Biopsychosocial Determinants of Quality of Life in Patients with Hepatitis B and C

consequences of


M E T H O D S
that higher scores on harm avoidance and low selfdirectness [6].It was also found that poor personality functioning marked by a lack of meaning and purpose in life and being unable to have close enjoyable relations is associated with poor mental health outcomes in HBV patients.Daida et al., found that over t hepatic encephalopathy (OHE) may be experienced by HBV and HCV patients.Research has also shown depression, anxiety and psychiatric comorbidities such as substance abuse are marked for being the leading disorders affecting those with chronic Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) [7].However, despite of the availability of effective treatments and screening measures, depression and chronic stress are underdiagnosed.Also, there is a general lack of understanding about the neuropsychological effects of HBV and HCV in those chronically affected with these fatal viruses [8].There is also limited research evidence in Pakistan documenting biopsychosocial determinants of Hepatitis B and C especially the role of resilience and perceived immune status in quality of life of those diagnosed with HBV and HCV [9].Apart from this, the present study assesses the protective role that resilience and social support may play in the quality of life of individuals with HBV and HCV.Moreover, there are no studies in Pakistan that have documented the frequency and prevalence and predictive association of cross cutting symptoms with quality of life in patients with Hepatitis B and C.

R E S U L T S
The results of the study showed the frequency and prevalence of cross cutting symptoms among the participants followed by correlations among cross cutting symptoms, health and lifestyle, resilience and its subscales and quality of life and its subscales.Table 1 shows prevalence rates of cross cutting symptoms among the participants with Hepatitis B and C in accordance with threshold (score of 1 or higher) for the psychopathology symptom criteria.previous year which comprised 7 items.Evidence suggests that the time restriction may be customized depending on the needs of the health condition [12].Resilience was assessed through Essential Resilience Scale.According to Chen et al., the Essential Resilience Scale assesses a person's capacity to prepare for, adapt to, and recover from three different types of stressful events: physical, emotional, and social [13].The DSM-5 Level 1 Cross-Cutting Symptom Measure analyses characteristics of mental health that are essential for all psychiatric diagnoses.It measures 13 psychiatric domains [14].The WHOQoL-BREF consists of 26 items [15].It is widely used questionnaire aimed at assessing an individual's perception regarding their quality of life.The questionnaire covers a number of domains and aspects associated with quality of life including perceptions about physical health, psychological health, social relations and the environment.Urdu translated version of the scale was used [16].To assess the level of biological wellbeing among those with HBV and HCV, items had been constructed in accordance with the ndings of Tartaglia [17] and through consultation with experts.All of the scales used in the study had acceptable levels of Cronbach's alpha reliability.Ethical approval for the study was accorded during the Advanced Studies and Research Board of GC University, Lahore, convened on the th 13 of September, 2023 vide Memo No. REG-ACAD-ASRB-55/23/037. Compliance was ensured with regard to the ethical guidelines of Declaration of Helsinki.Furthermore, informed consent was attained from all participants and their con dentiality and anonymity was further ensured.The booklet of the questionnaire took about 15 to 20 minutes to complete.The purpose of the study, right to anonymity and other ethical guidelines were complied with during this study.Data analysis was done using SPSS 21.0.Descriptive statistics, normality checks, reliability analysis, correlation analysis, hierarchical regression and structural equational modeling using path analysis were performed to identify predictive associations among the study variables.These statistical tests provide insights about the predictive associations among the constructs.
The study used a cross sectional correlational research design.It was conducted from August 15, 2023, till September 15, 2023.The sample size for the study was determined through G power analyses.Kang has reported that sample size calculations using effect sizes, power estimation, con dence intervals and elimination of chances of Type 1 and Type 2 errors can be done through G power calculators [10].G power analyses using 95 % con dence intervals revealed that a sample of 300+ participants would be su cient.The method is used for sample size determination.For the conduct of the present study, a sample size of 400 individuals (196 with Hepatitis B and 204 with Hepatitis C) with 210 males and 190 females in the age range of 20 to 71 years of age were selected with the mean age of 40.48 years were selected through purposive sampling.The participants were recruited from two major outpatient settings in Lahore located at Thokar Niaz Baig, Lahore, and the second one at Allama Iqbal Town, Lahore.Individuals who were non-hospitalized and chronically affected with Hepatitis B and C were selected for the current [11].For the purpose of data collection, Immunological Status Questionnaire (ISQ) was used to evaluate perceived immunological state during the Note.F=Frequency, participants scoring 1 or higher (cut-points) on any domain were identi ed as possessing the speci c symptomatology as per recommendations of Narrow et al., [14] Table 2 indicates the results of a correlation analyses performed to assess the presence of signi cant associations among the study variables.The assumptions for running a Pearson product moment correlation were tested.Normality checks were performed and the criteria were met.The study found that cross cutting symptoms had signi cant positive associations with one another but signi cantly negative associations with resilience, immune function and quality.
