QUALITY OF LIFE IN OLD AGE

Social Indicators Research Series

Volume 31

General Editor:

ALEX C. MICHALOSUniversity of Northern British Columbia,

Prince George, Canada

Editors:

ED DIENERUniversity of Illinois, Champaign, USA

WOLFGANG GLATZERJ.W. Goethe University, Frankfurt am Main, Germany

TORBJORN MOUMUniversity of Oslo, Norway

MIRJAM A.G. SPRANGERSUniversity of Amsterdam, The Netherlands

JOACHIM VOGELCentral Bureau of Statistics, Stockholm, Sweden

RUUT VEENHOVENErasmus University, Rotterdam, The Netherlands

This new series aims to provide a public forum for single treatises and collections of papers on socialindicators research that are too long to be published in our journal Social Indicators Research. Like thejournal, the book series deals with statistical assessments of the quality of life from a broad perspective. Itwelcomes the research on wide variety of substantive areas, including health, crime, housing, education,family life, leisure activities, transportation, mobility, economics, work, religion and environmental issues.These areas of research will focus on the impact of key issues such as health on the overall quality of lifeand vice versa. An international review board, consisting of Ruut Veenhoven, Joachim Vogel, Ed Diener,Torbjorn Moum, Mirjam A.G. Sprangers and Wolfgang Glatzer, will ensure the high quality of the seriesas a whole.

The titles published in this series are listed at the end of this volume.

QUALITY OF LIFE IN OLD AGEInternational and Multi-Disciplinary

Perspectives

Editors

Heidrun MollenkopfSenior Research Scientist (retired),

Formerly German Center for Research on Ageing at the University of Heidelberg

Department of Social and Environmental Gerontology,Germany

and

Alan WalkerProfessor of Social Policy and Social Gerontology,

Department of Sociological Studies,University of Sheffield,

UK

A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN 978-1-4020-5681-9 (HB)ISBN 978-1-4020-5682-6 (e-book)

Published by Springer,P.O. Box 17, 3300 AA Dordrecht, The Netherlands.

www.springer.com

Printed on acid-free paper

All Rights Reserved© 2007 Springer

No part of this work may be reproduced, stored in a retrieval system, or transmittedin any form or by any means, electronic, mechanical, photocopying, microfilming,

recording or otherwise, without written permission from the Publisher, with theexception of any material supplied specifically for the purpose of being entered

and executed on a computer system, for exclusive use by the purchaser of the work.

Heidrun Mollenkopf would like to dedicate this book to her grandchildren Anne Sophie, Marie Claire, Mathieu,

and Joscha, and Alan Walker to his children Alison and Christopher. We hope that their later lives will be high-quality ones.

TABLE OF CONTENTS

Preface ix

Section I – Understanding Quality of Life in Old Age

1. International and Multi-Disciplinary Perspectives on Quality of Life in Old Age: Conceptual Issues 3Alan Walker and Heidrun Mollenkopf

2. Quality of Life in Older Age: What Older People Say 15Ann Bowling

Section II – Key Aspects of Quality of Life

3. Well-being, Control and Ageing: An Empirical Assessment 33Svein Olav Daatland and Thomas Hansen

4. Social Resources 49Toni C. Antonucci and Kristine J. Ajrouch

5. Economic Resources and Subjective Well-Being in Old Age 65Manuela Weidekamp-Maicher and Gerhard Naegele

6. Quality of Life in Old Age, Inequality and Welfare State Reform: A Comparison Between Norway, Germany, and England 85Andreas Motel-Klingebiel

7. Environmental Aspects of Quality of Life in Old Age: Conceptual and Empirical Issues 101Hans-Werner Wahl, Heidrun Mollenkopf, Frank Oswald, and Christiane Claus

8. The Environments of Ageing in the Context of the Global Quality of Life among Older People Living in Family Housing 123Fermina Rojo-Pérez, Gloria Fernández-Mayoralas, Vicente Rodríguez-Rodríguez, and José-Manuel Rojo-Abuín

9. Perceived Environmental Stress, Depression, and Quality of Life in Older, Low Income, Minority Urban Adults 151William B. Disch, Jean J. Schensul, Kim E. Radda, and Julie T. Robison

vii

10. Ageing and Quality of Life in Asia and Europe: A Comparative Sociological Appraisal 167Mohammad Taghi Sheykhi

11. Ethnicity and Quality of Life 179Neena L. Chappell

12. Health and Quality of Life 195Dorly J.H. Deeg

13. Care-related Quality of Life: Conceptual and Empirical Exploration 215Marja Vaarama, Richard Pieper, and Andrew Sixsmith

Section III – Conclusions and Outlook

14. Quality of Life in Old Age: Synthesis and Future Perspectives 235Heidrun Mollenkopf and Alan Walker

List of Contributors 249

Index 253

viii TABLE OF CONTENTS

PREFACE

This book started its life during a symposium we organised on Quality of Life in OldAge at the Fifth Conference of the International Society for Quality of Life Studies(ISQOLS) in Frankfurt in July 2003. We are extremely grateful to Alex Michalos forsponsoring that session, encouraging us to use the symposium presentations as thebasis for a book and for his support during the commissioning and editing process.We are also very grateful to the authors of this volume for the prompt delivery oftheir manuscripts and responses to our editorial comments. Finally our specialthanks to Marg Walker for her expert and efficient preparation of the manuscript forpublication.

