Perceived health in the Portuguese population aged ≥ 35.

OBJECTIVE: To evaluate the exploratory relationship between determinants of health, life satisfaction, locus of control, attitudes and behaviors and health related quality of life in an adult population.
METHODS: Observational study (analytical and cross-sectional) with a quantitative methodological basis. The sample was composed oy 1,214 inhabitants aged ≥ 35 in 31 civil parishes in the County of Coimbra, Portugal, 2011-2012. An anonymous and voluntary health survey was conducted, which collected the following information: demographic, clinical record, health and lifestyle behaviors; health related quality of life (Medical Outcomes Study, Short Form-36); health locus of control; survey of health attitudes and behavior, and quality of life index. Pearson's Linear Correlation, t-Student, Wilcoxon-Mann-Whitney; One-way ANOVA; Brown-Forsythe's F; Kruskal-Wallis; Multiple Comparisons: Tukey (HSD), Games-Howell and Conover were used in the statistical analysis.
RESULTS: Health related quality of life was shown to be lower in females, in older age groups, in obese/overweight individuals, widows, unassisted, those living alone, living in rural/suburban areas, those who did not work and with a medium-low socioeconomic level. Respondents with poor/very poor self-perceived health (p < 0.0001), with chronic disease (p < 0.0001), who consumed < 3 meals per day (p ≤ 0.01), who were sedentary, who slept ≤ 6 h/day and had smoked for several years revealed the worst health results. Health related quality of life was positively related with a bigger internal locus, with better health attitudes and behaviors (physical exercise, health and nutritional care, length of dependence) and with different areas of life satisfaction.
CONCLUSIONS: Better health related quality of life was associated with certain social, psychological, family and health characteristics, a satisfactory lifestyle, better socioeconomic conditions and a good internal locus of control over health attitudes and behaviors.

INTRODUCTION

Society today is undergoing constant transformation (economic, political and social) and every day individuals are exposed to determinants that can influence their well-being, health and quality of life. It’s necessary to invest in health promotion in order to reduce the effects of certain factors responsible for morbidity and mortality. , Health and disease determinants are developments or events that produce health alterations in a specific clinical situation. In the life cycle of populations, there has always been a constant seeking after health and well-being, to the detriment of disease. However, there are intrinsic (biological personal, immunological and genetic) factors which determine the individual’s susceptibility to contracting disease, and extrinsic factors (environmental, behavioral, physical and social habits, among others) that compete to expose the individual to it.

Health related quality of life (HRQL) is a generic indicator of the state of health, integrating physical, psychological and social components. It enables the state of health to be characterized and predicted, relating it to different indicators. Evaluating HRQL goes beyond an objective medical clinical evaluation. It emphasizes the individual’s subjective perception of their own health. It is becoming increasingly common to evaluate individuals’ health behavior and control (locus of control) whether to avoid disease or to promote day-to-day health. The greater the individual’s level of personal control and capacity to decide about their own health (internal locus), the greater their satisfaction with HRQL. This condition will be inversely proportional to health related developments depending on “luck” or “powerful others” (external locus). Quality of life as an indicator of satisfaction with life seeks to understand how certain areas of life, valued by the individual, can influence the conditions of their health.

The aim of this study was to analyze the relationship between health determinants, satisfaction with life, the locus of control and health related attitudes and behavior in an adult population.

METHODS

This was an observational study, of a cross-sectional analytical nature, with a population aged ≥ 35 in the County of Coimbra, totaling 143,396 residents in 31 parishes. The selection strategy was incomplete (sample) and the observation unit was the individuals. The test for stratified samples was used, controlling the population parameter of “perceived state of health” (), total number of residents of the County (N), total number of residents per stratum (parish) (w ) with random error of (d /Z = 0.05) and a 95% level of confidence. The final sample was 1,214 interviewees.

The study was based on collecting data using a health survey (self-reporting, anonymous and voluntary). The survey used was adapted from the IV Inquérito Nacional de Saúde (IV National Health Survey), the result of various pre-tests with the population. The responses to the respective pre-tests led to some questions, words and terms being reformulated, the format being altered, redundant content eliminated and the topics being reorganized. A team of interviewers was trained to administer the questionnaire to the population. The survey included health indicators (demographic data, clinical inventory, health and lifestyle behavior) and indices seeking to capture, measure and qualify the state of health.

Perceived state of health on the MOS SF-36 Medical Outcomes Study, Short Form-36, Health Survey , , is described in eight health dimensions: Physical health measures (PHM), which include: physical functioning, physical performance and pain, which measure the limitations in performing activities of daily living, incapacity to execute everyday tasks due to physical problems and evaluate the severity of pain and resulting limitations; Mental health measures (MHM) including: social functioning, emotional performance and mental health. Social functioning and emotional performance evaluated perceived limitations/disabilities attributable to personal and emotional problems; mental health included anxiety, depression, loss of emotional/behavioral control and psychological well-being; Sensitive measures and physical and mental results included: individual’s vitality associated to energy levels and fatigue and general health with regards a holistic perception of health associated with current situation, resistance to disease and healthy aspect. Regarding the score (for each dimension): the “0” minimum value (worst perception) and the “100” maximum value (best perception of health).

The health locus of control was constructed, adapted and validated for Portuguese. The scale was structured of 14 items, resulting in two dimensions: locus of control and powerful others. The highest score in the locus control dimension corresponded to the premise that health largely depends on our own control. The highest score for powerful others indicated that health is controlled by doctors and other health care professionals. To confirm the author’s decisions regarding validation, factorial analysis was used to analyze the principal components. This solution produced two components (dimensions) estimated using the Orthogonal Varimax Rotation: the first dimension explained 24.3% of the total variance; the second explained 17.2% of total variance (41.5% of common variance). Of the 14 items, eight belonged to the first dimension (locus of control) and six to the second (powerful others). In the evaluation of internal consistency, the Cronbach’s alpha statistics were 0.763 for the first dimension and 0.697 for the second.

The Health Attitudes and Behavior Questionnaire (HABQ), adapted and validated for Portuguese (list of classification containing 28 items), summarizes behavior related to health and disease. Final classification varies between 28 and 140 points and the higher the score the greater the health protective behavior. The inventory in made up of five categories: physical exercise (pe); 2) nutrition (n); 3) self-care (sc); 4) motor safety; 5) drug or substance use. This is not a scale but rather an inventory and does not assume a close relationship between the items. However, Pais Ribeiro suggested estimating internal consistency. In the physical exercise category (three items with Cronbach’s Alpha of 0.683); nutrition (five items with Cronbach’s Alpha of 0.784); AC (11 items with Cronbach’s Alpha of 0.643); motor safety (three items with Cronbach’s Alpha of 0.447); drug or substance use (six items with Cronbach’s Alpha of 0.512). The Cronbach’s Alpha values estimated in the study were slightly higher than those obtained by Pais Ribeiro.

The quality of life index, geriatric version (III), is formed of 33 items (common to all validated versions and adapted for Portuguese) forming four domains: health and functionality; psychological and spiritual; and social, economic and family. Factorial analysis was used to analyze the principal components using the Orthogonal Varimax Rotation to validate the four dimensions. The first dimension explained 24.3% of total variance; the second 8.0%, the third 4.7% and the fourth 4.2% (58.3% of common variance). Regarding internal consistency: health and functionality (13 items with Cronbach’s Alpha of 0.901); spiritual and psychological (seven items with Cronbach’s Alpha of 0.894); social and economic (eight items with Cronbach’s Alpha of 0.832); family (five items with Cronbach’s Alpha of 0.835). Items with higher values had a greater impact on the result (satisfaction with different areas of life) than those with lower values. , The instruments were chosen for their precision, conciseness and ease of use and evaluation.

Anthropometric data such as height (m) (according to the identity document); weight (kg) (according to the subject’s perception, referring to the most recent time they weighed themselves and maintaining the same physical condition; body mass index (BMI) (underweight: < 18.50 kg/m , normal weight: 18.50 kg/m to 24.99 kg/m , overweight: 25.00 kg/m to 29.99 kg/m , obese: ≥ 30.00 kg/m ); waist and neck circumference measured using a tape measure. For men, risk of obesity according to waist circumference was ≤ 102 cm, normal risk and > 102 cm high risk, and for women ≤ 88 cm was normal risk and > 88 cm high risk. Chronic disease identified were re-grouped according the 10th revision of the International Classification of Disease (ICD).

Re-codified variables were: parishes classified as predominantly rural areas; predominantly urban areas and moderately urban areas. Profession was defined according to the Portuguese Classification of Profession and social class (adapted Graffer Scale) was defined as class I (high), class II (upper middle), class III (middle), class IV (lower middle) and class V (low).

