Sonja M. Hunt

The problem of quality of life

Over the past few years, expressions of disquiet about the term ‘Quality of Life’ and the way in which it is applied and measured in clinical settings and in Health Economics have slowly increased. Some of this criticism has arisen from the poor quality of both research and application, some from misleading claims about outcomes and some from the lack of conceptual clarity. Anecdotally, many clinicians comment on the frustration and confusion they feel when asked to deal with the administration of questionnaires which appear to have little or no rationale for being termed measures of ‘quality of life’ and the content of which differs one from the other, implying distinct divisions in definition. Indeed, clinicians are often asked to tolerate situations in relation to questionnaires which they would reject out of hand if they involved clinical measures. It is the first tenet of any scientific enterprise, where measurement is to be attempted, that the object of measurement be precisely and meaningfully defined and the measuring instrument be appropriate and valid for the task. Moreover, where decisions may be made on the basis of the results of the application of the measure it is essential that consensus exists in the scientific and clinical community in order that all concerned know exactly what is being evaluated and that priorities in medical care are set on a standard basis. In relation to quality of life there is little agreement about the meaning of the term itself, there are rival factions each tendentiously urging the adoption of a different approach and a plethora of measures purporting to address ‘quality of life. As a consequence there must be grave doubts about the wisdom of using ‘quality of life’ as an outcome which could influence the lives of patients. The scientific status of quality of life research

Perceived health: age and sex comparisons in a community.

The need to find accurate and reliable indicators on which to base the planning, provision, and evaluation of health services gave impetus to the attempt to develop reliable and valid measures of the perceived health status of the consumers of health care. Subjective measures can provide an important complement to traditional statistics by giving direct access to the personal feelings of discomfort or distress that influence the use of health services. Such measures also give meaningful criteria for the evaluation of the efficacy of such services. Self assessments of health obtained from surveys and interviews have consistently found age and sex differences in the tendency to report symptoms, ill-health, disability, visits to doctors, and sickness absence. Many of these data, however, may have been misleading in using instruments of unknown or uncertain validity and reliability. Nevertheless, subjective assessments of health have been shown to have value and to add a dimension to objective measurements of health. They have been considered to be one of the better predictors of mortality and of adjustment to major episodes of illness.

Housing conditions and ill health.

Lack of empirical evidence that living in damp houses has detrimental effects on health may partly be due to inadequate research. A preliminary study was therefore carried out of a random sample of council owned residences in a deprived area of Edinburgh, a respondent from consenting households being interviewed to obtain a profile of the physical and mental health of all adults and children. In addition, information was gathered about other factors that might be important, particularly smoking and selective bias in the allocation of tenants to houses. Independent measures of dampness were made by environmental health officers. No conclusive effects of damp on the health of adults were identified. Nevertheless, children living in damp houses, especially where fungal mould was present, had higher rates of respiratory symptoms, which were unrelated to smoking in the household, and higher rates of symptoms of infection and stress. Housing should remain an important public health issue, and the effects of damp warrant further investigation.

Cross-cultural variation in the weighting of health statements: A comparison of English and Swedish valuations

Abstract An understanding of social and cultural differences in the valuation of experiences associated with illness is essential for the design and interpretation of cross-cultural studies and can also contribute to theoretical formulations concerned with the relationship between adverse medical and social conditions, perceived health and illness behaviour. A comparison of weightings given to the items on the Nottingham Health Profile by Swedish and English samples is described. These items represent lay expressions of discomfort and distress in the domains of physical mobility, pain, sleep, social interaction, emotion and energy. The weightings were obtained by the Thurstone Method of Paired Comparisons and show high agreement between the Swedish translation and the English version. These results strongly suggest that the expression of perceived health problems has relevance in the Swedish as well as the British context; that valuations show few cultural differences; that the Thurstone Method is of high reliability and validity for this type of indicator; that it is feasible to adapt subjective health measures for other linguistic groups. Discrepancies in weightings are ascribed to differences in cultural values.