Heidrun Mollenkopf Alan WalkerHeidelberg Sheffield

ix

SECTION I

UNDERSTANDING QUALITY OF LIFE IN OLD AGE

ALAN WALKER AND HEIDRUN MOLLENKOPF

1. INTERNATIONAL AND MULTIDISCIPLINARY PERSPECTIVES

ON QUALITY OF LIFE IN OLD AGE

Conceptual issues

Quality of life (QoL) is a multidimensional, holistic construct assessed from manydifferent perspectives and by many disciplines. Moreover, the concept of QoL canbe applied to practically all important domains of life. Thus, QoL research has toinclude social, environmental, structural, and health-related aspects, and beapproached from an interdisciplinary perspective. This holds even more when QoLin old age is the focus because ageing itself is a multidimensional process. GeneralQoL studies have used age for many years as a social category like gender or socialclass, but apart from a few exceptions (e.g. Diener and Suh, 1997; Michalos, 1986;Michalos et al., 2001) they have largely neglected older people.

Recent research in gerontology has begun to systematically study QoL – followingthe World Health Organization (WHO) dictum ‘years have been added to life andnow the challenge is to add life to years’. However, there are very few overarchingtexts available on this topic and none of an international and multidisciplinarynature. Given the size and growth of this population, it is time to publish a volumeon this topic that systematically pursues a comprehensive perspective and includestheoretical approaches and empirical findings with respect to the most importantcomponents of QoL in old age.

This volume brings together leading researchers on QoL in old age and sum-marises, on the one hand, what we know and, on the other, what further research isneeded. It consists of three main parts with an extended introduction, the main chap-ters on the various aspects of what contributes to ageing people’s QoL, and finally aconcluding chapter pointing to knowledge gaps and necessary further developmentsin theory and methodology.

The introductory part emphasises the amorphous, multidimensional and complexnature of QoL as well as the high level of inconsistency between scientists in theirapproach to this subject. Drawing on an extensive literature review (Brown et al.,2004), eight different models of QoL are distinguished. These range from objectivesocial indicators, subjective indicators of life satisfaction and well-being, health andfunctioning, to interpretative approaches emphasising the individual values andtheories held by older people. Moreover, this chapter summarises the main areas ofconsensus about QoL in old age: its dynamic multifaceted nature, the combinationof life course and immediate influences, the similarities and differences in the factorsdetermining QoL between younger and older people, the most common associationswith QoL and the likely variations between groups, and the powerful role of subjectiveself-assessment.

The main part of the book spans the whole range of the most important issuesin ageing people’s QoL: their subjective evaluations (Chapter 2), personal control

3

H. Mollenkopf and A. Walker (eds.), Quality of Life in Old Age, 3–13.© 2007 Springer.

beliefs (Chapter 3), economic resources (Chapter 5), and social relations and net-works (Chapter 4). The impact of diverging national welfare systems and socialpolicies is investigated (Chapter 6) and environmental conditions are explored todetect their supporting or hindering potential with respect to older people’s well-being (Chapters 8 and 9). Differences in the conditions of ageing between Asiaand Europe are highlighted (Chapter 10) as is the diverging conditions of ethnicgroups ageing in different host countries (Chapter 11). Last but not least, QoL inthe case of decreasing health (Chapter 12) and the challenge of care (Chapter 13)are considered.

Not unexpectedly in view of the various topics and the empirical and scientificbackgrounds, the contributions differ in approach, style, and degree of differentia-tion. Some of them provide a comprehensive overview on the available knowledgein the domain they deal with while others focus on a specific study. Some throw lighton the micro cosmos of the individual, investigating psychological aspects and theirrole for well-being with increasing age, while others locate individual QoL in themeso and macro contexts of family, networks, cultural habits, societal structures, andnational or regional conditions.

We did not try to level out these differences. More important in our view, aseditors, was that the authors explained carefully their theoretical frame of referenceand methodological approach and that their specific contributions deepened ourknowledge about what makes up a good QoL in old age in different parts of theworld. That said, we have simultaneously touched a limitation to this volume: it wasnot possible to consider, in fact, all parts of the world. However, our aim was not toestablish a global map of older people’s living conditions. Instead, this volume pro-vides a comprehensive perspective on what we know – and what we do not know –about the most important components of QoL in old age from as many national anddisciplinary perspectives as possible.

Finally, the main research priorities and gaps in knowledge are outlined togetherwith the key theoretical and methodological issues that must be tackled if compara-tive, interdisciplinary research on QoL is to develop further. That part draws on theconclusions stated by the authors of this volume and charts, as an outlook, the recentevolution of a new perspective on ageing.

