The Quality of Life Profile - Adult Version
Two different studies, conducted in association with the Quality of Life Research Unit, have tested the adult version of the Quality of Life profile.
The first was a small study of 29 adults, conducted by Dennis Raphael, Jennifer D'Amico, Ivan Brown, and Rebecca Renwick. The results, not published in a peer-review journal, are reported below.
The second was a study of 219 gay men, half of whom were living with HIV. The research was undertaken by Dennis Raphael, University of Toronto, and Judith Waalen and Alexander Karabanow, both from Ryerson University, Toronto. Although the study was focussed on a specific population, the number of participants and the strength of the statistical outcomes, suggest that the instrument may be valid when used in the general population and that further investigation is warranted. Results of this study were published in:
Raphael, D., Rukholm, E., Brown, I., Hill-Bailey, P., and Donato, E. (1996). The quality of life profile—Adolescent version: Background, description, and initial validation. Journal of Adolescent Health, 19(5), 366-375.
A Generic Measure of Health and Well-Being
The following is an unpublished paper and may be cited, along with the current date, as:
Raphael, D., D’Amico, J., Brown, I., Renwick, R. (1998). The Quality of Life Profile: A Generic Measure of Health and Well-Being. Toronto: Quality of Life Research Unit; University of Toronto. Retrieved DATE from: http://www.utoronto.ca/qol/genericMeasure.htm
Quality of life approaches in the health field usually focus on illness and disability. There is also limited attention to environmental determinants of health and well-being. The Quality of Life Profile was developed to provide a measure that considers both the components and determinants of health and well-being. The Quality of Life Profile draws upon a conceptual model that is consistent with recent definitions of health and health promotion as provided by the World Health Organization. It emphasizes individuals' physical, psychological, and spiritual functioning; their connections with their environments; and opportunities for maintaining and enhancing skills. Preliminary validation of the Quality of Life Profile on 29 employees and volunteers at a social services agency is described. Potential applications are explored.
In this report we describe the development and initial validation of a generic measure of health and well-being, the Quality of Life Profile (QOLP). We first briefly discuss the concept of quality of life and our rationale for developing a new approach. We then describe our measure and its initial validation among a group of service agency employees and volunteers.
What is Quality of Life?
Quality of life (QOL) is concerned with what makes for the "good life." Philosophers have long been interested in this question, but empirical research in quality of life had, until quite recently, been the focus primarily of sociologists, social psychologists, and economists (Lindstrom, 1992). Quality of life is now an active area of inquiry in the health field, but most of these approaches focus upon assessing the effects of disease and illness and treatments for these conditions upon quality of life (Raphael, Brown, Renwick, & Rootman, 1996). These approaches are not particularly attractive to health promoters with an interest in the determinants of health and well-being of both well and unwell individuals. We felt that quality of life should be broadly conceived, identify environmental dimensions of health and well-being, and emphasize individuals' personal control and potential opportunities. No existent quality of life approach, in our mind, met all of these criteria. In essence, we wished to create a measure that would involve a person-centred approach to quality of life that would be consistent with emerging conceptions of health promotion (Raeburn & Rootman, 1997).
The Quality of Life Model
Our conceptual approach is influenced by the humanistic-existential tradition (Bakan, 1964; Becker, 1971; Merleau-Ponty, 1968; Sullivan, 1984; Zaner, 1981). More detailed discussion of these philosophical foundations appears elsewhere (Renwick & Brown, 1996), but by way of summary, this literature recognizes that individuals have physical, psychological, and spiritual dimensions. It also acknowledges people's needs to belong, in a physical and a social sense (i.e., to places and social groups), as well as to distinguish themselves as individuals by pursuing their own goals and making their own choices and decisions. We define quality as "The degree to which a person enjoys the important possibilities of his/her life." The enjoyment of important possibilities is relevant to three major life domains: Being, Belonging, and Becoming.
Being reflects "who one is" and has three sub-domains. Physical Being encompasses physical health, personal hygiene, nutrition, exercise, and general appearance. Psychological Being includes the person's psychological health and adjustment, feelings, and evaluations concerning the self, such as self-esteem and self-concept. Spiritual Being refers to one's personal values, standards of conduct, and spiritual beliefs.
The Belonging domain concerns the person's fit with his or her environments. Physical Belonging describes connections with the physical environments of home, workplace, neighbourhood, school, and community. Social Belonging are the links with social environments and acceptance by intimate others, family, friends, co-workers, and neighbourhood or community. Community Belonging represents access to public resources, such as adequate income, health and social services, employment, educational and recreational programs, and community activities.
Becoming refers to activities carried out in the course of daily living, including those to achieve personal goals, hopes, and aspirations. Practical Becoming describes day-to-day activities, such as domestic activities, paid work, school, or volunteer activities, and seeing to health or social needs. Leisure Becoming includes activities carried out primarily for enjoyment that promote relaxation and stress reduction. Growth Becoming activities promote the maintenance or improvement of knowledge and skills, and adapting to change.