Note. *p<.05, **p<.01,Suic.ide.psychosis=suicidalideation and psychosis, repet-tho.behav=repetitivethoughts and behavior, diss.personality.fun=dissociationand personality functioning Table 3 shows hierarchical regression analysis to examine the relationship between sociodemographic variables, biological determinants, and psychosocial determinants.The rst model showed that age and gender signi cantly predicted overall quality of life.The second model assessed biological determinants, including age, gender, time since diagnosis, liver function scores, stage of brosis, and health and lifestyle scores.The third model accounted for psychosocial determinants, including age, gender, ALT scores, AST scores, stage of brosis, resilience, depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, memory, repetitive thoughts and behaviors, dissociation, personality functioning, substance abuse, and social support.The three models explained 55% of the variance in the dependent variable, overall quality of life.Table 4 and Figure 1 depict path analysis executed via AMOS with 95 % con dence intervals and 2000 bootstrapped samples showing the indirect impact of social support on quality of life (β = .18,p < .01),which is signi cant, and the indirect effect of anger (β =-.61, p = .000),mania (β = -.44,p=.001), anxiety (β = -.21,p=.001), somatic symptoms (β =-.32, p = .000),suicidal ideation (β =-.62, p = .000),psychosis (β =-.42, p = .000),memory (β =-.03, p = .000),substance abuse (β =-.94, p = .000),and liver function/immune function test (β =-.01, p = .000)on quality of life is signi cant and thus provided evidence of a partial mediation.Please refer to gure 1 for more details.Table 5 and Figure 2 depict path analysis executed via AMOS with 95 % con dence inter vals and 2000 bootstrapped samples showing the indirect impact of resilience on quality of life (β = .38,p < .01),which is signi cant, and the direct effect of anger (β =-.33, p = .000),mania (β = -.66,p=.001), anxiety (β = -.27,p=.001), suicidal ideation (β = -.92,p = .000),psychosis (β =-.49, p = .000),sleep problems (β =-.12, p = .000),substance abuse (β =-.28, p = .000),and liver function/immune function test (β = -.01,p = .000)on quality of life is signi cant and thus provided evidence of a signi cant partial mediation.Please refer to gure 2 for more details.  2 depicts the mediating role of social support in the association between cross cutting symptoms and quality of life.The ndings showed that cross cutting symptoms signi cantly predicted resilience which in turn signi cantly predicted quality of life.However, only the indirect effect of anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, memory, substance abuse and liver function/immune function test on quality of life were signi cant thus providing evidence of partial mediation.The purpose of the present study was to assess the role of sociodemographic factors and biopsychosocial determinants in predicting quality of life in patients with hepatitis b and c.Moreover, the emphasis was on assessing how biopsychosocial determinants impact quality of life in the participants.The ndings were bene cial in identi cation and analyses of the determinants and the predictive role of sociodemographic and associated factors.First, it was hypothesized cross cutting symptoms such as depression, anger, suicidal ideation, repetitive thoughts and behaviors, substance etc. will have signi cant associations with resilience, social support and quality of life in HBV and HCV patients.The ndings offered a partial con rmation of this hypotheses in accordance with the relevant literature.The relevant literature identi ed that depression is a highly prevalent psychiatric outcome in patients with HBV and HCV [18].Speci cally, individuals with chronic HBV and HCV are often experience manic attacks, depression, anxiety and behavioral problems.These psychiatric outcomes may not be necessarily elicited as a side effect to alpha interferon therapy.Sertoz et al., also showed an agreement with the fact that depression, anxiety, stress, mania and associated behavioral problems and issues are associated with poor quality of life outcomes in HBV and HCV patients [19].
Research has also shown that depression, anxiety, stress, mania and anger have signi cant predictive associations in patients with chronic liver disease [20].Zhu, however, identi ed that depression, anxiety and stress may be seen as pre-existing problems among HBV and HCV patients.However, there is consistent evidence to show that a number of psychiatric conditions such as mania, suicidal ideation and psychosis may emerge during the course of treatment.The authors further raised the need of collaborative involvement and management of these conditions as they can lead to improvements in the wellbeing and quality of life of these patients.

