Health-related Behavior, Medical Service Use, and HRQOL in Elderly Korean Living Alone and Elderly Korean Living with Family: Using the
2018 Third-Year KNHAES Data
Dahye Park*
1*1 Professor, Department of nursing, Semyung University, 65, Semyung-ro, Jecheon, 27136, Korea [email protected]*1
Corresponding author*: mobile Phone: +82-10-2887-0608
Abstract
Background/Objectives: This study was to identify health-related behavior, medical service use, and HRQOL in
elderly Koreanliving alone and elderly Koreanliving with family.
Methods/Statistical analysis: We carry out a cross-sectional analysis using nationally representative data from the
KNHANES, 2018. A total of 1,528 elders in 2018. Data analysis and complex sampling design were performed using SPSS 25.0.
Findings: The HRQOL of elderly Korean living alone was lower than elderly Korean living with family. Among
the elderly Korean living alone, living in rural areas, aged 75 or above, elementary school graduation or lower education, unemployed, two comorbidities, drinkers, poor subjective health conditions, highly perceived their stress, and unmet medical needs showed low levels of HRQOL.
Improvements/Applications: In order to health promotion in elderly Korean, it is necessary to establish different
strategies according to their residence type.
Keywords: Health-related behavior, Medical service, HRQoL, Elder, KNHNES
1. Introduction
According to data from the National Statistical Office, the proportion of South Korea’s elderly population aged 65 or above ranked 51st (14.9%) in the world as of 2019 and is forecast to exceed that of Japan (36.7%), the world’s most aged country, at 37.0% in 2045[1]. With rapid increases in the elderly population, elderly Korean living alone accounted for 34.2%
of the total elderly households in 2019. At this fast rate, the number of elderly Korean living alone surged from 540,000 in 2000 to 1.51 million in 2019[2]. The current households comprised of elderly couples can also experience with time one partner’s death and the other partner’s solitary life[3], and the current increasing trend in the elderly Koreanliving alone is unlikely to improve.
In general, elderly Korean experience more frequent health problems with aging. These health problems, coupled with financial problems, affect their quality of life[4]. In other words, regarding the relationship between health and income, the low-income group’ burden for medical expenses is reported to have a negative impact on the health issues of individuals in this group[5]. An examination of elderly Korean living alone, who reach up to one third of the total elderly population, showed certain features. First, this group included many individuals with low income or education levels, as well as more women than men due to women’s longer life expectancy[6,7]. In addition, the prevalence of chronic diseases in the elderly Koreanliving alone was 93.5%, a higher level than that of the elderly living with family[8]. These economic difficulties and vulnerabilities including lack of a support system lead this elderly group to experience not only physical problems, but also feelings of helplessness, guilt, disappointment, and anger, which extend to psychological maladjustment[9,10, 16-19], thereby influencing their psychological health and HRQoL.
Because the depression or lonely deaths of elderly Korean who live alone are emerging as a social issue [11], social attention is required for them. Improving the health-related behavior of elderly Korean living alone is cost effective given that it can increase the prophylactic potential of the problems that they experience. This points to the need to identify their health- related behaviors such as drinking, smoking, and exercise, medical service use, and HRQoL.
Therefore, it is urgent to provide interventions and policy support that can improve the elderly’s HRQoL by identifying the factors that influence HRQoL in the elderly Koreanliving alone and elderly living with family. In this regard, this study was conducted to provide basic data for nursing strategies to improve and promote the health of elderly Korean living alone, who
are emerging as a new target group for future nursing, by examining basic data on elderly Koreanliving alone and elderlyKoreanliving with family.
The purpose of this paper is to identify health-related behavior, medical service use, and HRQoL in elderly Korean who live alone and live with family, and to confirm factors related to these variables. The study’s specific objectives are as follows:
• Identify differences in general characteristics, health-related behavior, medical service use, and HRQoL between the elderly who live alone and the elderly who do not.
• Identify whether the subjects have differences in their HRQoL according their general characteristics, health-related behaviors, and levels of medical service use.
• Identify factors that influence the subjects’ HRQoL.
2. Materials and Methods
2.1. Research design
This is a secondary data analysis study that identifies health-related behavior, medical service use, HRQoL in elderly Koreanliving alone and elderly Koreanliving with family by employing the 7th Third-Year KNHAES conducted nationwide in 2018.
