2 page reflection paper about a Leisure Questionnaire
coolbreeze22
QuestionaireRubric.docxOlder People’s Quality of Life Questionnaire (OPQOL) summed scoring and reverse coding:
OPQOL items coded 1-5; scoring = – reverse coding of positive items;
sum sub-scales – names as marked in table headers; sum total for overall score +/-OPQOL: reverse coding of positively worded items + (5-1) so higher scores represented higher QoL
OPQOL items:
Please indicates the extent to which you agree or disagree with each of the following statements (5-point Likert response scale: Strongly agree to Strongly disagree coded 1-5 as indicated in questionnaire)
Life overall
1. I enjoy my life overall 2. I am happy much of the time 3. I look forward to things 4. Life gets me down Health 5. I have a lot of physical energy 6. Pain affects my well-being 7. My health restricts me looking after myself or my home 8. I am healthy enough to get out and about Social relationships/leisure and social activities 9. My family, friends or neighbours would help me if needed 10. I would like more companionship or contact with other people 11. I have someone who gives me love and affection 12. I’d like more people to enjoy life with 12a.I have my children around which is important * 29. I have social or leisure activities/hobbies that I enjoy doing 30. I try to stay involved with things 31. I do paid or unpaid work or activities that give me a role in life Independence, control over life, freedom 13. I am healthy enough to have my independence 14. I can please myself what I do 15. The cost of things compared to my pension/income restricts my life 16. I have a lot of control over the important things in my life 32. I have responsibilities to others that restrict my social or leisure activities Home and neighbourhood 17. I feel safe where I live 18. The local shops, services and facilities are good overall 19. I get pleasure from my home 20. I find my neighbourhood friendly Psychological and emotional well-being 21. I take life as it comes and make the best of things 22. I feel lucky compared to most people 23. I tend to look on the bright side
1
24. If my health limits social/leisure activities, then I will compensate and find something else I can do Financial circumstances 25. I have enough money to pay for household bills
26. I have enough money to pay for household repairs or help needed in the house 27. I can afford to buy what I want to 28. I cannot afford to do things I would enjoy Religion/culture
33. Religion, belief or philosophy is important to my quality of life * 34 (35). Cultural/religious events/festivals are important to my quality of life *
[Note: the 32 item version was used in Qol follow-up survey; a 35 item version was used in ONS Omnibus and Ethnibus surveys; three additional items were included after holding focus groups with ethnically diverse older people - marked with *]
OPQOL norms, in 2007-8, for a national random population sample aged 65+, a national ethically diverse sample aged 65+, and a follow-up of people aged 65+ in 1999/200 are shown in Table 1.
|
Table 1. Older people’s Quality of Life Questionnaire (OPQOL) items+ |
|||
|
|
Ethnibus 2008 (35 items, range 35- 175) |
ONS Omnibus 2008 (35 items, range 35- 175) |
QoL Survey follow-up 2007/8 (32 items, range 32-160) |
