Measuring Quality of Life - Joint Debate Slides

Measuring Quality of Life Tuesday 10 th May 2011 www.ilcuk.org.uk

Baroness Sally Greengross
House of Lords
Measuring Quality of Life

Professor Ann Bowling
St. George’s, University of London and Kingston University

Quality of Life in older age A. Bowling, D. Banister, P. Stenner, H. Titheridge, K. Sproston, T. McFarquhar

To measure QoL in people 65+ in Britain To develop & test new ‘bottom up’ measure of QoL (OPQOL) Aims of Studies

Why another measure of QOL?
QoL:
Complex: objective & subjective concept
Existing measures developed ‘top down’ - are we measuring the right things?
Multidimensional measure with social relevance needed for use in multi -sector policy evaluation
Gap in market: global pop. ageing & increasing longevity

15 ‘Oldest’ Countries Sources: Carl Haub, 2006 World Population Data Sheet . % age 65+

Existing QoL measures (top-down):
Life satisfaction & well-being (single QoL domain)
Physical & mental functioning (2 health-QoL domains)
Broader health status (SF-36) (health-QoL domain s )
Economic utility measures (EQ-5D) (narrow health)
CASP-19 (single theory based: needs satisfaction & self-actualisation)
WHOQOL/WHOQOL-OLD (-24) multi-dimensional WHO perspective; tested across countries – convenience samples; ‘OLD’ ‘functioning added on’ by focus groups

ONS Omnibus 1999-2000: interviewed 999 people:
aged 65+ (77% r/r). ‘ Bottom-up’ Qs on QoL:
‘ Thinking about your life as a whole, what is it that makes
your life good - that is, the things that give your life
quality? You may mention as many things as you like.’
‘ What is it that makes your life bad - that is the things that
reduce the quality in your life? You may mention as many
things as you like.’

‘ Thinking about all these good and bad things you have
just mentioned which one is the most important to you?’
7-point QoL self-rating scale: ‘QoL so good, could not be better’ –
‘ QoL so bad, could not be worse’
National random sample, private PC files:77% r/r; 80 re-interviewed in depth

Measures also included:
Psychological: self-efficacy (mastery and control over life); social comparisons, expectations; optimism-pessimism
Health & functioning: Townsend ADL; Health status; health perceptions (SF-36), diagnosed conditions, longstanding illness
Psychological morbidity: General Health Questionnaire-12
Social network: contacts & support: family/friends/neighbours, social participation; perceived neighbourhood social capital
ONS: socio-demographic & socio-economic Qs.

Main QoL themes mentioned & used to develop OPQOL:
* Social & family relationships
* Social roles & activities
* Health & functional ability
* Home & neighbourhood (perceived social capital)
* Psychological well-being & outlook (life satisfaction; contentment; optimism; social comparisons)
Income
Independence & being in control over one’s life
Plus: religion, culture, children prioritised by 4 ethnically diverse focus groups
* Independently predicted global self-assessed QoL

Example: 81% said social relationships gave quality to life:
‘ for companionship’
‘ to do things with’
‘ to take me out’
‘ to make life bearable’
‘ to know there is someone there willing to help me’
‘ to look after me’
‘ for ‘confidence’.
… .Oh, and my little cat. I talk to her a lot, she’s just like a little child. She doesn’t like being left alone, I love her to bits. Now and again I give her a little kiss.’

Social relationships - neighbours & family: “ Four doors down the man called me to give me broad beans. When I did not put my washing line up he came round to see if there was any problem. The lady two doors down does my eye drops three times a week. They are all very good.” “ The quality of my life now is my family - my children and grandchildren. My life surrounds them. I go at weekends, they visit every week. Sometimes I have the younger grandchild staying overnight… I’m there if they need me.”

For 12% poor social relationships took quality away from life – e.g. difficulties maintaining contacts/relationships, due to:
geographical distance
families ‘too busy’ to visit
family feuds (‘If only we could be friends with our children.’)
Ill health/difficulties getting out

200+ lay items reduced to 50 & pre-tested with 100
survey volunteers, & re-reduced: OPQOL-32 & -35:
Life overall (4)
Health (4)
Social relationships & participation (8)
Independence, control over life, freedom (5)
Area: home & neighbourhood (4)
Psychological & emotional well-being (4)
Financial circumstances (4)
Religion & culture (2)
5-point Strongly agree to Strongly disagree response scales; reverse coding of positive responses & summed: higher scores = higher QoL
Scale ranges: 35 (QoL so bad could not be worse) - 175 (QoL so good could not be better) PLUS IMPORTANCE RATINGS