2.2.Subjects
The 2018 KNHAES involved 7,992 respondents in total. In the present study, 1,528 individuals without missing values were selected as final subjects from 1,653 elderly Korean aged 65 or above.
2.3.Instruments
2.3.1. Sociodemographic characteristics
As the subjects’ general characteristics, gender, age, areas of residence, education levels, marital status, income levels, and occupations were used. Of these variables, areas of residence were divided into ―urban‖ and ―rural‖. The current marital status was reclassified into ―having a spouse‖ and ―living together‖, and occupations were also reclassified into ―having‖ and ―not having‖.
2.3.2. Health-related behavior
Health-related behaviors include the number of comorbidities, smoking, drinking, engaging in exercise or not, subjective health conditions, suicidal thoughts, and perceived stress. The number of comorbidities means the number of diseases from which one suffers after doctors’ confirmation. For smoking, those who had smoked at least five packs in their lifetime and were currently smoking were classified as answering ―yes‖. For drinking, those who had drunk at least one glass of alcohol over the past one year were classified as answering ―yes.‖ In addition, those who performed at least one of 1) strenuous physical activities that cause severe SOB, 2) moderate physical activities that cause moderate SOB, and 3) walking were classified as engaging in regular exercise. Subjective health conditions were reclassified into ―good‖, ―average‖, and ―poor.‖ For suicidal thoughts, the original survey’s answers were used without change. In addition, perceived stress was reclassified into ―high‖ and ―low‖.
2.3.3. Use of medical services
For the study’s data on medical service use, data on whether the following medical needs were met or not were extracted from the KNHAES’s health survey results: 1) necessary medical services, 2) medical checkups, 3) cancer screening, 4) dental care, 5) oral examinations over the past one year. Unmet medical needs refer to cases in which an individual who needed services (examinations or treatments) from hospitals, clinics, or dental clinics could not receive them over the past one year. The answers to whether an individual used a specific medical service or not were classified into ―yes‖ and ―no‖.
2.3.4. HRQoL
For HRQoL, its values measured using the EuroQol-5 dimension (EQ-5D) were analyzed. The EQ-5D is a tool for measuring HRQoL. It comprises five multiple choice questions in five domains. . Each sub-question is designed to be answered with one of three choices: ―extreme problems‖, ―some problems or moderate problems‖, and ―no problems.‖ The EQ-5D Index is obtained by applying weighted values to measured values for these five questions. These obtained values are interpreted in the range from 1 point, meaning the state of being healthy, to -1 point, meaning the state of being unhealthy. In this study, the values that KNHAES produced by applying a weighted scoring model were used as they were.
2.4.Data analysis methods
The study’s data were analyzed using SPSS 25.0, and differences in general characteristics, health-related behavior,
medical service use, and HRQoL between elderly Korean living alone and elderly Korean living with family were
identified using descriptive statistics and t-tests. Differences in the subjects’ HRQoL according to their general
characteristics, health-related behavior, and medical service use were analyzed using the X2-test. To identify the
factors that influence HRQoL in elderly Korean living alone and elderly Korean living with family, a multiple
regression analysis was conducted using a concurrent input method by applying the significant variables resulting
from an univariable analysis as independent variables.
2.5.Ethical consideration
The KNHAES was conducted under approval by the Institutional Review Board (IRB) of KCDC (No. 2018-01-03-P-A). On April 5, 2020, the present study’s researcher received approval for data use and downloaded them via the link on the KCDC’s website, which releases and provides the KNHAES’s raw data. In addition, this study underwent a review for an examination exemption (IRB No. SMU-EX-2020-05-001) at the IRB of the organization to which the research belongs.
3. Results and Discussion
3.1. Differences in HRQoL according to sociodemographic characteristics, health-related behavior, and medical service use
In the study, Elderly Korean living alone showed higher proportions of women (χ2=77.60, p<.001), those living in rural areas (χ2=22.47, p<.001), and those aged 75 or above (χ2=57.80, p<.001) than elderly Korean living with family. Moreover, elderly Korean living alone included higher proportions of those whose education level was elementary school graduation or lower (χ2=39.30, p<.001) and those who were divorced, bereaved, separated, or single (χ2=698.93, p<.001). In terms of income levels, elderly Korean living alone had lower incomes (χ2=110.37, p<.001) than elderly Korean living with family. In addition, more elderly Korean living with family than elderly Korean living alone had occupations (χ2=6.21, p=.007).
