About the Author(s)


Boniwe P. Leeba Email symbol
Department of Clinical Medicine, Faculty of Anaesthesia, University of the Witwatersrand, Johannesburg, South Africa

Raphael N. Maja symbol
Department of Clinical Medicine, Faculty of Anaesthesia, University of the Witwatersrand, Johannesburg, South Africa

Citation


Leeba BP, Maja RN. Quality of life in patients diagnosed with chronic pain at a chronic pain clinic at Helen Joseph Hospital, Gauteng, South Africa. South Afr J Anaesth Analg. 2026;32(1), a1543. https://doi.org/10.4102/sajaa.v32i1.1543

Original Research

Quality of life in patients diagnosed with chronic pain at a chronic pain clinic at Helen Joseph Hospital, Gauteng, South Africa

Boniwe P. Leeba, Raphael N. Maja

Received: 08 Dec. 2025; Accepted: 08 Mar. 2026; Published: 05 May 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Chronic pain is one of the most prevalent chronic conditions globally. Health-related quality of life (HRQoL) is emerging internationally as a key outcome to inform management through evidence-based practices.

Aim: This study assessed the impact of chronic pain on patients’ quality of life (QoL) using a modified, generic and validated instrument (RAND 36-Item Health Survey 1.0).

Setting: Quality of life was assessed among patients diagnosed with chronic pain attending the only specialised public pain clinic in Gauteng, the Helen Joseph Hospital (HJH) Chronic Pain Clinic.

Methods: A descriptive, quantitative cross-sectional study was conducted among patients with chronic pain attending routine follow-up consultations at the HJH Chronic Pain Clinic. Quality of life was measured using a self-administered modified RAND 36-Item Health Survey 1.0.

Results: In total, 181 patients participated; 75.1% were female, and 59.7% were aged ≥ 60 years. Quality of life was assessed across eight RAND-36 domains scored from 0 to 100. Pain severity (0 = very severe pain; 100 = no pain) was the independent variable in regression and correlation analyses. Seven scales scored below 50, indicating poor QoL. Significant associations were found between pain severity and energy, emotional well-being, social functioning, and general health (all p < 0.001). Significant correlations were also observed with role limitations due to emotional problems and physical health.

Conclusion: Chronic pain significantly impairs multiple aspects of QoL. Integrating generic HRQoL measures into clinical practice may aid risk identification and guide targeted therapy.

Contribution: Given the paucity of literature on chronic pain in low- and middle-income countries such as South Africa, this research contributes to evidence on chronic pain by evaluating patient-reported outcomes and highlighting their multidimensional impact on QoL.

Keywords: quality of life; chronic pain; patient-reported outcome measures; pain clinics; South Africa.

Introduction

The International Association for the Study of Pain (IASP) defines chronic pain as ‘pain that persists or recurs for longer than three months’.1 It is one of the most prevalent chronic conditions in the world, with an estimated prevalence of 20% – 25% worldwide.2 One in five South Africans suffers from chronic pain.3

Chronic pain has been shown to have a negative impact on aspects that are considered major determinants of quality of life (QoL). Examples of these are mood, sleep, interpersonal relationships, physical functioning, work productivity and general activity.4 Furthermore, chronic pain has significant cost implications for the economy owing to increased healthcare utilisation and lost work productivity.5,6

The World Health Organization (WHO) defines QoL as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.7 Quality of life is a multidimensional concept, covering a broad range of categories. These include physical, functional, emotional and social well-being.8

Internationally, QoL research is increasingly emerging as an important health research endpoint in many clinical trials, often being used to evaluate the burden of disease and different intervention outcomes to produce best-evidence practice.8 Health-related quality of life (HRQoL) research also provides valuable information to clinicians and policymakers on how to prioritise and allocate resources within the healthcare system.8 Quality of life research is especially important and needed in low- and middle-income countries (LMICs) where psychosocial factors play an essential role in assessing the performance of health systems.9 Compared to developed countries, there is currently a lack of research regarding the impact of chronic pain in LMICs, and such research is important to highlight the burden of disease and decreased QoL in patients living with chronic pain.10

Instruments used to measure HRQoL are classified as either disease targeted or generic. Disease-targeted instruments are relevant and applicable to a particular disease. Generic instruments can be applied to different illnesses. They allow comparisons between studies of different disease states, severity and comorbidities.8,11

The RAND 36-item Health Survey 1.0 is one of the most frequently used HRQoL generic instruments in the world.12 It is a validated, generic, self-administered tool used to measure QoL.

