Background
Quality of life (QoL) is a multidimensional concept that refers to an “individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, and standards” and is affected by a person’s physical health and psychological state [
1]. It can therefore be assumed that the assessment of QoL should consider aspects of physical health, psychological state, level of autonomy, social relationships, beliefs, and relationship to salient features of the environment [
2].
Globally, the proportion of older persons is growing and survival rates for chronic noncommunicable diseases (CNCD) are improving. Quality of Life is clinically related to several CNCD, the most common of which are cardiovascular disease, diabetes, hypertension, dyslipidemia and obesity. Clinical and epidemiological research has therefore tended to emphasize the physical health aspects of QoL, focusing on individuals’ perceptions of their living conditions in face of illness and their capacity to lead a meaningful life [
3].
Given the complex nature of the concept, the assessment of QoL is a complex undertaking requiring multiple measures to capture subjectivity and multidimensionality. Various instruments have been developed to measure the above domains, adding the subjective parameters considered necessary for a comprehensive assessment of QoL [
4].
The most widely used instruments are either generic, which provide an overall assessment of the impacts of health status, or specific, designed to measure particular aspects of QoL, such as QoL related to oral health, visual function, cancer, HIV, etc. [
5].
The body of literature on QoL has steadily grown over recent years, spurred by the promotion of research and the cross-cultural adaptation and validation of assessment instruments in different languages [
5]. However, limited information exists on the most commonly used instruments against the backdrop of current demographic and epidemiological trends. In light of the above, the aim of this study was to identify QoL assessment instruments used in population-based studies conducted with adults.
Discussion
The findings show that the majority of surveys opted for generic QoL assessment instruments. This type of instrument, created to provide an objective measure of subjective sensations, has been widely used to assess the various domains of the health status of different populations [
11]. Because they are multidimensional, these instruments are widely applicable, allowing researchers to compare QoL between healthy and sick individuals, patients with the same disease, and across different social and cultural backgrounds. However, they are not sensitive to specific aspects of QoL related to a particular morbidity [
33].
Instruments used to measure health-related QoL (HRQoL) generally contain questions divided into groups (domains or components) and are designed to assess specific problems that limit health and well-being [
11]. The World Health Organization Quality of Life Assessment (WHOQOL), Medical Outcomes Study 36-Item Short Form (SF-36), and 12-Item Short-Form Health Survey (SF-12) are among the most widely used instruments for assessing HRQoL [
11].
With respect to administration of QoL instruments, the variety of methods used in the studies illustrates their practicality and ease of use for any study group and situation. The findings show that both generic and specific questionnaires can be administered by health professionals or properly trained third parties. Interviewing is the most commonly used method because it increases response rates and reduces mistakes due to misinterpretation or misunderstanding of questions. The findings show that 38.0% (
n = 19) of the articles did not report interviewer training. This is concerning, because lack of training and standardization of the interview format, process cost, and presence of an interviewer can influence results [
71].
In the case of self-administered questionnaires, understanding of questions and responses rates are influenced by the respondent’s education level. The absence of an interviewer increases the likelihood of misunderstanding and missing data due to missing responses and feelings of anxiety and insecurity experienced by the respondent [
71,
72]. Illiterate people are more likely to be excluded from studies if they do not have anyone to assist them [
71], which is an important consideration when conducting assessments with study groups with a low level of education [
29,
42,
48,
73,
74]. For these groups, face-to-face interview-administered questionnaires are likely to be the best option, as observed in studies from Brazil [
29], Mexico [
48], and Nigeria [
42]. Another bias that can arise from self-administered questionnaires is the tendency of respondents to distort responses in a favorable direction to avoid negative answers. On the other hand, privacy and low cost are potential advantages of this mode of administration [
71,
75].
Questionnaires can also be administered by telephone, online panels, or mailed [
71,
72]. The findings show that studies used email questionnaires [
12,
24] and online questionnaires via online panels [
10,
14,
20,
30,
57,
69]. The use of the internet to administer questionnaires, including QoL assessments, has risen considerably. This mode of administration has a number of advantages over pen and paper, including ease of completion, greater integrity, and elimination of data entry errors that can occur when transcribing responses from paper questionnaires. Studies have shown that the ease of use of electronic devices such as laptops, tablets, and smartphones results in greater questionnaire compliance and satisfaction, without compromising the psychometric quality of data, suggesting that electronic questionnaires can generally be considered equivalent to pen-and-paper versions, thus reducing bias, even among respondents who are less tech-savvy [
76‐
78]. However, for online administration of questionnaires to provide results that are equally valid as pen-and-paper administration, each questionnaire should be validated for internet administration [
79].
The majority of HRQoL studies related to CNCD focus on correlating the scores of subjective components of QoL with the CNCD and/or its risk factors. Our findings show that the main focus of QoL research was CNCD, notably cardiovascular disease, hypertension, diabetes, dyslipidemia, and/or obesity. The studies evaluated by the present study showed that the presence of these diseases and their risk factors has an impact on quality of life [
15,
57,
62,
67].
