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Are Adults a ‘Specific’ Population?

This chapter explores the quality of life of adults. ‘Adults’ are not commonly identified as a ‘specific population’ other than as distinct from children and adolescents. Rather, adult life and experiences are regularly assumed to be, and presented as, the ‘norm’ in research and in the undifferentiated application of research to services and policy. Critique of the validity and reliability of research, and its application to concrete situations, often rests on the inappropriate transposing of findings from a specific population to other populations or, in fact, to the entire population. For example, research on the eating habits of middle-aged males was used to develop the universal public health message ‘eat less fat, salt and sugar’ which has had unintended consequences on the well-being of adolescent girls who took the message too literally (Eckermann 1997). Thus, in considering the quality of life of adults, we need to identify the conditions and experiences adults share in common. However, we also need to be cognizant of the biological, psychological, geographical, historical, cultural, religious, social, political and economic circumstances that differentiate their experiences of the world and cause divergent quality of life outcomes.

Most of the literature on the quality of life of adults qualifies the word adult, e.g. ‘handicapped adults’, ‘older adults’ and ‘adults with chronic illness’. In fact, the only journal which addresses quality of life issues and that does not qualify the word ‘adult’ is the Journal of Adult Development. Psychology is the only discipline that has acknowledged adults as a separate population group. This is hardly surprising. Since most of the measurement tools for QOL come from psychology, researchers in the discipline have had to consider the appropriateness of domains of life to particular age groups. For example, the Personal Wellbeing Index (International Wellbeing Group 2006) has separate measurement tools and manuals for adults (PWI-A), school-aged children (PWI-SC) and pre-school children (PWI-PS).

For the purposes of this chapter, ‘adults’ will be defined as all persons aged 18–65 years. The 18 and 65 years’ cut-off points are purely instrumental to avoid repeating material covered in other chapters. Age will be the only criterion for inclusion or exclusion; other specific populations about whom chapters appear in this volume will not be excluded. However, generational and other differences within this very broad age range will be identified.

Is there anything unique about quality of life outcomes, experiences and issues for people aged 18–65 years that distinguishes them from children and adolescents and older people and overrides other dimensions of difference such as class, ethnicity and gender? Certainly there are factors that may contribute to shared experiences for this age group, such as issues of work/leisure balance (Fine-Davis et al. 2004) and generational squeeze between older parents and a younger generation (Vanderbeck 2007). However, there are more factors dividing than uniting this specific population. For example, the diversification of family structures (Kaufmann 2002; ABS 2006) as well as of work situations and environments (Japanese Ministry of Finance 2006) means that life experiences and circumstances vary enormously in the 18–65 age group.

The quality of life of adults has been shown to vary markedly across the dimensions of sex and gender socialisation (Ostlin et al. 2006; UNICEF 2006; Eckermann 2000), ethnicity and race (Cummins et al. 2002), culture (Lau et al. 2005), religion, socioeconomic class and social status (Green 2006), geographic location (Cummins et al. 2002), health status, personality and emotional state (Spiro and Bosse 2000), as well as across generations within the 18–65 age range (Levenson 2000). These aspects of social location cause differentiation in both objective and subjective dimensions of well-being. I will examine the work-life balance as a possible point of convergence of adult quality of life and lifespan and gender as possible points of divergence. Before exploring the convergence and divergence of quality of life experiences amongst adults, it is necessary to specify how the concept of quality of life is being used in this chapter.

Defining and Measuring Quality of Life

Quality of life consists of objectively measurable variables such as standard of living as well as more nebulous concepts such as freedom, happiness, art, environmental health and innovation, as represented in the Bhutanese concept of Gross National Happiness (Layard 2005). However, quality of life is defined differently across the disciplines which regularly use the concept, and even within disciplines, according to the reason for measuring it. The key disciplines utilising the concept of quality of life are, inter alia, philosophy, medicine, economics, psychology, sociology, political science, law and business studies.

