HEALTH-RELATED QUALITY OF LIFE:CONCEPTUAL ASPECTS
HEALTH-RELATED QUALITY OF LIFE: CONCEPTUAL ASPECTS
The importance of the concept of health-related quality of life (HRQoL) as a fundamental contribution in the evaluation of health outcomes is reviewed, as traditional measures of morbidity and mortality and life expectancy have become insufficient. The importance of taking into account the patient’s perception, desires and motivations in the health decision-making process as well as in the evaluation of the quality of health care is highlighted. The conceptual aspects of the construct “HRQoL”, its scope and limitations, as well as its historical development from three basic traditions, the investigation of the concept of happiness, in psychology, that of social indicators in sociology and the investigation of the state of health in the medical sciences are discussed. It also points out the historical-cultural relativity of the concept as well as the variability of priorities at different times of life. Finally, the conceptual framework from which we work in the Department of Medical Psychology of the Faculty of Medicine of the University of the Oriental Republic of Uruguay is exposed, as well as a conceptual model, which should be evaluated empirically allowing the scientific design of interventions aimed at promoting psychosocial well-being, improving the quality of life of patients.
Keywords: Health-related quality of life, conceptual sources, health assessment, health outcomes, quality of care.
The article reviews the importance of the concept of health-relatedquality of life (HRQL) as outcome in health evaluation. Traditional measuresof morbidity, mortality and life expectancy are no longer sufficient to determinedifferences. The need of taking into consideration patients perceptions, preferencesand motivations in decision-making and health evaluation is emphasized Conceptualissues on the HRQL construct are reviewed, its strengths and limitations. Historicaldevelopment of the concept coming from three basic traditions: psychological( study of happiness), sociological (social indicators) and medical sciences(health status profiles) is revised.
The HRQL concept is recognized as individual, age-dependentbut also culturally and historically dependent one. Finally the conceptual frameworkwe adhere to at the Medical Psychology Department of the School of medicine(University of the Republic of Uruguay) is developed as well as a proposal forempirical testing allowing scientifically-based psychosocial interventions.
Keywords: Health-related quality of life, conceptualissues, health evaluation, health outcomes, quality of care.
Reception: 20.11.2003. Accepted: 28.12.2003.” The profession of medicine is nothing but touching the curiousarchy that isthe human body and restore its harmony to it.”
Although the theme of quality of life or the “good life” is presented from the time of the ancient Greeks (Aristotle), the installation of the concept within the field of health is relatively recent, with an evident boom in the 90s, which is maintained in these early years of the XXI century.Annually more than 2,000 articles are published in medical journals,highlighting both the great interest and the wide range of meanings of the term.
On the other hand, current life, characterized by an increase in longevity, is not necessarily associated with better quality of life. The increase in the frequency and speed of changes (technological revolution), constant insecurity, excess of information, unemployment or multi-employment, changes in family structure (divorces, unstable unions, both parents in the labor market), the loss of motivations, loyalties, values, point out the multiple stressful factors to which most human beings are subjected. Stress is known to predispose to disease and impair quality of life. The European Working Group of the World Health Organization (Levi, L., 2001) estimates by 2020 that stress is the main cause of death, linking it in the first place to cardiovascular diseases and depressions with its consequent suicidal risk. This situation in which the permanent advance of science coexists, the enormous production of goods, large expenditures on health together with high amounts of stress and associated diseases, dissatisfaction in a large part of the users of health services, leads to question what happens in our societies, in general, and in particular what concept of health and defined by who we are using.
We are entering the twenty-first century, technology is advancing by leaps and bounds and medicine is no stranger to this growth. The available knowledge would make it possible to solve the problems of feeding humanity. However, as the Continental Meeting on Medical Education (1994) pointed out in the Declaration of Uruguay – in an affirmation that for almost 10 years remains fully valid – “the significant political and economic transformations and especially the reform of the health sector, initiated in most of the countries of the continent, have not been reflected positively in the development of living conditions,in order to promote with equity improvements in the health conditions of our populations”.
In relation to health care, the excessive emphasis on technological aspects and the deterioration of the health-patient team communication has been taking away from the relationship of professional help the relational quality that was once social support for the patient and source of gratification and recognition for the health professional. The diagnosis and treatment of the disease, at the biomedical level exclusively, the use of complicated technological procedures, which have undoubtedly represented a qualitative leap at the level of survival in previously rapidly fatal diseases, have often left aside the most holistic approach to health care, where it is not only sought to combat the disease but to promote well-being.
The prevalence of chronic diseases, in most countries, for which there is no total cure and where the aim of treatment is to attenuate or eliminate symptoms, avoid complications and improve the well-being of patients, means that the classic measures of outcomes in medicine (mortality, morbidity, life expectancy) are not sufficient to assess the quality of health services.
In this context, the incorporation of the Health-Related Quality of Life (HRQoL) measure as a necessary measure has been one of the greatest innovations in assessments (Guyatt, G.H.; Feeny, D.H., Patrick, D., 1993).
2. WHAT’S NEW THAT BRINGS TOHEALTH SCIENCES THE CONCEPTOF CVRS?
Essentially, it incorporates the perception of the patient, as a necessity in the evaluation of health outcomes, and must develop the necessary instruments for this measure to be valid and reliable and provide empirical evidence with a scientific basis to the decision-making process in health (Testa, M., 1996).
The sometimes indiscriminate application of new technologies, with the ability to prolong life at any price, the complicated decision of quantity versus quality of life, and the terrible ethical dilemma of the distribution of economic resources in health, put on the table the need to know the opinions of patients. (Are supposedly curative treatments still being made for a cancer patient, outside of these possibilities and even if the secondary effects far outweigh the benefits and deteriorate the patient’s quality of life?
The traditional biomedical model excludes the fact that, in most diseases, health status is profoundly influenced by mood, coping mechanisms to various situations, and social support. It is clear that these aspects of maximum importance in the life of human beings will be the ones that most influence when patients evaluate their quality of life.
3. WHY USE THE MEASURESOF CVRS?
1. Decision-making in the health sector should take into account the perception of users, supported by a deep empirical evidence of scientific basis, which considers, in addition to the classic quantitative indicators (mortality, morbidity, life expectancy) and costs, the qualitative indicators that express the impact on quality of life and patient satisfaction.