Comparison of HINT-8 and EQ-5D-5L for assessing Health-Related Quality of Life in patients with precancerous cervical lesions

Comparison of HINT-8 and EQ-5D-5L for assessing Health-Related Quality of Life in patients with precancerous cervical lesions | 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 Comparison of HINT-8 and EQ-5D-5L for assessing Health-Related Quality of Life in patients with precancerous cervical lesions Woo-Jeong Sim, Min-Ju Kim, Nam-Kyeong Kim, Gyeong-U Hong, Ah-Yeon Lee, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7158813/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 Backgroud Gynecological conditions can substantially affect various aspects of women’s lives; therefore, health-related quality of life (HRQoL) is regarded as a crucial measure in women’s health evaluation. This study evaluated the HRQoL of patients with cervical intraepithelial neoplasia (CIN) and carcinoma in situ (CIS). The EQ-5D-5L (EuroQol 5 Dimensions, 5 Levels) and the Korean HINT-8 (Health-related Quality of Life Instrument with 8 Items) assessment tools were compared to explore whether HINT-8 can be used as an alternative or complementary tool. Methods A cross-sectional study was conducted from August 2023 to February 2024 at 12 hospitals in Korea. A total of 80 women aged 19 or older with CIN or CIS participated. They completed the EQ-5D-5L and HINT-8 questionnaires. Demographic and clinical data were also collected. Data were analyzed using non-parametric tests, correlation, Bland-Altman plots, ICC, and Cronbach’s alpha. Results The average scores were 0.878 for EQ-5D-5L and 0.830 for HINT-8. Employment and marital status affected both scores. The ceiling effect was 35% for EQ-5D-5L and 15% for HINT-8. The two tools were strongly correlated (r = 0.792) with high agreement (ICC = 0.847). HINT-8 showed good reliability (Cronbach’s α = 0.859). Conclusions HINT-8 showed lower ceiling effects, higher internal consistency, and greater sensitivity to HRQoL changes than EQ-5D-5L. It may be a useful tool for assessing HRQoL in CIS and CIN patients. These findings contribute to improving the quality of women’s health assessment tools, particularly in the context of early-stage cervical conditions. Further research is needed to explore its applicability in diverse cultural contexts. This study is among the first to explore the potential global use of HINT-8, and it provides a meaningful starting point for future research. Cervical intraepithelial neoplasia (CIN) Carcinoma in situ (CIS) Health-related quality of life (HRQoL) EQ-5D-5L HINT-8 Figures Figure 1 Figure 2 Background Cervical intraepithelial neoplasia (CIN) is the most common precancerous lesion of the cervix, characterized by atypical squamous cell changes. CIN is classified into three grades—CIN 1 (mild), CIN 2 (moderate), and CIN 3 (severe)—based on the depth of epithelial involvement ( 1 ). Persistent infection with high-risk human papillomavirus (HPV) is a major etiological factor in the progression of CIN, leading to abnormal epithelial proliferation and the potential development of intraepithelial tumors ( 2 ). While low-grade CIN (CIN 1) often resolves spontaneously, high-grade lesions (CIN 2 and CIN 3) have a greater likelihood of progressing to cervical carcinoma in situ (CIS), a precancerous condition equivalent to stage 0 cervical cancer ( 3 ). Unlike many other malignancies, cervical cancer is largely preventable due to its long preclinical phase, allowing for early detection through routine screening programs ( 2 ). Despite a significant decline in cervical cancer incidence in high-income countries due to widespread screening and HPV vaccination, the disease remains a leading cause of cancer-related mortality among women in low- and middle-income countries ( 4 ). Although advancements in cervical cancer diagnosis and treatment have improved patient outcomes, their negative impact on health-related quality of life (HRQoL) begins even before a definitive diagnosis is made ( 4 ). Assessing HRQoL in women with CIN and CIS is of particular importance in women’s health, as these conditions can significantly affect not only physical health but also psychological and social well-being. HRQoL evaluation provides essential insights for patient-centered care, informs clinical decision-making, and helps tailor supportive interventions to improve overall outcomes in this population. Psychological distress, including fear of cancer, self-blame, pain, and anxiety, can significantly impair HRQoL in affected individuals, underscoring the need for comprehensive patient-centered care strategies ( 4 ). The World Health Organization defines quality of life as an individual’s perception of their position in life within the context of their environment and the value systems, including goals, expectations, standards, and concerns ( 5 ). HRQoL refers specifically to an individual’s perception of how their health status impacts their overall life functions, emotions, and daily activities ( 6 , 7 ). This subjective measure varies across cultures and nations; terms like "health," "sense of illness," "suffering," and "disease" can hold a range of meanings depending on one’s cultural values ( 8 ). Consequently, using HRQoL measurement tools that align with a specific culture’s language and practices is essential for accurate assessments ( 9 ). Developed by the EuroQol Group, the EQ-5D (EuroQol 5 Dimensions) provides a simple descriptive profile and single index value that can be used in clinical and economic evaluations of healthcare and in population health surveys ( 10 ). Its design allows for efficient data collection, making it suitable for large-scale studies. Additionally, the EQ-5D is recommended by several health technology assessment bodies internationally as a key component of cost-utility analysis ( 11 ). Originally developed with a 3-level response system (3L), the EQ-5D was later expanded to the EQ-5D-5L (EuroQol 5 Dimensions, 5 Levels) to improve sensitivity and reduce ceiling effects. Its generic nature enables its application across various diseases and health conditions, facilitating comparisons in health research and policy development. It is utilized both domestically and internationally. In Korea, it is employed in surveys such as the Korea National Health and Nutrition Examination Survey and the Korea Health Panel Survey ( 9 ). Since its development in Europe, the EQ-5D has been employed in numerous national health surveys, including the Health Survey for England, the Canadian Community Health Survey, the Japanese National Health and Nutrition Survey, and the German Health Interview and Examination Survey ( 12 , 13 ). In addition, the EQ-5D-5L is increasingly used across various clinical disciplines. Several studies have demonstrated its utility in assessing HRQoL in regards to women’s health conditions such as CIN, cervical cancer, and gynecologic oncology ( 14 – 19 ). However, Western-centric HRQoL measurement tools like the EQ-5D-5L may not fully reflect the cultural backgrounds and health perceptions of people from non-Western countries. In particular, in Asian countries, these HRQoL assessment tools may not accurately assess quality of life. Recognizing these limitations, the Korea Disease Control and Prevention Agency developed the HINT-8 (Health-related Quality of Life Instrument with 8 Items) in 2014 as a culturally appropriate alternative ( 5 ). Since its introduction, HINT-8 has demonstrated certain benefits over EQ-5D-5L, including reduced ceiling effects, suggesting an improved sensitivity in detecting variations in HRQoL ( 7 ). Studies have validated its use in breast cancer, type 2 diabetes, and elderly populations, where it has shown higher responsiveness compared to conventional tools ( 20 ). Although HINT-8 was developed in Korea, it has great potential to complement the limitations of the existing international standard assessment tool, EQ-5D, and holds significant promise for future international use. So far, HINT-8 has been officially utilized only in Korea. However, as it incorporates factors that enable a more comprehensive assessment of quality of life, it has strong potential for application in other countries, including those in Asia. Despite these advantages, HINT-8 has not yet been internationally recognized or validated for use beyond Korea. Given the increasing global demand for culturally adaptive HRQoL tools, further research is needed to assess the cross-cultural applicability of HINT-8 and to explore its potential for use in other countries. This study aims to evaluate the HRQoL of CIN and CIS patients using both EQ-5D-5L and HINT-8, providing a comparative analysis of their sensitivity and applicability. By assessing their agreement, ceiling effects, and ability to detect HRQoL variations, this research aims to determine whether HINT-8 can serve as a viable alternative or complementary measure to existing tools. Additionally, this study seeks to explore whether HINT-8 can evolve into an internationally applicable HRQoL assessment tool rather than being confined to use only in Korea. Given its strong potential to complement the cultural limitations of EQ-5D, this research will contribute to evaluating the international scalability of HINT-8. Furthermore, this study contributes a first step in exploring the potential for the international adaptation of HINT-8, highlighting the need for future cross-cultural validation studies. Methods Study design This cross-sectional study was conducted from August 2023 to February 2024 at 12 tertiary hospitals in South Korea. The study included 80 female patients aged 19 years or older who had been clinically diagnosed with CIN or CIS. Participants were required to understand the purpose and procedures of the study and to provide written informed consent before participation. The survey was administered in person during outpatient visits. A detailed study protocol, including a flow chart of participant recruitment and data collection, is provided in Additional file 1. The sample size (n = 80) was determined based on the primary objective of comparing the two HRQoL instruments. A brief justification is provided here, with comprehensive details and statistical rationale available in Additional File 2. In addition to response to the HRQoL questionnaires, demographic information (gender, age, education level, marital status, monthly household income, household size, employment status, and religion) and clinical information (disease and surgery status) were collected from each participant. Surgical status included whether the participant had undergone conization or hysterectomy following diagnosis. Missing values due to incomplete responses were not imputed; analyses were performed using available data for each participant. HRQoL measurement tools The EQ-5D-5L, developed by the Euro-QoL Group in 1987, is a widely used tool in the healthcare field to measure HRQoL. It consists of five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and five levels of response (no problems, slight problems, moderate problems, severe problems, extreme problems) ( 21 ). The EQ-5D-5L index was calculated using a previously described valuation set ( 22 ). The index value of the EQ-5D-5L ranges from − 0.066 (worst health state, 55555) to 1 (best health state, 11111), with higher scores indicating better health. The HINT-8, developed by the Korea Disease Control and Prevention Agency in 2014 for the general population in Korea, includes eight items (climbing stairs, pain, vitality, working, depression, memory, sleep, happiness) and four response levels (no problems, mild problems, moderate problems, severe problems), representing a total of 65,536 possible health states ( 23 ). The index value of HINT-8 ranges from 0.132 (worst health state, 44444444) to 1 (best health state, 11111111), with values closer to 1 indicating better health status. Further details on the development, scoring, and psychometric properties of HINT-8 are described in Additional File 3. Statistical analysis methods Descriptive statistics The general and clinical characteristics of the study participants were analyzed using descriptive statistics. Differences between two groups were assessed using the Mann-Whitney U test, while differences among three or more groups were evaluated using the Kruskal-Wallis test. A p-value of less than 0.05 was considered statistically significant. The proportion of respondents reporting the best health state in each tool was calculated to assess the ceiling effect, and the score distributions of the two tools were compared. Quality of life indices were