|
OPQOL items: |
% (n)
|
% (n)
|
% (n) |
|
1. Life overall: |
|
|
|
|
1. + I enjoy my life overall |
|
|
|
|
Strongly agree |
18 (73) |
38 (224) |
21 (59) **** |
|
Agree |
34 (137) |
53 (310) |
61 (171) |
|
Neither agree nor disagree |
37 (148) |
7 (42) |
14 (40) |
|
Disagree |
9 (35) |
2 (11) |
4 (12) |
|
Strongly disagree
|
2 (7) |
--- |
|
|
2. + I am happy much of the time
|
|
|
|
|
Strongly agree
|
10 (41) |
34 (197) |
18 (50)**** |
2
|
Agree |
32 (126) |
59 (344) |
66 (184) |
|
Neither agree nor disagree |
49 (196) |
5 (32) |
12 (32)
|
|
Disagree |
8 (33) |
2 (13) |
4 (12)
|
|
Strongly disagree |
1 (4) |
--- |
--- |
|
3. + I look forward to things |
|
|
|
|
Strongly agree |
15 (60) |
36 (209) |
21 (57) **** |
|
Agree |
42 (166) |
53 (312) |
58 (163)
|
|
Neither agree nor disagree |
38 (152) |
8 (47) |
17 (48) |
|
Disagree |
5 (21) |
3 (17) |
4 (11) |
|
Strongly disagree |
--- (1)
|
--- (2)
|
--- |
|
4. - Life gets me down |
|
|
|
|
Strongly agree |
14 (57) |
1 (8) |
2 (4) **** |
|
Agree |
47 (187)
|
12 (72)
|
7 (20) |
|
Neither agree nor disagree |
23 (92) |
17 (100) |
25 (69) |
|
Disagree |
12 (48)
|
48 (279)
|
44 (118) |
|
Strongly disagree |
4 (16)
|
22 (127)
|
22 (61) |
|
2. Health and functioning: |
|
|
|
|
5. + I have a lot of physical energy |
|
|
|
|
Strongly agree |
13 (53) |
12 (71) |
6 (17) **** |
|
Agree |
41 (165) |
34 (202) |
28 (76) |
|
Neither agree nor disagree |
30 (121) |
19 (113) |
36 (96) |
|
Disagree |
13 (51) |
29 (164) |
27 (74) |
|
Strongly disagree
|
3 (10) |
6 (36) |
3 (9) |
|
6. - Pain affects my well-being±
|
|
|
|
3
|
Strongly agree |
14 (56) |
8 (50) |
8 (21) **** |
|
Agree |
40 (161) |
29 (169) |
28 (76)
|
|
Neither agree nor disagree |
32 (128) |
15 (86) |
21 (56)
|
|
Disagree |
10 (39) |
35 (205) |
33 (89) |
|
Strongly disagree |
4 (16) |
13 (77) |
10 (28)
|
|
7. - My health restricts me looking after myself or my home |
|
|
|
|
Strongly agree |
15 (61) |
4 (26) |
5 (13) **** |
|
Agree |
33 (133)
|
15 (88)
|
12 (34) |
|
Neither agree nor disagree |
37 (148) |
7 (39) |
14 (39) |
|
Disagree |
11 (44)
|
47 (276)
|
43 (119) |
|
Strongly disagree |
4 (14) |
27 (158) |
26 (71) |
|
8. + I am healthy enough to get out and about |
|
|
|
|
Strongly agree |
8 (30) |
39 (227) |
29 (81) **** |
|
Agree |
32 (130)
|
47 (276)
|
51 (144) |
|
Neither agree nor disagree |
48 (192) |
5 (31) |
9 (24) |
|
Disagree |
11 (44)
|
5 (30)
|
8 (21) |
|
Strongly disagree |
1 (4) |
4 (23) |
3 (10) |
|
3a. Social relationships: |
|
|
|
|
9. + My family, friends or neighbours would help me if needed |
|
|
|
|
Strongly agree |
6 (26) |
49 (286) |
44 (125) **** |
|
Agree
|
31 (123) |
45 (263) |
49 (138) |
|
Neither agree nor disagree
|
55 (219) |
4 (23) |
6 (18) |
4
|
Disagree |
8 (31) |
2 (12) |
--- (1) |
|
Strongly disagree |
--- (1) |
--- (2) |
--- (1)
|
|
10. - I would like more companionship or contact with other people |
|
|
|
|
Strongly agree |
3 (13) |
4 (21) |
4 (10) **** |
|
Agree |
33 (134) |
16 (95) |
19 (53) |
|
Neither agree nor disagree |
42 (167) |
27 (157) |
42 (117)
|
|
Disagree |
20 (79) |
46 (272) |
29 (79) |
|
Strongly disagree |
2 (7)
|
7 (41)
|
6 (17) |
|
11. + I have someone who gives me love and affection |
|
|
|
|
Strongly agree |
10 (38)
|
50 (297)
|
45 (125) **** |
|
Agree |
45 (178) |
