environmental and health-related quality

8/7/2019 ENVIRONMENTAL AND HEALTH-RELATED QUALITY

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Pergamon 0277-9536(95)00122-0Soc. Sci. Med. Vol. 41, No. 10, pp. 137 3 13 82, 1995Cop yr igh t 1995 E ls e v ie r Sc ie nc e L tdP r in te d in G re a t Br i t a in . A l l r igh t s r e s e rve d0277-9536/95 $9.50 + 0.00

ENVIRONMENTAL AND HEALTH-RELATED QUALITYOF LIFE: CONCEPTUAL AND METHODOLOGICAL

SIMILARITIESROBERT J. ROGERSON

Quality of Life Research Group, Department of Geography, University of Strathclyde,50 Richmond Street, Glasgow G1 IXN, ScotlandAbstract--The recent revival of interest in the concept of quality of life by academics in both the socialand medical sciences and amongst politicians has focused attention on the continuing debate about thedefinition, measurement and utilisation of quality of life. In particular, the need amongst regulatory andfinancial authorities--both in the health sector and in local government--to know about the potentialimpact of intervention has encouraged further interest in the use of quality of life measures to assistresource allocation and assessing the impact of policy decisions. In this paper it is argued that whilst suchmeasures may be the ultimate goal of research, this can only be constructed on a fuller understandingof quality of life measures of current conditions and the relationship between components of life quality.A conceptual framework is developed to show the relationship between the way that quality of life, inboth environmental and health-related studies, has been conceived and measured. The strong similaritiesin both respects are discussed, pointing to the need for heightened interdisciplinary dissemination ofresearch methods and assessments.Key words--conceptualisation, quality of life, measurement, environment

I N T RODUCT I O N

It is widely recognised that the content and researchagenda of disciplines within the scientific communityare often developed in response to stimuli within thewider economic, social and political milieux in whichresearchers operate, a nd that, reciprocally, the actionof the research community helps to shape thesemilieux [1,2]. As with other research areas whereemphasis has been placed o n applying research find-ings, quality of life studies have responded to avariety of different environmental stimuli, mouldingthe agenda and approaches adopted by social andmedical scientists [3]. The mo tivat ion of the develop-ment of social indicators and social accounting aspart of quality of life studies, for example, in the1960s has been identified as a growing dissatisfactionamongst policy-makers with economic indicatorssuch as GNP per capita, arising because of theawareness that despite economic prosperity andgrowth in standard of living, groups of the popu-lation continued to be dissatisfied with their socialwell-being [4, 5].

In the 1970s, with a shift of focus to welfareeconomics and geography, increasing use was madeof quality of life measurements in the analysis ofsocial and economic problems arising from inequali-ties in the distribution of welfare resources amongstgroups in the population. At a time of fiscal con-straint by the state and new advances in technologyenabling more complicated but expensive interven-

tions, the research agenda shifted towards applied,'relevant' research aimed at recognising how differentneeds and aspirations of people had to be met withinthe welfare system. This research, with its explicitjudgement between alternative states of society andoutcomes of distri bution of resources, challenged theso-called objectivity and political neutra lity of earlierquali ty of life research [6]. Qual ity of life criteria wereused as measurements of the conditions which re-quired change through the application of welfaristapproaches and planning. As such, politically andideologically, quality of life was, and continues to be,related to a welfarist standpoint, concerned with theidentification of social and health inequalities, the(reallocation of resources on the basis of most needwithin the state-provided health sectors and moregenerally in the welfare system, and the view thatcollective or state int ervention represents the mosteffective method of alleviat ing areas of relative depri-vation [7]. As a consequence of this focus for qualityof life studies, increasing debate arose amongst re-searchers about who should be involved in the valuejudgements between alternative distribution of re-sources [8, 9]. In particula r the recognition that differ-ent evaluations of existing conditions and of theoutcomes arising from therapies and plan ning de-cisions fuelled this debate which has continued formore than a decade.

The recent, international revival of interest inquality of life in many respects continues to reflectthe same external pressures and internal responses.

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1374 Ro bert J. RogersonC o n t i n u e d f i sc a l p r e s s u r e o n c o l l e c t i v e l y f u n d e d a n dp r o v i d e d h e a l t h a n d w e l f a r e s e rv i c e s i s p r e v a l e n t i nm a n y c a p i t a l i s t e c o n o m i e s , w h i l s t t e c h n o l o g i c a l a d -v a n c e s h a v e r e s u l t e d i n a g r e a t e r r a n g e o f p o s s i b l et r e a tm e n t s . C o n s e q u e n t l y , m o r e p e o p l e a r e n o w c o m -p e t i n g f o r a s h r i n k i n g f u n d i n g b a s e a n d t h u s m e t h o d so f a n a l y s i s w h i c h a s s i s t i n t h e a l l o c a t i o n o f r e s o u r c e sa r e b e i n g s o u g h t b y p o l i t i c ia n s a n d d e c i s i o n - m a k e r s .W i t h i n t h e r e s e a r c h c o m m u n i t y , d e b a t e o v e r t h ed e f i n i t i o n o f q u a l i t y o f l if e , i t s m e a s u r e m e n t , a n d w h os h o u l d b e i n v o l v e d i n t h e e v a l u a t i o n r e m a i n a p p a r -e n t l y u n r e s o l v e d i s s u e s w i t h i n t h e i n t e r d i s c i p l i n a r yu s e o f t h e q u a l i t y o f l if e c o n c e p t [ 10 , 1 I ] .

