Measuring AgrAbility Outcomes with Quality of Life Indicators Robert A. Wilson, Ph.D., M.Sc. University of Delaware Center for Applied Demography and Survey Research Newark, Delaware Paper presented National AgraAbility Project Training Workshop Burlington, Vermont, November 8, 2005

Types of Program Evaluations Process Evaluations Impact Evaluations

Process Evaluations Analyze Program Inputs Client Records Outreach activity Services Delivered Procedures Followed Day-by-day Staff Activity Costs Materials

Impact Evaluations Measure Program Outputs Productivity Farm output Individual farmer or waterman output Efficiency Benefits/Costs Satisfaction with services provided Improvements in Quality of Life

Which AgrAbility outcome is most important? Improved Productivity? Satisfaction with services delivered? Improvements in the Quality of Life?

A farmer could increase productivity as a result of AgrAbility, but Register a low level of satisfaction with the services that were provided Experience no improvement in the quality of life

A farmer could be very satisfied with the services provided by AgrAbility but Register no changes in farm output Experience no improvement in the quality of life

A farmer could experience an improvement in the quality of life as a result of AgrAbility, but Be dissatisfied with the AgrAbility Program Register no changes in farm productivity as a result of the program

The 3 rd scenario: may be common among: Older Farmers Farmers with certain disabilities, e.g. arthritis Farmers who do not wish to retire from farming or who cannot retire from farming

With an aging agricultural labor force, improvements in the quality of life may be particularly important for AgrAbility programs.

Older farmers are particularly susceptible to the degenerative diseases of aging Arthritis Coronary disorders Cancer Tobacco-related diseases Diseases associated with exposure to toxic chemicals Clinical Depression Dementia (including Alzheimer’s Disease)

Degenerative diseases are normally marked with a decline in the Quality of Life

How is the quality of life measured in medicine and in rehabilitative services?

Quality of Life Measurements Disability-Adjusted Life Years (DALYs) Quality-Adjusted Life Years (QALYs)

Disability Adjusted Life Years (DALYs) Used to measure the burden of disease in large populations: countries, states, counties DALYs are a hybrid measure that combines premature mortality with time lived with a disease

One disability-adjusted life year (1 DALY) indicates that one person either died a year prior to life expectancy, or lived with a disability for a year at a psychometric threshold equivalent to death. If a disorder is severe, it receives a weight that is closer to one (the psychometric equivalent of death). If a disorder is not severe, it receives a weight that is closer to zero (the equivalent of perfect health). DALYs can be aggregated for groups of people and geographic areas. Health Services Policy Research Group University of Delaware DISABILITY ADJUSTED LIFE YEAR (DALY)

7 Example: If a population had 10 people at the beginning of 2002: …5 of the people lived in perfect health throughout the year = 0 DALYs …1 female, aged 80, died of alcohol-related cirrhosis, (Life Expectancy: 82) = 2 DALYs …1 male, aged 50, died of lung cancer, (Life Expectancy: 80) = 30 DALYs …2 males, both aged 20, died in alcohol-related accidents: (Life Expectancy: 80) = 120 DALYs …1 female (any age) lived with alcohol-related cirrosis for the entire year (1 year x disability weight.20).20 DALYs _____________ Total DALYs Health Services Policy Research Group University of Delaware

12 Disability-Adjusted Life Years (DALYs) per 1000 Population (Age-Adjusted) Attributable to Alcohol Dependence and Alcoholic Liver Cirrhosis by Census Tract, State of Delaware, Less than Delaware Mean Delaware =8.4 Greater than Delaware Mean Missing Data New Jersey Pennsylvania Maryland Atlantic Ocean

Quality-Adjusted Life Years (QALYs) QALYs are a summary measure used to measure the health-related quality of life for both individuals and groups. QALYs are frequently employed to gauge changes in the quality of life associated with therapy or new drugs There are a number of standardized instruments from which QALYs may be generated One instrument is the SF-36, which we are currently using in a small sample of farmers which is being carried by Peggy Mack.

