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An Integrative Approach to Quality of Life Measurement, Research, and Policy

While Quality of Life (QOL) has long been an explicit or implicit policy goal, adequate definition and measurement have been elusive. Diverse “objective” and “subjective” indicators across a range of disciplines and scales, and recent work on subjective well-being (SWB) surveys and the psychology of happiness have spurred renewed interest. Drawing from multiple disciplines, we present an integrative definition of QOL that combines measures of human needs with subjective well-being or happiness. QOL is proposed as a multiscale, multi-dimensional concept that contains interacting objective and subjective elements. We relate QOL to the opportunities that are provided to meet human needs in the forms of built, human, social and natural capital (in addition to time) and the policy options that are available to enhance these opportunities. Issues related to defining, measuring, and scaling these concepts are discussed, and a research agenda is elaborated. Policy implications include strategies for investing in opportunities to maximize QOL enhancement at the individual, community, and national scales.

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Sections: , editor's notes.

This paper is a shorter and revised version of an article that first appeared in Ecological Economics (Costanza et al 2007).

Received: 8 December 2006—Revised: 1 October 2007—Accepted: 3 October 2007—Published: 15 February 2008

Introduction

1 Enhancing Quality of Life (QOL) has long been a major explicit or implicit life-style and policy goal for individuals, communities, nations, and the world (Schuessler and Fisher, 1985; Sen 1985). But defining QOL and measuring progress towards improving it have been elusive. Currently, there is renewed interest in this issue both in the academic and popular press. A search of the Institute for Scientific Information (ISI) database from 1982-2005 reveals over 55,000 academic citations utilizing the term “quality of life,” spanning a large range of academic disciplines. In the popular press, quality of life is also a critical element in the ongoing discourse on economic prosperity and sustainability, but it has often been subsumed under the heading of “economic growth” under the assumption that more income and consumption equates to better welfare. This equation of consumption with welfare has been challenged by several authors, notably Sen (1985) and Nusbaum (1995) and is now also being challenged by recent psychological research (Diener and Lucas, 1999; Easterlin, 2003).

2 Alternative measures of welfare and QOL are therefore actively being sought. For example, both the New York Times and the Wall Street Journal have carried articles about the country of Bhutan’s decision to use “Gross National Happiness” as their explicit policy goal rather than GNP. Recent research on QOL has focused on two basic methodologies of measurement. The First—termed “subjective well-being” (SWB)—focuses upon self-reported levels of happiness, pleasure, fulfillment and the like (see Diener and Lucas (1999) and Easterlin (2003)).The other utilizes so-called “objective” measurements of QOL—quantifiable indices generally of social, economic, and health indicators (UNDP, 1998)—that reflect the extent to which human needs are or can be met. For example, objective measures include indices of economic production, literacy rates, life expectancy, and other data that can be gathered without directly surveying the individuals being assessed. Objective indicators may be used singly or in combination to form summary indexes, such as the UN’s Human Development Index (Sen, 1985; UNDP, 1998). While these measurements may provide a snapshot of how well some physical and social needs are met, they are narrow, opportunity-biased, and cannot incorporate many issues that contribute to QOL such as identity, participation, and psychological security. It is also clear that these so-called “objective” measures are actually proxies for experience identified through ”subjective” associations of decision-makers; hence the distinction between objective and subjective indicators is somewhat illusory.

3 Subjective indicators of QOL gain their impetus, in part, from the observation that many objective indicators merely assess the opportunities that individuals have to improve QOL rather than assessing QOL itself. Thus economic production may best be seen as a means to a potentially (but not necessarily) improved QOL rather than an end in itself. In addition, unlike most objective measures of QOL, subjective measures typically rely on survey or interview tools to gather respondents’ own assessments of their lived experiences in the form of self-reports of satisfaction, happiness, well-being or some other near-synonym. Rather than presume the importance of various life domains (e.g., life expectancy or material goods), subjective measures can also tap the perceived significance of the domain (or “need”) to the respondent. Diener and Suh (1999) provide convincing evidence that subjective indicators are valid measures of what people perceive to be important to their happiness and well-being. While both measurement methods have offered insight into the QOL issue, there are a number of limitations to using either of these approaches separately. What seems best, then, is to attempt an approach to QOL that combines objective and subjective approaches. Our integrative definition of QOL is as follows:

Quality of Life (QOL) is the extent to which objective human needs are fulfilled in relation to personal or group perceptions of subjective well-being (SWB, figure 1). Human needs are basic needs for subsistence, reproduction, security, affection, etc. (see figure 1). SWB is assessed by individuals’ or groups’ responses to questions about happiness, life satisfaction, utility, or welfare. The relation between specific human needs and perceived satisfaction with each of them can be affected by mental capacity, cultural context, information, education, temperament, and the like, often in quite complex ways. Moreover, the relation between the fulfillment of human needs and overall subjective well-being is affected by the (time-varying) weights individuals, groups, and cultures give to fulfilling each of the human needs relative to the others.

Figure 1: Integrative model of QOL

Quality of Life (QOL) is represented as the interaction of human needs and the subjective perception of their fulfillment, mediated by the opportunities available to meet the needs. 1. Opportunities to meet human needs now and in the future: Built, Human, Social and Natural Capital and time. 2. Human needs include: Subsistence, Reproduction, Security, Affection, Understanding, Participation, Leisure, Spirituality, Creativity, Identity and Freedom. 3. Subjective Well Being (happiness, utility and welfare) for individuals and/or groups.

4 With this definition, the role of policy is both to create opportunities for human needs to be met (understanding that there exists a diversity of ways to meet any particular need), and to create conditions that increase the likelihood that people will effectively take advantage of these opportunities (figure 1). Built, human, social, and natural capitals (Costanza et al. 1997) represent one way of categorizing those opportunities. Time is also an independent constraint on the achievement of human needs.

5 Social norms affect both the weights given to various human needs when aggregating them to overall individual or social assessments of SWB, and also policy decisions about social investments in improving opportunities. Social norms evolve over time due to collective population behavior (Azar, 2004). The evolution of social norms can also be affected by conscious shared envisioning of preferred states of the world (Costanza, 2000).

2. Human Needs, Opportunities and Preferences

6 The needs identified in Figure 1 were derived primarily from an integration of Max-Neef’s (1992) “Matrix of Human Needs” and Nussbaum and Glover’s (1995) “Basic Human Functional Capabilities.” We also consulted other research regarding basic human needs including Maslow’s “Hierarchy of needs” (1954), Sirgy et al.’s “Need Hierarchy Measure of Life Satisfaction” (1995), Cummins’ “Comprehensive Quality of life scale ComQol-A-5” (1997), Greenley, Greenberg, and Brown’s “Quality of Life Questionnaire” (1997) and Frisch’s “Quality of Life Inventory” (1998). It is important to acknowledge that some of the needs we propose are overlapping and some may be conflicting. For example, subsistence and reproduction needs may overlap, whereas the recreation needs of one person may conflict with the subsistence needs of another.

7 The ability of humans to satisfy these basic needs arises from the opportunities available and constructed from social, built, human and natural capital (and time). Policy and culture help to allocate the four types of capital as a means for providing these opportunities. Here we define social capital as those networks and norms that facilitate cooperative action (Putnam, 1995); human capital as the knowledge and information stored in our brains, as well as our health and labor potential; built capital as manufactured goods (tools, equipment, consumer goods), buildings, and infrastructure; natural capital as the structure of natural ecosystems. All forms of capital are stocks that generate flows of benefits. For example, the benefits of natural capital are the renewable and nonrenewable goods and services provided by ecosystems (Costanza and Daly, 1992).

8 These capitals and the benefits they provide, individually and in combination, comprise the inputs to satisfying the various human needs. The differing characteristics of these four types of capital can be used to help guide policy and decision making with regard to meeting human needs. For example, social capital and information (a component of human capital) do not wear out through use. They can actually improve and grow through use (this is how our social networks and scientific knowledge generally grow). However, they can also disintegrate extremely rapidly. Built capital and the labor element of human capital wear out through use, following the second law of thermodynamics. Some aspects of natural capital improve through use and repair themselves through solar energy capture. Recognition of the varying natures of these four types of capital will help to most efficiently provide opportunities to meet human needs.

9 From this perspective, QOL is a multidimensional construct emerging from the evaluation of multiple needs on the individual, community, national, and global levels. Each need is assumed to contribute to different degrees (that vary across time) to overall QOL. Overall QOL at any point in time is a function of (a) the degree to which each identified human need is met, which we will call “ fulfillment ” and (b) the importance of the need to the respondent or to the group in terms of its relative contribution to their subjective well-being. In the simplest of strategies, measurement would consist of two distinct scales to assess each item regarding a human need; one of the scales would record the degree of fulfillment and the other would record the relative importance of the need. A basic aggregation approach, such as simple summation or averaging, might be adequate to obtain a group assessment of QOL. Alternatively, a more complex aggregation scheme might be used for some purposes. For example, research on the relationship between the average of the individual assessments of a group and the whole group’s collective assessment after discussion might be used to build aggregation schemes that better reflect the group’s collective assessment than simple averaging.

10 Thus, in designing an assessment of QOL, the goal should be to create a tool that will capture the weighting that is being used by a particular person (or group of persons) at a particular time and place. In order to achieve this, useful population samples are needed to empirically identify and define the weights. This process would provide valuable information regarding:

potential relationships between the fulfillment and the importance of needs

possible discrepancies between fulfillment and importance grouped by type of capital required to fulfill each need

variation in weights by population characteristics

variation in overall QOL (e.g., from one community to another)

11 By their nature QOL measures represent a snapshot in time. It is understood that any measurement data used for predictive purposes would need to be collected over sufficiently long time periods to successfully capture or model the co-evolution of humans with their environment and develop an effective knowledge base. Of course weightings will fluctuate as a result of intentional as well as unconscious manipulation by individuals through re-evaluation strategies, such as social comparisons, and through goal attainment.

12 The analysis of QOL is further complicated by the different spatial and temporal scales of analysis at which human needs may be understood. There is no “correct” scale for such assessments. The “scale of interest” is determined by: 1) the question or problem of interest; and 2) the scale at which we look to find the pattern (e.g., individual, regional, or national level). For example, to identify patterns at the individual level or very small temporal scales, we must focus our attention on larger spatial regions or longer temporal scales so as to find statistical ensembles for which observations become more regular.

3. A Research Agenda

13 By integrating the so-called subjective and objective measures of QOL we get a more realistic picture of the important inputs and variables for improving QOL. Our integrative definition provides a framework for further research including questions such as: How can weightings be aggregated across various spatial and temporal scales? How do weightings vary over time? Research along these lines would prove invaluable for creating effective policy, especially where tradeoffs are present. It is also essential to investigate the ways in which individual and group weightings are vulnerable to (mis)information and (mis)perception, as well as to understand the relationship between individual and societal goals (Ehrlich and Kennedy, 2005).

14 In addition, various methods to measure people’s subjective preferences regarding objective functionings and capabilities could be compared, including choice experiments, multi-criteria decision analysis, and deliberative group methods.

15 The application of QOL assessment to sustainability issues presents another vital avenue of research. Answering the question: “What is the role of ecological sustainability for QOL?” could help integrate the social and scientific policy agendas and hence pay double dividends. An even bigger question involves examining how all of the four capitals, along with their attendant policies and macro-conditions, affect QOL (both directly and in transaction with one another) across temporal and spatial scales (Vemuri and Costanza, 2006). This issue may, in fact, be an umbrella theme for future interdisciplinary work on QOL.

4 Policy Implications

16 The policy implications of a better understanding and measurement of QOL are likely to be profound. As mentioned above, Bhutan has recently declared that “gross national happiness” is its explicit policy goal (Bond, 2003). In fact, several authors—including most recently Richard Layard (2005) —have recommended that our primary social policy goal should be the increase in QOL for this and future generations. We agree with Layard and recommend a refocusing of social policy around the goal of long-term, sustainable QOL improvement. As we have discussed, QOL improves according to our abilities to meet human needs as well as our perception of how well these needs are met. This integrated framework for analyzing and assessing QOL brings out several policy recommendations, including:

Investment in built, natural, human, and social capital in balanced ways that create the opportunities for people to fulfill their needs.

Investment in capitals and opportunity creation that provide the greatest return on investment, as measured by increase in QOL.

Divestment when the marginal utility equals zero and reallocation of resources where marginal utility is highest (e.g., urban investment in natural amenities or rural investment in built infrastructure).

Explicit adjustment of social norms and preferences, by correcting misinformation that leads to inefficient resource allocation; for example, people focus too much on increasing income despite research evidence that increases in individual income have no lasting effect on people’s reported level of happiness (Easterlin, 2003).

17 We have proposed an integrated definition and measurement tool for QOL that should guide a stronger research agenda and improve our understanding of QOL issues. This improved understanding can, in turn, be used to guide public policy toward the goal of enhancing QOL across multiple temporal and spatial scales, and across a broad diversity of cultural contexts in a long-term, sustainable manner. An integrated QOL measurement tool will aid in distinguishing between those policies or lifestyle choices that actually improve QOL and those that do not. In this way, informed policy can not only create the necessary opportunities, but also provide the information crucial to evaluating individual decisions with the result of long-term improvement in QOL.

This paper was the result of a conference of University of Vermont researchers representing a broad range of social and natural science and humanities disciplines. The goals of the conference were to gather members of the various research disciplines related to QOL in order to develop a new, broader consensus on this critical issue. The conference was supported by the University of Vermont Honors College.

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Electronic reference

Robert Costanza , Brendan Fisher , Saleem Ali , Caroline Beer , Lynne Bond , Roelof Boumans , Nicholas L. Danigelis , Jennifer Dickinson , Carolyn Elliott , Joshua Farley , Diane Elliott Gayer , Linda MacDonald Glenn , Thomas R. Hudspeth , Dennis F. Mahoney , Laurence McCahill , Barbara McIntosh , Brian Reed , Abu Turab Rizvi , Donna M. Rizzo , Thomas Simpatico and Robert Snapp , “An Integrative Approach to Quality of Life Measurement, Research, and Policy” ,  S.A.P.I.EN.S [Online], 1.1 | 2008, Online since 19 December 2008 , connection on 28 August 2024 . URL : http://journals.openedition.org/sapiens/169

About the authors

Robert costanza.

Gund Institute for Ecological Economics; Rubenstein School of Environment and Natural Resources

Brendan Fisher

Rubenstein School of Environment and Natural Resources

Caroline Beer

Department of Political Science*

Roelof Boumans

Nicholas l. danigelis.

Department of Sociology*

Jennifer Dickinson

Department of Anthropology*

Carolyn Elliott

Joshua farley.

Gund Institute for Ecological Economics; Department of Community Development and Applied Economics*

Diane Elliott Gayer

Department of Community Development and Applied Economics*

Linda MacDonald Glenn

Department of Nursing*

Thomas R. Hudspeth

Dennis f. mahoney.

Department of German and Russian*

Laurence McCahill

College of Medicine*

Barbara McIntosh

School of Business Administration*

Department of Physical Therapy*

Abu Turab Rizvi

Department of Economics*

Donna M. Rizzo

Department of Civil and Environmental Engineering*

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Robert snapp.

Department of Computer Science*

                             *The University of Vermont, Burlington, Vermont 05405 USA

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Social Indicators Research and Health-Related Quality of Life Research

The social indicators movement at 50: onwards in unity or divided, fifty years after the social indicators movement: has the promise been fulfilled.

• environment
• quality of life
• quality of life research
• social indicators

Table of contents (20 chapters)

Front matter, reflections on twenty-five years of quality-of-life research, combining social, economic and environmental indicators to measure sustainable human well-being, evaluation of equality policies for the status of women in canada, militarism and the quality of life, migration and the quality of life: a review essay, job satisfaction, marital satisfaction and the quality of life: a review and a preview, discrepancies between perceived income needs and actual incomes, optimism in thirty countries over a decade, health and the quality of life.

• Bruno D. Zumbo, Anita Hubley

Health and other Aspects of the Quality of Life of Older People

• Anita M. Hubley, Bruno D. Zumbo, Dawn Hemingway

Healthy Days, Health Satisfaction and Satisfaction with the Overall Quality of Life

• Bruno D. Zumbo

Leisure Activities, Health and the Quality of Life

Public services and the quality of life, criminal victimization and the quality of life, policing services and the quality of life, feminism and the quality of life.

• Deborah C. Poff

Ethnicity, Modern Prejudice and the Quality of Life

The impact of trust on business, international security and the quality of life, bibliographic information.

Book Title : Essays on the Quality of Life

Authors : Alex C. Michalos

Series Title : Social Indicators Research Series

DOI : https://doi.org/10.1007/978-94-017-0389-5

Publisher : Springer Dordrecht

eBook Packages : Springer Book Archive

Copyright Information : Springer Science+Business Media Dordrecht 2003

Hardcover ISBN : 978-1-4020-1342-3 Published: 31 July 2003

Softcover ISBN : 978-90-481-6304-5 Published: 15 December 2010

eBook ISBN : 978-94-017-0389-5 Published: 17 April 2013

Series ISSN : 1387-6570

Series E-ISSN : 2215-0099

Edition Number : 1

Number of Pages : XII, 492

Topics : Sociology, general , Quality of Life Research , Public Health , Economic Policy , Quality of Life Research

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Conceptual framework for the research on quality of life.

1. Introduction

2. education and training, 3. physical activity and healthy lifestyles, 4. food production and technology/food behavior, 5. organizational dynamics, 6. motor behavior, 7. individual and community health, 8. conclusions, author contributions, conflicts of interest.

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Rodrigues, J.; Chicau Borrego, C.; Ruivo, P.; Sobreiro, P.; Catela, D.; Amendoeira, J.; Matos, R. Conceptual Framework for the Research on Quality of Life. Sustainability 2020 , 12 , 4911. https://doi.org/10.3390/su12124911

Rodrigues J, Chicau Borrego C, Ruivo P, Sobreiro P, Catela D, Amendoeira J, Matos R. Conceptual Framework for the Research on Quality of Life. Sustainability . 2020; 12(12):4911. https://doi.org/10.3390/su12124911

Rodrigues, José, Carla Chicau Borrego, Paula Ruivo, Pedro Sobreiro, David Catela, José Amendoeira, and Rui Matos. 2020. "Conceptual Framework for the Research on Quality of Life" Sustainability 12, no. 12: 4911. https://doi.org/10.3390/su12124911

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• Research article
• Open access
• Published: 27 March 2018

Effectiveness of psychological interventions to improve quality of life in people with long-term conditions: rapid systematic review of randomised controlled trials

• Niall Anderson 1 , 2 &
• Gozde Ozakinci 2  

BMC Psychology volume  6 , Article number:  11 ( 2018 ) Cite this article

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Long-term conditions may negatively impact multiple aspects of quality of life including physical functioning and mental wellbeing. The rapid systematic review aimed to examine the effectiveness of psychological interventions to improve quality of life in people with long-term conditions to inform future healthcare provision and research.

EBSCOhost and OVID were used to search four databases (PsychInfo, PBSC, Medline and Embase). Relevant papers were systematically extracted by one researcher using the predefined inclusion/exclusion criteria based on titles, abstracts, and full texts. Randomized controlled trial psychological interventions conducted between 2006 and February 2016 to directly target and assess people with long-term conditions in order to improve quality of life were included. Interventions without long-term condition populations, psychological intervention and/or patient-assessed quality of life were excluded.

From 2223 citations identified, 6 satisfied the inclusion/exclusion criteria. All 6 studies significantly improved at least one quality of life outcome immediately post-intervention. Significant quality of life improvements were maintained at 12-months follow-up in one out of two studies for each of the short- (0–3 months), medium- (3–12 months), and long-term (≥ 12 months) study duration categories.

Conclusions

All 6 psychological intervention studies significantly improved at least one quality of life outcome immediately post-intervention, with three out of six studies maintaining effects up to 12-months post-intervention. Future studies should seek to assess the efficacy of tailored psychological interventions using different formats, durations and facilitators to supplement healthcare provision and practice.

Peer Review reports

Long-term conditions (LTC) are complex physical health issues that last a year or longer and require ongoing care and support [ 1 ]. As LTC may be treated but not reversed, long-term care for patients and specialised rehabilitation training for staff is required to deal with the permanent and/or disabling nature of conditions [ 1 , 2 ]. As a consequence of increased exposure to risk factors, the likelihood of experiencing a LTC shows a linear increase with age, with those aged 75 years or older being up to five times more likely to experience a LTC than any other age group [ 1 , 3 , 4 ]. As the proportion of those aged 65 years or older in Europe is projected to increase from 15% in 2000 to 23.5% in 2030, a major and increasing challenge is faced by public health to not only target LTC symptoms, but also the associated increased rates of disability and reductions in both healthy and overall life expectancy [ 5 , 6 ]. Furthermore, due to LTC resulting from a combination of genetic, physiological, psychological and socio-economic factors, LTC are also becoming increasingly prevalent in younger populations [ 6 ].

