5 Quality of life
‘Quality of life’ is beginning to be seen as significant by health policy makers. But this raises all kinds of problems about evaluating initiatives to promote wellbeing and quality of life.
If health is difficult to define then quality of life is even harder. You will have difficulty finding a tight definition. As George and Bearon state:
On the whole, social scientists have failed to provide consistent and concise definitions of quality of life. The task is indeed problematic, for definitions of life quality are largely a matter of personal or group preferences; different people value different things.
(1980, p. 1)
Seed and Lloyd (1997) present data from a Social Science Research Council survey which asked people what quality of life meant to them; 23 per cent said a happy marriage, 19 per cent related it to contentment, 10 per cent referred to social relations. The rest talked in terms of income, standard of living and having consumer goods, but overall humanistic concerns were mentioned more frequently than materialistic ones.
We all have ideas and opinions about what constitutes quality of life, but can it be defined in anything but individual personal terms?
Activity 8: Quality of life
Reflect on what you consider to be the essential elements in your own quality of life. Would you have said the same 10 years ago? Try to rank the elements in order, first for 10 years ago and then for now.
A report on this activity from our developmental testers revealed that a wide range of socio-cultural and biological factors influenced their judgement about quality of life. One of our testers, a woman in her early 20s, gave the following rankings
|Ten years ago||Now|
|security in home life||good home life|
|loving mum and dad||career|
|happy school life||a loving partner|
|friends to play with||financial independence|
|my own bedroom||a good social life|
|pets – for example rabbit||a place of my own|
|toys – for example a bike||time and space|
Did you find that what was important to your quality of life 10 years ago is not necessarily important now? Some things remain constant, others change.
Quality of life remains an elusive concept, and what makes for good quality of life is likely to be different for different people and at different times in their lives. We could become fascinated or we could become paralysed by dwelling on the diversity of meanings that people attach to quality of life but, if we want to highlight its importance in the health field, we need to draw up some broad parameters. Hughes has suggested a framework for studying aspects of quality of life which she has devised from reviewing a range of quality of life indicators used in social gerontology (Figure 8). Can it take us beyond an individual perspective?
Hughes emphasises the distinction between conditions of life and the experience of life. Conditions of life such as housing or income are considered to be objective, whereas experiences of life such as life satisfaction are more subjective. As she is keen to point out, these two dimensions are not unrelated: ‘the “conditions” of life influence the “experience” of life and therefore expressed satisfaction’ (Hughes, 1990, p. 54).
Integrating objective and subjective elements within a single concept, ‘quality of life’, is a fundamental problem when trying to define it. In terms of public policy it raises the question of who is responsible for these different elements.
Activity 9: A National quality of life service?
Think about the relationship of health to quality of life. Imagine we were to have a National Quality of Life Service (NQLS) instead of an NHS. Where do you think responsibility for the different elements in Hughes's diagram might lie?
Starting at the top right-hand corner of the Figure 8 and working round in a clockwise fashion we predict that, on balance, you might decide that the first three constituent elements, many of which fall into the category of conditions of life, are a matter of public responsibility, at least in maintaining minimum standards. That has been the situation since the Second World War with NHS and social security benefits, even if they have been eroded.
What was your view on the next three constituent elements? Some might say that the opportunity for purposeful activity, especially the availability of work, is the state's responsibility. Others will take a more self-help, ‘on your bike’ view.
Is social integration up to the individual or is it the responsibility of the social group to take some collective responsibility for its members?
Quality of life is threatened by discrimination in terms of cultural factors such as age, gender, class, race or religion. Combatting it is a political and public matter as well as a matter of individual conscience.
On the face of it, personal autonomy and life satisfaction seem to lie within the domain of personal responsibility. But choice and personal control, and indeed life satisfaction and self-esteem, are often restricted by socio-economic status and cultural factors, as well as social integration.
Designating responsibility becomes a very difficult and contentious affair, especially when the constituent elements are to a large degree interdependent. But quality of life is clearly not just a private issue but a matter of major public concern.
One of the major obstacles to getting quality of life in its broadest sense on to the health policy agenda is the difficulty of getting public agreement on priorities. Hughes's model is one way of breaking down the concept into more manageable constituent elements or subsystems of constituent elements, such as ‘quality of the environment’ or ‘social integration’, and so opens up the possibility of achieving a degree of public consensus. The more difficult but necessary task is to assess for a given constituent element the standard below which the quality of life would be thought to be unacceptably low. Then the next step is to design instruments to measure how an individual or a group of individuals fares in relation to that standard. This clearly would be easier for the conditions of life but more difficult for the experiences of life.
Measuring psychological wellbeing is a much more daunting task. Why not simply ask individuals about their sense of wellbeing? They would probably tell you without too much difficulty. But could you then compare what they tell you with others' subjective accounts? If quality of life is to be incorporated on the health policy agenda, measurements have to be found which satisfy individuals, researchers and policy makers, as Bowling maintains:
Progress is sometimes slow due to the differences of opinion between researchers and policy makers ... Researchers are increasingly inclining towards self-ratings of present health; personal evaluation of physical condition; feelings of anxiety, nerves, depression; feelings of general positive affect [sic]; and future expectations about health. On the other hand, policy makers may prefer more explicit indicators in their formation of health policy: limitations in activities of daily confinement to bed due to ill health; ratings of intensity, duration and frequency of pain ...
(Bowling, 1991, p. 11)
There are no obvious or easy solutions to these problems, but at least people are grappling with them and it is becoming increasingly accepted that quality of life should be a measurement of health. The other end of the health spectrum, illness and disease, is much more established.