Assessment of Health-Related Quality of Life and Influencing Factors among Patients with Advanced Schistosomiasis Japonica in the Southwest of China Using the EQ-5D-5L Scale

Assessment of Health-Related Quality of Life and Influencing Factors among Patients with Advanced Schistosomiasis Japonica in the Southwest of China Using the EQ-5D-5L Scale | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Health-Related Quality of Life and Influencing Factors among Patients with Advanced Schistosomiasis Japonica in the Southwest of China Using the EQ-5D-5L Scale Yu Zhang, Xiao-qin Gu, Jia-jia Wan, Jing-ye Shang, Nan-nan Wang, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8198015/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To assess health-related quality of life (HRQoL) and identify influencing factors impacting HRQoL among patients with Advanced Schistosomiasis (AS) in Sichuan Province, China, utilizing the EQ-5D-5L scale. Methods A cross-sectional study was conducted among 1,276 AS patients in Sichuan Province. Data on demographic characteristics, clinical history, and EQ-5D-5L responses were collected via structured face-to-face interviews and medical record review. Statistical analyses included reliability and validity assessments (Cronbach's α, exploratory/confirmatory factor analyses), univariate analysis, multivariate linear regression, and interaction analysis using Stata 16.0 and R 4.5.1 . Results The mean utility index (UI) score was 0.85 ± 0.20, with 35.6% of subjects reporting no impairment across all dimensions. The EQ-5D-5L demonstrated acceptable internal consistency ( Cronbach’s α = 0.795) and construct validity (CFA: χ²/df = 2.191, RMSEA = 0.031). The domains most affected were anxiety/depression (62.5% reporting any impairment) and pain/discomfort (54.7% reporting any impairment). Multivariate regression analysis identified advanced age ( β = -0.017, P < 0.001), a history of ascites( β = -0.041, P < 0.001), Upper Gastrointestinal Bleeding (UGIB) ( β = -0.025, P = 0.018), hepatitis ( β = -0.033, P = 0.04), and advanced liver fibrosis ( β = -0.024, P < 0.001) as significant independent predictors for poorer HRQoL. Interaction analysis revealed synergistic effects among risk factors, demonstrating that the detrimental impact of ascites was concentrated in the elderly, co-occurrence of bleeding and ascites compounded HRQoL reduction, and the effect of hepatitis was contingent upon the severity of liver fibrosis. Conclusion The EQ-5D-5L is a valid and reliable instrument for assessing HRQoL in patients with AS. Targeted interventions should address age-related functional decline, comorbidities(particularly ascites and severe fibrosis), and low educational attainment to enhance patient outcomes. Emphasis should be placed on multidisciplinary care strategies for older patients with advanced fibrosis or ascites in endemic regions. Schistosomiasis japonica Advanced schistosomiasis Quality of life EQ-5D-5L China Sichuan Province Health-related quality of life Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Schistosomiasis, a parasitic disease caused by Schistosoma species, imposes a significant global health burden. In endemic areas, it is a major cause of chronic morbidity, substantial socioeconomic loss, and mortality[ 1 , 2 ]. *Schistosoma japonicum* ( S. japonicum ) is the most prevalent species in China[ 3 , 4 ]. The primary pathology stems from granulomatous inflammation and subsequent fibrosis triggered by parasite egg deposition in host tissues, particularly the liver and intestinal walls[ 5 , 6 ]. While timely praziquantel t treatment effectively resolves infections in most cases, a subset of patients progresses to advanced schistosomiasis (AS). AS is characterized by severe liver pipestem fibrosis, intestinal strictures, and problems including portal hypertension, cirrhosis, and upper gastrointestinal bleeding (UGIB)[ 7 , 8 ]. Despite extensive research, the immunopathological mechanisms underlying AS development remain incompletely understood[ 8 ], underscoring the urgent need for better clinical management and interventions to improve the quality of life (QoL) of affected patients [ 9 , 10 ]. Sichuan Province, a hyperendemic region for S. japonicum ,faces particular challenges due to its hilly terrain and interconnected river systems that facilitate the reproduction and spread of Oncomelania hupensis snails, the parasite's intermediate host[ 11 , 12 ]. Historically, the Min River Basin reported prevalence rates of 40% among the local population during the mid-20th century, with over 1 million cases annually, leading to the prioritization of Sichuan for national control efforts[ 13 , 14 ]. Currently, Sichuan accounts for 32% of China's recorded AS cases(approximately 1,200 patients), with an annual death toll of 80 due to late-stage complications[ 15 , 16 ], despite integrated control policies successfully reducing human prevalence to less than 1% in sentinel sites since the 2000s[ 17 , 18 ]. In these areas, shortages of qualified medical professionals and an under-resourced healthcare system impede early diagnosis and follow-up treatment for AS patients[ 19 , 20 ]. Furthermore, individuals with AS endure physical limitations, psychological distress (including anxiety and depression), and catastrophic medical expenses, perpetuating cycles of poverty[ 8 , 21 ]. Early QoL studies in Sichuan, primarily conducted in the 1990s, focused on clinical outcomes and neglected psychosocial aspects. This gap underscores the need for contemporary, comprehensive evaluations using validated measurement tools. The EQ-5D-5L is a standardized instrument designed to assess health-related quality of life (HRQoL) across five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression[ 22 , 23 ]. Compared to its predecessor, the EQ-5D-3L, the EQ-5D-5L demonstrates increased sensitivity, reduced ceiling effects, and enhanced discriminant validity, making it especially useful for identifying subtle changes in chronic conditions like AS[ 24 , 25 ]. While the EQ-5D-5L is widely used globally, no studies have employed it in Sichuan since 2000 to assess advanced schistosomiasis, limiting the development of evidence-based rehabilitation programs. Furthermore, the unclear contributions of clinical severity, socioeconomic status, and psychological factors to HRQoL in this patient population impede the development of targeted interventions [ 26 , 27 ]. In this study, we assessed HRQoL in a group of patients with advanced schistosomiasis in Sichuan, China in order to evaluate overall quality of life for this population, and identify demographic and medical factors that contribute to HRQoL. Additionally, we evaluated the use of the EQ-5D-5L in this population. Together, we aimed to generate information that can be in the future used to monitor HRQoL and design evidence-informed interventions for people with Advanced Schistosomiasis. Methods Study Area and Population This study was conducted in Sichuan Province, a S. japonicum -endemic region in southwestern China. Participants were identified according to the Diagnostic Criteria for Schistosomiasis (WS261-2006) issued by the Chinese Ministry of Health. Patients were classified as having advanced schistosomiasis if they met the following criteria: 1. Documented history of residence in regions endemic to S. japonicum , as well as to the pathogen, is required. 2. Clinical manifestations including ascites, splenomegaly, portal hypertension, gastroesophageal variceal bleeding, colorectal granulomatous lesions, and severe growth retardation. 3. Seropositivity for anti- S. japonicum antibodies. 4. Pathological confirmation via stool examination or rectal biopsy. Inclusion Criteria: 1. Permanent residence in Sichuan Province. 2. Willingness to participate in the study. 3. Availability of comprehensive clinical and demographic documentation. Exclusion Criteria: 1. Refusal to participate. 2. Incomplete demographic or clinical data. 3. Loss to follow-up Method of Investigation Data were collected via structured face-to-face interviews and medical record reviews. Indicators Demographic characteristics, medical histories, and imaging data were collected using questionnaires and medical chart reviews. Variables included gender, age, education level, occupation, schistosomiasis subtype (splenectomy-associated, ascites, colon thickening, or dwarfism), and village endemicity classification (flatlands, hills, mountains). Medical histories encompassed prior splenectomy, ascites, UGIB, and hepatitis. Liver fibrosis severity was assessed via ultrasound by a trained ultrasonographer using the staging system outlined in the *Manual of Schistosomiasis Control*: Level I (scattered compact echo zones without clear boundaries), Level II (echo zones >20 mm), and Level III (dense network of echo bands) [28]. (Variable descriptions and categories are provided in Supplementary Table 1). EQ-5D-5L Scale The EQ-5D-5L descriptive system consists of five dimensions: Mobility (MO), Self-care (SC), Usual Activity (UA), Pain/Discomfort (PD), and Anxiety/Depression (AD). Each dimension encompasses five levels of severity: no difficulty (Level 1), slight problems (Level 2), moderate difficulty (Level 3), severe difficulty (Level 4), and extreme problems/unable to perform (Level 5). Participants rated their health