If someone were to ask you to assess your quality of life on a scale of 1 to 10, how would you answer?
More importantly, what aspects of your life would you be considering as you were selecting your rating?
If you’re unsure, you are not alone.
There are many scholarly schools of thought regarding assessment of a person’s quality of life. Consequently, there are many meanings for the term which can refer to attitudes across several domains, including health, physical functioning, the family environment, and more (Gill & Feinstein, 1994).
This article will offer a brief review of quality-of-life definitions, explore the concept’s applicability in the context of positive psychology, and outline five useful questionnaires to apply in practice.
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What is Quality of Life?
There is substantial debate in the literature about what is meant by the term “quality of life” (QOL), and there are several factors both in research and practice that drive this ambiguity.
First, researchers often cannot define what they mean when they refer to the term QOL. Indeed, in a comprehensive review of 75 articles on the topic, only 11 (15%) defined the concept before proceeding with their investigation (Gill & Feinstein, 1994).
A second issue is that people will vary regarding what they deem important for a quality life. For instance, one person may feel that a strong network of close relationships is necessary for a quality life. In contrast, another person may be inclined to forego such relationships in favor of personally meaningful activities or accomplishments, such as creative pursuits or professional advancement (Liu, 1976).
Finally, there is an overlap between the notions of QOL and life satisfaction, which researchers are still struggling to tease apart (Landesman, 1986).
4 Approaches to Defining Quality of Life
To address the above-mentioned challenges, Felce and Perry (1995) summarized four approaches to defining QOL.
First, QOL can be thought of as the sum of a range of objectively measurable life conditions. That is, a person’s QOL across a range of domains (e.g., social relationships, physical health, personal circumstances, etc.) is determined numerically and then compared against a larger population distribution.
A second approach is to define QOL as a person’s satisfaction with the sum of these life conditions. The difference between this and the first approach is that personal welfare is based on a subjective reaction to life conditions, rather than how a person’s standing on these conditions compares numerically to others in a broader population.
Another approach is to define QOL as a combination of both objective life conditions and satisfaction with those conditions (Brown, Bayer, & MacFarlane, 1989)–essentially a combination of the approaches above.
A fourth and final approach, forwarded by Cummins (1992), conceptualizes QOL as an objective assessment of life conditions and subjective assessment of satisfaction, weighted according to the significance an individual places on each particular domain.
To illustrate with an example, one might consider the role of income level and how it may affect (a) quality of life conditions and (b) life satisfaction. Regarding (a), income size may be critical in contexts where one’s welfare is dictated by annual salary, such as in countries without strong social welfare systems. In this example, the size of income would be weighted highly as a factor influencing the quality of life conditions.
However, to a fairly non-materialistic person who has sufficient income to meet their basic needs, income size may only be a small contributor to life satisfaction (b). In this situation, income would have a small weighting regarding this second, satisfaction-related component of QOL (Felce & Perry, 1995).
Overall, this final approach to defining QOL is considered the strongest, as it is the only one that ranks and applies weightings to the importance different people place on aspects of their life situation (Felce & Perry, 1995).
The Relevance of Quality of Life to Positive Psychology
The notion of QOL is particularly relevant in the field of positive psychology.
The concept regards several aspects of personal welfare and wellbeing, and a person’s attitudes toward various life circumstances and domains.
Likewise, positive psychology practitioners are often concerned with people’s wellbeing and their satisfaction when assessing the different domains of their life.
These domains can include:
- Mental and physical wellbeing;
- Relationships with other people;
- Social, community, and civic activities;
- Personal development and fulfillment; and
- Recreation and fun.
We can think about the overlap between QOL and positive psychology by considering QOL’s overlap with features of Martin Seligman’s PERMA model.
The PERMA model is one of the key theories underlying the field of positive psychology, representing the five key domains in which a person may experience psychological wellbeing and happiness.
Among these, Seligman lists domains such as Relationships, characterized by authentic connection, and Achievement, characterized by a sense of accomplishment in one’s activities.
It is clear to see that domains such as these, mirror several of the domains in which a person may rate their QOL. Therefore, there may be value in using QOL measures to tap into the various dimensions of positive psychology models such as PERMA.
How Can We Measure Quality of Life?
According to a review by Gill and Feinstein (1994), there are at least 150 instruments in existence to measure QOL. These scales can take a variety of different forms.
