Ann Bowling

Quality of life from the perspectives of older people

This paper report results from a national survey of quality of life (QoL), based on 999 people aged 65 or more years living in private households in Britain. The study produced both qualitative and quantitative interview data. The 999 survey respondents were interviewed in their own homes with a semi-structured survey instrument, and 80 were followed-up in greater depth at one and two years after the baseline interview. The material from the in-depth interviews is presented here. The main QoL themes that emerged were: having good social relationships, help and support; living in a home and neighbourhood that is perceived to give pleasure, feels safe, is neighbourly and has access to local facilities and services including transport; engaging in hobbies and leisure activities (solo) as well as maintaining social activities and retaining a role in society; having a positive psychological outlook and acceptance of circumstances which cannot be changed; having good health and mobility; and having enough money to meet basic needs, to participate in society, to enjoy life and to retain ones independence and control over life. The results have implications for public policy, and supplement the growing body of knowledge on the composition and measurement of quality of life in older age.

Just one question: If one question works, why ask several?

While shorter instruments are more limited than longer measures, they have obvious benefits for both research and policy in terms of reduced burden and costs, and ease of interpretation.

Being alone in later life: loneliness, social isolation and living alone

The context for the review of loneliness and social isolation in later life is that of ‘successful aging’ and ‘quality of life’. The term ‘quality of life‘ includes a broad range of areas of life and there is little agreement about the definition of the term. Models of quality of life range from identification of ‘life satisfaction’ or ‘social wellbeing’ to models based upon concepts of independence, control, and social and cognitive competence. However, regardless of how the concept of quality of life is defined, research has consistently demonstrated the importance of social and family relationships in the definition of a ‘good quality of life’.

Quality of life for the elderly: the transport dimension

The concept of quality of life is elusive and this paper reports on a study that has tried to deconstruct the concept in order to better understand what older people say quality of life means to them. The focus here is on the transport dimension where quality of life is broken down into mobility patterns, locality and social networks. The paper first sets the scene with a summary of secondary data and it then systematically presents data from interviews carried out with 1000 older people as part of the British Office for National Statistics Omnibus Surveys in Britain under the three headings mentioned above. A substantial amount of diversity and variation is found in the data by quality of life ratings and the expectations of the respondents. It is argued that both the active (travel related) and passive (locality and social networks) elements need to be brought together so that the quality of life for the elderly can be better understood.

A multidimensional model of the quality of life in older age

The broad aim of the research presented here was to define the constituents and indicators of quality of life (QoL) in older age, in order to offer a more multidimensional and useful model of quality of life, based on the perspectives of older people themselves. This paper focuses on the extent to which self-evaluations of global QoL are influenced by health, psychological and social variables, and social circumstances. It reports the results of a national survey of the quality of life in people aged 65 and over, living at home in Britain. Multiple regression analysis with the self-evaluation of quality of life rating as the dependent variable showed that the overall model (Model 9) of QoL indicators explained 26.7% of the variance in quality of life ratings. This is sizeable given the amorphous nature of this concept. The main independent predictors of self-rated global quality of life were: social comparisons and expectations, personality and psychological characteristics (optimism-pessimism), health and functional status and personal and neighbourhood social capital. These variables explained the highest proportion of the variance between groups in their quality of life ratings. Socio-economic indicators contributed relatively little to the model.

Aspirations for older age in the 21st century: What is successful aging?

The literature on successful aging reveals a wide range of definitions, generally reflecting the academic discipline of the investigator. Biomedical models primarily emphasise physical and mental functioning as successful aging; socio-psychological models emphasise social functioning, life satisfaction and psychological resources as successful aging. Several studies also identify these factors as the precursors of successful aging. Moreover, research shows that older people consider themselves to have aged successfully, but classifications based on traditional medical models do not. Fewer studies have explored lay views, and most of these have been exploratory or restricted to specific groups of areas. A model of successful aging needs to be multi-dimensional, incorporate a lay perspective for social significance, use a continuum rather than dichotomous cut-offs for “success” and lack of, and distinguish clearly between predictor and constituent variables.