THE SCOPE OF RESEARCH ON QoL IN OLD AGE1

QoL is a rather amorphous, multilayered, and complex concept with a wide rangeof components – objective, subjective, macro societal, micro individual, positive,and negative – which interact (Lawton, 1991; Tesch-Römer et al., 2001). It is a con-cept that is very difficult to pin down scientifically and there are competing disci-plinary paradigms. Three central limitations of QoL are its apparent open-endednature, its individualistic orientation, and its lack of theoretical foundations (Walkerand van der Maesen, 2004). The widely acknowledged complexity of the concept,however, has not inhibited scientific inquiry. As Fernández-Ballesteros (1998a) has

4 ALAN WALKER AND HEIDRUN MOLLENKOPF

shown, in the final third of the last century, there was a substantial increase incitations of QoL across five different disciplinary databases. While the growth wassignificant in the psychological and sociological fields, in the biomedical one, start-ing from a lower point, it was ‘exponential’ (e.g. increasing from 1 citation in 1969to 2,424 in 1995 in the ‘Medline’ database). This reflects the fact that in manycountries recent discussions of QoL have been dominated by health issues, and asubfield, health-related quality of life (HRQoL), has been created which emphasis-es the longstanding pre-eminence of medicine in gerontology (Bowling, 1997;Walker, 2005b).

Another key factor behind this growth in scientific inquiry is the concern amongpolicymakers about the consequences of population ageing, particularly for spend-ing on health and social care services, which has prompted a search for ways toenable older people to maintain their mobility and independence, and so avoid cost-ly and dependency-enhancing institutional care. These policy concerns are notpeculiar to Europe but are global (World Bank, 1994); nor are they necessarilynegative because the new policy paradigms such as ‘a society for all ages’ and‘active ageing’, both of which are prominent in the 2002 Madrid International Planof Action on Ageing, offer the potential to create a new positive perspective on age-ing and a major role for older people as active agents in their own QoL. A signifi-cant part of the impetus for this positive approach comes from within Europe(Walker, 2002).

MODELS OF QoL

Given the complexity of the concept and the existence of different disciplinary per-spectives, it is not surprising that there is no agreement on how to define and meas-ure QoL and no theory of QoL in old age. Indeed, it is arguable whether a theory ofQoL is possible because, in practice, it operates as a meta-level construct, whichencompasses different dimensions of a person’s life. Nonetheless, a theory wouldnot only lend coherence and consistency but also strengthen the potential of QoLmeasures in the policy arena (Noll, 2002). As part of the European FORUM project,Brown and colleagues (2004) prepared a taxonomy and systematic review of theEnglish literature on the topic of QoL. In this, Bowling (2004) distinguishes betweenmacro (societal, objective) and micro (individual, subjective) definitions of QoL.Among the former, she includes the roles of income, employment, housing, educa-tion, and other living and environmental circumstances; among the latter, sheincludes perceptions of overall QoL, individuals’ experiences and values, and relat-ed proxy indicators such as well-being, happiness and life satisfaction. Bowling alsonotes that models of QoL are extremely wide-ranging, including potentially every-thing from Maslow’s (1954) hierarchy of human needs to classic models basedsolely on psychological well-being, happiness, morale, life satisfaction (Andrews,1986; Andrews and Withey, 1976; Larson, 1978), social expectations (Calman, 1984),or the individual’s unique perceptions (O’Boyle, 1997; Brown et al., 2004, p.4).

INTERNATIONAL AND MULTIDISCIPLINARY PERSPECTIVES 5

She distinguishes eight different models of QoL which may be applied, in the adaptedform here, to the gerontological literature:1. Objective social indicators of standard of living, health, and longevity typically

with reference to data on income, wealth, morbidity, and mortality. Scandinaviancountries have a long tradition of collecting such national data (Hornquist, 1982;Andersson, 2005). Recently, attempts have been made to develop a coherent setof European social indicators (Noll, 2002; Walker and van der Maesen, 2004) but,as yet, these have not been applied to subgroups of the population.

2. Satisfaction of human needs (Maslow, 1954), usually measured by reference tothe individual’s subjective satisfaction with the extent to which these have beenmet (Bigelow et al., 1991).

3. Subjective social indicators of life satisfaction and psychological well-being,morale, esteem, individual fulfilment, and happiness usually measured by the useof standardised, psychometric scales and tests (Bradburn, 1969; Lawton, 1983;Mayring, 1987; Roos and Havens, 1991; Suzman et al., 1992; Veenhoven, 1999;Clarke et al., 2000).

4. Social capital in the form of personal resources, measured by indicators of socialnetworks, support, participation in activities and community integration (Wenger,1989, 1996; Bowling, 1994; Knipscheer et al., 1995; see also Chapter 4).

5. Ecological and neighbourhood resources covering objective indicators such aslevels of crime, quality of housing and services, and access to transport, as wellas subjective indicators such as satisfaction with residence, local amenities andtransport, technological competence, and perceptions of neighbourliness and per-sonal safety (Cooper et al., 1999; Kellaher et al., 2004; Mollenkopf et al., 2004;Scharf et al., 2004). Recently, this approach to QoL has become a distinct sub-field of ecological or architectural gerontology, with German researchers playinga prominent role (Mollenkopf and Kaspar, 2005; Wahl and Mollenkopf, 2003;Wahl et al., 2004; Weidekamp-Maicher and Reichert, 2005).