The following tests were used: the Student-t test for independent samples; the Wilcoxon-Mann-Whitney Test; the ANOVA test for one factor; the Brown-Forsythe F Test; the Tukey Multiple Comparisons Test; the Kruskal-Wallis Test; the Conover Multiple Comparisons Test and Pearson’s Coefficient of Linear Correlation. When r < 0.2, correlation was very low; [0.2 − 0.39] low correlation; [0.4 − 0.69] moderate correlation; [0.70 − 0.89] high correlation; [0.9 − 1.0] very high correlation. The statistical interpretation was conducted based on a level of significance of p ≤ 0.05 with a 95% confidence interval.

IBM SPSS Statistics and MedCalc Statistical Software was used.

The study was approved by the Ethics Commission of the Faculdade de Medicina da Universidade de Coimbra (Record 04-CE-09, 2009). Participants signed an informed consent form.

RESULTS

The majority of inhabitants in the study were female and lived in parishes classified as predominantly urban; 40.3% were aged 35-45 and 31.5% 45-55 years old; 25.0% had higher education and 23.2% secondary education. The majority of interviewees were Portuguese, Caucasian, married or in a stable relationship, cohabited, had religious beliefs but were not practicing, owned their own home and were middle class. With regards profession, 76.6% were working, of whom 87.5% had a permanent contract. The average length of retirement was 10 years (SD = 7.48 years) and unemployment of two years (SD = 3.39 years). Around 47.1% classified their health as “good” and 38.2% as “reasonable”; 78.1% considered it approximately the same as one year before. Mean height and weight were 1.65 m (SD = 0.08 m) and 71.65 kg (SD = 12.83 kg). Mean waist and neck circumference were 90.93 cm (SD = 15.50 cm) and 36.96 cm (SD = 5.51 cm), respectively.

The majority was overweight or obese and used the health center or hospital for health care; 61.2% reported that they had not been to a doctor in the preceding three months. The location of the most recent appointment was the health center (62.0%) or the GP (72.1%). The majority had consulted a health care professional or received health care in the preceding 12 months. The majority reported being in the habit of controlling arterial tension and cholesterol and 25.5% had had a flu vaccination.

Those who smoked, 20.8%, had been smoking for 25.6 years, on average (SD = 9.14 years) and ex-smokers for 20.0 (SD = 11.0 years); 43.4% said they had regularly or occasionally drunk alcohol for 31.5 years (SD = 11.97 years). The majority was sedentary, slept between seven and eight hours/day, had a Mediterranean diet, had between three and five meals a day, never changed their eating habits, drank less than one liter of water/day and worked a 35-40 hour week; 34.1% spent their working day “standing and walking, also walking up stairs and lifting objects”, 32.1% spend most of their time “sitting down”. The most representative group from the Portuguese Classification of Profession was “services” (19.9%), a group that includes salesmen and those who work in personal services, care and similar areas, those who work in protection/security an “unqualified” individuals (18.4%) encompassing those who worked as cleaners, agricultural workers, animal, forest and fishery workers, extraction industries, construction, industry and transport, among others. Of the 38.6% of individuals who reported having chronic disease, 70.9% had one or two (Table 1).

Table 1

Socio-biographical characterization, profile and health care of the population. County of Coimbra, Portugal, 2011-2012.

Variable		n	%	M	SD
Type of parish	FPU	789	65.0
	FMU	292	24.1
	FPR	133	11.0
	Total	1,214
Sex	Female	730	60.1
	Male	484	39.9
	Total	1,214
Age groups	35 ├ 45	488	40.3
	45 ├ 55	381	31.5
	55 ├ 65	195	16.1
	≥ 65	146	12.1
	Total	1,210
Schooling	1.º CEB incomplete	75	6.2
	1.º CEB	212	17.6
	2.º CEB	106	8.8
	3.º CEB	179	14.8
	Secondary education	332	23.2
	Further education	302	25.0
	Total	1,206
Nationality	Portuguese	1,196	98.5
	Foreign	18	1.5
	Total	1,214
Ethnic group	White	1,190	98.0
	Black	22	1.8
	Asian	2	0.2
	Total	1,214
Marital status	Single	128	10.5
	Married/Stable relationship	908	74.8
	Divorced/Separated	117	9.6
	Widowed	61	5.0
	Total	1,214
Cohabiting	Yes	966	79.6
	No	248	20.4
	Total	1,214
Children	Yes	1,064	87.9
	No	146	12.1
	Total	1,210
Continuation
Number of children	1	401	38.0
	2	502	47.6
	≥ 3	152	14.4
	Total	1,055
Religion	Yes	1,095	90.4
	No	117	9.7
	Total	1,212
If religious	Practicing	384	36.2
	Non-practicing	678	63.8
	Total	1,062
Current residence status	Homeowner	907	75.7
	Mortgaged	291	24.3
	Total	1,198
Type of residence	House	700	59.4
	Apartment	479	40.6
	Total	1,179
Professional situation	Active	930	76.6
	Non-active	284	23.4
	Total	1,214
Type of contract	Permanent	802	87.6
	Temporary	114	12.4
	Total	916
Social class	Class I	100	12.1
	Class II	247	29.7
	Class III	421	50.6
	Class IV	64	7.7
	Total	832
Retired	Length (years)			9.8	7.5
Unemployed	Length (years)			2.3	3.4
Self-perceived general state of health	Very good	103	8.9
	Good	543	47.1
	Reasonable	441	38.2
	Poor/Very poor	54	4.7
	No opinion	12	1.0
	Total	1,153
Describe your current state of general health compared with one year ago a	Much better	19	1.6
	Some improvement	74	6.1
	Approximately the same	946	78.1
	A little worse	160	13.2
	Much worse	13	1.1
	Total	1,212
Anthropometric data	Height (m)	1,169		1.65	0.1
	Weight (kg)	1,160		71.7	12.8
	BMI (kg/m2)	1,159		26.2	3.8
	PC (cm)	901		90.9	15.5
	Neck circumference (cm)	884		37.0	5.5
Body mass index	Underweight	4	0.3
	Normal weight	458	39.5
	Overweight	526	45.4
	Obese	171	14.8
	Total	1,159
Health centera	Yes	959	84.8
	No	172	15.2
	Total	1,131
Hospitala	Yes	564	49.9
	No	567	50.1
	Total	1,131
Private health carea	Yes	196	17.3
	No	935	82.7
	Total	1,131
Othera	Yes	5	0.4
	No	1,126	99.6
	Total	1,131
Visit doctor ≤ 3 months	Yes	471	38.8
	No	743	61.2
	Total	1,214
Type of consultation	GP	835	72.1
	Specialty	323	27.9
	Yes	1,158
Sick leaveb	Yes	14	1.2
	No	1,136	98.8
	Total	1,150
Feeling illb	Yes	267	22.0
	No	947	78.0
	Total	1,214
Requested prescription or testsb	Yes	184	15.2
	No	1,030	84.8
	Total	1,214
Other reasonb	Yes	740	61.0
	No	474	39.0
	Total	1,214
Visit dentist...	Yes	1,115	91.8
	No	99	8.2
	Total	1,214
Consulted dentist ≤ 12 months	Yes	736	66.2
	No	375	33.8
	Total	1,111
Flu vaccination	Yes	310	25.5
	No	875	72.1
	Don’t remember	29	2.4
	Total	1,214
Measured blood pressure	Yes	898	75.5
	No	283	23.8
	Don’t remember	8	0.7
	Total	1,189
Cholesterol	Yes	681	57.8
	No	484	41.1
	Don’t remember	14	1.2
	Total	1,179
Smoking	Smoker	250	20.8
	Ex-smoker	173	14.4
	Non smoker	780	64.8
	Total	1,203
Length of habit	Smoker			25.6	9.1
	Ex-smoker			20.0	10.3
Started smoking (age)	Smoker			17.5	4.6
	Ex-smoker			17.4	4.7
Alcohol intake	Yes	522	43.4
	No	646	53.7
	Ex-consumer	34	2.8
	Total	1,202
Alcohol intake (years)	Consumer			31.5	12.0
	Ex-consumer			21.8	16.5
Age started drinking	Consumer			18.0	3.8
	Ex-consumer			19.1	7.7
Physical exercise	Yes	332	27.7
	No	866	72.3
	Total	1,198
Hours of sleep per night	< 7	285	24.0
	7 to 8	797	67.2
	> 8	104	8.8
	Total	1,186
Hours worked per week	< 35	49	5.4
	35 to 40	612	67.4
	> 40	247	27.2
	Total	908
Type of work	a_1) Option	294	32.1
	b_2) Option	250	27.3
	c_3) Option	312	34.1
	d_4) Option	37	4.0
	e_5) Option	22	2.4
	Total	915
Portuguese classification of professions (PCP)	a_	49	5.7
	b_	135	15.7
	c_	103	12.0
	d_	125	14.5
	e_	172	20.0
	f_	9	1.0
	g_	87	10.1
	h_	23	2.7
	i_	159	18.5
	Total	862
Type of diet	Mediterranean	990	83.5
	Vegetarian	17	1.4
	Macrobiotic	10	0.8
	Fast-food	2	0.2
	Mixed	45	3.8
	Don’t know	122	10.2
	Total	1,186
Nº meals per day	< 3	49	4.1
	3 to 5	1,094	90.9
	≥ 6	60	5.0
	Total	1,203
Eating out	No	351	29.7
	Yes	832	70.3
	Total	1,183
Changed eating habits	Yes	194	16.4
	No	986	83.6
	Total	1,180
Glasses of water/day	Don’t remember	36	3.2
	< 5	683	60.0
	5 to 7	334	29.3
	8 to 10	73	6.4
	³ 11	13	1.1
	Total	1,139
Chronic disease	Yes	468	38.6
	No	746	61.4
	Total	1,214
Frequency of chronic disease	1 to 2	332	70.9
	3 to 4	91	19.4
	≥ 5	45	9.6
	Total	468