LTC encompass a wide range of conditions which impact upon one’s physical, psychological, and social functioning. However, as individual LTC may differ in aetiology, presentation and consequence, there is significant variability in the degree to which each LTC is medically understood, diagnosed and treated [ 1 , 6 , 7 ]. For example, cardiovascular disease and diabetes mellitus are two of the most prevalent and increasingly occurring LTC worldwide, and are associated with increased rates of long-term disability, dependency on others for everyday functioning, and depression [ 6 , 8 , 9 , 10 ]. Chronic obstructive pulmonary disease and dementia are prevalent but under-diagnosed LTC as symptoms may often be mistakenly attributed to an anticipated gradual age-related decline in functioning. However, both conditions relate to increased medical admissions, distressing symptoms, mortality, and disability [ 6 , 11 , 12 , 13 ]. Medically unexplained physical symptoms (MUPS) – such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia – are also LTC that (despite having unknown aetiologies) profoundly impact psychological, emotional and physical functioning, as well as healthcare costs and requirements [ 14 – 16 ]. Furthermore, aforementioned conditions only provide a snapshot of overall LTC types, and disorder-related fatalities are also predicted to increase for manageable conditions such as asthma without further public health intervention [ 6 ].

While it is important to understand the causes, presentations, and consequences of LTC in isolation, to effectively understand the burden of LTC it is critical to look at how multiple LTC may co-occur and interact. While the terms ‘ Multi-morbidity ’ and ‘ Co-morbidity ’ are often used interchangeably, the former refers to several LTC coexisting, while the latter refers to multiple disorders stemming from one predominant LTC [ 17 , 18 ]. Effective determination of the worldwide rates of specific and multi-morbid LTC is complex because of issues with insufficient or inappropriate health measures and analyses being used, and between-country differences in LTC definitions and inclusion criteria [ 19 , 20 ]. However, regardless of the figures assessed, LTC pose a key challenge as 14–29% of the European population report one LTC and 7–18% report two or more conditions [ 21 ]. Furthermore, these conservative estimates consider a limited range of conditions, and when a broader range of LTC is considered these figures may be considerably higher. For example, 27% of 75–84 year olds in Scotland experience two or more LTC [ 1 ]. Hence, policy and interventions must not only target specific LTC, but also account for the often multi-morbid nature of LTC.

Health status is an effective measure of healthcare and intervention effectiveness; however, using solely population-level mortality and morbidity rates may be problematic as they only provide a snapshot of effects [ 22 ]. As a consequence, subjective measures such as quality of life (QOL), health-related QOL (HR-QOL) and mental wellbeing (MWB) are increasingly being used in healthcare research to assess subjective health status and condition-related burden and coping [ 22 ]. QOL is a multi-dimensional concept that includes subjective evaluations of one’s physical, psychological, emotional, social, functional and/or environmental state. Due to the wide range of potential constructs, QOL may be assessed using uni-dimensional, multi-dimensional, and individual measures [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. HR-QOL and MWB are sub-domains of QOL that may be assessed using general or specific measures [ 23 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. HR-QOL relates to one’s perception of physical and mental health and may provide a valuable insight into symptomology–psychology links, while MWB relates to one’s ability to cope with life stressors and maintain a healthy mental state which may provide an insight into illness and coping perceptions [ 23 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ].

LTC diagnosis, treatment, and outcomes not only have a significant impact upon patients’ physical functioning, but may also have profound consequences for psychological wellbeing and QOL through affecting emotional, physiological and MWB. This may consequently impact upon medical outcomes through treatment choice and the likelihood of LTC relapse and survival [ 44 , 45 , 46 , 47 , 48 , 49 , 50 ]. Co-morbid mental health disorders are a key issue in LTC populations [ 11 ], with LTC patients being significantly more likely to be diagnosed with depressive and/or anxiety disorders [ 51 , 52 ]. This may relate to poorer health outcomes and self-care, more severe symptoms, reduced medical adherence, and increased unhealthy behaviours, healthcare spending, and disorder-related death rates [ 51 , 52 ]. Despite this, traditional medical models often overlook key psychological variables through employing a paternalistic care approach where clinicians exercise predominant authority over patients’ care [ 53 , 54 , 55 ]. Therefore, as LTC outcomes not only relate to healthcare treatment but are also intrinsically linked to psychological wellbeing and mental health, the provision of psychological interventions and therapies is critical for LTC healthcare services and patient outcomes [ 11 , 56 , 57 ].

Previous systematic reviews (SR) have demonstrated efficacy for psychological interventions (provided in a wide range of formats) to improve both QOL and physical health outcomes in specific LTC patients. For example, mindfulness for multiple sclerosis and cancer, psychosocial interventions for diabetes and cancer, cognitive behavioural therapy (CBT) and relaxation for recurrent headaches, and internet-based CBT or coaching for chronic somatic conditions [ 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. However, to the researchers’ knowledge, there has not previously been a SR that attempts to only assess studies with high scientific rigour that utilise psychological interventions across LTC in order to provide valid comparisons for the effectiveness of interventions and guide LTC healthcare development. As aforementioned, as research has demonstrated that LTC may have profound physiological and psychological effects [ 1 , 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ], rates of specific and multi-morbid LTC are high and predicted to rise [ 3 , 4 , 5 , 6 , 17 , 18 , 21 ], and psychological interventions may improve both QOL and physical functioning [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ], it is crucial to determine which interventions may be effective across conditions.

The rapid SR aimed to examine the effectiveness of a variety of psychological interventions that seek to improve generic or specific QOL, HR-QOL and/or MWB in people with LTC to determine whether specific interventions may be viable and efficacious for general LTC healthcare implementation. As randomised controlled trial (RCT) designs are the most rigorous and effective method for determining whether intervention–outcome relationships are present [ 67 ], and to ensure valid comparisons were possible between studies, only RCTs with a usual care control (UCC) condition which directly target and assess patients with a current LTC diagnosis were included. To ensure the review assessed the most up-to-date research, only studies published between 2006 and February 2016 were included. Furthermore, despite a general dose and duration effect being present for psychological intervention effectiveness, evidence relating to the optimum duration of psychological interventions for LTC to achieve maximum effectiveness is mixed [ 62 , 68 , 69 ]. Therefore, an ante hoc decision was taken to categorise studies by intervention facilitation duration, encompassing short- (0–3 months), medium- (3–12 months) and long-term (≥12 months) study classifications.

Rapid systematic review

Rapid SR are a form of streamlined SR that may be used by healthcare professionals to guide policy in a time-frame that may not be possible using traditional SR methods. While they do not provide as in-depth information and should not be viewed as a substitute for traditional SRs, rapid SR may have important implications for healthcare decision-making through using systematic methods to provide high-quality information and draw significantly similar conclusions to a traditional SR [ 70 , 71 , 72 ]. As the review was conducted during NHS employment and aimed to influence healthcare policy, utilizing a SR procedure was deemed the most feasible and practical approach based on two key considerations. First, in order for the research to have implications (not only for research but also) for healthcare, it was critical that high quality information was provided using limited time and resources [ 70 ]. Second, as the research was conducted during NA’s NHS employment as one competency of a two-year professional doctorate-level Health Psychology qualification, the ability to generate a complete draft of findings for NHS stakeholders within a maximum of 6 months (as opposed to up to 2 years for a traditional SR) [ 70 , 71 , 72 ] was deemed the most appropriate approach. Therefore, two researchers (NA, GO) followed traditional SR procedures but without searching grey literature and with only one researcher (NA) involved until data extraction was completed. The implications of adopting this approach are presented in ‘Rapid Systematic Review Strengths and Limitations’ .

Search strategy, selection criteria and data extraction

Searches were conducted on 19.02.2016 by one researcher (NA) using EBSCOhost to access PsychInfo (1967–2016) and PBSC (1974–2016), and OVID to access Medline (1946–2016) and Embase (1974–2016). Both databases were searched using key terms (Table  1 ), with potential citations suitability assessed using the pre-defined inclusion/exclusion criteria (Table 2 ). Due to the multi-dimensional nature of QOL there is currently no universally accepted definition of QOL [ 22 , 25 ]. Therefore, an ante hoc decision was made to manually assess individual studies for the presence or absence of QOL rather than include it in the search terms. Additionally, only RCTs with a UCC were included in order to ensure that valid comparisons of rigour and effectiveness were possible between different interventions and LTC [ 67 ]. Data were extracted using a template developed from the COCHRANE criteria [ 73 ]. As the SR aimed to guide public health policy, the Effective Public Health Practice Project (EPHPP) ‘ Quality Assessment Tool for Quantitative Studies ’ was used to assess study quality [ 74 ].

Study selection

The PRISMA flowchart (Fig.  1 ) demonstrates the process used to narrow 2224 prospective citations to 13 studies based on titles and abstracts [ 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 ], with 6 studies satisfying the inclusion/exclusion criteria based on full articles [ 82 , 83 , 84 , 85 , 86 , 87 ].

Study Selection Process

Study characteristics

Key study features, measures, results (including significance values and effect sizes where stated), and authors’ conclusions from the 6 eligible studies are presented in Table 3 . The six studies [ 82 , 83 , 84 , 85 , 86 , 87 ] encompass a variety of psychological interventions and durations: 2 were short-term (0–3 months) [ 82 , 85 ], 2 were medium-term (3–12 months) [ 84 , 86 ], and 2 were long-term studies (≥12 months) [ 83 , 87 ]. Facilitators of the interventions varied considerably between studies, with nurses facilitating 3 interventions [ 83 , 85 , 87 ], and the remaining 3 studies being facilitated by health educators [ 82 ], CBT therapists [ 84 ], and clinical psychologists [ 86 ]. Additionally, each intervention focussed on a different LTC; comprising asthma [ 82 ], human immunodeficiency virus (HIV) [ 83 ], MUPS [ 84 ], congestive heart failure (CHF) [ 85 ], knee osteoarthritis [ 86 ], and head & neck cancer (HNC) patients [ 87 ]. Five studies compared a UCC with one intervention [ 82 , 83 , 84 , 85 , 87 ], while one study contrasted multiple interventions with a UCC [ 86 ]. Furthermore, all 6 studies comprised samples of both genders aged 18 years or over, and assessed (among other measures) generic and/or specific measures of QOL, HR-QOL and/or MWB [ 82 , 83 , 84 , 85 , 86 , 87 ].

Study quality assessment

EPHPP quality assessment [ 74 ] involves assessing studies based on 6 key components (Table  4 ). Each component comprises multiple choice questions for which scores are combined to provide an overall component rating of ‘ Strong ’, ‘ Moderate ’ or ‘ Weak ’. All component ratings are then combined to provide an overall quality rating of ‘ Strong ’ for no ‘ Weak ’ components, ‘ Moderate ’ for one ‘ Weak ’ component, and ‘ Weak ’ for two or more ‘ Weak ’ components.

Short-term interventions (0–3 months)

Two short-term interventions were present. Baptist et al. [ 82 ] offered a 6-week health educator-led self-regulation intervention for asthmatic patients ( N  = 70), comprising 3 consecutive weekly health education group sessions followed by 3 weekly one-to-one telephone sessions. Health educators received a 2-day training session on self-regulation and asthma management principles which was used to conduct tailored self-regulation interventions. This involved patients’ self-selecting a specific asthma-related problem that they wished to address before planning how to achieve positive outcomes and cope with potential asthma-related issues. Significant improvements were present 12-months post-intervention for overall asthma-related QOL, activity, control and hospitalisations. QOL symptom and environment improvements were present 1-month post-intervention, and non-significant changes occurred for QOL emotions or emergency department usage.

Smeulders et al. [ 85 ] offered a 6-week, 150-min per week structured self-management programme for CHF patients ( n  = 317). The intervention was co-facilitated by a cardiac nurse specialist and a CHF patient (acting as a peer role model) who were both trained on a 4-day ‘ Chronic Disease Self-Management Programme ’ [ 88 ] by a research and CHF nurse specialist. This incorporated four strategies to enhance self-efficacy over one’s condition: skills mastery, behaviour modelling, social persuasion and symptom reinterpretation. Significant improvements were present immediately (but not at 6- or 12-months) post-intervention for cardiac-specific QOL, cognitive symptom management and self-care behaviour. However, non-significant intervention effects were present at all time-points for perceived control, general self-efficacy, and all other QOL outcomes (general QOL, perceived autonomy, and anxiety and depression).

Medium-term interventions (3–12 months)

Two medium-term interventions were present. Escobar et al . [ 84 ] offered 10, 45–60-min CBT therapist-led sessions over a 3-month period to MUPS patients ( n  = 172). Two therapists received training from two authors employed by Departments of Psychology and Psychiatry respectively, with protocol adherence routinely evaluated using “taped” recordings. Key topics included managing physical distress, relaxation, activity regulation, emotional awareness, cognitive restructuring and interpersonal communication. The intervention significantly improved patient-rated depression and current somatic symptoms, and physician-rated global severity of symptoms, immediately post-intervention. Only changes to patient-rated somatic symptoms were maintained 6-months post-intervention and no effects were present for anxiety or physical functioning.

Somers et al. [ 86 ] ‘ Pain Coping Skills Training ’ (PCST) and ‘ Behavioural Weight Management ’ (BWM) co-interventions for knee osteoarthritis patients ( n  = 232) were conducted by clinical psychologists (with 1–6 years experience in their respective area), under the supervision and training of an experienced senior clinical psychologist. The intervention spanned 24 weeks, comprising 12 weekly groups sessions followed by 12 weeks of sessions every second week for the remainder of the intervention. One group received BWM based on the ' LEARN ' programme [ 89 ], which focused on lifestyle, exercise, attitudes, relationships and nutrition. The second group received PCST, which focused on maladaptive pain catastrophizing and adaptive coping strategies. The third group received both BWM and PCST programmes. While the study did not utilise a generic measure of QOL, the combined intervention demonstrated significant improvements compared to UCC 12-months post-intervention for arthritis- and weight-specific self-efficacy, pain symptoms and catastrophizing, physical disability and stiffness, weight, and BMI.

Long-term interventions (≥12 months)

Two long-term interventions were present. Blank et al. [ 83 ] offered weekly community-based psycho-education and symptom management sessions (of unspecified duration) over a 12-month period to HIV patients ( n  = 238). Four Advanced Practice Nurses facilitated psycho-education sessions for coping with barriers and self-care, and provided resources to support patients’ to organise their medication regimens. In addition, the Practice Nurses coordinated a multi-disciplinary team of physical and mental healthcare providers to provide tailored medical and mental healthcare. Growth curve analyses were used to assess outcomes, demonstrating significant improvements 12-months post-intervention for the HR-QOL mental health subscale and viral load. However, non-significant improvements were present for the HR-QOL physical health subscale and immune functioning.

Van Der Meulen et al. [ 87 ] offered six bimonthly 45-min nurse-led, problem-focused counselling sessions for depressive symptoms to HNC patients ( n  = 205) over a 12-month period. Three experienced oncology nurses received a one-day training course from two psychologists and one investigator on the ‘ Nurse Counselling and After Intervention ’. Session recordings were reviewed every 2 months to assess intervention quality. The intervention focussed on managing the physical, psychological and social consequences of HNC, restructuring illness cognitions and beliefs, education and behavioural relaxation training, and providing emotional support. Significant improvements were present immediately post-intervention (both in the overall sample and depressive subgroup) for the primary endpoint of depressive symptoms and secondary endpoint of overall physical symptoms.

General statement

The review aimed to examine the effectiveness of psychological interventions to improve specific or generic components of QOL, HR-QOL and/or MWb in people with LTC, with a view to advising LTC healthcare provision. The findings, strengths, limitations and implications of studies, and the strengths and limitations of the current review and rapid SR procedure, are discussed.

Six-week self-regulation for older adult asthmatics

Baptist et al. [ 82 ] trained health educators on a two-day programme which enabled them to facilitate a six-week self-regulation intervention. As a consequence of the self-regulation intervention, significant improvements occurred for older adults’ overall asthma-related QOL and control up to 12-months post-intervention. The key hallmarks of the self-regulation approach was to facilitate patients’ self-identification of a specific condition-related issue and potential barriers and goals, in order to provide tailored support and increase patients’ self-efficacy over their condition. This approach has also been used to achieve positive outcomes for heart disease and medical noncompliance in older adults [ 90 , 91 ]. Therefore, when combined with the low attrition rate (7%) [ 82 ] and self-regulation concepts not being unique to asthma [ 92 ], self-regulation provides promise as an effective and acceptable form of intervention to improve QOL in older adults. Despite receiving ‘ Strong ’ ratings for all but one quality component, the study received a ‘ Weak ’ ‘ Selection Bias ’ rating due to only 54% of those approached agreeing to participate, which may have two potential implications. First, this may indicate a lack of interest in self-regulation interventions potentially due to this approach differing from anticipated traditional asthma care approaches [ 82 ]. Second, while double-blinding improves methodological quality [ 93 ], a lack of awareness of intervention procedures and potential benefits may have impact enrolment. Additionally, as highlighted by the authors, the study was limited by using a single site and required a certain threshold of patient communicative ability to contribute to group discussions. Therefore, while additional studies and a cost-benefit analysis would be required to determine the efficacy of larger scale programmes, and consideration is required for the enrolment confounds, the study demonstrated that a short-term, health educator-led self-regulation intervention may have promising implications for LTC healthcare.

Six-week structured self-management for CHF

Smeulders et al.’s [ 85 ] 6-week structured self-management intervention, co-facilitated by a trained cardiac nurse specialist and a CHF peer role model, significantly improved cardiac-specific QOL immediately post-intervention. However, effects were not maintained at 6- or 12-months follow-up, and no other QOL improvements occurred. Despite having four ‘ Strong ’ components, the study received an overall ‘ Weak ’ EPHPP quality rating due to unspecified ‘ Blinding ’ of patients and clinicians, and a ‘ Selection Bias ’ as only 44% of eligible patients participated. As justification for non-participation varied considerably – from a lack of interest to physical, psychosocial or cognitive problems preventing participation – a qualitative study to further explore enrolment issues may be beneficial to determine whether the intervention was sufficiently tailored to complex CHF needs. While the authors proposed that non-significant effects may have resulted from insufficient intervention length or intensity above the “relatively high level” of Dutch standard care, a similar medium-term (15 weeks) self-management intervention improved physical but not emotional QOL [ 94 ]. Therefore, despite positive short-term results, further research is required to understand the mechanisms behind the low participation and lack of long-term QOL effects for structured self-management, with a view to using this to develop and trial more tailored interventions.

Overall short-term interventions

Despite both short-term interventions reviewed [ 82 , 85 ] comprising 6-week programmes, considerable differences were present between-interventions that may have influenced outcomes. First, the self-regulation intervention was solely facilitated by health educators, while the CHF intervention was co-facilitated by a nurse and a patient ‘ peer leader ’. While peer leaders were trained to effectively facilitate the intervention, potential differences in pre-existing knowledge and experience associated with not being a trained healthcare professional may have influenced the content, approach and style of programme adopted, and subsequently QOL outcomes. Second, research into the mechanisms behind why the 2-day (but not the 4-day) training resulted in significant long-term QOL improvement would be beneficial. Three possible explanations for this include potential differences in the quality of training, that health educators may benefit more from short-term training than nurses and/or peer leaders, and/or that additional information provided during the longer training may have resulted in a more structured but less tailored approach being adopted with patients. Third, as asthma and CHF differ considerably in emotional, physical and social outcomes [ 95 , 96 ], this may have impacted the long-term maintenance of intervention effects post-intervention and consequently QOL outcomes. Fourth, methodological differences may have impacted outcomes due to the discrepancy between Blank et al.’s [ 82 ] ‘ Moderate ’ and Smuelders et al.’s [ 85 ] ‘ Weak ’ EPHPP quality ratings. However, despite considerable differences, both studies demonstrated that interventions which actively engage and involve the patient in their care may significantly improve at least short-term QOL, and that, while achieving initial buy-in for these types of interventions may be challenging, once enrolled attrition rates were low. Therefore, while cost-benefit analyses and further research are required to determine viability and overcome current limitations, short-term psychological interventions that actively involve patients demonstrated initial promise for improving QOL, with self-regulation demonstrating particular promise.

Three-month CBT for medically unexplained symptoms

Escobar et al.’s [ 84 ] structured CBT therapist-led intervention for MUPS significantly improved patient-rated depression and somatic symptoms, and clinician-rated severity of symptoms, immediately post-intervention. However, only improvements to patient-rated somatic symptoms were maintained 6-months post-intervention. While depressive and somatic symptom improvements were anticipated as CBT is widely advocated for depression, the improvements in both patient- and clinician-rated MUPS symptoms potentially indicate additional benefits for short-term perceived behavioural and cognitive control. Despite positive results, achieving patient buy-in was problematic as only 41% of eligible patients enrolled with an attrition rate of 45%. While the justification for this was not discussed, the study proposed that future programmes may benefit from using a staged-approach to tailor the intervention to patients’ needs, use of other services, costs, and the delivery setting. As MUPS patients do not benefit from reassurance alone [ 97 ] and a similar 6-week CBT programme for Breast Cancer patients demonstrated non-significant results [ 98 ], this highlights the need for at least moderate-length, tailored CBT-based interventions that are tailored to patients’ needs. Therefore, while research is required to overcome the confounds of participation and long-term effect maintenance, and to determine how to feasibly implement the complex and time-consuming intervention in practice, CBT demonstrated promise for improving QOL in LTC.

Six-month BWM/PCST for knee osteoarthritis

Somers et al.’s [ 86 ] clinical psychologist-led 24-week combined PCST and BWM intervention demonstrated significant improvements 12-months post-intervention for the QOL components of arthritis- and weight-specific self-efficacy, pain symptoms and catastrophizing, physical disability and stiffness, weight, and BMI compared to UCC. Additionally, the combined intervention was significantly more effective than the individual interventions for the aforementioned outcomes; excluding PCST for pain catastrophizing and one pain measure. This demonstrates that by conducting a programme which not only targets LTCs’ physical components, but also enables people to cope with the psychological effects and consequences, significantly improves both physical and psychological QOL. However, despite being one of only two studies reviewed to receive a ‘ Strong ’ quality rating, the study was confounded by the combined condition receiving double the intervention dosage than individual conditions. Additionally, as interventions were facilitated by highly trained clinical psychologists, additional research and a cost-benefit analysis comparing this approach with training existing staff involved in arthritis healthcare to provide the intervention would be beneficial. Therefore, while research for potential dose and expertise effects is required, the study demonstrated efficacy for a medium-term intervention to improve QOL 12-months post-intervention through targeting both the physical and psychological components of LTC.