38 (222) |
35 (96) |
|
Neither agree nor disagree |
--- --- |
5 (28) |
13 (36) |
|
Disagree |
44 (177)
|
5 (29)
|
6 (17) |
|
Strongly disagree |
2 (7) |
2 (10) |
1 (4) |
|
12/a - I’d like more people to enjoy life with |
|
|
|
|
Strongly agree |
3 (14) |
4 (25) |
5 (13) **** |
|
Agree |
32 (130) |
25 (149) |
21 (58) |
|
Neither agree nor disagree |
41 (164) |
27 (157) |
42 (116) |
|
Disagree |
22 (86) |
39 (229) |
27 (76) |
|
Strongly disagree |
2 (6) |
5 (27) |
5 (14) |
|
12/b. Aia.± + I have my children around which is important
|
|
|
|
5
|
Strongly agree |
10 (38) |
37 (217) |
n/a |
|
Agree |
34 (138) |
31 (182) |
|
|
Neither agree nor disagree |
39 (156) |
11 (63) |
|
|
Disagree |
15 (61) |
11 (64) |
|
|
Strongly disagree [includes no children] |
2 (7) |
9 (54) |
|
|
4. Independence, control over life, freedom: |
|
|
|
|
13. + I am healthy enough to have my independence (independence- health) |
|
|
|
|
Strongly agree |
7 (26)
|
39 (231)
|
32 (93) **** |
|
Agree |
23 (93) |
48 (282) |
50 (142) |
|
Neither agree nor disagree |
41 (163)
|
5 (25)
|
9 (26) |
|
Disagree |
23 (93) |
6 (37) |
7 (19) |
|
Strongly disagree |
6 (25)
|
2 (12)
|
2 (6) |
|
14. + I can please myself what I do (freedom, autonomy) |
|
|
|
|
Strongly agree |
10 (39) |
42 (246) |
30 (84) **** |
|
Agree |
45 (180)
|
48 (281)
|
53 (151) |
|
Neither agree nor disagree |
15 (62) |
6 (37) |
11 (31) |
|
Disagree |
24 (94) |
3 (15) |
5 (14) |
|
Strongly disagree |
6 (25) |
1 (8) |
1 (4) |
|
15. - The cost of things compared to my pension/income restricts my life (independence- financial) |
|
|
|
|
Strongly agree
|
12 (48) |
11 (64) |
8 (23) **** |
6
|
Agree |
15 (60) |
28 (162) |
23 (65) |
|
Neither agree nor disagree |
24 (96) |
20 (119) |
31 (86)
|
|
Disagree |
42 (169) |
36 (213) |
32 (91)
|
|
Strongly disagree |
7 (27) |
5 (29) |
6 (18)
|
|
16. + I have a lot of control over the important things in my life (control) |
|
|
|
|
Strongly agree |
13 (53) |
37 (219) |
26 (74) ****
|
|
Agree |
41 (163) |
53 (313) |
56 (161) |
|
Neither agree nor disagree |
29 (115)
|
6 (32)
|
14 (40) |
|
Disagree |
17 (69) |
4 (22) |
3 (8) |
|
Strongly disagree |
--- ---
|
--- (1)
|
1 (3) |
|
32. - I have responsibilities to others that restrict my social or leisure activities |
|
|
|
|
Strongly agree |
5 (18) |
3 (15) |
4 (12) **** |
|
Agree |
15 (59)
|
10 (60)
|
12 (33) |
|
Neither agree nor disagree |
20 (82) |
7 (40) |
16 (44) |
|
Disagree |
38 (152)
|
62 (365)
|
50 (135) |
|
Strongly disagree |
22 (89) |
18 (107) |
17 (47) |
|
5. Home and neighbourhood: |
|
|
|
|
17. + I feel safe where I live |
|
|
|
|
Strongly agree |
14 (190) |
46 (269) |
35 (99) **** |
|
Agree |
40 (161) |
47 (275) |
53 (151) |
|
Neither agree nor disagree
|
9 (36) |
4 (24) |
9 (26) |
|
Disagree
|
3 (12) |
2 (13) |
3 (7) |
7
|
Strongly disagree |
--- (1) |
1 (6) |
--- (1)
|
|
18. + The local shops, services and facilities are good overall |
|
|
|
|
Strongly agree |
32 (127) |
22 (132) |
23 (64) ****
|
|
Agree |
54 (216) |
50 (293) |
59 (168) |
|
Neither agree nor disagree |
13 (53) |
11 (60) |
9 (26) |
|
Disagree |
1 (4) |
14 (83) |
7 (20)
|
|
Strongly disagree |
--- --- |
3 (18) |
2 (5) |
|
19. + I get pleasure from my home |
|
|
|
|
Strongly agree |
5 (18) |
45 (263) |
44 (124) **** |
|
Agree |
33 (133)
|
51 (299)