FPU: predominantly urban parish; FMU: moderately urban parish; FPR: predominantly rural parish; a) SF-36 Scale item; BMI: body mass index; PC: waist circumference

Type of activity at work: a_1) mostly seated; b_2) standing and walking, without other physical activity; c_3) standing and walking, but also climbing stairs and lifting objects; d_4) Hard physical activity; e_5) standing and walking, but also climbing stairs and lifting objects. Hard physical activity;

Portuguese Classification of Professions: a: Representatives of the Legislative and Executive Bodies, Officers, Directors and Executive Managers; b: Technicians and Intellectual and Scientific Activities; c: Mid-level Technicians and Professionals; d: Administrative personnel; e: Personal Services, Safety and Security Workers and Salespeople; f: Farmers and Skilled Workers, Agriculture, Fisheries and Forestry; g: Skilled Industry and Construction Workers and Craftsmen; h: Equipment and Machinery Operators and assemblers; i: Unskilled workers.

a Usually rely on health services for health care.

b Main reason for most recent consultation.

Behavioral performance was significantly lower in women and they also showed greater disability and expressed more discomfort in activities of daily living compared with males regarding PHM. A similar pattern was observed in the ≥ 65 and 55-65 years old age groups compared with younger individuals. The interviewees with lower educational achievement had worse results for physical health than those with more schooling. The health indices were better in those who were single and those who were married/ in a stable relationship than those who were widowed. There was a similar pattern for those who lived alone. Regarding MHM, females, those aged ≥ 55, those with low levels of educational attainment and individuals who were widowed or living alone had worse health indices, with the exception of present or absent fathers (p > 0.05). The well-being of females, those with low schooling, widows and those with a father present was significantly worse at a health level and they had less energy in the general health and vitality measure. Those living in areas which were predominantly urban, those living in apartments and who paid monthly had better HRQL than those who lived in predominantly rural and moderately urban areas, those who lived in houses and those who owned their own homes. Those with a religion had worse physical functioning (p = 0.016) and mental health (p = 0.037) compared with those who had no religion. Those who were practicing had worse HRQL compared with non-practicing individuals. Low levels of HRQL were found in those who were inactive, and a similar pattern was found in those whose employment was precarious regarding physical performance, pain and vitality, with the exception of physical functioning (p = 0.450) and general health (p = 0.421).The lower middle class has a greater health deficit in terms of physical function (p = 0.002) and general health (p < 0.0001). However, MHM and vitality did not differ according to social class (Table 2).

Table 2

Relationship between individual, religious, social and professional characteristics and the perception of health status (Short Form-36 Scale). County of Coimbra, Portugal, 2011-2012.

	Physical dimension
	Physical functioning				Physical performance				Pain				General health
	n	M	SD	p	n	M	SD	p	n	M	SD	p	n	M	SD	p
Female	719	82.4	20.8	< 0.0001b	725	82.6	22.9	0.003b	727	67.4	24.3	< 0.0001b	726	60.7	18.4	0.01b
Male	478	87.7	19.9		479	86.4	21.6		484	74.7	23.3		479	63.4	17.2
Aged 35├ 45	487	92.8	13.2	<0.0001a	487	91.8	15.9	< 0.0001a	487	78.2	22.1	< 0.0001c	485	68.1	15.5	< 0.0001a
Aged 45├ 55	374	86.7	15.6		378	86.8	18.4		380	69.5	22.9		379	62.3	16.5
Aged 55├ 65	189	78.6	19.8		191	78.0	23.0		194	66.1	23.7		193	57.4	17.9
Aged ≥ 65	143	58.2	3.2		144	58.9	29.3		146	51.9	23.0		144	45.2	17.8
1.º CEB inc.	73	54.1	31.2	< 0.0001d	73	56.9	30.9	< 0.0001d	75	50.2	24.6	< 0.0001c	75	42.2	17.2	< 0.0001c
1.º CEB	207	76.9	23.3		208	80.1	24.4		212	66.3	24.0		209	55.3	16.9
2.º CEB	101	83.2	18.6		103	84.4	19.1		106	65.8	21.7		105	58.9	15.9
3.º CEB	179	87.8	16.8		179	86.3	19.8		177	72.9	22.4		178	62.4	15.7
Secondary	331	89.2	16.1		331	87.6	20.4		332	72.3	24.3		331	65.3	17.6
Further	298	90.5	13.7		302	88.3	18.1		301	76.1	22.5		300	67.9	16.3
Single	127	92.0	12.0	< 0.0001d	127	91.3	16.1	< 0.0001d	127	78.2	21.4	< 0.0001a	125	66.7	16.3	< 0.0001c
M/SR	896	85.0	19.8		901	84.8	22.1		906	70.0	24.2		904	61.8	17.8
D/S	116	86.0	19.6		117	83.1	20.8		117	73.2	22.4		117	63.8	16.9
Widowed	58	57.2	29.0		59	61.0	27.9		61	52.1	21.1		59	47.0	18.3
Yes V.C.	954	85.4	19.6	0.127e	959	85.0	21.8	0.012e	964	70.4	24.1	0.793b	961	62.2	17.8	0.103b
No V.C.	243	81.1	24.3		245	80.8	24.6		247	69.9	24.4		244	60.1	18.8
Children − Yes	1,048	83.7	20.9	< 0.0001e	1,054	83.6	22.5	0.002e	1,062	69.3	24.2	< 0.0001e	1,057	61.2	17.9	0.005b
Children − No	146	90.4	17.9		146	88.3	21.3		145	77.2	22.5		144	65.8	18.4
FPU	779	87.0	17.6	< 0.0001d	784	86.5	20.2	< 0.0001c	787	73.5	23.1	< 0.0001c	785	63.6	16.9	< 0.0001c
FMU	286	79.8	25.6		287	80.2	25.6		291	66.2	24.7		287	60.0	18.9
FPR	132	79.7	22.9		133	78.8	25.6		133	60.4	24.8		133	54.9	19.9
House	690	82.0	21.9	< 0.0001e	695	81.8	23.8	< 0.0001e	698	67.7	24.5	< 0.0001e	695	60.2	18.8	< 0.0001e
Apartment	475	88.8	16.8		476	88.2	19.1		478	74.8	22.5		476	64.4	16.1
H-P	892	82.6	21.9	< 0.0001e	898	82.1	23.7	< 0.0001e	904	67.6	25.0	< 0.0001e	899	60.6	19.1	< 0.0001e
Mortgage	289	90.1	15.2		290	90.4	16.5		291	78.6	18.4		290	65.1	13.1
Rel. Yes	1,078	83.9	21.2	0.016e	1,085	83.9	22.8	0.909e	1,092	70.1	24.5	0.229b	1,086	61.5	18.3	0.093b
Rel. No	117	89.6	14.1		117	86.6	18.3		117	72.2	20.7		117	63.9	14.3
Practicing	378	78.7	23.3	< 0.0001e	383	79.1	24.4	< 0.0001e	383	64.5	24.9	< 0.0001b	383	57.0	19.7	< 0.0001b
Not practicing	670	86.9	19.2		671	86.6	21.3		676	73.4	23.6		671	64.0	16.8
Inactive	279	68.5	27.9	< 0.0001e	281	67.0	28.6	< 0.0001e	283	59.1	25.1	< 0.0001e	281	51.0	19.8	< 0.0001b
Active	918	89.4	14.8		923	89.3	17.1		928	73.7	22.8		924	65.0	16.0
T.D.	114	87.7	15.7	0.450e	114	84.4	18.4	< 0.0001e	113	70.4	21.2	0.026e	114	63.9	16.4	0.421b
T.I.	792	89.6	14.7		797	90.1	16.6		801	74.5	22.7		796	65.2	16.0
Class Ia	99	90.2	15.3	0.002d	100	89.7	17.2	0.722d	100	76.5	22.9	0.559c	100	70.4	16.2	< 0.0001c
Class II	243	89.3	14.6		246	88.7	17.9		246	72.8	23.9		244	64.8	17.2
Class III	414	90.1	14.6		415	90.0	16.5		420	73.7	22.2		418	64.8	15.4
Class IV	64	86.1	13.7		64	87.9	17.3		64	72.4	22.1		64	59.0	12.9
	Mental dimension
	Vitality				Social functioning				Emotional performance				Mental health
	n	M	SD	p	n	M	SD	p	n	M	SD	p	n	M	SD	p
Female	725	62.6	21.9	< 0.0001b	728	80.2	21.9	< 0.0001b	724	85.0	21.7	0.006b	725	73.3	20.7	< 0.0001b
Male	477	70.3	20.6		484	85.5	19.0		478	88.3	19.8		476	79.2	17.4
Aged 35├ 45	486	71.6	19.9	< 0.0001a	487	86.8	19.1	< 0.0001a	487	90.8	17.3	< 0.0001a	486	79.7	17.5	< 0.0001a
Aged 45├ 55	377	66.0	19.9		381	82.6	20.2		377	88.8	17.6		377	76.1	18.3
Aged 55├ 65	190	60.9	22.9		194	78.9	21.2		190	81.3	22.8		190	70.7	22.6
Aged ≥ 65	145	51.7	21.3		146	71.3	23.2		144	71.2	28.7		144	68.2	21.3
1.º CEB inc.	74	45.7	24.1	< 0.0001a	75	68.5	24.9	< 0.0001d	73	66.8	27.4	< 0.0001d	72	63.2	23.4	< 0.0001d
1.º CEB	207	63.3	23.7		212	81.3	21.1		207	85.1	23.5		207	73.9	20.5
2.º CEB	105	63.1	18.7		106	81.7	19.4		103	87.2	19.6		104	74.9	17.8
3.º CEB	178	66.7	20.2		178	84.2	20.0		179	87.5	20.0		178	76.3	19.3
Secondary	330	69.1	20.9		332	84.0	21.3		330	87.8	19.8		330	77.1	19.9
Further	300	69.0	18.7		301	83.9	20.0		302	89.3	16.8		300	78.5	17.0
Single	126	69.3	19.7	< 0.0001c	127	82.6	19.4	< 0.0001d	127	89.4	18.7	< 0.0001d	126	78.8	17.8	0.005c
M/SR	899	66.0	21.6		907	83.7	20.5		899	87.1	20.4		898	76.0	19.6
D/S	117	66.3	21.1		117	80.2	20.3		117	82.4	22.5		117	72.9	19.8
Widowed	60	52.1	21.2		61	65.0	24.2		59	74.3	26.5		60	68.9	21.2
Yes V.C.	957	66.4	21.5	0.018e	965	83.7	20.3	< 0.0001e	957	87.2	20.4	0.003e	956	76.3	19.6	0.014e
No V.C.	245	62.9	21.8		247	76.8	22.4		245	82.9	22.9		245	73.2	19.5
Children – Yes	1,053	65.2	21.7	0.032e	1,063	82.3	20.9	0.669e	1,052	86.0	21.1	0.170e	1,052	75.3	19.9	0.065e
Children – No	145	69.3	20.7		145	82.2	20.9		146	88.7	19.7		145	79.0	16.9
FPU	783	67.9	21.4	< 0.0001c	788	83.3	20.4	0.038c	782	87.9	19.5	0.004d	782	77.2	19.3	< 0.0001c
FMU	286	64.5	19.9		291	81.3	22.3		287	83.4	23.3		286	73.9	19.8
FPR	133	55.2	22.6		133	78.6	20.9		133	83.2	23.3		133	70.4	20.0
House	691	64.0	21.5	< 0.0001e	698	81.0	21.6	0.005e	693	85.0	22.0	0.01e	690	74.2	20.1	< 0.0001e
Apartment	478	68.8	20.9		479	84.8	19.1		476	88.8	18.7		478	78.4	18.0
H-P	896	63.5	21.7	< 0.0001e	905	81.3	21.5	0.003e	896	84.8	21.9	< 0.0001e	895	73.8	20.0	< 0.0001e
Mortgage	290	72.7	19.7		291	85.6	18.7		290	91.3	16.6		290	81.8	16.6
Rel. Yes	1,083	65.8	21.7	0.519b	1,093	82.5	21.1	0.058e	1,083	86.1	21.4	0.549e	1,082	75.3	19.9	0.037b
Rel. No	117	64.5	19.9		117	80.2	19.2		117	87.8	17.1		1,117	78.6	15.4
Practicing	382	60.3	21.0	< 0.0001b	383	79.7	21.2	0.001b	382	83.5	22.3	< 0.0001e	382	72.3	20.4	< 0.0001b
Not practicing	670	69.0	21.4		677	84.1	20.9		670	87.7	20.7		669	77.4	19.2
Inactive	282	55.4	22.9	< 0.0001b	283	73.5	23.0	< 0.0001e	281	74.4	26.8	< 0.0001e	281	67.5	21.7	<0.0001e
Active	920	68.8	20.1		929	85.0	19.5		921	89.9	17.4		920	78.1	18.3
T.D.	114	64.1	18.7	0.007b	114	81.0	18.5	< 0.001e	113	85.3	17.8	< 0.0001e	114	75.0	16.9	0.004e
T.I.	793	69.5	20.2		801	85.5	19.6		796	90.7	17.1		793	78.6	18.4
Class Ia	99	69.0	19.4	0.742c	100	82.5	21.1	0.313d	100	89.5	15.8	0.074d	99	78.5	16.6	0.066d
Class II	244	68.1	19.6		246	85.4	19.4		244	87.3	20.3		244	76.0	19.4
Class III	415	69.8	20.7		421	86.1	19.3		415	91.2	16.3		415	79.4	18.7
Class IV	64	70.2	21.7		64	85.9	20.5		64	90.9	16.6		64	78.4	19.8