D I S C U S S I O N C O N C L U S I O N S
The quality of life in patients with Hepatitis B and C is signi cantly in uenced by biological, psychological, and sociological factors.The biopsychosocial burden of the disease is high, and enhancing resilience, social support, gender, and health and lifestyle factors may improve outcomes.It has been assessed that cross cutting symptoms, alperceived immune status, health and lifestyle factors, social support and resilience signi cantly impact quality of life.Providing ongoing monitoring and multidisciplinary care may be bene cial in managing these conditions.
Note. **p < .01.Standardized coe cients are shown.Somatic-Sympt.=Somatic Symptoms, Rep. Thot.Behav.=Repetitive Thoughts and Behaviors, LFT/IS=Liver Function AST/ALT tests and Immune System Functioning Figure1depicts the mediating role of social support in the association between cross cutting symptoms and quality of life.The ndings showed that cross cutting symptoms signi cantly predicted social support which in turn signi cantly predicted quality of life.However, only the indirect effects of anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, memory, substance abuse and liver function/immune function test on quality of life were signi cant thus providing evidence of partial mediation.

Figure 1 :
Figure 1: Social support as a Mediator between the Relationship of Psychological Determinants (depression, anger, mania, somatic symptoms, psychosis, memory, repetitive thoughts and behaviors, dissociation, personality functioning and substance) and overall Quality of Life

Figure 2 :
Figure 2: Resilience as a Mediator between the Relationship of Psychological Determinants (depression, anger, mania, somatic

Table 1 :
Frequency and Prevalence of Cross Cutting Symptoms among the Participants

Table 2 :
Correlation of Cross Cutting Symptoms Measure with Brief Symptom Inventory and Subscales of Essential Resilience Scale

Table 3 :
Sociodemographic and Biopsychosocial Variables as Predictors of Quality of Life Quality of Life in Patients with Hepatitis B and C

Table 4 :
Social Support as a Mediator between the Relationship of Psychological Determinants (depression, anger, mania, somatic symptoms, psychosis, memory, repetitive thoughts and behaviors, dissociation, personality functioning and substance) and overall Quality of Life Quality of Life in Patients with Hepatitis B and C PJHS VOL. 4 Issue.10 October 2023 Copyright © 2023.PJHS, Published Crosslinks International Publishers

Table 5 :
Resilience as a Mediator between the Relationship of Psychological Determinants (depression, anger, mania, somatic symptoms, psychosis, memory, repetitive thoughts and behaviors, dissociation, personality functioning and substance) and overall Quality of Life Note. **p < .01.Standardized coe cients are shown.Somatic-Sympt.=SomaticSymptoms, Rep. Thot.Behav.=RepetitiveThoughts and Behaviors, LFT/IS=Liver Function AST/ALT tests and Immune System FunctioningFigure , health and life style factors, depression, social support, perceived immune status, resilience and cross cutting symptoms would signi cantly predict quality of life in HBV and HCV patients.Youssef et al., identi ed that gender, presence or absence of cirrhosis or moderate to high level brosis (liver in ammation and injury) along with psychiatric comorbidities such as depression, anxiety, anger and substance abuse would signi cantly predict quality of life in patients with Hepatitis C [23].Lieber et al., identi ed how resilience and social support may play a protective role against different psychiatric and adverse physical outcomes in liver transplant survivors and in patients with chronic liver disease[24].Furthermore, it was hypothesized that social support and resilience would mediate the association among cross cutting symptoms (depression, anxiety, mania, suicidal ideation, dissociation, personality functioning etc.) perceived immune status functioning and quality of life.The results of the current study supported the above hypothesis.Gormley et al., assessed depression, social support and quality of life in drug users withHepatitis B and C [25].The ndings showed that social support signi cantly mediates the predictive association with quality of life.The research literature further shows that resilience signi cantly predicts and mediates the impact of the depressive symptoms, liver function, perceived immune status on quality of life in those diagnosed withHepatitis B and C [26].The authors also found that resilience had a large indirect effect on emotional distress and quality of life in patients with Hepatitis C.
c i r r h o s i s ) [ 2 2 ] .I t w a s a l s o h y p o t h e s i z e d t h a t sociodemographic factors such as gender, age, number of years, presence of other chronic diseases as well as biopsychosocial factors such as stage of brosis, liver function tests