In this respect, QoL assessment instruments have helped to raise important questions about the QoL of people with CNCD, particularly among adults, given they are the mainstay of a country’s productive capacity. Some of the studies indicated that research should be more focused on the development and review of national strategies for maximizing coordination of care for patients with chronic diseases and reducing the health burden and on the formulation of policies geared towards maintaining physical and mental well-being and improving HRQoL [
11,
19,
31]. Collective and individual actions to promote the health of people at risk of CNCD, focusing not only on risk reduction, but also on increasing the chances of improving quality of life, were also highlighted as solutions [
15].
Studies showed that QoL scores in the physical and/or mental health domains were lower in individuals with the following CNCD and/or associated factors: diabetes, high blood pressure, obesity, cancer, asthma, osteoarthritis, smoking, excessive alcohol consumption, neurological disorders, long term mental health disorders, chronic back problems, and back pain [
11,
15,
19,
26,
40,
57,
60,
65,
66]. In contrast, the highest scores in the physical health domain were associated with the absence of chronic diseases and higher levels of physical activity [
11].
The association between combinations of physical and mental health conditions and QoL was investigated by a study conducted by Mujica-Mota et al. [
57]. The findings showed that the association between physical health and HRQoL was stronger in the presence of long-term mental health problems, highlighting the importance of addressing these problems, which are often overlooked in patients seeking treatment for physical disorders. According to the authors, integrated approaches to the diagnosis and treatment of long-term health conditions are necessary [
57].
Chronic diseases are of long duration and generally slow progression, acting cumulatively to adversely affect health outcomes [
31]. With respect to work, consequences of chronic diseases include absenteeism, low productivity and performance, and disability and/or economic inactivity, ultimately affecting the productive capacity of the population [
10,
19,
30,
31]. Only a few studies explored the association between chronic diseases and work-related QoL [
10,
13,
19,
30]. It is also important to highlight that, besides high treatment costs, poor health outcomes create a financial burden for employers [
30,
31]. It is therefore vital to understand patterns of chronic conditions and their effects on QoL and health behaviors to inform interventions to prevent multiple chronic conditions, reduce their burden, and optimize service provision to affected individuals [
31].
Declining birth rates, improvements in healthcare, and rising life expectancy have led to a considerable increase in the population of older persons across the globe [
31]. Given that studies have reported an association between having a sedentary lifestyle and certain aspects of HRQoL during ageing [
80], it is essential to promote healthy lifestyles in order to prevent chronic disease, improve the functional capacity and well-being of older persons, and help maintain autonomy and independence, thus promoting healthy and active ageing [
45].
Active ageing is defined by the World Health Organization (WHO) as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” [
81], which is set against the term “health-related quality of life”, a narrow concept focusing on the effects of illness and treatment on quality of life [
82]. In this sense, researchers have shown a growing interest in the assessment of QoL in older persons to inform policies to prevent chronic health conditions, prolong life, provide necessary social support, and promote active aging [
38]. However, if aging is to be a positive experience, longer life should be accompanied by opportunities for health, participation and security, considering the specific needs, capacities, and preferences of older persons. It is therefore necessary to gain a better understanding of the factors influencing QoL in this group [
38].
The findings show that the choice of QoL assessment instrument depends on the type of study. There are no “better or worse” QoL assessment instruments and the decision to use one or another, or a combination of two or more instruments, should depend on the overall purpose of the research [
83]. This choice will be influenced by a series of factors, such as the characteristics of the study group and study context [
84].
Implications for health care systems, policy makers and researchers
Our findings show that QoL instruments can help health professionals make informed decisions about disease management. The approach adopted by the instruments assessed in this review and the wide range of aspects of QoL they cover make them valuable tools for monitoring HRQoL. In this respect, they can provide important inputs to support the formulation of policies for improving access to health services and inform the design of health education programs to promote healthy lifestyles and active aging [
11,
15,
38]. From a research perspective, we suggest that future population-based studies involving QoL assessment address issues that go beyond the effects of disease or treatment, thus filling the research gaps identified by this review.
Limitations
This review has its limitations. Despite the widescale use of the World Health Organization Quality of Life Assessment (WHOQOL-100) and its abbreviated version (WHOQOL-BREF) and version for older persons (WHOQOL-OLD) over the last two decades, these instruments were not identified in the studies. One study that used this instrument was preselected in the first stage of the article selection process (reading of titles and abstracts); however, after reading the entire article it was found that it did not meet the eligibility criteria. It is possible that the inclusion criterion population-based studies led to the exclusion of other studies that used this instrument. On the other hand, as our findings show that the widespread use of traditional instruments such as the SF-36 and its abbreviated version SF-12 in health research, coupled with the fact that they are quick and easy to use (and therefore particularly useful for large study groups), were reasons for choosing these instruments in the studies analyzed by this review.
Conclusion
The key findings of this study were as follows: the most frequently-used QoL assessment instrument was the SF-36; the preferred questionnaire administration methods were face-to-face and in-home interviewing with the presence of a trained interviewer; and the main focus of QoL studies was CNCD. There was also a lack of studies of work-related QoL and of positive experiences that promote and enhance the health, participation, and safety of older persons.
It is also important to highlight that while the use of such a wide range of instruments and modes of questionnaire administration may serve to address the specificities of particular study groups, it can hinder comparison between population groups with similar characteristics or needs, thus jeopardizing the validity, statistical reliability and, ultimately, the quality of findings.
This work brings to light important issues that should be addressed by future research aimed at investigating preferences for QoL assessment instruments and determining which instruments are best suited to population-based studies.
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