6. Health and functioning focussing on physical and mental capacity and incapacity(e.g. activities of daily living and depression) and broader health status (Verbrugge,1995; Deeg et al., 2000; Beaumont and Kenealy, 2004; see also Chapter 12).

7. Psychological models of factors such as cognitive competence, autonomy, self-efficacy, control, adaptation, and coping (Brandtstädter and Renner, 1990; Filippand Ferring, 1998; Grundy and Bowling, 1999; see also Chapters 3 and 9).

8. Hermeneutic approaches emphasising the individual’s values, interpretations, andperceptions usually explored via qualitative or semi-structured quantitative tech-niques (WHOQoL Group, 1993; O’Boyle, 1997; Bowling and Windsor, 2001;Gabriel and Bowling, 2004a). This model, which is growing in its research appli-cations, includes reference to the implicit theories that older people themselves holdabout QoL (Fernández-Ballesteros et al., 1996, 2001). Such implicit theories anddefinitions may be of significance in making cross-national comparisons by pro-viding the basis for a universal understanding of QoL (and will be revisited later).

A common feature of all of these models identified by Brown et al. (2004) is thatconcepts of QoL have invariably been based on expert opinions rather than on those

6 ALAN WALKER AND HEIDRUN MOLLENKOPF

of older people themselves (or, more generally, those of any age group). Thislimitation has been recognised only recently in social gerontology but has alreadyled to a rich vein of research (Farquhar, 1995; Grundy and Bowling, 1999; Gabrieland Bowling, 2004a, b). This does not mean, however, that QoL can be regarded asa purely subjective matter, especially when it is being used in a policy context. Theapparent paradox revealed by the positive subjective evaluations expressed by manyolder people living in objectively adverse conditions, such as poverty and poor hous-ing conditions, is a longstanding observation in gerontology (Walker, 1980, 1993).The processes of adjustment involved in this ‘satisfaction paradox’ have been thefocus of interest in recent research (Mollenkopf et al., 2004; Staudinger and Freund,1998), and this is emphasised in Chapter 5. As Bowling (2004, p.6) notes, there maybe a significant age-cohort effect behind the paradox, as older people’s rating of theirown QoL is likely to reflect the lowered expectations of this generation, and theymay therefore rate their lives as having better quality than a person in the next gen-eration of older people in similar circumstances would do (Schilling, 2006).

Empirical research is required to test whether or not the satisfaction paradox is afunction of age-cohort but, nonetheless, the caution concerning subjective data onolder people’s QoL is particularly apposite in a comparative European context whereexpectations may differ markedly on the north/south and east/west axes (Mollenkopfet al., 2004; Polverini and Lamura, 2005; Weidekamp-Maicher and Reichert, 2005).For example, there are substantial variations in standards of living between olderpeople in different European countries: in the ‘old’ EU 15 the at-risk poverty rateamong those aged 65 and over varied, in 2001, from 4% in the Netherlands to morethan 30% in Greece, Ireland, and Portugal (European Commission, 2003).

A recent review of QoL in old age in five European countries found a fairly wide-spread national expert consensus about the range of indicators that constitute theconcept, particularly in the two countries with the most developed systems of socialreporting, the Netherlands and Sweden, but with a dominance of objective measures(Walker, 2005b). The southern European representative, Italy, does not consistentlydistinguish older people’s QoL from the general population and frequently does notdifferentiate among the older age group. In all five countries health-related QoL isthe most prevalent approach in gerontology. Also, while there is no consensus onprecisely how QoL should be measured, there is evidence of some cross-nationaltrade in instruments, such as the adaptation of the Schedule for the Evaluation ofIndividual Quality of Life (SEIQOL) for use in the Netherlands (Peeters et al., 2005;see also Chapters 3, 6 and 8).

UNDERSTANDING QoL IN OLD AGE

In the light of the wide spectrum of disciplines involved in research on QoL in oldage and their competing models, is it possible to draw any conclusions about how itis constituted? The answer is ‘yes’, but because of the lack of either a generallyagreed definition or a way to measure it, such conclusions must be tentative. Firstly,although there is no agreement on these two vital issues, few would dissent from the

INTERNATIONAL AND MULTIDISCIPLINARY PERSPECTIVES 7

idea that QoL should be regarded as a dynamic, multifaceted, and complex concept,which must reflect the interaction of objective, subjective, macro, micro, positive,and negative influences. Not surprisingly, therefore, when attempts have been madeto measure it, QoL is usually operationalised pragmatically as a series of domains(Hughes, 1990; Grundy and Bowling, 1999).

