Health Care Services and Quality of Life
Quality of Life in Health Care,Approaches to Quality of Life,Measurement of Quality of Life,Quality of Life as a Research Variable,Quality of Life In Different Research Methods,Dynamic Nature of Quality of Life Measure and Challenges.
Quality of Life in Health Care
Quality of life (QOL) is a multifaceted construct without a single
definition. QOL is used by many disciplines concerned with conditions of human
life, including social, environmental, political, economic, and health
(Anderson, KL, & Burckhardt, 1999).
Nursing and health care researchers are
interested in determining how disease or injury, or the treatment of disease or
injury, affects QOL. Health promotion researchers may use QOL measures to
ascertain the effectiveness of measures taken to enhance or improve, physical,
social, or spiritual health.
Approaches to Quality of Life
Despite a lack of consensus on what quality of life is, three broad
approaches for defining QOL have been suggested (Haas, 1999; Carr , Gibson,
& Robinson, 2001; Dijkers , 2003).
One category characterizes QOL as
evaluations or reactions such as well-being, happiness, satisfaction, morale,
or positive and negative affect. Another category describes QOL in terms of
normality, meeting societal standards, and status or achievements. Ability to function
and fulfill basic needs are examples of this QOL domain.
A third approach
suggests QOL is a matter of perception regarding the differences between
expectations, what is valued or considered important in life, and current life
experiences. Many QOL instruments are multi-dimensional, combining the
conceptual dimensions of evaluation, normality, and/or perception. The
importance of quality-of-life research is evident through federal funding of
health research.
One of the five future research priorities identified in
September 2003 by the National Institute of Nursing Research includes
quality-of-life research in chronic illness. The Centers for Disease Control also
has a division for health-related quality of life that provides measures and
data for tracking various aspects of population health.
The prevalence of QOL as a variable in nursing studies is
demonstrated through a CINAHL search, using the phrase “quality of life” and
limited to research and nursing journals. The search yielded 1,744 articles
published between 1982 and November 2003, with 824 or 47% entered since the
year 2000.
Measurement of Quality of Life
QOL measurements are classified into five types (Garratt, Schmidt,
Mackintosh, & Fitzpatrick , 2002). Generic measures, such as the Medical
Outcomes Study SF-36, can be used with any patient population, or any disease
or health condition.
Disease or population specific instruments have been found
to be more sensitive to changes in QOL since these tools are designed to
measure more specifically how a disease or illness affects life dimensions. The
European Organization for Research into the Treatment of Cancer quality-of-life
questionnaire (EORTC QLQ-C30) is an example of a population specific tool.
Dimension specific measurements focus on specific aspects of health, such as
well-being or depression. Utility measures, exemplified by the Health Utilities
Index, are beneficial in evaluating economic aspects of health treatments and
require respondents to choose between alternative health states, with economic
or other costs associated with the choices.
Individualized QOL tools, such as
the Patient Generated Index or the Schedule for the Evaluation of Individual
Quality of Life, ask respondents to identify and weigh what they deem important
in their lives.
The individualized approach is considered by some to be the
most appropriate way to measure quality of life, because the research
participants are the only ones who can say what matters most in their lives (Joyce,
Hickey, McGee, & O’Boyle, 2003; Macduff, 2000).
Quality of Life as a Research Variable
Because QOL is defined in a variety of ways, many methods and tools
are available. to measure QOL as a research variable. The MAPI Research
Institute (Lyon, France) offers a free catalog describing over 1,000 QOL
instruments and provides access to these instruments for a subscription fee.
Considerations for selecting or developing a QOL
instrument include: deciding who is evaluating QOL, what aspects or dimensions
of QOL are to be evaluated, whether the measurement needs to be able to detect
changes over time, and how the information gained from the measurement will be
used.
The research participant’s age, communication ability, severity of
illness, and cognitive ability will determine whether QOL is scored by an
outside observer or proxy, such as a parent, spouse, or health care provider
(Addington-Hall & Kalra, 2001).
The Scientific Advisory Committee of the
Medical Outcomes Trust (2002) suggests the following criteria for evaluating
QOL instruments: the conceptual and measurement model underlying the
instrument, psychometric properties of reliability and validity, sensitivity or
responsiveness to change over time, case of interpreting and understanding
scores, respondent or administrative burden, alternative modes of
administration, and cultural and language adaptations of the instrument for use
in other populations.
Quality of Life In Different Research Methods
Whether a study is cross-sectional or longitudinal will also
influence the instrument choice. Tools used in longitudinal studies need to be
sensitive to change, without floor or ceiling effects associated with items in
the tool (Hyland, 2003).
Hyland also suggests that tools in longitudinal
studies be relatively short, have multiple response items such as Likert scales,
and include items that describe problems common and relevant to the population
being studied. QOL questionnaires used in cross-sectional studies need to be
able to discriminate among respondents who will have varying differences in QOL
(Hyland).
QOL tools for cross-sectional studies may have more items with two or
three response choices, may include items that have floor. and ceiling effects,
and may not be relevant to all respondents.
Because of the variety of definitions and tools, QOL may be
difficult to compare across studies (Garratt et al., 2002). Thorough knowledge
of conceptual and psychometric aspects of a QOL measure is essential for
selecting the right tool for a research study.
Using the same instrument as
other researchers may not be appropriate if the instrument does not adequately
capture the researcher’s conceptualization of quality of life, or if the tool
is not sensitive to change over time and the study is a longitudinal design.
Thus, definitional and measurement issues may hamper building a body of
knowledge about quality of life.
Dynamic Nature of Quality of Life Measure and Challenges
The dynamic nature of life also presents challenges for measuring
QOL ( Carr et al., 2001). People adapt to illness and their expectations about
interventions may change over time, so what effects QOL at one time may not at
another.
Priorities in life also change, so what a person considers important
at one time may be less important at another. Aggregation of QOL data within a
population may be difficult because people’s expectations regarding the effects
of a disease or intervention may differ.
Despite these difficulties in
measuring QOL, it is an important concept for nursing, and will continue to be
an outcome variable in nursing studies.