status on the survey day based on subjective perceptions. Health utility values were derived using a preference-weighted scoring system tailored to the Chinese population (Supplementary Table 2). The utility index (UI) score was calculated using a specified formula: UI = 1 − ∑ ( MOn + SCn + UAn + PDn + ADn ) where n denotes the severity level (1–5) for each dimension. For example, if all dimensions of a participant were rated at Level 2, the UI would be: UI =1−(0.066 + 0.048 + 0.045 + 0.058 + 0.049) = 1 - 0.266 = 0.734 The UI score ranges from −0.391 to 1, with higher values indicating better health-related quality of life[29,30]. Statistical Analysis Statistical analyses were conducted utilizing Stata 16.0 (StataCorp, TX, USA). The internal consistency of the EQ-5D-5L was evaluated using Cronbach’s α (α > 0.7 indicating acceptable reliability) [31,32]. Pearson correlation coefficients were employed to assess item-total correlations(acceptable range: 0.3-0.8) [33]. Exploratory factor analysis ( EFA ) using principal factor extraction and varimax rotation was performed to evaluate construct validity. The Kaiser-Meyer-Olkin ( KMO ) test (≥0.6) and Bartlett’s test of sphericity ( P < 0.05) confirmed data suitability for factor analysis [34]. Confirmatory factor analysis (CFA) based on maximum likelihood estimation assessed model fit using multiple fit indices, including the Goodness-of-Fit Index (GFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA). Continuous variables are expressed as mean ± standard deviation, categorical variables are reported as frequencies. Group comparisons used independent t-tests (two groups), one-way ANOVA (multiple groups), or chi-square tests (categorical data). Multivariate linear regression with stepwise selection identified predictors of HRQoL. Statistical significance was set at P <0.05 (two-tailed). Results A total of 1,346 advanced schistosomiasis cases were identified in Sichuan Province, 1,276 valid questionnaires were completed (response rate: 94.8 %). Among participants, 733 (57.4 %) were male and 543 (42.6 %) were female. The majority (31.3 %) was aged 70-79 years, followed by 50 -59 years (24.9 %) and 60- 69 years (24.7 %). Farmers comprised 95.8 % of the samples; 46.3% had only primary school education. Geographically, cases were distributed among three endemic subtypes: flatlands (40.1%, n = 512), hills (29.5 %, n = 376), and mountains (30.4%, n = 388). Splenectomy-associated advanced schistosomiasis was predominant (65.6 %, n = 837), while dwarf-type cases were rare (2.0%, n = 26) (Table 1). Table 1. Demographic characteristics of patients withAS (n = 1,276) Variables Number Percentage(%) gender Male 733 57.4 Female 543 42.6 Age 0-29 10 0.8 30-39 16 1.3 40-49 91 7.1 50-59 318 24.9 60-69 315 24.7 70-79 400 31.3 80- 126 9.9 Occupation Farmer 1223 95.8 Other 53 4.2 Education Level Illiteracy 319 25 Primary school 591 46.3 Junior high school 317 24.8 Senior high school 41 3.2 Junior college or above 8 0.6 Endemic type of the village Flatlands subtype 512 40.1 Hills subtype 376 29.5 Mountains subtype 388 30.4 Advanced Schistosomiasis Type Splenectomy type 837 65.6 Ascites type 367 28.8 Colon thickening type 46 3.6 Dwarf type 26 2 The Cronbach's α coefficient was 0.795 indicating acceptable internal consistency. Significant correlations were found among all dimensions ( P < 0.05), with dimension-to-dimension correlations ranging from 0.197 to 0.642 and dimension-to-total score correlations between 0.591 and 0.850. Exploratory factor analysis ( KMO = 0.761, P < 0.001) extracted two common factors explaining 77.3% of the variance. Factor 1 encompassed mobility, self-care, and usual activities (Active QOL). Factor 2 included pain/discomfort and anxiety/depression (Perceived QOL). (Figure 1). Figure 1 . Scree plot and total Variance Explained Confirmatory factor analysis demonstrated good model fit ( χ²/df = 2.191, GFI = 0.998, TLI = 0.998, RMSEA = 0.031), with standardized factor loadings ranging from 0.62 to 0.92 (Figure 2). Figure 2. Confirmatory factor analysis of the EQ-5D-5L scale. The figure displays the standardized structural equation model for the EQ-5D-5L, demonstrating the relationships between the latent constructs (Active QOL and Perceived QOL) and their observed variables. Standardized factor loadings are shown on the paths. MO, Mobility; SC, Self-care; UA, Usual Activity; PD, Pain/Discomfort; AD, Anxiety and Depression. The mean QoL utility index (UI) score was 0.85 ± 0.20, with 35.6% (n = 454) reporting no difficulties across dimensions (UI = 1). Among the five EQ-5D-5L dimensions, mobility (78.1%), self-care (88.6%), and usual activities (68.7%) showed the highest proportions of Level 1 responses (no problems), In contrast, pain/discomfort (45.3% reporting moderate-to-extreme problems) and anxiety/depression (62.5% reporting any problems) exhibited more pronounced impairment (Table 2). Table 2. Distribution of EQ-5D-5L response levels [number of cases (percentage)] Level 1(No problems) | Level 2 (Slight problems) Level 3(Moderate problems) Level 4 (Severe problems) Level 5 (Extreme problems) Mobility (MO) 996 (78.1%) 216 (16.9%) 50 (3.9%) 7 (0.5%) 7 (0.5%) Self-care (SC) 1130 (88.6%) 109 (8.5%) 22 (1.7%) 8 (0.6%) 7 (0.5%) Usual activity (UA) 877 (68.7%) 285 (22.3%) 72 (5.6%) 21 (1.6%) 21 (1.6%) Pain/discomfort (PD) 578 (45.3%) 563 (44.1%) 106 (8.3%) 20 (1.6%) 9 (0.7%) Anxiety/Depression (AD) 797 (62.5%) 388 (30.4%) 69 (5.4%) 19 (1.5%) 3 (0.2%) [Note: Level 1: No difficulty; Level 5: Extreme difficulty] Endemic subtype, age, occupation, advanced schistosomiasis type, education level, and clinical histories—including splenectomy, ascites, UGIB, hepatitis, and liver fibrosis—were found to significantly influence UI scores ( P < 0.05). Gender did not show a significant association ( P = 0.703) (Table 3). Table 3 Analysis of Factors Influencing Quality of Life Outcomes Categories UI mean 95% CI T/F price P Village Endemic Type 15.392 <0.001 Flatlands subtype 0.9 0.89-0.91 Hills subtype 0.84 0.82-0.86 Mountains subtype 0.89 0.87-0.91 Age(years) 6.645 <0.001 0-29 0.99 0.97-1.01 30-39 0.93 0.84-1.01 40-49 0.91 0.89-0.93 50-59 0.9 0.88-0.91 60-69 0.89 0.87-0.91 70-79 0.86 0.85-0.88 80- 0.81 0.77-0.85 Occupation 2.183 0.029 farmer 0.88 0.87-0.89 other 0.93 0.89-0.96 advanced S chistosomiasis Type 10.556 <0.001 Splenectomy type 0.89 0.88-0.91 Ascites type 0.84 0.82-0.86 Colon thickening type 0.89 0.85-0.93 Dwarf type 0.92 0.86-0.99 Education Level 6.724 <0.001 Illiteracy 0.85 0.82-0.87 Primary school 0.88 0.87-0.89 Junior high school 0.91 0.89-0.92 Senior high school 0.92 0.88-0.96 Junior college or above 0.97 0.92-1.02 Gender 0.382 0.703 Male 0.88 0.87-0.89 Female 0.88 0.86-0.89 History of Splenectomy 3.459 0.001 No 0.86 0.85-0.88 Yes 0.9 0.88-0.91 History of Ascites 6.069 <0.001 No 0.9 0.89-0.92 Yes 0.85 0.83-0.86 History of UGIB 2.736 0.006 No 0.89 0.88-0.9 Yes 0.86 0.84-0.87 History of Hepatitis 1.995 0.046 No 0.88 0.87-0.89 Yes 0.85 0.82-0.88 Liver Fibrosis level 10.434 <0.001 Level Ⅰ 0.9 0.89-0.91 Level Ⅱ 0.88 0.87-0.9 Level Ⅲ 0.85 0.83-0.87 Multiple linear regression dentified significant predictors of the UI score (P < 0.05). Higher education level correlated with increased UI ( β = 0.022, t = 3.708, P < 0.001). Increasing age correlated with a reduced UI ( β = -0.017, t = -4.275, P < 0.001). Negative associations with UI were found for history of ascites ( β = -0.041, t = -4.358, P < 0.001), UGIB(β = -0.025, t = -2.361, P = 0.018), hepatitis ( β = -0.033, t = -2.052, P = 0.040), and higher liver fibrosis level ( β = -0.024, t = -4.421, P < 0.001). History of splenectomy was a protective factor ( β = 0.031, t = 3.429, P = 0.001) (Figure 3). Figure 3. Predictors of health-related quality of life in patients with AS . The plot shows the adjusted β coefficients and 95% confidence intervals from the multivariate linear regression model for factors associated with the EQ-5D-5L utility index. Analysis of interactions produced several statistically significant findings ( P < 0.05 unless stated otherwise). The variation in UI scores indicated a significant correlation between age and the history of ascites. In patients under 60 years old, a history of ascites did not significantly affect UI scores ( P > 0.05). Conversely, in the 60 to 79 age group, it had detrimental effects. All patients aged 80 years and older exhibited lower UI scores, regardless of their history of ascites. The UI scores were influenced synergistically by the concurrent presence of a history of UGIB and ascites. A singular history of UGIB showed no statistically significant association with UI scores ( P > 0.05); however, when combined with a history of ascites, it resulted in significant adverse outcomes. The combination of ascites history yielded significant negative results, whereas a standalone history of UGIB did not demonstrate a statistically significant association with UI scores ( P > 0.05). Additionally, a history of hepatitis influenced UI scores through its interaction with the extent of hepatic fibrosis. Patients with Level I/II hepatic fibrosis exhibited stable UI scores irrespective of their hepatitis status ( P > 0.05). Conversely, individuals with Level III fibrosis experienced significant reductions in UI scores, irrespective of their hepatitis history. The age-modified effects of hepatic