Key Concepts in Health Studies View article on Credo

Quality of life measures
in Defining Health
from SAGE Key Concepts Series: Key Concepts in Health Studies
View article on Credo
The concept of ‘quality of life’ can be found in two distinct areas of health and social research. The
first has its origins in early twentieth-century eugenics, and was used as a descriptive assessment of
presumed life patterns resulting from a chronic condition, in particular, infants with severe disabilities.
These assessments combined clinical judgement (including moral and social concerns) with a set of
economic rationale in order to establish a systematic case for non-treatment of those whose physical
and cognitive abilities differed from the norm (Koch, 2000: 420). The second, more socially-orientated
conception of quality of life first emerged in the 1920s and was utilized in order to consider social
concerns about the general life or ‘social health’ of communities and the individuals and groups
which constituted the said communities. These concerns became pronounced in the 1970s in North
America and Western Europe, as the post-war optimism about the benefits of welfare states and the
opportunities offered by technological developments began to be widely questioned. Today, this set
of concerns continues apace with social and environmental concerns about the stresses of work on
individual health and the consequences of the internal combustion engine and nuclear power. The
more recent manifestations of this focus on the quality of life of communities are a concern with social
cohesion and social capital (discussed under Social inequalities in health).
Focusing on health-related quality of life (HRQL), the early twentieth-century concern with the
assessment of those with physical and cognitive impairments gradually moved away from the
dubious ethics of non-treatment towards a quantitative concern to measure functional disability. This
was primarily for the purposes of planning, assessing the outcomes of health service provision, and
of clinical decision-making generally. These concerns with prospective (future-orientated)
assessments of chronic illness and disability in order to effectively manage (some would say ration)
health care resources and plan for care have, since the 1980s, led to the development of a series of
quantitative ‘quality of life’ measurement instruments to ascertain the perceived health status of
specific population groups (the ‘elderly’, ethnic minorities, the ‘depressed’). However, the direct
concern of these instruments is less with ascertaining the social contributors to the life quality than
with the evaluation of health outcomes for particular population groups.
The emergence of scales to measure subjective perceptions of health, and therefore to act (initially)
as a supplement to clinical diagnosis, began in the mid-twentieth century with the development of
measures of psychiatric disorders. These early psychiatric instruments which employed a limited
number of items were used to demonstrate that neurosis could be measured relatively easily across
large groups. The success of these measurement instruments reflected a unique feature of
psychiatric disorders, that the expressed symptoms were themselves the ‘pathology’ (which would
not be the case for the physical symptoms of an organic disease). For example, those who scored
highly in terms of levels of anxiety could then be described as having an anxiety disorder, and those
who reported being depressed could be labelled as having clinical depression. It was precisely
because these psychological symptoms were also ‘subjective’, that it later became possible to
incorporate these types of questions into broader measures of subjective health status. Questions
such as ‘I have lost interest in my appearance’ taken from the 1983 Hospital Anxiety and Depression
Scale, could be integrated into subsequent Quality of Life instruments, e.g., ‘How satisfied are you
with the way your body looks?’, found in the World Health Organization Quality of Life (WHOQOL–
100) scale (Armstrong et al., 2007).
From the 1980s onwards, there has been an exponential increase in HRQL measurement
instruments and associated publications. The large variety and popularity of these instruments reflect
the wide range of population groups that are now subject to interrogation about their quality of life
(from the elderly to those with mental health problems, to those with cognitive and physical
impairments, the socially stressed and others), which in turn determines whether a disease-specific
or a generic measurement instrument is to be employed. The limitations of generic scales (such as
the SF-36 described below) is that they may not address topics of particular relevance for a given
disease or medical intervention. On the other hand, although more disease-orientated measures offer
greater specificity, this is often achieved at the expense of generalizability. The variety of instruments
also reflects the contested nature of quality of life and the range of theoretical assumptions
concerning the dimensions of HRQL, and the proxies for quality of life which are chosen for
translation into measurement items. The range of theoretical assumptions concerning the nature of
quality of life that can be found most frequently in measurement scales includes the following
(Bowling, 2005):
classic models of quality of life rooted in notions of subjective well-being and/or happiness;
needs-based approaches derived from Maslow’s hierarchy of human needs;
models which emphasize social-psychological constructs such as self-efficacy, perceived
behavioural control and personal autonomy;
social expectations approaches based on the perceived gap between desired and actual life
a phenomenological understanding of quality of life which conceives it as dependent upon
individual value systems rather than upon a set of universal conceptualizations;
one of the most frequently found assumptions concerning the measurement of quality of life is
that it can be defined in functional terms, usually in relation to physicality but sometimes also in
terms of social functioning (discussed in more detail under Functionality).
