Quantity and quahty are two important dimensions of life (Ware 1987). The
former tends to be evaluated in terms of survival rates, morbidity and
mortahty (NCHS 1981), whilst the latter is more (hfficult to define and often
involves a philosophical approach particularly in the medical arena
(Donabedian 1980). Because of the abstract nature of quahty, definitions
may be influenced by the person defining it, environmental factors and time
(Sherman 1968). The concept of QOL in the context of health and sickness
is relatively new (Mostehar et al 1989, Spilker et al 1990, Wilkin et al 1992).
The issue of quahty is inherent in the WHO definition of health (1947) which
enq)hasises aspects other than the absence of illness. These aspects are
inq)ortant for the person with a chronic disease or disabihty for whom
quahty, and not sinq)ly length, of survival is crucial. The definition of health
offered by the World Health Organisation is that it is
" a state of complete physical, mental and social weU-being and not merely the absence of disease or infirmity'* (WHO 1947).
This definition was later operationahsed by a working party (WHO 1957)
when health was described as.
" a condition or quahty of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental."
These definitions of health can provide a starting point for discussing how
However it is inq)ortant to enq)hasise that the concept of QOL is more
conq)rehensive than that of health (Ware 1984a). QOL can represent a
range of dimensions of life experiences. Single basic requirements such as
safety, food and shelter are iuq)ortant (Andrews and Withey 1976) and it is
only when these have been met that the higher order QOL factors such as
the achievement of self-fidfilment come to the fore (Maslow 1943).
It was following the Second World War that the term "quahty of life" first
appeared in the American vocabulary, although this was not linked with
health or health related concepts. Rather it referred to the acquisition of
material goods e.g. house, car, travel etc. A report in 1960 of President
Eisenhower's Commission on National Goals redefined or broadened the
concept so that it included education, economic development, defence,
health and welfare. This theme continued throughout the 1960s so that at
the beginning of the fohowing decade QOL was interpreted as being less
consumer oriented, and the achievment of "good" QOL dependent on more
than just the acquisition of material goods or wealth.
Health too may be an iroportant factor. Vanden Berg (1993) describes QOL
as "a concept of total weh-being incorporating both physical and
psychological factors". When illness or disabihty has affected an individual,
the perception of good QOL may be one which includes a return to the
premorbid state. Another individual may be concerned with achieving some
sort of ideal state (Caiman 1984, Schipper and Levitt 1986).
Recent years have seen a plethora of research into quahty of life (QOL)
issues, most noticeably in the last 20 years. It appears fi*om the hterature
that the construct of QOL is multidimensional. The variety in definitions of
been equally varied and hence the absence of a universal tool (Schmale
1980). The components of QOL may be as varied as individual personahties
(Gough et al 1983). It can mean different things to different people (Caiman
1984) and they should therefore be allowed to create their own definitions
so that the concept is described and measured in individual terms (Ebbs et al
1989).
Whilst professional clinical judgement tends to be based on the return to
optimum fimctioning e.g. return to work, abatement of synq)toms and
biochemical and physiological norms, patients with different medical
conditions tend to be more idiosyncratic in their criteria for QOL. They may
be more concerned with their abihty to enjoy themselves or to fulfill their
household duties or they may be disturbed by feelngs of lack of energy and
loss of interest (Hunt and McKenna 1993). Most authors recognise that the
issue of QOL must be based on individual judgement and that differences
will exist in patients' perceptions of their QOL (Selby 1993). A definition
which moves away fi'om the usual objective norms and focuses on individual
perceptions is appropriate:
" the individual's perception of their position in life, in relation to their goals and the value system which they have incorporated into their decision- making" (Sartorius 1993).
There is evidence of conceptual confusion m that the term quahty of life is
used interchangeably with fiinctional status and health status (Birren and
Dieckmann 1991, Brooks 1991). QOL has also been equated with
performance in social roles that conq)are to those of others similar in age,
sex or class. Objective indicators have been used for example, economic
status and human rights as weh as the subjective feelings of the individual in
"Just what constitutes quality of life for a particular patient is often extremely difficult to judge" (Elkington 1966).