Because of the paucity of literature that currently exists about chronic pain in LMICs, such as South Africa and other sub-Saharan countries,10 the current study aims to highlight the impact of chronic pain on patients’ QoL by using a generic, validated instrument to assess and to characterise QoL in patients diagnosed with chronic pain at the only specialised public pain clinic in the Gauteng province, Helen Joseph Hospital (HJH) Chronic Pain Clinic. The clinic also services neighbouring provinces such as North West, Mpumalanga and Limpopo.

Research methods and design

This is a descriptive, quantitative cross-sectional study. It aims to assess the impact of chronic pain on patients’ QoL at HJH Chronic Pain Clinic.

A consecutive, convenience sampling method was used to approach patients who were eligible to participate in the study as per the inclusion criteria until sample or time saturation. The inclusion criteria were age > 18 years, a diagnosis of chronic non-cancer pain and the ability to provide informed consent and to read and understand English. Exclusion criteria were patients diagnosed with cancer-related chronic pain, substance use disorders or uncontrolled psychiatric disorders, pregnant patients and patients who were unable to read or write English. The study used proxy data from similar studies conducted in primary healthcare centres to estimate the representative sample.4,13 As such, the margin of error was increased to 10% because the methodology had not been established in the setting of specialised pain clinics in South Africa. The Stata 18 statistical programme was used to estimate a sample size of 181.

Quality of life was measured using a modified version of the RAND 36-item Health Survey 1.0, which is a validated, generic, self-administered tool used to measure QoL. It is composed of 36 items (questions) that assess eight health concepts (scales). The 36 items were pooled from a larger group of items developed during the Medical Outcomes Study (MOS) by the RAND Corporation. One of the objectives of the Medical Outcomes Study was to develop practical tools to monitor patient outcomes and their determinants. The eight health concepts include: physical functioning, role limitation because of emotional problems, role limitation because of physical health problems, social functioning, emotional well-being, energy and fatigue, pain and general health perceptions. Each item is scored on a scale from zero to 100, with zero representing low QoL and 100 representing high QoL. The items on each scale are averaged to produce a single score for each scale.

The RAND 36-item Health Survey 1.0 was modified to include information about age (young adult: 18–39 years, middle-aged: 40–59 years and senior: 60+ years), gender, occupation (employed, unemployed and pensioner), diagnosis (chronic primary pain, secondary neuropathic pain, secondary visceral pain, secondary musculoskeletal pain and secondary post-surgical and/or traumatic pain) and location of pain (head, neck, upper limb, lower limb, lower back, unspecified back pain, pelvic, abdominal and generalised). The modification was made as per the terms and conditions outlined by the RAND Corporation. Study participants were approached as per the inclusion criteria. Patients were given an information sheet and asked to complete a single paper-based copy of the modified RAND 36-item Health Survey 1.0.

Statistical analysis

The data collected from the modified RAND 36-item Health Survey 1.0 were scored according to the scoring instructions provided by the RAND Corporation. The data were then entered into a Microsoft Excel spreadsheet. SPSS statistical software was used for data analysis. Mean/standard deviation (s.d.) was used to describe age, while frequency/percentage was used to describe gender, age group, occupation, location of pain and type of chronic pain.

Descriptive statistics in the form of mean/s.d. or median/interquartile range (IQR) was used to analyse the scales, where applicable.

Linear regression was used to determine the effect of pain severity (item 21) on five of the seven QoL scales. As the scales for role limitations because of physical health and emotional problems deviated from normality, Spearman’s correlation was applied to determine the association between pain severity and these two scales. A p-value of less than 0.05 was considered statistically significant. Missing responses were handled by reporting the percentage of missing data for each variable. No imputation was performed, and analyses were based on available data.

Ethical considerations

Ethical clearance to conduct this study was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical) (Ref. No. R14/49).

Approval to conduct the study was obtained from the HJH Medical Advisory Committee and the Head of Department (HOD) of Anaesthesiology at HJH and the Graduate Studies Committee of the University of the Witwatersrand.

Results

All 181 participants completed the questionnaire; however, some items had missing responses, which were reported as unspecified in the descriptive table (Table 3). Of the 181 patients who participated in the study, the majority were female, and the mean age was 60 years (s.d. 13.029), resulting in the majority being classified as senior adults, with most of the participants being pensioners.

The type of chronic pain reported as ‘diagnosis’ was self-reported by participants. Most of the respondents were unaware of this information, which resulted in a high percentage of non-response to this question. Of those who did know this information, the most common diagnosis was ‘musculoskeletal’, followed by ‘chronic primary pain’ and ‘neuropathic’ pain. Pain was most commonly experienced in the lower back and unspecified back (Table 3).