Y e t , i t i s a l s o p o s s i b l e to i d e n t i f y a t l e a s t o n ei m p o r t a n t s h i ft o f e m p h a s i s w h i c h h a s o c c u r r e d i n t h ew i d e r e n v i r o n m e n t a n d w h i c h h a s s t i m u l a t e d r e n ew e da w a r e n e s s o f q u a l i t y o f l i f e . T h a t i s t h e c e n t r a l i t y o ft h e i n d i v i d u a l , w h e t h e r a r i s in g f r o m s o c i al a n d e c o n -o m i c s h i f t s t o w a r d s p o s t m a t e r i a l i s t v a l u e s [ 1 2, 1 3]a n d p o s t m o d e r n i t y [ 1 4] o r p e r h a p s m o r e s i g n i f ic a n t ly ,i n t h e c o n t e x t o f w e l f a r e s e r v ic e s , w i t h i n t h e p o l i t i c a lm i l i eu w h e r e i n d i v i d u a l i t y a n d t h e c o n s u m e r h a sr e c e i v e d g r e a t e r p r i o r i t y [ 15 , 1 6] a s r e s p o n s i b i l i t y h a ss h i ft e d d o w n f r o m d o c t o r s t o p a t i e n t s in i n f lu e n c i n gi n t e r v e n t io n a n d n e w f o r m s o f r e s o u r c e a ll o c a t i o n sa r e s o u g h t b y h e a l t h c a r e , e d u c a t i o n a n d o t h e r w e l -f a r e m a n a g e r s [ 17 ]. W i t h i n t h i s n e w m i l ie u , q u a l i t y o fl if e h a s f o u n d f a v o u r a m o n g s t t h o s e w h o a d v o c a t e ap o s t - w e l f a r i s t a n d n e o - l i b e r a l i d e o l o g i c a l p o s i t i o n[ 18 ]. T h e a t t r a c t i o n o f t h e c o n c e p t l ie s f i r s tl y i n t h ei n t e r p r e t a t i o n t h a t q u a l i t y o f l if e e m p h a s i s e s t h ei n d i v i d u a l r a t h e r t h a n t h e c o l l e c ti v e i n it s c o n c e p t i o no f s a t i s f a c t i o n a n d s e c o n d l y i n t h a t t h e p r o v i d e r s o fs e r vi c es g o o d s a n d o t h e r c o m p o n e n t s o f q u a l i ty o f l if en e e d t o b e r e s p o n s i v e t o t h e c o n c e r n s o f t h e c i t i z e no r c o n s u m e r . E q u a l l y , w i th t h e c o n t i n u i n g r e s t r ic t e ds t a t e f u n d i n g o f w e l f ar e p r o v i s i o n , q u a l i t y o f l i fe h a sb e e n v i e w e d a s p r o v i d i n g a n a l t e r n a t i v e , n o n - e c o n -o m i c b u t s t a n d a r d is e d m e a s u r e o f ' v a lu e f o r m o n e y 'a l l o w i n g t h e t a r g e t i n g o f r e s o u r c e s to a r e a s w h i c h w i llo f f e r t h e ' b e s t ' r e t u r n f r o m i n t e r v e n t i o n .

I t is n o t t h e i n t e n t i o n h e r e t o p u r s u e t h e p a r a d o x -i c al p o s i t i o n t h a t c o n t e m p o r a n e o u s l y q u a l i t y o f l i fe isp e r c e iv e d a s a u s e fu l c o n c e p t b y p o l i t i c a l g r o u p s o fd i f f e r e n t i d e o l o g i c a l p e r s u a s i o n s , o t h e r t h a n t o n o t et h a t i n m a n y r e s p e c t s t h i s i s a r e f l e c t io n o f t h e v a r i e t yo f w a y s i n w h i c h q u a l i t y o f l if e h a s b e e n d e f i n e d b o t ha c a d e m i c a l l y a n d p o p u l a r l y . T h e p o l i t ic a l u ti l it y o fq u a l i t y o f l if e l i es th e r e f o r e i n i t s a c a d e m i c a m b i g u i t y .T h e c u r r e n t p o l i t i c a l u s e o f q u a l i t y o f l i fe is , h o w e v e r ,i m p o r t a n t i n t h a t i t h a s f o c u s s e d a t t e n t i o n w i t h i n t h em e d i c a l a n d s o c i a l sc i e n c e s o n t h e p o s s i b i l i t y o f u s i n gq u a l i t y o f li fe m e a s u r e m e n t a s m o r e t h a n a n i n p u ti n t o p o l i c y m a k i n g . I n s t e a d , i t h a s b e e n a r g u e d t h a tq u a l i t y o f l i fe c o u l d b e u s e d t o e v a l u a t e a n d p r e d i c to u t c o m e s f r o m i n t e r v e n t io n s [ 1 9] , t h u s p r o v i d i n g am e a s u r e a g a i n s t w h i c h r e s o u r c e a l lo c a t i o n c a n b eassessed [17] .

T h e u s e o f q u a l i t y o f l i fe a s a m e a s u r e o f p o s t - i n -t e r v e n t i o n o u t c o m e s i s p r e d i c a t e d o n t h e a s s u m p t i o n

