Review question/objective

What is the association between constipation and quality of life, health related quality of life and health status?

The objective of this review is to identify the association between constipation and quality of life, health related quality of life and health status in adults.

Background

Constipation is often an overlooked problem in health care.1 Four to 28% of the general population is estimated to be constipated2,3 and up to 50% develop constipation after a surgical procedure.4 In patients with complex disorders, up to 70% suffer from constipation.4 Constipation is about twice more common in women than in men.3 However reasons like deterioration of pelvic floor muscles following childbirth do not result in constipation5 and female hormones do not contribute to constipation, considering the prevalence of constipation in older women.6

Numerous studies indicate that the prevalence of constipation increases with age, especially after 65 years.3,7-10 However many studies also note no significant difference between constipation in the elderly and the rest of the general population.11-13

Abdominal pain, bloating, nausea and straining to defecate are the most common symptoms.14,15 Constipation increases the risk of postoperative complications, prolonged hospital stay, and added financial costs and staff nursing caretime.16,17

Belsey et al. conducted a systematic review on a similar topic. However, only patients with chronic constipation were included. The review also included children, so the results did not focus exclusively on adults.18 The same limitations were noted in a systematic review by Wald et al.19

Both chronic and acute constipation are a source worry for patients who experience distension, nausea and abdominal cramps.20 Furthermore, constipation is seen as a bodily ailment21 and increases the feeling of loneliness and social isolation.20-22

Constipation may have an impact on the patients' quality of life, health related quality of life or health status. Also, there is a perception among patients who report to be constipated that their general health, emotional health, social functioning and mental health are impaired.23,24

The impact on health related quality of life in patients with constipation seems to differ among different populations. Rao et al. report in a study of a population of 158 persons, among whom 88% were women with a mean age of 41 years admitted with constipation in a tertiary care centre, a decrease in health related quality of life especially in the domains of "mental health" and "bodily pain".25 However in a study of 1149 patients, Irvine et al. report a decrease in health related quality of life especially in the domains of "physical functioning" and "role-physical".26 Thus there is no common pattern of the impact of constipation on health related quality of life. In order to obtain a more correct picture of the magnitude of the problem, pooling of data will be necessary. Pooling will enable taking the different population sizes into account.

A comprehensive systematic review and/or a meta-analysis will create and improve knowledge on the problems and challenges patients with constipation face. It will highlight the need for assessing the effect of interventions applied in both hospital settings and patients' own homes. This knowledge will contribute to a better understanding of interventions needed and the implications of relevant practice.

Inclusion criteria

Types of participants

This review will consider studies that include all patients over the age of 19 years who have reported to be constipated, regardless of gender, ethnicity, diagnosis severity, co morbidity or previous treatment. The settings of the studies include hospitals, long-term care facilities and community.

Phenomenon of interest

The phenomenon of interest is constipation regardless of definition i.e. both acute and chronic and whether it is a diagnosed complication to surgery or a self-reported condition.

Types of outcomes

This review will consider studies that include the following measures:

Studies where quality of life, health related quality of life or health status are measured with a validated instrument, such as SF36 and others.

Types of studies

This review will consider cross sectional studies, cohort studies and case-control studies.

The review will also consider passive control patients in any experimental study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental trials, and before and after studies for inclusion (passive control patients who have not been exposed to any intervention and therefore must be assumed to be representative of the population under study). Baseline data from patients in intervention groups will be used where it is possible.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. The initial search terms will be chosen in discussion with a research librarian with the aim of identifying the maximum number of articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies as well as citation searches will be applied. Studies published in English, German, Danish, Norwegian and Swedish will be considered for inclusion in this review. Databases will be searched from their inception to 2014.

The databases to be searched include:

Pubmed, CINAHL, Embase, Scopus, Swemed+, Health Technology Assessment Database, Turning Research into Practice.

Additional searching for published studies will include:

Hand searching reference lists and bibliographies of included articles.

The search for unpublished studies will include:

Conducting an online search of databases and websites including:

MedNar, ProQuest Dissertations and Theses, National Institutes of Health (NIH) Clinical Trials Databases (Host: NIH (http://clinicaltrials.gov), College of Nurses of Ontario (http://www.cno.org/learn-about-standards-guidelines)

Initial keywords/search terms to be used will be:

Constipation OR obstipation

AND

Quality of life OR health related quality of life OR health status OR QOL OR HRQOL

AND

Chronic or acute, postoperative complication

Limits:

Age > 19 years

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Conflicts of interest

None identified.

References