calculated by linking EQ-5D-5L scores with each HINT-8 item, and score distributions were visualized as curves using a kernel density function. Agreement analysis To evaluate the agreement between the EQ-5D-5L and HINT-8 tools, Bland-Altman plots were used to determine the mean index and 95% confidence interval for the two tools ( 24 ). Additionally, Intraclass Correlation Coefficients (ICC) were calculated to assess the level of agreement between the two tools. An ICC value below 0.50 indicates poor agreement, 0.50–0.75 indicates moderate agreement, 0.75–0.90 indicates good agreement, and values above 0.90 indicate excellent agreement ( 25 ). Test performance Internal validity was assessed using Cronbach's alpha, where a value of 0.70–0.79 indicates acceptable reliability and 0.80 or higher indicates excellent reliability ( 26 ). Construct validity was evaluated by calculating correlation coefficients between the EQ-5D-5L and HINT-8 tools. Pearson correlation analysis was used for the indices of both tools, while Spearman correlation analysis was applied to individual items. Absolute correlation values of 0.8 or higher indicate a very strong association, 0.60–0.79 a strong association, 0.40–0.59 a moderate association, and 0.40 or lower a weak association ( 25 ). Cohen's d was used to estimate effect size ( 27 ). Statistical analyses were performed using IBM SPSS Statistics 27 and R version 4.1.3. Results General and clinical characteristics of study participants and score distribution of quality of life tools Table 1 presents the general characteristics of the study participants and their HRQoL as measured by the EQ-5D-5L and HINT-8 indices. The study included 80 female patients diagnosed with CIS or CIN. The participants were relatively evenly distributed across age groups, ranging from their 20s to 50s and above, with the largest group aged 30–39 years (31.3%, n = 25). There was a fairly even division in marital status, with slightly more than half of the participants being single (52.5%, n = 42). In regards to household size, multi-person households dominated (80.9%, n = 64). The majority of participants (68.8%, n = 55) had graduated from college or higher. The most commonly reported monthly household income was 5 million KRW or more, with 52.5% (n = 42) of participants falling into this category. A total of 61.3% (n = 49) were employed or self-employed, while 60.0% (n = 48) reported having no religious affiliation. Regarding disease status, 30.0% (n = 24) had CIN 1, and 70.0% (n = 56) had CIN 2/3 or CIS. Additionally, 63.7% (n = 51) had undergone surgery, while 28.7% (n = 23) had not. Significant differences were observed in the variables of marital status and employment status. In terms of marital status, significant differences were found in both the EQ-5D-5L index (p = 0.017) and HINT-8 index (p = 0.004). Similarly, employment status also showed significant differences in both the EQ-5D-5L index (p = 0.005) and HINT-8 index (p = 0.002). However, no significant differences were found for other variables, including age, education level, income level, family composition, religion, disease status, and surgery status (p > 0.05) (Table 1 ). Table 1 General characteristics of study participants and health-related quality of life Variables Categories N(%) EQ-5D-5L index HINT-8 index HRQoL (M ± SD) P-value HRQoL (M ± SD) P-value Gender Female 80 (100.0%) 0.877 ± 0.114 0.830 ± 0.117 Age(years) 20–29 20 (25.0%) 0.840 ± 0.129 0.235 0.781 ± 0.148 0.232 30–39 25 (31.3%) 0.886 ± 0.081 0.856 ± 0.084 40–49 15 (18.8%) 0.872 ± 0.093 0.827 ± 0.058 50 and more 20 (25.0%) 0.907 ± 0.143 0.853 ± 0.142 Marital status ✝ Single 42 (52.5%) 0.851 ± 0.121 0.017* 0.802 ± 0.122 0.004** No single 37 (46.3%) 0.908 ± 0.100 0.863 ± 0.105 Household Size ✝ One-person household 15 (18.8%) 0.825 ± 0.142 0.062 0.815 ± 0.112 0.381 Multi-person household 64 (80.0%) 0.887 ± 0.104 0.833 ± 0.199 Education ✝ Middle school or lower 6 (7.5%) 0.931 ± 0.169 0.065 0.882 ± 0.173 0.115 High school 18 (22.5%) 0.913 ± 0.095 0.836 ± 0.107 College or higher 55 (68.8%) 0.857 ± 0.110 0.820 ± 0.113 Monthly household income Less than 5 million KRW 38 (47.5%) 0.819 ± 0.123 0.748 0.829 ± 0.116 0.717 More than 5 million KRW 42 (52.5%) 0.875 ± 0.106 0.832 ± 0.120 Employment status Employed/Self-employed 49 (61.3%) 0.877 ± 0.093 0.005** 0.842 ± 0.087 0.002** Housewife 22 (27.5%) 0.914 ± 0.140 0.862 ± 0.130 Student/Unemployed 9 (11.3%) 0.787 ± 0.111 0.690 ± 0.117 Religion ✝ Yes 30 (37.5%) 0.877 ± 0.108 0.971 0.834 ± 0.102 0.575 No 48 (60.0%) 0.875 ± 0.120 0.826 ± 0.128 Disease status CIN 1 24 (30.0%) 0.856 ± 0.104 0.095 0.812 ± 0.128 0.239 CIN 2/3, CIS 56 (70.0%) 0.886 ± 0.118 0.838 ± 0.112 Surgery status ✝ Yes 51 (63.7%) 0.876 ± 0.127 0.971 0.832 ± 0.120 0.991 No 23 (28.7%) 0.890 ± 0.080 0.846 ± 0.096 *p-value < 0.05 ** p-value < 0.01 1 USD = 1,325.10 KRW Abbreviation: HRQoL, Health-Related Quality of Life; EQ-5D-5L, EuroQol 5-Dimension 5-Level; HINT-8, Health-related Quality of Life Instrument with 8 Items; CIN, Cervical Intraepithelial Neoplasia; CIS, Carcinoma in Situ; M ± SD, mean ± standard deviation. ✝ Variables not totaling 100% indicate the presence of missing values. Score distribution and mean differences between EQ-5D-5L and HINT-8 Table 2 presents the relationship between individual HINT-8 item levels and the mean EQ-5D-5L index scores. The overall mean score of the HINT-8 was 0.830 ± 0.117, while the mean EQ-5D-5L score was 0.878 ± 0.114. The EQ-5D-5L index scores were primarily concentrated between 0.8 and 1.0, with a ceiling effect of 35% and a floor effect of 1.25%. In contrast, the HINT-8 index scores were distributed across a wider range (0.6 to 1.0), showing a reduced ceiling effect of 15% and no floor effect (0%), indicating greater measurement diversity (Fig. 1 ). In addition, the mean difference between the EQ-5D-5L and HINT-8 index scores indicates a small to moderate effect size (Cohen’s d = 0.373, 95% CI: 0.213–0.533), suggesting that although there is a difference between the two tools, it is not substantial. Table 2 Distribution of the HRQoL scores HINT-8 EQ-5D-5L Mean of the index, M ± SD 0.830 ± 0.117 0.878 ± 0.114 Difference in paired samples t-test, p-value < 0.001 Ceiling effect a , N (%) 12 (15.0%) 28 (35.0%) Floor effect b , N (%) 0 (0.0%) 1 (1.3%) a Ceiling effect represents the best health state, defined as the proportion of respondents reporting no problems across all dimensions of the respective index. b Floor effect represents the worst health state, defined as the proportion of respondents reporting severe problems across all dimensions of the respective index. Comparison of EQ-5D-5L index to individual items in HINT-8 Table 3 presents the EQ-5D-5L index scores stratified by the levels of individual HINT-8 items, illustrating the relationship between specific health dimensions assessed by HINT-8 and overall health status as measured by the EQ-5D-5L. A general trend was observed across all HINT-8 items, indicating that the EQ-5D-5L index decreased as the severity levels of HINT-8 responses increased. Table 3 Comparison of the EQ-5D-5L index scores across individual HINT-8 items HINT-8 item Level N (%) EQ-5D-5L index, M ± SD a Climbing stairs 1 58 (72.5%) 0.898 ± 0.106 2 19 (23.8%) 0.850 ± 0.089 3 3 (3.8%) 0.638 ± 0.135 4 - - Pain 1 47 (58.8%) 0.929 ± 0.083 2 30 (37.5%) 0.824 ± 0.094 3 2 (2.5%) 0.558 ± 0.040 4 1 (1.3%) 0.671 Vitality 1 25 (31.3%) 0.949 ± 0.090 2 34 (42.5%) 0.886 ± 0.077 3 17 (21.3%) 0.798 ± 0.100 4 4 (5.0%) 0.685 ± 0.176 Working 1 52 (65.0%) 0.915 ± 0.078 2 22 (27.5%) 0.836 ± 0.127 3 5 (6.3%) 0.721 ± 0.123 4 1 (1.3%) 0.586 Depression 1 35 (43.8%) 0.963 ± 0.064 2 32 (40.0%) 0.829 ± 0.085 3 10 (12.5%) 0.786 ± 0.101 4 3 (3.8%) 0.689 ± 0.161 Memory 1 49 (61.3%) 0.906 ± 0.087 2 23 (28.7%) 0.86 ± 0.133 3 8 (10.0%) 0.752 ± 0.123 4 - - Sleep 1 35 (43.8%) 0.935 ± 0.078 2 33 (41.3%) 0.859 ± 0.108 3 12 (15.0%) 0.759 ± 0.118 4 - - Happiness 1 22 (27.5%) 0.975 ± 0.067 2 31 (38.8%) 0.886 ± 0.075 3 24 (30.0%) 0.793 ± 0.107 4 3 (3.8%) 0.741 ± 0.178 a M±SD indicates mean ± standard deviation Correlation analysis between EQ-5D-5L and HINT-8 Table 4 presents the correlation between individual HINT-8 items and EQ-5D-5L domains, along with the overall indices. The correlation coefficient between the EQ-5D-5L index and the HINT-8 index was 0.792 (p < 0.01), indicating a strong correlation between the two tools. For specific items, a high correlation was observed between the pain/discomfort item in EQ-5D-5L and the pain item in HINT-8 (0.702), as well as between the anxiety/depression item in EQ-5D-5L and the depression item in HINT-8 (0.824). Additionally, the anxiety/depression item in EQ-5D-5L showed moderate correlations with the vitality, sleep, and happiness items in HINT-8 (Table 4 ). Table 4 Correlation between EQ-5D-5L and HINT-8 HINT-8 item EQ-5D-5L domain Mobility Self-care Usual activities Pain/ Discomfort Anxiety/ Depression EQ-5D-5L index Climbing stairs 0.415** 0.197 0.352** 0.253* 0.320** - Pain 0.309** 0.088 0.344** 0.702** 0.314** - Vitality 0.255* 0.034 0.256* 0.403** 0.598** - Working 0.466** 0.105 0.403** 0.440** 0.423** - Depression 0.247* 0.186 0.318** 0.437** 0.824** - Memory 0.078 0.132 0.264* 0.317** 0.367** - Sleep 0.222* 0.176 0.192 0.359** 0.546** - Happiness 0.270* 0.184 0.275* 0.397** 0.688** - HINT-8 index - - - - - 0.792** * p-value < 0.05 ** p-value < 0.01 Agreement and Reliability of EQ-5D-5L and HINT-8 The Bland-Altman plot shows the agreement between the EQ-5D-5L and HINT-8 scores (Fig. 2 ). The mean difference was 0.047, indicating that EQ-5D-5L generally yielded slightly higher HRQoL scores than HINT-8. Most data points lie within the 95% limits of agreement (− 0.10 to 0.193), suggesting an acceptable level of agreement between the two tools. However, a few observations outside these bounds indicate individual-level discrepancies. The pattern of differences also suggests that the tools may not be fully interchangeable, especially at higher levels of perceived health. The ICC analysis showed a value of 0.847 (95% CI: 0.614–0.925), indicating a very high level of agreement between the EQ-5D-5L and HINT-8 index. Additionally, Cronbach's alpha analysis revealed an alpha value of approximately 0.678 for EQ-5D-5L and 0.859 for HINT-8, suggesting that HINT-8 has higher internal consistency and reliability compared to EQ-5D-5L. Discussion In this study, the HRQoL of patients with CIS and CIN was evaluated using the EQ-5D-5L and HINT-8 tools. CIN and CIS are recognized as precancerous conditions of the cervix, representing critical public health concerns in women's health ( 28 , 29 ). Due to their potential progression to invasive cervical cancer, early detection, timely intervention, and health behavior modification are essential to improving outcomes and preventing disease advancement ( 29 ). The differences in HRQoL between the tools were quantitatively analyzed, and the reliability and validity of the HINT-8 tool were verified. The HRQoL indices measured were 0.83 for HINT-8 and 0.88 for EQ-5D-5L, with the EQ-5D-5L index being significantly higher. The analysis of group differences in HRQoL revealed that marital status had a significant impact on quality of life indices measured by both EQ-5D-5L (p = 0.017) and HINT-8 (p = 0.004). This finding aligns with previous research suggesting that marital status is an important determinant of quality of life among cervical cancer patients. Although direct evidence on the impact of marital status on the quality of life in CIS and CIN patients is currently limited, studies involving cervical cancer patients provide useful insights due to the clinical and psychosocial similarities between the groups. Some studies have reported that married individuals experience better QoL outcomes compared to their single counterparts ( 30 , 31 ). For instance, marriage has been associated with earlier diagnosis and improved survival in cervical cancer patients, possibly due to healthier behaviors, broader health insurance coverage, and stronger socio-economic support available to married women ( 32 ). Conversely, another study has found that married cervical cancer patients may experience lower QoL than unmarried patients ( 33 ), which is consistent with the findings of the present study. These mixed findings suggest that the relationship between marital status and QoL is multifaceted and may be influenced by cultural, social, and individual contextual factors. Further research is needed to clarify these dynamics and to inform targeted interventions that consider marital status and other socio-demographic characteristics when addressing