t h a t a c o n s e n s u s e x i s t s a b o u t h o w c u r r e n t h e a l t h o re n v i r o n m e n t a l c o n d i t i o n c a n b e m e a s u r e d a n d e v a l u -a t e d . W i t h o u t s u c h a g r e e m e n t , i t is d if f ic u l t t o e n v i s -a g e t h e p o s s i b i l i ty t o m a k e c o n s e n s u a l j u d g e m e n t sa b o u t a c t i o n s a n d i n t e rv e n t i o n s . R e c e n t r e vi ew s[ 20 , 2 1 ] h a v e n o t e d t h e c o n t i n u i n g l a c k o f c o n s e n s u sa b o u t t h e m e a s u r e m e n t o f q u a l i ty o f l if e. I t h a s b e e na r g u e d t h a t t h i s r e fl e c ts s ig n i f i c a n t e p i s t e m o l o g i c a ld i s a g r e e m e n t a b o u t t h e d e f i n i t i o n o f q u a l i t y o f l i f e ,w i t h t h e t e r m b e i n g t a k e n a s s y n o n y m o u s w i t h i n d i -v i d u a l o r g r o u p w e l l -b e i n g , s a t i s fa c t i o n a n d h a p p i -n e s s, o r b e i n g c o n c e r n e d w i t h e n v i r o n m e n t a lc o n d i t i o n s i n p l a c e s o r w i t h h e a l t h c o n d i t i o n s a n dr e l a t e d t e c h n i c a l p r o b l e m s a s s o c i a t e d w i t h t h e p r o -d u c t i o n o f a ' s u i t a b l e ' m e a s u r e m e n t o f q u a l i t y o f li fe .T h e f a i l u r e t o f i n d a c o n s e n s u s o n t h e c o n c e p t u a l i s -a t i o n o f q u a l i t y o f l if e h a s , i n t u r n , t e n d e d t o l i m i t e di t s a d o p t i o n b y s c i e n t i s ts in t h e i r r e s e a r c h w i t h i n t h e i rd i s c i p l in a r y b o u n d a r i e s , a n d p r o d u c e d a r e l u c ta n c eb y r e s e a r c h f u n d i n g a g e n c i e s t o s u p p o r t s t u d y i n t h i sa r e a . M e t h o d o l o g i c a l q u e s t io n i n g h a s r e s t ri c te d a p -p l i c a t i o n o f q u a l i t y o f l i f e t o s o c i a l p r o b l e m s a n dp l a n n i n g ; t h e o r i g i n a l m o t i v a t i o n f o r c o n d u c t i n gq u a l i t y o f li f e r e s e a r c h . I n t h i s p a p e r , I w i s h t o s u g g e s tt h a t t h e r e a r e i n f a c t s i g n i f i c a n t a r e a s o f o v e r l a p i nt h e w a y t h a t q u a l i t y o f l i f e h a s b e e n c o n c e p t u a l i s e da n d s i m i l a r m e t h o d o l o g i c a l i s su e s w h i ch a r e b e i n ga d d r e s s e d i n t h e s o c i a l a n d m e d i c a l s c i e n c e s .T o w a r d s a c o n c e p t u a l f r a m e w o r k

C o n c e p t u a l i s i n g q u a l i t y o f l if e h a s p r o v e d t o b e ad i f fi c u l t p r o c e s s . T h e v e r y d i f f u s e n e s s a n d a m b i g u i t yo v e r q u a l i t y o f l i f e m a y e x p l a i n i t s c u r r e n t p o l i t i c a la t t r a c t i o n , b u t t h e l a c k o f a c l e a r c o n c e p t u a l i s a t i o ni s a h i n d r a n c e t o i t s i m p l e m e n t a t i o n i n d e c i s i o n -m a k i n g . I n p a r t t h e d i f f i c u lt y r e f le c t s t h e c o m p l e x ,m u l t i d i m e n s i o n a l i t y o f t h e t e r m , a n d t h e d e g r e e t ow h i c h t h i s m u l t i d i m e n s i o n a l i t y n e e d s t o b e r e f l e ct e di n t h e c o n c e p t s a n d m e a s u r e m e n t o f li f e q u a l i t y . I no t h e r w o r d s , a f u n d a m e n t a l i s s u e i n b o t h e n v i r o n -m e n t a l a n d h e a l t h - r e l a t e d q u a l i t y o f li f e r e s e a r c h h a sb e e n w h e t h e r q u a l i t y o f l if e s h o u l d b e m e a s u r e d a s aw h o l e , c o n c e i v e d h o l i s t ic a l l y , o r t h r o u g h a p e r s p e c -t i v e w h i c h s u b d i v i d e s l if e q u a l i t y i n t o a s e t o f c o m -p o n e n t s a g g r e g a t e d t o r e p r e s e n t t h e w h o l e . T h e s ed i f f ic u l t ie s a r e c o m p o u n d e d b y t h e f a c t t h a t b e i n g ac o n s t r u c t , q u a l i t y o f l i fe i s n o t d i r e c t l y o b s e r v a b l e[ 2 2 ] .

S i n g l e i t e m m e a s u r e s e i t h e r a s i n d i c a t o r s o f g e n e r a lw e l l- b ei n g c o n d i t i o n s - - s u c h a s m o r t a l it y r a t e s - - o ra s m e a s u r e s o f o v e r a l l p e r c e i v e d w e l l - b e i n g , s u c ha s l if e s a t i s f a c t i o n s c o r es , c o n t i n u e t o h a v e s o m eu s a g e i n q u a l i t y o f l i f e r e s e a r c h . H o w e v e r , t h e s eg l o b a l m e a s u r e s h a v e b e e n c r i ti c i se d o n c o n c e p t u a lg r o u n d s o n t h e b a s i s t h a t n o o n e u n i t a r y m e a s u r e c a nb e e x p e c t e d t o e n c a p s u l a t e a l l t h e c o m p o n e n t s o fw e l l -b e i n g , s a ti s f a c ti o n o r o p p o r t u n i t i e s [ 2 3 ] a n d o nm e t h o d o l o g i c a l g r o u n d s t h a t t h e r e a r e in h e r e n t p r o b -l e m s o f t e s t i n g f o r r e l i a b i l i t y , v a l i d i t y a n d s e n s i t i v i tyt o c h a n g e . W h a t e v e r t h e m e r i ts o f s u ch a p o s i t iv i s t


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Environmental and health-related quality of life 1375critique, more fu ndamen tally it has been suggestedthat "life as a whole is a concept of such breadth thatfew people are accustomed to thinking of their situ-ation in such a way" [24], a view which if correctmakes the value of a global score open to significantquestioning. Although it is unfashionable to advocatethe adoption of a global score to measure quality oflife, it is noteworthy that if we conceptualise ofquality of life as being holi stic --an issue itself whichmerits greater consid erati on--the n by definition, anynon-globa l scoring or eva luation will produce only apartial assessment of life quality. From a policyviewpoint, global scores provide problems in inter-preting the outcome as different sets of conditionsand perceptions can result in the same outcome.