Philosophy has the oldest claim on the term. Researchers from the philosophical traditions range from those who see traditional philosophical debates (dating back to Aristotle in the fourth century BCE) about ‘the good life’ and what constitutes the human subject as ‘the underpinning for quality of life research’ (Iseminger 1997; Saugstad 2000; Ventegodt et al. 2003) to those who propose an emerging meaning for quality of life as ‘fitness’ or ‘a multidimensional set of values, unique to each organism, person and context’ (Chris Lucas 2002 http://www.calresco.org/lucas/qol.htm). Researchers from the Quality of Life Research Centre in Copenhagen based their Danish Quality of Life Survey on basic philosophical questions using the validated SEQOL questionnaire of more than 300 questions (Ventegodt et al. 2003). The definition of quality of life that best represented what they were trying to assess was simply ‘being’ (Ventegodt et al. 2003). Another key synonym in philosophical research using the concept of quality of life is ‘happiness’. Aristotle in his Nicomachean Ethics used the Greek term ‘eudaimonia’, which translates to ‘happiness’ in English. The Journal of Happiness Studies, which started in 2000 as an ‘interdisciplinary forum on subjective well-being’, attests to how this philosophical definition now pervades all disciplines.

Medical definitions of quality of life vary from broad hedonistic definitions such as the patient’s ability to enjoy normal life activities and ‘the overall enjoyment of life’ (lymphomainfo.healthology.com/focus_article.asp), to more functional ones such as ‘an evaluation of health status relative to the patient’s age, expectations, and physical and mental capabilities’(www.oncura.com/glossary.html) and ‘the level of comfort, enjoyment, and ability to pursue daily activities’, a definition which is often used in deciding on treatment options (www.oralchemo.org/html/en/services/glossary.html). In the past, many medical uses of the term tended to rely on medical assessments, on behalf of patients, rather than on self-assessment. For example, Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QALYs), which used professional assessments of the impact of disability, were the main measures of quality of life used in medicine until the mid-1990s. However, more recently, especially for large-scale national surveys and cross-cultural medical research, subjective measures of quality of life (e.g. the SF-36 and WHOQOL) have been used routinely. In 1993, Ware and associates developed the Short Form-36 Health Survey Questionnaire (SF-36) which was used extensively in national health surveys and is now ‘the most frequently used measure of generic health status across the world’ (Bowling 2005:63). In the same year, researchers from the World Health Organization collaborated with 15 centres across the globe to develop two measures of quality of life, a long-form WHOQOL-100 and a short-form WHOQOL-BREF. The WHOQOL Group defined quality of life as ‘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, standards and concerns’(WHOQOL 1993:1). Thus, for the WHOQOL group, quality of life is

a broad-ranging concept incorporating in a complex way the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of the environment. This definition reflects the view that QOL refers to a subjective evaluation which is embedded in a cultural, social, and environmental context. As such, QOL cannot be simply equated with the terms ‘health status’, ‘life-style’, ‘life satisfaction’, ‘mental state’, or ‘well-being’. Rather, it is a multidimensional concept incorporating the individual’s perception of these and other aspects of life.

(http://www.coag.uvic.ca/documents/research_snapshots/Quality_Life_Definitions_Measurement_Application.htm)

The trajectory in the use of the term has been similar for economists, but they continue to use DALYs and QALYs as the gold standards in evaluating health outcomes. Basically this involves combining mortality and morbidity data rather than incorporating subjective assessments. Economics tends to view quality of life as a residual concept, encompassing all aspects of outcomes that do not have a monetary value. For example, the official definition of quality of life in the UK GCSE Economics curriculum is ‘a measure of the standard of living which considers non-financial factors’ (www.tutor2u.net/economics/gcse/revision_notes/key_terms.htm).

There has been some use by economists of scales such as AQOL (Australian Quality of Life measure), SF-36 and HUI versions 1, 2 and 3 (Health Utility Index). However, in contrast to developments in other disciplines, objective conditions of life are still emphasised, and amongst health economists in particular, a clinical focus prevails.