fibrosis severity exhibited two distinct patterns: Level III fibrosis significantly reduced UI scores exclusively in septuagenarians (70-79 years), while both Level II and III fibrosis adversely affected octogenarians (≥80 years). Figure 4. Interaction effects among risk factors on health-related quality of life. The matrix illustrates the statistically significant interactions ( P < 0.05) between key clinical and demographic variables (age, ascites, UGIB, hepatitis, liver fibrosis) and their combined effect on the utility index score. Discussion The mean UI score of 0.85 ± 0.20 observed in this cohort indicates significantly lower health-related quality of life (HRQoL) compared to the general Sichuan population (UI = 0.949 ± 0.008) [ 35 ]. Among the EQ-5D-5L dimensions, "pain/discomfort" (PD) and "anxiety/depression" (AD) showed the highest prevalence of moderate-to-severe problems (10.6% and 7.1% for levels 3–5, respectively). This finding underscores the substantial impact of physical discomfort and psychological distress on patients' daily lives. These findings are consistent with previous studies that emphasize the debilitating effects of advanced schistosomiasis on mobility and psychosocial well-being[ 36 – 38 ]. A chronic inflammatory drive in liver fibrosis, featuring Hepatic stellate cells (HSC) activation, collagen deposition, and the release of pro-inflammatory cytokines [including Tumor necrosis factor-alpha (TNF-α), Interferon-gamma (IFN-γ), Interleukin-6 (IL-6), and Interleukin-8 (IL-8)] and activation of signaling pathways such as Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), is a key mechanism of pain through nociceptor sensitization, further regulated by cytokines such as IFN-γ and IL-10 Interleukin-10 (IL-10)[ 39 – 41 ]. Depression in AS stems from the burden of chronic physical morbidity and disease-related discrimination, compounded by psychological stress, emotional dysregulation, lack of social support, all of which contribute to poor quality of life[ 42 , 43 ]. Our study validated the EQ-5D-5L as a reliable instrument for assessing HRQoL in this population. This is supported by acceptable reliability (Cronbach's α = 0.795) and structural validity demonstrated by confirmatory factor analysis ( χ²/df = 2.191, GFI = 0.998, TLI = 0.998, RMSEA = 0.031). Renowned for its cross-cultural adaptability, the scale exhibited acceptable internal consistency ( α > 0.7), though marginally below the "high reliability" threshold (α ≥ 0.8). This modest limitation may reflect the unique socioeconomic and clinical profile of the study cohort, predominantly comprising elderly individuals with limited education (46.3% had only primary schooling). Higher correlations between dimensions and the total score ( r = 0.591–0.850) compared to inter-dimension correlations (r = 0.197–0.642) affirmed its discriminative validity. Exploratory factor analysis categorized dimensions into "Active QOL" (mobility, self-care, UA) and "Perceived QOL" (PD, AD), aligning with the distinction between physical and mental health. The protective effect of higher education on HRQoL ( β = 0.022, P < 0.001) is consistent with global evidence linking education to enhanced health literacy and healthcare access[ 44 ]. Conversely, advanced age and comorbidities (ascites, hepatitis) were significant negative predictors, corroborating findings in other populations with chronic conditions[ 45 – 47 ]. The protective effect of splenectomy ( β > 0, P < 0.05) validates its role in mitigating portal hypertension[ 48 – 50 ], though long-term benefits require further study. Interaction analyses revealed complex relationships. Ascites significantly diminished HRQoL only in patients aged 60–79 years, likely due to cumulative organ damage in older adults[ 51 , 52 ]. Additionally, the co-occurrence of UGIB and ascites was associated with a significant decline in HRQoL, highlighting the necessity of integrated management strategies addressing complications of portal hypertension[ 53 , 54 ]. Furthermore, the interaction between hepatitis and fibrosis revealed that severe (Level III) fibrosis negated the positive impact of a history of hepatitis, suggesting that the severity of fibrosis is a primary driver of impairment in end-stage disease[ 55 , 56 ]. The complex interactions observed among risk factors highlight the limitations of a uniform management strategy. Our results support the adoption of a risk stratification framework to guide personalized care. Within this framework, three high-risk subgroups warrant particular attention: elderly patients with ascites, who may benefit from more vigilant monitoring; individuals with compounded complications (concurrent ascites and bleeding), who should receive aggressive management of portal hypertension; and patients with severe fibrosis, for whom integrated liver-protective and psychosocial support is indicated. Limitations and Future Directions Despite its substantial sample size (n = 1,276), this study has limited generalizability due to its focus on mountainous regions of Sichuan, where healthcare access inequities may exacerbate HRQoL deficits. Future research should replicate these findings in diverse settings (e.g., plains, coastal areas) and employ longitudinal designs to assess causality. Reliance on self-reported data may introduce recall bias; incorporating clinical biomarkers (e.g., liver elastography) could enhance robustness. Conclusions Our findings highlight a critical need for stratified management and call for targeted interventions tailored to high-risk subgroups of advanced schistosomiasis (AS) patients in Sichuan, notably the elderly with low educational attainment, ascites, or severe fibrosis. To address the significant HRQoL disparities identified, we recommend adopting a precision public health approach that includes region-specific risk stratification and the expansion of multidisciplinary care. A key recommendation is the systematic embedding of mental health screening and counselling into routine care for all AS patients, with prioritization given to those bearing the dual burden of ascites or advanced fibrosis. Abbreviations HRQoL Health-related quality of life AS Advanced schistosomiasis EQ-5D-5L EuroQol Five-Dimension Five-Level QoL Quality of life S. japonicum Schistosoma japonicum UI Utility index CFA Confirmatory factor analysis EFA Exploratory factor analysis KMO Kaiser-Meyer-Olkin RMSEA Root Mean Square Error of Approximation MO Mobility SC Self-care UA Usual Activity PD Pain/Discomfort AD Anxiety/Depression GFI Goodness-of-fit index TLI Tucker-Lewis Index UGI Upper gastrointestinal HSC Hepatic stellate cells TNF-α Tumor necrosis factor-alpha IFN-γ Interferon-gamma IL-6 Interleukin-6 IL-8 Interleukin-8 IL-10 Interleukin-10 NF-κB Nuclear factor kappa-light-chain-enhancer of activated B cells IRB Institutional Review Board SCCDCIRB Sichuan Center for Disease Control and Prevention Institutional Review Board Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of the Sichuan Center for Disease Control and Prevention (Approval No.: SCCDCIRB No.2023-015). The study was conducted in full compliance with both international and national ethical guidelines, including the Declaration of Helsinki and China's "Ethical Review Measures for Life Sciences and Medical Research Involving Humans". Written informed consent was obtained from all participants. Consent for publication Informed consent was obtained from all participants involved in the study. Competing interests We declare no competing interests. Funding The study was supported by Science and Technology Project of the Health Commission of Sichuan Province(24CXTD04): Schistosomiasis at the edge of elimination characterizing sources of new infections in residual transmission hotspots(1R01AI134673-01A1): Sichuan Science and Technology Program(2024YFFK0194) Author Contribution Yu Zhang, Yang Liu and Shi-zhu Li designed the study. Yu Zhang and Xiao-qin Gu took the lead in drafting the manuscript and interpreting the results. Jin-ye Shang ,Nan-nan Wang ,Lin Chen,Bo Zhong and Elizabeth Cartlon contributed to the interpretation of the results and the submitted version of the manuscript. All authors had final responsibility for the decision to submit for publication. Acknowledgement The authors sincerely thank all patients with advanced schistosomiasis who participated in this study. We are also grateful to the staff from the schistosomiasis control agencies for their essential contributions to the field investigation and data management. Data Availability The data supporting the findings of this study contain sensitive personal health information. To protect participant privacy and in compliance with ethical requirements, they are not publicly available. De-identified data may be made available by the corresponding author upon reasonable scientific request and subject to review and approval by the relevant ethics committee. References Buonfrate D, Ferrari TCA, Adegnika AA, Russell Stothard J, Gobbi FG. 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World J Surg. 2010;34(11):2682–8. Wei-Cheng D, Ding-Hua BAI, Zhi-Jian LI. Management strategy and technology of medical assistance to advanced schistosomiasis patients in Hunan Province. Chin J Schistosomiasis Control. 