To measure and operationalise quality of life,therefore, it has generally been accepted that it isnecessary to deconstruct the concept, either into itsmeasurable component parts or into the variousprocesses involved in the creation of quality of lifeand then representing the aggregate (or separate)measures of quality of life as an index or profile.Developing an understanding of the concept of lifequality through such means of empirical 'testing' andcomponent analysis will inevitably require the em-ployment of evaluative assumptions; evaluationabout the relationships of the component parts toeach other and to quality of life as whole.

There appears to be a consensus that in definingquality of life there are two fundamental sets ofcomponents and processes operating: those whichrelate to "an internal psychological-physiologicalmechani sm" [25] producing a sense of satisfaction orgratification with life either at an individual level orcollectively for co mmunitie s and other social groups;and those external conditions which trigger the in-ternal mechanism. The distinction between these twosets of elements has spawned different ways of con-ceptualising quality of life and subsequently differenttypes of measurement techniques and indicators.These various notions of qual ity of life have resultedin a debate within both medical and social sciencesabout the relative merits of each view as a means ofquality of life assessment, and over the relationshipsbetween the approaches [26, 27].

In order to advance this debate I wish to suggesta framework within which different conceptualis-ations of quality of life can be placed. Initially, thisis developed using examples from environmentalquality of life studies, although a comparable frame-work for health related studies is also discussed. Theframework provides an opportunity to consider therelationship between the different conceptualisat ionsof life quality, and the links between the conceptualviews and the methods employed in the evaluat ion ofquality of life. In addition, the parallels between theway that quality of life has been viewed in bothmedical and social sciences are highlighted.

In developing a conceptual framework, I wish tobuild on Culyer's recent, insightful expansion of Sen's

[28] division of things and people taken from aneconomic perspective [29]. Culyer argues that in orderto examine 'things' (or commodities as he termsthem) and 'people', research should include morethan the presence or absence of things and incorpor-ate an analysis of the characteristics of both thecommodities and people. In the case of things whichare consumed as part of life, it is these characteristicswhich often describe the quali ty of the goods orservices a nd influence the utility value- -the outcomeof the consumption process and which can bemeasured in terms of pleasure or satisfaction. Culyernotes that traditional welfare economic studiesneglect to consider the influence of the characteristicsof people in the assessment of the utility of a com-modity and he argues that this is also important inquality of life assessment. The characteristics ofpeople may be related causally to the consump tion ofthe commodity, to the inherent features of peoplethemselves or to relationships between groups ofpeople. Thus, for example, in relation to health careas a commodity, the characteristics of people could berelated to the outcome of earlier health treatment,their relative deprivation, or to the level of commu-nity support respectively for each interpretation. ForCulyer, inclusion of the 'characteristics of people"within the relationship between commodities andutilities has the advantage of offering an alterna-tive, non-uti lity focus for qual ity of life. If "thecharacteristics of people are a way of describingdeprivation, desired states or significant changesin people's character istics" [29, p. 12] then it ispossible to use these characteristics to assess theeffect of commodity provision in achieving the indi-vidual's desired states--a state which need not bepleasure in the utility sense. In other words, onepotential avenue to investigate quality of life is toevaluate the characteristics of people.

E N V I R O N M E N T A L Q U A L I T Y O F L I FE

Within environmental quality of life studiesCulyer's ideas have some immediacy. His distinctionbetween commodities and their characteristics andpeople and their characteristics can be developed byreducing the economic terminology and by relatingthe divisions to the interaction between the environ-ment and peopl e--a n interaction which has been thebasis of most conceptualisations of quality of life.Figure 1 provides a framework to portray the re-lationship in the context of place and environmentalresearch. It utilises the distinction between externalconditions or things (shown as the material life arena)and internal, personal factors of people (shown aspersonal life arena).The materia l life arena consists of a series of goods,services and other attributes related to the social,physical and economic environment in geographicalspace within which people live. These attributes--comparable with Culyer's more narrowly focused


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1376 Robert J. RogersonM a t e r i a l l i f e a r e n a Personal life arena

Attr ibuteso fenv i ronmentCharacter is t icso f

at tr ibutes _-I CharacteristiCSofpeop leSatisfact ionandwell-being

Fig. I. Environmental quality of life.

commodities--have been the traditional focus ofwelfare economics and geography concerned with thesupply and demand of such features and their spataildistribution [6,30]. The attributes include, forexample, services such as health care, educationfacilities, leisure and recreational facilities, physicalfeatures such as landscape and climate, and economicattributes of employment and labour market con-ditions. As Culyer notes, these attributes have differ-ing characteristics which are the way in which peopleoften describe the quality of, or obt ainable from, theattributes. These characteristics could include access,frequency of provision and efficacy.

The central thrust of these approaches is thatquality of life can be conceived of as pert aining to theprovision of the "necessary conditions for happinessand satisfaction" [31] to be achievable for individualsand groups in the population. In other words, thoseproperties of the enviro nmen t which are the trigger orstimuli for life satisfaction. Consequently, an evalu-ation of the quality of life opportunities present in aplace or region can be based on an assessment of thepresence and absence of these necessary conditionsand the characteristics of the features. A range ofobjective social indicators are commonly used tomeasure these conditions, with the indicators de-signed to measure 'objective reality' of the livingenvironment; "hard indicators describing the en-vironments within which people live and work"[25].