M: mean; SD: standard deviation; 1º cycle EB inc.: 1º cycle of elementary education incomplete; M/SR: Married/stable relationship; D/S: Divorced/Separated; Yes V.C.: yes cohabit; No V.C.: not cohabiting; FPU: predominantly urban parish; FMU: moderately urban parish; FPR: predominantly rural parish; H-P: homeowner; Rel. Yes: religion yes; Rel. No: religion no; a) Social class – Graffar scale; T.D.: temporary; T.I.: permanent

Tests: a F Brown-Forsythe; b t-Student; c ANOVA one factor; d Kruskal-Wallis; e Mann-Whitney.

Those who perceived their own health as reasonable, poor/very poor had worse HRQL. Those who were overweight and obese had lower HRQL at the physical level, and there was a similar pattern regarding waist circumference (presence of risk). Obese individuals had similar mean values for social function (p = 0.100), but worse performance for emotional and mental health compared with the other BMI groups. Being obese or overweight showed worse general health and vitality indices and there was a similar pattern regarding waist circumference, with the exception of vitality (p = 0.082). Those who consumed three to five or more meals a day had better PHM, MHM and general health. Regular/occasional alcohol drinkers perceived their physical function to be better, with the exception of physical performance (p = 0.081) and pain (p = 0.139). Concerning mental health, consumers revealed better emotional (p = 0.024) and mental health (p = 0.008) compared with those who did not drink, with the exception of social function and vitality. Significantly poorer health conditions were observed in smokers and ex-smokers who had smoked for a long time. This pattern was not present in MHM. Individuals who were sedentary, who slept ≤ 6h or fewer had worse HRQL.

Those who had seen a doctor in the preceding three months (health care) had a significant physical and mental health deficit, although the type of appointment (General/Specialty) was not a differentiator. Those who had taken prescribed medication in the preceding two weeks had worse PHM and mental health (p = 0.032), with the exception of social function and emotional performance. Those who had taken non-prescription medicine did not differ with regards HRQL measures. The physical functioning, physical performance and pain of those who had had a doctor’s, dentist’s or other appointment did not differ from those who had not seen any of those professionals (p > 0.05). However, the former indicated better quality of life in terms of mental and general health and vitality. Those who reported having seen a health professional in the ≤ 12 months tended to have worse HRQL indices compared with those whose last consultation had been more than 12 months before. Worse HRQL was observed, in the majority of indices, in those who had had a mammogram or a flu vaccination and those who controlled high blood pressure and cholesterol (Table 3).

Table 3

Relationship between state of health and quality of life related to the population’s health perception and care. County of Coimbra, Portugal, 2011-2012.