Secondly, QoL in old age is the outcome of the interactive combination of lifecourse factors and immediate situational ones. For example, prior employmentstatus and midlife caring roles affect access to resources and health in later life(Evandrou and Glaser, 2004). Fernández-Ballesteros et al. (2001) combined bothsets of factors in a theoretical model of life satisfaction. Recent research suggeststhat the influence of current factors such as network relationships may be greaterthan the life course influences, although, of course, the two are interrelated(Wiggins et al., 2004). What is missing, even from the interactive approaches, isa political economy dimension. QoL in old age is not only a matter of individuallife courses and psychological resources but must include some reference to theindividual’s scope for action – the various constraints and opportunities thatare available in different societies and to different groups, for example, by refer-ence to factors such as socio-economic security, social cohesion, social inclusion,and social empowerment (Walker and van der Maesen, 2004). Hence, a consider-ation of the overarching and framing macro conditions, which is a matter ofcourse in general QoL research and is the case in most of the contributions to thisvolume, should also become accepted practice in research on QoL in old age (see,e.g. Heyl et al., 2005).

Thirdly, some of the factors that determine QoL for older people are similar tothose for other age groups, particularly with regard to comparisons between midlifeand the third age. However, when it comes to comparisons between young peopleand older people, health and functional capacity achieve a much higher rating amongthe latter (Hughes, 1990; Lawton, 1991). This emphasises the significance of mobil-ity as a prerequisite for an active and autonomous old age (Banister and Bowling,2004; Mollenkopf et al., 2005), as well as the role of environmental stimuli anddemands, and the potential mediating role of technology, in determining the possi-bilities for a life of quality (Mollenkopf and Fozard, 2004; Wahl et al., 1999; see alsoChapter 7). In practice, with the main exception of specific scales covering physicalfunctioning, QoL in old age is often measured using scales developed for use withyounger adults. This is clearly inappropriate when the heterogeneity of the olderpopulation is taken into account, especially so with investigations among very frailor institutionalised older people. Older people’s perspectives and implicit theoriesare often excluded by the common recourse to predetermined measurement scales inQoL research. This is reinforced by the tendency to seek the views of third partieswhen assessing QoL among very frail and cognitively impaired people (Bond,1999). Communication is an essential starting point to involving older people andunderstanding their views, and recent research shows that this can be achievedsuccessfully among even very frail older people with cognitive impairments (Testeret al., 2004).

8 ALAN WALKER AND HEIDRUN MOLLENKOPF

Fourthly, the sources of QoL in old age often differ between groups of olderpeople. The most common empirical associations with QoL and well-being in oldage are good health and functional ability, a sense of personal adequacy or useful-ness, social participation, intergenerational family relationships, availability offriends and social support, and socio-economic status (including income, wealth,and housing) (Lehr and Thomae, 1987; Mayer and Baltes, 1996; Knipscheer et al.,1995; Bengtson et al., 1996; Tesch-Römer et al., 2001; Gabriel and Bowling, 2004a,b; see also Chapter 2). Still, different social groups have different priorities. Forexample, Nazroo et al. (2004) found that black and ethnic minority elders valuedfeatures of their local environment more than their white counterparts (see alsoChapter 9). Differences of priority have been noted in Spain between older peopleliving in the community and those in institutional care, with the former valuingsocial integration and the latter, the quality of the environment (Fernández-Ballesteros,1998b). Other significant priorities for older people in institutional environments arecontrol over their lives, structure of the day, a sense of self, activities, and relation-ship with staff and other residents (Tester et al., 2004). This emphasises the impor-tance of the point made earlier about the need to communicate with frail older peoplein order to understand their perceptions of QoL: although some recent research hasbegun to address this (Gerritsen et al., 2004), the QoL of the very old is still a rela-tively neglected area of gerontology (see Chapters 3 and 13). Comparative Europeanresearch also points to different priority orders among older people in different coun-tries: e.g. the greater emphasis on the family in the South compared to the North(Walker, 1993; Polverini and Lamura, 2005). Another example of variations withinEurope is the greater impact of objective living conditions on subjective QoL in for-mer socialist countries like East Germany and Hungary compared to the more devel-oped and affluent countries of most of the northern, western and southern parts ofEurope (Mollenkopf et al., 2004).

Fifthly, while there are common associations with QoL and well-being, it is clearthat subjective self-assessments of psychological well-being and health are morepowerful than objective economic or sociodemographic factors in explaining varia-tions in QoL ratings (Bowling and Windsor, 2001; Brown et al., 2004). Two sets ofinterrelated factors are critical here: on the one hand, it is not the circumstancesper se that are crucial but the degree of choice or control exercised in them by anolder person; on the other hand, whether or not the person’s psychological resources,including personality and emotional stability, enable him or her to find compensa-tory strategies – a process that is labelled ‘selective optimisation with compensation’(Baltes and Baltes, 1990). There is some evidence that the ability to operationalisesuch strategies, e.g. in response to ill health, disability, or bereavement, is associat-ed with higher levels of life satisfaction and QoL (Freund and Baltes, 1998).Feelings of independence, control and autonomy are essential for well-being in oldage (see Chapter 3). Moreover, analyses of the Basle Interdisciplinary Study ofAging show that psychological well-being is more strongly associated with a feelingof control over one’s life than with physical health and capacity among the veryelderly than among the young-old (Perrig-Chiello, 1999).