Sociologists and political scientists have also tended to emphasise the contextual objective measures of the conditions of life as the key features of quality of life (Pusey 2003) but do take account of subjective assessments. They tend to disaggregate global quality of life findings by gender, socioeconomic and other social and economic dimensions of differentiation and focus on the incommensurability between objective and subjective measures (Eckersley 2006; Eckermann 2000). For example, Pusey’s (2003) study of middle Australia found that despite significant economic growth and ‘reform’ over the last two decades of the twentieth century, ‘middle Australians’ were deeply dissatisfied with their lot in life. Eckersley (2006) and Eckermann (2000) similarly argue that objective and subjective indicators of quality of life are frequently at odds.

Psychology is the discipline which has produced the most prolific output on quality of life, and most measures of quality of life emerged from psychology. Comprehensive reviews of many of these definitions and measures are provided by Bowling (2005) and researchers from the Canadian University of Victoria’s Centre on Ageing (2005) (http://www.coag.uvic.ca/documents/research_snapshots/Quality_Life_Definitions_Measurement_Application.htm) and in the chapters in Volumes I and II of this handbook. The contribution that psychology has made to quality of life research is to insist on (and respect as scientific) subjective measures of well-being. All psychologists working in the field accept that quality of life is multidimensional; they just have differing ideas about which domains of life are core to subjective well-being. Some argue that a spiritual dimension is important (Haas 1999; WHOQOL 1993), others emphasise human rights (Schalock 2000) and most argue that the various ‘domains in aggregate must represent the total construct’ (Hagerty et al. 2001:7).

Thus, despite three decades of extensive research on quality of life, and the formation of several international multidisciplinary societies (the International Society for Quality of life Studies[ISQOLS], the International Society for Quality of Life Research [ISOQOL]) and many interdisciplinary journals, ‘the wider research community has accepted no common definition or definitive theoretical framework of quality of life’ (Bowling 2005:7). However, Bowling argues that quality of life refers to the ‘goodness of life’, so it implies a positive model rather than deficit model of life. In this respect, it reflects the WHO (1947) definition of health as ‘state of complete physical, mental and social well-being rather than an absence of disease or infirmity’.

Bowling (2005) argues that ‘what matters in the twenty-first century is how the patient feels, rather than how professionals think they feel. Symptom response or survival rates are no longer enough … therapy has to be evaluated in terms of whether it is more or less likely to lead to an outcome of life worth living in social and psychological, as well as physical, terms’ (Bowling 2005:1) and from the perspective of the person being assessed. Davis and Fine-Davis (1991) reiterate this point arguing that there is ‘no consistent relationship between objective social conditions …and perceived well-being’, which is why most researchers now tend to measure subjective and objective dimensions of quality of life separately and do not expect commensurability. For example, Cummins (2000) in the Australian Unity Wellbeing Index measures Personal Wellbeing Index, a totally subjective assessment, separately from the National Wellbeing Index, a more objective overview.

The first common feature across the definitions referred to above is the adoption of a positive stance on the ‘goodness of life’. All share an ‘implicit critique of traditional indicators of success and progress (which are often deficit measures)’. Second, all acknowledge, albeit with differing degrees of insistence, ‘the need to take account of both subjective and objective aspects of human experience in assessing wellbeing’ (Cummins 2000 www.deakin.edu.au/acqol). These are the two elements that are used to inform a definition in this chapter. I use the Australian Centre on Quality of Life generic definition of quality of life as follows: ‘Quality of life is both objective and subjective. Each of these two axes comprises several domains which, together, define the total construct. Objective domains are measured through culturally relevant indices of objective well-being. Subjective domains are measured through questions of satisfaction’ (Cummins 2000, www.deakin.edu.au/acqol). Obviously, which domains are included in any measurement tool varies with the purposes for which the research is being undertaken (Cummins 2000, www.deakin.edu.au/acqol).