the quality of life needs of patients with CIS, CIN, and related conditions. Employment status also showed a significant impact on HRQoL among patients with CIN and CIS in both EQ-5D-5L (p = 0.005) and HINT-8 (p = 0.002). Employment is widely recognized as a key determinant of HRQoL, offering benefits such as financial security, social engagement, and psychological stability ( 34 ). This association is especially important for patients with CIN and CIS. Although they do not face an immediate life-threatening condition like invasive cancer, they must deal with uncertainty about disease progression, regular medical check-ups, and possible surgical treatments. The psychological burden is further compounded by the stigma and emotional distress often associated with reproductive health issues. In this context, employment may serve as a stabilizing factor, providing daily structure, social interaction, and a sense of purpose, thereby helping to buffer against these stressors. Social determinants such as marital status and employment were found to significantly influence HRQoL in women with CIN and CIS ( 35 , 36 ). These findings underscore the broader social context of women’s health and support the need for holistic care strategies that consider both clinical and socio-economic factors in managing precancerous cervical conditions. This observation aligns with previous studies on women with low-grade cytological abnormalities, which similarly found that employment status affects the distribution of quality of life ( 15 ). It is also consistent with research demonstrating differences in HRQoL among cancer patients based on employment status ( 37 ), and among ovarian cancer patients according to occupation type ( 38 ). These findings underscore the crucial role of employment, not only in regards to psychological well-being, but also in fostering emotional support, financial stability, and ultimately, healthy behaviors and adherence to treatment. Beyond physical health, CIN and CIS diagnoses are often accompanied by significant psychological distress, including anxiety, depression, fear of cancer, and self-blame. These emotional burdens can substantially impair a woman’s HRQoL, highlighting the importance of addressing mental and emotional well-being in clinical care and quality of life assessments. However, due to differences in cancer types, occupation classifications, and the small sample size, the generalizability of the results is limited. Therefore, future studies should include larger sample sizes and a wider range of cancer types and occupational groups for further analysis. In contrast, other sociodemographic and clinical variables did not show significant differences in quality of life indices. The EQ-5D plays an essential role in research on women’s health. For instance, in China, it was used to evaluate the responsiveness and minimal clinically important difference of the EQ-5D-5L for assessing the impact of surgical treatment on CIN patients’ quality of life ( 14 ). In the United Kingdom, it was applied to measure the quality of life of women with low-grade cytological abnormalities using the EQ-5D-3L ( 15 ). In Japan, the EQ-5D-5L was used to assess the effects of nausea and vomiting on quality of life among patients with menorrhagia and anemia who were taking iron supplements ( 16 ). In Germany, the EQ-5D was used to evaluate the health utility of female patients undergoing treatment in gynecologic oncology and mammology ( 17 ). Additionally, Taiwan and Indonesia have applied the EQ-5D to assess the quality of life of patients with cervical cancer and HPV-related cancers, respectively ( 18 , 19 ). These studies demonstrate that the EQ-5D is a valuable tool for evaluating HRQoL in conditions affecting women’s health. However, the EQ-5D has some limitations, such as the ceiling effect, which may restrict its ability to detect subtle changes in quality of life, particularly in populations with higher health levels. To address these limitations, the HINT-8 was developed in Korea ( 39 ). The HINT-8 includes a broader range of health states compared to commonly used tools like the EQ-5D, and in comparison to the EQ-5D-5L, HINT-8 demonstrates favorable characteristics regarding the ceiling effect ( 7 ). A study evaluating the validity and reliability of the HINT-8 among Korean breast cancer patients found that the proportion of patients reporting a perfect health state was 21.0% with the EQ-5D-5L, while it was only 2.3% with the HINT-8 ( 23 ). The ceiling effect refers to a phenomenon where a tool fails to sufficiently distinguish among higher scores ( 9 ), meaning that when measuring HRQoL, it indicates the highest possible score when respondents report no problems across all domains of a tool. Lower ceiling effects suggest that the tool more accurately reflects variations in quality of life ( 5 ). In studies with breast cancer patients, the HINT-8 was found to capture changes in quality of life more precisely than the EQ-5D-5L and was evaluated as well-suited to reflect the cultural and social context of Korean patients ( 23 ). Additionally, in studies involving type 2 diabetes patients, the HINT-8 demonstrated increased sensitivity and specificity in measuring quality of life compared to existing tools, indicating that it is also an effective tool for assessing quality of life in patients with various chronic diseases ( 20 ). Analyses of data from the Korea National Health and Nutrition Examination Survey have also shown that the HINT-8 has strong internal consistency and can be appropriately applied across diverse demographic characteristics and health statuses ( 40 ). Both EQ-5D-5L and HINT-8 exhibited ceiling and floor effects; however, the ceiling effect was less pronounced in HINT-8 (15%) than it was in EQ-5D-5L (35%). This indicates that EQ-5D-5L tends to concentrate scores at the upper end of the distribution, while HINT-8 may be better suited for distinguishing individuals with a high quality of life. Furthermore, a study on breast cancer patients reported an 18.6% reduction in the ceiling effect for HINT-8 ( 23 ). Similarly, in this study, HINT-8 showed a 20% reduction in the ceiling effect, demonstrating a comparable trend. Since a pronounced ceiling effect can reduce the sensitivity of an instrument, HINT-8 may be a more suitable tool for detailed quality-of-life assessments. The correlation coefficient between the EQ-5D-5L and HINT-8 indices was 0.792, indicating a high level of consistency between the two tools. This value was higher than the correlation coefficients derived from studies validating EQ-5D and HINT-8 tools in populations such as breast cancer patients, diabetes patients, and older adults, suggesting that HINT-8 could complement or substitute EQ-5D-5L ( 25 ). Additionally, the combined use of these tools may yield synergistic effects. The ICC value (0.847) confirmed better measurement agreement compared to previous studies ( 20 , 23 , 25 ), indicating excellent consistency between the two tools. Cronbach's alpha analysis showed that HINT-8 exhibited higher reliability than EQ-5D-5L, demonstrating superior internal consistency. The effect size between the two indices was moderate, indicating minimal differences between the tools. This study was conducted with a relatively small sample size of 80 participants, most of whom had mild cases, resulting in fewer patients being included from tertiary hospitals. The sample size was determined based on the primary objective of comparing the two HRQoL instruments, with detailed justification provided in Additional File 3. While the sample size is sufficient for the main analyses, caution is warranted when interpreting subgroup analyses due to limited statistical power, which may also restrict the generalizability of the findings. Nevertheless,efforts were made to enhance the study's representativeness by including patients from various regions; this was accomplished by collaborating with 12 hospitals nationwide. CIN 1 typically undergoes spontaneous regression, while CIN 2–3 and CIS, which are considered pre-cancerous lesions, require surgical treatments such as conization or hysterectomy ( 41 ). Compared to CIN 1, the follow-up intervals for CIN 2–3 and CIS are shorter, and there is a higher concern for recurrence. These disease characteristics can potentially affect the HRQoL of the patients. The inclusion of only 56 patients with CIN 2–3 and CIS in this study was insufficient to perform a subgroup analysis. Further studies with larger sample sizes will be needed in the future. Additionally, the key strength of this study lies in its comprehensive examination of HRQoL differences by incorporating both sociodemographic and clinical factors through surveys and medical record analysis. Importantly, the comparison of two quality-of-life assessment tools adds significant value by verifying their respective characteristics and applicability. For patients with CIN and CIS in South Korea, the HINT-8 showed lower ceiling effects, higher internal consistency, and greater sensitivity to HRQoL changes compared to the EQ-5D-5L. However, if HINT-8 is to complement or replace EQ-5D-5L, international validation studies that include other ethnic populations will be necessary. Based on these findings, the HRQoL assessments using EQ-5D-5L and HINT-8 highlight the potential for developing tailored management programs for CIS and CIN patients. In South Korea, the prevalence and incidence rates of CIS and CIN are significant among women’s health issues ( 42 ), emphasizing the need to study their quality of life. Given the significant impact of employment status on quality of life, programs supporting job retention and return to work could be effective strategies. Utilizing the unique features of each tool allows for customized interventions, making it crucial to develop management strategies that address patients' needs and improve their quality of life. Additionally, although HINT-8 was developed in Korea, its strong cultural relevance, lower ceiling effects, and broader coverage of health domains—while maintaining a validated unidimensional structure— suggest its potential utility in other non-Western settings. This tool may be particularly valuable in low- and middle-income countries where culturally adapted HRQoL assessments are needed to capture diverse health perceptions and improve patient-centered care. Considering its potential for international expansion, it could become a widely utilized tool through multinational studies. To this end, this study holds significant value as a pioneering effort in validating the utility of HINT-8, and it may serve as a foundational reference for future international validation efforts. Conclusion This study compared the EQ-5D-5L and HINT-8 instruments to evaluate the HRQoL in women diagnosed with CIN and CIS. Compared to the EQ-5D-5L, the HINT-8 demonstrated lower ceiling effects, higher internal consistency, and the potential to more sensitively capture differences in quality of life. Based on its cultural appropriateness and psychometric advantages, HINT-8 may serve as a complementary or alternative tool to the EQ-5D-5L and holds potential for future application in international women’s health research and policy development. Declarations Ethics Approval and Consent to Participate All participants were informed of the study's purpose and procedures and provided written consent to participate. The study was approved by the Central Research Ethics Committee of Kongju National University (Approval No. KNU_IRB_2023-49). IRB approval numbers for each hospital are listed in (Additional file 4). This study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for Publication The authors confirm that all participants provided consent for publication. No identifying information is included in this manuscript. Availability of data and materials Data will be made available upon request. Competing interest s The authors declare that they have no competing interests Funding This study was supported by the Korea Disease Control and Prevention Agency [#2023-10-012]. Author contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Woo-Jeong Sim, Min-Ju Kim, Gyeong-U Hong, Ah-Yeon Lee, Ji-Eun An, Se-Ik Kim, Tae-Wook Kong, Byung-Su Kwon, Sung-Taek Park, Kyeong-A So, Won-Moo Lee, Jung-Yun Lee, Dae-Hoon Jeong, Min-Chul Choi, Youn-Jin Choi, Jae-Kwan Lee, Su-Yeon Yu, Kyung-Jin Min, and Soo-Hyun Lee. Data analysis was performed by Woo-Jeong Sim, Min-Ju Kim, Gyeong-U Hong, Ah-Yeon Lee, Ji-Eun An, Su-Yeon Yu, and Soo-Hyun Lee. The first draft of the manuscript was written by Woo-Jeong Sim, Su-Yeon Yu, Kyung-Jin Min, and Soo-Hyun Lee, and all authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript. Acknowledgements We extend our sincere gratitude to all the patients who participated in this study and to the clinical teams at the 12 participating hospitals for their valuable cooperation. References Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. 