Quality of Life

Quality of life describes how good your life feels to you, taken as a whole. The World Health Organisation frames it as a person’s own view of their life, measured against their goals.¹ That view is seen through the culture and values they live by.

It covers both the good and the difficult parts of life at a given point in time. The term applies in every clinical setting, not only where illness is grave.¹

What quality of life actually is

To capture a person’s overall quality of life, some subjectivity has to be built into the evaluation. The same set of circumstances does not carry the same weight for everyone.³

That is the reasoning behind subjective well-being. One over-arching definition describes it as a person’s subjective evaluation of the quality of life as a whole.³ Two people can meet the same objective circumstance. They may appraise it differently, and weight the areas of their lives differently.

The alternative approach is an objective list: a limited set of measurable dimensions, scored without input from the person being assessed. Researchers who work on subjective well-being object on two grounds. Drawing up a list of important domains that nobody disputes is difficult, if not impossible. The evidence also shows that people weight domains differently.³

Well-being consists of many aspects. It cannot be fully represented by any one measure.⁴

Well-being includes the lack of suffering, but it is more than that.⁴

Three things one score blends together

One useful way of sorting well-being is into evaluative, experiential and eudaimonic types.⁵ Evaluative refers to judgements of life satisfaction; experiential refers to emotions, often captured in real time. Eudaimonic refers to a sense of meaning and purpose in life.

The first two sit together under the hedonic heading.⁵ Hedonic well-being consists of frequent pleasant feelings, infrequent unpleasant feelings, and an overall judgement that life is satisfying.⁴

The eudaimonic tradition begins differently. It starts with the qualities a person needs in order to develop: autonomy, positive relations with others, environmental mastery, self-acceptance, purpose in life and personal growth.⁴

Measures of the two are highly correlated: positive feelings and positive functioning tend to occur together. A number of studies nonetheless show the two sets of measures are distinguishable from one another.⁴

Challenging activities are associated with a greater sense of eudaimonic well-being. They are sometimes associated with less positive emotion.⁴ A period of life that feels harder can also be a time when something is going better. A single overall figure cannot show which of the three has moved.

The domains of quality of life

Researchers group quality of life into broad areas, called domains, and the World Health Organisation’s WHOQOL-BREF questionnaire is a widely used example. It carries 26 items covering four dimensions, answered on a 1 to 5 scale.²

Each dimension breaks into finer facets,² from sleep and safety to money and support. These areas connect to your psychological wellbeing.

An instrument of this kind fixes the domains in advance; it asks everyone about the same ones, and that is what makes scores comparable between people. The person answering may not weight those domains the way the questionnaire does.³

Health-related quality of life

Health-related quality of life is the narrower idea used in care settings. It examines the relationship between health and quality of life rather than life taken as a whole. Clinicians use it most where cure is not the aim; hospice and palliative care are the clearest case. In those settings the aggressive pursuit of a cure is set aside in favour of the person’s own goals.¹

Studies show real variability between individuals in how disease processes, symptoms, prognosis and palliative treatments affect quality of life.¹ The most accurate meaning of the term may be the one a person gives while sitting across from their clinician.

What the questionnaires can and cannot tell you

Unlike height, weight or a school grade, there is no agreed standard against which self-report measures of subjective well-being can be compared.³ The evaluation is a subjective one by definition, and it captures thoughts and feelings that are not visible to an outside observer.

Self-reports are still not beyond question. People may misremember how they felt, or may give disproportionate weight to information that is not relevant.

They may be unable to translate an internal feeling into a meaningful response on somebody else’s scale. Or they may be unwilling to answer honestly.³

On the judgement model, respondents do not hold a ready answer in memory. They construct one at the time of asking, and may use mental shortcuts.³ The best known version of this claim involves mood: current mood substitutes for a judgement about life as a whole.

Later testing did not support that claim in full. Replications used samples five to ten times larger than the originals, and most returned effects that were not significant. The pooled estimate is the result when all the studies are combined. It came to less than a tenth of the average original effect.³

A study of almost a million residents found no evidence that weather systematically influenced satisfaction judgements. In another, mood fluctuated considerably across three months while life satisfaction judgements did not.³

So the instruments are more reliable than their critics argued, and they are also less precise than a single figure suggests. Two findings follow from that literature.