Some investigators, particularly in the medical context, will apply a single-item assessment of QOL. An example may be an item such as “What is your quality of life?”
While commonly used, a weakness of such measures is that they do not tap into specific domains nor the relative importance people place on these domains.
In line with this, many researchers present a series of items (known as an instrument or index) to assess QOL. They will then arrive at a final score for QOL by taking an average of these items.
Sometimes, such instruments may contain several subscales that tap into QOL across various domains, such as relationships, living conditions, professional life, and so forth. In this situation, the person administering the different subscales then has two options for presenting the final scores (Gill & Feinstein, 1994).
The first option is to present the results of each of the subscales individually, forming a kind of profile. In this, the respondent will receive feedback on how they fare on each of the individual subscales, perhaps using a radar chart or series of bar graphs.
The second option is to take an average of the respondent’s total scores across all the subscales to create a single composite score representing overall QOL.
The approach you choose in practice should balance both the recommendations of scale creators and your clients’ needs.
5 Quality of Life Assessments
Now that you have a basic understanding of QOL, let’s look at five useful questionnaires you can apply in practice.
These scales will vary in specificity, such that some drill down to assessing QOL in different domains, while others will serve as a more concise, global assessment.
1. The Quality of Life Scale (Flanagan, 1978)
Flanagan’s (1978) Quality of Life Scale (QOLS) is one of the most widely used QOL assessments, applied predominantly in the healthcare sector.
In developing the QOLS, Flanagan began by collecting responses to interview questions from 3,000 Americans, representing a broad range of ages, races, and backgrounds. In doing so, he aimed to pin down a definition of QOL as it related to a person’s different life domains.
Several questions were asked, but among them, participants were asked to recall life events that were especially satisfying to them or times when they witnessed harmful events that could detract from a person’s QOL.
These responses were filtered down to fifteen quality-of-life components (or domains), each represented by one item, using an inductive process.
Later, Burckhardt, Woods, Schultz, and Ziebarth (1989) added a sixteenth item, reflecting the notion of independence, or being able to care for oneself, after qualitative evidence indicated that this was important to particular subpopulations (e.g., the chronically ill).
For each item, respondents indicate their satisfaction across each of the 16 domains on 7-point scales, where 1 equals ‘terrible’ and 7 equals ‘delighted’.
The 16 domains are as follows:
Higher-order domain: Physical and material wellbeing
|Lower-level Domain||Defining Features|
|Material wellbeing and financial security||Having good food, home, possessions, comforts, and expectations of these for the future.|
|Health and personal safety||Freedom from sickness, physical and mental fitness, avoiding accidents and health hazards. Availability of effective health treatment.|
Higher-order domain: Relations with other people
|Lower-level Domain||Defining Features|
|Relations with spouse/partner||Being married/having a loving companion, sexual satisfaction, effective communication, and devotion.|
|Having and raising children||Becoming a parent, watching children develop, and enjoying spending time with one’s children.|
|Relations with parents, siblings, or other relatives||The presence of relatives with whom one feels belonging. Enjoying spending time with and visiting such relations.|
|Relations with friends||Having close friends with whom one shares activities, interests and views. Friendships are characterized by trust, support, love, and acceptance.|
Higher-order domain: Social, Community, and Civic Activities
|Lower-level Domain||Defining Features|
|Activities related to helping or encouraging other people||Efforts as an individual or as a member of a group (e.g., a church) to help others beyond one’s network of friends/relatives.|
|Activities related to local and national governments||Voting, staying informed through the media, having political, social and religious freedoms.|
Higher-order domain: Personal Development and Fulfillment
|Lower-level Domain||Defining Features|
|Intellectual development||Education access, ongoing mental stimulation/challenges, opportunities to improve problem-solving ability, comprehension, etc., in or outside of school.|
|Personal understanding and planning||The presence of guiding principles in one’s life. Developing maturity, personal growth, agency over decisions and one’s life-course (sometimes involving religious or spiritual experiences).|
|Occupational role||Interesting, worthwhile work at home or in one’s formal job. Being recognized for accomplishments and feeling competent at one’s tasks.|
|Creativity and personal expression||Expressing oneself or applying one’s imagination via artistic pursuits, such as writing, drama, music, etc.|
Higher-order domain: Recreation
|Lower-level Domain||Defining Features|
|Socializing||Meeting new people, participating in social group activities, hosting/attending events.|
|Passive and observational recreational activities||Appreciating passive or relaxed recreational activities, such as reading, media, or sports events.|
|Active and participatory recreational activities||Enjoying active recreational activities, such as travel, sports, nature activities, games, artistic activities, etc.|
Higher-order domain: Independence
|Lower-level Domain||Defining Features|
|Independence, doing for yourself||Remaining independent and being able to care for oneself, which is particularly relevant among populations with chronic illness.|
A copy of the full scale with scoring instructions can be accessed from the clinical assessment platform ePROVIDE. You can also access a convenient version of the scale, ready to administer to your clients, directly through our Positive Psychology Toolkit©.