Overall medium-term interventions

Overall, the medium-term studies [ 84 , 86 ] demonstrated effectiveness for interventions delivered by psychologically trained staff to improve QOL in LTC, with CBT resulting in short-term improvements and a combined physical and psychological intervention resulting in improvements 12-months post-intervention. While these studies highlighted the need for medium-term psychological interventions to be tailored to LTC patients’ physical and psychological needs in order to actively involve patients in their healthcare, three considerations are required. First, differences were present in the quality of studies, with Escobar et al. [ 84 ] receiving a ‘ Moderate ’ quality rating and Somers et al. [ 86 ] a ‘ Strong ’ rating. As this stemmed purely from the CBT-therapist intervention experiencing more problematic ‘ Withdrawals & Dropouts ’ [ 84 ], future research into the mechanisms behind this difference would be beneficial. Second, despite both LTC having profound physical and psychological consequences, current understanding of the causes and consequences of MUPS is less well defined than for knee osteoarthritis, which may have impacted outcomes [ 84 , 86 ]. Third, while the positive outcomes provide an important foundation for research to build upon, consideration is required for the level of staff input and training required to conduct such programmes. As becoming a chartered psychologist or CBT therapist typically takes at least 6–7 years of study and training in addition to vocational work, both programmes required highly specialised staff. While this appears beneficial for QOL outcomes, this raises potential practicality issues for healthcare implementation as considerations would be required to determine capacity, practicality and financial viability within existing or additional services. However, as Somers et al. [ 86 ] demonstrated greater improvements based on psychological intervention dosage, this highlights a potential opportunity to utilise psychological principles to improve QOL outcomes for LTC. Therefore, careful consideration is required for the implementation of medium-term interventions using psychologically trained staff; however, the positive effects for both physical and psychological QOL indicate promise for healthcare.

Twelve-month psycho-education and management for HIV

Blank et al.’s [ 83 ] 12-month, nurse-led community-based psycho-education and healthcare management intervention for HIV patients demonstrated significant improvements for mental health QOL and immune functioning 12-months post-intervention. However, no effect was present for physical health QOL or viral load. The rationale behind the study was that reforms to healthcare provide a challenge but also an opportunity to redesign systems in a more integrated manner. Through training nurses to facilitate psycho-education while providing tailored access to relevant professions within a multi-disciplinary healthcare team, significant improvements were present for condition-related immune functioning and mental health. However, future healthcare research would benefit from factoring in key confounds. First, as university-based nurses facilitated the intervention the additional research experience associated with this work setting may have influenced outcomes. Second, as viral load changes only occurred 12-months post-intervention, consideration of optimal intervention and assessment duration is required. Finally, while assessing different constructs at different time points may be the most feasible approach within multi-disciplinary interventions, careful consideration is required for the effect this may have on analyses and attrition, as 75% of patients completed the QOL measure 12-months post-intervention compared with only 61% providing bio-markers data. Therefore, while future work may benefit from overcoming practical confounds, altering existing services to provide psycho-education and tailored management of a multi-disciplinary team by nurses may be a feasible, cost-effective approach.

Twelve-month counselling for HNC

Van Der Meulen et al.’s [ 87 ] 12-month, nurse-led problem-focussed counselling programme significantly improved depressive and physical symptoms in HNC patients immediately post-intervention, with effects being more pronounced in the depressive-subgroup. As the authors proposed that those with greatest physical impairments were more likely to experience depressive symptoms and those with depressive symptoms benefited most from the intervention, problem-focussed counselling demonstrated efficacy both for the general sample and for those patients in greatest need. While the study was confounded by a ‘ Moderate ’ ‘ Selection Bias ’ with only 63% of eligible patients participating, it was one of only two studies to receive a ‘ Strong ’ overall rating and once enrolled attrition rates were low (13%). Therefore, as low attrition supports the authors’ claim that utilising nurse facilitators may not only reduce healthcare costs but also stigma, the intervention was feasible and cost-effective. Hence, due to the positive intervention effects a combined with the psychological elements of the interventions not being specific to HNC, theory-based long-term nurse-facilitated interventions provide promise for LTC healthcare delivery.

Overall long-term interventions

Overall, the long-term studies [ 83 , 87 ] demonstrated efficacy for long-term nurse-led interventions to improve QOL in LTC, with HNC counselling having significant post-intervention effects, and HIV psycho-education and care management improving QOL 12-months post-intervention. Despite differences in the format, content and delivery of interventions, significant QOL improvements were achieved through supporting nurses to facilitate interventions that enabled patients to develop the skills, knowledge and efficacy required to manage the physical and psychological components and consequences of their LTC. Furthermore, as both HIV and HNC are complex LTC that may have profound physical and mental effects and therefore require a large amount of medical support, the positive intervention effects provide promise for other complex LTC. As proposed by Van Der Meulen et al. [ 87 ], utilising nurses to provide long-term interventions may be both a financially and practically viable approach to implementing long-term psychological interventions, and may reduce stigma due to nurses already being intrinsically involved in LTC healthcare provision. However, consideration is require for the differences between Blank et al.’s [ 83 ] ‘ Moderate ’ and Van Der Meulen et al.’s [ 87 ] ‘ Strong ’ quality ratings, with this stemming from the ‘ Weak ' and ‘ Strong ’ ‘ Withdrawals & Dropouts ’ quality ratings respectively. Therefore, future research is required into the mechanisms behind between-study differences in enrolment and attrition despite both interventions utilizing nurse facilitators. Hence, long-term, nurse-led interventions which actively involve patients in their care and target both the physical and psychological constructs of LTC provide promise for healthcare. However, further research is required to determine the optimal approach to adopt in order to enhance patient enrolment for such programmes.

General discussion

Implications of findings.

The studies reviewed demonstrated that psychological interventions for LTC varied considerably in terms of duration, population, methods, quality ratings, facilitators and long-term effectiveness. Descriptive analysis of findings indicated that all interventions resulted in significant improvements to at least one component of QOL immediately-post intervention. Furthermore, the 6-week health educator self-regulation intervention for asthma [ 82 ], 6-month clinical psychologist-led combined PCST-BWM intervention for knee osteoarthritis [ 86 ], and 12-month nurse-led psycho-education and care management intervention for HIV [ 83 ] significantly improved QOL 12-months post-intervention. While further research is required to assess the mechanisms behind differences in the effectiveness of interventions and the feasibility of implementing interventions in LTC healthcare, the findings indicate that psychological interventions utilising different formats, durations and facilitators which actively involve and enable patients to have self-efficacy over their care may result in significant QOL improvements for LTC patients.

In addition to the effectiveness of interventions, the studies have important implications for future research and healthcare. First, across studies enrolment in psychological interventions was low, with one study only successfully enrolling 41% of potential patients [ 84 ]. While blinding was often used to increase methodological quality, this may have influenced participation rates through blinding patients to the potential components, goals and benefits of interventions. Additionally, at present LTC treatments typically promote pharmacological and/or medical treatments, with psychological interventions promoted as secondarily [ 1 , 2 , 3 , 5 , 6 , 7 , 11 , 19 , 22 , 23 , 26 ]. This may promote patients to seek quick-fix treatments and requires a change in approach in order to enhance participation in psychological interventions. Further, as only 6 RCTs from 2006 to February2016 were deemed suitable based on the inclusion/exclusion criteria, coupled with the review demonstrating that psychological interventions may improve QOL across LTC, this review highlights the need for high-quality research into this area and the application of methods in healthcare. Hence, future research and interventions across LTC that attempt to build upon the positive findings and resolve methodological confounds is recommended in order to build a greater evidence base for the effectiveness of psychological interventions on LTC.

General Strengths and Limitations

Many of the strengths of the review may also be regarded as limitations. First, an ante hoc decision was made to include only RCTs with a UCC in order to ensure that only high methodological quality studies were included and valid comparisons could be made between interventions despite considerable differences in the LTC targeted [ 67 ]. Furthermore, in order to ensure that only the most up-to-date research was assessed, only studies spanning the previous 10 years (2006 to February 2016) were included. While discussions were conducted with relevant experts (within Public Health, Health Psychology and Publishing) prior to the review to set a strict inclusion/exclusion criterion for only the most relevant research, it is possible that important and interesting studies, findings and interventions may have been excluded. Additionally, in order to improve the reliability of findings, only studies that directly targeted LTC patients for both the intervention and assessment were included. However, this may also have reduced the number of interventions through excluding those that indirectly target or assess patients through clinicians, carers or family members, such as communicative or learning disorder populations who may benefit from psychological interventions but are unable to communicate effects. Finally, while he COCHRANE data extraction framework is well validated and used across disciplines [ 73 ], the EPHPP quality assessment tool was used as the review aimed to guide public health policy [ 74 ]. However, as the review assessed psychological interventions, alternative tools may potentially have been more appropriate and may have resulted in different quality ratings. For example, Smeulders et al. [ 85 ] received a ‘ Weak ’ rating despite demonstrating four ‘ Strong ’ components, and Van Der Meulen et al. [ 87 ] received a ‘ Strong ’ rating despite only stating significance values as ‘ p ≤ 0.05 ’. Therefore, future replications and expansions should attempt to build upon the strengths, and generate solutions for the limitations, of the review in order to improve upon the quality of the review.

Rapid systematic review strengths and limitations

Previous research has discussed the relative strengths and limitations of the rapid SR approach compared to traditional SRs [ 70 , 71 , 72 ]. One primary benefit of this methodology is that it may be used to assess research and formulate conclusions that influence healthcare policy within a time-frame and budget that would not be possible using traditional methods. While significant work was subsequently conducted to improve the review to publication standard, this methodology allowed the review to progress from defining potential search parameters to providing a first draft to healthcare stakeholders within three-months. Rapid SRs may potentially suffer from using a non-iterative search strategy, narrow time-frame for retrieval, not performing quality analysis, and limiting consultation with experts. However, the present review did not suffer from these confounds as a strict ante hoc criteria was set and adhered to, and various contacts (Public Health, Health Psychology etc.) were sought out to discuss the suitability of the review. Therefore, active efforts were made to strengthen methodology by ensuring that many potential confounds of rapid SRs were accounted for.

Despite attempts to maintain as high quality methodology as possible, implicit limitations are associated with one researcher being involved until data extraction. First, practical constraints meant that grey literature, reference lists and additional databases were not searched, which may have provided additional findings. Furthermore, while all possible effort were made to maintain accuracy, ‘ human error ’ and ‘ selection bias ’ are possible, and as only articles published in English were included ‘ publication ’ and ‘ language ’ biases are also possible. However, given the relative strengths and weaknesses of rapid SRs, and that the review was completed during NHS employment ( See Authors’ Information ), overall utilising rapid SR methodology was useful for an initial study. Therefore, future attempts should be made to replicate and expand upon the findings using a larger research team to limit the aforementioned confounds through continuing to utilise a strict ante hoc criteria.

The studies reviewed demonstrated promising results for utilising psychological interventions to improve QOL in LTC patients, with short-, medium- and long-term interventions that promote patient involvement demonstrating positive outcomes. While confounds were present which require resolution, particularly with low participation from eligible patients, the positive results indicated that with high-quality methodology, actively involving patients in their care and tailoring of interventions to patients’ needs, psychological interventions may improve QOL in LTC. Hence, future studies should assess the efficacy of tailored interventions utilising different formats, durations, and facilitators to improve QOL in LTC, while the development and promotion of services should be promoted to utilise psychological interventions to supplement medical care,

Abbreviations

Behavioural Weight Management.

Cognitive Behavioural Therapy

Congestive Heart Failure

Effective Public Health Practice Project

Human Immunodeficiency Virus

Head & Neck Cancer

Health-Related Quality of Life

Long-Term Conditions

Medically Unexplained Physical Symptoms

Mental Wellbeing

Pain Coping Skills Training

Quality of Life

Randomised Controlled Trial

Systematic Review

Usual Care Control

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NA would like to thank Julie Murray and Dr. Allyson McCollam at NHS Borders, and Dr. Hannah Dale and Dr. Lloyd Wallace at NHS Education for Scotland, for their ongoing support and advice throughout the review.

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Anderson, N., Ozakinci, G. Effectiveness of psychological interventions to improve quality of life in people with long-term conditions: rapid systematic review of randomised controlled trials. BMC Psychol 6 , 11 (2018). https://doi.org/10.1186/s40359-018-0225-4

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Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries

• Kai Ruggeri 1 , 2 ,
• Eduardo Garcia-Garzon 3 ,
• Áine Maguire 4 ,
• Sandra Matz 5 &
• Felicia A. Huppert 6 , 7  

Health and Quality of Life Outcomes volume  18 , Article number:  192 ( 2020 ) Cite this article

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Recent trends on measurement of well-being have elevated the scientific standards and rigor associated with approaches for national and international comparisons of well-being. One major theme in this has been the shift toward multidimensional approaches over reliance on traditional metrics such as single measures (e.g. happiness, life satisfaction) or economic proxies (e.g. GDP).

To produce a cohesive, multidimensional measure of well-being useful for providing meaningful insights for policy, we use data from 2006 and 2012 from the European Social Survey (ESS) to analyze well-being for 21 countries, involving approximately 40,000 individuals for each year. We refer collectively to the items used in the survey as multidimensional psychological well-being (MPWB).

The ten dimensions assessed are used to compute a single value standardized to the population, which supports broad assessment and comparison. It also increases the possibility of exploring individual dimensions of well-being useful for targeting interventions. Insights demonstrate what may be masked when limiting to single dimensions, which can create a failure to identify levers for policy interventions.

Conclusions

We conclude that both the composite score and individual dimensions from this approach constitute valuable levels of analyses for exploring appropriate policies to protect and improve well-being.

What is well-being?

Well-being has been defined as the combination of feeling good and functioning well; the experience of positive emotions such as happiness and contentment as well as the development of one’s potential, having some control over one’s life, having a sense of purpose, and experiencing positive relationships [ 23 ]. It is a sustainable condition that allows the individual or population to develop and thrive. The term subjective well-being is synonymous with positive mental health. The World Health Organization [ 45 ] defines positive mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. This conceptualization of well-being goes beyond the absence of mental ill health, encompassing the perception that life is going well.

Well-being has been linked to success at professional, personal, and interpersonal levels, with those individuals high in well-being exhibiting greater productivity in the workplace, more effective learning, increased creativity, more prosocial behaviors, and positive relationships [ 10 , 27 , 37 ]. Further, longitudinal data indicates that well-being in childhood goes on to predict future well-being in adulthood [ 39 ]. Higher well-being is linked to a number of better outcomes regarding physical health and longevity [ 13 ] as well as better individual performance at work [ 30 ], and higher life satisfaction has been linked to better national economic performance [ 9 ].

Measurement of well-being

Governments and researchers have attempted to assess the well-being of populations for centuries [ 2 ]. Often in economic or political research, this has ended up being assessed using a single item about life satisfaction or happiness, or a limited set of items regarding quality of life [ 3 ]. Yet, well-being is a multidimensional construct, and cannot be adequately assessed in this manner [ 14 , 24 , 29 ]. Well-being goes beyond hedonism and the pursuit of happiness or pleasurable experience, and beyond a global evaluation (life satisfaction): it encompasses how well people are functioning, known as eudaimonic, or psychological well-being. Assessing well-being using a single subjective item approach fails to offer any insight into how people experience the aspects of their life that are fundamental to critical outcomes. An informative measure of well-being must encompass all the major components of well-being, both hedonic and eudaimonic aspects [ 2 ], and cannot be simplified to a unitary item of income, life satisfaction, or happiness.

Following acknowledgement that well-being measurement is inconsistent across studies, with myriad conceptual approaches applied [ 12 ], Huppert and So [ 27 ] attempted to take a systematic approach to comprehensively measure well-being. They proposed that positive mental health or well-being can be viewed as the complete opposite to mental ill health, and therefore attempted to define mental well-being in terms of the opposite of the symptoms of common mental disorders. Using the DSM-IV and ICD-10 symptom criteria for both anxiety and depression, ten features of psychological well-being were identified from defining the opposite of common symptoms. The features encompassed both hedonic and eudaimonic aspects of well-being: competence, emotional stability, engagement, meaning, optimism, positive emotion, positive relationships, resilience, self-esteem, and vitality. From these ten features an operational definition of flourishing, or high well-being, was developed using data from Round 3 of the European Social Survey (ESS), carried out in 2006. The items used in the Huppert and So [ 27 ] study were unique to that survey, which reflects a well-being framework based on 10 dimensions of good mental health. An extensive discussion on the development and validation of these measures for the framework is provided in this initial paper [ 27 ].

As this was part of a major, multinational social survey, each dimension was measured using a single item. As such, ‘multidimensional’ in this case refers to using available measures identified for well-being, but does not imply a fully robust measure of these individual dimensions, which would require substantially more items that may not be feasible for population-based work related to policy development. More detailed and nuanced approaches might help to better capture well-being as a multidimensional construct, and also may consider other dimensions. However, brief core measures such as the one implemented in the ESS are valuable as they provide a pragmatic way of generating pioneering empirical evidence on well-being across different populations, and help direct policies as well as the development of more nuanced instruments. While this naturally would benefit from complementary studies of robust measurement focused on a single topic, appropriate methods for using sprawling social surveys remain critical, particularly through better standardization [ 6 ]. While this paper will overview those findings, we strongly encourage more work to that end, particularly in more expansive measures to support policy considerations.

General approach and key questions

The aim of the present study was to develop a more robust measurement of well-being that allows researchers and policymakers to measure well-being both as a composite construct and at the level of its fundamental dimensions. Such a measure makes it possible to study overall well-being in a manner that goes beyond traditional single-item measures, which capture only a fraction of the dimensions of well-being, and because it allows analysts to unpack the measure into its core components to identify strengths and weaknesses. This would produce a similar approach as the most common reference for policy impacts: Gross Domestic Product (GDP), which is a composite measure of a large number of underlying dimensions.

The paper is structured as follows: in the first step, data from the ESS are used to develop a composite measure of well-being from the items suggested by Huppert & So [ 27 ] using factor analysis. In the second step, the value of the revised measure is demonstrated by generating insights into the well-being of 21 European countries, both at the level of overall well-being and at the level of individual dimensions.

The European social survey

The ESS is a biannual survey of European countries. Through comprehensive measurement and random sampling techniques, the ESS provides a representative sample of the European population for persons aged 15 and over [ 38 ]. Both Round 3 (2006–2007) and Round 6 (2012–2013) contained a supplementary well-being module. This module included over 50 items related to all aspects of well-being including psychological, social, and community well-being, as well as incorporating a brief measure of symptoms of psychological distress. As summarized by Huppert et al. [ 25 ], of the 50, only 30 items relate to personal well-being, of which only 22 are positive measures. Of those remaining, not all relate to the 10 constructs identified by Huppert and So [ 27 ], so only a single item could be used, or else the item that had the strongest face validity and distributional items were chosen.

Twenty-two countries participated in the well-being modules in both Round 3 and Round 6. As this it within a wider body of analyses, it was important to focus on those initially. Hungary did not have data for the vitality item in Round 3 and was excluded from the analysis, as appropriate models would not have been able to reliably resolve a missing item for an entire country. To be included in the analysis and remain consistent, participants therefore had to complete all 10 items used and have the age, gender, employment, and education variables completed. Employment was classified into four groups: students, employed, unemployed, retired; other groups were excluded. Education was classified into three groups: low (less than secondary school), middle (completed secondary school), and high (postsecondary study including any university and above). Using these criteria, the total sample for Round 6 was 41,825 people from 21 countries for analysis. The full sample was 52.6% female and ranged in age from 15 to 103 (M = 47.9; SD = 18.9). Other details about participation, response rates, and exclusion have been published elsewhere [ 38 ].

Huppert & So [ 27 ] defined well-being using 10 items extracted from the Round 3 items, which represent 10 dimensions of well-being. However, the items used in Round 3 to represent positive relationships and engagement exhibited ceiling effects and were removed from the questionnaire in Round 6. Four alternatives were available to replace each question. Based on their psychometric properties (i.e., absence of floor effects and wider response distributions), two new items were chosen for positive relationships and engagement (one item for each dimension). The new items and those they replaced can be seen in Table  1 (also see Supplement ).

Development of a composite measure of psychological well-being (MPWB)

A composite measure of well-being that yields an overall score for each individual was developed. From the ten indicators of well-being shown in Table 1 , a single factor score was calculated to represent MPWB. This overall MPWB score hence constitutes a summary of how an individual performs across the ten dimensions, which is akin to a summary score such as GDP, and will be of general value to policymakers. Statistical analysis was performed in R software, using lavaan [ 40 ] and lavaan.survey [ 35 ] packages. The former is a widely-used package for the R software designed for computing structural equation models and confirmatory factor analyses (CFA). The latter allows introducing complex survey design weights (combination of design and population size weights) when estimating confirmatory factor analysis models with lavaan, which ensures that MPWB scoring followed ESS guidelines regarding both country-level and survey specific weights [ 17 ]. Both packages have been previously tested and validated in various analyses using ESS data (as explained in detail in lavaan.survey documentation).

