Review articles
Measures of self-perceived well-being

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Abstract

As people lead longer and generally healthier lives, aspirations and expectations of health care extend to include well-being and enhanced quality of life. Several measurement scales exist to evaluate how well health care reaches these goals. However, the definitions of well-being or quality of life remain open to considerable debate, which complicates the design, validation, and subsequent choice of an appropriate measurement.

Objective

This article reviews nine measures of psychological well-being, tracing their origins in alternative conceptual approaches to defining well-being. It compares their psychometric properties and suggests how they may be used.

Methods

The review covers the Life Satisfaction Index, the Bradburn Affect Balance Scale, single-item measures, the Philadelphia Morale scale, the General Well-Being Schedule, the Satisfaction With Life scale, the Positive and Negative Affect Scale, the World Health Organization 5-item well-being index, and the Ryff's scales of psychological well-being.

Results

Scales range in size from a single item to 22; levels of reliability and validity range from good to excellent, although for some of the newer scales we lack information on some forms of validity.

Conclusion

Measures exist to assess several conceptions of psychological well-being. Most instruments perform adequately for survey research, but we know less about their adequacy for use in evaluating health care interventions. There remains active debate over how adequately the questions included portray the theoretical definition of well-being on which they are based.

Introduction

As therapeutic advances raised expectations for health, the focus of health measurements broadened, from recording death, disease, and disability toward function, thence to well-being and, most recently, to health-related quality of life. This was foreshadowed by the World Health Organization's (WHO) 1948 definition of health in terms of “physical, mental, and social well-being, and not merely the absence of disease and infirmity” [1] (p. 459). “Well-being” is now commonly proposed as a theme for outcome measures as it reflects the expanded goals of treatment, from medical treatment toward broader health care.

Early measures of well-being recorded it in terms of the absence of distress, so scales from the 1930s and 1940s contained checklists of behavioral and somatic symptoms of distress. Distress is relevant as it forms a common stimulus for seeking care. Furthermore, observable symptoms were considered appropriate for a generation of people who could be reticent in responding to questions about their feelings. For example, Macmillan felt it necessary to conceal the intent of his 1951 psychological screening scale, naming it the “Health Opinion Survey” to conceal its true intent [2]. Unfortunately, symptom checklists almost certainly misclassified some physical disorders as psychological; they can also only detect relatively severe forms of disorder and only emotional distress that is manifested somatically or behaviorally.

Over time, the argument that people will not respond honestly to direct questions about their emotional well-being passed from favor. Gurin, and later Bradburn, led a movement toward asking directly about feelings of happiness and emotional well-being. This reflected growing interest in positive mental health, which may be traced back, through Jahoda's work [3], to the WHO conception of health. The new measures recorded affective responses—the feeling states inspired by daily experience. They approached subjective well-being as a cognitive process in which people compare their perceptions of their current situation with their aspirations. This led logically to defining well-being in terms of morale and life satisfaction, as with the 1961 Life Satisfaction Index (LSI) and the 1972 Philadelphia Geriatric Center Morale Scale. While patient autonomy was becoming a central theme in medical ethics, subjective patient assessments came to play a prominent role in measuring the outcomes of care.

However, symptom checklists were not completely abandoned. Despite their limitations, numerous studies showed close agreement between checklists and psychiatric ratings, so scales such as Goldberg's 1972 General Health Questionnaire [4], and Dupuy's [5] 1977 General Well-Being Schedule (GWB) combined symptom checklists with questions on feelings to form a hybrid. Scales that are more recent have distinguished separate facets of well-being; Ryff's scales of psychological well-being are a leading example.

Section snippets

Conceptions of well-being

At its core, well-being refers to contentment, satisfaction, or happiness derived from optimal functioning. This need not imply perfect function; it is subjective and is a relative, rather than an absolute, concept. The reference point for judging well-being is person's own aspirations, based on a blend of objective reality and their subjective reactions to it [6]. However, this brings measurement challenges. Just as a person's objective health status can change over time, so can their

Review of measurement scales

Nine scales are chosen for review; they represent different conceptualizations of well-being. Any selection of methods for review is subjective, and space constraints forced the omission of several worthy scales. I have included some older scales to give a historical perspective, as many subsequent scales were developed out of criticisms of the earlier instruments. For simplicity, scales are presented in chronological order of their creation.