|
50 (140) |
|
Neither agree nor disagree |
49 (197) |
3 (17) |
5 (15) |
|
Disagree |
12 (48)
|
1 (8)
|
1 (4) |
|
Strongly disagree |
1 (4) |
--- |
|
|
20. + I find my neighbourhood friendly |
|
|
|
|
Strongly agree |
4 (15) |
36 (209) |
28 (80) **** |
|
Agree |
21 (86)
|
53 (314)
|
54 (152) |
|
Neither agree nor disagree |
58 (232) |
7 (44) |
15 (41) |
|
Disagree |
16 (62) |
3 (16) |
3 (8) |
|
Strongly disagree |
1 (5) |
1 (3) |
-- (1) |
|
6. Psychological and emotional well-being: |
|
|
|
|
21. + I take life as it comes and make the best of things |
|
|
|
|
Strongly agree
|
14 (57) |
43 (256) |
35 (98) **** |
8
|
Agree |
45 (179) |
51 (302) |
58 (164) |
|
Neither agree nor disagree |
35 (141) |
4 (22) |
7 (19)
|
|
Disagree |
6 (23) |
1 (6) |
---
|
|
Strongly disagree |
--- --- |
--- (1) |
--- |
|
22. + I feel lucky compared to most people |
|
|
|
|
Strongly agree |
6 (22) |
42 (243) |
33 (92) **** |
|
Agree |
23 (90) |
49 (289) |
54 (151)
|
|
Neither agree nor disagree |
42 (169) |
7 (43) |
12 (35) |
|
Disagree |
24 (98) |
2 (11) |
1 (3) |
|
Strongly disagree |
5 (21)
|
--- (2)
|
--- |
|
23. + I tend to look on the bright side |
|
|
|
|
Strongly agree |
10 (38) |
35 (208) |
27 (76) **** |
|
Agree |
33 (133)
|
55 (321)
|
56 (158) |
|
Neither agree nor disagree |
37 (147) |
9 (50) |
14 (40) |
|
Disagree |
20 (82)
|
1 (8)
|
2 (6) |
|
Strongly disagree |
--- ---
|
---
|
--- |
|
24. + If my health limits social/leisure activities, then I will compensate and find something else I can do |
|
|
|
|
Strongly agree |
24 (96) |
19 (114) |
21 (59) **** |
|
Agree |
28 (112) |
62 (365) |
55 (154) |
|
Neither agree nor disagree |
30 (121) |
14 (83) |
22 (62) |
|
Disagree
|
17 (67) |
4 (20) |
2 (6) |
|
Strongly disagree
|
1 (4) |
1 (4) |
--- |
9
|
7. Financial circumstances: |
|
|
|
|
25. + I have enough money to pay for household bills |
|
|
|
|
Strongly agree |
17 (67) |
25 (148) |
29 (81) ****
|
|
Agree |
17 (69) |
66 (388) |
59 (168) |
|
Neither agree nor disagree |
37 (149) |
5 (28) |
9 (24) |
|
Disagree |
25 (99) |
3 (18) |
3 (10)
|
|
Strongly disagree |
4 (16) |
1 (5) |
|
|
26. + I have enough money to pay for household repairs or help needed in the house ø |
|
|
|
|
Strongly agree |
12 (48) |
19 (107) |
21 (57) **** |
|
Agree |
11 (44)
|
51 (296)
|
45 (125) |
|
Neither agree nor disagree |
40 (161) |
19 (111) |
20 (57) |
|
Disagree |
31 (124) |
9 (53) |
13 (37) |
|
Strongly disagree |
6 (23)
|
2 (10)
|
1 (4) |
|
27. + I can afford to buy what I want to |
|
|
|
|
Strongly agree |
9 (37)
|
10 (58)
|
17 (41) **** |
|
Agree |
9 (37) |
47 (275) |
41 (114) |
|
Neither agree nor disagree |
38 (153) |
19 (110) |
23 (64) |
|
Disagree |
32 (128) |
21 (122) |
17 (49) |
|
Strongly disagree |
12 (45) |
3 (20) |
2 (6) |
|
28. - I cannot afford to do things I would enjoy |
|
|
|
|
Strongly agree
|
8 (31) |
5 (30) |
3 (8) **** |
|
Agree
|
9 (36) |
20 (116) |
19 (54) |
10
|
Neither agree nor disagree |
28 (112) |
20 (117) |
28 (77) |
|
Disagree |
34 (134) |
48 (283) |
38 (106)
|
|
Strongly disagree |
22 (87) |
7 (39) |
12 (35)
|
|
3b. Leisure and social activities: |
|
|
|
|
29. + I have social or leisure activities/hobbies that I enjoy doing |
|
|
|
|
Strongly agree |
8 (30) |
28 (165) |
20 (57) ****
|
|
Agree |
36 (144) |
51 (300) |
54 (149) |
|