Three QoL surveys 2007-8 to test
Older People’s
QoL questionnaire (OPQOL)
National ONS Omnibus Survey (sifted 65+: 589/61% r/r)
[94% white British; 45% aged 75+)]
National Ethnibus Survey (sifted 65+:400/70% r/r)
[Indian (38%), Pakistani (29%), Black Caribbean (22%), Chinese (11%) people; 9% aged 75+ ]
Postal follow-up of 1999-2000 ONS Omnibus QoL survey respondents (74+:287/58% r/r)
[100% white British; 83% 75+ at follow-up]
Analyses controlled for age, sex, SES

OPQOL item: 4. Life gets me down
Ethnibus ONS QoL follow-up
% % %
Strongly agree 14 1 2
Agree 47 12 7
Neither agree
nor disagree 23 17 25
Disagree 12 48 44
Strongly disagree 4 22 22

OPQOL item: 11. I have someone who gives me love and affection
Ethnibus ONS QoL follow-up
% % %
Agree 45 38 35
Neither agree
nor disagree --- 5 13
Disagree 43 5 6
Strongly disagree 2 2 1

OPQOL item: 25. I have enough money to pay
for household bills
Ethnibus ONS QoL f/up
% % %
Agree 17 66 59
Neither agree
nor disagree 37 5 9
Disagree 25 3 3 Strongly disagree 4 1 ---

OPQOL Total Score
Ethnibus ONS QoL f/up
% % %
QoL bad as can be ≤99 6 1 7
100-119 67 11 38
120-139 25 52 43
140-159 2 32 12
QoL good as can be 160-175 --- 4 ---
Cronbach’s alpha of
internal consistency 0.75 0.88 0.90
[Cronbach’s alpha threshold for consistency 0.70<0.90]
Current Gerontology and Geriatrics Research. Open access ‘Volume 2009 (2009).

CASP-19 Total Score (2 new samples only)
Ethnibus ONS
% %
≤ 19 ‘Absence of QoL’ ---- 1
20-29 23 7
30-39 68 27
40-49 8 46
50-57 ‘Satisfaction in all domains’ 1 19
Cronbach’s alpha 0.55 0.87
Scale range 0-57 (response scales 0-3; - reversed so positive=better & summed)

WHOQOL-OLD Total Score (2 new samples only) Ethnibus ONS % % ≤ 69 Lowest possible QoL 2 4 70-79 23 11 80-89 58 24 90-99 15 40 100-120 Highest possible QoL 2 27 Cronbach’s alpha 0.42 0.85 Scale range 24-120 (24 x 5-point response scales 1-5; - reversed so positive=better & summed)

WHOQOL QoL scale module: death & dying:
Ethnibus ONS
% %
7. Extreme fear of
not being able to
control death 43 17
9. Extreme fear of
pain before death 52 34
Extreme fears on any
1 of 4 DD items 77 41
& items: 8. Fear of dying; 6. Fear of way in which will die; Postgraduate Medical Journal, 2010: 86: 197-202.

Adjusted odds of OPQOL score being good (1 referent) vs. not good (0) (all p<0.001)
ONS sample (65+) QoL follow-up (74+)
O.R. (95% CI) O.R. (95% CI)
Unable to walk
400 yards
without help
or at all vs. rest 0 .128 (0.070 – 0.236) 0 .443 (0.312-0.631)
Actual number of
supporters
who would help in
a personal crisis 1 .159 (1.062 – 1.265) 1 .183 (1.070 – 1.308)
Self-efficacy+
High vs. rest N/A 3 .449 (1.681 – 7.078)
(+our belief in our ability to succeed)

Validity: OPQOL items (n. 273)
8. ‘I am healthy enough to get out & about’
Strongly disagree/ Neither Agree/
Disagree Strongly agree
% % %
10. ‘I would like
more companionship/
contact
with other people’
Strongly agree/Agree 48 21 19***
Neither 32 57 43
Strongly disagree/Disagree 20 22 39

Essential requirement for coping with challenges of older age:
Build up reserves of social support & psychological resources (self-efficacy) to optimise:
Skills
Opportunities
Abilities
To help compensate when unable to do things

SOC: 84 year old widower (carpenter):
After his wife died he had no-one to help him put on his socks, so he made a ‘ sock horn ’ ; ... to dry between his unreachable toes he made a V-shaped wooden implement.
“… I can ’ t reach. I made this up … this frame … stretches out, tightens up … I have given some of these to other people to help them … .a couple of people at the Church ... this woman ..keeps making me cakes (laughs). ”