The LSI (B.L. Neugarten and R.J. Havighurst, 1961)

The LSI records general feelings of well-being among older people in the general population to identify successful aging [25]. The authors viewed life satisfaction as closely related to morale, adjustment, and psychological well-being. They identified five components: zest (as opposed to apathy), resolution and fortitude, congruence among desired and achieved goals, a positive self-concept, and mood tone [25]. Positive well-being is indicated by the individual deriving pleasure from his daily

The ABS (Norman M. Bradburn, 1965)

Bradburn's 10 questions were designed to indicate the positive and negative psychological reactions of people in the general population to events in their daily lives. Bradburn described his scale as an indicator of happiness or of general psychological well-being; these reflect an individual's ability to cope with the stresses of everyday living. The scale was not intended to detect psychological or psychiatric disorders [36].

Originally, Bradburn and Caplovitz [37] proposed that subjective

Single-item health indicators (Various authors, circa 1965 onward)

A single question on well-being, along the lines of “Taking everything into consideration, how would you say you are today—excellent, very good, good, fair or poor?” offers a summary indicator of subjective well-being. This format could be applied to several aspects of health: health or quality of life in general, life satisfaction, or specific feelings [45]. Questions of this type are frequently used in surveys and are on the US Institute of Medicine's list of eight national health outcome

The Philadelphia Geriatric Center Morale Scale (M. Powell Lawton, 1972)

This scale was designed to measure three dimensions of emotional adjustment in persons aged 70 to 90, either in community or institutional settings. Lawton viewed morale as “a generalized feeling of well-being with diverse specific indicators …. The person of high morale has a feeling of having attained something in his life and of being useful now and thinks of himself as an adequate person” [59].

The scale includes 17 dichotomously scored items, such as “As you get older, you feel less

The GWB (Harold J. Dupuy, 1977)

The GWB offers a brief but broad-ranging indicator of subjective feelings of psychological well-being and distress for use in community surveys. Reflecting the theories of Kurt Lewin, the scale is designed to assess how the individual feels about his “inner personal state” rather than about external conditions such as income, work environment, or neighborhood [5]. The scale covers positive and negative feelings; six dimensions assessed include positive well-being, self-control, vitality,

The SWLS (E. Diener, 1985)

In Diener's formulation, subjective well-being includes the emotional components of positive affect and the absence of negative affect, plus one cognitive element: life satisfaction, which refers to the person's internal, subjective assessment of their overall quality of life. He argued that most measures had neglected the theme of life satisfaction [70]. The SWLS offers a brief measure of people's global satisfaction with their lives, originally designed for survey use. It provides an overall

The PANAS (D. Watson, L.A. Clark and A. Tellegen, 1988)

The PANAS provides a brief measure of positive and negative affect, developed partly out of criticisms of the Bradburn scale. It has been used mainly in studies of mood states rather than in evaluative studies of health care [38]. Mood may be measured in terms of specific types of affect such as depression or anxiety, or with nonspecific scales. Watson and Clark [19] argued that these represent different levels in a hierarchical structure in which generalized positive and negative affects

The WHO-5 Well-Being Index (P. Bech, 1998)

The WHO-5 gives a brief assessment of emotional well-being over a 14-day period. Reflecting the positive tone of the WHO definition of health, the five items record mental well-being as opposed to symptoms [86], [87]. The items cover positive mood (feeling in good spirits, feeling relaxed), vitality (being active and waking up fresh and rested), and being interested in things. The WHO-5 can be used as a survey measure of subjective quality of life and, despite its positive wording, as a screen

The Ryff's Scales of Psychological Well-Being (C.D. Ryff, 1989, revised 1995)

Ryff's scales were designed to test her six-component model of personal growth and psychological well-being. Ryff's work focused initially on definitions of successful aging; previous conceptions lacked clear theoretical foundation; they were negative, defining success in terms of the absence of distress, and ignored the potential for growth in old age. Ryff proposed six defining criteria for an integrated model of personal development in aging: self-acceptance (SA), positive relations with

Conclusion

Academic interest in the nature of psychological well-being has grown over the past 15 years, and major advances have been made. First, the importance of the topic has been emphasized by studies that link well-being to physiological changes [10], to enhanced coping with stress [103], and even to reduced mortality [9]. Second, the earlier conception that contrasted multiple forms of negative well-being (anxiety, depression, etc.) with one general dimension of positive well-being has been

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