INTERNATIONAL AND MULTIDISCIPLINARY PERSPECTIVES 9

With this contextual background in mind, we hand the baton over to the authorsof the subsequent chapters who deal with the various components of QoL in old age.Our concluding chapter highlights the main knowledge gaps and the next steps fortheory and methodology in this field.

NOTES

1. The following sections include parts of an article published previously in the European Journal ofAgeing (Walker, 2005a).

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INTERNATIONAL AND MULTIDISCIPLINARY PERSPECTIVES 13

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2. QUALITY OF LIFE IN OLDER AGE

What older people say

INTRODUCTION

The increasing number of older people, with higher expectations of ‘a good life’within society and with their high demands for health and social care, has led tointernational interest in the enhancement, and measurement, of quality of life (QoL)in older age. UK Government policy is also concerned with enabling older peopleto maintain their independence and active contribution to society and, in effect, toadd quality to years of life. QoL has thus become commonly used as an endpointin the evaluation of public policy (e.g. in the assessment of outcomes of health andsocial care). This indicates that a multifaceted perspective of QoL is required, witha shift away from single-domain approaches that focus only on single areas of life(e.g. physical health and/or functioning, mental health, social support, life satisfac-tion, and well-being) towards one that also reflects the views of the populationconcerned.

A measure of QoL requires a definition of the concept. QoL theoretically encom-passes the individual’s physical health, psycho-social well-being and functioning,independence, control over life, material circumstances, and external environment.It is a concept that is dependent on the perceptions of individuals, and is likely to bemediated by cognitive factors (Bowling, 2005a,b).

It reflects macro, societal, as well as micro, individual, influences, and it is acollection of objective and subjective dimensions which interact (Lawton, 1991).Lawton (1982, 1983a, b) developed a popular model and proposed that well-beingin older people may be represented by behavioural and social competence (e.g.measured by indicators of health, cognition, time use, and social behaviour), per-ceived QoL (measured by the individual’s subjective evaluation of each domain oflife), psychological well-being (measured by indicators of mental health, cognitivejudgements of life satisfaction, positive-negative emotions) and the external, objec-tive (physical) environment (housing and economic indicators). He thus developed aquadripartite concept of the ‘good life’ for older people (Lawton, 1983a), which helater changed to ‘quality of life’ as the preferred overall term, accounting for all oflife. However, there is no consensus within or between disciplines about conceptualdefinitions or measurement of QoL.

Most investigators have based their concepts and measures on experts’ opinions,rather than those of lay people (Rogerson et al., 1989; Bowling, 2001). Conse-quently, there is little empirical data on the extent to which the items included inmost measurement scales have any relevance to people and their everyday lives.In addition, a pragmatic approach prevails in the literature, clarification of the

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H. Mollenkopf and A. Walker (eds.), Quality of Life in Old Age, 15–30.© 2007 Springer.

concept of QoL is typically bypassed and justified with reference to its abstractnature, and the selection of measurement scales often appears ad hoc (Carver et al.,1999). This has resulted in many investigators adopting a narrow, or discipline-bound, perspective of QoL, and selecting single-domain measures such as scales ofphysical functioning, mental health, broader health status, life satisfaction, and soon. Some have used broader measures that aim to assess a person’s needs forresources or services, which also overlap with QoL domains. Others have selectedcombinations of single-domain measures, in an attempt to adopt a broader view ofQoL, although this often results in lengthy schedules with high respondent andresearcher burden (see Bowling, 2005a and Haywood et al., 2004 for reviews ofmeasures).

Moreover, the models of QoL that have been developed are not consistent. Somehave incorporated a needs-based satisfaction model, according to Maslow’s (1954,1968) hierarchy of human needs for maintenance and existence (physiological,safety and security, social and belonging, ego, status and self-esteem, and self-actualisation). Higgs et al. (2003), for example, based their model of QoL in olderage on self-actualisation and self-esteem. In contrast, traditional US social sciencemodels of QoL have been based primarily on the overlapping, positive, concepts of‘the good life’, ‘life satisfaction’, ‘social well-being’, ‘morale’, ‘social tempera-ture’, or ‘happiness’ (Andrews, 1986; Andrews and Withey, 1976; Lawton, 1996).The focus among psychologists is on psychological resources (Baltes and Baltes,1990). The World Health Organization quality of life (WHOQoL) Group adopted amultifaceted approach, while emphasising subjective perceptions, values andcultural context, from which was developed their WHOQoL (100 items and briefversion) (WHOQoL Group, 1993; Skevington, 1999; Skevington et al., 2004).Stenner et al. (2003), on the basis of ‘importance items’, agreed with the WHOQoLGroup during the development and testing of the WHOQoL-100. The analysesshowed that the common factors that emerged included areas relating to familyrelationships, independence, a ‘can do’ and positive approach to life, health and reli-gious trust. The version for use with older people – the WHOQoL-OLD – is beingfield tested (http://www.euro.who.int/ageing/quality). Brown et al. (2004)reviewed the literature on QoL and developed a taxonomy of QoL comprising thefollowing components: objective indicators; subjective indictors; satisfaction ofhuman needs; psychological characteristics and resources; health and functioning;social health; social cohesion and social capital; environmental context; ideographicapproaches.