These concepts have been operationalized for various population groups. Instrumentation was developed and validated for persons with developmental disabilities (Raphael, Brown, Renwick & Rootman, 1996b), seniors living in the community (Raphael, Brown, Renwick, Cava, Weir, & Heathcote, 1995), adolescents (Raphael, Rukholm, Brown, Hill-Bailey, & Donato, 1996) and persons with physical and sensory disabilities (Rudman, Renwick, Raphael& Brown, 1995). The development of each instrument included an examination of the relevance of the domains for each population, significant input from the population of interest in creating items, and ongoing validation.
Development of the Quality of Life Profile (QOLP)
Development of the QOLP was carried out in tandem with the development of our other quality of life instruments over a five year period. As we developed items for our populations through a process of focus groups, participant review, and pilot testing and validation, we set aside items that were clearly relevant to people-in-general. These items were collected and piloted with classes of our students at Ryerson University and the University of Toronto. Once reviewed by the authors, they were placed into the Quality of Life Profile.
Quality of Life Profile: Description and Content
The QOLP consists of 54 items, six in each of nine sub-domains. The respondent provides Importance and Enjoyment (operationalized as Satisfaction) ratings along a 5 point scale. The amount of Control and Opportunities perceived in the nine sub-domains is also indicated. A Profile is created for each individual based on domain and sub-domain scores. Table 1 provides examples of QOLP items.
Table 1: Examples of Items in the Quality of Life Profile
Preliminary Psychometric Evaluation
As part of a study of the quality of life of seniors in the community, the QOLP was administered to a service agency's employees and volunteers. The main purpose of this administration was to sensitize staff and volunteer to the quality of life concept. As part of this process, however, we ascertained the psychometric properties of the QOLP.
Participants were 21 staff and 8 volunteers at a multi-service agency in a large metropolitan suburb. The agency provides homemaking, respite care, congregate dining and meals, support for stroke survivors, and transportation services. Participants were told that completing the QOLP could provide insights into issues that clients deal with. Forms were distributed and if the individual wished to complete it (10-15 minutes), it could be dropped into a box. No identifying information was collected. Data were entered, checked and analysed using SPSS.
Scoring the QOLP
The Importance score served as a weight for converting satisfaction scores into quality of life scores (QOL = (Importance Score/3) * (Satisfaction Score-3). Items rated as especially important produce especially high quality of life scores where high satisfaction is indicated. Similarly, items rated as especially important produce especially low quality of life scores where dissatisfaction is indicated. Items rated as of less importance produce more moderate quality of life scores.
Average age of the respondents was 46 years (sd=16). Twenty one percent had not finished high school, 21% had done so, and 58% had at least some college or university education. The sample health status was positive with only one person reporting fair and no one reporting poor health (Excellent, 24%; Very Good, 48%; Good, 29%; and Fair, 3%). Virtually all were female.
Importance, Enjoyment, and QOL Scores
Mean scores are provided in Table 2. Importance and Enjoyment scores can range from 1 (Not at All Important/Not at All Satisfied) to 5 (Extremely Important/Extremely Satisfied). QOL Scores range from -3.33 (Not at All Satisfied with Extremely Important Issues) to 3.33 (Extremely Satisfied with Very Important Issues).
The Being domains were rated the most important and the Becoming domains the least so. Greatest satisfaction was found among the Belonging domains. Of specific note was the very high satisfaction scores returned for Spiritual Being, Physical and Social Belonging, and Practical Becoming. QOL scores showed this same pattern.
Control and Opportunities
The nine questions are How much control do I have over: and Are there opportunities for me to improve: My physical health; My thoughts and feelings; My beliefs and values; The places where I spend my time; Who I spend my time with; Being able to use what my community has to offer; The everyday things I can do in my life; The things I can do for fun and enjoyment; and The things I can do to improve myself. Control scores can range from 1 (Almost No Control) to 5 (Almost Total Control) as do Opportunity scores (Almost None ... Great Many).
There is a strong perception of the presence of personal control and potential opportunities across the QOL domains. Overall Control scores were 4.29 and all Control item means were >4 with the exception of Community Belonging (3.75). Many approached 4.5. Overall Opportunities scores were 3.92 with the lowest occurring for Physical Belonging (3.64) and the highest for Practical Becoming (4.12).
Reliability of the QOLP
Internal consistency coefficients (Cronbach's α) were calculated for Importance, Enjoyment, and QOL scores within each domain and sub-domain. For Importance, all domain and sub-domain indices exceeded .70, except for Spiritual Being (α=.68) and Community Belonging (α=.62). For Satisfaction, all coefficients exceeded .70 (all but two sub-domains were >.80). Table 2 shows the rather high values returned for QOL scores. The nine Control items were also internally consistent (α=.87) as were the nine Opportunities items (α=.92).
Table 2: Importance, Enjoyment, and QOL Mean Scores for the Nine Sub-Domains of the QOLP with Cronbach's Alpha for QOL in Parentheses
Correlates of QOL Scores
Health. Self-reported health was significantly correlated (all tests are one-tailed) with Being scores (r=.47, p<.01), but not with Belonging (r=.21, ns) or Becoming scores (r=.22, ns). To underscore this, health status was related to Physical Being (r=.49, p<.01), Psychological Being (r=.44, p<.01) and Spiritual Being (r=.29, p<.07). The only other domain where the relationship approached statistical significance was Growth Becoming (r=.30, p<.07). Partialling procedures revealed that the health/quality of life correlation was not mediated by age; that is partial correlations of health with quality of life remained significant, controlling for age.