It should be noted that Round 6 was treated as the focal point of these efforts before repeating for Round 3, primarily due to the revised items that were problematic in Round 3, and considering that analyses of the 2006 data are already widely available.

Prior to analysis, all items were coded such that higher scores were more positive and lower scores more negative. Several confirmatory factor analysis models were performed in order to test several theoretical conceptualizations regarding MPWB. Finally, factor scores (expected a posteriori [ 15 ];) were calculated for the full European sample and used for descriptive purposes. The approach and final model are presented in supplemental material .

Factor scores are individual scores computed as weighted combinations of each person’s response on a given item and the factor scoring coefficients. This approach is to be preferred to using raw or sum scores: sum or raw scores fail to consider how well a given item serves as an indicator of the latent variable (i.e., all items are unrealistically assumed to be perfect and equivalent measures of MPWB). They also do not take into account that different items could present different variability, which is expected to occur if items present different scales (as in our case). Therefore, the use of such simple methods results in inaccurate individual rankings for MPWB. To resolve this, factor scores are both more informative and more accurate, as they avoid the propagation of measurement error in subsequent analyses [ 19 ].

Not without controversy (see Supplement ), factor scores are likely to be preferable to sum scores when ranking individuals on unobservable traits that are expected to be measured with noticeable measurement error (such as MPWB [ 32 ];). Similar approaches based on factor scoring have been successfully applied in large international assessment research [ 21 , 34 ]. With the aim of developing a composite well-being score, it was necessary to provide a meaningful representation of how the different well-being indicators are reflected in the single measure. A hierarchical model with one higher-order factor best approximated MPWB along with two first-order factors (see supplement Figure S 1 ). This model replicates the factor structure reported for Round 3 by Huppert & So [ 27 ]. The higher-order factor explained the relationship between two first-order factors (positive functioning and positive characteristics showed a correlation of ρ = .85). In addition, modelling standardized residuals showed that the items representing vitality and emotional stability and items representing optimism and self-esteem were highly correlated. The similarities in wording in both pairs of items (see Table 1 ) are suspected to be responsible for such high residual correlations. Thus, those correlations were included in the model. As presented in Table  2 , the hierarchical model was found to fit the data better than any other model but a bi-factor model including these correlated errors. The latter model resulted in collapsed factor structure with a weak, bi-polar positive functioning factor. However, this bi-factor model showed a problematic bi-polar group factor with weak loadings. Whether this group factor was removed (resulting in a S-1 bi-factor model, as in [ 16 ]), model fit deteriorated. Thus, neither bi-factor alternative was considered to be acceptable.

To calculate the single composite score representing MPWB, a factor scoring approach was used rather than a simplistic summing of raw scores on these items. Factor scores were computed and standardized for the sample population as a whole, which make them suitable for broad comparison [ 8 ]. This technique was selected for two reasons. First, it has the ability to take into account the different response scales used for measuring the items included in the multidimensional well-being model. The CFA model, from which MPWB scores were computed, was defined such that the metric of the MPWB was fixed, which results in a standardized scale. Alternative approaches, such as sum or raw scores, would result in ignoring the differential variability across items, and biased individual group scores. Our approach, using factor scoring, resolves this issue by means of standardization of the MPWB scores. The second reason for this technique is that it could take account of how strongly each item loaded onto the MPWB factor. It should be noted that by using only two sub-factors, the weight applied to the general factor is identical within the model for each round. This model was also checked to ensure it also was a good fit for different groups based on gender, age, education and employment.

Separate CFA analyses per each country indicate that the final model fit the data adequately in all countries (.971 < CFI < .995; .960 < TFI < .994; .020 < RMSEA < .05; 0,023 < SRMR < 0,042). All items presented substantive loadings on their respective factors, and structures consistently replicated across all tested countries. Largest variations were found when assessing the residual items’ correlations (e.g., for emotional stability and vitality correlation, values ranged from 0,076 to .394). However, for most cases, residuals correlations were of similar size and direction (for both cases, the standard deviation of estimated correlations was close of .10). Thus, strong evidence supporting our final model was systematically found across all analyzed countries. Full results are provided in the supplement (Tables S 2 -S 3 ).

Model invariance

In order to establish meaningful comparisons across groups within and between each country, a two-stage approach was followed, resulting in a structure that was successfully found to be similar across demographics. First, a descriptive comparison of the parameter estimates unveiled no major differences across groups. Second, factor scores were derived for the sample, employing univariate statistics to compare specific groups within country and round. In these analyses, neither traditional nor modern approaches to factor measurement invariance were appropriate given the large sample and number of comparisons at stake ([ 8 ]; further details in Supplement ).

From a descriptive standpoint, the hierarchical structure satisfactorily fit both Round 3 and Round 6 data. All indicators in both rounds had substantial factor loadings (i.e., λ > .35). A descriptive comparison of parameter estimates produced no major differences across the two rounds. The lack of meaningful differences in the parameter estimates confirms that this method for computing MPWB can be used in both rounds.

As MPWB scores from both rounds are obtained from different items that have different scales for responses, it is necessary to transform individual scores obtained from both rounds in order to be aligned. To do this between Round 3 and Round 6 items, a scaling approach was used. To produce common metrics, scores from Round 3 were rescaled using a mean and sigma transformation (Kolen & Brennan 2010) to align with Round 6 scales. This was used as Round 6 measures were deemed to have corrected some deficiencies found in Round 3 items. This does not change outcomes in either round but simply makes the scores match in terms of distributions relative to their scales, making them more suitable for comparison.

As extensive descriptive insights on the sample and general findings are already available (see [ 41 ]), we focus this section on the evidence derived directly from the proposed approach to MPWB scores. For the combined single score for MPWB, the overall mean (for all participants combined) is fixed to zero, and the scores represent deviation from the overall mean. In 2012 (Round 6), country scores on well-being ranged from − 0.41 in Bulgaria to 0.46 in Denmark (Fig.  1 ). There was a significant, positive relationship between national MPWB mean scores and national life satisfaction means ( r =  .56 (.55–.57), p  < .001). In addition, MPWB was negatively related with depression scores and positively associated with other well-being measurements (see Supplement ).

Distribution of national MPWB means and confidence intervals across Europe

Denmark having the highest well-being is consistent with many studies [ 4 , 18 ] and with previous work using ESS data [ 27 ]. While the pattern is typically that Nordic countries are doing the best and that eastern countries have the lowest well-being, exceptions exist. The most notable exception is Portugal, which has the third-lowest score and is not significantly higher than Ukraine, which is second lowest. Switzerland and Germany are second and third highest respectively, and show generally similar patterns to the Scandinavian countries (see Fig. 1 ). It should be noted that, for Figs.  1 , 2 , 3 , 4 , 5 , countries with the lowest well-being are at the top. This is done to highlight the greatest areas for potential impact, which are also the most of concern to policy.

Well-being by country and gender

Well-being by country and age

Well-being by country and employment

Well-being by country and education

General patterns across the key demographic variables – gender, age, education, employment – are visible across countries as seen in Figs.  1 , 2 , 3 , 4 , 5 (see also Supplement 2 ). These figures highlight patterns based on overall well-being as well as potential for inequalities. The visualizations presented here, though univariate, are for the purpose of understanding broad patterns while highlighting the need to disentangle groups and specific dimensions to generate effective policies.

For gender, women exhibited lower MPWB scores than men across Europe (β = −.09, t (36508) = − 10.37; p  < .001). However, these results must be interpreted with caution due to considerable overlap in confidence intervals for many of the countries, and greater exploration of related variables is required. This also applies for the five countries (Estonia, Finland, Ireland, Slovakia, Ukraine) where women have higher means than men. Only four countries have significant differences between genders, all of which involve men having higher scores than women: the Netherlands (β = −.12, t (1759) = − 3.24; p  < .001), Belgium (β = −.14, t (1783) = − 3.94; p  < .001), Cyprus (β = −.18, t (930) = − 2.87; p  < .001) and Portugal (β = −.19, t (1847) = − 2.50; p  < .001).

While older individuals typically exhibited lower MPWB scores compared to younger age groups across Europe (β 25–44  = −.05, t (36506) = − 3.686, p  < .001; β 45–65  = −.12, t (36506) = − 8.356, p  < .001; β 65–74  = −.16, t (36506) = − 8.807, p  < .001; β 75+  = −.28, t (36506) = − 13.568, p  < .001), the more compelling pattern shows more extreme differences within and between age groups for the six countries with the lowest well-being. This pattern is most pronounced in Bulgaria, which has the lowest overall well-being. For the three countries with the highest well-being (Denmark, Switzerland, Germany), even the mean of the oldest age group was well above the European average, while for the countries with the lowest well-being, it was only young people, particularly those under 25, who scored above the European average. With the exception of France and Denmark, countries with higher well-being typically had fewer age group differences and less variance within or between groups. Only countries with the lowest well-being showed age differences that were significant with those 75 and over showing the lowest well-being.

MPWB is consistently higher for employed individuals and students than for retired (β = −.31, t (36506) = − 21.785; p  < .00) or unemployed individuals (β = −.52, t (36556) = − 28.972; p  < .001). Unemployed groups were lowest in nearly all of the 21 countries, though the size of the distance from other groups did not consistently correlate with national MPWB mean. Unemployed individuals in the six countries with the lowest well-being were significantly below the mean, though there is little consistency across groups and countries by employment beyond that. In countries with high well-being, unemployed, and, in some cases, retired individuals, had means below the European average. In countries with the lowest well-being, it was almost exclusively students who scored above the European average. Means for retired groups appear to correlate most strongly with overall well-being. There is minimal variability for employed groups in MPWB means within and between countries.

There is a clear pattern of MPWB scores increasing with education level, though the differences were most pronounced between low and middle education groups (β = .12, t (36508) = 9.538; p  < .001). Individuals with high education were significantly higher on MPWB than those in the middle education group (β = .10, t (36508) =11.06; p  < .001). Differences between groups were noticeably larger for countries with lower overall well-being, and the difference was particularly striking in Bulgaria. In Portugal, medium and high education well-being means were above the European average (though 95% confidence intervals crossed 0), but educational attainment is significantly lower in the country, meaning the low education group represents a greater proportion of the population than the other 21 countries. In the six countries with the highest well-being, mean scores for all levels of education were above the European mean.

Utilizing ten dimensions for superior understanding of well-being

It is common to find rankings of national happiness and well-being in popular literature. Similarly, life satisfaction is routinely the only measure reported in many policy documents related to population well-being. To demonstrate why such limited descriptive approaches can be problematic, and better understood using multiple dimensions, all 21 countries were ranked individually on each of the 10 indicators of well-being and MPWB in Round 6 based on their means. Figure  6 demonstrates the variations in ranking across the 10 dimensions of well-being for each country.

Country rankings in 2012 on multidimensional psychological well-being and each of its 10 dimensions

The general pattern shows typically higher rankings for well-being dimensions in countries with higher overall well-being (and vice-versa). Yet countries can have very similar scores on the composite measure but very different underlying profiles in terms of individual dimensions. Figure  7 a presents this for two countries with similar life satisfaction and composite well-being, Belgium and the United Kingdom. Figure 7 b then demonstrates this even more vividly for two countries, Finland and Norway, which have similar composite well-being scores and identical mean life satisfaction scores (8.1), as well as have the highest two values for happiness of all 21 countries. In both pairings, the broad outcomes are similar, yet countries consistently have very different underlying profiles in individual dimensions. The results indicate that while overall scores can be useful for general assessment, specific dimensions may vary substantially, which is a relevant first step for developing interventions. Whereas the ten items are individual measures of 10 areas of well-being, had these been limited to a single domain only, the richness of the underlying patterns would have been lost, and the limitation of single item approaches amplified.

a Comparison of ranks for dimensions of well-being between two different countries with similar life satisfaction in 2012: Belgium and United Kingdom. b Comparison of ranks for dimensions of well-being between two similar countries with identical life satisfaction and composite well-being scores in 2012: Finland and Norway

The ten-item multidimensional measure provided clear patterns for well-being across 21 countries and various groups within. Whether used individually or combined into a composite score, this approach produces more insight into well-being and its components than a single item measure such as happiness or life satisfaction. Fundamentally, single items are impossible to unpack in reverse to gain insights, whereas the composite score can be used as a macro-indicator for more efficient overviews as well as deconstructed to look for strengths and weaknesses within a population, as depicted in Figs.  6 and 7 . Such deconstruction makes it possible to more appropriately target interventions. This brings measurement of well-being in policy contexts in line with approaches like GDP or national ageing indexes [ 7 ], which are composite indicators of many critical dimensions. The comparison with GDP is discussed at length in the following sections.

Patterns within and between populations

Overall, the patterns and profiles presented indicate a number of general and more nuanced insights. The most consistent among these is that the general trend in national well-being is usually matched within each of the primary indicators assessed, such as lower well-being within unemployed groups in countries with lower overall scores than in those with higher overall scores. While there are certainly exceptions, this general pattern is visible across most indicators.

The other general trend is that groups with lower MPWB scores consistently demonstrate greater variability and wider confidence intervals than groups with higher scores. This is a particularly relevant message for policymakers given that it is an indication of the complexity of inequalities: improvements for those doing well may be more similar in nature than for those doing poorly. This is particularly true for employment versus unemployment, yet reversed for educational attainment. Within each dimension, the most critical pattern is the lack of consistency for how each country ranks, as discussed further in other sections.

Examining individual dimensions of well-being makes it possible to develop a more nuanced understanding of how well-being is impacted by societal indicators, such as inequality or education. For example, it is possible that spending more money on education improves well-being on some dimensions but not others. Such an understanding is crucial for the implementation of targeted policy interventions that aim at weaker dimensions of well-being and may help avoid the development of ineffective policy programs. It is also important to note that the patterns across sociodemographic variables may differ when all groups are combined, compared to results within countries. Some effects may be larger when all are combined, whereas others may have cancelling effects.

Using these insights, one group that may be particularly important to consider is unemployed adults, who consistently have lower well-being than employed individuals. Previous research on unemployment and well-being has often focused on mental health problems among the unemployed [ 46 ] but there are also numerous studies of differences in positive aspects of well-being, mainly life satisfaction and happiness [ 22 ]. A large population-based study has demonstrated that unemployment is more strongly associated with the absence of positive well-being than with the presence of symptoms of psychological distress [ 28 ], suggesting that programs that aim to increase well-being among unemployed people may be more effective than programs that seek to reduce psychological distress.

Certainly, it is well known that higher income is related to higher subjective well-being and better health and life expectancy [ 1 , 42 ], so reduced income following unemployment is likely to lead to increased inequalities. Further work would be particularly insightful if it included links to specific dimensions of well-being, not only the comprehensive scores or overall life satisfaction for unemployed populations. As such, effective responses would involve implementation of interventions known to increase well-being in these groups in times of (or in spite of) low access to work, targeting dimensions most responsible for low overall well-being. Further work on this subject will be presented in forthcoming papers with extended use of these data.

This thinking also applies to older and retired populations in highly deprived regions where access to social services and pensions are limited. A key example of this is the absence in our data of a U-shaped curve for age, which is commonly found in studies using life satisfaction or happiness [ 5 ]. In our results, older individuals are typically lower than what would be expected in a U distribution, and in some cases, the oldest populations have the lowest MPWB scores. While previous studies have shown some decline in well-being beyond the age of 75 [ 20 ], our analysis demonstrates quite a severe fall in MPWB in most countries. What makes this insight useful – as opposed to merely unexpected – is the inclusion of the individual dimensions such as vitality and positive relationships. These dimensions are clearly much more likely to elicit lower scores than for younger age groups. For example, ageing beyond 75 is often associated with increased loneliness and isolation [ 33 , 43 ], and reduction in safe, independent mobility [ 31 ], which may therefore correspond with lower scores on positive relationships, engagement, and vitality, and ultimately lower scores on MPWB than younger populations. Unpacking the dimensions associated with the age-related decline in well-being should be the subject of future research. The moderate positive relationship of MPWB scores with life satisfaction is clear but also not absolute, indicating greater insights through multidimensional approaches without any obvious loss of information. Based on the findings presented here, it is clearly important to consider ensuring the well-being of such groups, the most vulnerable in society, during periods of major social spending limitations.

Policy implications

Critically, Fig.  6 represents the diversity of how countries reach an overall MPWB score. While countries with overall high well-being have typically higher ranks on individual items, there are clearly weak dimensions for individual countries. Conversely, even countries with overall low well-being have positive scores on some dimensions. As such, the lower items can be seen as potential policy levers in terms of targeting areas of concern through evidence-based interventions that should improve them. Similarly, stronger areas can be seen as learning opportunities to understand what may be driving results, and thus used to both sustain those levels as well as potentially to translate for individuals or groups not performing as well in that dimension. Collectively, we can view this insight as a message about specific areas to target for improvement, even in countries doing well, and that even countries doing poorly may offer strengths that can be enhanced or maintained, and could be further studied for potential applications to address deficits. We sound a note of caution however, in that these patterns are based on ranks rather than actual values, and that those ranks are based on single measures.

Figure 7 complements those insights more specifically by showing how Finland and Norway, with a number of social, demographic, and economic similarities, plus identical life satisfaction scores (8.1) arrive at similar single MPWB scores with very different profiles for individual dimensions. By understanding the levers that are specific to each country (i.e. dimensions with the lowest well-being scores), policymakers can respond with appropriate interventions, thereby maximizing the potential for impact on entire populations. Had we restricted well-being measurement to a single question about happiness, as is commonly done, we would have seen both countries had similar and extremely high means for happiness. This might have led to the conclusion that there was minimal need for interventions for improving well-being. Thus, in isolation, using happiness as the single indicator would have masked the considerable variability on several other dimensions, especially those dimensions where one or both had means among the lowest of the 21 countries. This would have resulted in similar policy recommendations, when in fact, Norway may have been best served by, for example, targeting lower dimensions such as Engagement and Self-Esteem, and Finland best served by targeting Vitality and Emotional Stability.

Targeting specific groups and relevant dimensions as opposed to comparing overall national outcomes between countries is perhaps best exemplified by Portugal, which has one of the lowest educational attainment rates in OECD countries, exceeded only by Mexico and Turkey [ 36 ]. This group thus skews the national MPWB score, which is above average for middle and high education groups, but much lower for those with low education. Though this pattern is not atypical for the 21 countries presented here, the size of the low education group proportional to Portugal’s population clearly reduces the national MPWB score. This implies that the greatest potential for improvement is likely to be through addressing the well-being of those with low education as a near-term strategy, and improving access to education as a longer-term strategy. It will be important to analyze this in the near future, given recent reports that educational attainment in Portugal has increased considerably in recent years (though remains one of the lowest in OECD countries) [ 36 ].

One topic that could not be addressed directly is whether these measures offer value as indicators of well-being beyond the 21 countries included here, or even beyond the countries included in ESS generally. In other words, are these measures relevant only to a European population or is our approach to well-being measurement translatable to other regions and purposes? Broadly speaking, the development of these measures being based on DSM and ICD criteria should make them relevant beyond just the 21 countries, as those systems are generally intended to be global. However, it can certainly be argued that these methods for designing measures are heavily influenced by North American and European medical frameworks, which may limit their appropriateness if applied in other regions. Further research on these measures should consider this by adding potential further measures deemed culturally appropriate and seeing if comparable models appear as a result.

A single well-being score

One potential weakness remains the inconsistency of scaling between ESS well-being items used for calculating MPWB. However, this also presents an opportunity to consider the relative weighting of each item within the current scales, and allow for the development of a more consistent and reliable measure. These scales could be modified to align in separate studies with new weights generated – either generically for all populations or stratified to account for various cultural or other influences. Using these insights, scales could alternatively be produced to allow for simple scoring for a more universally accessible structure (e.g. 1–100) but with appropriate values for each item that represents the dimensions, if this results in more effective communication with a general public than a standardized score with weights. Additionally, common scales would improve on attempts to use rankings for presenting national variability within and between dimensions. Researchers should be aware that factor scores are sample-dependent (as based on specific factor model parameters such as factor loadings). Nevertheless, future research focused on investigating specific item differential functioning (by means of multidimensional item response functioning or akin techniques) of these items across situations (i.e., rounds) and samples (i.e., rounds and countries) should be conducted in order to have a more nuanced understanding of this scale functioning.

What makes this discussion highly relevant is the value of a more informed measure to replace traditional indicators of well-being, predominantly life satisfaction. While life satisfaction may have an extensive history and present a useful metric for comparisons between major populations of interest, it is at best a corollary, or natural consequence, of other indicators. It is not in itself useful for informing interventions, in the same way limiting to a single item for any specific dimension of well-being should not alone inform interventions.

By contrast, a validated and standardized multidimensional measure is exceptionally useful in its suitability to identify those at risk, as well as its potential for identifying areas of strengths and weaknesses within the at-risk population. This can considerably improve the efficiency and appropriateness of interventions. It identifies well-understood dimensions (e.g. vitality, positive emotion) for direct application of evidence-based approaches that would improve areas of concern and thus overall well-being. Given these points, we strongly argue for the use of multidimensional approaches to measurement of well-being for setting local and national policy agenda.

There are other existing single-score approaches for well-being addressing its multidimensional nature. These include the Warwick-Edinburgh Mental Well-Being Scale [ 44 ] and the Flourishing Scale [ 11 ]. In these measures, although the single score is derived from items that clearly tap a number of dimensions, the dimensions have not been systematically derived and no attempt is made to measure the underlying dimensions individually. In contrast, the development approach used here – taking established dimensions from DSM and ICD – is based on years of international expertise in the field of mental illness. In other words, there have long been adequate measures for identifying and understanding illness, but there is room for improvement to better identify and understand health. With increasing support for the idea of these being a more central focus of primary outcomes within economic policies, such approaches are exceptionally useful [ 13 ].