The dimensions along which the quality of life issues of adults converge and diverge are discussed using the above definition as a guide. I start with the dimension most likely to represent convergence of experiences, the work-life balance.

Work-Life Balance

The age range 18–65 years is the expected work span in most countries where life expectancy exceeds 70 years, unemployment is at relatively low levels and child labour has been ‘officially’ abolished. Thus, in such countries, juggling work/leisure activities is the sphere where one would expect most overlap in the experience of adults. Fine-Davis et al.’s (2004) comparative analysis of working parents juggling work and family life in France, Italy, Ireland and Denmark found some shared issues across the 4 European countries. However, major differences also emerged in the ­quality of life of parents of young children, depending on the level of gender equity in household division of labour and social policies to support working parents, which prevailed in each country. Fine-Davis et al.’s findings have been reinforced in more recent research.

Shepanski and Diamond’s (2007) research on work-life balance in Australia found that the marked economic prosperity over the past 30 years in Australia has ‘come at a price’ and that ‘only one quarter of those surveyed think that life is getting better’ (Shepanski and Diamond 2007:13–14). Although the improved objective economic conditions should have provided the potential for enhanced quality of life, the ‘harsh reality’ is that the large proportion of the population that works asocial hours (long hours, weekends and nights and often on a casual basis) suffers ‘relational breakdown and dysfunction’ (Shepanski and Diamond 2007:13). The specific outcomes include increased morbidity, ‘strained family relationships’ and ‘parenting marked by anger, inconsistency and ineffectiveness’, all of which ultimately lead to reduced well-being for their children. These problems affect all levels of society and override the socioeconomic class impact on health and well-being (Shepanski and Diamond 2007:13)

To the statement ‘A government’s prime objective should be achieving the greatest happiness of the people, not the greatest wealth’, 77% of the surveyed population of Australia in 2006 agreed. To the question ‘What is the most important thing for your happiness?’, about ‘60% of surveyed Australian cited partner/spouse and family’, and ‘a further 8% specified community and friends’ (Shepanski and Diamond 2007:14). This finding is repeated in other research in Australia (Evans and Kelley 2004) and across the globe. The strong ‘connection between changing working patterns and a general decline in wellbeing associated with relationships’ (Shepanski and Diamond 2007:14) both within the family and outside the family suggests that this may be one of the key areas of convergence in adult experience of quality of life.

Shepanski and Diamond’s study supports conclusions drawn by Pusey and Eckersley several years earlier. Pusey’s (2003) study of middle Australia also found that despite significant economic growth and ‘reform’ over the last two decades of the twentieth century, ‘middle Australians’ were deeply dissatisfied with their lot in life. Eckersley (2006:256) explains this apparent anomaly, suggesting that juggling the work-life balance is part of a wider phenomenon of alienation. He argues that for most of the twentieth century, in many countries, rising material circumstances were important in increasing life expectancy and reducing morbidity. By the end of the century, this connection was broken by a culture of excessive individualisation and materialism such that there is now an inverse relationship between material conditions of life and quality of life. ‘Materialism and individualism are (currently in most Western countries) detrimental to health and well-being’ (Eckersley 2006:252). He suggests that ‘individualization has transformed identity from a “given” into a “task”..’a fate, not a choice so we cannot choose not to play the game’ (Eckersley 2006:254). Individuals in their quest for a ‘separate self’ increase ‘objective isolation’ and ‘subjective loneliness’. In the process, they experience a ‘loss of moral clarity, a heightened moral ambivalence and ambiguity a …dissonance between … professed values and lifestyles and a deep cynicism about social institutions’ (Eckersley 2006:254), which alienate them from governments, communities, their families and friends.