Neither agree nor disagree |
30 (122)
|
10 (57)
|
18 (49) |
|
Disagree |
17 (68) |
9 (51) |
7 (20) |
|
Strongly disagree |
9 (36)
|
2 (13)
|
1 (4) |
|
30. - I try to stay involved with things |
|
|
|
|
Strongly agree |
8 (32)
|
26 (154)
|
18 (51) **** |
|
Agree |
30 (120) |
57 (335) |
57 (157) |
|
Neither agree nor disagree |
40 (159)
|
9 (55)
|
21 (57) |
|
Disagree |
17 (68) |
7 (39) |
3 (9) |
|
Strongly disagree |
5 (21)
|
1 (3)
|
1 (4) |
|
31. + I do paid or unpaid work or activities that give me a role in life |
|
|
|
|
Strongly agree |
8 (30) |
13 (79) |
9 (23) **** |
|
Agree |
18 (71) |
22 (128) |
18 (47) |
|
Neither agree nor disagree |
32 (128) |
9 (52) |
16 (42) |
|
Disagree
|
30 (121) |
41 (239) |
42 (113) |
|
Strongly disagree
|
12 (50) |
15 (85) |
16 (44) |
11
|
8. Religion/culture: |
|
|
|
|
Aic.± + Religion, belief or philosophy is important to my QoL |
|
|
|
|
Strongly agree |
11 (45) |
18 (106)** |
n/a |
|
Agree |
47 (187) |
37 (216) |
|
|
Neither agree nor disagree |
23 (92) |
21 (125) |
|
|
Disagree |
16 (65) |
18 (105) |
|
|
Strongly disagree |
3 (11)
|
6 (35)
|
|
|
Aid.±+ Cultural /religious events/festivals are important to my QoL |
|
|
|
|
Strongly agree |
13 (51)
|
12 (72)ns
|
n/a |
|
Agree |
51 (205)
|
29 (169)
|
|
|
Neither agree nor disagree |
23 (93) |
23 (135) |
|
|
Disagree |
11 (42)
|
30 (174)
|
|
|
Strongly disagree |
2 (9)
|
6 (37)
|
|
|
No. of respondents [item non-response] |
400 [item non- response 0%] |
585-587 [Ø 577 for financial item # 26; other item non- response: <1%] |
269-286 [item non- response 5-10% (+1 item only=11%] |
+ Please indicate the extent to which you agree or disagree with each of the following statements
+/-OPQOL: reverse coding of positively worded items + (5-1) so higher scores represented higher QoL
ns not statistically significant at least at p<0.05 level
12
** p<0.01 **** p<0.0001
± Additional items inserted in Ethnibus and ONS Omnibus Surveys recommended by Ethnibus focus group members and refined with Ethnibus staff (QoL follow-up questionnaires had already been mailed out and did not
include these additional items)
± Ethnibus feedback from interviewers: item 6 QOL is based on physical, psychological and emotional pain due to family and domestic issues. This is a cultural interpretation of the word “pain”.
Development of the OPQOL
The OPQOL was developed and tested with ESRC and cross-research council funding. It is a 32- to 35- item QoL measure. It was conceptually grounded in lay views from the baseline QoL ONS Omnibus Surveys. It has 5-point Likert scales from Strongly Agree to Strongly Disagree, with 32 or 35 items, representing: life overall (4 items), health (4 items), social relationships and participation (7 items in QoL follow- up survey, 8 items in Omnibus surveys), independence, control over life, freedom (5 items), area: home and neighbourhood (4 items), psychological and emotional well- being (4 items), financial circumstances (4 items), religion/culture (2 items; asked in Omnibus surveys only). Items are scored (with reverse coding of positive responses, so that higher scores equal higher QoL; the scale ranges are 35 (QoL so bad could not be worse) to 175 (QoL so good could not be better) (Omnibus surveys) and, correspondingly 32 to 160 in the QoL follow-up survey.