As noted above, the assumption usually made isthat the range of indicators can be defined on thebasis of a consensus amongst researchers of thedefinition of quality of life. Despite more than twentyyears of searching, no such consensus exists. Indeed,it has been quest ioned whether such a 'definitive' listof criteria can be produced for all quality of lifestudies [25, p. 498] given that perceptions of lifequality and the forces which impinge upon them arein a state of constant flux and operate in differentways at the variety of scales which are studied underthe umbrella of env ironmental quality of life research[32, 33]. 'Expert opin ion' has thus been used todetermine the components of quality of life and to

decide on the means of aggregation into an index--usually on the justification that without some societalagreement about the value of each indicator to theoverall quality of life, the researcher is likely to bringan informer and r ationally-based opinion. The adop-tion of such methods in the ambitious and much-quoted studies of American cities and their qualityof life by Liu [34, 35] and the Places Rated Ala-manac [36] has provoked considerable criticism[37, 38, 39, 40].

Largely in response to such criticisms, other con-ceptualisations of quality of life have been based onthe inc lusion of personal, subjective componen ts partof the personal life arena (Fig. 1) arising from theinteraction between people and the environment.This arena includes the subjective assessment of lifequality measures in terms of satisfaction, pleasure,happiness or other preference ordering. Within qual-ity of life studies this has been viewed as the utilityvalue--not necessarily in the narrow analytical con-vention of what people attempt to maximise, but inthe wider recognition that it is a construct form ofevaluat ion which is based on an individua l's overallassessment of the satisfaction achieved (against theirown terms of reference arising from the use ofattributes in the material life arena. The personal lifearena also includes the characteristics of people,which has been taken to include factors such aspersonal attributes (e.g. age, gender, social class),their past and current experiences and the impact ofrelationships with other people all of which areinfluential in shaping value systems and preferences.

With this arena, two broad but different sets ofquality of life definitions can be identified. The maindifference in the way that quality of life is conceptu-alised relates to whether the perceived values andpriorities associated with personal aspirations andneeds are identified explicitly and then utilised by theresearcher to assess the quality of life, or whethersuch priorities are employed by the individual them-selves in a phenomenological sense to identify ameasure of satisfaction with quality of life. Theformer approach uses an evalu ation of the character-istics of people to identify variations in the priorities


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E n v i r o n m e n t a l a n d h e a l t h - r e la t e d q u a l i ty o f li fe 1379t h e s c a l e s a n d q u e s t i o n s , t h e r e c a n b e d i f f ic u l ty i ns e p a r a t i n g b e t w e e n r e s p o n d e n t s i n t h e i r a s s e s s m e n t i ng o o d o r e x c e l l e n t h e a l t h [6 8] a n d t h i r d l y , t h e r e -s p o n s e s a r e t i m e a n d p l a c e s p e c if ic , a n d s h i f ts i nr e s p o n s e s s h o u l d b e a n t i c ip a t e d a s a c o n s e q u e n c e o fc h a n g e s i n e i th e r o r b o t h h e a l t h c o n d i t i o n s a n de x p e c t a t i o n s m a k i n g a p p l i c a t i o n o f t h e r e s u lt s ini n t e r v e n t i o n p l a n n i n g d i f fi c u l t [2 0] . T h e f o r m e r r e -s t ri c ti v e f a c t o r c a n b e p a r t i a l ly o v e r c o m e b y e m p l o y -i n g s a t i s f a c t i o n s c a l i n g a n a l y s i s f o r s e p a r a t ec o m p o n e n t s o f q u a l i ty o f li fe , b u t e v e n t h e n i n -t e r p r e t a t i o n o f t h e u n d e r l y i n g p r i o r i t i e s, a n d s y m p -t o m s i s d i f f i c u l t . T h e i n a b i l i t y t o r e v e a l w i t h i n t h e s es c a l i n g a p p r o a c h e s t h e r e a s o n s w h y p e o p l e a r e s a t -i s f i e d / d i s s a t i s f i e d , w h a t t h e y a r e a s s e s s i n g a n d t h et e r m s o f r e f e r e n c e t h e y a r e u s i n g h a v e a p p a r e n t l yr e d u c e d t h e p e r c e i v e d v a l u e o f th e s e m e t h o d s i nh e a l t h r e l a t e d q u a l i t y o f l i fe re s e a r c h .

1N S E A R C H F O R S O L U T I O N S

O n e o t h e r i m p o r t a n t w a y t o s e a rc h f o r s o lu t i o n si s t o r e c o g n i s e t h e m e r i t o f g r e a t e r i n t e r d i s c i p l i n a r yr e s e a r c h i n t o q u a l i t y o f l if e s o t h a t w e a l l c a n l e a r nf r o m o u r d i f f e r e n t e x p e r i e n c e s . T h e a b o v e d i s c u s s i o nh a s f o c u s s e d l e s s o n e m p i r i c a l r e su l t s t h a n o n c o n c e p -t u a l a n d a s s o c i a t e d m e a s u r e m e n t i s s u es in r e s e a r c h -i n g q u a l i t y o f li fe i n b o t h m e d i c a l a n d s o c i a l sc i e n c es .T h i s h a s b e e n d e l i b e r a t e , a s it a p p e a r s t h a t t h ec o n c e p t u a l a n d t e c h n i c a l c h a l l e n g e s w h i c h w e f a c e i nc o n d u c t i n g l if e q u a l i t y r e s e a r c h a r e s h a r e d p r o b l e m s .A t t h e c o n c e p t u a l l e v e l, a s t h e t w o f i g u r es i n th i sp a p e r h a v e a t t e m p t e d t o s h o w , q u a l i t y o f l if e h a s b e e nd e f in e d i n c o m p a r a b l e w a y s , a l t h o u g h u s i n g d i ff e r en ts c a le s o f a n a l y s i s i n t h e t w o s c ie n c e s . E q u a l l y ,a l t h o u g h a p l e t h o r a o f d if f e r e n t, s p e c i fi c t e c h n i q u e sh a v e b e e n d e v e l o p e d , t h e u n d e r l y i n g m e t h o d o l o g i -c a l i s s u e s i n b o t h e n v i r o n m e n t a l a n d h e a l t h - r e l a t e ds t u d i e s a r e s i m i l a r .