	Physical dimension
	Physical functioning				Physical performance				Pain				General health
	n	M	SD	p	n	M	SD	p	n	M	SD	p	n	M	SD	p
M.B.	103	96.3	7.3	< 0.0001c	103	97.0	8.7	< 0.0001c	103	88.2	16.9	< 0.0001c	103	82.2	11.7	< 0.0001a
B.	540	92.7	11.7		543	92.8	13.4		541	79.5	18.4		541	69.8	11.7
R.	433	76.6	21.7		435	75.0	23.8		440	59.4	22.4		437	51.8	14.3
M.M.M.	51	45.1	24.8		53	48.5	29.5		54	38.2	24.2		53	29.2	13.9
Underweight	4	97.5	2.9	< 0.0001c	4	95.3	9.4	< 0.0001c	4	84.0	19.1	< 0.0001c	4	72.0	10.8	< 0.0001c
Normal	452	87.3	19.3		455	86.9	2.4		456	73.8	23.4		453	64.4	17.9
Overweight	517	84.2	20.0		522	84.0	21.8		525	68.8	24.1		523	60.9	17.4
Obese	170	76.0	25.0		169	75.8	27.5		171	64.2	25.3		171	57.6	18.8
Normala	551	85.6	20.2	< 0.0001d	554	84.3	21.0	< 0.0001d	558	69.7	23.7	< 0.0001b	553	62.1	18.0	< 0.0001b
High risk	339	77.2	23.5		339	77.5	26.3		341	63.6	25.3		341	57.2	18.5
< 3 meals	49	78.6	25.9	0.161c	49	79.7	27.9	0.734c	49	63.1	30.5	0.212c	49	60.0	21.4	0.567c
3 to 5 meals	1,078	84.7	20.6		1,086	84.3	22.1		1,091	70.7	23.7		1,085	61.7	17.7
≥ 6 meals	60	85.6	16.4		59	84.9	22.1		60	67.9	24.7		60	64.4	20.4
Alc. Yes	515	86.3	19.6	0.001d	517	85.0	22.4	0.081d	521	71.4	23.5	0.139d	519	63.1	16.8	0.022b
Alc. No	670	83.0	21.5		675	83.3	22.4		678	69.3	24.5		674	60.7	18.8
Years smoking	246	-0.199		0.002e	246	-0.136		0.033e	247	-0.127		0.046e	245	-0.139		0.030e
Years ex-smoker	160	-0.224		0.004e	164	-0.232		0.003e	165	-0.323		< 0.001e	164	-0.237		0.002e
A.F. – Yes	328	90.4	15.8	< 0.0001d	329	88.2	19.8	< 0.0001d	331	76.6	23.5	< 0.0001d	328	67.2	16.8	< 0.0001d
A.F. – No	855	82.3	21.8		861	82.7	23.1		864	67.9	23.8		862	59.8	18.0
< 7 h/da	283	80.9	21.8	< 0.0001c	284	77.9	24.4	< 0.0001c	282	62.4	24.4	< 0.0001c	281	58.1	19.6	< 0.0001c
7 to 8 h/day	786	86.4	19.1		791	86.5	20.8		797	72.7	23.5		793	63.2	17.2
> 8 h/day	102	79.7	26.5		103	82.5	25.6		104	73.5	23.5		104	60.5	18.5
Vis.M – No	468	89.1	18.1	< 0.0001d	468	88.7	19.2	< 0.0001d	471	78.0	21.5	< 0.0001d	468	66.9	16.1	< 0.0001d
Vis.M – Yes	729	81.5	21.7		736	81.2	23.8		740	65.3	24.4		737	58.5	18.4
T.C. – CG	501	80.8	22.3	0.326d	506	81.0	23.7	0.754d	509	65.8	24.1	0.344d	509	58.6	18.1	0.811b
T.C – Esp	226	83.0	20.1		228	81.3	24.2		229	64.0	25.0		226	58.3	19.2
C.M.R –Yes	523	81.9	21.7	< 0.0001d	528	82.1	23.6	0.005d	529	66.2	24.7	< 0.0001d	527	59.9	18.5	0.001b
C.M.R – No	649	86.6	19.6		652	85.9	21.1		658	73.7	22.8		654	63.3	17.3
C.M.N.R Yes	321	84.4	20.8	0.936d	324	83.6	22.3	0.583d	324	69.7	24.1	0.437d	322	62.9	17.4	0.220b
C.M.N.R No	849	84.7	20.6		852	84.3	22.4		858	70.6	23.9		855	61.4	18.1
C.D. Yes	1,100	84.7	20.4	0.314d	1,106	84.2	22.5	0.520d	1,113	70.5	24.2	0.214b	1,107	62.1	17.9	0.036b
C.D. No	97	82.0	23.0		98	83.4	22.0		98	67.4	23.7		98	58.1	17.5
C.D.b Yes	724	85.2	19.6	0.997d	728	84.2	22.0	0.410d	734	69.9	24.6	0.202d	729	62.9	18.2	0.104d
C.D. No	372	84.0	21.8		374	84.1	23.5		375	71.8	23.4		374	60.7	17.6
Mam. Yes	506	80.9	20.6	< 0.0001d	513	81.8	22.6	0.007d	512	65.4	24.5	< 0.0001d	513	59.4	18.4	0.001b
Mam. No	201	87.4	19.0		200	85.9	21.5		203	72.8	22.6		201	64.7	17.5
Citol. Yes	436	83.9	17.9	0.902d	441	83.3	20.9	0.888d	441	65.1	24.3	0.005d	441	61.7	18.4	0.271d
Citol. No	227	80.4	24.6		228	81.3	25.3		230	70.1	24.5		229	59.2	18.3
Vacina Yes	305	76.5	25.7	< 0.0001d	307	75.8	27.7	< 0.0001d	310	61.4	26.1	< 0.0001d	308	54.9	20.9	< 0.0001d
Vacina No	863	87.6	17.4		868	87.3	19.2		872	73.6	22.6		868	64.5	16.0
CTA – Yes	886	83.0	21.5	< 0.0001d	891	82.9	23.2	< 0.0001d	896	69.2	24.3	0.007d	893	60.7	18.5	0.001d
CTA – No	281	89.4	17.2		282	89.0	18.5		282	74.0	22.8		281	65.2	15.7
Coles. – Yes	666	81.9	20.9	< 0.0001d	673	80.1	23.5	< 0.0001d	679	66.2	23.9	< 0.0001d	675	59.0	19.1	< 0.0001d
Coles. – No	484	88.5	18.8		484	90.4	18.4		483	76.2	22.8		483	65.8	15.4
Mental dimension
M.B.	103	78.3	15.2	< 0.0001a	103	93.1	13.0	< 0.0001c	103	95.9	9.5	< 0.0001c	103	86.3	12.7	< 0.0001a
B.	538	74.4	17.0		542	88.9	16.5		542	92.8	14.2		538	82.2	15.0
R.	440	55.9	20.5		440	75.0	21.2		435	79.2	23.6		437	68.0	20.7
M.M.M.	54	39.1	19.7		54	60.9	26.7		53	61.8	28.7		52	54.0	22.0
Underweight	4	72.5	9.6	< 0.0001c	4	87.5	10.2	0.100c	4	100.0	0.0	0.001c	4	80.5	7.7	0.024c
Eutrophic	453	68.6	20.8		456	83.4	21.4		454	88.2	19.5		453	77.2	19.6
Overweight	521	64.6	21.6		526	82.0	20.4		521	86.4	20.4		520	75.3	19.3
Obesity	170	60.3	22.6		171	80. 6	20.1		169	80.1	25.6		170	72.8	19.7
Normala	555	63.5	20.1	0.082b	559	81.1	20.1	0.133b	554	85.4	20.7	0.275d	554	74.2	19.0	0.321d
High risk	340	60.9	22.7		341	78.9	22.2		339	83.1	23.0		340	72.9	20.6
< 3 Meals	49	56.2	24.9	0.013c	49	70.6	25.0	0.001c	49	82.1	21.4	0.015c	49	64.9	22.7	0.002c
3 a 5 Meals	1,083	66.0	21.3		1,092	82.7	20.7		1,084	86.2	21.2		1,082	76.1	19.4
≥ 6 Meals	60	68.1	21.4		60	84.4	18.8		59	92.9	14.5		60	77.9	15.1
Alc. Yes	516	67.3	20.8	0.062d	521	84.1	18.5	0.110d	515	88.0	19.6	0.024d	515	77.8	17.7	0.008d
Alc. No	674	64.4	22.0		679	80.8	22.6		675	84.9	21.9		674	74.0	20.8
Years smoking	246	-0.080		0.209e	247	-0.005		0.937e	246	-0.038		0.555e	246	-0.084		0.190e
Years ex-smoker	162	-0.157		0.046e	165	-0.264		0.001e	163	-0.140		0.074e	161	-0.091		0.253e
A.F. – Yes	329	71.9	20.1	< 0.0001d	331	85.2	20.6	< 0.0001d	329	89.3	19.8	< 0.0001d	329	79.9	18.9	< 0.0001d
A.F. – No	859	63.4	21.6		865	81.2	21.0		859	85.3	21.2		858	74.1	19.6
< 7 h/daya	282	58.6	22.0	< 0.0001c	283	75.9	23.0	< 0.0001c	283	80.1	23.7	< 0.0001c	282	68.8	21.0	< 0.0001c
7 a 8 h/day	791	67.9	20.7		797	84.5	19.7		791	88.4	19.3		790	77.9	18.5
> 8 h/day	102	68.7	22.3		104	82.7	21.9		102	86.6	23.0		102	78.2	20.2
Vis.M – No	467	70.6	19.8	< 0.0001d	471	86.4	18.8	< 0.0001d	468	89.6	17.8	< 0.0001d	467	79.1	17.1	< 0.0001d
Vis.M – Yes	735	62.7	22.1		741	79.6	21.8		734	84.2	22.6		734	73.5	20.8
T.C. – CG	507	62.6	22.3	0.883b	510	80.4	21.1	0.206d	504	84.6	22.0	0.437d	506	74.1	20.9	0.156d
T.C – Esp	226	62.3	21.7		229	77.8	23.1		228	83.0	23.8		226	72.0	20.5
C.M.R –Yes	528	63.2	21.8	< 0.0001b	529	81.2	21.5	0.084d	527	86.1	20.5	0.196d	527	74.3	20.3	0.032d
C.M.R – No	650	67.8	21.2		659	83.3	20.3		651	86.7	21.2		650	76.9	18.8
C.M.N.R Yes	323	65.5	20.7	0.647d	324	81.6	20.9	0.317d	324	86.2	19.7	0.579d	323	75.7	19.2	0.655d
C.M.N.R No	852	65.8	21.9		859	82.8	20.8		850	86.4	21.4		851	75.9	19.7
C.D. Yes	1,106	66.1	21.6	0.026b	1,114	82.6	21.1	0.008d	1,105	86.5	20.9	0.040d	1,105	76.1	19.6	0.002d
C.D. No	96	61.0	20.3		98	78.8	18.5		97	83.3	21.9		96	70.6	19.4
C.D.b Yes	728	65.1	21.2	0.005d	735	81.9	21.2	0.037d	727	86.5	20.2	0.220d	727	75.3	19.8	0.035d
C.D. No	374	68.1	22.3		375	84.1	20.8		374	86.8	22.2		374	77.7	19.1
Mam. Yes	511	61.5	21.8	0.012b	513	79.4	22.1	0.041d	512	84.6	21.5	0.324d	511	72.4	21.8	0.059d
Mam. No	202	66.1	21.3		203	83.13	20.3		200	86.2	21.4		202	76.1	18.7
Citol. Yes	441	60.4	20.3	0.004d	442	78.80	21.7	0.029d	440	84.6	20.8	0.430d	441	71.7	19.8	0.006d
Citol. No	228	64.6	23.7		230	82.0	21.7		228	84.4	23.6		228	74.7	21.4
Vacina Yes	307	60.8	23.3	< 0.0001d	310	77.0	23.2	< 0.0001d	307	80.5	26.0	< 0.0001d	307	71.1	22.2	< 0.0001d
Vacina No	866	67.6	20.6		873	84. 5	19.6		866	88.5	18.4		865	77.4	18.2
CTA – Yes	889	65.5	22.1	0.955d	897	82.2	21.1	0.638d	890	85.5	21.6	0.019d	888	75.7	20.0	0.491d
CTA – No	282	66.5	19.3		282	83.2	20.0		281	89.5	18.1		282	75.7	18.4
Coles. – Yes	671	61.9	21.1	< 0.0001d	679	79.8	21.1	< 0.0001d	672	83.6	22.1	< 0.0001d	670	73.2	20.1	< 0.0001d
Coles. – No	484	70.9	20.5		484	86.4	19.3		483	90.5	18.3		484	79.1	18.0