The mean (s.d.)/median (IQR) RAND 36-item scores across the eight scales were: role limitation because of physical health 0.00 (0.00–25.00), role limitation because of emotional problems 0.00 (0.00–33.33), pain 32.22 (21.30), general health 40.82 (20.80), energy and fatigue 43.47 (16.32), physical functioning 44.1 (25.46), social functioning 47.03 (25.28) and emotional well-being 57.48 (20.65) (Table 1).

TABLE 1: Descriptive analysis of the RAND 36-item Health Survey Scale.

Data normality was assessed using the Kolmogorov-Smirnov test. The role limitation because of physical health and emotional problem scales showed significant deviation from normality. Descriptive analysis of the eight scales shows that mean scores range from 32.22 for pain to 57.48 for emotional well-being.

Results from linear regression show that while the R2 values are low, indicating that ‘pain’ only accounts for a small proportion of the variance in the QoL scales, there was a significant association between pain severity and energy, emotional well-being, social functioning and general health. Less pain was associated with better QoL scores in these areas. While pain severity was not significantly associated with physical functioning, results do show that less pain was associated with better physical functioning (Table 2).

TABLE 2: Effect of pain on quality-of-life scales.

Weak positive correlations were found to exist between pain severity and role limitation because of physical health (rho = 0.256, p = 0.001), as well as pain severity and role limitation because of emotional problems (rho = 0.199, p = 0.007). Increased pain was associated with more limitations.

Discussion

Chronic pain is one of the most common chronic conditions in the world,2 with a significant economic burden in the form of healthcare utilisation and lost work productivity.5,6 Globally, QoL research is increasingly emerging as an important health research endpoint in many clinical trials, often being used to highlight the burden of disease and to inform best evidence-based practice.8

It is important to note that previous South African studies reporting on chronic pain and QoL were conducted in primary healthcare centres on outpatients attending the clinic for other chronic conditions.4,13 Chronic pain is a complex phenomenon.14 The diagnosis of chronic pain involves a comprehensive evaluation that includes a thorough history, examination and investigations to rule out other possible causes of persisting or recurring pain.15 Currently, HJH Chronic Pain Clinic serves as the only specialised public pain clinic in Gauteng, accepting referrals from other hospitals within the Gauteng province as well as neighbouring provinces such as North West, Limpopo and Mpumalanga. This study aimed to assess the impact of chronic pain on patients’ QoL at HJH Chronic Pain Clinic using a validated, generic instrument.

Overall quality of life

Our study showed that chronic pain has a negative impact on QoL. Seven out of the eight RAND-36 scales scored below 50, indicating generally poor QoL in this study population (Table 1). The lowest scores were observed in role limitations because of physical health and emotional problems, bodily pain and general health perceptions. This finding is consistent with existing literature.3,16 Hadi et al.,17 demonstrated that chronic pain patients had significantly poorer QoL scores when compared to the general population and patients with other long-term conditions. Unlike prior South African studies conducted in primary healthcare settings, this study focuses specifically on patients referred to a tertiary-level specialised pain clinic. This likely reflects a population with more complex or longstanding pain conditions, potentially explaining the marked impairment observed (Table 1). The findings reinforce that chronic pain in the South African public sector is not merely a symptom but a multifactorial condition with broad functional consequences.

Contrary to previous studies, the emotional well-being scale scored above 50 in this study population, indicating a generally better QoL. This is possibly explained by the fact that well-being is a multidimensional construct, which cannot be adequately assessed by a limited set of items regarding QoL. Well-being is composed of both eudaimonic (meaning and self-realisation) and hedonic (pleasure and happiness) aspects. The items used to measure the emotional well-being scale in the RAND 36-Item Health Survey 1.0 focus predominantly on the hedonic aspect of well-being.18

Effect of pain severity on quality-of-life scales

Pain severity was statistically associated with poorer outcomes in social functioning, general health, emotional well-being and energy. While statistically significant, the effect sizes were modest (Table 2). This suggests that although pain contributes to impairment in these domains, additional factors, such as socioeconomic stressors, comorbid conditions and access to care, also influence the overall QoL. Therefore, while the results highlight important relationships, clinicians should interpret them within the broader biopsychosocial context of each patient’s experience, focusing on interventions that yield tangible improvements in QoL rather than relying solely on statistically significant but clinically modest effects.

The strongest association was observed with social functioning, suggesting that increasing pain severity interferes with patients’ ability to engage socially. Pain interference is known to affect social functioning, contributing to the inability to work and employment status,19 thus having a negative impact on QoL. The social consequences of chronic pain, such as social withdrawal and isolation, extend beyond the individual to affect personal and professional relationships.20

In a setting where many of the patients are pensioners or unemployed, social participation may represent one of the remaining meaningful domains of daily functioning. While this highlights the relevance of pain-related interference in social functioning, the modest association suggests that pain severity represents only one of the multiple factors influencing QoL in chronic pain.