H o w e v e r , w h i l s t t h e c e n t r a l th r u s t o f t h e p a p e r i st o r e c o g n i s e t h e s i m i l a r i t i e s t h a t e x i s t w i t h i n b o t hs c i en c e s , 1 w i s h t o c o n c l u d e b y c o n s i d e r i n g s o m e o ft h e d i ff e r e n c e s , n o t i n te r m s o f m e t h o d o l o g i c a l i s su e sb u t m o r e p r a c t i c a l a p p l i c a ti o n s o f t h e c o n c e p t o fq u a l i t y o f li fe . T w o a s p e c t s a r e d i s c u s s e d h e r e .

I n r e c e n t y e a r s , q u a l i t y o f li fe m e a s u r e s a r e b e i n ga d o p t e d b y a n e w b re e d o f h e a l th c a r e m a n a g e r s ,l o c a l a n d n a t i o n a l o f f ic i a ls a n d p o l i t ic i a n s , a n d t h eg r o u n d s o n w h i c h q u a l i t y o f li fe i s su e s a r e b e i n gd e b a t e d s h i f t t o w a r d s i s s u e s a s s o c i a t e d w i t h e v a l u -a t i n g t h e i m p a c t o f h e a l t h c a r e . I n a t t e m p t i n g t or e s o l v e t h e i s su e s a s s o c i a t e d w i t h t h e s e l e c t i o n o fi n d i c a t o r s o f h e a l t h c o n d i t i o n s , h o w t h e y h a v e t o b ea m a l g a m a t e d i n t o a n in d e x o r s c o re a n d t h e r o le o fp a t i e n t s o r r e s i d e n t s i n t h i s p r o c e s s , i t h a s b e e na r g u e d t h a t s o l u t io n s s h o u l d b e d e t e r m i n e d b y th ec o n t e x t o f p o s s i b l e p o l i c y a p p l i c a t i o n s . T h i s h a s b e e ns u m m a r i s e d r e c e n tl y a st he k i nd o f qua l i t y o f l i f e measur emen t s t ha t need t o be

ma de wi l l depen d o n the intende d use of such measure-m en t s . . . t h e r e cou l d be a va r ie t y o f appr oaches t o t he t a skof meas ur ing qu al i ty of li fe , none o f which co uld be sa id tobe r i gh t o r w r ong by any abso l u t e s t anda r d , bu t each o fw hi ch cou l d be j udged t o be mor e o r l e ss appr opr i a t e t o apar t icular t ask [69] .C o n s e q u e n t l y , o n e a r g u m e n t t h a t h a s b e e n m a d e t o

a d v a n c e t h e d e t e r m i n a t i o n o f a p p r o p r i a t e m e a s u r e -m e n t t e c h n i q u e s i s t o i d e n t i f y a s e ri e s o f ' d i a g n o s t i c 'q u e s t i o n s , t h e a n s w e r i n g o f w h i c h w i l l e l ic i t a n a p p r o -p r i a t e m e t h o d o f a n a ly s i s [2 2] . A n e x a m p l e o f s u c h a na r r a y o f q u e s t i o n s h a s b e e n s u g g e s t e d ( T a b l e 1 ).T h e r e i s l i tt l e d o u b t t h a t f r o m a p o l i c y p e r s p e c t iv e ,s u c h a n a r r a y o f q u e s t i o n s w o u l d e n a b l e m o r e c o n -s i s te n t m e t h o d o f e v a l u a t i n g t o b e i d e n t if i e d . W h i l s ti t i s p o s s i b l e t o a r g u e t h a t h i s s e v e n s t a g e s o v e r l o o ki ss u e s s u c h a s w h e t h e r t h e s tu d y s h o u l d b e c o m -p o n e n t / d i s e a s e s p e c if i c o r w i d e - r a n g i n g , t h e a p p r o p r i -a t e n e s s o f t h e te c h n i q u e t o t h e p o p u l a t i o n b e i n ge x a m i n e d , a n d t h e s e n s i ti v i ty o f s c a le u t i li s ed , t h e r ei s a m o r e f u n d a m e n t a l i s su e r a is e d b y s u c h a na p p r o a c h .

O n e s i g n i f i c a n t e l e m e n t i d e n t i f i e d i n t h e a b o v er e v i e w o f t h e c o n c e p t u a l i s a t i o n s o f q u a l i t y o f l i f e i st h a t v a r i o u s m e t h o d o l o g i c a l a p p r o a c h e s a r e ap p l i-c a b l e f o r e a c h c o n c e p t u a l i s a t i o n o f q u a l i t y o f l if e.T h u s , f o r e x a m p l e , r e s o l u t i o n o f is s u e s a b o u t t h ea g g r e g a t i o n o f d a t a i n t o a n i n d e x o p e r a t e s t o a la r g ee x t e n t i n d e p e n d e n t l y o f t h e w a y t h a t q u a l i t y o f li fe i sc o n c e i v e d . W i t h i n e n v i r o n m e n t a l q u a l i ty o f li fe re -s e a r c h t h e r e is a r e a l i s a ti o n t h a t , a l t h o u g h a c a d e m i c ,a t le a s t a s m u c h a t t e n t i o n s h o u l d b e p l a c e d a p r i o r io n s e l e c t i n g t h e c o n c e p t u a l i s a t i o n o f q u a l i t y o f li fe a so n t h e p o t e n t i a l a p p l i c a t i o n o f th e s t u d y i n o r d e r t oa s s is t I n t h e i d e n t i f ic a t i o n o f t h e m e t h o d s o f e v a l u -a t i o n . T h i s i s n o t t o s u g g e s t t h a t t h e r e i s a d e t e r m i n -i s ti c r e l a t i o n s h i p b e t w e e n c o n c e p t u a l v i e w s a n dm e t h o d s - - t h e w i d e ra n g e o f h e a l th - r e l at e d s c a le s a n dp r o f i l e s b e a r s w i t n e s s t o t h e s i g n i f ic a n t v a r i a t i o n s t h a td o a p p e a r - - b u t t o a r g u e th a t w h i ls t th e g o a l o f a n ya p p l i e d q u a l i t y o f li fe r e s e a r c h m a y b e t o s h a p e h e a l t hc a r e o r s o c i a l p l a n n i n g , t h i s m u s t b e c o n s t r u c t e do n a c o n s e n s u s o f h o w q u a l i t y o f li fe i s c o n c e i v e da n d h o w c u r r e n t c o n d i t i o n s c a n b e e v a lu a t e d . A st h e m a n y r e v i e w s o f r e c e n t q u a l i t y o f li fe r e se a r c h