What about the public views? Brown et al.,’s (2004) review concluded that olderpeople’s views of QoL overlapped with theoretical models. However, theoreticalmodels need to be multidimensional in order to encompass people’s values andperceptions. At present, QoL measures are based on the disciplines and perspectivesof investigators (see earlier). Bowling’s (1995a,b) earlier research on the mostimportant things in people’s lives, based on a random sample of adults in Britain,found that people prioritised their finances, standard of living, and housing;relationships with relatives and friends; their own health; the health of a close other;

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and social and leisure activities. But there were variations by age and gender. Forexample, social relationships and work have been reported to be prioritised more byyounger than by older adults, and health and family, more by people aged 65 andover (Brown et al., 1994; Farquhar, 1995; Bowling, 1995a,b, 1996; Bowling andWindsor, 2001). Also, people who have social care needs, particularly those livingin nursing and residential homes, might prioritise the ability to control their lives andthe way they structure their days as most important (Qureshi et al., 1994). Fry’s(2000) research, based on a combination of survey data and in-depth interviews witholder people living in Vancouver, reported that people valued most their personalcontrol, autonomy and self-sufficiency, their right to pursue a chosen lifestyle, andtheir right to privacy.

It is increasingly important to develop a multidimensional model of QoL, for usein both descriptive and evaluative research (e.g. in health and social policy), whichreflects the views of the population concerned. Such a model also needs to be devel-oped on the basis of results from longitudinal and repeated cross-sectional researchin order to measure any dynamic features, response shift, cohort, and ageing effects.Longitudinal research is also required to ascertain whether attempting to engineergains in subjective QoL is a realistic policy goal.

AIMS AND METHODS

The primary aim of this chapter is to explore the constituents of perceived QoL inolder age in order to deconstruct the concept of QoL. The second aim is to makecomparisons between older people’s perceptions of QoL and the content of existingQoL measures.

The Sample

Data were derived from a national interview survey of QoL in older age in Britain.Age 65 and over was taken to denote older age. The sample of people aged 65 andover was derived from four quarterly Office for National Statistics (ONS) OmnibusSurveys. Of the sample of 1,299 eligible respondents sifted by ONS from theOmnibus Survey, the overall response rate for the four QoL Surveys was 77% (999)(range over the four surveys: 69–83%); 19% refused to participate; and 4% could notbe contacted during the interview period. The interviews were conducted in respon-dents’ own homes. The sociodemographic characteristics of the sample were similarto those from mid-year population estimates for Great Britain (estimated from the lastcensus). Full details of the method and sample have been published elsewhere(Bowling et al., 2002, 2003; Bowling and Gabriel, 2004; Gabriel and Bowling, 2004).

Further in-depth interviews about QoL were carried out 12–18 months later witha subsample of 80 of the 999 participants in the QoL Survey. They were purposivelysampled, using a quota matrix based on respondents’ sociodemographic character-istics and health status, QoL ratings, and region of residence. The aim was to inter-view a broad cross section of respondents in order to obtain a better understandingof people’s interpretations of QoL.

WHAT OLDER PEOPLE SAY 17

Open-Ended Survey Questions on QoL and Analysis

A series of open-ended questions were asked at the beginning of the interview inorder to elicit people’s views of the things that gave their lives quality, the things thattook quality away from their lives, their priorities, and how QoL could be improvedfor themselves as well as for other people their age. Also included was a self-ratingof QoL overall on a 7-point Likert scale, ranging from ‘as good as can be’ to ‘as badas can be’. The open-ended questions were used as the opening survey questions inorder to prevent respondent bias towards the other, more specific questions andscales included in the questionnaire (see Bowling et al., 2002 for details of thestructured items and scales).

The detailed coding frames for the open-ended survey responses were developedafter AB and two coders independently read all of the scripts of responses, and wererefined as coding took place. The coding was carried out by two coders and checkedby an independent researcher. Main themes and detailed subthemes were coded inorder to capture the essence of people’s definitions and exactly what made the QoLgood and bad, and how life could be improved. These were entered onto SPSS10 andmerged with the main quantitative data-set. The main themes only are presentedhere. Detailed subcategories for each theme were also coded and, along with verba-tim statements from respondents as examples, have been reported elsewhere(Bowling et al., 2003).