2016;28(5):594. Mitchell GF. Effects of central arterial aging on the structure and function of the peripheral vasculature: implications for end-organ damage. J Appl physiol. 2008;105(5):1652–60. Poulose N, Raju R. Aging and Injury: Alterations in Cellular Energetics and Organ Function. Aging Dis. 2014;5(2):101–8. O’Neill S, Oniscu GC. Portal hypertension and ascites. Surg (Oxford). 2020;38(8):487–91. Huang J, Zhang HR, Cai CX. Analysis of causes of death among advanced schistosomiasis patients in Jiaxing City from 2010 to 2020. Chin J Schistosomiasis Control. 2022;34(3):307–10. Papastergiou V, Tsochatzis E, Burroughs AK. Non-invasive assessment of liver fibrosis. Ann Gastroenterol. 2012;25(3):218–31. Castera L, Pinzani M. Non-invasive assessment of liver fibrosis: are we ready? Lancet. 2010;375(9724):1419–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8198015","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557473684,"identity":"ec77ac46-387f-4f92-80b3-6d7ca1c8d721","order_by":0,"name":"Yu Zhang","email":"","orcid":"","institution":"Sichuan Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhang","suffix":""},{"id":557473685,"identity":"7a5f6f2b-bd8f-4640-9fa4-171277d4f8d5","order_by":1,"name":"Xiao-qin Gu","email":"","orcid":"","institution":"Zhongjiang County Schistosomiasis Control 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1","display":"","copyAsset":false,"role":"figure","size":325446,"visible":true,"origin":"","legend":"\u003cp\u003eScree plot and total Variance Explained\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8198015/v1/90bca87d71b06949ae249e18.jpeg"},{"id":98074198,"identity":"cd740e70-dbe1-45e6-ac09-18f9a7132004","added_by":"auto","created_at":"2025-12-12 13:26:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":25276,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis of the EQ-5D-5L scale.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8198015/v1/a18b2f377e7a1deba0346ae3.png"},{"id":98429754,"identity":"1f17caa9-5bfe-4703-8b43-ce3c3105637d","added_by":"auto","created_at":"2025-12-17 16:44:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":92599,"visible":true,"origin":"","legend":"\u003cp\u003ePredictors of health-related quality of life in patients with AS.\u003c/p\u003e\n\u003cp\u003eThe plot shows the adjusted β coefficients and 95% confidence intervals from the multivariate linear regression model for factors associated with the EQ-5D-5L utility index.\u003c/p\u003e","description":"","filename":"Figure3..png","url":"https://assets-eu.researchsquare.com/files/rs-8198015/v1/5c3374d24a27b65712ff71ad.png"},{"id":98074202,"identity":"fc6e51b8-1b7c-4311-845c-967e01339b66","added_by":"auto","created_at":"2025-12-12 13:26:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":249335,"visible":true,"origin":"","legend":"\u003cp\u003eInteraction effects among risk factors on health-related quality of life.\u003c/p\u003e\n\u003cp\u003eThe matrix illustrates the statistically significant interactions (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05) between key clinical and demographic variables (age, ascites, UGIB, hepatitis, liver fibrosis) and their combined effect on the utility index score.\u003c/p\u003e","description":"","filename":"Figure4..png","url":"https://assets-eu.researchsquare.com/files/rs-8198015/v1/712ba4a77c7770a83ed42112.png"},{"id":98909641,"identity":"cde069c7-d581-4350-84d8-54ed0c0fd03d","added_by":"auto","created_at":"2025-12-24 01:23:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1838803,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8198015/v1/697e2275-b474-404b-9424-9e61e75696c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Health-Related Quality of Life and Influencing Factors among Patients with Advanced Schistosomiasis Japonica in the Southwest of China Using the EQ-5D-5L Scale","fulltext":[{"header":"Background","content":"\u003cp\u003eSchistosomiasis, a parasitic disease caused by Schistosoma species, imposes a significant global health burden. In endemic areas, it is a major cause of chronic morbidity, substantial socioeconomic loss, and mortality[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. *Schistosoma japonicum* (\u003cem\u003eS. japonicum\u003c/em\u003e) is the most prevalent species in China[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The primary pathology stems from granulomatous inflammation and subsequent fibrosis triggered by parasite egg deposition in host tissues, particularly the liver and intestinal walls[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While timely praziquantel t treatment effectively resolves infections in most cases, a subset of patients progresses to advanced schistosomiasis (AS). AS is characterized by severe liver pipestem fibrosis, intestinal strictures, and problems including portal hypertension, cirrhosis, and upper gastrointestinal bleeding (UGIB)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite extensive research, the immunopathological mechanisms underlying AS development remain incompletely understood[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], underscoring the urgent need for better clinical management and interventions to improve the quality of life (QoL) of affected patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSichuan Province, a hyperendemic region for \u003cem\u003eS. japonicum\u003c/em\u003e,faces particular challenges due to its hilly terrain and interconnected river systems that facilitate the reproduction and spread of Oncomelania hupensis snails, the parasite's intermediate host[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Historically, the Min River Basin reported prevalence rates of 40% among the local population during the mid-20th century, with over 1\u0026nbsp;million cases annually, leading to the prioritization of Sichuan for national control efforts[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Currently, Sichuan accounts for 32% of China's recorded AS cases(approximately 1,200 patients), with an annual death toll of 80 due to late-stage complications[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], despite integrated control policies successfully reducing human prevalence to less than 1% in sentinel sites since the 2000s[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In these areas, shortages of qualified medical professionals and an under-resourced healthcare system impede early diagnosis and follow-up treatment for AS patients[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, individuals with AS endure physical limitations, psychological distress (including anxiety and depression), and catastrophic medical expenses, perpetuating cycles of poverty[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Early QoL studies in Sichuan, primarily conducted in the 1990s, focused on clinical outcomes and neglected psychosocial aspects. This gap underscores the need for contemporary, comprehensive evaluations using validated measurement tools.\u003c/p\u003e\u003cp\u003eThe EQ-5D-5L is a standardized instrument designed to assess health-related quality of life (HRQoL) across five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Compared to its predecessor, the EQ-5D-3L, the EQ-5D-5L demonstrates increased sensitivity, reduced ceiling effects, and enhanced discriminant validity, making it especially useful for identifying subtle changes in chronic conditions like AS[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While the EQ-5D-5L is widely used globally, no studies have employed it in Sichuan since 2000 to assess advanced schistosomiasis, limiting the development of evidence-based rehabilitation programs. Furthermore, the unclear contributions of clinical severity, socioeconomic status, and psychological factors to HRQoL in this patient population impede the development of targeted interventions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, we assessed HRQoL in a group of patients with advanced schistosomiasis in Sichuan, China in order to evaluate overall quality of life for this population, and identify demographic and medical factors that contribute to HRQoL. Additionally, we evaluated the use of the EQ-5D-5L in this population. Together, we aimed to generate information that can be in the future used to monitor HRQoL and design evidence-informed interventions for people with Advanced Schistosomiasis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Area and Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in Sichuan Province, a \u003cem\u003eS. japonicum\u003c/em\u003e-endemic region in southwestern China. Participants were identified according to the \u003cem\u003eDiagnostic Criteria\u003c/em\u003e for Schistosomiasis \u003cem\u003e(WS261-2006)\u003c/em\u003e issued by the Chinese Ministry of Health. Patients were classified as having advanced schistosomiasis if they met the following criteria:\u003c/p\u003e\n\u003cp\u003e1. Documented history of residence in regions endemic to \u003cem\u003eS. japonicum\u003c/em\u003e, as well as to the pathogen, is required.\u003c/p\u003e\n\u003cp\u003e2. Clinical manifestations including ascites, splenomegaly, portal hypertension, gastroesophageal variceal bleeding, colorectal granulomatous lesions, and severe growth retardation.\u003c/p\u003e\n\u003cp\u003e3. Seropositivity for anti-\u003cem\u003eS. japonicum\u003c/em\u003e antibodies.\u003c/p\u003e\n\u003cp\u003e4. Pathological confirmation via stool examination or rectal biopsy.