Table 1. Key stages in q ual ity of lif e mea surem ent for policydecisionsStage Question1. Select the salient descriptive characteristics relevant to h ealth2. Ch oo se an operational definition and ca tegorisation of theselected characteristics3. Ch oo se an approp riate typ e of measurement (if necessary)4. Ch oos e an appropriate valuation method5. Ch oos e appropriate respondents6. Analyse and present the data in a m ann er relevant to th edecision on which it is to bear7. Makeexplicit any ethical or mo ral implications of the techniqueof measurement that has been adoptedSou rce: [22, p. 428].

SSM 41 l O ~ O


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1380 Ro bert J. Rogersons h o w , d e v e l o p i n g su c h a n u n d e r s t a n d i n g r e m a i n s ac h a l l e n g e f o r t h e 1 9 9 0 s .

P e r h a p s m o r e s i g n i f ic a n t ly a s a n e x a m p l e o f t h ed e s i r a b i l it y o f c r o s s i n g d i s c i p l i n a r y b o u n d a r i e s i s th ed e b a t e o v e r t h e l a s t f e w y e a r s w i t h i n h e a l t h r e l a t e dq u a l i t y o f l if e r e s e a r c h a b o u t t h e w a y t h a t q u a l i t y o fl if e m e a s u r e m e n t s c a n b e u t i li s e d a s m e a n s o f m o n i -t o r i n g , e v a l u a t i n g a n d c r i ti c a l ly p r e d i c ti n g o u t c o m e sf r o m h e a l t h i n t e r v e n t i o n . T h i s f o c u s o n p r e d i c t i o nh a s m o v e d t h e d e b a t e w i t h i n t h e m e d i c a l l i t e r a t u r eb e y o n d t h e q u e s t i o n o f d e v e l o p i n g m e t h o d s o fm e a s u r i n g c u r r e n t h e a l t h s t a t u s i n t e r m s o f q u a l i t y o fl i f e o r i n d e e d i n t h e d e v e l o p m e n t o f t e c h n i q u e s t oa s se s s , p o s t - i n t e r v e n t i o n , i m p r o v e m e n t s i n q u a l i t y o fl i f e o f p a t i e n t s . A s t h e d i s c u s s i o n a b o v e i n d i c a t e ss u c h i s s u e s s t i l l r e m a i n u n r e s o l v e d i n t h e m e d i c a lsc i ences .

T h i s d e b a t e a b o u t q u a l i t y o f li fe a s p a r t o f m e a s u r -i n g t h e o u t c o m e s o f m e d i c a l c a re h a s a r i s e n i n p a r tf r o m t h e c h a l le n g e t o p r e v i o u s i n d i c a t o r s w h i c h h a v eb e e n p r e d o m i n a n t l y e x p r e s s e d in t e r m s o f r e d u c t i o n si n m o r t a l i t y a n d / o r m o r b i d i t y [ 7 0 ], a n d m e a s u r e s v i as t a n d a r d m o r t a l i t y ra t e s o r i n f a n t m o r t a l i t y r at e s f o ri n s ta n c e . M e d i c a l a d v a n c e s a n d t h e i n c r e a s in g a p p l i -c a t i o n o f t r e a t m e n t f o r l i fe - e n h a n c e m e n t ( c o m p a r e dw i t h l i f e -s a v i n g o r d e a t h - p o s t p o n i n g i n t e r v e n t i o n )h a v e e r o d e d t h e m e r i t o f s u c h i n d i c a to r s . U n d o u b t -e d l y th e f o c u s o f t h e d e b a t e h a s b e e n s h a r p e n e d b yt h e r e s o u r c e a n d f u n d i n g l i m i t a t i o n s b e in g p l a c e d o nh e a l t h c a r e , fo r c i n g d e c is i o n s to b e m a d e a b o u tp r i o r i ti e s a n d t h e d e v e l o p m e n t o f t e c h n i q u e s a n d s e tso f i n d i c a t o r s e n a b l i n g s u c h d e c i s i o n - t a k i n g to o c c u ra n d r a i s in g m o r a l a n d e t h i c a l c o n c e r n s a b o u t i f a n dh o w q u a l i t y o f l i fe c a n b e a p p l i e d t o e n a b l e j u d g e -m e n t s - - b y c l i n ic i a n s, h e a l t h m a n a g e r s o r o t h e r p r o -f e s si o n a ls , o r i n d e e d e v en p a t i e n t s - - t o b e m a d e a b o u tt h e r e l a t i v e m e r i t s o f a l t e r n a t i v e t h e r a p i e s .

