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ANNEX 2 - HEALTH RELATED QUALITY OF LIFE
The establishment in 1948 of the World Health Organization ( WHO) definition of health was an important milestone in the development of QOL studies within health care. WHO defined health as not only being the absence of disease, but the presence of physical, mental and social well-being. 398
Reflecting the growing interest in QOL within healthcare, between 1973 and 1993 the number of articles in the Medline database listing "quality of life" as a reference key word increased from 5 to 1252. 399 Armstrong and Caldwell report that over 5000 medical papers on QOL measurement are currently being published each year, "as new measures are tested and refined and old ones applied to more and more clinical situations". 400 As advances in medical technology and new and more aggressive treatments succeeded in increasing survival rates, attention increasingly turned towards the QOL of patients rather than longevity alone. Today QOL assessment measures are now routinely used to evaluate the human and financial costs and benefits of different health programmes and medical interventions.
Health-related QOL is concerned with QOL within the specific context of health. Slightly facetiously, Michalos, a critic of the term, suggests that health-related QOL
"…may be regarded as a particular species of the genus domain-related quality of life. O ther species would include, for example, job-related quality of life and marriage-related quality of life…". 401
As with the wider term, there is no uniform definition of health-related QOL, merely competing views. The debate around the definition of health-related QOL centres upon two issues. (1) differing conceptions of "health", that can be summarised as the "medical" definition, based on the absence of disease, as against the "positive" definition advanced by the WHO, and (2) the relationship and distinction between "health" and "quality of life". These fundamental questions remains unresolved, resulting in contradictory definitions of the concept health-related QOL. 402
One type of definition sees QOL as the effect of disease or illness on both the physical functioning and subjective well-being of patients, in other words health is regarded as a determinant of QOL, using a medical model of health. In contrast a competing conceptualisation of health-related QOL accords with the World Health Organization definition of health, in which QOL is regarded as a key determinant of overall health. 403 The US Department of Health definition accords with this, describing health-related QOL as
"those aspects of overall quality of life that can be clearly shown to affect health - either physical or mental". 404
And within these overall definitions of the concept of health-related QOL, the emphasis placed on either physical functioning or subjective well-being also varies according to the focus of specific investigations. As a result there are a wide range of different interpretations of health-related QOL, each tailored to specific purposes, and resulting in an even wider range of measurements that relate to these. For example, Raphael regards health-related QOL research as dominated by the psychological approach, 405 it is about
"individual responses to the physical, mental, and social effects of illness on daily living that influence the extent to which personal satisfaction with life circumstances can be achieved". 406
Alternatively, Rejeski describes the move from QOL to health-related QOL as "designed to emphasise an interest in the functional effects on patients of an illness and its consequent therapy" and notes the interchangeable use of the terms "health status" and "quality of life" - like health-related QOL, health status "defines function at either a generic or disease-specific level". 407 Understandably opinion is divided amongst researchers on the need for a separate health-related concept of QOL, but the concept is now extremely influential and most accept that it is here to stay .408 However the confusion over definitions has resulted in a plea for health researchers to make their definitions explicit and for journal editors to reject articles that do not do so. 409
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