Interestingly, and contrary to previous studies,21,22 pain severity was not statistically associated with physical functioning in the regression analysis. This finding may suggest that physical impairment in this predominantly elderly study sample is influenced by factors beyond pain alone, including age-related decline and comorbid disease. Weak correlations between pain severity and role limitations because of physical health and emotional problems further support the multifactorial nature of functional impairment in chronic pain.

Reflection on sample characteristics

Age: The majority of participants were elderly (Table 3), which may have contributed to lower QoL scores, as older adults are more likely to have comorbidities, reduced physical functioning and increased vulnerability to the negative impacts of chronic pain. As such, the findings may not generalise to younger adults with chronic pain.

TABLE 3: Summary of demographic and clinical characteristics (N = 181).

Social determinants: Over 80% of study participants were either pensioners or unemployed (Table 3). Unemployment is known to be associated with poorer health outcomes, reduced access to resources and increased psychosocial stress, all of which can exacerbate the impact of chronic pain on QoL.23 In the South African public-sector context, socioeconomic vulnerability may amplify the impact of chronic pain. While this study was not designed to formally analyse social determinants, the demographic profile further suggests that chronic pain management in the public-sector setting must account for broader biopsychosocial contextual realities.

Low response rate for pain diagnosis (Figure 1): The high proportion of missing diagnostic categorisation (61.3%) (Table 3) limits the ability to compare QoL across pain subtypes.

FIGURE 1: Type of chronic pain – Reported as diagnosis.

Pain site: Similar to existing evidence,3 the most frequent pain site was lower back pain, followed by unspecified back pain and lower limb pain (Table 3).

Limitations

The study has several limitations. Initially, it was conducted at a single specialised public pain clinic, which may limit the generalisability of the findings to other settings or populations. The sample was predominantly elderly and female, with a high proportion of pensioners and unemployed individuals, potentially biasing the results towards poorer quality-of-life outcomes. Additionally, the response rate for specific pain diagnoses was low, with over 60% of participants not specifying their pain type, restricting the ability to analyse differences between pain subtypes. The cross-sectional design of the study also precludes any conclusion about causality or changes in the QoL over time. The use of a self-administered, English-only questionnaire may have excluded non-English speakers and those with limited literacy, further affecting the representativeness of the sample. It should be noted that although the RAND 36-Item Health Survey 1.0 is widely used internationally, it has not been formally validated in the local population. This lack of local validation may affect its cultural relevance, construct validity and the interpretation of results within this setting. Therefore, the findings should be interpreted with this limitation in mind.

Future research should consider adopting a multicentre approach to enhance the generalisability of findings across diverse settings and populations. Additionally, longitudinal study designs could provide insights into causal relationships and changes in QoL over time. Finally, helping with questionnaire completion or using translated versions for non-English speakers could improve the response rate of missing items, representativeness of the sample and validity of the results.

Conclusion

This study aimed to describe and measure QoL in patients diagnosed with chronic pain at a specialised public pain clinic in a tertiary hospital. Chronic pain is a multidimensional condition that negatively impacts patients’ QoL. Biopsychosocial constructs play an essential role in determining patients’ QoL. In resource-limited environments, routine QoL assessment may assist clinicians in identifying high-risk patients, prioritising multidisciplinary interventions and monitoring treatment impact beyond pain intensity reduction alone. The study highlights the feasibility and clinical utility of integrating a generic QoL instrument into routine public-sector pain practice.

Acknowledgements

The authors would like to express their deepest gratitude to their supervisor, Dr Raphael Maja (Department of Anaesthesia), for his invaluable patience and feedback in supervising this research project.

Additionally, the authors want to express their sincere gratitude to Sister Janet Visagie and the Helen Joseph Hospital Chronic Pain Clinic personnel for their support of the research effort.

Finally, the author, Boniwe Leeba, wants to express her gratitude to her family and spouse for their encouragement and support during this study process.

This article is based on research originally conducted as part of Boniwe P. Leeba master’s thesis titled ‘Quality of life in patients diagnosed with chronic pain at a chronic pain clinic at Helen Joseph Hospital, Gauteng, South Africa’, submitted to the Department of Clinical Medicine, Faculty of Anaesthesia, University of the Witwatersrand in 2026. The thesis was supervised by Raphael N. Maja. The thesis was reworked, revised and adapted into a journal article for publication.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

CRediT authorship contribution

Boniwe P. Leeba: Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualisation, Writing – original draft, Writing – review & editing. Raphael N. Maja: Conceptualisation, Supervision, Validation, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

Because of ethical considerations and participant anonymity, the full dataset is not publicly shared. Access to de-identified data can be requested from the corresponding author, Boniwe Leeba, upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

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