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The impact of marital status on stage at diagnosis and survival of female patients with breast and gynecologic cancers: A meta-analysis. Gynecol Oncol. 2021;162(3):778–87. Jun EM. Factors influencing the quality of life in women diagnosed with cervical cancer. Korean Data Anal Soc. 2023;25(6):2407–18. Abdul Jalil NI, Tan SA, Ibharim NS, Musa AZ, Ang SH, Mangundjaya WL. The relationship between Job Insecurity and Psychological Well-Being among Malaysian precarious workers: work–life balance as a Mediator. Int J Environ Res Public Health. 2023;20(3):2758. Tosic Golubovic S, Binic I, Krtinic D, Djordjevic V, Conic I, Gugleta U, et al. Risk factors and predictive value of depression and anxiety in cervical cancer patients. Medicina. 2022;58(4):507. Basu P, Hassan S, Fileeshia F, Mohamed S, Nahoodha A, Shiuna A, et al. Knowledge, attitude and practices of women in Maldives related to the risk factors, prevention and early detection of cervical cancer. Asian Pac J Cancer Prev. 2014;15(16):6691–5. Park L, Jun S, Lee JA. Quality of life and associated factor among cancer survivors in Korea. Korean J Health Promotion. 2018;18(1):7–14. Shao Z, Zhu T, Zhang P, Wen Q, Li D, Wang S. Association of financial status and the quality of life in Chinese women with recurrent ovarian cancer. Health Qual Life Outcomes. 2017;15(1):144. Jo M. Development of the measurement tool for health related quality of life in the Korea National Health and Nutrition Examination Survey. Cheongju: Korea Centers for Disease Control & Prevention; 2014. p. 97. Lee E-H. Internal structure of the Health-Related Quality of Life Instrument with 8-items in a nationally representative population. J Korean Acad Nurs. 2023;53(3):359–69. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Lower Genit Tract Dis. 2020;24(2):102–31. Chang HK, Seo S-S, Myong J-P, Yu YL, Byun SW. Incidence and costs of cervical intraepithelial neoplasia in the Korean population. J Gynecologic Oncol. 2019;30(3):e37. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2.docx Additionalfile3.docx Additionalfile4.docx 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. 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(a) EQ-5D-5L index distribution, (b) HINT-8 index distribution. The blue bars represent the frequency of scores, while the red lines indicate the estimated density curve.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/e6815d080f72e71db888f2c4.png"},{"id":89573574,"identity":"5783cb31-88fd-4e7e-a09b-8f6ce6c7c4bb","added_by":"auto","created_at":"2025-08-21 12:40:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44292,"visible":true,"origin":"","legend":"\u003cp\u003eBland-Altman Plot of EQ-5D-5L and HINT-8. The red dashed line represents the mean difference between EQ-5D-5L and HINT-8 scores. The green dashed lines show the 95% limits of agreement. Each blue dot represents the difference between the two scores plotted against their mean for each individual.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/ac071103a307e7b3ff95c161.png"},{"id":104882901,"identity":"ffc07f64-7013-4b83-a75f-e96ca789fe5a","added_by":"auto","created_at":"2026-03-18 09:39:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1159498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/abcc13c5-c076-4fb3-b0e8-c01be6fe1343.pdf"},{"id":89573835,"identity":"df41b5b9-6bdd-4ea8-8340-d6601040cf07","added_by":"auto","created_at":"2025-08-21 12:48:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":92745,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/45c1221ee5673035753113a2.docx"},{"id":89573837,"identity":"9f2da601-21ae-4b8d-a256-0248545d0113","added_by":"auto","created_at":"2025-08-21 12:48:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22724,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/1cce495ebb8fc135dee767a9.docx"},{"id":89575534,"identity":"e54e1e76-a4ca-4220-a2fa-99347fbaf78e","added_by":"auto","created_at":"2025-08-21 12:56:49","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25091,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/5cc201958284858fd76ace19.docx"},{"id":89573583,"identity":"98ec03e7-f663-445c-8b57-cd16d75378c9","added_by":"auto","created_at":"2025-08-21 12:40:49","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18186,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-7158813/v1/fe8bc0e8fc468e058124d71e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of HINT-8 and EQ-5D-5L for assessing Health-Related Quality of Life in patients with precancerous cervical lesions","fulltext":[{"header":"Background","content":"\u003cp\u003eCervical intraepithelial neoplasia (CIN) is the most common precancerous lesion of the cervix, characterized by atypical squamous cell changes. CIN is classified into three grades\u0026mdash;CIN 1 (mild), CIN 2 (moderate), and CIN 3 (severe)\u0026mdash;based on the depth of epithelial involvement (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Persistent infection with high-risk human papillomavirus (HPV) is a major etiological factor in the progression of CIN, leading to abnormal epithelial proliferation and the potential development of intraepithelial tumors (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). While low-grade CIN (CIN 1) often resolves spontaneously, high-grade lesions (CIN 2 and CIN 3) have a greater likelihood of progressing to cervical carcinoma in situ (CIS), a precancerous condition equivalent to stage 0 cervical cancer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Unlike many other malignancies, cervical cancer is largely preventable due to its long preclinical phase, allowing for early detection through routine screening programs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite a significant decline in cervical cancer incidence in high-income countries due to widespread screening and HPV vaccination, the disease remains a leading cause of cancer-related mortality among women in low- and middle-income countries (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although advancements in cervical cancer diagnosis and treatment have improved patient outcomes, their negative impact on health-related quality of life (HRQoL) begins even before a definitive diagnosis is made (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Assessing HRQoL in women with CIN and CIS is of particular importance in women\u0026rsquo;s health, as these conditions can significantly affect not only physical health but also psychological and social well-being. HRQoL evaluation provides essential insights for patient-centered care, informs clinical decision-making, and helps tailor supportive interventions to improve overall outcomes in this population. Psychological distress, including fear of cancer, self-blame, pain, and anxiety, can significantly impair HRQoL in affected individuals, underscoring the need for comprehensive patient-centered care strategies (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe World Health Organization defines quality of life as an individual\u0026rsquo;s perception of their position in life within the context of their environment and the value systems, including goals, expectations, standards, and concerns (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). HRQoL refers specifically to an individual\u0026rsquo;s perception of how their health status impacts their overall life functions, emotions, and daily activities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This subjective measure varies across cultures and nations; terms like \"health,\" \"sense of illness,\" \"suffering,\" and \"disease\" can hold a range of meanings depending on one\u0026rsquo;s cultural values (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Consequently, using HRQoL measurement tools that align with a specific culture\u0026rsquo;s language and practices is essential for accurate assessments (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDeveloped by the EuroQol Group, the EQ-5D (EuroQol 5 Dimensions) provides a simple descriptive profile and single index value that can be used in clinical and economic evaluations of healthcare and in population health surveys (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Its design allows for efficient data collection, making it suitable for large-scale studies. Additionally, the EQ-5D is recommended by several health technology assessment bodies internationally as a key component of cost-utility analysis (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Originally developed with a 3-level response system (3L), the EQ-5D was later expanded to the EQ-5D-5L (EuroQol 5 Dimensions, 5 Levels) to improve sensitivity and reduce ceiling effects. Its generic nature enables its application across various diseases and health conditions, facilitating comparisons in health research and policy development. It is utilized both domestically and internationally. In Korea, it is employed in surveys such as the Korea National Health and Nutrition Examination Survey and the Korea Health Panel Survey (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Since its development in Europe, the EQ-5D has been employed in numerous national health surveys, including the Health Survey for England, the Canadian Community Health Survey, the Japanese National Health and Nutrition Survey, and the German Health Interview and Examination Survey (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, the EQ-5D-5L is increasingly used across various clinical disciplines. Several studies have demonstrated its utility in assessing HRQoL in regards to women\u0026rsquo;s health conditions such as CIN, cervical cancer, and gynecologic oncology (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, Western-centric HRQoL measurement tools like the EQ-5D-5L may not fully reflect the cultural backgrounds and health perceptions of people from non-Western countries. In particular, in Asian countries, these HRQoL assessment tools may not accurately assess quality of life. Recognizing these limitations, the Korea Disease Control and Prevention Agency developed the HINT-8 (Health-related Quality of Life Instrument with 8 Items) in 2014 as a culturally appropriate alternative (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince its introduction, HINT-8 has demonstrated certain benefits over EQ-5D-5L, including reduced ceiling effects, suggesting an improved sensitivity in detecting variations in HRQoL (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Studies have validated its use in breast cancer, type 2 diabetes, and elderly populations, where it has shown higher responsiveness compared to conventional tools (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although HINT-8 was developed in Korea, it has great potential to complement the limitations of the existing international standard assessment tool, EQ-5D, and holds significant promise for future international use. So far, HINT-8 has been officially utilized only in Korea. However, as it incorporates factors that enable a more comprehensive assessment of quality of life, it has strong potential for application in other countries, including those in Asia. Despite these advantages, HINT-8 has not yet been internationally recognized or validated for use beyond Korea. Given the increasing global demand for culturally adaptive HRQoL tools, further research is needed to assess the cross-cultural applicability of HINT-8 and to explore its potential for use in other countries.