Regarding the variables of health-related behavior, elderly Korean living alone exhibited higher frequencies of smoking (χ2=50.04, p<.001), drinking, (χ2=12.48, p<.001), poor subjective health conditions, (χ2=11.41, p=.003), and no regular exercise (χ2=21.82, p<.001).
In terms of the variables related to medical service use, elderly Korean living alone showed higher frequencies of not being able to receive necessary medical services (χ2=6.36, p=.009), medical checkups, (χ2=14.84, p<.001), and cancer screening (χ2=9.32, p=.002) than elderly Korean living with family. Moreover, compared to elderly Korean living with family, elderly Korean living alone showed higher frequencies of not being able to receive dental care (χ2=6.04, p=.008) and oral examinations (χ2=6.04, p=.008). The HRQoL of elderly Korean living alone was lower than elderly Korean living with family (t=24.48, p<.001) as shown in table 1.
Table 1: Demographic Characteristics of Two Groups (N=1,528)
Variables Categories
Elderly Korean living Alone(N=365)
Elderly Korean not living
Alone(N=1,163) χ2 or t (p) N (%) or M±SD N (%) or M±SD
Gender
Male Female
82 (22.5) 283 (77.5)
565 (48.6)
598 (51.4) 77.60 (.000)**
Living area Urban Rural
239 (65.5) 126 (34.5)
905 (77.8)
258 (22.2) 22.47 (.000)**
Age (years)
65–69 70–74
≥75
66 (18.1) 89 (24.4) 210 (57.5)
409 (35.2) 331 (28.5) 432 (36.4)
57.80 (.000)**
Education
≤Elementary school Middle school
≥High school
253 (70.3) 51 (14.2) 56 (15.6)
609 (52.6) 193 (16.7) 355 (30.7)
39.30 (.000)**
Marital status
Divorced, Unmarried, widowed Married, living with spouse
32 (8.8) 333 (91.2)
187 (16.1)
976 (83.9) 698.93 (.000)**
Income
Quartile 1 Quartile 2 Quartile 3 Quartile 4
147 (40.4) 109 (29.9) 80 (22.0) 28 (7.7)
233 (20.2) 267 (23.1) 302 (26.1) 354 (30.6)
110.37 (.000)**
Occupation
No Yes
255 (71.0) 104 (29.0)
739 (63.9)
418 (36.1) 6.21 (.007)*
Number of comorbidities
None 1 2
≥3
249 (68.2) 77 (21.1) 27 (7.4) 12 (3.3)
730 (62.8) 305 (26.2) 97 (8.3) 31 (2.7)
4.89 (.179)
Smoking status No Yes
75 (20.5) 290 (79.5)
687 (59.1) 476 (40.9)
50.04 (.000)**
Alcohol drinking status
No Yes
78 (21.4) 287 (78.6)
803 (69.0) 360 (31.0)
12.48 (.000) **
Subjective health status
Good Common Poor
61 (16.7) 166 (45.5) 138 (37.8)
260 (22.4) 564 (48.5) 339 (29.1)
11.41 (.003)*
Regular exercise No Yes
336 (92.1) 29 (7.9)
952 (81.9)
211 (18.1) 21.82 (.000)**
Suicidal ideation No Yes
347 (95.1) 18 (4.9)
1143 (98.3)
20 (1.7) 11.81 (.001)*
Perceived stress Low High
295 (81.3) 68 (18.7)
949 (81.7) 212 (18.3)
.041 (.447) Medical service use
Unmet medical needs
No Yes
315 (86.3) 50 (13.7)
1057 (90.9)
106 (9.1) 6.36 (.009)*
Medical check-up No Yes
129 (35.3) 236 (64.7)
291 (25.0)
872 (75.0) 14.84 (.000)**
Cancer screening No Yes
135 (37.0) 230 (63.0)
332 (28.5) 831 (71.5)
9.32 (.002)*
Unmet dental needs No Yes
200 (54.8) 165 (45.2)
718 (61.7)
445 (38.3) 5.58 (.011)*
Dental check-up No Yes
285 (78.1) 80 (21.9)
832 (71.5)
331 (28.5) 6.04 (.008)*
EQ-5D index 0.85±0.18 0.89±0.14 24.48 (.000)**
3.2.HRQoL according to sociodemographic characteristics, health-related behavior, and medical service use
Among the elderly Korean living alone, those living in rural areas (F=9.87, p=.002), those aged 75 or above (F=7.29, p=.001), those with elementary school graduation or lower education (F=6.20, p=.002), those who were unemployed (F=5.74, p=.017), those with two comorbidities (F=4.47, p=.004), drinkers (F=4.08, p=.044), those with poor subjective health conditions (F=92.04, p<.001), those who highly perceived their stress (F=20.75, p<.001), and those with unmet medical needs (F=33.23, p<.001) showed low levels of HRQoL.