In the development of the OPQOL, older people’s responses to open-ended questioning about the ‘good things’ that gave life quality were examined. These were categorised into main themes by two researchers, independently. These were, in order of magnitude: social relationships (mentioned by 81%), social roles and activities (60%), solo activities (48%), health (44%), psychological outlook and well-being (38%), home and neighbourhood (37%), financial circumstances (33%), and independence (27%). Smaller numbers mentioned various other things. These responses were consistent with older people’s views about what took quality away from life. The sub-scale domains in the OPQOL reflected this common core of main constituents of quality of life. The common sub-themes are listed in (Bowling 2007). The pool of actual verbatim responses was examined next by two researchers, again independently, to inform the inclusion of the items within each sub-scale. The main reasons given by people, at survey and in-depth interview, to explain the importance of these themes to their QoL were categorized, by two independent coders, as: freedom to do the things they wanted to do without restriction (whether in the home or socially); pleasure, enjoyment and satisfaction with life; mental harmony; social attachment - having access to companionship, intimacy, love, social contact and involvement, help; social roles; and feeling secure. These cut across the main themes (Bowling & Gabriel, 2007). The responses which were selected for inclusion in OPQOL represented the most commonly occurring sub-themes within each theme.
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The verbatim responses formed an initial pool of over 100 different statements, or attitudes. After reading and comparing the items, overlapping statements were deleted to leave 51 items. The revised items were first mailed to QoL Survey sample members in 2006 and 60% 179 of the respondents invited to participate returned the completed questionnaires). They were asked to complete the items, report any difficulties they had with it, and to make any other comments about it.
Psychometric tests for item redundancy, reliability and validity, led to the removal of redundant items (over-high correlations), items with high missing data, items where the Cronbach’s alpha of the scale improved with their removal, items which did not correlate with the overall scale score or a self-rated global QoL item. Exploratory factor analysis was used to explore the dimensions underlying the questionnaire. Amendments to wording were made following feedback from survey respondents and an opportunistic focus group of eight consenting people aged 65+ whose role locally was to provide feedback on research and services (seven of whom were white). This resulted in a reduced 32-item, multi-dimensional QoL questionnaire, with the methodological advantage that it separates constituents of QoL from QoL end states. The questionnaire was further assessed for interpretation, face and content validity with four focus groups of older people, three of which reflected ethnic diversity, and were organised by Ethnibus’s focus group arm before the Ethnibus and ONS Omnibus waves commenced (http://www.ethnifocus.com).
The OPQOL is copyrighted © Ann Bowling, and is made available free of use with acknowledgement by referencing the initial papers reporting its validity and reliability (these are in red below).
The report of this research: 'Good Neighbours' can be downloaded from the International Longevity Centre – UK website in summary and in full. Also available for download is the questionnaire used in the research (links below valid May 2011).
Good Neighbours Findings: http://www.ilcuk.org.uk/files/pdf_pdf_159.pdf Good Neighbours Summary: http://www.ilcuk.org.uk/files/pdf_pdf_162.pdf Questionnaire: http://www.ilcuk.org.uk/files/pdf_pdf_161.pdf
Further reading on the OPQOL questionnaire
Bowling, A. (2009). Psychometric properties of the Older People’s Quality of Life Questionnaire Validity. Current Gerontology and Geriatrics Research. www.hindawi.com/journals/cggr/2009/298950.abs.html Bowling, A. Iliffe, S., Kessel, A., Higginson, I. (2010). Fear of dying in an ethnically diverse society: cross-sectional studies of people aged 65+ in Britain. Postgraduate Medical Journal, 86: 197-202. www.pmj.bmj.com/content/86/1014/197.full Bowling, A. and Stenner, P. (2010). Psychometric properties of the Older People’s Quality of Life Questionnaire: which measure performs best with older people. Journal of Epidemiology and Community Health. www.jech.bmj.com/content/early/2010/08/18/jech.2009.087668.short?rss=1
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Bilotta, C., Bowling, A., Casè. A., Nicolini, P., Mauri, S., Castelli, M., & Vergani, C.(2010). Dimensions and correlates of quality of life according to frailty status: a cross-sectional study on community-dwelling older adults referred to an outpatient geriatric service in Italy. Health & Quality of Life Outcomes, 8, 56. www.hqlo.com/content/8/1/56
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