\u003c/p\u003e\u003cp\u003eThis study aims to evaluate the HRQoL of CIN and CIS patients using both EQ-5D-5L and HINT-8, providing a comparative analysis of their sensitivity and applicability. By assessing their agreement, ceiling effects, and ability to detect HRQoL variations, this research aims to determine whether HINT-8 can serve as a viable alternative or complementary measure to existing tools. Additionally, this study seeks to explore whether HINT-8 can evolve into an internationally applicable HRQoL assessment tool rather than being confined to use only in Korea. Given its strong potential to complement the cultural limitations of EQ-5D, this research will contribute to evaluating the international scalability of HINT-8. Furthermore, this study contributes a first step in exploring the potential for the international adaptation of HINT-8, highlighting the need for future cross-cultural validation studies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis cross-sectional study was conducted from August 2023 to February 2024 at 12 tertiary hospitals in South Korea. The study included 80 female patients aged 19 years or older who had been clinically diagnosed with CIN or CIS. Participants were required to understand the purpose and procedures of the study and to provide written informed consent before participation. The survey was administered in person during outpatient visits. A detailed study protocol, including a flow chart of participant recruitment and data collection, is provided in Additional file 1. The sample size (n\u0026thinsp;=\u0026thinsp;80) was determined based on the primary objective of comparing the two HRQoL instruments. A brief justification is provided here, with comprehensive details and statistical rationale available in Additional File 2.\u003c/p\u003e\u003cp\u003eIn addition to response to the HRQoL questionnaires, demographic information (gender, age, education level, marital status, monthly household income, household size, employment status, and religion) and clinical information (disease and surgery status) were collected from each participant. Surgical status included whether the participant had undergone conization or hysterectomy following diagnosis. Missing values due to incomplete responses were not imputed; analyses were performed using available data for each participant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHRQoL measurement tools\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe EQ-5D-5L, developed by the Euro-QoL Group in 1987, is a widely used tool in the healthcare field to measure HRQoL. It consists of five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and five levels of response (no problems, slight problems, moderate problems, severe problems, extreme problems) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The EQ-5D-5L index was calculated using a previously described valuation set (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The index value of the EQ-5D-5L ranges from \u0026minus;\u0026thinsp;0.066 (worst health state, 55555) to 1 (best health state, 11111), with higher scores indicating better health.\u003c/p\u003e\u003cp\u003eThe HINT-8, developed by the Korea Disease Control and Prevention Agency in 2014 for the general population in Korea, includes eight items (climbing stairs, pain, vitality, working, depression, memory, sleep, happiness) and four response levels (no problems, mild problems, moderate problems, severe problems), representing a total of 65,536 possible health states (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The index value of HINT-8 ranges from 0.132 (worst health state, 44444444) to 1 (best health state, 11111111), with values closer to 1 indicating better health status. Further details on the development, scoring, and psychometric properties of HINT-8 are described in Additional File 3.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical analysis methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDescriptive statistics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe general and clinical characteristics of the study participants were analyzed using descriptive statistics. Differences between two groups were assessed using the Mann-Whitney U test, while differences among three or more groups were evaluated using the Kruskal-Wallis test. A p-value of less than 0.05 was considered statistically significant. The proportion of respondents reporting the best health state in each tool was calculated to assess the ceiling effect, and the score distributions of the two tools were compared. Quality of life indices were calculated by linking EQ-5D-5L scores with each HINT-8 item, and score distributions were visualized as curves using a kernel density function.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAgreement analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo evaluate the agreement between the EQ-5D-5L and HINT-8 tools, Bland-Altman plots were used to determine the mean index and 95% confidence interval for the two tools (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Additionally, Intraclass Correlation Coefficients (ICC) were calculated to assess the level of agreement between the two tools. An ICC value below 0.50 indicates poor agreement, 0.50\u0026ndash;0.75 indicates moderate agreement, 0.75\u0026ndash;0.90 indicates good agreement, and values above 0.90 indicate excellent agreement (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTest performance\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInternal validity was assessed using Cronbach's alpha, where a value of 0.70\u0026ndash;0.79 indicates acceptable reliability and 0.80 or higher indicates excellent reliability (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Construct validity was evaluated by calculating correlation coefficients between the EQ-5D-5L and HINT-8 tools. Pearson correlation analysis was used for the indices of both tools, while Spearman correlation analysis was applied to individual items. Absolute correlation values of 0.8 or higher indicate a very strong association, 0.60\u0026ndash;0.79 a strong association, 0.40\u0026ndash;0.59 a moderate association, and 0.40 or lower a weak association (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Cohen's d was used to estimate effect size (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Statistical analyses were performed using IBM SPSS Statistics 27 and R version 4.1.3.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eGeneral and clinical characteristics of study participants and score distribution of quality of life tools\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the general characteristics of the study participants and their HRQoL as measured by the EQ-5D-5L and HINT-8 indices. The study included 80 female patients diagnosed with CIS or CIN. The participants were relatively evenly distributed across age groups, ranging from their 20s to 50s and above, with the largest group aged 30\u0026ndash;39 years (31.3%, n\u0026thinsp;=\u0026thinsp;25). There was a fairly even division in marital status, with slightly more than half of the participants being single (52.5%, n\u0026thinsp;=\u0026thinsp;42). In regards to household size, multi-person households dominated (80.9%, n\u0026thinsp;=\u0026thinsp;64). The majority of participants (68.8%, n\u0026thinsp;=\u0026thinsp;55) had graduated from college or higher. The most commonly reported monthly household income was 5\u0026nbsp;million KRW or more, with 52.5% (n\u0026thinsp;=\u0026thinsp;42) of participants falling into this category. A total of 61.3% (n\u0026thinsp;=\u0026thinsp;49) were employed or self-employed, while 60.0% (n\u0026thinsp;=\u0026thinsp;48) reported having no religious affiliation. Regarding disease status, 30.0% (n\u0026thinsp;=\u0026thinsp;24) had CIN 1, and 70.0% (n\u0026thinsp;=\u0026thinsp;56) had CIN 2/3 or CIS. Additionally, 63.7% (n\u0026thinsp;=\u0026thinsp;51) had undergone surgery, while 28.7% (n\u0026thinsp;=\u0026thinsp;23) had not.\u003c/p\u003e\u003cp\u003eSignificant differences were observed in the variables of marital status and employment status. In terms of marital status, significant differences were found in both the EQ-5D-5L index (p\u0026thinsp;=\u0026thinsp;0.017) and HINT-8 index (p\u0026thinsp;=\u0026thinsp;0.004). Similarly, employment status also showed significant differences in both the EQ-5D-5L index (p\u0026thinsp;=\u0026thinsp;0.005) and HINT-8 index (p\u0026thinsp;=\u0026thinsp;0.002). However, no significant differences were found for other variables, including age, education level, income level, family composition, religion, disease status, and surgery status (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral characteristics of study participants and health-related quality of life\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eN(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eEQ-5D-5L index\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eHINT-8 index\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHRQoL\u003c/p\u003e\u003cp\u003e(M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHRQoL\u003c/p\u003e\u003cp\u003e(M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.877\u0026thinsp;\u0026plusmn;\u0026thinsp;0.114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.830\u0026thinsp;\u0026plusmn;\u0026thinsp;0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.840\u0026thinsp;\u0026plusmn;\u0026thinsp;0.129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.781\u0026thinsp;\u0026plusmn;\u0026thinsp;0.148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.232\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (31.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.886\u0026thinsp;\u0026plusmn;\u0026thinsp;0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.856\u0026thinsp;\u0026plusmn;\u0026thinsp;0.084\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.872\u0026thinsp;\u0026plusmn;\u0026thinsp;0.093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.827\u0026thinsp;\u0026plusmn;\u0026thinsp;0.058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 and more\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.907\u0026thinsp;\u0026plusmn;\u0026thinsp;0.143\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.853\u0026thinsp;\u0026plusmn;\u0026thinsp;0.142\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMarital status\u003csup\u003e✝\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (52.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.851\u0026thinsp;\u0026plusmn;\u0026thinsp;0.121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.017*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.802\u0026thinsp;\u0026plusmn;\u0026thinsp;0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.004**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo single\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (46.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.908\u0026thinsp;\u0026plusmn;\u0026thinsp;0.100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.863\u0026thinsp;\u0026plusmn;\u0026thinsp;0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHousehold Size\u003csup\u003e✝\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-person household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.825\u0026thinsp;\u0026plusmn;\u0026thinsp;0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.815\u0026thinsp;\u0026plusmn;\u0026thinsp;0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.381\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMulti-person household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (80.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.887\u0026thinsp;\u0026plusmn;\u0026thinsp;0.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.833\u0026thinsp;\u0026plusmn;\u0026thinsp;0.199\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEducation\u003csup\u003e✝\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle school or lower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.931\u0026thinsp;\u0026plusmn;\u0026thinsp;0.169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.882\u0026thinsp;\u0026plusmn;\u0026thinsp;0.173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.115\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (22.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.913\u0026thinsp;\u0026plusmn;\u0026thinsp;0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.836\u0026thinsp;\u0026plusmn;\u0026thinsp;0.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (68.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.857\u0026thinsp;\u0026plusmn;\u0026thinsp;0.110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.820\u0026thinsp;\u0026plusmn;\u0026thinsp;0.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMonthly household income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess than 5\u0026nbsp;million KRW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (47.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.819\u0026thinsp;\u0026plusmn;\u0026thinsp;0.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.748\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.829\u0026thinsp;\u0026plusmn;\u0026thinsp;0.116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.717\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore than 5\u0026nbsp;million KRW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (52.