The question we now need to ask, against this backdrop of widespread dissatisfaction, is how is it that in large quality of life studies such as the Australian Unity Wellbeing Index (Cummins 2000) and in series of surveys, most respondents score quite highly on subjective well-being measures such as the Personal Wellbeing Index? Do factors such as gender, stage of adulthood and cultural traditions play a role?

Lifespan Effect: Continuous or Major Transitions?

There is ample evidence to support the argument that quality of life issues, and outcomes, vary across the lifespan (Merluzzi and Nairn 1999; Lang and Heckhausen 2001; Helson et al. 2002; Staudinger et al. 2003; Isaacoqitz et al. 2003; Jokisaari 2004; Wrosch et al. 2005; An and Cooney 2006; Oswald 2008; Blanchflower and Oswald 2008). There is some debate as to whether this is a continuous process or whether there are specific biological, psychological and social transitions in the life trajectory that make it possible to identify a generational effect (Turner 1994; Riggs and Turner 2000). Riggs and Turner’s (2000) study of an elite group of the baby boomer generation (born 1945–1950), which is often referred to as the ­privileged or ‘lucky generation’, points to particular generational experiences (such as being born in the aftermath of the Second World War) that made them as a cohort, and have a view of life which differed significantly from elites from subsequent generations.

Researchers from psychology and sociology have suggested that major transitions in a person’s life can cause dramatic changes (in either a positive or negative direction) in both the subjective and objective domains of well-being (Williams 2005; Muehrer and Becker 2005). Examples include the first sexual encounter, leaving school, entering the workforce, starting tertiary education, becoming unemployed, death of a relative, having an organ transplant (Muehrer and Becker 2005), leaving home, sudden financial independence, sudden financial dependence, marriage or first cohabitation with a partner, gaining voting and drinking rights, birth of the first child, divorce, menopause, sudden incapacitation (Mezey et al. 2002), retirement and birth of the first grandchild (Williams 2005). The palliative care literature is replete with evidence of the impact on quality of life, both positive and negative, of transition to incapacity and the role of resilience in maintaining good quality of life even in the face of major adversity (Mezey et al. 2002).

Adaptation and resilience, ‘the ability to bounce back or cope successfully despite substantial adversity’ (Rutter 1985 quoted in Earvolino-Ramirez 2007) is often associated with childhood, and the popular phrase ‘children are so resilient’ implies that adults are not (Earvolino-Ramirez 2007:73). However, increasingly the term resilience is used to refer to adult experiences too and the capacity of adults to adapt to, and be positive in the face of, major life transitions. A Resilience Scale for Adults (RSA) has been developed (Friborg et al. 2003). The role of resilience in helping people cope with the 11 September 2001 attacks on the World Trade Center in New York and the Pentagon in Washington has been explored in detail (Fredrickson et al. 2003). The evidence suggests that some aspects of resilience increase with age and with exposure to adverse circumstances and resilience has an important gender dimension (Carver 1998; Riggs and Turner 2000; Cummins 2011). In particular, the baby boomer generation (who are now in their late 50s and early 60s) seems more resilient, and optimistic, than subsequent generations, and women within that generation were more inclined to be resilient and optimistic than men (Riggs and Turner 2000:89; Cummins 2006).

The most recent research on generational effects across the lifespan is by Oswald (2008). Their research across 80 countries revealed that levels of happiness and life satisfaction across the lifespan can be represented as a U-curve with levels being their lowest between 44 and 46 years but increasing to almost the same high levels as for 20-year olds by the time people reach 70 years. This U-bend is thought to override any cohort, employment status, income and parenting status effect (Oswald 2008; Blanchflower and Oswald 2008). The research on affective changes with age by Stone et al. (2010), summarised in the Editorial of the Economist (2010, p. 3), suggests that

enjoyment and happiness dip in middle age, then pick up; stress rises during the early 20s, then falls sharply; worry peaks in middle age, and falls sharply thereafter; anger declines throughout life; sadness rises slightly in middle age and falls thereafter.