\u003c/p\u003e\n\u003cp\u003eInclusion Criteria:\u003c/p\u003e\n\u003cp\u003e1. Permanent residence in Sichuan Province.\u003c/p\u003e\n\u003cp\u003e2. Willingness to participate in the study.\u003c/p\u003e\n\u003cp\u003e3. Availability of comprehensive clinical and demographic documentation.\u003c/p\u003e\n\u003cp\u003eExclusion Criteria:\u003c/p\u003e\n\u003cp\u003e1. Refusal to participate.\u003c/p\u003e\n\u003cp\u003e2. Incomplete demographic or clinical data.\u003c/p\u003e\n\u003cp\u003e3. Loss to follow-up\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod of Investigation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected via structured face-to-face interviews and medical record reviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic characteristics, medical histories, and imaging data were collected using questionnaires and medical chart reviews. Variables included gender, age, education level, occupation, schistosomiasis subtype (splenectomy-associated, ascites, colon thickening, or dwarfism), and village endemicity classification (flatlands, hills, mountains). Medical histories encompassed prior splenectomy, ascites, UGIB, and hepatitis. Liver fibrosis severity was assessed via ultrasound by a trained ultrasonographer \u0026nbsp; using the staging system outlined in the *Manual of Schistosomiasis Control*: Level I (scattered compact echo zones without clear boundaries), Level II (echo zones \u0026gt;20 mm), and Level III (dense network of echo bands) [28]. (Variable descriptions and categories are provided in Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEQ-5D-5L Scale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe EQ-5D-5L descriptive system consists of five dimensions: Mobility (MO), Self-care (SC), Usual Activity (UA), Pain/Discomfort (PD), and Anxiety/Depression (AD). Each dimension encompasses five levels of severity: no difficulty (Level 1), slight problems (Level 2), moderate difficulty (Level 3), severe difficulty (Level 4), and extreme problems/unable to perform (Level 5). Participants rated their health status on the survey day based on subjective perceptions. Health utility values were derived using a preference-weighted scoring system tailored to the Chinese population (Supplementary Table 2). The utility index (UI) score was calculated using a specified formula:\u003c/p\u003e\n\u003cp\u003eUI = 1 \u0026minus; \u0026sum; ( \u003cem\u003eMOn\u0026nbsp;\u003c/em\u003e+ \u003cem\u003eSCn\u003c/em\u003e + \u003cem\u003eUAn\u003c/em\u003e + \u003cem\u003ePDn\u003c/em\u003e +\u003cem\u003e\u0026nbsp;ADn\u003c/em\u003e )\u003c/p\u003e\n\u003cp\u003ewhere n denotes the severity level (1\u0026ndash;5) for each dimension. For example, if all dimensions of a participant were rated at Level 2, the UI would be:\u003c/p\u003e\n\u003cp\u003eUI =1\u0026minus;(0.066 + 0.048 + 0.045 + 0.058 + 0.049) = 1 - 0.266 = 0.734\u003c/p\u003e\n\u003cp\u003eThe UI score ranges from \u0026minus;0.391 to 1, with higher values indicating better health-related quality of life[29,30].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted utilizing \u003cem\u003eStata 16.0\u003c/em\u003e (StataCorp, TX, USA). The internal consistency of the EQ-5D-5L was evaluated using Cronbach\u0026rsquo;s \u0026alpha;\u0026nbsp;(\u0026alpha; \u0026gt; 0.7 indicating acceptable reliability)\u0026nbsp;[31,32]. Pearson correlation coefficients were employed to assess item-total correlations(acceptable range: 0.3-0.8)\u0026nbsp;[33].\u0026nbsp;Exploratory factor analysis (\u003cem\u003eEFA\u003c/em\u003e) using principal factor extraction and varimax rotation was performed to evaluate construct validity. The Kaiser-Meyer-Olkin (\u003cem\u003eKMO\u003c/em\u003e) test (\u0026ge;0.6) and Bartlett\u0026rsquo;s test of sphericity (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05)\u0026nbsp;confirmed data suitability for factor analysis\u0026nbsp;[34].\u0026nbsp;Confirmatory factor analysis (CFA) based on maximum likelihood estimation assessed model fit using multiple fit indices, including the Goodness-of-Fit Index (GFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA).\u0026nbsp;Continuous variables are expressed as mean \u0026plusmn; standard deviation, categorical variables are reported as frequencies.\u0026nbsp;\u0026nbsp;Group\u0026nbsp;comparisons\u0026nbsp;\u0026nbsp;used independent t-tests (two groups), one-way ANOVA (multiple groups), or chi-square tests (categorical data). Multivariate linear regression with stepwise selection identified predictors of HRQoL. Statistical significance was set\u0026nbsp;at \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 (two-tailed).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,346 advanced schistosomiasis cases were identified in Sichuan Province, 1,276 valid questionnaires were completed (response rate: 94.8 %). Among participants, 733 (57.4 %) were male and 543 (42.6 %) were female. The majority (31.3 %) was aged 70-79 years, followed by 50 -59 years (24.9 %) and 60- 69 years (24.7 %). Farmers comprised 95.8 % of the samples; 46.3% had only primary school education. Geographically, cases were distributed among three endemic subtypes: flatlands (40.1%, n = 512), hills (29.5 %, n = 376), and mountains (30.4%, n = 388). Splenectomy-associated advanced schistosomiasis was predominant (65.6 %, n = 837), while dwarf-type cases were rare (2.0%, n = 26) (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic characteristics of patients withAS\u0026nbsp;(n = 1,276)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"587\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003egender\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e733\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e42.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e0-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e70-79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e31.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e80-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e9.9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOccupation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e95.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4.2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEducation Level\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;Illiteracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e25\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;Primary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e46.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e24.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003eSenior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3.2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 300px;\"\u003e\n \u003cp\u003eJunior college or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEndemic type of the village\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eFlatlands subtype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e40.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Hills subtype \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e29.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eMountains subtype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e30.4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdvanced Schistosomiasis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;Splenectomy type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e837\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e65.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eAscites type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e367\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e28.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;Colon thickening type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;Dwarf type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe Cronbach\u0026apos;s \u0026alpha; coefficient was 0.795 indicating acceptable internal consistency. Significant correlations were found among all dimensions (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), with dimension-to-dimension correlations ranging from 0.197 to 0.642 and dimension-to-total score correlations between 0.591 and 0.850. Exploratory factor analysis (\u003cem\u003eKMO\u003c/em\u003e = 0.761, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) extracted two common factors explaining 77.3% of the variance. Factor 1 encompassed mobility, self-care, and usual activities (Active QOL). Factor 2 included pain/discomfort and anxiety/depression (Perceived QOL). (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e Scree plot and total Variance Explained\u003c/p\u003e\n\u003ch4\u003eConfirmatory factor analysis demonstrated good model fit (\u003cem\u003e\u0026chi;\u0026sup2;/df\u0026nbsp;\u003c/em\u003e= 2.191, \u003cem\u003eGFI\u0026nbsp;\u003c/em\u003e= 0.998, \u003cem\u003eTLI\u003c/em\u003e = 0.998, \u003cem\u003eRMSEA\u003c/em\u003e = 0.031), with standardized factor loadings ranging from 0.62 to 0.92 (Figure 2).\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2. Confirmatory factor analysis of the EQ-5D-5L scale.