Among the elderly Korean living with family, women (F=26.98, p<.001), those living in rural areas (F=18.69, p<.001), those aged 75 or above (F=23.38, p<.001), those with elementary school graduation or lower education (F=24.09, p<.001), those who were unemployed (F=22.29, p<.001), those with at least three comorbidities (F=3.62, p=.013), smokers (F=14.86, p<.001), drinkers (F=31.54, p<.001), those with poor subjective health conditions (F=161.50, p<.001), those without regular exercise (F=14.52, p<.001), those with suicidal thoughts (F=9.99, p=.002), those who highly perceived their stress (F=75.39, p<.001), those with unmet medical needs (F=37.84, p<.001), those who did not take medical checkups (F=10.12, p=.002), those who did not take cancer screening (F=11.49, p=.001), those with unmet dental care needs (F=5.75, p=.017), and those
who did not take dental examinations (F=18.46, p<.001) exhibited low levels of HRQoL as shown in table 2.
Table 2: HRQoL(EQ-5D Index) Based on General Characteristics, Health-related Behavior, and Medical Service Use (N=1,528)
Variables Categories
Elderly Korean living alone Elderly Korean not living alone
M±SD F (p) M±SD F (p)
Gender
Male Female
0.87±0.19
0.84±0.18 1.51 (.219)
0.92±0.13
0.87±0.15 26.98 (.000)**
Living area
Urban Rural
0.87±0.17
0.81±0.19 9.87 (.002)*
0.90±0.13
0.86±0.15 18.69 (.000)**
Age (years)
65–69 70–74
≥75
0.90±0.13 0.88±0.15 0.82±0.20
7.29 (.001)*
0.92±0.12 0.90±0.13 0.86±0.16
23.38 (.000)**
Education
≤Elementary school Middle school
≥High school
0.83±0.19 0.89±0.14 0.90±0.13
6.20 (.002) *
0.87±0.15 0.91±0.12 0.93±0.11
24.09 (.000)**
Marital status divorced, Unmarried, widowed Married, living with spouse
0.84±0.18 0.89±0.14
1.73 (.188) 0.85±0.17 0.90±0.13
24.98 (.000)**
Income
Quartile 1 Quartile 2 Quartile 3 Quartile 4
0.82±0.19 0.81±0.19 0.92±0.11 0.89±0.17
7.47 (.000)**
0.88±0.14 0.89±0.14 0.89±0.14 0.90±0.14
0.63 (.595)
Occupation No
Yes
0.83±0.18 0.88±0.17
5.74 (.017)* 0.88±0.15 0.92±0.11
22.29 (.000)**
Number of comorbidities
None 1 2
≥3
0.87±0.16 0.82±0.20 0.74±0.23 0.82±0.23
4.47 (.004)*
0.90±0.13 0.87±0.16 0.89±0.13 0.87±0.16
3.62 (.013)*
Smoking status
No Yes
0.86±0.19
0.84±0.18 0.39 (.529)
0.91±0.13
0.88±0.15 14.86 (.000)**
Alcohol drinking status No Yes
0.88±0.15 0.84±0.19
4.08 (.044)* 0.93±0.10 0.88±0.15
31.54 (.000)**
Subjective health status
Good Common Poor
0.96±0.07 0.82±0.10 0.71±0.20
92.04 (.000)**
0.96±0.07 0.92±0.11 0.79±0.17
161.50 (.000)**
Regular exercise
No Yes
0.84±0.18
0.86±0.19 0.24 (.623)
0.89±0.15
0.93±0.10 14.52 (.000)**
Suicidal ideation No Yes
0.85±0.18 0.78±0.23
2.65 (.104) 0.89±0.14 0.79±0.27
9.99 (.002)*
Perceived stress Low
High
0.87±0.15 0.76±0.25
20.75 (.000)** 0.91±0.12 0.82±0.19
75.39 (.000)**
Medical service use
Unmet medical needs No Yes
0.87±0.16 0.71±0.23
33.23 (.000)** 0.90±0.13 0.81±0.18
37.84 (.000)**
Medical check-up No
Yes
0.82±0.20 0.86±0.16
3.73 (.054) 0.87±0.16 0.90±0.13
10.12 (.002)*
Cancer screening No
Yes
0.82±0.20 0.86±0.16
3.82 (.051) 0.87±0.16 0.90±0.13
11.49 (.001)**
Unmet dental needs No Yes
0.85±0.18 0.84±0.18
0.12 (.728) 0.90±0.13 0.88±0.15
5.75 (.017)*
3.3.Factors influencing HRQoL
To identify the factors that influence HRQoL in elderly Koreanliving alone and elderly Korean living with family, a multiple regression analysis using a concurrent input method was performed by applying the statistically significant variables resulting from an univariable analysis as independent variables. For elderly Korean living alone, household incomes, subjective health conditions, perceived stress, and unmet medical needs were associated with HRQoL, and the model’s explanatory power was 36.4%. In addition, those with lower income levels, poorer subjective health conditions, higher perceived stress, and unmet medical needs exhibited lower levels of HRQoL.