The recommended QALY measure is The SF-36 instrument

The SF-36 Health Survey 1. In general would you say that your health is 1. Excellent 2. Very Good 3. Good 4. Fair 5. Poor

2. Compared to a year ago, how would you rate your health now? 1. Much better 2. Somewhat better 3. About the same 4. Somewhat worse 5. Much worse

Vigorous activities, Such as running, lifting heavy objects, participating in strenuous sports?

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Lifting or carrying groceries

Climbing several flights of steps

Climbing one flight of steps

Bending kneeling, or stooping

Walking more than a mile

Walking several hundred yards

Walking one hundred yards

Bathing or dressing yourself

4. During the last 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health? -all of the time -most of the time -some of the time -a little of the time -none of the time

Cut down on the amount of time you spent on work or other activities

Accomplished less than you would like

Were limited in the kind of work or other activities

Had difficulty performing the work or other activities

5. During the last 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as being depressed or anxious)?

-All of the time -Most of the time -Some of the time -A little of the time -None of the time

Cut down on the amount of time you spent on work or other activities

Accomplished less than you would like

Did work or activities less carefully than usual

6. During the last 4 weeks to what extent has your physical health or emotional problems interfered with your normal social activities with friends, neighbors or groups? -Not at all -Slightly -Moderately -Quite a bit -Extremely

7. How much bodily pain have you had during the last 4 weeks? -None -Very Mild -Mild -Moderate -Severe -Very severe

.During the last 4 weeks, how much did pain interfere with your normal work? -Not at all -A little bit -Moderately -Quite a bit -Extremely

9. These are questions about how you feel and how things have been with you during the last 4 weeks. For each question please give the 1 answer that comes closest to the way you have been feeling. How much of the time during the last 4 weeks…

Did you feel full of life? All of the time Most of the time Some of the time A little of the time None of the time

Have you been very nervous? All of the time Most of the time Some of the time A little of the time None of the time

Have you felt so down in the dumps that nothing could cheer you up? All of the time Most of the time Some of the time A little of the time None of the time

Have you felt calm and peaceful? All of the time Most of the time Some of the time A little of the time None of the time

Did you have a lot of energy? All of the time Most of the time Some of the time A little of the time None of the time

Have you felt downhearted and depressed? All of the time Most of the time Some of the time A little of the time None of the time

Did you feel worn out? All of the time Most of the time Some of the time A little of the time None of the time

Have you been happy? All of the time Most of the time Some of the time A little of the time None of the time

Did you feel tired? All of the time Most of the time Some of the time A little of the time None of the time

10. During the past 4 weeks how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time None of the time

11. How TRUE or FALSE is each of the following statements for you? Definitely true Mostly true Don’t Know Mostly false Definitely false

I seem to get sick a little easier than other people

I am as healthy as anybody I know

I expect my health to get worse

My health is excellent

T he SF-36 is calculated for 8 health factors (0-100) 1. Physical limitations 2. Limitations in social activities 3. Limitations in work and home roles 4. Bodily pain 5. Psychological distress and wellbeing 6. Limitations because of emotional problems 7. Energy and fatigue 8. General health perceptions

Outcome: Mean SF-36 Score (Mean score for Experimental Group Time1- Mean Score for Experimental Group Time 2) minus (Mean score for Control Group Time1-Mean Score for Control Group Time 2)

2 Measurements Time 1 Assessment at Program Intake Time 2 Measurement following Intervention

Outcome: Mean SF-36 Score (Mean score for Experimental Group Time1- Mean Score for Experimental Group Time 2) minus (Mean score for Control Group Time1-Mean Score for Control Group Time 2)

Or 4 Measurements: Experimental Design Experimental Group Time 1 Assessment at Program Intake Time 2 Measurement following Intervention Control Group Time 1 Assessment at Program Intake Time 2 Measurement following Intervention