Better measures, better insights

Naturally, it is not a compelling argument to simply state that more measures present greater information than fewer or single measures, and this is not the primary argument of this manuscript. In many instances, national measures of well-being are mandated to be restricted to a limited set of items. What is instead being argued is that well-being itself is a multidimensional construct, and if it is deemed a critical insight for establishing policy agenda or evaluating outcomes, measurements must follow suit and not treat happiness and life satisfaction values as universally indicative. The items included in ESS present a very useful step to that end, even in a context where the number of items is limited.

As has been argued by many, greater consistency in measurement of well-being is also needed [ 26 ]. This may come in the form of more consistency regarding dimensions included, the way items are scored, the number of items representing each dimension, and changes in items over time. While inconsistency may be prevalent in the literature to date for definitions and measurement, the significant number of converging findings indicates increasingly robust insights for well-being relevant to scientists and policymakers. Improvements to this end would support more systematic study of (and interventions for) population well-being, even in cases where data collection may be limited to a small number of items.

The added value of MPWB as a composite measure

While there are many published arguments (which we echo) that measures of well-being must go beyond objective features, particularly related to economic indicators such as GDP, this is not to say one replaces the other. More practically, subjective and objective approaches will covary to some degree but remain largely distinct. For example, GDP presents a useful composite of a substantial number of dimensions, such as consumption, imports, exports, specific market outcomes, and incomes. If measurement is restricted to a macro-level indicator such as GDP, we cannot be confident in selecting appropriate policies to implement. Policies are most effective when they target a specific component (of GDP, in this instance), and then are directly evaluated in terms of changes in that component. The composite can then be useful for comprehensive understanding of change over time and variation in circumstances. Specific dimensions are necessary for identifying strengths and weaknesses to guide policy, and examining direct impacts on those dimensions. In this way, a composite measure in the form of MPWB for aggregate well-being is also useful, so long as the individual dimensions are used in the development and evaluation of policies. Similar arguments for other multidimensional constructs have been made recently, such as national indexes of ageing [ 7 ].

In the specific instance of MPWB in relation to existing measures of well-being, there are several critical reasons to ensure a robust approach to measurement through systematic validation of psychometric properties. The first is that these measures are already part of the ESS, meaning they are being used to study a very large sample across a number of social challenges and not specifically a new measure for well-being. The ESS has a significant influence on policy discussions, which means the best approaches to utilizing the data are critical to present systematically, as we have attempted to do here. This approach goes beyond existing measures such as Gallup or the World Happiness Index to broadly cover psychological well-being, not individual features such as happiness or life satisfaction (though we reiterate: as we demonstrate in Fig.  7 a and b, these individual measures can and should still covary broadly with any multidimensional measure of well-being, even if not useful for predicting all dimensions). While often referred to as ‘comprehensive’ measurement, this merely describes a broad range of dimensions, though more items for each dimension – and potentially more dimensions – would certainly be preferable in an ideal scenario.

These dimensions were identified following extensive study for flourishing measures by Huppert & So [ 27 ], meaning they are not simply a mix of dimensions, but established systematically as the key features of well-being (the opposite of ill-being). Furthermore, the development of the items is in line with widely validated and practiced measures for the identification of illness. The primary adjustment has simply been the emphasis on health, but otherwise maintains the same principles of assessment. Therefore, the overall approach offers greater value than assessing only negative features and inferring absence equates to opposite (positives), or that individual measures such as happiness can sufficiently represent a multidimensional construct like well-being. Collectively, we feel the approach presented in this work is therefore a preferable method for assessing well-being, particularly on a population level, and similar approaches should replace single items used in isolation.

While the focus of this paper is on the utilization of a widely tested measure (in terms of geographic spread) that provides for assessing population well-being, it is important to provide a specific application for why this is relevant in a policy context. Additionally, because the ESS itself is a widely-recognized source of meaningful information for policymakers, providing a robust and comprehensive exploration of the data is necessary. As the well-being module was not collected in recent rounds, these insights provide clear reasoning and applications for bringing them back in the near future.

More specifically, it is critical that this approach be seen as advantageous both in using the composite measure for identifying major patterns within and between populations, and for systematically unpacking individual dimensions. Using those dimensions produces nuanced insights as well as the possibility of illuminating policy priorities for intervention.

In line with this, we argue that no composite measure can be useful for developing, implementing, or evaluating policy if individual dimensions are not disaggregated. We are not arguing that MPWB as a single composite score, nor the additional measures used in ESS, is better than other existing single composite scoring measures of well-being. Our primary argument is instead that MPWB is constructed and analyzed specifically for the purpose of having a robust measure suitable for disaggregating critical dimensions of well-being. Without such disaggregation, single composite measures are of limited use. In other words, construct a composite and target the components.

Well-being is perhaps the most critical outcome measure of policies. Each individual dimension of well-being as measured in this study represents a component linked to important areas of life, such as physical health, financial choice, and academic performance [ 26 ]. For such significant datasets as the European Social Survey, the use of the single score based on the ten dimensions included in multidimensional psychological well-being gives the ability to present national patterns and major demographic categories as well as to explore specific dimensions within specific groups. This offers a robust approach for policy purposes, on both macro and micro levels. This facilitates the implementation and evaluation of interventions aimed at directly improving outcomes in terms of population well-being.

Availability of data and materials

The datasets analysed during the current study are available in the European Social Survey repository, http://www.europeansocialsurvey.org/data/country_index.html

Abbreviations

Diagnostic and Statistical Manual of Mental Disorders

European Social Survey

Gross Domestic Product

International Classification of Disease

Multidimensional psychological well-being

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Acknowledgements

The authors would like to thank Ms. Sara Plakolm, Ms. Amel Benzerga, and Ms. Jill Hurson for assistance in proofing the final draft. We would also like to acknowledge the general involvement of the Centre for Comparative Social Surveys at City University, London, and the Centre for Wellbeing at the New Economics Foundation.

This work was supported by a grant from the UK Economic and Social Research Council (ES/LO14629/1). Additional support was also provided by the Isaac Newton Trust, Trinity College, University of Cambridge, and the UK Economic and Social Research Council (ES/P010962/1).

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KR is the lead author and researcher on the study, responsible for all materials start to finish. FH was responsible for the original grant award and the general theory involved in the measurement approaches. ÁM was responsible for broad analysis and writing. EGG was responsible for psychometric models and the original factor scoring approach, plus writing the supplementary explanations. SM provided input on later drafts of the manuscript as well as the auxiliary analyses. The authors read and approved the final manuscript.

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Additional file 1: figure s1.

. Hierarchical approach to modelling comprehensive psychological well-being. Table S1 . Confirmatory Factor Structure for Round 6 and 3. Figure S2 . Well-being by country and gender. Figure S3 . Well-being by country and age. Figure S4 . Well-being by country and employment. Figure S5 . Well-being by country and education. Table S2 . Item loadings for Belgium to Great Britain. Table S3 . Item loadings for Ireland to Ukraine.

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Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18 , 192 (2020). https://doi.org/10.1186/s12955-020-01423-y

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Research that contributes to our ability to improve lives.

Though some research is aimed directly at supporting a particular premise in a normative argument, most research is more loosely related to ethics and normative claims.  It is this sort of research to which ethicists, policy analysts, and others turn to determine which course of action, policy, treatment program, aid initiative, etc. is best.

Some of that research attempts to expand our understanding of issues that are morally complex. For instance, research that details the ways in which tribal norms close off access to certain goods can help us determine the impact of certain types of aid.  Likewise, those attempting to determine which policy is most likely to strengthen a community rather than shatter it or disadvantage it often look to research projects that speak to the policy at issue, its implications, and the likely consequences of requiring folks to live by it.

Along the same lines, some research aims to provide us with tools or products that can be used to improve well-being. For instance, research that leads to the production of a prosthetic hand with increased dexterity aims at giving individuals in need of prosthetic hands the opportunity to pursue a certain life that they may find more enjoyable or fulfilling.  Likewise, a study that leads to the production of software for making more accurate predictions about when and where an earthquake of significant magnitude will occur can help us as we attempt to avoid catastrophes.

Of course, those involved may not have aimed at contributing to our ability to improve lives. And, that’s fine. Whether it implicitly or explicitly does so, it falls into this category of research. The concern for securing funding is whether you can make the connection explicit.  Also, the more direct the connection is between the research project and our ability to improve life the more valuable it is to those who might use it and those who might fund. To secure that tight connection, it is best to talk to an ethicist like our Assistant Director, Adam R. Thompson ([email protected]).  As these individuals are philosophers who specialize in value theory, they are in a good position to see exactly how your research might bear on quality of life issues.

The links below help to fill out your understanding of research that contributes to our ability to improve lives in three ways. The first offers some concrete examples of this sort of research.  The second lists examples of places that you might find funding opportunities for such research. And, the third delineates some approaches to help you make the link between your interests and ethics.

Example of Research Example of Funding Ops Checklist

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Healthy ageing, social psychiatry of older adults and family caregivers

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The global population is rapidly ageing, leading to increased focus on promoting healthy ageing and addressing the mental health needs of older adults. Social psychiatry plays a crucial role in understanding the social determinants of mental health and developing interventions that enhance the psychological well-being of older adults. Additionally, family caregivers play a vital role in supporting older adults' overall health and functioning, often facing unique challenges and needs themselves. Therefore, we invite researchers and scholars to submit their original research papers for an upcoming Research Topic. This Research Topic aims to explore the intersection of healthy ageing, social psychiatry, and the experiences of family caregivers in supporting the well-being of older adults. This Research Topic is of great significance due to its implications for healthcare, quality of life, family dynamics, and policy development in an ageing global population. By addressing these interconnected issues, we strive to improve the mental health outcomes and overall well-being of older adults and those who care for them. We welcome the submissions related to the following topics including but not restricted to: • Mental health promotion and prevention strategies for older adults. • Social determinants of mental health in older adults. • Psychosocial interventions and therapies for mental health issues in older adults. • Impact of social isolation and loneliness on mental health and well-being in older adults. • Caregiver burden and mental health outcomes for family caregivers. • Supportive interventions and strategies for family caregivers. • Role of technology and digital solutions in promoting mental health and well-being in older adults and family caregivers. • Policy and practice implications for addressing the mental health needs of older adults and family caregivers. We welcome original research articles, systematic reviews, meta-analyses, theoretical papers, and practice-based papers that contribute to the understanding of healthy ageing, social psychiatry, and the experiences of family caregivers.

Keywords : Healthy Ageing, Social Psychiatry, Elderly Mental Health, Family Caregivers, Quality of Life, Ageing Population, Psychosocial Factors, Caregiver Burden, Intergenerational Relationships

Important Note : All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.

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How does research impact your everyday life?

“Research is to see what everybody else has seen, and to think what nobody else has thought.” – Albert Szent-Gyorgyi

What would the modern world look like without the bedrock of research?

First and foremost – without research, there’s no way you’d possibly be reading this right now, as the Internet was pioneered and developed (via a whole heap of exhaustive research…) by the European Organization for Nuclear Research , or CERN, the same association that produced the Large Hadron Collider.

Without research, we’d likely also be utterly defenceless to the brutal forces of nature. For example, without meteorology, we’d be unable to predict the path of violent storms, hurricanes and tornadoes, while a lack of volcanology research would leave a huge proportion of the world susceptible to the destruction of volcanic eruptions.

And it doesn’t end there.

Medical technology and discovery would be non-existent – no MRi , no anaesthetic, no birth control, no X-Ray machine, no insulin, no IVF, no penicillin, no germ theory, no DNA, and no smallpox vaccination – which, by the way would have wiped out one out of every nine babies had Jenner not researched and found a cure.

Source: University of Surrey

So not only is research an invaluable tool for building on crucial knowledge, it’s also the most reliable way we can begin to understand the complexities of various issues; to maintain our integrity as we disprove lies and uphold important truths; to serve as the seed for analysing convoluted sets of data; as well as to serve as ‘nourishment’, or exercise for the mind.

“…Aside from the pure pursuit of knowledge for its own sake, research is linked to problem solving,” John Armstrong, a respected global higher education and research professional, writes for The Conversation. “What this means is the solving of other people’s problems. That is, what other people experience as problems.

“It starts with a tenderness and ambition that is directed at the needs of others – as they recognise and acknowledge those needs,” he continues. “This is, in effect, entry into a market place. Much research, of course, is conducted in precisely this way beyond the walls of the academy.”

Ultimately, when we begin to look at research for what it truly is – a catalyst for solving complex issues – we begin to understand the impact it truly has on our everyday lives. The University of Surrey , set just a 10 minute walk from the centre of Guildford – ranked the 8 th best place to live in the UK in the Halifax Quality of Life Survey – is a prime example of a university producing high-impact research for the benefit of our global society.

Surrey’s experienced research team found that pollution levels inside cars were found to be up to 40 percent higher while sitting in queues, or at red lights, when compared to free-flowing traffic conditions. And with the World Health Organisation (WHO) placing outdoor air pollution among the top 10 health risks currently facing humans, linking to seven million premature deaths each year, Surrey took on the research challenge of finding an effective solution…

…And boy, did they get the results!

“Where possible and the weather conditional allowing, it is one of the best ways to limit your exposure by keeping windows shut, fans turned off and to try and increase the distance between you and the car in front while at traffic jams or stationary at traffic lights,” says Dr Prashant Kumar, Senior Author of the study. “If the fan or heater needs to be on, the best setting would be to have the air re-circulating within the car without drawing air from outdoors.”

Researchers actually found that closed windows or re-circulated air can reduce in-car pollutants by as much as 76 percent, highlighting how Surrey’s research outcomes could bring a wealth of invaluable global benefits.

As further testament to Surrey’s impactful research success, a study that uncovered high levels of Vitamin D inadequacy among UK adolescents has been published in the American Journal of Clinical Nutrition , and has now been used to inform crucial national guidance from Public Health England.

“The research has found that adolescence, the time when bone growth is most important in laying down the foundations for later life, is a time when Vitamin D levels are inadequate,” says Dr Taryn Smith, Lead Author of the study. The study forms part of a four-year, EU-funded project, ODIN, which aims to investigate safe and effective ways of boosting Vitamin D intake through food fortification and bio-fortification.

“The ODIN project is investigating ways of improving Vitamin D intake through diet,” continues Dr Smith, “and since it is difficult to obtain Vitamin D intakes of over 10ug/day from food sources alone, it is looking at ways of fortifying our food to improve the Vitamin D levels of the UK population as a whole.”

But the impact of Surrey’s research is broad and all-encompassing, with on-going projects into things like radiotherapy, dementia, blue light and human attentiveness, disaster monitoring, sustainable development, digital storytelling, and beyond. And benefits of research produced at the University of Surrey is not meant for the UK population alone; these are the issues that face us as an increasingly international and interconnected society, making research produced by world-class institutions like Surrey the tools to pave the way to bigger, brighter and healthier global future.

Find out more about studying for a postgraduate degree at Surrey by registering for one of Surrey’s Webinars .

Follow Surrey on Facebook , Twitter , Instagram , YouTube , Pinterest and LinkedIn

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Dietary and lifestyle approaches to improving quality of life in multiple sclerosis, wahls lab, internal medicine.

Project Details The Wahls Research lab is interested in the relationship between diet quality and clinical outcomes. Motor function is assessed using timed walk and hand function tests. Vision function, quality of life and blood biomarkers are also assessed. The study Efficacy of Diet on Quality of Life in Multiple Sclerosis is a five year study, completing in 2027. 

Position Details Perform research activities based upon protocols and workflow practice guidelines developed by senior research staff or principal investigator of the research project; Recruit and/or interview subjects; Data entry and verification via REDCap (data entry platform); Scan, copy, fax, and file study materials, correspondence, and documents (paper and electronic); Laboratory kit set-up and transportation of specimens. Review of patient survey completion, Collect, record and consolidate data as directed by the Principal Investigator or Study Manager.

As individual skills develop: Perform participant assessments at study visits; troubleshoot, analyze and propose modifications to protocols; develop and implement procedures for monitoring data integrity; report present results at team meetings.

We hire research interns to support the lab.  High performing students will be encouraged to apply for research internships within the Wahls lab upon graduation. 

Qualifications Ability to utilize existing resources and learning to achieve or exceed desired outcomes of current and future organizational goals/needs. Able to demonstrate ethical behavior in diverse situations while producing results. Adhere to Quality Assurance protocols to maintain validity and integrity of research data. Ability to meet or exceed customer service needs and expectations and provide excellent service in a direct or indirect manner. Ability to effectively transmit and interpret information through appropriate communication with internal and external customers.

Students with an interest in nutrition assessment are needed. Students with an interest in neurology, vision, or multiple sclerosis are also needed. Any previous research experience is helpful. Basic Knowledge of Microsoft Office tools including Word, Outlook, and Excel are required.

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Compensation Volunteer (Optional 0-credit hour course for transcript recognition) Academic Credit (1-4 semester hours) Pay is available in addition to volunteer hours

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The Role of Infrastructure in Economic Development

13 Pages Posted: 26 Aug 2024

Constantinos Challoumis - Κωνσταντίνος Χαλλουμής

National and Kapodistrian University of Athens

Date Written: August 04, 2024

Infrastructure plays a pivotal role in shaping economic development by enhancing productivity, stimulating growth, and improving the overall quality of life. This paper delves into the critical contributions of infrastructure to economic development, highlighting how robust transportation networks, reliable energy systems, and advanced communication technologies serve as the backbone for economic activities. Infrastructure investments reduce operational costs, streamline logistics, and facilitate smoother interactions and transactions, thus significantly boosting productivity. Furthermore, the presence of quality infrastructure attracts both domestic and international investments, fostering a conducive environment for economic expansion. The impact of infrastructure on economic growth is profound and multifaceted. Improved infrastructure enables businesses to access broader markets and operate more efficiently, leading to increased competitiveness and innovation. The development of infrastructure also creates employment opportunities, not only during the construction phase but also through the enhanced economic activities it supports. By providing the necessary facilities for industries to thrive, infrastructure investment acts as a catalyst for sustained economic growth, driving a cycle of prosperity and development. Beyond productivity and growth, infrastructure profoundly affects the quality of life. Efficient transportation systems reduce travel time and costs, improving accessibility to jobs, education, and healthcare. Reliable energy and water supply systems ensure that basic needs are consistently met, enhancing living standards and fostering human capital development. Advanced communication infrastructure connects communities, promoting social inclusion and cohesion. Through an analysis of case studies and empirical data, this paper demonstrates the transformative potential of infrastructure investment and offers insights into strategic planning and policy formulation to maximize its benefits for sustainable economic development.

Keywords: infrastructure, economic development, productivity, growth, quality of life, transportation networks, energy systems, communication technologies, investments, competitiveness, innovation, employment opportunities

Suggested Citation: Suggested Citation

Constantinos Challoumis (Contact Author)

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• Treating iron deficiency in patients with heart failure: what, why, when, how, where and who
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• http://orcid.org/0000-0001-7539-9958 Fraser J Graham 1 ,
• Kaushik Guha 2 ,
• http://orcid.org/0000-0002-1471-7016 John G Cleland 1 ,
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• 1 British Heart Foundation Centre of Research Excellence, School of Cardiovascular & Metabolic Health , University of Glasgow , Glasgow , UK
• 2 Portsmouth Hospitals University NHS Trust , Portsmouth , UK
• 3 Cardiology , Portsmouth Hospitals University NHS Trust , Portsmouth , UK
• 4 University of Glasgow Institute of Health & Wellbeing , Glasgow , UK
• Correspondence to Dr Fraser J Graham, University of Glasgow, Glasgow, UK; fraser.graham{at}glasgow.ac.uk

For patients with heart failure and reduced or mildly reduced left ventricular ejection fraction, iron deficiency is common and associated with more severe symptoms, worse quality of life and an increased risk of hospitalisations and death. Iron deficiency can be swiftly, effectively and safely treated by administering intravenous iron, either as ferric carboxymaltose or ferric derisomaltose, which improves patient well-being and reduces the risk of hospitalisations including those for heart failure. However, the current definition of iron deficiency in heart failure has serious flaws. A serum ferritin <100 µg/L does not identify patients more likely to respond to intravenous iron. In contrast, patients with transferrin saturations <20%, most of whom are also anaemic, are more likely to have a beneficial response to intravenous iron. In this review, we summarise the available evidence for use of intravenous iron in heart failure and provide recommendations for targeted future research and practical considerations for the general cardiologist.

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Correction notice This article has been corrected since it was first published. Haemoglobin is now expressed in g/L in all instances.

Contributors Manuscript concept and design: PRK, FJG, KG. Manuscript writing: FJG, KG, PRK, JGC. Critical revision of manuscript for intellectual content: JGC, PRK. All authors approved the final version and are accountable for the integrity of the work.

Funding JGC is supported by the British Heart Foundation Centre of Research Excellence (RE/18/6134217). FJG and JGC have been awarded a project grant from the British Heart Foundation to assess the prevalence of iron deficiency in patients undergoing elective cardiac surgery (PG/2019/35089). PRK reports research grants from the British Heart Foundation and Pharmacosmos.

