part of a larger survey. Body mass index-for-age and -sex percentiles were calculated using actual height and weight, and students were classified as underweight, healthy weight, overweight, or obese according to Centers for Disease Control and Prevention (CDC) criteria. Two 4 (weight category: underweight vs. healthy weight vs. overweight vs. obese) x 2 (gender: male vs. female) factorial analyses of variance (ANOVAs) were calculated to compare mean scores of total HRQoL (both generic and condition-specific). Additionally, 7 factorial multivariate analyses of variance (MANOVAs) were conducted with each measure’s subdomains. Fisher’s Least Significant Difference post hoc analyses were run to assess differences between groups, at a significance level of p<0.05. The current study revealed no interaction effect between total HRQoL (assessed via the generic or condition-specific measure) and weight category and gender; however, main effects were found for both weight category (assessed via a generic measure only) and gender (assessed via both generic and condition-specific measures). Additional research is needed to examine the impact of utilizing different measures and the potential role of gender as well as other factors that may influence HRQoL across weight categories. These issues are important as researchers to date utilize a variety of HRQoL measures making interpretation of findings difficult and often do not consider other variables such as gender that may influence findings.

Suicidal behavior, including ideation and attempts, is a significant public health problem. Due to the complexity of suicidal behavior, it is necessary to consider an array of factors that could serve as risk and protective factors. Previous research has shown that deficits in social problemsolving ability are associated with increased risk for suicidal ideation and attempts; conversely, problem solving strengths are associated with reduced risk. This dissertation project, consisting of 3 individual manuscripts, was designed to explore the relationship between social problemsolving ability and suicidal behavior in low-income primary care patients. Furthermore, additional constructs including health related quality of life, interpersonal needs, neuroticism, and hopelessness were also explored as they related to social problem solving and suicidal behavior. In a sample of 220 primary care patients ages 19-79 (M = 44.08; SD = 12.11), we examined the following: 1) health related quality of life as a mediator of the relationship between social problem solving and suicidal behavior, 2) interpersonal needs as a mediator of the relationship between social problem solving and suicidal behavior, and 3) the potential mediating role of hopelessness on the relation between neuroticism and suicidal behavior and the moderating role of social problem-solving ability on these associations. Participants completed self-report questionnaires including the Social Problem Solving Inventory-Revised-Short Form, Suicidal Behaviors Questionnaire-Revised, Short-Form 36, Interpersonal Needs Questionnaire, NEO-Five Factor Inventory, and the Beck Hopelessness Scale. Scores were analyzed using bootstrapped mediation and moderated mediation techniques. In Manuscript 1 mediating effects were found for mental health related quality of life. In Manuscript 2 thwarted belongingness and perceived burdensomeness mediated the relationship between social problem solving and suicidal behavior. Finally, in Manuscript 3 there was a significant indirect effect of neuroticism on suicidal behavior through hopelessness, and this indirect effect was moderated by social problem-solving ability. Our findings indicate that social problem-solving ability serves as both a risk and protective factor for suicidal behavior and impacts other variables that influence suicide risk among primary care patients. Interventions that bolster social problem-solving ability may reduce suicide risk in primary care.

Suicide is a public health problem and complex relationships exist between intrapersonal suicide risk factors and interpersonal risk factors. Health-related quality of life (HRQL) may interact with difficulties with interpersonal relationships and psychopathology. We examined thwarted interpersonal needs and depressive symptoms as potential mediators on the association between HRQL and suicidal behaviors. It was hypothesized that thwarted interpersonal needs would mediate the association between HRQL and suicidal behavior, and that this mediating effect would be dependent on the moderating effect of depressive symptoms. It was hypothesized that thwarted interpersonal needs and then depressive symptoms would sequentially mediate the association between HRQL and suicidal behavior. The mediating roles of thwarted belongingness and perceived burdensomeness on the association between HRQL and suicidal behaviors were supported. Moderated-mediation results were not significant. Serial mediations analyses were partially supported. Our findings suggest the importance of considering both interand intrapersonal factors on suicidal behavior.

Background: Health-related quality of life (HRQoL) has been recognized as an important target and health outcome in obesity research. The current study aimed to examine HRQoL in overweight or obese children after a 10-week primary-care–based weight management program, Parent-Led Activity and Nutrition for Healthy Living, in southern Appalachia. Methods: Sixty-seven children (ages 5–12 years) and their caregivers were recruited from four primary care clinics, two of which were randomized to receive the intervention. Caregivers in the intervention groups received two brief motivational interviewing visits and four group sessions led by providers as well as four phone follow-ups with research staff. Caregivers completed the PedsQL and demographic questionnaires at baseline and at 3, 6, and 12 months postintervention. Child height and weight were collected to determine standardized BMI. Results: Caregivers of children receiving the weight control intervention reported no statistically significant improvements in child total HRQoL, as compared to the control group, across the course of treatment (β=0.178; 95% confidence interval, −0.681, 1.037; p=0.687). Additionally, no statistically significant improvements were found across other HRQoL domains. Conclusions: Future studies examining HRQoL outcomes in primary care may consider treatment dose as well as methodological factors, such as utilization of multiple informants and different measures, when designing studies and interpreting outcomes.