SOC: A keen bowler:
“ The beauty of the bowling, of course, is the fact is that if a partner dies they ’ ve got somewhere to go.
I mean they literally … play at our bowling club till 95 and even some of them have got new knees … some of them can hardly see, they have binoculars to see where the jack is, but there ’ s that companionship, somewhere to go... ”

Cont.
“ We ’ ve got a section for blind bowlers ... Amazing what they can do. We put a string down the centre ... so they can feel initially where they ’ ve got to go …
We ’ ve actually got somebody that could beat most of the club members … . he can ’ t see the jack, so we put the jack up for him. He then bowls against the string.
Then there ’ s another one who ’ s got tunnel vision, he uses binoculars. And he will put on these binoculars- there ’ s two of them - they will see where the jack is, and bowl … . ”

Cont.
“ We ’ ve had so many people having new knees …
The Australians have come out with an assistance for knees, bad arthritic knees, and it ’ s an extension of your arm … … mechanical, it fits the bowl at the end and you swing it. You don ’ t have to bend and you just release it. And you ’ d be surprised how proficient they are."

Summary
OPQOL: good reliability & validity in British pop. & ethnically diverse samples
There were marked differences between British pop. & ethnically diverse samples ’ OPQOL items & score
(& controlling x age)
Independent predictors of good Qol (OPQOL) in each sample:
Good health/functioning – esp. mobility,
More supporters,
Perceived self-efficacy (belief in our ability to succeed)

Mr Paul Allin
Office of National Statistics

Delivering wider measures of national well-being and quality of life – Paul Allin, Programme Director

Overview
What is national well-being (and how different from quality of life)?
Why measure national well-being?
How to measure it?
What matters to people?
What next?

What is national well-being?
Sum of individual well-being
How’s the UK doing? (more to life than GDP)
Measuring progress, true wealth and the well-being of the UK
Overall societal development and progress
The state of the nation
The ‘health’ of the nation
Economic performance and social progress (not forgetting sustainability and pressures on the environment)

Why measure it?
Better decision making (government, markets, public)
“ not focussing on the right set of statistical indicators”
“ to steer our economies better through and out of crises”
“ facing a looming environmental crisis”
What does this mean in practice?

How to measure national well-being? Stiglitz measurement framework: Economic Measures , e.g. Net national income per household Distribution of wealth, income, disposable income Effects of tax and benefits on distribution Human capital and growth rate Environmental Measures , e.g. Stocks of natural resources and depletion rates Indicators of climate change Quality of Life e.g. Health: life expectancy, expected disability free life years, Indicators of family life e.g. Single parent households Problem indicators e.g. Crime rate, Children in care, drugs, imprisonment rate Subjective wellbeing

Well-being New Economy Resources Environment Well-being Green Growth Quality Growth

How to measure national well-being?
Aggregate subjective well-being (only)
“ Happiness is the new GDP” (discuss!)
Wider measures
Many separate numbers – indicator sets
Few key numbers – based on consensus of what is important – dashboard
Combined index, using fixed weights?
Help-yourself index? - starting point: UK personal inflation calculator
Adjusted national accounts measures? - eg index of sustainable economic welfare

Measuring subjective well-being
Four overall monitoring questions from April 2011 in IHS (with socio-demographics)
Sample of 200,000 directly questioned adults each year across UK
Detailed questions – sample of 1,000 adults per month
Questions drawn from research and tested for use in IHS
Annual data available from July 2012
Experimental

Measuring subjective well-being
Overall, how satisfied are you with your life nowadays?
Overall, how happy did you feel yesterday?
Overall, how anxious did you feel yesterday?
Overall, to what extent do you feel the things you do in your life are worthwhile?
(all on scale 0 – 10)

What matters to people?
Wide range
Most frequently voted for:
Health (83% of survey monkey responses)
Friends & relatives (82%)
Job satisfaction (77%)
Partner/spouse relationship (71%)
Economic security (68%)
Environment now and future (67%)
*
*
Income and wealth (48%)
*
*

What next?
ONS work programme
Testing out what we’ve learned from the national debate and how to take forward
What do the subjective well-being data tell us?
Issues
Engagement
Meeting differing requirements
Well-being measurement and policy

Professor Emily Grundy
London School of Hygiene and Tropical Medicine

Professor Emily Grundy
( collaborators George Ploubidis and Harriet Young)
London School of Hygiene and Tropical Medicine
Older Europeans’ happiness and well-being

Country level differences in well-being
Why of interest?
Large differences between European countries in, for example, older people’s incomes; living arrangements and extent of family social activity – do these lead to differences in indicators of subjective well-being?
Might reveal policy relevant factors that potentially could be modified
Might increase our understanding of ageing and well-being processes
Problems and limitations:
Even if you ask the same questions, there may be differences between and within countries in how people answer them (c.f. Ann Bowling’s ‘bottom up’ approach).
Methods which aim to produce measures less subject to measurement bias are quite complex

Living arrangements of Europeans aged 60+ and 80+ by region. Source: Analysis of ESS 2002/4. North : DK, Fin, Norw, Swe; West : Aust, Belg, Ger, Neths, UK; East : CzR, Est, Hung, Pol, SlovK, Sloven, Ukr; South : Gre, Port, Esp.