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe figure displays the standardized structural equation model for the EQ-5D-5L, demonstrating the relationships between the latent constructs (Active QOL and Perceived QOL) and their observed variables. Standardized factor loadings are shown on the paths. MO, Mobility; SC, Self-care; UA, Usual Activity; PD, Pain/Discomfort; AD, Anxiety and Depression.\u003c/p\u003e\n\u003cp\u003eThe mean QoL utility index (UI) score was 0.85 \u0026plusmn; 0.20, with 35.6% (n = 454) reporting no difficulties across dimensions (UI = 1). Among the five EQ-5D-5L dimensions, mobility (78.1%), self-care (88.6%), and usual activities (68.7%) showed the highest proportions of Level 1 responses (no problems), In contrast, pain/discomfort (45.3% reporting moderate-to-extreme problems) and anxiety/depression (62.5% reporting any problems) exhibited more pronounced impairment (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2. Distribution of EQ-5D-5L response levels [number of cases (percentage)]\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eLevel 1(No problems) |\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eLevel 2\u0026nbsp;(Slight problems)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eLevel 3(Moderate problems)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003eLevel 4 (Severe problems)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eLevel 5\u0026nbsp;(Extreme problems)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cem\u003eMobility (MO)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e996 (78.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e216 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e50 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e7 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cem\u003eSelf-care (SC)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e1130 (88.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e109 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e22 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e8 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cem\u003eUsual activity (UA)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e877 (68.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e285 (22.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e72 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e21 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e21 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cem\u003ePain/discomfort (PD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e578 (45.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e563 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e106 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e20 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e9 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnxiety/Depression (AD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e797 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e388 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e69 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91px;\"\u003e\n \u003cp\u003e19 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e[Note: Level 1: No difficulty; Level 5: Extreme difficulty]\u003c/p\u003e\n\u003cp\u003eEndemic subtype, age, occupation, advanced schistosomiasis type, education level, and clinical histories\u0026mdash;including splenectomy, ascites, \u0026nbsp;UGIB, hepatitis, and liver fibrosis\u0026mdash;were found to significantly influence UI scores (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). Gender did not show a significant association (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.703) \u0026nbsp;(Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3 Analysis of Factors Influencing Quality of Life Outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"611\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCategories\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUI\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cem\u003eT/F price\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Village Endemic Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e15.392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eFlatlands subtype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eHills subtype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.82-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eMountains subtype\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge(years)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e6.645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e0-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.97-1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.84-1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.88-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e70-79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.85-0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e80-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.77-0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOccupation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eadvanced S\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003echistosomiasis Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e10.556\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;Splenectomy type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.88-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eAscites type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.82-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;Colon thickening type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.85-0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;Dwarf type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.86-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEducation Level\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e6.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;Illiteracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.82-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;Primary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eSenior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.88-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eJunior college or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.92-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGender\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.703\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.86-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Splenectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e3.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.85-0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.88-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Ascites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e6.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.83-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of UGIB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.88-0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.84-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Hepatitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.82-0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Fibrosis level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e10.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eLevel Ⅰ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.89-0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eLevel Ⅱ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.87-0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 292px;\"\u003e\n \u003cp\u003eLevel Ⅲ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.83-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMultiple linear regression dentified significant predictors of the UI score (P \u0026lt; 0.05). Higher education level correlated with increased UI\u0026nbsp;(\u003cem\u003e\u0026beta;\u003c/em\u003e = 0.022, \u003cem\u003et\u0026nbsp;\u003c/em\u003e= 3.708, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Increasing age correlated with a reduced UI (\u003cem\u003e\u0026beta;\u003c/em\u003e = -0.017, \u003cem\u003et\u0026nbsp;\u003c/em\u003e= -4.275, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Negative associations with UI were found for history of ascites (\u003cem\u003e\u0026beta;\u0026nbsp;\u003c/em\u003e= -0.041,\u003cem\u003e\u0026nbsp;t\u0026nbsp;\u003c/em\u003e= -4.358, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001), UGIB(\u0026beta; = -0.025,\u003cem\u003e\u0026nbsp;t\u003c/em\u003e = -2.361,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e = 0.018), hepatitis (\u003cem\u003e\u0026beta;\u003c/em\u003e = -0.033,\u003cem\u003e\u0026nbsp;t\u0026nbsp;\u003c/em\u003e= -2.052, \u003cem\u003eP\u003c/em\u003e = 0.040), and higher liver fibrosis level (\u003cem\u003e\u0026beta;\u0026nbsp;\u003c/em\u003e= -0.024, \u003cem\u003et\u003c/em\u003e = -4.421, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). History of splenectomy was a protective factor (\u003cem\u003e\u0026beta;\u003c/em\u003e = 0.031, \u003cem\u003et\u003c/em\u003e = 3.429, \u003cem\u003eP\u003c/em\u003e = 0.001) (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3. Predictors of health-related quality of life in patients with\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAS\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe plot shows the adjusted \u0026beta; coefficients and 95% confidence intervals from the multivariate linear regression model for factors associated with the EQ-5D-5L utility index.