Health care rationing: the public's debate

Abstract Objective: To elicit the views of a large nationally representative sample of adults on priorities for health services. Design: An interview survey based on a random sample of people aged 16 and over in Great Britain taken by the Office of Population Censuses and Surveys. Subjects: The response rate to the survey was 75%, and the total number of adults interviewed was 2005. Main outcome measures: A priority ranking exercise of health services supplemented with attitude questions about priorities, who should set priorities, and budget allocation. Results: The results of the main priority ranking exercise of 12 health services showed that the highest priority (rank 1) was accorded to “treatments for children with life threatening illness,” the next highest priority (rank 2) was accorded to “special care and pain relief for people who are dying.” The lowest priorities (11 and 12) were given to “treatment for infertility” and “treatment for people aged 75 and over with life threatening illness.” Most respondents thought that surveys like this one should be used in the planning of health services. Conclusions: The public prioritise treatments specifically for younger rather than older people. There is some public support for people with self inflicted conditions (for example, through tobacco smoking) receiving lower priority for care, which raises ethical issues. Key messages This study is the first exercise in health service priorities based on a random sample of the British population The highest priority of the public was the treatment for children with life threatening illness followed by special care and pain relief for people who are dying The lowest priorities were for treatment for infertility and treatment for people aged 75 and over with life threatening illness Most respondents thought that surveys of the publics opinions, like this one, should be used in planning health services

Ageism in cardiology

This article supports the argument that ageism exists in health care, particularly on the equity of access to cardiological services. Rates of use of potentially life saving and life promoting interventions and investigations decline as the patient gets older. Higher rates of cardiological interventions occur among younger people, despite the high incidence of the condition among older individuals. Any ageism in clinical medicine and policy is simply a reflection of the presence of ageist attitudes in wider society, where the youth receives a higher priority over age. Ageism in medicine needs to be addressed to preserve or recapture this trust within an aging population. A wide ranging approach is necessary if equity in the provision of health care services is to be ensured which includes improvement of clinical guidelines and more specific monitoring of health care. Educational efforts to raise awareness that age stereotyping and ageist attitudes are unethical should be initiated. Research initiatives, which cover large numbers of older people, should be developed and older people should be empowered to influence choices and standards of treatments. Finally, legislation may be required to eradicate ageism in society.

Impact of surgery for stress incontinence on morbidity: cohort study.

Abstract Objectives: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications. Design: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery. Setting: 18 hospitals in the North Thames region. Subjects: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278. Main outcome measures: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures. Results: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously. Conclusions: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised. Key messages Although surgery improves stress incontinence in most women (87%), only 28% are continent one year later The need for preoperative urodynamic testing should be reappraised Urgency and urge incontinence should not be considered contraindications to surgery Women considering surgery should receive more accurate information on the probability of an improvement in symptoms and possible complications There is a need for a rigorous, pragmatic, randomised trial of surgery for stress incontinence

Measuring patients' preferences for treatment and perceptions of risk

A greater understanding of patients’ preferences for mode of treatment is central to current models of shared patient-doctor decision making. It is also of potential importance in enhancing patient adherence to treatment and, in turn, patients’ health outcomes. Health services, with their emphases on patient involvement and satisfaction, audit and clinical governance, increasingly aim to be responsive to patients’ concerns and ultimately to enhance the quality of health care. Hence there is a need for awareness of patients’ preferences for treatment, and to develop appropriate, valid and reliable methods of eliciting these. The papers published in this supplement represent the output of an MRC Health Services Research Collaboration (HSRC) workshop, together with invited papers from other researchers in the area of patients’ preferences for treatment. The MRC HSRC has a special interest in the individualisation of health care and in methodological development; it is in the interface between patient preferences and evidence of benefit derived from groups that individualisation of care may be achieved. The aim of the workshop was to bring together an interdisciplinary group of UK experts to discuss the concept and measurement of patients’ preferences for treatment and directions for future research. The complexity and possible directions for research are summarised in fig 1. The supplement covers patients’ understandings of treatment risks, patients’ inclusion in decision making about treatment, diVerences in treatment preferences between doctors, and between doctors and patients, as well as methodological and ethical issues. It indicates the need for interdisciplinary collaboration on this topic. The literature on preferences spans a wide range of disciplines and journals including medicine, epidemiology, ethics, psychology, sociology, economics and policy areas from transport and environmental planning to agriculture. The knowledge base in this area of work is thus very diVuse which makes it diYcult for those with unidisciplinary approaches to become aware of all relevant research. It is intended that this collection of papers should stimulate further multidisciplinary dialogue, with involvement of representatives of patients, on the definition and measurement of patients’ preferences for treatment and their perception of its risks.