Recalled judgements are vulnerable to peak-and-end effects, the tendency to evaluate a past episode by its most intense moment and by its ending. How long it lasted counts for less.⁴

The second is about the person making the judgement. Happy people place more weight on the domain they are most satisfied with when judging their life. Unhappy people place more weight on the domain they are least satisfied with.⁴

Knowing this does not remove the difficulty, but it may change how much weight you give to a judgement made on a bad day.

None of this makes the exercise pointless. Set beside financial measures such as gross domestic product, quality of life has no exact means of measurement across world cultures, regions and demographics.¹

The words do not travel intact

Most of the popular scales have been successfully translated into a range of languages. Most have not been put through the more demanding psychometric analyses.⁶ Those are the statistical checks that test whether a scale measures the same thing in each language.

Comparing average scores between cultures calls for caution. Response style, self-presentational concern, and memory and judgemental biases all vary.⁶

The underlying concept varies too. A study of dictionary definitions of happiness across 30 nations found that 24 of them included good luck and fortune among the definitions.⁶

English uses the word more broadly: “happy” can describe a minor positive event. The French, Polish, German and Russian terms are reserved for rare ones.⁶

The same pattern appears inside the instruments themselves, where the Satisfaction With Life Scale was compared across Chinese and American student samples. The most equivalent item was the one explicitly concerned with favourable external conditions: “The conditions of my life are excellent”. The two items about past accomplishments showed a large discrepancy.⁶

This caveat applies when a personal score is set against a national average, and equally when one country’s figures are read beside another’s.

Circumstances, adaptation and what can change

For a long period the field held that this was largely fixed. Classical theories of hedonic adaptation assumed that well-being inevitably returns to a baseline level, and that baseline was taken to be a set point, primarily determined by heritable factors. Lasting change was therefore not possible.⁷

Longitudinal studies follow the same people over many years. Studies through the 2000s followed people through widowhood, marriage, divorce and unemployment, and overturned that position.⁷ It is now widely accepted that most people experience stable levels of well-being. Significant and lasting changes can, and do, occur.

The detail differs by event. On average, people appear to adapt within a few years to marriage, childbirth and divorce. Adaptation is found after widowhood and bereavement as well, though the rate is slower than after divorce. After unemployment and disability, the changes in well-being are more permanent.⁷

Adaptation is common, but it is neither automatic nor inevitable, particularly after negative life events.⁷ If your life has not gone back to feeling the way it did before, that is not a failure of recovery on your part.

That is a reason to look for support rather than to wait. Low quality of life can be linked to a health or mental-health difficulty. A qualified therapist can help you find a place to start, and you can find a therapist through TherapyRoute when you are ready.

This article is for general information and is not a substitute for professional assessment or care. If this is affecting your life, consider reaching out to a qualified mental health professional.

References

1. [1] Teoli D, Bhardwaj A. Quality of Life. StatPearls. Treasure Island (FL): StatPearls Publishing. ncbi.nlm.nih.gov/books/NBK536962 ncbi.nlm.nih.gov/books/NBK536962.
2. [2] World Health Organization Quality of Life-BREF (WHOQOL-BREF): 26 items across four domains. pmc.ncbi.nlm.nih.gov/articles/PMC6955708 pmc.ncbi.nlm.nih.gov/articles/PMC6955708.
3. [3] Lucas, R. E. (2018). Reevaluating the strengths and weaknesses of self-report measures of subjective well-being. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of Well-Being (2018 ed.). Salt Lake City, UT: DEF Publishers.
4. [4] Tov, W. (2018). Well-being concepts and components. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of Well-Being (2018 ed.). Salt Lake City, UT: DEF Publishers.
5. [5] Newman, D. B., & Graham, J. (2018). Religion and well-being. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of Well-Being (2018 ed.). Salt Lake City, UT: DEF Publishers.
6. [6] Oishi, S. (2018). Culture and subjective well-being: Conceptual and measurement issues. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of Well-Being (2018 ed.). Salt Lake City, UT: DEF Publishers.
7. [7] Luhmann, M., & Intelisano, S. (2018). Hedonic adaptation and the set point for subjective well-being. In E. Diener, S. Oishi, & L. Tay (Eds.), Handbook of Well-Being (2018 ed.). Salt Lake City, UT: DEF Publishers.