Although health status has often been equated with QOL, it does not in fact
encoDopass such aspects of QOL as self esteem, interpersonal relationships,
economics etc (Deyo 1993). In a study of patients with rheumatoid arthritis
self esteem, perceived control over health and a person's social network
were demonstrated to be important attributes that were not acknowledged
by health status measures (Burkhardt 1985). Spitzer (1987) offers a way
out of this confusion. He suggests that health status should be considered in
the context of "healthy individuals" and that QOL should be measured in
those who are "definitely sick". An alternative approach would be to
consider health or functional status as a facet of QOL .
Health status then may be defined as a measure of an individuars function in
terms of physical, social and mental well-being. Quahty of fife is more
related to how a person feels and fimctions in his everyday life i.e. it is
subjective. This concept has been described as encompassing several
characteristics - physical and psychological - as weh as limitations which
examine a person's abihty to function and derive satisfaction fi*om doing so
(Walker 1993). The confusion surroundiug the terms health status and QOL
has led to the emergence of the term health related quahty of life which has
been adopted by some researchers. This refers to the level of weh-being and
satisfaction associated with an mdividual's life and how this is affected by
disease, accident and treatment. It has also been defined as:
" the value assigned to the duration of life as modified by the impairments, functional states, perception and social opportunities that are influenced by disease, injury, treatment or pohcy" (Patrick and Erikson
Research in health care outcome measures seeking to monitor the effects of
different interventions has triggered the development of several tools
focusing on heahh-related QOL (Bergner 1989, Birren and Dieckmann
1991, Brooks 1991). However, although health i.e. the absence of disease,
may be regarded as a component of QOL it may not necessarily be an
in^ortant one for all individuals. Thus, a person who has a chronic disease
and is very disabled may perceive their QOL as being "good", whilst the
person in reasonable health may, for some reason, feel they have a "poor"
QOL (Birren and Dieckmann 1991).
An understanding of physical function may be an important aspect of
investigating QOL and has often been achieved by measuring restrictions in
certain activities e.g. walking and various self-care activities such as
washing, dressing and feeding (Patrick and Erikson 1993). Spitzer (1987)
argues that such measures are often a useful means of evaluating various
types of interventions e.g. therapeutic, preventative and rehabilitative and
therefore would be more appropriately employed by those interested in how
specific treatments may affect an indrvidual's level of function.
Hunt and McKenna (1993) described three components of QOL namely,
experiential, functional and symptomatic. The experiential category is
concerned with subjective values and expectations of the individual, feelings
of malaise, distress and discomfort. The functional category encompasses
activities of daily living e.g. social and occupational obhgations, intellectual
functioning and personal relationships. The final symptomatic category
examines consequences of disease, illness, disabihty and the adverse effects
of treatment. Hunt and Mckeima (1993) argue that these components are
A number of variables have been identified as important in determining
QOL. It has been suggested that QOL may be influenced by cultural,
financial, spiritual, psychological and political aspects (Caiman 1987).
Physical aspects would include a person's abihty to carry out activities of
daily living e.g. walking, washing and dressing. FinaUy the spiritual
dimension refers to a person's abihty to transcend every day life by aesthetic
or rehgious experiences (Fletcher and Bulpitt 1993). Levine and Croog
(1984) specified demographic variables such as status, income, family and
social interactions. The psychological dimension might incorporate
psychiatric morbidity, inteUectual performance, emotional level, hbido etc.
A common theme amongst these definitions is one of physical,
environmental and psychological factors ah contributing to QOL.
Gough and associates (1983) suggested that not ah of these components wih
constitute QOL for ah individuals. Values that are considered important
prior to the onset of an illness or disabihty may change during the treatment
stage or fohowing this period, so that "...what was once hqportant may seem
insignificant, whhst things once ignored have great weight" (Morris et al
1986). Patterson (1975) identified the main constituents of QOL as health,
fimction, comfort, emotional response and economics. This approach is
similar to that of Caiman (1987) and Levine and Croog (1984) in that
physical, psychological, social and economic domains are mentioned.