M: mean; SD: standard deviation; r: Pearson’s correlation; perception of general health: M.B.: very good; B.: good; R.: reasonable; M.M.M: poor or very poor; a) waist circumference; meals per day: < 3 Ref.: fewer than three; 3 to 5 meals; ³ 6 meals; Alcohol consumption: Alc. Yes: Alcohol consumption; Alc. No: doesn’t drink; Years smoking: Nº of years smoking; Years ex-smoking: Nº of years smoking; Physical activity: A.F. Yes (Does physical activity); A.F. No (doesn’t do physical activity); a) hours of sleep; Vis.M.: visited doctor in last 3 months; T.P.-CG: type of consultation (General Practitioner); T.P.-Esp: type of consultation (specialty); C.M.R.: Took prescription medicine in last two weeks; C.M.N.R.: took non- prescription medicine in last two weeks; C.D: Dentist consultation, stomatologist...; C.Db): If consulted a dentist, stomatologist, in last 12 months; Mam.: mammography: Cito: Cytology; Vaccine: Flu vaccination; CTA: control blood pressure; Coles: Control cholesterol

Tests: a F Brown-Forsythe; b t-Student; c Kruskal-Wallis; d Mann-Whitney; e Pearson’s Linear Coefficient of Correlation.

The most prevalent chronic diseases were: arterial hypertension (15.5%), rheumatic diseases (11.2%), depression (8.8%), allergies and rhinitis (7.7%). HRQL indices were worse in the presence of a chronic disease and its frequency were evaluated (Table 4).

Table 4

Relation between “Health Status and Quality of Life” in relation with clinical features. County of Coimbra, Portugal, 2011-2012.