Competing interests FJG reports receipt of sponsorship from Pharmacosmos to attend an international meeting and consultancy fees from Vifor. KG has received honoraria from Novartis, AstraZeneca, Pfizer, Bayer, Boehringer Ingelheim and Servier Laboratories. JGC reports receipt of personal honoraria for lectures and advisory boards from Pharmacosmos and Vifor, and from AstraZeneca, Amgen, Bayer, Novartis and Servier. The University of Glasgow has received research grants from Pharmacosmos and Vifor. PRK reports consulting fees from Amgen, Bayer, Boehringer Ingelheim, Pharmacosmos and CSL Vifor; payment for lectures from AstraZeneca, Bayer, Novartis, Pfizer, Pharmacosmos and CSL Vifor; and support for attending meetings from Pharmacosmos.

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The Mental Health Benefits of Exercise

You already know that exercise is good for your body. But did you know it can also boost your mood, improve your sleep, and help you deal with depression, anxiety, stress, and more?

Exercise is not just about aerobic capacity and muscle size. Sure, exercise can improve your physical health and your physique, trim your waistline, improve your sex life, and even add years to your life. But that’s not what motivates most people to stay active.

People who exercise regularly tend to do so because it gives them an enormous sense of well-being. They feel more energetic throughout the day, sleep better at night, have sharper memories, and feel more relaxed and positive about themselves and their lives. And it’s also a powerful medicine for many common mental health challenges.

Regular exercise can have a profoundly positive impact on depression, anxiety, and ADHD. It also relieves stress, improves memory, helps you sleep better, and boosts your overall mood. And you don’t have to be a fitness fanatic to reap the benefits. Research indicates that modest amounts of exercise can make a real difference. No matter your age or fitness level, you can learn to use exercise as a powerful tool to deal with mental health problems, improve your energy and outlook, and get more out of life.

Exercise and depression

Studies show that exercise can treat mild to moderate depression as effectively as antidepressant medication—but without the side-effects, of course. As one example, a recent study done by the Harvard T.H. Chan School of Public Health found that running for 15 minutes a day or walking for an hour reduces the risk of major depression by 26%. In addition to relieving depression symptoms , research also shows that maintaining an exercise schedule can prevent you from relapsing.

Exercise is a powerful depression fighter for several reasons. Most importantly, it promotes all kinds of changes in the brain, including neural growth, reduced inflammation, and new activity patterns that promote feelings of calm and well-being. It also releases endorphins, powerful chemicals in your brain that energize your spirits and make you feel good. Finally, exercise can also serve as a distraction, allowing you to find some quiet time to break out of the cycle of negative thoughts that feed depression.

Exercise and anxiety

Exercise is a natural and effective anti-anxiety treatment . It relieves tension and stress, boosts physical and mental energy, and enhances well-being through the release of endorphins. Anything that gets you moving can help, but you’ll get a bigger benefit if you pay attention instead of zoning out.

Try to notice the sensation of your feet hitting the ground, for example, or the rhythm of your breathing, or the feeling of the wind on your skin. By adding this mindfulness element—really focusing on your body and how it feels as you exercise—you’ll not only improve your physical condition faster, but you may also be able to interrupt the flow of constant worries running through your head.

Exercise and stress

Ever noticed how your body feels when you’re under stress ? Your muscles may be tense, especially in your face, neck, and shoulders, leaving you with back or neck pain, or painful headaches. You may feel a tightness in your chest, a pounding pulse, or muscle cramps. You may also experience problems such as insomnia, heartburn, stomachache, diarrhea, or frequent urination. The worry and discomfort of all these physical symptoms can in turn lead to even more stress, creating a vicious cycle between your mind and body.

Exercising is an effective way to break this cycle. As well as releasing endorphins in the brain, physical activity helps to relax the muscles and relieve tension in the body. Since the body and mind are so closely linked, when your body feels better so, too, will your mind.

Exercise and ADHD

Exercising regularly is one of the easiest and most effective ways to reduce the symptoms of ADHD and improve concentration, motivation, memory, and mood. Physical activity immediately boosts the brain’s dopamine, norepinephrine, and serotonin levels—all of which affect focus and attention. In this way, exercise works in much the same way as ADHD medications such as Ritalin and Adderall.

Exercise and PTSD and trauma

Evidence suggests that by really focusing on your body and how it feels as you exercise, you can actually help your nervous system become “unstuck” and begin to move out of the immobilization stress response that characterizes PTSD or trauma. Instead of allowing your mind to wander, pay close attention to the physical sensations in your joints and muscles, even your insides as your body moves. Exercises that involve cross movement and that engage both arms and legs—such as walking (especially in sand), running, swimming, weight training, or dancing—are some of your best choices.

Outdoor activities like hiking, sailing, mountain biking, rock climbing, whitewater rafting, and skiing (downhill and cross-country) have also been shown to reduce the symptoms of PTSD.

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Even if you’re not suffering from a mental health problem, regular physical activity can still offer a welcome boost to your mood, outlook, and mental well-being.

Exercise can help provide:

Sharper memory and thinking. The same endorphins that make you feel better also help you concentrate and feel mentally sharp for tasks at hand. Exercise also stimulates the growth of new brain cells and helps prevent age-related decline .

Higher self-esteem. Regular activity is an investment in your mind, body, and soul. When it becomes habit, it can foster your sense of self-worth and make you feel strong and powerful. You’ll feel better about your appearance and, by meeting even small exercise goals, you’ll feel a sense of achievement.

Better sleep. Even short bursts of exercise in the morning or afternoon can help regulate your sleep patterns . If you prefer to exercise at night, relaxing exercises such as yoga or gentle stretching can help promote sleep.

More energy. Increasing your heart rate several times a week will give you more get-up-and-go. Start off with just a few minutes of exercise per day, and increase your workout as you feel more energized.

Stronger resilience. When faced with mental or emotional challenges in life, exercise can help you build resilience and cope in a healthy way, instead of resorting to alcohol, drugs, or other negative behaviors that ultimately only make your symptoms worse. Regular exercise can also help boost your immune system and reduce the impact of stress.

You don’t need to devote hours out of your busy day to train at the gym, sweat buckets, or run mile after monotonous mile to reap all the physical and mental health benefits of exercise. Just 30-minutes of moderate exercise five times a week is enough. And even that can be broken down into two 15-minute or even three 10-minute exercise sessions if that’s easier.

Even a little bit of activity is better than nothing

If you don’t have time for 15 or 30 minutes of exercise, or if your body tells you to take a break after 5 or 10 minutes, for example, that’s okay, too. Start with 5- or 10-minute sessions and slowly increase your time. The more you exercise, the more energy you’ll have, so eventually you’ll feel ready for a little more. The key is to commit to some moderate physical activity—however little—on most days. As exercising becomes a habit, you can slowly add extra minutes or try different types of activities. If you keep at it, the benefits of exercise will begin to pay off.

You don’t have to suffer to get results

Research shows that moderate levels of exercise are best for most people . Moderate means:

• That you breathe a little heavier than normal, but are not out of breath. For example, you should be able to chat with your walking partner, but not easily sing a song.
• That your body feels warmer as you move, but not overheated or very sweaty.

Can’t find time to exercise during the week? Be a weekend warrior

A recent study in the United Kingdom found that people who squeeze their exercise routines into one or two sessions during the weekend experience almost as many health benefits as those who work out more often. So don’t let a busy schedule at work, home, or school be an excuse to avoid activity. Get moving whenever you can find the time—your mind and body will thank you!

Even when you know that exercise will help you feel better, taking that first step is still easier said than done. Obstacles to exercising are very real—particularly when you’re also struggling with a mental health issue.

Here are some common barriers and how you can get past them.

Feeling exhausted. When you’re tired, depressed, or stressed, it seems that working out will just make you feel worse. But the truth is that physical activity is a powerful energizer. Studies show that regular exercise can dramatically reduce fatigue and increase your energy levels. If you are really feeling tired, promise yourself a quick, 5-minute walk. Chances are, once you get moving you’ll have more energy and be able to walk for longer.

Feeling overwhelmed. When you’re stressed or depressed, the thought of adding another obligation to your busy daily schedule can seem overwhelming. Working out just doesn’t seem practical. If you have children, finding childcare while you exercise can also be a big hurdle. However, if you begin thinking of physical activity as a priority (a necessity for your mental well-being), you’ll soon find ways to fit small amounts of exercise into even the busiest schedule.

Feeling hopeless. Even if you’ve never exercised before, you can still find ways to comfortably get active. Start slow with easy, low-impact activities a few minutes each day, such as walking or dancing.

Feeling bad about yourself. Are you your own worst critic? It’s time to try a new way of thinking about your body. No matter your weight, age or fitness level, there are plenty of others in the same boat. Ask a friend to exercise with you. Accomplishing even the smallest fitness goals will help you gain body confidence and improve how you think about yourself.

Feeling pain. If you have a disability, severe weight problem, arthritis, or any injury or illness that limits your mobility, talk to your doctor about ways to safely exercise . You shouldn’t ignore pain, but rather do what you can, when you can. Divide your exercise into shorter, more frequent chunks of time if that helps, or try exercising in water to reduce joint or muscle discomfort.

Many of us find it hard enough to motivate ourselves to exercise at the best of times. But when you feel depressed, anxious, stressed or have another mental health problem, it can seem doubly difficult. This is especially true of depression and anxiety, which can leave you feeling trapped in a catch-22 situation. You know exercise will make you feel better, but depression has robbed you of the energy and motivation you need to work out, or your social anxiety means you can’t bear the thought of being seen at an exercise class or running through the park.

Start small. When you’re under the cloud of anxiety or depression and haven’t exercised for a long time, setting extravagant goals like completing a marathon or working out for an hour every morning will only leave you more despondent if you fall short. Better to set achievable goals and build up from there.

Schedule workouts when your energy is highest. Perhaps you have most energy first thing in the morning before work or school or at lunchtime before the mid-afternoon lull hits? Or maybe you do better exercising for longer at the weekends. If depression or anxiety has you feeling tired and unmotivated all day long, try dancing to some music or simply going for a walk. Even a short, 15-minute walk can help clear your mind, improve your mood, and boost your energy level. As you move and start to feel a little better, you’ll often boost your energy enough to exercise more vigorously—by walking further, breaking into a run, or adding a bike ride, for example.

Focus on activities you enjoy. Any activity that gets you moving counts. That could include throwing a Frisbee with a dog or friend, walking laps of a mall window shopping, or cycling to the grocery store. If you’ve never exercised before or don’t know what you might enjoy, try a few different things. Activities such as gardening or tackling a home improvement project can be great ways to start moving more when you have a mood disorder—as well as helping you become more active, they can also leave you with a sense of purpose and accomplishment.

Be comfortable. Wear clothing that’s comfortable and choose a setting that you find calming or energizing. That may be a quiet corner of your home, a scenic path, or your favorite city park.

Reward yourself. Part of the reward of completing an activity is how much better you’ll feel afterwards, but it always helps your motivation to promise yourself an extra treat for exercising. Reward yourself with a hot bubble bath after a workout, a delicious smoothie, or with an extra episode of your favorite TV show, for example.

Make exercise a social activity. Exercising with a friend or loved one, or even your kids, will not only make exercising more fun and enjoyable, it can also help motivate you to stick to a workout routine. You’ll also feel better than if you were exercising alone. In fact, when you’re suffering from a mood disorder such as depression, the companionship can be just as important as the exercise.

Easy ways to move more that don’t involve the gym

Don’t have a 30-minute block of time to dedicate to yoga or a bike ride? Don’t worry. Think about physical activity as a lifestyle rather than just a single task to check off your to-do list. Look at your daily routine and consider ways to sneak in activity here, there, and everywhere.

Move in and around your home. Clean the house, wash the car, tend to the yard and garden, mow the lawn with a push mower, sweep the sidewalk or patio with a broom.

Sneak activity in at work or on the go. Bike or walk to an appointment rather than drive, use stairs instead of elevators, briskly walk to the bus stop then get off one stop early, park at the back of the lot and walk into the store or office, or take a vigorous walk during your coffee break.

Get active with the family. Jog around the soccer field during your kid’s practice, make a neighborhood bike ride part of your weekend routine, play tag with your children in the yard, go canoeing at a lake, walk the dog in a new place.

Get creative with exercise ideas. Pick fruit at an orchard, boogie to music, go to the beach or take a hike, gently stretch while watching television, organize an office bowling team, take a class in martial arts, dance, or yoga.

Make exercise a fun part of your everyday life

You don’t have to spend hours in a gym or force yourself into long, monotonous workouts to experience the many benefits of exercise. These tips can help you find activities you enjoy and start to feel better, look better, and get more out of life.

More Information

• Greer, T. L., Trombello, J. M., Rethorst, C. D., Carmody, T. J., Jha, M. K., Liao, A., Grannemann, B. D., Chambliss, H. O., Church, T. S., & Trivedi, M. H. (2016). Improvements in psychosocial functioning and health-related quality of life following exercise augmentation in patients with treatment response but non-remitted major depressive disorder: Results from the TREAD study. Depression and Anxiety, 33(9), 870–881. Link
• Kandola, A., Vancampfort, D., Herring, M., Rebar, A., Hallgren, M., Firth, J., & Stubbs, B. (2018). Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety. Current Psychiatry Reports, 20(8), 63. Link
• Aylett, E., Small, N., & Bower, P. (2018). Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Services Research, 18(1), 559. Link
• Stubbs, B., Vancampfort, D., Rosenbaum, S., Firth, J., Cosco, T., Veronese, N., Salum, G. A., & Schuch, F. B. (2017). An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Research, 249, 102–108. Link
• Kandola, A. A., Osborn, D. P. J., Stubbs, B., Choi, K. W., & Hayes, J. F. (2020). Individual and combined associations between cardiorespiratory fitness and grip strength with common mental disorders: A prospective cohort study in the UK Biobank. BMC Medicine, 18(1), 303. Link

More in Exercise & Fitness

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Want to Improve Your Chances of Success in Life? Learn to Write This Way, Wharton Research Says

Improving how you write improves how you think, and that leads to greater success in life..

Jeff Bezos famously banned PowerPoints at his meetings and forced executives to write out six-page memos instead. Why? 

"When you have to write in complete sentences with narrative structure, it's really hard to hide sloppy thinking," the Amazon founder once explained . 

He's not the only super-smart business thinker who insists writing hones your thinking . 

"Everyone is full of ideas they're not aware of. They're gut feelings. Intuitions," VC and author Morgan Housel has argued . "Turning gut feelings into tools means understanding their origin, limits, and how they interact with other ideas. Which requires turning them into words. And writing is the best way to do that."

Writing, in other words, is a reflection of your thinking. And you can use your writing to refine your ideas. But can you also use your writing to predict whether you have the kind of mind that will help you succeed in life? 

A fascinating new study out of Wharton and Columbia Business School says yes, and suggests ways every business owner can improve their odds of success by improving their writing . 

'Language is a fingerprint.'

"Language in some sense is a fingerprint. It reveals or reflects something about the people that produce it," Wharton professor and author Jonah Berger said in a recent episode of the Knowledge at Wharton podcast , echoing Bezos and Housel.  

Sometimes it's vocabulary that's revealing. Previous research shows you can guess how extroverted someone is from their word choices , for example.

But sometimes it's the structure of your writing that gives you away. Together with his colleague Olivier Tubia of Columbia Business School, Berger sought to investigate what the organization of a piece of writing -- how one idea connects with the next -- says about how people think, and what that reveals about their chances of success in life. 

They used a clever approach to try and figure this out. First, they analyzed 40,000 college application essays across two measures of writing style . How much intellectual ground did writers cover? Did they talk about a lot of ideas and information or make just a few points? And how did they link those ideas? Did their essays jump all over the place or did they move crisply through a tidy, logical argument? 

Then they looked at their applicants' subsequent GPAs. Did a certain writing style suggest that a particular young person was likely to do better in college? 

College essays were a convenient data set that offered a straightforward way to link writing style to a defined measure of "success" in the form of academic grades. But Berger insists that his team's conclusions apply to basically any kind of writing. 

"Whether it's a cover letter that someone writes, whether it's an online review that someone puts together, whether it's the emails they write at the office, all these things provide insight into who people are and what they're likely to do in the future," he claims. 

The kind of writing that's a sign of future success

So what did the researchers find? There was indeed a style of writing that seemed to strongly predict future success . In brief, the students who did best later on covered a lot of ground in their essays (they had lots of ideas), but they did so in the most efficient way possible (they moved steadily from point to point without a lot of darting around). 

"Covering a broad array of things in the same amount of length was linked to greater success. But importantly, doing so while moving rather slowly was also important," Berger sums up. 

He offers a handy metaphor to illustrate: Think of ideas arrayed around a clock face from 1 to 12. All the essays were roughly the same length, but the applicants who went on to the greatest success covered the most time within the same word count. And they did it methodically by moving steadily around the clock rather than jumping from 1 to 7 to 3 to 11, for example. 

Wait, you might object, maybe this just indicates that students who are taught to write a certain way -- perhaps at fancy private schools or by expensive tutors -- also end up doing better. But no, the researchers controlled for factors like family income and parents' education. No matter their background, efficient, idea-stuffed writing was a sign that students were going to excel academically. 

A practical takeaway for non-students 

All of which is fascinating if you are an admissions officer or a college-bound senior. But what does this matter for folks who are well past the college admissions essay stage of life? Berger claims that by practicing writing in this way, you can actually increase your odds of success. 

"As we gain more knowledge in a given domain, we may talk differently. We may think about ideas differently," he says. "If people are able to cover a lot of ground really efficiently by moving slowly between points, not moving quickly between points, how did they get there? Are they naturally that way? Probably not. Probably they may have gained more knowledge along the way that allows them to represent their ideas differently." 

In short, by practicing writing in this particular style -- idea-rich but efficient -- you can hone not just your prose, but also your thinking. And that will make you more likely to succeed in your chosen endeavors. 

In light of this research, Bezos and Housel look pretty wise to insist that writing more makes you smarter. Remember that the next time you're tempted to push off a piece of writing to ChatGPT or to smash your keyboard and give up. Writing well can be frustrating and difficult. It's also the best mental workout to train your mind for success. 

A refreshed look at leadership from the desk of CEO and chief content officer Stephanie Mehta

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Quality of Life of Older Persons: The Role and Challenges of Social Services Providers

Mihaela ghenţa.

1 National Scientific Research Institute for Labour and Social Protection (INCSMPS), 010643 Bucharest, Romania; [email protected] (A.M.); moc.liamtoh@nedalmesiul (L.M.-M.)

Aniela Matei

Luise mladen-macovei, simona stănescu.

2 Research Institute for Quality of Life (ICCV), 050711 Bucharest, Romania; moc.oohay@acinov_anomis

Associated Data

Not applicable.

Considering the growing number of older persons, ensuring the quality of life of them, as well as the social services designed for this population category, has become more and more important. Especially in the case of dependent older persons, social services are essential components, as they contribute to a better quality of life. The aim of this paper was to examine the perspectives of social services providers for older persons with respect to their role and the challenges encountered in ensuring the quality of life of older beneficiaries. In order to answer our objectives, we employed a qualitative methodology, using the focus group method to collect information from social services providers (both residential and home care). Multiple factors are related to a good quality of life in old age: some are related to individual characteristics, while others are related to the provision of services. The provision of quality social services that adequately respond to the needs of beneficiaries contributes to increasing the degree of independence and maintaining the physical and mental health of dependent older persons.

1. Introduction

The share of the population aged 65 and over has continuously increased in recent years in Romania, from 17% in 2015 to 19.3% in 2021, and that of people aged 80 and over has increased in the same period from 4.1% to 4.8% [ 1 ]. Romania is expected to have 4.1 million people 65 years or older by 2035 and 4.5 million by 2050, accounting for 23.3% and 27.7% of the total population, respectively [ 2 ].

In 2019, life expectancy in Romania at age 65 for men was 14.9 years (compared to 18.3 years in the European Union) and 18.6 years for women (compared to 21.8 years in the European Union). However, in 2019, healthy life expectancy at age 65 was lower for both sexes: 6.7 years for men (10.2 years in the European Union) and 6.5 years for women (10.4 years in the European Union), resulting in a greater need for adequate social services to meet higher care needs [ 1 ]. At the European level, almost 50% of people 65 years or older reported long-term restrictions in daily activities, whereas more than two-thirds reported physical or sensory functional limitations [ 3 ]. Nevertheless, Romania allocates only 0.31% of its GDP to long-term care, compared to the 1.6% EU average [ 1 ]. Providing long-term, good quality care services that are integrated, people-centered, and properly managed is the right step for ensuring healthy lives and well-being in old age [ 4 ]. The difficulties older persons experience have been exacerbated due to the COVID-19 pandemic. Older persons have been recognized as the most vulnerable category of the population, and the need for policy measures directly targeted to them has thus became more necessary in this period [ 5 ].

Considering the current situation, the aim of this article is to examine the perspective of social services providers with regard to their role and the challenges encountered in ensuring the quality of life of older beneficiaries. The objectives of the research were: (1) to explore the opinions of social services providers with regard to their contribution to the quality of life of beneficiaries; (2) to highlight the views of social services providers in terms of their contribution to quality of care (autonomy and independence of older persons, freedom of decision, control, sense of security and respect for privacy, communication, and social interactions); and (3) to identify the difficulties experienced in the services delivery process.

1.1. Social Services for Older People Living in Romania

In Romania, social services addressed to older people are provided by both public and private social services providers (associations, foundations, cults recognized by law), and are offered on a residential or non-residential basis. The first category of services includes care and assistance centers for older people, such as nursing homes, respite/crisis centers, and sheltered housing, as well as residential care and medical-social assistance centers. The second category of services includes home care units and day centers for older persons, such as day and recovery centers and day centers for socializing and leisure.