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.875\u0026thinsp;\u0026plusmn;\u0026thinsp;0.106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.832\u0026thinsp;\u0026plusmn;\u0026thinsp;0.120\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed/Self-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (61.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.877\u0026thinsp;\u0026plusmn;\u0026thinsp;0.093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.005**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.842\u0026thinsp;\u0026plusmn;\u0026thinsp;0.087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.002**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousewife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (27.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.914\u0026thinsp;\u0026plusmn;\u0026thinsp;0.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.862\u0026thinsp;\u0026plusmn;\u0026thinsp;0.130\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent/Unemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (11.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.787\u0026thinsp;\u0026plusmn;\u0026thinsp;0.111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.690\u0026thinsp;\u0026plusmn;\u0026thinsp;0.117\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eReligion\u003csup\u003e✝\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (37.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.877\u0026thinsp;\u0026plusmn;\u0026thinsp;0.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.834\u0026thinsp;\u0026plusmn;\u0026thinsp;0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.575\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.875\u0026thinsp;\u0026plusmn;\u0026thinsp;0.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.826\u0026thinsp;\u0026plusmn;\u0026thinsp;0.128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDisease status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCIN 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.856\u0026thinsp;\u0026plusmn;\u0026thinsp;0.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.812\u0026thinsp;\u0026plusmn;\u0026thinsp;0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.239\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCIN 2/3, CIS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 (70.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.886\u0026thinsp;\u0026plusmn;\u0026thinsp;0.118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.838\u0026thinsp;\u0026plusmn;\u0026thinsp;0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSurgery status\u003csup\u003e✝\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (63.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.876\u0026thinsp;\u0026plusmn;\u0026thinsp;0.127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.832\u0026thinsp;\u0026plusmn;\u0026thinsp;0.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.991\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (28.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.890\u0026thinsp;\u0026plusmn;\u0026thinsp;0.080\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.846\u0026thinsp;\u0026plusmn;\u0026thinsp;0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003cp\u003e** p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003cp\u003e1 USD\u0026thinsp;=\u0026thinsp;1,325.10 KRW\u003c/p\u003e\u003cp\u003eAbbreviation: HRQoL, Health-Related Quality of Life; EQ-5D-5L, EuroQol 5-Dimension 5-Level; HINT-8, Health-related Quality of Life Instrument with 8 Items; CIN, Cervical Intraepithelial Neoplasia; CIS, Carcinoma in Situ; M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e\u003csup\u003e✝\u003c/sup\u003eVariables not totaling 100% indicate the presence of missing values.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eScore distribution and mean differences between EQ-5D-5L and HINT-8\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the relationship between individual HINT-8 item levels and the mean EQ-5D-5L index scores. The overall mean score of the HINT-8 was 0.830\u0026thinsp;\u0026plusmn;\u0026thinsp;0.117, while the mean EQ-5D-5L score was 0.878\u0026thinsp;\u0026plusmn;\u0026thinsp;0.114. The EQ-5D-5L index scores were primarily concentrated between 0.8 and 1.0, with a ceiling effect of 35% and a floor effect of 1.25%. In contrast, the HINT-8 index scores were distributed across a wider range (0.6 to 1.0), showing a reduced ceiling effect of 15% and no floor effect (0%), indicating greater measurement diversity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, the mean difference between the EQ-5D-5L and HINT-8 index scores indicates a small to moderate effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.373, 95% CI: 0.213\u0026ndash;0.533), suggesting that although there is a difference between the two tools, it is not substantial.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the HRQoL scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHINT-8\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEQ-5D-5L\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean of the index, M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.830\u0026thinsp;\u0026plusmn;\u0026thinsp;0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.878\u0026thinsp;\u0026plusmn;\u0026thinsp;0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDifference in paired samples t-test, p-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCeiling effect\u003csup\u003ea\u003c/sup\u003e, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (15.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (35.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFloor effect\u003csup\u003eb\u003c/sup\u003e, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eCeiling effect represents the best health state, defined as the proportion of respondents reporting no problems across all dimensions of the respective index.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eFloor effect represents the worst health state, defined as the proportion of respondents reporting severe problems across all dimensions of the respective index.\u003c/p\u003e\u003cp\u003e\u003cb\u003eComparison of EQ-5D-5L index to individual items in HINT-8\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the EQ-5D-5L index scores stratified by the levels of individual HINT-8 items, illustrating the relationship between specific health dimensions assessed by HINT-8 and overall health status as measured by the EQ-5D-5L. A general trend was observed across all HINT-8 items, indicating that the EQ-5D-5L index decreased as the severity levels of HINT-8 responses increased.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the EQ-5D-5L index scores across individual HINT-8 items\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHINT-8 item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLevel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEQ-5D-5L index, M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eClimbing stairs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (72.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.898\u0026thinsp;\u0026plusmn;\u0026thinsp;0.106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (23.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.850\u0026thinsp;\u0026plusmn;\u0026thinsp;0.089\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.638\u0026thinsp;\u0026plusmn;\u0026thinsp;0.135\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (58.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.929\u0026thinsp;\u0026plusmn;\u0026thinsp;0.083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (37.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.824\u0026thinsp;\u0026plusmn;\u0026thinsp;0.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.558\u0026thinsp;\u0026plusmn;\u0026thinsp;0.040\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.671\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eVitality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (31.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.949\u0026thinsp;\u0026plusmn;\u0026thinsp;0.090\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (42.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.886\u0026thinsp;\u0026plusmn;\u0026thinsp;0.077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (21.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.798\u0026thinsp;\u0026plusmn;\u0026thinsp;0.100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.685\u0026thinsp;\u0026plusmn;\u0026thinsp;0.176\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eWorking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (65.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.915\u0026thinsp;\u0026plusmn;\u0026thinsp;0.078\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (27.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.836\u0026thinsp;\u0026plusmn;\u0026thinsp;0.127\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.721\u0026thinsp;\u0026plusmn;\u0026thinsp;0.123\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.586\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (43.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.963\u0026thinsp;\u0026plusmn;\u0026thinsp;0.064\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.829\u0026thinsp;\u0026plusmn;\u0026thinsp;0.085\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.786\u0026thinsp;\u0026plusmn;\u0026thinsp;0.101\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.689\u0026thinsp;\u0026plusmn;\u0026thinsp;0.161\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMemory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (61.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.906\u0026thinsp;\u0026plusmn;\u0026thinsp;0.087\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (28.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.133\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.752\u0026thinsp;\u0026plusmn;\u0026thinsp;0.123\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (43.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.935\u0026thinsp;\u0026plusmn;\u0026thinsp;0.078\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (41.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.859\u0026thinsp;\u0026plusmn;\u0026thinsp;0.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (15.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.759\u0026thinsp;\u0026plusmn;\u0026thinsp;0.118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eHappiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (27.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.975\u0026thinsp;\u0026plusmn;\u0026thinsp;0.067\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (38.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.886\u0026thinsp;\u0026plusmn;\u0026thinsp;0.075\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.793\u0026thinsp;\u0026plusmn;\u0026thinsp;0.