Purpose

Health-related quality of life (HRQoL) is considered a representative outcome in the evaluation of chronic disease management initiatives emphasizing patient-centered care. We evaluated the association between receipt of processes-of-care (PoC) for diabetes and HRQoL.

Methods

This cross-sectional study used self-reported data from non-institutionalized adults with diabetes in a Swiss canton. Outcomes were the physical/mental composites of the short form health survey 12 (SF-12) physical composite score, mental composite score (PCS, MCS) and the Audit of Diabetes-Dependent Quality of Life (ADDQoL). Main exposure variables were receipt of six PoC for diabetes in the past 12 months, and the Patient Assessment of Chronic Illness Care (PACIC) score. We performed linear regressions to examine the association between PoC, PACIC and the three composites of HRQoL.

Results

Mean age of the 519 patients was 64.5 years (SD 11.3); 60% were male, 87% reported type 2 or undetermined diabetes and 48% had diabetes for over 10 years. Mean HRQoL scores were SF-12 PCS: 43.4 (SD 10.5), SF-12 MCS: 47.0 (SD 11.2) and ADDQoL: -1.6 (SD 1.6). In adjusted models including all six PoC simultaneously, receipt of influenza vaccine was associated with lower ADDQoL (β=-0.4, p≤0.01) and foot examination was negatively associated with SF-12 PCS (β=-1.8, p≤0.05). There was no association or trend towards a negative association when these PoC were reported as combined measures. PACIC score was associated only with the SF-12 MCS (β=1.6, p≤0.05).

Conclusions

PoC for diabetes did not show a consistent association with HRQoL in a cross-sectional analysis. This may represent an effect lag time between time of process received and health-related quality of life. Further research is needed to study this complex phenomenon.

Joint action is central to human nature, enabling collectives to achieve goals otherwise unreachable by individuals. It is enabled by humans capacity to understand and engage in joint commitments. Joint commitments are evidenced when partners in interrupted joint actions reengage one another. To date, there is no clear evidence whether nonhuman animals understand joint commitment, suggesting that only humans experience it. Here, we revisit this claim by interrupting bonobos engaged in social activities. Bonobos reliably resumed the activity, and the likelihood of resumption was higher for social compared to solitary activities. Furthermore, communicative efforts deployed to suspend and resume social activities varied depending on partners social relationships and interactive roles. Our results suggest that bonobos, like humans, engage in joint commitment and have some awareness of the social consequences of breaking it.

When humans engage in joint action, they seem to so with an underlying sense of joint commitment, a feeling of mutual obligation towards their partner and a shared goal. Whether our closest living relatives, bonobos and chimpanzees, experience and understand joint commitment in the same way is subject to debate. Crucial evidence concerns how participants respond to interruptions of joint actions, particularly if they protest or attempt to reengage their reluctant or distracted partners. During dyadic interactions, bonobos and chimpanzees exhibit evidence of reengagement following interruptions of naturalistic joint activities with conspecifics, according to recent studies. Yet, data are still inconsistent for triadic games, where two social partners engage with each other socially by focusing on a common object. We addressed this issue by engaging N = 23 apes (5 adult chimpanzees, 5 infant bonobos, 13 adult bonobos) in a tug-of-war game with a human experimenter who abruptly stopped playing. Following interruptions, adult apes readily produced communicative signals towards the experimenter (>60% of subjects on first trial), which we interpreted as reengagement attempts of their passive social partner, with no group differences in this respect. Infant bonobos, by contrast, communicated rarely with the experimenters compared to adult bonobos, and never during their first trial. Crucially, when infant bonobos signaled to passive partners, they predominantly used tactile signals, but rarely exhibited behaviors related to the game, which were instead commonly seen in adults. It is thus possible that bonobos and chimpanzees share some of the basic motivational foundations for joint commitment, yet that this capacity is subject to developmental effects.

Human joint action seems special, as it is grounded in joint commitment-a sense of mutual obligation participants feel towards each other. Comparative research with humans and non-human great apes has typically investigated joint commitment by experimentally interrupting joint actions to study subjects' resumption strategies. However, such experimental interruptions are human-induced, and thus the question remains of how great apes naturally handle interruptions. Here, we focus on naturally occurring interruptions of joint actions, grooming and play, in bonobos and chimpanzees. Similar to humans, both species frequently resumed interrupted joint actions (and the previous behaviours, like grooming the same body part region or playing the same play type) with their previous partners and at the previous location. Yet, the probability of resumption attempts was unaffected by social bonds or rank. Our data suggest that great apes experience something akin to joint commitment, for which we discuss possible evolutionary origins.

Many social animals interact jointly, but only humans experience a specific sense of obligation toward their co-participants, a joint commitment. However, joint commitment is not only a mental state but also a process that reveals itself in the coordination efforts deployed during entry and exit phases of joint action. Here, we investigated the presence and duration of such phases in N = 1,242 natural play and grooming interactions of captive chimpanzees and bonobos. The apes frequently exchanged mutual gaze and communicative signals prior to and after engaging in joint activities with conspecifics, demonstrating entry and exit phases comparable to those of human joint activities. Although rank effects were less clear, phases in bonobos were more moderated by friendship compared to phases in chimpanzees, suggesting bonobos were more likely to reflect patterns analogous to human "face management". This suggests that joint commitment as process was already present in our last common ancestor with Pan.