Within the current social protection system, older people have the right to social assistance in relation to their social and medical status and the economic resources (income, assets, etc.) they possess. The legal framework stipulates that decisions regarding admitting an older person to a residential center are made considering the following priority criteria: if the person requires special permanent medical care, which cannot be provided at home; if the person cannot manage on his/her own, is without legal supporters, or is unable to fulfill their obligations due to their health or economic situation and family responsibilities; if the person has no home and no income of his/her own. However, home care and keeping older people in their living environments are much more suitable for those in difficulty, with these measures having a multitude of benefits [ 6 ].

The field of social services is still poorly developed at the national level, with the number of accredited providers and licensed services being quite small compared to existing needs. The geographical coverage of these services is not balanced, with a higher concentration of providers in urban areas and in more developed counties [ 5 , 7 ]. The main source of funding for social services is the local budget, so the number and quality of social services for the elderly are highly dependent on the financial capacity of the administrative-territorial units [ 8 ]. The financing of social services is also derived from the contribution of the beneficiary and/or their family, from the state budget, as well as from other sources. The local public administration authorities finance the public social services under their authority. The rest of the social services are financed by contracts awarded through public procurement or by grants or subsidies. The standard cost of personal home care services varied in 2020 between 3225 EUR (15,600 RON) and 6450 EUR (31,200 RON) per year, and of residential social services for the elderly between 5321 EUR (25,738 RON) and 10,451 EUR (50,554 RON) per year, according to the degree of dependence in which the person is included [ 9 ]. In the same year (2020), the annual average pension for old age was 4061 EUR (19,644 RON) [ 10 ], and 24.5% of older persons aged 65 and over—22.3% of pensioners—were at risk of poverty [ 1 ].

Access to social services for older people is essential due to their specific needs, and offers them a dignified life. The quality of social services provided to these people is reflected in their quality of life. It can be stated that the quality of life of older people is closely linked to the social protection system and the quality of social services they receive [ 11 ].

1.2. Quality of Life of Older Persons in Home and Residential Services

Quality of life is a complex, multifaceted concept, having several components that interact simultaneously: objective, subjective, macro-societal, micro-individual, positive and negative components [ 12 , 13 , 14 ]. The macro- (societal, objective) component refers to the roles of income, employment, housing, education, and other living and environmental circumstances, while the micro- (individual, subjective) component considers perceptions of overall quality of life, individuals’ experiences and values, and related proxy indicators such as well-being, happiness, and life satisfaction [ 15 ].

Despite the growth in scientific inquiry regarding quality of life, there is no generally accepted definition of the concept or a way to measure it [ 12 ]. Quality of life in old age and well-being are more often associated with good health and functional ability, a sense of personal adequacy or usefulness, social participation, intergenerational family relationships, the availability of friends and social support, and socioeconomic status [ 16 , 17 , 18 ]. However, quality of life in old age often differs between various groups of older people [ 19 , 20 ]. For example, there are differences in perceptions between older people living in the community and older people in institutional care. The former values more social integration and the latter, the quality of the environment. Additionally, for older people in institutional environments, their significant priorities are in control over their lives, the structure of the day, a sense of self, activities, and relationships with staff and other residents [ 21 ].

A number of studies have focused on diverse quality of life issues of older people in residential care homes. The body of literature reveals that quality of life of these persons is greatly determined by their independence, individuality, and autonomy. It is also influenced by the quality of residential care and facilities [ 22 ]. Duncan-Myers and Huebner [ 23 ] identified a strong positive correlation between improved quality of life of older people and increased frequency of choices available to them in self-care and leisure activities. An important aim is to help older people in residential care to maintain self-control of their lives and care. People who have more independence in performing activities of daily living (ADL) and instrumental activities of daily living (IADL) have reported better quality of life [ 24 ]. Studies have also found a significant impact of social health on the quality of life of older people in residential care homes. Social factors, including socio-economic status, perceived social support from caregivers, and frequency of interactions with family have been reported as predictors of quality of life of older people in residential care facilities [ 25 ]. Institutionalization is a stressful experience for older people, having a detrimental impact on their physical and psychosocial well-being. Environmental modification in the sense of promoting a home-like physical and social atmosphere, autonomy, and individuality is seen to be beneficial for older people in residential care homes [ 22 ].

Research has also focused on the analysis of the quality of life of older people receiving community-based care. Large-scale studies indicate that the level, maintenance, and development of high-quality social support networks contribute to improved quality of life [ 26 , 27 ]. Older adults’ social networks could provide access to support and assistance from family members, neighbors, friends, and service providers. This type of support is essential and is related to older adults’ perception of control and improved well-being [ 27 ]. Studies detail that social participation opportunities and provision of care services that meet older adults’ needs are associated with higher quality of life [ 28 ].

The growth in the older population has contributed to an increased demand for social services that are cost neutral and that maximize the quality of life of beneficiaries [ 29 , 30 , 31 ]. Quality of life has become a standard measure of long-term care services outcomes [ 29 , 30 , 31 , 32 , 33 ]. Care homes could be an important part of caring for older dependent people. Despite this, across all cultures, up to 90% of older adults prefer to remain in their own homes for as long as they can [ 34 ]. The trend at the European level is to move from an institutional care system to a system that provides care for older people in a more familiar environment, i.e., at home. Existing studies have found that older people enjoy a higher quality of life if they remain in their home receiving the care they need than if they live in a residential care institution [ 22 , 35 , 36 , 37 , 38 ].

Other studies have not found differences in the quality of life between institutionalized older people and non-institutionalized ones [ 39 ]. At the same time, some studies have shown positive aspects of institutionalization, such as adherence to pharmacotherapy, improvement in social life, easing of depressive symptoms, and participation in leisure activities that benefit locomotion [ 40 ].

Irrespective of the type of social services, the quality of life of dependent older people is a difficult issue to manage, especially where there is no family support in the physical proximity of the older person, as in the case of transnational families [ 41 ], which changes the paradigm of understanding the family based on the idea of co-residence and physical unity [ 42 ]. Migration causes the spatial separation of families, with the care of dependent elderly people left behind in their home countries being a real challenge for members of transnational families, as shown by the studies conducted on this topic [ 43 , 44 , 45 , 46 , 47 ]. Although migration does not make mutual care obligations and expectations disappear, members of transnational families usually involved in different types of transnational care of relatives who remain in their countries of origin encounter difficulties in fulfilling their roles in the absence of a well-developed long-term care system in the home country. The forms of care provided by members of transnational families for dependent relatives left behind also depend on cultural norms that define the duties of the younger generation towards senior family members.

2. Materials and Methods

2.1. conceptual framework.

Studies in the field have identified, as the main determinants of quality of life in old age, psychological/emotional aspects (life expectations, acceptance of physical dependence), health (mobility, functional autonomy), social participation and social support (involvement in social, cultural, religious activities), social capital (relationships with family, friends, other residents), and the feeling of security [ 18 , 48 , 49 , 50 , 51 , 52 , 53 ]. A qualitative methodology was developed starting from this conceptual scheme that refers to general determinants of quality of life in order to generate information on the specific determinants of the quality of life of dependent elderly people in Romania. The qualitative methodology offers a research tool that enables the understanding of the complexity of the phenomenon of quality of life of dependent elderly people in Romania, measured from the perspective of social services providers involved in managing the phenomenon [ 54 , 55 ].

2.2. Study Area

The qualitative methodology developed by the research team was applied in eight focus groups organized in each of the eight development regions of Romania, participants in these focus groups being public and private providers of social services with and without accommodation for dependent older persons. According to the nomenclature of social services in Romania, accommodation services include social services provided in homes for the elderly—8730 CR-VI; respite centers—8730 CR-V-II; sheltered housing—8730 CR-V-III; services without accommodation, which include social services provided in day care and recovery centers—8810 CZ-VI; and home care units—8810 ID-I. The situation of participation in regional focus groups is presented in Appendix A .

2.3. Method, Recruitment, Data Collection, and Analysis

The authors developed a focus group guide within this qualitative methodology, with the conceptual dimensions of the research tool relying on scientific literature in the field. The focus group technique enables, through interactions with respondents, the development of a discussion about a topic [ 48 , 52 , 53 ]. Analysis of the information gathered enables the identification and study of the social meaning of the studied topic [ 7 , 56 ].

The study was carried out between May and June 2019. As the data collection occurred before 2020, the analysis provides a picture of the determinants of the quality of life of older persons in social services just before the COVID-19 pandemic. The sample size took into account the aim of the research, the sample specificity, and analysis strategy [ 57 ] (p. 402). Theoretical sampling was used in the selection of participants in the focus group, the main selection criterion being the relevance of the investigation unit for the research objectives. In the case of our research, the relevance of the investigation units was given by the information they have about the quality of life of the elderly [ 58 ]. The public and private providers that participated in the focus groups were selected from those included in the Single Electronic Register of Social Services provided by the Romanian Ministry of Labor and Social Justice (MMJS) in January 2019.

The tool used (focus group guide) addressed the following topics: (1) quality of life of dependent older people in Romania; (2) autonomy and independence, quality assurance of care; (3) freedom of decision, control, sense of security, and respect for privacy; (4) communication and social interactions, social participation/activities carried out ( Table 1 ).

Dimensions and indicators operationalized in the focus group guide.

Source: developed by authors.

Each focus group session lasted 60–90 min, was conducted by a moderator and an observer, and was digitally recorded with the participant’s oral consent [ 53 , 55 ]. All the social services providers for the elderly received an e-mail with an invitation to participate in the research. Social services providers willing to participate in the research appointed a person to participate in a focus group. Following this, informed consent was obtained from all participants of each focus group, and this consent was audio recorded.

The research team used the qualitative research software NVivo12Pro to record and manage the data ( Table 2 ). After all the focus groups’ data were transcribed, the transcripts were analyzed following the principles of thematic analysis, which reveals the content of and meanings behind patterns (themes) present across entire data sets [ 59 ]. The coding was conducted in two phases. In the first phase, two researchers assigned independently all the responses to each theme of the focus group guide. Inconsistencies in text coding between the two researchers were reviewed and refined after another revision of the transcripts and audio recordings. In the second phase, analyses of results were jointly conducted by all authors. As the participants of the focus group discussions were professionals nominated by each nationally accredited social services provider for the elderly that agreed to participate in the research; therefore, a good degree of credibility of the results can be assumed. Text passages are presented in the Results section by type of service and development region (Bucharest Ilfov, BI; Centre, C; East, E; Nord West, NW; South Muntenia, SM; South East, SE; South-West, SW; West, W).

Phases of data analysis.

3.1. Quality of Life of Dependent Older People in Romania

3.1.1. factors (positive/negative) that influence the quality of life of dependent older people.

The quality of life of dependent older people was defined by social services providers as meeting the daily needs of dignified care and proper access to various forms of support or to social services. Quality of life implies the ability of each person to satisfy his/her needs and to have access to medical services and social activities adequate to their health status.

“In general, the quality of life requires at least a satisfactory degree of fulfillment of a person’s specific needs, in our case semi-dependent or dependent older people.” (Residential care provider, BI.)

“First of all, the older person must have a permanent connection with the family doctor, the caregiver must take care of the older person’s scheduling and medical assistance. At home, personal hygiene is needed as much as possible, the older person must have a social life, if possible.” (Home care provider, SE.)

Social services providers considered that the main positive factors with an influence on the quality of life of older dependent persons that are receiving home or residential care were related mainly to income level, health status, and access to healthcare services, while the negative factors were related to health status, the ability to move independently, and relationships with family members ( Table 3 ).

Factors influencing the quality of life of older dependent persons.

In the case of home care services, the social services providers mentioned the risk of inadequate care despite the good intentions of the caregiver. Residential care was considered to be able to contribute to a better quality of life for dependent elderly people, as it facilitates access to adequate medication, staff, and medical care despite the social stigma associated with the institutionalization of older family members. The main disadvantage mentioned for home care services was the inability to respond positively to all the needs that an elderly person in home care has.

“ I think that the whole of society needs an education in this regard, which is why those who are at home suffer. Because of some mentality, a poor education, to do things in such a way as to reconcile society more than the older person in need. They come and say: I can’t take my mother or my father to a nursing home! What will my neighbors say?” (Residential care provider, C.)

“ They should have access to quality medical services, including an ambulance that fails to arrive.” (Home care provider, BI.)

In the case of residential social services, occupational therapy can positively contribute to a better quality of life for the elderly. It involves the provider access to different types of activities that give the beneficiary a feeling of freedom and sense of utility, and that fosters connections with the previous life and occupations of the beneficiary.

“ Occupational therapy helps a lot. The vast majority of the elderly who, at some point, end up accessing residential social services, want to continue the activities that they were taught and used to do.” (Residential care provider, SM.)

Communication and the involvement in different social activities improve the quality of life of older dependent persons and reduce social isolation in old age, but the scarcity of occupational therapists, physiotherapists, and psychologists is common with both residential and home care providers, and it is felt especially in small towns and rural areas.

For beneficiaries that have good relationships with family members, the effects are positive in regard to their emotional status and sense of belonging.

“ There were cases where grandchildren, uncles, and aunts came. The fact that they came is good. Older persons may have dementia, but you can talk to most of them and they know they have a family. It’s something that improves their daily mood.” (Residential care provider, W.)

Intergenerational activities provide the opportunity for older dependent persons to feel part of the community again, to exchange experiences and knowledge and to feel valued.

“Collaboration between generations is very important. Older people enjoy exchanging information with younger people, children, and teenagers.” (Home care provider, C.)

In terms of negative factors, the quality of care is limited by the available resources of providers and the time that human resources have at their disposal.

“And the services are not easy to provide, the nursing job is hard, difficult … it requires a lot of physical effort and mental consumption … and you end up being over-saturated in all respects … burnout.” (Residential care provider, NW.)

Last but not least, bureaucratic requirements directly diminish the ability of providers (irrespective to where the services are provided) to respond to the needs of beneficiaries.

“ I have to be available if the institution hires me and has 300 beneficiaries. I, a social worker, have to be available to prepare the files and you don’t want to know what a medical-social file means to be prepared, right? Or, when the ministry comes for an inspection and controls the paperwork, it’s extremely messy. A bunch of documents that from my point of view, forgive me … are made in vain. I don’t see the point … except that we cut down trees and throw them away, and the beneficiary receives what? My frustrations, his unresolved frustrations … […] The time allotted to the beneficiary is then shortened.” (Home care provider, BI.)

Other negative factors pointed out by the social services providers were related to the difficulty of meeting the quality requirements set in the national standards of quality for social services, the lack of adequate financial resources, the lack of specialized staff, and the changes to the legal framework in the field of social assistance.

3.1.2. The Impact of Social Services on Quality of Life

The provision of appropriate social services that adequately respond to the needs of beneficiaries, directly contribute to an increased degree of independence and maintenance of their physical and mental health was reported as being beneficial.

“The existence of the social service itself is beneficial for dependent and semi-dependent older persons.” (Home care provider, BI.)

Cases of significant improvement in health following residential care were reported. Meanwhile, for home care provided by untrained informal carers or family members, cases when the beneficiary’s level of dependence was accentuated despite good intentions were noted.

“We had positive results when they came on a cart or in bed and then they managed to walk without a cane.” (Residential care provider, SM.)

In the case of home care, the lack of human resources and services (e.g., personal hygiene), difficulties in complying with medication on time by the beneficiary, and the positive impact of social visits to the dependent elderly person were also mentioned.

Social services providers emphasized the importance of assessing the quality of social services provided in order to improve, diversify, and adapt them as best as possible to meet the needs of beneficiaries. Consultation with both beneficiaries and their relatives were taken into account. However, the bureaucracy related to admission into social services was cited as a barrier. Another problem faced by residential centers is the difficulty of managing the presence in the same home of dependent but mentally healthy elderly people and those with dementia (including persons over 20 years old diagnosed with autism).

Social services providers appreciated that a first direction is the continuous improvement of the quality of social services offered through individualization instead of diversification. Financial incentives for existing staff and the identification of ways to attract a young and skilled labor force could cover the necessary human resources.

Other areas mentioned were collaboration with medical staff, the local community, and volunteers (including older persons) and the development of national public information and awareness campaigns about the social services available for dependent older people. The possibility to visit residential centers and access direct information could allow for the overcoming of stereotypes related to the abandonment of older family members in residential settings. The development of such national education programs would allow for the provision of social services in residential centers or at home in time, preventively not at the moment when a person’s health status is far too deteriorated to be remedied.

The impact of social services on the quality of life of dependent older people is constantly measured through questionnaires, observations, activities carried out, and discussions whenever necessary. Measuring the influence of the quality of care on the quality of life of beneficiaries is requested within the national quality standards. In the present study, social services providers were concerned with overcoming the formal level of completing the questionnaire and identifying those issues that may contribute to a better quality of life of beneficiaries. In this respect, the information obtained from the beneficiaries was correlated with that obtained from the assigned staff and subjected to discussions in the team meetings.

3.2. Autonomy and Independence; Quality Assurance of Care

Within this dimension, the beneficiary’s ability to carry out basic activities of daily living, dependency, and mobility and their level of vitality were taken into account.

3.2.1. The Role of Social Services in Maintaining the Independence of Older People

Social services providers reported that concerns for the preservation of the functional autonomy of beneficiaries was the main aim of their activity. A first obstacle in this regard is the number of and the training of the human resources involved.

Social services contribute to the improvement of the quality of life of older person, as they cover activities of daily living that can no longer be carried out by the person. Moreover, in the case of residential centers, an older person has access to adequate health care and specialized staff trained to support the older person in maintaining a level of autonomy and independence.

“ I have found that at home, even if people are hired to take care of them, they are untrained. We have seen cases in which they have turned a semi-dependent person into a completely dependent person. Why? Because it’s very convenient to change a diaper. That person should stay in bed, calm, quiet and why waste time with mobilization?! And so it turns a semi-dependent people into a totally dependent people, through the care they provide. Their degree of independence has increased because we do physical therapy, we do treatment, we monitor, plus they socialize very well and there are also rules that they would not follow at home. At home they are very comfortable, at home they are used to taboos. Here, they are willing to accept rules that we are aware of and convinced that are to their advantage.” (Residential care provider, SW.)

In the case of residential services, due to the advanced state of dependence at admission, in many cases, the provider does not necessarily aim to improve the autonomy of the person through the services they offer, but rather to lower the process of physical or mental degradation, while taking into account the pathology of each person.

“When they get to a residential center, they find themselves cared for, nothing bad can happen to them. After a certain period of time of accommodation, they enter into a certain routine and everything is okay for them, no matter how sick they may be, especially in cases of dementia. They feel protected that nothing can happen to them, there is immediately someone next to them who helps them when needed, they enter a certain stage, the evolution is very slow, with the exception of the compensations that appear later due to other reasons.” (Residential care provider, SW.)

The involvement of beneficiaries in maintaining a degree of functional autonomy depends on their mental state, their degree of awareness with regard to their health status, the accessibility of the living environment, their feelings of trust in their care staff and their existence, as well as the involvement of family members.

Social services providers reported that the majority of beneficiaries were concerned with maintaining functional autonomy, especially in the case of home care beneficiaries where there are not always people available to help. These beneficiaries were characterized as healthier, more open to interaction, balanced, smiling, well-disposed, and able to decide on their own whether to move to a residential center.

Residential social services providers mentioned a number of autonomous activities that the elderly carry out: personal hygiene, serving meals, caring for plants, participating in various activities within the residential center (library, meetings) and community (church). In the case of those cared for at home, the following were mentioned: small walks in the park, shopping, and going to the market.

In addition to the social services provided, participants mentioned other types of services, which the beneficiaries request in order to maintain functional autonomy: prostheses, orthoses, hearing aids, and dental services and implants.

3.2.2. The Role of Dependent Older People/Legal/Conventional Representatives in Improving the Quality of Care

Beneficiaries, their families, or other legal representatives may influence the quality of care. In some cases, family involvement has positive effects on the well-being of the dependent older person, and these benefits were pointed out by both home care and residential services providers.

“The efforts of the team no longer lead to the same result, to the same quality of service, to the same degree of satisfaction for the beneficiary and the same quality no longer reaches the beneficiary.” (Residential care provider, SM.)

Participants in focus group discussions reported that semi-dependent older people are more interested in maintaining their level of autonomy. In the case of people with various cognitive pathologies, their interest in maintaining good physical health was reported as being rather low.

“It depends on the disease and how aware they are of this. Often there are certain relatives who make the decision on their behalf, especially in cases of dementia…. Many do not have the necessary will. It matters a lot! If they don’t get involved, you have no results. You need to find the ways to show them that what you are doing is for their own benefit! It takes a lot of patience and involvement!” (Residential care provider, SW.)

Maintaining the autonomy and independence of beneficiaries is a major concern among older people who are in a better emotional state, whether they receive home care or residential care. The participants mentioned that those persons who have a daily life schedule, with regular activities, are more interested in maintaining their autonomy and independence. The involvement of family members in providing services helps to improve the older person’s emotional state and is often essential.

“I say that it is very important to involve the family in everything you do. I had people who were in bed and benefited from this collaboration between the family and the organization.” (Residential care provider, C.)

3.3. Freedom of Decision, Control, Sense of Security, and Respect for Privacy

3.3.1. freedom of decision regarding the type of care.

Freedom of decision is limited by the degree of dependence (physical and mental) of each person, the social services available, the area of residence (rural or urban), and last but not least, the available financial resources.