Descriptions of health are typically placed on a nominal, ordinal or an interval scale. A nominal scale
uses numbers to classify a characteristic or item. This type of scale is often used as means for the
comparative evaluation of an intervention (before and after). The ordinal scale is used where objects
in one category of the scale are to be ranked against each other in some way, for example, ‘how
does X compare with Y?’. The interval scale is characterized by a common and constant unit of
measurement such as temperature, and is a precise quantitative scale; measures of health status
and disability because of their subjective qualities rarely reach an interval-level of measurement. As
Bowling (2005) has noted, problems associated with the validity of measuring health outcomes (does
an indicator measure the object that it purports to?) using such measurement scales are rife. This is
because no ‘gold standard’ of health exists against which the indices of health status used in a
particular scale can be compared; health is an essentially a subjective state.
The Short Form (SF)-36: This is the most commonly used measurement of generic health status (its
popularity reflecting its brevity and coverage), and as such its findings dominate the quality of life
literature. This 36-item questionnaire was developed in the USA in the early 1990s, and can be
administered by oneself, an interviewer, on the telephone or on the computer – it takes about five
minutes to complete. The instrument measures eight dimensions of health status: physical
functioning (10 items), social functioning (2 items), role limitations due to physical problems (4 items),
role limitations due to emotional problems (3 items), mental health (5 items), energy/vitality (4 items),
pain (2 items), general health perception (5 items), and one item about the individual’s perceptions of
changes in their health over the past year. The instrument claims to measure positive and not just
negative assessments of individual health status. In the original scoring method, the item scores for
each of the eight dimensions are summed and translated using a scoring algorithm, into a scale from
0 (poor health) to 100 (good health). The validity of the SF-36 can be judged by the fact that it is the
most widely evaluated generic health status instrument used across the world. In particular, it has
been reported that it is more sensitive to graduations in poor health than other broad health
instruments. It has good validity in a number of clinical areas associated with physical morbidities,
and also is of value in screening for psychiatric disorders, particularly depression. In terms of its
reliability, high inter-item co-efficiency correlations have been reported for its sub-scales. The health
perception dimension in particular has good correlation with the energy/fatigue scale, although less
well with the pain scale.
Finally, one of the interesting features of research that has examined how lay people define their own
quality of life (in contrast to the constructed HRQL measurement instruments) is its multidimensionality, embracing a positive psychological outlook, emotional well-being (which includes
good relationships with family and friends), physical health, personal safety, access to good services,
not being dependent upon others, and of course sufficient money (Bowling, 1995). This is in clear
contrast to the use of unidimensional indicators (psychological well-being; functionality; social
support, happiness, etc.) of quality of life traditionally found in both the broad generic and diseasespecific measurement scales described above, whatever might be said about the range of
independent or causal variables included in its formulation.
I. C.
Armstrong, D.; Lilford, R.; Ogden, J.; Wessely, S. (2007) ‘Health-related quality of life and the
transformation of symptoms’, Sociology of Health and Illness, 29: 570-83.
Bowling, A. (1995) ‘What things are important in people’s lives? A survey of the public’s
judgements to inform scales of health related quality of life’, Social Science and Medicine, 10: 1447-
Bowling, A. (2005) Measuring Health: A Review of Quality of Life Measurement Scales, 3rd edn,
Open University Press Maidenhead.
Koch, T. (2000) ‘Life quality vs the “quality of life”: assumptions underlying prospective quality of life
instruments in health care planning’, Social Science and Medicine 51: 419-27.
© Chris Yuill, Iain Crinson and Eilidh Duncan 2010
Quality of life measures. (2011). In C. Yuill, I. Crinson, & E. Duncan, SAGE key concepts: Key
concepts in health studies. Sage UK. Credo Reference:
“Quality of life measures.” In SAGE Key Concepts Series: Key Concepts in Health Studies, by Chris
Yuill, Iain Crinson, and Eilidh Duncan. Sage UK, 2011.
Quality of life measures. (2011). In C. Yuill, I. Crinson & E. Duncan, SAGE key concepts: Key
concepts in health studies. [Online]. London: Sage UK. Available from:
institutionId=5865 [Accessed 26 October 2020].
“Quality of life measures.” SAGE Key Concepts Series: Key Concepts in Health Studies, Chris Yuill,
et al., Sage UK, 1st edition, 2011. Credo Reference,
institutionId=5865. Accessed 26 Oct. 2020.

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