Gender and QOL

Reviews of quality of life measures up until 2000 argued that there was very little sex difference in quality of life outcomes. This was largely due to a lack of sex disaggregation of quality of life findings and the absence of any significant gender analysis of the outcomes and experiences. However, more recent research has identified significant gender differences (Cummins 2006; Fine-Davis et al. 2004) at several levels. Fine Davis et al. noted the differential quality of life outcomes (using both objective and subjective indicators) across the four European countries according to each country’s traditional practices in the household division of labour and in the government’s policies on supporting gender equity. Thus, differentials are located in relationship practices at the household level and policy at the state level.

Cummins (2006) observed sex differences in quality of life outcomes in the last sets of large-scale data using the Personal Wellbeing Index. Despite less favourable objective conditions, women consistently report higher levels of subjective well-being. Undertaking a gender analysis of these differences between the sexes points to resilience as a key factor in producing differential outcomes between men and women (Earvolino-Ramirez 2007). Gender acts in interesting ways in health and well-being. Evidence points to women’s longevity compared to men in most countries of the world but greater morbidity levels for females (UNICEF 2006). However, when it comes to quality of life, we get some complicated findings. The Longitudinal Study on Women’s Health (Women’s Health Australia) and other large-scale social surveys tell us that women’s objective ­conditions of life still seem to be worse than men’s (disposable income, job opportunities, access to power and decision-making, leisure time, competing roles). Some quality of life measures, especially those which examine both objective conditions and subjective per­ceptions, show that women’s quality of life is lower than men’s. However, the Personal Wellbeing Index (Cummins 2000) looks only at subjective measures and consistently reveals higher scores for women than men. The concept of resilience, which is so central to the theory behind the Index (Homeostatic Theory), is the most plausible explanation for such differences. Women appear to be more resilient than men in difficult circumstances. Maybe it is because they have had more practise. The greater emphasis on emotional literacy in the gender socialisation of girls appears to equip females of all ages to battle through difficult times and to draw others into the problem-solving process. In contrast, masculine socialisation has tended to emphasise independence and going it alone. It is of little wonder that men are less satisfied with their levels of social connectedness when they discover that the fortress response to problems does not work.

Conclusions

Stage of lifespan and gender are not the only factors which lead to differential quality of life experiences. Lau et al. (2005) found significant differences in personal well-being scores, using the PWI, between Australian adults and Chinese adults from Hong Kong, which they attributed to a cultural bias against reporting positive states of being amongst Hong Kong Chinese. These differences are also evident in the range of domains that different countries request to add to the International Wellbeing Index and their differential scores on the PWI. Even within countries, there are significant differences in PWI scores according to geographical location. The Australian Unity Wellbeing Index Report 13.1 (Feb. 2006) used a sample of 22,829 respondents to assess geographical differences in personal well-being. The two domains that were most sensitive to geographical influence were community connection and feelings of safety. Personal well-being was significantly higher in non-metropolitan areas as a result of high scores on these two domains. External circumstances such as socioeconomic class and poverty across nations (Cummins 2002) are also important variables in differential experiences of quality of life, but this issue has been explored elsewhere in this handbook. Similarly, personality characteristics (especially neuroticism and extroversion) obviously impact on well-being and quality of life.

There are factors which unite adults aged 18–65 years in terms of quality of life experiences, but there are more factors which divide them. The three key messages which emerge from this review of quality of life in adults are:

  • The importance of disaggregating all data collected by sex, age or generation, socioeconomic status, geographical location, ethnicity and health status

  • The need to undertake analysis to understand those differences, for example, using gender analysis to understand sex differences

  • The need to avoid extrapolating findings from specific populations (such as university students) to other populations (all adults) or the entire population

  • The need to question popular assumptions about the relationship between ageing and quality of life

This chapter should be read in conjunction with the chapters on specific populations that also address quality of life in adults such as adults with disabilities and adults from the diversity of cultural background covered in Volume III.