In elderly Korean living with family, age, marital status, occupations, subjective health conditions, regular exercise, perceived stress, and unmet medical needs were linked with HRQoL, and the model’s explanatory power was 29.0%. Moreover, those who were older and with poorer subjective health conditions, no regular exercise, higher perceived stress, and unmet medical needs showed lower levels of HRQoL as shown in table3.
Table 3: Factors Associated with HRQOL (N=1,528)
Model Variables
Unstandardized coefficient Standardized coefficient
t p
B SE β
(Constant) 1.01 .07
Living area -.02 .01 -.07 -1.60 .110
Age -.02 .01 -.08 -1.86 .063
Education (≥high school) -.00 .01 -.03 -.69 .486
Income (quartile 1) .01 .00 .09 1.99 .047*
Occupation (no) -.01 .01 -.04 -.97 .332
Number of comorbidities -.01 .01 -.07 -1.65 .098
Alcohol drinking status (no) .02 .01 .05 1.24 .215
Subjective health status (good) -.10 .01 -.42 -9.08 ＜.001**
Perceived stress (low) -.06 .02 .13 -2.94 .003*
Unmet medical needs .08 .02 -.16 3.60 ＜.001**
R2=.364, Adjusted R2=.346, F=19.75, p＜.001.
(Constant) .94 .07
Gender -.01 .01 -.03 -0.79 .048
Living area -.02 .00 -.07 -2.84 .005*
Age -.02 .00 -.12 -4.32 ＜.001**
Education (≥high school) .00 .00 .03 1.18 .238
Marital status (unmarried) -.02 .01 -.07 -2.74 .006*
Occupation (no) -.01 .00 -.06 -2.24 .023*
Number of comorbidities -.00 .00 -.00 -0.27 .787
Smoking status (no) -.00 .01 -.01 -0.46 .640
Alcohol drinking status (no) .01 .00 .04 1.65 .098
Subjective health status (good) -.07 .00 -.34 -12.89 ＜.001**
Regular exercise (no) .06 .03 .05 2.29 .022*
Perceived stress (low) -.05 .01 -.14 -5.48 ＜.001**
Unmet medical needs .05 .01 .10 3.93 ＜.001**
Medical check-up .01 .01 .04 0.90 .366
Cancer screening -.01 .01 -.04 -0.94 .344
Unmet dental needs .00 .00 .02 0.91 .359
Dental check-up .00 .00 .01 0.62 .530
R2=.290, Adjusted R2=.279, F=27.28, p＜.001.–.03
This study was conducted to identify factors influencing HRQoL in elderly Koreanliving alone and elderly Koreanliving with family by using the 7th Third-Year KNHAES conducted in 2018. As a result, compared to elderly Korean living with family,
elderly Korean living alone showed more frequent cases of smoking, drinking, and not engaging in regular exercise. When establishing drinking and smoking-related health care programs and policies, it will be necessary to consider these characteristics of the elderly Koreanliving alone. In the use of medical services, 13.7% of elderly Korean living alone and 9.1% of elderly Korean living with family experienced unmet medical needs. Moreover, in relation to this, 35.3% of elderly Korean living alone did not take medical checkups, compared to 28.5% of elderly Korean living with family. This result was also statistically significant. In the use of every medical service, elderly Korean living alone exhibited a higher ratio of non-recipients than those living with family. In a previous study on unmet medical services and HRQoL, elderly Korean with unmet medical needs showed lower levels of quality of life than elderly Korean without unmet medical needs[12]. Another previous research reported that the most influential factor related to unmet medical needs was household incomes, and a group with poorer subjective health conditions, lower household incomes, and lower education levels were most likely to experience unmet medical needs, and those with lower income and education levels engaged in fewer activities aimed at enhancing health, such as medical checkups[13]. In South Korea, the rate of experiencing unmet medical needs has continued to fall and is currently at a similar level to those of 27 countries in the European Union, but this rate is still shown higher in the country’s high-income group than low-income group[14]. Therefore, when establishing policies to resolve unmet medical needs, a focus should be placed on low-income elderly Korean who live alone. In addition, detailed and practical support should be provided by identifying factors related to the unmet medical needs and cancer screening of elderly Korean living alone.