Obesity is a serious health problem that leads to several chronic diseases and premature deaths. TheIn this project,was used to evaluate the effectiveness of the the Weigh Forward (WF) program, a 10-week weight-loss program administered in retail clinics, was evaluated, and it is provided in retails stores. The project analysis was completed on a limited data set on The population consisted of 15 obese participantsmembers of the program, 18 years and above, at 13 dispersed clinics in Maryland and Virginia.in the WF program from 13 dispersed clinics in Maryland and VirgiObesity is a body mass index (BMI) > 30 kg/m2. Participants were 18 years and above The theory of planned behavior (TPB) was used as the framework from which to view the project. The project was usedpurpose was to determine the efficacy of the WF program for weight reduction by comparing the baseline body mass index (BMI) and the waist circumference (WC) to the BMI and WC at the end of the program. Descriptive The aanalysis was done using correlation coefficient on the 15 participants,, who completed the 10-week WF program. The result, showed the mean and mode for BMI reduction to be 2 kg/m2, and the mean and mode for the WC reduction was 3 inches. The percentage weight loss varied from 3-11%, with the completion rate for the enrolled participants at 29%. Thise study has implications for the social change because the findings support intensive behavioral modification as an effective approach to weight loss. The study can help healthcare providers appreciate the is the need to complete preventive care assessment on patients, identify patients with obesity, and provide these patients with the requisite information on the need to lose weight. Also, the clinicians provide the patients with information and available resources to enable help them lose weight. The mean and mode of 2 kg/m2 for BMI reduction, and 3 inches for the reduction in WC at the end of 10 weeks, showed that the WF program was effective for weight loss because the participants lost significant amount of weight. The findings from the project can guide the development of practice guidelines for administering the WF program in the retail clinic.

Postpartum depression (PPD) is a significant public health issue. Up to 20% of women are affected by depression following childbirth. PPD is associated with anxiety, poor adjustment and health-related quality of life (HRQOL), and may lead to a woman's personal suffering, conflict with family members (especially in the relationship with partner) and developmental delays in children. Given the high prevalence of PPD and deleterious effects on both women and their families, adequate treatment is critical. While existing PPD treatments have strong efficacy data, the treatment literature suggests that many depressed postpartum women either do not receive treatment or receive suboptimal care. Further, barriers to care including medication side effects for breastfeeding women, stigma, and treatment preferences influence treatment decision-making. Thus, it may be worthwhile to examine the efficacy of a complementary and alternative medicine (CAM) treatment option for PPD that is associated with minimal risk and consistent with maternal preferences. The current investigation examined the efficacy of a Gentle Vinyasa Flow yoga intervention for PPD. Fifty-seven postpartum women with a score of ≥12 on the Hamilton Depression Rating Scale (HDRS) were randomly assigned to 1 of 2 groups − yoga n = 28) or wait-list control (WLC) ((italic)n(/italic) = 29). The yoga intervention lasted 8 weeks, and consisted of 16 classes taught by a certified yoga instructor in a studio and the recommendation to practice once a week at home with the use of a DVD that included a 30 minute yoga sequence. The primary outcome, depression, was assessed using the clinician-rated HDRS and self-report measures. The HDRS was administered over the telephone by blinded raters at baseline and after 2, 4, 6, and 8 weeks of treatment. Secondary outcomes were anxiety, postpartum adjustment, and HRQOL, with exploratory outcomes including mindfulness and physical activity. These outcomes were assessed using self-report measures completed on the same schedule as that for the HDRS. Growth curve modeling was used to test the hypotheses that women in the yoga group would experience a significantly greater rate of change over the course of the 8-week intervention on primary and secondary outcome measures, relative to the WLC group. As predicted, controlling for age and social anxiety at baseline, women in the yoga group experienced a greater rate of change in depression and well-being scores over the course of the 8-week intervention. The yoga group also experienced a significantly greater rate of improvement on scores of anxiety, postpartum adjustment, HRQOL, and mindfulness over the 8-week intervention, relative to the control group. These findings support yoga as a promising CAM intervention for PPD; large-scale replication studies are warranted. The findings also shed light on potential mediator and intervention-relevant variables for future research. Yoga is an acceptable and low-risk treatment option that may have broader clinical implications for the PPD treatment literature, and the field of CAM more generally.