	Physical dimension
	Physical function				Physical performance				Pain				General Health
	n	n	M	SD	p	n	M	SD	p	n	M	SD	p	n	M	SD	p
Aus. CD		737	90.1	15.4	< 0.0001b	742	90.0	17.1	< 0.0001b	743	77.9	20.9	< 0.0001b	740	67.1	14.7	< 0.0001b
Pres. CD		460	75.5	24.5		462	74.8	26.4		468	58.2	24.0		465	53.3	19.5
1 to 2 CD		330	81.9	20.4	< 0.0001d	330	80.8	22.6	< 0.0001d	332	64.1	22.8	< 0.0001c	332	57.7	17.4	< 0.0001c
3 to 4 CD		87	63.6	26.6		89	66.2	28.7		91	47.9	21.1		89	48.0	20.6
≥ 5 CD		43	50.2	24.2		43	46.1	25.0		45	34.9	16.9		44	31.6	14.7
1. Yes	51	49	60.8	25.7	< 0.0001b	50	62.6	29.8	< 0.0001b	51	50.4	23.8	< 0.0001a	50	43.7	18.7
No	1,163	1,148	85.5	19.8		1,154	85.0	21.6		1,160	71.1	23.8		1,155	62.6	17.5	< 0.0001a
2. Yes	24	22	65.2	30.2	0.001b	23	72.3	24.6	< 0.0001b	24	57.5	23.4	0.009a	24	53.8	22.5
No	1,190	1,175	84.9	20.3		1,181	84.3	22.3		1,187	70.5	24.1		1,181	61.9	17.9	0.093a
3. Yes	188	180	70.3	25.8	< 0.0001b	182	70.3	27.3	< 0.0001b	188	56.2	23.4	< 0.0001a	185	50.0	19.0
No	1,026	1,017	87.0	18.5		1,022	86.6	20.5		1,023	72.9	23.4		1,020	63.9	16.9	< 0.0001a
4. Yes	33	32	59.2	29.0	< 0.0001b	32	55.9	28.6	< 0.0001b	33	36.8	19.5	< 0.0001a	32	38.4	21.9
No	1,181	1,165	85.2	19.9		1,172	84.9	21.7		1,178	71.2	23.6		1,173	62.4	17.4	< 0.0001a
5. Yes	136	131	62.8	28.2	< 0.0001b	133	61.9	29.5	< 0.0001b	136	45.0	21.6	< 0.0001a	134	44.2	21.5
No	1,078	1,066	87.2	17.8		1,071	86.9	19.7		1,075	73.5	22.5		1,071	64.0	16.2	< 0.0001a
6. Yes	43	41	59.4	25.8	< 0.0001b	41	60.1	28.7	0.023b	43	42.9	20.8	< 0.0001b	42	37.3	19.1
No	1,171	1,156	85.4	19.9		1,163	85.0	21.7		1,163	71.3	23.7		1,163	62.7	17.3	< 0.0001a
7. Yes	10	9	64.4	26.5	0.006b	9	70.1	26.5	0.001b	10	58.0	16.4	0.066b	9	51.6	23.9
No	1,204	1,188	84.7	20.6		1,195	84.2	22.4		1,021	70.4	24.2		1,196	61.8	17.9	0.087a
8. Yes	30	29	75.2	20.8	0.002b	30	70.0	27.1	0.002b	30	54.0	24.6	< 0.0001a	30	50.1	17.0
No	1,184	1,168	84.7	20.6		1,174	84.5	22.2		1,181	70.7	23.9		1,175	62.1	17.9	< 0.0001a
9. Yes	44	44	74.1	25.6	0.002b	44	73.7	27.0	0.001b	44	58.1	24.7	0.001b	44	49.8	18.2
No	1,170	1,153	84.9	20.4		1,160	84.5	22.1		1,167	70.7	23.9		1,161	62.2	17.8	< 0.0001a
10. Yes	6	6	54.2	31.5	0.014b	6	33.3	34.8	< 0.0001b	6	35.0	16.2	< 0.0001b	6	28.3	12.5
No	1,208	1,191	84.7	20.5		1,198	84.4	22.1		1,205	70.5	24.0		1,199	61.9	17.8	< 0.0001a
11. Yes	16	16	49.4	21.1	< 0.0001b	16	47.3	25.7	0.003b	16	32.5	18.5	< 0.0001a	16	33.9	19.7
No	1,198	1,181	85.0	20.2		1,188	84.6	21.9		1,195	70.8	23.8		1,189	62.1	17.7	< 0.0001a
12. Yes	3	3	41.7	10.4	0.007b	3	22.9	25.3	< 0.0001b	3	42.7	35.8	0.120b	3	40.7	31.0
No	1,211	1,194	84.6	20.6		1,201	84.3	22.2		1,208	70.3	24.1		1,202	61.8	17.9	0.174b
13. Yes	13	12	54.2	24.2	< 0.0001b	12	52.6	22.4	0.013b	13	45.3	25.0	< 0.0001a	13	33.6	16.2	< 0.0001a
No	1,201	1,185	84.8	20.4		1,192	84.4	22.2		1,198	70.5	23.9		1,192	62.1	17.8
14. Yes	11	10	56.5	27.9	0.001b	10	60.6	31.3	< 0.0001b	11	42.3	11.5	< 0.0001b	10	47.4	13.6	0.011a
No	1,203	1,187	84.7	20.4		1,194	84.3	22.2		1,200	70.5	24.1		1,195	61.9	17.9
15. Yes	34	34	68.5	28.8	< 0.0001b	34	69.5	28.7	< 0.0001b	34	52.9	24.5	< 0.0001a	34	55.0	20.5	0.025a
No	1,180	1,163	85.0	20.2		1,170	84.5	22.1		1,177	70.8	23.9		1,171	62.0	17.9
16. Yes	107	104	75.3	22.7	< 0.0001b	105	67.7	26.1	0.016b	107	48.7	22.1	< 0.0001b	106	47.7	20.6	< 0.0001a
No	1,107	1,093	85.4	20.3		1,099	85.7	21.4		1,104	72.4	23.3		1,099	63.1	17.1
17. Yes	8	8	47.5	31.6	0.001b	8	57.8	35.2	< 0.0001b	8	52.3	23.7	0.034a	8	53.9	22.0	0.213a
No	1,206	1,189	84.8	20.4		1,196	84.3	22.2		1,203	70.4	24.1		1,197	61.8	17.9
18. No	33	1,164	85.2	19.9	< 0.0001b	1,171	84.8	21.7	0.008	1,178	70.8	23.9	< 0.0001b	1,172	62.3	17.6	< 0.0001a
Yes	1,181	33	59.1	30.4		33	60.6	33.2		33	52.2	23.4		33	42.2	20.9
19. No	94	1,105	85.0	20.4	< 0.0001b	1,112	84.7	21.9	< 0.0001b	1,117	71.1	23.8	< 0.0001b	1,112	62.2	17.6	0.012a
Yes	1,120	925	78.5	23.0		92	76.8	27.3		94	60.6	25.9		93	56.5	20.9
20. No	66	1,131	85.0	20.5	< 0.0001b	1,138	84.6	22.3	0.009b	1,145	71.0	23.9	< 0.0001a	1,139	62.4	17.6	< 0.0001a
Yes	1,148	66	75.6	22.0		66	76.5	22.8		66	58.2	24.4		66	50.4	20.4
Mental dimension
Aus. CD		738	71.5	19.2	< 0.0001b	744	86.7	17.9	< 0.0001b	742	90.1	17.4	< 0.0001b	738	80.3	16.4	< 0.0001b
Pres. CD		464	56.4	21.9		468	75.3	23.4		460	80.1	24.7		463	68.3	21.9
1 to 2 CD		330	60.7	21.0	< 0.0001c	332	78.3	22.0	< 0.0001c	328	83.9	22.4	< 0.0001d	330	71.8	20.8	< 0.0001c
3 to 4 CD		89	49.5	19.9		91	71.8	23.4		89	75.3	25.9		88	63.2	21.8
≥ 5 CD		45	38.6	20.1		45	59.7	26.1		43	61.1	27.6		45	52.8	23.0
1. Yes	51	49	51.0	22.8	< 0.0001a	51	72.6	23.9	0.001b	49	73.3	28.8	< 0.0001b	49	65.8	23.7	0.002b
No	1,163	1,153	66.3	21.3		1,161	82.7	20.7		1,153	86.8	20.4		1,152	76.1	19.3
2. Yes	24	24	63.8	17.2	0.440b	24	77.6	23.9	0.267b	23	78.3	27.0	0.092b	23	73.9	26.6	0.664b
No	1,190	1,178	65.7	21.6		1,188	82.4	20.9		1,179	86.4	20.9		1,178	75.7	19.5
3. Yes	188	184	53.6	21.0	< 0.0001a	188	74.7	23.1	< 0.0001b	181	80.3	24.1	< 0.0001b	183	67.4	20.6	< 0.0001a
No	1,026	1,018	67.9	20.9		1,024	83.7	20.2		1,021	87.3	20.2		1,018	77.1	19.1
4. Yes	33	33	42.1	25.6	< 0.0001a	33	63.3	28.8	< 0.0001a	32	66.7	28.2	< 0.0001b	33	56.2	23.8	< 0.0001a
No	1,181	1,169	66.3	21.1		1,179	82.8	20.4		1,170	86.8	20.5		1,168	76.2	19.2
5. Yes	136	135	48.3	22.6	< 0.0001a	136	69.6	24.7	< 0.0001b	133	71.8	27.1	< 0.0001b	134	61.5	23.4	< 0.0001a
No	1,078	1,067	67.9	20.4		1,076	83.9	19.9		1,069	88.1	19.4		1,067	77.4	18.0
6. Yes	43	43	42.8	19.0	< 0.0001a	43	68.0	28.1	< 0.0001b	41	74.4	25.4	< 0.0001b	43	58.9	22.3	< 0.0001a
No	1,171	1,159	66.5	21.2		1,169	82.8	20.5		1,161	86.7	20.7		1,158	76.3	19.2
7. Yes	10	9	57.8	21.2	0.271a	10	65.0	26.2	0.021b	9	80.6	17.2	0.148b	9	64.4	24.5	0.085a
No	1,204	1,193	65.7	21.6		1,202	82.4	20.8		1,193	86.3	21.0		1,192	75.7	19.6
8. Yes	30	30	55.7	21.0	0.010a	30	70.0	24.3	0.002b	30	81.7	24.9	0.244b	30	67.5	21.6	0.021a
No	1,184	1,172	65.9	21.5		1,182	82.6	20.8		1,172	86.4	20.9		1,171	75.9	19.5
9. Yes	44	44	55.6	20.8	0.002a	44	78.1	20.7	0.095b	44	75.8	28.1	0.003b	44	69.3	23.0	0.049b
No	1,170	1,158	66.1	21.5		1,168	82.4	20.9		1,158	86.7	20.6		1,157	75.9	19.4
10. Yes	6	6	28.3	18.9	< 0.0001a	6	70.8	23.3	0.110b	6	51.4	45.8	0.033b	6	37.7	15.9	< 0.0001a
No	1,208	1,196	65.9	21.4		1,206	82.3	20.9		1,196	86.5	20.7		1,195	75.8	19.5
11. Yes	16	16	37.2	19.6	< 0.0001a	16	50.0	24.6	< 0.0001b	16	52.6	25.8	< 0.0001b	16	39.0	23.1	< 0.0001a
No	1,198	1,186	66.1	21.3		1,196	82.7	20.6		1,186	86.7	20.6		1,185	76.2	19.1
12. Yes	3	3	28.3	22.6	0.017a	3	62.5	33.1	0.149b	3	22.2	31.6	0.002b	3	41.3	28.4	0.029b
No	1,211	1,199	65.8	21.5		1,209	82.3	20.9		1,199	86.4	20.7		1,198	75.7	19.5
13.Yes	13	13	51.9	17.4	0.021a	13	71.2	26.7	0.054a	12	69.4	29.2	0.004b	13	61.2	23.9	0.008a
No	1,201	1,189	65.8	21.6		1,199	82.4	20.9		1,190	86.4	20.9		1,188	75.8	19.5
14. Yes	11	10	39.0	11.7	< 0.0001a	11	61.4	18.1	0.001a	10	74.2	27.1	0.098b	10	58.2	19.9	0.005a
No	1,203	1,192	65.9	21.5		1,201	82.5	20.9		1,192	86.4	20.9		1,191	75.8	19.6
15. Yes	34	34	52.5	21.4	< 0.0001a	34	71.7	22.5	0.002b	34	74.8	26.2	0.002b	34	64.3	22.7	0.001a
No	1,180	1,168	66.1	21.4		1,178	82.6	20.8		1,168	86.6	20.8		1,167	76.0	19.4
16. Yes	107	107	46.4	19.8	< 0.0001a	107	61.8	24.9	< 0.0001b	105	68.3	25.2	< 0.0001b	107	55.2	22.0	< 0.0001a
No	1,107	1,095	67.6	20.8		1,105	84.3	19.4		1,097	88.0	19.7		1,094	77.7	18.2
17. Yes	8	8	60.0	20.4	0.456a	8	71.9	25.7	0.158a	8	69.8	31.5	0.026a	8	77.5	15.6	0.789a
No	1,206	1,194	65.7	21.6		1,204	82.4	20.9		1,194	86.4	20.9		1,193	75.6	19.6
18. No	33	1,169	66.1	21.3	< 0.0001a	1,179	82.4	20.9	0.108b	1,169	86.6	20.6	0.021b	1,168	76.0	19.4	0.001a
Yes	1,181	33	49.4	25.9		33	76.9	22.6		33	73.7	30.8		33	63.9	23.4
19. No	94	1,108	66.1	21.4	0.016b	1,118	82.7	20.6	0.016b	1,110	86.4	20.9	0.217b	1,107	76.0	19.2	0.134b
Yes	1,120	94	60.2	22.7		94	77.1	23.6		92	84.2	22.5		94	71.5	23.4
20. No	66	1,136	66.2	21.5	< 0.0001a	1,146	82.7	20.6	0.010b	1,137	86.7	20.7	0.011b	1,135	76.1	19.4	0.001b
Yes	1,148	66	56.0	20.5		66	75.0	24.9		65	79.7	24.6		66	67.8	21.4