In the present study, elderly Korean living alone showed lower levels of HRQoL than elderly Korean living with family.
These elderly Korean form a health-related vulnerable group that has relatively poor health conditions and lacks resources to respond to emergencies[15]. They also can have multiple health problems given their nature of being prone to irregular living habits and social isolation[13]. Accordingly, it is necessary to provide interventions and policy support to improve the HRQoL of the elderlyKorean living alone by identifying factors influencing their HRQoL. This may be an urgent task considering the recent increasing trend in the number of elderly Korean living alone.
The factors influencing HRQoL in elderly Korean living alone included household incomes, subjective health conditions, perceived stress, and unmet medical needs. The equivalent factors in elderly Korean living with family included age, marital status, occupations, subjective health conditions, regular exercise, perceived stress, and unmet medical needs. According to a previous study[9], elderly Korean living alone who had poor subjective health conditions either complained of their sufferings or expressed sadness about their solitary lives with sickness. Because the subjects showed differences between those living alone and those living with family in the factors influencing their HRQoL, these differences should be incorporated into the establishment of health-related policies for the elderly. Moreover, in the case of subjective health conditions, perceived stress, and unmet medical needs, both groups showed the impact of these variables on their HRQoL. Accordingly, these characteristics should be factored into new health-related policies. Furthermore, the suggestion of realistic policies and continuous monitoring are required to prevent or reduce unmet medical needs through the detailed identification of the current state and causes of unmet medical needs
4. Conclusion
The present study is a secondary analysis on data extracted from the 7th Third-Year KNHAES conducted by KCDC in 2018 in order to compare elderlyKorean living alone and elderlyKorean living with family in terms of their health-related behavior, medical service use, and HRQoL. The study results showed regarding their health-related behavior that elderly Korean living alone had higher frequencies of smoking, drinking, and no regular exercise than elderly Korean living with family.
In the use of medical services, elderly Korean living alone exhibited a higher ratio of non-recipients than elderly Korean living with family. In terms of HRQoL, elderly Korean living alone showed lower levels of HRQoL than those living with family. The factors influencing HRQoL were household incomes, subjective health conditions, perceived stress, and unmet medical needs among the elderly Korean living alone, and age, marital status, occupations, subjective health conditions, perceived stress, and unmet medical needs among the elderly Korean living with family. Consequently, the respective characteristics of elderly Korean who live alone and live with family in relation to their health-related behavior and medical service use should be reflected in the establishment of health-related policies. In addition, efficient and realistic tailored policies should be provided to both groups in consideration of the factors influencing their HRQoL.
Meanwhile, since the present study focused on identifying the subjects’ health-related behaviors and whether they were using medical services as a secondary analysis study based on the raw data of the 2018 KNHAES, it has a limitation of failing to identify various categories of health-related behavior and medical service use. Therefore, future studies are recommended to further segment and identify the subjects’ health-related behaviors and actual conditions of medical service use, and based on the results, understand the relationship between these variables and HRQoL.