Polycystic ovary syndrome (PCOS) is a chronic illness that affects approximately five million premenopausal women in the United States and is associated with significant cosmetic, reproductive, metabolic, and psychological consequences. Despite its prevalence, few studies have explored the lived experiences and illness perceptions of women living with PCOS. Identifying illness perceptions of women living with (WLW) PCOS is important, because mounting research suggests that a person's perceptions of their chronic illness and its management determine that person's coping behaviors (e.g., adherence, self-management) and, consequently, illness outcomes. In this dissertation, the Common Sense Model (CSM) is used as a framework to identify the illness perceptions of PCOS held by WLW the syndrome. As such, this dissertation is the first to test the ecological validity of the CSM in a population of women diagnosed with PCOS. In addition, the relationship between illness perceptions and (1) infertility, a common symptom of the syndrome, and (2) health-related quality of life (HRQoL) is explored. Lastly, this study makes a novel contribution to the literature by describing one of the first samples of WLW PCOS recruited through a social networking site. This includes a discussion of the participant's demographic information, fertility experiences, and HRQoL. This is a two-phase mixed methods study. Phase one consisted of an online quantitative survey capturing data on 376 participants' demographic information and medical history. Data were also collected on each participant's HRQoL using the SF-36, a generic, well-validated measure of the phenomenon. Of the 376 survey participants, 34 were interviewed via phone or video chat in the fall 2013 and spring 2014 semesters. Quantitative data were downloaded from Qualtrics® and analyzed using SAS statistical software version 9.3. In this analysis, descriptive statistics were generated to describe sample characteristics and SF-36 domain scores were calculated for each participant. In the qualitative analysis, data were analyzed through a series of sorting techniques and transcripts were imported into NVivo 10 and subjected to content analysis. The mean age of survey participants was 31.8 years (SD=5.8). Respondents were primarily non-Hispanic (92.5%), white (88.3%), straight (94.4%), and married (73.4%) with a college education (64.1%). On average, participants reported living with PCOS for 7.6 years (SD=6.1). Approximately half of the sample reported having biological children (47.9%) and currently trying to conceive (42.1%), and most participants reported a history of infertility (70.7%). In addition, almost half of the total sample reported heights and weights that placed them in the morbidly obese category (BMI>35). Lastly, a history of depression (63.6%) and anxiety (68.6%) was common among participants. Few survey participants reported their general health as being excellent (2.6%) or very good (27.4%). Similarly, women reported the lowest levels of functioning on the dimension of vitality, meaning that, in general, women reported feeling tired and being low in energy. Conversely, women reported the highest scores on the dimensions of physical functioning and role limitations due to physical health, meaning that, in general, women did not report that their health limited their physical abilities or caused problems with work or other daily activities. Interview findings suggest that WLW PCOS generally have illness perceptions of the syndrome that are consistent with the domains identified in the CSM. In addition, it was found that, in relation to their illness cognitions, WLW PCOS described the extent to which they felt they had a comprehensive understanding of the syndrome, a phenomenon labeled illness coherence. Similarly, participants identified PCOS as a common condition (i.e. labeled perceived prevalence). Lastly, a number of relationships were identified between illness perceptions and (1) infertility status and (2) HRQoL scores. Overall, this dissertation identifies a number of implications for patient education, provider education, clinical practice, and policy improvements. Examples include addressing (1) unmet information needs, (2) significant psychological morbidity and unmet mental health needs, (3) breastfeeding challenges and need for breastfeeding support, (4) poor quality of care and low patient satisfaction, and (5) limited access to care - all among women living with PCOS.

Fatigue secondary to chronic illness (FSCI) is a common experience in individuals with chronic conditions, with fatigue impacting on performance of daily activities and health-related quality of life (HRQoL). Due to the higher prevalence of FSCI in women, they may experience even greater disruption to roles and activity engagement. The literature consistently points to three main aspects when defining fatigue regardless of diagnoses; a physical aspect, a psychological aspect, and the impact on activity and participation. Research into the first two aspects has demonstrated relationships between fatigue, pain, depression, and social support. However, examination of the third aspect has been largely overlooked with respect its relationship to, and impact on, fatigue. Leisure theorists have hypothesized that engagement in leisure activities makes a positive contribution to physical and mental health. Previous research has measured leisure activities based on frequency of, or satisfaction with, participation. While some research has shown that physical and social activities have positive health benefits, gaps still exist in understanding the relative contribution of different types of leisure participation to fatigue and HRQoL.For example, little research has examined the contributions of leisure participation and leisure satisfaction to HRQoL and fatigue in women with chronic conditions. One explanation for the lack of research may be the absence of measurement tools developed to classify and quantify participation in different types of leisure activities for women with FSCI. Without a measurement tool, the relative contribution of participation in different activities (by frequency and/or satisfaction) to fatigue and HRQoL cannot be examined. / This PhD research aimed to fill the current gaps in understanding different types of leisure participation in related to fatigue and HRQoL. It sought to address two component parts: development and testing of the Classification of Leisure Participation (CLP) Scale; and an examination of the contribution of leisure participation to fatigue and HRQoL in women with FSCI.