A new measure of quality of life in depression: Testing the reliability and construct validity of the QLDS

Our previous paper described the development of a new quality of life scale for use with people suffering from depression; the Quality of Life in Depression Scale (QLDS). This paper reports on the testing of the scale for reliability and construct validity. Reliability was assessed by giving the questionnaire to the same set of patients on two occasions 2 weeks apart. This test-retest technique yielded a correlation of 0.94, with high internal consistency at both time 1 and time 2. A test of split-half reliability also indicated very high reliability. Construct validity was measured by comparing scores on the QLDS with those on an established scale of well-being from the same group of patients. The results gave a correlation between the two measures of 0.79, giving a satisfactory validity. It is concluded that the QLDS is a reliable and valid measure which is easy to use and acceptable to patients. Further tests of discriminative, concurrent and criterion validity are planned.

Housing conditions and mental health in a disadvantaged area in Scotland.

OBJECTIVE: To examine the mental health impact of different aspects of poor housing. DESIGN: This was a post hoc analysis of data from a household interview survey. SETTING: A public sector housing estate on the outskirts of Glasgow. SUBJECTS: These comprised 114 men and 333 women aged between 17 and 65 from 451 households. MEASURES: Dependent variable: scoring > or = 5 on the 30 item general health questionnaire (GHQ30). Independent variables: self reported data on household composition, whether ill health was a factor in the move to the current dwelling, length of time at address, household income, whether the respondent was employed, chronic illness, and 6 problems with the dwelling. RESULTS: Reporting a problem with dampness was significantly and independently associated with scores of > or = 5 on the GHQ30 after controlling for possible confounding variables. CONCLUSION: Initiatives to tackle housing dampness may be important in developing a strategy to improve mental health for the study area. More research on the mental health impact of different aspects of poor housing is required.

The health effects of improvements to housing: A longitudinal study

Abstract Although housing conditions were an integral part of the emergence of the Public Health movement, there has been relatively little research on the relationship between housing and health compared to that on social inequalities in general. This is surprising in view of the fact that one of the major links between social inequalities and health is adverse housing conditions. Findings from previous investigations in several countries of the presence of damp and mould in housing and symptoms in the occupants have indicated that the associations may well be causal. However, there have been no studies which have assessed the health of the residents before and after the elimination of dampness/mould. This paper describes a longitudinal study designed to evaluate the effects of an improved heating system on the symptoms of children living on a peripheral housing estate. The results suggested that the elimination of dampness/mould prevented a further deterioration in health rather than bringing about an i...

Measuring quality of life in psychiatry

Interest in quality of life measures for outcome assessment in psychiatry has been much slower to develop than in other disciplines such as cardiology, oncology and rheumatology. At first sight this is curious since it might be expected that psychiatrists would be more aware of the importance of social and psychological concomitants of illness and treatment. Unlike most medical specialties the accounts given by psychiatric patients and/or their relatives tend to form a major part of the material used in making a diagnosis and assessing improvement. However, even within psychiatry there is a strong tendency for the focus to be on the aetiology of the condition and those aspects of the patient’s function and feeling which are believed to be of clinical significance.

Self reports in research with non-English speakers

The challenge of language and culture is yet to be met

Attenders and non-attenders at a breast screening clinic: a comparative study

As part of the trial for assessing the value of breast screening, all women in the Edinburgh area who became eligible for screening over a nine-month period were sent a standard questionnaire of perceived health status. Results were analysed in the light of subsequent attendance or non-attendance at the clinic. Of those women who replied to the questionnaire, attenders at the clinic, those who did not respond to the questionnaire and those who declined the questionnaire were found to have a similar perceived health status, close to the population norm for this age and sex; those who accepted the invitation but failed to attend reported more health problems overall and these were statistically significant for emotional distress, social isolation and sleep problems. These differences were independent of postal code sector. It is suggested that more attention be paid to the heterogeneity of non-attenders for screening and the social and emotional context within which an invitation for screening is received and accepted.