Regarding reliability and validity, the QOLS has been shown to be reliable and internally consistent across several studies (see Burckhardt & Anderson, 2003; Burckhardt, Anderson, Archenholtz, & Hägg, 2003), suggesting the scale can be confidently applied in research and practical settings.
2. McGill Quality of Life Questionnaire — Expanded (Cohen et al., 2019)
Published in 1996, the McGill Quality of Life Questionnaire (MQOL) was designed to assess the QOL of patients facing life-threatening illnesses. Today, the questionnaire is used extensively in palliative care research.
While the original scale comprised only four dimensions, Cohen and colleagues’ (2019) expanded version includes eight to better assess the domains that people nearing the end of their life report as important to their QOL.
Unlike the QOLS, several of the domains in the MQOL-Expanded (MQOL-E) are assessed using multiple items. The response anchors for the subscales vary by item but are always on an 11-point scale ranging from 0 to 10.
Example items from each of the subscales (and their scale anchors) are as follows:
|Subscale||Example Item||Minimum Scale Anchor (0)||Maximum Scale Anchor (10)|
|Physical||My physical symptoms (such as pain, nausea, tiredness and others) were:||No problem||A tremendous problem|
|Psychological||I was depressed:||Not at all||Extremely|
|Existential||My life was:||Utterly meaningless and without purpose||Very purposeful and meaningful|
|Social||Communication with the people I care about was:||Difficult||Very easy|
|Environment||My physical environment met my needs:||Not at all||Completely|
|Cognition||I was able to think clearly:||Seldom||Always|
|Health Care||Getting the information I needed from the health care team was:||Difficult||Very easy|
|Burden||I felt badly about how my situation affected the people I care for:||Not at all||Completely|
A copy of the full scale can be found in the original article, published in the journal BMC Palliative Care.
The publishers of the MQOL-E found sufficient evidence for the internal consistency of the scale, as well as its factor structure across the eight identified domains.
While these findings are promising, the authors acknowledge that there is more work to do to confirm the test-retest reliability of the scale, its convergent and discriminant validity, as well as measurement invariance when administering the scale in different languages (Cohen et al., 2019).
3. Health-Related Quality of Life Questionnaire (CDC, 2000)
Health-related quality of life (HRQOL) can be defined as:
… aspects of overall quality of life that can be clearly shown to affect health–either physical or mental.
Centers for Disease Control and Prevention (CDC, 2000, p. 6)
The HRQOL Questionnaire combines three separate modules to assess perceptions of HRQOL. It is widely used by health professionals and was designed to bridge the gap between disciplines, such as sociology, psychology, and economics, about the drivers of QOL. It is for this reason that the questionnaire is fairly broad in its focus.
Rather than consisting of subscales, this questionnaire is made up of three modules. With this questionnaire, practitioners may choose to employ only the modules relevant to their clients.
The first module is a compact and validated set of four items to assess HRQOL broadly. These items, referred to as the Core Healthy Days Measures, were designed to be broadly applicable across a range of populations.
An example item from Module 1 is: “Would you say that in general your health is…” with responses ranging from 1 (excellent) to 5 (poor).
The second module is called the Activity Limitations Module, which assesses physical, mental, or emotional problems a person may face in their daily life.
The module begins by asking: “Are you limited in any way in any activities because of any impairment or health problem?”
If the respondent indicates ‘yes,’ he or she will be prompted to continue the module, which goes on to assess the nature of the impairment, the duration of time that the impairment has exerted limitations, and whether or not the respondent requires additional support in terms of personal care or maintenance of routine as a result of their impairment.
The final module is called the Healthy Days Symptoms Module. This module assesses how factors such as pain, depression and anxiety symptoms, insufficient sleep, and energy levels have affected functioning over the past 30 days.