Dataset 1: European Social Survey
Two cross-sectional rounds of data – 2002 and 2004
Used data from 19 countries
Sample size 18,131 people aged 60+
Scale: ‘Taking all things together, how happy would you say you are?’ – respondents rated their answer on a scale of 0 (extremely unhappy) to 10 (extremely happy).

Country groupings North West South East Sweden Norway Finland Denmark Germany Belgium UK Austria Netherlands Portugal Greece Spain Poland Slovenia Slovakia Hungary Ukraine Estonia Czech Republic N=3621 N=5867 N=3857 N=4786

Happiness among unmarried older women by European region: results from ordinal logistic models (Higher =happier), 2002-4 Analysis of European Social Survey; models control for age, widowhood indicator, long term illness & Whether living alone or with others. ( ) results from models not including social ties. North West South East Low education 1.27 (1.17) 1.19 (1.15) 0.76 (0.73) 1.10 (1.02) Low income 0.75 (0.74) 0.86 (0.87) 0.94 (0.81) 0.53** (0.45**) Moderate social ties 0.76 0.69** 0.62 0.92 Low social ties 0.41** 0.56** 0.34** 0.48** Least social ties 0.08** 0.19** 0.45** 0.24** N 840 1664 1055 1507

Associations between living arrangements and happiness (higher=better) by region; ref. group=living alone : results from analysis of ESS 2002-4. ***P<.001, *P<0.05 Controlling for age, education, income, social meetings, social activities, long term illness, availability of confidante, widowhood. Men Women Spouse only Spouse+others Others only Spouse only Spouse+others Others only North 2.59*** 3.36*** 0.73 1.94*** 1.86* 1.09 West 2.11*** 1.82* 1.34 2.11*** 2.69*** 2.06*** East 1.04 1.09 0.60 1.81* 1.50 1.36* South 1.61 1.47 1.10 1.77* 1.82* 2.08*

What is associated with happiness in the older population of Europe? (from ESS)
Region: N(best)W S E (worst)
Comfortable income
Frequent social meetings and social activities
Availability of confidante
No long-term illness
Older age
Lower education
Living with spouse;
For unmarried women those living with others (children) in S, E & W Europe happier than those living alone; not the case in Northern Europe.
Analysis of ESS, combined sample 18 countries fully adjusted ordinal logistic regression.

Dataset 2
We used data from 14 European countries included in the second wave of the Survey of Health and Retirement in Europe SHARE (n = 33,528)
The countries included are drawn from Northern (Denmark and Sweden), Western (Austria, France, Ireland, Germany Belgium, and the Netherlands), Mediterranean (Spain, Italy and Greece) and Eastern (Poland and the Czech Republic) regions of Europe.
Measure of well-being derived from several individual questions using a latent variable approach

Life satisfaction Look forward to each day Life has meaning Look back with happiness Full of opportunities Future looks good Optimistic about future Feel prepared for my future Happiness Enjoyed life Well-being Factor 1 Factor 2 Factor 3 Factor 4 Best fitting/invariant well-being model

Well-being country level comparison

Depression country level comparison

Conclusion
There is considerable between country variance in late-life mental health in Europe
The Scandinavian countries seem to do best (low depression/high well being) followed by central European countries, while residents of Mediterranean countries report the worst mental health (NB Eastern Europe not considered)
Results from analysis of ESS data also show older Northern Europeans happier than older Southern Europeans
Social factors and social support important in all analyses – but countries with the most family based social support systems have worse rather than better indicators of well-being
More innovatory approaches such as Ann Bowling’s needed to unravel meaning of measures and their implications.

Mr Paul Cann
Age UK Oxfordshire

* What are the best measures of wellbeing and happiness across the lifecourse? * How does wellbeing differ across the lifecourse and do we need to take age into account when developing measures of happiness? * What factors predict quality of life amongst older people? * How can quality of life amongst older people be improved? * How will the new ONS measures of national well-being, including quality of life, impact on public policy?

Measuring Quality of Life Tuesday 10th May 2011 www.ilcuk.org.uk

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