\u003c/p\u003e\n\u003cp\u003eAnalysis of interactions produced several statistically significant findings (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05 unless stated otherwise). The variation in UI scores indicated a significant correlation between age and the history of ascites. In patients under 60 years old, a history of ascites did not significantly affect UI scores (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Conversely, in the 60 to 79 age group, it had detrimental effects. All patients aged 80 years and older exhibited lower UI scores, regardless of their history of ascites. The UI scores were influenced synergistically by the concurrent presence of a history of UGIB and ascites. A singular history of UGIB showed no statistically significant association with UI scores (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05); however, when combined with a history of ascites, it resulted in significant adverse outcomes. The combination of ascites history yielded significant negative results, whereas a standalone history of UGIB did not demonstrate a statistically significant association with UI scores (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Additionally, a history of hepatitis influenced UI scores through its interaction with the extent of hepatic fibrosis. Patients with Level I/II hepatic fibrosis exhibited stable UI scores irrespective of their hepatitis status (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05). Conversely, individuals with Level III fibrosis experienced significant reductions in UI scores, irrespective of their hepatitis history. The age-modified effects of hepatic fibrosis severity exhibited two distinct patterns: Level III fibrosis significantly reduced UI scores exclusively in septuagenarians (70-79 years), while both Level II and III fibrosis adversely affected octogenarians (\u0026ge;80 years).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 4. Interaction effects among risk factors on health-related quality of life.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe matrix illustrates the statistically significant interactions (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) between key clinical and demographic variables (age, ascites, UGIB, hepatitis, liver fibrosis) and their combined effect on the utility index score.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe mean UI score of 0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20 observed in this cohort indicates significantly lower health-related quality of life (HRQoL) compared to the general Sichuan population (UI\u0026thinsp;=\u0026thinsp;0.949\u0026thinsp;\u0026plusmn;\u0026thinsp;0.008) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Among the EQ-5D-5L dimensions, \"pain/discomfort\" (PD) and \"anxiety/depression\" (AD) showed the highest prevalence of moderate-to-severe problems (10.6% and 7.1% for levels 3\u0026ndash;5, respectively). This finding underscores the substantial impact of physical discomfort and psychological distress on patients' daily lives. These findings are consistent with previous studies that emphasize the debilitating effects of advanced schistosomiasis on mobility and psychosocial well-being[\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A chronic inflammatory drive in liver fibrosis, featuring Hepatic stellate cells (HSC) activation, collagen deposition, and the release of pro-inflammatory cytokines [including Tumor necrosis factor-alpha (TNF-α), Interferon-gamma (IFN-γ), Interleukin-6 (IL-6), and Interleukin-8 (IL-8)] and activation of signaling pathways such as Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), is a key mechanism of pain through nociceptor sensitization, further regulated by cytokines such as IFN-γ and IL-10 Interleukin-10 (IL-10)[\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Depression in AS stems from the burden of chronic physical morbidity and disease-related discrimination, compounded by psychological stress, emotional dysregulation, lack of social support, all of which contribute to poor quality of life[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study validated the EQ-5D-5L as a reliable instrument for assessing HRQoL in this population. This is supported by acceptable reliability (Cronbach's \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.795) and structural validity demonstrated by confirmatory factor analysis (\u003cem\u003eχ\u0026sup2;/df\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.191, GFI\u0026thinsp;=\u0026thinsp;0.998, TLI\u0026thinsp;=\u0026thinsp;0.998, RMSEA\u0026thinsp;=\u0026thinsp;0.031). Renowned for its cross-cultural adaptability, the scale exhibited acceptable internal consistency (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.7), though marginally below the \"high reliability\" threshold (α\u0026thinsp;\u0026ge;\u0026thinsp;0.8). This modest limitation may reflect the unique socioeconomic and clinical profile of the study cohort, predominantly comprising elderly individuals with limited education (46.3% had only primary schooling). Higher correlations between dimensions and the total score (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.591\u0026ndash;0.850) compared to inter-dimension correlations \u003cem\u003e(r\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.197\u0026ndash;0.642) affirmed its discriminative validity. Exploratory factor analysis categorized dimensions into \"Active QOL\" (mobility, self-care, UA) and \"Perceived QOL\" (PD, AD), aligning with the distinction between physical and mental health.\u003c/p\u003e\u003cp\u003eThe protective effect of higher education on HRQoL (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) is consistent with global evidence linking education to enhanced health literacy and healthcare access[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Conversely, advanced age and comorbidities (ascites, hepatitis) were significant negative predictors, corroborating findings in other populations with chronic conditions[\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The protective effect of splenectomy (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) validates its role in mitigating portal hypertension[\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], though long-term benefits require further study. Interaction analyses revealed complex relationships. Ascites significantly diminished HRQoL only in patients aged 60\u0026ndash;79 years, likely due to cumulative organ damage in older adults[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Additionally, the co-occurrence of UGIB and ascites was associated with a significant decline in HRQoL, highlighting the necessity of integrated management strategies addressing complications of portal hypertension[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Furthermore, the interaction between hepatitis and fibrosis revealed that severe (Level III) fibrosis negated the positive impact of a history of hepatitis, suggesting that the severity of fibrosis is a primary driver of impairment in end-stage disease[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The complex interactions observed among risk factors highlight the limitations of a uniform management strategy. Our results support the adoption of a risk stratification framework to guide personalized care. Within this framework, three high-risk subgroups warrant particular attention: elderly patients with ascites, who may benefit from more vigilant monitoring; individuals with compounded complications (concurrent ascites and bleeding), who should receive aggressive management of portal hypertension; and patients with severe fibrosis, for whom integrated liver-protective and psychosocial support is indicated.\u003c/p\u003e\n\u003ch3\u003eLimitations and Future Directions\u003c/h3\u003e\n\u003cp\u003eDespite its substantial sample size (n\u0026thinsp;=\u0026thinsp;1,276), this study has limited generalizability due to its focus on mountainous regions of Sichuan, where healthcare access inequities may exacerbate HRQoL deficits. Future research should replicate these findings in diverse settings (e.g., plains, coastal areas) and employ longitudinal designs to assess causality. Reliance on self-reported data may introduce recall bias; incorporating clinical biomarkers (e.g., liver elastography) could enhance robustness.