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.741\u0026thinsp;\u0026plusmn;\u0026thinsp;0.178\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eM\u0026plusmn;SD indicates mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCorrelation analysis between EQ-5D-5L and HINT-8\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the correlation between individual HINT-8 items and EQ-5D-5L domains, along with the overall indices. The correlation coefficient between the EQ-5D-5L index and the HINT-8 index was 0.792 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating a strong correlation between the two tools. For specific items, a high correlation was observed between the pain/discomfort item in EQ-5D-5L and the pain item in HINT-8 (0.702), as well as between the anxiety/depression item in EQ-5D-5L and the depression item in HINT-8 (0.824). Additionally, the anxiety/depression item in EQ-5D-5L showed moderate correlations with the vitality, sleep, and happiness items in HINT-8 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between EQ-5D-5L and HINT-8\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHINT-8 item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eEQ-5D-5L domain\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMobility\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-care\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUsual\u003c/p\u003e\u003cp\u003eactivities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePain/\u003c/p\u003e\u003cp\u003eDiscomfort\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAnxiety/\u003c/p\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEQ-5D-5L index\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClimbing stairs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.415**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.352**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.253*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.320**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.309**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.344**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.702**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.314**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVitality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.255*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.256*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.403**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.598**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.466**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.403**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.440**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.423**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.247*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.186\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.318**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.437**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.824**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMemory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.078\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.264*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.317**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.367**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.222*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.359**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.546**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHappiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.270*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.275*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.397**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.688**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHINT-8 index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.792**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e* p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e** p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAgreement and Reliability of EQ-5D-5L and HINT-8\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Bland-Altman plot shows the agreement between the EQ-5D-5L and HINT-8 scores (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean difference was 0.047, indicating that EQ-5D-5L generally yielded slightly higher HRQoL scores than HINT-8. Most data points lie within the 95% limits of agreement (\u0026minus;\u0026thinsp;0.10 to 0.193), suggesting an acceptable level of agreement between the two tools. However, a few observations outside these bounds indicate individual-level discrepancies. The pattern of differences also suggests that the tools may not be fully interchangeable, especially at higher levels of perceived health.\u003c/p\u003e\u003cp\u003eThe ICC analysis showed a value of 0.847 (95% CI: 0.614\u0026ndash;0.925), indicating a very high level of agreement between the EQ-5D-5L and HINT-8 index. Additionally, Cronbach's alpha analysis revealed an alpha value of approximately 0.678 for EQ-5D-5L and 0.859 for HINT-8, suggesting that HINT-8 has higher internal consistency and reliability compared to EQ-5D-5L.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the HRQoL of patients with CIS and CIN was evaluated using the EQ-5D-5L and HINT-8 tools. CIN and CIS are recognized as precancerous conditions of the cervix, representing critical public health concerns in women's health (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Due to their potential progression to invasive cervical cancer, early detection, timely intervention, and health behavior modification are essential to improving outcomes and preventing disease advancement (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The differences in HRQoL between the tools were quantitatively analyzed, and the reliability and validity of the HINT-8 tool were verified. The HRQoL indices measured were 0.83 for HINT-8 and 0.88 for EQ-5D-5L, with the EQ-5D-5L index being significantly higher.\u003c/p\u003e\u003cp\u003eThe analysis of group differences in HRQoL revealed that marital status had a significant impact on quality of life indices measured by both EQ-5D-5L (p\u0026thinsp;=\u0026thinsp;0.017) and HINT-8 (p\u0026thinsp;=\u0026thinsp;0.004). This finding aligns with previous research suggesting that marital status is an important determinant of quality of life among cervical cancer patients. Although direct evidence on the impact of marital status on the quality of life in CIS and CIN patients is currently limited, studies involving cervical cancer patients provide useful insights due to the clinical and psychosocial similarities between the groups. Some studies have reported that married individuals experience better QoL outcomes compared to their single counterparts (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). For instance, marriage has been associated with earlier diagnosis and improved survival in cervical cancer patients, possibly due to healthier behaviors, broader health insurance coverage, and stronger socio-economic support available to married women (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConversely, another study has found that married cervical cancer patients may experience lower QoL than unmarried patients (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), which is consistent with the findings of the present study. These mixed findings suggest that the relationship between marital status and QoL is multifaceted and may be influenced by cultural, social, and individual contextual factors. Further research is needed to clarify these dynamics and to inform targeted interventions that consider marital status and other socio-demographic characteristics when addressing the quality of life needs of patients with CIS, CIN, and related conditions.\u003c/p\u003e\u003cp\u003eEmployment status also showed a significant impact on HRQoL among patients with CIN and CIS in both EQ-5D-5L (p\u0026thinsp;=\u0026thinsp;0.005) and HINT-8 (p\u0026thinsp;=\u0026thinsp;0.002). Employment is widely recognized as a key determinant of HRQoL, offering benefits such as financial security, social engagement, and psychological stability (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This association is especially important for patients with CIN and CIS. Although they do not face an immediate life-threatening condition like invasive cancer, they must deal with uncertainty about disease progression, regular medical check-ups, and possible surgical treatments. The psychological burden is further compounded by the stigma and emotional distress often associated with reproductive health issues. In this context, employment may serve as a stabilizing factor, providing daily structure, social interaction, and a sense of purpose, thereby helping to buffer against these stressors. Social determinants such as marital status and employment were found to significantly influence HRQoL in women with CIN and CIS (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). These findings underscore the broader social context of women\u0026rsquo;s health and support the need for holistic care strategies that consider both clinical and socio-economic factors in managing precancerous cervical conditions.\u003c/p\u003e\u003cp\u003eThis observation aligns with previous studies on women with low-grade cytological abnormalities, which similarly found that employment status affects the distribution of quality of life (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). It is also consistent with research demonstrating differences in HRQoL among cancer patients based on employment status (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), and among ovarian cancer patients according to occupation type (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). These findings underscore the crucial role of employment, not only in regards to psychological well-being, but also in fostering emotional support, financial stability, and ultimately, healthy behaviors and adherence to treatment. Beyond physical health, CIN and CIS diagnoses are often accompanied by significant psychological distress, including anxiety, depression, fear of cancer, and self-blame. These emotional burdens can substantially impair a woman\u0026rsquo;s HRQoL, highlighting the importance of addressing mental and emotional well-being in clinical care and quality of life assessments.\u003c/p\u003e\u003cp\u003eHowever, due to differences in cancer types, occupation classifications, and the small sample size, the generalizability of the results is limited. Therefore, future studies should include larger sample sizes and a wider range of cancer types and occupational groups for further analysis. In contrast, other sociodemographic and clinical variables did not show significant differences in quality of life indices.\u003c/p\u003e\u003cp\u003eThe EQ-5D plays an essential role in research on women\u0026rsquo;s health. For instance, in China, it was used to evaluate the responsiveness and minimal clinically important difference of the EQ-5D-5L for assessing the impact of surgical treatment on CIN patients\u0026rsquo; quality of life (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the United Kingdom, it was applied to measure the quality of life of women with low-grade cytological abnormalities using the EQ-5D-3L (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Japan, the EQ-5D-5L was used to assess the effects of nausea and vomiting on quality of life among patients with menorrhagia and anemia who were taking iron supplements (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In Germany, the EQ-5D was used to evaluate the health utility of female patients undergoing treatment in gynecologic oncology and mammology (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Additionally, Taiwan and Indonesia have applied the EQ-5D to assess the quality of life of patients with cervical cancer and HPV-related cancers, respectively (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These studies demonstrate that the EQ-5D is a valuable tool for evaluating HRQoL in conditions affecting women\u0026rsquo;s health. However, the EQ-5D has some limitations, such as the ceiling effect, which may restrict its ability to detect subtle changes in quality of life, particularly in populations with higher health levels. To address these limitations, the HINT-8 was developed in Korea (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe HINT-8 includes a broader range of health states compared to commonly used tools like the EQ-5D, and in comparison to the EQ-5D-5L, HINT-8 demonstrates favorable characteristics regarding the ceiling effect (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A study evaluating the validity and reliability of the HINT-8 among Korean breast cancer patients found that the proportion of patients reporting a perfect health state was 21.0% with the EQ-5D-5L, while it was only 2.3% with the HINT-8 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The ceiling effect refers to a phenomenon where a tool fails to sufficiently distinguish among higher scores (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), meaning that when measuring HRQoL, it indicates the highest possible score when respondents report no problems across all domains of a tool. Lower ceiling effects suggest that the tool more accurately reflects variations in quality of life (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In studies with breast cancer patients, the HINT-8 was found to capture changes in quality of life more precisely than the EQ-5D-5L and was evaluated as well-suited to reflect the cultural and social context of Korean patients (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Additionally, in studies involving type 2 diabetes patients, the HINT-8 demonstrated increased sensitivity and specificity in measuring quality of life compared to existing tools, indicating that it is also an effective tool for assessing quality of life in patients with various chronic diseases (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Analyses of data from the Korea National Health and Nutrition Examination Survey have also shown that the HINT-8 has strong internal consistency and can be appropriately applied across diverse demographic characteristics and health statuses (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBoth EQ-5D-5L and HINT-8 exhibited ceiling and floor effects; however, the ceiling effect was less pronounced in HINT-8 (15%) than it was in EQ-5D-5L (35%). This indicates that EQ-5D-5L tends to concentrate scores at the upper end of the distribution, while HINT-8 may be better suited for distinguishing individuals with a high quality of life. Furthermore, a study on breast cancer patients reported an 18.6% reduction in the ceiling effect for HINT-8 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Similarly, in this study, HINT-8 showed a 20% reduction in the ceiling effect, demonstrating a comparable trend. Since a pronounced ceiling effect can reduce the sensitivity of an instrument, HINT-8 may be a more suitable tool for detailed quality-of-life assessments.