Several studies have been published evidencing the validity of the HRQOL. To summarize, numerical responses have been found to be internally consistent and reliable.
Responses have also been shown to correlate as expected with other established measures related to health, such as the Medical Outcomes Study Short Form (Andresen, 1999; Newschaffer, 1998), thereby evidencing convergent validity.
Research has also demonstrated that the scale can predict physical and mental wellness (CDC, 2000), evidencing predictive validity.
What makes a good life? – Robert Waldinger
4. World Health Organization Quality of Life Instrument (WHO, 2012)
Another trustworthy measure of QOL has been developed by The World Health Organization (WHO). The instrument is called the WHOQOL-BREF.
The 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.
WHO, 2012, p. 11
The WHOQOL-BREF is widely used for comparing indices of QOL across cultures. It is for this reason that the scale is available in over 40 languages.
The instrument assesses QOL in the context of six domains:
- Physical health
- Psychological health
- Level of Independence
- Social relationships
- Spirituality/Religion/Personal beliefs
The instrument also contains several items assessing general health.
The response anchors for the subscales vary by item but are always on a 5-point scale ranging from 1 to 5.
A copy of the full scale can be accessed by completing a user’s agreement at the University of Washington’s website.
Regarding reliability and validity, the publishers of the scale field-tested the WHOQOL-BREF with a diverse sample of approximately 4,500 people, drawn from WHO’s centers worldwide.
Based on this sample, the researchers found evidence for internal consistency, discriminant validity, content validity, and test-retest reliability, suggesting that the scale is suitable for use with populations across various cultures.
5. Global Quality of Life Scale (1996)
Finally, for an ultra-succinct and fascinating approach to assessing QOL, take a look at Hyland and Sodergren’s Global QOL scale.
Rather than adopting a multi-dimensional (or multi-domain) approach like several of the questionnaires above, Hyland and Sodergren (1996) argued that respondents can mentally apply their own weighting system when assessing the various facets of their life.
In doing so, they can make an overall judgment about their QOL by indicating a number on a scale ranging from 100-0, where 100 is labeled ‘Perfect quality of life,’ and 0 is labeled ‘Might as well be dead’.
Eight additional labels are positioned along the scale as follows:
- 95 = Near perfect quality of life
- 85 = Very good quality of life
- 70 = Good quality of life
- 57.5 = Moderately good quality of life
- 40 = Somewhat bad quality of life
- 27.5 = Bad quality of life
- 15 = Very bad quality of life
- 5 = Extremely bad quality of life
For a useful visual representation, take a look at Figure 1 (H4) in Hyland and Sodergren’s original article, published in the journal, Quality of Life Research.
How to Select the Best QOL Assessment
As noted, there are at least 150 measures assessing QOL in existence (Gill & Feinstein, 1994).
Therefore, it is essential to do your research when selecting a scale to suit your needs as each scale will have different strengths, weaknesses, and psychometric properties.
In many cases, scholars will lean toward choosing scales that are highly cited in reputable journals when designing research. While this approach may serve as a good rule of thumb, selecting a measure of QOL requires an extra level of due diligence.
For instance, QOL scales will differ in whether they are appropriate for longitudinal clinical trials versus cross-sectional research.
You will also want to choose a scale that avoids what is known as floor and ceiling effects. A floor effect is a problem in your data that occurs when most of your subjects score near the bottom of a scale. Likewise, ceiling effects are present in data when the majority of respondents score near the top of a scale.
The trouble with either of these distributional characteristics is that your data will contain limited variance. Put differently, your respondents will not have differed very much in how they have responded to your scale.
If you are planning on comparing scores between different populations, or groups who have been exposed to different interventions, this may be a problem.
For a comprehensive guide on selecting the best QOL questionnaire for your needs, take a look at Hyland’s (2003) Brief Guide to the Selection of QOL Instrument, published in the journal, Health, and Quality of Life Outcomes.
A Take-Home Message
Hopefully, you now have a better sense of how you might rate your own QOL and some of the domains you’ll want to consider when selecting an appropriate rating.
While, at face value, the term “quality of life” may seem a little general, you as a researcher or practitioner have the option to drill down to whatever level of domain specificity you want, depending on the assessment tool you decide to employ.
More importantly, by applying one of the assessments above, you will gain a better insight into the effect that factors like pain, illness, or mental health conditions may have on your clients’ daily functioning. And this knowledge will empower you to better tailor the support you provide to better their quality of life.
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