T h e r e c a n b e l i t tl e d o u b t t h a t t h e Q u a l i t y A d j u s t e dL i f e Y e a r ( Q A L Y ) m e a s u r e m e n t s , f i rs t p r o p o s e d b yh e a l t h e c o n o m i s t s in t h e U n i t e d S t a t e s a n d d e v e l o p e db y W i l l i a m s a t t h e U n i v e r s i t y o f Y o r k [ 71 , 7 2 ] h a v eh i g h l i g h t e d t h e c r i t i c a l a s p e c t s o f t h e d e b a t e . A s ar e c e n t e d i t o r i a l i n T h e L a n c e t a c k n o w le d g e s, Q A L Y sa r e g a i n i n g c u r r e n c y [ 7 3 ] d e s p i t e t h e w i d e s p r e a dc o n d e m n a t i o n s [ e .g . 7 4 - 7 6 ] . O t h e r s d o n o t d i s m i s s t h eu s e o f s u c h q u a l i t y o f l if e m e a s u r e s , b u t r e m a i nc a u t i o u s a b o u t t h e a p p l i c a t i o n o f Q A L Y s , n o t l e a stb e c a u s e o f th e m a n y t e c h n ic a l a n d e t h i c a l a s s u m p -t i o n s w h i c h t h e y c o n s i d e r n e e d t o b e a d d r e s s e d a n dr e s o l v e d b e f o r e s u c h i n d i c a t o r s c a n b e i m p l e m e n t e d[77].

S i d e - s t e p p i n g th e d e t a i l s o f t hi s d e b a t e , f r o m t h ep e r s p e c t i v e o f a n e n v i r o n m e n t a l q u a l i t y o f l i f e r e -s e a r c h e r, w h a t i s p e r h a p s m o s t s i g n if i ca n t a b o u t t h ed e b a t e i s t h a t i t is o c c u r r i n g , t h a t t h e e t h i c a l q u e s t i o n so f w h o s h o u l d j u d g e c l i n ic a l o u t c o m e s a n d h o w t h e ys h o u l d b e e v a l u a t e d a n d p r e d i c t e d a r e b e in g d i s -c u s s e d . W i t h i n e n v i r o n m e n t a l q u a l i t y o f l i f e s t u d i e s ,s u c h a s t h o s e a s s e s s i n g u r b a n q u a l i t y o f l i f e , f e wr e s e a r c h e r s h a v e a t t e m p t e d t o a d d r e s s s u c h i s s u e s ,

p r e f e r r i n g t o f o c u s t h e i r a t t e n t i o n o n t e c h n i c a l l yc o n t e n t i o u s e v a l u a t i o n o f c u r r e n t c o n d i t i o n s a n dm o n i t o r i n g c h a n g e s i n s u c h e n v i r o n m e n t s . E v e n i nt h e f ie ld o f u r b a n d e p r i v a t i o n a n d q u a l i t y o f li fes t u d i e s , l i t tl e r e s e a r c h h a s b e e n u n d e r t a k e n w h i c hi d e n t i fi e s t h e r e l a t i v e m e r i t s o f d i f f e r e n t ' t h e r a p i e s ' f o ru r b a n e n v i r o n m e n t s o r c h a l l e n g e s t h e v a l u e s y s t e m se m p l o y e d b y p l a n n e r s a n d o t h e r p o l i c y m a k e r s a sp a r t o f t h e i r i n t e r v e n t i o n . A s r e c e n t r e s e a r c h , i nG l a s g o w f o r e x a m p l e , h i g h l i g h t s t h e e m p h a s i s r e -m a i n s o n p r o v i d i n g a s s e s s m e n t s o f th e s t r u c t u re a n dd i s t r i b u t i o n o f q u a l i t y o f l i f e w i t h t h e g o a l o f e n a b l i n go t h e r s ( p o l i c y - m a k e r s ) t o d e f in e a n d r a n k p r i o r i t i e sf o r s o c i a l p r o g r a m m e s a n d t o t a r g e t t h e i r ef f or t s fo rm a x i m u m e f fe c t [ 7 8 - 80 ] . E q u a l l y , s t u d i e s o f p a t t e r n so f q u a l i t y o f l i f e i n c i t i e s a n d r e g i o n s o f t h e w o r l d[36, 41 , 46] have fa i l ed t o t a ck l e t he i s sues o f eva lua t -i n g p r e d i c t e d c h a n g e s i n q u a l i t y o f l i f e a r i s i n g f r o mp a r t i c u l a r p o l i c i e s .

W h i l s t h e a l t h p r a c t i t i o n e r s m a y , r i g h t l y , c a u t i o na g a i n s t a h e a d l o n g d a s h t o u n d e r t a k e r e s e a r c h in t h i sd i r e c t i o n , t h e r e i s t h e p o t e n t i a l f o r s i g n i f i ca n t i n s ig h tt o b e g a i n e d b y e n v i r o n m e n t a l q u a l i t y o f l i f e r e -s e a r c h e r s f o r t h e i r r e s e a r c h a g e n d a s f r o m t h e c u r -r e n t t e c h n i c a l a n d e t h i c a l d e b a t e s i n t h e m e d i c a ls c i e n ce s a b o u t h o w t o r e s p o n d t o r e s t r i c t i o n s inr e s o u r c e s a n d t h e c o n s e q u e n t n e e d t o b e a b l e t oe v a l u a t e i n a d v a n c e t h e d i s t r i b u t i o n o f r e s o u r c e s t om a x i m u m e f fe c t. T h e i m m e d i a c y a n d d i r e c t i m p a c t o fh e a l t h d e c is i o n s w i ll u n d o u b t e d l y m e a n t h a t m u c h o ft h i s d e b a t e w i l l b e c o n d u c t e d w i t h i n t h e m e d i c a ls c i e n c e s , b u t w i t h i n o t h e r a s p e c t s o f s o c i a l p l a n n i n gc o n c e r n e d w i t h r e s o u r c e a l l o c a t i o n s w h i c h i n f l u e n c et h e q u a l i t y o f l i f e o f i n d i v i d u a l s , t h i s i s a n a r e a o fd e b a t e w h i c h i s r ip e f o r s o c i a l s c i e n t i s ts t o e n t e r a n dm a k e t h e i r c o n t r i b u t i o n .

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