“And mental health, depending on each individual, the social situation in which they are… And secondly, the range of social services within the region or within the community. In rural areas they are non-existent.” (Residential care provider, SM.)

Freedom of decision is also limited by the lack of information about available services that an older person can access.

“Unfortunately, this freedom of decision does not exist as it should, because even if they want a specific service, they want a specific care … they can’t find it or don’t know where to look for it.” (Home care provider, BI.)

Family members also perform an important role in choosing the social services for dependent older people, as the costs associated with such services are often supported by them.

“There are extraordinary differences and the family says: up to here, up to the money.” (Residential care provider, SM.)

According to social services providers, the decisions of beneficiaries are respected, and they take into account the characteristics of the social services provider. However, the spectrum of services from which dependent older people can decide is limited.

According to the social services providers, collaboration with beneficiaries and family members is vital in ensuring the quality of care, irrespective of where the social services are provided (at home or in a residential setting). Reduced understanding of the limits of social services provision both by beneficiaries and relatives leads to unrealistic expectations and even tensions.

The quality of life of beneficiaries is also influenced by the way in which connections with the human resources involved in care are built. The skills reported as necessary to perform the tasks of care were professional skills and the ability to manage difficult situations. Due to the specific nature of caring for dependent elderly people, some employees decide not to stay (even after care experiences abroad) and some volunteers do not continue their activity. Another problem is the ageing of the care staff, which reduces their physical capacity to manage certain situations that appear during the care process.

3.3.2. Safety of Social Services Provided

According to social services providers, when beneficiaries consider that their personal safety is endangered, written complaints are addressed to the authorities in charge. Social services providers also emphasized their compliance with standard protocols and procedures (strict guidelines for medication and care, evaluation, and monitoring visits). A positive image of care staff in the eyes of beneficiaries is important in a good care process.

“Procedures should be followed ad literam. If you have a procedure, you follow it. […] Where there is a lack of procedure, there is chaos.” (Home care provider, BI.)

With regard to the security felt by beneficiaries during the provision of services, the order and the daily routine of care can provide them with a feeling of security. Safety in the provision of social services requires the existence of qualified staff, continuous collaboration between the members of the provider’s team, and control and supervision over the way in which the care is provided by the staff.

“First of all, continuous surveillance. They keep going to the sick persons and observe them. I don’t know how home caregivers cope because the condition of an elderly person can be so misleading. They might be fine now and then fall on their feet in five minutes.” (Residential care provider, C.)

3.3.3. Respect for Privacy

Respect for the privacy of a dependent elderly person is important regardless of where the services are provided, the provider having the responsibility to ensure the training of staff in this regard. A first step in this delicate process is to understand the meaning of privacy for a dependent person. The patience and training of the care staff influence the way in which beneficiaries perceive that their privacy is respected.

“You shouldn’t ask him more than he wants and can give you as information. You have to have some limits. If he doesn’t want to tell you more, you don’t insist upon asking annoying questions.” (Home care provider, BI.)

Representatives of residential social services and home care providers reported that care for the safety of a beneficiary is ensured by following the standard procedures of caregivers. Respecting the privacy of an elderly person implies respect for his/her religious beliefs, and in the case of home care services, it is important to respect the wishes of and restrictions imposed by the person during the provision of services.

“The person’s privacy package, the bedside table where the person has their personal belongings, in the immediate vicinity of the bed there are icons or photos from their youth, indicating their desire to arrange their own corner.” (Residential care provider, SM.)

3.4. Communication and Social Interactions, Social Participation/Activities Carried Out

3.4.1. the importance of social interaction activities.

Providers of social care services for dependent elderly people reported that they appreciate that communication and involvement in social activities are important. In the case of residential social services, the frequency of social activities depends on a number of factors, such as the availability of human resources, the occasion for which they are organized, available income, the health state of beneficiaries, and their willingness to engage. In the case of home care services, involvement in social activities depends on the level of autonomy of each person. Carrying out such activities changes the mood of beneficiaries and maintains good emotional well-being.

“They want to have someone to talk to, to have someone to socialize with. Not to feel alone, not to fall into a depression, not to feel insignificant in this world.” (Residential care provider, NW.)

Social services providers noted that care staff are ready to support elderly beneficiaries’ involvement in social activities. The involvement of human resources depends on the level of professional training and of personal skills. Compliance with internal regulations supports the development of care. From this perspective, the high load of care staff and the involvement of volunteers were mentioned.

Residential social services providers mentioned a wide range of activities: art courses (painting on canvas and glass), sports activities (dancing, table tennis, cycling in the yard), activities organized within the center (folk performances, marching bands, songs and poetry, counseling on various topics, meeting with the priest, visits to the chapel, and involvement in culinary activities), other leisure activities (choir, karaoke, rummy, chess, backgammon, watching movies, prayer in the chapel of the residential center), and trips outside the home (walks, pilgrimages, going to church, watching shows or movies, short visits to home or relatives). Participation in mountain or sea trips depends both on a beneficiary’s ability to travel independently and logistical aspects specific to transport (e.g., covering the costs involved). In the case of beneficiaries cared for at home, they may be accompanied to carry out various activities. Within the focus group discussions, there were representatives of social services providers who stated that they managed to collaborate with different private organizations in organizing trips for dependent older people.

Regarding the interaction of dependent elderly people with other categories of people outside the organization, social services providers mentioned: relatives, friends, community members, and neighbors (in the case of rural areas).

3.4.2. Factors Limiting the Social Participation of the Elderly

In the opinion of social services providers, the factors that limit the participation of dependent elderly people in social activities are: the existence of different health problems (including depression), their limited physical capacity, their previous social status, their previous lifestyle, their interest in involvement in social activities, the characteristics of those with whom they would interact, the attitude of the community towards them, their income level and, last but not least, solving the various logistical aspects related to the organization of such activities (ensuring private transportation means, difficulties in accessing accessible public transport means, availability of staff, etc.). Representatives of social services providers emphasized the importance of permanent supervision when traveling outside the center in order to avoid walking difficulties and falls. Often, the authorized attendant is a family member or a trusted person who can ensure the physical safety of the elderly person while traveling.

3.4.3. The Attitude of the Elderly towards IT Technology

Regarding the attitude of dependent elderly people towards modern means of communication, social services providers reported that beneficiaries are interested in using the Internet and electronic devices related to the field of information technology. Communication and social applications (e.g., Skype, Facebook, email, WhatsApp) are used on various devices (e.g., smartphones, tablets, laptops, and computers). Beneficiaries’ families perform a major procurement and learning role in older people’s accessing and using modern means of communication. Older persons communicate with family members (especially when their children are abroad), receive photos, read the press, search for various information on the Internet, and shop online. Computer rooms are available in some centers. However, not all elderly people are technologically connected in this way. Those who have various mental illnesses are neither interested in nor able to access IT technology. One of the beneficiaries of social services at home interviewed had only a landline phone. Difficulties were also mentioned regarding the use of mobile phones (e.g., abandonment or blocking of telephones, loss of chargers, etc.), cases in which relatives call the care staff for help.

4. Discussion

4.1. limitations of the research.

Some limitations of the present study can be highlighted. The main limitation was that it explored the meaning and the determinants of the quality of life of older persons from the perspective of providers, reflecting only one facet of the issue. Another limitation of the study was that providers of residential services were greater in number compared to home care providers, and thus a less comprehensive picture for understanding the influences of social services on the quality of life of beneficiaries resulted. However, this study contributes to a better understanding of the role of social services providers in ensuring the quality of life of dependent older beneficiaries of social services, and these results could also serve as an evidence base to improve policies regarding older persons.

4.2. Suggestions for Services and Policy

This study presents the roles involved and challenges encountered in ensuring the quality of life of older beneficiaries. Our findings revealed aspects related to the objective quality of life of older dependent persons, quality of care, freedom of decision, control, sense of security, respect for privacy, the role of communication and social interactions, and social participation/activities.

With respect to the quality of life , previous studies [ 60 ] outlined objective measures of quality of life that support social policies and programs (and thus a better adequacy of the social services to meet the needs of older beneficiaries), as they capture the effects of such interventions. Other studies [ 61 ] argued that objective measures do not reveal the individual perspective. However, the assessment of quality of life cannot remain a purely subjective matter, especially when it is used in a particular social policy context [ 12 , 56 , 62 ], being one of the most important objectives in caring for older persons [ 63 ]. Quality of life of dependent older persons is related to the ability of each person to be able to satisfy their needs and have access to social and health services; it also includes attention to their emotional state.

Multiple positive factors were pointed by the participants as being related to a good quality of life in old age: an adequate level of income, a healthy lifestyle, access to necessary and affordable healthcare services, good relationships with family members, and involvement in social activities. Participants highlighted certain advantages of residential care compared to home care, for instance, despite their good intentions, family caregivers do not possess the knowledge to provide adequate care. These findings suggest the need for the training and education of caregivers and family members using various methods (video, the Internet, etc.) to inform and train them on how to perform caring tasks, as other studies related to older persons have concluded [ 64 ]. Existing studies have highlighted that the COVID-19 pandemic increased the care burden of older people’s family members [ 65 , 66 ]. In our study, residential care was found to contribute to a better quality of life for dependent elderly people, as it facilitates access to adequate medication, staff, and medical care. In other studies, the results suggested that elderly residents are more likely to experience a deterioration in quality of life due to changes in their living conditions, impaired health, reduced functional autonomy, and decreased social interactions [ 22 , 67 ].

Factors with a negative impact on the quality of life relate to the physical and mental health of older persons, the characteristics of their environment, and the limited availability of social services, especially in small towns and rural areas. Adequate and trained social and healthcare professionals are essential to ensure the quality of care and to prevent the risk of burnout or abusive care practices in caring for the elderly. Our findings are consistent with studies that suggest the negative impact of burnout on the level of stress of staff [ 68 ], as well as the quality of care [ 8 , 69 ].

The providers’ preservation of the functional autonomy of beneficiaries was reported as the main aim of their occupation, and this implies both the effort of professionals, beneficiaries, and family members. The influence of the quality of care on the quality of life of beneficiaries is under constant monitoring, and the involvement of older persons and families in the care process is a constant measure for the quality of services delivered (at home or in a setting), as well as for the quality of life of beneficiaries. The process of service delivery becomes an important indicator for outcomes in terms of satisfaction with quality of life of beneficiaries [ 11 , 70 ].

Communication and social participation improve the quality of life of older dependent persons and reduce social isolation in old age, but the scarcity of occupational therapists, physiotherapists, and psychologists is common to both residential and home care providers. The results in this study are consistent with previous national and international studies [ 11 , 63 ], according to which social participation has proven to be an important explanatory factor for the quality of life of the elderly. Providers argued that social interactions with family and the community maintain and improve the emotional well-being of older persons, as other studies proved [ 71 , 72 ].

5. Conclusions

This study shows that quality of life of older beneficiaries of social services is an important aspect that gives sense and meaning to social services provision for older persons. Our results point to the convergent opinions of providers with respect to the understanding of the quality of life of older dependent persons. Multiple positive factors were pointed out by the providers as being related to a good quality of life in old age: some of the factors are related to individual characteristics, while some of them are related to services provision. Access to necessary and affordable healthcare services is a factor that positively impacts the quality of life. The provision of quality social services that adequately respond to the needs of beneficiaries, increase their degree of independence, and maintain their physical and mental health is also vital. Quality assurance is an important aspect that providers take into account in the provision of social services, and the participants in the qualitative research pointed to some factors that negatively affect this provision (lack of human resources, bureaucracy, etc.). Social services play an important role in maintaining the autonomy of older beneficiaries, and the participating providers stressed that the involvement of beneficiaries and families is very important in this regard. Different opinions in regard to the impact of social services on quality of life of older persons were revealed by home care and residential providers.

The results of our research conducted among social services providers highlight the need for a fundamental change in the construction and governance of the national system of social services for older persons. This change must take into account the existence of multidisciplinary teams, continued investment in the workforce, better public allocation of resources for social services, finding innovative ways to attract and to maintain the young and specialized workforce (beyond financial motivation, and especially by providing concrete prospects for professional development and increasing professional prestige of the social work profession), and development and diversification of the available social services, especially in rural areas and in communities with high migration rates. All these factors could improve the overall functioning of the social assistance system for older persons and, most importantly, the quality of life of beneficiaries. However, further research should evaluate, on a periodic basis, the quality of life of older persons receiving social services, as well as the effects of high migration flows of labor forces on the older population left behind, and the results should substantiate subsequent improvements of the social policy for this age group.

Situation of social services providers who participated in the regional focus groups.

Funding Statement

Part of this work was developed and funded under The Research and Development Programme of the Ministry of Labour and Social Justice for the period 2018–2020, project number 3676/2018, and part under the Nucleu Programme, supported by the Ministry of Research, Innovation and Digitalization (PN 19130401 and PN 19130203). (Această lucrare a fost realizată prin Planul sectorial de cercetare—dezvoltare al Ministerului Muncii și Justiției Sociale pentru perioada 2018–2020, proiect nr. 3676/2018 și prin Programul-nucleu, derulat cu sprijinul MCID, proiect nr. PN 19130401 și proiect nr. PN 19130203). The APC was funded by the Nucleu Programme, supported by the Ministry of Research, Innovation and Digitalization (MCID) (PN 19130401 and PN 19130203).

Author Contributions

Conceptualization and design: M.G., A.M., S.S. and L.M.-M.; Investigation: M.G. and L.M.-M.; Literature review, discussion: M.G. and L.M.-M.; Methodology: A.M.; Analysis and interpretation of data: M.G. and S.S.; Validation: M.G., A.M., S.S. and L.M.-M.; Writing—original draft preparation: M.G., A.M., S.S. and L.M.-M.; Writing—review and editing M.G., A.M., S.S. and L.M.-M.; Funding acquisition M.G. and A.M.; Project administration M.G. and A.M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the Code of Ethics and Integrity of the National Scientific Research Institute for Labour and Social Protection— INCSMPS, and approved by the Internal Approval Commission of the Scientific Board of National Scientific Research Institute for Labour and Social Protection—INCSMPS document number 268 from 28 March 2019.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study, according to the sociological methodology used. All the social services providers for the elderly received an e-mail with an invitation to participate in the research. Social services providers willing to participate in the research appointed a person to participate to focus group discussions. Following this, informed consent was obtained before each focus group from all participants, and this consent was audio recorded.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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What ails Indian research papers? Poor quality or just bad grammar? Premium

India comes third after china and the u.s. in the number of research papers published, but the rejection rate of indian papers is also high, not so much due to poor research but more so due to weak language and grammar.

Updated - August 20, 2024 02:23 pm IST

Published - August 20, 2024 11:34 am IST

Image for representation

K.M. Ajith’s first research paper, co-authored with his supervisor in 2005, was about mathematical physics they had worked out in quantum field theory. The U.K. journal to which the paper was submitted had no hesitation in accepting the quality of the research work, yet the review was quite scathing.

“The reviewer pointed out grammatical errors, including for punctuation marks. And asked us to re-write from scratch,” says Mr. Ajith, who is now a professor at the National Institute of Technology, Karnataka.

The authors may have known quantum mechanics but not how to write succinctly. They asked for help from friends who were also pursuing research but whose English was better. Part of the difficulty was in rewriting the technical terms. Yet they managed to avoid jargon as much as possible to make it to the journal.

Mr. Ajith studied in a Malayalam medium school, and his exposure to English was minimal at that time. Twenty years into research and publishing, Mr. Ajith now speaks about why budding researchers should be good writers too.

India comes third after China and the U.S. in the number of research papers published, says a paper titled, Academic Writing in India: A Research Scholar’s View . But in the same paper, the authors also say the rejection rate of Indian papers is high, not so much due to poor research but more so due to weak language and grammar.

In a 2019 public notice, UGC said that writing programmes should be organised in research institutions to overcome this skill deficiency.

Somadatta Karak, head of science communication and public outreach at the Centre for Cellular and Molecular Biology, says, despite the courses, Indian students struggle with writing. She is concerned about the intensity and reach of the writing workshops and frameworks.

“When I go to tier 2 cities and take workshops on science communication, students there have not even heard or thought about all of these,” says Ms. Karak.

According to Kanika Singh, who directs the writing program at Ashoka University, the higher education system in India has no separate emphasis on writing. “If writing is institutionalised as part of your curriculum and you write in different ways daily, then your science research thesis will become better,” says Ms. Singh.

Eldho Mathews, programme officer (Internationalisation of Higher Education), The Kerala State Higher Education Council, says even students who join top-tier research institutions are trained in a way that gives little importance to writing.

“At the level of screening [for admissions to research institutions], it is important to evaluate the level of language skills. By incorporating this factor into testing systems, the government and institutions can effectively motivate students to develop their writing skills early on,” he said.

Why writing should be taught as core skill

Asha Channakar, a researcher at the Institute for Stem Cell Science and Regenerative Medicine (InStem), Bengaluru, had a similar experience like Mr. Ajith with her first paper. “The first time I wrote, it took a lot of time to understand how to write.”

Ms. Channakar says that when she started to write, she read a lot of papers, and tried to connect the writing and presentation with what she wanted to convey. This was while she was a project assistant at the National Brain Research Centre in 2019. Later, she took research writing classes at the National Centre for Biological Sciences as part of her PhD at InStem.

“They taught how to write a scientific manuscript, and there was also an assignment to write for the non-scientific community,” says Ms. Channakar. She has now grown to become the first author of a paper published recently at InStem.

Ranjana Sarma, who has a PhD in Biochemistry from Montana State University, says, “Our researchers struggle with the flow of ideas more than the language.”

Unlike Mr. Ajith and Ms. Channakar, Ms. Sarma got the benefit of the U.S. research ecosystem. When she first wrote a review paper, the feedback was, “Ranjana doesn’t know English.”

“Coming from India, this was a huge ego-crusher,” says Ms. Sarma, who consistently scored high in English back home.

In 2004, she was put into a course offered by Penn State University to learn not only writing but also how to present and peer review. In the U.S., she learned that writing should be simple and easy to read with short sentences. The writing classes Ms. Sarma took influenced her not only to write but also to think and how to pay attention to what she reads.

“Language does look like a challenge for most researchers, as they write in a heavy, academic style. Despite English being the language of science in India, most researchers find it difficult to express themselves in plain, simple English,” says Subhra Priyadarshini, Chief Editor of Global Supported Projects, Nature Portfolio.

Can AI help?

Of late, students use software like Grammarly to correct language and grammar. Although Mr. Ajith appreciates such software, he also says that the tools will not help students to do the critical thinking while writing. “Grammarly is not writing a paper for you; all it does is to check the grammar of what you have already written,” says Anannya Dasgupta, Associate Professor of literature and arts at Krea University, Andhra Pradesh.

Ms. Dasgupta, who is now the director of the Centre for Writing and Pedagogy at Krea University, started her writing stint as a course coordinator while pursuing her PhD at Rutgers University, the U.S. According to Ms. Dasgupta, to improve the quality of writing, more people should be trained to teach writing.

Teaching writing also involves teaching how to think through the questions and how to build an argument, says Pooja Sagar, who teaches the Writing for Research and Analysis at the Indian Institute for Human Settlements (I.I.H.S.), Bengaluru.

Can AI help? Almost all the established researchers said it could help to an extent. But at the level of research papers, a lot of critical thinking is required that AI can’t deliver. They also cautioned about AI providing false information.

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education / research / science (general)

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Being flexible can actually help you live longer, scientists say. Here's why.

• Being more flexible is linked to a lower risk of dying early, new evidence suggests.
• Incorporating more flexibility exercise may boost longevity in older adults, a researcher said.
• Previous studies show flexibility exercise like yoga and tai chi have other health benefits too.

Longevity is one of the hottest trends in fitness, and new research points to key metric to watch if you're working out for a longer life.

Flexibility, measured by how well your joints move through a range of motion, is linked to a lower risk of dying early, according to a study published August 21 in Scandinavian Journal of Medicine & Science in Sports.

Researchers from more than half a dozen clinics and universities around the world, including Stanford, analyzed data from 3,139 men and women, aged 46 to 65 years old. They assessed participants' flexibility, based on a range of motion through the ankles, hips, knees, shoulders, torso, wrists, and elbows. The researchers then compared that score with participants' risk of dying over an average of almost 13 years of follow up.

The results suggests that people with a higher flexibility score were significantly less likely to die during the study than participants with a lower score.

Women were 35% more flexible, on average, than men, according to this study (and tend to live longer, too, per CDC data) .

A caveat is that this study was observational, meaning more research is needed to see if improving flexibility can help people live longer.

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Still, researchers say this tracks. We already know that cardio, strength training, and other types of exercise can help extend lifespan . "Being aerobically fit and strong and having good balance have been previously associated with low mortality. We were able to show that reduced body flexibility is also related to poor survival in middle-aged men and women," Araújo said in a press release.

The best exercises to improve flexibility

More research could also help determine which exercises are best for improving flexibility , and longevity. There's already promising evidence that flexibility-boosting workouts like tai chi and yoga can be good for overall health, too.

For now, findings suggest that doing flexibility exercises as we get older could be beneficial, according to Dr. Claudio Gil S. Araújo, lead author of the study and doctor at the Exercise Medicine Clinic Clinimex in Rio de Janeiro.

Exercises like a runner's lunge or 90/90 stretch are great for building flexibility. You can also try yoga.

Don't forget mobility, too

Mobility , which is similar to flexibility, can also improve your chances not only of living a long life, but being able to stay active and healthy for longer, trainers previously told Business Insider.

That's all the more reason to have a well-rounded workout routine that includes working in a full range of motion, with movements like deep squats, to improve mobility.

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