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings highlight a critical need for stratified management and call for targeted interventions tailored to high-risk subgroups of advanced schistosomiasis (AS) patients in Sichuan, notably the elderly with low educational attainment, ascites, or severe fibrosis. To address the significant HRQoL disparities identified, we recommend adopting a precision public health approach that includes region-specific risk stratification and the expansion of multidisciplinary care. A key recommendation is the systematic embedding of mental health screening and counselling into routine care for all AS patients, with prioritization given to those bearing the dual burden of ascites or advanced fibrosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHRQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth-related quality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdvanced schistosomiasis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEQ-5D-5L\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuroQol Five-Dimension Five-Level\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eS. japonicum\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSchistosoma japonicum\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUtility index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfirmatory factor analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExploratory factor analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKMO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKaiser-Meyer-Olkin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRMSEA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRoot Mean Square Error of Approximation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMobility\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSelf-care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUsual Activity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePain/Discomfort\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnxiety/Depression\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGFI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGoodness-of-fit index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTLI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTucker-Lewis Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUGI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUpper gastrointestinal\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHepatic stellate cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTNF-α\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTumor necrosis factor-alpha\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIFN-γ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterferon-gamma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIL-6\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterleukin-6\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIL-8\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterleukin-8\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIL-10\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterleukin-10\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNF-κB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNuclear factor kappa-light-chain-enhancer of activated B cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInstitutional Review Board\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSCCDCIRB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSichuan Center for Disease Control and Prevention Institutional Review Board\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of the Sichuan Center for Disease Control and Prevention (Approval No.: SCCDCIRB No.2023-015). The study was conducted in full compliance with both international and national ethical guidelines, including the Declaration of Helsinki and China's \"Ethical Review Measures for Life Sciences and Medical Research Involving Humans\". Written informed consent was obtained from all participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Informed consent was obtained from all participants involved in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eWe declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe study was supported by Science and Technology Project of the Health Commission of Sichuan Province(24CXTD04): Schistosomiasis at the edge of elimination characterizing sources of new infections in residual transmission hotspots(1R01AI134673-01A1): Sichuan Science and Technology Program(2024YFFK0194)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYu Zhang, Yang Liu and Shi-zhu Li designed the study. Yu Zhang and Xiao-qin Gu took the lead in drafting the manuscript and interpreting the results. Jin-ye Shang ,Nan-nan Wang ,Lin Chen,Bo Zhong and Elizabeth Cartlon contributed to the interpretation of the results and the submitted version of the manuscript. All authors had final responsibility for the decision to submit for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors sincerely thank all patients with advanced schistosomiasis who participated in this study. We are also grateful to the staff from the schistosomiasis control agencies for their essential contributions to the field investigation and data management.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study contain sensitive personal health information. To protect participant privacy and in compliance with ethical requirements, they are not publicly available. De-identified data may be made available by the corresponding author upon reasonable scientific request and subject to review and approval by the relevant ethics committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBuonfrate D, Ferrari TCA, Adegnika AA, Russell Stothard J, Gobbi FG. Hum schistosomiasis Lancet. 2025;405(10479):658\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop. 2000;77(1):41\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi ZJ, Ge J, Dai JR, Wen LY, Lin DD, Madsen H, Zhou XN, Lv S. Biology and Control of Snail Intermediate Host of Schistosoma japonicum in The People's Republic of China. Adv Parasitol. 2016;92:197\u0026ndash;236.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou YB, Liang S, Jiang QW. 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Lancet. 2010;375(9724):1419\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Schistosomiasis japonica, Advanced schistosomiasis, Quality of life, EQ-5D-5L, China, Sichuan Province, Health-related quality of life","lastPublishedDoi":"10.21203/rs.3.rs-8198015/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8198015/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTo assess health-related quality of life (HRQoL) and identify influencing factors impacting HRQoL among patients with Advanced Schistosomiasis (AS) in Sichuan Province, China, utilizing the EQ-5D-5L scale.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted among 1,276 AS patients in Sichuan Province. Data on demographic characteristics, clinical history, and EQ-5D-5L responses were collected via structured face-to-face interviews and medical record review. Statistical analyses included reliability and validity assessments (Cronbach's α, exploratory/confirmatory factor analyses), univariate analysis, multivariate linear regression, and interaction analysis using \u003cem\u003eStata 16.0\u003c/em\u003e and \u003cem\u003eR 4.5.1\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean utility index (UI) score was 0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20, with 35.6% of subjects reporting no impairment across all dimensions. The EQ-5D-5L demonstrated acceptable internal consistency (\u003cem\u003eCronbach\u0026rsquo;s α\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.795) and construct validity (CFA: \u003cem\u003eχ\u0026sup2;/df\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.191, \u003cem\u003eRMSEA\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). The domains most affected were anxiety/depression (62.5% reporting any impairment) and pain/discomfort (54.7% reporting any impairment). Multivariate regression analysis identified advanced age (\u003cem\u003eβ\u003c/em\u003e = -0.017, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a history of ascites(\u003cem\u003eβ\u003c/em\u003e = -0.041, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Upper Gastrointestinal Bleeding (UGIB) (\u003cem\u003eβ\u003c/em\u003e = -0.025, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018), hepatitis (\u003cem\u003eβ\u003c/em\u003e = -0.033, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04), and advanced liver fibrosis (\u003cem\u003eβ\u003c/em\u003e = -0.024, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as significant independent predictors for poorer HRQoL. Interaction analysis revealed synergistic effects among risk factors, demonstrating that the detrimental impact of ascites was concentrated in the elderly, co-occurrence of bleeding and ascites compounded HRQoL reduction, and the effect of hepatitis was contingent upon the severity of liver fibrosis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe EQ-5D-5L is a valid and reliable instrument for assessing HRQoL in patients with AS. Targeted interventions should address age-related functional decline, comorbidities(particularly ascites and severe fibrosis), and low educational attainment to enhance patient outcomes. Emphasis should be placed on multidisciplinary care strategies for older patients with advanced fibrosis or ascites in endemic regions.\u003c/p\u003e","manuscriptTitle":"Assessment of Health-Related Quality of Life and Influencing Factors among Patients with Advanced Schistosomiasis Japonica in the Southwest of China Using the EQ-5D-5L Scale","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 13:26:03","doi":"10.21203/rs.3.rs-8198015/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7ffa580-2119-4248-9478-f646e39def16","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-24T01:23:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 13:26:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8198015","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8198015","identity":"rs-8198015","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}