M: Mean; SD: standard deviation; Pres-CD: chronic disease; Aus-CD: No chronic disease; CD: chronic disease

Chronic disease: 1. Diabetes; 2. Asthma; 3. High Blood Pressure; 4. Chronic pain; 5. Rheumatic disease, Rheumatoid Arthritis and Musculoskeletal Diseases; 6. Osteoporosis; 7. Glaucoma; 8. Tumor Malignant/Cancer; 9. Kidney stones; 10. Kidney deficiency; 11. Chronic anxiety; 12. Chronic injury; 13. Chronic Bronchitis, Emphysema, DPOC; 14. Stroke; 15. Obesity; 16. Depression; 17. Myocardial infarction; 18. Other heart disease; 19. Allergies and rhinitis; 20. Other chronic disease.

Tests: a t-Student; b Mann-Whitney; c ANOVA one factor; d Kruskal-Wallis

Those with worse physical health conditions had a proportionally worse state of mental health, a lower indices for general health and vitality and vice-versa when the inter-relationship between the different measures and HRQL was evaluated. Those who considered that their health depended on their personal health behavior (locus of control) had better indices of physical functioning, physical performance and general health, although not of MHM. However, those who believed that their health depended more on external entities (powerful others) had worse HRQL indices. As for the HABQ, those who sought a better physical condition (physical exercise) and took more care with their diet (nutrition) had higher indices of HRQL. A pattern of positive correlation was observed with the development of better preventative behavior (self-care) and avoided accidents/injuries (motor safety) in terms of measures of mental health. Lower dependence on chemical substances (e.g., drugs) correlated positively with mental health. As for the quality of life index, the more satisfied the individual was with life in general (general index), health and functionality, social relationships and economic conditions (social and economic), belief and psychological well-being (spiritual and psychological) and family support (family) the higher the indices were for HRQL (Table 5).

Table 5

Relationship between “state of health and quality of life” and indices of locus of control, health attitudes and health behavior questionnaire and rate of quality of life of the inhabitants. County of Coimbra, Portugal, 2011-2012.

Indices	Dimensions		Physical function	Physical performance	Pain	General Health	vitality	Social function	Emotional performance	Mental health
SF-36	Physical function	R	1	0.675a	0.585a	0.585a	0.539a	0.471a	0.519a	0.398a
		N		1,195	1,195	1,194	1,194	1,196	1,194	1,194
	Physical performance	R		1	0.584a	0.591a	0.587a	0.546a	0.731a	0.465a
		N			1,201	1,200	1,198	1,202	1,202	1,197
	Pain	R			1	0.610a	0.670a	0.585a	0.500a	0.553a
		N				1,204	1,201	1,211	1,199	1,200
	General health	R				1	0.607a	0.520a	0.474a	0.550a
		N					1,200	1,205	1,198	1,199
	Vitality	R					1	0.638a	0.555a	0.733a
		N						1,202	1,197	1,201
	Social function	R						1	0.605a	0.675a
		N							1,200	1,201
	Emotional performance	R							1	0.574a
		N								1,196
	Mental health	R								1
		N
Locus of Control and Health	Locus of control	R	0.103b	0.072c	0.040	0.143a	0.019	0.013	0.035	0.038
		N	1,193	1,200	1,207	1,201	1,197	1,207	1,198	1,196
	Powerful others	R	-0.065c	-0.067c	-0.083b	-0.146a	-0.084b	-0.064c	-0.093b	-0.092b
		N	1,194	1,201	1,208	1,202	1,199	1,209	1,199	1,198
Health Attitudes and Behaviors Questionnaire (QACS)	Physical activity	R	0.151a	0.077c	0.135a	0.143a	0.130a	0.085b	0.053	0.113a
		N	1,067	1,074	1,082	1,075	1,072	1,082	1,072	1,071
	Diet	R	0.059	0.063c	0.146a	0.084b	0.210a	0.161a	0.111a	0.193a
		N	1,055	1,062	1,069	1,063	1,060	1,069	1,060	1,059
	Self-care	R	-0.011	0.028	0.017	0.026	0.114a	0.116a	0.054	0.119a
		N	986	992	997	993	989	997	991	988
	Motor safety	R	0.060	0.079c	0.065c	0.039	0.097b	0.104b	0.100b	0.119a
		N	1,026	1,032	1,036	1,032	1,029	1,037	1,030	1,028
	Drug or substance use	R	-0.038	-0.001	0.022	-0.012	0.044	0.017	-0.012	0.106a
		N	1,040	1,046	1,053	1,047	1,044	1,053	1,044	1,043
Quality of life index	Global index	R	0.452a	0.483a	0.499a	0.536a	0.557a	0.584a	0.462a	0.578a
		N	1,184	1,191	1,198	1,192	1,189	1,199	1,189	1,188
	Health and functioning	R	0.571a	0.576a	0.593a	0.634a	0.621a	0.616a	0.502a	0.585a
		N	1,184	1,191	1,198	1,192	1,189	1,199	1,189	1,188
	Social and economic	R	0.289a	0.293a	0.305a	0.354a	0.360a	0.387a	0.281a	0.382a
		N	1,178	1,185	1,191	1,186	1,183	1,192	1,183	1,182
	Spiritual and psychological	R	0.230a	0.294a	0.320a	0.332a	0.400a	0.464a	0.354a	0.490a
		N	1,178	1,185	1,191	1,186	1,183	1,192	1,183	1,182
	Family	R	0.322a	0.365a	0.356a	0.370a	0.425a	0.463a	0.374a	0.486a
		N	1,179	1,186	1,192	1,187	1,184	1,193	1,184	1,183

r: Coefficient of Correlation; Test: Pearson’s Linear Coefficient of Correlation.

a p < 0.0001

b p < 0.01

c p ≤ 0.05

DISCUSSION

The majority of the different indicators/indices monitored (personal, clinical, health behavior, life styles and satisfaction with life) were shown to have significant impact on the HRQL of our inhabitants.

The personal characteristic with the greatest impact on HRQL was the biological factor, gender. Thus, as in the literature, women tend to be the group with the highest rates of morbility and worse HRQL in both physical and mental terms. , They also make more use of health care. , Age was shown to be an important marker in understanding a population’s HRQL. HRQL deteriorates as age increases, as seen in the literature. , ,

In the inhabitants studied, the perception of HRQL was also negatively influenced by the conjugal situation and area of residence, by characteristics of the residence and type of ownership, as well as the socioeconomic conditions and work status. , , ,

Extrinsic determinants gained more importance and weight in characterizing and understanding the health profile of a population. HRQL deteriorates in individuals who are outside of the “norm” (overweight/obese, sedentary, with a poor diet, smokers, type of alcohol intake, fewer hours of sleep, among others). , , ,

Those with worse HRQL believe that it does not depend solely upon themselves (locus of control), as has been shown in other studies, , , and therefore seek health care more frequently. , Suffering from chronic disease and its frequency suggest a negative impact on HRQL. ,

Individuals who have worse results for physical health also tend to have worse results for mental health. However, the presence of better habits and health related behaviors and more satisfaction with the various areas of life promoted better HRQL indices in our population.

The limitations of the study concerned weight, height and presence of chronic disease, time spent doing exercise/day, identifying and quantifying food intake, as these were self-reported. The investigation was limited to generalizing the results based on cross-sectional data.

These indicators call for pertinent “reflections” on public health policies and the performance of different health care professionals to promote/develop new strategies and decision making instruments and actions to alter the impact of risk factors on the population’s health. A step has been taken towards creating a new study in the definition/prediction of health profiled in the adult population in the present and how these profiles may be grounded in determinants for the future (adolescence).