In-Depth Interviews and Analyses

The subsequent in-depth interviews with a subsample of respondents were based ona semi-biographical interview technique, whereby the interviewer asked respondentsfirst to describe key events in their histories, including marriage, work, and/orparenthood where relevant. This aimed to facilitate people talking about QoL in thecontext of their overall life, and to enhance the researchers’ understanding ofpeople’s perspectives on life. Then the interviewer used a checklist and askedrespondents what they thought of when they heard the words ‘quality of life’, todescribe their QoL, what gave their life quality and what took quality away from it,how it could be improved, what would make it worse, and about any changes sincethe survey interview. The interviews were audio-recorded, transcribed, categorisedby one researcher, and checked by an independent researcher. They were analysedusing NU*DIST (version 5).

RESULTS

The Survey Data

About half, 48% (480), of the QoL Survey respondents were female and 52% (519)were male. The comparable figures for respondents aged 65 and over to the BritishGeneral Household Survey (GHS) in 2000 were 51% female and 49% male (Walkeret al., 2001). Of the QoL Survey respondents, 62% (624) were aged 65–74 and 38%(375) were aged 75 and over; the comparable figures for the 2000 GHS were 58%

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and 42% respectively. A total of 98% (983) of QoL respondents were white, aswould be expected from national statistics.

Similar proportions of men and women, within each age group, rated their over-all QoL as good or less than good (see Figure 1). Just 4% (21) of males and 6% (32)of females rated their QoL as ‘so good it could not be better’; 78% (404) of malesand 70% (362) of females labelled it as ‘very good’ or ‘good’; and the remainderrated it as ‘alright’, ‘bad’, ‘very bad’, or ‘so bad it could not be worse’. Associationswith QoL ratings have been reported elsewhere (Bowling et al., 2002).

The main themes categorised from responses to the open-ended survey questionon the constituents of the ‘good things’ that gave quality to life were, in order ofmagnitude: social relationships (81%), social roles and activities (60%), solo activi-ties (48%), health (44%), psychological outlook and well-being (38%), home andneighbourhood (37%), financial circumstances (33%), and independence (27%).Smaller numbers mentioned a wide range of other things. Poor health was mostoften mentioned as the thing that took ‘quality away’ from their lives (by 50%).Other commonly mentioned things that took quality away from life were home andneighbourhood (30%), financial circumstances (23%), and psychological outlook(17%). Good health, followed by better finances (i.e. having enough or moremoney), were the two most frequently mentioned things that respondents said wouldimprove their QoL. While a common core of main constituents of QoL clearlyemerged from the data, there was more variance in the subthemes underlying these,reflecting individual circumstances. These are displayed, under each main theme, inAppendix 1.

WHAT OLDER PEOPLE SAY 19

Could not be worse

Very bad

Bad

Alright

Good

Very good

Could not be better

Figure 1. Quality of life ratings

In-Depth Follow-Up Interviews

Of the 80 survey respondents who were re-interviewed in-depth 12–18 months later,40 were male and 40 female; 26 were aged 65 < 70, 20 were 70 < 75, 20 were75 < 80, and 14 were 80 and over. As many as 37 were married and the rest weresingle: never married (5), married but separated (1), divorced (6), or widowed (31).They were purposively selected using a grid to ensure representation of peopleacross social classes, with different levels of abilities in activities of daily living, andin QoL ratings, with a range of income, and with a wide geographical spread.

The main themes categorised from the in-depth interviews with the subsampleof respondents on the ‘good things’ that gave quality to life were, in order ofmagnitude: social relationships (96%), home and neighbourhood (96%), psycho-logical outlook and well-being (96%), solo activities (93%), health (85%), socialroles and activities (80%), financial circumstances (73%), and independence(69%). Poor home and neighbourhood, poor health, and poor social relationshipswere the themes most often mentioned as those that took quality away from theirlives (by 84%, 83%, and 80% respectively). These were followed by psychologi-cal outlook and well-being (63%), not having enough money (53%), and losingindependence (46%). A range of other areas were mentioned by smaller numbers.The most commonly mentioned things that respondents said would improve theirQoL were having a better home and neighbourhood, enough money, and betterhealth.

Comparison of Lay Views and Regression Modelling

In sum then, the most frequent QoL themes raised by older people, both in the mainsurvey and in the in-depth follow-up were: social relationships, social roles andactivities, other leisure pursuits and activities enjoyed alone, health, psychologicaloutlook and well-being, home and neighbourhood, financial circumstances, andindependence. Modelling, using multiple regression, of the main independentpredictors of QoL ratings (using the theoretically important structured scales anditems administered in the survey) confirmed the importance of most of these themes(see Bowling et al., 2002 for details of approach and results). The main independ-ent indicators of self-rated good QoL in the regression model, which explainedmost of the variance in QoL ratings, were: (downward) social comparisons betweenoneself and others, positive social expectations of life, optimism, better reportedhealth and functional status, more social activities and social support, less repor-ted loneliness, better ratings of the quality of local facilities (in their area of residence)and perceived safety of the area. None of the sociodemographic and socio-economicindicators were statistically significant in the model. Although self-efficacy (andsense of control over life), level of income, and other indicators of socio-economicstatus were not significant in the modelling, it is important to include these areas inthe concept and measurement of QoL given that older people themselves raisedfinancial circumstances and independence in, and control over, their daily lives, asimportant to their QoL.

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