\u003c/p\u003e\u003cp\u003eThe correlation coefficient between the EQ-5D-5L and HINT-8 indices was 0.792, indicating a high level of consistency between the two tools. This value was higher than the correlation coefficients derived from studies validating EQ-5D and HINT-8 tools in populations such as breast cancer patients, diabetes patients, and older adults, suggesting that HINT-8 could complement or substitute EQ-5D-5L (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Additionally, the combined use of these tools may yield synergistic effects. The ICC value (0.847) confirmed better measurement agreement compared to previous studies (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), indicating excellent consistency between the two tools. Cronbach's alpha analysis showed that HINT-8 exhibited higher reliability than EQ-5D-5L, demonstrating superior internal consistency. The effect size between the two indices was moderate, indicating minimal differences between the tools.\u003c/p\u003e\u003cp\u003eThis study was conducted with a relatively small sample size of 80 participants, most of whom had mild cases, resulting in fewer patients being included from tertiary hospitals. The sample size was determined based on the primary objective of comparing the two HRQoL instruments, with detailed justification provided in Additional File 3. While the sample size is sufficient for the main analyses, caution is warranted when interpreting subgroup analyses due to limited statistical power, which may also restrict the generalizability of the findings. Nevertheless,efforts were made to enhance the study's representativeness by including patients from various regions; this was accomplished by collaborating with 12 hospitals nationwide. CIN 1 typically undergoes spontaneous regression, while CIN 2\u0026ndash;3 and CIS, which are considered pre-cancerous lesions, require surgical treatments such as conization or hysterectomy (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Compared to CIN 1, the follow-up intervals for CIN 2\u0026ndash;3 and CIS are shorter, and there is a higher concern for recurrence. These disease characteristics can potentially affect the HRQoL of the patients. The inclusion of only 56 patients with CIN 2\u0026ndash;3 and CIS in this study was insufficient to perform a subgroup analysis. Further studies with larger sample sizes will be needed in the future. Additionally, the key strength of this study lies in its comprehensive examination of HRQoL differences by incorporating both sociodemographic and clinical factors through surveys and medical record analysis. Importantly, the comparison of two quality-of-life assessment tools adds significant value by verifying their respective characteristics and applicability. For patients with CIN and CIS in South Korea, the HINT-8 showed lower ceiling effects, higher internal consistency, and greater sensitivity to HRQoL changes compared to the EQ-5D-5L. However, if HINT-8 is to complement or replace EQ-5D-5L, international validation studies that include other ethnic populations will be necessary.\u003c/p\u003e\u003cp\u003eBased on these findings, the HRQoL assessments using EQ-5D-5L and HINT-8 highlight the potential for developing tailored management programs for CIS and CIN patients. In South Korea, the prevalence and incidence rates of CIS and CIN are significant among women\u0026rsquo;s health issues (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), emphasizing the need to study their quality of life. Given the significant impact of employment status on quality of life, programs supporting job retention and return to work could be effective strategies. Utilizing the unique features of each tool allows for customized interventions, making it crucial to develop management strategies that address patients' needs and improve their quality of life. Additionally, although HINT-8 was developed in Korea, its strong cultural relevance, lower ceiling effects, and broader coverage of health domains\u0026mdash;while maintaining a validated unidimensional structure\u0026mdash; suggest its potential utility in other non-Western settings. This tool may be particularly valuable in low- and middle-income countries where culturally adapted HRQoL assessments are needed to capture diverse health perceptions and improve patient-centered care. Considering its potential for international expansion, it could become a widely utilized tool through multinational studies. To this end, this study holds significant value as a pioneering effort in validating the utility of HINT-8, and it may serve as a foundational reference for future international validation efforts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study compared the EQ-5D-5L and HINT-8 instruments to evaluate the HRQoL in women diagnosed with CIN and CIS. Compared to the EQ-5D-5L, the HINT-8 demonstrated lower ceiling effects, higher internal consistency, and the potential to more sensitively capture differences in quality of life. Based on its cultural appropriateness and psychometric advantages, HINT-8 may serve as a complementary or alternative tool to the EQ-5D-5L and holds potential for future application in international women\u0026rsquo;s health research and policy development.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were informed of the study\u0026apos;s purpose and procedures and provided written consent to participate. The study was approved by the Central Research Ethics Committee of Kongju National University (Approval No. KNU_IRB_2023-49). IRB approval numbers for each hospital are listed in (Additional file 4). This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that all participants provided consent for publication. No identifying information is included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be made available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;interest\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Korea Disease Control and Prevention Agency [#2023-10-012].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Woo-Jeong Sim,\u0026nbsp;Min-Ju Kim, Gyeong-U Hong, Ah-Yeon Lee, Ji-Eun An, Se-Ik Kim, Tae-Wook Kong, Byung-Su Kwon, Sung-Taek Park, Kyeong-A So, Won-Moo Lee, Jung-Yun Lee, Dae-Hoon Jeong, Min-Chul Choi, Youn-Jin Choi, Jae-Kwan Lee, Su-Yeon Yu, Kyung-Jin Min, and\u0026nbsp;Soo-Hyun Lee. Data\u0026nbsp;analysis was\u0026nbsp;performed by Woo-Jeong Sim, Min-Ju Kim, Gyeong-U Hong, Ah-Yeon Lee, Ji-Eun An, Su-Yeon Yu, and Soo-Hyun Lee. The first draft of the manuscript was written by Woo-Jeong Sim, Su-Yeon Yu,\u0026nbsp;Kyung-Jin Min,\u0026nbsp;and\u0026nbsp;Soo-Hyun Lee, and all authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to all the patients who participated in this study and to the clinical teams at the 12 participating hospitals for their valuable cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMartin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2010;6(6):CD001318.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim J, Lee D, Son K-B, Bae S. The burden of cervical cancer in Korea: a population-based study. Int J Environ Res Public Health. 2020;17(17):6308.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrciani M, Caffarini M, Lazzarini R, Delli Carpini G, Tsiroglou D, Di Primio R, Ciavattini A. 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Asian Pac J Cancer Prev. 2014;15(16):6691\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark L, Jun S, Lee JA. Quality of life and associated factor among cancer survivors in Korea. Korean J Health Promotion. 2018;18(1):7\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShao Z, Zhu T, Zhang P, Wen Q, Li D, Wang S. Association of financial status and the quality of life in Chinese women with recurrent ovarian cancer. Health Qual Life Outcomes. 2017;15(1):144.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJo M. Development of the measurement tool for health related quality of life in the Korea National Health and Nutrition Examination Survey. Cheongju: Korea Centers for Disease Control \u0026amp; Prevention; 2014. p. 97.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee E-H. Internal structure of the Health-Related Quality of Life Instrument with 8-items in a nationally representative population. J Korean Acad Nurs. 2023;53(3):359\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Lower Genit Tract Dis. 2020;24(2):102\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang HK, Seo S-S, Myong J-P, Yu YL, Byun SW. Incidence and costs of cervical intraepithelial neoplasia in the Korean population. J Gynecologic Oncol. 2019;30(3):e37.\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":"Cervical intraepithelial neoplasia (CIN), Carcinoma in situ (CIS), Health-related quality of life (HRQoL), EQ-5D-5L, HINT-8","lastPublishedDoi":"10.21203/rs.3.rs-7158813/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7158813/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackgroud\u003c/h2\u003e\u003cp\u003eGynecological conditions can substantially affect various aspects of women\u0026rsquo;s lives; therefore, health-related quality of life (HRQoL) is regarded as a crucial measure in women\u0026rsquo;s health evaluation. This study evaluated the HRQoL of patients with cervical intraepithelial neoplasia (CIN) and carcinoma in situ (CIS). The EQ-5D-5L (EuroQol 5 Dimensions, 5 Levels) and the Korean HINT-8 (Health-related Quality of Life Instrument with 8 Items) assessment tools were compared to explore whether HINT-8 can be used as an alternative or complementary tool.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted from August 2023 to February 2024 at 12 hospitals in Korea. A total of 80 women aged 19 or older with CIN or CIS participated. They completed the EQ-5D-5L and HINT-8 questionnaires. Demographic and clinical data were also collected. Data were analyzed using non-parametric tests, correlation, Bland-Altman plots, ICC, and Cronbach\u0026rsquo;s alpha.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe average scores were 0.878 for EQ-5D-5L and 0.830 for HINT-8. Employment and marital status affected both scores. The ceiling effect was 35% for EQ-5D-5L and 15% for HINT-8. The two tools were strongly correlated (r\u0026thinsp;=\u0026thinsp;0.792) with high agreement (ICC\u0026thinsp;=\u0026thinsp;0.847). HINT-8 showed good reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.859).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eHINT-8 showed lower ceiling effects, higher internal consistency, and greater sensitivity to HRQoL changes than EQ-5D-5L. It may be a useful tool for assessing HRQoL in CIS and CIN patients. These findings contribute to improving the quality of women\u0026rsquo;s health assessment tools, particularly in the context of early-stage cervical conditions. Further research is needed to explore its applicability in diverse cultural contexts. This study is among the first to explore the potential global use of HINT-8, and it provides a meaningful starting point for future research.\u003c/p\u003e","manuscriptTitle":"Comparison of HINT-8 and EQ-5D-5L for assessing Health-Related Quality of Life in patients with precancerous cervical lesions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 12:40:44","doi":"10.21203/rs.3.rs-7158813/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":"77fc53fe-78cd-4458-99d8-da67d9a2ca3c","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:38:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 12:40:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7158813","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7158813","identity":"rs-7158813","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}