Age and education. Age was related to Becoming scores (r=.33, p<.05), but not to Being (r=.25, p<.10) or Belonging scores (r=.21, ns). Education was not related to any QOL score.
Control and opportunities. Overall Control was strongly correlated with overall QOL (r=.61, p<.001), Being (r=.45, p<.01), Belonging (r=.54, p<.01), and Becoming scores (r=.66, p<.001). Opportunities however, was correlated only with Being scores (r=.42, p<.05). This reflected its relationship with Physical Being (r=.27, p<.10), Psychological Being (r=.48, p<.01), and Spiritual Being (r=.39, p<.05). Control and Opportunities were not significantly related to each other (r=.22, ns).
Finally 64% of respondents found filling out the QOLP "helpful", 14% found it "somewhat helpful," and 21% "not helpful" in relation to their agency duties.
In this study, our intention was to sensitize agency employees and volunteers to the types of questions and issues that would be asked of agency clients. This process was found to be helpful to our staff. As a by-product of this process, we obtained initial data on the psychometric properties of the QOLP. This study suggests that the QOLP has promise as a measure of general health and well-being. It appeared to reliably discriminate even among individuals who are generally well and also demonstrated some suggestive relationships with self-reported health, age, and perceptions of personal control.
Specific Importance, Satisfaction and QOL Findings
The QOLP explores issues hypothesized as being important components of health and well-being. The present study provided an opportunity -- as part of the scoring of the QOLP -- to check this process by having participants rate each item for importance. The very high Importance ratings provided for the items found in the QOLP indicated that its content assessed relevant aspects of these individuals’ lives. Also of note was the rather high Satisfaction and QOL scores achieved by this group.
This could be expected as all reported rather positive health status and were either employed full-time or served as volunteers for a reputable and very progressive community oriented service agency. Of note then was the rather strong evidence of reliability for these indices even among this somewhat homogeneous group. Additionally, there was initial evidence of criterion and construct validity.
Domains and sub-domains scores were reliable, and Being scores correlated with health status; a significant finding considering the relatively good health of study participants. That this relationship was significant only for the Being sub-domains provides some evidence of discriminative validity among the sub-domain scores. We expected that QOL scores might be correlated with age and education, but this was not the case. Interestingly, these findings are similar to our findings from studies we have carried out with seniors (Raphael, Renwick, Brown, et al., 1995).
Relationship With Personal Control
The correlational nature of this study precludes any conclusion concerning the direction of effects of the Control and QOL relationship. This finding has been apparent in our work with seniors (Raphael, Renwick, Brown, et al., 1995) and adolescents (Raphael, Rukholm, Brown, et al., 1996) and appears to be reliable. If Control scores could be demonstrated, in longitudinal study, to be predictive of QOL, it would support the increasing importance being ascribed to control as a determinant of health (Rodin, 1986; Walston, Walston & Kaplan, 1976).
Future Psychometric Work
We have continued to carry out psychometric evaluation of the Profile. Initial analysis of a recent administration of the Profile to a group of 65 women attending a leadership camp for low income women returned virtually identical levels of reliability as obtained in this study (Raphael & Okata, 1998). Work needs to be done on whether the measure is sensitive to program effects and its relationship to determinants of health such as income, housing quality, and employment status.
Applying the QOLP
One use of the QOLP is to sensitize staff to the kinds of questions being asked of clients during quality of life assessment. Of perhaps more practical importance may be the use of the QOLP with those who use services or are involved in health promotion activities. We are of the strong belief that it is important to understand the context within which people come to require and receive services. Service agencies may focus on their own mandates and limit their consideration of client needs solely within this mandate. Such an approach is problematic for many reasons. First, it ignores the reality that people who receive specific services may have broad needs that any one program cannot provide. Secondly, it fosters the fragmentation of services such that clients may need to shop around to have their full range of needs addressed. Thirdly, it may focus service provision solely on providing narrow and short term solutions rather than addressing structural issues related to service need.
A quality of life approach allows for the addressing of the full range of components and environmental determinants of health and well-being. Therefore, we feel that application of the QOLP should be considered by agencies and service providers who share our view that needs can be best met through understanding the range of factors that affect clients. While any one agency may not be able to meet all client needs, it will at least make explicit the conditions under which clients are living. We administered the QOLP to a healthy sample, but clearly, if the instrument could discriminate among these individuals it would be sensitive to those whose life situations are somewhat more problematic.
Quality of life is an increasingly important focus in health and health promotion studies (Renwick, Brown, & Nagler, 1996). Emerging perspectives emphasize the broader determinants of health (World Health Organization, 1986) and considering aspects of personal control and presence of opportunities. The QOLP may prove to be a useful tool in considering these issues and examining how they impact upon health and well-being.
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